Michael L. Arnold, RN, RCIS is the Clinical Nurse Leader for the EP lab at Tucson Medical Center. Read more about him here. Why did you choose to work in the field of cardiac electrophysiology (EP)? What interested you about this field? EP is a dynamic field, ripe with technical and intellectual challenges and seemingly boundless frontiers. I chose to specialize in EP for two reasons. First, it involves constantly learning new techniques, new principles, and new technology. And, although the science is ever changing, it requires a strict, constant adherence to the rules of logical arguments. Secondly, it is a young field, and many of us have the honor of working alongside past and future pioneers on a day-to-day basis. Not only could you be working with a person who has just invented the next great technique, but many of us work side by side with the same physicians who have catheters, sheaths, and procedures named after them already. It is great to be a part of it all. Describe your role in the EP lab. What is a typical day like for you? I am the Clinical Nurse Leader for the EP lab in a large community hospital with a new EP program. My job includes participating directly in the care of the patient during the procedure, coordinating support services for the case, as well as handling the materials ordering, policy and procedure writing, training of staff, and business development. I usually start the day at my desk catching up on administrative tasks and then check the status of the morning patients (i.e., the lab results, EKG, transesophageal echocardiogram or CT scan if indicated). Thanks to the quick comprehension of several staff and patience of the physicians, I have recently been able to allow others to start the procedure set-up and baseline recording of the case, which in turn has allowed me to scrub-in and continue learning to position catheters for recording and pacing. As the solitary fully-trained EP staff member at my hospital, I am often required to be in early in the morning and stay into the evening for cases running late. I usually end the evening back at the desk following up on product orders, hospital education issues, or assisting the director with administrative needs for the cath lab and EP service. As other staff become fully trained, I hope to dial-back my schedule to allow me more time with my family and the opportunity to work on my ‘extracurricular’ projects, which include a book about preventing healthcare errors and a local EP allied health professionals society, to name a few. Tell us about the first EP case you took part in. What do you remember about that day? I was lucky enough to start my cath lab career in a hospital that performed EP and coronary cases in the same department, so I was allowed to scrub EP cases and device implants as part of my initial training. One of the first EP cases I saw involved electroanatomical mapping of a focal tachycardia using Carto (Biosense Webster, Inc., a Johnson & Johnson company), which really helped me visualize the process of mapping a site of earliest activation in relation to a reference EKG. I had always had a strong interest in 12-lead EKGs, beginning when I was working in the non-invasive cardiology setting, which allowed me to catch on immediately and jump right in to the first PVC pace-mapping procedure I watched. As I spent more time in the lab, I found I had to work harder to understand the standard EP electrograms (and quickly realized that my mind had to start working much faster than 25 mm per second!), but found accessory pathway and typical atrial flutter mapping to be easy to comprehend. I have had to work steadily since that day, reading articles and text related to a case from earlier that day, or on a case for the next day, and still find myself having those ‘aha!’ moments every few days, which also speaks to the first question about why I chose to work in the field. What aspects of your work do you find most challenging? One of the most challenging portions of my job is the lack of understanding in the medical and lay community about what it is we do in EP. Thankfully, with the EP program being a new service at Tucson Medical Center (TMC), I have been given many opportunities to teach the public, our patients, and my peers about electrophysiology. Of course, for every five people I discuss EP with, one always seems to ask me “so how many stents do you use for that?!” Another challenge I think we all face is as the field of electrophysiology becomes more and more computer based, the amount of technical know-how necessary to troubleshoot equipment problems becomes greater. In addition to the standard ‘connectology’ we all have to become familiar with, there is a whole programming and software component that is beyond what can be easily worked around in a pinch. In my lab at TMC, we have the Artis and Leonardo (Siemens) imaging systems, WITT/Xper (Philips) hemodynamic recording system, EP Workmate (EP MedSystems, Inc./St. Jude Medical), Carto RMT (Biosense Webster, Inc., and Johnson & Johnson company) electroanatomical mapping system and the Odyssey (Stereotaxis) magnetic navigation system, often in use simultaneously. These varying systems must be able to work as programmed onto themselves, as well as communicate with each other for the case to run smoothly. Over time I have found there are fewer issues I can troubleshoot myself and more situations where I need to call tech support for ‘software’ issues. Thankfully, when