Chapters Transcript Video Building/Expanding a Lead Management Program: Advice for a Successful Transition from Fellowship Dr. Kiehl will take you through the importance of lead management in your practice and what to expect when transitioning to practice. corrupt me but um so I just kinda wanna walk through my experience and then hopefully that'll you know provide you some kind of basis on what maybe you guys want to do when you go out and any questions just just please ask. So um I remember not that long ago not having any disclosure. So it's kind of weird to have disclosures but there was an attending in in Cleveland, he's actually vascular and cardio thoracic surgeon eric Roselli who wanted him give a talk and say it's better to have lots of disclosures than none because then you're working with everyone. I think there's some wisdom to that actually. So I'm not going to kind of gloss over this slide actually for a second from an extraction purpose. Uh you know, I do receive consulting compensation from phillips. I still do research actually with Cleveland clinic and get paid to do that. Um and then you research on both the ablation and the device side with pretty much all the companies. So um in any event that those are my disclosures to take that with a grain of salt. So this is gonna be the worthiest slide. I apologize in advance for the first slide being really wordy but you know, I think so some of you are in your second year of ep fellowship, some of you are about to start ep fellowship. Some of you still have another year of ep fellowship to go. I kind of tried to tailor this talk to second year ep fellows but kind of put yourself in the position where you're in and kind of use that to try and figure out what you should be doing in the time you have left in fellowship. What I would say is second year of the fellowship should be the best year of training that you have. It certainly was for me, everyone's fellowship works different. But our fellowship in Cleveland the way we did our case elections, we have this magnet order. And so the second years all had a rotating magnet order. In the first years, all had a rotating magnet order. So second year, you're pretty much getting to pick whatever case you want to do with the attending you want to do it. And what happened is kind of from first year to second year, people would kind of take uh, the attending they wanted to work with, they didn't get to work with that much as a first year. And then as you get along, you can see the wisdom kind of grow and the fellas and you're taking the case, not the attending because you're not gonna have that attending when you, when you leave. So pick the cases that you feel are good cases and pick the cases. This is my advice that are that you're not good at. So, I did a kind of a deep dive to say what I felt like I was not strong at kind of in my last six months and that's kind of where you're at now. So I'd say take the cases that make you feel uncomfortable because this doesn't just pertain to extraction, of course, you know, pertains to VT ablation and, you know, device management in terms of implantation as well. So, um, I tried to do that. I think it's been beneficial for me going out because I felt like I was able to kind of not fixed but, but address all the weaknesses in some manner before I went out on my own. So from an extraction perspective, I would say there's no such thing as too much femoral staring as a fellow. Um, you know, snaring is I don't find it that easy, but I've gotten better at it over time by doing more of it. And I think I should have done more in fellowship. So I would try and do that as you can, you know, the more cases that have abandoned leads in very old leads, you're gonna, you know, kind of have a sense of how to do that when you're when you're the primary operator. So how many of you just show of hands for the second years, how many of you don't know where you're going next year are still looking for deciding where you're going to work versus how many have already know where they're going. Is anyone still deciding where they want to go. Okay. So for the people then who are first year ep fellows and then general fellows, if you want extraction to be part of your workflow, you need to do some research about that before you before you sign a contract. So and I'll go through, I did this when I was looking for jobs and and I'll kind of walk through how I did that. But there are some programs where the surgeons extract. There are some programs or surgeons and gps extract. There's some programs were just gps extract. There are some programs where all the extractions are done in the E. P. Lab and the surgeons are available somewhere and kind of, you know, somewhere in the hospital hopefully. And then there are some where it's very regimented, which I assume is the way you guys are at Hopkins certainly was the way we're in Cleveland where um you know, we had a surgeon or a surgical fellow in the room with us or 11 door down the road in the hybrid O. R. That's an important thing to look into when you're looking for a job because the ability for you to extract may not be um getting the patients. It may not be your ability to do it. It may actually be having the team and the protocols in place to be able to do the procedure. Um The other thing to kind of look into is, you know, how complicated is the case? Mix of the place that you're going. Are you gonna be walking in as the first extractor and being expected to do very difficult cases. Are you going to be the second extractor? You're gonna be the third extractor. That's helpful to kind of get a sense of how you should grow your program and how you should grow your practice. Um And what I would say is the best thing this is probably the best advice I can give in this entire talk is just be respectful the whole way through every single person that's involved in the extraction program at your hospital is important. And that goes from the surgical text to the surgical assistance to your schedule, ear's to the charge nurse in the operating room to the charge nurse. In the E. P. Lab two you're referring providers to the infectious disease doctors. It sounds like really simple advice but being nice goes a really long way. So be proactive to try and get yourself in a position where you can you know start you know hit the ground running for lack of a better term but um but just be nice along the way and be patient. So I'll actually add to that. I've got some slides about how I actually did that but I'll actually add to that that not only are you bringing in more volume and potentially more complexity to lead extraction but generally speaking if you're at a hospital that's able to do lead extraction or a hospital system that's able to do lead extraction to that extent. You're probably at a place where there's also other high end stuff being done usually within structural heart or cardiothoracic surgery. The more high end stuff that's brought in, the better the reputation for the institution is more likely there's gonna be growth in other areas and you can leverage that in your discussions and I certainly did that. There's an Ohio state person in the room, I'm sorry, but I'm a michigan person. And though there's been some controversy in recent years, I really like this, you know, the famous speech that both Sam Benko gave about the team, the team, the team. And I know just kind of said this in the prior slide, I just kinda want to go through