The authors provide an overview of their educational course “Order and Disorder in the Cardiac Rhythm — Beyond the Basics,” held December 2 and 3 in Chicago.

Figure 1.

Beyond the Basics program.

Background
       The Order and Disorder Training Program was developed a little over 10 years ago to fill a gap in education for staff employed in electrophysiology laboratories throughout the country. Its ‘Beyond the Basics’ course marked the tenth year this past December in Chicago. Beyond the Basics is a two-day course designed for electrophysiology-associated professionals with at least six months of experience in an EP setting, and is recommended for those who have completed the Basics course, a more fundamental course designed for anyone new to the field of electrophysiology. Beyond the Basics is usually offered twice a year at various locations throughout the country.
       Typical of most of the Order and Disorder programs, participants at the Chicago course traveled from a wide range of states, from California to Georgia. Attendance for each course generally ranges from 50–100, with roughly 70% representing nursing or cardiovascular/radiology technicians and the remaining from the catheter or device industry. Electrophysiology fellows, cardiologists, nurse practitioners and physician assistants also attend.

Figure 2.

Participants in the December Beyond the Basics Course.

The Beyond the Basics Course
       The Beyond the Basics course began with a review of material taught in the Basics program, in order to put everyone ‘on the same page’ by the midportion of the first day. Those who have attended the Basics course generally find the review helpful since it reinforces knowledge learned in prior settings, and because the repeat exposure is heard with different ears as the learner makes that trek from novice to expert over time. By observing EP studies on a relatively frequent basis, one becomes a slightly different person with each successive exposure to the material. Topics covered in the review section included aspects of anatomy and physiology that are practical and relevant to what one expects to see in the EP lab, basic principles pertaining to electrode recordings, catheter placement, pacing techniques and propagation of the cardiac impulse. Figure 3, an example of a slide from the course, is an RAO view of a dissected heart with slow and fast pathway locations superimposed.

Figure 3.

RAO view of a dissected heart with fast and slow pathway locations superimposed.

       Also covered were topics relating to fluoroscopic anatomy for navigating around the heart, types of EP studies, and the common indications for undergoing such evaluations. Because of the importance of understanding what is normal before going on to the abnormal, there was considerable emphasis on the behavior of impulse conduction through the AV junction. The focus then shifted to the components of the typical comprehensive EP study, in which the participants were taught a systematic approach to assessing the conduction system. An abundance of intracardiac tracings illustrating the salient features of each step were used, and in the process, the expected physiology was reinforced.

Figure 4.

Tracing from course book illustrating retrograde atrial activation sequence during orthodromic reciprocating tachycardia involving a right-sided, posteroseptal, and left-sided accessory pathway.

       The second half of the first day and most of the second day got into the ‘meat of the matter’, by walking the participant through the problems of supraventricular tachycardia, wide QRS complex tachycardia and general principles relating to catheter ablation. The section on supraventricular tachycardia highlighted AV nodal reentrant tachycardia, reciprocating tachycardias due to both rapidly and slowly conducting accessory pathways and ectopic atrial tachycardias. Commonly observed eletrophysiologic phenomena were illustrated in a manner that brought together the pacing technique used to produce the recording with the type of impulse conduction behavior one would expect to see. Figure 4 illustrates a tracing used in the course; the figure shows the different retrograde atrial activation sequences during orthodromic reciprocating tachycardia involving a right-sided, posteroseptal and left-sided accessory pathway. Figure 5 is an example of bracketing the atrial insertion site during retrograde preexcitation.
       The 262-page syllabus for Beyond the Basics is rich in annotated intracardiac tracings and other illustrative diagrams to help the participant better understand the fundamentals of interpreting recordings and how this leads to the laboratory diagnosis of cardiac arrhythmias. Questions from the audience are frequently fielded and are considered an absolute necessity.
       The program concluded with a practice tracing session, which allowed the learner an opportunity to work with his or her neighbors to problem-solve and voice opinions with other class members. This unassuming and casual atmosphere is intended to promote audience interaction.

Figure 5.

An example of bracketing the atrial insertion site during retrograde preexcitation.

About the Order and Disorder Program
       The course offered an excellent opportunity for networking among the attendees. Similar to that of other regional and national meetings, the Order and Disorder program provides attendees a unique setting of give and take while sitting together during the breaks and luncheons to discuss experiences unique to their individual hospital settings and share helpful information with each other. Nearly all programs have exhibitor booths allowing industry representatives the opportunity to show their product lines. These include companies representing catheters, recording systems, implantable devices and radiology equipment (Figure 6).

Figure 6.

Participants visiting an exhibitor during break.

       The success of the Order and Disorder Program is largely attributed to the continued need for education and the presentation of a large, detailed core curriculum with an emphasis on visual images and focus on basic principles as they apply to the activities in the course of routine electrophysiologic testing. The primary faculty for the Order and Disorder program are Linda and Kriegh Moulton. Dr. Moulton emphasizes that “what all of us are doing during a case is really quite comparable. We may dress it up with many different looks and do things in differing sequences, but the outcome is the same. The important thing is to know why you’re doing what you’re doing. As long as you know the rules of the game, the game is fun.” Linda’s style has always been to ‘teach’, rather than ‘tell’ staff members what electrophysiology is all about. She offers that “teaching needs to begin where the learner is and mandates consistent reinforcement of ideas and concepts. Our training program was split into basic and advanced curricula for this very reason, to meet the learner at their level.” Donna Vomachka is the administrative assistant at Critical Care ED and has been an absolutely indispensable part of the program’s development and implementation. The support of industry is also essential for keeping the tuition costs down, and this has been challenging over the past two years due to the increase in funding restrictions. The programs are approved for nursing CEUs by Critical Care ED, which is an AACN Certification Corporation-approved provider, the California Board of Nursing and the American Society of Radiology Technicians. Approximately 15 contact hours of credit are usually earned by completing the Beyond the Basics Course.

Figure 7.

Home page of the Order and Disorder website: www.orderanddisorder.com

       Future programs include EP Update, a program offered for the last two years, an EP Review Course and the development of an online curriculum. The online curriculum can be accessed through the website “www.orderanddisorder.com”. Course materials are also available for purchase on the website (Figure 7). The Basics and Beyond the Basics courses are also conducted at specific hospitals by special request. The next Beyond the Basics program will be held March 6 and 7 in Los Angeles.

Figure 8.

The Order and Disorder booth at HRS last May. From left to right, Linda Moulton, Michele Johnson, Donna Vomachka, and Tony Johnson.

Faculty Bios
       Linda Moulton has been involved in nursing education for more than 30 years. Her teaching interests have included cardiology and critical care, with an emphasis on electrocardiography and arrhythmias. For the past 15 years she has operated an education company, Critical Care ED, and during that time worked as an electrophysiology research nurse and provided consultative services. Dr. Moulton has been teaching arrhythmias since the early 1970s, and has enjoyed both watching and participating in the many developments in the field of cardiac electrophysiology. He practices with Prairie Cardiovascular Consultants and is the co-director of Cardiac Electrophysiology at the Prairie Heart Institute in Springfield, Illinois.