in doubt, backing out and booting back up seems to resolve a lot of glitches, or as we have renamed them, ‘unpublished features’ found in every system. What motivates you to continue your involvement with the EP lab? I hope to become a nurse practitioner and continue to work in the EP lab performing the diagnostic mapping portions of procedures, device change-outs, event recorder implants, etc. To accomplish this goal I have returned to school, taking classes at night (which are occasionally interrupted by late-running cases) to finish my BSN in preparation for starting the Nurse Practitioner program this fall. To me, the EP lab is the perfect combination of settings: a place where one can use the manual dexterity needed in the surgical theater, the diagnostic acumen of a clinical specialist, the strategies of a chess player, and the technical skills of a computer programmer. It is because of the opportunity to stay in the lab as a mid-level provider I saw at other facilities in the country that I have decided to return to school to further advance my level of practice. What is one of the more unusual EP cases that you have ever been involved with? A few months ago, I was able to watch a perinodal atrial tachycardia case at the University of California - San Francisco while I was there to learn about the Stereotaxis system we were having installed in our new lab. It was a complex case made more challenging by the patient’s absolute refusal to allow any ablation that might put her at risk for a pacemaker. The procedure progressed from right to left atrial mapping, but nothing was ‘especially early’ and the site of origin continued to elude us for hours. A visiting electrophysiologist suggested that they map the non-coronary cusp of the aorta, which I had never seen before. Sure enough, the arrhythmia was mapped earliest there and terminated after seconds of radiofrequency ablation. Afterwards I learned that the visiting EP was Dr. Mark E. Josephson, the namesake of the Josephson catheter curve and author of the EP textbook I keep on my nightstand. We have had two cases since then in our own lab in Tucson that have turned out to be tachycardias originating from that same site, and mapping the aorta has become my favorite suggestion to pester the physicians with when the origin of a seemingly low-septal atrial tach is unclear. 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 can only imagine the coming improvements in the quality of imaging modalities and therapeutic devices, which I am sure will make the systems we use today look quite crude. The better tools we have at our disposal, the safer our procedures, the better the outcomes, and the further EP will grow. In terms of the field as a whole, I believe we will see more people coming for care of dysrhythmias in the future, especially as genetic testing and micro-alternans assessment grow into more common use. I think a more expanded application of these technologies will screen in more patients in need of diagnostic EP assessment, and more insurance coverage will be available for those who may not have traditionally been given the opportunity for evaluation. To accommodate this potential boom in diagnostic procedures, I hope to see this role shift more to a model of mid-level providers (i.e., PAs or NPs) handling the increased load of diagnostic work-ups to free electrophysiologists up for more therapeutic procedures (which I believe will also grow in volume as disease occurrence rates and healthcare coverage continue to climb). I have also been glad to see the advances in sudden cardiac arrest (SCA) prevention, screening and treatment over the past five years. In the next five years, I hope to see these areas continue to move forward in increasing awareness, preventing occurrence, and improving survivability in those with the different conditions that contribute to it. When I was in junior high school, a classmate of mine died of SCA in front of us at a school dance. A couple hundred people all stood by, and no one really knew what to do about it. Everyone assumed it was an epileptic-type seizure because no one suspected a cardiac cause in someone so young. The more we teach the community about it, the better the chances of saving lives on the front and back ends, both in young and old alike. What advice would you give to others in EP who are currently at the start of their career? I think it is important to find the balance between reading about EP and doing it. I first tried to go into the lab as well read as possible, but it became difficult to comprehend without actually doing it. That may just be a reflection of my particular learning style, but I think it is easy for people who are motivated to try to learn too much about EP in a vacuum, without watching cases or asking staff, reps, and physicians the questions they may have. I first felt like there was no way I was going to get it, because it seemed so abstract. I actually gave up on reading my Fogoros book altogether for a while, because I thought I was never going to understand it. However, many conversations and observations later, things started making more sense, and everything clicked. I liken it to learning math in school. I always assumed I was just not a ‘math person’ because I was horrible at it, until I had the right teacher (who actually happened to be my chemistry professor), who helped me understand it. EP is not for everyone, simply because some people are not