Cover Report by Marie Nordberg
Associate Editor
Shortly after 10 a.m. on July 3, 1999, two officers from the South Lake Minnetonka (MN) Police Department responded to a call for a man having a heart attack in the parking lot of a convenience store. As the officers approached the victim, who was slumped over in the passenger's seat, they recognized him as a fellow police officer.
After their initial surprise, the officers quickly retrieved a recently acquired defibrillator from their squad car, hooked it up to their 46-year-old colleague, and, with five shocks, regained a heartbeat. The officer was transported by the Excelsior Fire Department to a local hospital, where he was stabilized and later released.
It's no surprise that this incident took place in the state that gave birth to the AED program for law enforcement. What is believed to be the first program of its kind was launched in November 1990 by Mayo Clinic physician Roger D. White, MD, in Rochester, MN.
"My reasoning behind the program was that if we could do something to reach patients more quickly with defibrillators, we should try to enhance our survival rate, which was already high," says White. "We were running a 28%-32% survival rate from ventricular fibrillation, but it seemed like we could get to some higher plateau by placing defibrillators in police cars that were already out on the street. The program was set up as a trial to see if the police could get there quicker than an ambulance in a sufficient number of cases to warrant maintaining the program."
After a 2-year trial period, it was proved that the police did, in fact, reach a considerable number of patients before the ambulance, says White, so the program was expanded, and continues to expand.
How did the police officers react to this added responsibility?
"With rare exception, they were very receptive," says Dr. White. "They knew from experience that if all they could do for a victim in cardiac arrest was CPR, it wasn't enough, and they also knew that when an ambulance did arrive, the paramedics carried the definitive intervention device, which was a defibrillator. They had seen over and over again what a difference the defibrillator made, so it wasn't difficult at all to convince them that this was worth a try."
Of course, says White, the defibrillators used back in 1990 were quite different from those the Rochester police officers use today. That defibrillator weighed 13 lbs., had audible prompts but no screen to display an electrocardiogram, and the batteries were rechargeable. The final disadvantage, he says, was that the defibrillator's clock had to be synchronized daily to keep it in sync with dispatch in order to obtain accurate data.
The Rochester pilot program was so successful that, 10 years later, police officers across Minnesota are clamoring for defibrillators for their own departments. According to Layne Nelson, a spokesperson for the Minnesota Department of Administration, the 1998 legislature provided $450,000 to purchase 220 units, which have been distributed to law enforcement agencies across the state.
"We had more than 600 requests for the defibrillators," says Pamela Docken, former grant administrator for the Minnesota Department of Public Safety Grant Program, "so there was a strong interest. There are currently 120 departments using them. From February until the end of June, whenever a defibrillator was used, the department had to report it to me within 24 hours, and reports were coming in every day. That convinced me that this is a good program, and the AEDs are being used and highly coveted by other departments."
Most grantees were excited about the program, says Docken, with the exception of one small-town department that began having second thoughts about participating."From the information on their grant application about ambulance response time, I knew no one would ever survive there if they didn't do this," she says. "I finally said, 'What if I was driving through your town and had a heart attack? Are you telling me you'd rather I die than take a chance of putting the pads on me and bringing me back?' They thought about that for a couple of days, then called and said, 'We want this.' "
As word of the AED program gets out, departments across the country are taking notice. In July 1997, the Downers Grove (IL) Police Department started a pilot program with two vendors: Survivalink and Medtronic Emergency Response Systems.
"Our fire and EMS departments were approached by the vendors, and the fire department approached us," says Deputy Chief Mark Weimer. "We're fortunate to have a close and well-established working relationship with our fire department, so it was relatively easy for them to say, 'We think this is a good idea. Let's try this.' We told the vendors if they each gave us an equal number of units, we would give them an equal shot, so we split them between the squad cars and the civic center police facility.
"I put the cart before the horse, because we didn't have funds specifically allocated to do this, and certainly not to the degree we ended up with," says Weimer. "We had budgeted money for the '98-'99 fiscal year for buying one or two defibrillators, and we now have 26 units: 25 in squad cars and one here in the police facility. We did some publicity with both Chicago and local media, which made it hard, at that point, for the city council to say no. They realized it was a good project, and we had money that wasn't going to be used in both the police and fire budgets, so they transferred the funds to us so we were able to do this."
Even with funding, the project was not undertaken without some hesitation, says Weimer.
"We agreed to look at the program, but our initial response was still, 'We aren't firemen or EMS. It's their responsibility. We're the police; we're different.' But once the fire department laid out the benefits, it took some of our hesitation away, and we started realizing how many people across the country die of sudden cardiac arrest and how poor the survival rate is with CPR alone."
In spite of its proximity to Chicago, Downers Grove is a community that covers only 13 square miles and has a sleep population of about 50,000 and a daytime population of approximately 120,000, due to the large number of high-tech research buildings in the area.
