Is Screening all Young People for Cardiac Disease Cost Effective?

In Western medicine, especially the U.K. and U.S.A., mandatory screening for cardiac disease in young people doesn’t exist.

The NHS currently offers screening for the following:

  • Newborns (blood, cardiac, hearing tests, and physical examination)
  • Pregnancy (foetal abnormalities, blood tests, and infectious disease)
  • Diabetic eye testing (annual follow-ups for cases confirmed in >12 year olds)
  • Cervical (every 3 years for 26-49 year olds, and every 5 years for 50-64 year olds)
  • Breast cancer (50-70 year olds, 70+ individuals can self-refer)
  • Bowel cancer (55-74 year olds)
  • Abdominal Aortic Aneurism (65 year old men. Over 65s can self-refer)

These tests are designed to aid in patient healthcare and to alleviate the long-term financial burden on the heath service, but as you can see, they’re fairly narrow in their scope. Aside from newborns, the vast majority of the screening programmes cater to individuals in later life, or after index presentation/diagnosis. If one suspects an abnormality, then of course, there are many private options available, and in fact, cardiac screening for precursors to sudden cardiac death (such as hypertrophic cardiomyopathy) is in place for young athletes. Given that the estimated number of young people with the abnormality currently stands at 1 in 500, it has been theorised with this and other cardiac diseases in mind, that mandatory screening for young people could ease the cost on the NHS, enhance patient treatment/safety and the emotional fallout that comes as a result of the morbidity associated with serious cardiac conditions.

The results of a nationwide U.K. screening programme known as Cardiac Risk in the Young imply that mass-screening that also encompasses ECG in addition to the standard physical exam and history increases the likelihood of early diagnosis and actually saves money.

The results are the endpoint of a 4-year process, involving roughly 30,000 young persons who were screened using the above methods, all of which were performed and interpreted using the relevant professionals and governing body guidelines.

8.1% of the 30,000 were deemed to produce an abnormal 12-lead ECG, 3.5% had an abnormal physical exam and/or history, and 0.5% showed abnormality in all three areas. 11.7% underwent echocardiography to confirm or deny the presence of dysfunction, 0.9% were referred for cardiac MRI, 1.7% were moved on to longer-term ECG monitoring, and 1.7% had exercise stress testing.

87 abnormalities associated with SCD syndrome were positively diagnosed at the 2-year follow up mark, accounting to 0.3% of the cohort, and 83% of this number was done so using the ECG alone. Interestingly this 83% was found in individuals who presented as asymptomatic, and would likely go undiagnosed otherwise.

The cost of this screening and subsequent treatment of a positive identification is estimated to be 20% lower than the cost of treatment and screening using current requirements, due to its lowering of false positives from 21.8% to 4.3%. This, in turn, lowers the amount of unnecessary follow ups, so this study may have great implications for young athletes, and non-athletes alike in helping to spot these potentially fatal conditions, many of which can be managed.

More on this story and more at: Cardiac Risk in the Young

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Detecting CAD with Vocal Biomarkers

Beyond Verbal, an Israeli company leading the market in voice/emotion analysis software are making headlines thanks to their study with the Mayo Clinic, that shows that voice analysis can indicate the presence of coronary artery disease (CAD).

CAD is responsible for one of the highest cardiovascular mortality rates in developed countries globally, and whilst lower in developing countries, this figure is quickly rising. With this in mind, inexpensive, low-risk  and non-invasive screening methods are a very desirable prospect. Currently, ECG, Exercise Tolerance Testing (ETT), Radionuclide testing and Pharmaceutical Stress Testing are the most common procedures used to screen for CAD, but, aside from ECG, each has contraindications, and/or is fairly invasive. Again, aside really from a simple ECG, each has a middling to significant associated cost attached to it. Technology that could reduce these costs and the potential for unnecessary testing presents a possible alternative to patients being referred to chest pain clinics and such, without a sure fire reason to do so.

Beyond Verbal have already used their vocal analysis software to find audio characteristics associated with Parkinson’s disease and autism, and have now turned their technology to CAD.

The Beyond Verbal/ Mayo Clinic study hypothesised, due to the association coronary atherosclerosis has with other systemic pathologies, that vocal processes and the structures responsible may also be affected.

