Life Lost Contributed by Misplaced AED with Flat Batteries
The scene was replayed so many times on national television that it is burned into memory: Wes Leonard, the star high school basketball player, was lifted into the air by his teammates after making a game-winning shot to give Fennville an undefeated season. But suddenly, Wes slipped out of their arms and suffered cardiac arrest.
Wes Leonard just before his collapse
But here is the part that has been lost: At first, nobody realized what was happening, and there were a series of mistakes.
“Everybody thought he was dehydrated or overheated,” said Fennville Superintendent Dirk Weeldreyer.
Somebody went to get ice and cold cloths.
Wes gasped for air, which some thought was a good sign. But that is actually a warning sign, commonly seen in cardiac arrest. “That led to the confusion,” Weeldreyer said. “People didn’t recognize what was happening.” Jocelyn screamed for the AED that she thought was on the wall. “I yelled for it because that’s what you are trained to do,” she says.
Jocelyn was trained in CPR. She had taught choir for six years at Fennville High in the music room across the hall from the gym. Day after day, year after year, she walked down the hallway past an AED fixed to the wall. She never noticed that it had been taken down.
“For every minute that the heart is stopped, it’s 10% less likely that you will get the heart restarted,” Jocelyn says. “So after 10 minutes, you don’t have much of a chance.”
Fennville principal Amber Lugten found the machine in a storage room and brought it out for Wes, 16. But the battery was dead. Ten minutes passed, and any hope of saving him was gone. Big Wes, the handsome, small-town hero, was dead.
“You are mad,” Jocelyn Leonard says. “There is no one to blame. I’ve never blamed anyone. I’m just so sad about it. I’m sad that it’s a $1,500 fix.”
Lugten said the AED was taken down because kids would open the case as a prank, which caused a loud, distracting alarm. “We made a very poor decision to take it down,” she said.
There was a working AED in a nearby building, but nobody thought to get it. “It probably would have taken three or four minutes to run there and get it,” Weeldreyer said. “That’s why we are trying to teach everybody these warning signs.”
Lifesaving Opportunity Lost Due to Flat Battery
On Monday June 28th 2010, 62 year old Kentucky resident John Hess entered the water in the Gulf behind Hidden Dunes Resort in Miramar Beach.
Surf conditions were rough and red flags were flying.
Sean Hughes of the South Walton Fire District says the waters were not safe for the public to swim in that day.”Under red flags, knee-deep is too deep, so… certainly at the shoreline, but any deeper than that you run a serious risk of getting into trouble.”
Hess did get into trouble. He was pulled from the water at 1:20 in the afternoon.
Walton County Sheriff’s deputies arrived on scene two minutes later, with the South Walton Fire District arriving six minutes after deputies.
By 2:00 John Hess was dead.
Before the fire district paramedics arrived, an off-duty doctor on the scene, asked one of the walton county deputies for an automatic external defibrillator, or a-e-d, to treat hess.
“We were made aware that they were asking for that and there wasn’t one available” says Hughes.
Camile Cox,Public Information Officer for the Walton County Sheriff’s Office says the AED was on scene but didn’t have working batteries. She says the deputies on scene did all they could to find an alternative defribillator.
“They actually went to Hidden Dunes to see if there was one in their workout room, but his (the deputy’s) just did not have a battery, a working battery. He had notified our AED coordinator. The battery was ordered and was replaced the very next day.”
Sheriff’s officials say they don’t have any records of that particular AED’s last inspection.
They are not checked daily because the batteries usually last four-to-five years.
“The AED by design is not necessarily supposed to be checked daily because it’s long term, sitting idling, waiting for use. I can’t speak to what their maintenance schedules are or how they’re being maintained” Hughes says.
Back in 2005, The South Walton Fire District gave the Sheriff’s Office thirty brand new defibrillators obtained through a grant, but the upkeep is the responsibility of the Sheriff’s Office.
Sheriff’s officials say they ordered a battery for the AED in question before the incident because of a routine inspection
“We have a Lieutenant at the Sheriff’s Office who monitors that equipment. They do an inspection once every three months” Cox says.
When asked when the last inspection was Cox stated “I’m not sure, but I know they do them periodically”.
Even if the defibrillator was working, it’s no guarantee Hess would have survived.
Hughes says there’s no way to tell.
“Not every heart attack is a shockable rhythm. Shocking everyone?… If you’re under the belief that’s the course of action, it’s not necessarily the course of action. It interprets it and if it’s a shockable rhythm it will deliver a shock. It’s all speculation in these set of circumstances. Would it have made a difference? I don’t think anyone could say conclusively yes or no” Hughes says.
Paramedics Saved Teen after On-Site AED Failed
Last year, Lahey, 14, was playing hockey in Chester, N.S., when a puck hit him in the chest, causing heart failure.
