Chapters Transcript Video Starting a New Program Dr. Love covers establishing a new extraction program at your hospital, safety protocols, go-live process. So let's uh let's get moving on here. Here are my disclosures have the same as eric quite a few things out there. So the general strategy um is careful consideration with the patient on the decision whether to abandon or remove the leads and document it. And remember I do a lot of medical malpractice where 15 cases sitting in in my computer at home right now, nothing's going through because the courts have been all shut down because of covid. But a lot of these have to do with lead management cases and a lot of it is, you know, they're going to hammer you on. You didn't tell the patient and the family that this could happen. You didn't give them the the alternative elite advantage. You didn't document this. So documentation is really, really important document that you've had these discussions with them that you offered to lead abandonment. Um then the reasons why that may not be the best strategy for the patient like their septic at the time or you know, they're 26 years old and they've got six leads in already or things like that. I like to make sure that we say the risks and the benefits of each course of actions were discussed and the decision is the patient's preference comorbidities, future vascular access, all available programs take all of those things into account when you're having these discussions and document them and you now with epic and all these things, you know, it's it's it's a smart phrase. You know, I put my dot C. J. L consent extraction. You know, all that stuff just pours into there and I can, you know what's with it. Just a little bit to make it obvious that we're talking about that individuals patients that individual patients issues. Um I have a shared decision making document that I hand to the patient, you are all welcome to it. We developed it I developed and it was it was kind of buffed up at our Miami conference a few years ago. You're you're absolutely welcome to it. It's written in very lay terms, talks about lead extraction, talks about what can happen. Talks about what can happen if you don't have your leads removed. And it's really really good and document that you gave it to because that otherwise they'll say, well you never gave that to me here in my ladies and gentlemen of the jury, here's my note and it says that I gave it to them and that anymore with epic you can even send it to them via my chart and it's now documented in my chart that you've done that as well. So you can really cover yourself. I hate to put so much in terms of medical legal stuff. But if you're gonna do lead management eventually you're gonna have an adverse effect. You know, you're gonna have somebody that's gonna you know, you're gonna tear a cave, you can tear your heart, you're gonna have a death and it's just the nature of what we do. It's not it's a wonderful procedure. It saves many many more lives then we lose. But if something happens you can always guarantee that at some point somebody's gonna call one of these shysters out here. So as you get ready to do these things you want to make sure that you've got this whole plan. We talked a lot about planning yesterday. Are you gonna do this per catania slee or via open extraction instead a hybrid approach where you do both And by open I mean so there's sometimes where you have to have an open chest they're doing something else. They're they're doing a valve procedure or whatever and and you like a open try try custom valve removal. Um And sometimes you do these things with an open chest. It's not common but you can do a lead extraction in the O. R. With a cardiac surgeon with the chest open. What's your goal in this? Are you going to be taking out a single lead? Multiple leads? Are you going to be having non targeted leads? You want to make sure you minimize damage to non targeted lead. There's certain extraction techniques that we're gonna want to consider for non for if we're going to be leaving leads behind versus if we're not because certain techniques are more likely to damage uh create collateral damage and what's your post extraction plan. And very importantly it was discussed as though a few moments ago by eric what were the indications for C. I. E. D. Implant. I've just got referred a case of a patient who's got a fractured I. C. D. Leader and actually noticed the eroded guy just with erosion. And it turns out he had a VF arrest in the year 2000 and it was in the setting of an acute myocardial infarction and he's gone you know 20 years without another event. And now he's got an eroded device. And the question is does he really need a device? Well probably not probably not. So when you look at even pacemakers you find about 18% maybe even more. Don't need a device after you've extracted leads certainly for infection erosion, things like that. So go back look at the original indications and see where is that patient today? Do they still need that that device that they have an inferior wall M. I. And had transient a. V. Block and now that's gone. They don't need to have a device anymore. What do they have? Visa vagal syncope? I just saw a follow up in clinic from a gentleman that we removed the device because he passed out when his his daughter was born and then he drank five years later he drank cactus juice and passed out from this cactus juice. But he had these two bizarre episodes and some of y'all who put a pacemaker in the fella and then he ended up with a fractured lead and the whole thing it's like you know what, you don't need another device. So look back and consider these things T. E. Very helpful. But it has to be monitored and how many times my fellows will tell you, we're in the middle of the procedure and the pressure is getting a little soft and you look up there and the C. RNA standing there and looking at her iphone. And uh and the the