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by Paul Auerbach, M.D.
Increasing numbers of young people participate in outdoor
activities, including strenuous competitive athletics. In so doing, they
subject their bodies to stresses that are more intense and prolonged than those
presented by a largely sedentary life. Every story of a sudden death in a young
person is a tragedy, and usually accompanied by commentary pondering the role
and utility of pre-activity screening. Could the death have been prevented? What
was the physiological condition of the deceased? Could the collapse, often
attributed to a heart problem, have been predicted? Was there an examination or
evaluation that might have indicated that the deceased was at greater risk, or
should have been held out of the activity? These are all important questions, with
no simple answers.
Sudden collapse and cardiac arrest in a young person seems
wrong. It shouldn’t happen. It is a parent’s worst nightmare. Similar horrors occur
on the freeway when a teenage driver is killed, or at the beach when a surfer
is tossed in a monster wave and drowned. We know a great deal about injury
prevention; much of our teaching and experience points to errors in judgment.
But the situation is different when the seemingly healthy slumps to the ground
without a pulse. That person has been taken by surprise in a cruel act of fate.
Sometimes we learn that the victim had a congenital or
acquired heart abnormality, such as idiopathic hypertrophic subaortic stenosis,
a seizure disorder, or a propensity to abnormal heart rhythms. A young person
may be walking around with an inflamed heart muscle after apparently recovering
from a viral infection, and not know until it is too late that his or her heart
is operating at a greatly reduced capacity, such that heart failure is just
around the corner. The young person with a brain aneurysm is in great shape
until the dilated blood vessel bursts and leaks a lethal torrent into the
confined space within the skull.
A large proportion of sudden adverse health events—whether a
first serious attack of ketoacidosis associated with diabetes, a stroke in a
person with a brain aneurysm, or cardiac arrest in a person with a potentially
lethal heart rhythm disorder—come without any antecedent event or other warning.
To what degree should apparently healthy persons be screened for the
possibility of an occult problem?
To begin with, the child should receive a prompt physical
examination if there is a chronic problem with any of the following:
The doctor will screen for heart problems and other
abnormalities. Routine parameters of good health, such as appropriate pulse
rate, blood pressure, ease of breathing and breath sounds, and ideal body mass
and total weight are essential. Similarly, routine laboratory testing, such as
blood counts, urinalysis, blood glucose, and essential electrolytes establish what
is hopefully a normal baseline for the participant.
An electrocardiogram (ECG, EKG – “heart tracing”) is not
usually part of a basic physical examination in youth. The test will detect
arrhythmias and certain structural abnormalities of the heart. An
echocardiogram bounces sound waves off the heart and determines anatomy and
function. Combined with the ECG, an ultrasound becomes a very reasonable heart
screening regimen for persons of all ages.
Exercise-associated events, such as dizziness, fainting or
chest pain, should be examined with an ECG and echocardiogram, and perhaps a
stress test (“treadmill”). Further testing is guided by the results of these
Certain congenital conditions and many medical disorders
have a basis in genetics. Knowing whether or not your father or mother had
heart problems is useful to help determine your risk, but in my opinion, a
“negative” family history does not rule out the need for a physical examination
and proper testing. The person who collapses with a heart attack may be the
first one in the family to do so.
There is always a possibility that the results of a test
deemed positive for a problem are in fact incorrect—there is not a problem, so
the test is “false positive.” If the false positive rate is high, then there
will be too much unnecessary follow-up testing, and, furthermore, persons may
be precluded from activities when they are perfectly normal.
How many lives are saved for what total dollar amount? How
much is it worth to society to save a small number of athletes who, without
screening, might go on to collapse and die? Finally, what is the quality of
“mass screening?” Do we rush through the exams and make mistakes with the
interpretations because we don’t have a high index of suspicion combined with a
My recommendation, which is entirely based on opinion, is
that a healthy child, who has received all the normal examinations and
healthcare, should have a comprehensive physical examination prior to
undertaking a new and very strenuous activity (be it on the playing field,
underwater, or climbing a mountain). A baseline EKG is good for people to have
in their possession for future medical reference, provided that it will be
safely stored, and not misplaced or lost. If there is any suggestion of a heart
problem by virtue of history or exam, or if there is a significant family
history of heart abnormalities, an echocardiogram should be obtained.
reposted with permission from the Medicine for the Outdoors Blog
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