On behalf of the School of Nursing I
would like to welcome you all to the 26th
annual Helen Nahm Research Lecture Award
The Helen Nahm Research Lecture Award
recognizes a University of California
San Francisco School of Nursing faculty
member or graduate who has made an
outstanding contribution to nursing
science and research. It honors Helen Nahm
RN, PhD, FAAN, and late dean of the UCSF
School of Nursing from 1958
to 1969 to her
research findings dr. Nam shared her
ideas and vision with a new generation
of nurses it is it is to exemplify this
excellence of the scholarship and
dedication of purpose that the Helen on
research lecture award was inaugurated
in 1981 and with that I'd like to
introduce our Dean Kathleen drinking
good morning i want to welcome you all
and Christmas Kelsey and I were just
chatting about this is our favorite day
of the year the combination of the hell
anam where we get together to honor
someone who has made a real contribution
to the research findings that nurses use
everyday is a very exciting and
celebratory event and then cap stoned by
launching our graduates each year so
it's a very happy day in the school and
I really welcome each of you as Brad
mentioned the hell anam research award
it wasn't initiated in 1981 and I know
that there are several awardees in the
audience i was just wondering if you
would mind standing to be acknowledged
and so of course the tradition carries
on today we really thank you all for
coming and I know that you share my
eagerness to hear about Barbara Drew's
research the tradition of the hell
anomaly ward program has been that one
of the nominees of the award receivers
recipient provides the introduction and
this year
Claire summer grand myself and Christmas
kowski nominated Barbara I don't know if
many people know but I learned how to be
a dissertation chair from Barbara she
was my first doctoral student and
everything I've learned about being a
dissertation chair i learned from barb
rest I so it is really my pleasure to
introduce Chris who is going to
introduce barber today thank you
good morning and welcome again to this
wonderful wonderful occasion
I'm it's my privilege to introduce to
you this morning dr. Barbara drew he's
going to give us the 20th tell anam
research lecture now I did some thinking
about how could I characterized garbage
research career and all of you that know
barber or have known about her search
knows i guess we would crown her the
queen of acronyms and acronyms for her
research projects and the people in the
back of work with Barbara recognize that
so I decided to get you familiar those
of you that are not in in in not
familiar with electric rd ography that
Barbara will share with us her great
research in this is kind of the standard
elect picture of the electrical activity
of the heart the pqrst complex and
Barbara's going to tell us how she
studied that in a few minutes but i'm
going to use that complex as the
framework for my introduction and so
what I've decided to talk about is the
PQRS peas of an outstanding research
career now on that list the queue was
the toughest alright so you'll have to
bear with me as I do some of this so p
is for preparation q is for questions
r is for responsibilities S is for
support and key is for triumph and
travels and that's the context that I'm
going to use to share a little with you
about Barbara groups now preparation a
barbara was born and raised in Wisconsin
and I thought it would be kind of fun
alright and i went on their website to
do a little quiz I mean this is a
research lecture so let's see and them
Mike Enzi lived in wisconsin he got
every one of these right all right but
do we know the state bird of Wisconsin
recognize the picture that's Robin
that's right pretty good how about the
state and the mall badger you got it
Otis some real Wisconsin fans here the
state flower you know you guys are good
well
alright the state dance now I take
umbrage with this I must tell you on the
website it said the reason the Polka is
the state dancing with constant because
of the German influence now I'm of
Polish heritage and the pasta is really
from Poland so we can argue about that
later
and lastly the state drink milk
you got it all right yeah you did very
well art now Barbara grew up there and i
want to show you a few photos from axis
oh wait wait i asked her how old she was
there and she couldn't remember mom do
you remember how old she was there no 23
maybe maybe huh interesting
barbers one of five children
she's the second youngest you've
pictured there with her brother her
other three sisters and her mom and dad
I'd like to take a moment to introduce
to you barbarous three sisters Mars wind
and Kathleen her here with us today
they're sitting in the second row you
would just give them a warm welcome and
you'll get to meet them later at the
reception
um I think that this Beach i speaking
personally is one of the highlights of
our researchers academic career and none
of us would be here without our parents
so I want to take a moment to introduce
you to Edna and James growth
unfortunately barb dad couldn't be with
us tonight but just at this morning but
Bob's mom is here sitting in the
audience and on behalf of the Department
of physiological nursing we'd like to
say welcome to you we just wanted to
give you a small token of our
appreciation for giving us such a
wonderful wonderful daughter and raising
her to be sitting outstanding
individuals
ok moving on in terms of the P Barbara
graduated as an RN some Saint Anthony
School of Nursing in rockford illinois
she achieved the baccalaureate nursing
in 1997 from California State University
and then came to the university of
california where she was awarded a
master's degree in 1980 and a PhD in
1990 here's a picture of Barbara and she
graduated from nursing school in moving
on with preparation barbers had a
variety of rich experiences in clinical
practice serving as a critical-care
nurse a head nurse of the coronary care
unit a director of cardiac nursing and
alta bates hospital and then in 1995 and
in 1990 forgot with your you came here
Barbara I didn't write that again 94 93
90 80 one sorry about that works alright
in 1981 she joined the faculty in the
School of Nursing at UCSF and served as
vice chair of the department of
physiological nursing from 1995 to 2005
I want to step back a second as i did
introductions and acknowledge that
coming over the golden gate bridge this
morning i forgot to include one picture
in this presentation of supportive
people in Barbara's families and I
apologize for that i skipped over it i
had intended to do it after I introduce
Bob's mom I'd like to acknowledge Dennis
true bard husband who's here with us
today as well and i forgot to put his
picture in the slideshow so Dennis thank
you for being here with us and stronger
for Barbara took her extensive clinical
experience and brought it to her
research life here looking at questions
related to the care of patients
primarily in the cardiac care unit
I'm not going to share with you the
litany of research projects that Barbara
has been engaged in because she's gonna
