Why Are 12-Leads Not Required For School Physicals

[usafmedic45]

If you read the links and articles I posted you would see a new protocol and guideline for physicians to use to distinguish between these variants to reduce false-positives is already being implemented.

So we're supposed to take the word of a group with an agenda and MSNBC over one of the leading cardiology journals that says you're wrong? Now who is assuming that the other side of this argument isn't in possession of supratentorial function? In other words: "What do you think we are, brain dead?"

 

[18G]

Its a good option.That's all I have said and support. The only reason the conversation has turned into what it has is because of your usual arrogance and the fact that I am bored. But it's really starting to become redundant so my replies are going to stop coming... actually I said that a few posts ago.

I don't need absolute and numbers 100% of the time to support something or to see the potential good in it.

I can do something 5000 times over and know first hand that what I do works the way I say it works and gives an awesome result. Just because I don't scientifically validate it right then and there doesn't make it any less valuable and true now does it?

Routine screening with a 12-lead is a new concept. It's gonna take some study and validation before widespread acceptance and science can say one way or another if it's really beneficial. This is what I have been saying all along. I am the one who is open to the results. Your the one already shooting it down as worthless because you don't currently have a chart to tell you it works which I find idiotic.

Sometimes we need to employ our ideas to know if they are really good or not. My question posed was should 12-leads be mandated. Or should community programs be created and highly advocated until more research is conducted? I would be happy with either one as long as the public education is put out there and parents have the open option for the ECG for their child.

 

[18G]

So we're supposed to take the word of a group with an agenda and MSNBC over one of the leading cardiology journals that says you're wrong? Now who is assuming that the other side of this argument isn't in possession of supratentorial function? In other words: "What do you think we are, brain dead?"

Are you drunk or high tonight? I never insinuated what your suggesting. I referenced the articles to inform the other person that a protocol was developed to help reduce the false positives and to help GP physicians do a better job at looking at the ECG and understanding the the findings.

The articles, although not a journal, sheds light on the issue and shows that people other than myself (shocker) support 12-leads for students and have actually implemented programs with decent results. Why would volunteer physicians and cardiologists participate in these programs if they're was no value at all?

And what is this journal your referring to? What does it say? Is it a study? How big was it? Just one study? We all know how single studies shouldn't dictate anything, right?

 

[Akulahawk]

You bring up good points.

Implementing this type of program requires planning and I would expect wouldn't happen with ordinary visits and office schedules. Why couldn't student's be scheduled for ECG's in large sessions a few times a month? Where on certain day's all that happens is student ECG screenings? That doesn't seem like a huge hurdle to clear.

Certain places already do this so obviously it can be done.

It would be far better to develop screening tools to identify those athletes that may be at greater risk. Basically, you develop a checklist and hand it to the clinician doing the physical exam. Positive findings of those criteria would then trigger further examination. That's not too far off the mark from what's done already. When I did my portions of the preparticipation physicals, if I saw something that was abnormal, I would then flag that student specifically for further evaluation. By the end of the day, we might see 200 athletes and only maybe 10 or 20 needed to be specifically screened for some abnormality. Italy front-loads this by (apparently) having the athlete's primary MD do the screening. Doing cattle-call style sport-specific screening is very efficient and it does catch stuff quite often because the staff know what they're looking for.

Also, something to consider... "athlete heart" is a diagnosis of exclusion and on ECG can look a lot like a heart with hypertrophic cardiomyopathy. I don't know about you, but most of the athletes I worked on have resting rates between 45 and 60. They're going to have some hypertrophy and an increased stroke volume, thus to maintain an adequate CO, their hearts don't have to beat as fast.

Now here's something else to chew on: take a cardiomyopathic heart and place some athletic stress on it and suddenly what do you have? An enlarged heart... who would have guessed?

 

[18G]

It would be far better to develop screening tools to identify those athletes that may be at greater risk. Basically, you develop a checklist and hand it to the clinician doing the physical exam. Positive findings of those criteria would then trigger further examination. That's not too far off the mark from what's done already. When I did my portions of the preparticipation physicals, if I saw something that was abnormal, I would then flag that student specifically for further evaluation. By the end of the day, we might see 200 athletes and only maybe 10 or 20 needed to be specifically screened for some abnormality. Italy front-loads this by (apparently) having the athlete's primary MD do the screening. Doing cattle-call style sport-specific screening is very efficient and it does catch stuff quite often because the staff know what they're looking for.

