DR. SALGO: WHAT IF SUDDENLY SOMEONE NEXT TO YOU COLLAPSED? WOULD YOU KNOW WHAT TO DO?  AND, WHAT IF CPR ISN'T ENOUGH?  FIND OUT HOW YOU CAN BE PREPARED TO SAVE A LIFE...NEXT ON SECOND OPINION.

MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION.  THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE.  WITH ADDITIONAL SUPPORT FROM THE FOLLOWING.  THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.

DR. SALGO: WELCOME TO SECOND OPINION, WHERE EACH WEEK WE SOLVE A REAL MEDICAL MYSTERY.  WHEN WE CLOSE THIS CASE FILE A HALF HOUR FROM NOW, YOU'LL NOT ONLY KNOW THE OUTCOME OF THIS WEEK'S CASE, YOU'LL BE BETTER ABLE TO TAKE CHARGE OF YOUR OWN HEALTH CARE. THAT'S OUR INTENTION OVER HERE. I'M YOUR HOST DR. PETER SALGO, AND TODAY OUR CASE FILE CONTAINS THE STORY OF MICHAEL.  NOW AS ALWAYS, WE'VE ASSEMBLED A HEALTH CARE TEAM TO TACKLE THE CASE. SOME ARE DOCTORS, SOME ARE NOT.  NO ONE ON THE PANEL KNOWS THE CASE EXCEPT FOR ELISSA ORLANDO, OUR CIVILIAN.  AND THIS WEEK'S PRIMARY CARE PHYSICIAN IS DR. LISA HARRIS.  WELL NOW IT'S TIME FOR OUR FIRST LOOK INTO MICHAEL'S CASE FILE.  MICHAEL, I CAN TELL YOU, IS A 60-YEAR-OLD CONSTRUCTION WORKER.  HIS CASE SAYS THAT HE IS MARRIED, HE HAS TWO TEENAGE CHILDREN, AND HE SMOKES, HE SMOKES A LOT, IT DOESN'T SAY HOW MANY PACKS A DAY, YOU KNOW DOCTORS OFTEN DO IT IN PACK-YEARS, BUT HE SMOKES A LOT, HE OCCASIONALLY EXERCISES, AND HE DRINKS A LOT OF COFFEE.  APPARENTLY HE WAS AT A HIGH SCHOOL FUNCTION, I'M GUESSING HERE, THOUGH THE CHART IS NOT SPECIFIC, THAT IS WAS HIS HIGH SCHOOL REUNION, AND WHILE AT THIS HIGH SCHOOL FUNCTION, HE FELL, UNRESPONSIVE, ONTO THE FLOOR.  AT WHICH TIME ALL THE ADULTS IN THE ROOM APPARENTLY SCREAMED, "GIVE HIM AIR!" AND WENT THE OTHER WAY.  BUT A KID IN THE ROOM, SAID, "I KNOW WHAT TO DO, I'VE HAD THE COURSE" AND RUSHED TO MICHAEL'S SIDE TO HELP HIM OUT. SO, WHAT'S THE RIGHT THING TO DO HERE?

DR. KERBER: FIRST, ESTABLISH WHETHER THE PATIENT IS RESPONSIVE OR NOT, AND USUALLY THE WAY YOU DO THAT, IS GENTLY BANG THE PATIENT, SLAP THE PATIENT, AND SEE IF THE PATIENT CAN RESPOND. IF NOT, THEN WE GO TO THE FAMOUS ABC'S.  AIRWAY, OPEN THE AIRWAY, MAKE SURE THE PATIENT CAN BREATHE, IF THE PATIENT ISN'T BREATHING, BEGIN BREATHING FOR THE PATIENT, THEN BEGINNING CLOSED CHEST MASSAGE.  THEN WE HAVE TO WORRY ABOUT DEFIBRILLATION, ETC. 

DR. SALGO: SO CLOSED CHEST MASSAGE IS WHAT WE SEE ON TELEVISION ALL THE TIME THIS CPR STUFF. SO WE'VE GOT AIRWAY, BREATHING, COMPRESSION BUT THEN THERE'S THIS "D".  LISA WHAT IS THIS "D"?

DR. HARRIS: THE "D" IS THE DEFIBRILLATION.  PEOPLE DIE BECAUSE OF A FATAL HEART RHYTHM, AND IN THE PAST, BEFORE THESE DEVICES WERE AVAILABLE TO THE PUBLIC, THERE WERE NO WAY TO KNOW WITHOUT BEING IN A TERTIARY CARE CENTER.  SO NOW WE HAVE DEVICES THAT A LAY PERSON CAN USE, CAN LAY RIGHT ON THE CHEST WALL AND SEE IF THIS PERSON IS IN A VERY DANGEROUS HEART RHYTHM OR NOT.

DR. SALGO: LET ME JUST CENTER US HERE, WE'VE GOT MICHAEL, HE'S ON THE FLOOR, SOMEONE SAYS "I KNOW WHAT TO DO", THEY'RE DOING CPR, BY THE WAY I CAN ALSO TELL YOU THAT WHAT WAS VERY GOOD ABOUT THIS, IS THAT THIS YOUNG MAN ASKED SOMEBODY ELSE TO CALL 911, WHILE HE STAYED AT THE PATIENT'S SIDE, MICHAEL'S SIDE AND TRIED TO HELP HIM.  BUT THEN THERE'S THIS BOX, AND THIS IS WHAT PEOPLE HAVE SEEN ON TELEVISION ALL THE TIME THIS DEFIBRILLATOR THING. YOU'RE THE WORLD EXPERT ON THIS, TALK TO US.

DR. KERBER: THIS IS AN AUTOMATIC EXTERNAL DEFIBRILLATOR.  BUT THE BEAUTY OF THESE DEVICES IS THAT THEY WILL WORK EVEN WITH RELATIVELY UNTRAINED RESPONDERS BECAUSE THEY BASICALLY INSTRUCT YOU WHAT TO DO AS YOU DO IT. SO, IF YOU SEE THIS LITTLE TAB THAT SAYS PULL, I'LL PULL IT.

