Defibrillator here, defibrillator there, defibrillator everywhere

Response time is fast, but not fast enough;
What about value for money?

By Graham Furness

The defibrillator is just the kind of medical wonder weapon that patients love. Nothing could be more telegenic than the doctor's shout of "clear!" followed by the reassuring blip from the monitor as the heart springs back to life. It's perhaps a mercy that most people don't know the grim prognosis facing those who suffer heart attacks away from medical help.

In recent years, several countries have experimented with the idea of giving automatic defibrillators to police and firemen, and even installing them in public places to be used by the public if they witness a heart attack. But two studies in the British Medical Journal (BMJ) have thrown cold water on this attractive solution.

In Amsterdam, researchers issued automatic defibrillators to police and firemen, reasoning that they would usually reach the scene of a heart attack before a trained ambulance crew. Automatic defibrillators listen to the rhythm of fibrillation, using software to decide whether it is a shockable case.

The defibrillators performed as expected, but gains in survival were insignificant, mainly because the researchers' assumptions about faster response time from police and firemen turned out to be false. While all three types of emergency vehicles were impressively fast at arriving on the scene, critical moments were wasted before witnesses called in the heart attack, and while the dispatchers decided how to react. Since the chance of surviving ventricular fibrillation decreases by about 15% per minute, this lost time usually proved fatal.

One proposed solution to the problem of reaction time is to distribute automatic defibrillators in public places, but Scottish research in the December 2003 issue of the BMJ suggests this is not a cost-effective strategy. They studied the hypothetical costs of installing defibrillators in 17 airports, bus and train stations and gathered data on heart attacks suffered at those locations and throughout Scotland in general.

Unfortunately, scope for improvement is limited in these locations because it is in such public places that response from ambulances is already fastest. Moreover, even if defibrillators were as common as fire extinguishers, only one in five heart attacks would occur near enough to a defibrillator to make a difference.

With defibrillators costing over $5,000 apiece, distributing them at transport centres would save one quality-adjusted year of life for every $94,500 spent, say the researchers. That exceeds the unofficial minimum value-for-money limit of Britain's National Health Service, which is $69,000 per quality-adjusted year of life gained. The researchers conclude there are better ways to spend the money. Their proposed solution? Give automatic defibrillators to policemen.