Do you arrive too late for highrise SCA's?

[djones44]

I'm an AED consultant researching whether or not EMS crews actually reach victims of sudden cardiac arrest inside four minutes, after which survival rates fall off fast.

I feel that this short a time is unreachable, in practical terms, since you can't negotiate with city traffic, building security schemes, and unconscious patients.

The only solution to my mind is to have an AED in-house, preferably as a PAD in the elevator lobby.

Can you share your experiences or suggestions on SCA's in tower buildings?

 

[dixie_flatline]

I'm an AED consultant researching whether or not EMS crews actually reach victims of sudden cardiac arrest inside four minutes, after which survival rates fall off fast.

I feel that this short a time is unreachable, in practical terms, since you can't negotiate with city traffic, building security schemes, and unconscious patients.

The only solution to my mind is to have an AED in-house, preferably as a PAD in the elevator lobby.

Can you share your experiences or suggestions on SCA's in tower buildings?

High-rise shmi-rise. I can think of maybe a handful of calls, SCA or otherwise, that had EMS on-scene in under 4 minutes (excluding a witnessed arrest at a sporting event or the like).

The sad fact is that here in Howard County, our ambulances average a response time of almost 90 seconds from tone out until they're rolling out the door. (Yes, it's being looked at, especially since fire calls average 45 seconds for a unit with twice the personnel on board who have to throw on pants before they're ready to go. One of the many downsides to a department full of people who mainly want to fight fire and see EMS duty as almost a punishment).

Assuming a caller actually got a hold of 911 within 30 seconds of SCA, at best that gives us maybe 2 minutes of drive time (and that's discounting time to park, grab the gear, get to the pt, and complete any type of assessment). If you don't live within maybe half a mile to a mile of the station, I don't see EMS personnel getting to you in less than 4 minutes.

Now OK, 2 minutes is actually a fair amount of time if you're really moving. But wait, there's more! Protocol still dictates that if the arrest isn't witnessed by an EMS provider or allied health professional, we do 2 minutes of CPR before the AED even gets turned on (at least for a Basic; unsure if ALS has more leeway in their handling of a full arrest). So yeah, unless that protocol changes or you are very, very lucky, it is functionally impossible for us to get to you and have you riding the lightning inside of 4 minutes. (Sadly, I'd be surprised if the average arrest was on a 12-lead/AED within 8 minutes from actual arrest)

Frankly, AEDs need to become cheaper and the education needs to be pushed much more aggressively. I'm sure that's music to your ears as a consultant for them, but look at Seattle and their efforts to push Community Responders. That's the kind of thing that really makes a statistical difference in survivability, not the ability of EMS to respond faster. But I'm sure you already knew that.

 

[GirevikMedic]

I think it's quite unlikely that EMS crews would arrive on scene to a full arrest within 4 minutes. By the time the call is placed by the reporting party, the call routed through dispatch, EMS crew assigned and responding, 4 minutes is usually unattainable.

Some systems may be better at moving the process along quicker, or maybe some call takers and dispatchers are the key. Also, the responding EMS crew could be nearby or mere seconds away prior to dispatch. Perhaps the crew is on stand by at an event and right there to begin with. These things can make a difference in improving response time but still... from the time the patient goes down to the arrival of EMS (more specifically, the application/use of AED), 4 minutes is a very small window.

You are right, though. If the AED is more accesible and more people are aware of it, trained, etc., you can effictively cut out much of the middle portion of the equation and the AED can be put into play sooner.

 

[djones44]

I think it's quite unlikely that EMS crews would arrive on scene to a full arrest within 4 minutes. By the time the call is placed by the reporting party, the call routed through dispatch, EMS crew assigned and responding, 4 minutes is usually unattainable.

You are right, though. If the AED is more accesible and more people are aware of it, trained, etc., you can effictively cut out much of the middle portion of the equation and the AED can be put into play sooner.

Thank you, I do agree of course. I wonder if ambulance people could inspect AEDs in high rises? I'm having some trouble getting fire people to see this as a future responsibility. Heart safety is a critical matter, and in high-rises you don't survive an SCA without and AED of some sort being in-house.

That's a huge loss of life within our densest populations, who are the cheapest to protect on a shared basis.

 

[94H]

Thank you, I do agree of course. I wonder if ambulance people could inspect AEDs in high rises? I'm having some trouble getting fire people to see this as a future responsibility. Heart safety is a critical matter, and in high-rises you don't survive an SCA without and AED of some sort being in-house.

That's a huge loss of life within our densest populations, who are the cheapest to protect on a shared basis.

