These simple-to-use devices are crucial after cardiac arrest

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Last year, Buffalo Bill's safety Damar Hamlin collapsed in cardiac arrest during a football game. He was resuscitated on the field in Cincinnati, and he's since recovered and played football this season. But he's become a big advocate for the importance of CPR and the use of AEDs, or automated external defibrillators. Before the end of the year, Governor Kathy Hochul signed into law a requirement that camps and youth sports programs provide access to AEDs. For help understanding how these machines work and how this may affect sporting events, I'm talking with Dr. Christian Knutsen, an associate professor of Emergency Medicine, and Dr. Guillermo Negrete, an EMS fellow, both from Upstate. Welcome to "The Informed Patient," Dr. Knutsen and Dr. Negrete.

[00:01:00] Christian Knutsen, MD: Thank you, Amber.

[00:01:01] Guillermo Negrete, MD: Thank you Amber.

[00:01:02] Host Amber Smith: Mr. Hamlin has said that by requiring at least one person to be trained to use an a ED at every sports event, camp and practice, tens of thousands of kids will be protected. Is he exaggerating? Dr. Knutsen?

[00:01:17] Christian Knutsen, MD: I'd say he's not. I think (there are) different ways of looking at that. By protecting tens of thousands of athletes, yes. I mean, obviously, all these children are playing sports at potentially large events. But in terms of protection for sudden cardiac death, the numbers are fortunately fairly small for children. The incidence is not that common. There's only, nationwide, we think between 2,000 and 7,000 events per year. Most of those occur at home and don't happen at sporting events. We think for sporting events themselves, there's only about a hundred cases per year. So tens of thousands are protected; the actual numbers who require it are very small.

[00:01:56] Host Amber Smith: But in addition to the athletes, there's coaches and spectators that are older. Are they more likely to have an event?

[00:02:04] Christian Knutsen, MD: By far. For adults, there's somewhere around 350,000 sudden cardiac deaths per year, nationwide that's about a thousand people per day. So compare that, a thousand per day with a hundred per year for children. Obviously if you bring AEDs and CPR-trained people to events, you're really trying to protect the adults as well as the student athletes.

[00:02:25] Host Amber Smith: I'd like to ask you to tell us about the history of the AED. Is this a machine that was first used in the hospital before it was brought out into the public?

[00:02:34] Christian Knutsen, MD: It was. For over a hundred years now, we've been testing electricity on the heart. We know from the 1900s that the first studies were done looking at animal models using electricity on the heart, and it could show that even back then, electricity could take a heart into rhythm and take it out of rhythm, into something called ventricular fibrillation where the heart does not beat properly and kind of quivers. And they could show that a small shock could take it into this bad rhythm. And then a larger shock would put it back into a normal rhythm.

Fast forward to the 1940s. There's a cardiac surgeon who is the first person to have a patient go into ventricular fibrillation during a heart surgery case. He was the first person to shock the rhythm from v-fib or ventricular fibrillation back into normal sinus rhythm or a normal rhythm for the heart.

And then fast forward to the 1960s. Dr. Paul Zoll was the first one to use a large machine on wheels. It had to weigh hundreds of pounds. It had to be wheeled into rooms. But he was the first one to show that electricity across the heart would work to fix these funny rhythms.And it wasn't until the late 1970s that we miniaturized that to a small enough portable device to use on people in the public.

[00:03:50] Host Amber Smith: Is there data about the success rate of defibrillators used by the medical staff in the hospital compared with AEDs used by the lay public?

[00:04:01] Guillermo Negrete, MD: I can jump in, if you don't mind, for this specific question. There's always new data coming out. This is a very big topic, and actually there is a recent article that came out in 2018, which actually shows the benefit and how important, time sensitive it is when bystanders use AEDs, prior to the patient actually getting to the hospital. And it has shown a better survival and functional outcomes in people who actually are being treated sooner, while they're in the field, before they even get to the hospital.

[00:04:41] Host Amber Smith: Well, Dr. Negrete, can you go over the instructions for how and when to use an AED? How would a bystander know what to do?

[00:04:51] Guillermo Negrete, MD: Sure. So. The most common scenario is when you see somebody on the ground, the first thing you're going to do is basically go and check to see if they're conscious or not, or if they're breathing or not. The most common recommendation is to call 9-1-1, put the phone on speaker and start CPR.

Obviously the ideal scenario will be to have somebody else with you, to be able to lay a hand and help you with the instructions.Whenever we use an AED, there's different types and shapes of them nowadays, but for the most part,they're standardized on the same way they are used. So, what I mean by that is, all AEDs that you use, they have three main components, which is basically some pads that are going to come in the box, and they may be either pediatric or adults. Inside, they will also have instructions. And when you are able to put those pads on the actual person, the box itself, the AED has, for the most part, an automated voice which can actually give instructions to you to follow.

