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Too Much: Testing?

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BOSTON, Mass. ( Ivanhoe Newswire) - High blood pressure, diabetes and cancer. We're taught to catch diseases early you need to get screened and get tested, but is it always the right thing to do? Could we be doing more harm than good?

"No family history, no symptoms," Michelle Stapleton, a breast cancer survivor, told Ivanhoe.

But when Michele went in for a mammogram at 41, they found nothing but a suspicious spot. Turns out it was cancer. Michele opted to have both breasts removed to avoid chemo and keep the cancer from coming back, but a later test predicting recurrence still put the mother of two in the gray zone, so she opted for 12 weeks of chemo anyway, raising her chance of survival from 85 to 91 percent.

"It seems small to me for what you have to go through at one time but that's 6 percent more of a chance that I won't have it, so anything more that I can do to insure that I'm going to be here for my children is worth it," Michele said.

It was worth it for her but maybe not you. Dartmouth's doctor Gilbert Welch said we all have abnormalities in our bodies but most are harmless.

"We don't know which abnormalities will matter but we tend to treat them all and thereby some people are being treated for things that will never bother them and yet they can be harmed by treatment," Dr. H. Gilbert Welch for the Dartmouth Institute for Health Policy and Clinical practice and author of Overdiagnosed, explained.

A recent study out of Norway estimates between 15 and 25 percent of breast cancers found by mammograms would not have caused any problems during a woman's lifetime, but were treated anyway. The study found for every 2,500 women screened, one death would be prevented but six to ten women will be overdiagnosed and treated. Doctor Welch said this is especially true of women in their forties.

"Maybe not starting mammograms at age 40 and starting them at age 50 and maybe not doing them every year but doing them every other year might actually be in their interest," Dr. Welch said.

He also believes there's too much testing for prostate cancer.

"Twenty years ago a simple blood test was introduced called the prostate specific antigen and twenty years later about a million men have been diagnosed with a cancer that was never going to bother them," Dr. Welch said.

That's prompted the U.S. preventive services task force to advise against the test in healthy men.

"I think our focus in medicine has been traditionally in the one out of 1000 we can help, and I think the question the patient needs to ask is what happens to the other 999?" Dr. Welch said.

Then there are conditions defined by numbers like high blood pressure, diabetes and osteoporosis. Over the last twenty years, those numbers have expanded labeling more Americans as abnormal and in need of treatment.

"All of these things have a way of finding people who otherwise might never come to our attention and might live a normal life," Dr. Welch said.

Ultimately, Doctor Welch said it comes down to finding the right balance.

"I'm not saying that people either should or shouldn't be screened, I think we should tell the truth. We need to tell them about both sides of the story," Dr. Welch said.

Allowing patients like Michelle to make better decisions.

"I have young girls," Michelle said. "I've got to be here."

In a recent medical survey, 42 percent of primary care physicians thought their patients were overtreated. The reasons include malpractice concerns and not enough one-on-one time with patients. 28-percent of the doctors in the survey admitted to practicing too aggressively.

RESEARCH SUMMARY

BACKGROUND: Anywhere from one-fifth to nearly one-third of tests and treatments are estimated to be unnecessary, and they may lead to dangerous side effects. Overtreatment occurs because doctors engage in defensive medicine, or ordering tests and procedures to protect themselves against lawsuits. Also, the fee-for-service system compensates them for ordering more tests. It also has become much easier to order tests because of the Internet. Patients also contribute too, as they demand routine tests because they're bolstered by advertisements, medical information online, and doctors, and for many, tests provide reassurance. (Source: CBS News)

POTENTIALLY HARMFUL SIDE AFFECTS: Americans get the most medical radiation in the world, and much of it comes from repeated CT scans (too many scans increase the risk of cancer). Thousands who get stents for blocked heart arteries should have tried medication first. Doctors prescribe antibiotics tens of millions of times for viruses like colds that drugs can't help. Back pain is the No. 1 overtreated condition, from repeated MRI scans that can't pinpoint the trouble to spine surgery on people who could have gotten better without it. About one in five who gets that first back operation will wind up having another in the next decade. There are many reasons that one of three U.S. births now is by cesarean section, but an inaccurate monitor strapped to women in labor may be to blame. (Source: CBS News)

