‘As Ken Peterson addressed his ball trapped in sand on the 18th hole at La Jolla Country Club, the 75-year-old felt his chest tighten.

“He collapsed in sudden cardiac arrest. His next memories are of the hospital — three days later.

“That he can talk about the day he nearly died and the triple bypass surgery that followed can be attributed to an automated external defibrillator and a quick thinking golf professional, who shocked Peterson's heart to life.

“‘I was very, very lucky,’ said Peterson, a San Diego resident. ‘I feel like a tiger now. Some guys get all the breaks.’

“Peterson's story is not that unusual, though. The New England Journal of Medicine says that 74% of those who experience sudden cardiac arrest survive when shocked within three minutes of collapse. Only 4% of sudden cardiac arrest patients survive with cardiopulmonary resuscitation alone.”

This highly publicized golf course save, as described in The San Diego Union-Tribune, propelled an important message all over our community — automatic external defibrillators save lives. It came just nine months after the country club had purchased its AED (a small, easy-to-use device about the size of a notebook computer) and trained several staff members in its use.

The patient fully recovered and, in a bit of understatement, his wife told the reporter that the purchase of the AED was “well worth the investment.”

A major problem

Sudden cardiac arrest, or SCA, is a major unsolved health problem and the leading cause of death in the United States. More than 465,000 Americans die each year from SCA in and out of the hospital.

Currently, the national survival rate from SCA is less than 5%, which is a shocking and outrageous statistic considering that, while we have not yet found the cure for cancer, we have found a “cure” for most people suffering SCA: automated external defibrillators. According to the American Heart Association, children as young as 9 years old can be trained to use AEDs and can become nearly as proficient as adults in their use during an emergency.

An AED is a critical part of what's known as the chain of survival, which was designed to streamline early access to 911, early delivery of CPR, early defibrillation and early access to advanced care. While AEDs won't save everyone, they have been proved to dramatically improve survival rates. In a study of Las Vegas casinos conducted between 1997-99, survival rates from SCA were only 14% before the deployment of AEDs but jumped as high as 74% after security guards were equipped with these life-saving tools.

Nearly 90% of victims stricken with SCA are in a chaotic cardiac rhythm known as ventricular fibrillation, and the heart is unable to pump oxygen rich blood to the body's vital organs. Often there is no prior warning, and death occurs within a very short time. The only known effective treatment for ventricular fibrillation is delivery of a defibrillation shock to the heart to stop its ineffective activity and allow it to restart in an organized rhythm.

AEDs gain popularity

AEDs automatically detect ventricular fibrillation and other life threatening cardiac rhythms, eliminating the need for ECG interpretation. Error-proof safeguards are built into AEDs that prevent delivery of a defibrillation shock to a patient whose condition doesn't require it. This technology provides the basis for public-access defibrillation programs, which allow lay rescuers to come to the aid of a stricken co-worker, friend or passerby.

Public-access defibrillation programs all over the country have proved the theory at the heart of their mission: Lay rescuers using AEDs can dramatically increase SCA survival rates. Chicago's O'Hare International Airport, which in June 1999 became the first in the country to place AEDs in terminals, is one example, as noted in The New England Journal of Medicine: “Eleven patients with ventricular fibrillation were successfully resuscitated [since the onset of the program], including eight who regained consciousness before hospital admission.”

These kinds of results have not been lost on our federal and state legislators. At the federal level, recent legislation was introduced that will provide $50 million in federal grants to help launch public-access defibrillation programs in metropolitan and rural communities across the nation.

In response to an FAA mandate, airlines are equipping their airplanes with AEDs. These devices also are being deployed in more and more airport terminals and even places like amusement parks. Restaurant and bar owners began placing AEDs in their establishments once they understood the protection such units could provide.

San Diego gets on-board

In San Diego, we looked at the positive results Chicago enjoyed in its airport and applied them to our own metropolitan area. If they can save lives at O'Hare, we surmised, why couldn't we place AEDs all over San Diego and increase our community's survival rate from SCA to between 40 and 80%?

Our challenge became devising a plan that would allow us to be successful in actually placing AEDs throughout the community. Kevin Lyon, a paramedic, was given the task to start what we initially thought would be a small project — perhaps eight hours a week — but eventually evolved into Project Heartbeat, a countywide coalition that is a public-private partnership in the best sense of the term.

Today, nearly two years later, Lyon has become a vigorous champion of the AED effort in our community and has served as public-access defibrillation coordinator for the project, a consortium that now includes the city, the county, San Diego Fire Department, San Diego Medical Services Enterprise LLC, the American Heart Association and Cardiac Science Inc.

