Correspondence
Automated External Defibrillators
N Engl J Med 2001; 344:771-773March 8, 2001
- Article
To the Editor:
We congratulate Valenzuela et al. and Page et al. (Oct. 26 issue) on their studies of defibrillation in casinos1 and airplanes.2 The advantage of immediate diagnosis and treatment is certain. However, the authors missed the opportunity to demonstrate sustained preservation of neurologic, neuropsychological, and behavioral brain function.
Discharge from the hospital is a crude criterion for survival with a healthy brain.1-3 The best function, according to another commonly used standard, the Glasgow Cerebral Performance Scale, includes “minor psychological or neurological defects (mild dysphasia, non-incapacitating hemiparesis, or minor cranial nerve abnormalities).” Memory testing is not specified. This level of function is not likely to be sufficient to allow one to resume running a business or pursuing a profession. In our review of studies of cardiopulmonary resuscitation (CPR) that provided even crude, varied measures of extended outcome, at least 50 percent of survivors had neuropsychological impairment and pathologic depression.3
A reluctance to acknowledge that neurologic injury occurs need not diminish enthusiasm for CPR. Most persons who undergo CPR out of the hospital do not provide informed consent in advance. We believe that follow-up assessments of both the benefits and the risks of out-of-hospital CPR should be made widely available. The value of reliable mental-function tests has been well demonstrated in studies of degenerative brain disease, obstructive sleep apnea, the acute respiratory distress syndrome, and coronary bypass surgery.4,5 We have proposed that such evaluations be included in all new trials of CPR.6
6 ReferencesAllan Jaffe, M.D.
Mayo Clinic, Rochester, MN 55905William M. Landau, M.D.
Richard D. Wetzel, Ph.D.
Washington University School of Medicine, St. Louis, MO 631101
Valenzuela TD ,Roe DJ ,Nichol G ,Clark LL ,Spaite DW ,Hardman RG . Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000;343:1206-1209
Full Text | Web of Science | Medline2
Page RL ,Joglar JA ,Kowal RC , et al. Use of automated external defibrillators by a U.S. airline. N Engl J Med 2000;343:1210-1216
Full Text | Web of Science | Medline3
Jaffe AS ,Landau WM . Death after death: the presumption of informed consent for cardiopulmonary resuscitation -- ethical paradox and clinical conundrum. Neurology 1993;43:2173-2178
Web of Science | Medline4
Hopkins RO ,Weaver LK ,Pope D ,Orme JF Jr ,Bigler ED ,Larson-Lohr V . Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J Respir Crit Care Med 1999;160:50-56
Web of Science | Medline5
Shaw PJ ,Bates D ,Cartlidge NEF , et al. Neurologic and neuropsychologic morbidity following major surgery: comparison of coronary artery bypass and peripheral vascular surgery. Stroke 1987;18:700-707
CrossRef | Web of Science | Medline6
Jaffe AS ,Landau WM ,Wetzel RD . Resuscitation 2000: the need for improved databases in regard to neurological outcomes. Resuscitation 1998;37:65-66
CrossRef | Web of Science | Medline
To the Editor:
Page et al. conclude that their study and others on the use of automated external defibrillators provide “evidence of the safety and efficacy of widespread placement of these devices as part of a program to enhance public access to defibrillation.” Do the authors believe that studies performed in such unusual settings as airplanes1 and casinos2 provide proof that public access to defibrillation will improve survival in cases of out-of-hospital cardiac arrest that occur in most public places in North America? Although there is little doubt that early defibrillation, if it can be performed, can save lives, it has not been determined whether communities can develop an infrastructure to provide public access to defibrillation.
2 ReferencesWilliam J. Groh, M.D.
Indiana University, Indianapolis, IN 46202Marcel E. Salive, M.D., M.P.H.
National Institutes of Health, Bethesda, MD 20892Lynne D. Richardson, M.D.
Mount Sinai Medical Center, New York, NY 10029for the Public Access Defibrillation Trial Investigators
1
Page RL ,Joglar JA ,Kowal RC , et al. Use of automated external defibrillators by a U.S. airline. N Engl J Med 2000;343:1210-1216
Full Text | Web of Science | Medline2
Valenzuela TD ,Roe DJ ,Nichol G ,Clark LL ,Spaite DW ,Hardman RG . Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000;343:1206-1209
Full Text | Web of Science | Medline
To the Editor:
The successful use of automated external defibrillators, reported by Valenzuela et al. and Page et al., has important implications for patients considering advance directives, particularly the elderly, their physicians, and policymakers. The low expectation of a benefit from cardiopulmonary resuscitation in elderly persons, which has hitherto guided decisions about advance directives, may need to be reconsidered. It would be helpful if the authors of these (and future) reports could provide results stratified according to age. As automated external defibrillators become available in public places, congregate housing for the elderly, assisted-living facilities, and nursing homes, it would be helpful to have information on the expectation of a benefit from the use of these new devices in elderly persons. Because the reported benefit in casinos and airplanes may not be generalizable, it is important to study the use of automated external defibrillators in other settings. Persons who do not want to have death from natural causes interrupted or deferred by the use of an automated external defibrillator or who want defibrillation without further heroic measures, such as mechanical ventilation, might be well advised to wear bracelets noting such directives before they visit a casino or even the local supermarket.
Roy E. Fried, M.D., M.H.S.
Riderwood Village Retirement Community, Silver Spring, MD 20904To the Editor:
In their report on the use of automated defibrillators by American Airlines, Page et al. do not mention the costs of this ambitious program. According to its Web site, American Airlines has 722 aircraft, and according to a representative of Hewlett–Packard, the list price of the defibrillator is $4,600. Assuming that this kind of equipment has an average life span of five years, the cost per year to equip the entire fleet would be $664,000.
