AED DEFIBRILLATOR. What's the current thought?

[taitharris]

What is current first aid training thoughts on whether AED can be used aboard RIBs?

[Last Tango]

This is going to depend on the conditions in the RIB. If everything is swimming in salt water I could see issues with the unit not being able to analyse a "shock-able wave pattern" in which case it won't fire but more concerning is the risk of shocking someone else standing in a connected pool of water. The 150 joules that an AED delivers is in the form of around 1600 volts at about 30 amps. If everything is dry I don't see it being any different from using it in any other exposed location.

[willk]

Originally Posted by taitharris

What is current first aid training thoughts on whether AED can be used aboard RIBs?

There's a bit of debate going. The obvious concern is the salt water! The other that I recall is the amount of *stray* current around that may interfere with the sensor on the AED. I can offer no advice. RNLI don't currently (see what I did there?) carry them - and it's not the money that's holding them back!!!

[Last Tango]

Originally Posted by willk

The other that I recall is the amount of *stray* current around that may interfere with the sensor on the AED.

The units use differential analysis from the diffib pads to establish the ECG waveform and the filtering is very good. It's unlikely that it would shock someone who didn't need shocked as it has to see a recognisable VF waveform before it will charge & fire, and it's not going to mistake that with "noise" from stray currents. They are looking for around 50 ohms to establish the pads are properly connected to prevent burning so the ECG is generally well defined. However, I wouldn't use one if the patient is lying on a soaked deck, pretty dangerous.

[ShinyShoe]

Something makes me think Tower RNLI does have a defib, but possibly not intended for use afloat just as a convenient way to get it en scene without traffic.

It does surprise me that ALBs don't carry them. But perhaps they rarely have someone that critically ill inside in the dry on an ALB. If you go on a yacht and are doing CPR you are not going to transfer them back to the ALB as you'll want them helo'd off. shocking them on a yacht with confined space, wet gear etc will be a challenge.

Waterproofing the unit will also be an issue.

My sailing club has a defib. In the event of an incident (only been used once and wasn't actually a CPR job "just" a head injury with LOC) the casualty is brought to the slipway where the defib meets the casualty.

You are going to need to consider what your options might be...

[Andy_Rs600]

By way of background I'm a current A&E and pre-hospital doctor. This questions comes up a fair bit in water rescue scenarios. There are several issues regarding AED use in open boats and for those who don't want the war-and-peace version my advice would be there are FAR better things to spend that kind of money on. I own 2 defibs for my pre-hospital work, and neither ever comes on a RIB with me!

Issues as I see them:

1) Safety - if there is lots of water around is it fairly likely someone unintended will get a shock? Answer - yes, it's pretty likely. If there is a cardiac arrest in the boat I would suggest keeping the deck dry is going to be the lowest priority. Equally space will be extremely limited, and there are lots of bits of metal to provide other conduction pathways even without the water. Having said that if you read this:

https://www.ncbi.nlm.nih.gov/pubmed/18458166

you might well reach the conclusion that you likely won't feel the shock anyway, since these researchers connected themselves to a simulated patient by a metal return wire, and then shocked the simulator with their hand on the "patients" chest. Do not ask who they got to volunteer for the study...

2) Defib use - will an AED work reliably on a RIB? Answer - it will not be put off at all by the electronics on board. In my resus we have lights, mobile phones, PCs, tablets, other monitors, electric beds, pumps, etc. The only thing I can think of that might cause an issue is radar near the device. As already mentioned the filters are very good, and sophisticated. If they aren't sure what the rhythm is they will fail-safe to "No Shock". HOWEVER - Will the AED survive living in a RIB - I would imagine not! None of the devices I know of are anywhere near waterproof, and the designers clearly don't intend them to be stored anywhere near salt water. Down below on a boat with a dry cabin would probably be fine, but if you think it's going to live in the same locker as your flare pack and then work when you need it think again.

3) By far the biggest issue - are you ever going to use it effectively? Likely not. If you come across a cardiac arrest in an open power-boat of any kind the most likely causes are 1) drowning 2) hypothermia related to immersion and 3) trauma. I'd suggest that asthma and anaphylaxis are also a good bit more likely than a cardiac arrest caused by ischaemic heart disease. Generally all of the above (trauma, drowning, etc) other than heart disease will give a non-shockable rhythm - meaning the defib won't shock (correctly) and won't be of any use.

