Season 1, Episode 9 Transcript
Ramzy: Hello, and welcome to a very special edition of the ISAVE That Podcast. This is Ramzy Nasrallah. I'm joined by Dr. Ken Symington, President-Elect for the Association for Vascular Access. This is the oral history of AVA edition of the podcast. And after we finish talking, you're going to get to listen to Suzanne Herbst, the founder of this association, walking you through the timeline of how this association came to be, how the Vascular Access specialty was identified, and then slowly defined and elevated through her work. Ken, you actually appear in this oral history that we're going to be hearing, because through serendipity we're both in upstate New York around the same time.
Ken: It's crazy. Absolutely crazy. Yeah. I was just thinking this morning when I woke up and anticipation of this, I can't remember the very moment that I first met Suzanne. But I do remember when I started working with her with through patients and I got to tell ya, I immediately I was sort of hooked on her. Her penetrating blue eyes, her devotion to patients. She was just such a sweet, kind person. And I wanted to do everything I could to help her and to help patients. And that turned into being quite a project. We did a Vascular Access symposium that first year and I think 400 people came to it.
Ken: It was a huge success, you know, out of nowhere, out of the blue. And then after that she got me hooked into doing other things with her and stuffing flyers for her at her house and in her garage and tripping over her large dog. All these crazy things, this mom and pop operation, it's just amazing memories of her and I couldn't be happier to see that she's doing this, and she deserves every bit of credit and recognition that she could possibly get.
Ramzy: Yeah. And speaking of credit and recognition, this, this episode is the brainchild of Dr. Jack LeDonne. So, hearing about the grassroots inception of how AVA came to be, to now we have thousands of members. We had well north of a thousand people, clinicians, at our conference in Columbus. That all started somewhere, and it started with Suzanne Herbst, who we will turn it over to now.
This episode has been made possible by sponsorship from BD. A great partner to Vascular Access and to AVA. For more information on BD, please visit www.BD.com. And now we'll give you Suzanne Herbst and the oral history of the Association for Vascular Access.
Suzanne: I'm going to just start with where I was in 1965. I was a senior in nursing school, and I had a diagnostic tumor on my thyroid. And so, I have a positive tumor. And my first IV was on me. I never thought that would ever happen. And then the day of graduation from the school of nursing, I went high school, senior ball with Phil, my, my wonderful new husband, and the day of graduation, the night of the senior ball, I had extreme pain. So, I didn't do the all-nighter thing that you do when you're crazy and graduating. So, it turned out that they figured out that I needed an appendectomy. And so I said, I'm going, I'm going to get my diploma and then discuss this. So again, with the surgeon, we had a discussion and I had my number two Vascular Access or IV and those are ancient in 1965. Both of those.
In 1966, I have one sibling, my brother Herb. And he was diagnosed with leukemia when he was 24. And I was going to do all this stuff and go to Europe. But we found out he had leukemia and he was getting his doctorate at Columbia and it was like two weeks before his wedding that he found out all this. Anyway, I didn't go to Europe, but my brother and I talked, and I just traveled through the United States. And kept in touch with my brother and then I remember coming back to Syracuse where he was being treated at Upstate. And all I could remember was how bad has arms looked from all the intravenous drugs at that time for leukemia. And you know, it was awful. His arms just looked awful.
So anyway, unfortunately, a few months later, my brother died and praise God, I could be like with him when he went to God. So, the thing that I had, the great thing to do was to, I went to California and I loved it. And after my brother died, I left town, I got out of dodge because it was too painful for me. And so I went to California, went back to San Francisco working in critical care. And the director of the critical care unit asked me if I'd like a job in research. I went, 'Research? A nurse in research?' And so, I started working at what's called Riverside Research Institute. And it was the US Division of the eastern research institute in New York. So, we started and one of our first projects was to look at different polymers, look at different, pieces of plastic, so to speak and see what would be the most biocompatible with the body.
I actually put these pieces of different polymers into rabbit's ears so that, you know, I could take them out and see which ear got really red and inflamed, and so on. So I ran the animal research institute there in California. I couldn't do it again because I was working with the sheep and dogs. But I had this opportunity to work with some wonderful engineers and we went to Seattle and met Dr. Hickman and Dr. Broviac, who were developing catheters to stay in people for long periods of time. And it was, they wanted a way to secure the catheter in place. And so, they found out, they wanted some kind of material on the catheter itself. So we looked at Dacron and we looked at different materials that would adhere to the subcutaneous tunnels and secure the catheters in place.
