WhiteCoat

Should AEDs be required?

AsystoleInteresting question posed in a California court case. There’s that state acting up again.

In Verdugo v. Target Corp (.pdf file) a 49 year old woman collapsed in a Target store. Paramedics were called, but it took them several minutes to arrive and several more minutes for them to find the patient. They were unable to resuscitate her and she died.
The family sued Target for failing to have an automatic external defibrillator (“AED”) in its store, apparently alleging that their mother would (might?) have been saved had an AED been available (there are those thingees called “damages” again, Matt).

In its opinion, the US Court of Appeals noted that “defibrillation is the only definitive treatment for cardiac arrest.” That isn’t true. Defibrillation only works on the patients who have ventricular fibrillation or pulseless ventricular tachycardia as the cause of their cardiac arrest. Defibrillation does not work on asystole, PEA, or agonal rhythms. While there may be an increase in survival to admission rates when care is received sooner, there was no statistical difference in survival to discharge rates inĀ some studies, while other studies did show an improvement in survival to discharge. Also note that in this study, the number of patients with out of hospital cardiac arrest who were in asystole (and who therefore would not benefit from an AED) was between 72 and 84%.

Now the California Supreme Court will decide whether every commercial business should be required by law to have an AED on premises.

This case troubles me. If we start down the path that an AED must be available at every business, then it becomes a “slippery slope” argument. How close do the AEDs have to be? If a building has multiple floors, does there have to be an AED on every floor? For large businesses, how close do the AEDs have to be to each other? What about shopping malls? Will every store in the mall be required to purchase one? Even the kiosks? What will be the requirements for maintaining them? How many people will need to be trained how to use them?
It isn’t just about the AEDs, either. What other medical care will be required the next time someone dies from low blood sugar, an allergic reaction, or a choking episode. What about for people who fall and could die from a head injury? On site CT scanners and drill bits to relieve deadly subdural hematomas?
Where would the requirements for medical care to business invitees logically stop? I’m having a difficult time coming up with a rule that requires AEDs but that doesn’t require additional medical equipment and training of employees. And if the laws require that business owners afford special medical care to business invitees, wouldn’t invitees to one’s home – to attend a party, for example – fall under the same legal rule?

Another example of fearing the bad outcome.

Say – if California rules that AEDs are required, anyone want to join in funding a startup AED manufacturing company? There will suddenly be a lot of AEDs that need to be purchased.

Hat tip to Walter Olson at Overlawyered.com

16 Responses to “Should AEDs be required?”

  1. PJ says:

    Even for California, this is pretty astonishing.

  2. Ed says:

    Time to buy stock in medical equipment companies that provide AEDs

  3. No, but thanks for asking. says:

    You may want to file an amicus brief in this case, stating your main points of reason as outlined in your post. While the judiciary isn’ generally a fan of being corrected, I can’t imagine they’re impervious to logic, and you may well interject medical fact into an otherwise emotional discourse.

  4. Christopher says:

    Using Taipei’s study, or even OPALS, to show that asystole would be more common than VF simply illustrates that if you wait 8+ minutes to apply a defibrillator you are more likely to find the patient in a non-shockable rhythm.

    I think the better angle of attack is that most cardiac arrests occur in a home. Of those 700 OOHCA per day, most studies show 70%+ are going to be at home. Therefore only ~25 patients will collapse into cardiac arrest in California outside of a home each day, and of those only 6 will be in LA County. LACounty.gov reports 244,000 businesses…giving us a ballpark of a 2 in 100,000 chance of having a cardiac arrest occur in their Target.

    The question then is would a $1,200 AED per store be worth it to the community in QALY to impose a common law burden on each business?

    • WhiteCoat says:

      Interesting, yet the law seems arbitrary, doesn’t it? The final version is here:
      http://www.oregonlaws.org/ors/431.690
      Also did a little further research and found that several other states have passed mandatory AED laws.
      http://www.ncsl.org/issues-research/health/laws-on-cardiac-arrest-and-defibrillators-aeds.aspx

      Don’t expect you to answer the questions below, but consider the following with respect to Oregon:

      Are there any studies showing that sudden cardiac death occurs more often in businesses with more than 50 congregants per day or more than 50,000 square feet? If not, why the distinction?
      What is the rational basis for excluding churches and church schools from the law?
      Notice how the law doesn’t require training in how to use the AED or require anyone to actually use the AED – only that one be available.

