'We Try to Give That Sense of Urgency to Act'

Trainers continue to hear about perceived liability and DNRs. They want to ensure trainees understand when the AGA compression-only guidelines apply.

Editor’s note: AEDs are much improved since they began showing up in airports, arenas, and workplaces. Training is an essential part of getting workers to use them when necessary, and that training performs a valuable service in accurately educating the trainees about the latest guidelines for performing CPR, said Pam Erno, national account manager for the Health & Safety Institute. She discussed the training she delivers and some of the questions she hears from employees and trainees in an Oct. 1, 2008, conversation with Occupational Health & Safety’s editor. Excerpts from the discussion follow:

Our magazine’s first article about automated external defibrillators was published more than 10 years ago. What has changed since then in the performance of AEDs and in end users’ expectations and readiness to use them?
Pam Erno: So much has changed in the design and user-interface of the devices.Most designs today, from 10 years ago, are sleeker and [more] user friendly. From a therapy standpoint, the algorithms have changed with the 2005 guidelines:We went from three shocks, one minute of CPR to one shock, two minutes of CPR.No longer is it a standard in the industry to have a device with escalating power.

We have devices that have pediatric capability as a standard—some with pediatric pads, and some with a key to turn the device from adult to pediatric mode without having to take the time to change pads. We also have more manufacturers who see the value of CPR tutorials and have added them into newer devices. Battery technology has advanced, so that makes maintenance easier, also.

Because we have placed so many devices in public settings and our trainings have relieved a lot of fears that some people have had about AEDs of the past, I think that more people are better prepared to act in case of need today, and more facilities have first responders who receive more advanced training and drills to be prepared for all types of emergencies.

What about the training you deliver? Has it changed significantly since AEDs were first introduced?
Erno:
I would say yes and no. The dramatic difference is that we know time is of the essence for these people, and we have been able to express this and educate the public in a way to motivate them to have an AED if they are a public place and to start CPR as soon as possible. We still struggle to get the public to attend classes and get trained in first aid, CPR, and AED.

I think a big hurdle is educating beyond what comes out in the press and what people see on TV. Sometimes we have to go back and re-emphasize the importance of CPR, even if there is an AED present.

We have a more hands-on approach to CPR and AED training; responders will have more confidence with “hands on training.”Having people practice with an AED will make them less intimidated during a real event. There are some industries where it is required to be trained and certified regularly, but there is a large group of our population [who] have never had training. Many of us would like to see training within our neighborhood associations so that more people at home would be trained to respond in an emergency.

We know that a person’s chance of survival is diminishing 10 percent for every minute that they are in sudden cardiac arrest. Making this a point in class to motivate people into action is important.We want to alleviate the fears of catching something, hurting the person, doing it wrong, being sued (and the list could go on) . . . so that they might be able to increase a person’s chance of survival by being available to do CPR and use an AED. People still have fears about what to do in an emergency; we can help change that in our classes.

In recent years, there have been several recalls of AEDs, usually because they did not read the patient’s condition correctly or did not deliver a shock when needed. What about now?
Erno:
Unfortunately, there is a large statistic on that, in part because of failures in the devices to alert the owner that there is a problem with their device—pads or battery issues. There are also issues on how a manufacturer responds to issues with their devices, and the FDA mandates a lot of this.

I think today we don’t see as many recalls for misdiagnosis. I hear more about the function and human interface with the AED. One of the most recent recalls involves something about the visibility of the shock button.

Does your training encompass both CPR and AED use? Are end users aware of the latest CPR advisory from the American Heart Association?
Erno:
Yes, in general, most classes that we teach today encompass both CPR and AED, regardless if they have an AED or not. We may be in another location where a device may be available to use, so we should expose and train as many people as we can to do both.

Some people are aware of the compression- only press release.We make sure we clarify that [refers only to] a witnessed arrest, and not a drug overdose,drowning,electrocution, or a child. Most of us would rather you do compression-only CPR than nothing at all.

For some people, getting down on the floor to do compression is difficult, let alone getting right down on the face to give breaths, and it can take more time in the long run. And then all the good efforts of the compressions become a wash.