How is a checklist going to determine if a child has an enlarged heart? A checklist isn't going to know about long-QT or other abnormal ECG findings. I agree a specific checklist is a good idea but doesn't take the place of an ECG.

What were some typical findings that caused you to flag someone?

 

[usafmedic45]

The only reason the conversation has turned into what it has is because of your usual arrogance and the fact that I am bored.

Why is it arrogance to say "Show me the evidence"? It's much more arrogant to say "I'm right and you have to prove me wrong". If you're so humble, why are you hesitant to play your cards. If you have the means to prove yourself correct and me wrong, do it. I want you to prove me wrong. I would love to have a simple and easy solution to this issue. The problem is what you're suggesting doesn't appear to work like you think it does.

Routine screening with a 12-lead is a new concept.

Not really....they've been trying it for years now hence why that Italian study says it doesn't work. Also, they regularly screen much higher risk groups than this one and still have a relatively low diagnostic yield.

I can do something 5000 times over and know first hand that what I do works the way I say it works and gives an awesome result.

Google "confirmation bias" and report back.

Just because I don't scientifically validate it right then and there doesn't make it any less valuable and true now does it?

Technically, yes it does. Welcome to science. Assume nothing, prove everything. You know, as opposed to standard EMS thinking "Eh....we've always done it this way".

I don't need absolute and numbers 100% of the time to support something or to see the potential good in it.

Maybe you don't but most professionals are going to ask for it. This is what keeps EMS from being viewed as a real medical specialty by other specialties.

It's gonna take some study and validation before widespread acceptance and science can say one way or another if it's really beneficial. This is what I have been saying all along.

Uh....no, you didn't say that until I pointed out that you don't have any evidence to back up your stance. As soon as something was said that was "You're right! Let's save all 45 kids who will die this year from SCA during high school sporting events through your plan to 12-lead everyone of them!", you backpedaled. Nothing more, nothing less.

Your the one already shooting it down as worthless because you don't currently have a chart to tell you it works which I find idiotic.

No, I'm thinking you are wrong because I've seen the studies that say it's equivocal at best or just flat out doesn't work at worst.

My question posed was should 12-leads be mandated.

Actually it was "Why aren't we doing this?" which I answered for you and apparently that wasn't what you expected so instead of untwisting your panties you decide I was being a ****.

Or should community programs be created and highly advocated until more research is conducted?

You know that's absolutely *** backwards right? And when previous studies say "This doesn't work" why is more research indicated?

parents have the open option for the ECG for their child.

That's pretty much how it is. It's the only way to shut the more overbearing ones up. Personally, I think if one helicopter parents they should be forcibly sterilized to prevent further procreation.

 

[Akulahawk]

How is a checklist going to determine if a child has an enlarged heart? A checklist isn't going to know about long-QT or other abnormal ECG findings. I agree a specific checklist is a good idea but doesn't take the place of an ECG.

What were some typical findings that caused you to flag someone?

The findings were often quite sport specific, so they're not applicable here. However, abnormal heart sounds, positive family history of heart disease... things like that would/could warrant further evaluation. Instead of doing 200 ECG's you might end up referring one or two athletes out. Then a specialist can see them and further determine the risks.

 

[18G]

Why is it arrogance to say "Show me the evidence"? It's much more arrogant to say "I'm right and you have to prove me wrong". If you're so humble, why are you hesitant to play your cards. If you have the means to prove yourself correct and me wrong, do it. I want you to prove me wrong. I would love to have a simple and easy solution to this issue. The problem is what you're suggesting doesn't appear to work like you think it does.

BECAUSE IT IS A SIMPLE DISCUSSION THAT YOU TURNED INTO A PISSING CONTEST! And as a result caused your high degree of arrogance to come out once again. One doesn't need evidence to give an opinion on what they think may be a good idea. Is that a new concept to you? I gave my opinion to spark discussion... big :censored::censored::censored::censored:..

Is that a requirement now, that before we give an opinion on anything we need to do a study first and have evidence before we proceed or open our mouths? Grow up.

 

[usafmedic45]

Are you drunk or high tonight?

Nope. I have to work in the morning.

I never insinuated what your suggesting.

Read this: http://en.wikipedia.org/wiki/Hyperbole

You're asking us not to think but to just assume that what this group has to say is correct. That's pretty much the same thing as asking us to shut off our brains.