MACHINE: BEGIN BY REMOVING ALL CLOTHING OFF THE PATIENT'S CHEST...

ORLANDO: IT TALKS TO YOU!

DR. KERBER: THE DEVICE ACTUALLY TAKES AN EKG FROM THE PATIENT AND IF THE PATIENT HAS AN ABNORMAL RHYTHM, THIS DEVICE WILL SENSE THAT, WILL SOUND A WARNING TO TELL EVERYBODY TO STAND BACK AND THEN RIGHT THROUGH THE SAME PADS THAT WERE PUT ON THE PATIENT'S CHEST, IT WILL FIRE A DEFIBRILLATING SHOCK WHICH WILL TERMINATE THAT RHYTHM AND ALLOW A NORMAL HEART RHYTHM TO RE-ESTABLISH ITSELF.

DR. MOSS: SO CAN YOU SAY ANYTHING ABOUT THAT, TRACEY?

CONWAY: WELL, I AM A SURVIVOR OF SUDDEN CARDIAC ARREST AND AS ALL OF YOU WHO ARE IN THE MEDICAL COMMUNITY KNOW, THE PEOPLE WHO SURVIVE ARE IN A VERY SMALL PERCENTAGE. I AM AN ACTRESS, AND I WAS DOING A LIVE TELEVISION TAPING OF A SKETCH COMEDY SHOW, AND IRONICALLY OUR SHOW WAS TITLED "ALMOST LIVE".  WE HAD JUST FINISHED TAPING, WE WERE SAYING GOODBYE TO THE AUDIENCE AND, I HAVE NO MEMORY OF THIS BECAUSE OF THE EXTREME TRAUMA, BUT APPARENTLY I TURNED TO MY FELLOW CAST MATES AND I SAID "BOY, I DON'T FEEL TOO..." AND THEN I HIT IT HARD.

DR. SALGO: DID THEY DEFIBRILLATE YOU?

CONWAY: WELL, EVENTUALLY THEY DID.  AT THIS POINT IN THE STORY, I JUST COLLAPSED AND OUR HOST TURNED TO THE AUDIENCE AND DIDN'T WANT TO SAY "IS THERE A DOCTOR IN THE HOUSE?" BECAUSE THAT IS SUCH A CLICH, IT IS A COMEDY SHOW AFTER ALL, AND FORTUNATELY A YOUNG MAN AGAIN, A YOUNG FELLOW STOOD UP AND SAID SHE LOOKS LIKE SHE MIGHT BE HAVING HEART PROBLEMS, AND RAN DOWN AND ASSESSED.

DR. MOSS: 200,000 PATIENTS A YEAR WHO HAVE THIS TYPE OF EPISODE, MAYBE 400,000 A YEAR...ARE THEY ALL DUE TO A HEART ATTACK OR THAT WHAT WE CALL A HEART ATTACK OR CAN IT BE DUE TO JUST A PRIMARY RHYTHM DISORDER?

DR. GOLDSCHLAGER: EVEN THOUGH THEY ARE ASSOCIATED WITH BLOCKAGES AND ARTERIES, MOST EVENTS LIKE THIS, THEY ARE NOT CAUSED BY A HEART ATTACK.  IT IS A VERY IMPORTANT POINT, BECAUSE PATIENTS, PHYSICIANS OR OTHER PEOPLE WILL THEN SOMEHOW BE TOLD THAT WELL, IT MUST HAVE BEEN A HEART ATTACK, SO THAT MYTH GETS PERPETUATED.

CONWAY: IF YOUR BODY WAS YOUR HOUSE, IT'S A PROBLEM WITH THE PLUMBING WHEN YOU ARE HAVING A HEART ATTACK, AN ELECTRICAL PROBLEM IS WHEN YOU ARE HAVING A SHORT CIRCUIT AND IT GOES "PFFFT," AND SUDDENLY YOU'RE DOWN.

ORLANDO: IF YOU GO DOWN, AND YOU GET SHOCKED BY ONE OF THESE, YOU HAVEN'T HAD A HEART ATTACK?

CONWAY: NO NO, NOT A HEART ATTACK.

DR. MOSS: YOU COULD HAVE HAD A HEART ATTACK, BUT MOST OF THE TIME, YOU HAVE NOT.

ORLANDO: I HAVE ONE QUESTION.  DO THESE TAKE THE PLACE OF CPR...DO YOU DO CPR FIRST?

CONWAY: IT IS IN CONJUNCTION WITH CPR.

DR. KERBER: AND, THAT IS A VERY IMPORTANT POINT. WE USED TO SAY CPR WAS VERY IMPORTANT BECAUSE IT EXTENDED THE WINDOW OF TIME DURING WHICH THIS ELECTRIC SHOCK COULD BE EFFECTIVE, BUT WE NOW ACTUALLY KNOW MORE.  WE NOW KNOW THAT CPR PROPERLY DONE SEEMS TO PREPARE THE HEART SO THAT WHEN THE SHOCK IS ULTIMATELY GIVEN, IT'S MORE LIKELY TO BE EFFECTIVE. CPR IS ESSENTIAL.

DR. SALGO: ALL RIGHT, LET ME SUM THINGS UP.  IF SOMEONE COLLAPSES IN YOUR PRESENCE, YOU'VE GOT TO REMEMBER THE LETTERS A,B,C,D. A IS FOR AIRWAY, B FOR BREATHING, C FOR CIRCULATION, D FOR DEFIBRILLATION.  AND IT IS THE D THAT'S NEW HERE, BECAUSE WE HAVE THE NEW TECHNOLOGY.  SO LET'S MOVE ON WITH THIS CASE, BECAUSE I'M SURE YOU WANT TO KNOW WHAT HAPPENS.  THE TEENAGER WHO WITNESSED MICHAEL'S COLLAPSE DID EVERYTHING RIGHT.  HE DEFIBRILLATED MICHAEL. MICHAEL IS REVIVED AND THE AMBULANCE ARRIVES AND RUSHES HIM TO THE HOSPITAL.  NOW LISA, YOU'RE THE EMERGENCY ROOM DOCTOR AT THIS TIME, WHAT ARE YOU GOING TO DO AS MICHAEL ROLLS THROUGH THE DOOR?  WHAT DO YOU DO NOW?