anesthesiologist is not in the room and the T pictures frozen. And it's like what the hell? You know, so having a T. E. A. Is great. But you gotta have somebody looking at. I like to have general anesthesia in my in my O. R. S. Because it's not mandated. But boy, when something happens, the last thing you want to have to have happen is now we've got to control the airway. In the meantime they should be pushing blood products, they should be pushing fluids, they should be cooling the patient, they should be pushing camp. And there's a lot of things they should be doing other than intubating the patient at that time. So anybody that I think is above minimal risk really, I think having a cardiac anesthesiologist in the room and a general anesthesia is probably a good way of doing it get. So what is lead extraction? So this gets to be important when you're starting a program, What are you gonna call an extraction? Well we in a document, we say one year of elite that's really for statistical purposes because as you know you can take leads that are two sometimes three years old. Even older and they just come right out. Is that really a lead extraction? Well you know there are people that are gonna count that in that 20 leads you're supposed to do. Let's say oh I just did a light extraction. Well yeah but no you you you really need to understand that. The reason we said that was one year is we had to have some general cut off and that was for statistical purposes. But the basic definition doesn't correlate to identifying your high risk patients. That's gonna be really. How old are the leads? One of the total total lead years of implant that you have. How many leads are in there? And what are the outpatients comorbidities. Generally pacing leads that have been in for more than three years and I C. D. Leads in more than two years are more likely to require advanced techniques. But I've had leads that are in nine months. We had a we had a patient colleague of mine had there's something going on had to take a lead out after nine months and I said, you know you know what I mean? Just just pull it out. Well geez for some reason this particular patient that thing was already fibrosis in. I'd go in and I thought just give it a pull, he's not pulling hard enough as it was. It wouldn't come out and I ended up using a tight really get this stupid thing out. And again we talked about over prepared. Eric talked about that yesterday when especially when you're first starting out you cannot be over prepared. You cannot be you know we're gonna I'm gonna tell you my 10 commandments in my summary talk here for again for identifying these high risk cases. It is our responsibility to do that. You can't rely on other people. It includes all patients undergoing planned sheet assisted extraction. And I say that with the exception if you've had a relatively recent implant and you've got a localized occlusion in the subclavian or approximate and nominate area. You can put a sheet through that. You know just pop through the inclusion and then the league will come out or you can regain vascular access. But if I have to take a sheet, if I have to make that bend into the S. V. C. And go down from there, that's a high risk procedure right there really you have to be prepared for any eventuality or you're gonna one day pay the price for that patient. So as a general rule if elite has been in place for more than three years and I've basically three years on I. C. D. For more than two years again calling that a kind of a high risk procedure. Okay so the venue when you start doing these where are you going to do this? All piras patients should be booked in a quote hybrid operating room capable of open heart surgery. So what's a hybrid operating? That's the next slide probably. So cases will preferably be booked during block time. So if you can negotiate this, we talked about this up front that you can have block time reserved for you. Uh that's really important. Otherwise you're gonna be telling charlie they're gonna want to put you in at five o'clock on friday afternoon to start leading extractions. Not a good idea. And we'll talk about why? That's a bad recognizing some cases are gonna need to be done electively and urgent. I don't like to start cases after three o'clock in the afternoon. Why? Because by the time you get that patient on the table prep draped all your lines in it's gonna be 4 35 o'clock. And guess what? You're all the people are starting to go home. And when one of these things happens you don't just need like a cardiac surgeon in there. You need two surgeon or a surgeon in a pa or a surgeon and a fellow there's I don't know how to put somebody on bypass and it takes more than two hands to put somebody on bypass. So you need all these extra people in there. They're gonna be extra profusion ist extra circulators. All these people and if they're gone after 5:00 you have a skeleton crew there. That's not the time you want to be doing these kinds of things. But most often you're gonna get stuck doing these things. You really have to get a case done. They're gonna want to make you do this later. But you gotta make sure you've got these right people around. And again, if it's gonna be after three o'clock, we want to make sure it's approved by the surgeons. Everybody is still on on point that this is gonna be an okay time to do this. So how many people know about swiss cheese? I've been hearing good. Oh good, good. That's a lot of people know about swiss cheese. So for those that you don't know about swiss cheese. If you have a loaf of swiss cheese and you sliced it up and you kind of just randomly put it all back together again, are those holes gonna line up? Probably not. But one time out of 200 all the holes will line up. And when those holes line up, bad things are gonna happen, What we want is a piece of cheese with no holes. So what happened to me, this happened occurred to N. Y. U. And this is actually a lot