# Why Are 12-Leads Not Required For School Physicals



## 18G

I think it's time to mandate 12-leads as a standard part of a school physical. This is happening way too much. 

http://www.foxnews.com/us/2011/10/0...l-cheerleader-collapses-dies/?test=latestnews


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## JPINFV

Is it occurring more or just being reported more?


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## medicdan

Although the minority of these cases are sensationalized in the news, what is the real rate of cardiac abnormalities in those less than 30, especially high school athletes? Do we know what actually happened here? How do we know this wasn't a drug interaction or commino cordis (sp?)?

Is it worth the additional expense to the healthcare system for the testing and analysis? What is the rate of "false positives" requiring additional testing? At what point does the benefit outweigh the costs?

Can you pull up any epidemiological data describing the rate of congenital abnormalities? Do you believe this event to be a result of CAD in a high school cheerleader?


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## JPINFV

emt.dan said:


> Although the minority of these cases are sensationalized in the news, what is the real rate of cardiac abnormalities in those less than 30, especially high school athletes? Do we know what actually happened here? How do we know this wasn't a drug interaction or commino cordis (sp?)?



If I was a betting man, I'd bet on hypertrophic cardiomyopathy, of which one of the leading presenting symptoms is cardiac arrest in young adults.


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## Imacho

Are you saying the government should pay for this? Or when student athletes get their physical screening, the 12 L is part if it paid by their insurance?


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## Aidey

I will try and find it, but last year someone did an analysis for how useful 12 leads would be as a routine part of a school physical. There was a significant concern about false positives and the number of students that needed to be tested to find one legit case was pretty high.


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## usafmedic45

18G said:


> I think it's time to mandate 12-leads as a standard part of a school physical. This is happening way too much.
> 
> http://www.foxnews.com/us/2011/10/0...l-cheerleader-collapses-dies/?test=latestnews



Because of low diagnostic yield.  Many of the things that cause sudden cardiac death in young athletes are not likely to be picked up on a 12-lead.  Hypertrophic cardiomyopathy will show up, but it's not specific because of the hypertrophy that naturally happens in well trained athletes so you're going to wind up referring a lot of kids out for echos that don't need them and, in many cases, can't afford them.  Most cardiac dysrhythmias that you see in young people (outside of Brugada in some cases and LQTS) are not going to show up on a resting 12-lead.  Cardiac valve issues, abnormal origin of the coronary vessels, myocardial bridging or even frank coronary atherosclerosis or vasospasm are not going to be picked up.  Granted, it's a cheap and easy test but you asked why it's not done.  All of the reasons above are why.


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## 18G

These are perfectly healthy, young kids who should not be dying. If a 12-lead can potentially pick up on a cardiomyopathy or prolonged QT or some other risk factor for sudden death than I think it needs to be happening. It's very simple and takes no time at all to do. 

Even if the 12-lead shows something suspect and the child needs an echo, so what. If it can prevent one child from dying than it is worth it in my opinion. I'm aware that a 12-lead won't pick up everything but if it can be used as a screening tool to help reduce SCA it should be employed.

I did a 12-lead on myself at work that showed LVH which I wasn't real concerned about but it was still a little concerning. I went to my doctor for another problem and told him my finding. He ordered an echo with no questions asked. Insurance paid for the echo.  

Parent's need to be paying attention to these media reports and requesting 12-leads during physical's for their kids if they are not going to be mandated. States should also be mandated to have AED's in schools and at the sidelines of all sporting events.


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## usafmedic45

> what is the real rate of cardiac abnormalities in those less than 30, especially high school athletes?



It's not all that high but it's considered to be more significant because of the age and popularity of the person.  You can look on Pubmed for the actual numbers as this has been studied to death.  If it were members of math bowl team suffering a berry aneurysm rupture during intense calculations or the drama geeks suffering spontaneous tension pneumos while singing in school musicals, I don't think it would get as much attention.  Just my two cents....


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## 18G

I highly doubt only the popular students get their deaths reported.


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## usafmedic45

> If a 12-lead can potentially pick up on a cardiomyopathy or prolonged QT or some other risk factor for sudden death than I think it needs to be happening. It's very simple and takes no time at all to do.



That's the problem.  It can't in most people.



> These are perfectly healthy, young kids



Technically, no they are not, otherwise they would not be dead.



> I did a 12-lead on myself at work that showed LVH which I wasn't real concerned about but it was still a little concerning.



Would it surprise you that simply misplacing the leads can produce that?  Also, even with perfect placement, about 30-40% of adult men are going to show up with LVH based off of electrocardiographic criteria. 



> I went to my doctor for another problem and told him my finding. He ordered an echo with no questions asked. Insurance paid for the echo.



Yeah, good on you that you have insurance.  A lot of people don't.  You want to pay $500 for an echo that in all likelihood is going to be clear?  Also do you want to backlog the echo techs even further keeping people who really need echos from getting them just so you can assure that Susie Q. Cheerleader will be able to keep her mouth firmly on someone's jock until she's too battered and worn for anyone to want her anymore?



> Even if the 12-lead shows something suspect and the child needs an echo, so what. If it can prevent one child from dying than it is worth it in my opinion.



So then by your logic, let's  require rear facing passenger seats in all cars, buses and airplanes.  Let's switch from using gasoline to using something like JP-5 (the Navy's version of jet fuel) which is less flammable but more expensive.   I mean, it's inconvenient and expensive but hell, if it saves a single child's life then it must be worth it right?  

Why is a teenage athlete's life worth more than a non-athlete or an older person?  Why not just screen all teens?  The ones with more going for them than a minor physical skill are more likely to contribute something to this world and anyways, their sedentary lifestyles put them at greater risk of real cardiac threats both in the short and long term.


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## usafmedic45

18G said:


> I highly doubt only the popular students get their deaths reported.




There's a statistical difference in the reporting of lightning fatalities between immigrant workers and American workers in Florida as we identified in a study that we did looking at the accuracy of reporting.  The National Weather Service actually uses newspaper articles to track them (yeah, seriously....) and if you start comparing it to other sources of data (death certificates, autopsy reports, etc) you start to see trends where folks who aren't white, young and/or otherwise sympathetic victims do not appear in the data set as often.  If you need another example, there's always this: http://en.wikipedia.org/wiki/Missing_white_woman_syndrome


I can't see why other biases would not exist.


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## 18G

usafmedic45 said:


> Would it surprise you that simply misplacing the leads can produce that?  Also, even with perfect placement, about 30-40% of adult men are going to show up with LVH based off of electrocardiographic criteria.



And that is why I said I wasn't too concerned. But I'm not going to assume that the high voltage criteria and ECG finding were from misplaced leads or is a benign finding. I placed the leads so I knew they were not misplaced. 

My oldest son takes a stimulant ADHD med daily and has for years. A potential cardiac effect exists in children who takes these meds daily. And because it was requested, my son has a 12-lead performed annually as ordered by his pediatrician. As a parent you need to take control and be informed of all things that can harm your kids as much as possible. These media report's should be making parents perk up. 

And by using your logic, these incidents are so rare and these kids are that unimportant that we should not invest thousands of dollars into AED's for school's?


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## Tommerag

18G said:


> And that is why I said I wasn't too concerned. But I'm not going to assume that the high voltage criteria and ECG finding were from misplaced leads or is a benign finding. I placed the leads so I knew they were not misplaced.
> 
> My oldest son takes a stimulant ADHD med daily and has for years. A potential cardiac effect exists in children who takes these meds daily. And because it was requested, my son has a 12-lead performed annually as ordered by his pediatrician. As a parent you need to take control and be informed of all things that can harm your kids as much as possible. These media report's should be making parents perk up.
> 
> And by using your logic, these incidents are so rare and these kids are that unimportant that we should not invest thousands of dollars into AED's for school's?



Sure if the parent wants to take control and be informed then have them take their kid in for it, but it should not be required for every student.


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## Handsome Robb

Tommerag said:


> Sure if the parent wants to take control and be informed then have them take their kid in for it, but it should not be required for every student.



Oy! look who it is!

18g I'd love to hear more about this medication. I personally have been taking stimulant ADHD meds since I was younger. 

PM me if that's ok with you.


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## usafmedic45

> But I'm not going to assume that the high voltage criteria and ECG finding were from misplaced leads or is a benign finding.



You know more than 95% of the board certified cardiologists out there?  Very few people get kicked to an echo for asymptomatic EKG findings of LVH.  Usually, it's done in those cases only to shut up those patients who are either hypochondriacs and/or have spent too much time watching House or reading WebMD. 



> My oldest son takes a stimulant ADHD med daily and has for years. A potential cardiac effect exists in children who takes these meds daily



And that pertains to your picture of a "perfectly healthy" child how?  Are we talking about screening everyone or just those with known but likely insignificant risk factor?  Hell, taking aspirin regularly leads to a potential gastrointestinal hemorrhage...should we start screening every member of this forum for ulcers simply to avoid Tommerag or Chimpie eventually going bloody version of The Exorcist on their surroundings from a complication of stress-induced headaches?  The risk of bleeding complications with aspirin is a lot higher than the risk of cardiac effects from properly prescribed (pun intended here) ADHD medication.



> As a parent you need to take control and be informed of all things that can harm your kids as much as possible



But not to the point of subjecting them to every medical test under the Sun simply to allow the parents to sleep better at night.  You can't make life perfectly safe and we breed neurosis and insecurity in our children by trying to give them an allusion of perfect safety.  Welcome to why your child is likely on psych meds.  We've turned kids who doesn't get smacked frequently or hard enough when they misbehave into a clinical diagnosis.  



> And by using your logic, these incidents are so rare and these kids are that unimportant that we should not invest thousands of dollars into AED's for school's?



I didn't say that and there is a high risk population at schools.  They are called "adults".  You really aren't very good at intellectual debate, you know that right?


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## usafmedic45

> 18g I'd love to hear more about this medication. I personally have been taking stimulant ADHD meds since I was younger



There's a risk of premature atherosclerosis with prolonged use of stimulant medications and some concern over the risk for the development of cardiomyopathies associated with them as well.  Do a PubMed search for "methylphenidate, cardiovascular disease" and you should learn a lot more than you would otherwise.


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## Handsome Robb

Good thing I don't take methylphenidate.


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## 18G

usafmedic45 said:


> There's a risk of premature atherosclerosis with prolonged use of stimulant medications and some concern over the risk for the development of cardiomyopathies associated with them as well.  Do a PubMed search for "methylphenidate, cardiovascular disease" and you should learn a lot more than you would otherwise.



Both the AHA and the American Academy of Pediatrics find it acceptable for physicians to screen kids who are on ADHD meds with an ECG. 

If your one of the many parents who want to leave your kids to chance than good for you. That's your choice. I do not take that approach however, and will assure my kids are screened with risks minimized as much as possible.


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## usafmedic45

> Both the AHA and the American Academy of Pediatrics find it acceptable for physicians to screen kids who are on ADHD meds with an ECG.



Yes and it is because of the low risk involved, but this discussion wasn't about that.  It was about screening kids with no risk factors.  Do try to stay on topic and not bring in unrelated information to try to win the debate. 



> If your one of the many parents who want to leave your kids to chance than good for you. That's your choice. I do not take that approach however, and will assure my kids are screened with risks minimized as much as possible.



There's a difference between minimizing appropriate risk and being overprotective and borderline paranoid.  It's not a matter of leaving things to chance but simply the difference in where one chooses to deem risk existing.


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## Aidey

18G said:


> My oldest son takes a stimulant ADHD med daily and has for years. A potential cardiac effect exists in children who takes these meds daily. And because it was requested, my son has a 12-lead performed annually as ordered by his pediatrician. As a parent you need to take control and be informed of all things that can harm your kids as much as possible. These media report's should be making parents perk up.
> 
> And by using your logic, these incidents are so rare and these kids are that unimportant that we should not invest thousands of dollars into AED's for school's?



So in other words your son has a risk factor aside from just being a kid? Funny how that works. 

Schools are not closed systems, there are a number of people besides children at them. Especially when you consider how big high school sports are in some areas of the country. 

You sound a lot like the people who got drop side cribs banned. I did the math one time, it came out to something like .0000000068%* chance a child would die in a drop side crib. 

I bet the numbers are similar for the percentage of deaths that would be prevented with a 12 lead. There are millions of school athletes, and how many cases of SCA are publicized each year? 6-8? Even if there are twice that many deaths there is no guarantee that all of them would be caught by a 12 lead ahead of time. 


*I took the total number of cribs recalled, assumed each crib was used by 2 children, and those children slept in them for 12 months and divided that by the total number of deaths. Crude, but puts the numbers into perspective.

Edit: As usual USAF beat me to the punch.


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## 18G

USAF..Actually I dont even consider this a debate and don't care if I convince you or not. I have my own informed opinion and life experiences on the subject and that is what I am relaying. 

