Kudos to Pennsylvania General Assembly

It is always heart warming to see government act to serve and protect. Today the Pennsylvania General Assembly passed House Bill 1610 which defines warning signs for sudden cardiac death and details the actions required of coaches and trainers to remove and re-instate players from participation. There is a huge debate across the country on screening procedures, the number of students at risk, the cost and effectiveness of screening. No one disagrees that there is a problem. It is refreshing to see something done about it to positively protect student athletes from the risk of cardiac death.

In Texas legislation was passed last year to protect students from the risk of concussions. The medical advisory board of the UIL admits that screening through history and physicals by physicians, nurse practitioners, and chiropractors is not an optimal solution. The concussion screening protocol was mandated by the State Legislature. Will it take a state law to enforce similar guidelines for cardiac screening?

The Pennsylvania law is simple. If a student exhibits "fainting, difficulty breathing, chest pains, dizziness and

abnormal racing heart rate" then they are prohibited from returning to participation until cleared by a medical professional. This law is less complex than the concussion law passed last year in Texas. In my opinion it should be passed in all fifty states. If we can't get screening a suggested part of pre-participation physicals the least we can do is define a protocol on what to do before the use of an AED is required.

growth vs fiscal responsibility

As I listen to news about the Greek and Spanish Debt Crisis, I wonder at what point should I worry about debt. Running a small business has been interesting this year. We have generated more income in the first half of the year than we did all of last year. I started learning a new accounting system to track income, expenses, profitability, and viability of the company. Last year when I got a check I was excited because I was not spending my own money and not taking personal funds to pay for new equipment. Upon advisement of my board of directors I took on debt in the form of an American Express card. The interest rate wasn't that much but it was more than I had the previous year.

After paying finance charges for a year on about $10K in debt, I question the viability of floating loans. Is it better to conservatively grow and buy equipment when you have cash or should I manage the amount of debt so that we can grow the company. New equipment means more potential for earning money. New equipment also means more debt. The question that I am facing now is how much new equipment follows new expenses? Looking at QuickBooks, I do notice that some of our accounts tend to generate more income than others. Some of our early deals loose us money for each transaction. I think I figured out how to leverage the equipment and have it drop the price of other customers screenings.

As my focus changes from how do I make payroll for a new employee to how do I grow the company fast enough to minimize debt and maintain monthly income and expenses. The fledgling company that we started 18 months ago is almost ready to step out and walk on it's own. We still need a little help when it comes to climbing the stairs and getting out of holes that we fall into but given another 18 months it will be interesting to look back and realize that $10K in debt wasn't much to worry about and ordering two new machines is something that hopefully happens on a regular basis.

We are on our way to screening 20,000 students this year. The spring was an excellent start to this goal but we need to start screening more and more in the fall to make this target.

if I talked to our team doctor

I had a question the other day that I had to pause a second or two and figure out how to answer. The question was "If I talked to our team doctor and asked her what she thinks about your screening process, what would she say". It took me a while to think of an answer.

There were three things that I debated talking about. First, not all doctors are qualified to talk about cardiac screening. Having worked with a group of doctors, each has their own specialty. We go to a Pediatrician but I would not trust her reading an ECG. We go to an Orthopedist but I would not trust him with interpreting an Echocardiogram. I go to a Chiropractor and he was smart enough to say that using a stethoscope is something beyond his abilities. Each of these doctors has a specialty and a focus just like every one else in the world. I don't ask my Cardiologist about a pain in my lower back or an ankle injury. He isn't up to date on childhood diseases and immunizations that are needed for middle school.

My first thought was that the doctor that the school has a relationship with is probably an Orthopedist but I didn't want to jump to conclusions. I assumed that they were qualified on cardiac screening and that led me to the next quandary. If they know anything about cardiac screening there are two camps of thought. One group says that simple screening with an ECG will yield about one in two thousand at risk kids. Given that the school has over 23,000 students, that means that there are about 11 kids are potential sudden cardiac death candidates at one of twenty four schools. There is about a fifty-fifty chance that there is one kid has a serious problem in one of the schools and does not know about it. A screening program for all athletes will pick up five or six of these kids assuming a 40% participation in athletics. A doctor who believes in ECG screening would be behind a $15 screening program that hits 80-90% of all student athletes, band members, and ROTC participants.