In an innovative move, Project Heartbeat developed a marketing agreement with Cardiac Science of Irvine, Calif., a leading defibrillator manufacturer. The agreement allows any user in our community to purchase an AED at a discounted price. Furthermore, Cardiac Science is working directly with the coalition's marketing arm to offer any group in San Diego County one-stop shopping for the purchase of an AED, including training and medical direction. The arrangement also calls for the proceeds of each sale over a specified number of AEDs to go back to Project Heartbeat to offset training and administrative costs.

To get to this point in San Diego, however, it took a lot of diligence and hard work from several members of the community, as well as the political will of some of our key elected officials and an outreach to our local media. It took a team-up between San Diego City Councilman Jim Madaffer and Dr. James Dunford, the city emergency medical director, to really kick this project into gear. Until they became involved, the program's good intentions had a very narrow focus and little in the way of a plan to reach fulfillment.

Public support

In November 2000, Madaffer, as a newly elected council member from the city's 7th District, took the idea of a public-access defibrillation program and made it one of his district's top priorities. His success ultimately enabled the program to win $100,000 in initial funding to help buy AEDs.

Dunford provided key introductions within the AHA, which had the national scope and expertise in SCA and emergency services to help us assemble a far-reaching, countywide plan. The AHA's first piece of advice was significant: Identify a public champion, someone in the community who is not an elected official, firefighter or city bureaucrat, who will become a key member of the project team. In other words, find someone who speaks to the citizens as an equal, but who has had a personal experience with SCA. That person was Karen McElliott.

McElliott had a heartbreaking story to tell. Her husband, a healthy man with no history of cardiac problems, was running a 10km race in the city when he was stricken with SCA. There was no AED nearby, and by the time an ambulance arrived, it was too late. He had no chance to survive. As McElliott told the community, if an AED had been available to bridge the gap between the time of collapse and the arrival of EMS, it's very likely her husband would still be alive today.

Madaffer initially bought 40 AEDs and began placing them in his district, as he and McElliott took her story throughout the San Diego area. Madaffer also challenged council members in other districts to buy an AED, offering to match each with one of his own. The fire department then went to Madaffer with a request for AEDs for its lifeguard service — the department had wanted them for years on the city's beaches and in its rescue boats. Madaffer ultimately presented the lifeguards with 11 AEDs.

AED deployment

At about the same time, representatives from San Diego's Lindbergh Field International Airport came to the fire department with their intention to start a program similar to O'Hare's, but they needed some direction. Project Heartbeat created a service contract with the airport that became the model for other contracts throughout the private sector.

Project Heartbeat charged the airport a fee for medical direction and program management, which included setting up the AEDs and a pager system and placing them throughout the airport. The contract also includes establishing a liaison between the fire department and the private contractor, who ensures compliance with state laws and rules concerning retraining, installation and the roles of the local emergency service providers.

Currently, Project Heartbeat staff responds whenever a cardiac-related 911 call is generated at the airport. Training classes are conducted for airport staff in the use of AEDs and how to recognize and treat SCA when it occurs. Psychological counseling is also available to those who are traumatized by seeing or helping someone stricken with SCA.

Thanks to compelling stories about McElliott, the public-access defibrillator programs and the benefits of AEDs that appeared in our local media, it didn't take long before many other members of the public and private sectors asked for guidance in setting up their own AED programs. They included law offices; public parks and government agencies such as the San Diego Port District; senior citizen centers; golf courses at Torrey Pines, Balboa Park and La Jolla; The San Diego Union-Tribune newspaper; Qualcomm Stadium, where the Chargers and Padres play; community colleges; and San Diego State University, just to name a few.

As of today, more than 850 AEDs have been deployed throughout San Diego, thanks to Project Heartbeat and the work of our fire department personnel and many members of our community. But, almost as importantly, the program has raised citizens' overall awareness of the frequency of sudden cardiac arrest, the importance of AEDs as life-saving tools and of the need to be prepared for medical emergencies of all kinds. That's a huge accomplishment and, along with saving lives, another example of the collateral value of a program like this.

Eight lives were saved in the first year of the program, and survival rates from SCA at the San Diego airport have increased from the countywide average of 5% to 75%. In addition, Project Heartbeat has trained hundreds of people in AED usage and created a community that is much more informed about general emergency services.

Room for growth

We still have lots of work to do to finish and fine-tune this program. We need to deploy more AEDs throughout the community and bring all of the schools into the program. Ideally, AED and CPR training will become part of our school health curriculum. As awareness grows, the deployment of AEDs eventually could become as widespread as first-aid kits and fire extinguishers. At that point, then we can say our work here in San Diego has been an unqualified success.

As firefighters we all have responded to victims of SCA. We have experienced the disappointing void that is created when we can't make a save, and the sense of despair when we can't offer hope of survival to the victim's family members or co-workers.