There's a Hickman Catheter named after Dr. Hickman and a Broviac catheter named after Chuck Broviac. And then I worked with Dr Swan and Ganz to develop critical care catheters again to look at how long you could keep the men and so I had this incredible mentorship of these brilliant scientists. I had the opportunity to work with them. So, my research just kept moving on. And I started working for Eliza Corporation and it was, Alexandro Saferoni who was president of Syntax Americana and he raised a whole bunch of money. He was making the birth control devices. And again, I was asked to join that group because they were making a portable infusion device and it was called the Allezor Research Medical Device. And it was a small pump because people needed the pump for insulin, for some of the drugs we were learning were better given for hematology problems if they were given over a period of time.
And so I worked with that and it was called the, R-med infuser. And again, there were no batteries or anything like that in this device. It was a balloon. And we had to work with the engineers to keep the pressure in the balloon constant so that you just have this little piece of plastic that was like a turnkey, you turn it on and then the fluids could be delivered through this balloon on a consistent basis. I had a lot of background on pump development, the portable infusion pump that was developed by Dr. Ensminger in Michigan. And then I started working with home infusion because I knew a lot about the pumps. We had developed the first volumetric pump with the research institute. And so, these pharmacists from Stanford started Stanford Home Treatment Services and so they were mixing up the bruise, the TPN in their garages and standard wasn't interested in doing that kind of thing. I said, well, I can do that. I know the pump, no problem. Got to know and work with the varying newness of pumps as they came along. And then I got into home infusion doing total parental nutrition on many of the people. That's all they were using. And I suggested that, you know, they could be giving chemotherapy drugs through these pumps they could be giving in infection control.
Suzanne: Yeah. So, I sit within, and HIV was just running wild in San Francisco and I had people that just wouldn't come to work with me because they didn't want to see these patients, people with AIDS. So I just started, doing 24/7, going to these people's homes. And one of the things that would would happen is I called it catheter abuse. That was – an AIDS patient would go into the hospital and have a fever and everybody, they all did. And infection control, people just wanted to pull the line and they did. And oftentimes that was the only line we had left. I had two of my best friends were getting sicker and sicker.
Jack: What kind of lines are you're talking about?
Suzanne: These were tunneled catheters supports the Groshar catheter. And so, I would get really upset because in many cases, that was also the only line we had available with people with Kaposi sarcoma everywhere. Infection control wanted to pull that line and then we had no place to put it because of all the lesions from the Kaposi sarcoma. So, I had two friends that were dying, but I was ministering to them, but I was seeing patients 24/7 and I ended up in the critical cardiac unit with severe chest pain. I was in San Francisco and I said, 'Well, I'll stay in the right hand lane and I'll drive to my internist' who was in Redwood City/Menlo Park area near Stanford. And so, I drove down, he did an EKG and his wife took me right to the hospital. So, my friends, my two friends said, 'Suze, are you going to die before us?' I said, 'Uh, no. I, well, yeah, I could.' So, the cardiac cath showed that my heart was fine, but the cardiologist that they sent me to said, you just can't do this, you can't be doing 24/7, because I would be on call and I hire someone and get them up to speed on all the things you needed in home infusion.
And the next thing I know, I was at the one nurse's house. And so, she was in the bathroom and she had gotten blood on her hands and she was going nuts, you know, so she, she left. And then suddenly else, I hired her, and then she got pregnant. She left. And so, I was doing call 24/7 like I said, and my cardiologist said, no, you're not going to, you're not going to do it. So, I went a disability for like 6 months. I mean, he would not let me. He said: "Suzanne, you can't do this. You can't keep doing that.' But I stuck with my friends who had these lines: Gary and Bobby. Gary said to me, 'Suze, you got to do something about this' because he had gone to the hospital, he had a fever and they had pulled his line and we were using that for pain control, for morphine and for his Kaposi Sarcoma. And I got to his house and I was livid that they would just pull the line and have no options for that.