this lawsuit's been pending for five years now. Um 72 year old woman who happened to be the wife of a very wealthy individual who owns the senior care ambulance service that that shuttles. People around new york state had came in. She's pacemaker dependent had a fractured right ventricular lead intermittently on capturing. And we had a discussion, shared decision making. Yes, we wanted to take the lead out. So we booked the case the following day, which happened to be a friday. So in friday was not my block day. So in the hybrid room they decided there was going to be one open heart case in the morning And then they did three hernia repairs in our hybrid room. Okay. And when they got the last patient off the table, they broke the control panel that allows you to move the table around so that somebody had to come in and fix that we confirmed the surgeon to be. So we ended up getting very delayed towards the end of the day. The surgeon was confirmed to be available. Um, but his case actually turned out finished. He was doing a case right next door and there was a fellow in the room and everything. His case finished a little bit early and he decided to leave and not tell us the on call surgeon didn't answer his page for two hours When the blood pressure fell and there was another surgeon, we finally found 30 minutes after hypertension started to come and do the repair. So any one of these things, we probably could have dealt with, you know if the delay occurred. But the surgeon was still there or he leaves and the on call surgeon answers his page. I mean, any one of those things is not gonna hurt you. Maybe in two of the things aren't going to hurt you. But all of these things occurred. And it was late in the day on a friday and people boom. All of a sudden we had a bad neurological outcome. She survived but she ended up with some degree of love and this was the sledging case that I talked about that. I learned a probably a good idea to give Hepburn. So anyway, confirm that your surgeon is available. This is really, really important when you're, when you're not even when you're starting a program. When you are in a program confirm that they're available discuss the case with the surgeon so that they're aware of the type of operation being done. My favorite surgeon is the young guy that just came out of training at at Hopkins because he took an interest. He came in, we let him get his hands on an extraction sheet and and he got a feel for tight trail and laser and things. So he now understands the forces that were using where that sheet is traversing. We discussed. Okay, this is gonna be a a star fix lead. So perhaps we're gonna have a tear in the back of the heart which actually occurred. Not for star fix but for a different lead. Um that they have to not only understand what that you're doing a case but where where is that injury going to occur and how am I going to approach This isn't valve surgery. This is a coronary bypass surgery. This is trauma surgery. Okay this is somebody's been shot in the chest with a shotgun and they gotta put stuff back together again if you've if you've never seen what happens when you open the chest when a cave has been lacerated or or ventricles been shredded. They as soon as they open the pericardium, there is just blood everywhere. So it can it can shock a surgeon that's not ready for that. It's really something is you never want to senior. So I think it's a good idea when you're starting a program again, work with a surgeon uh talk with them. Can we do formal consults prior to the procedure? So they get to meet the patient. They say oh you've had bypass, let's get a Ct. So we know where your lima is. We know what kind of things are going on here. They like that an awful lot and it lets them get some rvs. So buy it will buy them into that process. And now they they're not walking into a case where they know nothing about a patient. They've seen this patient, they've got a relationship with the patient and the family and they'll many of them will appreciate that. Make sure you document your interaction with the surgeon I always tell the document or nurse when I walked in and said I talked to DR. So and so please put that in document that in the end of the record. So that's clear that I had that exchange with the surgeon pre procedurally. Again. That helps in a court of law because a number of cases occur where there's always a question. Did the E. P. Talk to the surgeon and discuss the case beforehand? We talked about the standard of care being on bypass in 10 minutes. But that's that's really tough. That's a difficult metric. But the surgeon really should be in the room within 10 minutes and 10 minutes is an eternity when there's no blood pressure when the right floral cavity is filling up with fluid. When the pericardium is tense. That's an eternity. So if the case is deemed to be very high risk get your surgeon in the room with you get and certainly when you're on sheath that's the time you want them there. They don't need to be there while you're putting lines in and dissecting the device out. Although if you want to do work with the surgeon you can have a surgeon put the lines in. You can have a certain do I enjoy dissecting an infected pocket apart. Hell no. Okay get the surgeon in there. Let them get some our views for a pocket debridement and let them take all that infected material out of there. They love doing that stuff. Um So just prior to the sheath on the O. R. Staff will notify the surgeon again and we document that the surgeon is aware and available. That's and and this this has to be closed loop. This was another situation that occurred to me many years ago to Ohio state excuse me. This actually occurred the lab staff sent a text page to the surgeon. Please contact us if you are not available. Sounds good. Right. Um Never got the page. Never never saw the text and wasn't available. So uh this kind of thing about not being available. So