These pads for the most part are going to be put one pad on the front of the chest on the top right, and another one on the bottom left of the chest.For the most part we try to keep those areas clean and dry, if possible, for the machine to be able to have a better read on the patient's electrical rhythm. By doing so, the machine will activate on its own and will tell you if the patient will require or if it recommends to be shocked. If that does happen, there's a really clear, either a color or a bright button on the AED machine, which it will tell you when to not touch the patient, so you can actually push that button. The button basically will just deliver the necessary electric current into the patient before you can start continuing CPR once again.

[00:07:25] Host Amber Smith: And these pads have to be on bare skin, is that right?

[00:07:29] Guillermo Negrete, MD: That is correct. And again, sometimes patients, or people, they can be wet or they can be sweating. So if possible, when you remove the clothing, you can use their same clothing to kind of just wipe any excess water that the patient might have on the skin so the actual pads can have a better touch on the actual skin for better reading.

[00:07:53] Host Amber Smith: How old does somebody need to be to use the AED? Is there an age limit?

[00:07:59] Guillermo Negrete, MD: There's actually no age limit. I mean it all kind of depends on the individual. You know, nowadays we can see the kids are getting more mature, and there's having even reported even 6th graders successfully using AEDs like under 90 seconds. So with that in mind, anyone can use it. It's just a matter of just following the instructions.

[00:08:26] Host Amber Smith: Is there a possible danger to using the machine by a member of the public?

Could the jolt hurt someone?

[00:08:33] Guillermo Negrete, MD: No. The answer to that is no.

[00:08:36] Host Amber Smith: What if it's a pregnant woman? Would it hurt the baby?

[00:08:39] Guillermo Negrete, MD: Well, in that case, the best thing to do is to save the mom to be able to save the baby.

[00:08:46] Christian Knutsen, MD:

[00:08:46] Guillermo Negrete, MD: So when you have somebodyunconscious or what we call in cardiac arrest, you are not going to hurt them per se, right? Because they are, in other words, dead. So anything that you can do for this person is going to be to their benefit. That is from giving the electricity or the CPR at the same time to be able to help have a better outcome.

In regards to a bystander, if by delivering electricity to the patient, you are still touching the person, yes, you will have a jolt that can cause you to feel the electricity going to you, too. For the most part it won't harm you, but it can cause pain because of the transfer of electricity.

[00:09:40] Host Amber Smith: So the person using the AED may feel it?

[00:09:46] Guillermo Negrete, MD: If you are touching the patient when delivering electricity.

[00:09:52] Host Amber Smith: I see.

So it would be important to tell people, "get away," or "stand back."

[00:09:57] Guillermo Negrete, MD: Correct. And the AED machine itself is very good at actually verbalizing, in a pretty good volume, telling you to please stay cleared from the patient. And even yourself, you can also speak out loud, which is a good exercise to do, to "remain clear from the patient," before you push the button on the box to deliver the electricity.

[00:10:26] Host Amber Smith: You said that the machines are pretty good about talking the bystander through how to use it. How many times might a person have to use the machine before the ambulance arrives?

[00:10:38] Guillermo Negrete, MD: As many times as the machine is able to detect a rhythm that is what we call "shockable," we would follow its instructions. If the machine does not suggest for a shock, we would just continue doing CPR.

[00:10:55] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with two emergency medicine doctors from Upstate, Dr. Christian Knutsen and Dr. Guillermo Negrete, about automated external defibrillators.

Now Dr. Knutsen, are schools in New York State already required to have AEDs on site and people trained in CPR and how to use an AED?

[00:11:21] Christian Knutsen, MD: Yes. Schools are required. All federal buildings and state buildings are required to have AEDs in them. Ideally, they should be within a three-minute walk between any event, and where the AEDs are stored. There should be enough, depending on the size of the building, to be close by for these kind of events.

In terms of staff, at least in schools, some of the teachers need to be trained on AED use, the more the better, obviously. I know in my school district, all of the gym teachers and coaches are trained how to .Use AEDs, for two reasons. 1., they'll be in the school, during school hours, and 2. as coaches, if they go to events with their athletes, they'll know how to use an AED in the field as well.

[00:12:07] Host Amber Smith: Now, what about the upkeep of these machines? Because they don't last forever, and they have batteries, right? Who's in charge of making sure they're working well?

[00:12:18] Christian Knutsen, MD: Every group that has AEDs or a PAD program, or peripheral automated defibrillator program, should have a system in place to do maintenance, checking on the AEDs on a regular basis. The two disposables are 1., the battery and 2., the pads. Depending on the manufacturers, they should be replaced at some point, roughly every three years. And there should be a system in place to go monitor them. At Upstate for our system, our folks will check them every three years to make sure they're still working and functional. So every school should do the same.

[00:12:50] Host Amber Smith: Do you know how well the machines work in extreme weather? Because here in Central New York, it could be super hot or it could be super cold. Do the machines work in extremes?

[00:13:02] Christian Knutsen, MD: They do. They're made to work in all environments. Obviously if they're kept outdoors, the heat and cold can degrade the battery faster, which makes the importance of upkeep even more important. But they can work in all conditions.

[00:13:16] Host Amber Smith: Now this new legislation says that camps and youth sports programs with five or more teams participating have to have an AED and at least one person trained to properly use it at the camps and games and practices. Is that going to be a challenge for teams to comply with?

