A Day in the Life

This “Day in the Life” feature comes from the Charge RN in the EP, Ablation, and Implant Labs at Halifax Health Medical Center. Halifax Health Medical Center is a 764-bed facility in Daytona Beach, Florida. We are always jam-packed busy, with at least 55 EP studies, 15 ablations, 60 implants and explants of ICD and PPM leads, new devices, and upgrades per month. We do it all with one RN and three EP techs who are very proud of what we do. A typical day in our lab lasts from dawn to past dusk. Hansey Seide, MD, is our Chief of Electrophysiology, and Okatar Quadrat, MD and Dr. Huijian Wang are our other electrophysiologists. All three physicians work diligently not only to keep the staff content and happy, but more importantly, to keep our patients alive and happy! Typical Morning It is 4:30 a.m. and our automatic coffee maker at home starts to brew. My wife gets me a tall cup of java with protein powder mixed in. I finish my first cup as I am getting ready for my 40-minute commute from Palm Coast to Daytona Beach. The jolt starts to kick in and my wife pours me a second tall one without protein for the ride. “See you around 8 p.m., honey,” I say as I am walking out the door. I arrive in the employee parking lot at 5:45 and head up to the second floor to check the schedule and say a little prayer to keep my patients safe and allow a smooth running day. I think to myself, nothing added on today, just one atrial flutter ablation, two other SVT ablations, one EP study and a BiV to follow, one defibrillator lead extraction and a possible dual chamber pacemaker insertion. All these cases are with Dr. Hansey Seide, our motivated electrophysiologist who always has a positive attitude; Dr. Seide’s sensitive and caring attitude helps keep us going each day. He always asks for our input during each case, and makes us feel like we actually know, even though he already knows, what must occur. This is his way of keeping everyone involved and expanding our knowledge. At 6:00 a.m., both Dale and Don, our invaluable x-ray techs, arrive ready for the long day. While Dale has more of a type-A personality, Don is super mellow. We also have an RCIS named Rita, who is very sweet. My personality is more service oriented to make sure Dr. Seide has everything he needs to do a case at our hospital. Our team has a great balance that allows everything to flow smoothly. I used to put daily assignments on the board, but with this crew, we all know what needs to be done. We all have consideration for each other so that days like today run smoothly. At 6:45 a.m., the room is set up and drugs for the day are pulled. Vancomycin and Ancef are mixed for IV infusion, and Isuprel 1mg in 250cc n/s is mixed to assist in the induction or post-ablation re-induction attempts. Heparin bags are mixed for flush, and we are ready for the first patient. All outpatients are prepared and instructed in our Diagnostic Outpatient Cardiac Unit (DOCU). Dale and I head for the first patient. All consents are signed; armbands are checked, allergies re-checked, NPO status is checked, IV fluids flowing, and all questions are answered. We begin our trip to a very cold EP Lab 6. The Camtronics Medical System (Camtronics Medical Systems, Ltd., a subsidiary of Emageon Inc.) is turned on, the Bard® LabSystem™ PRO EP recording system (Bard Electrophysiology Division, Lowell, MA) is opened, and the patient information is entered into both systems. Tim from Bard Electrophysiology is here to support the recording system as well as the Bard catheters, and we appreciate this support. During this time, the patient scoots onto the table and the connecting process begins. Before a case can even start, we pull a total of 5 leads from Camtronics, 3 leads and 2 defibrillator pads from Zoll, 5 leads from Daytex, 11 pads for the EnSite mapping system (St. Jude Medical, St. Paul, MN), 12 leads for the Bard LS PRO recording system (Bard Electrophysiology Division), 1 ground pad for the Stockert generator and 1 for the breakout box. We always joke with the patient by telling them they are now wired for sound and that if they open their mouth just enough, we could probably hear Howard Stern on the radio! It makes them laugh, instantly reducing their stress. Then they request, “Now put me to sleep!” Next I call Dr. Seide on his mobile and ask for his ETA. He replies, “Steve, I am basically here in the hospital,” at