this one that you'll hear today. So just to warm everyone up, so just go with this, right? OK, so we're talking about the ERCP room. So all of you have obviously been visiting GI labs and know how a regular diagnostic room where they do EGD colon looks like. ERCP room has several different salient features that you all should be aware of. Basically, the first thing is the area. With so much of equipment, and we'll go over why and where all these are positioned, the area should be at least 400 to 500 square feet, which is much bigger than a usual room where you do EGD and colonoscopies or diagnostic procedures. The main reason for this is the fluoroscopy. So this is the epicenter of the room, the central portion where everything is positioned all around the fluoroscopy table. Now, this could be a mobile one, or it could be a fixed one. There are pros and cons to a fixed fluoroscopy equipment or a mobile fluoroscopy table with a C-arm. But that is the main area in the center of the room where everything is focused on. So if you look at the orientation, you have the anesthesia cart here, because all these procedures are by and large performed under general anesthesia. So you have the anesthesia personnel with the anesthesia cart at the head end of the table. You have multiple monitors. That's another unique thing for an ERCP room is that just having one monitor is not enough, because you have at least to have two and maybe four monitors, because you're seeing multiple images. You're seeing an endoscopic view. You're seeing a fluoroscopic view. If you're doing EUS, you're seeing an EUS view. Plus, we do cholangioscopy, which can be a separate monitor or a picture in pictures. At least two, maybe four monitors, which should be all maneuverable. Or you can move them not only up and down, depending on the height of the person who's doing the procedures, but also to be rotated around, almost to all around here. Because it depends on what the position of the patient is. That's how the orientation of the endoscopist is. If you have a supine patient getting ERCP in a supine position, these monitors have to be swung around a little to the right, because you're facing rightwards to get a good view of the papilla and stay on first to the papilla. Whereas if you're doing it in the prone or the semi-prone then they are in this position. So you have to have enough room. And with the booms, it becomes easy to rotate these monitors. But that is very important to have the ability to maneuver these monitors and have multiple monitors. Then we have the EUS machine, because you'll see more and more now they have become like a combined procedure, doing an EUS ERCP. You have a patient with a pancreatic head mass, you do an EUS, take biopsies, and then you do an ERCP to put the stent in. So a lot of our procedures are combined. So EUS equipment is integral part of an ERCP room. You'll have cholangioscopy, you'll have electrohydraulic lithotripsy equipment. Now with disposable scopes, you have to have another processor, because you have the ability to decide which patients you want to do with a disposable scope. So for all this equipment, you have to have space. And that is the most important point that I would like to mention regarding an ERCP room is adequate real estate, square footage, to be able to accommodate everything. So here is the CRM, you have the fluoroscopy, the anesthesia person sits here. The endoscopy tech, who's a very, very important part of the team, obviously, with the nurse, is on the right-hand side, being able to get you all the accessories, the supplies. These are the cabinets, where you have tons of equipment. And we'll show you a couple of pictures. The endoscopy card is behind here. Endoscopy nurse could be this way, or could be sitting in this area, so that you at least need two assistants. So that is the other thing important for ERCPs and these complex procedures is just having one assistant or one technician in the room is not enough. You have to have two assistants, at least a tech and a nurse at the very least. And then the fourth person is the anesthesiologist. Some places will have a fluoroscopy tech also. So either you can manage the fluoroscopy yourself, depending on the institution you're practicing, but some places have a fluoroscopy tech who's managing the fluoro equipment. Now, all this is very important, mainly for ergonomics also. I mean, we know there's mounting evidence every year that all of us who are doing these complex procedures have musculoskeletal problems. And you want to have an idle room set up so that you're not bending, crouching, tripping over wires, and so on and so forth. So all the area and this arrangement is very important to have it in such a way that is ergonomically ideal and not taxing to your physique. So to avoid congestion and enough space, adjustable monitors on booms. I mean, you can have anti-fatigue mats and easy access to supplies and the patient. Because you know, patients are sick. You have to have the ability to be able to, everyone should be able to access the patient quickly in case things go downwards as far as the hemodynamic stability of the patient is. You should be able to flip the patient quickly. I mean, we've had codes in the ERCP room. So all that requires a clear delineation of where the equipment should be and adequate space to keep all this equipment. So talking about the fluorotable, I mean, this is a usual garden variety fluorotable. You have to have certain equipment on the fluorotable. This is a gel roll with a pillow because the patient is lying supine and a little bit, sorry, prone with a little bit of a tilt. So it's kind of a semi-prone. Not every ERCP has done that. There are several situations which we can talk later where you do it supine. So in that case, you will not need this. You have a head support here. You have another padding in patients who have a port or cancer. So you don't want pressure on the port. So you have a gel pad for that. Or pacemakers, you have to have a grounding pad because most of our ERCPs are therapeutic procedures. Now we do synchrotomy. So you have to have a grinding pad and usually have Velcro straps. So not only to secure the patient basically, right? So patient is lying there on the fluorotable. There are no railings like you have in bed. So you can just, you strap them with Velcro after they've been positioned for the procedure. So this is just a snapshot of a room. Look at how congested it is. And this is without having the fluorotable here. And by the way, this room is our room in our unit, which is