Defibrillators Let Lay People Save Lives

By Denise Grady

October 26, 2000 - Many people who suffer cardiac arrest and would otherwise die can be saved if ordinary people are trained to use defibrillators to shock them back to life, researchers are reporting today.

In two studies, one conducted at casinos and the other on airliners, survival rates were 53 percent and 40 percent for people who had cardiac arrest and who were treated almost immediately with portable defibrillators, a smaller version of the electrical paddles used in emergency rooms.

Those survival rates are far greater than overall rates in the United States, which are dismally low, 2 percent to 5 percent, because most victims are not defibrillated fast enough. About 225,000 Americans a year suffer cardiac arrest.

Ideally, the shock to the chest should be given within three minutes of the victim’s collapse and is unlikely to work after ten minutes. Each minute of delay drops the odds of survival by 7 percent to 10 percent. Defibrillation is the only effective treatment of ventricular fibrillation.

The two new studies, which appear in the New England Journal of Medicine, reflect a larger trend in the United States to train lay people to use portable defibrillators and make the devices available in large workplaces and public places like sports stadiums, train and ferry terminals, airports, amusement parks, health clubs, community and senior citizen centers and shopping malls.

The drugstore chain C.V.S. has begun offering defibrillators on its Web site by prescription for about $3,000, for people at risk of cardiac arrest.

A rule adopted by the Federal Aviation Administration that took effect in September gave airlines three years to train flight attendants and put defibrillators on all planes that can carry at least 30 passengers and one attendant. American Airlines has defibrillators on all its flights, and most other airlines in the nation have begun including them, as have some foreign airlines.

Portable defibrillators weigh four to seven pounds and cost $2,500 to $4,000. Lay people can be taught to use them in five or six hours.

The American Heart Association estimates that if the national survival rate for cardiac arrest victims could be increased to 20 percent, 50,000 lives would be saved.

The people in the studies were treated with a type of portable defibrillator that first monitored the heart and then shocked it only if the machine detected a particular abnormal rhythm, ventricular fibrillation, which accounts for 80 percent of all cases of cardiac arrest. In that condition, the main pumping chamber of the heart quivers instead of beats and loses the ability to pump blood. People in that condition have no heartbeat or breathing but do have some electrical activity in their hearts. In some cases, ventricular fibrillation is brought on by underlying heart disease, and in some cases the cause in unknown. Ventricular fibrillation causes sudden death and is different from the more common type of heart attack, myocardial infarction, in which blockages in coronary arteries choke off blood supply to the heart. People with myocardial infarction would not be helped and instead would be harmed by defibrillation.

Portable defibrillators, sometimes described as "idiot-proof," will not deliver a shock for any condition other than ventricular fibrillation, because shocking a healthy person or someone with another type of heart problem could be dangerous or even fatal. The machine will not fire if a patient’s heart has no electrical activity, because a shock will not restart such a heart.

The machines have recorded voices that talk users through the steps of defibrillation and cardiopulmonary resuscitation. A study last year showed that sixth-grade students could follow the directions and took only 27 seconds longer to do so than emergency medical technicians or paramedics.

The idea of equipping casinos with defibrillators came from Richard Hardman, an author of one study and coordinator of emergency medical services in Clark County, Nev., which includes Las Vegas. Mr. Hardman said that in 1995, his department noticed that the county had a higher rate of cardiac arrests than other areas with similar populations and that more than 60 percent occurred in hotel casinos.

Dr. Terence Valenzuela, one of authors and a professor of emergency medicine at the University of Arizona, said: "I don’t think there’s anything dangerous to your health about casinos. There are just a lot of high-risk people there. They’re older; there are a lot of smokers; and they congregate there for long periods of time."

Hoping to improve survival, Mr. Hardman and his colleagues approached the casinos about defibrillators. Initially, he said, they resisted, mistakenly fearing that people could be harmed by defibrillators and that the casinos would be liable.