The ADHD med and ECG screening is kinda related to the routine screening of student athletes. The ECG screening is deemed reasonable BEFORE starting the ADHD med and while taking the med. These meds are stimulants which can aggravate underlying heart conditions just the same as catecholemine release can aggravate heart conditions during extreme physical activity. So, if were gonna screen for one than how is the other not even remotely reasonable? I see a relation

Hmmm.... stimulant ADHD med... may aggravate an unknown cardiac abnormality... lets use the ECG as a risk reduction tool.... deemed REASONABLE.

Hmmm.... high exertional state during sports activity - extreme catecholemine release... may aggravate an unknown cardiac abnormality in a similar way as an ADHD med.... lets NOT use the ECG as a risk reduction tool. MAKES NO SENSE TO ME. 

No conclusive evidence has been found to say one way or the other on the benefit of routine 12-lead testing. I think it is very reasonable for a child to receive a routine 12-lead prior to sports participation. How many kids have t go unscreened and die before studies can say for sure if these deaths can be prevented. It is known that a 12-lead can catch some abnormalities that will pose a threat to a student athlete so it is prudent to perform these until direct evidence says other wise. 

If nothing else... to the parents on the forum... consider it for yourself and spread the word to other parents so they too can be informed and make a decision that may potentially save their child's life.


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## usafmedic45

> USAF..Actually I dont even consider this a debate and don't care if I convince you or not. I have my own informed opinion and life experiences on the subject and that is what I am relaying.



I don't care if I convince you or not, but I am not about to let groundless supposition and illusory correlations based on what is- at best- a questionable grasp on the subject matter to rule the day so long as I have anything to say about it. 



> Hmmm.... high exertional state during sports activity - extreme catecholemine release... may aggravate an unknown cardiac abnormality in a similar way as an ADHD med.... lets NOT use the ECG as a risk reduction tool. MAKES NO SENSE TO ME.



It's a piss poor reduction measure and likely to simply result in the same rate of deaths and, if anything a false sense of security.   If you'd pull your head out of the cavity in which you have it lodged and actually read what I am saying then you would see that.  It's like saying that having an normal RBC count rules out anemia when it does nothing or the sort.  If you need me to explain how that one works, let me know.



> If nothing else... to the parents on the forum... consider it for yourself and spread the word to other parents so they too can be informed and make a decision that may potentially save their child's life.



Why don't you just change your screen name to Jenny McCarthy because you have about the same burden of proof standards as she does.



> No conclusive evidence has been found to say one way or the other on the benefit of routine 12-lead testing.



Low specificity and high sensitivity is a pretty good bit of evidence.  Just because it doesn't fit your standards doesn't mean that it's not relatively conclusive to a reasonable person. 



> The ADHD med and ECG screening is kinda related to the routine screening of student athletes. The ECG screening is deemed reasonable BEFORE starting the ADHD med and while taking the med. These meds are stimulants which can aggravate underlying heart conditions just the same as catecholemine release can aggravate heart conditions during extreme physical activity. So, if were gonna screen for one than how is the other not even remotely reasonable? I see a relation



Because there's a difference between the effects of periodic exercise and the effect of more or less continuous up-regulation?  Your oversimplification of this and false analogy isn't going to stand up before anyone with even a moderate knowledge of physiology and pharmacology.  




> "Education is the discovery of one's own ignorance"



You'd be well advised to spend more time reading your own signature.  There is nothing more dangerous than sincere ignorance or conscientious stupidity, to quote Martin Luther King, Jr.  I'm pretty sure you meet the criteria for both of those based upon your statements here in this thread.


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## 18G

Your entitled to your opinion which is fine. I simply raised a question for discussion and gave my input. You however want to hijack the thread and make it a pissing contest like you do the majority of times. 

I never said a 12-lead is an absolute solution and realize it's short comings in the issue at hand. I also know they're are physicians who advocate for it and those who advocate against it. 

Excerpts from the article:
http://savingyounghearts.org/?p=1125

"As more high schools and colleges require that athletes get an EKG to detect potentially deadly heart defects, an international group of experts has issued recommendations to help make the test more reliable. "

“It’s an excellent effort to try to give guidance” that should minimize false-positive and false-negative results, said David E. Haines, director of the Heart Rhythm Center at Beaumont Hospital in Royal Oak, Mich., who was not part of the current study.

His hospital conducts mass screenings of high-school athletes in the community. The program has screened 6,685 students over four years, with 41 told to stop exercising pending further medical evaluation and another 663 sent on for follow-up but not told to stop exercising."

"A study published in April in Circulation found that 45 NCAA student athletes suffered sudden cardiac death between 2004 and 2008. That translated to one student out of every 43,770 participants each year, a greater incidence than previously thought."

"Some individual colleges require screening, though, and hospitals are increasingly offering community screening programs for high-school athletes.

And this.... http://today.msnbc.msn.com/id/41392...etes-sudden-deaths-spur-call-heart-screening/

So I'm really the only ignorant one advocating and giving support to routine ECG's for student athletes???? 

Your obviously being antagonistic intentionally so your not worth my time in this discussion. You really sound like a reinvented VentMedic.


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## usafmedic45

> So I'm really the only ignorant one advocating and giving support to routine ECG's for student athletes????



I didn't say you were the only one.  But the problem with that reference is it doesn't give us a measure of how many actually turned out to have a real problem and how many were false positives.



> Your obviously being antagonistic intentionally so your not worth my time in this discussion



No, I'm disagreeing with you because you have nothing to substantially back up your argument.  I am being intentionally antagonistic.  The only way I could not be doing so is to agree with you and you haven't given me anything to base agreement with your stance upon.   Learn to debate and you'll see why where you see someone spitting in your face, someone with an academic background sees someone demanding proof.  This isn't a bar room debate over whose fantasy football team is better.  It's a debate on medical science.  I'm treating it as such.  You think I'm being nasty, you should see how ugly debates like this at conferences can get between PhDs and between MDs.

Just for clarification, I'm not against screening.  I just think 12-leads are a poor way of doing it.  Screen for symptoms or family history and find those with high risk and refer them for echos.  Better yet, find someone with money to burn and the need for a tax write-off and hire echocardiographers such as myself to scan everyone.


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## Akulahawk

18G said:


> USAF..Actually I dont even consider this a debate and don't care if I convince you or not. I have my own informed opinion and life experiences on the subject and that is what I am relaying.
> 
> The ADHD med and ECG screening is kinda related to the routine screening of student athletes. The ECG screening is deemed reasonable BEFORE starting the ADHD med and while taking the med. These meds are stimulants which can aggravate underlying heart conditions just the same as catecholemine release can aggravate heart conditions during extreme physical activity. So, if were gonna screen for one than how is the other not even remotely reasonable? I see a relation
> 
> Hmmm.... stimulant ADHD med... may aggravate an unknown cardiac abnormality... lets use the ECG as a risk reduction tool.... deemed REASONABLE.
> 
> Hmmm.... high exertional state during sports activity - extreme catecholemine release... may aggravate an unknown cardiac abnormality in a similar way as an ADHD med.... lets NOT use the ECG as a risk reduction tool. MAKES NO SENSE TO ME.
> 
> No conclusive evidence has been found to say one way or the other on the benefit of routine 12-lead testing. I think it is very reasonable for a child to receive a routine 12-lead prior to sports participation. How many kids have t go unscreened and die before studies can say for sure if these deaths can be prevented. It is known that a 12-lead can catch some abnormalities that will pose a threat to a student athlete so it is prudent to perform these until direct evidence says other wise.
> 
> If nothing else... to the parents on the forum... consider it for yourself and spread the word to other parents so they too can be informed and make a decision that may potentially save their child's life.


Kids with ADHD that might be or will be put on a stimulant... is a relatively small population (one at a time) and that stimulant use is a known risk factor. Athletics is a MUCH larger population. You're asking for a couple HUNDRED athletes to be screened via 12-lead, all at once. While each student may get clearance from their personal physician, that physician isn't likely to be knowledgeable in the stresses of athletic competition. We also know that generally, athletics (exercise) is good for you. The stresses on the heart are normally a very good thing for you. 

Now, add in the fact that these physicals are not cardiac stress tests. Given that athlete hearts are already somewhat enlarged because of the stresses put on them, you're going to get a LOT of false positives. It's possible that even an echo might not pick up on anything. 

A school athletics department would do MUCH better to purchase a couple AED units and have them available at every school-sponsored sporting event. Often the only presenting symptom is the athlete dropping dead... However, since these events happen to athletes only a few times per year, schools may not even consider doing that because of the cost. So they require that all the coaches and athletic training staff be CPR trained and at certain events, they pay for an ambulance stand-by. 

This is a prime example of risk-benefit analysis... 

Personally, I like the idea of having an AED unit at every sporting function, designated for use on the team. It's just that they're expensive.


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## usafmedic45

> Often the only presenting symptom is the athlete dropping dead... However, since these events happen to athletes only a few times per year



It's roughly twice the lifetime risk of being killed by a crashing airplane....when you're not on it.  It's tragic, a minority of them are preventable but as you said, risk/benefit analysis.


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## 18G

USAF45...And you have yet to provide absolute proof that this screening tool is absolutely useless and worthless. All I've heard you spew is speculation based on some limited data in which you are trying to disparage me with. Your the one spouting the absolute, not me. 

I'm simply saying I feel there is a great benefit and for the time being it is better than nothing as an attempt to save some of these kids. If years down the road after routinely doing these ECG's the data say's something else, than let's reexamine. 

Italy mandates routine ECG's for students and have found a reduction in student deaths. How about that? Are they idiotic too and have flawed numbers???

The point is this.... evidence does suggest benefit and I also see the other side of false positives and the limited evidence and groups that say it's not worth the effort (although I don't agree). 

But standing back and doing nothing to screen for these lethal abnormalities is certainly not good practice. I would rather have a false positive and a kid not play a sport than to have that same kid dead on a football field.

And this is a discussion for raising points... its not about who's wrong and who is right. And further, I am not here for a scientific debate. It is 12:21am, I am bored, and is a simple forum on the Internet!


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## 18G

Akulahawk said:


> Kids with ADHD that might be or will be put on a stimulant... is a relatively small population (one at a time) and that stimulant use is a known risk factor. Athletics is a MUCH larger population. You're asking for a couple HUNDRED athletes to be screened via 12-lead, all at once. While each student may get clearance from their personal physician, that physician isn't likely to be knowledgeable in the stresses of athletic competition. We also know that generally, athletics (exercise) is good for you. The stresses on the heart are normally a very good thing for you.
> 
> Now, add in the fact that these physicals are not cardiac stress tests. Given that athlete hearts are already somewhat enlarged because of the stresses put on them, you're going to get a LOT of false positives. It's possible that even an echo might not pick up on anything.
> 
> A school athletics department would do MUCH better to purchase a couple AED units and have them available at every school-sponsored sporting event. Often the only presenting symptom is the athlete dropping dead... However, since these events happen to athletes only a few times per year, schools may not even consider doing that because of the cost. So they require that all the coaches and athletic training staff be CPR trained and at certain events, they pay for an ambulance stand-by.
> 
> This is a prime example of risk-benefit analysis...
> 
> Personally, I like the idea of having an AED unit at every sporting function, designated for use on the team. It's just that they're expensive.



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.


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## 18G

> “Good scientific data neither supports nor refutes the benefit of ECG screening,” according to Marek. “We will therefore give the youth in our community the benefit of the doubt and continue with our incredibly successful and efficient Youth Hearts for Life Cardiac Screening model.” - Dr. Marek



http://www.sca-aware.org/sca-news/three-deaths-in-one-week-are-student-athletes-safe-at-school

Exactly what I been trying to say.


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## Smash

18G said:


> Both the AHA and the American Academy of Pediatrics find it acceptable for physicians to screen kids who are on ADHD meds with an ECG.



You do realise that those organizations are essentially lobby groups for their members don't you?  What they find acceptable is what improves the lot of their members or makes them more money, and often has no bearing on what is useful, or even safe in real life. 

Any test is only as good as your pre-test suspicion that there is something wrong. I presume that, as you assume your child has cardiovascular disease, in the absence of a positive ECG, you would insist upon bloods, or maybe an angio?  After all, this is where we need to go in a suspected ACS with a negative ECG.


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## usafmedic45

> And you have yet to provide absolute proof that this screening tool is absolutely useless and worthless. All I've heard you spew is speculation based on some limited data in which you are trying to disparage me with. Your the one spouting the absolute, not me.



The burden of proof is on the person making the extraordinary claim.  You're claiming that the 12-lead is a great tool for this.  You have the burden to prove it.  I'm not trying to disparage you, I'm trying to make you think before you cram your foot in your mouth by making questionable statements based off of emotion and reflex.  If I were trying to disparage you, I'd have simply told you that you're a simpering moron who incapable of learning and left it at that.  