we always like there this was was cheese. Okay how many cases that I've done and you don't need him. The one case where this happened we needed a surgeon and he wasn't there. He was actually in a car halfway up to Toledo And the patient ended up dying though it was salvageable for about 30 minutes and we just couldn't find a surgeon because of this whole thing. So this was an entire thank you. This was an entirely avoidable situation. So always make it a positive have them they have to text you back or verbally confirm. We haven't do that. Especially when we're ready to go on sheets. So once the leads are removed your patient is stable the or staff can go ahead and notify the surgeon if they're not in the room that the high risk portion is over. Um There are some complications that seem to come on a little bit later but those are relatively rare. We like to wait at least five minutes. Make sure the T. E. Looks good. Heart motion is good. No evidence of pericardial effusion. Um You know you always want to take a look at that right pleural area, make sure that you don't have an that the right chest isn't becoming a pacified. Things like that. Anesthesia is an integral part of this team. And they are typically running two cases and leave with a C. RNA. In the room. But I really want them there during this critical period of time. They like they need to be there looking at the echo and a lot of extractions only take several minutes. They don't take a lot of time. But some of them take an awful lot of time, an hour, hour and a half. You're switching above below one lead to the other lead, you're going through a laser to a tight trail or whatever. Um And it takes a lot of time. They get bored. So they're gonna go out and do something else. But you need them there because when that pressure drops you want to know what's going on right away. So we like to look at ventricular filling uh is eventually not filling. It's not filling blood's going somewhere else. Is there a pericardial effusion etcetera. So those are things that are really really important if there's a contra indication to placing a T. E. Probe, we discussed that ahead of time. We wanna make sure we've got one of those little handheld echo probes uh in the room so that we can take a look externally if we have to transfer drastically if possible. And we like to have that image on our big screen. We like to have that T. E. Image there so that we can look at it as well and we know whether that that image is moving or not although I'm fixated on the floor. Oh um you know when the when the pressure drops your eyes go right to that echo very quickly to see what's going inside the hearts. Are you inverting the right ventricle? That's very common. What's happening if you're pulling on that lead really hard and you got the RV apex pulled halfway up into the atrium. There's not gonna be a lot of forward flow. So you can kind of figure all that out. But so when you're on the sheet you really want your anesthesiologist in the room uh and all that before you start. These are the big five. Before you start you should document by T. E. If you've got it in what's the ef is there a pre existing pericardial effusion, how many times you drop into probe in there and there's like a little rim of confusion there and it's like okay fine but you know it was there when you started. You know where your starting point is. So that's really really important vegetation bicuspid insufficiency was a trace. Now it's moderate or severe you can do a lot of damage to a try custard valve with an extraction sheet. That's one of the risks of the procedure. On the other hand they may have a lot of tr before he even started. Sometimes it gets better. Not too often as it was. It was brought up a few moments ago by eric but it's good to know where you started. And is there a right to left shot? Very important because you can stroke a patient you're gonna you're gonna have clot, you're gonna have debris that comes off. You can stroke a patient. So there's actually an abstract that I just read for I think it's era talking about pre closure for for semi elective lead extractions, closing a. S. D. S before you extract if you identify that there's an asd that. Um So in terms of your your patient prepped obviously you really want as you're getting into this thing and even when you're very experienced always you want to be ready for stern artemis or thoracotomy prep them around really far into the right side. Especially if they had a prior stern economy we use sterile defib pads on the front of the chest. Um So we prepped the chest and the first thing we do is put that sterile defib pads on the front and they've had one on the back before we prep them separate femoral arterial line. If there's a prior astronomy so you can jump on em bypass very quickly. There's some surgeons that prefer no matter what, even if it's a virgin chest to go on em bypass, just because they can get you on that get the patient stabilized, get circulation going and they can do that in in a much more rapid order than unzipping a chest. Although they can unzip a chest pretty damn fast to make sure you've got a good femoral sheath. Now this is really critical not just a femoral sheath but A lot of these sheets like 12 French sheet that we use for the bridge balloon. The side port on that is a very thin tube. Look at that tubing that comes off, it's very small. So you've got this big catheter and you've got the really small tube. So what's your rate limiting step? It's the size of that I. V. Tubing that goes into the side there. So we use these corgis um sheets that made by arrow that are very large. They're 8.5 french but they have a really thick tubing that comes out. And the tubing that we sent up to the anesthesia is also very thick because if you use standard I. V tubing it's not gonna be able to handle the volume and when it hits the fan you want as much volume as quickly as possible. And when you've