DR. HARRIS: WELL, WE USUALLY ASK A FEW PERTINENT QUESTIONS AS TO WHAT HAPPENED AT THE SCENE, HOW LONG THE PATIENT WAS DOWN, WHAT TREATMENT WAS GIVEN AT THE SCENE.

DR. SALGO: HE WAS DOWN PROBABLY FOUR OR FIVE MINUTES, DOWN MEANING THAT HE HAD FAINTED, WAS ON THE FLOOR, BEFORE THE DEFIBRILLATION AND BEFORE THEY GOT A PULSE BACK.

DR. HARRIS: THEN YOU CALL A CARDIOLOGIST IMMEDIATELY.

[LAUGHTER]

DR. SALGO: IS THAT ALL YOU ARE GOING TO DO; YOU'RE GOING TO CALL THE CARDIOLOGIST?

DR. HARRIS: I MEAN YOU PUT IN AN IV, AND YOU GET THE PATIENT ON A MONITOR, YOU ARE GOING TO CHECK YOUR VITAL SIGNS AND MAKE SURE THEY ARE STILL IN A STABLE HEART RHYTHM.

DR. SALGO: DID YOU WANT DID I HEAR SOMEONE WANT A CARDIOGRAM?

DR. MOSS: I DEFINITELY WANT AN ELECTROCARDIOGRAM.

ORLANDO: I HAVE A QUESTION ABOUT THE OTHER THINGS HAPPENING IN THE EMERGENCY ROOM.  YOU SAID IV, WHAT ARE YOU PUTTING IN HIM OR TAKING OUT OF HIM?

DR. HARRIS: THE REASON YOU WANT AN IV IS THAT MANY OF THE MEDICATIONS THAT WE GIVE TO STABILIZE THE HEART ARE GIVEN INTRAVENOUSLY SO YOU NEED TO HAVE ACCESS THERE.

DR. SALGO: DID YOU PUT OXYGEN ON?

DR. HARRIS: ABSOLUTELY.

DR. SALGO: I'M SURPRISED YOU GUYS AREN'T PRESSING ME ON THIS ELECTROCARDIOGRAM.  DON'T YOU WANT TO KNOW?

DR. MOSS: I'M INTERESTED IN THE ELECTROCARDIOGRAM.  I WOULD LIKE TO KNOW WHETHER THIS PERSON HAS HAD A MILD CARDIO A HEART ATTACK OR NOT.  AND WHAT THE ELECTROCARDIOGRAM SAYS-NOT JUST THE RHYTHM ON THE MONITOR BUT I WOULD LIKE TO SEE A 12-LEAD ELECTROCARDIOGRAM.

DR. SALGO: A STANDARD CARDIOGRAM.

DR. KERBER: BEFORE WE GET TO THAT

DR. SALGO: THEY'RE NOT GOING TO LET ME GIVE IT TO YOU.

DR. KERBER: WE'RE NOT GOING TO GIVE IT TO YOU BECAUSE THERE IS ONE MORE IMPORTANT THING IN THE HISTORY THAT WE HAVEN'T ASKED ABOUT, AND THAT'S PREVIOUS BLACK OUT SPELLS, FAINTING SPELLS-

DR. SALGO: NONE.

DR. KERBER: NONE?

DR. SALGO: NO FAMILY HISTORY EITHER. THIS IS THE FIRST TIME IT'S EVER HAPPENED TO HIM. HE IS AS SURPRISED BY THIS AS YOU ARE.

DR. KERBER: SO NOW WE CAN GO TO THE EKG.

DR. SALGO: NOW YOU'RE GOING TO LET ME GIVE HIM THE CARDIOGRAM.

DR. MOSS: NOW LET ME JUST SAY, I DON'T LIKE THE SEQUENCE...NO, NO, NO I THINK THAT'S IMPORTANT INFORMATION, BUT IT IS NOT NEARLY AS CRITICAL AS KNOWING WHAT THE ELECTROCARDIOGRAM IS RIGHT THEN AND THERE.

DR. HARRIS: LET'S BE REAL ABOUT THIS, WHAT HAPPENS IN THE EMERGENCY ROOM, THE EMT COMES RUSHING IN AND SAYS "CARDIAC PATIENT."  SOMEBODY IS ASKING THE EMT A LITTLE BIT ABOUT THE HISTORY.  SOMEONE IS PUTTING LEADS ON. YOU ARE LOOKING AT THE RHYTHM STRIP. YOU ARE GETTING AN EKG. AND YOU'RE ASKING A HISTORY ALL AT THE SAME TIME, IT'S NOT LIKE ONE THING HAPPENS AND THEN YOU WAIT TO GET INFORMATION. YOU'RE MULTI-TASKING, IN 30 SECONDS ALL OF THAT IS HAPPENING.

DR. SALGO: WILL YOU LET ME GIVE YOU THE CARDIOGRAM RESULTS?

DR. GOLDSCHLAGER: SURE.

DR. SALGO:  THE ELECTROCARDIOGRAM DOES NOT SHOW AN INJURY PATTERN, BUT IT DOES SHOW THAT HE IS IN ATRIAL FIBRILLATION, WITH OCCASIONAL VENTRICULAR PREMATURE DEPOLARIZATIONS.  THERE'S A WORD SALAD FOR YOU.  YOU WANTED THIS CARDIOGRAM ART, YOU TRANSLATE IT.

DR. MOSS: OK, SO FIRST, WHAT WAS SAID IS THAT THERE IS NOT INJURY CURRENT, WHICH IS SAYING THAT IT DID NOT LOOK LIKE THE ONSET OF AN ACUTE HEART ATTACK, AN OCCLUSION OF A BLOOD VESSEL, BUT RATHER, THERE SEEMED TO BE A PRIMARY RHYTHM DISORDER, THIS ATRIAL FIBRILLATION AND EXTRA HEART BEATS, SO IT WOULD IMMEDIATELY RAISE THE QUESTION WHETHER THIS IS A MUSCLE DISORDER.

