BMJ  2004;328:E269 (28 February), doi:10.1136/bmj.328.7438.E269

BMJ USA: Editor's choice

A shocking issue

It has been only a dozen years since the American Heart Association suggested that cardiac defibrillators, sophisticated instruments that previously required expert administration, could be made simple enough for lay bystanders to use safely to treat out-of-hospital cardiac arrest. Since then, "public access defibrillation" has spread in two directions. The automated external defibrillators (AEDs) that were developed in response to the AHA's challenge are now routinely given to police and fire first responders to use while awaiting ambulance and paramedic arrival. They have also been located in airports, stadiums, and other public places.

We devote a good part of this issue to discussing these expensive, high-tech instruments. Liddle et al describe and illustrate the AED and its use (p 45). Dutch investigators led by van Alem report a controlled trial of out-of-hospital AED use by first responders (p 23). Although patients treated with AEDs had a better chance of reaching hospital alive, they did not have significantly improved rates of survival to hospital discharge. As the authors point out, at least part of the problem was the amount of time it took to reach patients and administer shocks.

Walker and colleagues (p 28) analyze the cost-effectiveness of deploying AEDs in public places, modeling their placement and use in all major Scottish airports and railway and bus stations. Using common cost-effectiveness criteria, they find that AEDs are not a bargain.

We asked prominent US AED researchers to comment on these rather negative studies. Pepe and Caffrey-Villari point out (p 7) that AEDs should be seen as a part—an important one, but just a part—of CPR. Weisfeldt (p 8) focuses on the importance of time-to-shock intervals and speculates on the future of AEDs. Finally, Kottke and Wu (p 32) remind us that there are proven ways for primary care doctors to prevent sudden death that are less expensive and more "low-tech" than electric shocks.

You may have received a slight shock yourself on seeing this month's issue. We are starting off the new year with some changes in BMJ USA, including following BMJ's lead and placing a photo on our cover. Other changes that we hope will make our pages more lively and interesting (if not shocking) include increased use of graphics and illustrations in our articles, a redesigned and expanded RE-VIEWS section, and the inclusion of more Patient-Oriented Evidence that Matters (POEMs) in each issue. Please let us know what you think of our new cover and content. Send emails to bmjusa{at}rti.org.

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