It Takes a System to Save a Life
EMS and Early
Defibrillation Programs
On September 11,
2001 we as a nation were shocked by and
continue to grieve the unbelievable tragedy that in less than an hour, nearly
3000 healthy, productive and irreplaceable lives were prematurely lost. But, on
average, each hour of every day in the US
alone, 42 vigorous, invaluable lives are lost to an easily treatable cause of
death. Each week of the year more
than 3000 people would be able to continue life—and have their premature
deaths averted—if only someone would simply attach an automated external
defibrillator (AED) to the chest of each
sudden cardiac arrest (SCA) victim and push a button.
For those who
suffer SCA, the medical evidence is now clear: the sooner they are defibrillated
the better their chance of many more years of a loving, fruitful life. The
“Mobile Coronary Care Units” of the late 60’s and early 70’s proved the need and value of early, on-scene care
of cardiac patients. However, with
average SCA survival rates of 5% or less, the EMS System has not
delivered on our promise of 30 years ago.
That is until the advent of AEDs and their very impressive "50-75%
save rates" when these “death defying devices” are used within three minutes on victims of sudden cardiac arrest.
But SCA survivors aren’t just
statistics; they have names, faces and a story to tell. I recently met 42 such warm, wonderful
and grateful people at a conference in Washington, DC. Teenagers like Andrea, Nick and Amber;
moms like Mary and Marsha; and grand-dads like Phil
and Jack -- all the recipients of a 2nd chance at life thanks to the
availability and prompt use of an AED by a bystander
or first responder. For those with
“hearts and brains too good to die” AEDs are essential protection
from premature death.
There is however,
another significant EMS System incentive to growing the number of early defibrillation
programs. Public Access Defibrillation (PAD) programs are now providing
those of us in the EMS community with a sorely needed “banner” to help us attract
and motivate the general public to take on their important role in the EMS system. AEDs can
and are generating growing awareness throughout the all segments of society
regarding the need for and importance of immediate, onsite initial emergency
care—for all types of serious medical emergencies.
Prompting People to Act
Average people are infrequent and
often reluctant responders. Since
they generally do not want to deal with death (nor be near anyone who is
dead or likely to be dead soon), they need to first of all be well informed
and motivated to get ready for medical emergencies (including
acquiring an AED –
regardless of the color they like and with whatever features will meet their
needs.) They then need to be properly trained following
approved/recognized curricula and most of all effectively prepared
– not just be awarded a “certification card” – so that
they will have the willingness and courage to properly respond (including
“take the AED off the
wall” and use it) if ever needed.
The significant missing link in EMS
system development and operations has long been effective EMS
public education and the lack of citizen action on scene. The incidence of
appropriate care delivered by a lay responder when EMS
arrives continues to be appallingly low.
EMS public
education and preliminary function can be simply defined as:
knowing where to call, how to call, and what to do to support life until EMS
arrives. And most important—having the
confidence and the courage to do all three!
The importance
and real benefit of AEDs and early defibrillation programs must
be viewed within the context of total onsite emergency medical
preparedness and each community’s EMS System. Most guidelines and regulations created
for early defibrillation programs call for integrating AED programs into
each site’s emergency medical response plans. Since few locations
and facilities have prepared such plans, creating AED programs is an
excellent opportunity to help corporations, small businesses, schools,
churches, and other public and private sites to do just that as they become
prepared to deal with all types of perceived medical emergencies.
EMS Should be “Driving the
Car”
Early defibrillation programs
just don’t happen. While using an AED
is fairly simple, developing, implementing and
managing a community PAD or private site AED
program requires a concerted effort and assistance from qualified organizations
and individuals. In order to assist
local businesses, companies, professional offices and various community
agencies & organizations in implementing a life saving AED
program, competent and committed individuals must be the champions, architects,
and managers of these vital programs.
In the early 1900’s,
Henry Ford had a great product, a revolutionary new production method and a
talented sales force but without the infrastructure of highways, bridges and
service stations, his dream would have never become a widespread reality. The same can be said
of the efforts to make the availability and use of AEDs a widespread reality
– and premature death from V-fib as rare as possible. In our society
we certainly have the technology, we have the resources and we CAN extend life
for many of the victims of sudden death.
It is usually CPR/AED
instructors—the vast majority of
whom are emergency care professionals—who
are the key to building the “bridges” (community awareness and
motivation), maintaining the information “highways” (training
programs) and providing the “service stations” (planning and operations support)
needed. Thousands of individual EMS
professionals are currently directly involved as instructors and program
managers of this vital component of the EMS
system, but many more are needed.
A number
agencies and organizations have developed and provide excellent guidelines for
early defibrillation program establishment and operation. Likewise there
are a variety of well-established, approved curricula for training people in
basic CPR and AED use. Regardless of which guidelines are followed or training program utilized, EMS
can and should be leading the way to placing AEDs in workplaces or community
settings as an integral part of every community EMS
System.
As in the broader EMS System, several different
activities and services are necessary to implement on-site emergency medical
response programs (and in the case of AED and PAD programs
many are currently legally required); these generally include:
·
Initial Care Program Promotion &
Awareness
·
Site survey & needs analysis
·
Emergency Medical Response Planning
·
Identification and procurement of
needed emergency care
equipment and supplies
·
AED
Acquisition and set-up
·
Initial emergency care training (First Aid, CPR and AED)
·
The conduct of periodic on-site
drills & scenarios
·
Medical oversight and leadership
·
Incident/case review and analysis
·
Post-Incident responder support
services
EMS
professionals—whether paid or volunteer—are perhaps the best
prepared, best suited and most motivated to create and implement the
“infrastructure” required in order for early defibrillation
programs to achieve maximum benefit.
