What 1,000 AED Users Said About Saving a Life

Public safety professionals are trained to use AEDs. What many don't know is that most will never use one, and those who do may lose confidence in a trying emergency situation.

Editor's note: ZOLL Medical Corp., a producer of defibrillators and pacing devices for hospital physicians, nurses, and emergency medical technicians, introduced its first automated external defibrillator (AED) for public safety professionals and lay responders last year. To guide its development process, ZOLL interviewed more than 1,000 first responders who had been trained to use an AED in a life-saving situation, many of them trained professionals. In a conversation with First Responder, Wayne Reval, ZOLL Marketing Director, EMS and Public Safety, explains what was learned from the interviews and which businesses, organizations, and public service forces need to know about AEDs.

First Responder: Tell us about the interviews with AED users. Whom did you interview, and what did you hope to learn?

Reval: We talked to both trained laypersons--like security guards, health club employees, flight attendants, lifeguards, and office managers--as well as public safety professionals: policemen, firemen, and EMTs. We wanted to learn about response time and the emergency scene environment, and about what they did right and what they may have done differently looking back on the situation. We wanted to know if there were ways we could improve the resuscitation process. Defibrillators have always been designed to help the patient; our goal was to help the responder help the patient. The only way to do this was to learn about the experiences and the challenges the responders faced.

Q: So you talked about more than just using AEDs?

A: AEDs are remarkably simple and easy to use, but there are a number of steps that must be taken to optimize the opportunity to save someone's life. Some of them may sound pretty mundane, but in a crisis situation they can easily be forgotten. For example, if you focus on getting the AED attached to the patient and forget to call 911 for help, the patient can be down for a very long time before an ambulance arrives. Or, if you forget to open the patient's airway, he or she may not be able to breathe no matter how much CPR and mouth-to-mouth breathing you administer. A defibrillator by itself will not save a life. People save lives, and that's why our goal was to accurately evaluate what we could do to help the responder. We had to examine the whole lifesaving process.

Q: What did you learn in your interviews?

A: We learned a lot on a wide range of issues, but two findings really stood out to us. First, we learned that even trained rescuers sometimes find it difficult to remember everything they are supposed to do when treating a victim of sudden cardiac arrest. Second, we learned that CPR skills may be forgotten over time, and maintaining good CPR for the duration of a rescue can be physically and emotionally challenging for rescuers. They often do not compress hard enough or fast enough. So, we started looking at ways to help them perform this crucial element.

This wasn't a surprise, because there are studies that show CPR retention declines dramatically after six months, particularly in people who have not had repeat training. This doesn't necessarily mean they forget how to perform CPR; they just aren't as effective as they can be. In fact, one study showed that almost 90 percent of about 250 trained responders failed to administer CPR effectively. The prevailing view is that good CPR is crucial in the treatment of a sudden cardiac arrest (SCA) victim. The widely accepted American Heart Association Chain of Survival calls for three shocks, one minute of CPR, three shocks, another minute of CPR, and so on.

Q: So CPR and the AED have equally crucial roles in saving the life of a sudden cardiac arrest victim?

A: Yes, we know that a type of arrhythmia called ventricular fibrillation causes most SCAs. It occurs when the nerves in the heart malfunction and cause the main pumping chamber to quiver. With this chaotic rhythm, the heart can't effectively pump oxygen-rich blood to the brain and other vital organs. CPR, which includes chest compressions and mouth-to-mouth breathing, creates blood flow, providing oxygen to the brain and organs. But only defibrillation can return the heart to its normal rhythm.

Q: How did you use the information that you gathered in your interviews?

A: The input from the interviews guided our early prototype designs that were field-tested with public safety forces throughout the country. And we've had several success stories from people who haven't used defibrillators before or used less user-friendly AEDs. As to how we applied the information about CPR to our AED design, we developed a one-piece electrode pad with a CPR landmark right where the responder is supposed to compress on the chest. When he or she compresses, there is an adaptive metronome in the landmark that begins beeping at the rate the responder is compressing. If the rate is too slow, the metronome gradually increases in speed until the responder is compressing at 100 beats per minute. There also is depth feedback that tells the responder to push harder if they are not pushing hard enough. When they comply, there is a voice prompt that says "good compression."

Until now, AEDs seemed to be developed for frequent users like EMTs in busy urban areas, but did not address the needs of security guards, occupational health nurses, police officers, or many other first responders who seldom see a cardiac arrest. And because AEDs have the potential to save thousands of lives that could be lost if treatment is delayed until an ambulance arrives, we really support the public access defibrillation movement.

On average, nationwide, there is about one cardiac arrest per year per 10,000 people. If you are a first responder in a town of 30,000 people, chances are there will be three cardiac arrests in your town over the next year. What is the chance that you will be on duty when one of those occurs? It's not great. That's why even public safety professionals who are trained to use AEDs use them infrequently or never at all, and as we've already discussed, they tend to forget elements of the lifesaving process. They can apply the AED pads and push the button, but they may forget to open the airways, to do proper CPR, and so on. It is important to reinforce all of the lifesaving steps to help the rescuer maintain their confidence.

Q: Was there anything else you learned in your interviews that would be of value to our readers?

A: Generally, they told us that they are often first at the scene of an emergency, sometimes arriving minutes before other emergency personnel. They told us there should be no ambiguity in how to use an AED, and that it should have visual and audio prompts. They even talked about the color of the device, making the recommendation that it be brightly colored to prevent the possibility of leaving it behind at an emergency scene.

Q: Let's shift gears for a moment and talk about the AED marketplace. Is it a mature marketplace or is it still growing?

A: It is not a mature market, so the advances made to support first responders and the public access defibrillation movement will have an even greater impact in the coming years. This growing movement towards widespread early defibrillation aims to put AEDs in the hands of all emergency responders and in public places like airports, shopping malls, health clubs, and office buildings. In some cases, Federal Public Access Defibrillation guidelines require AEDs be placed in government buildings, schools, and universities. And many companies are taking the initiative and wanting to provide a safe environment for employees. As a result, the potential market for AEDs is very large.

Also, keep in mind that the numbers of sudden cardiac arrests will rise as our population ages. SCA occurs on average at about 60 years of age, and the underlying reason is coronary heart disease. As a society, we're getting older and our lifestyles to do not promote good coronary health. With many cardiac arrests occurring at work or at a public place, you can see why we need to equip our safety forces, businesses, and public places with AEDs.

Q: If a community's or business's leadership were considering buying AEDs, how would you recommend they implement a program?

A: I would say that any community interested in making AEDs available for its citizens should look first to its public safety departments. Put AEDs in the squad cars or fire vehicles and train personnel in their use and in CPR. A survey conducted last fall in Miami-Dade County reported that the police arrived at emergency scenes six minutes earlier than ambulances. With each passing minute after arrest, the odds of a victim's survival decreases about 10 percent. After 10 minutes, very few attempts to revive a patient are successful.

Q: From your 1,000 interviews, what is the single most important thing you learned?

A: That even trained professionals can use a coach during a crisis. Many corporate safety managers and public safety officials who have had training consider a simple, easy-to-use AED as being good for "someone else," like the lay responders. The fact is that many of them will be that "someone else" who benefits from those visual and audio instructions that are included with an AED. Unless you are a physician, nurse, or paramedic, simple is better.

This article originally appeared in the May 2003 issue of Occupational Health & Safety.

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