Defibrillation at a football stadium: an experiment with Brighton and Hove Albion

A national scheme for public access defibrillation in England and Wales: early results

BACKGROUND

Automated external defibrillators (AEDs) operated by lay persons are used in the UK in a National Defibrillator Programme promoting public access defibrillation (PAD).

METHODS

Two strategies are used: (1) Static AEDs installed permanently in busy public places operated by those working nearby. (2) Mobile AEDs operated by community first responders (CFRs) who travel to the casualty.

RESULTS

One thousand five hundred and thirty resuscitation attempts. With static AEDs, return of spontaneous circulation (ROSC) was achieved in 170/437 (39%) patients, hospital discharge in 113/437 (26%). With mobile AEDs, ROSC was achieved in 110/1093 (10%), hospital discharge in 32 (2.9%) (P<0.001 for both variables). More shocks were administered with static AEDS 347/437 (79%) than mobile AEDs 388/1093 (35.5%) P<0.001. Highly significant advantages existed for witnessed arrests, administration of shocks, bystander CPR before arrival of AED and short delays to start CPR and attach AED. These factors were more common with static AEDs. For CFRs, patients at home did less well than those at other locations for ROSC (P<0.001) and survival (P=.006). Patients at home were older, more arrests were unwitnessed, fewer shocks were given, delays to start CPR and attach electrodes were longer.

CONCLUSIONS

PAD is a highly effective strategy for patients with sudden cardiac arrest due to ventricular fibrillation who arrest in public places where AEDs are installed. Community responders who travel with an AED are less effective, but offer some prospect of resuscitation for many patients who would otherwise receive no treatment. Both strategies merit continuing development.

Out-of-hospital resuscitation in East Sussex: 1981 to 1989

OBJECTIVE

To assess the impact of extended training in advanced life support on the outcome of resuscitation.

DESIGN

Analysis of the successful resuscitations from 1981 to 1989.

SETTING

Brighton and East Sussex.

RESULTS

248 patients were resuscitated from cardiac or respiratory arrest in the community and subsequently survived to leave hospital. Their mean age was 64 years and one year survival was 77%. In most cases the cause of collapse was cardiac but 38 (15%) suffered a respiratory arrest. In 140 of the successful resuscitations (56%) collapse occurred before the arrival of the ambulance. Basic life support, with ventilation and chest compression where necessary, was sufficient to revive 35 (14%) of the patients. Defibrillation was also required in 107 patients (43%), and in a further 106 patients (43%) who had prolonged cardiorespiratory arrest requiring endotracheal intubation and the use of several drugs. Review of ambulance forms and case notes showed that in 87 cases (35%) the abilities of the paramedical ambulance staff in advanced resuscitation techniques contributed decisively to the success of resuscitation. These skills are illustrated by eight case reports.

CONCLUSIONS

Extended training for ambulance staff increases the likelihood of successful resuscitation from out-of-hospital cardiopulmonary arrest. Though instruction in defibrillation must have the highest priority, full paramedical training can bring appreciable additional benefits.

Physician integration into mass gathering medical care. The United States Air Show

INTRODUCTION

Limited information exists concerning physician staffing at mass gathering events.

METHODS

A retrospective review of the preparation, planning, and provision of medical care for the United States Air Show was performed. Patient encounters from the air show for the years 1981-1991 also were evaluated.

RESULTS

The frequency rate of overall encounters was 8.45 patients/10,000 spectators and hospital transport rate was 0.6/10,000 spectators. The majority of complaints were related to heat or minor injuries. During this period, emergency physicians played a vital role in both medical planning and on-site staffing. Emergency medicine residents also participated. A small patient population received direct benefit from on-site physician intervention.

CONCLUSION

The on-site emergency physician is of benefit in event preplanning and reducing the burden on the EMS system during mass gathering events.

Using regression analysis to predict emergency patient volume at the Indianapolis 500 mile race

BACKGROUND

Emergency physicians often plan and provide on-site medical care for mass gatherings. Most of the mass gathering literature is descriptive. Only a few studies have looked at factors such as crowd size, event characteristics, or weather in predicting numbers and types of patients at mass gatherings.

PURPOSE

We used regression analysis to relate patient volume on Race Day at the Indianapolis Motor Speedway to weather conditions and race characteristics.

METHODS

Race Day weather data for the years 1983 to 1989 were obtained from the National Oceanic and Atmospheric Administration. Data regarding patients treated on 1983 to 1989 Race Days were obtained from the facility hospital (Hannah Emergency Medical Center) data base. Regression analysis was performed using weather factors and race characteristics as independent variables and number of patients seen as the dependent variable. Data from 1990 were used to test the validity of the model.

RESULTS

There was a significant relationship between dew point (which is calculated from temperature and humidity) and patient load (P less than .01). Dew point, however, failed to predict patient load during the 1990 race. No relationships could be established between humidity, sunshine, wind, or race characteristics and number of patients.