> Italy mandates routine ECG's for students and have found a reduction in student deaths. How about that? Are they idiotic too and have flawed numbers???



Let's see the actual source of the numbers.  The peer-reviewed article on it, not some press release from a group with an agenda to push. 



> I'm simply saying I feel there is a great benefit and for the time being it is better than nothing as an attempt to save some of these kids. If years down the road after routinely doing these ECG's the data say's something else, than let's reexamine.


...or you apply the data that exists from other studies and save yourself the time, the effort and the expense.  Would you rather wait ten years to find out that it doesn't work or maybe save 5-10% of these kids by using more sensitive and specific screening measures?  You're talking 45 lives a year nationwide.  It's not a huge loss and there are problems much more easily rectified that affect far more people.  



> And this is a discussion for raising points... its not about who's wrong and who is right.



Then stop getting your panties in a twist every time I raise one and request more than "I feel....".  The only person whom I give more than a roll of the eyes to when they start a sentence with that phrase is Kat. 



> But standing back and doing nothing to screen for these lethal abnormalities is certainly not good practice.


No one is advocating that.  You're viewing this as either we do it your way or we're throwing up our hands and saying ":censored::censored::censored::censored: it!".  I really hate false dichotomies especially when put forward to save face.  



> I would rather have a false positive and a kid not play a sport than to have that same kid dead on a football field.


So you're more comfortable falsely consigning a kid to a sedentary lifestyle with the much more realistic risks involved than the infinitesimal risk of an athletic SCA in a teen?


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## usafmedic45

> 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.



The issue comes back to "Is the benefit worth the effort?".  Inconveniencing thousands of people to maybe prevent one or two deaths a year nationwide isn't going to be practical except to someone who ideologically melded to the idea on grounds other than scientific proof.


----------



## Aidey

18g I read about Italy too. You're leaving out all the details that make their practice not really applicable to the US. They have a significantly smaller population, and thus fewer student athletes. Their pre screening death rate is higher than the US, and consequently their post screening death rate is the same as the US. The practice is not standard nationally because of the cost, and as I said, they are dealing with a lot fewer student athletes. 

Other studies have also found that 12 leads really only useful when combined with a thorough pre-screening. 

I'll dig the links back up.


----------



## 18G

usafmedic45 said:


> The burden of proof is on the person making the extraordinary claim.  You're claiming that the 12-lead is a great tool for this.  You have the burden to prove it.  I'm not trying to disparage you, I'm trying to make you think before you cram your foot in your mouth by making questionable statements based off of emotion and reflex.  If I were trying to disparage you, I'd have simply told you that you're a simpering moron who incapable of learning and left it at that.



Im not making an extraordinary claim or making any statement based on emotion. I've been a supporter of this for a few years now and is a topic I take great interest in. I never said this is the "golden answer" to kids killing over. I never said that at all. You like to put words in my mouth. 

They're are quite a few groups of physicians that have the same outlook and support of routine ECG's as I do. And they run the programs that screen kids. Would you tell them they are just as dumb too because they are doing something that numbers don't back up??? I highly doubt that you would. 

Think and support what you want. I do. And I believe in programs and physicians that support the routine screening of student athletes with ECG's. They're is some evidence from programs in the US and Italy that show's benefit and also numbers that show the incidence is much greater than once believed.  

I believe it is a worthwhile endeavor and Im not trying to convince anyone else of that. It is what it is. Make the decision for yourself.


----------



## Aidey

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

Something else to note, how many GPs are proficient in differentiating clinical LVH from normal EKG variants and lead placement errors? I think it would be very interesting to see a study comparing the % of students would be referred for an echo after their 12 leads are reviewed by each a GP, a cardiologist, and a pediatric cardiologist.

This link also explains some of the limitations to the Italy study: http://www.theheart.org/article/1270485.do

I think it is also worth pointing out that a screening prior to the student starting sports may not accurately reflect the stress the body is under while in the middle of the season. Especially in highly competitive activities, like wrestling, football, cheerleading/gymnastics, and basketball. High school and college students will do stupid stuff in order to make weight, look good, and improve their game. I could very easily see how someone with a borderline abnormality missed on a 12 lead could drop dead because they fark up their magnesium or potassium by doing something stupid during the season, or even inadvertently due to excessive water intake causing an electrolyte imbalance.

Edit: For those following along who are not paramedics long Q-T syndrome is another cause of SCA that can go undetected, and magnesium deficiency can aggravate it or cause it.


----------



## 18G

usafmedic45 said:


> The issue comes back to "Is the benefit worth the effort?".  Inconveniencing thousands of people to maybe prevent one or two deaths a year nationwide isn't going to be practical except to someone who ideologically melded to the idea on grounds other than scientific proof.



I guess it only becomes worth it when its your kid. After your kid dies playing soccer and is found to have cardiomyopathy, than tell me if your opinion is still the same (after the funeral of course). 

Maybe it's some people just don't place a whole lot of value on a child's life and losing a few here and there unnecessarily is okay with them?


----------



## 18G

Aidey said:


> 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
> 
> Something else to note, how many GPs are proficient in differentiating clinical LVH from normal EKG variants and lead placement errors? I think it would be very interesting to see a study comparing the % of students would be referred for an echo after their 12 leads are reviewed by each a GP, a cardiologist, and a pediatric cardiologist.



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.


----------



## usafmedic45

> Im not making an extraordinary claim or making any statement based on emotion. I've been a supporter of this for a few years now and is a topic I take great interest in. I never said this is the "golden answer" to kids killing over. I never said that at all. You like to put words in my mouth.



Well, it sure seems like you're saying that it's a great option but you're not offering any peer-reviewed evidence to substantiate that claim.



> They're are quite a few groups of physicians that have the same outlook and support of routine ECG's as I do.



Have any of them published their results in a journal?  If they have evidence to support their approach why aren't you trotting it out to make your case?



> Would you tell them they are just as dumb too because they are doing something that numbers don't back up??? I highly doubt that you would.



You don't know me very well do you?  LOL  I have no problem telling someone regardless of their title or degree that I don't simply take their word for it.  If someone persists, I will tell them that I think they are full of it.  Welcome to being a scientist and not a sycophant. 



> Think and support what you want.



Will do.



> I do.



OK.  I'm still waiting to see proof of why you do lest this simply be a reminder of why Churchill once commented that the best argument against democracy was a five-minute conversation with the average voter.



> And I believe in programs and physicians that support the routine screening of student athletes with ECG's.



You know that what you're describing is religion and not medical science right?  



> They're is some evidence from programs in the US and Italy that show's benefit



Then let's see it.  You keep mentioning it but until you bring it out for review and to let us see that you're not misunderstanding or wrongfully attributing a downward tick in the death rate to your beloved 12-leads when it might be do to other actions associated with screening, the professionals here are just going to work from the position that you're talking out your *** and are making this stuff up to win a debate that you're thus far not doing so hot in.



> and also numbers that show the incidence is much greater than once believed.



Yeah, it's amazing that when you look at a nationwide count that the numbers are going to be higher than in a regional study, right?  Totally :censored::censored::censored::censored:ing mind-blowing....didn't see that coming for sure.


----------



## usafmedic45

> I guess it only becomes worth it when its your kid. After your kid dies playing soccer and is found to have cardiomyopathy, than tell me if your opinion is still the same (after the funeral of course).



So by the same token do you believe in flying people unnecessarily simply to give the perception that we are doing everything possible?  That was the very argument put out in Maryland to keep the MSP helicopter system intact.  It's a pretty **** move if you ask me.  "I don't have any evidence, but what if it was YOUR child?" 

Are you just going through the Wikipedia list of logical fallacies tonight or something? 




> Maybe it's some people just don't place a whole lot of value on a child's life and losing a few here and there unnecessarily is okay with them?



It's not that at all.  I maybe a misanthrope, but kids are the one group I generally have a positive outlook towards.  It's the dull intellect of the average adult that makes me question whether the human race has any inherent value whatsoever.  That said, I'm realist and recognize that we're not going to eliminate SCA in kids and most of the ones who do die would only be avoided by an angiogram, an echo and genetic screening for LQTS, etc.


----------



## usafmedic45

18G said:


> 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

usafmedic45 said:


> 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

18G said:


> 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

Akulahawk said:


> 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

18G said:


> 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

usafmedic45 said:


> 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

usafmedic45 said:


> 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

usafmedic45 said:


> 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

18G said:


> 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.


----------



## 18G

systemet said:


> 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.



Cardiologists at Stanford University School of Medicine did perform research that was published in the Annuals of Internal Medicine. It showed cost effectiveness and benefits which include saving lives. 

Why is this research being dismissed and the research USAF provided being upheld? The Italian study I've read reveals a decreased death rate of 90% andwith screening programs in the US using the data from the Italian study as a model. 

So I'm not even sure what research people are referring to that USAF provided that say's ECG screening is absolutely a waste. 

Because what I've read is multiple studies and professional opinion thatsay either 1) ECG screening is beneficial and saves lives, 2) Not enough data exists to say either way, 3) ECG screening does not help save lives. 

There is no absolute as USAF is portraying.


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## Aidey

The decrease of 90% was TO the level that US deaths are already at. They also state that the subjects in the Italy was made up of a higher % of males and older males, who are a higher risk group. The US has a larger % of younger and female athletes. 

No one is saying it is a total waste, just that automatically screening 25,000,000 athletes a year in order to detect a handful of at-risk people and causing several thousand false positives may not be a very efficient way of going about things. Especially because screening is not going to catch everyone and there will always be deaths from SCA.


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## 18G

So what is the threshold? How many kids a year need to die before we deem screening a worthwhile endeavor?


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## terrible one

18g with all due respect you are the one that is out of line here. USAF, while his tactics and upfront attitude may be a little brash, all he has asked for is statistical peer-reviewed research to support your claim that 12-leads should be mandated in high schools.
You have responded emotionally and without proper documentation to all of USAF's responses. There are several reasons why this practice isn't utilized all of which USAF has stated, yet you continue to ignore many of them and repeat your opinion, not facts on the subject.
It's great that you are highly motivated to protect and initialize prevention for our youth, something highly lacking in the paramedic culture, however, continuing down the path of "what if it was your kid" is not the correct way to go about it.
Do not take this as an attack against you, I admire anyone that takes interest in furthing medical care, I am simply an outsider looking in.


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## usafmedic45

> 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.



I could also offer the benefit of a reacharound.  Alas, I don't.  No offense intended though if I was kind of excessively harsh. 



> So what is the threshold? How many kids a year need to die before we deem screening a worthwhile endeavor?



Screening is worthwhile,_ if_ it has a demonstrated and positive impact.  Crude analysis and assumptions are not sufficient to say "This works".  That's why people are not so eagerly supporting your idea.  I actually think screening should be mandatory (and used to volunteer doing echos on cases where it was clinically indicated) but also realize the shortcomings of the technology and the fact that you're not going to eliminate most of these cases simply because they don't show up on affordable screening tests until they present as a fatal occurrence.  



> The decrease of 90% was TO the level that US deaths are already at. They also state that the subjects in the Italy was made up of a higher % of males and older males, who are a higher risk group. The US has a larger % of younger and female athletes.



Bingo.  You can't compare non-alike populations without recognizing those limitations and differences.



> So I'm not even sure what research people are referring to that USAF provided that say's ECG screening is absolutely a waste.



Go back up and read the post where I cited the study from either early this year or late last year.  2 cases out of 950 or so screened were picked up by combined echo and EKG.  Not exactly a significant rate.



> Because what I've read is multiple studies and professional opinion thatsay either 1) ECG screening is beneficial and saves lives, 2) Not enough data exists to say either way, 3) ECG screening does not help save lives.



Likely because you're looking at wildly varying study populations with the inherent variability in risk factors.  Most of the studies in the US (which is the population we are concerning ourselves with) show no appreciable benefit because of an already freakishly low rate of SCA in student athletes.




> There is no absolute as USAF is portraying.



When did I say it was an absolute?  I simply stated that there is no evidence that it works as well as you are hoping in the population you are concerning yourself with.  Even if we TEE, treadmill stress test and angio every last kid who sets foot on the field, we're still going to miss some.  That is the only absolute in this discussion.


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## 18G

Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?


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## JPINFV

18G said:


> Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?




Anything from Stanford isn't worth the Redwood it's written on.  Stanford, the only school with a mascot more hideous than the banana slug.


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## Tigger

Part of my job at school is to assist with the rather overwhelming process of ensuring that every collegiate varsity athlete has his or her medical history reviewed. We start the process with a three page health history questionnaire that covers both orthopedic and general health issues. If an athlete answers "yes" to any of the questions, he will see one of our staff Family Practice/Sports Medicine certified physicians or staff orthopedists, depending on the history. Depending upon the doctors examination, the athlete can be referred to a specialist (free of charge) for further follow up. Anyone with a significant cardiac history (murmur, high/low BP, arrhythmia, significant family history) will see a cardiologist, and he will make the decision on what sort of additional diagnostic testing is needed.