Kenzie Lahey the Survivor
“Kenzie grabbed his chest, dropped to his knees and fell to the ice,” said his mother Tanya Lahey, who spoke about the importance of defibrillators during a Heart and Stroke Foundation event Saturday.
“The referee immediately called for help. I dropped everything and ran out on to the ice.”
She was joined by an off-duty respiratory therapist, a doctor whose son played on the opposing team, and others. All originally thought her son was having a seizure.
“It wasn’t long before we realized we were dealing with much more than a seizure.”
CPR was performed and the rink was equipped with a defibrillator, but the battery for the potentially life-saving equipment was not charged.
However, a nearby ambulance had a working defibrillator and after two shocks, Kenzie’s heart regained regular rhythm.
He was then stabilized, sent to the IWK hospital and released a few days later. Six months after the March 27 incident he was back on the ice.
“Tests showed he had no underlying heart condition, so it was determined a one-in-a-million shot sent his heart into defibrillation,” Lahey said.
One doctor told her the stars had to align for her son’s heart to stop and a lot more had to align to save him.
She’s hoping other lives won’t be left to chance, which is why she shared her memories of the incident on Saturday and emphasize the importance of defibrillators.
“Kenzie’s story definitely has a happy ending, but the fact the defibrillator at the rink did not work is very unfortunate,” she said.
“The first thing I do when I enter an arena is check to see if the light is on on the defibrillator. If you see a flashing light, you know you are good to go.”
Misplaced AED Contributes to Family’s Loss
The daughter of a 55- year old man who suffered a fatal heart attack at an arena in the Abitibi just before Christmas says the family will not pursue the case.
Denis Letourneau collapsed during an old timers hockey game.
It turns out the defibrillator that normally hangs on a wall near the rink was missing.
It was only found much later in the office of the arena manager who apparently removed it because of renovation work.
Annie Letourneau says her father had just recently been given a clean bill of health by his doctor and there was no indication of heart disease.
My opinion : Just because your venue has installed an AED does not exclude you from any liability. Having a misplaced, missing or stolen AED is just as bad as not having any AED at all.
We provide consultancy for risk management in the view of the organisation installing AEDs on their premises. With better risk management comes better protection for both the rescuer and victim.
Contact us at enquiry@liferesus.com.
Hooray! Another Life Saved!
On 3rd November 2011 at 12:12pm, one of our clients responded to a an apparent case of “seizure”. Upon arrival to the victims side, he was found to be unresponsive with some foaming at the mouth. Although checking of pulse of not needed now in the guidelines, being veterans of life saving, they checked it anyway and found none. They immediately switched on the AED and applied the pads.
This is the first ECG analysed just after applying the electrode pads :
The large spike shows the shock that is delivered to the victim. The following ECG strip shows that his heart came back to normal rhythm :
They then continued CPR just as the AED prompted them to. At the next AED analysis, this was recorded :
This tells us that his heart rate is about 6 times a minute. His blood pressure is definitely low. The AED still prompted them to perform CPR, which they did.
At the next analysis, this is what was recorded :
His heart rate is now approximately 100 beats per minute!
After this time, the emergency ambulance arrived. The victim started waking up as they stretched him into the vehicle.
Kudos to our client!
Deaths from AED Failures
A new study was just published, showing the number of deaths occurring because of failures in AEDs.
The top reasons were :
1. The AED failed to be switched on.
2. The AED failed to complete the heart analysis.
3. The AED failed to deliver the recommended shock.
4. The AED switched off automatically.
The full article can be viewed HERE.
This is why our company has been very meticulous in the deployment and use of the AEDs at our clients’ locations. Just ask Sentosa Island, our best client.
The evidence of the outstanding performance of our clients can be viewed HERE.
Favourable Outcomes by Our Clients
We have been asked recently on how good our service to our clients is, in view of natural concerns of device failure.
This is something I am conscious of, since I am a medical practitioner and advocate for early CPR and early defibrillation in the community. This is the reason why I have been monitoring all the AED uses that I have helped my clients deployed in Singapore since we started, and I am now proud to say that our clients have passed with flying colours on all 3 possible scenerios that any public AED can encounter.
Scenerio 1
This is when the victim’s heart is in ventricular fibrillation (VF). This occurred in September 2008.
The victim’s heart was shocked back to normal sinus rhythm eventually, and he was discharged from the hospital after a heart bypass surgery with no neurological deficit. The story can be read HERE.
Scenerio 2
This is when the victim’s heart is in normal sinus rhythm, but he is unconscious for any reason other than VF. This occurred this month in July 2011.
The AED correctly announced ‘No Shock Advised”. The victim started regaining consciousness while being stretchered into the waiting ambulance, and was informed by doctors that he did not have neurological deficit. The story can be read HERE.
