SMS Post – Sports Physical EKG’s

A heart ds. that kills 6% of young athletes a year may be identified by EKG…but few sports exams include the cheap, quick test. Why!?

Precordial Thump

DON’T YOU DIE ON ME, JOHNNY!!

Hollywood – ever scavenging for dramatic and at least obliquely true material – loves the precordial thump. The “thump” is basically a whomp on the chest when someone has had a heart attack. How cool. How many times in your life can you physically assault someone and then be regaled as a hero for it later? Kinda the Dr. Jekyll + Mr. Hyde amalgam of the medical world. Melt evil and goodness into one fantastic smashing fist on a dead man’s chest and viola…you saved a life.

Of course, you could just get sued for it. Or maybe prosecuted. The next time you’re in a bar fight, you might try the Precordial Thump defense (the bastard half-cousin of the Temporary Insanity defense). “Yeah, so I hit ‘im. So what? I thought he was dyin’. I was giving the jerk a precordial thump.”

“But he’s missing teeth.”

“Well, I aimed too high.”

Anyway, probably the thing that movies and T.V. most often get wrong is that CPR – especially with The Thump – pretty much never works. If it DOES work, it needs to have been successful reallyreallyreallyreally soon after the patient collapsed. Some people say 10 minutes. I think it’s actually more like 4. They may come around after 4 minutes, but they will have permanent brain damage of varying severity.

I’ve recently found myself sucked into the “Lost” T.V. show vortex (thanks to my wife, an ardent fan). I’m still working my way through the first season, which involves a bunch of people who are planwrecked on a South Pacific Island. Most annoying about the show is that there are in fact really crummy waves, which makes no sense to me, since I constantly dream of head-high barrels surrounding every S. Pac Island (all 10,000 of them) at all times. They might as well show me some great waves.

Anyway, there’s a doctor among the castaways and he helps out the sick people whenever he can. Often the medicine is realistic and/or simplistic enough to be enjoyable. But at one point he found one of his fellow castaways in a tree – hung by a bad guy. It took a few minutes just for the doc and his super-model gorgeous sidekick with eternally perfect makeup hair and lighting despite the remote island locale…to cut him down. Then the doc proceeds to pound this guy on the chest repeatedly for A LONG TIME. And (I shouldn’t be spoiling anything here since Season 1 was 4 years ago), he saved the guy. No brain damage. Talking by the end of the show.

Not realistic. For many reasons. Works for Hollywood, though. Bugged me, of course.

So here’s the deal. Thumps can be used when the heart needs electricity, which isn’t all the time. The most common type of heart rhythm that needs electricity is ventricular fibrillation, when the ventricles are trying to pump, but doing a bad job of it. They’re basically quivering. But they’re responding to electricity and doing what they can to get blood out into the body. The most likely heart rhythm after prolonged asphyxiation is going to be asystole. No heart beat at all. Dead. Flatline. You could plug that heart into a city power plant and it wouldn’t help.

Precordial thumps generate about 20 Joules of energy. It isn’t much more than the static zap you get from walking around a Sasquatch rug in your socks. By contrast, we give at least 200J of energy in defibrillation shocks. These days, we usually give even more than that. So the only time you can really hope for the thump to work is immediately following the heart attack. At that point, the heart may only need just need a little jump-start. The blood isn’t acidic yet, and everything is still kinda holding together. Even a few minutes later and El Thumpo will be nothing more than a weak legal defense to get out of a bar fight.

A more useful time to have used the thump may have been with the recent heart attack and death of Tim Russert, the journalist icon who collapsed in the sound studio while at work. His co-workers did everything they should have, including starting CPR and calling 911. And the paramedics tried real defibrillation unsuccessfully. But a thump may have helped because Russert’s collapse was witnessed, which means the small 20J jolt would have arrived almost immediately after his heart rhythm had switched. Also, the myocardium (heart muscle) usually goes into ventricular fibrillation first, then progresses to asystole a bit later. Russert was in Vfib when the paramedics arrived.

The thump probably won’t help anyone ever. In a thousand thumps, probably about 1/3 of a human actually benefitted from it. It’s more theory than realism and isn’t even taught in CPR or advanced CPR classes. But if you see someone drop, they have an open airway and they have no pulse…punching them in the chest might be justified. It probably won’t help, of course, and might get you sued or thrown in jail.

That said, if someone happens to film your medical heroics, you could always send the tape out to Southern California. Who knows…you might end up on T.V.

