Sudden cardiac arrests in youths

News-watchers were shocked to learn how a young robust 19 year-old Vishwanath, collapsed suddenly and died while playing football (soccer) recently in Bangalore. This happened at a time when soccer lovers were recovering from a similar incident in which the Bolton midfielder Fabrice Muamba, collapsed on the field from a sudden cardiac arrest (SCA) and had to be rushed to hospital.

The possibility that young, well-trained athletes at the high school, college, or professional level may die suddenly of heart disease seems incomprehensible. It is a dramatic and tragic event that devastates families and the community, especially as these young people seem to be the fittest in society.

SCA in young athletes triggered by vigorous activity occurs in 1 of 100,000 sportsmen annually. FIFA lists around 92 players who died while playing soccer, half of whom from SCA.YouTube contains an interesting video showingMiklosFeher slumpingsuddenly to the ground and dying, and another of Anthony van Loo who suffers a SCA but is revived by a timely thump on the chest by a coach.

The first recorded incident of sudden death of an athlete occurred in 490 BC when Phidippides, a young Greek messenger, ran 26.2 miles from Marathon to Athens, delivered the news of Greek victory and then collapsed and died. Today, the 2 sports that claim most lives from SCA are soccer and basketball.

Unlike people over 30 years of age in whom the cause is usually blockage of flow of blood by a clot or narrowing in the coronary, the causes in young athletes are:

1.  Abnormal thickening of heart muscles called hypertrophic cardiomyopathy, especially common in Afro-Americans, who indeed are more prone

2.  Developmental anomalies of coronary arteries, which can often arise from abnormal sites and may be prone to kinking

3.  Long QT syndrome (LQTS),an inherited heart rhythm disorder that can cause fast, chaotic heartbeats. The rapid heartbeats, caused by changes in the part of the heart that causes it to beat, may lead to fainting, which can be life threatening. In some cases, the heart's rhythm may be so erratic that it can cause sudden death. Young people with long QT syndrome have an increased risk of sudden death.

These shocking events and our growing understanding of the reasons behind SCA have generated considerable debate regarding our state of preparedness on the field. Developed countries have called for cardiac screening for all athletes undertaking vigorous sports. Anyone with a history of fainting or a family history of early cardiac events should undergo thorough evaluation.

We need to be better prepared at the venue. Coaches and players should be trained in resuscitation techniques. Anthony van Loo survived only because of timely action by his coach. It should also be mandatory to have hand-held defibrillators available on the field and people should be trained to use them. And the need for prompt transfer to ICU cannot be overstressed, if damage to the brain and other organs is to be prevented.

As published in HT City (Hindustan Times) dated 25 March, 2012.

DISPOSABLES ARE COSTLY

The “use-once-and-throw” habit that has come to characterize modern living has ushered in considerable individual safety that most of us have become familiar with, but for a price. Single-use syringes and needles for instance, have become a norm in all clinics and hospitals, with the old fashioned “heat sterilize and re-use” glass syringes going into disrepute and oblivion.

While this “u-o-t” phenomenon is being seen with other commodities like shaving razors, water bottles and shampoo pouches, its most profound impact is being felt in the health care industry. Numerous scientific studies have shown greater safety from transmissible infections such as HIV, Hepatitis B and Hepatitis C with the use of disposable single-use needles and syringes.

The cost and hastle of disposables are however beginning to be felt in tertiary care hospitals where several procedures that involve puncturing the body are performed routinely. In coronary angiography for instance, catheters or long special tubes are inserted in the patient’s groin and dye is injected through them near the heart to assess the patency of arteries. In gastroenterolgy, we routinely use long tubes or accessories that pass down endoscopes to take samples from the intestines, inject medicines into bleeding veins, or remove stones from the bile duct 

The vexing issue is whether all these elegant accessories need to be brand new for each patient, or whether they may be re-used with care.

The “u-o-t” approach is what wealthy litigant societies use and is safer. If a patient with obstructive jaundice for instance, has to have an endoscopic procedure called ERCP to get the offending stone removed from his bile duct, he would need at least 3  fresh accessories: a guide wire, a cannulotome to inject dye and widen the bile duct, and an extractor to pull the stone out, together costing aorund Rs 60,000/-. Add to that the hospital procedure charges and you would get a bill of around Rs 70,000/- , that most patients find hard.

This partly explains why the cost of the same procedure varies so widely between hospitals. Government as well as many affordable centres provide the same service at one-tenth the price and come to the rescue of people with limited resources whose choice is often between a scientific predictable treatment that he can afford and faith-healing.

Most Indian hospitals, caught in this dilemna, therefore re-use some accessories for some procedures. If defined guidelines are followed the risk of transmitting infection is low while the treatment remains within reach. American health care is so very expensive that an Americans without insurance cannot afford it, and the government, reeling under pressure has been trying desperately to reform.

Indian doctors are therefore perpetually caught in the crossfire between what is preached in books published in the west, and their ability to face reality and render the maximum good to maximum patients who throng their doors.

Between the ideal and the practicable, often falls the shadow!

As published in HT City (Hindustan Times) dated 11 March, 2012.

Parents under Exam Stress!

How wired parents get when their stressed kids take the board exams showed up yet again when they went on a ruckus over a question that appeared in the English paper asking students to provide an imaginary account of a bomb blast in a crowded place. Opinion seemed sharply divided with some parents on edge calling it “insensitive”, while ex-students terming it contemporary and relevant.

Parents argued that stressed to the hilt that exam-goers are at these times, asking them to imagine and describe a gory scene of a bomb blast would add to their children’s distress. Could not the paper -setters’ think of pleasant topics that could soothe their raw nerves?

Some students garnered their parents’ sympathy and mentally cushion them in the event of a less than expected performance. “It is all the insensitive board’s fault!” is what they are chanting along with their parents, having found a convenient scapegoat should it be necessay when the results come in.

Successful ex-students and teachers however had a differnt take on this topic. If the English paper was to test thier linguistic skills, what was wrong in testing them on issues a bit beyond the text book? Why do students and their parents expect “smooth” questions that seek answers that can be provided by rote? Is that the best way to test linguistic skills? Why then do we have students with adeqaute decoratve degrees in English who cannot speak, write, describe or narrate anything beyond what Jack and Jill didon that fateful day?

 Mrs Bhargava, a young smart school teacher, surprised me with her response when I posed this issue to her. “Contrary to what w expect, students actually perform better when asked such unconventional questions”, she said. “I have seen students write much better essays on issues such as corruption, scams, terrorism or elections than they do on the old-world topics such as honesty, beauty, gratitude and valour”, she said, making me wonder if we are indeed being separated from our present-day kids by the proverbial generation gap.

While anxious parents do deserve as much sympathy as their stressed out exam going children, they have heaped more flak to the CBSE board than they deserved. To start with, the question was not a compulsory one; any stressed-out student could choose the other option. Further, describing vivid, albeit imaginary scenes is often easier and more scoring than writing on abstract issues. And if education is what we are all trying to provide, then touching on and creating awareness on “real” topics is a step in the right direction. The feelings of a bomb blast surviver are more relevant today than that of a ship-wrecked sailor of 2 centuries ago.

And if our 17 year olds need to be protected from exposure to horror and violence, they should not be watching Bollywood movies but reading fairy tales instead.

By seeing parents behave unreasonably under stress, as on this issue, students are likely to do much the same.

As published in HT City (Hindustan Times) dated 5 March, 2012.