Caring for Patients in an Office-Based Lab Versus Hospital Setting

[Michael Barraza]
… What about the experience for the doctor? How does your approach for the procedure change when you're doing in the OBL rather than the hospital?

[Mary Costantino]
I ended up having to go to several hospitals because of insurance issues. If patients had a certain type of insurance, I'd have to go to hospital A or certain type of hospital B. I was going between two hospitals and in two hospitals, you have multiple techs, multiple nurses, it can really take a long time. It takes about a year before people get used to the things you do, if they ever do. You have to be pleasant. You have to be patient. You have to willingly wait for an hour or two. You have to accommodate. You have to turn around and say, "Can you open the Renegade?" It turns out they're out of them. You have to be very flexible on what equipment you use because you find out that some order didn't come in or maybe you have three UAEs that afternoon, but they only have a box of embolic.

I like it because when you're not a hospital IR and you're not there all the time, you're putting out little fires. Inevitably, there's always the tech that you love working with. The case is just so stress-free. Once in a while, you'll sense that. You'll have some case that goes quick and easy. You'll think, "Why are these so stressful all the time? This is so easy." It's because you're working with the guy who's one step ahead of you and usually, you're not and you're having to say. I literally have said to techs, "Okay, hand me the wire and they hand me the glide wire even though I have a microcatheter in," and I would say, "No, the little wire. Can you hand me the little wire?" You just end up having to do that over and over. You become the person who is working 10 times as hard, but that's just natural.

Now, I'm in the OBL with my one tech who's amazing. It's almost too easy. For the doctor, yeah, it's way easier. I also think that UFE generally isn’t a procedure where you need multiple IRs. You don’t need to collaborate with anybody.

[Michael Barraza]
What are your strategies in the OBL? Because you're in a situation that, barring a disaster, you absolutely need to get these patients home the same day. You don't really have that same option of keeping them there overnight. What do you do to ensure that you're going to get them home that day?

[Mary Costantino]
Yeah. Well, UFE patients, it's always interesting how they respond to UFE. I've carefully monitored what kind of medications patients have needed overnight in the hospital. We have them on 24-hour obs. I would generally start the cases around 3:00 or 4:00. Part of the reason I kept people in the hospital overnight was because I didn't want them driving home at 11:00 p.m. I tried to recreate the outpatient scenario in the hospital even though they spent the night in the bed. One thing is, do your cases early. I would never start a UAE in an OBL at three o'clock.

We start about 7:00, 8:00, 9:00. Then, you always have to have a nurse monitoring. That nurse's job is to pay close attention to the patient, how they respond to medications. I usually use some Dilaudid. I start them on OxyContin extended release prior to the procedure. They get some narcotic onboard. Then I use intraarterial lidocaine. I think that's really important. They do really well, actually, for the first about four hours. The challenging part comes between hours 5 and 10.

Because they're feeling fine and then they go home. What happens is, there can be a gap in their medication. I just recently went to just saying, "Take a Percocet every two hours." Now, we're not even going to try to have you judge whether or not you need it because they misjudge. We can keep the OBL open as long as we need to. If I have a patient who is not doing well, then we both stay there. The nurse might stay there until they're doing well. We take full responsibility for it. If they need to be admitted for pain control, then I have to admit them. At this point, I can't imagine that their pain would be that bad, that we can't get it under control in an OBL.

I did have to come back one night. I had a patient who was throwing up, she couldn't take her Percocet, she was panicking, the family was panicking. The nurse and I just drove in at nine o'clock at night. We got her settled. We gave her some fluids. She couldn't pee. We put her in a Foley. She felt much better. We got her some Dilaudid. We watched her for a couple hours and she did fine. She was great, went home, and had no other issues. We are available to open up our lab should that need to be done. You have to be open to doing all of the stuff because ultimately, it's your responsibility.

[Michael Barraza]
I guess I didn’t really think about that. That flexibility to keep it open because it is your office. You stay long as you want.

[Mary Costantino]
Yeah. I can use whatever I want in there. I just walk in.

[Michael Barraza]
Right. Exactly. I'm used to the more general inflexibility of hospitals.

[Mary Costantino]
Yeah. You just have to have a nurse. This is getting your team on the same page, right? Look, we're here for patients, first and foremost. Even if that means that we have to go in for an hour or two at nine o'clock. However, that's not the goal of an OBL. Then it's like being on-call. We like to avoid that situation. The other thing is, a lot of the surgery centers have 24-hour recovery. You just have to have two people there.

Let’s say I was doing 10 UFEs a day, which I can't imagine I'll ever be doing, but let's say I am. As long as you have two people, you can keep these places open overnight. This is what a lot of the surgery centers are moving to. Generally, people will hire a paramedic and a nurse.