who I think of as the team for extraction because a lot bigger than you think. So at least in my group and certainly in other groups, all the other mps are part of the team. Whether they extract or not, they're going to be the ones that are managing the devices, whether they're in your group or there another group that's who's gonna be referring to you. So that's probably gonna be your biggest referral network. There are other places around the US where general cardiologists follow devices and um they're going to be referring you cases directly. Um you're gonna have your device clinics if you're in a really big center where they're gonna be, you know, checking a wound and they're gonna see device erosion or they're gonna be checking a lead and start seeing lead noise or impedance alarms in depending kind of how much follow up capacity you have and what the practices and following up devices it may be that devices are actually kind of followed more passively than you might like just because of availability. That's certainly the way it is in our in our practice. And so the device nurses maybe what's going to the people that are most apt to catch things. Um cardiothoracic surgery may be calling you for a variety of reasons. I didn't put this on here but actually structural heart for me has become a much bigger referral for extraction for increasing try custard work that's being done infectious disease. Hospitalists picking up on an infection any sort of you know gram positive bacteria mia with the device is something that should be raising alarms. And actually and I haven't put this into place yet at my institution but actually your EMR can be a referral base. You can their epic can be extremely powerful if you have epic to basically put in a workflow that will flag consider electrophysiology consultation for device infection. Right? And it's not just you know a month versus two weeks that actually days matter in that. So um from your ep team in terms of who else is on the team. So you might have people that extract together. So you might have again another one of your E. P. S. Um the fellows if you're in an in an academic center or if you're at a place that doesn't have a fellowship. Sometimes residents can be involved that they're very interested. Um The text the nurses um the device reps actually who are I'm gonna be helping with the implants are part of the team and they'll have all the lead information which I would strongly encourage. You become as comfortable as you can with the lead information and how different leads behave. Make sure you know the age the models before you go. And don't be asking when the patient is open because that should be part of your planning before going in And then whether you're a cook side or Philip side your extraction reps are extremely important to in terms of the surgical team. The ct surgeon who's backing you up or potentially even helping you out is part of the team, your anesthesiologist as part of the team. Um We are fortunate that we have C. T. Anesthesia for all of our cases. And so they're usually running the T. E. We're talking through thermodynamics as we go along the surgical assistance that scrub in with me. In addition to the Ep team the scrub techs who are giving you equipment and then having perfusion in the room uh and having profusion capability. And and talking through if we have a tear this is how we're gonna perf use this is our rescue strategy all of these things are important. So the team is actually humongous. Such that Sometimes if you had just a casual observer, they have no idea what was going on. They walked in the room, they said why they're 20 people in this room. But but that's how big the team is. I mean so so my first advice is you know, start with some low hanging fruit. So um just kind of talked to the Hopkins table because you guys are really well trained in extraction, you're gonna go out and you're gonna say well I can handle this. I've handled it before. I mean I had a similar experience, right? I trained at Cleveland clinic, we're at tertiary referral center, we get lead fragment referrals all the time. I can handle this. It's hard to say this. But you know, if the first case that you do is results in a vascular complication, it's not gonna look good. And so even if you can do it it's not to say don't do it but maybe don't do it first in your new face. If you're going from Hopkins to Hop Hopkins, you're you're kind of insulated already. So you can you can probably be a little bit more aggressive. But if you're going from Cleveland clinic to Sentara and no one knows you. Um If the first couple of cases you do don't have the best results, no one's gonna wanna send you patients and no one's gonna want to help support you. And so you know, probably shouldn't be taking five abandoned leads, you know, you know, multiple abandoned dual coil leads. Um you know, occluded bilaterally because they have five lead cases right away. Doesn't mean that you can't do them in time. But you know, pacemakers, single coil I. C. D. S. These are things that are, you know, you should probably be able to handle. Um and those are the ones you should start with. What that means is you might, if you're the only refer or you're the only operator, you might have to refer some cases out. That's okay. It doesn't mean you have to do it forever and ever but just be cautious about the early process of starting out from fellowship. Um If there's another person that's there, even if you might be better trained in extraction than them have them come in and co scrub with you. Good good groups and good programs are gonna force that in so that you feel safe going in but it's to your benefit and you would be surprised what you might learn from that other person. So for instance, um when I started and we'll go through my my kind of experience in a second but when I first started um probably the biggest extractor at our at our hospital was one of the other surgeons, A guy named john philpot was actually an excellent surgeon um and actually an excellent extractor in his own right. He just was kind of sick of doing it. Um and I in in Cleveland, we didn't really ever put figure of eight sutures around the leads prophylactically. Um Bruce Wolkoff and always just say my thumbs strong and just hold down for five minutes and it would stop bleeding. Well, you know, I end up and we'll go through workflow in a little while, but I end up extracting lead to lead a lot and so I'll be taking the sheath out, then it'll bleed and I'll go to the next one and I'll go back and I can cause a fair amount of bleeding if I don't, I'm just having to hold my thumb down to hold pressure. And so I've started putting figure of sutures that I can put down and up down and up throughout the case. And I found it to be quite helpful. I learned that from, from john philpot and I've never done it in fellowship despite, you know, learning from what I thought were very, very good extractors. So you can pick up things from different people that you might not think you would have. Um And so just be open minded about what other people have to say, even though I said, you know, start with low hanging fruit, don't shy away from the cases that need to be done. So, you know, don't ship away an infected patient that's septic and really needs to be done because you're afraid. Um you know, you need to be confident in your abilities and just be be cautious and careful over preparing is never is never a mistake. So