By Liz Freeman
Naples Daily News (Florida)
NAPLES, Fla. — The sudden death of a student-athlete leaves a grieving community to ponder why it can happen in this day and age of precise diagnostic testing.
Maybe the student’s doctor didn’t suspect an underlying heart abnormality and cardiac screening was not performed.
Perhaps the physical examination at the high school isn’t all that it is believed to be and parents put too much faith in it.
“The typical school physical is looking for the glaring abnormalities,” said Dr. Robert Tober, medical director of Collier County’s Department of Emergency Medical Services who has led EMS on several cardiac care programs that have gained national recognition.
“The presence of a heart abnormality or a heart rhythm disturbance, those are rarely found at a school physical. They are occasionally detected,” he said.
Routine use of an echocardiogram, an ultrasound image of the heart’s chambers, to screen athletes for abnormalities is a contentious issue revolving around cost and rarity of sudden cardiac death among young athletes.
Some high schools and universities are moving toward screening with portable echocardiograms that in some cases is underwritten by medical imaging companies initially or by researchers.
The University of Tennessee in 2007 began using echocardiograms and tested 523 athletes. The cost was picked up by a UT fan who is chief executive officer of a medical imaging company. Another company is offering its cardiac screening to middle and high schools in Long Branch, N.J., for research purposes.
The Collier County School District is among those school systems looking at what more could be done beyond family history and the free physicals, which comes at a time when the community is grasping with the loss of two star athletes in the span of two weeks.
Chris Simmons, 18, a senior at Golden Gate High School, died March 6 after three days in the hospital with two collapsed lungs. He was a linebacker for the Titans football team.
On March 18, former Lely High School football star Ereck Plancher, 19, and a freshman at University of Central Florida, died in Orlando after an indoor workout. A preliminary autopsy did not determine the cause of death and more tests are being done.
Plancher is the fourth university football athlete to die suddenly in Florida since 2001. Heatstroke and a cardiac condition were blamed in two of the athletes’ deaths, and the third student was found to have sickle cell trait, which can be linked to sudden death in athletes.
“We are at the very starting stage of reviewing the literature,” Joe Kemper, coordinator of student drug testing and interscholastic sports for the Collier School District, said of materials received some time ago about cardiac screening.
What needs to be weighed is the reliability of the tests, the costs, and how much parents would rely on them, he said. Not all sudden deaths are caused by heart abnormalities; athletes can take a blunt blow to the center of the chest to cause the heart to stop.
Hypertrophic cardiomyopathy, where the heart muscle thickens, accounts for the majority of sudden deaths among young athletes. An echocardiogram can detect the abnormality and other cardiovascular conditions.
The estimated risk is one sudden death for every 200,000 young athletes, according to the Minneapolis Heart Institute Foundation, which began a national registry in 1985 and has reviewed information about 600 sudden deaths since then.
Doing cardiac screening at the local school district level has come up recently because of Plancher’s death, said Eileen Vargo, the district’s health coordinator. But there isn’t enough time to take action before the start of school physicals in May, she said.
Families are advised that the free school physical is not intended to be the only source of a medical evaluation for student athletes.
“The physical isn’t meant to replace an annual physical (with a primary care doctor),” she said. “We encourage all students to have a primary relationship with a doctor.”
The School District is a member of the Florida High School Athletic Association and follows the association’s protocols for preparticipation screening of the 2,500 student athletes in the district, including band members, Kemper said. The School District uses the association’s two-page physical exam form, where the student fills out one page and the physician completes the second page.
At the bottom of the form, with both the student’s and parent’s signatures, is a statement that the student is advised to undergo a cardiovascular assessment. That may include an electrocardiogram, EKG, to see if there is an abnormal heart rhythm, an echocardiogram, and perhaps a cardiac stress test.
In addition, the student and parents must sign a release freeing the School District of any liability arising from participating in sports and the students must have health insurance.
The free school physicals are done by volunteers in the medical community and when a student is not cleared to participate in sports, he or she can not play until a follow-up examination with a doctor who clears the student, Kemper said.
In recent years, it has been getting harder to retain the physicians, nurses and other medical personnel to do the physicals because of growth in the number of schools and students in sports, he said. It takes 20 to 30 volunteers at each school site to do the exams.
He suspects the free physical may be the only examination that some students receive, but he had no figures for how many that is the case. Each year, the district reviews the program and whether the district can keep it going, he said.
“You just hope you don’t get to the point where the district has to quit offering that free service because there are groups out there who feel we should be testing for everything,” he said.
At UCF, student athletes undergo a physical examination every year and fill out a lengthy medical history that is about 20 pages, said Joe Hornstein, spokesman for the university’s athletic program. The medical exam may include an EKG or echocardiogram when warranted by the medical team.
“Requiring an EKG as part of the preparticipation physical is something that should be discussed and determined by the medical experts,” he said.
The regulations are reviewed every year and may be updated depending on changes with medical standards, he said.
“All policies by the nature of what we do go through an annual review,” he said.
Since the autopsy did not determine Plancher’s cause of death and further tests are being done, Hornstein declined to speculate whether any policy changes may be forthcoming.
“A lot of this discussion should not occur until after we learn a cause of death,” he said. “That is critical. You have to understand our cautiousness. We do not know what he passed away from. That is an important piece of information for closure that many parties need.”
The University of Florida in Gainesville includes an EKG as part of its annual physical of student athletes, which has been policy for more than 15 years, said Anthony Pass, associate director of sports health and head athletic trainer for football.
“The (national) debate out there now is should we do echocardiograms,” he said. “There is a medical review committee that reviews the research. Each year it is addressed.”
The American Heart Association, or AHA, in 2007 reviewed its policy regarding screening athletes for heart conditions and whether an EKG and echocardiogram should be included.
The AHA reaffirmed its long-held position that routine use of an EKG or an echocardiogram is not warranted because of low incidence of sports-related deaths from cardiovascular conditions, the cost and implications with false results.
Several studies in recent years that have examined use of EKG’s in prescreening athletes conclude it may be helpful but the researchers fall short of recommending it be a mandate, essentially on the basis of the size of the screening population and incidence of sudden cardiac death.
In addition, an EKG is limiting and athletes can have a normal EKG result, but later, an echocardiogram identifies an abnormality.
Dr. F. Jay Fricker, division chief of pediatric cardiology at the Congenital Heart Center at UF, said he sees two camps on the cardiac testing of student athletes.
“The line seems to be drawn on everyone getting an echocardiogram,” he said. “As a pediatric cardiologist, we do not have the manpower. I don’t think there are enough physicians to do this when you think of the thousands of kids involved.”
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