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Automated External Defibrillators (AEDs) Are Great, But Don’t Fix All Heart Problems

I think one of the greatest public safety advances of the last 15 years has been the widespread installation of automated external defibrillators (AEDs). Automated external defibrillators are medical devices designed to deliver an electrical shock to the heart in ventricular fibrillation – a cardiac rhythm that is commonly associated with cardiac arrest.

VFib.jpg
Figure 1: ECG of a heart devolving into ventricular fibrillation.

I was working in emergency medicine when medical device companies first began to advocate for the placement of AEDs in public places and worked closely with many companies, organizations, and government agencies to incorporate AEDs into their emergency response plans. This wasn’t an easy sell in the late 1990s. People were worried about safety, liability, and cost. But, AED programs have been a great success. AEDs are most effective when they are used within 3-5 minutes of arrest. For example, if you have a cardiac arrest with ventricular fibrillation in New York City, where bystander defibrillation is largely unavailable, your likelihood of survival is only 1-2%. If you were in Seattle, where defibrillation is more readily available and the public is well-trained, your likelihood of survival rises to ~30%. If you were in a Las Vegas casino, where AEDs are readily available and the staff is regularly trained in their use, your likelihood of survival approaches 74%. (See source of statistics here.)

I’ve been a long-time advocate for the widespread placement of AEDs. Ideally, they’d be as common as fire extinguishers. But, I’m not a fan of AED manufacturers taking advantage of tragedy.

On Tuesday, a 13 year old boy was killed during a baseball game after a pitch hit him in the chest. He had turned to bunt when the pitch struck him. From the story in the Huffington Post:

“He took an inside pitch right in the chest,” Jones said. “After that he took two steps to first base and collapsed.” He died the next morning at a local hospital.

The boy’s parents, who were at the game, are heartbroken, shocked and unable to speak to members of the media, league president and family spokesman Dale Thomas said.

“It’s a hard thing to handle for everyone,” Thomas said. “When you’re touched by something of this magnitude, it sends shock waves throughout the community.”

The untimely and unanticipated death of a child is always a tragedy. It’s a tragedy that often leaves people grasping for reasons and solutions. Manufacturer Cardiac Science took advantage of this by posting this to their Facebook page after the tragedy occurred:

Insensitive Cardiac Science.jpg
Figure 2: “An AED might have helped.”

“An AED might have helped.”  Except, probably not.  There’s not evidence that an AED would have been useful at all.  Their post might as well say “a rhinoceros and a banana might have helped.”  Cause, you know, they might have.

As I noted above, AEDs are useful in the first 3-5 minutes after cardiac arrest with ventricular fibrillation.  This unfortunate young man died the next morning while in the hospital. Not, while at the ballpark.  There is no report that he needed to be defibrillated at the ballpark or that there wasn’t a defibrillator available when he needed one.  He died many hours after leaving the ballpark while in a medical facility.

That leads me to conclude one thing – that Cardiac Science is taking advantage of our fear of unexpected death to sell a few more AEDs.  They’re also potentially starting a dangerous round of “Could have, would have, should have” with people who knew this boy who might come across their post while searching for information about him immediately after his death.  How heartbreaking must it be to think that there might have been technology that would have saved your child, even when it might not have.  Especially when the suggestion is made by people with no firsthand knowledge of your child’s case.

If you look at Cardiac Science’s Facebook feed, you’ll notice that they have been on a campaign to bring AEDs to student athletic events and schools.  It appears this young man is a pawn in their marketing campaign.  Looks like these children are being used similarly. It feels heartless and cruel. Although AEDs may be lifesaving in these situations, these ends don’t necessarily justify these means.

Thing is, I can’t envision a pharmaceutical company getting away with these shenanigans.  I can’t imagine the FDA not intervening if a pharmaceutical company maintained a blog where it displayed new stories and claimed that their product might have saved the decedent’s life, connecting individual, unconsenting faces to the drug.  Perhaps that’s the dangerous bridge AED companies straddle – part medical device, part public safety device.

Part smidge of insensitivity?

*This blog post was originally published at On Becoming a Domestic and Laboratory Goddess*


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One Response to “Automated External Defibrillators (AEDs) Are Great, But Don’t Fix All Heart Problems”

  1. Tony Ceci says:

    After researching the news reports of the incident I see that multiple media outlets report that this child suffered commotio cordis after being struck by the ball. Commotio cordis occurs when a blow to the chest causes Ventricular Fibrillation. So if these reports are accurate an AED at the park would have increased the childs chance for survival. The chances for surviving Ventricular Fibrillation decrease 7-10% for every minute that passes without defibrillation. I know that AEDs will not save everyone, but if the media reports of the event are accurate it would be reasonable to believe that an AED would have increased the odds of surviving the event.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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