going through the process of you know going through your protocol, having extremely effective time out. My time out is probably not as good as yours but it's pretty thorough I think. Um And and over imaging ct is your friend T. E. Is your friend arterial and venous access Is your friend having perfusion in the room. These are these are all things that even if you think this lead may just pull out on its own if you're wrong and you haven't prepared that's where you're gonna put yourself into trouble. Alright so like I said prepare for the worst but expect the best. So this is kind of my workflow. So pre procedurally I'm going to get all the lead information. I'm going to verify that it's correct that part of things actually is important because sometimes it's not right in the system for us. So we have we have pace art and sometimes it gets entered in wrong and then the day of the procedure actually Find out if I haven't vetted well enough that actually the lead I thought was seven years old is 17 years old and that's a little bit different. Um so you know if you have accurate lead information you're gonna plan better look at the chest x ray beforehand there's going to be a chest somewhere in the medical record. If there isn't one get one because it's gonna tell you kind of without getting a ct where you're going to have issues. And then I I use a lot of C. T. For preoperative planning. Um You know if somebody has a really bad creatinine I may not but but I find extremely valuable to look and see where there's calcium and that will help me decide if I'm gonna use a laser or tight trail in certain locations location of the procedure and this is going to be dependent on where you're at. We do most of our cases in the hybrid O. R. But we've moved some cases to the E. P. Lab and the institution where you go maybe different just because of what their availability is. So early on the hybrid O. R. F. Is available to you is better than the E. P. Lab. Just because there's more access and more space generally speaking and that's just more of the home environment of a surgeon. Um On the day of the procedure um I always do this pre pre pre procedural huddle and sometimes you know being frank maybe we're a little bit lazy the day can get busy but in an ideal world you should be in the room cardiac surgery that's backing you up should be in the room. Anesthesia should be in the room and all the people who are gonna be scrubbed and should be in the room? And what you should go through? Is the patient? What the rescue strategy is going to be? The biggest thing is where is this where are you going to rescue? Medium anatomy or right thoracotomy and why? And make sure the surgeon um is able to weigh in on what they would want. Therefore they may prep the patient differently if they're going to do a thoracotomy. If you think there's a high risk of bleeding you might want to get placeholder accesses for for perfusion. And I do that. Not infrequently particularly if somebody has had a prior sonata me before because if they've had a prior to anatomy it's not gonna be as easy to get in and fix a terror. It's true that's true. Not Amis provide provide some protection against terrors but if you have a tear it can be a bigger deal. And so going through what patients need and what all the different providers want and where they want them is helpful. Um So we go through and say you know I want to get a large bore access for anesthesia. So they have a dedicated resuscitation line. I'm concerned about this patient based on their C. T. The fact that they've had a prior strain on me I'm gonna put placeholder A and V. Access and do you want them on the left or the right. Where is it easier for you from a perfusion perspective. Are they are they dependent or not? Do I need ephemeral temporary wire or not? Um I would strongly advise you to use the bridge balloon the first year post fellowship. Even if you think you don't need it there will be some slides I'll go through tomorrow that it's it's reasonable to do that just as you're starting out and then I still use it a fair amount patient positioning and prepping. I kind of talked about that already in terms of whether you would bump the patient up a little bit for right through economy or not. Nowadays. I don't use T. E. And general anesthesia for all cases but it does make things a lot easier and I would tell you early on until you really get into your workflow just over use anesthesia and T. Um You know we have a national blood blood shortage right now says it's actually a bit of a problem presently but um having blood in the room not just typed and cross is helpful. Um And having the perfusion equipment in the room as well as the cardiothoracic surgery equipment in the room and making sure that it works is all useful. Um hypothermia can be used as a rescue strategy. I don't didn't put some slides in there but there's some data for deep hypothermia bypass when you have a tear. And so talking through that with anesthesia as an option. Um If you're really concerned about a case is not an unreasonable thing to do, always clarify where the surgeon is going to be. So there's there's different, different amounts of, you know, backup. There's in the room, sitting there typing notes, there's scrubbed in with you, there's in clinic next door but not operating can get over in five minutes, that there can be any other room operating. Uh and then there can be not in the hospital. And those are all different things when you're talking about time to to rescue. So make sure that you're kind of on the left side of what I just discussed. If you can comparative complication rates in terms of major adverse events and then mortality. And this is a little bit of an older study, I don't think. Yeah, it's a bit of an older study. But if you just look at it people, I think in the general population within cardiology view, lead extraction. Is this very scary, dangerous life threatening procedure. Why would you ever want to go through that? What I what I like to tell patients is that the the consequences of a complication can be higher if you if you didn't prepare for it. But the complication rate isn't really higher. And this is just a slide basically showing compared to a lot of things that we kind of cavalierly do. Like pc. I lots of different places and a fib ablation kind of increasingly moving off site from major surgical surgical centers, you know, lead extraction doesn't have that high of a major adverse event rate compared to those. It's just that if you have a terror and you're not prepared you can bleed to death very quickly. So one of the things that I would tell you that I have found extremely effective and helpful for me being you know in my third year out from fellowship now is actually the support that phillips provides. Um if you have a tough case. So I'm at a place where I don't have um you know another really high volume extractor to say hey what would you do in this case? Um I have the benefit of having Bruce will cough cell phone And so I use it a lot. Um But 11 week I had a really difficult case and I got a C. T. And it was red as an extra vascular segment and I didn't think it was extra vascular but I just didn't want to be the one to make that call on an older case. So I was gonna call will cough. And he was in maine on vacation. So um so Courtney was nice enough to set up a teleconference with me and roger Carrillo in Miami after work. We're both at home and we went through the cT