In Ontario, Canada the billing price for an ECG is $14.00. The cost of accessing health care services is different in every country as is the ability of each system to deliver services. However the real cost of ECG is minuscule relative to the information it provides and the ease with which that information can be acquired. Virtually everyone in the health care system from Paramedics to RN's to GP's to Cardiologists are trained (and often equipped) to acquire an ECG. Reading and interpreting ECG's requires special skills and training however many health care professionals are very good at spotting suspicious ECG's that should be referred to a specialist. The current generation of ECG monitors are programmed with excellent algorithms that are more accurate than many people at spotting trouble.
When people set out to do a repetitive task they design efficiencies into the system and continually refine their methods while monitoring for quality assurance and quality improvement. I submit that within two years a digital system that acquires an ECG for every Grade 9 student in Ontario and attaches it to their permanent health record could be in operation and the cost per child would be less than $7.00.
This long preamble is my way of saying we should acquire an ECG for every teenager in Canada or your Country here. My personal interest in ECG Screening is that I advocate for individuals and families living with an Inherited Heart Rhythm Disorder; those that have a diagnosis and more importantly those that are unaware that they are living with a potentially lethal disease. A complete patient and family history along with an ECG provides an excellent starting point for identifying at-risk individuals and families. Papers published on various screening programs that have been piloted around the world suggest that somewhere between 1 in 120/150 young people screened will be recommended for follow-up with a cardiologist. I have seen no published articles that follow these individuals however given that most heart rhythm disorders are genetic the yield for individuals with a definitive diagnosis as result of screening will be multiplied as affected family members are identified. In addition to screening for arrhythmia an even greater benefit to the patient and the health care system will come from having a baseline ECG attached to every patients permanent file, which Doctors can and will refer to throughout that patients life.
All children should be screened. So much of the conversation around screening speaks to athletes. Genetic disease does not recognize athletic ability. Only one third of young people killed by an Inherited Heart Rhythm Disorder were engaged in physical activity preceding sudden death. Intense physical activity is one known trigger for cardiac arrest in patients with an inherited heart rhythm disorder, as is auditory startle, from an alarm clock perhaps, as is emotional distress, such as a pending Math exam. When a young athlete dies in a filled to capacity sporting venue there is going to be a media storm. For every athlete that dies during a game there are two or more children that die outside of the media spotlight, many, perhaps most, are non-athletes. The prevalence of genetic heart disease is spread equally across children of all different abilities and capabilities. Every child deserves equal attention.
All medical screening program generates a small percentage of false positives. An ECG that requires follow-up is not a positive test it is an ECG that requires follow-up. There is no diagnosis until the Cardiologist has completed their work and made a determination. An ECG that does not require follow-up is not a negative test, it is simply an ECG that is not suggestive of heart disease or defect.
In the world of "Do No Harm" the harm is done by not screening.
Tuesday 8 January 2013
Thursday 3 January 2013
STEMI/PPCI Awareness: Part 2
Time is Muscle
Since the turn of the century I have had the privelege of discussing heart attack and stroke recognition and management with hundreds of older adults. What I've learned from these discussions is that when it comes to heart attack seniors are burdened with some very realistic fears and a very scary lack of knowledge.
I've also found that filling the knowledge void goes a long way toward reducing the fear. Adult learners want to know the hows and whys and once they do they will buy into the message and be better prepared to act in a way that insures the best possible outcome.
In the vast and evolving universe of Myocardial Infarction (MI) there is one constant that all Cardiologists agree on - "Time is Muscle".
Blood carries oxygen, all human tissue needs oxygen, in the absence of oxygen all human tissue dies. When a person is having a Heart Attack part of their heart muscle is not getting any blood, is therefore not getting any oxygen and is therefore dying. If blood flow is not restored to the affected part of the heart within 90 minutes heart muscle will be dead. The longer it takes to restore blood flow the more heart muscle that dies. The more heart muscle that dies the greater the likelihood of permanent disability or death.
In every community where I teach there is a hospital with a team of interventional cardiologists, working in a cardiac catheterization lab, that specializes in restoring blood flow to the affected part of the heart within 90 minutes thereby minimizing damage and insuring the best possible outcomes for Heart Attack patients. Virtually none of my students know this.
