AEDs: A pathetic tale of apathy-by PRAMOD DE SILVA

A few weeks ago, there was a news item to the effect that a leading home-grown company in the Pharmaceutical and FMCG sector had donated an Automated External Defibrillator (commonly known as AED) to the Bandaranaike International Airport (BIA) in Colombo. This was no doubt a noble gesture on the part of the company concerned.

Before I delve further into today’s topic, a short primer on AEDs. An AED is a portable device that can apply a small electrical charge to revive a heart that has seemingly stopped (Sudden Cardiac Arrest or SCA). You might have seen professional defibrillators in hospitals or even on TV, in programs such as ER, The Good Doctor and Grey’s Anatomy. These mighty machines are generally very expensive.

But an AED is a smaller, portable version of the same machine which can be installed almost anywhere people gather in large numbers – Airports, Railway Stations, Shopping Malls, Schools, Hotels, Places of Worship, Cinemas and of course, hospitals themselves. There are even AEDs that are specifically designed for home use, which is useful if there is a heart patient at home.

In scientific terms, an AED is a machine that is used to treat SAC, a life-threatening condition where the heart suddenly stops beating properly. By sending an electric shock to the heart of a person in cardiac arrest, the AED restores a normal heart rhythm. They can “buy” crucial seconds until professional medical personnel arrive on the scene.

AEDs are designed for use by laypersons with very little training; All you have to do is check out the device’s user manual for instructions on how to use a specific AED. The manual is usually found with the device but most AED machines will also give clear, step-by-step audio instructions.

Electrode pads

While AED machines use advanced algorithms and offer lifesaving therapy, they are actually built with only a few key components. The main AED parts are: Electrode pads: Electrode pads are the sticky pads that are applied to the patient’s chest. The electrode pads are what reads the patient’s heart rhythm. If a shock is determined to be necessary by the AED’s processor, then the shock travels between the pads and through the patient’s heart.

Battery: The battery is used to charge the AED’s capacitor so that it has enough energy to deliver a life-saving shock. The battery also plays an important role in running self-tests and AED diagnostics to make sure that the AED is functioning properly. Capacitor: The capacitor stores and releases energy. Capacitors are very common electrical components and they come in different sizes or capacities. For AEDs, the capacitor has to be large enough to store enough energy, and then release it all at once, to save a patient’s life. Processor: The processor is the brains behind the AED. The processor is used to analyse the patient’s rhythm to determine whether or not the patient is in a shockable rhythm.

AEDs are capable of automatically detecting two forms of cardiac arrhythmias or irregular heart rhythms: ventricular fibrillation and pulseless ventricular tachycardia. If either of these rhythms are detected by the AED, the device delivers a controlled electric shock to the victim. AEDs are “automated” and completely take the guesswork out of determining whether or not someone needs a shock. AED operators do not need to read and interpret a patient’s ECG which depicts the heart rhythm. The AED performs the heart rhythm analysis for them.

Immediate use

If a shock is required the AED will charge and tell you to stand clear from the patient. Then, it will count down and automatically deliver the shock without requiring you to press a button (some semi-auto will ask you to do this). AEDs can often be used immediately when a person goes into cardiac arrest instead of having to wait for the paramedics to administer life-saving treatment.

However, it is still vital to call an ambulance (and the Police if needed) even if CPR (Cardiopulmonary Resuscitation) is performed and AED treatment is given. Note that for children, AEDs might come with special electrode pads or attenuators that reduce the strength of the shock.

AEDs are not that expensive when compared with the cost of most other medical devices which are used almost entirely in a professional (i.e. hospital) setting. A brand new AED costs anywhere between US$ 1,500 (Rs.550,000) and US$ 3,000 (Rs.1.1 million) without any taxes and duties. That is simply peanuts when you consider how precious a life is. But then the question arises as to why we have not seen AEDs anywhere in Sri Lanka apart from some hospitals?

Indeed, it is horrendous that there was no AED all this time at the main international airport in the country. Given its vastness, it should have at least five AEDs, not one. Indeed, by now AEDs should have been a common fixture in many of the public spaces outlined above. This is the case in many other countries, including developing countries like ours. But this is where our authorities have fared rather badly – I wonder whether they even have an AED at the Parliament itself, where lawmakers should give priority to matters such as these.

Mixing up priorities

This is a country where we mix up our priorities really badly – we apparently cannot spare US$ 3,000 to import an AED, but we have no qualms about splashing US$ 55,000 (Rs.20 million) to import a super luxury, gas-guzzling V8 SUV for a lawmaker – and that too, from the public purse with the MP paying a laughable Rs.1,750 to release it from the Customs.