together and he agreed with me. I don't think this is extra vascular. I think your radiologist is strong and that was extremely helpful to give me the confidence to go for it and what was a pretty tough case. And so um just know you have a bunch of resources. Um You know, I think if you're always looking for a complication, you're gonna get yourself in trouble. If you prepare for them, don't be afraid of the complications. Just know how to act when they happen and they will happen and I've had one and I'm gonna go through that with you too. Um Just take your time to these aren't procedures you need to rush through. Um You probably shouldn't be scheduling to lead extractions and three A. Fib abrasions or something like that, you know have a have a lead extraction day and just don't rush through cases. So I don't want to scare you too much. But it is important to think through these things. All right, I'm gonna go through my story here in a second. But any questions about anything, I'll just kind of stopped from any of the fellows, Hopkins or otherwise. Okay so um I as Courtney said I did my fellowship both general cardiology and E. P. At Cleveland clinic From 2014 to 2019. And my two primary uh staff that I did lead extractions were Bruce Willis is on the left and then Dave martin who's in the right and they're very different extractors and I think I learned a lot from both of them because the way that our fellowship works. It's very difficult to get lead extractions until you're a secondary fellow. So I didn't made things a little bit more difficult when I was looking for a job because I didn't realize I really, really loved it until the second year of ep fellowship. Hopefully those of you who are first years have gotten some, you know, some experience now to, to try and get a sense of whether you like it or not. So you might think that, you know, how many extractions that this guy doing fellowship, I only did about 50 systems, which I don't think is really that many now that I've been out for three years. Um, and the vast majority of them were the last year. One of the advantages of Cleveland clinic and everyone's training program is different. You can't force your attendings to let you do more, They have to trust you and they have to be, you know, feel comfortable with whatever you're doing. But in our center, even when it was like the first extraction with or with martin, it's the fellow doing the case and if they don't like what you're doing, they'll stop you and they'll say, I don't like how you're doing this because of X, y and Z change this. They might, you know, take the sheets from you or, or make you stop. But in general, we're the ones doing the case and they're sitting there, you know, kind of grunting sometimes. So, um, you know, it's a safety surveillance advice if asked and then yeah, yeah, let you flail away. And that's extremely important. That experience is extremely important. There's a difference between doing 50 extractions and being the one who actually did them and being doing 100 extractions and you're watching them because it's a feel thing for me. It's a big, it's very much a feel thing. So in any event when you leave fellowship, all the people you did extractions with get their cell phone numbers and you should hopefully already have their email address and when you have a tough case just reach out to them because they're gonna want you to succeed. It's, you know, your their legacy to some degree. So training at a high volume, high complexity center um is extremely valuable as I just brought up and this, you know, this is data out of Cleveland clinic from 2013 to 2017 basically showing similar things that I'm sure you guys experienced at Hopkins but 98% success rate of getting leads out, you know, emergency surgery less than 1% of the time, mortality rates less than 0.5%. And that's kind of in an era where we weren't doing all the things that we're doing now. So this rate should be even lower than they are now. So it gave me the confidence to know that I can do this when I left. Um and so one of the things that was extremely valuable for me actually was seeing some spc terrors and I can tell you that Um you know, one of the two was definitely my fault, the other one it was not, but it doesn't matter whose fault it was, you learned something from it. And so um 50 cases I had to tears, that's 4%, that's way higher than everything I showed you on the prior slide in this slide, so maybe I shouldn't be doing this right. Um Both of my patients on postoperative day one were excavated there were up, you know, just like a just a routine bypass the day after. But we were very aggressive with hypothermic bypass in both in both cases. Ct surgery was in the room. We have always had a fellow there and so if there was a tear, you know, we'll go through the bridge workflow tomorrow morning but the floor is getting pushed out or bridge balloons up the chest is being opened and you know, time to, time to bypass was quick. And so both patients did well. So it gave me the confidence to know I can do complicated cases. I know cases will go not the way you want them, but patients can do okay if you prepare correctly. So um I decided kind of very early in my second year of ep fellowship that I really wanted extraction to be part of my um part of my practice moving forward. And so I use that actually as a as a big decider in terms of where I was going to go and what kind of job I wanted to take and so where that comes into contract negotiation, I used that and I couldn't agree more the minute you signed the paper, if it's not in the contract doesn't mean it's gonna happen. So I used that as as leverage for when I was doing my job search. So I'm gonna be very upfront about my job search um because I think it's helpful for those of you who haven't already signed a job to know what you know kind of what I went through. So um aside from lead extraction, I do a lot of research, I did a master's when I was a fellow at Case Western and kind of clinical trial design. So I think everyone and their mother thought I was gonna do an academic job. So I I talked to University of Virginia pretty extensively Andy Darby is a good friend of mine and then I was very interested in staying in Cleveland, although my wife was not just the weather and so she kinda wanted to go back to Virginia and so the way I actually ended up kind of finding out about Sentara was one of my friends who actually is at Sentara too was a co fellow of mine is a structural attending now for sure. Wanted to go back to Virginia. So he would go someplace and say, hey this place is pretty good, you should check it out. So that's how I ended up interviewing at both Sentara and then Virginia cardiovascular specialist, which is a really big group in Richmond that's, that's private. And so what I, what I found is I started looking at jobs as these triple threat jobs where you get to teach, you get to, you get to do research and you get to do clinical medicine. They're really hard to find these days, you're gonna always kind of have to give on one of them. So you have to do a little bit of soul searching and decide what is most important to you and what I think the teaching element is one thing that I've kind of evolved on over time is that teaching doesn't have to be teaching medical students. Doesn't have to be teaching residents. Doesn't have to be teaching fellows. Even though I do some of that teaching pia is, can be helpful. Teaching the lab