Sudden cardiac arrest (SCA) can hit almost anyone, anywhere, at any time. Striking more than 350,000 people each year -- nearly 1,000 lives each day -- SCA is one of the leading causes of death in the United States. The current SCA survival rate is less than 5 percent, according to the American Heart Association (AHA).
When a person goes into cardiac arrest, the rhythm of the heart becomes chaotic, most frequently due to a specific disorder called ventricular fibrillation. The heart is twitching but not pumping blood. Once blood stops circulating, a person loses consciousness. Breathing stops. There is no pulse. A defibrillator sends a jolt of electricity through the heart to restore its natural rhythm. Without this intervention, the victim will die within minutes.
While CPR may help prolong the window of survival, it cannot reverse sudden cardiac arrest. Defibrillation is the only definitive treatment for SCA. This is why groups like AHA are advocating wider accessibility to automatic external defibrillators (AEDs).
"We know that there are a thousand sudden cardiac deaths in the United States every day," said Dr. Brooks Watt, corporate medical director for the Gillette Co. "We know that the vast majority of those are ventricular fibrillation arrests, and we know that 95 percent of them die before they reach the hospital. Those are pretty compelling numbers."
So compelling that Watt spearheaded an effort to install AEDs at virtually every Gillette facility in the United States. Now the company has more than 50 units installed across the country.
Although AEDs have been around since the 1980s, their cost, size and maintenance prevented them from being deployed widely, according to Robert Thompson, president of Complient, a company that provides AED training and consulting services.
Today's AEDs do not resemble the defibrillators depicted on television hospital dramas. There are no big paddles or beeping monitors. Instead, they are portable, lightweight, easy-to-use devices with adhesive pads instead of paddles and few buttons to push. "That means these products are readily available and inexpensive enough to be widely distributed," Thompson said.
The devices are called "automatic" because there is little operator involvement required. The operator only has to do three things: turn on the machine, attach the pads to the patient's chest, and follow visible and audible instructions the machine provides.
"Anyone who can learn CPR can learn to use AEDs," said Dr. Larry Alexander, a member of and spokesperson for the American College of Emergency Physicians (ACEP).
Time Is Everything
It is not a lack of effective treatment, but the lack of warning and limited time for intervention that accounts for the high death rate following SCA. "Time is heart muscle," Alexander said. "The longer you delay in turning things around, the more damage to the heart muscle there will be. The more damage, the greater likelihood of death."
For example, a study published in the Journal of the American Medical Association found that in New York City, where the average response time from patient collapse to delivery of the first electric shock is more than 12 minutes, only 1 percent of patients survive SCA.
In Seattle, by contrast, a city with less traffic and fewer high-rise buildings, the survival rate is 30 percent -- one of the highest in the country. AHA believes access to timely defibrillation will greatly improve the national survival rate above the current 5 percent. The organization suggests that 50,000 lives could be saved if the cardiac arrest survival rate increased from 5 percent to 20 percent.
Setting Up a Program
Hawaiian Electric Co. (HECO) became the first utility in the country to equip its field crews with AEDs. "For us, it's no different than CPR. AED training is just another component of our overall safety program," said Jim Beavers, manager of safety, security and facilities for HECO. Beavers said it makes sense for HECO to have AEDs readily on hand because of the inherent risk of electrical exposure to its employees. The company has also offered its AEDs for emergency public use in the event that one of its field crews is more readily accessible than medical help.
According to Beavers, support from upper management was crucial to implementing HECO's AED program. A company executive who also served on the board of directors of the local American Red Cross chapter attended an AED demonstration and asked Beavers if he was familiar with the devices.
"He asked me if an AED could have made a difference to one of the field employees who was recently killed by an electrical shock. I said it certainly could have." Beavers can provide a litany of similar incidents from his nearly 35 years at HECO in which AEDs could have had a profound effect. It was then he decided to take the case to upper management. Today, HECO has more than 100 AEDs in the field and in the company's power plants and offices.
Beavers cautioned against merely looking at the costs incurred when deciding whether to institute an AED program. "You can get into crass economics, but really, what is a life worth?"
Gillette's Watt asked the same question when he petitioned his company's management to establish an AED program. What started off with the purchase of three units three years ago has grown into a full-fledged program throughout every major Gillette facility. "As I looked into it, it soon became clear that there was more to it than simply showing employees the device and explaining how easy it was to operate." Watt decided to hire Thompson's Complient to conduct an assessment of each Gillette facility and handle the training needs.