DR. HARRIS:  YOU'VE GOT THAT "WHAT IN THE WORLD ARE YOU TALKING ABOUT?" LOOK.

ORLANDO: RIGHT, I DO.

DR. HARRIS: TRACEY'S ANALOGY OF A HEART ATTACK BEING THAT THE PLUMBING BROKE AND NOW YOUR HOUSE HAS BEEN DAMAGED FROM THE FLOOD OF WATER AND THAT WOULD BE ANALOGOUS TO A HEART ATTACK, THAT THE ARTERIES, THE PIPES THAT CARRY THE BLOOD HAVE BEEN BLOCKED, AND THE MUSCLE TISSUE IS DAMAGED.  WE DON'T REALLY SEE THAT, OR WHAT WE CALL AN INJURY PATTERN, BUT THE ELECTRICAL SYSTEM HAS GONE HAYWIRE AND WE NEED TO FIGURE OUT WHY.

ORLANDO: OK, SO IT'S AN ELECTRICAL PROBLEM PROBABLY.  THAT'S WHAT THE ATRIAL FIBRILLATION IS REFERRING TO?

DR. SALGO: NORA, HELP WITH THIS ATRIAL FIBRILLATION WITH PREMATURE VENTRICULAR DEPOLARIZATION. WHAT'S THAT?

DR. GOLDSCHLAGER: THERE ARE FOUR CHAMBERS TO THE HEART THE UPPER CHAMBERS RECEIVE BLOOD THE RIGHT SIDED ONE FROM THE BODY, THE LEFT SIDED ONE FROM THE LUNG.  THERE ARE TWO LOWER CHAMBERS WHICH PUMP THE BLOOD OUT SOMEWHERE--YOUR BLOOD SUPPLY TO THE BODY.  WHAT ATRIAL FIBRILLATION IS, IS THAT THE UPPER CHAMBER RHYTHM--NOT THE LOWER, THIS IS NOT VENTRICULAR FIBRILLATION--THE UPPER CHAMBER RHYTHM IS ALL HAYWIRE. AND IT HAS THE CAPABILITY OF BEING AT RATES OF 500, 600, 700, 800 A MINUTE, OF STIMULATING THE LOWER CHAMBERS TO TRY AND BEAT AT A VERY HIGH RATE. 

ORLANDO: SO IF I'M THE WIFE OR FAMILY MEMBER, I MEAN IS THERE A WORD YOU CAN TELL ME BESIDES THESE REALLY LONG ONES?

DR. GOLDSCHLAGER: NOT YET.  IF WE TOLD YOU A WORD, IT MIGHT NOT BE THE RIGHT WORD.

DR. SALGO: WELL, THE WORD YOU MIGHT USE IS THAT HE HAD AN ARRHYTHMIA RIGHT?

DR. GOLDSCHLAGER: THAT'S FINE, BUT IN TERMS OF THE CAUSE OF THE ARRHYTHMIA, WE DON'T KNOW.

DR. SALGO: AN IRREGULAR HEARTBEAT.

ORLANDO: I'VE HEARD THAT WORD BEFORE.

DR. HARRIS: HE HAD AN IRREGULAR RHYTHM OR BEAT TO HIS HEART. THE ELECTRICAL SYSTEM THAT ALLOWS THE HEART TO BEAT REGULARLY WENT HAYWIRE AND HE PASSED OUT AND THERE'S A LOT OF REASONS WHY THAT MAY HAPPEN, IT MAY BE A PROBLEM WITH THE HEART MUSCLE, WITH THE STRUCTURE, WITH THE WAY THE HEART WAS BUILT, IT MAY BE A PROBLEM WITH THE WIRING IN AND OF ITSELF.  IT COULD BE SOMETHING TOTALLY UNRELATED, WE'RE NOT SURE.

DR. SALGO: ART, YOU'RE A CARDIOLOGIST AMONG CARDIOLOGISTS AND OTHERS HERE, WHAT CAUSED HIS ARRHYTHMIA?

DR. MOSS: WELL, IT IS ENTIRELY POSSIBLE THAT WE WILL NOT KNOW.  BUT FORTUNATELY THERE IS VERY GOOD THERAPY TO PREVENT AND TO AVOID A FATAL RHYTHM IN THE FUTURE.  BUT IT IS GOING TO TAKE, I WOULD SAY, A FULL WORK-UP TO GO AFTER WHAT THE CAUSE OF THIS IS.

CONWAY: THAT'S WHAT HAPPENED WITH ME. JUST TO LET YOU KNOW, I DID KNOW THAT I HAD AN ARRHYTHMIC HEART WHEN I HAD MY SUDDEN CARDIAC ARREST. I'D BEEN DIAGNOSED WHEN I WAS 24. I JUST WENT IN FOR A FEMALE CHECK-UP AND HE SAID, "WHILE YOU'RE HERE, I'M JUST GOING TO LISTEN TO YOUR HEART AND LUNGS, OH, I'M CATCHING A LOT OF EXTRA BEATS IN THERE, YOU SHOULD GO IN, AND GET A WORK-UP". I GOT PUT ON A BETA-BLOCKER AT THE AGE OF 24, KNEW I HAD MITROVALVE PROLAPSE SO I ALSO HAD AN UNDERLYING PROBLEM.

DR. SALGO: WHICH IS A DISORDER IN THE HEART UNDERLYING.

CONWAY: EXACTLY, SO I KNEW THESE THINGS, AND YET, I THOUGHT, WELL MY DOCTORS ARE GIVING ME DRUG THERAPY, I FEEL FINE, I'M RESPONDING WELL TO THE DRUG, WENT ON WITH MY LIFE AND 14 YEARS LATER (SLAP)-ULTIMATELY WHEN PEOPLE ASK ME, WELL YOU KNEW THAT YOU HAD THE ARRHYTHMIA, YOU KNEW THAT YOU HAD MITROVALVE PROLAPSE, DID THEY EVER TELL YOU THAT YOU MIGHT HAVE THIS KIND OF FATAL TYPE OF ARRHYTHMIA? NO, AND THEY CAN'T TELL ME EXACTLY WHY IT HAD HAPPENED EITHER.

