AEDs in the Community: EP Lab Digest Speaks With Dr. Winston Gandy

In April 2003, Atlanta's Hartsfield International Airport launched one of the nation's biggest automatic external defibrillator (AED) programs, Hartsfield Operation HartBeat. The program made national headlines as it quickly established the need for AEDs in densely populated public places, and rallied for community support and awareness education for sudden cardiac arrest. Then, almost three months after the HartBeat program went into effect, a traveler on an Atlantic Southeast Airlines flight collapsed after departing his plane on June 25. Thanks to the help from nearby passengers and the AED program, he was defibrillated before the paramedics even arrived. In this interview, EP Lab Digest speaks with Dr. Winston Gandy, Medical Director for Hartsfield.

How did the HartBeat program come about? Going back three years, a number of major airports had emergency resuscitation equipment such as AEDs. In Atlanta, the airport and community has been growing by leaps and bounds, so it came to our attention (with a recent event at that time) that people were having cardiac arrests in the airport, and the success rates were plus or minus. In other words, we have an excellent EMT network related to Hartsfield, but with the growth and number of people coming in, it sometimes took an average of 8-10 minutes to get to people who actually had collapsed out there on the concourse. So we were charged with the task of trying to determine how we could improve the health, safety, and welfare of the traveling public at large at what was the number one airport in the world at the time. We looked at the layout of the airport, the areas that were accessible to passengers, and what type of an impact we could have in those environments if we did indeed install some type of program that made automatic defibrillators available. We worried, however, in looking at others who had already done these types of things, in a very short period of time these technologies became outdated at a tremendous expense. Thus, what we did differently at Hartsfield was send out a proposal to partner the city of Atlanta and the airport together with these devices in a way that would make Hartsfield, in our mind, the safest airport in the world to travel in.

How was the HartBeat program funded? The city of Atlanta put a bid out to all AED companies with the specifics of what they were looking for. They had seven or eight companies bid on the project. This bid included supplying the AEDs, service, monitoring, and maintenance on the devices, installation of the special cabinets that conform to FAA rules and regulations, and hooking it into the 911 system at the airport. Therefore, when someone uses an AED at the airport, it automatically tells the 911 operator their location and that the device has been removed from its case, and immediately responds with security and EMS.

Who was responsible for starting the HartBeat program? Bill Campbell, the former mayor of Atlanta, originally commissioned the program. It was carried through and ultimately succeeded under the direction of Shirley Franklin, the current Mayor of Atlanta. Ben DeCosta [Aviation General Manager] at Hartsfield International Airport, and Laney Thomas, who is a PR Director at the airport, also certainly did a lot of legwork in doing what it took to bring this to fruition. The EMS staff at the airport, led by Captain Dennis Grey [of the Atlanta Fire Department s Airport Division], have been the ones on the forefront to carry this program not only at the airport, but into the community as well.

How did you go about setting up the program? We walked the concourses at different times of the day, including peak hours of the day, and came up with a need of somewhere in between 180-200 devices, each of which would be located in strategic areas in the airport. We set this up so that the walk to and from a defibrillator would be no more than one minute total. As it turns out now, there is not a place publicly accessible in the airport where you cannot see an AED. Another thing we looked at is rush hour at the airport. There are some times of the day when the airport is virtually deserted, but within 30-40 minutes it can be elbow-to-elbow in people. We were able to plan our density in which we took this into account. Just before the transportation module, where the concourses come into the middle, you will see AEDs that are only a matter of feet apart. If someone were to go into cardiac arrest in the near proximity either up or down the concourse at certain points in the day it would take them almost 30 seconds just to go 200 feet. By having a dense number of AEDs at those points, no matter which direction you re coming from, an AED will be accessible. The AEDs are only placed up to about 200 feet beyond the concourse; they are also not placed in the parking lots. You have to have the AEDs in an environment where there will be people to respond, and so we felt that it would be more useful to have the people that patrol the parking lots have the devices in their vehicles and be trained in the use of AEDs. We have also instituted a program to train all of the people who work at the airport; this is an ongoing program, because with that many employees, the turnover is constant. In addition, we also train the vendors, because in case you collapse in front of Wendy s, they will all have been trained in how to use and apply the AEDs and will be able to help.

Are only those trained allowed to use the AEDs? Anyone can use them. It s just like a fire extinguisher; in fact, the location density is similar. The first time I used one was right before the press conference when we installed the AEDs at the airport. I had no idea that I was going to have to demonstrate one, but at the press conference they said, and now Dr. Gandy will demonstrate the use of an AED. Literally you just open it up and follow the voice prompts it s that simple. My first time through, I was successful. In fact, there have been a number of studies using school-age children sixth graders I believe that show they were every bit as effective as adults or trained medical personnel in applying the patch and operating the device.