At the same time, I was doing research at MD Anderson in Houston and they sent me to the hematology meetings and while I was there, one of the things that was hard to do, you had to cut down to put a soft, silicone catheter in. You couldn't put it really through anything or around anything. Anyway, it was this, it looked like a fishing pole out of spool and it fed the catheter. The catheter was on a wire in this spool, and then I called it 'the bayonet' would come out of this end and you'd, you'd stick 'the bayonet,' 18-gauge, pretty large slit sided needle and start turning the round part of the, where the catheter was coiled. It will go right through and into the body. And I said, 'Brilliant!' Because people were doing cut downs and doing and terrible jobs doing cut downs.
I brought that back to MD Anderson and I said, 'Can we try this?' And so, I practiced and practiced and practiced. Dr. Frye Reich who was the head of the leukemia hematology groups and looking a lot into AIDS and HIV. So, I said, 'Can we try this?' So, I kept practicing on these arms that they were making.
Jack: What year was this? Roughly.
Suzanne: 1968, 1970. So, Dr. Frye Reich let me put in the first line. And so, I did. And it was very successful. I put in the, the first PICC line in the United States as a nurse. There were docs that would put them in here and there, but they didn't, they put in two a year, maybe. And you needed some skill, you needed to put in more than just one.
Jack: Funny how that works.
Suzanne: Yeah. So, then I brought them back and we started using them and then manufacturers got involved with them and improved the technique of not just the polymer itself, but the ways you could put it through the body without putting it through this 18-gauge 'bayonet.' And so, I did my disability and recovered, but you know, at the same time I was just so, so excited about these catheters. I stayed in touch with Dr. Hickman and Dr. Broviac. Dr. Swan wanted not just one lumen –, they wanted one or two or three lumens and they wanted the balloon and the catheter. We had to figure out how to do all that. And I worked with these wonderful engineers. So here I am watching this abuse take place. Like you'd have a patient come home from the hospital and they'd say they just got stuck like 5 times, by the same person, and they never had another person that was up to speed.
So, I did a survey on 370 patients and clinicians who put these lines in and most of the clinicians put lines in like twice a year. Again, you got all these physicians, they were doing them. It didn't really become a nursing specialty until I could kind of prove something. And so I just saw this abuse over and over and over. And so I was one of the founders of the Oncology Nursing Society and we wrote the first guidelines for the oncology nursing group. We had our, I had thought we had our protocols down pretty consistent and so on, but the rest of the world didn't have that. And so, I've wrote a letter, I was coming back from an oncology meeting and again, witnessing all kinds of abuse, people being stuck way too many times. And I know what happens.
I was working on my doctorate at the time. And I understand that, you know, you just can't keep repeating sticking someone because their veins are going to constrict. They're going to get fearful, they're going to be more, have morbid fear of an IV being started. I wrote a letter, I had this idea if I could get everyone that was putting these lines and like in most of the major hospitals in the San Francisco Bay area and I started, it was called the Bay Area Vascular Access Committee – BAVAC.
Jack: What year?
Suzanne: 1979. BAVAC.
Jack: This was your idea: To put together a, say it again. This was your idea – to put together a group of who?
Suzanne: A group of people that were putting in lines and dealing with...
Jack: Nurses? Doctors? Who?
Suzanne: Nurses, primarily. Doctors just felt they knew what they were doing. So, I wrote this letter, and I still have it and I wrote down what I saw as a benefit of bringing everyone together. That was a piece of the pie, including manufacturing at the time because they were coming out with things, but they weren't listening to the nurses that were at the bedside. And the consumers were very important to me that I just didn't want to see any more abuse. And so I wrote this letter and I showed what my mission was to bring everybody that was a piece of the pie – pharmacists, because they could change the pH and the fluids that was going in so that it wouldn't burn the vein so badly. And so, that day 15 people came from Presbyterian Hospital, St. Luke's Children's Hospital, Oakland, Stanford, of course.
Ramzy: Where did you have it? Menlo Park?
Suzanne: Menlo Park. That's where I was living. And so I, I wrote, I was on the airplane and I, I wrote this idea down and then sent it out. And the people that said they couldn't come – they had reasons.
Jack: Were the 15 people San Francisco-based? Or?
Suzanne: San Francisco-based. And so, I invited, I wrote the letter to oncology nurses primarily because then we're the ones doing IVs.