share that as part of her lecture but
what I'd like to comment on in terms of
the cute part
the pqrst complex is that outstanding
research questions have guided her
research career and you're going to hear
more about those as she gets her talk
the goal if you read Barbara cv in terms
of the research that she does is to
improve the care of patients who require
cardiac monitoring largely critically
ill patients but also patients on at
home who need this type of monitoring as
well and as i've looked at her research
career one of the hallmarks of it from
my perspective is her ability to ask
really important clinical questions and
her ability to link trying to understand
these clinical questions trying to do
better assessments of patients to the
use of technology there really are very
few nurse scientists were able to build
that bridge and we're going to hear a
lot about that i'm sure in her
presentation today
Barbara has had an extraordinary amount
of funding since she launched her career
in 1987 she's been funded by the
american heart association by the
national institutes of health through
not only the national institute of
nursing research but also through the
National Heart Lung and Blood Institute
she has completed over 15 research
projects and has been awarded over 6.9
million dollars in research grants in
terms of responsibilities back at home
I've listed a few that I think exemplify
her career she served as vice chair of
academic programs in the Department of
physiological nursing and too many
committees that could be enumerated on
this slide
she served as chair of the faculty
search committee for the four FPE some
of us remember that daunting task to
bring together a consensus about new
hires within the school and she's also
served served as chair of the faculty at
the campus level she's been she's done
service on the Academic Senate Research
Committee she served on the executive
committee and on several chances
committees her most outstanding
leadership contributions however come in
her service to professional
organizations Barbara has been
a leader at the local level of the
American Heart Association serving as a
member of the board of directors sharing
the orc that organization at the local
level and was the founder of the public
access defibrillation project here in
San Francisco that got public access
defibrillators available in key public
spaces in the city and she has also
served in key leadership positions at
the national level of the American Heart
Association holding several positions on
the council for cardiovascular nursing
she served as liaison from that counsel
to the clinical cardiology committee she
served on the board of directors of the
Western affiliates the regional group
for the American Heart Association and
it served on the acute care committee of
the Council of clinical cardiology for
the American Heart Association if that
wasn't enough she is also for the
American Heart Association shared a
multidisciplinary committee that
develops practice standards for
electrocardiograph months
electrocardiographic monitoring in
hospitals across this nation taking an
exemplifying I think with Barbara does
really well taking her research findings
and moving them into practice in a very
evidentiary based way Barbara has been
exceedingly active in the international
society for computerized electric-car
Diaw graffiti serving as a member of the
board of directors and then as a chair
of the budget finance and awards
committee doing such outstanding jobs in
that organization that they had the good
sense to name her elector the first
nurse ever to be President of that i
guess i can say it largely male
dominated the organization uses we need
to congratulate her for that
um in terms of the essence of the pqrst
complex i have to state that i think one
of the hallmarks of Barbara's career is
her ability to support students as well
as new scientist and i use this picture
of her with Marion Michelle in the
Netherlands to exemplify that in in
terms of the honors she's received in
recognition of her mentorship activities
she was selected as one of the ten
critical care nurses in one of the top
critical-care nurse mentors in the
united states by the American
Association of critical-care nurses a
very large national organization that
recognize 10 individuals for their
exemplary mentorship Barbara has also
received from the ucsf you know
university california san francisco the
outstanding faculty mentorship award if
you review her CV she has shared six
masters thesis committees 13 doctoral
dissertation committees of which he has
served on as chair of 11 of those um in
terms of the t part of that complex I'd
like to just enumerate the number of
Lifetime Achievement Awards that Barbara
has received starting in nineteen ninety
she was honored by the American
Association of critical-care nurses with
their research award she was elected a
fellow of the Council of cardiovascular
nursing in 1994 sigma theta tau
recognize two contributions to research
with their award in 1995 and in that
same year she was elected to fellowship
in the American Academy of Nursing in
1997 she received the young investigator
award from the american heart
association
she then received the John Jay Samson
exemplary volunteer award from the local
affiliate of the american heart
association in 2001 again honored for
her contributions to cardiovascular
nursing she received and gave the
lecture in the name of Catherine a limb
right
the following year the american
association of critical-care nurses
named her their distinguished research
lecture she received from the ucsf alpha
a chapter of sigma theta tau of the
Margaretta styles award and on Sunday
she leaves for Switzerland she's just
been awarded a fulbright instead of as a
capstone of her her achievements
she has served on nine expert panels for
government and professional
organizations she's written over a
hundred original articles and i stopped
counting the presentation
is that she gave both regionally
nationally and internationally
I think one of the ones on however that
is worth mentioning because I think
Barbara was very very proud of it was to
be named the only nerves to be invited
to present at the I sovan foundation
celebration of a hundred years of
electric RT of the electrocardiogram in
Switzerland and some of you may not know
who Einthoven was. He was the man that did
the first electrocardiogram. So to be
honored as a nurse to speak at that was
absolutely wonderful and I hear two
photographs with you. Here is Barbara the
museum they are enlightened with the
first EKG machine and she has the
privilege of meeting Dr. Einthoven's son
August grandson right
what are the third asked us the
celebration and I remember her coming in
with the when I was when we were when I
was sitting in my office one day with a
letter inviting her to come and she was
just beaming at this honor so I share that
one with you.
Um, it is my distinct pleasure to
introduce to you the 26th Helen Nahm lecture.
Dr. Barbara Drew who's going to share
with us her talk
Electrocardiographic Monitoring: Two
Decades of Discovery.