I referenced the articles to inform the other person that a protocol was developed to help reduce the false positives and to help GP physicians do a better job at looking at the ECG and understanding the the findings.

And that's going to change the low specificity- even in the hands of a board certified cardiologist- of an EKG for the problems that induce SCA in young people how?

The articles, although not a journal, sheds light on the issue and shows that people other than myself (shocker) support 12-leads for students and have actually implemented programs with decent results

There are lots of people who support crap with little to no evidence behind it: www.aams.org That's what we have lobbies for. LOL

And what is this journal your referring to? What does it say? Is it a study? How big was it? Just one study? right?

This study....you know the one with actual data from Italy.

This discusses Italy and other countries that use 12 leads as part of athlete screening. The end conclusion is that it should not be used as routine screening, and only done when indicated by assessment. There is also an interesting rebuttal at the end.

http://circ.ahajournals.org/content/116/22/2610.full

We all know how single studies shouldn't dictate anything,

If the findings are significant enough you can base things off of it. I'm gathering that you've had at most one class in statistics since you don't seem to understand much beyond the catchphrases. Pilot studies are done all the time to determine whether further research is needed. A good number of them are the last research done because the original hypothesis doesn't turn out to be nearly correct.

How is a checklist going to determine if a child has an enlarged heart? A checklist isn't going to know about long-QT or other abnormal ECG findings. I agree a specific checklist is a good idea but doesn't take the place of an ECG.

You do realize how infrequent LQTS actually is and that it's not a constant thing in a lot of patients right? There was a study done in a series of athletes (n=964) where 1 case of LQTS was identified. Only one athlete was permanently disqualified based on EKG findings and three more were temporarily sidelined until treated for WPW based on EKG findings. This despite a full 10% of the cases having "abnormal" EKGs. That's a pretty low yield (0.1%-0.4%). Here's the citation: Am J Med. 2011 Jun;124(6):511-8

It doesn't hurt to do EKGs but they aren't terribly helpful it the take home point here, which is the other point (besides "In G-d we trust, all others bring data") that I have been trying to get across.

 

[usafmedic45]

BECAUSE IT IS A SIMPLE DISCUSSION THAT YOU TURNED INTO A PISSING CONTEST

It was a simple discussion and when you say something like "Why aren't we doing this?", isn't the expected response to answer the question. When someone says "I believe....", is not the standard follow-up: "Why do you believe that?" or "Oh really? Care to prove that?"

And as a result caused your high degree of arrogance to come out once again.

Just because I don't pat you on the head for an idea and blow sunshine and rainbows up your butt doesn't make me arrogant. Neither does the fact that I know this subject pretty well and you made the move of trying to call me on it.

One doesn't need evidence to give an opinion on what they think may be a good idea. Is that a new concept to you?

Nope....not at all. However, if you want to have a discussion about something, it's generally good to know about the subject matter before wading into it.

I gave my opinion to spark discussion

Which is what you did. It seems you're only upset because everyone who has posted has more or less disagreed with your stance. Perhaps the best advice is be careful what you ask or go looking for. Trying to have a discussion when you have a tenuous grasp on the subject and are surrounded by people who have a better grasp is a lot like walking into a bar full of SEALs and going "Which one of you peer *****s wants to **** me?". In other words, it just generally doesn't not end well for the guy "sparking the discussion".

Is that a requirement now, that before we give an opinion on anything we need to do a study first and have evidence before we proceed or open our mouths?

No, but is it not reasonable or fair that if one says something that others should be allowed to question it? I mean this is a forum and not your blog after all. Either it's a discussion or its a monologue. Which do you want? You can't have both.

 

[18G]

lol... no, the bottom line is they're is not enough data to say yes or no to 12-leads for student athletes. Yet, you keep mentioning the one SINGLE Italian study to back up your stance that they are a waste yet we don't know yet if they are or not. It's obvious your really reaching to maintain your position and to continue antagonizing me.

And the Israel study found 12-leads made no difference but they only used media reports for death tracking. How scientific is that? Studies don't tell all which is why right now the debate is open. They're is simply limited data. But there is reasonable cause to do these screenings which are being done by high schools and colleges. Who do you think is informing them? Do you think the cardiologist who does the high school screenings is wasting his time? You think your smarter and know more than he does? You think his own education and experience doesn't count?

