Defibrillators versus Tasers

The front page of my hometown newspaper, The Hamilton Spectator, carried a story today on a police services request for $1million for the purchase of Tasers. I was struck be the similarity between the price of an X26 Taser and a top of the line Automated External Defibrillator (AED), a virtual dead heat at $1,455. The 687 AED’s that could be purchased with $1 million would allow for an AED to be placed in every Hamilton Police Services vehicle with many left over to be placed strategically throughout the community. In the first eight years of carrying AED’s in their police cruisers and responding to cardiac arrest calls Ottawa Police saved 20 lives. In Rochester, Minnesota a small city of 100,000 people police have been carrying AED’s since 1990 and have been credited with 127 lives saved.

In the Fall of 2012 every Ambulance Service in the Ontario submitted their new response time commitments to the Ministry of Health and Long-term Care. Hamilton EMS agreed to “endeavour” to achieve the Ministry established benchmark of having a trained responder equipped with an AED arriving on scene at 75% of all cardiac arrest calls within 6 minutes of EMS receiving the 911 call. The 6 minute benchmark is a worthy target and taking any longer to arrive at the side of a cardiac arrest victim will not likely result in a life saved. However several Ambulance Services have indicated to the Ministry that, while it is desirable, it is unlikely that responders will be arriving on scene in 6 minutes at or near the 75^th percentile. Historically this target has been difficult to achieve and increasing demand and scarce resources suggest it is unlikely to improve significantly as long as EMS is the sole responder to cardiac arrest events.

The communities that will meet or exceed the standard when the 2013 reports are submitted to the Ministry in March of next year will be those with deep and wide Public Access Defibrillation (PAD) programs and excellent Police and Fire tiered response protocols for cardiac arrest. Any event where an AED arrives at the patient’s side within 6 minutes whether it is manned by a teacher, a hockey coach, a co-worker, a family member, a firefighter, a paramedic or a police officer contributes to achieving the benchmark.

Why is the 6 minute standard so critical? The key statistical factor for improving outcomes is time, specifically the time from when the patient collapses to the time when they receive the first shock from a defibrillator. The places with the highest survival rates for Out-of-Hospital Cardiac Arrest (OOHCA) have the shortest time to first shock. Each year in Ontario over 7,000 people experience OOHCA and overall survival is less than 8%.  In Hamilton that translates to roughly 400 events per year with less than 32 survivors.

Across North America there are a growing number of communities committed to improving cardiac arrest response protocols that are achieving survival rates in excess of 20%. Large urban areas such as Seattle WA and Tucson AZ are reporting at 20%, Halton Region reported a 30% survival rate in 2010 and Rochester Minnesota reports a 42% survival rate. If survival rates for cardiac arrest in Hamilton doubled to 16% that would represent 32 additional lives saved each year and if they tripled to 24%, a lofty but realistic target, it would represent more than one additional life saved every week of the year.

Even $500,000 would purchase over 300 AED’s, more than enough to put one in every frontline police vehicle. Police officers are currently required to be trained in Basic Life Support/CPR so there is no additional training burden. The ability of police to be first on scene at most serious medical calls has been proven in dozens of urban centres including Ottawa. Equipping police with AED’s would go a long way to assisting Hamilton EMS achieve the benchmark of 6 minutes at the 75^th percentile.

It’s popular and easy (although not always productive) to suggest alternative uses for budget lines. In this instance one can’t help but see the irony. Hamilton Police are requesting $1 million to purchase hundreds of high energy devices that are used to debilitate and even "accidentally" kill people. That same dollar amount, or less, could just as easily be applied to the purchase of  high energy devices that police forces around the world are using daily to save lives.  

A Five Point Cardiac Arrest Prevention Strategy for Canadian Schools

Here is an excerpt from an article written on research presented by Dr. Andrew Krahn at the 2012 Canadian Cardiovascular Congress.

“Our research gives us an idea of the scope of the problem – there are almost 200 young people who die suddenly every year in Ontario. A good proportion of them have unrecognized heart disease. So the question is: How can we catch this before it happens,” says Krahn.

He suggests that more attention be paid to possible warning signs such as fainting. He believes that teachers, coaches and an aware public may be key to detecting risk, ensuring prevention and formal medical evaluation and therapy.

“I would advocate for careful screening of people who faint, using questionnaires and education of healthcare professionals so that when warning signs present themselves, they recognize them and this information gets passed on to the right people,” he says.

http://news.bioscholar.com/2012/10/hidden-disease-sports-sudden-cardiac-arrest.html

With virtually no hard cost every School Board could implement Dr. Krahn’s recommendations for preventing sudden death in children. The five key elements of a Cardiac Arrest Prevention Strategy are: 

A 20 Minute Arrhythmia Awareness Training Program that provides some background on Inherited Heart Rhythm Disorders (IHRD) and explains the warning signs and how to respond appropriately to those warnings. It should be available on-line to all staff and families but should be mandatory for all staff taking AED/CPR certification training and for all Physical Education Teachers and Coaches

A Pre-Participation Screening Questionnaire that would be completed by all parents/guardians at the time of enrolment at a new school. When there are positive answers in both the patient history and family history sections of the questionnaire the family should consult a physician immediately.
http://leadingcause.blogspot.ca/2013/05/inherited-heart-rhythm-disorder-pre.html

Mandatory 9-1-1 Calling  for Loss-of-Consciousness Fainting (syncope) It may be mandatory 9-1-1 for all syncope or at the very least mandatory 9-1-1 for all syncope occurring during or shortly after physical activity. In most communities ambulance are equipped with ECG monitoring equipment and paramedics are trained in heart rhythm recognition. Our tax dollars paid for this equipment and training it only makes sense to use it. 

Mandatory Notification of Parents/Guardians of all Syncope including providing them with information about IHRD’s. Parent's must be informed on the day of the event and must be provided with information that will help them understand the significance of fainting and other warning signs and the importance of physician follow-up. 

Mandatory Medical Clearance for Return to Play Post Syncope Perhaps the most tragic teen deaths are those where there is one or more fainting episodes in the weeks or months prior and the child is allowed to continue to participate in physical activity and dies because of it.

Pennsylvania has passed a law that includes several of these elements. Many other states including Maryland, Ohio and Indiana have pending Sudden Cardiac Arrest Prevention Legislation. Ontario allowed a bill to die on the order paper and it has yet to be revived despite having unanimous support at first and second reading.

If provincial or state legislation is not pending in your jurisdiction go ahead and implement these policies and best practices in your School Board. Work together with local paediatric cardiologists/electrophysiologists to develop the messaging around warning signs. Work with local EMS and ER Physicians to develop policies and practices around 9-1-1 calling for syncope. Trust that mandatory 9-1-1 calling for syncope (especially a child's first faint) occurring on school property will not create an avalanche of unnecessary "nuisance" calls, it won't. Remember that Automated External Defibrillators don't always work, it is better to prevent cardiac arrest than to try and reverse it with an AED.

One in twenty paediatric faints are sinister (the good news is that 19 in 20 are benign) but that number goes up if physical activity was the obvious trigger.  From a risk management standpoint it makes sense to be proactive on fainting and for the well being of our children it is imperative that all fainting be investigated.