"But defibrillators are applied to somebody who’s essentially dead, with no pulse and no breathing," Mr. Hardman said. "You really can’t make that condition any worse."

Once that was understood, the casinos agreed to have their security guards trained. The first to try it was Boyd Properties, which owns the Stardust, the El Dorado, the California and other casinos in Las Vegas and elsewhere.

The officers, already certified in CPR, then had five to six hours of training to use defibrillators, which were brought into the casinos in March 1997.

The first person saved, on July 1, 1997, was a man in his 70’s who collapsed at a slot machine in a Boyd casino. He was staying at a hotel that didn’t have a defibrillator.

"His wife observed the defibrillator being used and was made aware that if it had happened where they were staying, he probably wouldn’t have survived," Mr. Hardman said, adding that the wife moved into the Boyd hotel.

The man recovered; the idea caught on; and more than 70 casinos, most in Nevada, now have defibrillators, Mr. Hardman said. The study included 105 people who collapsed and were defibrillated between March 1997 and October 1999; 56 recovered. None had brain damage, which can follow cardiac arrest if the heart was not restarted quickly and the brain was deprived of oxygen.

Nevada, New York and at least a dozen other states have passed laws to exempt people from liability when they use a defibrillator to save someone.

A surveillance tape from one of the casinos, provided by Dr. Valenzuela, shows a man collapsing at a roulette table. Guards rush to him, remove his shirt and frantically shave his chest, while nearby casino patrons gamble on, barely looking away from their cards or dice. The guards slap two large adhesive patches, containing the defibrillator’s electrodes, onto the man’s chest. Within seconds, the defibrillator commands them to deliver a shock. They move clear of him to avoid being shocked, one presses a button, and the man’s body jerks as the defibrillator fires. The victim’s heart rate and breathing are restored, and within minutes he is sitting up and talking. An ambulance team wheels him out on a stretcher, past other gamblers, most still oblivious of the man who has essentially died and been revived in their midst.

The second study, by researchers at the University of Texas Southwestern Medical Center at Dallas, examined the use of defibrillators by American Airlines, which began putting them on planes in March 1997. The airline now includes them on all flights and has trained its 24,000 flight attendants to use them.

Six of fifteen passengers who needed shocks between June 1997 and July 1999 survived.

Copyright © New York Times, Inc.

A Defibrillator Near You? Advocates call for distribution in schools, public areas

By Felice Buckvar.

July 18, 2000 - WHEN JOHN ACOMPORA answered the telephone early June 12 the first words he heard were, "There was another incident on Long Island." Acompora knew exactly what the caller, a doctor friend, was referring to. Another youngster had suffered cardiac arrest from a fatal blow to the chest. This time it was 7-year-old Ryan Blanco of Centereach, hit by a line drive while practicing baseball with his brother.

"Not again!" Acompora exclaimed, immediately reliving March 25 when his son Louis, 14, a healthy, athletic lacrosse player, blocked a ball with his chest during a game, and in front of players, coaches, friends and his parents, walked a few steps, then collapsed. His heart had gone into arrhythmia; the heart was not pumping because the rhythm was chaotic.

With the memory of that day and the sorrow of losing their son still so achingly fresh, the Acomporas have found a cause. "The only known way to reverse a death like Louis' is with a defibrillator," John Acompora said. "It should be readily available. We're on a campaign now to get every school district in Suffolk County, New York State and the United States of America to have a defibrillator program."

In addition to the equipment carried by ambulances, almost every fire truck and police car on Long Island now comes equipped with an automated external defibrillator. Their use is also being expanded in the city. This easy-to-use, lightweight machine is attached with wires to pads placed on a victim's chest and transmits the shocks that can re-establish a viable heart rhythm. But this device usually must be brought to victims after 911 has been called and a vehicle has arrived at the emergency site. The window of opportunity for defibrillation is five minutes or brain damage occurs, and each minute that passes from the beginning of the attack reduces the likelihood of survival by 10 percent.