got the sbc included with your bridge balloon or if you've got a gaping hole and everything you put in from above is going out in the right pleural space. You want that volume, everything going in through the femoral vein. You gotta teach your anesthesia people that do because they're gonna want to use all these nice I. V. S. They put in from above. But you got a balloon blown up in the superior vena cava. So um you know a lot of this stuff is gonna take, it's a good old time to get down to the central circulation. So that's a scientific thing. Um The amplats super stiff. We just talked about this 12 french introducer again you can use that for additional volume. You can hook another I. V. Line up to that. It's gonna limit you a bit because of the size. But every I. V. Access you have can be utilized. Okay stuff in the room, you want to make sure all this stuff is there, you get a checklist and go through all this stuff you want to make sure you've got your your economy or sternum E. Trade if you don't have a cardiac scrub tech in there with that stuff in there. It's got to be immediately available. The proper working style. Yeah sometimes the battery's dead. So they gotta test this stuff um and there's a virgin Chester redo. We had one of the cases where we we've had to uh stern economies in 4.5 years at Hopkins that I've been there. And one of them we caught that they had the wrong song there in and it was we ended up saving a person's life because everything was right. We had the right stuff. Um It was it was actually they had a redo saw and it was a virgin chest. So usually it's the other way around it. You need the it's a stern out of me. Do you think you got the wrong song? The pericardium synthesis trade? Although you don't want to spend a lot of time monkeying around with pericardial synthesis when you should really be opening the chest. It is if you have a very slow accumulating infusion, maybe have a little atrial perforation or something like that. A lot of those will stop and you can you can drain the pericardium, you'll be all right. The trans venus patiently. Even if they aren't pacemaker dependent when you start, they might become. So at some point during the procedure and you want to have this available, we talked about the syringe, the inclusion balloon and then making sure that your defibrillator is not just in the room, but it is attached. Uh And that you have certain TCG leads attached to your defibrillator so that you can see whether you're capturing or not when you have to pace externally. Your wife has pump cell saver laser has to be on and calibrated, make sure it's working because sometimes it gets knocked down a calibration, not so much with the newer generation, the original generation get knocked out kind of easily the extraction cards. Do you have everything you need? Okay? You have to have somebody that is assigned to making sure that the cart is fully stocked at all times. That there has to be somebody assigned to do that. And the time to find out that oh we're out of 13 french tight trails is not when you need your 13 french tight trail. After the 11 french jams up on having your blood available and getting more blood. If something goes sideways, the first thing you want to do, one of the first things you want to do is get more blood in the room. You probably can never have enough blood in the room when this stuff starts happening. We actually did a study at Hopkins. If they don't have antibodies, we can we have a him a safe where they've got all this type specific blood literally right around the corner and we can have that blood in the room in less than 60 seconds. So we in in our protocol we say it's ok for certain cases where we utilize the most safe and we don't actually have the blood, it's actually sitting in the room. Um If you have a grossly infected pocket, you know, you got us in the pocket, we like to have a separate instrument trade. Why? Because if you have to open the chest and this happened to me at N. Y. U. Case You're going to go into that pocket with this 10 blade and it's gonna be full of pus. And the surgeons are gonna come in to open the chest when you have the M. E. And they're gonna grab that 10 blade and open the chest with that. And they're just going to inoculate the sternum with that. And that actually happened in a case where the certainly got there very quickly and the patient did great, everything was fine but they ended up with a massive staff of cockle infection of the media stein and everything because they just got inoculated with us. Uh This could have been avoided. And if you have a separate tray you try as best you can to kind of separate all these nasty pussy instruments from the stuff they're going to use when they open the chest. So just a little little uh kind of thing that we go through the cart, you really want this to be again having a staff member identified, assured that it's always there again because you're gonna use stuff and if you happen to have two or three cases in a couple of days, it's amazing how much stuff you go through, especially certain sheets and you're not gonna have the backups? Uh And what happens if you drop something on the floor? You don't want to. We just have one L. L. D. We only have one laser sheath if that breaks if it drops on the floor whenever all of a sudden you're you're out of business and what you gonna do. So here's uh some of the things that are on my checklist. We again we go through this is literally checklist that the surgeon has been contacted. Their available the blood is in the room. Antibiotics have been given. We got the consent signed. The appropriate rep is available if needed. O. R. Nurse ct and ct surgery. People are available. Perfusion is aware of the pump ready prime proper extension tubing. Is there all the relevant phone numbers are there if they you know for the uh the O. R. Desk, anybody else that needs to be contacted in the emergency situation? The