I nearly forgot that there are 225 of them, so the total bill would have come to Rs.4,500 million. With that kind of money, we could have purchased nearly 4,500 AEDs for installation practically everywhere. Something clearly is not right.

I also noticed that the company which donated the AED to the BIA had estimated the cost of the machine at Rs.2.5 million, which could have included a fair amount of duties and taxes. Which other country levies such a high quantum of duties and taxes on an essential medical device such as an AED? And we do not think twice about allowing duty free cars for our lawmakers, which deprives the Exchequer of billions of Rupees. (This scheme is apparently temporarily stopped, but there is no doubt it is going to come back). In fact, there should be zero duties and taxes on all essential medicinal drugs and devices from blood pressure monitors to MRI Scanners. This is because health matters and lives matter. This is indeed so in most other countries.

While Sri Lanka has a very good health service, proper investments have not been made in it. We still wait for donor countries to donate ambulances for our hospitals. During the Covid-19 pandemic, many private companies donated Reverse Transcription Polymerase Chain Reaction (RT-PCR) machines to State hospitals.

Considering that a basic PCR machine can be had for just US$ 5,000 (Rs.1.9 million), the State had failed again to make that investment for hospitals islandwide. Granted, some highly advanced PCR machines cost US$ 15,000 to US$ 90,000, but we could have had at least a few of those as well at the rate we have wasted forex for less important purposes. Sri Lanka was also practically the only country in the world not to allow retail sales of Covid Antigen Test Kits, which could have been a very minor investment. In Singapore, for example, one can buy a five-test pack for just SIN$ 42 (Rs.11,500) from a vending machine.

Pathetic situation

It also beggars belief that there are only two ECMO (Extra Corporeal Membrane Oxygenation) machines in State hospitals in the whole island – one at the Karapitiya Teaching Hospital in Galle and the other at the Lady Ridgeway Hospital for Children (LRH) in Colombo. This fact also came to light during the Covid-19 days, though we do not whether another machine or two had been imported in the meantime. It is also not known whether any private hospital has an ECMO machine.

ECMO, also known as extracorporeal life support, is an extracorporeal (“out of body”) technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life. This is the last hope for those suffering from acute respiratory and organ failure and has a remarkable success rate when it comes to saving lives. It is a machine worth having in every hospital in the country.

Careful assessment, a must

These state-of-the-art Life Support machines are somewhat expensive, ranging from US$ 150,000 (Rs.54 million) to US$ 500,000 (Rs.182 million), but it is a worthwhile investment in every sense of the word. In a country where two loss-making State institutions recently paid a staggering Rs.1,800 million in bonuses, money can easily be found for worthy causes such as purchasing ECMO machines. After all, 10 ECMOs could have been imported with those funds.

Health planners should make a careful assessment of such essential needs and suggest that funds be allocated at least from the next Budget for purchasing the same. There is no need to wait till the next time – now is the time to take stock, address any lacunae and keep our health system ready for any challenge including the next pandemic which could be more virulent than Covid-19. Yes, Dollars are in short supply, but the health of the Nation should come first and critically important medical equipment must be imported by prudently managing the forex resources.

Health must also be thought of as being an essential part of National Security and no expense should be spared to give priority to this crucial sector. Having more AEDs in public spaces around the island can be a good starting point.

Why are AEDs important?

AEDs make it possible for more people to respond to a medical emergency where defibrillation is required. Because AEDs are portable, they can be used by nonmedical people (lay-rescuers). They can be made part of emergency response programs that also include rapid use of 9-1-1 and prompt delivery of cardio pulmonary resuscitation (CPR). All three of these activities are vital to improving survival from SCA.

How does an AED work

A built-in computer checks a victim’s heart rhythm through adhesive electrodes. The computer calculates whether defibrillation is needed. If it is, a recorded voice prompts the rescuer to press the shock button on the AED. This shock momentarily stuns the heart and stops all activity. It gives the heart the chance to resume beating effectively. Audible prompts guide the user through the process. AEDs advise a shock only for ventricular fibrillation or another life-threatening condition called pulseless ventricular tachycardia.

Who can use an AED

Non-medical personnel such as police, fire service personnel, flight attendants, security guards and other lay rescuers who have been trained in CPR can use AEDs.

Although formal training in the use of an AED is not required, it is recommended to help the rescuer increase their comfort and level of confidence. However, AEDs are intended for use by the general public. Most AEDs use audible voice prompts to guide the user through the process.