The emergency call box system at Rockrimmon CC in Stamford, Conn., has boxes located throughout the facility. This means that AEDs can be brought to cardiac arrest victims quickly anywhere on the course.

2001 Leo Feser award candidate

A golf course is the fifth most likely place where cardiac arrests may occur; almost 20 percent of all golf facilities will have a cardiac emergency; and it's now the No. 1 cause of death at golf facilities worldwide. AEDs are designed so nonmedical personnel with only a little training can use them effectively. A comprehensive safety training program is essential to combat the natural desire to panic. It's important to promote the program aggressively to prevent a tragedy because patrons are not aware of the facility's emergency capabilities. Legal considerations and possible ramifications should not be a deterrent to implementing an AED program.

Every day around the world, doctors, scientists, technicians and researchers are working to find ways to improve our general health, well-being and life expectancy, as well as to combat and repair the systemic problems of disease and injury that can affect us all. With greater and greater success, these professionals find ways to achieve these goals.

In the area of emergency cardiac care, a technological breakthrough now enables nonmedical personnel to save the life of another. That technological breakthrough is called the Automatic External Defibrillator, or AED, and it may stand as the one of the greatest emergency safety measures ever developed in the golf and recreation fields.

The cases of Garland Dempsey and Jerry Fuents demonstrate the value of this new tool at golf facilities. Fuents was a spectator at a 1999 PGA event in Texas, and Dempsey was working inside the ropes as a caddie. Each suffered a heart attack during the event. Both men received prompt EMS care, and both men were saved because medics were equipped with AED units, which restarted their malfunctioning hearts and helped save their lives.

Over the last two years, I've been fortunate to observe firsthand the initial implementation of an AED device at my golf facility, Rockrimmon Country Club in Stamford, Conn. It is one of the first clubs to develop a safety and training program centered on this life-saving equipment. In the course of the programs development, we have really had our eyes opened to the extreme value of the AED in facility safety.

The facts
The AED is primarily a device used to assist someone suffering from cardiac arrest. Cardiac arrest is defined as a sudden cessation (stopping) of one's heartbeat. In many cases cardiac arrest occurs when the heart has been, or is in, ventricular fibrillation: a disruption in its proper muscular rhythm and pulse resulting in a disruption of blood circulation.

Despite general advances in medicine and individual health and dietary practices, more than 800 people still die every day from cardiac arrest. That's one person every 29 seconds and more than 300,000 deaths from cardiac arrest each year.

If that figure can be swallowed, then here's one that will be of interest to all those in the golf business. Statistics have shown that a golf course is now the fifth most likely place where those 300,000-plus cardiac arrests may occur. When you consider that hospitals and homes are No. 1 and No. 2, the golf course's No. 5 ranking is surprising indeed.

CGCS Anthony Girardi (shown with his dog Baron) has made Rockrimmon CC a safer place for golfers with the introduction of AEDs and a staff well-trained in their use.

In addition, it's estimated that almost 20 percent of all golf course facilities will have a cardiac emergency, and it's now the No. 1 cause of death at golf facilities worldwide.

Technology to save lives
In the event of a cardiac arrest, time is perhaps the most crucial element for a person's survival. According to cardiologists, for every minute that passes without defibrillation (the act of restoring normal beating rhythm to a heart in cardiac arrest), a victim's chances of survival decrease by 7 to 10 percent. After 10 minutes, very few resuscitation attempts prove successful.

The AED is a device that provides defibrillation, via electric current, to restore normal rhythm to the heart. Although this sounds like a complex process, the machine is designed so nonmedical personnel with only a little training can use it effectively. The unit is relatively light, weighing less than 15 pounds, and has very clear and self-explanatory controls that, with the support of instructional training, can be deployed efficiently and, most important of all, quickly.

There are four basic steps involved in using the AED, which the machine, through audible voice prompts, "talks" the user through -- a revolutionary innovation in and of itself. Once it is brought to the victim's side, the unit's power must be turned on (it's battery-charged, thus making it portable) and the "diagnostic" phase of the machine's capabilities becomes the first priority.

Next is the placement of the unit's two electric pads that serve as a conduit for both electric analysis and, later, administration of defibrillation. These pads are placed on the victim's chest, one under the right armpit and the other under the general area of the heart. This step serves to establish the condition of the heart's rhythm and beat.

The most fascinating feature of the AED is what happens next: The machine automatically assesses whether or not shock stimulation is necessary in that particular victim's case. If the assessment is affirmative, the unit then automatically administers an electric charge to begin defibrillation. If the assessment is negative, no shock is applied.

Studies have shown that AED units are remarkably accurate in making this crucial assessment of a victim's condition. They make the correct "shock" decision 90 out of 100 times, and the correct "no shock" decision 95 out of 100 times. In this regard, the AED unit is nearly as adept as having a cardiologist administer the victim's emergency care.

Training lifesavers
However, for a facility to make proper and effective use of the technology, while integrating it with a total health and safety program, it takes more than just having the AED unit on hand. It cannot be stressed enough that a comprehensive program is important to the success of the AED in saving lives.

By their nature, cardiac arrest situations are ones of great emergency and, sometimes, great panic. Every facility needs a reliable system of training, practice and education to combat the natural desire to panic.

A variety of issues need to be covered: staff training, maintenance and upkeep of the unit, deployment and emergency access, and communication and promotion. The most important of these factors is the staff training program.

At Rockrimmon, our approach was to train personnel in a group format. From the maitre d' to the receptionist to the starter, the club included an array of personnel whom management believed it was vital to train in AED and emergency care administration.