150 patients, 120 of which presented for angiography of the coronary arteries and 50 healthy, or non-cardiac control patients had their voice recorded prior to the test. Beyond Verbal then used a variety of their analytical software to record three 30 second voice clips from each patient; the first (R1) was a predetermined script, R2 was a description of a positive experience, and R3 was personal like R2, only a negative experience.

The analysed results show a 19-fold increase in the likelihood of CAD in R3, the negative voice clip, irrespective of traditional cardiac risk factors such as age, suggesting there is indeed a link between CAD and voice.

BV hope that future development of this technology can be used to screen patients telephonically.

 

The poster outlining the study can be found here

Beyond Verbal on the web.

The TSP resources relating to CAD can be found here and here.Heart

Review: R-CAT ECG Analysis Badge

Price: £9.99/ $8.00

Developer: EKG Concepts (U.S. only. UK Stockist here)

I’m used to reviewing mobile apps and, to a lesser extent, PC and Mac software, so this is something of a new experience for me. I’ve frequently used rate rulers and pocket tools in the past, but the Rapid Cardiac Analysis Tool (R-CAT) is seemingly different to such an extent that I felt it made sense to put it through its paces.

This tool is designed to enable a healthcare professional of any specialism to quickly assess some of the basic criteria of a 3 or 12 lead ECG, such as heart rate, interval and segment duration as well as waveform deviation from the isoelectric baseline.

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I prefer landscape orientation, but the R-CAT accommodates portrait also.

First, the card itself; it’s well crafted, durable, flexible at the same time, is roughly the same size as an I.D. card/driving licence, and its structure and non-embossed build mean it’s easily disinfected, much the same as many other pieces of equipment you would use in a clinical environment. There are two cutaway sections that allow you to attach R-CAT to your lanyard in either a portrait or landscape orientation, and it sits snugly behind the badge holder without getting in the way.

It is, however, too large to slot into the standard NHS card holders which is a minor niggle, but this isn’t too much of a bind as it doesn’t take a huge length of time to remove, and if you have a pull-reel badge holder, it’s no problem whatsoever, as you can use it without removing the card or your lanyard.

The R-CAT focusses specifically on heart rate, segment and interval length, and baseline deviation (if you’re looking for a cardiac axis diagram, then you’ll have to keep looking, I’m afraid). The heart rate measurement works in exactly the same way as a regular rate ruler, with a similar error margin. It doesn’t have as many timing markers as similarly priced full rulers, but I guess it was a necessary concession to make in order to accommodate everything else on its small frame. Whatever the reason, you get a rough to fairly accurate indication of the true R-R interval.

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R-CAT HR circa 37bpm. The HR given by the equipment and my own calculation was 36bpm

 

The segment/interval indicators are found on the opposite side of the rate calculator, and span two of the outer edges of the card. The smallest measurement is 0.03s, and the printed values then increase from 0.04s by two, up until the largest at 0.44s. In practice, this system takes a little longer to use than simply measuring with a ruler, but once you’ve used it a couple of times, and get an eye for it, it doesn’t add too many vital seconds to quick analysis.

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R-CAT measured the PR interval at 0.36s, as did my pencil and paper, and standard rate ruler

 

The hook, as it were, that R-CAT introduces, is in the big window through the centre of the card designed to be used in ST segment and Q wave analysis.
Whereas using the edge of some paper, or a ruler can obscure or distort the view of 50% of the waveform under scrutiny, R-CAT uses a thin, red bar in the middle of a clear window, allowing for quick assessment of Q waves and ST segments simultaneously.

 

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It’s possible to view both positive and negative sections of a waveform at the same time

 

The window works well, and also functions in the presence of baseline wander, so when such an occurrence is unavoidable, it isn’t a detriment to your analysis.

The company website states it to be more accurate than marking in pencil, as graphite marks can be up to 0.4mm thick, and that is has a greater longevity than callipers, which can loosen with time, and be moved involuntarily. These are excellent points, but with wear and tear printed graphics deteriorate, so I assume that scratches on the measurement indicators could reduce the accuracy of this tool, rendering these comparisons obsolete. Nothing lasts forever, though, and out of the box it works perfectly well.

All in all, I can’t really see this product replacing already-existing products en masse, as this is £10/$8 and the analysis aids already circulating are either slightly cheaper or free, and some provide more functions, but as a learning tool the R-CAT is really effective. During my testing for this review I asked a few cardiology veterans for their immediate impressions, and all shared this opinion. New products in this category are often more of the same; a different colour here, an additional picture there, but R-CAT isn’t one of these products. It shines with its novel portability, and its gimmick; the window. I almost feel bad calling it such, as I feel the word “gimmick” detracts from the product which is, overall, a very cool bit of kit. I won’t say this is an absolutely essential purchase for current professionals who operate outside of an A&E or non-cardiac ward, but it’s certainly worth a purchase. Universities and students however, should take the plunge.

