Three Lives Saved: UWA s Experience With Defibrillators

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1 Three Lives Saved: UWA s Experience With Defibrillators Eddie Stoelwinder University of Western Australia eddie.stoelwinder@uwa.edu.au ABSTRACT Over a period of 20 months three lives have been saved at the main campus of the University of Western Australia using an Automated External Defibrillator (AED). A staff member, a student and a visitor were resuscitated. While two were in older age groups, one was a younger person with no previous heart signs or symptoms. The introduction of the AEDs to the campus was part of a comprehensive first aid program. The advantages of the AEDs and the resistance to their implementation are discussed. The planning of the AED program considered maintenance, training and the criteria for the location of the AED units, including the age demographic of the workforce. The value of the AED is highlighted by the three cases presented. BACKGROUND Sudden Cardiac Arrest Death from Sudden Cardiac Arrest (SCA) is sudden and unexpected, occurring instantly or shortly after the onset of symptoms. The most common cause of SCA is ventricular fibrillation, a life threatening arrhythmia characterised by rapid, chaotic contractions of the heart, which leads to the inability of the heart to pump blood to the body, particularly to the brain. SCA is different to a heart attack, when blood flow to a part of the heart is blocked with deprivation of oxygen supply, although SCA almost always occurs in the context of other heart conditions, particularly coronary artery disease (Mayo Clinic staff 2008). According to St Johns Ambulance, SCA is one of the leading causes of death in Australia. Each year five times more people die from cardiac arrest than from car accidents. The survival rate is between 2% and 5%. There are many contributing factors to SCA including: pre-diagnosed heart disease degeneration of the heart muscle enlargement of the heart due to high blood pressure hardening of the arteries unexplained electrical interruption. One to two percent of SCAs occur in young people i.e. under 35 years of age, with two thirds showing heart abnormality at autopsy and the remaining third being unexplained, but suspected to be a genetic disorder. The risk of SCA in susceptible young people is increased by physical activity (Mayo Clinic staff 2007). For each minute that passes after an SCA, the chance of survival is reduced by 10%. Therefore there is only a 10-minute window of opportunity (Finn et al. 1999). Fewer than 5% survive beyond 12 minutes even with early institution of Cardio Pulmonary Resuscitation (CPR). On the other hand, with immediate defibrillation, survival for SCA is close to 90% (Ramaswamy & Page 2003). Considering the average ambulance response times are Page 1 of 7

2 between 10 and 12 minutes the only alternative is having an Automated External Defibrillator (AED) on campus. Automated External Defibrillator The only definitive treatment for SCA is a defibrillation shock, an electrical pulse through the heart, which restores a normal heart rhythm. Defibrillation within the first few minutes of a SCA can save up to 30% of victims (Cummins 1993; Davies et al. 2005). Public Access Defibrillation (PAD) involves making the modern technology of Automated External Defibrillator (AED) available in the workplace and public areas, thereby greatly improving the emergency response (Colquhoun et al. 2008). St John Ambulance Western Australia (2008) strongly supports and promotes the availability of both PAD and supplementary oxygen, which can improve the outcome of First Aid. This approach has been termed New Century First Aid (Oxer 2008, p1). There are two types of AEDs: Automatic and Semi Automatic. The rescuers are given voice prompts in use of the defibrillator and CPR, which is supported by a metronome, to direct compressions and breaths. The AED only delivers a shock when one is needed and is safe for the user and the patient. For the Semi Automatic AED a button is required to be pushed to apply the shock. Text prompts assist rescuers in noisy environments. The AED unit self tests daily, weekly and monthly. AEDs require minimal maintenance consisting of biannual servicing, checking supplies and battery, and recommissioning following discharge, which includes replacing used electrodes and testing batteries. This means that the AED is always ready and easy to use. Age Demographic of the Workforce People are living longer and the population continues to grow. Gabrielle Carlton (2009) stated at the Safety in Action conference, that, according to Australian Safety and Compensation Council, the Australian work force has 32% of it made up by workers in the age group, and this group has a number of physiological changes including a decline in aerobic capacity and chronic disease. At the University of Western Australia (UWA), considering only permanent full time and part time staff, 47% are in the age group. There are a further 92 workers older than 64 at UWA. Therefore UWA has a much higher percentage of the workforce in this category, compared to the general work force. THREE INCIDENTS IN TWENTY MONTHS From February 2007 to November 2008 three incidents of Sudden Cardiac Arrest (SCA) occurred at the Crawley Campus of the University of Western Australia. In all three cases an Automated External Defibrillator (AED) was used and the persons affected each made a full recovery. Debriefing following each incident was not only very useful for determining how response could be improved but it was also useful for the rescuers to discuss their experiences and to be supported by the University community. Incident 1-26th February 2007 A 64 year old UWA staff member collapsed in a University car park. Another staff member noticed the collapse from a third floor window in an adjacent building and called the emergency number and attended the patient. The rescuer was a trained Senior First Aid Officer and was able to commence CPR. UWA Security and Parking attended with their defibrillator. It took approximately 5 minutes for the AED to arrive and six shocks were given. When the ambulance arrived more shocks were applied. The staff member was taken to Hospital where he was kept in an induced coma for four days. He was fitted with a pacemaker and returned to work later that year. The staff member had been on medication since his first heart attack five years ago, but had no warning of the second attack in February. Page 2 of 7

