heart – The Student Physiologist

Healthcare Science Week 2018 – #2

In amongst busy shifts, I’ve been tweeting about HCS Week 2018, and chatting to other scientists about their experiences. Yesterday, I tweeted a picture of Helen, a specialist Echocardiographer, whilst she was hard at work analysing pulse wave data, and today I’m sharing the answers she gave to a couple of questions I asked her about what she remembers about the history of her job in her 30 years of experience, and her feelings on the changes she’s seen over the years.

With 30 years under your belt, you must have noticed changes in your profession. What’s different now, compared with when you started?

Firstly, my job title has changed. I was a “Cardiac Technician” and began as a student working in Cardio-Respiratory, with a full-time, guaranteed job at the end of my training. I studied on a day-release basis for an ONC then HNC, eventually topping up to BSc when this became compulsory.

Technology has had a big impact on advancement of procedures, which is better for patient quality of life, etc; Cardiac Techs performed all the ECG’s in the hospital, carrying a crash bleep for A&E, and now, of course, there is provision for ECG’s on every ward and dept.

Procedures such as angioplasty and bi-vent pacemakers were not as widely available, either; most CAD patients went on to undergo CABG and only relatively basic bradycardia devices were on offer. Obviously this is all change now.

Alongside this, we are now much busier than ever before and our roles have changed massively. We now carry out duties which years ago only consultants could do. I think this is good for everyone but does mean we have much more responsibility, in addition to greater autonomy. We are, however, still part of a team, which is vital to remember.

Did you have any reservations about the changing nature of your specialism?

I used to worry that becoming more busy and more academic would threaten our profession, that less qualified staff would have to take on more of our roles. Fortunately, routes into this career seem to be more widely available and thus, accessible. Emphasis seems to be more about finding the right person for the job, and training is focused, usually by specialist Scientists who understand the needs of both the students and patients.

It’s important to realise that anyone can be shown how to perform an ECG or assist in a cath lab, but qualities such as initiative, kindness and compassion are inherent traits which cannot be taught, and are absolutely vital in this profession.

Healthcare Science Week 2018 – #1

It’s been a little while since I’ve posted to the blog, but Healthcare Science week seems like as good a time as any to do pick it up again. I’ll try my best to upload here or to Twitter, each day, be it information on what might be happening up and down the country, or things going on within my own Trust. I’ve also roped some colleagues into answering a couple of questions, too.

HCS week is an annual event celebrating all 85 specialisms within the discipline. As the oft-overlooked scientists within the NHS, it falls to us to put ourselves out there, and this week is the time to do it! Biomedical Scientists, Physiologists (there are a few different types of this particular scientist), Audiologists, Vascular Scientists, and many, many more are showcasing what they do for patients they treat in the NHS, and using the hashtags #HCSWeek18, and #HCSWeek2018, they’re getting it to the masses. We need to inspire the next generation of scientists to join our ranks, so HCSWeek gives us the perfect opportunity to show students and potential scientists exactly how far-reaching their options are.

Today, I spoke to my colleague Oli, who like me, is a newly-qualified Physiologist, about why he opted to undertake a career as a Physiological Scientist, and what he plans on doing, moving forward.

20180313_164931 — Clinical Physiologist, Oli. Here, he is setting up an exercise tolerance test in an attempt to induce ECG changes associated with angina, and ischemia

What attracted you to this particular scientific career in the first place?

It’s as simple as being able to help people, really. Clinical Physiology allows for patient-facing tests to be performed, so I felt like it would let me make an immediate difference.

Now that you’re qualified, and are well-versed in the basics of the job, are there aspects that you appreciate more from a post-graduate perspective?

Definitely. Every day presents a different challenge, because every patient is different. In the RUH, we have a wide array of clinical skills we have to learn, and as a result, I find that I’m adding to my knowledge every day.

Where do you see your career heading, moving forward?

I’m hoping to specialise in Cardiac Imaging, and have applied to the STP programme to help with that speciality. There are a wealth of options, even after that, so whilst I’m not entirely sure at this stage, I may look at the Higher Specialist Training after that!