which time I give Derek Hincley, CRNA, the approval to grant the wish of the patient. I tell the patient, “Have a good sleep and see you when we are done.” The table warmer is turned on; Dale sets up his table and preps both groins. Don records a 12 lead and makes measurements on the Bard LS PRO recording system (Bard Electrophysiology Division); I am working the St. Jude Medical EnSite mapping system, and Rita is in the control room entering in everything. The lab door opens and Dr. Seide says, “Good morning, everyone!” He shakes hands with most of us and says, “Don, no sleeping today, we are going to work and save some lives!” Ha, ha! He is always very happy when he arrives in the lab, and it is very contagious. The realization then kicks in as to how busy we are. So we will work steadily, and hopefully get a couple of bathroom breaks and 20 minutes for lunch. The days always go by so quickly and almost every case is interesting. Dr. Seide scrubs and comes into the lab for sterile gown and gloves, at which point I do the Time Out to start our busy day. It’s 7:30 a.m., and both groins have lidocaine injected and access is achieved. Three 5 French sheaths are in the left femoral vein, and a 6 French and an 8 French in the right femoral vein are in place as well. Dr. Seide’s Pandora radio on his iPhone is plugged in, and Bob Marley begins the day singing, “Every little thing is gonna be alright.” Three Tango quadripolar catheters, from Bard Electrophysiology, as well as a St. Jude Medical quadripolar catheter, are advanced and placed in the appropriate location within the heart. Dale breaks scrub during the mapping period and bolts for a quick bite to eat as well as a bathroom pit stop. Rita, Don and I stay as Dr. Seide checks thresholds and atrial pacing begins. We also try to induce from the ventricle. Forty minutes pass and still no SVT. Dr. Seide orders Isuprel at 2mcg/min, which goes in for 15 minutes, and still nothing has happened, except for a slight increase in heart rate. Isuprel is increased to 4mcg/min for 7 minutes, and we are running singles from the atrium until we finally see the SVT. “Don, put some sensed PVCs into the SVT and let’s see if we advance the A.” With that completed, we have AVNRT. Dr. Seide orders Isuprel discontinued and he asks for his ablation catheter of choice. He says, “Get me a Stinger ‘D’ curve 4 mm tip.” He advances the catheter into the right atrium and says to Steve, “Let me give you some points as landmarks, and let’s find the correct spot and fix this problem.” We optimize and map until he finds the correct location and burns. We immediately get accelerated junctional beats. Dr. Seide asks, “Steve, am I stable? Talk to me, please.” I reply, “Yes, Dr. Seide, you are stable.” We have fixed the problem and will try to re-induce and turn the Isuprel back on. We complete all the pacing protocols and wait 30 minutes. Dr. Seide then asks Rita to pull the catheters and sheaths, and asks me to get the next patient ready. Derek says the patient is awake. “We are all done, sir. You can open your eyes. We will get you on your bed and take you to your room where you can have all the beef broth and Jell-O you can eat. Isn’t that great?” “No way,” says the patient, “I want a burger and fries!” “Yeah,” says Don, smiling. “We want a burger and fries, too!” Its 9:30 a.m. and the DOCU calls to tell me that Dr. Seide’s next SVT ablation is at another nearby hospital by mistake. I say, “Well, tell the patient to get over here ASAP and we will do the atrial flutter ablation now.” Dr. Seide agrees. “Let’s get this flutter done before lunch!” So, Dale and I go to the DOCU and get the next patient, while Don and Rita clean and set up the lab for the next case. By 11:30 a.m., the TEE is completed and the flutter line is complete, so we were done — no more flutter. The patient had been in a very typical flutter, so we first entrained, and then we were in the circuit. Once we completed the line, we checked for bi-directional block and found it in both directions, with a delay of over 150ms. It was a smooth-flowing flutter ablation. Dr. Seide tells us, “Let’s break and take 20 minutes for lunch.” I reply, “Sure, partner. Let’s take 30 minutes.” Dr. Seide turned with a smile on his face and we take 30 minutes. A Busy Afternoon It’s now 12:30 p.m., and everyone is rejuvenated. My cell phone rings and it is Dr. Seide: “Hey, Steve, send