Suffolk County Legis. Andrew Crecca (R-Hauppauge) agrees with the Acomporas' goals. He sponsored a bill to grant $2,500 to Suffolk school districts to purchase a defibrillator. Discussion on the bill was tabled in a budget committee meeting in June, but Crecca said, "It was more of a monetary issue than anything else. Members liked the idea of getting defibrillators not only into the schools but into other public places." The legislature will vote on the establishment of a task force on the issue at its meeting on Aug. 8.

At a meeting on July 10 in Albany, members of the Community Health and Pupil Services team and others at the state Education Department decided they would send a document as soon as possible guiding schools on proper placement and use of defibrillators, according to Donna J. Kopec, regional manager in eastern New York State for Emergency Cardiovascular Care Programs for the American Heart Association. She attended the meeting, as did school nurses and administrators and a physician-moderator.

"The tone from the state Education Department was very supportive of the concept. They did not have to be talked into it," she said.

In Queens, fire trucks, EMS vehicles, ambulances in the 911 system and police emergency services trucks carry defibrillators. In general, patrol cars do not, but each precinct has at least one defibrillator and staff trained in its use. Some precincts are involved in a pilot program to train officers.

In addition, enterprises such as the U.S. Tennis Association and the Sheraton LaGuardia East Hotel have the devices, with security personnel trained to use them.

One Long Islander who unqualifiedly supports public access to automated defibrillators in schools and elsewhere is Julie Lycksell, an operating room nurse in cardiovascular procedures at St. Catherine's Hospital in Smithtown. In 1998, she collapsed while celebrating her birthday at a Port Jefferson restaurant with her husband. Luckily, all the steps the American Heart Association considers important in its "chain of survival" fell into place.

Among other things that went according to recommendations: 911 was called, early CPR and defibrillation were administered, and she received early advanced care.

Lycksell was later moved to St. Francis Hospital in Roslyn where doctors implanted an internal defibrillator. Since then, she has had no further incidents, and she is back to work.

The majority of victims of cardiac arrest are older than 65. Although a recent brochure from the American Heart Association states that only 5 percent of those who suffer sudden cardiac arrest now survive and predict that 20 percent more may be saved under optimum conditions, even more dramatic results seem to be coming about.

James Sciammarella, a doctor of emergency medicine at Mercy Medical Center in Rockville Centre and volunteer chairman of Operation Heartbeat for the Long Island region, said, "Nine out of 12 who suffered cardiac arrest at Chicago's O'Hare Airport were resuscitated" with emergency treatment that included use of automated defibrillators.

In Nassau County, of 27 uses of automated defibrillators by police in the latter part of 1999, when the program was implemented, there were four positive pulse reactions. Since Jan. 1, 74 uses resulted in 10 positive pulses. The present scenario is usually that the police car is the first responder to a 911 call, followed by an ambulance with emergency medical technicians who take over at the scene after the police have started CPR and defibrillation.

Pearl Logliandro, 81, of Mineola, is a recent survivor. On April 30, she collapsed. "She was pretty much gone," Mary Warnecke, her daughter, said. A registered nurse at Mercy Medical Center in Rockville Centre and a trustee of the village, Warnecke added, "I would say that usually in the community, there is a 1 percent chance of survival when an elderly person suffers sudden cardiac arrest." Warnecke was at work, but her husband, Thomas Warnecke, was with Logliandro in their home. A volunteer emergency medical technician, he called 911 and started CPR. Police on patrol in Mineola arrived quickly and used an automated defibrillator to establish a pulse. They were followed by an ambulance with emergency personnel who took over the procedures. Logliandro eventually required bypass surgery and returned home June 22.

One of the police officers, John Larson of Nassau's Third Precinct, did the CPR while his partner, Michael Walters, set up their automated defibrillator.

Larson said he had been trained in an extensive program on emergency medical techniques and then received additional training in a four-hour course reviewing CPR and adding the use of a defibrillator.