DR. SALGO: LET'S STOP HERE FOR A MOMENT, BECAUSE WHAT I WANT TO DO IS SUM UP SOME OF THE KEY THINGS TO REMEMBER BEFORE WE MOVE ON.  AGAIN, A LOT OF MATERIAL GOING ON HERE. ARRHYTHMIA MEANS, SIMPLY, AN IRREGULAR HEARTBEAT THAT SOMETIMES CAUSES SUDDEN COLLAPSE FOR WHATEVER REASON.  THE RISK FACTORS OF ARRHYTHMIA CAN BE DEHYDRATION OR THYROID DISEASE, CALCIUM DEFICIENCY, MAGNESIUM DEFICIENCY, CAFFEINE SOMETIMES, DRUGS, SPECIFICALLY STREET DRUGS, BUT DON'T THINK THAT THEY ARE THE ONLY ONES.  PRESCRIBED DRUGS, OVER THE COUNTER DRUGS, ALL CAN LEAD TO ARRHYTHMIAS, AND OF COURSE THERE IS THE BIG ONE NO ONE THINKS ABOUT, CORONARY ARTERY DISEASE, YOU COULD HAVE HAD A HEART ATTACK, WHICH COULD HAVE LED TO AN ARRHYTHMIA AS WELL.  ALL RIGHT, LET'S GET BACK TO OUR CASE OVER HERE, BECAUSE I KNOW YOU WANT TO KNOW WHAT HAPPENS TO MICHAEL.  THE DOCTORS CARING FOR MICHAEL CAME TO THE CONCLUSION THAT THE IRREGULAR HEART RHYTHM OR HIS ATRIAL FIBRILLATION DID IN FACT LEAD TO HIS FALLING DOWN IN THE GYM, NEEDING TO BE DEFIBRILLATED. IS THAT A FAIR CONCLUSION?

DR. MOSS: THAT'S ONE SCENARIO, THAT THE ATRIAL FIBRILLATION CAUSED IT, BUT IT'S NOT A VERY SATISFACTORY ONE AT LEAST FROM MY STANDPOINT. THIS PERSON WHO HAD A CARDIAC ARREST NEEDS THE FULL AND TOTAL WORK-UP INCLUDING A CARDIAC CATHETERIZATION. HE'S ALREADY HAD AN ECHOCARDIOGRAM. HE NEEDS WHAT HAS JUST BEEN REFERRED TO AS AN ELECTRO PHYSIOLOGIC STUDY.

DR. SALGO: WHAT DO YOU THINK MICHAEL WANTS TO DO, LISA?

DR. HARRIS: HE WANTS TO GO HOME.

DR. SALGO: HE WANTS OUT, HE WANTS OUT. SO HIS DOCTORS SAY, OK BUT WE NEED YOU TO TAKE SOME MEDICATION TO PREVENT THIS FROM HAPPENING AGAIN.  WHAT ARE YOU GOING TO GIVE HIM? HE'S GOING; YOU ARE NOT GOING TO HAVE ANOTHER SHOT RIGHT NOW TO DO ANYTHING ELSE.

DR. MOSS: WHAT DO YOU MEAN HE'S GOING?

DR. SALGO: HE IS LEAVING THE HOSPITAL. WHETHER YOU WANT HIM TO OR NOT.

DR. MOSS: OH NO HE'S NOT--NOT IF I'M TAKING CARE OF HIM!

DR. SALGO: THERE ARE A NUMBER OF NOTES HERE ABOUT "PATIENT WANTS OUT," THAT THEY ACTIVELY CONSIDERED GIVING HIM A PAGE CALLED AMA AGAINST MEDICAL ADVICE.  WE KNOW YOU WANT TO GO, WE DON'T THINK YOU SHOULD.

DR. HARRIS: WHERE IS THE PRIMARY CARE PHYSICIAN IN ALL OF THIS? BECAUSE RIGHT NOW YOU HAVE A LOT OF SPECIALISTS THAT HE DOESN'T KNOW, THAT HE HAS NEVER MET BEFORE, HE'S FRIGHTENED OUT OF HIS MIND, SO HE HAD THIS EVENT, HE DOESN'T REALLY KNOW WHAT HAPPENED EXCEPT THAT MAYBE HE DIED, AND HE WAS BROUGHT BACK TO LIFE. THAT'S WHAT PEOPLE TELL HIM. 

DR. SALGO: YOU'RE HIS PRIMARY CARE PHYSICIAN, WHAT WOULD YOU TELL HIM?

DR. HARRIS: I WOULD TELL HIM, IT IS NOT SAFE FOR YOU TO GO HOME.

DR. SALGO: "I DON'T CARE," SAYS OUR FRIEND MICHAEL.

DR. HARRIS: WE DON'T REALLY KNOW WHAT HAPPENED, NOW IF YOU GO OUT, AND YOU ARE NOT ON THE RIGHT MEDICATION, YOU COULD DROP DEAD. WHAT IS THAT GOING TO DO TO YOUR FAMILY? TO YOUR KID? TO OTHER PEOPLE THAT WERE THERE THAT WERE HELPING YOU? TO FRIENDS? AND SO ON AND SO FORTH.  IT WILL NOT KILL YOU TO STAY HERE ANOTHER DAY, TO DO THE ONE OTHER TEST OR TWO TESTS THAT WE NEED TO DO TO BE ABSOLUTELY CERTAIN THAT YOU'RE SAFE. THIS ISN'T FOR MY HEALTH, IT'S FOR YOU.

DR. SALGO: I CAN TELL YOU THAT MICHAEL DOES LEAVE THE HOSPITAL, SO WE DON'T HAVE THE OPTION OF KEEPING HIM IN. YOUR ONE SHOT IS TO HELP HIM OUT, MAYBE WITH SOME MEDICATION ON THE WAY OUT THE DOOR.  WHAT DO YOU WANT TO DO RICHARD?

