COUNTDOWN TO

SURVIVAL
PUBLIC ACCESS DEFIBRILLATION IN MALAYSIA

TABLE OF CONTENTS

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1. ABSTRACT……………………………………………………………3

2. PROBLEM STATEMENT…………………………………………….4

3. INTRODUCTION……………………………………………………..5

3.1 Automated External Defibrillators…………………………….5

3.2 Public Access Defibrillators…………………………………...6

3.3 Operating an AED……………………………………………..6

4. STRATEGIC LOCATIONS FOR AED……………………………….8

5. APPENDIX……………………………………………………………12

6. CONCLUSION………………………………………………………..17

7. REFERENCE………………………………………………………….18

1. ABSTRACT

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Every minute of every day in all over the world, sudden cardiac arrest (which often leads
to heart attack) claims another victim. A heart attack occurs when the arteries that
supply blood to the heart become blocked, the flow of blood which carries oxygen
to the heart is slowed or stopped, and the muscle fibers contract chaotically rather
than in synch with each other as they normally do.

Placement of Automated External Defibrillators (AED) in strategic locations throughout

the city, in addition to an ever-increasing number of citizens trained in their use will
improve cardiac arrest survival rates in Malaysia. Once established, the Public Access
Defibrillators (PAD) program will continue to fund itself in future years, without further
need for grant source funding.

2. PROBLEM STATEMENT

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Everybody knows that heart disease is the number 1 killer in Malaysia and almost in
every country in this world. It doesn’t just lead the dangerous disease chart but the
amount of death patients due to heart disease goes to 6,500 cases compared to loss of life
due to accidents (6,000 cases).

The possibilities Malaysians suffered heart disease is actually equal to developed

countries population that is 1 case for every 200,000 people. Even though the rate is
small but it cannot be neglected as there are many factors contributing to heart disease.

It is estimated that 1/3 of world population that is about 17 million people died from
cardiovascular disease every year.

Most of these deaths occur with little or no warning, from a syndrome called sudden
cardiac arrest. The most common cause of sudden cardiac arrest is a disturbance in the
heart rhythm called ventricular fibrillation.

Ventricular fibrillation is dangerous because it cuts off blood supply to the brain and
other vital organs.

• The ventricles are the chambers that pump blood out of the heart and into the
blood vessels. This blood supplies oxygen and other nutrients to organs, cells, and
other structures.
• If these structures do not receive enough blood, they start to shut down, or fail.
• If blood flow is not restored immediately, permanent brain damage or death is the
result.

Ventricular fibrillation often can be treated successfully by applying an electric shock to

the chest with a procedure called defibrillation.

• In coronary care units, most people who experience ventricular fibrillation

survive, because defibrillation is performed almost immediately.
• The situation is just the opposite when cardiac arrest occurs outside a hospital
setting. Unless defibrillation can be performed within the first few minutes after
the onset of ventricular fibrillation, the chances for reviving the person
(resuscitation) are very poor.
• For every minute that goes by that a person remains in ventricular fibrillation and
defibrillation is not provided the chances of resuscitation drop by almost 10
percent. After 10 minutes, the chances of resuscitating a victim of cardiac arrest
are near zero.

Cardiopulmonary resuscitation, usually known as CPR, provides temporary artificial

breathing and circulation.

• It can deliver a limited amount of blood and oxygen to the brain until a
defibrillator becomes available.

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 • However, defibrillation is the only effective way to resuscitate a victim of
ventricular fibrillation.

3. INTRODUCTION

3.1 Automated External Defibrillators (AED)

In the mid-1980s, a new generation of computerized defibrillators was introduced. Called

Automated External Defibrillators or “AEDs for short, these devices were capable of
interpreting a person's heart rhythm and automatically delivering a defibrillation shock
with only minimal input from the operator.

Variety of AED

For the first time, EMS personnel such as basic emergency medical technicians (EMTs)
were able to provide the life-saving technique of defibrillation without having to interpret
ECG rhythms.

As AEDs began to be placed in more and more "basic life support" ambulances (those not
staffed by more advanced paramedics), the survival rates for out-of-hospital cardiac arrest
began to rise. However, the problem of getting the defibrillator to the victim in less than
10 minutes remained a challenge.

The next step in reducing the amount of time it took to get a defibrillator to a cardiac
arrest victim came with the recognition that the police are often the first to arrive at the
scene of a medical emergency, ahead of an EMS unit.

• With this knowledge, some EMS systems began to train and equip police officers
to provide defibrillation with AEDs.

• This allowed defibrillation to be performed sooner, often before an ambulance

arrived.

