The Next City Laura Pratt
September 21, 1998
THROUGH THE USUAL GAMBLING NOISE, CAROLYN MCCLOUD HEARD THE SOUNDS of a commotion. An old hand at betting establishments, McCloud knew that fights frequently broke out, so she barely looked up from her slot machine. But when her friend stood on a stool for a better view and said, “Carol, that’s no fight. There’s someone down,” McCloud guessed that her husband was in trouble. She jumped out of her seat and ran, weaving around gaming tables and pushing through a sea of gawkers. Billie McCloud, who had had an artificial aortic valve installed after the last of his three triple bypasses, lay on the floor staring straight up, his eyes fixed and his skin grey blue. She saw a man breathe into Mr. McCloud’s mouth, saw his chest rise and fall. Someone said, “Get her out of here, he’s gone,” and then Mrs. McCloud fainted. When she came to, both she and her husband were at the Hôtel-Dieu Grace Hospital in Windsor, Ontario. Mr. McCloud was hooked to a respirator and still a little blue, but he was alive. The employees at Casino Windsor had brought this 64-year-old retired autoworker, visiting from “just across the river” in Michigan, back from death three times with their new semi-automatic cardiac defibrillator. If he had been tugging at the slot machines of almost any other North American casino on that day in April 1996, Mr. McCloud — who doesn’t recall whether he was winning that night — would be dead right now. “There’s all kinds of luck in the world,” Mrs. McCloud says. “Not just money.”
The definitive textbook, Fighting Heart Disease and Stroke: Advanced Cardiac Life Support, calls early defibrillation a cardiac arrest victim’s most important link in the chain of survival and recommends that automatic external defibrillators be widely available for appropriately trained people. In other words, nurses, paramedics, and fire fighters — as well as anyone else with defibrillator training — should have access to those electric shock paddles the doctors on ER get such a charge out of. It’s a risky idea. But, says Ross McLeod, a Toronto sociologist turned businessman, ignoring this idea is riskier still to the Billie McCloud’s across the country.
From an east-end office lined with books such as Martin’s Annual Criminal Code and The Logic of Social Systems, along with a party-size box of Milk-Bones for his huge rottweiler, he discusses his plan to transform the staff of his security firm, Intelligarde International, into “Medigardes.” “We take our mandate quite broadly,” he says. “We’re in the protection business, and this is part of protection.” McLeod believes the apartment complexes, office towers, and shopping centres his company protects will welcome the value added of having on-site defibrillators and trained personnel for an extra two dollars an hour. “The winner will be the public,” he says. “If the guard in your lobby can either be trained in cardiac defibrillation or not, which would you choose?”
Once people accept the prospect of a security guard delivering a shock to a fallen executive on an office building’s 22nd floor, McLeod would like to extend defibrillation training to everyone — flight attendants, long-distance bus drivers, transit employees, lifeguards, and teachers. “Eventually, cardiac defibrillators will be as common as fire extinguishers, and boy scouts will be trained in how to use them.”
Last spring, McLeod consulted Dr. Kenneth Melvin, staff cardiologist at the Sunnybrook & Women’s College Health Sciences Centre, about the legalities and technicalities of his plan. Dr. Melvin believes that once operators are well trained and appropriately certified, McLeod may have “something very big to offer people.”
MEDICAL PROFESSIONALS HAIL THE CARDIAC DEFIBRILLATOR AS ONE OF THE 20th century’s most important lifesaving inventions: The powerful shock it delivers to the heart muscle is the only consistent way to re-establish a pulse in victims of cardiac ventricular fibrillation, a severe heart attack that leads to cardiac arrest. Most Canadian ambulances carry automatic external defibrillators (AEDs), but relatively few fire trucks do. Yet many are realizing the benefits of training fire fighters, who are often sent in dire medical emergencies. While ambulances take 6 minutes in Toronto and 8.5 minutes in Vancouver to respond to a 911 call, those cities’ fire fighters take only about 3.5 minutes. Extenuating factors such as vehicle trouble and lost drivers can lengthen the wait: Because of heavy traffic, an ambulance took 20 minutes to reach René Lévesque, who died in 1987 from a heart attack at home.
Although heart disease’s morbidity and mortality rates have declined in the past 20 years, it remains the leading cause of death, giving heart attack victims a grim survival rate. A heart that goes into ventricular fibrillation can lead to brain damage after 4 minutes. When the heart goes into ventricular fibrillation, there is only a 10-minute window in which it is treatable. And for each passing minute, the chance of survival declines by up to 10 per cent.
When Hamilton, Ontario, outfitted its fire department with cardiac defibrillators in 1989, that city’s cardiac arrest survival rate jumped by 50 per cent — from 12 to 19 per cent. Dr. Rick Verbeek, the medical director for the Toronto ambulance and fire services’ semi-automatic defibrillation program, says, “There’s no doubt in my mind that, if I had a heart attack in the street, and I could be assured that I was going to get safe defibrillation, I would want it as soon as possible. With public access defibrillation, you would definitely have people walking the streets tomorrow who wouldn’t have been.”
Because cardiac defibrillation does carry some risk, the medical colleges’ protocol requires that operators be approved by a physician, serving as a particular geographic territory’s medical director. Canada’s colleges of physicians and surgeons tacitly support doctors training nurses, fire fighters, and paramedics to use cardiac defibrillation, without expressly naming these personnel categories, so that conceivably a physician could legitimately certify civilians as well. A spokesperson from the College of Physicians and Surgeons of Ontario said that civilian cardiac defibrillation is “not a big deal” to them, but refused to offer an official opinion.