Ah what the heck, it’s unobtrusive and is genuinely helpful when you don’t have a calculator or a rate ruler to hand. If you’ve got a spare £10/$8 kicking about(!), then you should definitely buy one.

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Virgin Care Wins Bath and North East Somerset Adult Services Contract

On the 10th of November, after a long process of meetings between local council members, healthcare union staff and members of the public, Bath and North East Somerset council voted in favour of Virgin Care for its delivery of adult services in the area, rejecting the rival bid from ousted former controllers, Sirona CIC.

B&NES council have given their reasons for preferring Virgin Care for this role, citing their transforming services across the country and positive collaboration with GPs, care centres and charities as two of those at the forefront of the decision.

It is important to note that B&NES has made this decision with deep input from the local Clinical Commissioning Group and community champions over two years, so it is the culmination of a number of differing viewing perspectives and backgrounds.

The vote, which was 35/22 in favour of the Richard Branson-owned healthcare firm, marks the first time a for-profit organisation has been in charge of NHS contracts in the B&NES area. It has been met with vehement opposition from numerous individuals and local organisations since the bid was announced, and the company itself has previously been under scrutiny for its use of tax havens, quality of care, and alleged mistreatment of staff.

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National outlets have lambasted VC in the not too distant past

In 2012, a Dispatches documentary revealed how under-target a Virgin Care centre was regarding Chlamydia screening, exposed a memo asking staff to take test kits home with them, in order to increase the number of screens executed and keep them in line with national targets.

A year later, emergency department medics and the CQC expressed deep concern with practice policy, after a VC-run centre triaged a patient using a receptionist as oppose to a healthcare professional. This proved fatal, but Virgin still defended their actions at a hearing, saying that the patient was appropriately treated.

Despite only being in the market since 2010, Virgin Care currently has NHS contracts worth a reported £1bn, and provides services across the country. It being a Virgin subsidiary and having its head offices in the British Virgin Islands, means it is exempt from corporation tax, but, tax aside, the company has said that all profits made by its B&NES services are to be re-invested into local healthcare delivery. At the same time, however, it has been made clear by the company itself and from other sources that Virgin Care are not looking to make profit from this deal.

Confused yet? I am.

With this deal citing a new precedent in the volume of healthcare services of which Virgin Care have control in the UK, confusion isn’t something that benefits patients, and the majority of middling to major news networks have sensationalised this to the point of farce;

The Canary used the headline “While We’re Still Recoiling from Trump, Branson Quietly Buys up the Biggest Chunk of our NHS…”

Given that this deal has been featured in local and national news for well over a year, spawned public and political backlash (acclaim too, in fairness), and has only now reached a conclusion, the word “quiet” isn’t even slightly appropriate in this case. Headlines such as these only serve to stoke the fire.

In order to try to cut through media Chinese whispers and rhetoric, I spoke to Liberal Democrat Councillor for Oldfield Park, Bath, Will Sandry. Will attended, and was an active part of the B&NES meeting, so I asked him for his thoughts on the deal itself, and what he thinks this means for service users in the Northeast Somerset area.

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Cllr Will Sandry (Lib Dem)

Virgin Care have never had charge of a number of the services, such as social work, which are contained under this Adult Services umbrella. As I see it, this makes service users guinea pigs in this case. Would it be fair to say that this is something of a risky move on B&NES’ part?

It’s fair to describe service users as “guinea pigs” because some of the services have not been provided by a private company before, and a key element of Your Care Your Way is a redesign of services so the services themselves will change during the contact. I don’t think this is “risky” because I have faith that the wellbeing of service users will remain paramount.

During the meeting you were, along with one of your Labour counterparts, in favour of moving for a deferral of the vote so as to further scrutinise numbers you felt didn’t “stack up”, appearing to cite distraction techniques and I quote, “Jedi mind tricks”. What about the numbers and overall proposal sounded alarm bells for you?