Barbara, please. Well, I've uh titled my
presentation Electrocardiographic
Monitoring: Two Decades of Discovery.
Because it was exactly two decades ago
that I entered the doctoral program in
nursing here at UCSF but first a little
history. Hospital ECG monitoring was
introduced by Dr. Day in Kansas City in
the mid-1960's when I was a
nursing student. As a new graduate RN in
1968 I was hired along with 12 other
nurses to establish the first coronary
care unit at Evanston Hospital in
Illinois. The goals of monitoring then
were simple. We were simply to track
heart rate and to detect ventricular
fibrillation and standstill. In fact,
here's an ad for a early cardiac
monitor
skating is a simulation is it stand
still or has it started? Get the answer
from your bed cardiac monitor I think
you'd agree with me that this nurse
probably could rule out fibrillation and
standstill without the cardiac monitor
just by noting this guy's tricky little
grin. While lead II was universally used
for cardiac rhythm monitoring in the
early years because it required just
three electrodes on the patient's chest
and it provided a very clean signal
that's because it has a high
signal-to-noise ratio so it was perfect
for accurate heart rate detection. Now,
another glimpse of what it was like in
the early years can be seen by a
promotional film that Hewlett Packard
company filmed in my CCU 35 years ago.
If you have trouble figuring out which
of the two nurses I am I'm the one with
under Burnett with the larger nurses hat
nurses in a busy urban hospital keep a
watchful eye on their patients using a
cubic accurate monitoring system heart
rate calls and other vital functions are
continuously displayed diversity station
oh there he is
how to plug it into the wall
Shh shouldn't have to deal worried about
half of the patients are local sales
rest of the attackers we had those sound
effects in those years to know that if
your relation work reported every year
well from nineteen sixty eight to
nineteen eighty-six i worked in coronary
care unit and staff nurse manager and
clinical nurse specialist role and I
became very interested in two aspects of
cardiac monitoring using a CG
information to improve patient care and
improving nursing practice related to
ECG monitoring some of you will
recognize the very famous patient here
is scott seems but when entering the
ucsf doctoral program in 1986 I had to
ask the question what research should I
focus on first now at the time there was
up there republication like this one in
the annals of internal medicine about a
misdiagnosis dilemma related to ECG
monitoring and to quote these authors
they state wide complex tachycardia is
often incorrectly diagnosed as super
ventricular tachycardia when in fact the
12-lead electrocardiogram strongly
suggest ventricular tachycardia
verapamil is commonly administered in
these circumstances and it's frequently
associated with a poor outcome
now I realize that some of you are late
persons in the audience and that you may
not know these terms so let me just
briefed you here super ventricular
tachycardia
or SE ki arises from above the
ventricles and it enters the ventricles
over the specialized electrical
conduction system of the heart and
spreads rapidly to both ventricles
simultaneously producing a narrow
normal-looking QRS complex rapid melting
be administered intravenously which
blocks impulses at the AV node so
impulses can't enter the ventricle and
it either abolish is the tachycardia or
at least slows it down in contrast
ventricular tachycardia arises from the
ventricle it never gets into the
specialized conduction system but rather
spreads in an unorthodox manner through
the ventricles producing a wide bizarre
cute-looking QRS complex verapamil not
only doesn't work to terminate his
tachycardia but it has a negative
inotropic properties which can cause
hemodynamic collapse and even death
well most of you might say what's the
problem
I could tell the difference between the
narrow normal-looking qrs tachycardia
and a wide QRS tachycardia
however the rub is that svt can also
have a wide QRS complex that there is a
Berenson tricular conduction so this
makes the differential diagnosis of a
wide QRS tachycardia challenging and
some researchers such as the famous dr.
wells from the Netherlands somehow
netherlands really produces wonderful
electric rd ographers had published that
the QRS configuration in lead v1 is
valuable to distinguish the key from svt
with the Baron see one of these such one
of these criteria is shown here when the
wide complex is positive and wide with
two peaks at the top which nurses dubbed
rabbit ears and the left peak is taller
than the right peak well and found that
this was likely to be ventricular
tachycardia
whereas if the complex had the right
rabbit-ear pattern it was likely to be
SCT with a barren see while monitoring
lead v1 requires five electrodes and
early cardiac monitors did not provide
this capability we had instead the
simple three-electrode style monitors
for monitoring lead to sew a famous
electracard iographer by the name of
Henry jl marriott also known as Barney
marriott who had been oxford trained a
famous cardiologist who had the best
sellers of ECG interpretation books
developed a workaround for this
situation first recorded in this 1970
article he said of the conventional ECG
leads the one that contains the most
information about disturbances of rhythm
is the one which should therefore make
the best lead for routine monitoring but
v1 is mechanically inconvenience and so
four electrodes must remain constantly
attached in addition to a fifth chest
electrode so he goes on to talk about
his work around and here is dr. mary its
modified b1 which he called mcl-1 it
used just three electrodes and we could
do it with our current bedside monitors
mcl-1 monitoring became so common in the
nineteen seventies in nineteen eighties
that EKG monitoring companies built it
right into their lead selection choices
but i always wondered is it valid to
apply ECG criteria developed using v1
when monitoring and mcl-1 so if you're
patient monitored and mcl-1 developed a
wide QRS complex like this one that has
the left rabbit-ear rule can we be
certain that it's ventricular in origin
well I decided that I should call dr.