Also note that every freshman must have a full physical performed by their own physician/pediatrician, meaning that we are usually aware of those that need an additional cardiac workup prior to them even arriving on campus. 

I just don't see it as logistically possible nor cost efficient to mandate 12 leads for all athletes. Good medicine is targeted medicine. We at Sports Medicine do not mandate physicals for every athlete every season if they have a "clean" history. Is it possible that something drastic has changed in their medical history? I guess, but at this point we are willing to accept that infinitesimal degree of risk.


----------



## 18G

JPINFV said:


> Anything from Stanford isn't worth the Redwood it's written on.  Stanford, the only school with a mascot more hideous than the banana slug.



Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?


----------



## 18G

Tigger said:


> I just don't see it as logistically possible nor cost efficient to mandate 12 leads for all athletes



You know they're was a time when people said the same thing about AED's and their widespread deployment? Cost vs benefit was once an early argument. 

When AED's first hit the scene I don't think anyone imagined AED's would be found in malls, schools, police cars, and office buildings, due to perceived logistical concerns with liability, purchasing, and training. But they were wrong. 

It has been shown that an ECG can be performed along with follow-up care including an echo for as low as $88.


----------



## JPINFV

18G said:


> Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?


I think that went over your head...


----------



## Smash

Where does it end?  If we start doing an ECG on every school athlete in the offchance that it may pick up an abnormality and that it's not a false positive and that it actually has any positive result anyway, do we extend that?

Do we start doing a CTA on every student to make sure they don't have an AVM, which tend to kill people in their teens and can be triggered by increased shear forces that we get when people exercise?  After all, if we can save one life it must be worth it right?


----------



## Akulahawk

JPINFV said:


> Anything from Stanford isn't worth the Redwood it's written on.  Stanford, the only school with a mascot more hideous than the banana slug.





18G said:


> Again, what is to be made out of the research at  Stanford? Is the Annuals of Internal Medicine not peer-reviewed?





JPINFV said:


> I think that went over your head...


JP: I think you're correct. Right over the head...


Tigger said:


> Part of my job at school is to assist with the rather overwhelming process of ensuring that every collegiate varsity athlete has his or her medical history reviewed. We start the process with a three page health history questionnaire that covers both orthopedic and general health issues. If an athlete answers "yes" to any of the questions, he will see one of our staff Family Practice/Sports Medicine certified physicians or staff orthopedists, depending on the history. Depending upon the doctors examination, the athlete can be referred to a specialist (free of charge) for further follow up. Anyone with a significant cardiac history (murmur, high/low BP, arrhythmia, significant family history) will see a cardiologist, and he will make the decision on what sort of additional diagnostic testing is needed.
> 
> Also note that every freshman must have a full physical performed by their own physician/pediatrician, meaning that we are usually aware of those that need an additional cardiac workup prior to them even arriving on campus.
> 
> *I just don't see it as logistically possible nor cost efficient to mandate 12 leads for all athletes*. Good medicine is targeted medicine. We at Sports Medicine do not mandate physicals for every athlete every season if they have a "clean" history. Is it possible that something drastic has changed in their medical history? I guess, but at this point we are willing to accept that infinitesimal degree of risk.



Funny how I've been saying something pretty similar...



18G said:


> You know they're was a time when people said the same thing about AED's and their widespread deployment? Cost vs benefit was once an early argument.
> 
> When AED's first hit the scene I don't think anyone imagined AED's would be found in malls, schools, police cars, and office buildings, due to perceived logistical concerns with liability, purchasing, and training. But they were wrong.
> 
> It has been shown that an ECG can be performed along with follow-up care including an echo for as low as $88.



18G - we're talking about apples and avocados here. Generally speaking, athletes are quite healthy and don't have lots of events of VF or VT. The same can not be said of the general population. Although I don't have the numbers in front of me, I would expect that the incidence of those kinds of SCA is higher (if not _far_) in the general population than it would be/is in the athletic populations. Because of the higher incidence, it makes excellent sense to put AED units where lots of people congregate and/or on Police units because they _usually_ have faster response times than ambulance units... 

Also, something else to consider: it was stated above that a 12-lead and echo followup would cost $88? AED units can be purchased for the equivalent of a dozen of those checkups. One question that remains outstanding is where will the 12-lead machine come from? I doubt that a physician is going to want to bring it from his/her office and therefore deny it's use by other providers in the office, I doubt that EMS providers will lend use of one of their machines for the same reason... so what remains is: who is going to purchase the unit? I'd expect that a good AED unit would be less expensive than a 12-lead monitor.... To me, it just makes better sense to screen initially, send any suspect cases out, and buy AED units for use at school events. Long-term, that's probably the best answer for the athletic population in the US.


----------



## 18G

Akulahawk said:


> JP: I think you're correct. Right over the head...
> 
> 
> Funny how I've been saying something pretty similar...
> 
> 
> 18G - we're talking about apples and avocados here. Generally speaking, athletes are quite healthy and don't have lots of events of VF or VT. The same can not be said of the general population. Although I don't have the numbers in front of me, I would expect that the incidence of those kinds of SCA is higher (if not _far_) in the general population than it would be/is in the athletic populations. Because of the higher incidence, it makes excellent sense to put AED units where lots of people congregate and/or on Police units because they _usually_ have faster response times than ambulance units...
> 
> Also, something else to consider: it was stated above that a 12-lead and echo followup would cost $88? AED units can be purchased for the equivalent of a dozen of those checkups. One question that remains outstanding is where will the 12-lead machine come from? I doubt that a physician is going to want to bring it from his/her office and therefore deny it's use by other providers in the office, I doubt that EMS providers will lend use of one of their machines for the same reason... so what remains is: who is going to purchase the unit? I'd expect that a good AED unit would be less expensive than a 12-lead monitor.... To me, it just makes better sense to screen initially, send any suspect cases out, and buy AED units for use at school events. Long-term, that's probably the best answer for the athletic population in the US.



This is the main problem with this discussion. People misconstrue what I am saying even though I have repeated it several times. 

The AED mention was simply to point out the position of many people during the early days of the public access concept. Many people thought a defibrillator would never hang on the wall outside of a mall but they were wrong. 

For the last time:

1) There IS evidence that shows ECG screening in athletes IS a HELPFUL screening tool and HAS been shown to reduce deaths. I AM WELL AWARE THIS IS NOT CONCLUSIVE EVIDENCE - see #2. However, several studies do support screening programs and these programs ALREADY exist with GOOD results - several students ended up on medication and several were identified as needing surgery as a result of this routine screening.

2) There is NO evidence that say's ABSOLUTELY without a doubt that ECG screening is not useful and life saving. Evidence exists that says screenings make no difference or more so, makes so little difference that cost is not warranted.  

3) It HAS been found that the logistics that many people cite as a roadblock can be overcome and these screenings can be cost effective - including the ECG, echo, and follow-up care. 

4) I am well aware of the limitations of 12-lead screening. I know they will not catch everything. I am well aware some students will still slip through. I am well aware a 12-lead will NOT end student athlete deaths but it CAN identify some at risk and save lives. 

5) Based on current data, research, and cardiologists opinion, it is NOT unreasonable for a person to be willing to further explore these programs and support their implementation in their own community until more conclusive data says otherwise.     

I know in my area, the local hospital has an annual health fair where they offer free diagnostic testing at the local high school. They offer free ECG's, echo's, and lab work. Why is that? Because benefit does exist in routine diagnostic testing and it's important to establish a baseline to identify changes later on in life. These tests are performed as an endeavor to improve community health. But according to you all, the hospital should have big studies to justify the testing performed at the health fair. Without a study its just a waste of time to try to make a difference, right? Why waste time screening people in the community with an echo who are asymptomatic, right? The thought of picking up on something insidious is like finding a million dollars tonight, right?  

Just because a patient is not symptomatic or rise to the level of suspicion for a physician to order a test, doesn't mean a problem isn't in the making.  

I agree with routine diagnostic testing during certain times and events. It can be truly life saving. 

Continue to think what you want. It's cool. I'm not going to criticize anyone for it. It's very reasonable to be against the 12-lead testing at this point in time. I see both sides. I just choose to err on the side of benefit and saving lives even if that is only 50 a year.


----------



## Tigger

18G said:


> You know they're was a time when people said the same thing about AED's and their widespread deployment? Cost vs benefit was once an early argument.
> 
> When AED's first hit the scene I don't think anyone imagined AED's would be found in malls, schools, police cars, and office buildings, due to perceived logistical concerns with liability, purchasing, and training. But they were wrong.
> 
> It has been shown that an ECG can be performed along with follow-up care including an echo for as low as $88.



Yes there was. But that's an entirely different comparison. The reoccurring cost to the organization is quite low with the AED once its been purchased. The same is not true for getting 12 leads for every freshmen.



18G said:


> This is the main problem with this discussion. People misconstrue what I am saying even though I have repeated it several times.
> 
> The AED mention was simply to point out the position of many people during the early days of the public access concept. Many people thought a defibrillator would never hang on the wall outside of a mall but they were wrong.
> 
> For the last time:
> 
> 1) There IS evidence that shows ECG screening in athletes IS a HELPFUL screening tool and HAS been shown to reduce deaths. I AM WELL AWARE THIS IS NOT CONCLUSIVE EVIDENCE - see #2. However, several studies do support screening programs and these programs ALREADY exist with GOOD results - several students ended up on medication and several were identified as needing surgery as a result of this routine screening.
> 
> 2) There is NO evidence that say's ABSOLUTELY without a doubt that ECG screening is not useful and life saving. Evidence exists that says screenings make no difference or more so, makes so little difference that cost is not warranted.



No doubt that testing can save a life. There are lots of other tests that can do the same, where do we draw the line, especially when faced with inconclusive evidence on EKG's effectiveness? Sorry, but I don't buy the "if it saves one life it was worth it" line of thinking.



> 3) It HAS been found that the logistics that many people cite as a roadblock can be overcome and these screenings can be cost effective - including the ECG, echo, and follow-up care.



Have these practices been implemented in sustainable ways? Just because an organization is getting a good deal now on bulk testing does not mean that continues, schools lose their staff physicians and associated perks fairly frequently. Also, the $88 statistic for testing sounds nice, but completely fails to address the logistical hurdle of having to test 100+ athletes annually. There is no possible way that we could conceivably test these athletes before the season starts, there isn't the time, space, or staff available.


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## Aidey

One of the studies approximated there were 25,000,000 student athletes in the US. If just a 12 lead costs $30 that is 750 million dollars. If 50 lives are "saved" that comes out to 15 million per life saved just for the 12 lead costs. 

I'm pretty sure that is waaaaay outside NICE's criteria for a cost effective tool.*

I put saved in quotes because the people may still die even if they don't play sports. 

That is a lot of money. Where is it going to come from? A lot of kids are on some sort of public insurance, and states like California and New Jersey do not have the money to pay for 12 leads for all of them. 

* I know NICE is a UK agency, but they put out good information and it would be a good idea to pay attention to what they're doing.


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## Aerin-Sol

usafmedic45 said:


> Why don't you just change your screen name to Jenny McCarthy because you have about the same burden of proof standards as she does.



That is a wonderful insult.


----------



## systemet

18G said:


> So what is the threshold? How many kids a year need to die before we deem screening a worthwhile endeavor?



This is a call to pathos.

It's easy to say "you can't put a value on a human life", but we do this on a daily basis.  We often make the judgement that a given life-saving intervention is not justified based on cost.

For example, we could:

* Lower the BAC to 0.02 or lower to reduce the number of DUIs and highway fatalities (this has been done with positive results in many European countries).

* Lower highway speed limits

* Increase driver training standards, etc.

All of these things would results in lives saved, including the lives of children.  Much as the current discussion about ECG screening is motivated to do.  But for whatever reason, many societies have decided the cost is not worth it.

That kids are precious, is definitely an argument that we should devote resources to them.  But when are resources are finite, it doesn't logically follow that we should (i) devote all our resources towards children, or (ii) devote a large percentage of the available resources to a given intervention without critically examining whether that money could be better spent elsewhere.


----------



## systemet

18G said:


> This is the main problem with this discussion. People misconstrue what I am saying even though I have repeated it several times.



This seems to happen a lot in the forums.  I would assume that most people are not deliberately twisting your words, or trying to set up strawmen.  Perhaps if you feel you're being misconstrued you can restate your position?




> 1) There IS evidence that shows ECG screening in athletes IS a HELPFUL screening tool and HAS been shown to reduce deaths. I AM WELL AWARE THIS IS NOT CONCLUSIVE EVIDENCE - see #2.