"The fire department arrives on scene about the same time we do the majority of the time, but in the evening hours, after 8 p.m., we're out and about, and it's much easier for us to be first on the scene of a medical emergency," says Weimer. "When we explained that to our officers, it helped, but they really didn't lose their hesitation until we showed them the unit and explained how simple it is to use. They were a bit standoffish, and I think they were afraid of what they'd seen on TV--the gel going on, rubbing the paddles together, someone yelling, 'Clear!' I think that's what they were hesitant about."
That reaction is not unique to Downers Grove, says TJ Kennedy, a former trooper and EMS coordinator with the Utah State Highway Patrol, who has just assumed the awesome responsibility of being a public safety planner for the 2002 Winter Olympics in Salt Lake City.
"We heard the whole gamut of reactions, from 'It's not my job' to 'We should have had this 20 years ago,'" says Kennedy. "On a practical level, the most important thing we've noticed is that troopers who used to say, 'I've done CPR numerous times during my career and it's never worked,' are now saying, 'I used an AED and it worked. I actually saved somebody's life.' "
Because Utah is so rural and state troopers are usually first on trauma scenes, about 2 years ago the Utah State Highway Patrol decided that the troopers needed training beyond first aid, says Kennedy.
"We adopted the California Highway Patrol model of training them all as EMT-Basics, which included AED use," he says. "But we had divisions within the Department of Public Safety, which is the parent organization of the highway patrol, that included people who weren't required to take EMT training, and we wanted to include everyone in AED. I went to conferences to see how other police departments were implementing AED and, along with the Orem Department of Public Safety, which had the first police agency in Orem City to implement an AED program, we managed to get the law changed in Utah to public access defibrillation by saying that anyone with a CPR card and training could use an AED. Since then, four or five other departments in the state have added AEDs, although we're by far the largest with 55 defibrillators in use."
Like most departments, successful resuscitations have been few, says Kennedy, although he believes it's just a matter of a trooper being in the right place at the right time. "With Utah so rural, even though a trooper is first on scene, it may take 15 minutes or more to get there, so you aren't going to have success with those situations," he says. "Initially, we put the AEDs in the most rural areas, but we've moved them to the more intermediate areas that troopers can reach in 4 or 5 minutes and there might not be immediate full-time ALS available. That doesn't mean the rural trooper would never have a success, but he might only have one chance in a year."
In larger areas, like Salt Lake City, law enforcement officers frequently see cardiac arrest, says Kennedy, but they're usually so busy with other duties that they're more likely to let EMS handle the situation. If EMS is delayed, however, they're grateful that the police can now take over until they arrive.
"Our EMS people love the fact that a trooper might arrive and defibrillate a patient until they can take over," says Kennedy. "That's a model of success. And with their EMT training, we've seen that the police officers are more aware of EMS's situations and concerns. Before now, many police officers didn't realize how important it was to get a quick response from the ambulance or think about how to get the arriving ambulance closer to the patient. So the interaction between EMS and police officers has improved as a side result."
Not only are city police departments and highway patrol officers using AEDs, but sheriff's departments are also getting on the bandwagon. Last year, after being approached by Survivalink Corporation about putting AEDs into law enforcement, the Maricopa County Sheriff's Office, which includes the city of Phoenix, AZ, was awarded a grant to purchase 45 units.
"Most of the large departments have a good response time from fire and EMS, but Maricopa County covers more than 9,000 square miles, and we have a long EMS response time in some areas, so we hoped this would fill the gap," says Sergeant Wayne Lupinski. "The initial response from our people was generally very positive; I don't recall any negative comments. The administration was behind it, and our guys are very pro-public, so this was just another tool they were able to use to serve the citizens."
Like Utah's highway patrol, many of Maricopa County Sheriff's Office employees are EMT-trained, says Lupinski, who, along with two others, is a paramedic. "The area I'm assigned to covers the recreational areas of Maricopa County, including several lakes and a large recreation area in the national forest," he says. "Being in a remote area, it was not unusual for us to have a 35-40-minute response time for EMS, and that's a long time to stand around telling the victim everything is going to be fine. Although everyone was trained in first aid, in 1990 we started training people as basic EMTs, and our office has seen the benefits. We've had a number of rescues that were directly attributed to the program, so the move to AEDs was not an unreasonable transition."
Lupinski took on the task of training the employees with full support from a medical control advisor at Phoenix Memorial Hospital, which oversees the program. The defibrillators have only been used in a handful of instances, and there have been no successes to date, but Lupinksi attributes that to the types of calls rather than any failing of the machines.
"We had two drownings, where the victims had been down for extended periods of time, and three motor vehicle accidents where the victims suffered severe trauma and were not viable," he explains. "The one time shocks were indicated and administered, the person was too far gone."
