Why Are 12-Leads Not Required For School Physicals

[Rogue Medic]

IMHO, money that would be spent on doing 12-lead EKGs would probably be better spent on obtaining AED devices and placing them in the hands of Coaches and Athletic Trainers who will carry them to each practice and game event.

That is probably a much better use for any such money that we might spend.

Remember that the AEDs are much more likely to be used on the coaches, umpires, and people in the stands than on any child athlete. The AEDs will occasionally be used, but they will be overwhelmingly used on adults, not on children.

The whole purpose of this is to provide theater for anxious people who do not understand math, medicine, or logic.

Why don't they just stick to forwarding emails about getting millions of dollars from Bill Gates? :unsure:

.

 

[18G]

If 60-80% of at risk kids (no matter how many) are being missed by physical and history alone, how is that acceptable and effective? If that is an accurate statistic how can anyone be satisfied with that? That is instilling a false sense of security in both kids and parents. Prevention through screening is better than treatment of a cardiac arrest on the playing field.

And by the same argument, if the risk of cardiac arrest in children is so small and is such a rare occurrence, then why even invest thousands of dollars to place AED's over a school campus? Would we say because every child's life is worth that investment? Honestly, when I see AED's hanging on the walls of my kids school, it does make me feel better.

Is there a mandated reporting of cardiac arrest in student athletes? How do we know what the real percentage is?

I still think it makes perfect sense.

 

[Tigger]

If 60-80% of at risk kids (no matter how many) are being missed by physical and history alone, how is that acceptable and effective? If that is an accurate statistic how can anyone be satisfied with that? That is instilling a false sense of security in both kids and parents. Prevention through screening is better than treatment of a cardiac arrest on the playing field.

And by the same argument, if the risk of cardiac arrest in children is so small and is such a rare occurrence, then why even invest thousands of dollars to place AED's over a school campus? Would we say because every child's life is worth that investment? Honestly, when I see AED's hanging on the walls of my kids school, it does make me feel better.

Is there a mandated reporting of cardiac arrest in student athletes? How do we know what the real percentage is?

I still think it makes perfect sense.

My take on that statistic is that of the 100 or so children that die of SCA while engaged in athletics every year, 60-80 of them had per-existing cardiac conditions that could have conceivably been found with further screening. From the realist perspective, 60-80 children out of the millions that play sports is not a high number. There is inherent risk in athletics and no matter how extensive screening efforts are, we will not eliminate these deaths.

There are plenty of athletes with heart conditions that leave them statistically more susceptible to cardiac problems while competing that still play sports, the above statistic does not likely account for this. If the child's family and doctor deems the cardiac history and symptoms as an acceptable risk and the child dies, is anyone to blame? I can't point a finger there.

 

[Tigger]

IMHO, money that would be spent on doing 12-lead EKGs would probably be better spent on obtaining AED devices and placing them in the hands of Coaches and Athletic Trainers who will carry them to each practice and game event.

Every event we cover has an AED present, and that rule is strictly enforced. For contact sports we try to have at least one EMT-B trained staff member at practices and all of our ATCs have also taken the EMT class. We figure we could deliver a shock within 90 seconds of a player going down if it came to it.

Managing the six AEDs that we as a department own can be a pain and is expensive, but it is done so willingly and without thought for expense (i.e. expired pads and batteries are always replaced promptly). We are only a 2000 person school but we take SCA seriously and have made the investment to be prepared for it.

 

[Aprz]

TomB just shared this on Facebook.

http://www.drjohnm.org/2012/05/the-ny-times-gets-it-wrong-on-ecg-screening-of-young-athletes/

 

[systemet]

TomB just shared this on Facebook.

http://www.drjohnm.org/2012/05/the-ny-times-gets-it-wrong-on-ecg-screening-of-young-athletes/

Here's another (less well written) blog post:

http://drwes.blogspot.se/2012/05/da...pot/TuRAx+(Dr.+Wes)&utm_content=Google+Reader

 

[Aidey]

TomB just shared this on Facebook.

http://www.drjohnm.org/2012/05/the-ny-times-gets-it-wrong-on-ecg-screening-of-young-athletes/

Very good points made here, including in the comments. One of the commentors describes that in one of the cases mentioned in the NYT article no one recognized the cardiac arrest right away, the AED was in another place and it hadn't been maintained properly and didn't work once they did track it down.

