“It is a big problem if you do have epilepsy but even a bigger problem if you don’t have it.”

Dr Adam Fitzpatrick, consultant cardiologist, electrophysiologist, and leading authority on blackouts, spoke to the Manchester Cardiovascular Society for an exclusive interview where he talked about his ‘blackouts’ clinic set up in 2007 and the challenges in his line of work.

Dr Fitzpatrick, tell us a bit about your background.
My father was in the air-force and I was the first person in my family to go to university. I suppose I was rather unsure about the variety of options but it then narrowed to a choice of either doing medicine or law. In fact, I did A-levels in arts and eventually did a one year conversion to do medicine. I then trained at St Bartholomew’s Hospital Medical College in London.

Why did you specialise in cardiology?
It was quite a difficult choice. Cardiology was the right combination of research and intellectual challenge, with big content for procedural activities. There are cardiologists involved in stenting for patients with angina, others look at congenital disease of the heart, and my particular area of interest has been heart rhythm disorders.

How did your interest in arrhythmias begin?
At first it is difficult to develop a real understanding of the different subspecialties. Working in cardiology for about five years and doing research for two years in an area related to arrhythmia helped to make my decision.

What is your typical working week like?
It is a mixture of clinics. About two thirds of patients are follow-ups, the remaining are new patients with arrhythmias considered for ablation. I also have two days in the catheterisation laboratory. The usual procedure is ablation, which involves getting access to the heart and assessing its rhythm and the abnormal tissue; this takes about 2-3 hours. In some cases, we can actually cure the patient and they can leave the next day. Other patients coming in may need a pacemaker or a defibrillator. We also insert a cardiac monitor (implantable loop recorder) under the skin in quite a lot of patients each week.

How does this monitor work?
It continuously monitors [a patient’s] heart rhythm for about three years and can report the last ten minutes of activity when the device has been activated, say when the patient has fainted. We access this data during the episode and follow-up on our patients. There are about 400-500 patients monitored with this device.

You and your team set up the first ‘blackouts’ clinic in 2007. How is it going?
Every week, we see about 16 new patients in our triage clinic and 13 follow-up patients. It is a large number of patients; this is a problem in the community. Many patients coming into casualty have a blackout. The faint is quite often jerky, which looks like a fit and is mistaken for epilepsy. It is a misdiagnosis and there are about 120,000 such cases across the UK.

What are the consequences of such a misdiagnosis?
Imagine having a sibling or child diagnosed with epilepsy. This can have a big impact on the family and on the individual themselves. Schools are anxious about students with epilepsy. Employers are less likely to employ you if you are applying for a specific job, say a driving job. Meanwhile, you take the wrong treatment for the wrong diagnosis. It is a big problem if you do have epilepsy but even a bigger problem if you don’t have it.

How is this misdiagnosis avoided in clinic?
Through triage, we look at the clinical history and make sure that we find the ones that sound suspiciously like epilepsy and send them to a neurologist. The others, we investigate in the clinic. Many get the implantable loop recorder, which helps us monitor their heart activity. This is useful, for example, if an abnormal heart rhythm has been detected and is the cause of the blackout – not epilepsy. The average age for the blackout patients we see is 40 but can range from 16 to 95.

How effective is triage?
We have seen about 2500 patients in Manchester and about 3000 patients in a Middlesbrough clinic which uses our methods. It is a very long process to tract and contact the patients to investigate about the outcomes and go through all the records. So far we have analysed 700 patients and will soon be able to look at the outcomes.

Is the ‘blackouts clinic’ used elsewhere?
We have given the opportunity for other clinics to use this triage system including Middlesbrough. Specialist nurses in clinic use an assessment tool we devised and answer questions relevant to blackouts. At the end, it will automatically generate a list of conclusions, investigations and risk assessments. The clinics can then save and encrypt their data onto our servers.

You can access the demo site [HERE].

Where do you see this system in 10 years?
There has been quite a lot of interest in the system but the hard truth is that not many doctors are particularly interested in people with blackouts; they have their own specialty to look at. This is why we only presented the system as a triage and we are not trying to do the whole pathway. We offer A&E patients with blackouts the possibility to come to this clinic and we can try sorting out the best way for them to go. Thus, we can avoid the risk of getting stuck: stuck on a neurological pathway, getting stuck on epilepsy drugs they cannot get off again because there is nowhere to go. Quite a lot of neurologists send patients to this clinic as well. This provides a resource where we can look at everything again with an open mind and not jump to conclusions.

What challenges do you face in your field?
Like every specialty, people get used to thinking inside the box but we have to remind ourselves that there is a whole wide range of possibilities outside the box concerning the patient’s symptoms. We should not give our own duties too much importance compared to other people’s and should mutually respect our needs. In fact, the more specialised we get, the more natural it is to think that our area is more important but the reality is totally different; when you put your head up and look around, you realise that you are only one tiny part of the whole picture.

Any others?
There seems to be no break on demand; everyone can demand unlimited resources but we know they are limited. So this creates pressures which are difficult to work with.

Do you think these challenges will be the same when we, medical students, will become doctors?
I think they will potentially be very changed. There might be some sort of insurance or co-payment for certain services, that would be a reasonable break on demand without being unsafe. Other things might be the scaling back on activities like research which may be completely separated off into different entities like public health which is no longer part of an NHS trust.

What advice would you give medical students?
I think there is no alternative to getting into a programme and completing it. You should find something that you want to do, something that engages you and excites you. Do not let it go. Stick to it and ultimately if you are determined enough you will succeed.

Do you have to think ahead, in 10 years where and what I want to be?
Yes, and also how to want to get there is the question and make sure that along the way you find something that makes you passionately excited.

Would you have changed anything when you were training until now?
I would have been much more diplomatic, dealing with the challenges and the personalities. However, generally speaking, I am pretty happy with what I did, and how it worked out. I know I had to put lots of effort to achieve what I have achieved but this makes it more gratifying when it works out. I think I would do it all again.

Any dreams that you have missed?
Playing the guitar!

Your quote to end?
You only get out of life what you put into it.

*****

The Manchester Cardiovascular Society, well established amongst the student community, organises events and caters for students with an interest in cardiovascular medicine. Previous talks include: ‘Maternal and Paediatric Cardiology’, ‘Treatment of Aortic Aneurysms’ and ‘Rhythm of Life’, delivered by Dr Fitzpatrick himself.

Cardiology is no stranger to students given that it plays a substantial part in Years 1 and 3. With the positive feedback received from third years for our ‘HLB OSCE Revision Day’, we have decided to line up a new series of revision events for students across all years including Years 1 and 5.

In parallel, our usual series of lecture events to further your interest in cardiology will be running all along the year. Find us on Facebook and Twitter (@UOMCVS) for further details, which will be revealed soon.

Cedric Ho Tiu
Medical Student
Manchester Cardiovascular Society

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