Had they been elsewhere, it is unlikely they would have survived. Few places have the easy-to-use devices for shocking the heart - automatic external defibrillators (AED).
These devices, the American Heart Association says, could save 50,000 lives a year, five times the number now being saved, if more of them were in airports and airplanes, office buildings, sports arenas, gyms, golf courses, train stations, office buildings and other places where large numbers of people gather.
In the last five years - since defibrillators became small enough, cheap enough, and foolproof enough for anyone to use - the devices have increasingly been viewed as a critical public-health advance.
The FAA has ordered airlines to put the devices on airplanes within three years. Last year, 64 passengers died in the air of cardiac arrests; only four people were saved because so few airplanes carry AEDs.
Congress has passed a bill, expected to be signed by President Clinton, that would urge departments to put AEDs into federal buildings and extend Good Samaritan laws to protect people who use them from being sued if something goes wrong.
Courts are beginning to hold groups liable if someone dies because no AED was available when needed. One airline was ordered to pay $2.7 million and an amusement park, $350,000.
Yet it has been largely through the determination of individuals - not mandates - that AEDs are taking hold.
Many lives are being saved in Chicago's airports because Sherry Caffrey, a 27-year-old paramedic trainer, developed a plan to distribute AEDs throughout the terminals.
Casinos have the devices now because one man argued in their favor for 11/2 years. And all police cars in central Bucks and eastern Montgomery Counties have them because Mark Rosenthal, an Abington cardiologist, pressed for their use and his hospital raised the money to buy the AEDs.
Although AEDs are popping up everywhere, there are still many places where the devices are conspicuously absent. Philadelphia's police cars do not carry AEDs. Philadelphia International Airport has no units inside the terminal. Most office buildings and high-rises do not have them, according to the American Heart Association.
The city's sports arenas and the Convention Center have no installed AEDs. Instead, the buildings are covered by mobile paramedic units in accordance with Pennsylvania regulations, which require that crowds be covered by paramedics who carry defibrillators. A crowd of 10,000 requires one ambulance with a defibrillator; 60,000 people get three ambulances with three defibrillators and one emergency physician.
In Philadelphia, the Fire Department has primary responsibility for responding to cardiac arrests. Ralph Halper, chief of the department's emergency medical services, said all firefighters were trained in cardiopulmonary resuscitation and defibrillators were in all of the department's 90 vehicles, including fire trucks, which respond to cardiac arrests if they are closer to the victim than rescue vehicles.
Halper said the department averaged four to six minutes in responding to a call, which is barely within the window that defibrillation is likely to work. And this does not include the time it takes for someone to call for help, for the dispatcher to ascertain the nature and location of the call, or for the firefighters to get from theirvehicle to the victim, which can take several minutes in high-rises or busy stores.
As a result, fewer than 5 percent of cardiac-arrest victims in Philadelphia are saved.
In Las Vegas casinos, the save rate is 57 percent. That is because the casinos do not have to depend on swift ambulance response - AEDs are widely distributed, and casino guards are trained to act quickly.
Since AEDs were put into the casinos three years ago, 116 of the 204 people who suffered cardiac arrest were saved.
Among the nine people saved at Harrah's in Atlantic City was Tony Pancari, 69, one of the 170 security officers trained to use the 12 AEDs distributed throughout the sprawling casino.
Pancari, who has a history of heart disease, was standing in the security office at 8 a.m. Jan. 17, only a few yards from an AED, when he complained about the cold weather and collapsed.
Within seconds, his colleagues, including Mark Faison and Jim Cahill, were ripping off his shirt and applying the electrodes. Cahill, 23, who had resuscitated a half dozen people in the casino, pushed the button on the AED and saved him.
"I love this life, and I love that machine," Pancari said recently. "I've carried that thing a lot of times but never thought I'd need it for myself."
After his rescue, doctors determined that Pancari was vulnerable to lethal heart rhythms and implanted in his chest an automatic defibrillator that would stop abnormal rhythms the moment they occurred.
Most resuscitated cardiac-arrest victims, however, are treated with drugs or heart surgery, but some do not even require additional care.
No medical emergency requires a more urgent response than cardiac arrest. It is the final stage of a heart attack or the result of a rare misfiring of the heart's electrical system. Usually, there is no warning when the heart misfires; the first symptom is death.
