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.
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.
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!
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!
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.
Barely a month goes by without a national newspaper displaying words like “science says _________ is bad for your health”.
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 Expresstells 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.
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).
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.
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
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.
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.
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.
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.
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?
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
On the 24th of September, the BBC reported the story Nina Adamowicz. Nina, a 72 year old lady with an Implantable Pulse Generator (IPG) who, after having the device for almost 20 years, has requested it be switched off.
After suffering a minor infarct, Adamowicz had said that her continued deteriorating health became too much to bear, said she felt like she was waiting in line to be executed, so she requested her device be switched off. She is reported as stating “It isn’t about ‘I want to die’; I’m dying”.
Her case was referred to her local trust’s ethics committee, who, after careful deliberation decided to proceed in line with the wishes of Mrs Adamowicz.
Before passing away on the same night that her device was switched off, Nina Adamowicz stated that she believed she had the right to decide whether or not she wanted the IPG on or off, and stood by her decision.
This case is thought to be the first of its kind in the UK, but Chicago device specialist Dr Westby Fisher professes to doing this exact thing on a dozen separate occasions. Westby considers the ceased action of an implantable device to removing a feeding tube, or switching off a ventilator.
In particular, in a piece for massdevice.com, Fisher tells of a patient who refused dialysis, saying he’d rather let nature take its course. The patient, who also had an IPG, requested that this was switched off, so Westby agreed, and the next day switched off tachyarrhythmia detection on the device. Fisher says that he feels that both he and his patient did the right thing, together.
I for one, am confused as to the ethical pathway involved in coming to both this decision, and that of the ethics committee associated with Nina Adamowicz.. Assisted suicide is complex, but with respect to these scenarios, is defined as the intentional encouragement or assistance to a patient in ending their own life and it is still illegal under the 1961 Suicide Act of UK law . A medic who administers an overdose of muscle relaxants to a patient whose condition is diagnosed as being terminal, even at the behest of that patient, would be punishable by UK law with manslaughter or murder and potentially serve the maximum terms associated with each.
Why then, is hitting the off switch on a pacemaker not considered to be comparable to the example given previously? Patients with implantable devices often have them to combat life-threatening arrhythmias, so in turning them off, this can effectively issue a death sentence to that patient. I’m not arguing for or against any form of assisted death; I neither understand its intricacies or feel it is my place to denounce or advocate something with which I have had precisely zero experience, I’m simply confused as to why an immediate form of assisted dying is outlawed, and something so similar (on the surface at least), is not. Adamowicz’ clinician has said that other professionals are split in their opinion on his decision, with some feeling it to be “uncomfortably close to euthanasia”.
Is it fair to patients with terminal diagnoses that are forced to travel to countries such as Switzerland, wherein some forms of euthanasia are legal, simply because they do not have an IPG? Does the severity of the condition have any part to play? How similar do individual cases have to be so as to render one illegal and another not so? I have a feeling that this case will spark long debate throughout the medical and legal professions in the UK, and will follow its progress closely.
Recently, in a Holter clinic, I dealt with an 8 year old patient who was on the road to recovery after a diagnosis of congenital defect, Tetralogy of Fallot. As a result, I got hold of the most interesting ECG I have recorded to date.
ToF is a rare congential defect affecting the heart, that results in an insufficiency of oxygenated blood leaving the heart through the systemic circulation. Thus, it is considered a cyanotic disorder.
The disorder affects roughly 5 in 10,000 infants, and has an equal gender distribution.
Generally, four pathologies comprise ToF. Whilst all four are not always present, three can consistently be found. ToF is a progressive disorder, in that each pathology gives rise to the others.
Hole in septum, due to malformation, causing oxygenated and deoxygenated blood to mix within cardiac structure
Aorta is placed over VSD, transporting blood with low O2 content to wider systemic circulation
Cyanotic episodes require immediate correction, before surgical intervention.
High flow O2 administration
Knees to chest
Parent cradling the child will illicit this effect naturally
NaCl fluid bolus
Increases systemic vascular resistance, shunting blood through pulmonary system.
Continuous ECG and SpO2 monitoring
Surgical intervention usually repairs the VSD and addresses pulmonary pathology, often at the same time.
Prognosis for ToF patients is generally very good.
Overall outcome improved since surgical treatment has improved
Survival of surgery is currently 95-99%
36 year post-surgical survival is currently 96%
Patients who undergo surgical treatment are at greater lifelong risk of ventricular arrhythmia
Complications can arise as a result of a transannular patch repair, specifically;
Heart block (risk of HB has dropped to around 1%, in recent studies)
Recurrent or residual VSD
Previous diagnosis of ToF
Transannular patch repair
This patient was having a 24hr Holter recording to assess cardiac recovery after their most recent procedure; the PV replacement. Physical examination showed a RVOT murmur, whilst echocadiography displayed a mild RVH and PV regurgitation. Left heart functionality has been classed as excellent.
Previous ambulatory study has shown no arrhythmic action, save for that considered normal in a child of this age. No previous ECG recordings were available.
Upon monitor removal, a 12-Lead ECG was performed, the resulting trace was as follows:
Ambulatory analysis relating to the most recent study did not differ greatly from previous monitoring, showing occasional sinus arrhythmia and bradycardia, five non-conducted P waves were found, and two of these gave rise to periods of sinus bradycardia. All other instances were gradual onset/offset.
Nocturnal bradycardia reached rates as low as 34bpm.
What does everyone think of this ECG and brief ambulatory report? Let us know by leaving a comment below!
