They used a different brand: Defibrillators

In yesterday’s story, Dave described how he was brought back to life by a mix of competent providers at two Wisconsin hospitals, loving family members, automated electronic defibrillation (AED) and cardiopulmonary resuscitation (CPR).

The technology helped to save Dave’s life – and yet there is still great room for improvement.

Troy Betts, now a nurse manager in another hospital, was working in the Emergency Room of a Wisconsin hospital five years ago when paramedics brought in a man whose heart had been restarted by a defibrillator. Hospital nurses had to change the chest pads on the patient’s defibrillator because of a compatibility issue: the paramedics used a different brand of defibrillator. When the nurses changed the pads, the patient died.

Emergency workers later told Troy more stories of patients who died after their chest pads were switched, causing the patients to lose the electricity that had been regulating their erratic heartbeats. Heart attack patients frequently face two or three pad switches en route to the Emergency Room. Different businesses, schools, malls and other public places often use brands of AEDs that are incompatible with the ones used by paramedics and hospitals. And if police and Med Flight are involved, "it’s not unheard of to have four or five changes," Troy said.

But the pads’ likely role in their deaths generally remains unknown. "Most reports just say the heart stopped," Troy said.

Troy saw an error, and then took initiative to learn its root causes through talking with colleagues. The solution lies in standardization – a particularly difficult challenge when it requires either government policy or a formal decision by a professional association to coordinate action among competing vendors and healthcare provider organizations.

Advice for healthcare providers: When facing a problem this tragic and knotty, the best thing you can do may be to tell your story publicly, to rouse others to act.

Read Dave’s story, told here yesterday, and the source story by David Wahlberg in the Wisconsin State Journal of June 25.