In EP Lab Digest’s “Day in the Life” feature, we follow an EP lab staff member through a typical day at work, with brief descriptions of tasks and activities during the day. Morning Rush It's 5:30 am, and the humid Florida air is a shock to my semi-awake condition as I head off to work this morning. After a 30-minute drive, I’m pulling into the parking garage at Orlando Regional Medical Center (ORMC) with the day’s agenda already on my mind. Having taken a quick peek at the schedule of procedures just before leaving the day yesterday, I already know it’s going to be a busy day as usual. The room to which I am assigned would likely go at a non-stop pace until quitting time…hopefully around 5:00 pm. I grab a quick cup of coffee from Starbucks, which is thankfully located inside our hospital. Then I’m off to the lab to pull supplies for our day’s first case, an SVT ablation with Dr. Aurelio Duran, one of our busiest electrophysiologists. I once told him that he was an “EP machine,” thinking that would get a laugh out of him. But if he laughed, I didn’t hear it — he was in a hurry to get to his next case. Working with Dr. Duran is always fun and challenging. I say “Good morning” to the crew with which I’ll be working. Nicole, our circulating nurse, is prepping IV lines and pulling medications we’ll need for the case. Nicole always seems to have a smile on her face and has a great laugh. She is also always on top of what is going on in the lab. Melissa is also in the lab this morning. Hired out of CVT school a little over a year ago, Melissa has caught on quickly. Like Nicole, it is a joy to work with her. Finally, there’s Nick, a radiology technician who transferred to ORMC about the same time Melissa was hired. He is easily the funniest person in the department. Nick can get me laughing so hard, my sides will hurt. It’s a good crew to spend the day with, and it’s going to be a hectic day indeed. My hopes of getting a bite to eat before our patient arrives are quickly dashed. My beeper goes off, and even before I check the message, Melissa has poked her head into the control room to confirm what I had already suspected: the patient is on the way! I make a few entries into our monitoring system, check the morning lab work and do a once-over of the supplies we pulled for the case. Everything seems to be in order. A moment later, I hear the automatic door opener click and our first customer of the day is rolled into the room. Most of our patients have a good understanding of what they are being treated for before the procedure starts. Either through online literature, the physicians or the nursing staff on the floor to which they are admitted, they are reasonably prepared. Still, when the patients arrive and get their first look at what the inside of an EP lab looks like, there is always a moment of “holy cow!” expression upon their face. With the A & B plane of the fluoroscopy equipment, the wall of monitors by the bedside, and overhead surgical lamps and mapping equipment, it is completely understandable how overwhelming it must be to suddenly become the center of all this attention in this unfamiliar environment. Some patients ask questions about their procedures, while others just ask “How soon can I get some sedation?” Regardless, everyone working in the room is usually doing something to make the patients feel more comfortable. We are barely halfway through setting up the patient when I hear the door open. I look up and see Dr. Duran come into the lab. He greets everyone with “Hello” or “Good morning.” But when he sees me ‘throwing’ supplies onto the surgical table, he says, “Well, well, well…NASA didn’t need you to repair the space shuttle this morning?” We all have a good laugh. It’s a couple minutes past 7:00 am, and without hesitation we are quickly underway. Sheaths are inserted followed by catheters, with Melissa at the Bloom stimulator getting thresholds. Sinus node recovery times, our first part of the study, all come back normal. We get to the AV node effective refractory period study and notice a “jump” in the A-H. No tachycardia is induced, so at Dr. Duran’s request we start an isoproterenol drip. We continue pacing, but we are not seeing any tachycardia. The isoproterenol drip is increased, and a few minutes later, that does the trick. We induce a textbook AV node reentry tachycardia (AVNRT). I take my seat at the mapping system and make a few landmark lesions at the bundle of His and CS ostium for Dr. Duran. Of all the procedures we do in electrophysiology, cardiac mapping has been by far the most enjoyable area for me. From an anatomical standpoint, it has cleared up a lot of ‘gray’ areas I previously had. But from an electrophysiological perspective, it is the single most beneficial tool in the lab that has helped me understand the complexities of tachycardia ablation. If my main focus is to assist the physicians in performing an ablation (or any other procedures for that matter) in a safe and timely manner, it is with cardiac mapping that I feel one can really make a difference. After a few well-placed radiofrequency lesions, we are again pacing to try to re-induce the tachycardia. There are no ‘echo’ beats or ‘jumps’, so we conclude that our patient has had a successful ablation for her AVNRT. It’s now 9:15 am, and not having had anything