interested, but anyone can learn EP. I’m proof! Has anyone in particular been helpful to you in your growth as an EP professional? In addition, what medical textbooks or online EP resources have you utilized that you can recommend? First and foremost, I have to thank my wife Laura and my son Seamus. I have spent the last few months essentially on-call for EP cases five days a week, temporarily foiling any plans they may have had for a normal life, and spending the evenings and weekends studying, writing, or doing research. Without their patience and support, my growth as an EP professional would have never been possible. I have also been fortunate to have many excellent influences and teachers along the way, some before I even entered the cath lab. I need to thank the following people for their help and support: Dr. Charles Katzenburg, for teaching me to love 12-lead EKGs and teaching me to fully interpret every EKG I can get my eyes on (I’m getting closer everyday to the 10,000 you told me to read!); Stuart Scherger, for letting me into the lab in the first place and giving me a chance; the local electrophysiologists I have worked with who have taught me so much: Drs. Benigno Decena, Lionel Faitleson, Santiago Valdes and Jerrold Winter; the old EP staff at Tucson Heart Hospital who gave me a solid foundation to build upon: John Hinsberg, Geoff Leonard, Talha Qureshi, Patrick Smith, and Peter Weiser; Anita Bach, Director of Cardiac Services at the Tucson Medical Center, and the staff of TMC, for allowing me and the EP program to grow together in a new home; and finally, Dr. Darren Peress, the medical director of the EP program, who has given me articles to read, the direction and guidance I have needed, slack when I have stumbled while trending new ground, and the respect to treat me as a peer. You have all influenced me in so many ways, and although I cannot possibly pay you all back, I hope one day I can ‘pay it forward.’ In addition to the support and training I received from the individuals named above, I have learned much from many physicians I have never had the pleasure of working with or meeting in person, through textbooks, articles, and educational presentations. One of the first ones was Electrophysiologic Testing by Richard N. Fogoros. I struggled through it at first, through no fault of Dr. Fogoros, but because of the nature of the subject and my own inexperience with it. It was a great book that was equally reflective of what a complex and yet amazingly simple a field EP can be. It took me several tries to get through it, then on a flight to a class, I had one of those ‘aha!’ moments discussed earlier about halfway through it, and finished the book in a day. I recommend this as the first “must read” for anyone interested in learning about EP. If you are anything like me, be patient and persistent — it will click eventually, even if it does not seem like it ever will. I have graduated to Clinical Cardiac Electrophysiology: Techniques and Interpretations, by Dr. Mark E. Josephson. As mentioned earlier, I keep this book by my nightstand, and we also keep a copy handy in the lab for frequent reference. I have also found that most of the major industry companies offer high-quality EP training programs complete with heart dissections, wet-labs, and access to computer-based learning systems. I highly recommend attending any of these offered in your area, and if they are not offered in your area, I recommend encouraging your local industry reps to either sponsor one or find one for you to attend. Just be willing to help and attend it if they are kind enough to take the time and money to put one together. Finally, there are several excellent online resources and periodicals at everyone’s disposal. EP Lab Digest, of course, has been an invaluable tool, as is the Heart Rhythm Society’s journal (Heart Rhythm), and their online tools (which is even more reason to join as an allied health member). I have also recently discovered www.eprewards.com, which offers a cornucopia of free educational resources. Steve Miller and his staff have complied strictly for the betterment of the EP community. These resources are all out there for each of us to use, we just have to take the time to find them. The EP Lab Digest you are reading now truly is one of the best first steps you can take to finding the tools you need to ensure a successful career in electrophysiology. Is there anything else you'd like to add? In the foreword of his book, Dr. Josephson wrote “although much has been accomplished, much still remains. We certainly must not let technology lead the way. We… must maintain our interest in understanding the mechanism of arrhythmias.”1 I think that is key. It is easy to become a tool of the machine instead of remembering that the technology is there to help us. We must try to maintain the human side of things, especially in a field so heavily dominated by abstract concepts and technological wonders. There is a patient under that drape, and we are there to diagnose, treat, and hopefully cure a condition they have. We have to remember that they are someone’s family member or loved one and treat them like we would want our loved one treated. We joke in our lab that magnets and robots will soon replace EP technologists, and even that a computer program could replace the EPs, but our humanity is what will keep us in the fold. We are still healthcare providers taking care of people in a time of crisis, disease, and need.