The current incidence, risk, benefit, cost, cardiologist opinion, and my own understanding, make 12-leads for students a worthwhile cause in the present until further study can be performed to say otherwise. And that is my opinion. It's not scientific based. Agree or disagree with it.

 

[usafmedic45]

no, the bottom line is they're is not enough data to say yes or no to 12-leads for student athletes

I would call multiple studies showing that there is little to no benefit "enough data" for anyone but a zealot.

The current incidence, risk, benefit, cost, cardiologist opinion, and my own understanding, make 12-leads for students a worthwhile cause in the present until further study can be performed to say otherwise.

"Further study" isn't likely to show anything different.

And the Israel study found 12-leads made no difference but they only used media reports for death tracking.

How do you think the US deaths are tracked? There isn't a handy little box on the death certificates here that says "Died while participating in HS athletic event".

But there is reasonable cause to do these screenings which are being done by high schools and colleges.

It may be reasonable to do them, but it's a red herring because it's not having an appreciable effect. That's the point. Doing something simply because it's cheap, easy and gives the impression of action doesn't mean that it's solving the problem. Is that clear enough? I don't think 12-leads are a bad idea, it just seems like you believe them to have this major "magic bullet" quality on the mortality rate.

 

[usafmedic45]

et, you keep mentioning the one SINGLE Italian study to back up your stance that they are a waste

You keep mentioning some Italian study that says they are and have not provided a citation for it.

Actually I have cited one and mentioned the Italian one Aidey posted. Thanks for noticing.

yet we don't know yet if they are or not.

How much evidence do you need before that happens in your book? I'm honestly asking because it is important to this discussion.

 

[18G]

It may be reasonable to do them, but it's a red herring because it's not having an appreciable effect. That's the point. Doing something simply because it's cheap, easy and gives the impression of action doesn't mean that it's solving the problem. Is that clear enough? I don't think 12-leads are a bad idea, it just seems like you believe them to have this major "magic bullet" quality on the mortality rate.

Short retention you have. I've already stated the complete opposite which is I don't believe a 12-lead is the golden answer to the problem. But you seem to know all and have all the answers so go ahead and solve this problem that actual doctors can't.

 

[usafmedic45]

I've already stated the complete opposite which is I don't believe a 12-lead is the golden answer to the problem.

Then why are you being so persistent in proving they have an impact or at least rebuffing the evidence that doesn't say they are a big help? Either you believe they are a big help or you're simply trolling.

But you seem to know all and have all the answers

I never said I do. In fact, I know the limits of my knowledge quite well. That's why I don't get into debates I know I am going to lose.

so go ahead and solve this problem that actual doctors can't.

Eh....45 deaths a year isn't worth the trouble. More power to you. I'm too busy with trying to prevent far larger numbers of deaths with my research.

 

[usafmedic45]

BTW, have a nice night. I'll pick this back up in the morning.

 

[18G]

Then why are you being so persistent in proving they have an impact or at least rebuffing the evidence that doesn't say they are a big help? Either you believe they are a big help or you're simply trolling.

I believe they do have substantial potential and are needed for student screening. What I meant was they are not the only part of the solution and will not catch 100% of all cases.

Routine testing of the hearts of young American athletes using electrocardiograms to screen for sudden death is “reasonable in cost and effective at saving lives,” according to a new study by cardiologists at the Stanford University School of Medicine.

The findings challenge the conventional wisdom in the United States that conducting routine electrocardiograms, known as ECGs, is too expensive to be required of young American athletes prior to engaging in competitive exercise, despite saving lives. The study was published in the March 2 issue of the Annals of Internal Medicine