DR. KERBER: WELL, THE BETA-BLOCKERS HAVE BEEN MENTIONED, THEY'RE DRUGS THAT CALM THE HEART DOWN, THEY LOWER BLOOD PRESSURE, THEY SLOW THE HEART RATE.  A MORE POTENT DRUG, IS A DRUG CALLED AMIODARONE, WHICH IS WIDELY USED FOR MALIGNANT CARDIAC RHYTHM DISTURBANCES, BUT THE TROUBLE IS YOU'D LIKE TO HAVE GOTTEN SOME OF THE TESTS THAT LISA WAS JUST TALKING ABOUT BEFORE YOU PRESCRIBE THAT.  SO I WOULD, IF I WAS IN THAT UNSATISFACTORY SITUATION, I WOULD GIVE HIM EITHER A BETA-BLOCKER OR AMIODARONE.

DR. SALGO: BUT HIS DOCTORS ALSO WANTED TO GIVE HIM AND ANTI-COAGULANT DRUG. WHAT WOULD THAT DO, ART?

DR. MOSS: THERE ARE TWO ASPECTS OF THIS. FROM THE STANDPOINT OF HIS ATRIAL FIBRILLATION HE STANDS THE RISK OF DEVELOPING A BLOOD CLOT AND HAVING A STROKE AND THERE'S VERY GOOD EVIDENCE THAT A BLOOD THINNER WILL REDUCE THE RISK CONSIDERABLY.

DR. SALGO: MICHAEL SAYS "I'M A CONSTRUCTION WORKER, I DON'T WANT MY BLOOD THINNED, BECAUSE IF I GET HURT ON THE JOB I'M GOING TO BLEED TO DEATH, CAN'T YOU GIVE ME ANYTHING ELSE? SO THEY GIVE HIM AN ASPIRIN. GOOD IDEA?

DR. GOLDSCHLAGER: IT'S A SUBSTITUTE.

DR. SALGO: HOW DOES THAT WORK?

DR. GOLDSCHLAGER: IT'S AN AGENT THAT PREVENTS CLOT FORMATION DUE TO ONE OF THE BLOOD ELEMENTS CALLED PLATELETS.

DR. HARRIS: YOU'RE JUST PUTTING A BANDAGE ON A HEMORRHAGE. YOU'RE TRYING TO PACIFY HIM BECAUSE HE'S LEAVING, BUT CLEARLY THAT'S NOT ADEQUATE AS WE'VE ALREADY MENTIONED.

DR. SALGO: SO NOBODY IS HAPPY WITH THIS? WELL THE CHART SAYS THAT NEITHER WAS MICHAEL IN ABOUT FOUR MONTHS WHAT DO YOU THINK HAPPENED?

DR. HARRIS: HE COLLAPSED AND DIED...

DR. SALGO: HE HAD ANOTHER COLLAPSE. HE ENDS UP IN THE ER AGAIN, AND I'M READING FROM THE CHART NOW, A CARDIOGRAM IS DONE, ONCE AGAIN HE'S IN ATRIAL FIBRILLATION AND AGAIN HE HAS THOSE PREMATURE VENTRICULAR DEPOLARIZATION--THE BOTTOM CHAMBERS OF HIS HEART ARE ALSO NOT DOING WELL. THIS TIME HE'S GOT INJURY CURRENT. THIS TIME THERE'S SOMETHING WRONG WITH HIS HEART. WHAT'S GOING WRONG HERE AS COMPARED TO THE FIRST TIME, NORA? AND DID THEY MISS THIS THE FIRST TIME, DO YOU THINK?

DR. GOLDSCHLAGER: THE FIRST QUESTION LAST. WHAT'S GOING WRONG WITH HIM NOW, MY VIEW, GIVEN EVERYTHING WE KNOW ABOUT THIS INDIVIDUAL AND ALL NORMAL LABORATORY AND ELECTROCARDIOGRAMS LAST ADMISSION, I THINK WHAT'S PROBABLY HAPPENING IS THAT THE RHYTHM ITSELF PRODUCED INSUFFICIENT BLOOD SUPPLY FOR A LONG ENOUGH PERIOD OF TIME TO THE HEART MUSCLE THAT HE'S GOT AN INJURY TO THAT MUSCLE, AS A RESULT OF THE RHYTHM.

DR. MOSS: 60 YEARS OLD, A HEAVY CIGARETTE SMOKER, WHO DRINKS A LOT OF COFFEE, HE IS AT HIGH RISK FOR CORONARY DISEASE AND THIS WOULD BE IN A NORMAL SIZED HEART THAT HE COULD WELL HAVE A CORONARY DISEASE THAT CAUSED THE ORIGINAL PROBLEM AND NOW THIS PROBLEM WITH MORE MANIFESTATIONS OF THE INJURY CURRENT THAT WASN'T SEEN BEFORE, AND HAD THEY HAD TIME OR HAD THE APPROVAL TO DO A CARDIAC CATHETERIZATION, A CORONARY ANGIOGRAM TO LOOK AT THE BLOOD VESSELS, AND HAD THEY FOUND SOMETHING, WE DON'T KNOW THE ANSWER, BUT HAD THEY FOUND SOMETHING, ONE MIGHT HAVE PREVENTED THE SECOND EPISODE.

DR. SALGO: THEY'RE ALL VERY, VERY WORRIED ABOUT THIS NOW. THEY SEE THIS INJURY PATTERN, SAYS THE CHART ON HIS CARDIOGRAM. SO, THEY DO EXACTLY WHAT YOU WANTED THEM TO DO, THEY LISTEN TO YOU, DOES THAT CHEER YOU UP?

DR. MOSS: IT MAKES ME FEEL BETTER.

DR. SALGO: GOOD! BECAUSE THEY TAKE HIM TO THE CATH LAB WHERE THEY DO AN X-RAY OF THE BLOOD VESSELS THAT CARRIED BLOOD TO HIS HEART THAT ACTUALLY FEEDS THE HEART MUSCLES.  I WILL TELL WHAT, ART, I AM GOING TO GIVE YOU CATH REPORT BECAUSE I KNOW YOU WANTED IT. HE GOES TO THE CATH LAB, I WILL GIVE YOU SOME NUMBERS. HIS EJECTION FRACTION IS 28%, THERE IS EVIDENCE OF A HEART ATTACK ON THE CATH, AND THERE ARE IN FACT SOME ARTERIES AT RISK. WHAT ARE YOU GOING TO RECOMMEND FOR MICHAEL, ARE YOU GOING TO DO AN ANGIOPLASTY AT THIS POINT?

