AED vs. ET – Where is the money better spent?

by Charles E. Truthan, D.O., FACOFP
Copyright 1998 by FD Doc®

aka: Doc T

The American Heart Association is a highly respected organization in the minds of the medical profession and the lay public as well. They have earned this well deserved reputation. The American Heart Association has a well-defined and very specific goal: to reduce mortality and morbidity associated with heart disease.

The American Heart Association has done a marvelous job in research and education. Education of not only the lay public, but the medical profession (including Emergency Medical Service [EMS] personnel) as well. Nearly everyone who reads this article is familiar with Cardio-Pulmonary Resuscitation (CPR) and Advanced Cardiac Life Support (ACLS). No one will deny that the American Heart Association has had a tremendous impact on the improvement of EMS care, both in the hospital and on the streets. They continue to perform research to reduce the risk of heart attacks, increase access to EMS, and yes, to continually revise (to the despair of most of us) the algorithms for ACLS.

When ACLS was first introduced back in 1974 or so, there was a great deal of discussion as to whether or not "non-medical" personnel (read EMT’s) should be allowed to take the course. ACLS was originally designed for physicians only. However, the "cook book" approach to treating acute cardiac conditions, was simply to compelling to be denied to out-of-hospital EMS personnel. Thank goodness for that, as it has undoubtedly saved countless lives and significantly reduced morbidity.

No one can mount any reasonable argument that the American Heart Association is not improving the heart health of this country’s citizens. In fact, it is the fore leader for the world in heart standards.

We need to constantly remember, however, that the American Heart Association is emphasizing one organ, and one organ only, the heart.

This is what the American Heart Association exists for, period. It does not exist for the care of trauma patients. It does not exist for the care of acute asthmatics. It does not exist for the care of fulminate pulmonary edema patients. It does address airway care, but only for heart patients. It naturally follows then, that the American Heart Association will lobby heavily for universal access to CPR and Automatic External Defibrillators (AED). I commend them for their (successful) efforts.

What we must question is the cost effectiveness of their efforts. Do we, as a nation, get the "biggest bang for the buck" in training personnel and equipping police vehicles, ambulances and fire trucks with AEDs that cost an average of $7,500? Is there some other piece of equipment that is equally effective, or a more vital skill or procedure that may better the care of ALL critical patients, not just heart patients, that require EMS intervention? I submit that yes, there is a procedure that is far less expensive, easily learned and will be a positive intervention in a far greater number of patients than an AED. That procedure is one that obtains a patent airway (not just an "open" airway). This procedure is endotracheal (ET) intubation.

Endotracheal intubation provides a patent airway for all cardiac arrest patients. It is an essential life saving procedure in the management of patients who have suffered inhalation burns and burns to the face and neck. It is also essential in managing patients in fulminate pulmonary edema and frequently makes the difference between mortality and morbidity in trauma patients.

Let us take a look at Kent County in state of Michigan and determine the costs to equip the law enforcement vehicles and the fire department (first responder only) vehicles. From figure one, we find that there are 177 law enforcement vehicles (not counted are unmarked or detective vehicles that do not routinely respond to emergency scenes) in eleven departments. There are thirty fire departments in Kent County. Let us assume that only one vehicle per fire department will be similarly equipped. That gives us a total of 207 AED units that would need to be purchased and maintained for the 536,100 residents in the 864 square miles of Kent County. With an average cost of $7,500 per AED, that comes to $1,552,500. This does not include the costs of training the 776 Law Enforcement Officers and the 1,036 Firefighters. We shall assume that the training time for each procedure is equal, and therefore cancels out for the sake of our comparisons.

Now let us look at the costs of equipping these same vehicles with a "complete" endotracheal intubation kit. This type of kit averages $179, which includes a container to hold everything neatly in place. That comes to $37,053 to equip all 204 vehicles, or just 2% of the AED cost. The cost to equip the 1,829 police officers and firefighters in Kent County with their own personal ET kits ($327,391) is still only 21% of the cost to equip just the 207 police and fire vehicles in Kent County with AEDs. Let us take this one step further and purchase every fire department and law enforcement agency (adult and child) endotracheal manikins at $1,750 per department (total = $71,750). Putting this all together ($108,803) is still only 7% of the cost to equip the vehicles with AEDs (or $399,141 [26%] to equip every firefighter and police officer).

So, there we have the numbers for Kent County, Michigan. Those are some amazing, and mind boggling figures, and just for one county in one state. The problem is that the American Heart Association wants to do this nationwide. I have had some trouble coming up with the exact numbers, but "ballpark" numbers come out to 1,000,000 firefighters in approximately 36,000 fire departments and 750,000 police officers in 10,500 police departments with approximately 165,500 police vehicles. Let’s look at the numbers in Figure 3.

By using the same labels from figure 2, and inserting the National "guesstimates", we find that as a country, for just 26% of the cost to equip all police vehicles and one fire vehicle per department with an AED, we can equip every firefighter and police officer in the United States of America with endotracheal intubation equipment and provide every police department and fire department with adult and pediatric intubation training manikins. Further, let us not forget that we are not even considering the purchase of any training manikins for the AED units. Being more realistic, equipping the same vehicles with an ET kit and each department the needed training manikins is an astounding 8% of the cost of equipping those vehicles with AEDs.

The American Heart Association’s goal, of an "AED in every police car and fire truck", will cost this country 1.5 billion dollars. To equip every police car and one fire truck per department with the equipment necessary for endotracheal intubation and training manikins for every individual department, the cost is only 117 million dollars. That is only eight percent the cost of the AED.

There is no data available on the number of lives that could be saved with early endotracheal intubation. I am sure, however, that if EMT’s were asked to compare the number of times they wished they could establish a patent airway by endotracheal intubation verses an open airway and having an AED available, there would be a significantly greater number for the patent airway. After all, virtually every cardiac arrest patient needs a patent airway.

In summary, the American Heart Association does a wonderful job at promoting their heart agenda. They provide excellent training and research into heart disease. But their interest is in the heart and nothing but the heart. There are a significantly greater number of lives that could be saved, and the morbidity lessened in even more, if we were to insist on early endotracheal tube intervention on all appropriate cases. So, let us exhibit some financial responsibility and common sense in how to spend our limited health care dollars.

Doc T.

Charles E. Truthan, DO, FACOFP
President & Medical Director, F.D. Doc ®
25 Years Fire Service Experience
Member of Advisory Board, The American Firefighter

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