Our initial training session, sponsored by the AED manufacturer in conjunction with the local EMS, lasted 3 to 4 hours and was conducted with the supervision of a certified physician. During the session, which included a review of basic CPR (cardiopulmonary resuscitation) techniques (CPR certification is also desired) and a discussion of the signs of cardiac arrest, the group got a thorough overview of the device and its usage through lecture, demonstration and hands-on experience. By the time the session was over, our attendees knew how to administer AED aid to a victim within 90 seconds of arriving at his or her side.

Some states require EMS notification of your AED program, but even if yours does not, it's a smart idea to link and integrate local EMS in your total program. They can help provide additional training and periodic update reviews; they can store your AED locations in their dispatch database; and they will become familiar with your trained staff and facility in the event of cardiac arrest (or any other) emergencies.

Modern technology has made AEDs smaller and less expensive and thus available for use in public places such as golf courses. Most brands have similar features and cost around $3,000.

Keeping your AED program healthy
Maintaining your AED's function via inspection -- a critical element of your defibrillator program -- is easy because of some of the built-in features found in most brands of AED units. One of these is a self-test feature that will engage periodically and sound an alarm if a problem is noted. Another is a maintenance checklist that makes inspections reliable and standardized no matter which of your trained staff members is performing it.

The AED unit must be placed in a central and accessible location. As mentioned previously, time is the crucial element in a victim's chances of surviving cardiac arrest. It's the goal of our club to place the unit where it can be retrieved and brought to the victim within 3 minutes of receiving a distress call. This would allow for actual aid to be administered in no more than 4 ½ minutes from the time of alert.

How does a distant location distress call reach the staff? At Rockrimmon, this is achieved through a complete and thorough deployment of a "satellite" communication system with emergency call boxes located at key points and central locations throughout the facility. Over the last decade, many golf courses have set up similar emergency systems, and these are helpful additions to an AED program.

Call boxes are engaged by pressing an oversized red button in the center of the box, at which point the person reporting the emergency can engage in two-way communication with two "home base" locations. At Rockrimmon these locations are the clubhouse's front reception desk and the golf starter's office. But each facility may determine a different scheme, depending on its physical layout.

With prudent deployment, no area should be more than moments away from emergency call access. However, in addition to the "satellite" emergency communications, our club has regular phone lines that can connect two club locations and that have dial-out capabilities as well. These phones have been long stationed at fixed points on our golf course and are usually used for a variety of pedestrian and member-convenience reasons. But they also serve as a support to the emergency "satellite" system and can get aid to a victim just as quickly.

For the AED unit itself, periodic maintenance and inspection should be part of your program routine -- perhaps with reviews at the beginning, middle and end of the season.

Communicating the program
None of the training, deployment strategy or communications setup will matter if people don't know about your AED program and the support emergency services that you offer. The worst thing imaginable would be to have someone die from cardiac arrest because he or she, or others, did not know that life-saving assistance was only minutes away.

The only way to prevent a tragedy caused by a lack of knowledge is to promote your program aggressively throughout your facility. Two time-tested ways are club/organization mailings, usually at the outset of the golf season with reminders in subsequent seasons; and in club bulletin board postings, whether in the front lobby or near the entrances and exits of locker rooms.

Another valuable resource in spreading the word is member committees. We have found that keeping our various governing committees (green, golf, house, etc.) up to date on the program helps disseminate the facts among the entire membership.

In addition, we have developed a small emergency-notice placard that we place in every golf car that provides information on our entire safety program and identifies the emergency communication locations.

Liability concerns
In our increasingly litigious society, some facilities may be concerned about legal issues and use of AEDs. Often, increased capability means increased responsibility, which sometimes brings the fear of increased liability for facilities enacting an AED program. The main question in this regard is, "Can I or my facility be, in any way, held liable for someone's death or injury in properly administering AED emergency care?"

Thankfully, the answer is no. Most states have enacted some form of a "good Samaritan" law, which removes liability from those legally trained to administer a variety of first-aid measures, AED assistance among them. A federal law, titled "The Cardiac Arrest Survival Act," is pending before Congress. It would further insulate aid providers from litigation.

To date, no known suits or compensation claims have been brought against any individual or organization for emergency aid rendered with an AED unit. In fact, the growing volume of cases in both civil and criminal law are indicating that courts would be more likely to hear suits against those who do not provide safety options such as an AED to the people who use the facility. Legal considerations and possible ramifications should not be a deterrent to getting an AED program installed at your golf facility.

A small price to pay. . .
Selecting an AED unit is a fairly straightforward procedure. There are three principal manufacturers who distribute the unit: HP Heartstream's Forerunner, Physio-Control's Lifepak and Survivalink's FirstSave. All three meet FDA guidelines and standards, and all have similar features. The choice can be based solely on the system you believe works best for the needs of your facility. Most units cost about $3,000, a small price to pay for someone's life.

The Automatic External Defibrillator is a cutting-edge piece of technology that allows laypersons to save the life of another at a place where statistics show a high incidence of cardiac arrest. It is an efficient, accurate and time-tested piece of medical equipment that, when integrated into a well-developed program, can mean the crucial difference between life and death.

Anthony Girardi is CGCS at Rockrimmon CC in Stamford, Conn., and a 10-year GCSAA member. He presented this information at the Innovative Superintendent Sessions at the New Orleans conference and show. The American Heart Association and Golf Digest's Links for Life campaign provided some of the information in the presentation and article. GCSAA is a member of the Links for Life coalition.