In California, the San Fernando Police Department, a tiny city nestled on the northern fringes of the San Fernando Valley just outside Los Angeles, recently implemented an AED program, thanks to the tireless efforts of Sergeant Alan Cowen, retired deputy chief of the Los Angeles City Fire Department's Bureau of EMS.
Cowen, a paramedic and reserve police officer with San Fernando for more than 15 years, had always known that quick defibrillation is the key to successful resuscitation. Selling the concept of police officers providing that service was another matter.
"About six years ago, I approached Chief Dominick Rivetti with the idea of putting defibrillators on police vehicles, based strictly on response time, which is anywhere from 1 to 3 minutes in this 2.4-square-mile city," says Cowen. "I'm thinking, since we have our own dispatch center, we could intercept the9-1-1 calls, be on scene in a minute and defibrillate, and it would be the ideal solution. The chief listened and said he didn't think we were ready for it, but thanks a lot. Six years went by before I brought it up again."
In 1998, says Cowen, he went back to the chief with the information that airlines were now carrying defibrillators, and some police departments were using them as well. In addition, the city of San Fernando had long since abandoned its two fire stations and contracted with the Los Angeles City Fire Department for fire and EMS services.
"The public wasn't aware that the closest ambulance station to San Fernando is not a paramedic service," Cowen adds. "It's an EMT-staffed ambulance out of one of the L.A. fire stations. I told the chief I knew we could do better and could raise the level of care to the community."
Chief Rivetti agreed to look at a proposal, which Cowen presented within a week, complete with cost, budget, training, DHS and EMS agency approvals--the works.
"I realized that we might only use an AED once or twice a month, so we weren't looking at heavy-duty use," says Cowen, "but if we could save one life, it would be worthwhile."
The chief liked the idea, presented it to a somewhat apprehensive city council, and the rest is history. On March 30 this year, San Fernando PD became the owners of three Laerdal Heartstart defibrillators, two of which were placed in patrol cars and one at the police station, which is located in the city hall.
With support from a Los Angeles-based medical director, Cowen undertook the job of training the department's 35 regular and 45 reserve officers, first reviewing CPR and first aid, then teaching defibrillation.
"A few of the officers grumbled about having to learn one more thing, but the union said nothing, and they didn't ask for more money," says Cowen.
Cowen attributes much of the response to his position as one of them, as well as his experience as a paramedic.
"They know if there's a medical crisis or, worse, if one of them gets hurt, shot or stabbed, or someone has a heart attack, they feel comfortable having me around. So everyone climbed on board, and the training went very well. Our first call came just 6 days after the program began, when one of our officers responded to a nursing home. Unfortunately, when he hooked the patient up, it said 'Do Not Shock' because the patient was already dead. The AEDs haven't been used since, but it's not a matter of 'if'--it's a matter of 'when.' We'll have a save, and it will be a big deal."
Adding AED use to the already wide range of responsibilities of law enforcement is a terrific public relations tool, says Minnesota's Pamela Docken. Not only that, it eases the burden on the EMS system, she says.
"It doesn't do the paramedics any good if an officer gets to a scene 5 minutes ahead of EMS and just stands around," she says. "That creates such a sense of loss for everyone involved if they lose a life that could have been saved. It's also good for bystanders to hear the machine give directions and know that the officer is doing what he's supposed to do. It removes a lot of anxiety for onlookers.
"Even though there has been some publicity, most of the public isn't aware that police officers are carrying AEDs," Docken says. "It needs to be more highly publicized. It's important for citizens to know that when an officer shows up, he's going to do something good."
"I think it's an obligation of the medical director in every city where this sort of program is being implemented to inform the community of what is taking place," adds Roger White. "We've done that, not only when we started the program, but periodically during the conduct of the program. We've seen areas where the public needed to be reminded of their role in this by activating 911 more promptly."
Downers Grove PD makes sure the local papers know about police and fire department open houses, and officers willingly show off the AEDs to curious citizens, says Weimer.
"We saw this as an extremely positive way to tell the community that we're well-equipped to deal not only with the criminal element, but also with the more human side of life. I know when our city's economic development people talk to businesses about moving to our community, they talk about ratings for the fire department and law enforcement, that we have an outstanding EMS program and level I trauma center here, and that the PD is equipped with portable defibrillators."
The Utah Highway Patrol has had good media coverage in local newspapers and on television, says Kennedy. One positive article was about a successful resuscitation at the University of Utah during a basketball game between the University of Utah and its rival, Brigham Young University.