The recent change in CPR recommendations happened because bystanders are generally reluctant to intervene and deliver lifesaving aid. How do you encourage your trainees to overcome this reluctance? Does the training succeed in this regard?
Erno:
We all want to give people the sense that they can help. Most of us have that standoffish hope that someone else will jump in and know what to do so that we don’t have to.We try to give that sense of urgency to act and do the best they can and to get others to help if they are around.

I think the training does succeed. Classes today have role playing, as well, to practice. We see a lot of people in our classes who haven’t had training for years, so they say that they would not know what to do and probably would not help. I think training is important because we can show people that they can give care and, with all the changes by the AHA and all the organizations doing research, make giving CPR [and] AED use simpler and more effective, especially for lay responders.

Your work also involves the initial sale of AEDs, correct? What are the barriers that potential adopters mention when they consider deploying these devices? How do you answer their concerns?
Erno:
Perceived liability: Can we hurt someone with the AED? Can I be sued if they don’t survive? And DNRs. I usually answer those concerns based on the location and situation.

Do they come up a lot? Erno: More today than in the past. I was at a show recently where someone told me they didn’t want an AED used on them.

Did you ask why the person had this point of view?
Erno:
People have different reasons . . . religion, personal choice, illnesses. In the EMS field, their duty is to answer the call. We teach in our classes: If you’re unconscious, unresponsive, it is perceived consent that you want care.

DNRs vary from state to state, and sometimes they can become problematic. There are some specific things that need to be documented, and other people need to know this information. Family members don’t always know what people’s wishes are in the event of an emergency.

It is more common to get questions about DNRs when assisted living centers or senior living communities are involved. Today, there are medical bracelets that can show DNR information.

You mentioned perceived liability.
Erno:
That’s a big holdback for some larger companies that have lawyers that control some of the decisions and say whether they can put in an AED or not. One of the things I have to do is rebut that perceived liability. Today, our liability is much greater for not having one than putting one in. AEDs have become the standard of care, the standard of training.

If we looked up how many sites across the country have been sued for having an AED and its use being questioned, you won’t find many. There is a greater number of laws, as a result of litigation from sites that did not have AEDs, that mandate or require some industries to have AEDs in all of their locations. In some states, dentists are required to have AEDs. In other states, all health clubs are required to have AEDs. Schools, municipalities, and other public places in some states are mandated to have AEDs. These mandates and requirements are not always the result of litigation; it is a proactive position to be prepared.

People also say, “It’ll get stolen, and we will have to purchase another.” I’ve had one device that was run over and one that disappeared in shipping in the territory that I cover. I’ve only heard of one school district, across the country, that has had one disappear. It’s just not something that happens. I won’t say that it won’t happen, but I haven’t heard of it happening as a rule.

People whose lives have been saved by use of an AED are the most passionate advocates of the devices, for obvious reasons. Does your training include “save” stories like these?
Erno:
My training involves one or two stories. I have many.What is nice is that we get to hear new stories all the time.When I first started, there were not as many save stories to share.

I had one device that was used to save a life two weeks after it was installed [and] saved a 36-year-old woman.

I realize and hope that many of the AEDs will not get used, but if and when one gets used to either save a life or give peace of mind, that we did everything we could to help the person in need. I know it might be someone near and dear to you who needs this help, so I try to train as many people as I can.

These devices have been around for a while. I gather people are not puzzled when you introduce one into a workplace now?
Erno:
Every once in a while, but that’s OK. I figure that’s our job. When I started doing this about five years ago, I was knocking on doors where people were doing CPR training but had never heard of defibrillators or AEDs.What’s nice and fortunate for me is that some people who said, “No, forget it, are you kidding me?” are now loyal customers who have AEDs, who have used them.

Cost of initial purchase and maintenance of these has dropped. That’s helped them be more broadly adopted, hasn’t it?
Erno:
Yes, it has, definitely. I think people should still be careful and do their research on devices. Just because it’s the cheapest device doesn’t necessarily mean it’s the best device for them.You have to look at the cost of ownership, and reliability factors, and the therapy that the device is giving.

A lot of businesses have become more proactive instead of reactive. It can be devastating to family and co-workers when a cardiac event happens. I always say in class, too, it’s a life-changing event if you’re involved doing this with somebody, whether they survive or not. It’s life-changing for both.

This article originally appeared in the December 2008 issue of Occupational Health & Safety.

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