staff can be helpful. I mean there's ways to be involved in education in a different way and I don't think I really appreciated that until I was kind of doing my job search. So salary and location matter too. So you know, I'm about to have my fourth kid and two weeks 3 weeks and so you know where we live in Norfolk, The public schools are terrible. So you know, for private schools, it's expensive. So salary will matter and you have to have a talk with your significant other about that. And location matters if your wife is miserable when you don't see the sun from october through may in Cleveland, you know than the sun in Virginia is a little bit nicer. So you just gotta figure out what from a from outside the hospital and an inside the hospital is important to you. So for me, the most important thing for me was clinical mix. I I spent five years in Cleveland. I got to do a lot of cool stuff. I didn't want to go to a place where I couldn't do the stuff I want to do an extraction was I really, really wanted to do. So I was looking at each of these different places saying where would I be from an extraction perspective, I knew I could do it in Cleveland but I'd be like the, you know fifth or sixth extractor up there, am I really gonna get to do a lot of things. Um U. V. A would have been would have been fine from that perspective. Vcs was a little bit difficult to get extraction time in there because of the way the surgical backup is so Sentara the surgeons were doing it but they were really interested in not doing it as much. So there was an opportunity there. Um location like I said, it's important for my wife, I still am able to do a lot of research even though I'm not an academic medical center in the classic sense of the term. And research has changed a lot too. So if you're a big researcher you can get involved in clinical research, you can get involved in guideline committees. I'm on the um the HRS guideline committee for cardiac physiologic pacing right now. So I'm not an academic medical center. So you can you can do things at places that you don't normally think of like that. Um And and so I actually ended up making education my my least important thing even though I love teaching. Um and I find that I do more education in a non academic center than I did in an academic center. Um So in any event those are, those are the jobs I was looking at and ended up choosing Sentara because the clinical volume is is immense. Um I do every every procedure I did in fellowship. Um I did a 12 hour epic our govt ablation a couple weeks ago. I you know, do a lot of extractions. Um I do watch men's, I do everything I did in fellowship. I liked the people I worked with or thought I was going to work with. They seemed like nice men and women. Um They were well trained. They were on the cutting edge of everything and I didn't want to kind of fall behind and I felt like there was an ability to grow and lied and lied, extraction and clinical research and then actually we're in the process of actually trying to start a fellowship and putting together funding and basically an application to start a fellowship. So I thought those were all kind of exciting things to be you know involved in. And the salary was was you know reasonable and my wife liked the area and frankly that was probably more important than anything. You know the old saying of happy wife, happy life is very true. So a lot of you may not have even heard of Sentara that's I didn't really know about Vcenter even though it's a big medical system and I was at U. V. A. Before other than there was this hospital called Martha Martha jefferson down the road. And so it's it's keeping an open mind when you're looking for jobs. Okay so contract negotiations, this is actually really important and and I don't think people think about it so mm. From an extraction perspective. So that's john Philpott, I've mentioned his name a couple of times and then Chris Pereira is on the right. He actually was trained at Hopkins as a surgeon. Most of our our surgeons are all Hopkins trained um And they're excellent. Um and this was their this may not be completely exhausted but from 28 to 2019, to 2019. They did a total of 42 lead extractions and that kind of shows you the breakdown of indications. It was mostly infectious reasons. Um Probably because that's what they're getting referred. They're not they're not actively involved in lead management. It's what comes to them. And so that's not a particularly high volume center um In the distant past way before I think I was even even in training they used to do extractions in the E. P. Lab and there was one people just it's all anecdote there was this one tear in the E. P. Lab that didn't go well and that moved everything up to the hybrid. Um And then the surgeons got involved and they were reimbursement issues. And so um the surgeons said well I'm not gonna get not paid to back you up so I'm just gonna learn how to do this. So that's kind of how it evolved from E. P. Doing it to to surgeons doing it. And then I think because of that and it's out of sight out of mind mentality that sometimes the surgeons will have because you know they're not the ones managing pacemakers in clinic. They're not the one managing defibrillators and crts and implanting them. It just wasn't something that was thought of. And so um over time it became an increased desire to find somebody like me that was interested in taking this back on. And the surgeons had had become so busy with other things that they actually wanted it to. So I actually negotiated language in my contract for an extraction program and I talked with the service line directors about what I would need equipment wise and that I would eventually need block time and that I need to figure out a way that I could still have the surgeons back me up. And so um we'll get into exactly what that what that ended up being. But I think the reason my program has been successful thus far and is growing rapidly is because I had those conversations before I even set foot in Norfolk. That's your one of the things that is in the E. R. G. Surgeons coast. But the DRG that the hospital gets paid a chunk of money the hospital gets for that patient includes reimbursement for answer. So it's actually the hospital are actually they should two why money for that. That surgeon should be don't ask that procedure. And so what we did this wasn't the the eventual compromise we came to but for all I. C. D. Leads. We basically for the first three months I was there we just I just let the surgeon billet and I did all the pacing leads and we figured it would be about even and we're trying to build a program. You know if you go to a place where RV us are kind of how you get compensated. You might have to give up a little bit to get what you want in the future. It's not all about money so at least that's my take. So um here is my extraction change over time. So here's 2019 of which I did about half of them in the last three months of the year. Around 20. And then in 2020 again with Covid basically shutting us down for 3.5 months. Um We doubled our volume to 45 and then in 2021 we did 92 lead system extraction. So I don't think we're gonna get to 8 180 this year. I don't think that's possible but I do project will probably around 100 and 20 or 100 and 50 provided that I can get in the hybrid as much as I need to. And another thing I wanted to point out is Look at how the indications have changed those 50% infection before now