CONCLUSION

Although higher dew point was associated with higher patient load during the 1983 to 1989 races, dew point was a poor predictor of patient load during the 1990 race. Regression analysis may be useful in identifying relationships between event characteristics and patient load but is probably inadequate to explain the complexities of crowd behavior and too simplified to use as a prediction tool.

Provision of services for the diagnosis and treatment of heart disease. Fourth report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England

The principal conclusions of the fourth report of the Joint Cardiology Committee are: 1 Cardiovascular disease remains a major cause of death and morbidity in the population and of utilisation of medical services. 2 Reduction in the risk of cardiovascular disease is feasible, and better co-ordination is required of strategies most likely to be effective. 3 Pre-hospital care of cardiac emergencies, in particular the provision of facilities for defibrillation, should continue to be developed. 4 There remains a large shortfall in provision of cardiological services with almost one in five district hospitals in England and Wales having no physician with the appropriate training. Few of the larger districts have two cardiologists to meet the recommendation for populations of over 250,000. One hundred and fifty extra consultant posts (in both district and regional centres) together with adequate supporting staff and facilities are urgently needed to provide modest cover for existing requirements. 5 The provision of coronary bypass grafting has expanded since 1985, but few regions have fulfilled the unambitious objectives stated in the Third Joint Cardiology Report. 6 The development of coronary angioplasty has been slow and haphazard. All regional centres should have at least two cardiologists trained in coronary angioplasty and there should be a designated budget. Surgical cover is still required for most procedures and is best provided on site. 7 Advances in the management of arrhythmias, including the use of specialised pacemakers, implantable defibrillators, and percutaneous or surgical ablation of parts of the cardiac conducting system have resulted in great benefit to patients. Planned development of the emerging sub-specialty of arrhythmology is required. 8 Strategies must be developed to limit the increased exposure of cardiologists to ionising radiation which will result from the expansion and increasing complexity of interventional procedures. 9 Supra-regional funding for infant cardiac surgery and transplantation has been successful and should be continued. 10 Despite advances in non-invasive diagnosis of congenital heart disease the amount of cardiac catheterisation of children has risen due to the increase in number of interventional procedures. Vacant consultant posts in paediatric cardiology and the need for an increase in the number of such posts cannot be filled from existing senior registrar posts. All paediatric cardiac units should have a senior registrar and in the meantime it may be necessary to make proleptic appointments to consultant posts with arrangements for the appointees to complete their training. 11 Provision of care for the increasing number of adolescent and adult survivors of complex congenital heart disease is urgently required. The management of these patients is specialised, and the committee recommends that it should ultimately be undertaken by either adult or pediatric cardiologists with appropriate additional training working in supra-regionally funded centers alongside specially trained surgeons. 12 Cardiac rehabilitation should be available to all patients in the United Kingdom. 13 New recommendations for training in cardiology are for a total of at least five years in the specialty after general professional training, plus a year as senior registrar in general medicine. An additional year may be required for those wishing to work in interventional cardiology and adequate provision must be made for those with an academic interest. 14 It is essential that both basic and clinical research is carried out in cardiac centres but these activities are becoming increasingly limited by the lack of properly funded posts in the basic sciences and restriction in the number of honorary posts for clinical research workers. 15 A joint audit committee of the Royal College of Physicians and the British Cardiac Society has been established to coordinate audit in the specialty. All district and regional cardiac centres should cooperate with the work of the committee, in addition to their participation in local audit activities.

The limited potential of special ambulance services in the management of cardiac arrest

For six months a survey was made of all the patients in the Nottingham District Health Authority who died or who were brought to hospital after a cardiac arrest outside hospital. During this period just under half of the emergency ambulance shifts were covered by specially trained crews with defibrillators. During the study period the ICD coding of death certificates indicated that 894 (25%) of the 3575 deaths were due to ischaemic heart disease. During this period the ambulance service received 17,749 emergency calls, which included 445 patients who had cardiac arrests outside hospital. One hundred and forty seven of these patients were carried by ambulances equipped with defibrillators and resuscitation was attempted in 83. Seven patients survived to leave hospital. The special ambulance service was cost effective--a simple calculation suggests that the cost per life saved was approximately 2600 pounds, but it seems unlikely that special ambulance services will materially affect community fatality rates from ischaemic heart disease.

Disease surveillance and emergency services at the 1982 World's Fair

We designed a special surveillance system to detect health complaints of visitors to the 1982 World's Fair. Heat-related illness occurred during the first month of the Fair but was substantially reduced by public education, environmental modification, and provision of additional water fountains. There was no disruption of emergency health services in the communities surrounding the Fair. Advance planning and the provision of on-site medical services can minimize the public health impact of large gatherings.