AF Association Pulse Check Event

Myself and some of my colleagues recently relinquished a Saturday off, and braved the icy cold (read: British) weather to try to meet with the public, and raise awareness of atrial fibrillation through a project spearheaded by the AF Association.

I didn’t organise the event, but was kindly invited along, and jumped at the chance to help some of my amazing Cardiology workmates by checking pulses, and recording rhythm strips using the AliveCor mobile ECG monitor (which I have previously reviewed here).

AF is an atrial arrhythmia, wherein the sinus node does not cause appropriate, rhythmic depolarisation as it normally would. Rather, multiple foci activate, facilitating a motion akin to ‘quivering’, which raises the risk of embolism through the inefficient pushing of the blood into the ventricles. It’s an incredibly dangerous problem if left untreated, so it’s vital that it gets detected, and preferably this would happen early.

I go into detail about AF, it’s mechanisms and ECG presentation in this study guide, so have a look at that if you want to understand it further.

As you may or may not be aware, atrial fibrillation is, globally, the most common clinically significant cardiac arrhythmia, and it is thought that whilst 1.2 million people (a conservative estimate) in the UK are known sufferers of the sinus node disorder, a 500,000 have it, and live undiagnosed. The estimated cost of AF to the NHS was somewhere in region of £2.2 billion, in 2008, and given that the prevalence of the arrhythmia has increased year on year, this number may well be higher now.

Obviously, this is far from an exhaustive exploration of AF, but hopefully it gives some insight into why it’s so important to detect and treat, and why initiatives such as this one are a good idea.

We set up shop in Frome’s Westaway shopping centre at around 10am, where members of the public who’d read about the event in the local newspaper were already queueing. We four clinical scientists proceeded to advise and check 85 people throughout the day. We had a surprise visit from Cardiologist’s Kitchen, too!

IMG_-7mgkhu — Mary, of Cardiologist’s Kitchen fame, showed up to say hello!

Many people we talked to had little-to-no idea what the condition was, its risks, or how it was treated, so we used literature, ECG examples, and a scale model of a heart, to educate, and taught people how to check their own pulse before performing quick rhythm recordings which we analysed on the spot. More than a few people who attended had known AF, and their questions largely involved their current treatment, and the potential impact AF might have on their life. Most, however, visited so they could get checked over, hopefully putting their mind at rest, and learning something in the process.

We didn’t find any new atrial fibrillation (although we did discover two cases of previously undiscovered AV Block), but of equal importance to arrhythmia discovery, was the community engagement, particularly in a public setting. In clinics it’s easy to fall into a cycle with patients, due to schedules and time pressures, and whilst we all try our hardest to make sure everyone is treated individually, seeing the problem before the person is always possible. Interacting with patients on “their turf” meant the ball was in their court, if you like, and the sheer volume of people who expressed an interest meant it couldn’t have been further from a wasted day.

The feedback we received was overwhelmingly positive, and there was a recurring theme in the gratitude people felt for the healthcare environment coming to them, as oppose to the other way around. Many of those to whom we chatted understand the strain that hospitals and GP surgeries are under, and felt that visiting to be checked for AF, and other such things, would be inappropriate. In many ways, I suppose they’re right, too; regardless of the importance of finding these things, especially as they do not always present with obvious symptoms, healthcare centres, unfortunately, cannot cope with the demand a service such as this would present. To this end, I was glad to have ventured out to participate in this, an outdoor clinic of sorts, and educate the public on what to look for, as well as how they can guage their own heart rhythm and take some more control over their own health. I sincerely hope to do it again soon!

The AFA is a fantastic charity, so it’d be great if you were to find out a bit more about them by visiting them here.

I’d like to thank my colleagues for asking me to participate, and generally being fantastic people, those who visited us and asked lots of challenging questions, and the kind souls who bought us ginger ale and flapjacks when the temperature reached what *felt* like sub-zero levels.

The statistics used in this post are taken from the BHF. If you want to take a look for yourself, visit the British Heart Foundation, here.