it's 25% infection showing that we're being more thoughtful about lead management kind of proactively and reactively of things that aren't just we're trying not to just abandon leads. Um One of the reasons the growth has been there is I'm not sure how many of you have spent time in Hampton roads but Hampton roads, Virginia beach, Norfolk, Chesapeake, Suffolk Portsmouth, Hampton Newport news and if you look at the largest cities in the state of Virginia Those are like five of the top seven or 8 um bigger than Richmond. You know obviously Arlington in the D. C. Area. We'll get in there. But you're talking about a population of patients that's it's about two million. And when I got down there basically I became the only lead extractor for the area. And so everything just started coming to me all the small volume uh programs where they're doing 34 leads kind of closed down because people weren't enjoying doing leads and it's better to have a high volume person do it, it's gonna be safer. And so um what we did in 20 so I referred to in 2019 what I did is I basically I build for the pacemakers the surgeon's bill for the I. C. D. S. And I said I don't care about the money. Let's just do this right in 2020. The way our compensation works is We are to some degree RV. You base for compensation. Um but about 14% of our salaries based on quality metrics that we as a group put together and that's whether you're an ep or an endocrinologist or a cardiac surgeon. And so um what the service line did. So service line being all of cardio cardio thoracic surgery and cardiology said is this is our priority for 2020. We want to do this correctly. So um these metrics that we set are often difficult for us to meet their designed for program growth. And so um sometimes will only meet 80% of the metrics And therefore you're basically losing you know, three or 4% of your salary if you don't meet them. The service line went to the surgeons and said your quality metric is just supporting the lead extraction program. So there's 14% of your salary and that was kind of the DRG payment and and that's been kind of a promise in perpetuity that their quality metric is just supporting not just me but also structural heart for for travers and kind of moving them over time down to the Cath lab. And so the financial part just got taken, taken care of, they didn't have to worry about compensation. So um as volume went up, we had to be more thoughtful about how are we gonna get all these cases in knowing that the hybrid, we only have one hybrid room at our main hospital. How are we going to get all of our cases allocated? And so what we did um is we scheduled basically I have the 1st, 3rd and 5th Tuesdays of the month and I have every friday afternoon for extraction. Um and basically the concept is this that if I've got cases on Tuesday and friday every other week I guess Tuesday and friday No patient that's got back dream is going to go more than 72 hours without getting extracted and Thursdays are a flex day that if we had to, we could get somebody in there Mondays and Wednesdays are kind of the only no go days in the hybrid just because of taverns scheduling, but That's what got us from 45 to 92 cases. And then, you know, Covid has forced us to be different in a lot of ways, but um in terms of how we approach seeing these patients. So I actually do most of my initial consultations by telehealth. I've used a lot of face time and a lot of toxicity and I flip around the screen and I show them their X ray and I use a mouse and I say, well this is where I'm concerned about, you know, this spc coil. Um that's why we're gonna get a ct or not get a ct and show them what a bridge balloon looks like. And um you know, so I have patients that live in the Outer banks patients that actually have a couple of patients that live in Maryland. Um and I have a couple of patients that live in western north Carolina. I don't know how they got to me, but they did and so um we can do this kind of virtually and it's a little uncomfortable, but I need a lot of the patients the day of the procedure and I feel like I already know them and it doesn't feel awkward and so there's lots of different ways that we've kind of expanded growth and so I know I spent a lot of time talking about, you know, start slow, take easy cases. Um It's not to say that I don't take complicated cases. So these are x rays of people that I have taken myself. These are actual patients. So um From September of 2019 through basically end of last year I've extracted 150 Systems 271 leads in 2174 lead years. I think we've done about 10 already this year. Um I've had patients that are up to 90 years of old, 90 years of age. I think the indication that was infectious the mean case lead ages 15 years the max was 79 years. 51% of our cases are I. C. D. S. Of which 50% are dual coil I. C. D. Leads, 32% have leads that are more than 10 years old and 13% have had abandoned leads. Um success rates for complete extraction. This is my own data. Very transparent, 97%. I've shown you that slide before, 98% for Cleveland. Um 81% of the cases I needed to use laser or or tight rail, 19% of the time I was able to just just have traction and pull the lead back. I had one vascular injury in the denominator that's actually this case here. This is the 79 years of fleet age and I learned a lot from it. It happened about a year a year into my practice and it was a gentleman. It was not an infectious reason. It was a guy who basically was included bilaterally and was having had complete heart block and um he was intermittently non sensing and was uh was dependent and um was passing out. So it wasn't a you know elective case. And we went through a lot of different options for him given that his C. T. Was a little bit tricky. Nothing was extra vascular but I knew that it would be difficult. Um And had a very forthright discussion with him and his wife about what we should do. And um I actually tore with a sub sea without any resistance right into the phenomenon and I think probably there was an extra vascular element there that I didn't see. We did a very good job of resuscitating him. We had already had a bridge balloon in place which obviously wasn't that helpful where the terror was. But we had perfusion access for for for bypass. The surgeons were in the room quickly. Actually two surgeons in the room quickly he survived to discharge. He had some neurologic impairment but did go home kind of like your case were discussing earlier where you know patient at a stroke or a P. E. He actually had an aspiration event about a year later and died from that which I think probably was somewhat related to his neurologic injury. But but in any event the point is you can you can leave fellowship, you can start slow and if you feel like you're well trained you can you can do this. It's not, I wouldn't say it's not, I don't want to say it's not hard. It is hard but it's doable. Um And so and this is again at a site that probably a lot of you haven't heard of or haven't thought of at a non academic medical center. Um I referred a little bit to my protocols. It would be funny if you videotaped me and you, I bet you're our timeouts are very similar actually. But so this is a slide, I'll show again tomorrow. But this is how in the first year I I chose what to use a bridge balloon on. So female patients have a slightly higher risk of terror than than than than than males. If you control for other things low B. M. I, low ejection fraction