"A couple of our troopers were working security in the stadium and heard a radio call for a full arrest in the area where they were standing," says Kennedy. "One had just finished an EMT class and the other had finished 6 months before, and they had both just completed their AED in-service. They found a 73-year-old male in a wheelchair in full arrest, so they put him on the ground and began their assessment. Someone handed them a bag-valve-mask, which they hooked up to the homebound O2 that was hanging around the victim's neck. Our troopers' equipment was in their car, so they sent someone to find the on-call ambulance. The EMT grabbed his LifePak 500, ran back through the tunnel to where the troopers were, and the troopers hooked it up and defibrillated the man. They got him back with the first shock at 200 joules and continued with the BVM until the Salt Lake City Fire Department paramedics showed up. The paramedics didn't believe he'd been in arrest until we downloaded the defibrillator, which showed v-fib at the time it was hooked up, and showed the shock. This guy had suffered a major heart attack just a few weeks before, which is why he had O2, and he was awaiting a heart transplant. Four days after the incident, he was discharged with no neurodeficit, so it was successful."
Alan Cowen never does things half-heartedly, as evidenced by a press conference that announced the advent of the AED program in San Fernando.
"Everyone knew it was a drill," he says, "but when I put out the call, we heard sirens, a police car came screeching up to city hall, the officers jumped out, and, instead of drawing their guns, they opened the trunk, put on gloves and pulled out their defibrillator. They did a great job.
"When you do one of these programs, you not only need support from the department members, you need a city council, mayor and police chief who are willing to get the budget for it," Cowen continues. "You also need to get the equipment at a good price, a contract that will cover the equipment if it fails, and good, solid training and retraining."
According to the departments that are already using AEDs, there's little doubt that this is the wave of the future.
"It's so important, especially in remote areas," says Wayne Lupinski. "Studies show that if a person who is having a heart attack can be defibrillated within the first 10 minutes, the chances of recovery are significantly improved. Beyond that time, the chances for survival diminish to nothing. It's another tool we can use to help the public, and it's a very valuable tool. Unfortunately, we haven't seen a lot of success with it yet, but I think it's just a matter of time before we do.
"One of the big concerns for those learning is that the machine will misdiagnose the patient and they'll shock someone who doesn't need it," Lupinski adds. "All of the studies I've read show these AEDs to be pretty accurate in their interpretation and reliable. Within the last couple of months, I've received many requests for information from various agencies around the country, so I think we're going to see a change and more agencies getting involved."
Even though the department has AEDs, they don't automatically go on all medical calls, says Mark Weimer.
"We limit it to calls like a subject with chest pain or a victim down and not breathing," he says. "But we're too busy to follow the fire department on a call for a broken leg. Anything that has the potential for using the AED, we go on, and the officers are quick to use them. Our fire department uses Physio-Control's LifePak 12, and our Survivalink units have an adapter that allows us to leave our pads on a patient and the Physio unit plugs right in as backup.
"We're one of the communities that's still looking for what the vendors call a 'save,' and I know the officers who are involved with it want to see that happen. We've had some officers who were first on a scene and performed CPR until the fire department came in with its defibrillators and converted somebody, and that's pretty awesome, knowing they played a big role in keeping that patient around. So our officers keep their AEDs right in the front seat of their squad cars so they don't have to think about where to find them. They've become part of our normal equipment."
As a medical director, Mayo Clinic physician Roger White believes it's critical that wherever the program is being done, data are collected to define what benefit, if any, it has.
"It's not enough to exploit the interest in it and the glamour of using them," he says. "It's important that it be approached as a clinical investigation from which data are collected, analyzed and reported as such if it's worth expanding, and we have evidence that it is. If it isn't, we can share that evidence with others who are contemplating such a program."
Evidence of the program's worth has been proved by the unprecedented level of care being provided to the citizens of San Fernando, says Cowen.
"It's now probably one of the safest cities in the world," he says confidently. "Officers who were initially apprehensive are now highly supportive, and if anything happens in the community or any of the city buildings, an officer can be there in the blink of an eye. It's my understanding that, in some cities, police officers are told to not even render first aid; they aren't qualified to touch patients. Well, we have to get rid of that archaic type of thinking. As a police officer, I'm a patient-care advocate. I'm here not only to take bad people to jail, but when a little kid gets hit by a car, I need to know what to do.
"The standard of care has been changed by this action by police departments," Cowen adds, "and because the airlines are now carrying AEDs, the public is starting to expect it. I think this will change the image of the police department. Instead of the image of officers writing tickets and beating people up, they'll become peoples' best friends when they save their lives."
TJ Kennedy also believes this is an ideal way to bolster the law enforcement image.
"One thing I've found regarding the publics' perception of the police is that when they call 9-1-1, they expect somebody in a uniform to show up and do something," he says. "They don't care if the uniform is blue, black or brown. They expect that a public servant, whether he shows up with a gun or a fire hose, ought to be able to deal with any situation, and that may include doing CPR on their child or a parent who is in full arrest. The standard across the country right now is for police officers to carry a mask and do CPR, but I think we have to improve on that."