SAVING LIVES:

Cardiac Arrest, AED's, CPR, and the ACBL

CARDIAC ARREST:

It is a fact that at least one out of eight American deaths will be the result of sudden cardiac arrest (SCA). Cardiac arrest is caused by an electrical malfunction in the heart, and must be distinguished from what is referred to as a "regular" heart attack or myocardial infarction, which occurs when blood flow to a portion of the heart is blocked. Although there are usually warning signs before a heart attack, cardiac arrest often strikes down people with no history of heart problems. Although most heart attack victims can survive for at least several hours without medical attention, in the case of cardiac arrest death is virtually certain if there is no defibrillation within (roughly) five or six minutes.

When someone collapses into unconsciousness with no pulse or breathing, more often than not it is due to cardiac arrest. This can usually be corrected with a short but precise burst of electricity from a defibrillation device. If such a device is employed within one minute of cardiac arrest the chance of survival can be as high as 90%; if defibrillation is delayed for five or six minutes the chance of survival drops to 5%. The American Heart Association estimates that widespread use of defibrillation could save as many as 40,000 American lives per year.

AED's

Automated External Defibrillators (AED's) have been around since the mid-1990's. An AED first analyzes the patient's heart and, if indicated, administers an electrical shock; it can cause no harm, except perhaps to waste valuable time. "Automated" means just that. You press the "on" button and the device voice prompts you through the process step by step. Although trained personnel are preferred, the device can be successfully operated by someone with no training whatsoever. The American Heart Association reports that a test demonstrated that 11 year olds with no training were able to use an AED only slightly slower than trained personnel. A two year study at Chicago airports showed that more than half the lives saved by using AED's were accomplished by untrained bystanders.

AED's currently cost around $1300, but there are many programs providing them to qualifying organizations for free. The major requirement is that the organization serves a large number of people . One current Colorado program provides a substantial discount for private individuals or smaller groups wishing to purchase AED's. AED's have become commonplace in airports, casinos, government buildings, and most larger hotels.

CPR

AED's should be used in conjunction with cardiopulmonary resuscitation (CPR). Chest compressions and (often) rescue breathing are used to force oxygen into the lungs of an unconscious person. CPR alone cannot prevent death from SCA, but it can buy time until the arrival of an AED. Close to 50,000,000 Americans have received basic CPR training and the number is growing by 12,000,000 per year.

A rescuer should always call 911 as soon as possible. Hotel security should also be contacted - they might be able to provide prompt assistance, especially if there is an AED on the premises.

STATISTICS and PERSPECTIVE

There's no doubt that AED's save lives. But before we all go rushing out to buy one, we need to put these statistics into perspective. First of all, since the victim of cardiac arrest is immediately unconscious, someone else must witness the event before any life-saving steps can be undertaken. About 20% of SCA's are witnessed. And having a witness doesn't do much good if you're more than a minute or two away from a defibrillator and your would-be rescuer doesn't know CPR.

Thus, the best chance of surviving cardiac arrest is to be in a crowd of people, with an AED being employed within one minute. It should come as no surprise that the best survival rates are found in places such as Las Vegas casinos, airports, and airplanes. (Your chance of surviving SCA in a hospital is considerably less.). The FAA has required all larger airplanes to carry one since the mid-1990's, and many government locations are required to have one by federal and state law.

` Without going through all the calculations, and taking into account the advanced age of ACBL members, the bottom line is that the statistics indicate that among all our sectionals, regionals and NABC's we can expect one to three cases of SCA per year. This is consistent with the experience of the airlines. American Airlines reported that over a ten-year period 76 lives were saved by the use of AED's. In fact they were all invited to a reunion and they had one hell of a party. This estimate is also consistent with unofficial reports from our more traveled tournament directors.

A FEW QUICK AND EASY STEPS

Is saving one or two lives per year worth at least some effort? I certainly believe so. While more sophisticated programs are possible, here's what I think can be easily and quickly accomplished:

1. Everybody needs to become more familiar with AED's and how they work. If you're still reading this article you've probably satisfied this requirement.
2. You've got three minutes before the odds of survival drop below 50%. When somebody collapses at a bridge tournament there is a good chance of chaos, controversy, and debate about how to proceed - while the crucial three minutes tick away.
3. Everyone, including tournament directors, needs to be aware that when somebody suddenly collapses with no pulse, no breathing, and loss of consciousness, the odds are that it's cardiac arrest. Like it or not, tournament directors are considered by most players to be in a position of command. At present tournament directors are not required to receive First Aid or CPR training, and receive little or no guidance from the ACBL as to what to do in a medical emergency. They seem to do a pretty good job, but I think we can be much better prepared.
4. When someone collapses from cardiac arrest three things need to be done immediately, maybe four. A tournament director could determine who is to perform each task or a team leader(s) could be designated in advance; once the rescue team is in place there is no need for further involvement of the tournament directors.
A. Call "911".
B. Commence CPR.
C. Get an AED.
D. If you're in a public building with an AED on site, phone "security".
It's not that difficult to determine the location of the closest AED in advance. Most large hotels have them, but a few do not. If they don't, calling security is a much lower priority than the first three steps.

It might also be helpful to identify in advance at least some of those players who are certified in First Aid, CPR, and AED's. If we can organize committees when masterpoints are at stake how can we make any less effort when we're dealing with human lives?

ACBL POLICY

The ACBL'S policy with respect to AED's is that they have no policy. Although there is some merit to the legal argument that this approach will minimize the risk of legal liability, I think they can do better. If the playing site has an AED readily available, there is no need for any bridge organization to purchase one. If a small and perhaps unofficial emergency rescue team can be formed out of the many CPR and AED certified players, further training is not necessary.

First of all, the American Heart Association did a survey a couple of years ago and found no instance of a lawsuit where it was alleged that someone was liable because they operated an AED negligently. But they did find several cases where liability was based on the failure to provide an AED.

Second, every state except one has what are called Good Samaritan laws that protect providers of emergency medical help from legal liability, even untrained bystanders. (see also, Luke 10:25-37) The legalities get a little more complex when you are dealing with organizations that establish "Programs", but I'm sure we can find a way to minimize the risk. If the Las Vegas casinos have managed to do it why can't we?

Third, the reality is that tournament directors, who are ACBL employees, are very involved in health emergencies whether they like it or not. In the case of cardiac arrest, "Is there a doctor in the house?" is not nearly as effective as simply announcing "CPR Table B7". I guarantee that I'm not the only trained CPR person who will jump into action.

Fourth, perhaps the most unfortunate result of the ACBL's approach of non-involvement is that it discourages Districts and Units from doing the right thing because, if the ACBL is afraid of lawsuits, why shouldn't they also be? And finally, the notion that the ACBL is more concerned about possible legal liability than the health of our aging membership is just not going to be very popular with our membership.

It's just a matter of time before the next victim of SCA goes down at a bridge tournament. Will we be ready?

THE AUTHOR:

I'm a lawyer, not a doctor, although I have been trained and Red Cross certified in First Aid, CPR and AED's. My degree in Economics has given me some ability to deal with statistics. I've spent more 40 hours researching the subject of SCA's and AED's, with a lot of help from Google. I've been a regular subscriber to the New England Journal of Medicine since 2006, when I (successfully) defended a shaken baby case. I'd be glad to provide cites for everything I've said. I certainly don't know everything and I'd like to learn more. If you'd like to discuss this further, please give me a call.



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