AED's - The Barriers to Entry

Melinda Beck of the Wall Street Jounal, did a nice piece on the need for automatic external defibrillators (AEDs) in public spaces today and started to address some of the issues of why these amazing gizmo's aren't available more widely:

Some states now require AEDs in schools; some require them in health clubs, shopping malls and golf courses. There's little uniformity; despite their foolproof nature, some businesses oppose them out of fear of being sued if something goes awry with an on-site AED. "I predict that 10 years from now, people will say, 'I'm not going to work in a building or stay in a hotel or eat in a restaurant that doesn't have an AED," says San Diego city-council member Jim Madaffer, who helped place nearly 5,000 AEDs in public facilities since 2001. They've saved 49 lives.

Schools have been a tough sell, too, largely because of cost. Some parents are raising money for AEDs themselves, often after a tragedy. Evelyn and Larry Pontbriant have donated 32 AEDs to Norwich, Conn., schools since last summer, when their 15-year-old son, an athlete with no known heart problems, suffered a fatal cardiac arrest during a running event in the local park. An AED arrived on the scene too late. "It's a good investment to have on hand in your school," says Mrs. Pontbriant. "It benefits not just the athletes, but also the teachers, coaches, referees, grandparents and siblings."

As electrophysiologists, we often get to see the "saves" made by these devices: the young boy playing baseball, struck in the chest by a fast ball ("commodio cordis") that fibrillates his heart and the police officer who responds with the AED in the trunk of his squad car to save the boy's life; or the father who collapses just outside the fire department and is rescued by their defibrillator. These event happen every day, but unfortunately as experienced in the Tim Russert case, many more are not so fortunate.

So why aren't these devices more readily available?

First and foremost: is cost. These devices are still expensive: the cheapest quoted goes for about $1300. But there are other costs not commonly discussed: like the cost of new batteries every 2-7 years (depending on the cost of the model) that can set folks back at least a $100 for each device. And what about those defibrillator patches placed on the chest? They contain a gel that improves the conductivity of the patches on the chest, making the devices more reliable at correcting the normal heart rhythm. That gel degrades and the patches must be replaced every two to seven years, too - to the tune of about $100 a set, too. These are the unspoken issues with AEDs that are never written about and schools and institutions must understand these additional costs and maintenance requirements if they are to assure the proper functioning of these devices.

Next, is the location consideration: where will these devices be used? Will they be in the office setting, car trunk, or placed next to the baseball field? Humidity, motion, and other environmental issues might require a more expensive device to be deployed without the bargain-basement price. Certainly, in the NIH-sponsored trial "Home Automated External Defibrillator Trial (HAT)," home use has not been found to be more effective than a conventional call to 911: in part because of the low incidence of events that occur in the home when a responder is present (58 patients out of 7001 studied, and only 32 had AEDs used and only 4 survived to hospital discharge).

But the cost and efficacy considerations might be offset if more defibrillators were deployed in public spaces where more responders were present and events occurred - thereby driving down the costs. I suppose it would be utopia if these devices could be deployed and maintained within 3 minutes of whereever a person traveled. But the path to implementation, especially with staffing and budget shortfalls, is a lengthy one. As a case in point: many doctors' offices, dialysis centers, and rehab units still do not have these devices and instead rely on calling 911 for a response in emergencies.

Sad, but true.

-Wes