“Greater AED availability amounts to little if people are unable — or unwilling — to use them”

In capable hands

More AED machines meaningless without more awareness

Text by Justin McCurry / Illustration by Guillaume Babusiaux

It is said that in Tokyo you are never more than a few hundred metres from an automated external defibrillator, or AED. The device is now a familiar sight at railways stations, hotels, government buildings, police boxes and, increasingly, convenience stores.

Since the use of AEDs by non-medical professionals was approved in 2004, AED sales in Japan have risen to the point that they are second only to those in the US, with 70,000–80,000 units being added each year.

There are now about 600,000 AED devices installed around the country. About 500,000 can be found in public places, schools and corporate facilities, with the remainder in “specialist” locations, such as hospitals and ambulances, and on board Japan Maritime Self-Defense Force ships.

But greater awareness and availability has not been matched by increased public utilisation, despite figures showing that tens of thousands of Japanese people die from cardiac arrest every year.

In the 23,800 cardiac arrest cases recorded in 2012 by the Fire and Disaster Management Agency, the rate of survival was 41.4% when AEDs were used. The problem was that the devices were deployed in just 3% of all cases.

“Japan has a pretty good per capita AED ratio; the problem is the public’s ability to use them,” said Michael Van Zandt, president of Laerdal Medical Japan, which sells Philips Medical AEDs, as well as its own range of cardiopulmonary resuscitation (CPR) training devices.

“For some companies the problem is that they’ve put the cart before the horse, thinking that all they have to do to save lives is install an AED machine,” he added. “They have good intentions, but they haven’t thought through the ‘chain of survival’.”

That chain begins with the speedy deployment of an AED in cases of sudden cardiac arrest. Used properly, the machine delivers an electric shock to a heart that is “shuddering” rather than pumping, in an attempt to restore a normal rhythm.

Greater AED availability amounts to little if people are unable — or unwilling — to use them. Van Zandt believes a cultural reticence is affecting rates of usage. “We have to be aware of cultural sensitivities, but that’s why training is so important,” he said.

Laerdal, ZOLL Medical Corporation, Netherlands-based Philips Medical, and Japanese distributors such as Fukuda Denshi and Nihon Koden, believe the lead-up to the 2019 Rugby World Cup and the Tokyo Olympics a year later will offer an ideal opportunity to raise awareness of CPR and the use of AEDs.

The Japanese Red Cross Society has instructed more than three million people in AED-use as part of its first-aid course, and training is also now part of driving instruction programmes. The Osaka Life Support Association’s nationwide PUSH Project encourages AED-users to remember the three “pushes” after calling the emergency services: first, they should push the victim’s chest using CPR, then push the device’s buttons and, finally, push themselves — an exhortation not to let lack of confidence prevent them from potentially saving a life.

To encourage non-medical bystanders to take the plunge, manufacturers are adopting new technology to make AEDs easier to use.

Philips’ R3 model has a bilingual function that allows users to choose from one of several languages alongside the preset Japanese, while its FRx+ and HS1+ models offer real-time instruction in more than 20 languages, according to Megumi Baba of Brand, Communications and Digital at Philips Japan.

“Philips Japan has been making continuous efforts to raise awareness of the proper placement of AEDs within two-minute distances [in public places] so that we can increase the likelihood of saving as many people’s lives as possible,” Baba said.

“Philips plans to introduce new, easier-to-use AED models that are lighter and smaller than existing models,” she added. “For the 2020 Tokyo Olympics, Philips Japan is working to ensure there are sufficient volunteers who are trained to operate AEDs, as well as to ensure proper placement of these AEDs so there is always a device nearby to help save lives.”

ZOLL’s models for the Japan market feature Japanese-language instructions, but include visual icons that provide guidance to non-Japanese speakers as well. The firm’s AED Plus model “is specifically designed to be easy to use with audio and visual guides to performing the rescue and delivering high-quality CPR,” according to Elijah White, vice president of marketing at ZOLL, which is part of the Asahi Kasei group.

There is a wealth of medical evidence attesting to the critical role CPR and AEDs can play in cases of sudden cardiac arrest, or what some call bystander interventions.

Published in the 21 July, 2015 issue of the Journal of the American Medical Association, one study of more than 167,000 patients in Japan found that bystander-initiated defibrillation had twice the survival rate for the victim than that performed later by emergency medical services.

It confirmed what medical professionals have known all along: the earlier the intervention, the higher the chances of survival.

Takuro Tsukube, director of the Center of Cardiovascular Disease at the Japanese Red Cross Kobe Hospital, said there were many instances of patients arriving at his hospital having been given a lifeline by timely AED interventions. But he cautioned: “No one can say that there are enough AED devices.”

ZOLL’s White applauded the increasing prevalence of AED machines in Japan, but added: “Like most countries there is still a long way to go to ensure the whole population has timely access.”

Laerdal Medical Japan, a subsidiary of Laerdal Medical Norway, distributes Philips AEDs, as well as its own CPR training devices, from basic models costing around ¥5,000 that come with DVD training instructions, to professional models that can cost up to around ¥10,000,000.

The firm’s high-end models provide instant feedback to users by measuring, for example, the depth of compression during CPR. They can also record data so users can go back and look at how they have performed, the point being to allow them to hone their technique on training devices before they may need to use them on people.

Van Zandt was quick to point out that CPR and AED are not either-or options. “CPR is a bridging mechanism until the AED shows up,” he said. “If the heart stops altogether, it’s all over. The aim is to keep it pumping. There’s a symbiotic relationship between CPR and AED.”

Tsukube said that the AED devices currently available are “technically easy” for bystanders to use, adding that every minute-long delay in treating a sudden cardiac arrest lowers the survival rate by 10%. “But one problem we have experienced is that actually using an AED takes a great deal of courage on the part of a bystander, especially if they have no medical experience.”