In our meeting papers the costs of the services were listed as remaining static for 7 years. I did not have confidence that was achievable. The papers were glossy but had scant financial detail. I had also asked for details of the Virgin Care management team that would deliver the contact, but I could not get a clear answer as to how much of their time would be allocated to delivering the B&NES contact. These are the main reasons I wanted more time for scrutiny.

The most vocal reactions from the public have been almost unanimously negative; a petition, anti-privatisation websites and protest marching, as well as cries of “shame” from those who attended the meeting. We know from recent referenda and elections that small samples of public opinion may not represent the view of the community, so with that in mind, what have you and your colleagues heard from service users on the street?

Apart from the vocal reactions you describe I’ve not had any direct concerns raised by service users. I suspect that the vast majority of people don’t know or mind who delivers their care as long as it remains available to them and free at the point of use.

Conservative councillor Anthony Clarke assured the meeting that Virgin Care were not looking to make profit from this deal. I personally find it strange, and indeed improbable that a for-profit organisation isn’t looking to make a profit from a £700m deal. How is the proposed budget going to monitored and how will it be enforced by the council?

I don’t know, but would presume it will be by the Council’s Health Scrutiny Panel or the B&NES Heath and Wellbeing Board. Profit is an interesting thing. An organisation can have legitimate costs (for example the cost of using the “Virgin” brand) but not record any profits for accounting purposes. I don’t know what (if anything) Virgin Group will be charging Virgin Care for the use of the Virgin brand.

What happens if this figure is exceeded? Comparing news reports from this year, it already appears to have increased by £200m, so how does the council aim to allay concerns and potential indignation that a for-profit organisation (who controversially escape corporation tax) may possibly have a future need to utilise tax payers’ money in order to do its job? 

Savings can also be made by redesigning a service to deliver the same outcomes – this was always the aim of Your Care Your Way. Ultimately if that doesn’t work I imagine that the tax payer (local or national) will pay or there will be a reduction in the levels of service available.

Has anyone shed any light on how Virgin Care plan to reinvest profits that they have assured us they aren’t trying to make?

No

We in healthcare treat patients using a risk:benefit ratio, wherein the potential risks of a treatment should be less than the benefits they could provide in order to make them viable. Given that the issues surrounding Virgin Care’s practices have been documented nationally, were these problems taken into account and considered to be outweighed by the benefits a VC-driven service could provide?

As an opposition Councillor who voted against the deal, this is a question for those who voted in favour of it. In B&NES we have good Heath and Social Care, in part because we don’t play a political game over it. Nobody would thank us for that. If it could have been proven to me that the deal was the best for our residents I would have supported it despite any personal political concerns about privatisation. Let’s hope it is a good deal for service users, but I could not be convinced about the finances of it.

Finally, Will, our whole healthcare system hinges on its patient-centred approach. Given the vote for Virgin Care, despite the vocal opposition to it, it can be logically assumed that the majority of the council feel it will bring about positive changes. What sort of changes can service users expect to see under Virgin Care? What has been proposed that betters the existing system?

I can’t speak for those who voted for the deal, but it is logical to assume they did feel it would bring about positive changes. The contact is too big to list what specific changes might be made, but I imagine any changes will attempt to keep the same beneficial outcome for service users while reducing costs.

These represent the thoughts and opinions of Cllr Sandry himself, and are not necessarily indicative of those held by his associates, or by Bath and North East Somerset Council

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Fitbit’s Familiarity with Class Action Lawsuits

Fitbit, the wearable fitness tracker, has gone from strength to strength since its launch. The company recorded a record $1.858 billion (!) in revenue at the close of the 2015 financial year, and, due to its affordable price tag, everyone from we regular folk, to soon-to-be ex-P.O.T.U.S. Barak Obama can be seen wearing one. That said, Fitbit are known to court controversy; in 2015, it was suggested that the advertised “sleep-tracker” in the company’s Flex model was inaccurate, and over-logged sleep. This case is still ongoing, but it is important to note that it is not suggesting negligence with regards to health; rather that the product itself was falsely advertised. It remains to be seen how this case will play out, but as if that wasn’t enough, at the beginning of the year, a multiple-plaintiff class action lawsuit was filed, with a study showing evidence that Fitbit’s PurePulse technology was woefully inaccurate during exertion.

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The study, performed by a team at California State Polytechnic, compared exertional heart rates acquired via the wearable device and from an ECG. After exercising 43 individuals for 65 minutes, it was noted that the various Fitbit models displayed a heart rate that differed by up to 22bpm compared to that on the ECG, and that some didn’t display a heart rate at all.