Scenerio 3
This is when the victim’s heart is already in asystole (flatline) or in pulseless electrical activity (PEA). This occurred in September 2010.
The AED correctly announced ‘No Shock Advised”. The victim apparently had a preexisting medical condition, and was found near the toilet with blood in his mouth. The story can be read HERE.
So ultimately, the outcomes of rescue attempts by any organisation which is considering deploying AEDs are dependent on their medical emergency response plan.
For our clients, as you can see, are very satisfied with our services.
Another Life Saved!
One of our clients has saved another life!
On 19th July 2011 in the evening, after 4 minutes under water, the victim was pulled out and CPR applied with 5 cycles of 30:2 compression:ventilation ( approximately 2 minutes ), until the AED was brought to the victim’s side and started analysing.
Here is the screenshot of the initial ECG reading..
2 minutes later, the AED analysed the victim again and here is the strip..
The first application of the AED showed that the victim’s heart was in sinus rhythm ( normal ), but his heart rate was slow. With further perfusion of the heart via CPR, his adrenaline kicked in and his heart rate rose.
In my opinion, either the victim’s heart was in ventricular fibrillation (VF) and then converted to sinus rhythm just with good CPR technique before the AED was applied, or he was about to go into VF. But either way, it was quick recovery from the water and good CPR technique that saved this life.
So our AED worked wonderfully by advising “No Shock Advised”.
Another client had the experience of saving a life recently too. The story can be found HERE.
Kudos to our clients!
2 Minutes of CPR after Every AED Shock
It is important that rescuers of cardiac arrest victims provide 2 minutes of CPR after every shock delivered by the AED, according to guidelines provided by the International Liasion Committee on Resuscitation (ILCOR), the European Resuscitation Council (ERC) and American Heart Association (AHA).
The extracted documents with the highlighted statements (3rd page) from the ERC can be found HERE. The flow chart is as follows :
The extracted documents with the highlighted statements (2nd page) from the AHA can be found HERE.
The reasons for this is because pauses to provide shocks is detrimental to the overall outcome, provided the victim is not revived by the first shock.
According to Dr Kramer-Johansen J et al in his paper “Pauses in chest compression and inappropriate shocks: a comparison of manual and semi-automatic defibrillation attempts” published in the journal Resuscitation 2007 May;73(2):212-20, the amount of time chest compression is not done is 22 seconds (median) pre-shock and 20 seconds (median) post-shock.
What this means that in a 5 minute window period of rescue time ( starting with the first shock ) , if rescuers performs chest compression of 2 minutes in between shocks, the total time without compression is 84 seconds, compared to 168 seconds if the interval between shocks is 1 minute.
What this means is that if someone performs 1 minute of CPR in between shocks, the total time of not performing chest compressions, ie not perfusing the vital organs like the brain and the heart itself, is 2.8 minutes out of 5 minutes (56%), compared to 1.4 minute (28%) when the interval is 2 minutes of CPR in between shocks.
Local evidence that 2 minute CPR in between shocks is the right protocol is seen by the experience of one of our clients, who saved a life recently. The story can be found HERE.
However, there is clinical evidence that rescuer fatigue can set in easily, as shown below.
This is the reason why we encourage our clients to pre-plan deployment of teams to all corners of their area of coverage, and to rotate among the rescuers in providing chest compressions, if need be every minute. 5 cycles of 30:2 compressions:ventilation will last approximately 2 minutes.
Only with teamwork will we be able to achieve the best outcomes.
Why Using an AED on Any Unconscious Person Makes Sense
It was recently reported that the family who lost their husband and father on a country club grounds is suing the club owners for his death.
One of the reasons is that the club staff did not use their automated external defibrillator (AED), thinking that the victim had a “weak pulse”.
I had an article published in a local newspaper on this matter some time back, about the difficulty of healthcare workers not able to judge well the presence of a pulse in a cardiac arrest victim, let alone a layperson rescuer.
It seems that the public does not really understand the usefulness of using an AED on an unconscious person ( regardless on the rescuer’s perception of whether the victim has a pulse or not ).
The real value of an AED in your workplace or home, is that it is a heart monitor first, life-saving device second.
It does not matter what the reason is for the person to become unconscious. If the heart is in ventricular fibrillation ( the only proven time when the person can be saved ), the AED will tell you to press the button to give a shock. Otherwise, the the victim is already clinically dead or is still alive, in which situations the AED will disable the shock button and will not allow you to shock the victim.
We already have 2 events experience by our clients.
In this event, the victim was saved successfully and went back to his normal life and work ( as described by his sister about a year later ).
In this event, the victim was already clinically dead when the AED was applied.
Any comments on this?
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