Assuming a cost of $150 for the 4-hour initial training required for each of the airline's 24,000 flight attendants (primarily reflecting lost hours of work), a 10-year average tenure per flight attendant, and a cost of $75 per attendant for the annual 1.5-hour refresher course and examination, the annual training costs would be $2,160,000.
Over the two-year period covered in the report, six lives were saved, but the number of flights on which defibrillators were present accounted for just 80 percent of a single year's flights. Thus, if defibrillators were present on all flights, we could assume that approximately seven lives would be saved annually. Hence, the estimated cost of saving a single life would be approximately $400,000. From a public health perspective, this is a very large sum of money, even when compared with the cost of other life saving or life-extending medical treatments.
Mayer Bassan, M.D.
Clallit Health Services, Jerusalem, Israel 94110Author/Editor Response
The authors reply:
To the Editor: In response to Jaffe et al.: in order to assess neurologic function in a person who has had an out-of-hospital cardiac arrest, that person must survive the arrest. Such survival remains a rare phenomenon in the United States. One hopes that early-defibrillation programs will provide a much larger pool of subjects for an evaluation of the health-related quality of life, as well as neurologic function, after cardiac arrest. We are unaware that among researchers in this area, there is “a reluctance to acknowledge that neurologic injury occurs.”
In response to Groh et al.: our study demonstrated that early defibrillation provided by nonmedical personnel using current-generation, automated external defibrillators resulted in dramatically improved survival after out-of-hospital cardiac arrest. Although there is a strong belief in the probable success of early defibrillation (defined as a delay of less than five minutes between collapse and defibrillation), there are few outcome data in support of this proposition as it pertains to settings outside the hospital. Whether our results can be duplicated in other settings will depend on the intelligence, creativity, and hard work brought to bear on early defibrillation in these places.
Stratification of data on survival according to age, as Dr. Fried suggests, would have required a larger number of subjects than were available to us, in order to generate reliable conclusions about the survival of elderly persons. However, our earlier logistic-regression analysis of data on survival in over 1700 cases of out-of-hospital cardiac arrest showed that age was a weak predictor of survival.1 The low expectation of a benefit from the resuscitation of elderly persons with cardiac arrest results from reports involving institutionalized patients. We do not share this low expectation. Depending on the definition of elderly that is used, functional status and coexisting conditions are more important predictors of survival.
1 ReferencesTerence D. Valenzuela, M.D., M.P.H.
University of Arizona, Tucson, AZ 85724-50571
Valenzuela TD ,Roe DJ ,Cretin S ,Spaite DW ,Larsen MP . Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation 1997;96:3308-3313
Web of Science | Medline
Author/Editor Response
We agree that the status of neurologic, neuropsychological, and behavioral brain function after resuscitation is important, so we stated in our report that the six survivors of cardiac arrest were “discharged home with full neurologic and functional recovery.” This follow-up information was obtained through telephone and personal contact by the medical department at American Airlines. A standardized instrument for the assessment of functional capacity would indeed be of value in future trials.
As Groh et al. point out, our study was not designed to provide proof that public access to defibrillation improves survival in the community, although it is our opinion that this benefit will be demonstrated in future trials. We await the results of the Public Access Defibrillation Trial, sponsored by the National Institutes of Health, which should provide insight into the efficacy of programs providing public access to defibrillation. Clearly, an organized infrastructure for the support of any defibrillator program is necessary to maximize the benefit of the devices.
In response to Dr. Fried, our study population was relatively young; the mean age of the 36 passengers who were resuscitated or who died after cardiac arrest was 60 years, and the mean age of the 6 survivors was 62 years. We believe that the vast majority of persons in the community would desire this emergency care. However, an exception may exist in senior housing and nursing homes, where advance directives should be considered.
We reject Dr. Bassan's estimate of the cost of this therapy because of several problems with his analysis. First, our data were based on the 650 aircraft in use at the time of the study, not the 722 airplanes now in use. Second, the cost of the device, when purchased in such large quantities, was approximately half the $4,600 cited by Dr. Bassan. Third, and most important, the time required for instruction in use of the defibrillator was incorporated into the established training curriculum and did not prolong training or increase the cost. Only one employee has been added to the medical department for logistical support. Thus, the cost of training the flight attendants and coordinating the program was minimal. These data suggest that the cost per life saved is less than $50,000 and that the cost per year of life saved is substantially lower (especially in view of the relatively young age of survivors). A full cost analysis of the American Airlines program is under way. Pending the results, we believe this cost is justified, since it compares favorably with that of established medical treatments,1 implantable cardioverter–defibrillator therapy,2 and a community-based defibrillation program.3
3 ReferencesRichard L. Page, M.D.
Robert C. Kowal, M.D., Ph.D.
University of Texas Southwestern Medical Center, Dallas, TX 75390-9047David K. McKenas, M.D., M.P.H.
American Airlines, Fort Worth, TX 75261-96161
Mason J ,Drummond M ,Torrance G . Some guidelines on the use of cost effectiveness league tables. BMJ 1993;306:570-572
CrossRef | Web of Science | Medline2
Stanton MS ,Bell GK . Economic outcomes of implantable cardioverter-defibrillators. Circulation 2000;101:1067-1074
Web of Science | Medline3
Nichol G ,Hallstrom AP ,Ornato JP , et al. Potential cost-effectiveness of public access defibrillation in the United States. Circulation 1998;97:1315-1320
Web of Science | Medline