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 • The use of AEDs by law enforcement personnel has begun to have a significant
impact in resuscitating victims of sudden cardiac arrest.

3.2 Public Access Defibrillators

The evolution of early defibrillation took another major step forward with the concept of
public access defibrillation or "PAD."

• It is now recognized that AEDs are extremely easy to use.

• Formal training programs, such as those offered by the American Heart

Association's Heartsaver AED course, can be taught in as little as 4 hours.

• However, operating an AED is so simple that it can be done successfully even

without formal training. Training is recommended for as many people as possible.

• Local and state regulations determine the training requirements for PAD
programs.

The legal requirements that allow the lay public to use AEDs are determined on a state-
by-state basis.

• In some countries there is true public access defibrillation, meaning that anyone
with knowledge of an AED can use one any time it is available. For example, a
traveler in an airport may retrieve and use an AED mounted in a public location.

• In other coutries, use of AEDs is more restricted. Some states require a formal
training program, the direct involvement of an authorizing doctor, or that the AED
rescuer is part of a formal in-house response team.

• In most countries, any individual using an AED in a good faith attempt to save the
life of a cardiac arrest victim will be covered by some form of a "good Samaritan"
statute.

3.3 Operating an Automated External Defibrillators (AED)

• Regardless of which brand of AED is used, the only knowledge required to

operate it is to press the "ON" button.

• Once the AED is turned on, it actually speaks to you in a computer-generated

voice that guides you through the rest of the procedure.

• You will be prompted to place a set of adhesive electrode pads on the victim's
bare chest and, if necessary, to plug in the pads' connector to the AED.

• The AED will then begin to automatically analyze the person's ECG rhythm to
determine if a shock is required. It is critical that no contact be made with the

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 person while the machine is analyzing the ECG. If the person is touched or
disturbed, the ECG may not be accurate.

• If the machine determines that a shock is indicated, it will automatically charge

itself and tell you when to press the button that will deliver the shock.

• Once the shock is delivered, or if no shock is deemed necessary, you will be

prompted to check to see if the person has had a return of normal breathing or
circulation. If not, you will be reminded to start CPR.

Operating an AED is as easy as 1,2,3

4. STRATEGIC LOCATIONS FOR AED

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In Malaysia, Automated external defibrillators (AED) should be located in places where
large groups of people gather and the risk of a sudden cardiac arrest incident is likely
such as:

• Government office (Putrajaya and etc.)

• Shopping Centers

• Airport

• Restaurants

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• Hotels

• Stadium

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 • Schools and Universities

• Fitness centers and Health Club

In some countries, all police vehicles carry an AED, and they are on board all
commercial passenger airplanes. In order to make them highly visible, public AEDs often
are bright red, green, or yellow in color, and are mounted in protective cases near the
entrance of a building. When these protective cases are opened, and the defibrillator
removed, most will sound a buzzer to alert nearby staff to their removal. Most of these
alarms do not summon emergency services, so emergency services should be called as
soon as an AED is sent for or used.

An AED at Chūbu Centrair International

Airport in Aichi, Japan.

Typically, an AED kit will contain a face shield, for providing a barrier between patient
and first aider during rescue breathing; a pair of Nitrile rubber non-allergenic gloves; a
pair of Tuff cuts scissors, for cutting through a patient's clothing to expose the chest; a

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small towel for wiping away any moisture on the chest and a razor for shaving those with
very hairy chests.

An AED at a railway station in Japan.

The AED box has information on how to use it in
Japanese, English, Chinese and Korean, and station
staffs are trained to use it.

AEDs can also be kept and used in the home, particularly important for those with
existing heart conditions. The number of devices in the community will continue to grow
as more and more citizens begin to understand their importance in providing first aid.

Increasingly, many Ambulances are carrying AED or AED-Capable Defibrillators to

allow Basic Life Support personnel such as First Responders and EMT-Bs/IVs to give
electrical therapy to patients when the providers aren't trained in EKG administration or
rhythm analysis.

A public access automated external defibrillator in Monaco. These can be used by

bystanders.

5. APPENDIX

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AED to heart attacks
By Shamala Velu
Monday, December 20, 1999

HEART attacks can strike anywhere, anytime. The good news is that if an automated
external defibrillator (AED) is within reach of a person suffering a cardiac arrest, his
chances of survival are greater.

"It makes sense to have AEDs all over the community to get victims of sudden cardiac
arrest defibrillated as quickly as possible," said Dr Jon R. Krohmer, president of the
National Association of EMS (emergency medical services) Physicians in Michigan,
United States.