Review: The Bunch of Grapes

14 Silver Street
BRADFORD ON AVON
BA15 1JY
To book, call 01225 938 088

Price: Lunch £20 (3 courses), Dinner £6.50-£18.50

I (probably) know exactly what you’re thinking; “why is a a cardiology website reviewing a restaurant?”

The reasons are three-fold: firstly, before I began this career, I was a professional chef, and as such, I know my way around food and kitchens. Secondly, The Bunch of Grapes features a menu developed in part by Ali Khavandi, the man behind Cardiologist’s Kitchen, and finally, I was invited to an evening hosted by Ali himself and project manager Mary, and we ate some of the food, so it seemed entirely appropriate.

I’ve always had a lot of love for Bradford on Avon. It looks like the generic description of a town in this country that you’d receive if you were to ask an American to describe “England-but-not-Central-London” – picturesque, quaint, cobbled, Downton Abbey, etcetera. Its subtle gentrification has given rise to a few more shops with the word “craft” in the name, but it isn’t a detriment to the town, and I didn’t see pulled pork on any menu as I wandered around. In fact, this shift has kick-started the local economy, and allowed middle-to-high end gastropubs like The Bunch of Grapes to open.

The eatery sits at the end of a terraced row, and looks rather unassuming from the outside. Once through the doors, however, oak furniture leads you past the deceptively wide casual dining/drinking area, and into the bar.

Now, if you’ve ever been to an establishment that serves both Butcombe Bitter and duck confit (read: gastropub), you’ll know two things are an absolute certainty:

1) Refreshments are the usual fayre, encompassing local ciders, lagers, ales and fancy-looking soft drinks (if you’ve ever tasted an “artisanal” cola, you’ll be well aware that they’re not bad, but they aren’t normally any better than the usual suspects). There isn’t a huge selection of each, but all are reasonably priced and work well with the surroundings and menu.

2) The bar area is found before the more formal dining room, which features smaller, more intimate tables and is far enough away that one can avoid the loud, busy Friday and Saturday evening drinkers.

Both of these things are true here, but The Bunch of Grapes still has a certain individuality to it.

The restaurant offers two main types of menu, one that presents as a kind of upmarket but classic pub food list, and another, more refined selection that seemingly draws more influence from French cuisine. There exists a third nestled in amongst them, however: the CardioKit menu. Consultant Interventional Cardiologist, Ali Khavandi and head chef Steve Carss have joined forces to create a professionally cooked, heart-healthy range of dishes for patrons. Dishes which I was invited to sample.

First up, the whole roast poussin. It arrived on a heavy, ceramic plate (not a wooden board, thank heavens), and despite having a rather downplayed menu description, was something of a delight! Liberally doused in apple and wholegrain mustard during cooking, and stuffed with whole sprigs of rosemary, the slow roasting process meant that not only was it incredibly tender, but the flavour of both the baste and the rosemary permeated through the wonderfully textured skin and the soft meat. The accompanying mixed leaves and ash roasted leeks were a more underwhelming by comparison, but they weren’t a bad thing by any stretch. Besides which, they were never really going to be the star of the dish. Both elements combined didn’t quite sate my hunger as I wished, and could have done with a starch to accompany them, but it didn’t detract from what was there.

Whole chicken picked clean, dessert was served, and it was another knockout. Indulgence and healthy don’t usually go together when dining out, so it was a refreshing change to be presented with just that. A sweet, roasted half peach served on a just-bitter-enough berry compote. On top of that was a big scoop of vanilla ice cream and a smattering of cress, because healthy eating is boring without something that feels a lot naughtier than it actually is.

In all honesty, it’s just nice to eat a dessert in a gastropub that isn’t cheesecake, or something that’s been baked in the same ceramic bowl that you eat it from. The peach had a lovely crunch to it, and given that the rest of the dish effectively existed as a cold sauce, it summed up both courses; this was an exploration of textures as much as it was of healthy flavours.