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Suzanne: So, we met at Presbyterian Hospital and like I said, 15 people came. But one of the things that I had learned is that if you bring some food, people will come. So, I made this great big thing of ziti and said food will be there available, whatever. So anyway, we started meeting on a monthly basis and coming up and changing, I had written down five of my goals. I said, 'We all have to be on the same page and our consumers need to understand that they do not have to put up with this abuse.' OK. So that happened. And then we named it BAVAN after the committee. The Bay Area Vascular Access Network we called it. And so, it was networking everyone that I could get my hands on to come.
Well the FDA, it was just starting a central venous catheter working group. And when they looked at their statistics, they found that the failure rates were due to healthcare professionals not having enough training and teaching and never heard about it in schools, nursing or medicine. But our pharmacists were very well involved in this kind of thing. So, every month I had a good friend who was a caterer and she would make awesome things and people would come and eat and talk. And so, 15 came, then 30, then 35 and then 40. And then I get a call from the person who's heading up the central venous catheter working group and had just gone over the statistics. And His name was Dr. Walter Scott. And he and his nurse practitioner came to San Francisco to one of our meetings. And then I said, I want to be on the central venous catheter working group. He said, 'Well, you know, you can sit in the gallery.' But you know, I wouldn't have a seat at the table. So, I went to Washington and sat down in the gallery and kept looking at this name tag in front of this chair and it says 'Suzanne Herbst.' So, I went, 'Holy smokes! I could sit at the big table with all those big guys!' Because they were primarily men.
Jack: What year are we? Just for the timeline sake. Early 80s?
Ramzy: So, BAVAC '79, BAVAN a couple years later.
Suzanne: Right. And then, then I got asked to be on the central venous catheter working group and I said, you have to come to some of our meetings. I remember wanting to have my version of the first meeting, like a convention. If we had 50 people, that would be wonderful. But what we did was we had tables around this ballroom or this room at the Holiday Inn in San Francisco. And I remember writing my personal check to cover the space. And we had, it was George Cinco, and he had a pediatric catheter silicone that you could put in these little kids. There were Menlo Park, I mean it was called Menlo something and they were coming out with some different new, new newness, this new technology. I think they spent like $25 to have the tables. And so, we had like 50 people come that first year and it was only from 12 p.m. – we did it in the afternoon – 12 to 6 p.m., something like that. So, people getting off at 3 or 4 could come. That was the first meeting, general meeting. And then, it just kept growing and catching on. And people would call and say, 'could we join?' And it was southern California, Orange County, Josie Stone, called me up and said, 'We'd like to start a network in our area.' And she came up to San Francisco and I remember that the rooms were shrinking, and people were sitting on the floors. Then it took off from there.
Ramzy: So, the second network was in Southern California?
Suzanne: Yes. Orange County. San Diego. Then one of the doctors from MD Anderson went to Utah, Salt Lake City, and he started a group there. And so it was like, 'OK, now we gotta call it NAVAN – National Association.
Jack: What year was this?
Suzanne: It was like '84, '85. It was amazing because I just felt that something was happening, something, something that was really grabbing people to keep coming and making phone calls to us. And so, then we called the NAVAN, National Association. One of the board members on the very first board, gave me a globe and I laughed. International? I don't think so.
Ramzy: Not possible.
Suzanne: No, not at all. No. We're lucky to be in it as big as we were getting in California. Yeah. So, we changed it to NAVAN and then it ultimately got changed to AVA because it's all over the world now.
Jack: So, let's go back. So, NAVAN – let's start, so you're at NAVAN and you went national, so let's say when it became AVA. Talk a little bit about what you were doing. There's a little bit of a big jump there.
Suzanne: I moved back from San Francisco, back to Syracuse, New York. That's where I was born and raised. I kept hearing about these interventional radiologists and what they were doing and so on. And so, I stayed as President for as long as I could.
Jack: What time frame? What year – the late '80s?
Suzanne: Yeah, I think AVA came up in '92, '93, they changed NAVAN to AVA.
Jack: And were you involved with that change?
Suzanne: Yes. I just said, one of the things, Jack, that you've heard me say this many times, but I worked for an incredible boss. You know, my license plates read 'CEO FOR GOD.' And We actually had a group of people who would pray before these meetings. Anyway, so I came back to Syracuse and I got a call from Ken Symington at Crouse Hospital in Syracuse. And he wanted to put together a workshop day about Vascular Access and explain what interventional radiologists had to offer in terms of imaging and visualizing. At that time there was a big war between the surgeons and these interventional radiologists that wanted to start doing it because they could see what they were doing as opposed to blind.