Dr Krohmer was in Kuala Lumpur recently to give a talk on the latest developments in
AED use for emergency medical service programmes in the community.

The seminar, entitled Motherhood, Applepie or AED? was organised by Mastem

(Malaysia Society for Traumatology and Emergency Medicine).

Dr Krohmer, who has over 20 years' experience in emergency medicine and is an expert
in the field of emergency trauma management, said the National Society of EMS had
been focusing on the concept of early defibrillation for the last 10 years.

In the United States, a programme has been developed to allow public access to
defribrillators.

"The latest defibrillators require little training to use because they automatically detect
erratic heart beats and decide when the shock is needed," explained Dr Krohmer.

But why use defibrillators when paramedics can be called to assist victims in emergency
situations?

According to Dr Krohmer, it takes at least 10 minutes for paramedics to arrive at an

emergency scene. It can take longer if one is on a busy highway or stuck in a traffic jam.

"Ten minutes is a lot of time when someone is fighting for his life. The earlier one
initiates resuscitation, the better the chances of survival," he explained.

In fact, one of the objectives of creating the AED is to be able to defibrillate a patient
within four minutes of a cardiac arrest.

However, the use of AEDs needs careful analysis and consideration. The community's
resources and needs must be looked into as well.

"They are best placed where there is a high likelihood of a cardiac arrest occurring," he
said.

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This includes large office buildings (where it may take a longer time for EMS rescuers to
reach the patient), senior citizen facilities and crowded public places. .

However, he stressed performing cardiopulmonary resuscitation (CPR) is still a crucial

factor in saving lives and should not be taken out of any emergency context.

(CPR is a procedure used to keep blood circulating for victims of heart attacks or other
causes of cardiopulmonary arrest.)

"What's important is that there should be appropriate foresight in an AED programme. A

physician's involvement in the development, training and assessment of the programme is
essential," he emphasised.

Dr Krohmer said AEDs would also be set up in patrol cars in the United States because
police officers are often the first to arrive at any emergency.

"What we have found from placing AEDs in police cars is that it can increase the number
of patients successfully defibrillated. In fact, many of them are being discharged alive
from hospitals," he said.

With public access to defibrillators steadily becoming popular, manufacturers have had to
improve the technology for defibrillators as well.

The latest equipment is designed with simpler operation procedures. Improved

technology increases costs--a defibrillator costs a hefty US$4,000 (RM15,000).

According to Dr Krohmer, health care workers are also looking into equipping all
ambulances throughout the United States with AEDs.

However, despite the advantages of installing AEDs and training people, not everyone is
comfortable using a defibrillator.

One reason is the impression that AEDS should be handled by trained professionals like
paramedics.

In addition, many physicians express concern over their liability in prescribing the
device.

"What many people are worried about is landing up with unwanted lawsuits. However,
there are also people who want to use defibrillators because they want to help people," he
said. Nevertheless people who use AEDs are protected by the Good Samaritan Laws in
the United States.

"The United States has very good Good Samaritan Laws which provide immunity to
people who provide medical care. It protects people from being found guilty of
negligence in caring for a patient," he explained.

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"Though the laws vary from state to state, in most cases they encourage people to provide
CPR or rescue breathing."

Dr Krohmer explained that because AEDs were considered advanced medical devices, in
many cases, Good Samaritan legislation didn't apply to their use.

"We have had to change our Good Samaritan Laws to cover the use of AEDs," he said.

However, it will be a long time before Malaysians see a defibrillator installed in any of
our public facilities--there are no plans to bring AEDs into the country.

Most health care workers here assist patients with CPR because they don't have access to
defibrillators.

According to Datuk Dr Low Bin Tick, commander-in-chief of St Johns Ambulance

Malaysia, first responders who are trained in first aid are not covered by the law to use
defibrillators just yet.

"Establishing legislations takes time, but we will have to use defibrillators some day," he
said, adding that it would be excellent to have the Good Samaritan Laws established in
Malaysia as well.

"I hope the authorities will look into the matter as it's very important. It will certainly
enable paramedics to save more lives," said Dr Low.

Dr Low said defibrillators had proven to be safe and having such medical devices would
help save lives.

"In any case we are working towards training our first-responders in the use of
defibrillators because the time will come when ambulances will have to carry them and
we want to be ready when it happens," he added.

The Star Online > Asia

Monday January 8, 2007

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Workers agree defibrillators in office is a must, bosses don’t

LAST month, a man running a marathon suffered a heart attack and collapsed metres
from the finish line. He survived, largely because an automated external defibrillator was
on hand, and a doctor happened to be running beside him.