dual coil I. C. D. Leads abandoned leads, multiple leads, combined lead age. Uh And then there's also, you know, if you have an extractor who's new to practice less than one year out. So I I use that as an argument to use the bridge balloon and almost everyone in the first year out just because I felt like it gave me extra an extra amount of support. Um I know not everyone does this but I um I tie every element of the lead that I can so I tie to the insulation I tie to the high voltage elements. I think the more things I can I can hold on to the better. Um As I told you before I use a lot of cts who do I get C. T. S on for sure old leads, dual coil leads that aren't like a year old abandoned leads and anyone they're just you know is kind of frail in general anesthesia. Use a radial arterial line. I have a dedicated federal venus resuscitation line and we'll use the T in all cases. Um CT surgery is in the room. That's the agreement that we have there. Usually writing their clinic notes and just kind of chatting with me about life. Um If they have had prior ct surgery we usually write to our economy as a rescue strategy and prop the patient up as such and we'll put a placeholder and the access in talked about the insulation time and then this is just a thing that I find helpful is I'll go lead to lead If I'm if I'm having a hard time on you know the I. C. D. Lead I'll switch the atrial lead. Maybe there's some lead lead adhesion and I'm gonna break it up better if I start feeling like I'm hitting calcium or I see something and I'm using a laser. I'm switching to mechanical and so I have a this cost related to switching back and forth but I don't really think about that. My goal is to get the patient through safely and do what I'm supposed to do, you know, effectively. So if if it means that I have to use two tools that's fine. You know I've not had a hospital administrator come and yell at me about that yet. So um I have a very low threshold to switch lead to lead in a very low threshold to switch tools. Um and up size. I think one of the best pieces of advice I got in fellowship is that generally speaking A bigger sheet is a is a good idea because you don't know how much junk is around the lead. So yeah, the lead may fit through 12 French but I almost never use a 12 French laser. I I think you're gonna end up upsizing so God right. Yeah exactly. Outside always go up one from there. That's exactly what I do too. Yeah. So what's the future of my program? So um I didn't say my program, I should say our program, that's not fair. But so we basically used so if you look at the guidelines and this is in my slides for tomorrow. But if you look at the guideline document from HRS one of the things that's technically required is for you to keep data on your extraction program and be able to present that to patients so that when you're having an informed decision about discussion about procedures beforehand. You can say my terror risk is this you know this is who I've been extracting, this has been our success rate. The other thing is you can use that for quality improvement. So we looked through lead by lead Pacer vs. I. C. D. And lead age to say every case doesn't need to be done in the hybrid. The hybrid is a resource that's difficult to book other services need to use it. And so we've moved all pacemaker leads that are less than four years old down to the E. P. Lab with the exception of in jeopardy plus leads because those I find break apart a little bit more frequently. I'm having to use mechanical tools more and so we can look you know you can look by lead type to make informed decisions. There are other cases I'm gonna move down to the E. P. Lab but I want it to be successful. So I'm gonna do one thing and then I'm gonna do another thing over time. Once I feel like we have enough data. I've actually with Covid I've done some same day discharge for extractions that I do in the morning that I don't have to use power tools or I have to use very minimal power tools. I watch them all day but you know as we've been doing a lot of same day discharge for a fib over time as a different procedure but I've been piloting doing that. I think in time I may try and publish that. We talked about the EMR flag alert that we're in the process of trying to put in place. The only reason I haven't done it yet is I just don't have the bandwidth to do the procedures right now. Um There is a real world extraction registry that whenever our I. R. B. We will be contributing. I think you guys, I think you guys might have been approached to atrium health is the the center basically the idea is to try and have a real world extraction registry that we can all put our data into and publish you know information on leads and um just kind of outside of major academic medical centers kind of in the real world which I think is much needed just like it is in in a fib is the real Afis database that that's been done right now. So we have projected growth I showed you um and I think if we had more lab availability we probably could double uh you know in another year but we've we've decided that I need, there's other things I like to do an ep other than extraction believe it or not. So I needed more help. So we just hired two new E. P. S. Both were co fellows with me in Cleveland Jeff Hedley and Deep Patel who are going to join in august and so now we're gonna have three extractors and we we kind of rearranged the schedule. So there's going to be someone available every day and we're working with hospital administration as part of their contract negotiations, contract negotiations to get more time in the hybrid, which meets the system goal of moving more towers down into the Cath lab. So um my take home messages and I promise I'll be quiet is first of all have confidence in your training. You know, you you you do fellowship for a reason. Um, but despite that starts slow when you start over prepare. And frankly, even as you continue over preparing is always a good thing. And seek out help from your your former attending, seek out help from the ct surgeon, seek out help from your your partners. Even if they're not extractors now they might have been in the past and they may be helpful, it's okay to say no. So you know, just because someone wants a procedure done doesn't need, I mean it has to be done if you don't think it should be. So it's okay to say no if you don't think you're ready to do it, it's okay to say no. If you don't think it should be done, be patient with the politics and the finances of lead extraction. Um just focus on the element of patient care. It if you get into a situation where you have to do co surgery building to get the procedures done and it affects your take home compensation but you want to do extraction, just do it. The team, the team, the team. So just not just know who's on the team, but make sure they feel appreciated. Say that they did a good job. Those things go a long way and then they want to, they want to do cases with you. So I think a good example, Courtney can kind of test this is, I think when I first started doing lead extractions, the surgical team was like, oh, I don't want to be in here and they kind of like choose which rooms they want to be in and it was like, I don't want to. So not because I mean, but because it was scary and new and now particularly the scrub texts are like, oh great. You know, I, I feel like I'm getting the hang of this now and like I don't have to walk them through wire