With its electrical system disrupted, the heart's left ventricle goes into fibrillation. Instead of pumping blood, it shudders wildly. The heart quivers like jelly, and blood flow to the brain ceases.
Within 10 seconds, the victim loses consciousness. Within two to three minutes, the brain starts dying. After 10 minutes, brain damage is almost always irreversible. With every passing minute after the victim collapses, the likelihood that defibrillation will be successful decreases by 7 to 10 percent.
Passersby can forestall this for a few minutes with CPR - by rhythmically pressing on the victim's chest, forcing blood to the brain and heart. But only a shock from a defibrillator will stop the wild, useless beating of the heart. Sixty to 80 percent of victims have the type of arrhythmia that can be corrected with a shock.
If defibrillation is done within a minute of the arrest, it alone may revive the patient. If defibrillation happens after one minute of the arrest, a brief period of CPR is usually also needed to restore blood flow.
In 1996, Sherry Caffrey, a paramedic dispatcher, was asked to see what could be done about cardiac arrests in Chicago's airports. Mayor Richard M. Daley's wife, Maggie, had seen someone collapse from cardiac arrest and die in O'Hare International and urged her husband to install AEDs.
Caffrey walked through Midway and O'Hare airports with a stopwatch, ordering placement of 49 defibrillators so no victim would be more than a minute away from one.
The devices are mounted on walls in plainly marked boxes. When the cabinet is opened, an alarm sounds, alerting any medically trained people in the vicinity, while police and paramedics are summoned.
The program was launched in June 1999. Airlines paid the $500,000 cost. Less than two months later, a 72-year-old man was saved by, of all people, Caffrey. He collapsed 10 feet from where she was checking out the new equipment.
The defibrillators have now been used on 12 people, and nine have been saved.
Airports are one of the most likely spots for sudden death. Researchers do not know why but assume it is because there are so many people, many out of shape and under emotional stress, who are overexerting themselves by rushing to catch airplanes while carrying heavy bags.
A spokesman for Philadelphia International Airport, which has no numbers on cardiac arrests at the facility, said that this fall the airport would consider whether to install the devices. The airport is served by a single fire-paramedic unit stationed there.
The person responsible for bringing AEDs into casinos is Richard Hardman, emergency-medical-service training coordinator for the Clark County Fire Department, which covers Las Vegas.
After witnessing one failed resuscitation attempt after another as a paramedic, Hardman determined that 64 percent of cardiac arrests happened in gambling halls. He lobbied the casinos relentlessly and got his first casino to sign on in March 1997.
Now, 73 Las Vegas casinos have the devices.
Twelve years ago, the Tredyffrin Police Department in Chester County became one of the first to equip patrol cars with AEDs because of three men - James McCorry, at the time an emergency-room physician at Paoli Memorial Hospital; Mark Ralston, a paramedic and administrator of Jefferson Health Ambulance; and Thomas Baynard, formerly Tredyffrin's police superintendent.
They teamed up to raise $50,000 from local businesses to buy five AEDs, when the cost and weight were three times more than they are now. Since then, six lives have been saved.
Leon Andersen, a New York cardiologist who retired in Lancaster County, spearheaded a drive five years ago to put an AED in every patrol car in every one of that county's 33 police departments.
With the support of the Lancaster Heart Foundation, which finances research and related activities, Andersen, 73, raised $600,000 to buy 300 AEDs. Thirty-two people have been saved with the devices, including a 26-year-old woman who collapsed on a club dance floor.
Rosenthal, director of cardiac electrophysiology at Abington Memorial Hospital, did the same thing in Bucks and Montgomery Counties. As a specialist in the very condition that was killing so many people, Rosenthal knows firsthand how easy it is to calm a fibrillating heart and the tragedy that results when no defibrillator is available.
Responding to Rosenthal's entreaties, Abington Memorial Hospital raised $250,000 in donations and bought 117 AEDs. On Valentine's Day, the devices were given to 26 police departments in central Bucks and eastern Montgomery Counties. Every patrol car has one.
In December, Kravco Co. provided AEDs to malls it operates in the region - Oxford Valley, King of Prussia, Deptford, Montgomery and Lehigh Valley malls in Pennsylvania and the Hamilton and Quaker Bridge malls in New Jersey.