I didn’t know what to expect from the CardioKit menu items, to be completely truthful, as I doubted how versatile it was possible to be to justify charging restaurant prices for healthy food, but I was (and still am) happy to be proved misguided. I worked in kitchens that revelled in being an unhealthy treat, but I almost find myself regretting not having brought something like this to customers myself. As a result, I’ll be championing The Bunch of Grapes and Cardiologist’s Kitchen, and I’ll be back to taste the rest of the menu.

Oh, and CardioKit patients get 50% off their food, so there’s no excuse for those in the South West not to visit.

For more information abut both The Bunch of Grapes and Cardiologist’s Kitchen, visit their websites:

cardiologistskitchen.com

thebunchofgrapes.com

Cardiologist’s Kitchen

Barely a month goes by without a national newspaper displaying words like “science says _________ is bad for your health”.

Daily_Mail_24_1_2017 — Don’t get me started…

I concede that *some* of these headlines might be correct, but it’s worth taking them with a pinch of salt, if you’ll pardon the pun; firstly, “science” isn’t an all-powerful being that performs every possible study single-handedly, so it’s difficult to know exactly who has put forth the particular claim and how many people through whom the information has passed before it gets to the news media, and secondly, “science says…” doesn’t necessarily mean it’s double-blind, peer-reviewed, evidence-based or ethically funded, so between the debunked results of Andrew Wakefield’s infamous autism/ MMR study and big pharmaceutical companies potentially protecting their interests by omitting unfavourable study data, it isn’t a great idea to believe that eating bacon causes your lips to fall off, simply because the junior science editor for The Daily Express tells you it does.

What, then, do you believe? Nobody wants to find themselves being brought into a Cath Lab, and they don’t want the uncertainty that comes with not knowing whether the food that they’re eating is going to help put them in that position. This is where Cardiologist’s Kitchen comes in; Consultant Interventional Cardiologist Ali Khavandi would rather intervene well before you’re being consented for an invasive procedure, and addresses issues with cholesterol, weight, blood pressure and diet by way of a pre-emptive strike using evidence-based dietary and lifestyle changes.

alikhavandi — Cooking Cardiologist, Ali Khavandi

Not unlike this site, the initiative began as a humble health-based blog in 2015, featuring advice and recipes, and was borne through personal, clinical experience. Khavandi’s passion for both cardiology and cooking pushed him to create a resource, and seek a wider market using the same mechanisms employed by the media and the food industry, but using an evidenced basis in cardiovascular wellbeing. The Health Foundation has since granted the Cardiologist’s Kitchen project an award that has allowed the trial of this innovative approach to healthcare to really take off!

Currently, Cardiologist’s Kitchen has partners in GP surgeries, a restaurant and various South West England food suppliers that combine to make conduit for the project’s entire message. Despite still being in relative infancy, Cardiologist’s Kitchen has made headway, and continues to open up avenues via which to get the message out there.

Patients with new or existing high blood pressure can get a CardioKit pack at affiliated GPs. I got one to sample, which contained some money off vouchers, health advice and information about the project. In addition, The Bunch of Grapes gastropub, found in Bradford on Avon, just outside Bath, offers some menu heart-healthy menu items devised by both Ali Khavandi and head chef Steve Carss (I’ve sampled some of these too; they’re delicious).

Chinese Chicken — *The recipe for this Chinese chicken and more, is available on the Cardiologist’s Kitchen website*

The website is the real central feature of the initiative, with healthy recipes, incentives for transforming your attitude to heart health, and evidence-based discussion on food fact, cutting through scaremongering in the bad science which can sometimes surround food.

Rather marvellously, it encourages the use of local suppliers by offering deals and home delivery on their seasonal produce. They’re also in the process of developing ready meals specifically designed to improve cardiovascular health.

By using CardioKit, the aim is to lessen the need for medication, and support local business as well as your own heart. If you’re reading this, and it applies to you as a patient, then I urge you to have a look. If you’re a practitioner, definitely do the same, and get in contact with the CardioKit team to see how you can get involved.