He explained how easy the device is to use: "The machine advises you to shock or not to shock. The machine tells you to stand clear if a shock is going to be administered." In both Lycksell's and Logliandro's cases, the police officers administered the shocks. Increasingly, public access defibrillators are being purchased for use by trained lay persons such as the lifeguards at Splish Splash, a 40-acre water park in Calverton, staff members at the Mid-Island Y Jewish Community Center in Plainview and the security staff of Cablevision Systems Corp. in Bethpage. The latter owns 28 defibrillators, one for each security office and patrol vehicle.

In the Three Village School District Herbert Friedman, director of Health, Physical Education, Recreation and Athletics, plans to "move forward and implement a defibrillator program for the fall," he said.

Meanwhile, in other states, such as Florida and Wisconsin, fund-raising drives by students, parents, businesses and service organizations, with grants for training, have been putting automated defibrillators into schools.

Felice Buckvar is a freelance writer.

Copyright © Newsday, Inc. Produced by Newsday Electronic Publishing.

Matters of the Heart: A Comprehensive Look at Commotio Cordis, and What is Being Done to Prevent It

by Paul Ohanian, Lacrosse Magazine Online Staff

In March 2000, Louis Acompora was a goalie on the Northport (N.Y.) High School freshman lacrosse team. He likely shared the same hopes that many other 14-year-old players harbor: enjoy a good season, improve on his skills and prepare to join the varsity team in future seasons.

Sadly, Acompora never had a chance to realize those goals.

During a game, Acompora absorbed a shot that hit him in the chest. Despite wearing a chest protector, the impact of the ball sent him into cardiac arrest. Coaches and officials performed CPR on site, but Acompora was pronounced dead-on-arrival at the hospital.

Following his death, Louis' parents -- Karen and John -- learned that the rare incident that claimed their son's life actually has a name: commotio cordis. It occurs when an individual receives a blow to the chest in a very precise spot over the heart at a very precise moment in the cardiac cycle. The blunt blow -- which doesn't even need to have extreme force -- imparts an electric charge to the heart, causing ventricular fibrillation in an otherwise normal heart.

The Acomporas also learned that their son might have survived if Northport had had an automated external defibrillator, commonly known as an AED, onsite. These portable machines help increase the likelihood of surviving sudden cardiac arrest (SCA) by shocking the heart back into its normal rhythm.

Data collected by Dr. Barry Maron of the Minneapolis Heart Institute chronicles 188 cases of commotio cordis, encompassing a variety of sports-related and non-sports-related instances. His findings reveal that victims who receive defibrillation within one to two minutes of sustaining impact have the best chance for survival. Additionally, the data suggest that early CPR application is just as important as early AED application in helping victims survive.

What's Being Done

US Lacrosse recently took a leadership role among sport-based organizations in addressing commotio cordis.

"Injury research shows that lacrosse is a relatively safe sport to play, but the risk of catastrophic injury still exists, as it does in every sport," said Steve Stenersen, executive director of US Lacrosse. "In the rare case of a commotio cordis episode, or if SCA should afflict a spectator or official, the prompt and proper use of an AED greatly increases the odds of the victim's survival."

In May, the organization hosted the first commotio cordis summit in Baltimore, bringing together leading researchers, medical experts and equipment manufacturers. The Acomporas, along with two other lacrosse families that have been victimized by commotio cordis -- the Boiardis and the Macks -- were among those in attendance.

George Boiardi was a senior defenseman at Cornell when he was stuck in the chest by a ball during a game in March 2004. He lost consciousness and, despite resuscitation efforts that included the application of CPR and an AED, passed away. An autopsy was not performed, but many believe commotio cordis caused his death.

John Mack was a 17-year-old player at Binghamton (N.Y.) High. During an indoor game in late November 2006, he was struck in the chest by a stick. He spent two days in a hospital on life support before passing.

"We are committed to the health and safety of all lacrosse players," said Dr. Vito Perriello, a member of US Lacrosse's Sports Science and Safety Executive Committee. "We will not rest until this is where it should be."