Marriott and ask him about how he
developed the mcl-1 lead and he said in
developing mcl-1 I
confirm that it matched v1 in an
outpatient clinic population i did not
compare these leads during arrhythmias
but i would expect them to be comparable
during wide QRS tachycardia
he went on to say this would be a great
project for you Barbara you could
confirm the value of my MCL 1 lead which
would convince clinicians to switch from
lead to two mcl-1 so that was
encouraging and I decided to take this
on is my dissertation project that of
course i needed a gold standard for a
correct diagnosis
now the gold standard for correct
diagnosis of wide QRS tachycardia is an
invasive cardiac EP study and the
director of the EP lab at UCSF in those
years with dr. Melvin Scheinman who was
like a rock star in because he had just
introduced catheter ablation therapy
which has become the standard of care
now for the treatment of tachycardias he
changed the whole paradigm and is the
reason why every hospital wants to have
a cardiac EP lab this is the way the
ucsf EP lab look during the year that I
was collecting data there in 1989 notice
that's the year of the San tradition of
the earthquake this is how my patients
look I was collecting data for more than
my dissertation study because i felt as
long as I was going to be there for a
year I had better get busy with more
data that i could look at later
now male is back east and unable to be
here today but he asked me if he could
say a few words so here goes
you didn't need a very great pleasure
from you to honor dr. drew
I'm just so sorry that I can be in
person to witness
this auspicious event I don't Barbara
for well over a hundred years can test
it against her work we have worked
closely together already is first on
analyzing the different EKG waveforms to
differentiate super ventricular from the
trigger tachycardia and Barbara
independently came up with their own
that criteria which is a lasted the test
of time and we finally here before this
too has to be drew criteria subsequently
Barbara has a range that done just
wonderful independent research
firstly focusing on the body surface map
in ischia showing the importance of
these parameters and following your
applications are admitted to hospital
with various problems related to the
contrary occlusion and in addition she
has done wonderful work collimating the
site of infection with the EKG
parameters so in some it has been
incredible pleasure for me to watch the
growth and development of Barbara drew
i'm really honored to be part of these
celebrations and know that she's going
to continue to do exemplary work in the
future
well we found that mcl-1 is often not
the same as be wondering why did complex
tachycardia and here's just an example
of that and let me orient you to this
slide the top of waveform is mcl-1 dr.
marriott's lead and then the next is the
true v1 and the bottom two are
intracardiac electrograms the
ventricular electrogram and his bundle
electrogram which is used as the gold
standard for a correct diagnosis
now the correct diagnosis here is is a
non sustains and tricular tachycardia
which ends right here and the last two
beats are normal beats notice that mcl-1
and v1 are identical during normal
rhythm but they're completely different
during the wide complex tachycardia the
true v1 has the accurate left rabbit-ear
pattern which is correctly indicative of
ventricular but mcl-1 would lead to a
wrong diagnosis so melon i published the
mcl-1 we'd recorded clearly different
urs morphology than lead v1 and forty
percent of VT cases and was
diagnostically interior 2v1 we concluded
the ncl one we cannot be substituted for
v1 in the use of morphologic criteria
for VP now I worried a little bit about
doctrine areas finding out about this
I did warn him before this publication
came out and he didn't want to see the
waveforms which I showed him and he did
agree with me he was very surprised and
over the years we've remained friends
doctor Barney Mariette turns 89 next
week and he couldn't be here but he also
wanted to say a few words
and Bob roses Barney had a super
occasion and thanks for inviting me i
really wish i could be there to
celebrate with you but I can't so I
promise I'll toast you here in Florida
on jun 2nd you're doing a great job
among other things keeping all of us
monitoring freaks on our toes have
everything goes swimming the other
friday all the best to the best and God
bless
well while I was in the throes of my
dissertation I received a letter from
anita christensen a clinical nurse
specialist from good sam hospital in San
Jose showing me some rhythm strips from
a patient they had in their unit who had
these common wide QRS complex
tachycardias and in the v1 we'd they
noticed that it did not have the left
rabbit-ear pattern and she decided to
look at the patient's electrode
placement and she noticed that the
electrode for the chest leads v1 was one
intercostal space too low it was in the
fifth rather than the fourth intercostal
space so she decided to correct that
while she was in the room and the next
time the patient had the same
monomorphic tachycardia it now with
correctly indicative of it
ventricular tachycardia which was
confirmed by invasive study so I
fermented with this while I was in the
EP lab and realized i could turn sec
criteria into the key criteria and and
vice versa by just moving the chest
electrode as little as one intercostal
space away from the correct anatomic
position that was scary because I didn't
think nurses knew that and I talked to
our clinical nurse specialist in
cardiology some of you recognize Bridget
I'd she didn't think nurses knew the
importance of accurately placement and
we decided together and a third person
that Pat saraceno who was because
medical nurse specialist for
cardiovascular surgery and we decided to
report on the accuracy of bedside ECG
monitoring which was published in heart
and lung in November of 1991 we did a
national random survey of american
association of critical-care nurse
members working in critical care and
telemetry units and 302 responded to our
survey and they had the demographics of
average ACN members now when i got these
302 surveys back I worried about their
safekeeping until such time as I could
analyze the data i was in the midst of
my dissertation and my dissertation
chair was whipping me to get that whose
name shall remain of so I had just been
through the the earthquake in 1989 so I
decided the best thing to do would be to
buy a three drawer file cabinet that was
both earthquake-proof and fireproof and
put it in my home in the berkeley
oakland hills
well many of you know what happened in
October 1991 in the Oakland Berkeley
hills and when we return to our house
this is what it looked like
however I found that treasure our file
cabinet and the nurse surveys although a
little brown and wrinkled were there and
we were able to analyze that data so i
always say that God really wanted this
message about accurately placement out
there
the only thing we salvaged from our
house fire
well uh we decided that we had a lot of
work to do because the survey showed
that seventy-seven percent of nurses got