By the time a 911 call is made, screened, dispatched and responded to by an emergency service agency with life-saving defibrillation equipment, precious time (approximately six to nine minutes on average) has elapsed. A victim's chance for survival is reduced by 10% for every minute that defibrillation is delayed.

Someday I would like to know that anywhere we go, people have the protection of AEDs. On our 27th wedding anniversary, my wife and I went to her favorite restaurant. Just as our dinner arrived, my wife witnessed an elderly woman collapse several tables from ours. I asked her to call 911, knowing that, with luck, the district engine company and ambulance could arrive within six minutes. I also asked a waiter if there was an AED in the restaurant. He didn't know what I was talking about. Fortunately, the woman was not in cardiac arrest, though she had a history of heart disease and was transported to an emergency room.

As you can see, we still have a way to go, but we are on our way. Because of AEDs, we no longer have to accept the bleak historical statistics of a 5% survival rate from SCA in our communities. We can make a difference.

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August Ghio has been a member of San Diego Fire and Rescue for 27 years. He began his career as a firefighter and has developed his career through management assignments in fire dispatch, hazmat response, emergency management, support services and emergency medical services. He was promoted to assistant fire chief in June 2002.

For more information on Project Heartbeat, call Maureen O'Connor at 619-243-0911.

Public-access defibrillation program checklist

The main challenge for this program is coming up with a plan.

1. Determine program targets and choose a leader. It's logical that the fire service take the lead in this kind of program, since up to 80% of our runs are medical aids. But you'll need a leader, so designate a program coordinator and a medical director. Then pick the targets in the community for deploying AEDs.

   Typical targets include:

   • Airports.
   • Businesses.
   • County jails.
   • Dialysis centers.
   • Gaming establishments.
   • Golf courses.
   • Large industrial sites.
   • Homeless shelters.
   • Nursing homes.
   • Physician offices (cardiology, internal medicine, family medicine).
   • Schools.
   • Shopping malls.
   • Sports complexes.
   • Streets and highways.
   • Trains and ferries.
   • Urgent care centers.

2. Choose an AED manufacturer. Write generic AED specifications so that all AEDs qualify for your selection. Establish an evaluation committee to select the preferred device. Keep in mind that this is a lay-rescuer tool. We chose our Cardiac Science AED because it was simple, easy to use and requires very low maintenance.

3. Remember the need for medical direction. Because an AED is an FDA-approved device, a medical director must approve its deployment wherever one is located. Designate a physician to act in this capacity. Any large establishment with an AED program will use the medical director for quality assurance. The medical director also will coordinate with local EMS and 911 centers and provide guidance in equipment selection.

4. Develop guidelines for responder actions. Oversee medical care that is rendered through the program, including reviewing all responses to medical emergencies and ensuring initial training and skill maintenance. Assume overall responsibility for the conduct and operation of all patient care — related activities

5. Identify a training program. The American Heart Association, American Red Cross or some other equivalent agency will help set up a training program for lay rescuers.

6. Generate support in the community. For your program to be a success you should generate community support with the help of a private citizen or a government official champion. Typically that means someone who has experienced the tragedy of sudden cardiac arrest or someone who knows a survivor story. An AED advocate will help with generating support among government officials for funding and aid from either public or private sources.

7. Funding. Obviously, this is key. Finding funds to support implementation and maintenance of AED programs in the community is easier than many people realize. Here are some important steps in this process:

8. 7a) Estimate projected program costs. Annual costs can include the following:

   • Devices (about $3,000 per unit). Remember to divide initial cost by projected life, usually five years.
   • Peripheral equipment (about $75 per device).
   • Maintenance (about $100 per device).
   • Insurance (variable).
   • Training (variable). Cost includes personnel and equipment.
   • Program management (variable).
   • Event documentation (variable).
   • Quality assurance tools (variable).
   • Community-wide CPR training (variable).

   7b) Explore direct funding options. Determine whether costs can be funded directly through community or agency budgets. This is the simplest, most direct approach, and it may be all that you need to do. For example, a city council that has been educated about sudden cardiac arrest and the need for prompt universal access to defibrillation may simply vote to include AED program implementation costs in the next budget cycle.

   7c) Explore alternate funding options. Alternative funding sources include:

   • Local corporations and industries.
   • Local civic organizations.
   • Private foundations.
   • Public charities.
   • Government grants.
   • Traditional fund-raisers.

9. Develop a media plan. Working with the media is always a challenge, so it's important that your department put together a plan at an early stage. Involve your public information officer in writing your media plan. Be sure to include your public champions, those with personal stories or experience as an advocate, to draw public support.