New Ways of Thinking
In my own
emergency care planning and training business—sparked largely by the
availability and publicity of AEDs—I have seen a marked increase in
interest by businesses and corporations and willingness to consider overall
emergency care preparedness. I now see AEDs as being analogous to a
remarkable and efficient new automobile carburetor that a lot
of people “just have to have.” Moreover
they want it so much that they are willing to buy a new car to get it. The
“car” in my silly analogy is an onsite emergency medical response
program and the “people” are those responsible for safety in public
places and corporate sites.
A good example of
this phenomenon occurred in the airline industry. With the advent of AEDs
came a major revision of the way most airlines now prepare for and respond to
not just cardiac arrests but all perceived in-flight medical emergencies. We now enjoy
reasonable and appropriate, comprehensive in-flight emergency medical response systems which include a number of key components that only
5-10 years ago, were inconceivable in the commercial aviation industry.
Early
defibrillation programs can also help accomplish the important need to prepare
our citizens for response to all types of crises and disasters for which we
must now be ready. Post
“9/11” there is an obvious and urgent need for everyone to have a
greater sense of emergency preparedness.
The “mind set” needed for proper and effective initial
response to medical emergencies is the same that is needed and must be
developed for effective response to all sorts of man-made
or natural disasters and crises. Moreover, as we in EMS learned long ago in preparing for mass casualty incidents (MCIs), “if you can’t properly handle one
patient, you can’t properly handle dozens or hundreds.”
EMS and the Community
Our collective EMS System mission
is much more than saving lives. Not all patients to whom we provide care
and service are dead or even near death. (Actually, compared to the number
of people who are seriously ill or injured, SCA numbers are relatively
small.) Clearly, our true and total mission is to reduce mortality and
morbidity by providing an important and much-needed human service to our
individual communities and to all in need of our knowledge, skills and
compassion.
Therefore
another vitally important benefit of creating AED and early defibrillation programs is the opportunity for the EMS System community to develop, reinforce and/or expand our relationships
with our constituency. By taking the leadership
role with AED and PAD programs—either as entrepreneurs or
intrapreneurs—the individuals, agencies, and institutions in the EMS system provide an additional invaluable service to
our clients and communities while we interact with the community other than
times of disaster or crisis.
This
raised awareness regarding our purpose, service and function should in turn
help enhance the funding needed to sustain our vital work of reducing premature
death and minimizing the complications of illness and injury. Moreover, such
involvement in the planning, implementation and operation of early
defibrillation programs in businesses and many public places is most often
revenue producing and fiscally self-sustaining. Most corporations and many community
locations have demonstrated that they are willing to pay for this service. Why shouldn’t
EMS be the recipient of some of that revenue?
Conclusion
To focus only a
“shock box” and early defibrillation programs in and of themselves will be of little value to most patients and not
very cost effective for society.
“I have an AED but you’re not dead yet”
will be of little consolation to the victim of a myocardial infarction or
major trauma. Moreover just defibrillating a victim in V-fib without providing
all the actions of resuscitation and life support is dangerous. The late “Father of
Resuscitation”, Dr. Peter Safar said it best when he noted, “My greatest
fear regarding AEDs is that people will be defibrillated out of ventricular
fibrillation only to die of hypoxia because no one maintained their
airways.”
The true value of
AED availability and use can be achieved only
within the context of the total standard of care needed for the resuscitation
of those who sustain sudden death.
That requires that EMS not only “take over” the care of the patient from the first
responders (ala the “Chain of Survival”), but that EMS provide the awareness, leadership and guidance needed to promote, set
up and manage early defibrillation and on scene emergency medical care
programs. To paraphrase the
early EMS System mantra “It Takes a System to Save a Life”.
The amazing and
growing number of sudden cardiac arrest survivors is certainly reason enough
continue expanding early defibrillation programs throughout the country.
However, to quote veteran radio commentator Paul Harvey, let’s
not lose sight of the “rest of the story.” Just 30 short
years ago, the vision, determination
and tenacity of a few emergency care pioneers helped to catalyze and launch the combination of public safety,
medical care and public health we now know as the EMS System.
In the
1970’s, early “Mobile Coronary Care Units” were replaced by
more comprehensive, more practical and equally effective Paramedic EMS Units. Today,
AEDs and early defibrillation programs can help our emergency care
enterprise—and labor of love—advance to a higher level of
sophistication; help enhance the continuity of our important public service;
and most of all, achieve a significantly greater reduction in mortality from
preventable premature death.
__________________________________
About the Author
Frank
J. Poliafico, RN is an Emergency Nursing and EMS System pioneer.
In the 1970’s he held a variety of clinical (ER and pre–hospital)
and managerial positions, including director of EMS for the City of New York.. He was
also a major contributor to the early development of educational programs for
EMTs, Paramedics and ER Nurses.
Through
the ‘80s and ‘90s he operated his own
initial emergency care training and consulting company where he created and
conducted innovative “Pre-EMS” training programs for non-medical workers on
land, at sea, on the rails and in the sky.
Frank authored the textbook Emergency
First Care (Brady/Prentice Hall) with forward by Dr. Peter Safar. He has also published
numerous articles and papers and is a frequent and popular presenter at
national and international EMS and safety
conferences and symposia.
He is currently Executive Director of the Initial Life
Support Foundation, (originally the AED Instructor Foundation), a nonprofit
group that provides professional support and assistance to CPR and AED instructors and emergency care
management consultants.
He can be reached at director@ilsf.info
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