Jack: Were they using fluoroscopy at the time, do you know?
Suzanne: No, it was, I'm trying to think of when, because I worked on that the first ultrasound thing. But then I went to their suite and the interventional radiologist showed me what they could see and how, you know, they could, they could actually trace the vessel rather than shoot blindly.
Jack: Now, were these an ultrasound? Or fluoro? At that time.
Suzanne: I don't know. I was just learning about what they could do. And so, I remember that Ken got me involved with Crouse Hospital and we would have these meetings and the CEO would never show up for these meetings and they started at 6 a.m. So, we could plan how, how to not convert so much as to if the technology's there, why not use that rather than have the surgeon put in two (catheters) a year? I remember having that. Everybody got a folder and my parents stuffed the folders with information and Ken came over to the house and my mom and dad were so helpful. My mom and dad founded the leukemia society in central New York after my brother died. And so, they really got involved more and more with the leukemia and lymphoma society.
Jack: When did you move back to Syracuse?
Suzanne: '91. So, that's pretty much it unless you have some questions for me.
Jack: OK – so at this point it was the Association for Vascular Access.
Ramzy: Moved back in '91 – '92, '93, it's AVA now.
Ramzy: Which means we're 25 years into being AVA.
Jack: And how many, about how many members did you have at that time?
Suzanne: Maybe 250.
Jack: Members – almost exclusively nurses?
Suzanne: Yes. And interventional radiologists.
Jack: OK. At this point were you're holding, when did you start holding annual conferences? Around then? In the early 90s?
Jack: And you would move it around to different cities?
Suzanne: No, there was – Marcia Ryder, I hired her, so to speak as a Director of Education and she had a lot of background from Davis Hospital. I had helped develop the first ports, a lot of the catheters and such. And so, I knew generally about it. I would give a general overview of Vascular Access and then she would go more into the PICC lines. The two of us went from city to city and it was supported by Menlo Care. It was called Menlo Care. And I'm trying to think of, Dwayne Hardy, he was our first financial treasurer of the board, and it was called Menlo Care. And they supported it. They supported us for a while. But my checkbook getting lower and lower and lower and lower because I was ready to take a risk. And I knew I was doing something right because people were just showing up and making phone calls and talking to me and I was talking to them and they did not work with me somewhere else and I'd go wherever they wanted me.
Jack: What's your impression about how the BAVAC developed into AVA and how it's related to Vascular Access in the United States today?
Suzanne: Well, I think that just from the very, very first meeting back when we just called it a committee, that we started bringing Vascular Access more into the real world of education. But it still isn't in nursing schools and medical schools and so on. And today I think we're getting there. I think that, well you helped so much with that, Jack. You made it so real. I mean, when I first saw some of your presentations, I was like, wow. Correct me if I'm wrong, but the Sonograms are set up so that if you're right handed, you could put the Sonogram on the right side and you have a video where you took the bed out, turn it around in case somebody wanted a left-side orientation or whatever. It was just a riot. And I went, 'Gosh, he's got it. He has a got it. He just knows it and he is aware that there's one way of doing it and then there's all the others. That's what your mother would say, right?
Jack: Pretty much.
Suzanne: Yeah. For me, I really still get frustrated when, here's Crouse that I help set up the interventional radiologist group and Ken Symington left and went to outside of Spokane. But you know, we just became really, really good friends, before he had moved back. And when he told me he was moving to the northwest, I was like, 'No, you can't do that!'
Jack: So how do you feel about the overall state of Vascular Access today? Like its recognition, education, where it is compared to where it started?
Suzanne: Oh my goodness. It's moving. I think with the boards, The Foundation, the support that we're getting more and more that the education is coming. One of the things I also wanted to make sure of is that we all use the same terminology. I mean everything was a Hickman Catheter. But I think we're moving in the right direction. I've recently over the past year have had some very bad experiences with IVs. We still have some, a lot of work to do and we will do it.
Ramzy: You have been listening to the oral history of the Association for Vascular Access as told by its founder, Suzanne Herbst. Thank you, Suzanne for your time and your decades of work in advancing Vascular Access. And AVA would like to give a special thank you to BD for its sponsorship of this special episode of the ISAVE That Podcast. AVA members can listen to the entire unedited history of AVA by going to www.avainfo.org/podcast. If you have any comments or questions, you can send them to email@example.com. Thank you.