The article also mentions that a MD received a $5 million grant to screen 10,000 kids (so $500 per kid). How many AEDs would $5 million buy?

In my area the FDs to annual pre-fire inspections of schools, large businesses etc. For the people concerned about maintaining the AEDs why not have the FD check them out during their pre fire inspections?

 

[Aidey]

Edit: I checked, $5 mil would buy at least 5,000 AEDs. The average price for an AED is $1,000. I'm sure most of the companies offer a volume discount and so $5 mil would actually buy more. That is enough AEDs to put an AED in every public school in the districts covering NYC, LA, Chicago, Miami, Las Vegas, Houston, the entire state of Hawaii, and Philadelphia.

Those schools have about 3.35 million students combined. So, we can spend $5 mil to screen 10,000 students, or $5 mill to buy enough AEDs to cover 3.35 million students.

 

[18G]

From my home state

Pennsylvania just signed into law legislation called, "Sudden Cardiac Arrest Prevention Act" geared towards educating parents and students / athletes about SCA. The law also mandates coaches and athletic trainers to receive training in recognizing S/S that could progress to SCA and mandates pulling students from games who exhibit certain S/S. Once pulled, medical clearance needs to be received before the student can resume playing. There will be penalties for school staff who do not pull students from playing.

Pennsylvania is the first state to enact such legislation and recognize SCA in athletes as a vital concern and need for specific attention.

Hopefully momentum is built and other states follow Pennsylvania's example.

http://www.jems.com/video/news-video/new-bill-protects-pennsylvania-student-a

http://www.prweb.com/releases/2012/5/prweb9562083.htm

http://www.prnewswire.com/news-rele...-cardiac-arrest-prevention-act-155771735.html

"Victoria Vetter, M.D., M.P.H., is a pediatric cardiologist and medical director of Youth Heart Watch at The Children's Hospital of Philadelphia. Youth Heart Watch is dedicated to ensuring access to automated external defibrillators (AEDs) and screening for underlying heart conditions. Dr. Vetter is a nationally recognized leader in pediatric electrophysiology.

Dr. Vetter has a study underway screening healthy children for underlying conditions that could cause SCA. She recently published a pilot study in healthy children and adolescents that showed that it is feasible to screen for undiagnosed heart conditions that increase the risk of SCA. The study also found that adding a 10-minute electrocardiogram to a history and physical examination identified unsuspected cases of potentially serious heart conditions. She also has another study underway to look at novel ways of teaching CPR and AED use to high school students.

 

[Veneficus]

Pennsylvania just signed into law legislation called, "Sudden Cardiac Arrest Prevention Act" geared towards educating parents and students / athletes about SCA. The law also mandates coaches and athletic trainers to receive training in recognizing S/S that could progress to SCA and mandates pulling students from games who exhibit certain S/S. Once pulled, medical clearance needs to be received before the student can resume playing. There will be penalties for school staff who do not pull students from playing.

Pennsylvania is the first state to enact such legislation and recognize SCA in athletes as a vital concern and need for specific attention.

Hopefully momentum is built and other states follow Pennsylvania's example.

http://www.jems.com/video/news-video/new-bill-protects-pennsylvania-student-a

http://www.prweb.com/releases/2012/5/prweb9562083.htm

http://www.prnewswire.com/news-rele...-cardiac-arrest-prevention-act-155771735.html

"Victoria Vetter, M.D., M.P.H., is a pediatric cardiologist and medical director of Youth Heart Watch at The Children's Hospital of Philadelphia. Youth Heart Watch is dedicated to ensuring access to automated external defibrillators (AEDs) and screening for underlying heart conditions. Dr. Vetter is a nationally recognized leader in pediatric electrophysiology.

Dr. Vetter has a study underway screening healthy children for underlying conditions that could cause SCA. She recently published a pilot study in healthy children and adolescents that showed that it is feasible to screen for undiagnosed heart conditions that increase the risk of SCA. The study also found that adding a 10-minute electrocardiogram to a history and physical examination identified unsuspected cases of potentially serious heart conditions. She also has another study underway to look at novel ways of teaching CPR and AED use to high school students.