I don't think anyone is arguing that ECG screening can identify patients at risk for hypertrophic cardiomyopathy or ARVD, LQTS, etc. I think that's common ground. 

I think we also have a general consensus that the ECG is not a particularly sensitive or specific means of evaluating hypertrophy.  But that it is much more pratical than echocardiography.



> However, several studies do support screening programs and these programs ALREADY exist with GOOD results - several students ended up on medication and several were identified as needing surgery as a result of this routine screening.



I'm not sure that you've adequately supported this statement.  One paper you linked [1] evaluated 1,424 students, found ECG changes worthy of restricting activity in 12 patients, who were then subsequently cleared to return to exercise following echo.  

It's probably likely that these patients may receive further follow up testing, and be aware of the potential for future problems to develop.  If followed up long enough, it's possible that one of these students might have a syncopal episode, that someone might attribute to electrocardiographic abnormalities identified in this study.  It might be beneficial in this instance.  But this study failed to demonstrate a benefit.

The second study you presented [2] uses the Italian data, and attempts to extrapolate it to the US population and present a model of the theoretical economic benefits.  It's not without merit -- but it's not a report of an existing screening program.  It could be used to make inferences about the likely cost or benefit of such a program once it was introduced in the US, but this is still quite  aleap.




> 2) There is NO evidence that say's ABSOLUTELY without a doubt that ECG screening is not useful and life saving. Evidence exists that says screenings make no difference or more so, makes so little difference that cost is not warranted.



And that seems to be the issue here.  Is whether it's worth the cost.  The study that attempts to address this, is available free here, for anyone who wants to read it:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2873148/?tool=pubmed

At $89/test, with 25 million student athletes, it could become very costly.

They're projecting a cost of $21,200-71,300/ year of useful life saved, and assuming a post-testing life expectancy of 60 years for all identified patients (which may not be a valid assumption).  If we define a "life saved", it looks to me like there's a cost of $1.2-4.2 million / life saved.  But that might not be a valid inference from the text.



> 3) It HAS been found that the logistics that many people cite as a roadblock can be overcome and these screenings can be cost effective - including the ECG, echo, and follow-up care.



I don't think that the data you've presented supports that statement.  They've reported cost-effectiveness numbers, but whether this intervention can be considered cost-effective probably depends on what other avenues for healthcare dollars are available and the relative merits of increasing funding in those areas. 




> 4) I am well aware of the limitations of 12-lead screening. I know they will not catch everything. I am well aware some students will still slip through. I am well aware a 12-lead will NOT end student athlete deaths but it CAN identify some at risk and save lives.



I don't think this is being disputed, is it?

What I don't think is being discussed enough is the burden of a false-positive.  The ECG and echocardiogram themselves are pretty benign.  But what's the cost to the student athlete who's told they can't compete until follow-up has been performed, and loses a half-season, or a place on a team?  What's the dollar value of having some sort of minor-normal variant identified on your ECG and spending the rest of your life worrying about your CVD risk?  

I appreciate these things are hard to quantify, but they're worth mentioning.



> 5) Based on current data, research, and cardiologists opinion, it is NOT unreasonable for a person to be willing to further explore these programs and support their implementation in their own community until more conclusive data says otherwise.



I'm not sure I agree with this either.  Is it worth introducing this if the benefit is small, and the cost high?

I mean, I don't mind paying taxes.  I'm pretty left wing.  I like supporting the health care system.  I think it's fantastic.  But I'm not convinced that this is the best area for my tax dollars to be spent in.

It might be interesting to see some sort of study performed to compare a screening program with ECG to a screening program without.  But this might also be very expensive.  

To make a (non-evidence based, and completely anecdotal) EMS comparison -- if I have a patient who's overdosed on INH, I'd love to have a bucket load of pyridoxine (B6) on the ambulance.  It would be potentially life-saving.  But I've seen this once.  The crew that had the patient gave massive amounts of benzodiazepine and ran to the first ER we could find that actually had pyridoxine on hand.  I can motivate the cost of putting the B6 on the trucks by the potential that it might save lives, but if we throw it out every couple of months, and the system sees this sort of call every couple of years, is it going to be worth it?




> I know in my area, the local hospital has an annual health fair where they offer free diagnostic testing at the local high school. They offer free ECG's, echo's, and lab work. Why is that? Because benefit does exist in routine diagnostic testing and it's important to establish a baseline to identify changes later on in life. These tests are performed as an endeavor to improve community health.



Are they trying to improve community health?  Or is it an attempt to advertise service and provide PR?  Educate the students about health?  Promote health care careers?

If the benefit is there, why hasn't it been shown in the peer-reviewed literature?  And if it has, why not link to it here?




> But according to you all, the hospital should have big studies to justify the testing performed at the health fair.



I know this isn't directed at me personally, but yes.  They should.

If we're going to spend finite resources doing something, we should demonstrate that what we are doing is worthwhile.  Otherwise we should direct those finite resources elsewhere.



> Without a study its just a waste of time to try to make a difference, right?



No.  It's not a waste of time to try and make a difference.  But we might be wasting our time because we're not making a difference.  There's an important distinction there.




> Why waste time screening people in the community with an echo who are asymptomatic, right? The thought of picking up on something insidious is like finding a million dollars tonight, right?



Well, this is the question?  Are we spending 10 million dollars that could be spent in an area where there's demonstrable benefit to save a million dollars elsewhere?



> Just because a patient is not symptomatic or rise to the level of suspicion for a physician to order a test, doesn't mean a problem isn't in the making.



I don't think anyone is arguing against this point.  



> Continue to think what you want. It's cool. I'm not going to criticize anyone for it. It's very reasonable to be against the 12-lead testing at this point in time. I see both sides. I just choose to err on the side of benefit and saving lives even if that is only 50 a year.



You're entitled to your opinion.  Just as other people are entitled to disagree with you.  

But at the same time, if you can't justify that opinion in the basis of peer-reviewed research, you are going to have difficulty convincing people with an academic background to side with you.

It's been fun discussing this, though. I hope there's no hard feelings.


[1]Lacorte MA,  Boxer RA,  Gottesfeld IB, Singh S, Strong M, Mandell L.  EKG Screening Program for School Athletes Clin. Cardiol. 12, 42-44 (1989)

[2]Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA.
Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010 Mar 2;152(5):276-86.


----------



## 18G

I'm curious... if your taking your child for a sports physical and knowing its possible that an ECG could be life saving,  would you personally ask for a 12 lead or would you be willing to assume the risk of death and not want the extra level of screening for your son or daughter? 

This is a general question to all.


----------



## Rogue Medic

> I think it's time to mandate 12-leads as a standard part of a school physical.





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




Can you even produce numbers 90% of the time?

How about 50%?

How about 10%?

1%?

Less?

-



> The program has screened 6,685 students over four years, with 41 told to stop exercising pending further medical evaluation and another 663 sent on for follow-up but not told to stop exercising."



You want to force everyone to participate, or do you define mandatory in your own particular way? As many have pointed out, the research does not support your conclusion.

A much greater problem for children is obesity, but you come up with a plan to discourage exercise, Brilliant!

Should we label children as too sick to exercise, even though we cannot reliably identify which children will have problems?

What we are telling children is that "Exercise is dangerous."



> stop exercising pending further medical evaluation



Were any lives saved, or were a bunch of student athletes victims of exaggerated anxiety that would have been better treated by giving the "Stop exercise" people some Ativan. 

We need proof of benefit, not some omniscient Monday morning quarterbacking using only the bad outcomes to pretend we would have prevented those deaths. 

.


----------



## Rogue Medic

> I'm curious... if your taking your child for a sports physical and knowing its possible that an ECG could be life saving, would you personally ask for a 12 lead or would you be willing to assume the risk of death and not want the extra level of screening for your son or daughter?




I'm curious... if your taking your child for a sports physical and knowing its possible that having a _*witchdoctor chant magical incantations over your daughter*_ could be life saving, would you personally ask for a _*witchdoctor to chant magical incantations over your daughter*_ or would you be willing to assume the risk of death and not want the extra level of screening for your son or daughter?

.


----------



## 18G

Good discussion and points


----------



## systemet

18G said:


> I'm curious... if your taking your child for a sports physical and knowing its possible that an ECG could be life saving,  would you personally ask for a 12 lead or would you be willing to assume the risk of death and not want the extra level of screening for your son or daughter?
> 
> This is a general question to all.



This is also a call to pathos, right?  

I mean it doesn't logically follow that if I want my child to have ECG screening, that universal screening should be introduced for all athletes.  Nor does any hypocrisy in me wanting a child to receive an ECG mean that the logical reasoning that ECG testing may not be cost-effective or desirable on a population level is somehow invalid.

If I can get something for free, I'll take 5.  But if an ECG screen showed changes suspicious for HCM, I don't know if I'd support exercise restriction.  

If someone offers a free whole body CT scan, I'd have a bit of a think about the risk of unnecessary radiation exposure, the risks of detecting a subclinical AVM that results in potentially hazardous neurosurgery that might never have been necessary nor performed if no physical symptoms manifested, and the psychological cost of finding out about an inoperable high risk leson.  But I'd probably say yes.

It doesn't logically follow that we should CT scan every child in the high school population, just because we might identify some kids who could benefit from neurosurgery, etc.

[I'm not suggesting that something as expensive as CT is equivalent to ECG, my point is simply that an individual parent's wishes might not be a solid basis on which to form policy that affecting use of the health care resources available to an entire country.]


----------



## usafmedic45

> I'm curious... if your taking your child for a sports physical and knowing its possible that an ECG could be life saving, would you personally ask for a 12 lead or would you be willing to assume the risk of death and not want the extra level of screening for your son or daughter?



No, I wouldn't.  The risk of things that could be identified by a 12-lead is so low as to be akin to the risk of my daughter being struck by lightning while the storm is 40 miles away ("bolt out of the blue").  If I were to worry about things with that level of risk, she'd be anemic- if not flat out hypovolemic- from all the screening tests she'd need for genetic disorders and the annual tests for non-genetic issues.


----------



## usafmedic45

18G said:


> Good discussion and points



Just out of curiosity, how is Rogue smacking you upside the head with the falter points of your theory any different from what Smack, SystemET, Aidey and myself have been doing all along that got us (or at least me) labeled as being arrogant?


----------



## Sasha

usafmedic45 said:


> Just out of curiosity, how is Rogue smacking you upside the head with the falter points of your theory any different from what Smack, SystemET, Aidey and myself have been doing all along that got us (or at least me) labeled as being arrogant?



You freely admit you're arrogant, so why are you taking issue with him labeling you arrogant?


----------



## firetender

*Kids die, too.*

Yes, it seems all that more tragic, especially when a kid dies doing what he/she loves (sports) but the incidence is so small that it truly does not necessitate the words "mandatory screening".

I have no scientific evidence to back this up but I'm not convinced that the numbers would change if the supposed 25,000,000 kids were to be tested. With an incidence of 45 deaths, let's face it, every one of them slipped through the cracks somewhere.

Isn't this a "slipped through the cracks" sort of thing by its essence?

Now if it were mandated that ambulance medics were the persons trained to do the EKG's and get PAID for it, maybe it would make perfect selfish sense. If we were a real profession we could then take a few studies as shown that SUGGEST mandatory screening could help, publicize them and then lobby for us to get to do the work.

But still, who's gonna pay for it?


----------



## usafmedic45

Sasha said:


> You freely admit you're arrogant, so why are you taking issue with him labeling you arrogant?



I freely admit many things, but I'm not excessively arrogant at least not in the sense that I don't know what I am talking about or that I exhibit an undeserved level of respect for my own knowledge.  I'm a smartass but not arrogant.  I only take issue because he soundly rejected any attempt by the folks I listed, including myself, to rebuff his stance but yet views it as a positive thing when someone else does the same thing.  My only issue therefore is with the appearance of a double standard.


----------



## Rogue Medic

> Just out of curiosity, how is Rogue smacking you upside the head with the falter points of your theory any different from what Smack, SystemET, Aidey and myself have been doing all along that got us (or at least me) labeled as being arrogant?



I have very good karma. I am willing to sell it for a reasonable price. :wacko:

Or maybe he did not intend that to apply to me.

Either way, there is a two-for-one sale on the good karma. 

.


----------



## usafmedic45

Rogue Medic said:


> I have very good karma. I am willing to sell it for a reasonable price. :wacko:
> 
> Or maybe he did not intend that to apply to me.
> 
> Either way, there is a two-for-one sale on the good karma.
> 
> .



LOL No thinks, I like my scratch and dent conscience.


----------



## 18G

usafmedic45 said:


> Just out of curiosity, how is Rogue smacking you upside the head with the falter points of your theory any different from what Smack, SystemET, Aidey and myself have been doing all along that got us (or at least me) labeled as being arrogant?