According to the study’s team, there exists a distinct lack of rigorous, scientific testing in the wearables market (this is further suggested by lawsuits filed against other, similar product developers), but Fitbit have dismissed both this statement and the study itself, citing bias and, perhaps humorously for reasons I shall soon disclose, a lack of scientific methodology. Fitbit have stated that they perform extensive testing during development, and have pointed towards another study which purports to have found PurePulse products to be highly accurate, although it is important to note that this particular study tested a sample size of two (yes… two).

Wearable devices aren’t anything new, but with technological advances, they are no longer being seen as simply fitness trackers and companies are exploring their application in healthcare. As this gains further traction, accuracy will be incredibly important. In fact, one of the plaintiffs in this case, an 82 year old woman, has alleged that her device underestimated her heart rate by such a margin, that were she to have tried to reach her supposed target heart rate, she would have likely done serious damage to her health, so it is already having a potential impact.

The company’s financial growth since the launch of this generation of devices is thought to be largely due to PurePulse, what with it being the most heavily marketed new feature, so Fitbit’s request that the case be dismissed has last week been denied. Judge Susan Illston has decided that the plaintiffs case has sufficient merit, with regard to fraudulent claims about Fitbit’s accuracy, so it will be considered in court. This does not necessarily give an indication as to the outcome, however.

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The Royal National Hospital for Rheumatic Diseases: History and Bath Medical Museum

I must have walked past this building thousands of times over the years. I’d always admired its exterior, whose 18th century aesthetic still fits perfectly with the rest of Bath’s modernised Georgian motif. The stonework might be slightly mottled and tarnished by years of pollution, and its being surrounded by coffee shops and high-end clothing outlets *almost* detracts from the majesty the building exudes, but the Royal National Hospital for Rheumatic Diseases, nestled right in the North Somerset city’s centre still looks beautiful. I remember the public outcry when it was announced that a large chunk of the building had been sold, and subsequently leased to a novelty Mexican food chain; this building is a part of this city, not just for the patients treated within it, but for all of the residents of Bath.

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Despite admiring it from the outside, I’d never consciously considered its interior. I’m not sure how many people actually have, to be honest; those I questioned had either never looked past the front doors, or had simply “heard it was quite nice” through the grapevine. I recently had the opportunity to begin to learn echocardiography at the RNHRD in Bath, and whilst I was waiting for my superiors to arrive I decided to have a look around, as it was clear from stepping through the front doors that it was a building steeped in history.

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The main foyer is rather breathtaking: the original marble floors are still a prominent feature just past the reception area, paintings, such as that which is the header on this article adorn the walls and connecting the ground and first floors are beautiful, finished wood staircases that look like something out of Disney castle. I had to stop for a moment just to take it all in. Having spent a fair amount of time in hospitals, I had assumed that they (for all intents and purposes) look pretty similar; white walls, long corridors with small, commissioned pieces of generic mixed media/ abstract work hung at eye level along them, and that style of lino flooring that evokes memories of the school gymnasium, squeaking underfoot at the slightest hint of moisture on one’s shoes. Now, I’m not saying this is a bad thing (far from it), but the RNHRD has a unique character. It has charm and detail that I’ve only found in stately homes and upscale galleries. It also has history to rival these places.

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Frances MacDonald, 1949

The funding for the hospital was procured predominantly via a public subscription set up by Richard (Beau) Nash in 1732. Names such as Lord Palmerston, Mr Jeremiah Pierce, and Dr William Oliver are listed as donors, as well as other local and national figures, and as a result of their capital, the building, constructed as a hospital for the sick poor opened in 1742. Built using stone gifted by local legend Ralph Allen, the then Bath General Infirmary was the first hospital to offer treatment to the entire UK, leading many to view it as a foundation of the National Health Service devised in 1948.

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Locals, or those fond of UK trivia will likely already be aware of the hot springs on which Bath sits, and these were utilised in the hospital for therapeutic purposes (interestingly, Bathonians were, for a time at least, not permitted to become patients of the Infirmary, presumably because they as residents, already had a right of access to the spring waters), and these were made available to patients on condition that a fee be paid upon admission. For English patients, this was around £1.50, which later became £3, and for those from Scotland and Ireland, £3, which became £5. These sums were either paid for by the patients themselves, or on their behalf by wealthy benefactors, and covered the cost of treatment and the return home, or, in the worst case, mortality and the subsequent burial arrangements.

