AEDs at High School Athletic Events

This past winter, at a high school volleyball tournament in Northport, Michigan the mother of one of the girls competing collapsed amongst the crowd of spectators. A paramedic in attendance immediately recognized this as a cardiac arrest, and according to Principal Patrick Lamb, sprinted outside and up the hill to the nearby health center, and returned with an automatic defibrillator and shocked the woman's heart back to life. In the opinion of health professionals involved this mother would have died if an Automatic External Defibrillator hadn't been close to the school.

This was not only a life-threatening emergency; it was a wake-up that fortunately demonstrated dramatically how an AED can save a life. Based on this experience, the community has now purchased AEDs for the schools; in fact Lamb stated that following this incident, three organizations stepped forward with offers to buy an AED for the school. American Heart suggests that if donations are made for the specific purpose of establishing an AED program in a school or schools in a community, priority should be given to those schools that are farthest from EMS response, those with the largest student population and schools that are used as community meeting sites or that sponsor large student or adult gatherings. High schools should generally be given higher priority than elementary schools.

Automatic External Defibrillators are relatively inexpensive, (around $ 2,000-3,000), easy to use (there are courses designed to be easily taught to lay people) and they have saved several lives in Michigan. (These rescuers and the lives saved are recognized every spring by the American Heart Association at Save a Life Day luncheon ceremonies held in Lansing and Detroit.

The confusion, however, lies in whether they are appropriate in schools. Zealous athletic boosters may like to have the purchase of an AED as a goal for fundraising. However, if the argument is made that it could save the life of an athlete, statistically, that is highly unlikely. In an American Association Advisory on AEDs in schools, it was stated: There is limited epidemiologic data about the risk of sudden cardiac arrest in anyone younger than 35 years of age. But we know that in children and adolescent's death from cardiovascular disease is much less common than in older adults. In 1999 a nationwide total of 923 deaths due to all diseases of the heart was reported in children and adolescents 1 to 19 years of age (299 deaths in children 1 to 9 years of age and 624 deaths in children 10 to 19 years of age). This number includes sudden cardiac arrest but also includes in-hospital deaths and a wide variety of cardiovascular deaths that were not sudden.

In regard to high school athletes, the same advisory goes on to say: Sudden cardiac arrest in young athletes is reported approximately 12 to 20 times nationwide per year. Most arrests occur in high schools, and few of these deaths occur in elementary schools. The median age of athletes who die suddenly is 17 years; only 3 percent of athletes who experienced sudden cardiac arrest were suspected to have underlying cardiovascular disease before the arrest. Most deaths occur among basketball and football players during or immediately after a training session or formal athletic contest, between 3 p.m. and 9 p.m.

Those in athletics have heard of instances where an athlete's heart has been struck with great force by a blow to the chest, (commotion cordis) to cause the heart to stop beating. However, this is extremely rare, only 5 cases per year in the US, which occurred to athletes 10-18 years old (nearly two thirds of those died were playing baseball or softball).
A school administrator, coach or athletic director has to decide if the cost of the AED and training is worth the cost based on the rare instances that it will save a high school athlete's life. (It should be noted that most AEDs are designed for adults but can be used on children who are eight years or older - special pediatric AEDs are recommended for younger children). Some may decide it is, others may decide that resources can be better spent, elsewhere. But it is important to focus on the benefits to others who use the school facilities.

The Northport experience shows us that the life that is saved is NOT likely to be between the lines in high school athletic competition; it is much more likely to be in the stands. It is not unusual at all to hear about a spectator dying or having a cardiac event while watching a game or meet. An important factor that should not be overlooked is the fact that during athletic event, that there is likely to be a large number of adult and older adult fans, many of whom will become emotionally involved in the outcome of the event. Many of these fans will be at high risk for heart disease and sudden cardiac arrest and death. Northport has a new Community Arts Center/Auditorium adjoining the high school which has regular programs attended by senior citizens.