For more on Cardiologist’s Kitchen, visit their website at: cardiologistskitchen.com

Inspired by the advice presented on Cardiologist’s Kitchen, I made a rather lovely Jamaican beef curry, the (really easy) recipe for which I will share here:

250g lean diced beef

4 banana shallots, thinly sliced

1 x jalapeno chili, diced. (Leave the seeds in if you’re a daredevil)

1 x carrot, peeled and chopped

1 x small sweet potato, peeled and diced

1/2 mango, diced

2 garlic cloves, sliced

1 box passata

1 tbsp. jerk paste (jerk seasoning will do fine, but add 2 tbsp.)

1tbsp garlic granules

1 tsp. tomato puree

100ml chicken stock

Greek yoghurt

Flat leaf parsley, roughly chopped

Salt and Pepper, to taste

Rice, any kind, and enough to feed 2 people

With a little oil, brown the beef until sealed sufficiently. Add the shallots, sweet potato, and sliced garlic, and cook for another few minutes. Throw in all of the other ingredients and reduce heat. Simmer for 60 mins, or until the beef is tender, and use this time to cook your rice. Serve with some chopped parsley and a dollop of yoghurt.

PPG Change Complications; What Textbooks Don’t Tell You

I recently spent the day inside the catheterisation laboratory, specifically in the pacing lab. After a few relatively straightforward implants, we reached the final case of the day; a pacemaker change. The patient in question had 4 months of reported battery life left on his pulse generator, so on paper, it was merely a case of opening the pocket in which his old device was housed, and switching it out for a new one that would stimulate his heart for the years to come.
Textbooks are great, in that they detail a procedure from start to finish, usually from everyone’s perspective, covering all bases regarding technique, equipment, potential emergencies, and possible troubleshooting options should the need arise.

These emergencies range from device malfunction to cardiac complications, and cover most things in between. I haven’t read a textbook that outlines what should be done if the patient suffers from dementia, however…

The procedure began late due to the difficulty in cannulating the individual, given they didn’t really understand where they were, and began thrashing around wildly in confusion as soon as the needle was introduced, but eventually they were brought into the lab and set up on the table. Local anaesthetic was administered whilst myself and other members of staff present tried to ensure that the patient was as calm as possible.

This proved rather difficult, as the patient was understandably scared; bright lights and masked strangers staring down at you aren’t a pleasant experience for anyone, so add a severe perception deficiency into the mix, and it’s only going to be worse.

Once the procedure proper had begun, it got so much worse.

If you’ve ever been in a lab or theatre when an electrocautery is being used, you’ll know how loud it is. Trying to keep a confused patient calm, and focussed on your voice alone, is incredibly difficult when you’re being drowned out by a deafening beeping noise. The consultant performing the change was having to work 3 times harder than normal whilst completing his task, because of the patient’s inability to understand what was happening, and more importantly, why it was happening.

There were 6 staff in the operating lab, and of those six, the only one able to fully focus on their job was the consultant. The rest of us tried to hold a limb each, to stop them from flailing and causing potential injury.

The chief priority was the patient’s overall well being, so when the radiographer received a rather nasty set of deep scratches, she endured the pain and tried to reassure the patient.

When the registrar’s fingers were being held so tightly together that they almost broke, she quietly asked if I could free them using one of my available hands, and continued talking to the patient.

When I was struck in the face as a result of removing a hand from the patient’s leg in order to do the above, I didn’t make a sound, as I didn’t want to frighten the patient anymore.

In this patient’s mind, we were causing discomfort for no reason, and as a result, this patient was fighting as though his life depended on it, but nobody said anything that might give cause to further agitate him no matter how much was thrown at them in that situation, because the fact is, we were there to help the patient and their safety came before our own.

No amount of reading could have prepared me for that situation, but even a small amount of warning, or advice, would have been a boon. To that end, I’ll say this;

Scenarios such as the above WILL happen. It’s inevitable. Just stay calm, communicate with everyone around you and never forget why you’re there. Of course it’s not right that you sustain an injury on the job, but the bigger picture comes first and then you can set about producing system changes.

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.

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.