Will My Kid Have A Heart Attack?

I do physicals on teenage kids all the time. Usually, I’m clearing them to play sports at their school. I’m often temped do a fairly perfunctory exam because…really, how unhealthy can someone be at 13?

Statistically, there isn’t much to worry about. Most kids are just fine. Pretty much almost every kid is perfectly healthy and there’s nothing to find on physical exam because there’s nothing there to find. But, like everything in life, this isn’t 100%. There will always be a small percentage of kids who are, literally, living on borrowed time because of a congenital heart defect that nobody detected when they were born. Some defects don’t show up until the child is in h/er late teens and usually only cause problems during a strenuous workout or just afterward (probably because their heart was already starting to fail but they couldn’t tell).

Every time I do a sports physical on a child or young adult, I’m reminded of the Russian pairs figure skating couple Sergei Grinkov and Ekaterina Gordeeva. If you have heard of them, it isn’t likely you’ve forgotten them. They were arguably the best pairs figure skaters in the history of the sport – certainly they were the undisputed champions from the mid-1980’s through until the mid 1990’s. I was pretty young kid when I saw them win their first gold medals at the 1988 Calgary Olympics, and I still remember their performance. This was one of the greatest years in figure skating history. It was the year of Katerina Witt (meeeow to this 14 year old), and the stratospheric leaps of Brian Boitano.

In all, the pair skated in 31 senior and professional competitions, winning 24 of them, including gold again at the 1994 Lillehammer Olympics. Woven throughout their skating careers is an inspiring romantic tale as well. The pair fell in love in the late ’80’s and were married in 1991. By the time they won their second gold medal, much of the world was in love with them, too. They skated with impeccable skills, but unlike many of the technical wizards of today, they were pure art in fluid motion. To prepare for some of their greatest performances, the pair traveled throughout Europe and studied sculpture masterpieces of the Renaissance – then mimicking on ice the poses they saw captured in marble. Their love story was touching, their success inspiring, their artistry was eternal.

Then suddenly, after a ho-hum practice in Lake Placid, New York in November 1995, Sergei collapsed while still on the ice. He’d had a massive heart attack, and died later that day. He was 28.

Aside from the tragedy of the event, the question remains: What happened? Why would someone simply drop dead at such a young age and in such excellent physical condition? It’s a scary thought and happens with a reasonable amount of regularity. Sergi was a very young man, but it can happen to teenagers. It can be boys or girls. It happened to a pretty good soccer player while I was in medical school.

What happened to Sergi Grinkov was different than the cardiac condition that more commonly afflicts young adults and kids. He had clogged arteries. Although his heart muscle itself was young and very strong, the coronaries that supply blood to that muscle were clogged so much that one pathologist said they looked like the coronaries of a 70 year old man. So, he had a heart attack normally reserved for septuagenarians. Could his neighborhood family doctor have prevented the condition? Then, no. Today…maybe. The only indication that there was a problem with Sergi’s coronaries was based on a family history of men in his family dying in their early 50’s of heart attacks. Today we have better cholesterol measures and might even have considered angiography for him. So, he might have lived…if his childhood screening physicals were done well.

The more common condition to affect kids and young adults – and it often leads to them dropping dead during physical activity, is called hypertrophic cardiomyopathy (HCM). HCM is the leading cause of sudden cardiac death in adolescent children. There are lots of variants of the disease, but the most worrisome is when the heart muscle is so large that it can’t push blood out of the left ventricle – usually because the septum between the left and right side of the heart is too big.

Things to watch out for are similar to the things any mother would worry about in their kids. Shortness of breath “is the most common symptom”. So? The kid’s been running. But you can also look for dizziness, feinting and be attuned to the description of “feeling my heart beating in my chest.”

HCM is rare in general. Something around .5% to .2% of the U.S. population are estimated to have it. In people with a strong family history of the diesease and thus get echocardiographs, around 25% of them will turn out to have the disease. However, mortality in those who have the disease is about 2-4%, which is a bit dicey.

HCM, and Sergi’s condition, both can be treated if they can be detected. The best way to catch both is to be suspicious about the possibility in their first place. A primary care doc can start with an EKG, and then get the patient in for an echo if there is any concern. One thing to be happy about – it is VERY rare for either of these diseases to show up in someone without any sort of family history. Knowing history, then, is the secret.

Below is a YouTube video of Grinkov and Gordeeva at the Lillehammer Olympics. It’s grainy, but still amazing to watch.