I know this sounds great and supported on the surface, but forgive me for pissing in your cornflakes.

A reknowned electrophysiologist can screen for these underlying conditions...

Which are not always identifyable as pathologic.

So is the plan to pull all kids on a "what if?"

Are they going to be screened by said specifically skilled electrophysiologist?

Law based on emotion is a really bad idea.

 

[18G]

As you know already, I really don't think this is a law "out of emotion" and think it makes perfect sense. The law is aimed to mandate annual training and add the necessary emphasis to school staff on recognizing potential S/S that can progress to SCA. Hopefully, it will also make school staff want to grab that AED when going outside for gym class and practices and have the AED on the sidelines at ALL games.

I'm certainly not a doctor but am sure a risk stratification can be utilized to determine which students get referred for additional testing and which don't. Parent's deserve the chance to make an informed decision and not proceed blindly. This legislation aims to make parents and students informed about the risks involved. My guess is 99% of parents and students have no clue of the risk involved and that dropping dead from SCA is even a possibility.

Physical exam alone has been found to not be real effective in identifying at-risk children. As Dr. Vetter (and many others) have found through research and EVIDENCE, an ECG is very important in the screening process.

http://www.simonsfund.org

 

[18G]

So is the plan to pull all kids on a "what if?"

This is for the parents to ultimately decide. It's their child and they need to be making an informed decision and not be given false confidence by a physical exam that is not real effective.

 

[Veneficus]

I think it is guided by emotion, saving kids, is a powerful heartstring.

I also think there is a considerable financial incentive.

Who is paying for this screening?

Who is paying for ongoing observation?

Who is the beneficiary of this payment?

How much is it going to cost to save even one person?

What happens to the kid if the parent cannot afford such screening?

Since sports physicals are usually done by GPs of various variety are we now forcing sports physicals to be done by a subspecialty of a specific discipline of medicine?

Who is going to be responsible for "missed" diagnosis?

Who is going to be responsible for kids pulled that have changes that do not ultimately result in pathology?

Who pays for an appeal process or a second opinion?

How are conflicting opinions resolved?

Some people live their entire lives with "abnormal" electrophysiology without deficit.

Physical exam is also not unreliable, it is user dependant.

You are now going to mandate layperson "training" on physical exam as a screening tool and call the physical exam of a doctor inadequete in the same sentence?

 

[18G]

I think it is guided by emotion, saving kids, is a powerful heartstring.

I also think there is a considerable financial incentive. By who?

Who is paying for this screening? No new screening is being mandated by this new law, but if it was it would be part of the regular school physical which parents already pay for.

Who is paying for ongoing observation? This is what we all pay insurance premiums for.

Who is the beneficiary of this payment? ??

How much is it going to cost to save even one person? How much does it cost to keep one building from burning down???

What happens to the kid if the parent cannot afford such screening? What happens now when parents can't afford the school physical? An Urgent Care in my area does sports physicals for $20 so adding an ECG wouldn't be that much more

Since sports physicals are usually done by GPs of various variety are we now forcing sports physicals to be done by a subspecialty of a specific discipline of medicine? I don't see why we would. Just make GPs more aware.

Who is going to be responsible for "missed" diagnosis? Who is always responsible for a missed diagnosis?

Who is going to be responsible for kids pulled that have changes that do not ultimately result in pathology? Parent's can sign a waiver after they are informed of the risks and have all information in hand

Who pays for an appeal process or a second opinion? Parents pay for second opinion or get a referral that the insurance pays for

How are conflicting opinions resolved? How are conflicting medical opinions resolved with other medical problems?

Some people live their entire lives with "abnormal" electrophysiology without deficit. And some people die from SCA

Physical exam is also not unreliable, it is user dependant. Studies show PE used in a sports physical is not very reliable. Adding an ECG makes the PE much more effective - not opinion, actually evidence based.

You are now going to mandate layperson "training" on physical exam as a screening tool and call the physical exam of a doctor inadequete in the same sentence? Why not? A teacher with a college education with a health background (ie gym teacher, athletic trainer) can't be taught to recognize a subtle complaint of dizziness, SOB, chest pain, etc and have an understanding of the possible significance and risks?

