10-Minute Interview: Claudia A. Irmiere, RN, MS, CCRN

Why did you choose to work in the field of electrophysiology? I had attended a presentation given by Mary Ann Leffler, an advanced practice nurse who worked with Dr. Leonard Horowitz (a grandfather of electrophysiology who advanced the field of electrophysiology), at a critical care nursing conference. She gave an excellent presentation about the field of electrophysiology, and what was considered cutting edge (way back in 1988!). I was just fascinated by the concept of looking at the heart from a completely different perspective and managing patients with life-threatening arrhythmias. When it came time for a career change, I looked for an institution that had an electrophysiology program. I was fortunate that St. Joseph s Regional had an EP program, so I chose to come here, even though their program was still in its infancy at that time. I have loved it ever since. I find EP fascinating and challenging, even after 14 years.

Describe your role as an advanced practice nurse. What is a typical day like for you? Every day is different. My role is unique and truly encompasses all of the responsibilities of an advanced practice nurse. I care for patients with arrhythmias including those with implanted cardiac devices. I care for both inpatients and outpatients. Patient and family education is always a priority. The nursing staff will call me for questions about patients with arrhythmias or devices that are acting different. In addition, I receive several calls from patients and families throughout the day concerning everything from medication renewals to receiving ICD shocks. I also follow devices remotely, thus I review those transmissions as well. Daily rounds are made on the telemetry and CCU unit to identify patients with atrial fibrillation for a PI project that I am currently working on. I am involved with numerous research projects, so data collection and patient enrollment is a daily activity. I am responsible for the EP statistics and tracking complications. I follow patients with atrial fibrillation on long-term anticoagulation, monitoring their PT/INRs. I also present nursing lectures on all aspects of the field of electrophysiology, from antiarrhythmics to device therapy. Often what I intend to do gets changed quickly based on the needs of the patients and nursing staff.

What is the most bizarre or unusual case you have ever been involved with? There has not been a day since I have been in this position that I haven't learned something about this field or something about myself or patient care. Over the years, there have been many memorable situations with patients and their families. Device patients have a tendency if not feeling well to put the blame on their device (especially if it is something they can't understand). A favorite incident of mine was the patient who insisted her pacemaker was beeping (pacemakers don't beep). We had her come to the hospital, did a full evaluation, and she agreed it was no longer beeping. About a half hour after she left our office, she called us back, yelling that the device was beeping yet again! I reassured her it was not her device. Not satisfied with my answer, she stated she was coming back yet again to the pacemaker center and hung up. Moments later, her daughter called from the patient s house, very apologetic for her mother's behavior. It seems the fire alarms were beeping as the battery needed to be changed! The most bizarre or unusual cases are patients with Twiddlers' syndrome or device extrusion. We had one patient from a nursing home, about eight weeks post pacemaker implant, who opened her wound by persistently picking at it. She was brought to the emergency room with the header of the device peeking out, along with a foul exudate. Another patient was a nervous person who had twisted her ICD (which was implanted in her chest). She presented to our pacemaker center after receiving several shocks due to inappropriate sensing. A chest film confirmed lead dislodgement. In the EP lab, when the pocket was opened, Dr. Biehl counted 23 turns while unwinding the device. Those are just a few of the interesting situations we ve encountered.

What aspects of your work do you find most rewarding and/or challenging? I really enjoy caring for patients and their families, whether it is helping to understand their disease process, teaching them about their device, explaining their medications or helping them to make the right decision about withdrawing care. Albeit some days are more challenging than others, they are still rewarding in their own right.

Are you currently involved in any other EP- or cardiology-related projects or groups (i.e., research or writing projects, etc.)? Here at St. Joseph s, we have numerous research projects in the field of EP. Currently I am the study coordinator on four projects. My responsibilities in research are administrative, from protocol submission to patient enrollment, data collection, and follow up. We just recently closed the DAVID II trial. We have also participated in the AVID trial, SCD-HeFT, and DAVID trial all landmarks in the field of EP. In addition to device trials, we have participated in numerous drug trials. I am the associate chairperson of the IRB here at St. Joseph s. I enjoy the challenge and vigor of research and the opportunity to change practice-based science.

What advancements do you hope to see in the field of cardiac electrophysiology in the next five years? What specific areas of EP and/or patient care need more attention? I hope to see the development of better antiarrhythmic medications, smaller and smarter devices for patients, mapping and catheter systems that help shorten procedure time and provide better success, and ongoing success with the non-thoractomy mini Maze procedure to help cure atrial fibrillation. We have come so far in 14 years since I first started in this field. I am looking forward to seeing how much further we can go!

Are there any particular Web sites or texts you would recommend to others in the field of EP? I have found the Heart Rhythm Society s Web site to be very useful. In addition, the device companies, such as Medtronic, St. Jude Medical, and Boston Scientific, all have Web sites that contain a wealth of information about arrhythmias and treatment options. There are also so many great texts available today that I would not want to limit myself to recommending just one particular text.

What advice would you give to EP allied professionals who are currently at the start of their career? My advice would be to observe a few EP cases first, then have someone who is passionate about the field explain the procedure or process to you. Get as much information as possible about the particular procedure, and supplement it with readings about it. Attend symposiums and conferences, not only for the education and information, but for the opportunity to network with other allied professionals. My colleagues are my greatest source of information; they can always provide alternative ways of approaching a problem.

Has anyone in particular been helpful to you in your growth as an EP professional? There have been several people who have greatly influenced my career in EP. The first is Dr. Nicholas Tullo, who hired me into the APN position and dedicated the time to educating me in the field and teaching me the proper way of managing arrhythmia patients. He encouraged me to be the smartest person in the field, and to be someone who could answer the questions not just correctly, but also answer the why behind it. He challenged me to strive for excellence in all aspects of arrhythmia management. Another great influence and source of support is Janice Fulton, Nurse Practitioner. When I first started in this position, there weren t many advanced practice nurses working in the field. Jan had been working at St. Michael s in Newark, New Jersey in the EP lab. Jan knew everything about setting up the EP lab, as well as EP lab policies and how to care for patients, not to mention device follow up and arrhythmia management (and physician management!). She is always a great source of support and knowledge about electrophysiology. Dr. Michael Biehl, one of my colleagues here at St. Joseph s, has always encouraged me to think independently, not accept the routine, and keep what is best for the patient and family in mind. He is supportive of my practice and presents me with challenges daily. I am fortunate to have all of them in my personal and professional life. Finally, I need to acknowledge the influence my parents, Dr. Victor and Eleanor Irmiere, have had on my career. They taught me that the tools you need to care for patients are just the tools you were born with the ability to listen, the power of observation, the sense of smell, the use of touch during an assessment, and use of your voice to advocate for those who have no voice. And don t forget to think!