My comment was laced with just pinch of sarcasm. I must admit I do intentionally push the envelope sometimes with discussions to get more input  

I'm still on the fence though. I'm not totally convinced the idea should be abandoned but a lot of good points were made. If I would have agreed right from the start these points and great responses would have never came. 

I think more debate and research needs to happen and still think value is contained in doing these 12-leads. Now whether or not it makes sense on a large scale is a whole other issue. But individually speaking I think a 12-lead as a screening tool in conjunction with a good exam can make a difference.  

Again, good discussion and points


----------



## Akulahawk

18G said:


> I'm curious... if your taking your child for a sports physical and knowing its possible that an ECG could be life saving,  would you personally ask for a 12 lead or would you be willing to assume the risk of death and not want the extra level of screening for your son or daughter?
> 
> This is a general question to all.


I would not ask for a 12-lead. I would expect that the clinician doing the screening exam would go over risk factors and do a good, targeted CV, Resp, and Ortho exam. I would further expect that my daughter's primary Doc would do a good general physical exam covering all the systems adequately enough to clear her for general physical activity. 

While I'm playing the odds, I'm quite comfortable with them. Males are about 7x more likely to die from this than females... and the overall risk is very, very low to begin with. 

The other issue is that athletes can get an enlarged heart from physical activity and some of those changes can be permanent. So, if you see some of those changes on an ECG and you don't recognize that you're dealing with a garden variety "athlete heart" you can easily end up restricting that athlete from all physical activity (not just practice) and deconditioning becomes a HUGE issue, so that when you eventually do get them in for an echo, generally nothing is found... you've just cost the athlete 2-3 weeks of deconditioning, another 5-7 weeks of reconditioning/rehab, and the mental anguish from being "benched" for the majority of that time, not to mention the worry that something horrible is about to befall them. Then on top of all that, you do have the cost of the echo. 

Now, I would imagine that MOST of the athletes that perform at a fairly decent level (say top 10-15% of all humans) would likely have these changes, do you propose benching most of a competitive team because of something that's of very low risk? Now granted, benching an athlete for 3 weeks to allow deconditioning to occur will allow sufficient time for changes to be evident on an echo to conclusively see that it was "just" athlete's heart... but by then the damage is done.


----------



## systemet

A few interesting links here:

http://stanfordhospital.org/clinics...iseasesConditions/hypertrophicCardiomyopathy/

* A long video and document on hypertrophic cardiomyopathy.

http://familyheart.stanford.edu/clinics/arvc1.html

* A little bit about inherited CVD including ARVD

http://athletesheart.blogspot.com/2010/03/in-news-get-ekg.html

* A really neat cardiac surgeon's blog, discussing these topics  (he equivocates, but 18G might be happy to see that in his opinion any intervention with a cost of <$100,000 / year of useful life saved is probably worthwhile.


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## jjesusfreak01

firetender said:


> Now if it were mandated that ambulance medics were the persons trained to do the EKG's and get PAID for it, maybe it would make perfect selfish sense. If we were a real profession we could then take a few studies as shown that SUGGEST mandatory screening could help, publicize them and then lobby for us to get to do the work.



Which would actually be preferable, because I don't know about your experience with this, but from what i've seen your garden variety PCP/GP isn't an expert at reading 12-leads and probably hasn't done it more than a handful of times since med school. PCPs refer their patients to appropriate specialists when need be, they don't replace the specialists.

PS: I'm running standby at a high school athletics event tomorrow...maybe i'll do a 12-lead on an athlete? I'll let everyone know if I find anything.


----------



## Akulahawk

jjesusfreak01 said:


> Which would actually be preferable, because I don't know about your experience with this, but from what i've seen your garden variety PCP/GP isn't an expert at reading 12-leads and probably hasn't done it more than a handful of times since med school. PCPs refer their patients to appropriate specialists when need be, they don't replace the specialists.
> 
> PS: I'm running standby at a high school athletics event tomorrow...maybe i'll do a 12-lead on an athlete? I'll let everyone know if I find anything.


Find one with a resting rate at say 50 or slower. I doubt you'd find anything of note in an athlete with a resting HR >60 or so.


----------



## 18G

Came across this write up titled "Should Young Athletes Be Screened for Heart Risk?" that appeared in the New York Times on 4/30/2012. It reminded me of the strong debate in this thread. 

Apparently, the requirement for 12-leads in student athletes is gaining support with new data to support it. 



> While it can strike those who are sedentary, the risk is up to three times greater in competitive athletes. According to some experts, a high school student dies of cardiac arrest as often as every three days. Only the most sensational cases make headlines, said Darla Varrenti, executive director of the Nick of Time Foundation





> For years, the argument against EKGs was that for something as rare as sudden cardiac death, there is no sense in mandating costly tests. EKGs can be unreliable, too, producing false-positive results 20 percent of the time, critics say.
> 
> But that argument pivots on old data, including outdated numbers on the prevalence of sudden cardiac death, and fails to take into account improvements in the standards for interpreting EKG results, said Dr. Jonathan Drezner, an associate professor of family medicine at the University of Washington and vice president of the American Medical Society for Sports Medicine.
> 
> Even physical exams that include extensive medical histories typically fail to identify 60 percent to 80 percent of student athletes at risk, Dr. Drezner said. Adding an EKG to the sports physical would flag many young athletes whose heart defects would otherwise go unnoticed.



A physical exam alone misses 60-80% of students at risk???? And we're okay with missing this many!?

http://well.blogs.nytimes.com/2012/04/30/heart-risk-in-athletes-is-gaining-attention/


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## Rogue Medic

A false positive only 20% of the time?

2,000 deaths per year?



> 2 studies from Maron et al 10,11 estimate fewer than 100 cases of SCA in young US competitive athletes each year.



That is from the position paper the article links to as supporting the 2,000 deaths per year.

2,000 vs fewer than 100, but we can make the number whatever we want, because *we can make reality whatever we want it to be.*

The article lists the cost of an ECG as both $1,400 and $89. 

This completely ignores the children who will be discouraged from exercise, and the possible negative effects of lack of exercise.

Then they repeat the idiotic emotional appeal - If it saves just one life, who cares how many others die because of this. 

They have a grant to do some research. They are looking for more money. This was written to get money. 

This is not journalism.

This is an advertisement.  :sad:

.


----------



## Tigger

18G said:


> A physical exam alone misses 60-80% of students at risk???? And we're okay with missing this many!?



No, where I work we are not ok with that. However I would like to see some evidence behind that number. SCA is still incredibly rare in athletics, and not that any deaths are acceptable, but pragmatically all are not preventable.

Incidentally my Sports Medicine department was recently gifted a 12 lead machine from the campus health center. We will (hopefully) be able to acquire 12 leads at the request of a doctor for our athletes and then fax them to our cardiologist for interpretation. Hopefully this will make the cardiac screening process a little bit easier and will prevent athletes from "forgetting" to go to the cardiologist.


----------



## Akulahawk

That article (and the other article linked in there) state that 2,000 young people die each year from SCA... and defines that as people under 25 years of age. They then go on to further state that about 100 athletes (presumably from the same age group) also die from SCA each year. Given that (probably millions) a sizable population of K-12/College students engage in competitive athletics each year, the chances of finding an athlete who is at risk for SCA would be probably be quite low. 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.


----------



## 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

18G said:


> 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

Akulahawk said:


> 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/


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## systemet

Aprz said:


> 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

Aprz said:


> 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

18G said:


> 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

Veneficus said:


> 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

Veneficus said:


> 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. 



Veneficus said:


> 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

Veneficus said:


> 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*



18G said:


> 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?


----------



## 18G

What happened to "studies don't prove something as fact???"  The US has great healthcare... I see it firsthand.


----------



## Veneficus

*Oh what a tangled web we weave*



18G said:


> What happened to "studies don't prove something as fact???"  The US has great healthcare... I see it firsthand.



When we use propaganda to deceive.

http://www.ncbi.nlm.nih.gov/pubmed/21610339

http://www.ncbi.nlm.nih.gov/pubmed/17993963

http://www.ncbi.nlm.nih.gov/pubmed/18936372

http://www.ncbi.nlm.nih.gov/pubmed/19853754

http://www.ncbi.nlm.nih.gov/pubmed/17998346

http://www.ncbi.nlm.nih.gov/pubmed/18191781

there are a total of 2384 publications about this on pubmed. Maybe it is true?


----------



## Veneficus

18G said:


> What happened to "studies don't prove something as fact???"  The US has great healthcare... I see it firsthand.



the first article wasn't a study.  

Studies as proof rest in Preponderance of the Evidence.

Do you see other health systems healthcare first hand?

Does your anecdote supercede objective measure?

I would also point out that the first article was published in the number 1 US medical journal, by US experts, so maybe the insiders have a perspective on this that differs from yours?

Hate to pull the flag out from in front of your eyes, but the main thing US healthcare is #1 at is price.

I would also point out that second year death rates in a population have been used to qualify healthcare effectiveness in both medicine and anthropology. (2 seperate disciplines!)

In 2012 in order to find a place worse than the US, you would have to go to Africa. Even China and Russia do better. (Epic fail)

and before we talk about technically complicated medicine:

http://www.ncbi.nlm.nih.gov/pubmed/20883546

I have 11 more like it.

and somebody will inevitably say that wealthy people from the middle east always go to the US, but wealthy and smart are not =


----------



## Sasha

18G said:


> What happened to "studies don't prove something as fact???"  The US has great healthcare... I see it firsthand.



If you are lucky enough to be able to afford it.


----------



## Veneficus

Sasha said:


> If you are lucky enough to be able to afford it.



If you can pay cash, you can have the same other places too. At a much lower cost.

The propaganda machine ever turns to passify the ignorant masses.

and don't be an elitist and get an education either...

I am looking for a study that compares the amount of people who leave the US for medical care compared to the amount that go to the US.


----------



## 18G

Yet another study and evidence for use of an ECG and Echo to screen student athletes. 

July 1, 2012

http://cincinnatichildrensblog.org/...ing-method-for-sudden-death-in-teen-athletes/

http://www.cincinnatichildrens.org/news/release/2012/sudden-death-in-athletes-07-21-2012/


----------



## VFlutter

Here is an article regarding SCA in the NFL. None of these are scientific by any means but puts a broader perspective on the topic. 
http://http://www.livingheartfoundation.org/suddencardiacdeath.pdf

"The electrocardiogram (1,282 players) revealed that more than 50% of these selected athletes had abnormal findings in spite of being asymptomatic and appearing fit. The prevailing opinion is that the electrocardiogram in young, asymptomatic, large-sized males is non-specific and sometimes misleading. The echocardiogram (156 players), a more sensitive testing method, showed that many of these football players showed hearts that were larger and thicker than accepted standards for people in the general population. The authors noted that these changes on echocardiogram were correlated with the playersí body size. The significance of these findings requires further serial testing and correlations with future clinical outcomes, before conclusions may be made."


Imagine if 50% of those 25,000,000 athletes were referred for further evaluation. 

http://http://www.sca-aware.org/sca-news/nfl-may-mandate-heart-ultrasounds

This seems to be a case of falling through the cracks, but this particular athlete had numerous physical exams throughout his entire athletic career as well as en EKG performed at the combine but still died. 

So even if every student athlete received an EKG or even an Echo for that matter, would it really have any drastic change in the number of deaths? Enought to justify it?

You stated this should be mandatory.  What about the athlete who is informed of the risk and does not want to have an EKG but is forced into getting one which results in the discovery of some abnormality that may or may not ever cause an issue but is then benched losing his college scholarship or not drafted because a team does not want to risk it. But due to your paternalism you "potentially saved his life" but also ruined it at the same time. I know it's a very far fetched and slippery slope argument but I think the false positives can create a problem. 


PS: I love the quote at the top of the page. "To save one life is as if to save the world" : I guess I am heartless and do not share the same opinion


----------



## 18G

ChaseZ33 said:


> PS: I love the quote at the top of the page. "To save one life is as if to save the world" : I guess I am heartless and do not share the same opinion



If that one life is your son or daughter, than yes, that is the same as saving the world.


----------



## VFlutter

18G said:


> If that one life is your son or daughter, than yes, that is the same as saving the world.



That is just emotional bias and semantics. This is why the average person can be so easily convinced that this would be a great idea. Your tugging on heart strings to support something that most likely will have very little reduction of deaths.


----------



## 18G

ChaseZ33 said:


> That is just emotional bias and semantics. This is why the average person can be so easily convinced that this would be a great idea. Your tugging on heart strings to support something that most likely will have very little reduction of deaths.



Yeah, and you know so much more than the cardiologists from the multiple studies advocating this, right?

It's not emotional bias when it's your kid. Do you even have kids? It's not something to be written off.


----------



## dewey

18G said:


> It's not emotional bias when it's your kid.



