UPDATE: This amendment to the International Code Council (ICC) is the second that Elevaed sponsored for adjudication in 2013, having earlier entered an amendment to the National Fire protection Association (NFPA). Both coding bodies revise their statutes on a three year cycle. At stake will be heart safety in high rise buildings, where survivability for sudden cardiac arrest (SCA) is now under 8%.
Hard Times for AEDs
AEDs are remarkable devices that can bring someone who is clinically dead back to life, and do it with a 75% success rate. While the sudden cardiac arrest (SCA) victims they rescue understand this AED miracle, the general public is poorly informed, and unsure whether you have to be trained to use one, or somehow licensed – and when told that they can go ahead themselves in an emergency, their answer is likely to be “Uh, yeah, sure…”
And where is that AED to be found in a crisis, if it exists in the first place? “Oh, it’s upstairs in the lunch room. Or, maybe there in that cabinet – who has the key?”
Some are whispering that few SCAs are actually treated with an AED – currently just 2.1% have an AED applied by bystanders (Weisfeldt JACC 2010) – if an AED is not properly deployed and maintained, its successful use is unlikely. The time has come to bring some order to the situation.
The Political Non-Solution
The legislative front is ad hoc – a patchwork of locally concocted regulations – when there are any regs at all. Approximately 17 states now have laws mandating AEDs for public buildings, but it is not a foregone conclusion that this will grow to be country-wide any time soon.
The FDA is beginning an initiative to “foster the development of safer and more effective external defibrillators through improved design and manufacturing practices”, and to urge industry to “address current practices for identifying, reporting, and acting on the device complaints”. Despite the fact that such ‘complaints’ are being driven more by the expanding numbers of AEDs in place, the FDA is putting pressure on their makers to increase reliability, and deal with their recall when their warranty dates expire.
It is not really fair to ask the manufacturers to track every device until the end of its service life, and then recall it, when they have little idea after those years where they might be – but that seems to be the case right now. The FDA needs to take a more productive tack here – and recognize that AEDs need to be on the Internet, for monitoring functions, and in standardized locations the public can identify with and trust. An AED with a fixed IP address gets looked after.
An AED Pilot Registry?
One way to review the deployment and maintenance of AEDs is from the perspective of a public AED Registry, for which a pilot project is now underway at the University of Denver. The idea is that if 9-1-1 dispatchers know where the AEDs are, they can direct assisting callers to the nearest one in an emergency. So their locations will be mapped, aided by GPS data.
But this model cannot be a solution by itself, and has severe limitations.
- Sudden Cardiac Arrest victims are not breathing, have no pulse, and are clinically dead. There is a time radius of just two minutes to access an AED – no more.
- Given the time required to call and be directed by 9-1-1 to the nearest AED, the device would have to be very close indeed. Anything more than a city block is clearly too far, and in rural areas – it’s patently hopeless.
The benefit of a national AED registry will likely be centered on the data it accumulates, around the distribution and efficacy of these devices, rather than any influence it will have on real-time rescues. The game is just too fast-paced, and cities are far too chaotic to cooperate.
Emergency Vehicles? (EMS)
AEDs are intended to be a tandem device to bridge the time until EMS can arrive, thus preventing brain damage or death due to the formidable time limitation (3-5 minutes) that an arrested heart imposes. When someone has a heart-based ‘event’, it may be an SCA (electrical problem) or a heart attack/stroke (plumbing problem). In either case it’s certainly warranted that EMS attend with all speed – but the prime issue we have to address is the SCA’s narrow time constraint.
For a true cardiac arrest, scrambling the EMS vehicles may prove to be no more than a Chinese fire drill with real fire trucks, because they will rarely succeed in saving that victim’s life – four minutes is just too tight, and it’s going to stay that way or get worse. A late resuscitation can leave traumatic brain damage, and families that must deal with that or the premature death of a loved one. We can do better than this, and must – cardiac illness is our major killer and we have to get a handle on it.
A real danger is that the existence of 9-1-1/EMS services will become proxies for in-house SCA resources, when they are likely to be useful only in consolidating a rescue already effected by an AED. Time is a ruthless enemy, and sirens and lights have no effect at all on an SCA – but the whole production will be very expensive. Redundant vehicles, no matter how high-tech they become, will not address SCA’s current single digit survival rate. Patients have 4 minutes and no more.
Legislation? We need a wider approach.
If registry mapping and emergency vehicles are too slow to deal with SCA’s brutal time frame, can legislation evolve to progressively mandate that AEDs be placed in close proximity to the people they are designed to serve?
In theory, yes, but in practice – no. Two decades of trying have failed to do so, and thousands continue to die needlessly. Been there, done that. The problem with legislation is that there are too many AHJ’s (Authorities Having Jurisdiction). These range from federal/state/county/municipal governments, to medical and legal associations, who all deem themselves to have a proprietary interest in AEDs.