it incorrect in in the survey so i spent
a campaign of of mine and my students to
improve these practices so to summarize
my dissertation findings regarding wide
QRS tachycardia I learned that being
12-lead I ECG was best and I with if it
weren't so cumbersome wouldn't it be
great to be able to monitor all 12 leads
continuously the one was the best single
lead but misdiagnosis can occur if the
electrode is as little as one
intercostal space away from its correct
anatomic location mcl-1 is not a valid
substitute for v1 forty percent of the
keys have different QRS criteria in
mcl-1 vs v1 and the universally
monitored lead to is poor correctly
identifying only thirty-four percent of
wide complex tachycardia
well my dissertation committee thought
this was good enough so i got the PhD
and I was thrilled that Maryland odd
hired me as a assistant professor in the
Department of physiological nursing so
here I am starting out alone in 1990
wondering what i should do next
well I had to examine the trends in
cardiac hair in the nineteen nineties
new drugs antibiotic and antiplatelet
and new procedures like coronary
angioplasty and stenting were available
for aggressively treating patients with
unstable angina and acute myocardial
infarction the whole umbrella area or
population with acute coronary syndrome
and we needed to know if a steamy was
present and if after treatment whether
ischaemia was abolished so I needed to
really review how does myocardial
ischaemia affair
the ECG now Chris mentioned that one of
the smartest things I ever did in the
early 1990s as an assistant professor
was to join the international society of
computerized electric cardiology this
group is an interdisciplinary group of
people comprising engineer scientists
physicists computer experts cardiologist
basic scientists and one nurse and I've
learned so much from this
interdisciplinary collaboration and one
of these people is a engineer scientists
from the Netherlands Adrian venue stream
who has developed a wonderful computer
simulation using known heart properties
and I think that's best teaches you how
the micro how myocardial ischaemia
effects ECG in this model you see the
heart in its three-dimensional shape and
the body torso with the sixth record
'i'll leads you see the surface ECG down
here and i'm going to change it to the
standardization we use in clinical
practice now the portion of the cardiac
cycle that is sensitive to ischaemia is
where I put the cursor on here following
the QRS in the SP segment or T wave and
on a body surface map if you were
measuring the potentials electrical
potentials recorded all over the torso
there would be zero potential during
this time
that's and body surface maps are
color-coded so green is good
green means there's no current injury
current flow if there was current flow
of injury current flow toward the
outside of the torso it would turn red
and if it was traveling away from it it
would turn blue so red and blue are bad
and green is good
now if i pick a spot on the tort on the
heart and make it ischemic you notice
that the normal cellular action
potential from that area of the
myocardium looks like that the action is
cellular action potential can be thought
of as the ECG for a single cell and when
all the cells are doing it at the same
time and we record from the body surface
we get the electrocardiogram well
ischemic cells have changed of action
potentials and i'm going to simulate
what these changes cause on these mass
first of all the action potential
duration is shortened that's one change
and another change is that injury
reduces the resting transmembrane
potential now notice that that has
created a injury current flowing right
toward the body surface here toward the
bullseye lead is v3 and continuously b2
and before are also involved so that's
turned red and you can see that the 2
and B 3 and before have these striking
changes we can actually look at dynamic
body surface maps throughout the cardiac
cycle so st-segment elevation is limited
to leave that directly face the ischemic
my cardio wall so here you see a patient
with anterior mi who has been striking
st-segment deviations in v1 through the
five but notice that all six of limb
leads and universally used lead to our
have normal isoelectric st-segment
therefore to identify schema in all
potential myocardial zones of the heart
we really should be monitoring all 12
leads
however the standard 12 lead ECG is
impractical for continuous monitoring
every
requires 10 electrodes and lead wires
which often get in the way they tether
the patient and they create an
unacceptably noisy signal when people
brush their teeth or do activities of
daily living in the hospital
not only that the test we take such as
when we put the echocardiographic
transducer the v2 location needs to be
visualized as well as the b4 and b5 and
in a patient who needs to have a
defibrillator pad place because they're
prone to VT f it gets in the way as well
and women with large breasts or Angeles
breasts these are positions that are
difficult to maintain they interfere
with chest x-rays all kinds of reasons
so the problem is how can we detect
ischaemia and all my cardio zones of the
heart without an excessive number of
electrodes now I became aware of the
fact that NASA used reduced leave set
technology to record astronauts 12-lead
ECG in Skylab to and in looking into
this
well what reduce lead set technology is
is it a method to mathematically derive
12 ECG leads from a smaller number of
leads and electrodes I think you could
tell from that ECG simulation that
there's redundancy in side-by-side or
continuous leads and so you could skip
some of those and interpolated
mathematically if you get the leads with
the real power of the independent
information
well the person who had developed the
NASA reduced Lisa picture of technology
with the Canadian cardiologist by the
name of Gordon hour and he had published
how to do this also from just for what
he called easy electrodes his idea was
that it could be used by NASA for a few
astronauts every 20 or 30 years but he
thought it could be applied for
ambulatory outpatient halter monitoring
little did he know that I would look at
this and said
this would be perfect for hospital ECG
monitoring so i called dr. dauer and
came down to San Francisco bringing his
invention with him and that's why the
patients in the EP lab looks so wired
because i wanted to test out dr. towers
invention in all sorts of cardiac
arrhythmias while it was collecting data
for my research and it was comparable to
the standard 12-lead and so I thought it
was ready to um submit my first ro1
application to NIH to answer the
question "how does EASI 12-lead
monitoring compared to routine CCU
monitoring for detecting acute
myocardial ischemia?" This was funded by
NR and was known as the step study or ST
analysis trial in which we enrolled 490
patients admitted to 10 icc unit here at
UCSF and between the years of 1993 1996
the project director for the step study
was a master student who many of you
will recognize as Mary Adams here today
with her husband Pete the patient served
as their own control being monitored
both with the bedside monitor and dr.