Largely through the efforts of the American Red Cross in Philadelphia, AEDs and resuscitation training have been provided to the bottling company Crown, Cork & Seal, the local and nationwide law offices of Cozen & O'Connor, Shops at the Bellevue, Loews Hotel and the Philadelphia Water Department.
Paul E. Pepe, an international authority on cardiac-arrest resuscitation and chairman of the emergency-medicine department at the University of Texas Southwestern Medical Center, thinks the American Heart Association goal to save 50,000 lives a year is conservative. He said significantly more people than that could be saved if most people were trained in CPR and AEDs were easily available.
"When they get cheap and small enough, we should have AEDs everywhere," Pepe said. "They should be as common as fire extinguishers. We put sprinkler systems in buildings even though the risk of fire is very low."
AEDs cost $2,500 to $3,500 and are about the size of a laptop computer. Pepe said the price could drop to $250 within 10 years.
Although health insurance companies will not pay for AEDs, some individuals and families have started buying them.
Eric Swiggum, local territory manager for Survivalink, one of three companies with FDA-approved AEDs, said he had sold one to a family with a child who had heart disease, several wealthy people who equipped their limousines with the devices and trained the drivers in CPR, and someone who wanted one for his yacht.
If it is too costly to put AEDs everywhere, what is the most cost-effective way to use the devices?
In Seattle, where more than 50 percent of the city's residents know CPR and are trained to quickly call 911, public health officials studied that question.
They found that if 276 AEDs were put at the places with the most cardiac arrests (the airport, county jail, large shopping malls, sports stadiums, industrial sites, golf courses, shelters, ferry-train terminals, health clubs and senior centers), up to 32 lives could be saved in a five-year period.
At a minimum cost of $2,500 per AED, this would come to $690,000 - less than $22,000 per life saved.
The researchers thought it would cost too much to cover lower-incidence sites, such as restaurants, retail stores, hotels and government offices. This would require 71,000 AEDs at a cost of $177 million or about $2 million per life saved.
Yet some companies have found an investment of a few thousand dollars worthwhile if it gives employees the security of knowing that if they had a cardiac arrest, their lives could be saved.
But many have held back out of fear that they could be sued for a botched rescue attempt.
Susan O. Cassidy, a Connecticut lawyer specializing in health and disability issues, reviewed court cases involving AEDs and could not find any for the misuse of an AED.
The four suits she did find - against two airlines, an amusement park and an organization that held a large dance - were for not having AEDs or not using one when it was available.
Promoters of the little device see them as a major public-health advance.
If the devices were placed everywhere and the American Heart Association's goal of saving 50,000 lives a year was achieved, it would be the equivalent of eliminating murder, suicide, diabetes or AIDS as a killer.
Donald C. Drake's e-mail address is firstname.lastname@example.org
For More Information About Defibrillators
To learn about the nearest training courses for automatic external defibrillators (AEDs), go to the American Heart Association's Web site at www.cpr-ecc.americanheart.
org. Classes cost $40 to $50.
Or you can call the association's national number at 877-AHA-4CPR (877-242-4277), from 6 a.m. to midnight.
In New Jersey, call the association's Audubon office at 856-546-5600 for information about training and the "Links for Life" program, which is working to get AEDs on golf courses.
Companies, hotels, golf courses and other public venues wanting an on-site presentation about instituting resuscitation programs may contact:
Cyndee Hamm, the association's territory director for emergency coronary care, 610-940-9540.
Kathleen Cassidy, AED program specialist for the American Red Cross, 215-299-4032. Cassidy also will provide information to individuals who buy an AED or want to know the nearest location of a Red Cross affiliated CPR-AED training center.
To volunteer for Operation Heartbeat, an association program that trains volunteers to educate the public about cardiac arrest, contact Kristen McAloon, associate director of education for the association, at 610-940-9652.
The three FDA-approved AEDs on the market are:
FirstSave, from Survivalink. Cost: $3,000 to $4,000, depending on features; 7.4 pounds; 800-991-5465.
LifePak 500, from Medtronic Physio-Control. Cost: $3,200; 7 pounds; 800-442-1142, then choice number seven.
Heartstream FR2, from Agilent Technologies. Cost: $3,000 to $3,500; 4.7 pounds; 800-263-3342.
Individuals buying an AED must have a doctor's prescription, though the person does not have to have heart disease to qualify. Insurance companies do not pay for AEDs.
PHOTO AND CHART
Abington cardiologist Mark Rosenthal
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