I dont see that happening unless there is some sort of incentive for them. Most stations are busy enough with their own equipment/problems. I know here no company is going to take on the extra responsibility of inspecting AEDs.

I also thought that AEDs need to be maintained by a licensed person

 

[JPINFV]

Now OK, 2 minutes is actually a fair amount of time if you're really moving. But wait, there's more! Protocol still dictates that if the arrest isn't witnessed by an EMS provider or allied health professional, we do 2 minutes of CPR before the AED even gets turned on (at least for a Basic; unsure if ALS has more leeway in their handling of a full arrest). So yeah, unless that protocol changes or you are very, very lucky, it is functionally impossible for us to get to you and have you riding the lightning inside of 4 minutes. (Sadly, I'd be surprised if the average arrest was on a 12-lead/AED within 8 minutes from actual arrest)

However, for an arrest sans-bystander CPR, you want the 2 minutes of CPR prior to attempting to defibrillate. This was introduced in the AHA 2005 guidelines because there's evidence showing that those 2 minutes can convert fine V-fib to course V-fib and that course V-fib is more likely to convert to a perfusing rhythm instead of into asystole.

 

[djones44]

I dont see that happening unless there is some sort of incentive for them. Most stations are busy enough with their own equipment/problems. I know here no company is going to take on the extra responsibility of inspecting AEDs.

I also thought that AEDs need to be maintained by a licensed person

AEDs are serviced by shipping them in, with loaner replacements often. Anybody can perform that function. Who inspects is flexible, the building ownership's designated employee can do that.

What we need is a Fire Code mandate for an AED in the elevator lobby, and it would be nice if the Fire Dept could also take them in under their wing, inspection-wise, like fire extinguishers.

As compensation, my company Elevaed extends a discount to rescue professionals, and they can be part of service agreements. If you have interest, the code is EMS in our catalog.

Personally I want to see AEDs beside elevators, and feet on the ground looking after them. That will take some time pressure off vehicular resources for SCA's.

 

[mycrofft]

AED ownership is not simple.

Best deal is to pay a company to take care of them for you. You need to buy them, make sure they will have charged and unexpired batteries, have a protocol for employees to use them, incident reporting for when/if they are ever used, insurance against theft or misuse, documentation fopr all these, etc etc etc. Sometimes you are required to have medical control...yes, even for a simple AED.
As for four minutes...if they could get there in four minutes CPR would almost be unnecessary...almost.

 

[18G]

Agree with Mycrofft... best bet would be for Companies to invest in the maintenance contract. I know my old Department invested in the maintenance contract and it covered batteries, annual inspection and service, and some other stuff. Plus it adds an extra level of liability protection since your devices are being serviced by a authorized service Tech.

EMS PLAYS A VERY VITAL ROLE IN SURVIVAL FROM SCA. I think it is within the role of EMS to improve response times to SCA victims no matter where they are located.

 

[boingo]

I'm an AED consultant researching whether or not EMS crews actually reach victims of sudden cardiac arrest inside four minutes, after which survival rates fall off fast.

I feel that this short a time is unreachable, in practical terms, since you can't negotiate with city traffic, building security schemes, and unconscious patients.

The only solution to my mind is to have an AED in-house, preferably as a PAD in the elevator lobby.

Can you share your experiences or suggestions on SCA's in tower buildings?

My department runs a public access defib program and has outfitted numerous high rise office bldgs with AED's. Usually it is a one day program generally for the security staff and has been very successful.

 

[djones44]

My department runs a public access defib program and has outfitted numerous high rise office bldgs with AED's. Usually it is a one day program generally for the security staff and has been very successful.

Good suggestions, very much appreciated.

I agree with you all that the service agreement is a must, it's about $20 a month and it's all done by Physio-Control people (in my case). The AED purchase itself brings insurance with it (indemnification).

It's going to be interesting how the fire code people react to my proposal that an AED in every elevator lobby be mandated.

From my perspective, if AEDs are not seen by them as efficient and effective enough when just one protects so many, then why have them at all?

Still my key point (to them) so far is that it's unfair to all concerned to expect EMS to be there in <4 min. As citizens high rise people have a right to know that, and as safety professionals, do we not have a duty to beef things up for them, with in-house AEDs for these big buildings?

 

[mycrofft]

AED's are becoming a canary in the budgetary mine so to speak

1. The time element and absolute need for an AED to respond meaningfully to a SCA mandates their widespread positioning.
2. The absolute number of SCA's and cost/liability versus benefit of AED's versus SCA's makes them cost-prohibitive and in many cases illogical.
3. Human life is priceless.
4. Budgets are finite and AED"s need updating and replacement occasionally due to changes in the state of the art, not to mention battery monitoring and replacement.