Among the conclusions reached by summit participants was that greater knowledge of and access to AEDs was critical to countering commotio cordis. US Lacrosse has committed to simplifying the process for schools, teams and leagues to obtain AEDs.

The organization recently announced a strategic alliance with Cardiac Science Corporation to increase the awareness and availability of AEDs to its members and affiliated programs (see sidebar).

"We encourage lacrosse organizations around the country to purchase AEDs as an additional step in the quest to provide the safest possible environment for players, coaches, officials and spectators," said Stenersen.

Since Louis' death, the Acomporas have taken a leading role in increasing the access to AEDs. They established the Louis Acompora Foundation, the primary mission of which is to lobby all states to pass laws requiring schools to have a defibrillator. In 2002, New York became the first state to pass such a law.

"These machines are of obvious benefit after a [commotio cordis] event occurs," Maron said.

Checking Gear

Summit participants also concurred that continued work towards the prevention of commotio cordis incidents is as important as treatment.

"Prevention is the best method and our ultimate goal," said Perriello. "Discovering what materials are the most effective is the goal."

The research of Dr. Mark Link of the New England Medical Center and Dr. Cynthia Bir of Wayne State University -- who have used animal surrogates and mechanical models to study the causes of commotio cordis -- is providing equipment manufacturers with greater understanding of the phenomenon. Initial findings indicate that two contributing factors in occurrences of commotio cordis are the density of the impact object and the ability of the protective device to dissipate the energy of the impact.

Using that data, equipment manufacturers can pursue chest protector design variances that may help curb future incidents. Prototypes with air pockets or shape geometries that dissipate and reflect force are being considered. Developing softer balls, especially for use in youth baseball and lacrosse leagues, also remains an option.

Kyle Sweeney, a member of the U.S. men's team and a vice president at equipment manufacturer Maverik, attended the summit. He said that the information is still far from conclusive and that making equipment changes now would be premature.

"There was nothing that we could take away from that meeting regarding changes in protection," said Sweeney. "There's lots of research being done, but no real answer. There are so many variables that come into play on this issue. I'm glad I was there, even if it was just to confirm that we don't have an answer yet."

Dale Kohler, general manager for Brine, also attended the summit.

"More evidence needs to be compiled, and we need to keep working the problem," said Kohler. "We're all touched by the tragedy of commotio cordis, and there is no denying that it is happening. We walked away from the summit compelled to do something. We just don't know what that is yet."

The National Operating Committee on Standards for Athletic Equipment (NOCSAE) determines specifications for equipment. With commotio cordis research still incomplete, no current standard for chest protectors has been established. Lacking that standard, a national governing body, like US Lacrosse, cannot modify its rule book.

"The tough part is waiting for the science," said Dr. Trey Crisco, director of the bioengineering laboratory in the department of orthopaedics at Brown Medical School and Rhode Island Hospital. "Once you figure out the science, establishing the standard is pretty cut and dried."

Crisco said that mandating and enforcing the use of non-compromised equipment would go hand-in-hand with its production. Players would be prohibited from altering the protective gear to make it more comfortable, lightweight or form-fitting.

"Once adopted, compliance is done by self-certification by the manufacturers," said Crisco.

"We've got to continue to build on these points of discussion," said Dr. Fred Mueller of the Center for Catastrophic Sport Injury and a member of the US Lacrosse Sports Science and Safety Executive Committee. "Does equipment that appears effective in the lab also work in the field? Will organizations accept a mandate to use this equipment? Will manufacturers produce it?"

In many respects, the summit created more questions than it answered. Nevertheless, all participants agreed that the issues surrounding this phenomenon need to be explored further, with continued research, product testing and education, to make the sport safer.

For more information on AEDs and the partnership between US Lacrosse and Cardiac Science, including the special pricing options, visit www.uslacrosse.org or www.cardiacsciencepartners.com/usl.