HOW OVERTREATMENT IS BEING ADDRESSED: Beginning next year, Medicare will penalize facilities where patients get a lot of hospital-acquired infections, and where a lot of patients are readmitted shortly after being discharged. The Affordable Care Act by the Obama Administration provided funding for a research center that compares existing treatments against each other, something that's not usually done when new drugs are approved. The American College of Physicians (ACP) is creating guidelines to help doctors better identify when patients should screen for certain diseases and when they can be spared the potentially costly and invasive procedures that follow. The health cooperative HealthPartners in Minnesota saw use of MRIs and radiation-heavy CTs growing between 15 percent and 18 percent a year, so the insurer began a new program: National radiology guidelines pop up on each patient's electronic medical record whenever a doctor orders a scan. It's not required, but a reminder of when certain tests are recommended. After 2 years, HealthPartners estimates it avoided 20,000 unnecessary tests, preventing dangerous radiation exposure and saving $14 million. An American Medical Association journal, Archives of Internal Medicine, just began a "Less is More" series to educate doctors about the risks of overused treatments. The journal Annals of Internal Medicine began publishing American College of Physicians' guidelines for "high-value, cost-conscious care." To increase patients' awareness, around a dozen health centers around the country are testing "shared decision-making," a process using plain-English guides or DVDs to explain the advantages and disadvantages of test and treatment options. (Source: CBS, Reuters, USA Today)

INTERVIEW

Dr. H. Gilbert Welch, from The Dartmouth Institute for Health Policy and Clinical Practice and Author of "Overdiagnosed, talks about how modern medicine could be making healthy people sick.

How are we making people sick then in the pursuit of health?

Dr. Welch: I think it is because we have taken what most of us assume is a good idea, preventive medicine, and we have turned it into a search for early disease. The reality is, we all harbor abnormalities and increasingly our tests are able to find them. As we look hard at the well, we find more and more of them harbor some abnormalities and we do not know which ones are really important, but we tend to intervene on all of them. Whenever we look for early forms of disease, we find a lot more people have them than we ever believed was possible.

How would you define overdiagnosing?

Dr. Welch: Over-diagnosis has a fairly formal definition. It is the diagnosis of a condition or abnormality in a patient where it will never progress, or will regress or it will progress so slowly that the patient dies of something else before he or she ever experiences symptoms from the disease. It is literally a diagnosis in a patient who would otherwise never know about it.

When is it too much?

Dr. Welch: We have to think about two very different types of prevention. On one hand, there is health promotion. That is the things that your grandmother would have told you, "Don't smoke, eat your fruits and vegetables and go play outside." I have no problems with any of that. But the problem is when prevention came into medicine, it really became about early detection which is not about preventing things at all. It is about finding things wrong. It is the kind of things that tests would tell you. I think it is very important that people understand there are two very different aspects to preventive medicine.

How do we come into problems with early diagnosis?

Dr. Welch: The reality is that we all harbor small biochemical abnormalities, small structural abnormalities, small abnormalities in our genome. Increasingly, our tests are able to find them. So, as we look harder and harder for early forms of disease, we end up labeling more and more of the well population as having something wrong with them. We do not know which abnormalities will matter, but we tend to treat them all. Thereby some people are being treated for things that will never bother them. Yet, they can be harmed by treatment.

When is having an early diagnosis and having these screenings a positive thing versus when it becomes a problem?

Dr. Welch: Let me say that most screening first is probably accompanied by some benefit and some harm. That is kind of news to most people. Most people think well, of course, screening only can help people, but the reality is, because it finds so many people to have abnormalities, it leads some people to be treated unnecessarily. It is probably helpful to talk about a real condition, so people understand what we are talking about and the poster child for the problem of over-diagnosis is prostate cancer screening. Twenty years ago, a simple blood test was introduced called the prostate-specific antigen and 20 years later about a million men have been diagnosed with a cancer that was never going bother them. That is a huge problem. There are side effects from the surgery. Side effects like impotence and problems urinating and there are side effects from the radiation therapies that are given. Here is a place where probably 1 or 2 men per thousand screened over 10 years may benefit from the screening test. While at the same time, 30 to 100 men are treated unnecessarily. I am not saying that people either should or should not be screened. I think we should tell them the truth. We need to tell them about both sides of the story and the only way for them to make an informed choice about how they want to proceed is to know something about both the benefits and harms of screening.