There is very little money in the AED industry to lobby for or to earmark, outside of Seattle, where most AEDs are manufactured. The politicians eat the American Heart Association’s filet mignon, drink their fine wine, and go home after yet another pleasant soiree paid for by the donations of AHA supporters. Enough already.
The resulting laws that emerge from such jurisdictions are of uneven quality, and often become dated. Oregon’s 50-50 Law requires buildings over 50,000 sq.ft. or 50 visitors a day to have an AED, and as such addresses buildings by size rather than by function, whether public or not. Fair enough – we need more of that.
Contrast that good law with the one in New York that prevented off-duty EMT’s and paramedics from carrying AEDs in their personal vehicles. Hello? You can buy an AED at Costco without a prescription and do with it what you like, yet rescue professionals could not equip themselves to be Good Samaritans. Our thanks to the legal profession…
The legislative route must be supplemented with a wider initiative open to universal adoption, and detailed for every possible location. Which agency, then is best positioned to address this public health issue?
A Comprehensive and Lasting Solution: The Building Codes
The best hope for the optimal deployment of AEDs lies with the fire and building safety code administrators – the NFPA (National Fire Protection Association) and the ICC (International Code Council). These stolid institutes of safety professionals assemble and maintain model codes for municipalities’ adoption around the world, most US cities abide by them chapter and verse, and many countries use them as well.
If the NFPA and ICC resolve that there should be a fire extinguisher on each floor of every apartment building, and your municipality follows their model code, then you will have them. It’s a very elegant system guided by engineers and long time fire administrators, and it largely flies below the political radar (which is a good thing).
We can ask ourselves a simple question: is an AED analogous to the (ubiquitous) fire extinguisher?
- Both devices are scaled down versions of what the firemen have (monitor/defibrillators, pumper trucks).
- Both SCA’s and fires can become irretrievable in a matter of minutes.
That is why both devices must be on site. A single line of code could protect residents and workers in high-rise buildings, worldwide.
Living and Working Naked
Again, people who live or work in high-rise buildings are poorly protected against an SCA at present, because such buildings are more difficult to access for EMS crews. There is call volume, dense traffic, entrance security, address confusion and elevator fobs/keys to deal with, to access the victim, in four minutes or less. You can bet your life on this race, and you will lose both.
This problem with SCA’s is the rationale for a lot of EMS vehicular strategies, yet these arrests remain an intractable point of failure for EMS Admin and municipalities – they cannot overcome those largely physical limitations given that time frame, and cities get more complicated every day.
If an AED PAD (Public Access Defibrillator) is mandated for each elevator lobby, it’s already in-house. And that is surely the key – the exact circumstances for which these devices were developed – AEDs are electronic concierges watching over your heart, they are there to bridge the time gap until EMS can arrive – this is the sole function of an AED.
One groundfloor PAD serves a whole tower effectively, perhaps several, with any elevator as its partner, and its cost is inconsequential in relation to the number of suites it serves, whether offices or residences. This is a high risk/high opportunity for safety code, not rescue (EMS) people, to complement their confrères and resolve a public health soft spot – high rises offer compact advantages for sharing AEDs, assembling volunteer teams, fast elevator delivery, and 24/7 surveillance of the AED’s readiness and internal data via the Internet.
Elevaed Technologies has proposed that the two coding agencies insert provisions into their safety regulations to harmonize AED deployment, beginning with a consensus location standard (elevator lobbies) that the public can recognize and trust. It would read as follows:
Public Access Defibrillation
In a building with an occupied floor over 75 ft (23 m) in height above the lowest level of fire department vehicle access, the main elevator lobby shall include an automated external defibrillator (AED) that is accessible to the public, in an approved and visible location.
Returning to the AED Registry project, how would code support alter that strategy?
The Registry could concern itself with putting reliable, uploaded heart event data into its databases, after detailing these mandated, fixed sites that have real permanence. An AED on the Internet maps itself, and given the digital options offered in the Next Gen 9-1-1 Cloud, such data will underpin the AED revolution in heart safety.
The cost per person in high rises is estimated at <$2 a month for advanced, fully monitored, and cellular-enabled model – supported by in-house volunteers working under a paramedic’s supervision. The concept of “heart safety” is admissible toward “green building” precepts.
AEDs can be available to rent by patients awaiting/following heart surgery or otherwise at risk – especially in rural areas. This is clearly where the medical or legal professions can assist by not intruding – we’ll need their concurrence.
One added line in our safety codes could move AEDs into their proper place within large buildings around the world, to take up their proper stations – staying the hand of brain damage and death, as only this singular instrument can.Fire Code Image courtesy of the National Fire Protection Agency Registry image courtesy of www.myheart.org.sg