card is stocked the lasers in the room near the head of the bed, calibration checked separate instrument table for dealing with an infected pocket. The patch is attached to the patient. Para carted synthesis train in the room for economy trade working saw T. E. In the room turned on, verified to be working and we'd like to know the big five before we start arterial line. I think if I did for years just use noninvasive monitoring but you know it's you need to know right now when that pressure's dropping. It's very very important I think and then you've got your big sheet turned on culture supplies, certain lab values, allergies device information which you should know. Certainly ahead of time. Are they dependent? And remember? They may be dependent right now. They may not be dependent right now but when you start monkeying around and they're sometimes they do become dependent. How's your device program? Make sure your I. C. D. Is turned off. Make sure your your program mode is correct that your activity sensors off all that kind of good stuff. And then we talked about the bridge rescue stuff. I'm not gonna go through that again here. So here's my time out. I don't know if this is we'll see if this is going to play. Yeah I can't hear it. All right. Well I kind of went through that but I go through the whole time out. We we talk about the first thing we do is we talk about what is the procedure gonna entail in this case that we're talking about. We're gonna go into the right femoral vein. We're gonna put in uh the large volume she's we're gonna put up a stiff wire we're gonna put in a temporary pacemaker wire we're gonna go up top we're going to remove the device. We're gonna reuse that particular device so it's going to be kept on the side because this was a fracture. We're gonna extract the lead, put in a new lead. Um and put that same device back in. Um And so we go through that whole thing. So everybody in the room understands exactly what the processes and there might be a question doctor do you wanna hire ex envelope for this? To a good point. I forgot to mention that everybody participates. Really really important that you get you know the reps the circulating nurse, the anesthesia people. Everybody should be participating in this in this kind of description about what you're going to be doing. And then we go through that whole checklist that I talked about. Um And it took a while to change the culture at johns Hopkins. It took a while when I went to N. Y. U. It took a while at Ohio state. And generally what changes that culture. It didn't have. I was able to change it at Hopkins before we had an adverse event but typically it's an adverse event that changes the culture. Nobody wants to sit around and talk about what are we gonna do when this happens? Because these doctors have done 100 and 5200 cases and you don't have any problem. You never have any complications until you do. So you want to make sure that you get cardiac anesthesia. The C. RNA is the scrub text, the circulating nurse is the profusion ist all of the people that and the cardiac surgeons certainly all of the people that have interest in surviving that patients sit down around the table and you explain to them what can happen. You talk about how we're gonna manage these things and get them all to buy in on this and develop a written protocol as to how this is all going to happen and how you're going to be making sure that all of the procedures and equipment is ready to go. People are ready to go. Very very important. Get them to buy into it because the time to do that is not after your first death and you have a sentinel event kind of thing. And then all of a sudden everybody's interested in trying to prevent another one, prevent the first one complication. Doesn't have to be immortality. That's that's the mantra there. So when the guano hits the fan should more than a transient drop in blood pressure occur. Or if there's a confirmed a significant consideration that surgical interventions gonna be needed. We call the O. R. Desk. The surgeon is called if not already in the room for fusion. Additional four units of blood is requested stat. And if the patient's gonna need a stern on to me um think about giving Hepburn. Think about chilling that patient down, protect the brain. Okay you can survive so many patients and then they come out and they have anoxic encephalopathy. I've got three cases pending right now where The f. was 60% the next day and the brain is dead. Okay that doesn't work. That doesn't. So partnering with your surgeons when you we talked a little bit about that yesterday. It's the most challenging aspect I think about starting a program. The best option is to have them completely involved with the procedure there in the room. They're helping, they've got their hands on something. They're helping with the dissection there helping putting lines in there. We'll teach them a little bit about the sheets. You know they will help them to understand what's going on and the forces that you use. I mean it's amazing how much force we use sometimes especially with mechanical types of sheets. Uh and you know working together as a team through the whole thing and it keeps them interested and invested in the process for billing. Again we talked about you can use coast surgery when you're extracting I. C. D. Leads. You can do alternating billing, you can do all kinds of different things with this. They can build for for the breed mints and all the other kinds of things. And you can build for other parts of the procedure. So you can work that out if it's a fully employed model. Again, everybody is on the on the same getting paid from the same source. You can give virtual our views to the surgeon for standing by or simply say that's part of your job. You gotta be there. I know they do that down at Sanger clinic in north Carolina where one of my former fellows is the surgeon. That's his job. He is being paid to