My boat's medical kit (when I finish building it) is going to fill a decent sized pelican case, and won't include a defib despite the fact I probably will put in a small portable cardiac monitor.

Just my opinion.

p.s. GMC number available on request.

[Poly]

Originally Posted by ShinyShoe

It does surprise me that ALBs don't carry them. But perhaps they rarely have someone that critically ill inside in the dry on an ALB.

If they know they are going to an "ill" patient or doing a medical transfer (e.g. from an island) they will usually take a local paramedic or doctor along, who comes with their own kit.

I am sure I recall seeing a "return on investment" calculation* of when it was worth putting in AED's. There were three criteria: (i) the ambulance would take longer than 5 minutes; (ii) the AED could be on scene in less than 5 minutes; (iii) it would be used at least once every 5 yrs. It will be exceptional that any lifeboat arrived within 5 minutes of the incident.

* they don't call it that - but its what they mean!

Originally Posted by Andy_Rs600

3) By far the biggest issue - are you ever going to use it effectively? Likely not. If you come across a cardiac arrest in an open power-boat of any kind the most likely causes are 1) drowning 2) hypothermia related to immersion and 3) trauma. I'd suggest that asthma and anaphylaxis are also a good bit more likely than a cardiac arrest caused by ischaemic heart disease. Generally all of the above (trauma, drowning, etc) other than heart disease will give a non-shockable rhythm - meaning the defib won't shock (correctly) and won't be of any use.

Andy - my gut feel was this was exactly the issue; but its nice to see some substance behind it.

I see a reasonable number of media reports of divers who are taken "unwell" (and sadly usually don't make it). I'm not a diver, and have always wondered if that was a simple "bend" [which as an outsider seems odd as divers know about such risks and issues] or if it was an underlying issue like a heart problem - perhaps exacerbated by exercise, pressure, temperature etc.? Not sure if you'd have a feel for that? Do you think there is any more sense for a club full of tubby middle aged divers than normal people?

I also have wondered with the increased emphasis on "Cold Shock" in recent years whether that actually brings about a "Heart Attack" as is sometimes suggested (and if they mean an MI - is it likely to result in a shockable rhythm if the casualty is recovered quickly).

Down below on a boat with a dry cabin would probably be fine,

ignoring the waterproofing I think the issue on a rib is the vibration/shock. Whilst obviously some AED's get thrown around by paramedics they are also regularly tested and faults will be picked up. On board a boat I can imagine they will be easily neglected.

There's been some work on AED's in poolside environments: https://www.ncbi.nlm.nih.gov/pubmed/12879378 http://r.think-safe.com/documents/De...al_surface.pdf which suggests the wet is not too much of an issue for rescuers/bystanders.

[Andy_Rs600]

Originally Posted by Poly

I see a reasonable number of media reports of divers who are taken "unwell" (and sadly usually don't make it). I'm not a diver, and have always wondered if that was a simple "bend" [which as an outsider seems odd as divers know about such risks and issues] or if it was an underlying issue like a heart problem - perhaps exacerbated by exercise, pressure, temperature etc.? Not sure if you'd have a feel for that? Do you think there is any more sense for a club full of tubby middle aged divers than normal people?

I also have wondered with the increased emphasis on "Cold Shock" in recent years whether that actually brings about a "Heart Attack" as is sometimes suggested (and if they mean an MI - is it likely to result in a shockable rhythm if the casualty is recovered quickly).

I think a lot of the diving incidents genuinely are bends - often caused by loss of buoyancy control and uncontrolled ascent, although there are the unlucky few who get bent diving within the tables/computer limits.

I would guess that medical cardiac arrests (as in - ischaemic heart disease type) are more common in the diving community due to average age, weight, diet and cold water immersion. Having said that if you go into VF at depth by the time you are recovered to the boat you will likely no longer be in a shockable rhythm, and if you ever return to one it will be after a hefty dose of IV adrenaline. Either way your chances are slim. As you said, you would have to recover the casualty quickly for them still to be shockable, and that is most likely in a casualty already on the surface (such as an MOB with a lifejacket).

Cold water immersion can certainly precipitate a shockable-rhythm (VF or VT) cardiac arrest. Sudden immersion in cold water increases heart rate, breathing rate and releases a lot of stress related chemicals (adrenaline, cortisol, etc). Coupled with that all your peripheral blood vessels constrict to preserve heat. This means you heart is trying to pump a lot harder against a suddenly increased resistance. If your heart is already a bit dodgy (technical term) then that can precipitate something bad... That badness is likely to be shockable initially (for a few minutes) so this is perhaps the only time I can think of that an AED might come in handy.