http://med.stanford.edu/ism/2010/march/ecg.html

Abstract
Hypertrophic cardiomyopathy is the most common cardiovascular cause of sudden death in adolescent athletes. The electrocardiogram is abnormal in more than 90% of these individuals. An EKG screening program was developed in order to ascertain the role of the electrocardiogram in identifying athletes at risk for sudden death. A training program was created to instruct school nurses on how to perform electrocardiograms. A questionnaire/consent from was sent to the parents of the athletes. This form asked basic questions concerning the child's past medical history and family history. The electrocardiograms were interpreted by staff pediatric cardiologists. A total of 1,424 students, ages 13 to 18, had 12-lead electrocardiograms performed. In 88.8% the electrocardiogram was normal and the health screening questionnaire revealed no abnormalities in family or personal medical history. In 6.5% of the students, the family history or screening blood pressure recording justified further evaluation. In 72 students abnormalities on the electrocardiogram were noted (5.1%). There were 87 abnormalities noted in the 72 students. Conduction disturbances and arrhythmias were the most common abnormalities noted. In 12 students evidence of ventricular hypertrophy was found. Echocardiograms and stress tests were normal in these individuals. No student was found to have hypertrophic myopathy and no student was restricted from participating in competitive athletic activities. Despite the apparent negative results of this program there were benefits of the screening project. The program resulted in a closer working relationship between school health officials and a major health care facility. The program also served as a useful teaching tool for the school nurses. The screening electrocardiogram also provided a measure of reassurance to families of youngsters participating in competitive athletics. The authors believe an EKG screening program for school athletes is a useful endeavor.

http://onlinelibrary.wiley.com/doi/10.1002/clc.4960120108/abstract

 

[18G]

It is noteworthy that a 25-year interval was required to generate these Italian results. Until other studies, either observational or randomized, on athletic populations of comparable size and follow-up are conducted, the existing data provide good evidence that ECG screening decreases the risk of SCD in athletes. Accordingly, pre-participation ECG screening is currently recommended by the International Olympic Committee (“Lausanne Recommendations”) (32) as well as by most European Cardiologic Societies and Sports Medical Federations (Table 2). However, major obstacles for a definitive screening launch still exist and rely on the lack of national legislation. Thanks to the continuous and cooperative efforts of Medical Societies and Sports Organizations, the hope is that in the near future public health care policymakers will actually consider implementation of such a screening program aimed to reduce the number of preventable athletic-field SCDs.

http://www.sciencedirect.com/science/article/pii/S0735109708031811#sec2


Gee... isn't that what this dumb Paramedic has been saying as well?

 

[Smash]

No student was found to have hypertrophic myopathy and no student was restricted from participating in competitive athletic activities. Despite the apparent negative results of this program there were benefits of the screening project. The program resulted in a closer working relationship between school health officials and a major health care facility. The program also served as a useful teaching tool for the school nurses. The screening electrocardiogram also provided a measure of reassurance to families of youngsters participating in competitive athletics.

I'm sorry, but if you are going to try to support routine screening tests, then the outcomes of "all getting along better" and "making overprotective halfwits feel better about their little darlings playing sport" are probably not going to cut it.

The Italian study is also not necessarily applicable (as the authors themselves recognise) to other places.

So what happens when someone who has had a "screening" ECG then dies of sudden cardiac arrest? Do we move on to stress tests for all school children? Sestamibi scans? Angiograms? Any one of these may save one persons life, so surely they are worth it too?

 

[systemet]

http://www.sciencedirect.com/science/article/pii/S0735109708031811#sec2


Gee... isn't that what this dumb Paramedic has been saying as well?

The difference is that you're now trying to support this statements with peer-reviewed research.

I think usafmedic sometimes comes across as a little abrasive. I'm not sure if he's aware of this, or if he cares if he is. But what he was asking isn't unreasonable, even if his frustration was clear from some of his posts. Perhaps he could have been gentler.

Personally, I've got some reading to do before I have an opinion on this area. So far, I'm more convinced by the information that usafmedic has put forward, because his arguments have been supported by an evaluation of peer-reviewed research, which he and other people have linked to. But I'm keeping an open mind, and interested in seeing other data.

I think key points that have been made here include:

* Any diagnostic test carries a certain false-negative and false-positive rate. When considering the benefit of a given test, this has to be balanced against the potential cost / risk / negatives of both false-positives and false-negatives.

* The ECG is less sensitive and specific than the echocardiogram for identifying cardiac hypertrophy. (Although, I think the sensitivity improves dramatically if we have voltage criteria + signs of LV strain).

* Any time you have a rare condition (i.e. low prevalence), any test with a low specificity will throw a lot of false-positives. This can result in unnecessary expense, alarm for the patient, and exposure to potentially dangerous medical treatments for healthy patients that would never had been exposed to this risk had they not been tested.

* Peer-reviewed research trumps anecdote. What a particular cardiologist, tree surgeon or supermarket cashier "thinks", is not that interesting. Obviously we should listen first to the cardiologist, but this remains "expert opinion" at best. What we should do, is demand research, and demand real data.

I hope this can remain a productive discussion.