3 Incident 2-4th June 2008 A 20 year old UWA student suffered a sudden cardiac arrest whilst attending an oral exam. The patient appeared to have convulsions then collapsed. Fellow students and a staff member commenced CPR and the University Emergency number was called. A Senior Security Officer attended. He cleared the airway and applied CPR and four defibrillations over 20 minutes before the patient commenced breathing. When the ambulance officers arrived they worked for 30 minutes, including applying more shocks, to stabilise the patient before transporting her to hospital, where she made a full recovery following surgery. From the time of Security call out to application of the AED was approximately 7 minutes. Incident 3-18th November 2008 A 65 year old visitor to the UWA Sports and Recreation Centre suffered a cardiac arrest whilst waiting to play squash. Fellow squash players and UWA Sports and Recreation staff commenced CPR. An AED is permanently located at the Sports and Recreation Centre and this was used to provide one shock. The patient regained consciousness following this shock. The ambulance arrived within four minutes of the alarm being raised. After delivering him to hospital the St John Ambulance staff returned to the campus to personally compliment staff on their first aid response and effective use of the AED. The patient had three blocked coronary arteries and had triple bypass later in that week. INTRODUCTION OF THE AEDS The public perception that deployment of AEDs alone saves lives is incorrect; rather the implementation and maintenance of AED programs embedded in the chain of survival saves lives (Zed 2008, p 2340). The concept of a chain of survival emphasises the steps to achieve survival from SCA: early access to the emergency medical system early initiation of CPR early defibrillation early advanced cardiac care (Ramaswamy & Page 2003). The plan of Public Access Defibrillation is to eliminate delays by having nontraditional first responders (e.g. security staff) and trained laypersons to apply the technology of defibrillation. PAD is a very effective strategy for patients suffering SCA in public places where AEDs are installed. However, while a mobile response team with an AED is less effective, it does offer some prospect of resuscitation (Colquhoun 2008, p275). The value of mobile response is supported by a study of security officers working in casinos. When the mean time for delivery of the first shock was 4.4 minutes there was a 53% recovery (where the rhythm was ventricular fibrillation). When the shock was delivered within 3 minutes there was a 74% recovery. A call-to-shock time interval of 5 min is the goal ( Ramaswamy & Page 2003, p240). Drezner et al. (2007) in their consensus statement on emergency preparedness in athletic programs in high schools and colleges state the essential elements are: effective communication system training of anticipated responders in cardiopulmonary resuscitation and AED use access to an AED for early defibrillation acquisition of necessary emergency equipment coordination and integration of onsite responder AED programs with the local emergency medical services system practice and review of the response plan. Page 3 of 7