to eat, my stomach is really starting to growl. With the patient off the table, I make a beeline for the cafeteria. I grab a bacon and egg sandwich. I also spot Natalie, another EP tech, who is trying to get a quick breakfast break as well. I’m doing my best not to inhale my sandwich when my beeper goes off. I read the message on my screen, which says “Patient having respiratory problems in Room 2.” When a page comes to me under these circumstances, I drop what I am doing and go straight to the room where assistance is needed. Having spent my first 14 years here at Orlando Regional Medical Center as a respiratory therapist, the ability to assist with airways and ventilation has come in handy on a regular basis. In addition to myself, we also have Mike and Michelle who are also respiratory therapists in the EP lab. We are always first responders when needed. I nudge open the door to Room 2 and ask Jessica at the monitor, “What’s going on?” Jessica says, “Airway.” I quickly put on a hat and mask, grab some lead and make my way to the head of the table where I find Jean inserting an oral airway. The patient, a robust gentleman getting an AICD implanted, is having obstructive issues. We reposition the patient’s airway and I feel a rhythmic warm breath blowing against my palm. Problem solved. I remain at the patient’s head until we start breaking down. When I finally make it back to my assigned room I find Nick and Melissa pulling for our next case: an EP study with possible pacemaker implant. Even though it’s been a busy morning, it only takes a few moments to recharge and prepare for the next case. I head over to our EP office to see how the rest of the cases are going. Courtney, our office coordinator, tells me that she is sending for our next patient. A glance at the patient board and I see that we are knocking out the cases right on schedule. As I head toward my room, I see Dr. Luis Alvarez, the physician for our next case. I report to him that his patient will be in Room 1 and should be ready in 20 to 30 minutes. With the patient set up and ready to go, we give Dr. Alvarez a call. A moment later, he’s walking through the door and hanging up his lab coat. “How’s everyone doing this morning?”, he asks with his usual cheerfulness. He wastes little time heading to the wash room to start scrubbing. When our EP study is finished, Dr. Alvarez reviews the results and doesn’t find a pacemaker necessary. To that he says, “We’re done here. I’m going to go talk with the family. Thanks for your help everybody!” In a flash, he’s out the door and gone. We get the patient off to recovery and do a little housekeeping. Our pagers all start beeping with the same message: “Go to lunch.” I look up at the clock and it is 5 minutes until noon. Afternoon Cases The fastest 30 minutes of the day, our lunch break, ends all too soon. We disperse to check on the other rooms with cases. I head over to Room 4 and relieve Ralph at the monitor for Dr. Roland Filart’s Bi-V implant. I look through the leaded glass window from the control room and see Mike, scrubbed in, giving me a thumbs-up. When Ralph returns, I head over to the EP office where Courtney is busy rearranging the afternoon’s case assignments. We were originally scheduled to get to Dr. Pavel Guguchev’s implant case, but with Dr. Filart’s patient still on the table in Room 4, we are going to be getting Dr. David Bello’s patient with WPW instead. We prepare our room, and although it would be nice to have a few more minutes of downtime, our patient arrives. A short time later, we have sheaths placed and Dr. Bello is trying to get the CS catheter positioned. However, despite trying every angle imaginable, Dr. Bello is having no luck. All indications show this pathway to be on the left side. Not having CS catheter access, this case is going to be a little more challenging. The decision is made to try a retrograde approach for this patient. We get the ablation catheter positioned in the left atrium and begin searching for a pathway potential. Finding some interesting electrograms, Dr. Bello asks Nicole to get ready to start ablating. Almost as soon as Dr. Bello applies his first ablation lesion, Melissa at the monitor exclaims, “Hey, do you see that?” Our delta wave disappears and is replaced with a beautiful sinus beat. Having expected this to be a tougher case, Dr. Bello turns around with a smile on his face and says, “Who’s your daddy now?” We all burst out laughing together. With the patient case finished, the room cleaned up and shut down, we are still chuckling as we shut off the lights in Room 1 and call it a day. I say good-bye to my co-workers and a few others I bump into on my way to the locker room to get my car keys. I clock out and take a look at tomorrow’s schedule. It is going be another busy day again! I head out to my car, and the stifling Florida heat hits me like a wool blanket. It’s 5:00 o’clock and I’m going home! Richard Fish, RRT also wrote about his first-year experiences in the lab in our May 2008 issue. To see the article, please visit: http://eplabdigest.com/articles/My-First-Year-Electrophysiology-What-Have-I-Got-Myself-Into. For more information on Orlando Regional Medical Center, please visit: www.orlandoregionalmedicalcenter.org or see their Spotlight Interview at http://eplabdigest.com/article/8010.