Part of the Job: Handling Bad Outcomes in the Cath Lab

“You can’t get much more serious than life and death. And if you can handle that, you can handle anything.” – Ken Jeong, MD

No one suspected left main disease until the catheter engaged and we saw the pressure waveform. We quickly withdrew the catheter; it seemed that a crisis had been averted. The patient’s blood pressure was fine, and her ECG hadn’t changed. “I feel funny,” she said. What happened next was a whirlwind of action—CPR, intubation, support device placement, venous access, vasopressors, more CPR, a couple shocks. Ninety minutes later the code was stopped and the patient pronounced dead. We were devastated. This was our first patient of the day, and we had 4 more to go. While the family processed their loss, my team needed to review our next case and go back to work.

Emotionally recovering from bad outcomes is one of the hardest things we do as interventional cardiologists. To routinely perform procedures we must accept a certain level of tolerance for their occurrence, but they always sneak up on us no matter how skilled or careful we are. We recite the risks to each patient when we obtain consent, often quoting the complication rates from memory. We accept the risks because procedures are without complication 99.9% of the time, and we know the how much patient quality of life can improve. But even that knowledge doesn’t ease the grief that comes with bad outcomes.

During our training we learn to treat the complications of coronary angiography and PCI. We deal with groin bleeds, allergic reactions to contrast, dissections, strokes, and stent thrombosis, and by the time we finish fellowship we can manage these in our sleep. Unfortunately, however, we don’t receive comparable training in managing the emotional and psychological stress of bad outcomes. It isn’t covered at all in Grossman and Baim’s.

As fellows, we can learn from watching our mentors in these situations. I have observed a wide range of responses to catastrophes in the lab. Some view them as inevitable events, while others are affected on a much more personal level. In my experience, talking about these events calms my mind and prepares me to best take on my next case.

I’m not condoning the belief that all bad outcomes can be chalked up to bad luck, the phase of the moon, or imbalances in the Force. Sometimes they could have been prevented, and it is worth a thorough review afterward to determine if this is true. This is what we do at my institution. While presenting a case at these meetings is certainly anxiety provoking, there is some comfort in hearing experienced interventionalists discuss my cases and find they would have taken the same steps.

Dealing with adverse events isn’t something I necessarily want to practice, but I know it comes with the job. Fellowship is the best time to soak in these lessons, especially because I’ll be the attending of record in a few short months with no one to specifically guide me on how to handle tough situations. So I will take the practice now, and recommend you do the same.