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.

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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.

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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.

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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!

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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.

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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!

 

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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!

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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.

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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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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.

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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