The incident prompted a Sunday Times reader to suggest that all offices should invest in
a defibrillator, since the workplace is where people spend most of their time.

Many workers in Singapore agreed. Companies and doctors did not. A defibrillator can
make a big difference between life and death. When a person goes into cardiac arrest, the
heart rhythm will be chaotic and irregular.

This hinders blood flow, limits oxygen supply to the brain and can kill a person in five to
10 minutes. With a defibrillator, the heart can be shocked into action again and resume its
normal pumping pattern.

However, the shock has to be delivered within a matter of minutes for the patient to
survive. According to a National Heart Centre survey in 2004, an average of one to two
Singaporeans under the age of 60 die from sudden cardiac arrest every day.

If the cardiac arrest takes place outside a hospital, there is only a 2.7% chance of
surviving. Defibrillators are mostly found in hospitals and ambulances. In the United
States, where such devices can be found in offices, schools and even casinos, the survival
rate is 45%.

Professor V. Anantharaman, senior consultant at Singapore General Hospital’s

department of emergency medicine, said that ideally, the life-saving device should be as
ubiquitous as the fire extinguisher.

“For every one-minute delay, the person’s chance of survival decreases by seven to 10%.
It is crucial to have a defibrillator close by and available for use in a matter of minutes,”
he said.

Administrative officer Nancy Tan, 25, said: “It can happen to anyone at any time. The
office is the best place to have it since we spend at least 10 hours working each day.”
Sam Lee, 42, a security guard, agreed. “If I have a sudden heart attack at work, it’s good
to know that I still have a chance.”

However, all eight companies – mostly small and medium-sized enterprises – that The
Sunday Times spoke to said they would not even consider getting one, given their limited
resources. For one thing, at S$3,000 (RM6,854), a defibrillator is considered too
expensive. Getting one would also involve training staff members on how to use it and
maintaining the device.

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Leslie Leo, general manager of 1 Workshop, a company that makes exhibition booths,
said investing in a defibrillator was not feasible.

He said: “With that kind of money, we’d probably invest in work-related tools rather than
in this device. Plus, our 22 staff members are quite young and have no heart-related
problems.” SEPL, an IT solutions firm with four staff members, said the device might be
more appropriate for larger firms with older workers.

Doctors agree, adding that it is more important for defibrillators to be made available in
high-traffic areas such as the airport, MRT stations and schools. Associate Professor Tan
Huay Cheem, chief of the cardiac department at the National University Hospital, said:
“As 80% of cardiac arrests occur in the home rather than public places, the absolute
benefit from ... the widespread installation of defibrillators remains limited.” – The Straits
Times/Asia News Network

6. CONCLUSION

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Unlike regular defibrillators, an automated external defibrillator requires very little
training to use. It automatically diagnoses the heart rhythm and determines if a shock is
needed. Automatic models will administer the shock without the user's command. Semi-
automatic models will tell the user that a shock is needed, but the user must tell the
machine to do so, usually by pressing a button. In most circumstances, the user cannot
override a "no shock" advisory by an AED. Some AEDs can even be used on children
(those under 55 lbs [25 kg] in weight, or under age 8). If a particular model of AED is
approved for pediatric use, all that is required is the use of more appropriate pads. Some
organizations, such as the American Heart Association, recommend that if pediatric AED
pads are not available, adult pads should be used to determine if the child is in a
shockable rhythm. There is insufficient evidence to suggest that a child, in a shockable
cardiac arrest, can be "hurt" by an adult defibrillation energy setting.

When AEDs were first introduced, they were used predominantly by EMS agencies, and
their use was regulated strictly. As more and more states came to realize that AEDs are
simple to use, the restrictions became less stringent. Today, many countries have true
public access defibrillation programs.

With defibrillators becoming more prevalent in communities, and with the greater public
awareness of their value, the number of deaths each year from sudden cardiac arrest can
be dramatically reduced.

It is hoped that, eventually, AEDs will become as easily available as fire extinguishers:
on display everywhere and able to be used by anyone in an emergency.

7. REFERENCES

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1. American Heart Association, International Liaison Committee on
Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Supplement to Circulation. 102. 2000:8.

2. Aufderheide TP, Stapleton ER, Hazinski MF. Heartsaver AED for the Lay Rescuer
and First Responder. American Heart Association; 1998.

3. Stapleton ER. AEDs in the School. The Louis J. Acompora Memorial

Foundation; 2001.

4. http://en.wikipedia.org/wiki/Automated_external_defibrillator

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