Are people being unnecessarily treated when it comes to prostate cancer?

Dr. Welch: Absolutely right. Yes, people are being unnecessarily treated.

How do you know when you should go or when you should not go get screened?

Dr. Welch: This is the reason in prostate cancer that the U.S. Preventative Health Services Taskforce, the group of independent experts that looks at screening decisions has now recommended against prostate cancer screening. For the simple reason it leads to way too much over diagnosis.

How about aggressive treatments and all of these screenings, are they really the right way to health?

Dr. Welch: I think that is a very personal question, but I think everyone should understand that aggressive screening has probably been oversold in terms of its benefits. The problems associated with it, like over-diagnosis have been downplayed or ignored. That is changing now. Just the fact you are talking to me reflects that is changing now. That we all need to understand that screening is a delicate balance of benefits and harms. It is not a free lunch.

What are some of the harms that come along with over-diagnosis?

Dr. Welch: The major harm with over-diagnosis is unnecessary treatment. All of our treatments have some harm. Some people have died from treatments. But there are also harms that occur to more people and those are the problems of false positive tests that make them worry about the disease. There is the problem of being labeled as somehow abnormal that makes people feel more vulnerable about their own health that they say, well you do not have cancer, but you are also not normal. You have some dysplasia or you have something that is worrisome that we ought to check more often. That just leads to a population that is more anxious about their health. They feel more vulnerable. I think one of the questions we have to ask as a healthcare system is looking hard for things to be wrong a good thing for healthcare system to do?

Are we creating just a population of anxious people?

Dr. Welch: Are we creating a population of anxious people and giving them too much treatment? That is a very legitimate question that we need to be very careful with well people. I want to be clear. I am a conventionally trained western physician. I believe in medical care for the sick. There are a lot of good things we can do for the sick. The question I am asking is to what extent do patients want to enter the system when they are well. I am not saying they should never do it, but they should understand that there is some harm associated with that process.

Are we creating sick people who were just fine before?

Dr. Welch: That's right and are we doing things to them. The truth is, it is hard to make well people better in the short run, but it is not that hard to make them worse.

Can you tell us a little bit about you book?

Dr. Welch: The interest in writing the book was I had been studying the problems associated with cancer screening for about two decades. Then I recognized and my co-authors and I recognized it is part of a larger problem in medicine which is to always look for disease early. Whenever you look for a disease early, you end up finding more people have it and then you start doing things to people. And I recently heard a story that I thought was kind of interesting where a patient, older man, came to a physician for a regular checkup and the physician, very thorough physician, felt his belly and thought maybe he had an abdominal aortic aneurysm which is a little enlargement in his aorta. He then sent him for an ultrasound. The ultrasound said no, the aorta is fine, but then found an abnormality on the pancreas. Well, maybe the pancreas has cancer. So, then he gets a CT scan of the pancreas. The pancreas is fine and then there is an abnormality in the liver. He gets a needle biopsy of that abnormality. It turns out to be something called a hemangioma, which has a fair amount of blood in it. He starts to bleed and he needs an operation to get fixed. Now, here is someone who started well and went through a cascade of events all in the effort to try to keep him well and he ends up being hurt in the process.

Besides cancer, what are maybe some other specific disease that you find are being too often screened for?

Dr. Welch: Aortic abdominal aneurysm is one. Another one is vascular problems in the neck where people are screening for carotid blockage of the carotid arteries. Of course, we are screening for osteoporosis. We are screening people for diabetes. All of these things have a way of finding people who otherwise might never come to our attention and who might live a normal life without ever suffering any problems from their disease.