not ideal because we have, it's an older room when we were doing much less complicated procedures. So now with the EOS equipment and everything else, it's become so much more congested that we've outgrown this room. But you can imagine how much equipment and how much stuff there is in this room and how cumbersome it can be to just negotiate your way around. These are the storage cabinets, tons of equipment. That's very important for the nurses and the techs to be familiar with this, where everything is kept because you don't want to be waiting for hours for them to find out, you know? So much, this is just part of it. There are a couple of cabinets on the other side also. So there's so much equipment, so many stands, so many wires, which you'll go through in the lab. You'll get a snapshot of at least what equipment we use. But that is why you need all this extra space. Personal protection, obviously, is very important. Most important is the lead apron. You know, everyone should be fitted. Whoever is in the room should have their fitted lead apron so that they are ergonomically ideal for them. Usually we use the split ones because this decreases, it splits the weight. So you have an upper portion and a lower portion so that the entire lead is not on your shoulders and the back. So this way, the weight is distributed. Lead goggles are important too. Shoe covers, gowns, gloves, those are the basic stuff that we need for any procedure. So what are the essentials that we need in every procedure or ERCP that we do? Just normal saline, syringes, gauze, basin. You have to have the contrast for the procedure. Pillows, gel roll, we talked about. Head support, grounding pads, bite block, personal equipment protection for protection and lead. And endomethrosine suppository, I just added this because this is something that, by and large, we're giving it to majority of our patients who undergo ERCP. So just having them in the room avoids hassle of running around in the middle of a procedure, going out of the room and disrupting the flow of work. Most important, one of the important things about ERCP is preparation. As you'll see, before the procedure, the nurses and the techs have to do some basic preparation. It's not that you do get done with one procedure and the next patient just rolls in. It doesn't happen like that. So what is the preparation? You have to set up the table at the back to prepare for the procedure. With normal saline, you have to have saline syringes, basin, where we can put the contrast diluted if you want, and different types of sizes of syringes. This is the back table that you have where, before the procedure, the nurse and the tech will just lay the groundwork, right? Get everything in there so that once the procedure starts, there is least amount of time wasted trying to find stuff that you need, just the basic stuff. What about the scopes? This is standard. We have reusable scopes that we've been using for years, and now we have the disposable scopes for the last several years. Not only that, I mean, it's just not one scope. You can have patients with altered anatomy, right? Ruined by gastric bypass, hepatic adrenostomy, so on and so forth where you don't have the native papilla or not. You don't have the access to the papilla straightaway as you would do in a regular case. So for that, you need different type of scopes. And this is all in the planning. When you have a patient, you have to tell your nurses and your techs what scope you need. It may not be an ERCP scope, right? I mean, sometimes I'll tell my nurses who have not been in the unit for too long and haven't seen different types of cases, I need a colonoscope. And they'll say, doc, this is an ERCP, by the way. Yeah, it's an ERCP. But it's an ERCP with altered anatomy, right? So you have to be prepared for it, knowing what procedure you're doing, and getting the EOS scope or a single balloon enteroscope or a double balloon enteroscope or a colonoscope. This is something that we use here just because there's a lot of spillage of bile during the procedure, especially long procedures. So we have a small U-bag that we just attach around the biopsy port so if it spills out, it's not spoiling the floor and getting on your shoes or something I thought I'll show you. As far as the equipment goes, I mean, there's too much equipment. You'll see some of it in the bioskills lab or the simulation lab today. Basic equipment, what are the basic equipment for cannulation? You have the cannulas and the cutting, the sphincter tomes. Sphincter tomes basically means that you have a wire that you can cut the sphincter. Cannula does not have the wire, does not have the ability to cut the sphincter. You can have long exchange, short exchange, different types of wires, different diameters, different flexibility, tip is straight, curved, angled. So all these we'll go through in the simulation lab. Balloons are very basic. There are two types of balloons, one for removing stones, which are called the sweeping balloons or the stone extraction balloons. Different sizes can go up to 18 to 20 millimeters in size. And then you have the dilation balloons, which are used to dilate the stricture. So you have a narrowing in the bile duct or the pancreatic duct, you want to stretch it open, just like you have balloons for esophageal stricture, similar to that, you have these dilation balloons where you can pass it through the scope into the duct over wire and blow it across a stricture to open it up. And you have different sizes going from four millimeters to 10 millimeters. Now the stents, I don't know how many variety of stents, it's impossible to even keep up. But the two main groups are plastic stents and metal stents. And we'll go over again in the lab as to where we put which type of stent. But basically the plastic stents of different sizes go up to about 10 French in size. They have these flanges. They could be for the pancreas, they could be without the flanges. You have the pigtail stents, all different configuration. There are different indications to put plastics versus metal, which we'll go over in the lab also today. The metal stents are basically two types, fully covered or uncovered. Some of them are partially covered too. They have different indications, but these are the ones that usually we put in for cancer patients because they stay there permanently. We don't have to pull them out. Sometimes we put them for benign indications also when they can be removed. I think that's about it.

ERCP room

fluoroscopy tables

ergonomics

medical staff

patient care