management and stuff. They've already got everything ready and sometimes have to be like, no, no, no, no, no, we don't need to open lock in silence yet. So um, you know there, I think they enjoy working with me now and I think that's because we've work together, complications will occur. So don't, I think that you're infallible and be humble when they occur be a human when they occur to, you know, to the family members, it's okay for you to personally grieve from a complication because it's, it sucks. Um and but don't let them crush you don't say like I had this happen. I don't wanna do this anymore. The case I had that was a terror. I had a case in the afternoon. I did it because the patient needed to get done and it went fine. So have an iterative internal analysis in a database first of all because you're supposed to and second of all because you'll get better from it And then I can't emphasize .7 enough extraction should make you a better implant. ER Like does somebody need a trans venous device? It's not a surprise that I implant a lot of sub Q. I. C. D. S because I extract a lot of devices. I don't use a lot of dual coil I. C. D. S. I'm a very heavy implant of leave the spacing if I think it's the right thing. And then um honestly all these talks have been about you know medicine and extraction or all these slides but work life balance is so important. Like you'll leave fellowship and you're trying to create this extraction program. You're trying to like you know get your volumes up and you know make connections whether you're in academics or not in academics with your referring base and these are all important things but also senior kids is important because we're all leaving at the time when our kids are five and eight or two and then I think You know if you just put your head down down and you don't think about anything else? They'll be in high school. So um and then .9 I've said this multiple times. Just just be nice. It's it makes everything better. Um So I promise you my contact info. This is my personal cell phone number. It's a Missouri area code because I'm from ST louis and I'm just not going to change it. That's my gmail address. That's my work email address. Um and this is my family who've been nice enough to let me come up here even though my wife is 33 weeks pregnant. And so sometimes you know just in the topic of work work life balance. Sometimes you're there late. It turns out that you can face time with your kids when they're eating dinner too. It's just better to be there in person. So. All right I'll be quiet any questions you guys have. I'm happy to happy to answer them. Mhm. Yeah. So um first of all any time you're keeping databases just know that you have to be hipaa compliant. So don't keep it on your you know just don't don't don't keep it and email it to yourself on gmail but so I keep a database of the date of the surgery. I keep a database of the medical record number the patient age. Um I have a database that has basically how many leads I extracted? How many of them are I. C. D. Leads versus pacing leads. What the total lead age was what the oldest lead was what tools I needed to use for it. Um uh If I didn't need to use tools I have that as a marker to because it helps me decide which ones I can do in the E. P. Lab whether it's infectious or non infectious whether it's dual coil versus single coil whether it was C. S. Upgrade. I use that for timing active case time. So it uses me to help kind of prioritize which cases go into the hybrid on which days and then I have a comment section and that's just for me. I don't mind that but you know it helps me remember which case it was without having to look up patients. And then if I start noticing a trend in the comment section then I don't know the column. So that's that's what we've been using. Um We're in the process of trying to get actually an institutional database to use. Other than just kind of me and my pa and my nurse keeping it actually Courtney Courtney is actually extremely helpful in keeping the database to. We have a log book that we write in actually on our on our laser machine as well. So we can double check if we just forgot one case and you don't have to have power points to. Honestly we did we just did an in service for the E. P. Lab because we've had a lot of turnover because of covid and retirements and just literally it was this is the extraction cart, this is what this is, this is what this is, this is what this is, this is what this is. If I want this I'm gonna need this too and people just got to ask me questions and honestly that was probably more effective than probably half of their in services. You had a question I'm sorry? Sure. Pathway. So I. Yeah. Oh my God why? Yeah sec when you were jobs? How is are there a lot not. Yeah I know but that's an awesome question. Um I do more, I do more ablation than I do devices, my work schedule. I have clinic every monday in Newport News which is kind of an underserved population every other Wednesday I do clinic in Williamsburg which is an extremely affluent population. Um And then Tuesdays, I alternate extractions with abrasions and watchman's at our main hospital uh Wednesday that I'm not in Williamsburg. I'm usually trying to catch up on abrasions Thursdays despite the fact that I did, it kind of created this extraction program. We actually opened a new E. P. Lab at the center. There wasn't one there before and so I do initially I started doing S. V. T. S. And flutters there and devices and now I do a fibs and pvcs there as well on Thursdays and Fridays mornings or appellations, afternoons or extractions, so I don't end up doing a lot of de novo device implants actually end up doing a lot of them doing extractions and I try and shunt some of my device implants too, my partners that that either have more availability and we actually have some kind of older school physicians that are, you know, we're like trained to do devices and kath and they kind of do diagnostic cath and devices. So I kind of shunt that just because there's stuff that I you know, I can do that they can't. One of the reasons we're hiring Dave and Jeff is that I'd actually like to do a little bit more routine device stuff too. And we just being the only lead extractor, it's it's kind of like you're you're always on call, not like truthfully, but you're always getting called in terms of your second question about are there places looking for lead extractors? I don't think it's something that's advertised actually, it may put that question to the phillips teams in the room but um I think if you are interested in lead extraction you could utilize phillips and you can utilize your attendings um to reach out to the areas that you might want to go to and see where there are lead extraction programs where there may be room for growth, I didn't notice that there was somebody coming looking for me because I was a lead extractor if that answers your question. But I think I think they can pull data on which sites extract and which do not and which ones. There may be opportunities. If you already know where you might want to go. If you say the whole United States is a swat that I'm willing to go to and I want to, that may be a little hard for them to pull, but you know, they may be able to put together, they're looking for a job and there's an opportunity. Published July 8, 2022 Created by Related presenters Erich L. Kiehl, M.D., M.Sc. Sentara Norfolk General HospitalEastern Virginia Medical School