Today, I was present during a Brugada provocation test using ajmaline, a class 1a antiarrhythmic drug much like class 1c drug, flecainide, in that it acts as a Na channel blocker. As its action lengthens the action potential phase 0, in non-pacemaker myocytes, it induces bradycardia, and encourages the transient Brugada rhythm to present itself.
Indications for the test are outlined here, and the procedure itself, is a relatively simple one;
Ajmaline is prepared at a total dose of 1mg/kg-1
12 lead ECG is applied to the patient
V1 and V2 should be positioned on IC3 or IC2
The ECG should be viewable in real time, as well as be printable
Intravenous Ajmaline is administered in a 10mg bolus, every 2 minutes
Fractions should be administered slowly over 1 minute
ECG should be printed after each dose
Indications for terminating the test are as follows:
ST coving present in more than 1 right precordial lead
J point elevation greater than 2mm
AV Block (2nd° or 3rd°)
During the test, the patient indicated that the initial 10mg was very unpleasant, and caused “a horrible feeling” at the back of her throat. She did say that this initial bolus was the worst, however, and that subsequent injections were bearable, by comparison. Towards the end of the test, i.e., one injection from termination, the patient indicated that her lips had become almost completely numb.
The test, in this case, was negative, and the patient’s ECG showed no changes to suggest Brugada at any point throughout the procedure.
Ajmaline is unlicensed in the UK, but this is not indicative of its level of safety, rather it is because it is manufactured in Germany, and imported to trusts in this country. Curious as to why ajmaline was being used, I asked the nurse practitioner who was on hand to implement the test, who informed me why the trust opted to use ajmaline as oppose to flecainide, when both seemingly do the same thing. She cited the time taken for each pharmaceutical agent to leave the patient after the test; in the event of a negative outcome, ajmaline allows a patient to be discharged safely in around 3 hours, whereas flecainide takes a great deal longer to be removed.
Not knowing the costs associated with each drug, I decided to look for other reasons as to why an imported medication is used in this provocative study, and discovered research by Wolpert et al published in 2005, that tested ajmaline and flecainide against each other in a blind trial.
22 patients for whom a diagnosis of Brugada was already known, underwent IV flecainide and ajmaline testing, and the results were then studied by 3 physicians who were unaware of the drug being used in provocation.
The results for flecainide showed
Significant ST changes in 15/22 of the patients tested (68%)
Mean V1 amplitude of 0.19mV
Mean V2 amplitude of 0.31mV
Mean V3 amplitude of 0.1mV
The results for ajmaline showed
Significant ST changes in 22/22 of the patients tested
Mean V1 amplitude of 0.22mV
Mean V2 amplitude of 0.39mV
Mean V3 amplitude of 0.1mV
It is important to note, that whilst these results show a more favourable outcome when using ajmaline over flecainide, in provocative studies, this research is limited in that, despite being a blinded study, it was not a randomised trial and was not repeated. Nevertheless, it does suggest that provocative studies using flecainide may not successfully unmask Brugada syndrome in patients, and its longer life within the patient may favour the use of ajmaline in investigations.
Exams are over, coursework is in, and I’ve FINALLY got some time to devote to TSP, so I’ll endeavour to post updates with the same level of regularity as I did a few moths ago. It’s been a while since I added anything other than study pages, so it’s proving difficult to get back into the swing of reflective writing. I shall try to be clear, however.
The first week of my 15 week placement has been an interesting and challenging one. I’ve been in pacing clinics (the third of which allowed me to have some hands-on experience), tape clinics and have analysed my first full 24 hour ECG recording, so the amount of information I’ve absorbed has been of a high volume in a short space of time.
I’m not going to comment on tape analysis or clinics just yet, as I’m yet to have my completed work assessed, so I’ll wait until I’ve gained some feedback on my current performance. Pacing, however, is extracurricular, so I’ll glady share my experience.
Pacing checks were very fun; during eight or so hours of lingering/observation, I was gradually allowed to do a bit more with regards to clinical practice; analysing lead outputs and EGM readings, setting up programming equipment and learning my way around each box-specific bit of software, etc.
The majority of patients that came into the clinic were annual follow-ups, and six week post-insertion assessments, wherein the overestimated pacing parameters are altered so as to preserve battery life, and due to their nature, each was simply a case of checking each value and adjusting accordingly, meaning each 15 or 20 minute consult went off without a hitch, and I got a feel for the regular procedure and could have some of the physics explained to me. It also allowed my tutors to ask me questions and test me a bit.
The third and final clinic, however, allowed me to assume the role of primary (under strict supervision, of course) and perform threshold tests on my patient. It’s amazing how quickly it’s possible to forget everything you’ve spent the last few days learning, when it comes to actually doing it; the sudden pressure of being thrown into practical learning caused my mind to go completely blank, but with a bit of time, I settled into the role and things started to make sense as I was doing them. There’s a really overwhelming feeling of resposibility when you’re charged with manually increasing or decreasing your patient’s heart rate during threshold tests, and in addition, spotting the loss of atrial capture is, in most cases, far more difficult that that of ventricular capture. It was an exillerating experience, though, and I really felt like I had accomlished something at the end of the clinic. In three days I felt like I could quantify my progression, so the first week has left me feeling excited for the rest of the placement block.
Until this week, I’d never considered pacing as a future specialism – I was focussed on echo – but getting some real exposure has shown me how much I could enjoy a future in the discipline. I can’t wait to do more.
I’ll write more about my own research into pacing as I do it, so keep an eye out for that.