DR. MOSS: HE'S NOW HAD TWO EPISODES, NEITHER ONE CLEARLY PRECEDED BY CHEST PAIN, BUT HE HAS COMPROMISED CIRCULATION OF THE HEART SO EVEN IF YOU CORRECT THAT THE PROBLEM IS HE HAS AN EJECTION FRACTION, WHICH IS THE MECHANICAL EFFICIENCY OF THE HEART. YOU AND HOPEFULLY EVERYBODY ON THIS PANEL HAS AN EJECTION FRACTION AROUND OF 60%.  60% OF THE BLOOD GETS PUMPED OUT OF THE HEART WITH EACH HEARTBEAT. AT 28% OR 27% THAT IS SIGNIFICANTLY REDUCED AND THAT PUTS HIM AT RISK FOR RECURRENT RHYTHM DISORDERS, FATAL RHYTHM DISORDERS, AND HE WOULD BE A CANDIDATE REGARDLESS OF WHAT YOU FIND ON THE CORONARY ANATOMY, HE WOULD BE A CANDIDATE OF AN IMPLANTABLE DEFIBRILLATOR.

CONWAY: I'M GOING TO JUMP RIGHT IN, BECAUSE I HAVE AN IMPLANTABLE CARDIOVERTER DEFIBRILLATOR INSIDE OF MY BODY RIGHT AT THIS MOMENT.

DR. SALGO: DOES IT LOOK LIKE ONE OF THESE?

CONWAY: EXACTLY.

DR. SALGO: THIS IS EXACTLY WHAT ONE LOOKS LIKE. ART YOU ARE THE EXPERT IN THIS AREA AREN'T YOU? THIS IS ONE OF YOUR BABIES.

DR. MOSS: WE'VE BEEN INVOLVED IN THE STUDIES OF THE IMPLANTABLE DEFIBRILLATOR, AND THIS IS THE SIZE OF THE DEVICE, THE CURRENT GENERATION, AND THIS IS ONE SIMILAR TO THE ONE IMPLANTED IN YOU TRACEY, IS THAT CORRECT?

CONWAY: YES, I'VE GOT MY FINGERS ON IT

DR. SALGO: TRACEY, TELL ME YOUR STORY ABOUT THIS. YOU'RE WEARING ONE RIGHT HERE ON THE SET.

CONWAY: I AM INDEED. I'M ON MY THIRD IN FACT. THEY KEEP GETTING SMALLER AND SMALLER, AND THEY KEEP GIVING ME THE NEWEST MODELS AS THEY COME ALONG.

DR. SALGO:  AT THE RISK OF EMBARRASSING YOU, BUT CAN YOU SHOW WHAT IT LOOKS LIKE TO HAVE ONE?

CONWAY: WELL, I CAN. WHY DON'T I JUST PLACE IT HERE...I DON'T KNOW WHAT THE SHOW IS RATED RATED SO...

[LAUGHTER]

DR. SALGO: IT'S RATED ANYTHING YOU WANT IT TO BE.

CONWAY: ACTUALLY, ALL RIGHT--ACTUALLY IT SITS RIGHT ABOVE MY BREAST, AND YOU CAN ACTUALLY SEE THE SCAR. MINE'S HEALED UP NICELY SINCE THE LAST IMPLANT, AND IT SITS RIGHT HERE, UNDER THE SKIN, IN A POCKET AND THEN THESE LEADS GO DOWN, THIS ONE HAS LEADS MAYBE A LITTLE BIT LONGER THEN THE ONE THAT I HAVE, BUT IT DROPS DOWN INTO MY HEART AND IT DELIVERS THE THERAPY IF NEEDED DIRECTLY TO THE AREA THAT REQUIRES IT.

ORLANDO: A SHOCK? IT SHOCKS YOU?

CONWAY:  IT HAS NOT ME PERSONALLY, BUT PEOPLE LIKE ME WHO HAVE ICDS. IT'S THE SAME THING AS HAVING ONE OF THESE BOXES (AED), AND A PAIR OF PARAMEDICS INSIDE YOUR CHEST.

ORLANDO: CAN YOU FEEL IT IN THERE?

CONWAY: YOU ONLY FEEL IT WHEN THEY FIRST IMPLANT IT, AND THE NERVES ARE HEALING, AFTER A WHILE, I MEAN, I CAN PUT MY FINGERS HERE AND FEEL IT BUT I'M NOT AWARE OF IT...I'M NOT AWARE OF IT.

DR. SALGO: YOUR BROTHER HAD AN ISSUE WITH THIS TOO, RIGHT?

CONWAY: WELL, UNFORTUNATELY, MY ONLY BROTHER WHO IS--WAS, SEVEN YEARS OLDER THEN I HAD THE SAME UNDERLYING MEDICAL CONDITIONS AND DIED AT THE AGE OF 39, BECAUSE HE WAS NOT BE ABLE TO BE REACHED WITH A DEFIBRILLATOR IN TIME, AND SO WHEN THIS HAPPENED TO ME, ABOUT EIGHT YEARS LATER, I WAS VERY FORTUNATE THAT I WAS IN THE CIRCUMSTANCE WHERE I WAS ABLE TO BE REVIVED.

DR. SALGO: ART, YOU DID A STUDY, THE MADIT TRIAL. WHAT DID THAT SHOW ABOUT THE EFFECTIVENESS OF THESE THINGS?

DR. MOSS: WELL, THIS IS VERY INTERESTING. WE DID A STUDY INVOLVING 1,200 PATIENTS AND WE HAD HALF OF THEM ON THE IMPLANTED DEFIBRILLATOR AND HALF NOT, AND BASICALLY WE FOUND 31% REDUCTION IN THE MORTALITY FROM THE PATIENTS (WITH ICD'S) UNDERLYING HEART DISEASE.

