A safe play

An automated external defibrillator could be the critical link
between your golf course and life-saving cardiac treatment.

Edward Schuster, M.D.

Sudden cardiac arrest occurs all too frequently on golf courses, but devices known as automated external defibrillators can provide life-saving treatment in the critical minutes before the ambulance arrives.

About a year ago, an article in USA Today caught my eye. It listed the five most common places where sudden cardiac arrest (SCA) occurs. As an avid golfer, I was a little dismayed to see golf courses on the list, although as a cardiologist, I wasn't all that surprised. For me, the article wiped out the line between work and play and spurred me to try to save a few more lives even when I'm away from the office.

That doesn't mean you'll see me treating patients out on the links. Instead, I'm spreading the word about being prepared when SCA strikes on your turf -- or in your clubhouse. Thanks to a generation of devices known as automated external defibrillators (AEDs), even people without extensive medical training can provide life-saving treatment in the critical minutes before the ambulance arrives. The expertise needed to analyze the heart's electrical function is programmed into the device, enabling non-medical professionals to respond to cardiac emergencies.

Last year my home course, Rockrimmon Country Club in Stamford, Conn., became one of the first in the country to establish an AED program. All managers and any other interested employees were trained to use a LifePak 500 AED, manufactured by Physio-Control Corp. of Redmond, Wash. The unit is kept in the clubhouse, and there's always someone on site who knows how to use it in case of an emergency. There are also mini-transistor radios strategically placed throughout the course so individuals can call for help.

What is sudden cardiac arrest?
SCA is one of the leading causes of death in the United States, striking about 350,000 people a year, killing nearly all of them. The overall survival rate is only about 5 percent.

There are no early-warning signs of SCA and no way to predict when and whom it will strike next. The arrest itself is often the first symptom of underlying heart disease.

SCA is usually caused by an electrical malfunction of the heart called ventricular fibrillation (VF) -- an ineffective quivering of the heart muscle that makes it unable to pump blood through the body. Once blood stops circulating, a person quickly loses both consciousness and the ability to breathe and will die without effective treatment. The chance of survival drops about 10 percent with each passing minute.

Saving SCA victims requires a coordinated response. The American Heart Association introduced the chain of survival model in 1990 to symbolize the sequence of events that must occur -- quickly -- to increase the survival rate from sudden cardiac arrest:

Early access, the first link, has two components: educating citizens to recognize cardiac arrest and having an emergency dispatch system in place to send trained personnel and equipment to the scene quickly.

Early CPR is the second link. Bystanders who perform CPR provide circulation and respiration to victims, buying time before the Emergency Medical Services (EMS) team arrives.

Link three, early defibrillation, is the most critical connection in the chain and often the hardest to come by. It calls for victims to be defibrillated within a few minutes of the onset of the cardiac event, so it is usually administered at the scene.

The fourth link is advanced cardiac life support, including medications and hospital care.

Smaller than a laptop computer and weighing less than 10 pounds, an automated external defibrillator enables golf course personnel without extensive medical training to provide defibrillation therapy that may save the life of a golfer.

Defibrillation is the definitive treatment for VF, but it's effective only if it reaches the victim in time. A brief but powerful electrical shock is applied to the person's chest, interrupting the VF and allowing the heart's natural rhythm to regain control. The sooner defibrillation is applied, the better the chance of survival.

How long will it take for a paramedic unfamiliar with your course to find a fallen golfer on the 14th fairway? No matter how fast response is to the clubhouse, critical minutes can be lost before the EMS team actually reaches the victim's side. Having an AED at the course doesn't replace EMS response, but in those few minutes it can make the difference between life and death.

Starting an AED program
Just as no two golf courses are the same, your plan to implement an AED program will probably be different from mine. But here are some tips to help keep you out of the rough.

Talk to the area EMS coordinator
In about 15 states, only paramedics, emergency medical technicians and other medical personnel are allowed to use defibrillators, even AEDs. The EMS coordinator will know whether trained laypersons or first responders can legally operate AEDs in your state.

If so, he or she can also help you determine your AED response protocol, recommend training for staff members who will use the devices and help you get a handle on what overall implementation costs will be.

Most states require medical direction for AED users, and the EMS coordinator can refer you to an emergency department physician or cardiologist -- assuming none of your club members steps forward to volunteer.

Enlist the aid of physician members
Is there a private golf course that doesn't have at least one physician on the membership rolls? As a rule, health care providers understand the importance of early defibrillation in saving victims of SCA. I initially floated the idea past many of the other physicians at Rockrimmon, and their responses were uniformly favorable.

Be aware, though, that some doctors and nurses aren't familiar with AEDs. If they think you're proposing to put a manual defibrillator in the hands of a layperson, they'll be resistant to the idea -- and rightly so. Have some background information handy on AEDs so everyone is clear about what's on the table.

Make sure board or management understands the scope of the problem
Even with several other physician-members supporting an AED program, we initially faced some resistance from the Rockrimmon board. A golf course is a place for rest and relaxation, so management and board members don't expect to deal with matters of life and death.

But a golf course is one of the few places where 70- and 80-year-olds are routinely physically active, and the incidence of cardiac emergencies increases markedly with age. Retired members who golf every day may spend almost as much time at the club as they do at their own homes.

What about liability?
Probably one reason more courses don't have AEDs is the concern over liability that might result from putting a medical device in the hands of a layperson. At first blush, it would seem the safer course is to do nothing. But there may actually be a greater liability risk for not equipping your course with the devices.

As AEDs become more common in public places -- from sports stadiums to high-rise buildings, manufacturing plants to shopping malls -- they will soon be considered the standard of safety, not unlike fire extinguishers.

Until that day comes, how can you convince your facility's lawyers and insurers that an AED program is a good idea? A few simple facts will help make your case:

If someone is in cardiac arrest, nothing you can do will make the situation any worse. The heart will not spontaneously regain a normal rhythm, and without defibrillation an SCA victim will die.

An AED won't shock a person who is not in cardiac arrest. The devices use highly accurate automated detection algorithms to determine whether a shock should be administered.

Using an AED is easier than performing CPR. The devices actually talk the user through the process with audible voice prompts, so even an infrequent user doesn't have to worry about forgetting an important step.

A few states have already passed Good Samaritan laws that exempt properly trained AED users from liability, and more states are considering similar legislation. Regardless of whether you're in one of those states, Physio-Control also offers an indemnity program to users of its LifePak 500 AED.

At an average cost of about $3,000 for an AED, taking this next step to protect the health and safety of your golfers is certainly cost effective.

There's one more reason I think you should get an AED. Every once in a while, I might want to play a course other than Rockrimmon.

Edward Schuster is a cardiologist with Cardiology Associates and a member of Rockrimmon Country Club in Stamford, Conn.