Everything under the stars, whether made by man or found in
nature, is seeking equilibrium. All forces seen and unseen gravitate toward
Momma Bear – not to hot, not cold, but just right. Canada’s national
broadcaster, the CBC, recently aired an expose on Automated External
Defibrillators on their consumer information show Marketplace. Most of the
opinions and concerns expressed on the broadcast and in the blogosphere
afterward seemed to come from one end of the spectrum or the other.
Some “experts” were promoting Public Access Defibrillation
(PAD) programs where every aspect of the program was rigorously controlled and
monitored. Only targeted, trained responders who are working under medical
directives from an overseeing physician can deploy an AED. These responders
attend re-certification training on a regular basis and before they deploy an
AED in a real emergency they must check their wallet card to insure that it has
not expired. The devices are kept under close scrutiny, perhaps even lock and
key while their readiness status is checked daily. A rigid response protocol
must be adhered to anytime there is a suspected cardiac arrest. Anyone not
following the protocol explicitly will be spanked, regardless of patient
outcome.
Other “experts” were promoting the Willy Nilly model (or
Higgledy Piggledy, your choice) where AED’s are scattered generously and
randomly around the community. Because the device is so simple to use the
success of the program relies on the innate ability of untrained responders to
do the right thing in an emergency. If the responder has ever watched a 45
second PSA with attractive young women pushing on a patient’s chest to the beat
of an old Bee Gee’s song they will certainly be able to perform effective
CPR. Hopefully, someone associated with the program
will check the readiness of the equipment on a somewhat regular basis – but
perhaps not.
The most effective PAD programs lie right in the middle of
these two extremes. Well-designed programs are based on a targeted responder
model and the greatest number of people possible should receive some level of
training, from a half day CPR “C” certification course to a 40 minute overview
of the AED and how to perform a chest compression. Individuals not trained in
Basic Life Support are encouraged to get the AED and use it to the best of
their ability if they find themselves in a situation where no trained responder
is present. However the hope is that at some point during the resuscitation
attempt a trained responder will get involved and help insure that all of the
links in the cardiac chain of survival are being addressed appropriately.
All medical emergencies follow a natural tiered response
algorithm. The chance that the very first responder to a motor vehicle
collision is an osteopathic surgeon that can immediately assess and begin to
treat a shattered tibia are pretty slim. The first responder is most often a
good Samaritan that may know little more than how to call 911. Then a passing
off duty firefighter, paramedic or nurse may stop and begin to help out. Then
the on-duty paramedics, police and firefighters arrive with their tools and
knowledge and prepare the patient for transport to hospital. Once at the
hospital a team of Emergency Room Doctors and Nurses assess and treat the
patient. If the ER Doctors believe that
the patient’s leg requires surgery the Osteopath is paged and a surgical suite
is booked. Our goal has to be to build communities where a similar algorithm is
in place for cardiac arrest. The initial witness to the patient collapse calls
for help. The next people to arrive on scene are lay responders that regularly use
the facility and are trained in CPR and proper AED use. By the time the
Paramedics arrive these lay responders have performed quality CPR and deployed
the AED and the patient’s heartbeat has been restored. The Paramedics stabilize
and transport the patient, the ER Docs cool the patient, Cardiologists assess
and treat the patient and when all of this goes to plan the patient is home,
neurologically intact within a couple of weeks. If you take the trained lay responders out of
this model it collapses almost every time. An enormous body of evidence
including the scientific review of tens of thousands of out-of-hospital cardiac
arrest cases shows this to be a simple truth.
Place AED’s throughout the community wherever people gather.
Insure that they are highly visibly, easily accessible and properly maintained.
Train as many people as possible how to recognize and manage a cardiovascular
emergency (cardiac arrest, heart attack and stroke). A great initial target (on the road to
everyone knowing CPR /AED) would be to train 25% of the people that are regular
facility users. The training can be extensive or brief but it should be formal.
Pay for the equipment and training using public or private money, doesn’t
matter. If you are able to increase the percentage of cardiac arrests where a
properly trained and equipped responder arrives on scene within 6 minutes of
patient collapse you will see an increase in survival rates for out-of-hospital
cardiac arrest in your community. Uber regulated programs will not achieve this
goal and neither will uber lax programs