American Heart Association suggests that you can view the risk of sudden cardiac arrest in schools as a school issue or a community issue. The low risk of sudden cardiac arrest in the young (estimated to be 0.5 to 1 death due to sudden cardiac arrest per 100,000 young persons under 35 years of age per year) will translate into an extremely low risk of sudden cardiac arrest in any single school. No school is likely to have sufficient attendance to have a risk of a single sudden cardiac arrest even in a 10- to 20-year period. But if 150,000 children and adolescents attend schools in a metropolitan school system for 10 hours per day, 5 days per week, 40 weeks per year, one sudden cardiac arrest would likely occur within that school system every three to six years. To have the opportunity to resuscitate that single victim of sudden cardiac arrest, every single school in the system would need to establish a PAD/AED program with well-trained rescuers and a practiced, rapid response to an emergency.

The American Heart Association's Public Access Defibrillation (PAD) program strives to encourage communities and organizations to place in AEDs where large numbers of the public gather, such as airports, shopping malls, large athletic venues such as high school athletic events. AEDs are also being placed in police and fire vehicles that may be the first respond to a cardiac arrest, before an ambulance arrives.

Some legal and even health professionals, (who are ignorant of the physiologic changes that occur immediately follow the stoppage of the heart), may say that “if we have an emergency we will call 9-1-1.” That is the same as saying they won't buy fire extinguishers because they can always call the fire department. Just as early use of a fire extinguisher will either put out the fire or keep it from spreading – an AED shocks the heart back to life before the metabolic by-products of unoxygenated, uncirculated blood build up, (including a condition called "acidosis"), so that the heart and brain cells can no longer regain function, and death can occur in as little as 10-12 minutes.

Others wills say that CPR saves lives - but even though it is important that people are trained in CPR, the likelihood of survival decreases about 10 percent EVERY MINUTE that goes by without defibrillation. For example, a good response time in many communities is the arrival of an ambulance with trained paramedics with a defibrillator within eight minutes – that means there is only a 20 percent chance (one chance in five) that they will save that person's life!
Some lawyers mistakenly advise school boards and administrators that having an AED exposes them to liability, however Michigan has a Good Samaritan Law in place that protects organizations and those who use an AED (and even the physician who writes the authorization necessary for the purchase of an AED) from successfully being sued.
It is easily assumed that if an AED is purchased and in place, that an emergency will be handled expeditiously. The AED is not a "magic box;" there must be training done to insure that rescuers know CPR, are trained to still call 9-1-1 and have been taught to use the AED in a variety of situations and that re-training is done regularly.

Training in CPR and the use of AEDs is offered by American Heart Association, the National Safely Council and the American Red Cross for those who are not health professionals. Learning how to use an AED is simple; (a study reported in the Journal of the American Medical Association found that even 6th-graders trained in the use of AEDs could effectively use a device within 30 seconds of the time taken by trained paramedics). One manufacturers, Zoll Medical Corporation, has put extensive research and development in designing an AED that is user friendly and easy to understand for the average person who has no medical background.

Training staff in CPR and the use of automatic external defibrillators and having these proven devices readily available is an important community service that can prevent a needless tragedy and community groups are looking for the type of project that can make this kind of difference.

Whenever a young athlete loses their life, there is usually a grass-root movement in the community to raise funds so that a similar tragedy doesn't occur to another child. One example is the Project A.D.A.M. a successful PAD program. A joint effort of David Ellis and Children's Hospital of Wisconsin, the program honors the memory of Adam Lemel, a 17-year-old Wisconsin high school student who collapsed and died during a basketball game. Project A.D.A.M. has expanded from its original goal of establishing a PAD program in one high school in Wisconsin to a national program with the goal of establishing PAD programs in high schools throughout the country.

Visit the American Heart Association Web site at americanheart.org/cpr for further information.

— John D. McPhail

John Mc Phail, MA, CRC, has extensive experience in cardiac rehabilitation and has been an American Heart Association Instructor-Trainer for over 25 years