On the other hand, the American Heart Association is split on this issue. The doctor could fall into the camp that ECG screening catches the worst cases and produces about 10% false positives. To truly catch disease you would need to include Echo screening and the cost of doing that is really expensive. Once they find out that we charge $25 for ECG and Echo screening combined they might recommend the program but admit that not everyone can afford the $25 screening or the $200 doctor visit if something is found.

Either way, everyone agrees that the standard questions posed by the American Heart Association that has been included in the standard physicals is neither comprehensive, effective, or practical. If you answer that you have a family history of cardiac problems you immediately fail your physical and need to see a family physician for a full workup. If you answer that you have fainted or felt dizzy while running you fail your physical. A University of Washington study last fall showed that the majority of doctors don't ask every student the standard questions that are required and the students don't answer the questions correctly because they don't know or don't want to fail the physical.

I did answer the question after about 20 seconds of hesitation as all of these thoughts went through my head. I said that the doctor will either be 100% behind ECG screening and strongly recommend it or hesitate and say that it should include Echo screening. They will also advise that you need to think about what to do with the 5% of the kids that are not categorized as low risk and need a doctor visit. They might also ask how low income kids are going to come up with $25. They should also ask who you are using for screening and what is their history at screening other schools. Fortunately for us, we have faced these questions from other schools and have recommendations on follow up requests as well as eight years of history screening high school athletes.

Hopefully a study in 2012 will show that ECG screening is either effective, a waste of time, or Echo screening is needed to find the leading indicators resulting in sudden cardiac death. Until then, we will continue to have this discussion as well as offer both services to schools that get recommendations that both are needed.

Doing the right thing and subcommittees

At what point do you stop doing the right thing and start protecting yourself? I have a friend that was elected to the city council of our small town. When re-election came he decided not to run again. His frustration level was so high because the other people on the council didn't want to vote for or against anything controversial or co-sponsor bills because they were afraid of being sued.

We have presented three times to the UIL Medical Advisory board and all three times have gotten the impression that our input is valued but nothing will be done. The board is the same group of people every time with very little change in the membership. They are required to listen to the public twice a year. If you want to say something, you get five minutes. The first time we presented we went with another non-profit organization and had them present the risks of sudden cardiac death and asked that the UIL website be changed because it showed that one in three hundred thousand high school kids are at risk for sudden cardiac death. Recent studies have shown that the number is more like one in three thousand for sports like basketball, cross country, and water polo. Our request was denied because the recent publications focused on NCAA sports and not high school sports in Texas. The doctor that came with me to testify left in anger saying that the board was a waste of her time and she would never return to present. The second time we presented we cited high school deaths in the state and the board questioned our numbers. They don't record or track athlete deaths and wanted to know why we had access to data that they did not. A subcommittee was formed to look into getting the data for the board. The third time that we presented we asked for an update on the subcommittee and presented new data that the history and physicals used to screen athletes are ineffective and generate way too many false results both negative and positive. We got agreement that there was debate over the questions used but our screening results were not 100% so recommending a change was not suggested at this time. They will get back to us in October about the subcommittee because they need to consult with the Attorney General of the state and he had not returned their calls from the previous October.

Here we are 18 months later and nothing has changed. We have concussion screening, which no one has died from, that they are 100% focused on because the state legislature passed this as a requirement. The medical board decided that concussion screening was too controversial and did not need to be done when it reviewed the options. The state legislature mandated it and everyone in the state needs to be screened for concussions prior to participating in athletics.

Our programs growing but not fast enough in my opinion. We cover about 6% of the state. If we had something like a checkbox on the physical form suggesting cardiac screening for those doctors that do not know how to perform screening that number would be significantly higher. If the UIL would acknowledge that a higher number of students are at risk, people would take screening more seriously. I don't understand the reservation in protecting student athletes as more and more die each year from sudden cardiac death. The board is more concerned with not being at risk themselves than adequately protecting students.

I realize that my statements are a bit inflammatory but it is frustrating when a leading Cardiologist who volunteers his time to screen students in a non-profit organization recommends against cardiac screening across the state. I'm not sure if he is against ECG screening, ECG and Echo screening, or screening of any type. We were not recommending any specific type of screening just that something be done. Death of students is something that needs attention. Doing nothing to protect your job is something that does get me angry.