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Patient sedan chair

 

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A brass badge, worn by a patient whilst under hospital care

Patients were taken to the bath sites via hospital sedan chairs (designed by surgeon Archibald Cleland, subsequently dismissed for improper conduct in 1743), and impelled to wear brass badges that both identified the patient number and their ward, and to prevent drunkenness whilst out of the hospital grounds. Local landlords were forbidden from serving alcohol to patients, as it was detrimental to their recovery. Failure to adhere to this rule would have risked their licence, so it was likely seldom flouted.

The hospital was initially far smaller than its current size, with new wings and blocks being added throughout the years, including the top floor in 1793 (costing £900), renovation efforts and the implementation of additional units continuing well into the tail-end of the last century.

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The Roman pavement, discovered in 1859

When the building was being extended in the late 1850’s, a Roman pavement was discovered during the foundation digging. It is dated as hailing from between AD60 and AD410 and is still in place at the bottom of the stairs to the basement level. The mosaic is still part of a larger floor and runs underneath much of the building itself.

Given the tenure of the building within the city, it has seen its fair share of conflict; as well as being used to treat the wounded during the Jacobite Rebellion, the Crimean War, South African War and both World Wars I and II, it suffered damage due to ordinance during the latter conflict in 1942 wherein it received a direct hit. Despite this, however, the roughly 200 patients still within the confines of the hospital were uninjured.

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Damage to the RNHRD in 1942

As far as treatment goes, the hospital has been a specialist rheumatology centre since it opened, and continues to operate as such. It offers treatments for pain management, chronic fatigue and utilises hydrotherapy as it did when it was concieved. It also functions as a research centre in these areas, encompassing both in-house studies and those of a more national variety. In addition, and I feel rather interestingly given its history with servicepersons, the centre offers specialist support to ex-military personnel, regardless of the time of onset of condition, and provides pain-management and post amputation complication therapy amongst other things.

Royal Patrons have presided over the RNHRD since its foundation, with the current President being Camilla, Duchess of Cornwall, who has been in the position since 2006. The first, in 1745, was Frederick, Prince of Wales. In 1991, the RNHRD became an NHS Trust, and was upgraded to an NHS Foundation Trust in 2005. In February 2015, the hospital was acquired by the Royal United Hospital (RUH), Bath, which now manage the centre.

The Royal National Hospital for Rheumatic Diseases truly is a wonderful hospital, and the patients who use its services do so over a number of years,  crediting it with a “family feel”. Whilst researching this article, I spoke to a volunteer at the hospital, who told me of her time as a patient, both in and out, and her desire to provide a friendly ear to current service users. She told me that volunteers had relaxed her when she herself needed the hospital’s facilities, and it was that, combined with the care she was provided that inspired her to give back to the trust.

The family feel of the RNHRD was in jeopardy whilst the hospital was under considerable financial strain, but its acquisition by the RUH allowed it to continue to function with only minimal service absorption by the Royal United. This continued service will surely help the current patient base, and will enable the hospital to remain the part of the city that it has been since its conception.

 

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This flag hangs over the museum, and was made to celebrate the 250th anniversary of the RNHRD.

 

Rather wonderfully, the hospital contains a museum, situated in the chapel, which outlines the history of the building and the staff and patients who have used it throughout the years. Many of the photographs found in this article were taken in the museum, and it’s full of information about the building and its history; well worth a visit if you’re in the area!

Thanks to the museum staff at the RNHRD for taking the time to talk to me and allow me to take photographs. Without them, I wouldn’t have been able to write this article.

If you’re eager to explore more, head over to Medical Heritage or visit the RNHRD homepage, and if you’re local to Bath, then be sure to drop into the Bath Medical Museum, situated within the RNHRD.


 

SCST Diploma Day: A Reflection

Myself and OliGS recently sat the SCST Electrocardiography Diploma and Practical Examination, so I thought I’d jot down some of my experiences in the run up, and my retrospective thoughts on the day itself.

If you’re thinking of doing it, or have your PTP finals looming, then read on, as this will give you an idea of what to expect.

I’ll start by saying this: Oli and I have NEVER been so stressed in our entire lives.