Originally Posted by Poly

ignoring the waterproofing I think the issue on a rib is the vibration/shock. Whilst obviously some AED's get thrown around by paramedics they are also regularly tested and faults will be picked up. On board a boat I can imagine they will be easily neglected.

Yep - the ones we use on ambulances get checked twice a day by the paramedics, and regularly by the support staff. They still break. I can't think of one that would like being in a RIB. Wrapped in bubble wrap inside a pelican case would be OK I imagine, but who's going to give up that much storage space for something you will use on average once every 28 lifetimes.

[Hf500]

Really don't think there is much I can add other than to say the RNLI have been pushing ( certainly at dive conferences ) for divers to consider getting their health checked professionally before diving. Commercially they must have a yearly medical but not for sports diving. If it drops the numbers of divers 'not making it' by one then it is worth it. Personally , if I have recovered a diver to a rib , they will be dripping wet with large puddles of water before having to cut off a dry suit and set up a defib ... the risk of shocking somebody else through the water is far too great.
Carry a really good first aid kit and know how to use it would be my advice to all.
( For what it's worth , I am a commercial diver and rib operator , have completed dive related first aid training including defibrillator stuff and my company never take our defibs on a boat )
Hope that helps

[Poly]

Originally Posted by Hf500

Carry a really good first aid kit

I'm always a bit sceptical about anyone with a really "good" first aid kit. There is very little in a first aid kit you will actually use for anything serious, and even less that can't be improvised. I tend to focus on the stuff that makes or breaks a day with the kids... plasters, paracetemol/calpol, etc.

and know how to use it would be my advice

That I would agree with - and understand the principles of what you are trying to achieve as learning rote fashion the correct treatment probably isn't going to apply well outside the comfort of a classroom.

[Hf500]

Originally Posted by Poly

I'm always a bit sceptical about anyone with a really "good" first aid kit. There is very little in a first aid kit you will actually use for anything serious, and even less that can't be improvised. I tend to focus on the stuff that makes or breaks a day with the kids... plasters, paracetemol/calpol, etc.

That I would agree with - and understand the principles of what you are trying to achieve as learning rote fashion the correct treatment probably isn't going to apply well outside the comfort of a classroom.

I suggested a really good first aid kit as the enquirer was discussing a defibrillator for a boat which is well beyond the contents of a basic first aid kit. Ultimately it depends on where you plan to go on your boat and who you can reasonably expect to be treating.
If you are going 20miles offshore you need to carry a lot more than if you are never further than 3miles from a safe haven etc etc.
Whatever works for each boat user that they are suitably trained to use.

[Pikey Dave]

I have the HSE 3 day FA at work card & the emphasis is very much on keeping the casualty alive until the experts arrive. The actual equipment required is minimal & could easily be carried in a pocket or small pouch. IMO, realistically the best you could hope to do in a RIB at sea is control bleeding. Looking at my boat, there's no way could I get a casualty in a position to perform CPR or into the recovery position, due to lack of floor space.

[willk]

Some interesting comments there - and somewhat cheering for me because I've quit diving and my "working" first aid kit is a Pelicase containing:

1. An Aldi vehicle first aid pouch
2. A CPR mask (full size)
3. Trauma Shears
4. A pulse oximeter
5. A Ventolin inhaler
6. An RNLI first aid diagnostic flow chart
7. Painkillers with codeine (for that last wee late drachm )

My CAT C kit has a few doses of Glyceryl trinitrate in it for the angina patients - but at £75 to open the kit, they'd want to be damn sure they were needing them

[Andy_Rs600]

Originally Posted by Poly

I'm always a bit sceptical about anyone with a really "good" first aid kit. There is very little in a first aid kit you will actually use for anything serious, and even less that can't be improvised. I tend to focus on the stuff that makes or breaks a day with the kids... plasters, paracetemol/calpol, etc.

This is often very true. A lot of the commercially available kits contains loads of dressings that can easily be improvised, and not much else. Having said that there are things you can't improvise and wont have on a boat. £50 spent on a "really really bad day" first aid kit is probably not a bad idea, especially if you are on the Scottish coast, out at night, or going any distance offshore. Things that keep people alive and you can't make/steal really are 2 good tourniquets, an epi-pen, means to keep a casualty warm, and perhaps a pocket mask for doing ventilation if you do have a cardiac/respiratory arrest on board.