.....

 

[18G]

http://www.simonsfund.org/

 

[Veneficus]

So what about the kids that don't have insurance?

You may also want to google the average prices for an EKG and consider market forces.

Laws and mandates do not just affect middle and upper income people.

I am sorry, but claiming that studies show... does not automatically make something fact or best practice.

Unfortunately in is an intrinsic limitation in modern science that people not expert in interpretation of studies think they are simple and ready made to be accepted at face value.

If I publish a handful of studies on a topic that is near and dear to me, with a method that doesn't have overt bias, on a topic that nobody else spends time with, then all the studies support my position.

Who financially benefits from forcing people to have a specific exam, consultation, and follow up observations for sudden cardiac arrest from a medical condition?

Hmmm... Maybe a cardiologist that specializes in pediatric electrophysiology?

Really, in a medical system that spends more than 4 times every other civilized country to deliver some of the worst healthcare in the world, you plan to mandate more procedures and spending?

Excellent plan.

How many GPs are going to accept responsibility of performing and interpreting an EKG in a pediatric population where the consequence of a missed diagnosis is a wrongful death suit?

 

[Veneficus]

Google says...

http://newchoicehealth.com/EKG-Cost

 

[18G]

I think the bottom line with you is that your mind is made up and you're not going to give any support to this initiative.

So what about the kids that don't have insurance? What about the kids without insurance now? Same scenario.

You may also want to google the average prices for an EKG and consider market forces. I just did one better. My daughter get's her sport's physical next week at an Urgent Care for $20 and is also getting a 12-Lead. Out-of-pocket the 12-lead through UC is $62 but with insurance it's just the co-pay... so not real cost prohibitive.

Laws and mandates do not just affect middle and upper income people. Regardless of economic status all children need to be protected. Low income children qualify for Medicaid or low-premium insurance. As a tax payer, I have no problem paying for this.

I am sorry, but claiming that studies show... does not automatically make something fact or best practice. Very true, but it does lend strong support and offers guidance for best practice. And eventually yes, some studies do make something fact.

Unfortunately in is an intrinsic limitation in modern science that people not expert in interpretation of studies think they are simple and ready made to be accepted at face value. Never claimed to be an expert but I'm not an idiot either.

If I publish a handful of studies on a topic that is near and dear to me, with a method that doesn't have overt bias, on a topic that nobody else spends time with, then all the studies support my position.

Who financially benefits from forcing people to have a specific exam, consultation, and follow up observations for sudden cardiac arrest from a medical condition? Who benefits now from forcing people to undergo a work or sports physical??? I'm not sure why you keep bringing up financial incentive.

Hmmm... Maybe a cardiologist that specializes in pediatric electrophysiology? That would be nice.

Really, in a medical system that spends more than 4 times every other civilized country to deliver some of the worst healthcare in the world, you plan to mandate more procedures and spending? The worst healthcare in the world comes from the US??? Are you serious?

Excellent plan.

How many GPs are going to accept responsibility of performing and interpreting an EKG in a pediatric population where the consequence of a missed diagnosis is a wrongful death suit? The GP only makes a preliminary report. All ECG's are confirmed by a cardiologist... just like x-rays are read by a radiologist.

I think your questions posed are really weak and you're really pulling to maintain your position that this is a worthless initiative.

 

[18G]

http://newchoicehealth.com/EKG-Cost

Umm.. that is just a tad bit OVER INFLATED... My daughter is getting a 12-lead for $62!!! but more than likely insurance will cover it so it's just the co-pay.

Again, you're really trying to maintain your weak position.

 

[Veneficus]

US healthcare stats

I think the bottom line with you is that your mind is made up and you're not going to give any support to this initiative.

I think your questions posed are really weak and you're really pulling to maintain your position that this is a worthless initiative.

don't take my word for it:

http://www.nejm.org/doi/full/10.1056/NEJMp0910064

edit:

a meat and potatoes quote:

Despite the claim by many in the U.S. health policy community that international comparison is not useful because of the uniqueness of the United States, the rankings have figured prominently in many arenas. It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy.3 These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?