towers device which we monitored with a
separate of cardiac monitor we kept this
monitoring going during inter Hospital
transport and also during interventions
in the cardiac cath lab and here's a
second master student Michelle health
care who's here today who did these
helped with these recordings in the
cardiac cath lab the advantage of
recording at that time in the cardiac
cath lab is that when they did
angioplasty they included the balloon
with the balloon catheter catheter they
included a vessel and we knew where the
anatomic site of that vessel was and we
could correlate this with the ECG
findings
it was a nice model of acute coronary
occlusion or acute MI
right and this just shows you that when
you inflate the angioplasty balloon
either for angioplasty or to see to
stent you interrupt the blood flow and
downstream the muscle becomes a scheming
justice though this would have been
included with a thrombus as in it and
acute MI now just to show you what we
found with the step study i want to show
you a case that illustrates our findings
this was a 47 year old male awaiting a
cardiac cath for diagnostic purposes
with a possible percutaneous
intervention plan here is his easy
12-lead ECG of 70 3am five minutes later
he developed begins to develop
st-segment elevation which becomes very
what we would call screaming two minutes
later and then begins to resolve and
then finally goes back to the baseline
during this 30-minute episode the
patient never put on is called light and
here are the five easy 12 leaves that I
just walk you through and when you
compare what was happening with his
routine CCU monitoring leads before and
during that event you will see that this
was totally would have been totally
clinically Jason to the silent and what
we found was that of 463 ischemic events
detected with easy 12-lead monitoring
67% had no evidence of ischaemia in
routine CCU monitoring leads and eighty
percent of these episodes were
asymptomatic or or silent ischemia when
we published this in the american
journal of critical-care the giant of
cardiac monitoring company which is
today
Phillips decided they should put this in
their monitors and they tell me that
they are now selling these all around
the world in the countries that you see
listed here now our lab has also been
involved in the research and development
of st segment model
true software for automatic ischaemia
detection and cardiac monitors and most
of these systems work on the principle
that they measure the st amplitude at
some point beyond the j point the j
point is the junction of the end of the
QRS complex in the beginning of the st
segment so on the monitor for patient be
it would say plus for meaning that at 80
milliseconds beyond the j point at this
point there is four millimeters of
st-segment elevation relative to the
true isoelectric PR interval patient see
would have minus 4 on their cardiac
monitor showing 4 millimeters of st
segment depression many of our
publications have talked about the
measurement errors and problems that can
occur with st-segment monitoring one of
them that we have really raise awareness
about our false SP alarms with body
position changes
here's a patient from our staff study in
the supine state when he rolls onto his
left side it triggers a SP alarm because
the j + 80 point is depressed but if you
look carefully something else has
changed what does which does not reflect
ischaemia that is the QRS amplitude has
more than doubled this is a sign of a
false SPL arm due to body position
change and mary adams and I wanted to
raise awareness of this because of a
patient who got an unnecessary cardiac
cath and procedure and complications
related to it and we raised the question
is this a hazard of st segment
monitoring so nurses have to know how to
troubleshoot these scenarios and I think
we can change the algorithm to have the
auger ism also take into account QRS
changes as well as SP changes now Mary
went on to
test the efficacy of two strategies to
detect body position SP changes during
monitoring here you see her at the 2002
international society of computerized
electric cardiology meeting in the
Netherlands as a young investigator
finalists
well the next research question was is
st-segment monitoring valuable in
patients who present to the emergency
room with possible acute MI and this
form the basis of the Stampede study
funded by nima are between 1996 and 2000
where we enrolled 621 patients
presenting to the ed with chest pain i
had now sucked
Mary Adams and Michelle culture into the
doctoral program so they served as co
project directors for the Stampede study
this is a good example of what we
learned from the Stampede study a 76
year old female presenting to the ER
with chest pain has some slight ST
depression and beef 1 through before but
nothing too striking but eight minutes
later she had striking st-segment
elevation which meets the criteria for
acute MI and when we looked at the
patient's st monitoring trends in the
emergency room in the one-hour period of
time
1422 15-20 that she was being observed
we noticed these waves of st elevation
interspersed by normal SP segments and i
can show you three waveforms at three
time points to show you how dynamic
these changes were now apart from our
continuous monitoring the clinical
decision-making and this patient was
done with the routine cereal snapshot
standard 12 lead ECG they recorded a
total of five twenty minutes apart and
all of the Mist the period of st
elevation so we realized that may
any of these patients have very dynamic
st segments and continuous monitoring
improve the detection now I've been very
fortunate that students i have extended
light program of research in important
ways one of the projects that was
interested in with the problem of trying
to detect posterior wall my party
infarction as you see unlike the
anterior wall when it's injured which is
very close to the anterior cordial leads
the posterior wall is quite a distance
away people in the literature said we'll
put electrodes on the back which face
that posterior wall
the problem is it's still a long ways
away from the current of injury and more
importantly i had learned from is key
colleagues at the worst conductor of
electricity in the heart is air and so
if you want to get a waveform you don't
go on the other side of the love so
shootin one introduced a new ECG
criteria for posterior wall acute
ischemia validated by our PPC a model of
acute in line i'm glad to say that she's
here from the University of Arizona
today the shelter went on to tell us
about her to show us the important
adverse are the significant prognostic
significance of seeing these events
these st events by showing an important
link between st events and adverse
outcome and she won the Martha hill
young investigator award at the American
Heart Association scientific sessions in
November of 2001 and i'm glad to say
Michelle is here from reno today Claire
summon who is also here today taught us
about electrocardiographic
repolarization abnormalities in patients
with subarachnoid hemorrhage as part of
the crash study which stands for
cardiac responses to aneurysmal
subarachnoid hemorrhage the principal
investigator is John's are off from the
division of cardiology so we found a
reason to look at st segments in the
neuro ICU now all of our work in
ischaemia monitoring culminated with a
consensus statement for healthcare
professionals where we told people how
to do this right so what are we doing
now well one of the studies were
involved in is the immediate aim study
funded by the National Heart Lung and
Blood Institute we want to determine
whether body surface mapping is superior
to standard electric rd ography for
detecting ischaemia we've been rolled
over 1,300 patients presenting to the
emergency department here with chest
pain are a national equivalent and
people who have been instrumental in
this study are shown in blue letters of
michelle peltor on yung Lee dance
schindler who's back there at the video
Jessica's egg with the project director
for the immediate and study and dr.