      Also curious if any of these laws have actually been shown to save any lives.
      Would be an interesting follow up study to see how well these unfunded mandates actually work.

  5. ? says:

    My first thought was that the Standard of Care Project by epmonthly should discuss best practices from standard of care for this question. In an effort to be positive, could we incentivize businesses that have a higher level of medical care available with an award, while acknowledging that this best practice may exceed the standard of care?

  6. Tarl says:

    I’m interested in what happens when someone uses an AED and it was deemed to be either unnecessary or harmful. Because after all, applying a burning jolt to the chest is beneficial only if the alternative was death. But if someone wasn’t dying and they get 400 joules through their pericardium, that’s not good either.

    (Yes, AEDs are supposed to check to make sure they are needed before applying the juice. And accelerators don’t stick, either).

    • Christopher says:

      Depends on when the defib happened, worst case they’d go into VF/VT so good thing you have an AED attached! As for energies, they’re no longer 400J, most typically 120-200J biphasic. The amperages generated at the heart won’t cause physical harm. Inappropriate application of the pads can cause skin burns.

      But honestly as long as they weren’t screaming for you to stop, how would you as a lay rescuer know not to press shock? Most AED failures are operator error, next most are battery related.

      Liability wise I don’t see how the store would be liable if an AED incorrectly applied therapy given they properly maintained the device.

      • Thomas Bliss says:

        AED’s will only deliver a shock to a shockable rhythm. And most have voice coaching will guide you to deliver good CPR while waiting on EMS to arrive.

        No shockable rhythm, no shock will be delivered.

        There are a few success stories over on our website.
        http://northwestresponse.com/stories-of-survival/

      • Christopher says:

        Yep, a properly functioning AED will not shock a non-shockable rhythm.

        Many AEDs will not shock rhythms that it believes are likely to be associated with a pulse too.

        My point was there is no risk to the owner from the AED performing an inappropriate shock (they have occurred).

  7. The typical solution to this sort of thing is a label, a giant label at the entrance to the store describing exactly what emergency treatments are not available.

  8. DefendUSA says:

    Aye, yi-yi!!! What I think is that stores should use an enter at your own risk mentality and state with a physical sign:

    “Should medical care be required, 911 will be called. Said retailer is not responsible for providing care for accidental injuries or emergencies while perusing the premises.”

    And the bullshit will stop. Political correctness is killing our Country. There are NO guarantees in life!!

  9. CJL says:

    Do any of those studies mention the neurological status of the patients who survived to hospital discharge?

    Maybe that doesn’t matter to some people, and alive in any condition is better than dead, but it’s part of this discussion…

  10. SeaSpray says:

    We had to be AED certified in patient Access/Admitting-ED Reg every year. However,considering ED staff was right around the corner from me I’d yell for help stat (if I knew they were close and available and/or call a code. That being said, I’d still do what I had to if they weren’t.

    Just that on one shift, a man walked in not looking good, greeted me and said he had chest pain …sat down and died in front of me. All happened quickly and I did holler for help-STAT and they did respond in a heartbeat. (No pun intended) They brought him back, he was shipped out to a larger facility and lived.

    During certification, we were told that local stores, schools and police officers had AED machines.

    Stats might be low on how many people these machines help …but I’d be grateful if I were one of the 16% or 28% of the population that survived.

  11. DensityDuck says:

    but on Grey’s Anatomy they always do that thing where they yell CLEAR and there’s that “boomp” sound and then the person comes back to life!! I think that all the stores should have these magic come-back-to-life machines. I even have one in my own home in case I die.

    (At least, that’s pretty much the reasoning behind requiring AED to be present in retail stores and such places. Anyone remember that bit with Dan Hedaya on “e.r.”?)

    ******

    I agree about the “training” bit. I always wonder who they expect to use these machines. Are they assuming that retail stores routinely train their employees in first-responder techniques that enable them to judge when an AED is needed and how it should be employed? But then, see above about the AED being a magic come-back-to-life machine.

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