Are y0ou saying that you can have some of this genesis of disease in your body, but it does not mean that it is necessarily going to progress to the point where it would ever affect you?

Dr. Welch: Absolutely. That is right. We can all harbor abnormalities that may not be meaningful to us. In fact, the vast majority of them will not be meaningful to us. You might remember a few years ago there was a flurry of interest in total body CT scanning. That is where people, I believe, like Oprah Winfrey underwent a full body CT scan in an effort to see if anything was wrong. We now have studies and we realized that among about 1200 healthy volunteers that underwent that screening, people who felt perfectly well, about 80 percent of them had at least 1 abnormality and the average patient had 2.6 abnormalities. So, there is a vast reservoir of abnormalities that we can find now with our imaging tests. The same is true with our blood tests and the same is true with genetic tests. We all harbor genetic variants.

In a lot of ways, abnormalities though are normal?

Dr. Welch: That is right. And we probably need to recalibrate ourselves, so that we are not so reactive to small abnormalities.

How can a person protect themselves then from the over-screening?

Dr. Welch: It is a balance. I think one thing patients need to do is to begin to understand the problem. Begin to understand there are two sides to screening and that is why my colleagues and I wrote the book to try to explain the problem of over-diagnosis, and why there should be a little bit of hesitancy, at least, towards early diagnosis efforts. They should recognize that there are a lot of forces pushing early diagnosis. Some are very well intended, but others are quite frankly financially motivated because it is a great way to find new patients. I think a little bit of healthy skepticism on the part of the patient is a very useful thing. I think it helps patients understand why the suggestions such as maybe not starting mammograms at age 40, but starting them at age 50 and maybe not doing them every year, but doing them every other year might actually be in their interest. These questions of when to start screening, how often to screen, how hard to look are all motivated by trying to keep this balance, so we do not do too much over diagnosis and we find the cases that really matter.

We are constantly seeing guidelines coming out that are saying you need to be screened and if you are not screened you are going to die.

Dr. Welch: Isn't that a horrible message to give people. If you do not come to get medical services, something bad is going to happen to you. The reality is there is so much more that determines our health than simply medical care for the well. In fact, the most important things for our health when we are well are things that have nothing to do with medical care. It is about our diet. It is about our exercise; about whether we have jobs, about whether we have meaning in life; all those .

What about people with family genetics that have certain things in their family?

Dr. Welch: That highlights this question of who stands the most to benefit from early diagnosis efforts. The people that stand the most to benefit are those that are at the highest risk of having the disease. My comments do not apply for example to someone who has BRCA1, the so-called breast cancer gene in their family. They are at substantially elevated risk, not 20% higher. They stand to benefit more from mammography than the average woman does and they are less likely to be overdiagnosed. This is a balance. I think the message that is important is this is not something where doing more is always in your interest. Instead, it can create a whole bunch of problems.

Are there any recent studies that have come out to show this trend?

Dr. Welch: Absolutely. I suppose the thing that I think is most relevant is now there is a growing group of people including the U.S. Preventative Health Services Taskforce is now suggests recommending against prostate cancer screening. I think breast cancer screening recommendations are getting more conservative in this country. I think there is an effort to try to explain to women why this is such a close call and I think we will continue to see that in the next 4 or 5 years.

Why do you think that doctors do this?