This exam was a nightmare for which to prepare; I have extensive experience in taking exams, and it is my view that they’re 50% what you know, and 50% what the examiners want you to tell them. Without having met these examiners or seen a previous paper, it was very difficult to know what to really nail, in the revision stage. The syllabus was long, detailed, and contained what seemed like an entire career’s-worth of things to learn, so we already knew it was going to be a slog, but nothing prepared us for the written paper…

Read these. Lots.

We studied, sometimes sleeplessly, for weeks. Tested each other on rare arrhythmias, read textbooks cover-to-cover (repeatedly), and watched each other’s once sunny outlooks and youthful (ahem) features rapidly wither as the examination date draw closer. It consisted of 20 multiple choice questions, 10 arrhythmia analysis and knowledge questions, and 4 full ECG analysis recordings. Some of these were almost instantly recognisable, but others were brutally difficult to analyse. The MCQs (often the most looked-forward to section of any exam) were equally tough. Those 3 hours lasted a lifetime…

We left the exam battered and bruised, but glad it was over.

But it wasn’t over. It was far from over. As well as the written paper that had almost ruined us, we had the practical exam to do as well.

We had made sure that during our post-ECG placements we still got ourselves in the clinic so as to keep everything fresh, as performing a perfect ECG is not like riding a bicycle.

 

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The last attempt before test day

It turns out that this was the correct call, as was practicing on one another in the hotel the evening before the exam; the margin for error in the exam is 2mm(!) Anyone who’s had an informal assessment, or had their Direct Observed Practice scrutinised whilst training knows that it’s very easy to second-guess when it comes to electrode placement, and despite having 20 minutes to complete the whole thing, this timeframe becomes devastatingly short once you’re in there. It’s a clinical assessment, so one needs to complete the necessary ID checks, explain the procedure to the patient AND to the examiners (i.e. in two different ways), perform it whist answering questions, and then complete a verbal examination.

Three hours after we had finished the written paper, we were called to attempt our practical exam. There were ashen faces all around. Some were on those still waiting for their number to be called as ours had just been, others had been told that their 2 attempts had been unsuccessful. Neither of us were looking forward to this. Now, given that I’ve already stated that each electrode is allowed to deviate only 2mm from the precise, gold standard location, the internet-purchased electrodes pictured in the above image would be somewhat unfair, right? It seems that the examination board concur, as they provide some rather cool, transparent electrodes complete with crosshairs. They doesn’t make it easier, per se, but they certainly go some way eliminate that lingering trepidation when it comes to deciding you’re happy with your placement and ready for judgement.

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Crosshair emblazoned electrodes(!)

I opted for the “all at once” technique: I explained everything to the patient before I started, gained consent, then explained everything I was doing as I went along. Once was put simply to the patient, then once to the examiners, using correct terminology. I paid extra special attention to V1, V2 and V4, as my patient had a particularly wide sternum, so I wanted to be totally sure that I had the sternal border, especially given the electrodes were rather far apart when placed and looked slightly odd to me. After I took a step back and looked at my work, I was incredibly tempted to move the aforementioned electrodes, but either due to fear, fatigue, or a combination of the two, I decided to leave them as they were, opting to go with my initial judgement. After that, I waited.

I’m not entirely sure how the placements are measured, as candidates are asked to leave the room whilst they are checked by two examiners. I heard someone mentioning special rulers, but I didn’t get a look at them (it’s all very cloak and dagger), in any event, you’re called back into the room and, in my case at least, informed of your passing or failing grade. I’m pleased to report that I passed on the first attempt, which as I’m sure you can imagine, was a tremendous relief; I lost my cool somewhat, and expressed my joy rather loudly, as I was informed I wouldn’t have to do it again. Oli soon found me in the waiting area and, grinning wildly, slapped me on the back and hissed “YESSSSS!” before promptly throwing himself into a chair. It was over, and we were victorious.

We didn’t speak too much about it, on the way home, but in the couple of days that have passed since the exam, we both feel a tremendous sense of pride that we actually did it, and did it successfully. If I were to give you all some advice, it would be the following:

  1. Be prepared for anything and everything, including waiting around for a long while
  2. Practice analysing ECGs until you hate them
  3. Practice performing ECGs until you hate them
  4. Go with your gut as much as you can during the practical exam
  5. Bring lunch
  6. Don’t under ANY circumstances, stay at the Ibis Hotel in Birmingham’s Chinatown district (I can’t stress this enough because it backs onto a nightclub that doesn’t stop playing the most bass-heavy music until the wee hours of the morning)

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