Virtually none of these adult learners know that every ambulance in their community is equipped with an ECG monitor and every paramedic is trained to identify the electronic signature (ST Elevation) of a heart attack that requires direct transport to the cath lab. None of them know that using a personal vehicle to transport a patient to the closest (and often wrong) hospital could result in the 90 minute window being closed and the worst possible outcome.
Governments and health care systems take billions of tax dollars from the people most at risk of morbidity and mortality resulting from Myocardial Infarction and use that money to build state of the art treatment programs; training and equipping paramedics and interventional cardiologists, so that blood flow can be restored to the affected part of the heart effectively solving the age old "Time is Muscle" dilemma. And then the entire system fails to invest one nickel in educating those same taxpayers on how and why to access the progams that they have paid for.
Since the turn of the century I have had the privelege of discussing heart attack and stroke recognition and management with hundreds of older adults. What I've learned from these discussions is that when it comes to heart attack seniors are burdened with some very realistic fears and a very scary lack of knowledge.
I've also found that filling the knowledge void goes a long way toward reducing the fear. Adult learners want to know the hows and whys and once they do they will buy into the message and be better prepared to act in a way that insures the best possible outcome.
In the vast and evolving universe of Myocardial Infarction (MI) there is one constant that all Cardiologists agree on - "Time is Muscle".
Blood carries oxygen, all human tissue needs oxygen, in the absence of oxygen all human tissue dies. When a person is having a Heart Attack part of their heart muscle is not getting any blood, is therefore not getting any oxygen and is therefore dying. If blood flow is not restored to the affected part of the heart within 90 minutes heart muscle will be dead. The longer it takes to restore blood flow the more heart muscle that dies. The more heart muscle that dies the greater the likelihood of permanent disability or death.
In every community where I teach there is a hospital with a team of interventional cardiologists, working in a cardiac catheterization lab, that specializes in restoring blood flow to the affected part of the heart within 90 minutes thereby minimizing damage and insuring the best possible outcomes for Heart Attack patients. Virtually none of my students know this.
Virtually none of these adult learners know that every ambulance in their community is equipped with an ECG monitor and every paramedic is trained to identify the electronic signature (ST Elevation) of a heart attack that requires direct transport to the cath lab. None of them know that using a personal vehicle to transport a patient to the closest (and often wrong) hospital could result in the 90 minute window being closed and the worst possible outcome.
Governments and health care systems take billions of tax dollars from the people most at risk of morbidity and mortality resulting from Myocardial Infarction and use that money to build state of the art treatment programs; training and equipping paramedics and interventional cardiologists, so that blood flow can be restored to the affected part of the heart effectively solving the age old "Time is Muscle" dilemma. And then the entire system fails to invest one nickel in educating those same taxpayers on how and why to access the progams that they have paid for.
Tuesday 1 January 2013
Teaching CPR to Adults versus Teens
I write this blog at my own peril. Whenever I promote this concept the push back is always intense, but I remain steadfast. That said I want to be clear right off the top I am not talking about a 90/10 deal but more of a 55/45 arrangement. I simply feel it would be beneficial to re-direct some of the universal enthusiasm for teaching CPR to teenagers toward teaching CPR to Adults. I don't believe teens should not be taught CPR, I just know that more adults should.
Adults hang with adults, teenagers hang with teenagers. I get it, it's not an absolute, but it is a fairly accurate generalization. There are not too many teenagers in a typical workplace. There are not too many teenagers at the gym at 11:00 pm when the senior men's league is playing basketball. There are not too many teenagers living in adult only condos and communities.
In the game of resuscitation the prize is increased survival to discharge for out-of-hospital cardiac arrest (OOHCA) and we need to build a team that can win now and win in the future. To win now we need adults to find a few hours in their busy schedule to learn CPR.
Adults experience the vast majority of cardiac arrest and they must take the majority of the responsibility for responding to cardiac arrest. Although teenagers are capable of performing appropriately during a cardiac emergency we cannot download the responsibility for saving our lives onto them. Think about all of the places where you spend significant blocks of time. Think of all the places where you are engaged in activity that may place you at increased risk for cardiac arrest. How often are there teenagers about?
In Ontario there is a well supported push to teach CPR to every grade nine student. My thought is that yes we should teach CPR to every grade nine student - right after we teach CPR to every elementary and high school teacher, principal and support staff that work in our schools. If a student or a teacher collapses to the ground, VSA, in cardiac arrest, adults should not be watching helplessly and praying that a thirteen year old student steps up and saves the day. In Ontario cardiac arrest kills more than 9,000 people each year. I'm not sure that deferring improving that statistic until the current cohort of grade nine students comes of age is the best strategy. We need to be looking at much shorter term fixes.