ORLANDO: THEY'RE NOT THE SAME THING AS PACEMAKERS AND THEY DON'T REPLACE THEM? I DON'T HEAR THE WORD PACEMAKER VERY MUCH ANYMORE...

DR. KERBER: A PACEMAKER IS A SIMILAR LOOKING DEVICE THAT IS PUT INTO PEOPLE WHO HAVE ABNORMALLY SLOW HEART BEAT, AND IT'S MAIN FUNCTION TO KEEP THE HEART BEAT UP TO THE ACCEPTABLE LEVEL SO YOU DON'T GET DIZZY AND PASS OUT.

DR. MOSS: THE TERMINOLOGY IS A BIT CONFUSING BECAUSE THIS IS AN IMPLANTABLE CARDIOVERTER DEFIBRILLATOR, AN IMPLANTABLE DEFIBRILLATOR. WHEN VICE PRESIDENT CHENEY HAD HIS IMPLANTABLE DEFIBRILLATOR THEY WERE TRYING TO DOWNPLAY IT SO THEY CALLED IT A PACEMAKER PLUS...AND THEY CREATED A NEW TERMINOLOGY THAT WE IN THE MEDICAL AND CARDIOLOGIC PROFESSION HAD NEVER HEARD BEFORE--A "PACEMAKER PLUS."

DR. SALGO: I AM GOING TO STOP IT RIGHT HERE BECAUSE I HAVE TO SUM UP SOME OF THE KEY THINGS WE HAVE BEEN TALKING ABOUT. REMEMBER THAT STUDIES HAVE SHOWN THAT TREATING AN ARRHYTHMIA THAT CAUSES SUDDEN COLLAPSE CAN SAVE LIVES. ART PROVED THAT AND HIS BUDDIES PROVED THAT. TREATMENTS INCLUDE MEDICATIONS, IMPLANTABLE DEFIBRILLATORS AND ALSO SOMETIMES PACEMAKERS. ALL OF THESE THINGS ARE IMPORTANT.  I CAN TELL YOU NOW WHAT HAPPENED TO MICHAEL. IT SAYS HERE HE QUIT SMOKING, WHICH IS TERRIFIC, HE'S EATING A BETTER DIET, HE GOT AN ICD, THE IMPLANTABLE DEFIBRILLATOR, AND HE'S TAKING SOME MEDICATIONS TO HELP HIS HEART AND HE PROMISES, ART, HE WILL NEVER SIGN OUT AGAINST YOUR ADVICE AGAIN.

DR. MOSS: GOOD!

[LAUGHTER]

ORLANDO: ONE QUESTION ABOUT MICHAEL'S JOB. CAN HE AFFORD A DEFIBRILLATOR ON A CONSTRUCTION WORKER'S SALARY? IS IT COVERED?

DR. SALGO: APPARENTLY HIS HEALTH CARE I THINK COVERED IT...DOES MOST HEALTH CARE COVER IT?

DR. KERBER: YES IT DOES.

DR. GOLDSCHLAGER: IT IS A VERY GOOD QUESTION.

CONWAY: THAT IS A VERY GOOD QUESTION, ONE THAT I PERSONALLY HAVE TO DEAL WITH ALL THE TIME BECAUSE I AM AN ACTRESS, I DON'T WORK FOR A MAJOR COMPANY AND HEALTH CARE IS A HUGE ISSUE FOR PEOPLE WHO HAVE THESE WONDERFUL DEVICES.

DR. MOSS: FORTUNATELY, IT IS NOW APPROVED BY THE FEDERAL GOVERNMENT AND BY INSURANCE COMPANIES, PARTICULARLY WITH THE PATIENTS WHO HAD A CARDIAC ARREST IT'S 100% APPROVED BY EVERY INSURANCE COMPANY THAT EXISTS IN THE UNITED STATES.

DR. SALGO: WELL YOU KNOW WE'VE COVERED THE WHOLE A LOT OF GROUND HERE. THIS IS ALL THE TIME WE HAVE FOR THIS CASE, THIS TIME. BUT I WANT TO THANK YOU ALL. YOU GUYS ARE JUST TERRIFIC. I WANT TO REVIEW THE INFORMATION THAT YOU REALLY NEED TO REMEMBER FROM THIS CASE. IF SOMEONE COLLAPSES IN YOUR PRESENCE-REMEMBER THE LETTERS A, B, C AND D--AIRWAY, BREATHING, CIRCULATION, AND DEFIBRILLATION. YOUR EARLY INTERVENTION CAN SAVE LIVES, AND LIVES OF PEOPLE THAT YOU KNOW AND LOVE. ARRHYTHMIA MEANS AN IRREGULAR HEARTBEAT THAT SOMETIMES CAUSES SUDDEN COLLAPSE. THE RISK FACTORS OF ARRHYTHMIA ARE DEHYDRATION, THYROID DISEASE, CALCIUM DEFICIENCY, MAGNESIUM DEFICIENCY, CAFFEINE, DRUGS--BOTH STREET, PRESCRIBED AND OVER THE COUNTER DRUGS--AND OF COURSE CORONARY ARTERY DISEASE, WHICH CAN LEAD TO A HEART ATTACK. STUDIES HAVE SHOWN THAT TREATING AN ARRHYTHMIA THAT CAUSES SUDDEN COLLAPSE CAN SAVE LIVES. AND THE TREATMENTS HERE INCLUDE MEDICATIONS, IMPLANTABLE DEFIBRILLATORS AND SOMETIMES PACEMAKERS. ONCE AGAIN, OUR FINAL MESSAGE IS THIS, TAKING CHARGE OF YOUR HEALTH MEANS BEING INFORMED AND HAVING QUALITY COMMUNICATION WITH YOUR DOCTOR.  I'M DR. PETER SALGO, I'LL SEE YOU NEXT TIME FOR ANOTHER SECOND OPINION.

SEARCH FOR HEALTH INFORMATION AND LEARN MORE ABOUT DOCTOR/PATIENT COMMUNICATION ON THE SECOND OPINION WEB SITE.  THE ADDRESS IS PBS.ORG.

MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION.  THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE, WITH ADDITIONAL SUPPORT FROM THE FOLLOWING.  THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.

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