be there and he can be there reading a book, he can be there signing off charts, he can be scrubbed in but he's in that room that's his or her job. And at N. Y. U. The surgeon was next door but was always at a point where they could break. We do sometimes at Hopkins the surgeon will be finishing a procedure once they come off pump and there through that critical part we know we can go on sheet because they can always break and this fellow can can you know do that Wire up the sternum or whatever but you can work that out so that you know you don't necessarily need that surgeon completely uh standing in the room they can be doing other things but literally no more than 50 ft away. They're doing something but something they can break away from. Sometimes they just kind of hang out because they're good folks and that that's a nice thing. And consider a formal consult. We talked about that partnering again the hospital makes a good profit on lead extraction on most most hospitals most of the time. But that depends on the products you use. Sometimes you'll go through a case and use about $20,000 worth of product and they probably don't like that so much by and large they make money except in Maryland where everything's cost in Maryland Maryland decapitated state. So the hospital gets x numbers of dollars pretty much every year. And everything we do comes off the pile of money. They don't get additional money for doing additional things. But that's unique in the 50 states, referring physicians as you get out into practice. And I and so many of my fellows that got great fellas, they're wonderful people but some of them still don't understand the importance of making sure we get information back to the referring doctor. They always need to know what you're you've done and what you're doing and your patient's gonna be safe. So as eric talked about yesterday, the first case you want to do is it gonna be 30 year old leads 15 leads in the patient, that kind of thing. You want to start slow. You want to have successes and build on your successes. So people will say oh yeah yeah yeah dr so and so he has good results over there. You know they used to have not had a lot of complications so they want to know that their patients are gonna be safe when they send them to they need feedback about your procedure and your outcomes, pick up the phone as soon as you're done with talking to the family, pick up the phone dr smith. I just finished john doe we extracted three leads, we put in a new device and uh I'll see him back in four weeks and after that he'll he'll go back to you for all of his follow up care. Thank you so much for sending my way. They love that they want to hear about their patients. It's so important and send him a copy of the op note. Ah They need to get the patient back okay if you start taking the patients and and some patients say oh I dr love I you know I just want to come to you now. Doctor Dr smith. He's very nice but you know you took care of me watching you know dr smith. He's a really good doctor. You really should stay with you. I really try to get him back because if you start taking patients from from your referring doctors you're not gonna have referring doctors, they're just not going to send to the patients anymore. Uh And sometimes we talked about the re implant is delayed. You know, maybe there's you're waiting for a pocket to heal up or there's a number of reasons why you might delay doing another device. Um If they're good. You know if they're an ep or whatever, send it back to them, let them do the implant, okay? You don't need that. You don't need to do that, they will love you for that. You know this is this is important to them. They have to make a living too. So obviously the patients dependent there in your hospital and you're waiting for them to you know you're going to put the new device in there, that's that's one thing but give your patients back if you can let them do that that secondary procedure and never ever speak badly of your referring physician's. I mean listen there's a lot of lot of yahoos out there the people that are gonna treat folks with antibiotics for for six months for recurring infections and do all kinds of crazy stuff but you never want to say something about patient. Your doctor really screwed up. You should have sent sent you to me six months ago, it always gets back to that doctor, it always gets back. So I always say oh yeah dr so and so he's a really good guy. He was really trying to avoid an operation for you but you don't really want to speak badly of people trying to educate them actually. Um It's better to help to say, you know, um I know you really want to avoid that that operation and the extraction but you know the data really says, it just doesn't work with the prosthetic material in there and maybe next time if you think getting to me a little bit earlier stand maybe stand a better chance of a better outcome, something like that then be kind be educating that's a much better approach to doing this billy building is kind of a mess and and probably none of the fellows here know anything about building. I mean eric did you know anything about building before you went into practice? Nothing. I mean it's like nothing. And all of a sudden you're responsible for your RV us and all this billing stuff and compliance and it's it's a it's crazy. Um But so you you're gonna start to learn about this stuff as soon as you get you get out into practice and and it's important you build for the right things. Um You don't wanna get a lot of denials if you if you put too many things in, the systems are pretty good at anymore. They electronically, we just say oh no, you can't build this with that. It's their exclusionary codes and stuff, but you want to get what you're entitled to, you really want to get what you're entitled to. So you're gonna build for removal of a device that can be a pacemaker, an I. C. D. Extraction of the leads. And it's