Implementing public-access programs for automated external defibrillation

CMAJ 2000;162(13):1804-5

It makes little sense to us, though, why the authors would suggest an emergency medical service (EMS) response time of 15 minutes for a decision to implement lay defibrillation when, at 10 minutes, the potential for benefit from EMS defibrillation approaches zero. Lay defibrillation programs should be considered whenever the EMS system cannot provide effective service and lay providers can.

The effectiveness of AEDs, even when used by lay responders, is no longer in question. What holds back the widespread use of AEDs is the misconception that AEDs require medical delegation or physician supervision.

In 7 provinces and the 3 territories, AED use is not regulated, has already been deregulated or is regulated but does not require delegation. AED use is still regulated in Saskatchewan, Manitoba and Quebec, but the Quebec College has recommended that the law governing the use of AEDs be amended. There is a widespread belief that Ontario requires physician delegation and supervision of an AED program, but the College of Physicians and Surgeons of Ontario advised us that "the use of an AED in the circumstances of a collapse is not a controlled act by virtue of ss.30(5)(a) of the Regulated Health Professions Act. There is therefore no need to make any legislative change to permit an AED or public-access AED program to be established" (Dr. John Carlisle, College of Physicians and Surgeons of Ontario: personal communication, 2000). In most of the country, then, College regulations support lay AED use.

We would also like to address some of the "problems" the authors list in their article. First, whether or not a lay provider can detect a pulse is not really an issue: Eberle and colleagues convincingly showed that neither lay people nor health care professionals are very accurate in detecting a pulse.² Fortunately, as Schwartz and Verbeek point out, the AED will only shock a shockable rhythm.

Second, EMS medical directors should urgently address the issue of efficient transfer of care to EMS personnel. It should not be a barrier to the lay use of AEDs: at present, over 95% of people in this country who have a cardiac arrest outside of a hospital die, and efforts to improve the availability of a treatment proven to increase survival should not be held back by concerns about how to care for the survivors.³

Third, Gundry and colleagues' study showing that grade 6 students can use AEDs effectively and safely after 1 minute of instruction⁴ goes a long way toward alleviating concerns regarding cost effectiveness of training and maintenance of skills.

Fourth, the newest AEDs perform their own maintenance, and a proactive EMS service can list all sites with AEDs and can provide a random check of AEDs in their neighbourhood.

After early treatment with fibrinolytics was proven to increase survival from acute myocardial infarction, it took more than 10 years before physicians were routinely providing the treatment in a timely manner to all who should receive it. We mustn't let the same thing happen with AEDs.

Michael Shuster
Emergency physician
Past chair
Emergency Cardiac Care Coalition
Banff, Alta.
Wes Clark
Manager
Emergency Cardiac Care
Heart and Stroke Foundation of Canada
Ottawa, Ont.

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1. Schwartz B, Verbeek PR. Automated external defibrillation: Is survival only a shock away? CMAJ 2000;162(4):533-4. [MEDLINE]
2. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation 1996;33:107-16. [MEDLINE]
3. Stiell IG, Wells GA, De Maio VJ, Spaite DW, Field BJ, Munkley DP, et al. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS study phase 1 results. Ann Emerg Med 1999;33:44-50. [MEDLINE]
4. Gundry JW, Corness KA, DeRook FA, Jorgenson D, Bardy GH. Comparison of naïve sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation 1999;100:1703-7. [MEDLINE]

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