Why Are 12-Leads Not Required For School Physicals

[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?

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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.

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[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?

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[18G]

Good discussion and points

 

[systemet]

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]

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]

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]

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.

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[usafmedic45]

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]

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]

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.

 

[jjesusfreak01]

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]

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/

 

[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:

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[Tigger]

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.