Yes, it is.  That is the epitome of emotional bias.

Very interesting read.  Why do I have the sneaking suspicion that OP is either a politician, or directly involved financially in pushing these ECG's?

Glad to see OP also seemed to learn the difference between there/their/they're, and your/you're towards the end!


----------



## Tigger

18G said:


> Yeah, and you know so much more than the cardiologists from the multiple studies advocating this, right?
> 
> It's not emotional bias when it's your kid. Do you even have kids? It's not something to be written off.



I don't think I need kids to determine that the above statement is an excellent example of letting emotions effect one's view on a practical issue.


----------



## 18G

For everyone on here that preaches the, "show me evidence, show me evidence".... studies are being done by leading pediatric cardiologists at major US hospitals and evidence is being provided yet people are still discounting the potential positives of this. 

Is it absolute? No, and I'm not saying that at this point. Is the research going in that direction? I think so.

So what are the opinions of the studies that have been done recently on this issue? Are you all saying the research was flawed or done poorly?


----------



## 18G

Tigger said:


> I don't think I need kids to determine that the above statement is an excellent example of letting emotions effect one's view on a practical issue.



You know there was a time when AED's in malls, office buildings and airports was deemed very impractical with much resistance against it? Some were saying defibrillation was an advanced skill, was dangerous for minimally trained people, etc, etc. Guess who was wrong??


----------



## VFlutter

18G said:


> For everyone on here that preaches the, "show me evidence, show me evidence".... studies are being done by leading pediatric cardiologists at major US hospitals and evidence is being provided yet people are still discounting the potential positives of this.
> 
> Is it absolute? No, and I'm not saying that at this point. Is the research going in that direction? I think so.
> 
> So what are the opinions of the studies that have been done recently on this issue? Are you all saying the research was flawed or done poorly?



There seems to be a few arguments going on. I am not saying that doing these EKGs would not have a positive outcome, I am arguing that the small potential positive outcome is not worth the cost. I do not agree with the "if we save one child it is all worth it" mentality. If I was some politican with $xxx,xxx,xxx to spend I wouldn't be looking to dump it into this.


----------



## 18G

ChaseZ33 said:


> There seems to be a few arguments going on. I am not saying that doing these EKGs would not have a positive outcome, I am arguing that the small potential positive outcome is not worth the cost. I do not agree with the "if we save one child it is all worth it" mentality. If I was some politican with $xxx,xxx,xxx to spend I wouldn't be looking to dump it into this.



And the thousands of $$$ for AED's and the maintenance contracts in schools is worth it for the small chance they may be needed? Why not just save the money and depend on EMS?  If the patient dies oh well, it only happens on rare occasion.


----------



## jwk

Good grief, it's exhausting reading through this thread.

"...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..."

This is one of the more absurd quotes from this lengthy thread.  I'm curious - what signs and symptoms could be recognized that could progress to SCA are there, besides SCA?  Seriously?

Anyway - there are a lot of emotional arguments floating around - "saving even one life is worth the cost" sounds very noble - but in this day and time, you're going to have to REALLY justify the cost.  And that's only going to get more and more difficult with Obamacare on the horizon.  Here's an option I haven't seen mentioned:   

My son started playing high school football the year after one of our athletes died from SCA due to previously undiagnosed cardiomyopathy.  This happened about 10 years ago.  At that time, AED's were not routinely available in our public schools, nor was any kind of routine screening of athletes.  To say that we had a vested interest in "doing something" would be a gross understatement.  Athletes, coaches, and athlete families were affected by this tragedy for years.

Our solution at our local high school went something like this.  I realize it won't work everywhere, but it worked for us.  The first thing that happened following this was to purchase AED's for the school (there were none on-site).  They are fairly readily available any time of the day that school is in session, and immediately available for all events.  For football, which for better or worse is the big money sport, an ambulance is present for every game, along with a few thousand fans.  If we can't get the local public or private EMS service to do their "stand by" at our games, the booster club will foot the bill to make it  happen.  

Every athlete in Georgia high schools is required to have an annual physical exam by their physician.  If anything is going to be mandatory, this is it.

And finally, for our program, every athlete is offered the opportunity to have an echocardiogram done when they start their athletic career.  It's totally optional, but many take advantage of it.  The cost is $75 total for exam, tech, and interpretation by a cardiologist.  Parents pay for the exam, and if they can't afford it and want it, it magically gets taken care of.  We refer a few athletes each season for follow-up.  I would guess we do about 100 exams per year for our large high school.

Obviously nobody is making any real money off this program, and the charge is drastically reduced from what a hospital or cardiologist would normally charge.  It's voluntary, but available to all regardless of ability to pay.  I'm aware of other schools that strike a deal with a local hospital to run similar programs, with the hospital of course getting a ton of free publicity and "sponsor" status for various sports.

Mandatory screening with EKG / echo ?  I dunno, I'm not convinced - but the peace of mind was well worth the $75 it cost us 9 years ago.  I'd do it again in a heartbeat.


----------



## 18G

jwk said:


> And finally, for our program, every athlete is offered the opportunity to have an echocardiogram done when they start their athletic career.  It's totally optional, but many take advantage of it.  The cost is $75 total for exam, tech, and interpretation by a cardiologist.  Parents pay for the exam, and if they can't afford it and want it, it magically gets taken care of.  We refer a few athletes each season for follow-up.  I would guess we do about 100 exams per year for our large high school.
> 
> Obviously nobody is making any real money off this program, and the charge is drastically reduced from what a hospital or cardiologist would normally charge.  It's voluntary, but available to all regardless of ability to pay.  I'm aware of other schools that strike a deal with a local hospital to run similar programs, with the hospital of course getting a ton of free publicity and "sponsor" status for various sports.
> 
> Mandatory screening with EKG / echo ?  I dunno, I'm not convinced - but the peace of mind was well worth the $75 it cost us 9 years ago.  I'd do it again in a heartbeat.



I like this solution. Educating the students and parents first and offering the screening at a reduced costs sounds reasonable. At least parents and students are informed of the risks and given the chance to have the screening which is better than playing off ignorance and not even giving the family a chance to decide for themselves. 

As far as S/S to recognize, they are referring to dyspnea, dizziness, chest pain, syncope, stuff like that.


----------



## Veneficus

18G said:


> For everyone on here that preaches the, "show me evidence, show me evidence".... studies are being done by leading pediatric cardiologists at major US hospitals and evidence is being provided yet people are still discounting the potential positives of this.
> 
> Is it absolute? No, and I'm not saying that at this point. Is the research going in that direction? I think so.
> 
> So what are the opinions of the studies that have been done recently on this issue? Are you all saying the research was flawed or done poorly?





18G said:


> For everyone on here that preaches the, "show me evidence, show me evidence".... studies are being done by leading pediatric cardiologists at major US hospitals and evidence is being provided yet people are still discounting the potential positives of this.
> 
> Is it absolute? No, and I'm not saying that at this point. Is the research going in that direction? I think so.
> 
> So what are the opinions of the studies that have been done recently on this issue? Are you all saying the research was flawed or done poorly?



My reservation isn't about not helping, it is how much is it going to cost and how much damage will it do for any benefit?

If a parent wants their kid to have an EKG today, for piece of mind, for protection, etc. There is nothing that stops them from getting one.

But as cold as it sounds, costing millions if not hundreds of millions to save a handful of people per year is just not realistic.


----------



## Smash

Veneficus said:


> But as cold as it sounds, costing millions if not hundreds of millions to save a handful of people per year is just not realistic.



It doesn't sound cold, it sound entirely sensible.  There is no health system in the world (as far as I am aware) that does not have to ration the health dollar.  Spending enormous amounts of money screening a population that is, almost by definition, low risk makes no sense whatsoever.

I'm becoming increasingly convinced that _any _screening program causes more problems than it solves.  One only has to look at the debacles of mammography or PSA screening to see that.  Or closer to home for us EM types, the delightful saga that is PE diagnosis.


----------



## Tigger

18G said:


> You know there was a time when AED's in malls, office buildings and airports was deemed very impractical with much resistance against it? Some were saying defibrillation was an advanced skill, was dangerous for minimally trained people, etc, etc. Guess who was wrong??



Never mind the fact that AEDs have come a long way in terms of simplicity of use in the last 15 years, I see this comparison as rather apples to oranges. Those AEDs have a very low reoccurring cause and have the potential to save many more thousands of people per year. I doubt it's been studied, but I'd put money on school AEDs being used more on adults than children. I'd much rather see an AED at every youth sporting event before mandatory 12 leads, no screening program is going to prevent any comotio cordis type incidents that a rapidly used AED has the ability to remedy.


----------



## 18G

Tigger said:


> Never mind the fact that AEDs have come a long way in terms of simplicity of use in the last 15 years, I see this comparison as rather apples to oranges. Those AEDs have a very low reoccurring cause and have the potential to save many more thousands of people per year. I doubt it's been studied, but I'd put money on school AEDs being used more on adults than children. I'd much rather see an AED at every youth sporting event before mandatory 12 leads, no screening program is going to prevent any comotio cordis type incidents that a rapidly used AED has the ability to remedy.



It's the mentality surrounding that was the point.

Everyone speaks of the "high cost". It's being shown that the cost isn't that high at all. Like JWK pointed out, an echo performed and read by a cardiologist for only $75. 

I think mandatory 12-leads should still be required. But I also think that as long as parents/students are given information by the physician directly and in the form of a hand-out at the time of the physical and a discounted rate is offered for a 12-lead and echo, that would be a great option too.

I think by law parents should have to be informed of the potential risk and benefit of additional screening level with ECG and Echo.


----------



## Veneficus

18G said:


> It's the mentality surrounding that was the point.
> 
> Everyone speaks of the "high cost". It's being shown that the cost isn't that high at all. Like JWK pointed out, an echo performed and read by a cardiologist for only $75.
> 
> I think mandatory 12-leads should still be required. But I also think that as long as parents/students are given information by the physician directly and in the form of a hand-out at the time of the physical and a discounted rate is offered for a 12-lead and echo, that would be a great option too.
> 
> I think by law parents should have to be informed of the potential risk and benefit of additional screening level with ECG and Echo.



How many kids play school sports across the country?

At $75 each, (which I think is area dependant anyway) every year, in just a few short years, that is going to be a lot of money.

If there are 1 million high school athletes in the US per year, that is 75 million a year.

Let's say you save 10 lives (probably over estimated by double) You are still spending 7.5 million per year for that. 

I can think of dozens of ways to save a lot more lives than 10 for $7.5 million


----------



## 18G

Veneficus said:


> How many kids play school sports across the country?
> 
> At $75 each, (which I think is area dependant anyway) every year, in just a few short years, that is going to be a lot of money.
> 
> If there are 1 million high school athletes in the US per year, that is 75 million a year.
> 
> Let's say you save 10 lives (probably over estimated by double) You are still spending 7.5 million per year for that.
> 
> I can think of dozens of ways to save a lot more lives than 10 for $7.5 million



That's a nice spin on numbers. 

If parent's want to spend money they worked for to screen their child then your numbers become irrelevant since it's not millions of dollars. It then becomes only $75. 

What's the difference if someone spends $75 on an ECG or Echo or spends it at Wal-Mart?? A parent is free to spend their money on whatever they choose and if they feel it's a worthwhile investment into their child's well being then what's it matter to anyone else? At the end of the day it's not you that has to see the $75 come out of your bank account or possibly see the result of not having the screening done. $75 isn't much for having peace of mind. 

The only people this screening would be affecting are the ones paying for it out of pocket if this model is used.


----------



## Veneficus

18G said:


> That's a nice spin on numbers.
> 
> If parent's want to spend money they worked for to screen their child then your numbers become irrelevant since it's not millions of dollars. It then becomes only $75.
> 
> What's the difference if someone spends $75 on an ECG or Echo or spends it at Wal-Mart?? A parent is free to spend their money on whatever they choose and if they feel it's a worthwhile investment into their child's well being then what's it matter to anyone else? At the end of the day it's not you that has to see the $75 come out of your bank account or possibly see the result of not having the screening done. $75 isn't much for having peace of mind.
> 
> The only people this screening would be affecting are the ones paying for it out of pocket if this model is used.



but if it is mandated, then somebody has to pay. What about the people who cannot afford it, should they be prohibited from playing?


----------



## Akulahawk

18G said:


> That's a nice spin on numbers.
> 
> If parent's want to spend money they worked for to screen their child then your numbers become irrelevant since it's not millions of dollars. It then becomes only $75.
> 
> What's the difference if someone spends $75 on an ECG or Echo or spends it at Wal-Mart?? A parent is free to spend their money on whatever they choose and if they feel it's a worthwhile investment into their child's well being then what's it matter to anyone else? At the end of the day it's not you that has to see the $75 come out of your bank account or possibly see the result of not having the screening done. $75 isn't much for having peace of mind.
> 
> The only people this screening would be affecting are the ones paying for it out of pocket if this model is used.