for my next patient.” I am already in the DOCU for the next patient, which is the second SVT. The next patient still has not shown up, but the EP study and BiV patient to follow has consented and is ready, so we move them to the earlier spot. Dale comes into the unit to help get the patient checked and taken to the lab. I start the antibiotics, and Derek begins his interview. The patient is on the table and we are set up for the EP study. It is 1:15 p.m., and we have 1 Tango (Bard), 1 Response (St. Jude Medical) and 1 Decapolar (Bard) catheter in place. The Decapolar catheter is unique because it covers both RVA and HIS locations with one catheter; that is really good for the patient because it is one less stick in the groin. With this catheter, it has 4 poles in the RVA and 6 poles on the HIS. Dr. Seide walks to the recording system and says, “Let’s see what we can induce.” The EP study takes about 30 minutes. Isuprel (2mcg) is started, and we are pacing in the ventricles when we find a VT. The ventricular tachycardia had a 213ms cycle length. Dr. Seide tells Rita, “Pace him out and pull the catheters, but leave the quad in the CS as a reference for the BiV.” Dale is putting on sterile gloves and talking to Don when he pulls all the quads. I yell, “Dale, you pulled the CS quad out!” Dale feels terrible and says, “Dr. Seide, I really messed up. I pulled the CS quad out by mistake.” Being the kind of person he is, Dr. Seide tells Dale, “Don’t fret, just prep the patient for the device and move on.” Afterwards, there is a slightly depressed feeling in the room, as though we all messed up. The patient is prepped and draped for the BiV. As noticed during the EP study, the patient has an unusually large heart and a really small coronary sinus (CS), as well as the heart being rotated to the left. Therefore, CS access takes a little longer than expected to re-access from above. A COGNIS® biventricular ICD (Boston Scientific, Natick, MA) was implanted. Dr. Seide asks Melissa, the Boston Scientific representative, “Can we test the device?” She tests the device and says, “Here is 3 volts.” Dr. Seide tells her, “We have diaphragmatic stimulation, so try unipolar. Wow, this abdomen is bouncing like a basketball.” At this point, he decides to locate another branch. Once that is achieved, we again test and it is successful at 1.2 volts without diaphragmatic stimulation. Dr. Seide happily says, “Hey, does anyone want any better than that?! Come on, looking good and good looking!” We laugh and agree. The device and leads are connected, the pocket is flushed and closed, and we successfully test at 15 joules. Its 3:45 p.m., and we need to get done by 7:00 p.m. Dale, Rita and I are on call at 7:00 p.m. and we still have an SVT as well as a defibrillator lead extraction and replacement, so we really need to get moving. Fortunately, things go smoothly for both cases. The SVT was a WPW, and the lead extraction was not too difficult. Time to Go Home! The workday is finally over, and it is 7:30 p.m. Dr. Seide walks over to each one of us and shakes hands and says, “You guys are the best, and I really appreciate you.” I tell him, “Dr. Seide, we know that, but you have got to get moving. It’s your wedding anniversary and the real boss — your wife — is waiting to go out to eat before it gets too late!” Dr. Seide agrees and says, “Thanks again, guys,” and leaves. We take the last patient back to her room, terminally clean the lab and punch out at 8:15 p.m. As we are walking out to our cars, I announce in a tired voice, “Great teamwork today, guys, but tomorrow we have an 8:00 a.m. SVT ablation with Dr. Quadrat. Remember, he likes a quadripolar in the RV, octapolar on the HIS, hexapolar in the lower right atrium, a RADIA* in the HRA and a Decapolar for the CS via the right internal jugular vein. Now, let’s get out of here and get some rest! It’s going to be another long day tomorrow with the SVT ablation, as well as two EP studies and a BiV with Dr. Quadrat, who called me today and said he would be on time.” That is a typical day in our busy EP lab. We’re tired, but we love it. We are a great crew that is dependable and motivated every day. We support our great doctors, and know that that is what you need to do in order to succeed. For more information, please visit: www.halifaxhealth.org/ * RADIA™ Steerable Diagnostic 20-pole catheter (Bard Electrophysiology Division)