How A Sudden Cardiac Arrest Survivor Handles the World Cup

It's a story as incredible as it is incomprehensible: On 17 March, 2012, a world-class soccer player from England, Fabrice Muamba, has sudden cardiac arrest (SCA) on a European soccer field.  The audience and remaining players stand stunned as CPR is initiated (video here).  An automatic external defibrillator (AED) is applied to his chest.  Two shocks from the AED are delivered on the field, another as he was carried to the ambulance nearly five minutes later, and 12 more shocks were delivered on the way to the hospital.  None of them worked.  Ultimately, 78 minutes of CPR were performed before the sixteenth shock miraculously restored sinus rhythm.  He then underwent therapeutic hypothermia, and, just as incredibly, awakened neurologically intact some time later.  He later undergoes implantation of an implantable cardiac defibrillator (ICD) as secondary prevention against future sudden cardiac arrest.

Fast forward just three months later.

Yesterday, England's soccer team reached the quarter finals of soccer's World Cup tournament against Italy.  In a hard-fought match, time ran out after 90 minutes of play with the score tied 0-0.  To advance to the semi-final match, a shoot-out must decide the victor. 

The air is tense.  The world watches in anticipation.  Mr. Muamba, also watching it all, can only sit and watch as his country's players take the field.  So what does he do?

He sends a Tweet containing a joke and a picture of his remote monitoring device for his ICD:

https://twitter.com/fmuamba/status/217002769578590208/photo/1

(No, the device pictured does not "charge" his ICD)

It was the humorous mark of a champion who is indeed happy to be alive.  Sadly, England lost to Italy in the shootout and although we have yet to learn if Mr. Muamba required the use of his device yesterday as a result, we certainly learned a lot about the character of the man and the remarkable efforts of the medical team who made this remarkable story possible.

-Wes

h/t: C.G., a faithful reader.

ACLS Recertification Issues

I recently recertified in Advanced Cardiac Life Support, and really wasn't doing to say much, but then, I blog.

Sooooo, I thought it might be informative to discuss a few issues I had with my ACLS recertification process this year.

The American Heart Association provides a course for health care professionals to learn the latest techniques for Advanced Cardiac Life Support in the event an individual collapses of cardiac or respiratory arrest. The certification process is partially performed by company called CardioConcepts (although now it looks like its called 'Scitent') based in Virginia. The recertification process demands a fee for their course and includes an online registration where doctors must now surrender their most personal information (address, phone number, e-mail) to their website on an electronic registration form. You can bet this information is sold, but I digress...

I have some constructive (I hope) criticisms.

If a company is going to teach ACLS instead of doctors, then either the members of this company must first learn EKG's - especially is I have to PAY for the priviledge of undertaking this experience every two years - or else the American Heart Association needs to do a better job proofing the work for hire for which they have contracted.

For the student's pre-test (available on a CD within the ACLS provider book), we find this tracing:

Click to enlarge

So what is this rhythm? The publishers of the student pre-test for ACLS would have you believe it was "Reentry Supraventricular Tachycardia." I wonder if these guys know basic medical terminology. The correct term should be "reentrant supraventricular tachycardia." *Sigh*

But that's not the real problem with this tracing. My guess this tracing is not even reentrant. (I'm open to what other cardiology and EP docs think, here). Look carefully at how this arrhythmia initiates - a slightly premature beat that looks quite similar to the sinus beat - followed in rapid succession by other P waves with a sudden onset with a "warm-up" phenomenon. See the small indentations in the T wave? These suggest a superimposed P wave. I have placed lines above the P waves below:


These findings seem most consistent with an atrial tachycardia to me. Atrial tachycardias usually have an automatic mechanism, not a reentrant one.

And don't get be started about this tracing of Torsade de Pointes which appears on the Student pre-test:


The correct answer (according to their student pre-test) was "Coarse Ventricular Fibrillation." Wrong again. Most texts and online resources I've seen have classified this as arrhythmia as one form of "Polymorphic Ventricular Tachycardia," not coarse ventricular fibrillation. Certainly the treatment for Torsades is very different (consider magnesium, pacing, isuprel, lidocaine, etc.) than for "coarse ventricular fibrillation" (shock, drugs and shock again) and should be recognized by everyone who cares for heart patients.

And I was surprised procainamide was removed from the Tachycardia with Pulses algorithm, especially for irregular, wide tachycardia algorithms as well. I've already discussed my preference for this drug (and why) in an earlier post (See Part I and Part II). Instead, they've decided a "Phone a Friend" option (actually, it says, "expert consultation advised") works best. But sometimes experts aren't there right away...

I do appreciate the folks at the American Heart Association's efforts. I can't imagine what an undertaking organizing the training of the nation's doctors must be like. But we must assure that we train folks correctly and give good examples.

After all, people's lives are at stake.

-Wes

Image credit.

Thankless Dummies

I just saved three people's lives - but I never heard a word from them.

The NERVE!

Could the fact that they were plastic have had anything to do with it?

Ah well, at least I passed ACLS. I'm set for another two years...

-Wes