Kirsten fleischmann from the division of
cardiology was also involved notice I'm
not standing alone at that door to the
ICC anymore
well we haven't begun to see all the
analysis of this were just in the throes
of looking at way more information than
we know what to do with but i would like
to show you a body surface map so that
you see what it looks like this was the
body surface map in a patient who is
discharged where they presumed
noncardiac chest pain diagnosis who died
15 days later so obviously we missed the
boat on this one and he had an acute
coronary syndrome
now remember on body surface math green
is good
red and blue are bad and then I want you
to look at where the sixth standard
procore do leads are located relative to
where all this action
news so the blue dots are where standard
electric cart there's the event major
mrs. so six electrodes so so it's a
major event is there's no question and I
think that this kind of full body
mapping in the future if we can get the
map we can tailor where to put those
electrodes to line them to the worst
areas because we never know how that's
going to project from their coronary
anatomy out to the torso and this kind
of a hot spot monitoring will be a very
individual way of of of improving the
sensitivity of detection the other study
were involved in is the SP smart study
which stands for census size 12 weed st
monitoring and real-time tell electric
rd ography i am the acronym Queen funded
by an inr and the perp this is a
five-year countywide prospective
randomized clinical trial ending in 2008
Claire immigrant is the project director
for the SP smart study and the study aim
is to determine whether individuals who
call 911 for chest pain will have
shorter time to treatment when they
reach the hospital and have better
survival over the five years of the
study if ER clinicians are provided with
ECG ischaemia monitoring information
from the field
notice how in my program of research and
marching closer and closer to the onset
of the am I started in the ICU the cath
lab and the ER now i'm in the
pre-hospital arena as time is muscle
that we chose Santa Cruz County for this
study because it's a large County with
both urban and rural areas mountainous
areas with potentially long the
ambulance transit times there are two
community hospital servicing the county
dominican and Watsonville and both are
involved in the study and I'm pleased
that
at least one of the Dominican nurses
here with us today ray at Anders has
been so instrumental with the study we
have equipped all EMS vehicles that
respond to 911 calls in the county with
portable monitor defibrillator devices
with special study software that which i
call my dream machine because I got to
work with engineers at medtronic to
develop the software this is installed
in 16 fire department rings and 13 AMR
ambulances the special study software is
designed to synthesize the 12-lead ECG
from five rapidly applied electrodes we
want those medics to scoop and run and
get to the hospital and not valley
around with lots of cumbersome things in
the field
it analyzes SP segments every 30 seconds
and automatically transmits an ECG to
the target emergency room by cell phone
if ischaemia occurs if the first
transmission failed automatic redialing
occurs for a total of three attempts now
we're just in the middle of this study
but so I don't want to talk about data
but i do want to talk about a case
example this is a fifty-year-old with
onset of chest pain on sunday morning he
sent me this picture to explain to me
why he didn't call 911
he lives up in the woods in the
mountainous region in a trailer that's
very well-camouflaged and he didn't
think the medics would find him because
he lives alone and he's probably right
so he climbed into his truck and started
driving to the hospital and got so ill
and weak that he pulled off to the
roadside and fell out onto the ground
and was found by a passerby who called
911 and along came the AMR ambulance
with the dream machine in it it
randomized into the experimental group
which means that his emergency that is
ECG was printed out in the
dominican hospital emergency department
with a voice alarm saying an incoming
ECG from the field
this isn't his ECG transmitted from the
field showing acute st-segment elevation
myocardial infarction the ER physician
showed it to the cardiologist on call
who said when this guy reaches the
hospital he goes straight to the cath
lab and dominican hospital after hours
doesn't have people in the cath lab so
they have to be what they have to go
live 30 minutes away and so they were
able to activate the staff get them in
and get things set up while this patient
was in route if you look on the left you
see what his cardiac cath showed and for
those of you who know how to read these
things you feel the blood flow stops
right here in the mid right coronary
artery that's where the robotic
occlusion is and he gets the stent there
and this is what it looks like
afterward a good outcome and the
exciting thing was that the door to
balloon time which is our big dependent
variable of interest was just 46 minutes
on a sunday and their pre-study average
at that hospital is hundred and five the
American Heart Association wants
hospitals to strive for adorable in time
of 90 minutes so we're hoping this
translates to better outcomes in the SP
smart study he was so proud of this
outside
that he talked to about it to a santa
cruz sentinel reporter who made it a
front-page talk about a wonderful way to
get community consent which we were
asked to do by chr at any rate here is
after his mi back in his trailer and we
got great press it said a life-saving
experiment County chosen as test site
for new heart monitor
well our future plans are to develop QT
interval measurement algorithms for
cardiac monitors to and to determine
whether QT interval monitoring will
prevent cardiac arrest from to asada
plant which can occur as a reaction to
certain drugs
this is what your thought pot looks like
this was in a patient in our 10 icc unit
started on IV erythromycin for pneumonia
which is a drug that can cause this
deadly arrhythmia
there's a lot of lift there's a lot of
drugs that can cause prolonged
ventricular repolarization and caused
this dangers arrhythmia well as Chris
mentioned i did lead the pack to develop
a American Heart Association scientific
statement entitled practice standards
for ECG monitoring and hospital settings
of a wonderful group of international
experts got together to describe what
are the best practices for arrhythmia
ischaemia and QT interval monitoring and
two and it was and it is on the American