Expecting young teens to perform CPR in a real life situation places an unfair emotional burden on them. I've listened to dozens of real life CPR stories: the storyteller speaks as if it happened yesterday even if it happened 15 years ago, their voice waivers and their eyes may fill with tears. Performing real life CPR is a traumatic experience that most people never forget. It seems a little weak and irresponsible to look to our children to fix the problem of historically dismal survival rates for out-of-hospital cardiac arrest.
Physically people weighing less than 120 lbs find it very challenging to perform effective chest compressions for more than a few seconds. I've evaluated CPR compressions performed by over 300 grade nine students on metered Laerdal manikins and the smaller kids are too fatigued to achieve an effective compression depth after only a few reps. Poor CPR is the equivalent of no CPR. All of the research on improving survival to discharge rates for cardiac arrest points to other solutions, none of the research suggests that teenagers are the answer.
The evidence is unequivocal, most cardiac arrest survivors benefit from an effective bystander intervention which includes quality CPR and/or the application of an AED. The communities with the highest survival rates for OOHCA are the communities with the highest rate of bystander intervention. Over the next ten years the communities that will enjoy the greatest improvement in survival rates for cardiac arrest are the communities that teach CPR to the greatest number of ADULTS.
Teaching CPR to thirteen year olds may pay dividends in 2025, in the meantime if you are over age twenty five recognize your civic responsibility and learn CPR this year.
Adults hang with adults, teenagers hang with teenagers. I get it, it's not an absolute, but it is a fairly accurate generalization. There are not too many teenagers in a typical workplace. There are not too many teenagers at the gym at 11:00 pm when the senior men's league is playing basketball. There are not too many teenagers living in adult only condos and communities.
In the game of resuscitation the prize is increased survival to discharge for out-of-hospital cardiac arrest (OOHCA) and we need to build a team that can win now and win in the future. To win now we need adults to find a few hours in their busy schedule to learn CPR.
Adults experience the vast majority of cardiac arrest and they must take the majority of the responsibility for responding to cardiac arrest. Although teenagers are capable of performing appropriately during a cardiac emergency we cannot download the responsibility for saving our lives onto them. Think about all of the places where you spend significant blocks of time. Think of all the places where you are engaged in activity that may place you at increased risk for cardiac arrest. How often are there teenagers about?
In Ontario there is a well supported push to teach CPR to every grade nine student. My thought is that yes we should teach CPR to every grade nine student - right after we teach CPR to every elementary and high school teacher, principal and support staff that work in our schools. If a student or a teacher collapses to the ground, VSA, in cardiac arrest, adults should not be watching helplessly and praying that a thirteen year old student steps up and saves the day. In Ontario cardiac arrest kills more than 9,000 people each year. I'm not sure that deferring improving that statistic until the current cohort of grade nine students comes of age is the best strategy. We need to be looking at much shorter term fixes.
Expecting young teens to perform CPR in a real life situation places an unfair emotional burden on them. I've listened to dozens of real life CPR stories: the storyteller speaks as if it happened yesterday even if it happened 15 years ago, their voice waivers and their eyes may fill with tears. Performing real life CPR is a traumatic experience that most people never forget. It seems a little weak and irresponsible to look to our children to fix the problem of historically dismal survival rates for out-of-hospital cardiac arrest.
Physically people weighing less than 120 lbs find it very challenging to perform effective chest compressions for more than a few seconds. I've evaluated CPR compressions performed by over 300 grade nine students on metered Laerdal manikins and the smaller kids are too fatigued to achieve an effective compression depth after only a few reps. Poor CPR is the equivalent of no CPR. All of the research on improving survival to discharge rates for cardiac arrest points to other solutions, none of the research suggests that teenagers are the answer.
The evidence is unequivocal, most cardiac arrest survivors benefit from an effective bystander intervention which includes quality CPR and/or the application of an AED. The communities with the highest survival rates for OOHCA are the communities with the highest rate of bystander intervention. Over the next ten years the communities that will enjoy the greatest improvement in survival rates for cardiac arrest are the communities that teach CPR to the greatest number of ADULTS.
Teaching CPR to thirteen year olds may pay dividends in 2025, in the meantime if you are over age twenty five recognize your civic responsibility and learn CPR this year.
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