4 The UWA Experience The first two AED s were installed at UWA in 2003 at the School of Human Movement Rehabilitation Unit and the UWA Medical Centre. The University Safety Committee has approved the purchase of a further ten AEDs over the past four years. These units were installed considering the criteria for deployment and were a part of a comprehensive first aid training programme. Criteria for Deployment The criteria UWA used are outlined below: areas of medical need mobile first response sport venues location central or distant populated areas after hours requirements hazardous environments. The criteria for placement of the first two units considered the special medical needs of the Medical Centre and the Rehabilitation and Stress testing unit of Sport Science, Exercise and Health. Security and Parking, being mobile and first responders were supplied with two units to be carried in their vehicles. This was followed by installation of two units at Oral Health which has medical needs, large numbers of people and an off campus location. Another unit was installed at the Sports and Recreation Centre, which also has a large number of patrons and their own particular medical needs. According to Norton and Norton (2008, p86) Fitness centre placement is particularly important if the clientele is older or has a 'high-risk' profile, for example, clients with cardiovascular, respiratory or metabolic disease and suggest that the standard of care required in health and fitness centres is increasing and that it is prudent for AEDs to be installed. Other areas to receive units were the Library and Business School, which have large numbers of patrons and include significant after hours opening times, the Chemistry building, which has high numbers of occupants working in a hazardous environment and the UWA Sports Park, which is one of the off campus locations and also has out-of-hours operation and specific medical needs. Drezner et al. (2007, p549) support AED at athletic venues and further state In any collapsed and unresponsive athlete, SCA should be suspected and an AED applied as soon as possible for rhythm analysis and defibrillation if indicated. Placement The placement of the AED should be located close to where a SCA may be witnessed and be visible and easily accessible. Reception, common areas and main corridors may be convenient locations. Emergency Preparedness UWA has an effective communication system with a 24 hour manned control room with an emergency response officer (Security and Parking) in contact via two-way radio. These officers are trained in cardiopulmonary resuscitation and AED use. A comprehensive training programme of other staff supports this. There are twelve AEDs on site. UWA is a member of the St Johns first responder scheme and regularly reviews the need for further AEDs and has a debriefing after each incident. Currently UWA has 26 Security and Parking officers who have both senior first aid and defibrillator training. These officers have radio contact and vehicles equipped with first aid kits, oxygen and defibrillators. The Security and Parking have central first responder role in the UWA Emergency Procedures via the University s emergency phone number, which is Page 4 of 7

5 extensively promoted in induction and training, as well as on posters and on all University phones. In addition to the trained security and parking officers, the University has 76 designated first aid officers with senior first aid training. Other first aid trained staff as required for the local circumstances support these officers. The formal first aid programme is supported by 3.5hr, 1 and 2 day first aid courses provided to the University workforce, with 312 staff in 2008 and 160 in 2009 staff undertaking this training. Eighty UWA staff members have had specific defibrillator training over the past five years. Various levels of training in defibrillators are included in first aid training and refresher training. CHALLENGES TO IMPLEMENTATION Apart from the financial and cost effectiveness issues, UWA encountered other challenges to implementation of AEDs. During the planning process senior staff raised a number of points. These included the possibility that the rescuer might be blamed in the event of an unsuccessful use of an AED, the legal position of the responder and what support would be provided by the University, the logistics of responding in an adequate period of time, the training regime that would be necessary and the competencies required. Training needs to include discussion of these issues. Education on the legal position of responders in Good Samaritan legislation and the support of the University should be clearly explained. It is important that responders understand that there are conditions that a defibrillator can not correct, if there is no electrical activity in the heart or if the heart muscles have been damaged they will not contract, a defibrillator will not correct the situation. The only alternative is Cardio Pulmonary Resuscitation (CPR) until advanced life support treatment can be applied. DEBRIEFING FOLLOWING THE THREE INCIDENTS AT UWA Debriefing following each incident has been very useful in determining the adequacy of the response and areas that can be improved. The earlier that debriefing can occur, the more clearly the events of the incident can be determined and the better the opportunity to engage those involved and to put in perspective any lingering doubts on performance. Counselling can be offered. Providing support to the rescuers and bystanders has been appreciated by all of those involved in these incidents. Some of the specific issues raised in the debriefing of the incidents at UWA include: emergency equipment maintenance (oxygen bottle valve malfunction) lack of practical training simulation (such as detail like removing the backing material, the sound of the unit and the effect on the body of the patient) crowd control issues (inappropriate comments from crowd, interference in administration of the shock by touching the patient and also exposing them to electric shock) emergency Response Confusion (multiple phone calls to 000 and UWA emergency number) rescuer exposure to bodily fluids (Masks and gloves should be available in first aid kits) procedure for clean up of the scene. Emergency Response Confusion confirms the importance of the recognition that the UWA emergency call number is the first number to call. All of those involved in the three incidents have become advocates for AED. One officer, who was present at two of the incidents and who had lost a close friend from SCA where a defibrillator was not available, has become a strong advocate for its use. A second officer Page 5 of 7

