AED in the rhythm of saving lives: installing automatic external defibrillators at aquatic facilities can help save lives

Parks & Recreation, Nov, 2005 by Gerald M. Dworkin

IN THE RHYTHM OF SAVING LIVES

On July 13, 2004, a 55-year-old man collapsed in the Medina (Ohio) Aquatic and Fitness Center. The aquatic manager for the city, Darlene Donkin, responded and assessed him to be in cardiac arrest. Although Donkin was a CPR instructor and taught more than 100 classes on the subject, she had never actually performed it in a life-and-death situation prior to this incident.

Donkin administered two rounds of CPR while the automatic external defibrillator, or AED, was brought to the victim's side and the electrodes were attached. The AED assessed him to have a shockable rhythm, then charged itself and instructed the rescue personnel to administer the shock. After one shock, the victim's heart returned to a normal sinus rhythm. The patient had triple bypass surgery the next day and did not suffer any hypoxic brain damage as a result of this incident, mainly because Donkin administered CPR and used an AED in a timely manner.

Sudden cardiac arrest is a condition in which the heart stops suddenly and unexpectedly, and is caused by life-threatening arrhythmias in the heart's electrical system. Most victims of witnessed sudden cardiac arrest are in ventricular fibrillation (VF), which is an abnormal, chaotic heart rhythm that prevents the heart from pumping blood. The only effective treatment for ventricular fibrillation is defibrillation--the delivery of a shock to the heart that stops VF and allows a normal heart rhythm to resume.

Each year, about 225,000 people suffer out-of-hospital sudden cardiac arrest, of which only 2 to 5 percent are successfully resuscitated. These numbers are in stark contrast to the high success rate when defibrillation is performed immediately after the onset of VF. Studies have shown that when a person suffers a sudden cardiac arrest, chances of survival decrease by 7 to 10 percent for each minute that passes without defibrillation.

A sudden cardiac arrest is not the same thing as a heart attack, although a person suffering a heart attack is more likely to develop abnormal heart rhythms and sudden cardiac arrest. Sudden cardiac arrest is unpredictable and can happen to anyone, anywhere--even a child, although risk does increase with age. Although pre-existing heart disease is a common cause of cardiac arrest, many victims have never suffered from any heart problems.

The Chain of Survival

In 1991, the American Heart Association (AHA) published "Improving Survival from Sudden Cardiac Arrest: The Chain of Survival Concept" This paper identified the idea that all communities should adopt the principle of early defibrillation, and that all personnel who are expected, as part of their professional duties, to perform basic CPR, should be equipped with an AED and be trained to operate it. Since then, the AHA has advocated that health professionals who have a duty to respond to a person in cardiac arrest should have a defibrillator available either immediately or within one to two minutes.

The definition of a lifeguard, published by Chronicle Guidance Publications, says that "lifeguards ... prevent incidents, perform rescues and administer first aid and resuscitation to incident victims." Therefore, they certainly meet the criteria established above for health professionals with a duty to respond to people in cardiac arrest.

The AHA's "Chain of Survival" depicts the critical actions required to treat life-threatening emergencies, including heart attack, cardiac arrest, stroke and foreign body airway obstruction. The links within this Chain of Survival include:

1. Early access to the emergency response system;

2. Early CPR to support circulation to the heart and brain until normal heart activity is restored;

3. Early defibrillation to treat cardiac arrest caused by VF; and

4. Early advanced care by EMS and hospital personnel.

However, in order for the patient to have the best chance of surviving an out-of-hospital cardiac arrest, CPR and early defibrillation must be provided within the first four minutes of the cardiac arrest, followed by advanced life support (ALS) within the first eight minutes of the arrest.

CPR: Life-Saving or Life-Sustaining Procedures?

Although the performance of CPR on a cardiac arrest patient prolongs the time that defibrillation can be effective, CPR should not be considered a "life saving" procedure, but rather a "life sustaining" procedure in that it typically will not restore a heartbeat to a cardiac arrest victim. CPR only temporarily sustains the cardiac arrest victim in that gray area between clinical death and biological death, hopefully long enough to obtain defibrillation and care.

Considering this fact, the standard of care for the emergency management of cardiac arrest patients, regardless of the cause, is immediate life support (early access, early CPR and early defibrillation) immediately followed by ALS. If an AED is not immediately available for the response to cardiac arrest victims within your facility, then the claim can be made that your facility has breached the standard of care.