How often will the AEDs need to be replaced? In the case of Hartsfield, they are monitored on a daily basis. The AEDs have indicators that will tell whether or not there is an issue with the battery or the electrodes. They undergo a self-test, and if an abnormality is detected, the device will emit a high-pitched chirp. When staff are surveying the airports at night, they will be able to update that. The battery life is generally in excess of two years. It is measured mainly in the number of shocks. This obviously hasn t been an issue yet since this is only the first year of the program, but the plan is that as these AEDs are used, they will be outfitted with new electrodes and a new battery.

So it isn't necessary to replace the device entirely? No. You can change out the electrodes or the pads. The electrodes that hook up to the patient are interchangeable with the electrodes and monitors that the EMTs use. This way, when they show up, they replace the old set of pads with a new one, and the old pads plug into the monitors that they use to transport the patient to the hospital.

Does Atlanta's HartBeat program cover places other than the airport? One of the things that is ongoing is a public education campaign to inform what AEDs are, how they are used, and what their benefits are. We had one of the local TV stations partner with us in some public service announcements about sudden cardiac death and the use of these devices. The Atlanta City Council is working to bring AEDs to public buildings in the city of Atlanta. The Fulton County Commission worked with a couple of community programs and organizations to figure out the best way to place a number of AEDs in Fulton County public buildings as well. We have had some of the local police departments start to carry them in the trunks of their vehicles. There are also efforts on the way now for AEDs to be put in places like the Civic Center, as well as in a number of schools, where parents or local PTAs are looking to have these devices.

How is the issue of cost-effectiveness dealt with? Also, how effective would AEDs be in buildings with a younger overall age? I balance need with ethics. If I were to tell the school administrator that one child out of every 100,000 in their system is going to die of sudden cardiac death it may be at school or at home, but they re going to die the school may say that s acceptable. They may expect one child to die every other year or so. However, from a parent standpoint, when it s your child, or when that same school administrator s child becomes one in that 100,000, suddenly it has a different ring to it. That is how I approach this whole entity. If you ask any one of the parents in Atlanta in the last 10 years who had children who had died suddenly from cardiac arrest if they would personally spend $3,000 to have this device at their kid s school, such that they could have used this when their child collapsed and died, well, I tell you, I d have paid $50,000. That s the way that I choose to look at this. Many parents with a kid that participates in athletics will go out and not think much of spending $100 on a pair of tennis shoes and $150 on registration fees for some soccer or basketball league. Given the number of people who participate, if you tack on a $2 surcharge to participate in the league, you can have an AED at every game. That is my approach. What we have done is we have spoken to parent teacher associations and different leagues, and it is usually not a big deal to them. You always have parents that feel it s important, and if you get four or five parents together to give a couple hundred bucks each, then you have a device, forever. You can imagine it is a very small investment relative to the potential benefit. What we re finding is that at a lot of these youth soccer and basketball leagues, where there are events with student athletes, the AED that may have been in the nurse s office during the day is now down on the field during the game. We can all relate to the ambulance parked beside the end zone at all high school football games, but if someone collapses in the stands, it might take the emergency crew five or ten minutes to get to them. They don t have the ability to deal with those situations. An AED is something that could turn the situation around instantly. Our efforts are providing education and, ultimately, access. What we are finding is that for a lot of recreational activities around town, these devices are being purchased and are now available.

Can you tell us about the patient from the Atlantic Southeast Airlines flight? He had a cardiac arrest, and the device was immediately available. Very simply, some bystanders hooked him up to the device. They followed the audio prompts, and he had a heart rhythm that they could terminate, which I believe was ventricular fibrillation. By the time the EMS people got there, he was conscious and talking. It wasn't airport personnel there were two nurses I think who started CPR, and a third person who went and grabbed the device. They hooked him up, and everything went fine.

Is there anything else you would like to add? I just think that it s important that we put things in perspective. We buy $100 tennis shoes, pay participation fees in excess of a hundred dollars for hundreds of athletes, and these devices now only cost between $1,500-$2,500. Certainly, when purchased in volume or by bulk, they can be even cheaper than that. As both technology and awareness improve, the price of these devices has been steadily coming down. In 1993, these devices were about $5,000. In the last several years, these devices have steadily dropped in price. You don t really appreciate it until you need it. The way I look at it is we pay a lot of money in car insurance. We realize that it s just a necessary cost of doing business, and the benefit of auto insurance is pale in comparison to the benefit of an AED. You can find more information about Atlanta's HartBeat program at www.atlanta-airport.com.