Lessons Learned, Part II

Over the 18 years that I have been working as a cardiac electrophysiologist, I’ve learned a lot of things that aren’t written about in journals and textbooks. In February 2013, EP Lab Digest allowed me to compile and publish a list of some of these "lessons learned" from my experiences. Since then, I’ve come up with a few more and am thrilled to have the opportunity to share again. Although these tips often directly relate to my primary focus as a doctor that implants and follows patients with ICDs and pacemakers, I hope others will find them to be of value.

Everything here is subjective, and none should be considered medical advice. I’d be thrilled to hear your own thoughts, disputes or additions. Let’s start a dialogue on Twitter at @EJSMD or at my blog, Left to My Own Devices.

• Never start a case unless you are prepared to be late for whatever comes next.
• It is bad form to blame your lead dislodgments on the patient. 
• If your patient tells you they think they might have gotten a shock from their ICD, they didn’t get a shock. 
• If your patient doesn’t smile or laugh at least a little during your office encounter, you probably aren’t reaching them.
• If a hospital monitor tech tells you your pacemaker is malfunctioning, what they really mean is “can you look at this for me and figure it out?”
• A simple but powerful question to ask every office patient: “Are you better, the same, or worse since the last time I saw you?” Placing symptoms in context is critical.
• A 5 Fr Amplatz left coronary catheter is a great tool for accessing high coronary sinus takeoffs.
• When placing LV leads, engage the coronary sinus in LAO, but advance the sheath in RAO.
• You may be smart, skilled, and have great outcomes, but if you don’t take the time to sit down and talk with your patients, you really aren’t a good doctor.
• If you preserve a Fidelis ICD lead at gen change: program for tip-distal coil pacing and sensing, excluding anode ring. Exclude SVC coil and test DFT if appropriate. This excludes 2 of 4 conductor elements from the ICD circuit.
• If you preserve a Riata or Riata ST ICD lead at gen change: give a high-energy shock into sinus rhythm with old can, checking impedance. Examine under fluoro for externalization. Using new ICD generator, program to exclude SVC coil and do DFT.
• I believe in single-coil ICD leads. I also believe in withholding DFT testing. Both of these in the same patient? I’m not so sure about that.
• If you can give me a convincing reason to use primarily DF-4 ICD leads, send me your reasoning on Twitter, @EJSMD. In ten years, I’m pretty sure I won’t look back and say, “darn, I wish I’d put in more DF-4 leads.”
• Make your device pocket extend both cephalad and caudal to the incision line — that way, the device edge will not push through the sutures, and the pulse generator will cover the suture tie-downs.
• A difficult case almost always is in some way related to vascular access.
• Electrocautery can melt polyurethane and Optim, but not silicone.
• Consider trying to do all your fluoro panning yourself. You’ll spend less time on the pedal and be able to frame the images better than any tech.
• In the morning when making post-op rounds, don’t flip the lights on and blind your patients. (Thanks to my Aunt Harriet for that tip!)
• In descending level of importance, this is what to prioritize in LV lead placement: position, diaphragmatic stimulation, pacing threshold, stability, and sensing. A stable lead with low threshold at the apex or on the phrenic nerve does no one any good. 
• Treat your office counseling kind of like a stand-up comedy routine that you refine each time you give it. Try out new things to keep it fresh. Eventually you’ll come up with a good “act” that plays well to your audience.
• Triage decisions can involve the timing of a procedure, but never what is actually done. No procedure should be altered or hurried because there are patients waiting in the office.
• Lab staff and industry personnel should be encouraged to speak up during cases. The doctor may not know or see everything important. The EP lab should be an open, collaborative environment.
• You can deliver a lot of healthcare from your desk by careful review of device interrogation data.
• Patients should be encouraged (within reason) to use their arm soon after device implant. Lead dislodgments after the first day are much more rare than frozen shoulders.
• When called to see a patient with heart block, your first question should be “is the QRS wide or narrow?”
• Financial incentives should never affect any individual patient relationship. It is, however, reasonable to see fewer patients if your time is not valued appropriately.
• An understanding of a patient’s needs, expectations, and risk tolerance is critical to have while doing a procedure. You won’t get that information without a face-to-face pre-op conversation. Ideally, that talk should occur while everyone is wearing his or her normal clothes.
• Most ICD shocks should not prompt an ER visit, much less hospital admission. That’s one of many reasons EP specialists need to make themselves readily available on call.
• Your primary mission is to provide high-quality care for your patient. Sometimes that means referring to another EP specialist.
• Not all mode switch events are atrial fibrillation episodes. Don’t commit a patient to anticoagulation until you confirm the diagnosis with electrograms, cycle lengths, or ECGs.
• Hospital inpatients should be referred to by their names, not their bed numbers or diagnoses. 
• Modern device follow-up is way more complicated than battery voltage, thresholds, and sensing. If you delegate all of this work to allied staff, industry, or general cardiologists, your patients are probably missing out.
• The electrocardiogram is an essential part of the workup of syncope. If you order head MRI, EEG, and carotid ultrasound and don’t get an ECG, please come over here so I can kick you in the butt.
• If you want to distinguish yourself from your competition, all you really need to do is care more about your patients. Any doctor can do this.
• Consider doing a stand-alone subclavian vein angiogram (to evaluate venous patency around existing leads) on a separate day before committing to device upgrade. This allows you to have an informed risk/benefit discussion with the patient and mobilize resources for the case.
• If you are using ultrasound for axillary vein access and can only see one blood vessel, you’re looking at the artery. Don’t stick it.
• If back bleeding from your axillary vein access is brisk and a little more red than usual, you may have gone through an artery on your way into the vein. Pull out and stick again to avoid getting a subpectoral hematoma.
• When somebody answers “safety pacing” when trying to explain a complex pacemaker rhythm strip, eight times out of ten he or she will be wrong.
• If your coronary sinus angiogram does not show any decent venous branches, it’s probably not a good angio. Reposition the balloon and try again.
• Why use a $400 steerable EP catheter for CS access when you can do the same job with a $10 coronary angiography catheter?
• Never enter into an industry arrangement that you would not proudly declare to the Wall Street Journal when they call you.
• The decision to turn off ICD therapies is as important a part of the care of your patients as was the decision to implant in the first place. 

Read the first installment, Lessons Learned in 18 Years of Device Implant and Follow Up, here.