Heart dot-org website and it was awarded
the American Heart Association clinical
article of the year last year now we
want to implement these practice
standards and to determine whether it
improves nurse behaviour in patient
outcomes
dr. Marge funk from Yale University
School of Nursing and i just submitted a
revised grant to ninr march one we and
here pictured are
advanced practice nurses from 20
institutions around the country who want
to be involved in this study we had an
acronym contest and i'm proud to say
that our very own Gnarlies of Salazar
who I see in the back here one she came
up with pulse which stands for practical
use of the latest standards for electric
rd odyssey well i'm also celebrating 25
years of and 225 cardiac rhythm theory
and analysis and i would like to see a
show of hands of everybody in the
audience has ever taken this course in
the last 25 years
it's such a pleasure to peak students
lessons we've learned in our research as
well as to equip them with tools to
improve practice they don't have to take
this course for their program to
graduate in most cases but they come
anyway and I think part of the reason is
they like to see my underwater scuba
diving slides and another reason is that
i shamelessly advertise it all over the
world including here i am at the floor
of the ocean at the great barrier reef
with an 225 UCSF and v1 and lead to so
finally I'd like to give tribute to
individuals who have been critical to my
development as a scientist
well after seeing the presentation it
feels as yes everyone in this room has
either had one of Barbara's EKGs or red
one in Barbara's EKGs so of course it is
my pleasure to award Barbara this small
monetary acknowledgement of her
wonderful work and their respect with
which he is held by all their colleagues
at UCSF and the Helen um metal which all
of you will be invited to come and see
we don't think she's going to wear it or
she'll have back problems but on it is a
wonderful tradition i think in this very
marvelous day of celebrating one of the
researchers who has really put UCSF
School of Nursing on the map and I
really want to have you join me in
acknowledging barbers wonderful
contribution
and now we have a little surprise for
Barbara I think everything else was very
well-choreographed choreographed and if
you can tell Barbara very used to
choreographing carefully but one of her
family members Kathy get trust is going
to come and just have a few comments
from the families
I'm februari third and said that she was
this year resistance of the hell anomaly
ward of course with conversation she had
to make Kathy I can't imagine leaving
this award without family being present
and we hardly agreed and that's because
we have a very close family and we are
able to push forward in this world much
because we know that we have a
supportive group that is offering us on
Barbara is the second youngest of five
children and we grew up in humble but
very proud mr. Midwestern farm family
out of necessity we develop strong work
ethic and leadership skills team
building skills as we planted crops and
baled hay threw down salads and numerous
other activities just to make the farm
work and he got a living there is no
doubt that the success that you have
heard about Barbara today would have
been achieved if it hadn't been for this
seller advice and leadership skills of
those of us that are a little bit older
than CEA's
barbie and the rest of us went to a
one-room country school and that serve
grades one through eight far excelled
academically and repeatedly carries the
distinction of top of her class of for
students
barb had a very close relationship with
dad who modeled for her very calm very
steady approach to life and and farm
problems in particular this certainly
would serve her well as she went on in
as a critical-care nurse during cardiac
crises and cardiac arrest our parents
really encouraged all five of us to get
a good education and mom had a
particular interest in our choosing
nursing as a career
I'm had a very troubled childhood and
during her early teen years she found
herself literally at the doorstep of a
nurses residence in lacrosse Wisconsin
typically this nursing home as it was
called was a the housing for nursing
students as they were in their nursing
program there was very little patient
contact as there is with nursing
assistants today as a result of that she
really grew to admire the comfort and
care that she saw nurses really taking
on and providing so skillfully as young
children we all have wonderful stories
about mom that she shared of her
experiences both in the nursing home as
well as in the hospital next door
barb and i had a very close relationship
but she had a very bad habit of being
able to do a disappearing act
just about the time work was needing to
be done but it was very easy to follow
the trail to her bedroom where she was
wanting her thirst for research by
reviewing notable literature such as the
Boxcar Children black beauty or the
Sugar Creek Gang when she wasn't reading
barb was Calamity Jane or Annie Oakley
or other spirited woman from the Old
West and we should have known then that
she had her sights fixed on a future in
the wild wild west of California barb
was musically inclined and considered
that as well as some other career
options but in the end he and I and our
youngest sister marks decided that we
would take our mothers good advice and
choose to pursue nursing and none of us
have felt that that was a mistake we're
all very happy with the decision that we
have made we were all very proud of barb
as she continued her academic climb
while working full-time as a nurse
manager in critical care i recall her
telling me quite a number of years ago
about a potential faculty position at
UCSF and she was thinking through maybe
i'll just try that for a year and
knowing Barb's inquisitive mind and love
for learning iphigin Oberg you pick that
position that faculty position you're
never going going to be happy going back
to hospital nursing and I know that
you've never regretted that decision
either want to thank all of you for
allowing me this opportunity on behalf
of my family my mother my sisters and
there is an extensive set
family throughout the united states that
we were able to get together recently
who also want to extend their best
wishes to Barbara and hurt their love
barb we are extremely proud of you and
cannot think of a more deserving
recipient
congratulations
this concludes our portion of the
program i'd like to invite you to join
us across the street parnassus to milder
union where we'll have the reception to
celebrate Arbor