interesting that the codes, you can take a single lead out, but if it's a dual chamber system, you actually build it as extraction of from a dual chamber system. It's not a single lead, it's from a dual chambers system. It's a funky way that they've done that. I don't why? Um And and obviously I. C. D. Is a little is a different code as well And you you actually don't get paid if they're like four leads in, you don't really get paid more for four leads than you do for for two leads. Um, but if it's a very long and challenging case, you can learn to use modifiers. The 22 modifier means it's a difficult case and there's actually some definitions in terms of how long it takes. I think I think you're entitled to something, It's like 90 minutes or something. It takes more than 90 minutes to get the lead out or something. I think you can start building 22 modifier, but every time you build a 22 modifier, that's a challenging case, it will be immediately denied and go for review. And and so if I use a 22, you've got to document why was this a challenging case? This? This took four times longer than normal or we ended up doing this, that and the other that that there were four leads that needed to be extracted and when it's a two lead billing code et cetera. So be very careful about your documentation, you can get a little bit more money for that as you deserve. But make sure you document it, you can build for exceptional debris mint. If you have a pocket that's all infected you built for exceptional debris mint of that infected material if you've got to go from the groin and snare a piece of of, you know, you've now broken that wire and you're gonna snare that little tip out or a piece of the wire that's retrieval of fractured catheter fragment I built for that on top of that. Um This is a little more controversial about building for the central line, the A line ultrasound guidance. I put all those building codes in. I'm not sure whether we're getting reimbursed for that or not, but I put all that stuff in there and don't forget to build for your temporary pacing lead. And sometimes we do two of them, we put in one through the groin while we're doing the case so that if it dislodges which happens all the time, you just have to reach down and and and reposition it and then we're done and if they're dependent we put attempt permanent. And that's a whole separate procedure and again more. Um These are the different kind of building codes and if I think they're gonna put this presentation up on their website. So if you want to look at this stuff you can always go back and look at that. But again, these are system codes when you're extracting. So even if you have a single lead you're taking out of a dual chamber device, actually build it into a dual chamber system code which is again a little kind of funky excision and debridement, Nice 1 to have and here's these modifiers. Again, we talked about 22 but then you have multiple procedures like if you're gonna take an I. L. R. At the same time, you stick A. 51 on there and you get credit for a separate kind of procedure if you're going to do a an ablation after an implant or something like that 62 for the coast surgeon and X. S. For a procedure done via separate site. So if you're gonna do a like a temporary pacemaker through a separate site or whatever if you have two sites that you're doing you've got to learn how to use some of these modifier codes because they will increase your reimbursement because remember you get You get paid 80% on your first code, 50% on your second code. And then you know you don't get paid each additional code you put in, you don't get paid the full our view value of that. But if you use these modifiers it can actually increase what you get back. So you're the new guy doing extraction or woman doing extraction start slow. Uh don't try you know terrible leads for your first lead, cherry pick those first cases so that you have success and you build on your success. Get proctor. You know if you if your first time you know you're a little nervous your place where you don't have another extractor, let Phillip snow. They'll or you know call me call eric um call you know whoever is training you say hey can you come and just kind of hang out. I'm gonna be doing my first case next thursday. Um If you're able to they'll get a proctor to come and just kind of make sure that you know all your ducks in a row and just be there is a little birdie behind your ear to give you some some tips or whatever. They're happy to do that, we're happy to do that and find out what works well for you. I mean some people I know people that they love that laser man, they can use the laser in every case I happen to like mechanical. I start off with a tight roll in almost every case and I switched the laser. If I need it then we'll talk about that in just a minute to so if something's not working, try something else. Don't keep doing the same thing over and over again. It's not working. That's the definition of insanity, right? Don't work harder, work smarter. So that's kind of like as you get out there and start start thinking about doing your own stuff. Kind of a big overview of how between eric's talk last night about starting the program and this kind of stuff. Be ready for everything. We're gonna talk a little bit more about that with with my 10 commandments later, but be ready be trained. Uh build a team like that. Just you just can't hammer that enough, build a team, get everybody involved invested, give some talks about it, let them know they want to know that it's amazing how interested these people into what we're doing and the more and the more they know about what we're doing, the more invested they become in that as well. Any questions about that. Published July 8, 2022 Created by Related presenters Charles J. Love, MD, FACC, FAHA, FHRS, CCDS Professor of MedicineJohns Hopkins HospitalPresident, International Board of Heart Rhythm Examiners