And it goes on and on.

 

[djones44]

1. The time element and absolute need for an AED to respond meaningfully to a SCA mandates their widespread positioning.

No argument there.

2. The absolute number of SCA's and cost/liability versus benefit of AED's versus SCA's makes them cost-prohibitive and in many cases illogical.

1) It's not cost-prohibitive at any level - I sell an AED in a stainless enclosure for $1295 and can still give you 15%. Even for private buyers, that's about what Prozac costs for two years.

And I think we can do some scaling here:

2) At the level of a tower building with hundreds of people in it - including an onsite service plan - maybe $2/person/year. You want a Starbucks coffee or a 4 minute window from death?

It's a character issue for safety professionals - we're paid to figure these things out, and get it done. Sure a lot of people die of SCA's each year - 360K US only - that doesn't mean we throw up our hands. Either we step up, or a lot of those putting their trust in us go down, when they don't have to.

Human life is priceless.
Budgets are finite and AED"s need updating and replacement occasionally due to changes in the state of the art, not to mention battery monitoring and replacement.

The PADs we sell have 8 year warranties and two year service intervals. We are moving toward getting them on the Internet for monitoring. So there should be no barriers there.

I do appreciate your comments, because I need to know how the rank and file see AEDs, particularly within the EMS community, to have a realistic chance of getting them mandated under the watch of the fire code people.

 

[Foxbat]

I remember being taught "2 min of CPR before AED, except for witnessed arrest". But recently I was renewing my CPR cert and the instructor told me that even in unwitnessed arrest I must go straight to AED. Was she wrong, or are these new guidelines?

 

[dixie_flatline]

I remember being taught "2 min of CPR before AED, except for witnessed arrest". But recently I was renewing my CPR cert and the instructor told me that even in unwitnessed arrest I must go straight to AED. Was she wrong, or are these new guidelines?

As referenced above by JPINFV, as far as I know 5 cycles of CPR are still called for by most protocols unless it's a witnessed arrest. We haven't fully switched over to the new AHA protocols yet though, so our state/county system won't be fully in line with the state-of-the-art until next year.

 

[djones44]

As referenced above by JPINFV, as far as I know 5 cycles of CPR are still called for by most protocols unless it's a witnessed arrest. We haven't fully switched over to the new AHA protocols yet though, so our state/county system won't be fully in line with the state-of-the-art until next year.

Here is a link to a study on that question.
http://www.resuscitationjournal.com/article/S0300-9572(10)00244-3/abstract

Personally I would defer to the AED's known falloff after 4 minutes, and shoot first.

-Dwight

 

[mycrofft]

Hi DJONES! et al

Whether it is five or two cycles of CPR before AED, unless you are resuscitating someone who doesn't need it or it was transient such as a borderline electrocution, anyone without cardiac activity is going to need AED and pormpt ALS transport to survive. Period.

DJ, as a retired-nurse sideline I work for a small AED distributor, (and I think we can actually shave under your cost because we're retirees and don't need as much money!). Yes, people want their Starbucks over their AED, until there's a heart attack, then they want both. Thankfully most AED's will never be "fired in the line of duty", but each one of those is an expenditure managers see as wasted (same as they do with decent fire extinguishers). Many areas they could be posted would experience pilferage. We see many AED's sited behind the manager's desk in a l,ocked office, used as a doorstop, or messed with so the electrodes are breached and/or batteries discharged. They never learn, they never drill or train unless we sweet talk them or someone enforces the regs.

I think maybe a plug-in AED for use in places like restaurants, nursing homes, assisted living facilities, health clubs etc. would be a good and cheaper product.

Eight year pad shelflife! Great!

 

[JPINFV]

pormpt ALS transport to survive. Period.

What does prompt ALS transport have to do with cardiac arrest survival rates?

 

[mycrofft]

Diagnosis, drugs, IV establishment, and getting to a hospital?

Basically, everything Joe Bystander does not bring to a field arrest, including a telemetry ICU, maybe a cath lab or OR, and Dr Gregory House.
Time is tissue, and IQ points.
If we didn't need them, then we could zap folks on the scene, declare them healed, and send 'em home.

 

[JPINFV]

...however the benefit of rapid transport doesn't materialize unless and until you get a pulse back. What's the purpose of, say, hauling a patient in asystole to a hospital when the paramedics can do everything for that patient that the hospital can.