6 had been involved in the use of AED in previous employment and reported recovery in 12 of 14 incidents. Staff have responded very favourably to aspects of the introduction of AEDs. They have commented on their ease of use and simple guided operation and that little training is required. This training could be easily incorporated into Senior First Aid training rather than wasting time and resources on specific AED courses. Finding a training provider who can incorporate defibrillator training into Senior First Aid training and refresher training would make logistics easier. CONCLUSION The modern technology of the Automated External Defibrillator is playing an important role in New Century First Aid. AEDs, along with comprehensive emergency planning to ensure a quick response, and first aid training, have saved three lives at UWA over twenty months. The incidents described had profound impacts on not only the victims and their families but on all concerned, particularly the rescuers. While each incident provided challenges and difficulties, a sound foundation of first aid knowledge and the use of the AEDs ensured a good outcome. The incidents gave examples of different ages, status of people on campus and medical complexities. The implementation of AEDs has hurdles apart from costs to the organisation. These include training and competency, logistics of quick response and emergency planning, and resistance from first responders due to personal and legal concerns. The latter concerns should be carefully allayed with accurate information. Other issues highlighted by our experience are emergency equipment maintenance, lack of practical training simulation, emergency response confusion, crowd control, exposure to body fluids, and the importance of quick and thorough debriefing following collection of accurate information. Criteria suggested to consider in determining the location of AEDs include: areas of medical need mobile first response sport venues location central or distant populated areas after hours requirements hazardous environments. As SCA is one of the leading causes of death in Australia, and Medical authorities strongly support and promote the availability PAD, Universities have a responsibility to review the need for PAD on their campuses. ACKNOWLEDGMENTS The author wishes to thank Michael Rafferty, Manager UWA Safety and Health, for his assistance and support in the preparation of this paper. Mr Rafferty initiated and oversaw the program of implementation of AEDs at UWA. The author also wishes to thank the staff of UWA Security and Parking for their involvement in the three incidents and the two officers who kindly agreed to being interviewed. Page 6 of 7

7 REFERENCES Carlton, G 2009 Safety in Action conference, OSH Alert. [Tuesday 7April]. Colquhoun, M et al A national scheme for public access defibrillation in England and Wales: early results Resuscitation, 78(3) pp Available from: PubMed. [17/4/2009]. Cummins, R 1993 Emergency medical services and sudden cardiac arrest: the chain of survival concept, Annual Review of Public Health, vol. 14 pp Available from: PubMed. [17/4/2009]. Davies, C et al A national programme for on-site defibrillation by lay people in selected high risk areas: initial results, Heart, 91(10) pp Available from: PubMed. [17/4/2009]. Drezner J et al Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement, Heart Rhythm, 4(4) pp Available from: PubMed. [17/4/2009]. Finn, et al Outcomes of out-of-hospital cardiac arrest patients in Perth, Western Australia , Resuscitation, vol. 51 pp Mayo Clinic staff, 2008 Sudden cardiac arrest Definition, Mayo Clinic, Available from: < [15 April 2009]. Mayo Clinic staff, 2007 Sudden death in young people Heart problems blamed, Mayo Clinic, Available from: < [15 April 2009]. Norton, K & Norton, L 2008 Automated external defibrillators in the Australian fitness industry, Australian Journal of Science and Medicine in Sport, 11(2) pp Availablefrom: PubMed. [17/4/2009]. Oxer, H 2008 New Century First Aid, 8 edn, St John Ambulance Australia (Western Australia) Inc, Perth, pp 1. Ramaswamy, K & Page, R 2003 The automated external defibrillator: Critical link in the chain of survival, Annual Review of Medicine, vol. 54 pp Available from: PubMed. 17/4/2009]. Zed, P 2008 Update on cardiopulmonary resuscitation and emergency cardiovascular care guidelines, American Journal of Health-System Pharmacy, vol 65 pp Available from: PubMed. [17/4/2009]. UWA RELATED MEDICAL INCIDENT STORIES ARE AVAILABLE AT: 1: < (front page) February Staff member resuscitation 2: < (page 9) March Rebecca Joel 3: < (page 3) June student resuscitation (further information below) 4. < (page 15) September the Last Word by Richard Small Page 7 of 7