Veneficus said:


> but if it is mandated, then somebody has to pay. What about the people who cannot afford it, should they be prohibited from playing?


I agree greatly with Vene here. If 12-leads and/or echo tests become mandatory, that will automatically cut out a LOT of kids from playing simply from the family economics. Must the kids be tested once? Annually? Since it is mandatory by a public agency, will there be subsidized testing for those that cannot afford it? Who will do the means testing to determine that? While an ECG and/or echo could catch some problems early on, those things won't help those that can't pay, nor will it really help prevent problems later on. Why? You're not going to keep your heart rate down to a non-stressed level, even if you're not an athlete. Could it be that vigorous horizontal activity (say in a bed or back seat of a car) might just get your heart going? Could it be that you experience something really scary and your heart goes racing? 

Then suppose that a problem is found that is correctable, say, surgically. Who pays for the procedure now that it has been found by a mandated program? 

Personally, I think that doing these studies should be completely upon the request of the family of each athlete. It would be nice to have info by the team physician and/or ATC, but, I feel that money would be far better spent purchasing AED's and having them immediately available during practices and games than purchasing 12-lead machines. 

Oh, and what about private sports leagues? Who regulates who plays there? Certainly schools can't... so those kids that can't get the studies done and are prevented from playing in a school-sanctioned sports program can just find a private group and play there. Imagine the lawsuit for being refused to play by a school because the kid can't get a screening done and then the kid suffers a cardiac event during that non-school regulated play and this could have been caught by this mandated but uncompensated screening? 

Oh... Yeah, I can go on...


----------



## 18G

Akulahawk said:


> I agree greatly with Vene here. If 12-leads and/or echo tests become mandatory, that will automatically cut out a LOT of kids from playing simply from the family economics. Must the kids be tested once? Annually? Since it is mandatory by a public agency, will there be subsidized testing for those that cannot afford it? Who will do the means testing to determine that? While an ECG and/or echo could catch some problems early on, those things won't help those that can't pay, nor will it really help prevent problems later on. Why? You're not going to keep your heart rate down to a non-stressed level, even if you're not an athlete. Could it be that vigorous horizontal activity (say in a bed or back seat of a car) might just get your heart going? Could it be that you experience something really scary and your heart goes racing?
> 
> Then suppose that a problem is found that is correctable, say, surgically. Who pays for the procedure now that it has been found by a mandated program?
> 
> Personally, I think that doing these studies should be completely upon the request of the family of each athlete. It would be nice to have info by the team physician and/or ATC, but, I feel that money would be far better spent purchasing AED's and having them immediately available during practices and games than purchasing 12-lead machines.
> 
> Oh, and what about private sports leagues? Who regulates who plays there? Certainly schools can't... so those kids that can't get the studies done and are prevented from playing in a school-sanctioned sports program can just find a private group and play there. Imagine the lawsuit for being refused to play by a school because the kid can't get a screening done and then the kid suffers a cardiac event during that non-school regulated play and this could have been caught by this mandated but uncompensated screening?
> 
> Oh... Yeah, I can go on...



Screenings take place for a reason. Is it fair some people are disqualified from going into the military because of seemingly stupid medical reasons? If a diabetic takes insulin, they cannot hold a DOT certificate and as such can not work. For me, that would mean I couldn't work as a Paramedic. Is that fair??

Yeah, guess what, your kid can't play sports but instead we're going to inform you of a problem you wouldn't have otherwise known about and give you options for dealing with it. 

A parent could have the right to sign a waiver and allow their kid to play anyway. It should ultimately fall on parent and student for deciding. But they need armed with the information first.


----------



## Tigger

18G said:


> Screenings take place for a reason. Is it fair some people are disqualified from going into the military because of seemingly stupid medical reasons? If a diabetic takes insulin, they cannot hold a DOT certificate and as such can not work. For me, that would mean I couldn't work as a Paramedic. Is that fair??
> 
> Yeah, guess what, your kid can't play sports but instead we're going to inform you of a problem you wouldn't have otherwise known about and give you options for dealing with it.
> 
> A parent could have the right to sign a waiver and allow their kid to play anyway. It should ultimately fall on parent and student for deciding. But they need armed with the information first.



I don't think a waiver is going to be enough to protect a school district from getting sued if they screen a child and discover that they have a cardiac condition yet the parents allow to play. Peoria sign away their right to sue all the time, and then still sue anyway. Even if the school could easily found liable they still have to pay legal fees. Why would any school allow someone to compete in their program with a known heart condition?


----------



## Smash

18G said:


> Yeah, guess what, your kid can't play sports but instead we're going to inform you of a problem you wouldn't have otherwise known about and give you options for dealing with it.



Or we are going to "inform" you about a false positive, meaning your kid, who is absolutely healthy, doesn't get to play sport.  Or worse, we are going to inform you of a false negative, so your kid dies anyway.  Then you can come back and sue the doctor, the tech, the school, the state, whoever the hell you feel like taking to the cleaners.  

After the first (inevitable) death, when a kid has had it's ECG and echo, both of which appear normal, do you then start demanding genetic screening or biopsy?  It's insanity to require an inexact science to screen for something that really isn't (in the overall scheme of things) an issue.

Again, look at the harm the breast screening can do to see what the application of widespread screening programs can achieve.

If the kid has something like exercise related sycnope or chest pain, sure, go get an ECG.  But to screen the millions of kids who play sport is just mental.  One of the biggest emerging health issues the developed world has is childhood obesity.  Why the hell would you throw up more impediments to kids being active by instituting a program that is going to cost a lot of money for little (if any) gain?


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## 18G

Smash, 
Instead of offering your own opinion, what is your view on the research findings obtained by leading cardiologists? They used a scientific method and yielded results that say offering a 12-lead as part of the exam is beneficial and cost effective and increase the chance of catching at-risk youth. And not just one study but several coming to the same conclusion. 

It's also been studied and found that the typical physical exam and questionnaire alone is not very specific at all and by adding an ECG, it significantly increases the sensitivity of the exam.


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## VFlutter

18G said:


> Smash,
> Instead of offering your own opinion, what is your view on the research findings obtained by leading cardiologists? They used a scientific method and yielded results that say offering a 12-lead as part of the exam is beneficial and cost effective and increase the chance of catching at-risk youth. And not just one study but several coming to the same conclusion.
> 
> It's also been studied and found that the typical physical exam and questionnaire alone is not very specific at all and by adding an ECG, it significantly increases the sensitivity of the exam.



Wouldn't his view on research still just be his opinion? I still do not think you will win the argument that it should be required or mandated. I think we will all agre that yes it's a great idea and every parent should be given the information and opportunity and then be allowed to make an informed decision.


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## Smash

18G said:


> Smash,
> Instead of offering your own opinion, what is your view on the research findings obtained by leading cardiologists? They used a scientific method and yielded results that say offering a 12-lead as part of the exam is beneficial and cost effective and increase the chance of catching at-risk youth. And not just one study but several coming to the same conclusion.
> 
> It's also been studied and found that the typical physical exam and questionnaire alone is not very specific at all and by adding an ECG, it significantly increases the sensitivity of the exam.



I have yet to see these studies.  I have trawled through every link posted so far in this thread.  The vast majority of the support for ECG screening comes from such luminaries of the medical literature as NBC News' Today Health or the New York Times, or from organisations with a vested interest in such a program.
There's a press release from Stanford (without the actual study referred to) and the previously discussed "ECG screening is not clinically useful but makes us all get along better, and is therefore worth the cost" study.
There is the Italian study, and the reasons why this is probably not relevant to other areas has already been discussed.  There are also a couple of negative studies.

So if you would like to post these studies you refer to, please do and I will give you my opinion on them.


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## Akulahawk

18G said:


> Screenings take place for a reason. Is it fair some people are disqualified from going into the military because of seemingly stupid medical reasons? If a diabetic takes insulin, they cannot hold a DOT certificate and as such can not work. For me, that would mean I couldn't work as a Paramedic. Is that fair??
> 
> Yeah, guess what, your kid can't play sports but instead we're going to inform you of a problem you wouldn't have otherwise known about and give you options for dealing with it.
> 
> A parent could have the right to sign a waiver and allow their kid to play anyway. It should ultimately fall on parent and student for deciding. But they need armed with the information first.


The screenings you describe all are quantifiable. You either meet the criteria or you do not. Those screenings use tools that are fairly definitive. In the Military, they use screenings for determining fitness as a combatant. Lets use color blindness: you can either see the full spectrum or you can not. Not being able to see the full color spectrum could lead you to put others in danger because you couldn't see something was amiss. How about hearing? They require binaural hearing. If you can't locate sounds well, you may not be able to determine where a threat sound came from and respond appropriately... thus leading to possibility of injury/death. These are quantifiable things. 

Screening every athlete for cardiac problems by ECG and/or Echo will cost a LOT and hopefully someone doing the screening would be familiar with the anatomical and physiological changes that do occur in athletes. There will be false positives and false negatives. Those will be problematic... especially from a legal standpoint.

It's quite unlike being an insulin-dependent diabetic and not being able to get a commercial driver's license. You either need it or you do not. Needing it puts you at risk for accidental overdose of the insulin, which as we all know, is NOT a good thing for safety reasons. Now if the IDDM is able demonstrate good control of their blood sugar and is also therefore able to correctly dose their insulin, I personally have ZERO issues with them getting a commercial driver's license or any other license/certificate allowing them control of even a passenger carrying airliner.

If athletes were willing to be completely honest during their exams about symptoms that may point to cardiac issues, then I can see mandating and paying for ECG and Echo studies on a case-by-case referral system. I have seen just how deceptive that athletes will be just so they can play. Not just once, but many times. I'm sure Tigger has too...


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## Tigger

Akulahawk said:


> The screenings you describe all are quantifiable. You either meet the criteria or you do not. Those screenings use tools that are fairly definitive. In the Military, they use screenings for determining fitness as a combatant. Lets use color blindness: you can either see the full spectrum or you can not. Not being able to see the full color spectrum could lead you to put others in danger because you couldn't see something was amiss. How about hearing? They require binaural hearing. If you can't locate sounds well, you may not be able to determine where a threat sound came from and respond appropriately... thus leading to possibility of injury/death. These are quantifiable things.
> 
> Screening every athlete for cardiac problems by ECG and/or Echo will cost a LOT and hopefully someone doing the screening would be familiar with the anatomical and physiological changes that do occur in athletes. There will be false positives and false negatives. Those will be problematic... especially from a legal standpoint.
> 
> It's quite unlike being an insulin-dependent diabetic and not being able to get a commercial driver's license. You either need it or you do not. Needing it puts you at risk for accidental overdose of the insulin, which as we all know, is NOT a good thing for safety reasons. Now if the IDDM is able demonstrate good control of their blood sugar and is also therefore able to correctly dose their insulin, I personally have ZERO issues with them getting a commercial driver's license or any other license/certificate allowing them control of even a passenger carrying airliner.
> 
> If athletes were willing to be completely honest during their exams about symptoms that may point to cardiac issues, then I can see mandating and paying for ECG and Echo studies on a case-by-case referral system. I have seen just how deceptive that athletes will be just so they can play. Not just once, but many times. I'm sure Tigger has too...



Everything I wanted to say and more. And while we will never have a 100% compliance rate with athlete honesty on health questionnaires (I've stopped counting how many times I've misled on concussion tests) I do not think that is a reason to implement an ECG screening program. This is especially true considering that the majority of the athletes in question are under 18 and therefore subject to parent answering of health questionnaires. If risk factors exist I think these select kids should have mandatory screening, and this is already the case at most institutions.


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## 18G

These programs are becoming more and more prevalent. 

http://www.columbian.com/news/2013/feb/25/heart-screening-effort-gets-national-attention/


"The Young Champions program holds biannual mass screening events; the most recent event was Saturday. During those events, physicians and nurses volunteer their time to screen more than 300 kids. The screenings are free, although the program asks for a $25 donation to help pay for future efforts.

The program also offers heart screening appointments throughout the week. Physicians at the Heart and Vascular Center schedule the screenings for when they have breaks between adult appointments, said Matt Nipper, an exercise physiologist for the center.

Those screenings cost $50, but the foundation helps cover that cost for families who cannot afford the visit.

The Young Champions model is unique, Nipper said, because it partners a community hospital with a local nonprofit organization. Most groups that offer heart screenings partner with one physician or one medical office, not an entire health system, he said.

"We're on the cutting edge of providing these screenings, especially within a health system environment," Nipper said.


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## Chewy20

Toniov said:


>



You seriously brought up a thread from over two years ago just to leave a "smiley face"?

I award you no points, and may god have mercy on your soul.


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