As for finding doctors willing to put their licences on the line to train a gaggle of Medigardes, most physicians don’t anticipate a problem. “A lot of us in the medical community right now would embrace this,” says Dr. Michael Murray, president of the Canadian Association of Emergency Physicians and a doctor at the Royal Victoria Hospital in Barrie, Ontario. And with no limit to the number of operators a doctor can approve, a large security company could theoretically operate under the auspices of just one physician. Besides, it could mean a few more dollars to spend at the golf shop: “Many physicians augment their income by doing private things such as insurance and legal work,” points out Dr. Melvin. “This could become one of those avenues.”
JUST OUTSIDE AN UNSIGHTLY, SCORCHED BUILDING — the Etobicoke Training and Development Centre — seven Toronto fire fighters are training to become cardiac defibrillation instructors. With “Vanessa” tattooed on one of his massive forearms and “Annette” on the other, one fire fighter kneels beside a rubber dummy and applies adhesive defibrillation pads to its chest. The Heartstart machine’s disembodied voice instructs him to “Check pulse,” to “Stand clear,” and, occasionally, bursts into an alarmed imperative to “Check patient! Check patient!”
Although a buzz has surrounded civilian cardiac defibrillation for several years, defibrillators’ complicated technology made its realization impossible until recently. In the early days, defibrillators were too cumbersome for public use and had a readout that only a cardiologist could interpret. According to Dr. Graham Nichol, a University of Ottawa general internist and clinical epidemiologist who’s studied public access defibrillation for four years, “people have always thought it was too complicated. But they’re increasingly recognizing that this is actually a simple task.” Indeed, certification on a cardiac defibrillator requires only a three-hour course. “In my opinion,” says Dr. Verbeek, “someone from the public could learn to use this as easily as they could learn CPR.”
But even the movement’s loudest proponents do offer a word of caution. “You could,” says Dr. Melvin, “make a bad situation infinitely worse” by applying defibrillators to people who have simply fainted or blacked out because of an insulin reaction or a drug overdose. “It’s not so much knowing how to use the machine,” says Dr. Verbeek. “The much more difficult thing is knowing when to use it.” Bystanders can also unwittingly touch the patient receiving a shock, get thrown across the room and, occasionally, lose their own heart rhythms in the process. Although safeguards should ensure that the machines will fire only on patients in shockable rhythms, “nothing,” intones Dr. Nichol, “is perfect.”
A FEW EARLY MODELS OF CIVILIAN CARDIAC DEFIBRILLATION ARE ALREADY operating across the continent, including Casino Windsor’s setup, which Dr. David Paterson started in May 1996. Calgary’s City Hall has a new defibrillator and a handful of people trained to use it, and the Indianapolis Colts carry a defibrillator wherever they go. In March 1996, Skyservice, a licensed Canadian international air carrier, became the first North American airline to adopt an on-board defibrillation service. Qantas, Virgin Atlantic, and Air Zimbabwe have followed suit, and, last summer, American Airlines joined them by adding defibrillators to 40 per cent of its fleet — 262 planes — and training 2,300 crew members in their use.
Since one AED unit costs about $4,000, and training fees add to the bill, cost has slowed their adoption. “If the health ministries would have to pay to put one in every phone booth — because there’s talk of them being that common — that could be quite a burden,” says Dr. Ian Stiell, an associate professor at the University of Ottawa’s emergency medicine division. McLeod plans to pass on the devices’ cost, in small doses, to property managers. Besides, points out this 52-year-old Montreal native, “people who lie on their office floor waiting for a paramedic to defibrillate them suffer major organ damage and, if they survive, soak up a tremendous amount of resources in intensive care and rehabilitation. The government must ultimately be interested in a program that would reduce the morbidity, particularly if that program is going to be funded by the private sector.” He also predicts that defibrillator prices could plummet to $500 as demand increases.
FIVE YEARS AGO, MCLEOD, A FORMER ACADEMIC WHO MIGHT seem out of place in the blue-collar world of security, told his Medigardes idea to a few buddies in the security business, talked to a couple of medical professionals, and came away convinced it could be done. About two years later, he put a paramedic from Metro Toronto Ambulance on his payroll and worked with him, 25 hours a week for a full year, developing a training course. Next, McLeod gathered information about the equipment and contacted Metro Toronto Ambulance, who agreed to alert Intelligarde International security staff of medical emergencies in the buildings they guard, an arrangement that could slash response times. Then, he applied to Ontario’s Ministry of Health for a small grant to run a pilot project. “The ministry said, basically, ‘Go away,'” McLeod says. And his insurance company added insult to injury by declining to insure his venture. Since then, he’s had a breakthrough: Hewlett Packard, the manufacturer of McLeod’s defibrillators, has agreed to indemnify all its users. Although McLeod continues to lobby his local insurers, he can now proceed without their blessing.
In the meantime, McLeod trained eight officers. “It would just be nonsensical not to do it. Think if your dad was lying out there on the sidewalk and a security guard could save him, but, just because he couldn’t get insurance, he wouldn’t do it. I feel the weight of history on my side. What we’re advocating is new here but not elsewhere. We’re just bringing news of success in distant kingdoms home.”
Last September, another man, a 70-year-old Californian visiting relatives in the area, went into cardiac fibrillation in front of a slot machine at Casino Windsor. The nurses and security guards arrived at the scene in a heartbeat. When the fully revived victim reached the hospital, doctors told him that he wouldn’t have survived without the prompt defibrillation. “I can imagine they’re a lot of money and that it’s a scary idea to equip regular people with these things,” says Carolyn McCloud. “But if they save even one life, they’re worth it.”