Dr. Welch: I think there are a lot of answers to that question. Why is this happening? It is a complex web of forces. First, there is true belief that it is always in your interest to look for early forms of disease. But there is also a lot of money behind this. This is a great way to create new patients. It is a lot easier to expand the indications for a drug to well people than it is to build a better drug. It is a lot easier for hospitals to recruit new patients by advertising screening through screening efforts than it is to actually provide better care. There are a lot of financial forces that make this early detection paradigm quite ruminative. The other thing to say and all my physician colleagues would want me to say this, is the legal climate. The way we doctors feel is that we could be punished legally for under-diagnosis, but there is no corresponding punishment for over-diagnosis. We are not stupid people. When we see that set of incentives, we are always pushed to test and treat and always intervene. The other factor I have to say is the news media who has focused on these very appealing survivor stories. The presumption is that any person who has had a screen detected, say breast or prostate cancer has benefitted from the procedure. In fact, actually the reverse is true. Most of these survivors are actually more likely to have been unnecessarily treated for a disease that was never going to bother them. Ironically, the survivor's stories reflect the harm, but they are perceived as the benefit. I hate to have to say that. I would like everyone to have benefitted from the procedure, but the truth is more people have been harmed. Now, the people who have benefitted have benefitted big. They have avoided a cancer death, but those numbers are vanishingly small. They are literally on the order of 1 in a 1,000 people who participate in screening. I cannot tell people what the right thing to do is, but what I can tell them is that there is a tradeoff here and they ought to start to think about it; because we are only going to be inventing new screening tests every day.

What would you say is the key message that you would want to get across then on this story?

Dr. Welch: I would like patients to be just a little bit more skeptical about the value of looking for things to be wrong. I would like them to ask a couple of follow-up questions.

Like what?

Dr. Welch: Does it really work? Do we know it actually makes people better and how often are people harmed? Those are the real questions to ask. I think our focus in medicine traditionally has been in the 1 out of 1000 we can help and I think the question the patient needs to ask is what happens to the other 999.

Are there any other questions that you think that people need to really consider before they decide to undergo some of these screening tests?

Dr. Welch: Talking to their doctor if they can. If the doctor is open to talking about both sides; reading a little bit more about it, and thinking about how they want to approach life. Not all patients in the exact same situation can reasonably make different choices based on how they want to approach life. I think some people are willing to take on all medical interventions, all efforts to try to prolong their life and avoid various forms of death and accept the downsides of perhaps unnecessary intervention, unnecessary treatment, unnecessary harm from treatment complications, etc. Other people may prefer to take a different approach and accept the fact that they might miss some small benefit, but they avoid all the unnecessary contact with the system and premature medicalization while they are well. Again, I want to emphasize, this is while you are well. When you are sick, I encourage you to see a doctor.

Is it about being in tune with your own body?

Dr. Welch: It is being in tune with your own body, in tune with your own preferences. What is health to you and how do you want to pursue health? Do you want to pursue it by engaging with the system, understanding that you might be over medicating the process and overtreatment? Or, do you want to enjoy your health while you have it and then by all means come to the system when you suffer problems.

Do you feel that in some ways we were better off 20 or 30 years ago when perhaps we did not have all these screenings?

Dr. Welch: I think the well were better off. I want to be clear. I think the sick are better off now. Our treatments for cancer for example, is much better now than it would have been 30 years ago. That is a great improvement. I think medicine has made some real improvements in treating people. I think the question of what we do to well people is a little bit more of an open question, whether we are really treating them better now than we would have in the past.

What about high blood pressure, high cholesterol and diabetes?

Dr. Welch: Let's be clear that treating really high blood pressure is probably one of the most important things we do. That is a useful intervention without a doubt. It is probably the most important preventive intervention we do. At the same time, we are probably overdiagnosing hypertension. It is all a matter of how high the blood pressure is. Our threshold to say someone has high blood pressure has fallen precipitously since I was in medical school. We are just treating a whole bunch of patients that we would not have treated before. These are patients with very mild elevations in high blood pressure. The problem with treating those patients is they are also the same patients in whom we can make their blood pressure too low and then they can fall and they can break their hip. We have to again, find that balance. Same true in diabetes. It is really bad to have very high blood sugars. But we are also treating a group of milder diabetics; patients who are quite old and now we face a new risk that we drop their blood sugar too low. In fact, a recent randomized trial done by the NIH demonstrated that being too aggressive in blood sugar control in mild diabetics can actually lead to higher mortality. So again, it is about finding the balance. Treat people who are extreme, with extreme elevations, but not over treating people with mild abnormalities.

FOR MORE INFORMATION, PLEASE CONTACT:

Annmarie Christensen
The Dartmouth Institute for Health Policy and Clinical Practice
(603) 653-0897
annmarie.christensen@dartmouth.edu

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