The implementation of an effective “chain of survival” is a community-wide responsibility. Lifeguards and lifesavers should be part of this chain. Early access to the Emergency Medical System (EMS) should be facilitated, ensured and planned. Early delivery of Basic Life Support (BLS) skills when needed should be expected. All lifeguards and lifesavers should be trained and encouraged to provide these skills when needed.
The availability, placement and use of defibrillators within a community should be a community decision based on the principles of “chain of survival,” proximity and time to advanced life support, community priorities and training available to personnel.
Decisions about the availability, placement and use of defibrillators should always be made in conjunction with, and with the awareness and endorsement of, the community emergency service delivery system.
Within a community emergency service delivery system where lifeguards and lifesavers are intended to operate automated external defibrillators, they must receive training in the use of the machine as well as the associated issues related to outcomes, stress and grief.
The Lifesaving Society should participate in the development of training policies for the use of defibrillation in the non-medical setting by non-medical personnel. This training policy development should be done with the Heart and Stroke Foundation of Canada and our national affiliated training agencies.
The Lifesaving Society should encourage the establishment of research tools to gather data on incidence, outcomes and unique concerns in the application of defibrillation in the aquatic environment.
Current state of defibrillation in emergency cardiac care
Since the mid 1980s many lifesaving standard-setting agencies have endorsed and promoted the consensus that a strong community wide "system" for emergency cardiac care improves outcomes. The system has been referred to as the "chain of survival" and involves four mutually dependent components:
Early access to EMS
Early advanced care
The American Heart Association (AHA) and the Heart and Stroke Foundation of Canada (HSFC) recommend that "all emergency personnel should be trained and permitted to operate an appropriately maintained defibrillator if their professional activities require that they respond to persons experiencing cardiac arrest." The technology that allows minimally trained people to successfully defibrillate is currently available: however, the HSFC stresses that "such programs must have strong medical control."
Demographic shifts in our society would allow us to predict that out-of-hospital cardiac arrest will become a more common issue. There will be discussion, debate and stress for individuals, employers, facilities and organizations to respond to this issue. Recreation facilities are likely to continue to encourage the use of the facility by high-risk individuals. A thoughtful plan for all of the events that they are likely to encounter should be in place.
Even in centres with optimum response systems, outcomes to hospital discharge and/or one-year functioning survival are low. Death is by far the most frequent outcome of sudden cardiac arrest.
In an effort to maximize intact survival from sudden cardiac death, each component of the "chain of survival" needs careful evaluation, implementation planning, activation and reevaluation. It is recognized that, in addition to the actual application of knowledge and skill of each component, other issues need attention, such as stress and grief for victims, relatives, bystanders and care providers.
As momentum grows for the activation of the "early" aspects of the "chain of survival", standard-setting bodies need to reevaluate their positions on issues to best guide their care providers and their working structures. The Lifesaving Society - as Canada's Lifeguarding Experts - needs to identify a position on the use of defibrillators by lifeguards.
A review of world literature in the spring of 1997 identifies the following consensus:
The single most important factor in survival from sudden cardiac arrest may be early defibrillation therapy.
Training programs of as few as eight hours have been evaluated in the medical environment with medical and paramedical practitioners. These studies are supportive of short-course certification.
There are few reports in the literature of lay-persons or minimally trained first aid providers, in the non-medical context, being trained and delivering automated defibrillation in the field. These few studies are supportive.
There are few reports of the cost effectiveness of a program of widespread early defibrillation.
There has been minimal activation of the 1992 AHA recommendation (endorsed in 1993 by the HSFC) to enhance availability and delivery of defibrillation in the field by minimally trained individuals. The application of the automated technology is increasingly accepted at the paramedical level, sporadically among fire and police personnel and rarely used by professional lifeguards or non professional first aid responders.
Efforts to enhance the penetration of traditional BLS skills to target audiences remains a priority. Many reports persist of bystander BLS at the sub-50% level.