Complient came back to Watt with suggestions of how many AEDs to buy and employees to train. Watt chose to lease 50 or so AEDs. "I decided to lease the devices only because the technology has changed a lot in the last two or three years, and I didn't want to be owning obsolete equipment in five years," he explained.
Eventually, the company instituted the AED program at the Gillette corporate headquarters in Boston, a blade factory in South Boston, a toiletries plant in Andover, Mass., batteries plants in four different Southern states, the Duracell headquarters in Bethel, Conn., a chemical plant in North Chicago, the Oral B toothbrush plant in Iowa City and the Papermate pen plant in Santa Monica, Calif. "Any facility that had more than 50 people, we required to participate," Watt said.
Of course, it was not as simple as deciding which brand to use and how to train employees. Watt said it took considerable effort to get all the elements of Gillette's program in place. "You also have to give employees bloodborne pathogen training and offer them Hepatitis B vaccinations because you're exposing them to that risk. These are things to consider."
Even then, he still encountered reluctance on the part of some locations. In fact, his greatest resistance came from his site. "Here at the corporate headquarters in Boston, the attitude some people have taken is that we don't need this because we have medical clinics on site." Watt had to explain that he or other medical personnel could not get to a victim's side in the necessary three or four minutes. "It takes awhile for that to sink in."
Beverly Tobias, a board member of the American Association of Occupational Health Nurses (AAOHN), suggested additional factors to consider before setting up an AED program. "First, conduct an assessment which would involve finding out what community resources are available to you." This includes researching a facility's location in relation to the fire department and paramedics.
Because every minute counts for a victim suffering from cardiac arrest, EMS access and response time to a particular facility is an important consideration, according to Tobias. "Are the local paramedics trained to use AEDs, and do they carry them as standard equipment in their vehicles? What's the average response time in your community? These are questions you need to ask."
Another factor to consider is protocols associated with AEDs. "The AED has to have a training component," Tobias said. "You can't just shock somebody and hope for the best. There has to be an entire program." Tobias also stressed the need for regular maintenance of AED equipment and as recurring training for designated users.
Liability Issues Loom Large
Liability is a perennial concern whenever the use of AEDs is mentioned. "People are pretty well tuned into learning CPR," Watt said, "but for some reason, the defibrillator scares them. It's a big, scary medical device, and liability is often an issue."
AED manufacturers, however, say there is little cause for concern. Most states have Good Samaritan laws providing protection for people using the devices, explained Mark Altmann, education manager for Survivalink Corp. and a registered paramedic. He said some statutes cover organizations purchasing AEDs. "Besides," he added, "in any negligence lawsuit, one thing you must prove is that, by using an AED, you've made the patient worse off than he was before you got there. It's hard to make a dead person deader."
According to Altmann, AED lawsuits in regard to misuse have never been won. He does caution, however, against "reverse liability," or instances in which lawsuits have been won because AEDs were not available for someone to use.
Complient's Thompson agrees. "There was a time when you got on an airplane, and it wasn't equipped with an AED," he said. "Today, it's just the opposite. Why? The standard of care is changing."
In fact, the courts have found more than one airline guilty of negligence for not having AEDs available, according to Altmann. Successful suits have been filed against carriers on which passengers died because there was no AED available for use.
Still, AAOHN's Tobias maintained there remains cause for concern. "The fear we have is that if you are paid -- if it's part of your job to render first aid -- then you may not be covered under the Good Samaritan laws in any given state." She suggested checking a state's laws as a precautionary measure.
The Chain of Survival
AHA has incorporated defibrillation into the "chain of survival" that is necessary if victims of sudden cardiac arrest are to survive. "The sooner you start an intervention, the better chance you have to save someone's life," ACEP's Alexander explained. "That's why we started an initiative to train people across the country in CPR."
Although he supports placing AEDs in areas where large numbers of people work to offer opportunities to save more people, Alexander cautioned that the devices will not save everybody. "We, as physicians, can't even do that." What AEDs can do is give many SCA victims a better chance at survival through earlier intervention. Said Alexander: "Even though we can't save everybody, those that we can save -- it's worth it."