[00:13:34] Christian Knutsen, MD: It will. Obviously there are two parts to that. One is the physical purchase of the AED. So teams will have to budget to purchase the right equipment, to take care of it and travel with it and have enough AEDs on site to be safe. The second part is training. There'll have to be some pre-planning or foresight to get those folks trained on the devices and trained in CPR ahead of time, and then upkeep or update their certifications on a regular basis. I'm not sure how often that is. Likely every two to three years, so that those folks on a site are properly trained how to use AEDs and perform CPR.

[00:14:09] Host Amber Smith: Do you have a ballpark estimate for how much an AED machine would cost someone? And then replacement batteries too, right?

[00:14:18] Christian Knutsen, MD: They range in cost somewhere between $750 up to $3,000, depending on the model. Most, at least in my limited Google searches, were about $1,500, but there's a price range you can pick from. For upkeep, somewhere between $75 and $300 for pads and batteries, depending on the model as well.

[00:14:40] Host Amber Smith: Now, where would coaches or parents, I guess, or umpires, where would they go to get trained in AED use?

[00:14:47] Christian Knutsen, MD: I think there's always lots of local resources. You can always check with your local fire departments to see if they have these kind of classes for the public. You can go on the American Heart Association website, or the American Red Cross website and search for AED / CPR training, and they should have references to local sites providing this training for people.

[00:15:06] Host Amber Smith: Would you say that it's more involved, or more difficult to use an AED than a fire extinguisher?

[00:15:12] Christian Knutsen, MD: I'd say no. Both can be fairly stressful. And that's probably the hardest part. But in terms of instructions, the AEDs come with, like I said before, clear instructions how to use, they're fairly simple and made for the public to use.

[00:15:25] Host Amber Smith: Dr. Knutsen and Dr. Negrete, I really appreciate you both making time to tell us about AEDs.

[00:15:32] Christian Knutsen, MD: Thank you. Amber.

[00:15:34] Guillermo Negrete, MD: Thank you, Amber.

[00:15:36] Host Amber Smith: My guests have been Dr. Christian Knutsen -- he's an associate professor of emergency Medicine at Upstate -- and Dr. Guillermo Negrete. He's an EMS fellow at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

[00:15:49] Host Amber Smith: So let's do a quick review kind of, of the order of things. If you come upon someone who has collapsed and is unconscious, and you're there all by yourself, but you do have an AED, is it CPR first, or AED?

[00:16:03] Christian Knutsen, MD: Obviously you want to activate EMS (call 9-1-1 for an ambulance) as early as possible, because you need additional resources to come help you.

[00:16:09] Guillermo Negrete, MD: If you're by yourself, you would call 9 1 1. Put the speaker on the phone because then the 9-1-1 dispatcher can help, actually, provide you with some additional help. They can send somebody to help you.Because at the end of the day, what the person needs is perfusion. So you would want to do some high quality CPR. You can scream for help, see if somebody stops by, But so they can go and get an AED. But you basically should not stop doing CPR because that's what you want is, basically, blood flow, as much as you can maintain it, while somebody else will come and help with the AED.

[00:16:49] Host Amber Smith: So it sounds like you need both. You need the CPR to get the blood circulating, but you also would benefit from having the AED to shock the heart back to work.

[00:17:03] Guillermo Negrete, MD: Exactly. They're both, very, very important and time sensitive to get the best outcome.

[00:17:10] Christian Knutsen, MD: AEDs are important, but like Dr. Negrete said, it's high quality CPR, as much as possible, when you're preparing the AED, after you give a shock. CPR is important. It is just as important as the AED.

[00:17:23] Host Amber Smith: Let me ask you, Dr. Knutsen, have you seen someone be revived with CPR and / or AED?

[00:17:32] Christian Knutsen, MD: Similar. I've certainly run plenty of arrests in the field with my fire departments and my paramedics. And the paramedics don't use AEDs. We use defibrillators, which is a little more advanced than the AEDs. But yes, we've certainly, with high quality CPR, defibrillation, have had plenty of cases of lives saved by a combination of early bystander CPR, early 9 1 1 activation, early paramedics coming onto the scene, and treatment as fast as possible. I've definitely seen plenty of success stories.

[00:18:02] Host Amber Smith: It's good to know. I think people can feel intimidated about trying to learn this skill, but if they know it could honestly save a life, it might be more motivation to get trained.

With a little practice, it is very easy to do. I taught my 6th grade daughter how to do CPR and use an AED years ago. and, well, I don't want her to use it unnecessarily, but she's trained, and she's ready to do it just in case. Dr. Knutsen and Dr. Negrete, I really appreciate you both making time to tell us about AEDs.

[00:18:35] Christian Knutsen, MD: Thank you. Amber.

[00:18:36] Guillermo Negrete, MD: Thank you, Amber.

[00:18:38] Host Amber Smith: My guests have been Dr. Christian Knutsen; he's an associate professor of emergency medicine at Upstate. And Dr. Guillermo Negrete; he's an EMS fellow at Upstate. The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcast, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.