Most of the times you're going to open your kit are, like Poly says, for simple painkillers, plasters, tape, ices packs, etc

[Poly]

Originally Posted by Andy_Rs600

Things that keep people alive and you can't make/steal really are 2 good tourniquets,

interestingly I don't think that is generally taught on ordinary first aid courses, however clearly it could make a difference in a really nasty incident. I've never seen tourniquets in any "public" first aid kit - would some rope (and twisting with something like a screwdriver to get it tight) not be an easy improvisation on a boat?

an epi-pen,

are these available OTC for members of the public? None of my regular crew have known allergies so not something I'd have bothered about.

means to keep a casualty warm,

certainly although the foil in most FA kits is of minimal value. My preferred approach is a small KISU/bothy bag, as I've used them in anger effectively.

[Hf500]

It most definitely isn't taught on ordinary first aid courses due to the high risk of subsequent amputation. ( I'm sure Andy will be able to advise ) By my understand tourniquets are taught to non medical professionals on enhanced first aid courses for people who will be operating in remote locations e.g. jungles , mountains and properly offshore. Basically anywhere medical help cannot get within a reasonable time.
Epipens are great for anaphylactic shock but you need a prescription for them.
Ultimately take what you need to deal with whatever you can reasonably expect to encounter and be trained in its use. If you are taking your children local trips then a first aid course and whatever kit works for you. Simples. I

[Tim M]

Originally Posted by Poly

I'm always a bit sceptical about anyone with a really "good" first aid kit. There is very little in a first aid kit you will actually use for anything serious, and even less that can't be improvised. I tend to focus on the stuff that makes or breaks a day with the kids... plasters, paracetemol/calpol, etc.

Totally agree with that, and that's the principal I've always taught teaching powerboat courses. I work on the basis in a RIB that if it's anything worse than something really basic like a small cut or graze, headache or seasickness we're going to need outside assistance, in which case we'll either head ashore or call in outside assistance asap.

The worst injury I've encountered on a small open boat was somebody who ended up with a broken collarbone. In this situation we made her comfortable and decided to proceed back to base as swiftly as we could given the situation. We didn't touch the first aid kit. An example of the above principal.

I'm currently working on a 155ft vessel that makes some reasonable offshore passages. We carry a pretty comprehensive medical kit but an AED isn't on that list.

[John Kennett]

Originally Posted by Poly

interestingly I don't think that is generally taught on ordinary first aid courses, however clearly it could make a difference in a really nasty incident. I've never seen tourniquets in any "public" first aid kit - would some rope (and twisting with something like a screwdriver to get it tight) not be an easy improvisation on a boat?

Tourniquets are back in these days, and are routinely covered on outdoorsy first aid courses (not paper-cut FAAW courses, but not just expedition medic level). Apparently its due to the trauma care trials that military medics have done over the last few years. The Combt Application Tourniquet (CAT) seems to be the most popular.

Apparently it's quite difficult to improvise anything that will work efficiently enough to be worthwhile.

[Andy_Rs600]

Originally Posted by John Kennett

Tourniquets are back in these days, and are routinely covered on outdoorsy first aid courses (not paper-cut FAAW courses, but not just expedition medic level). Apparently its due to the trauma care trials that military medics have done over the last few years. The Combat Application Tourniquet (CAT) seems to be the most popular.

Apparently it's quite difficult to improvise anything that will work efficiently enough to be worthwhile.

This...

It's actually very difficult to improvise anything effective, and given we all have fairly effective leg-slicers attached to our boats I certainly carry 2. You are, just like the AED though, very unlikely to have that bad a day ever. The amputation problem isn't a real problem - we routinely put tourniquets on anyone in theatres having a normal knee replacement and leave it on for 45 minutes without so much a hint of harm.

Epi-pens are exempted from requiring a prescription to administer and posses - anyone can administer them for life-saving purposes. GPs are generally happy to write prescriptions for them for people going climbing/sailing/powerboatnig/whatever to remote places.

[Hf500]

I learn something every day. It's been very informative everybody. Thanks. Lots for us all to consider. I'm curious taitharris ... will you buy a defibrillator?