Migo Biciunas almost didn't live to celebrate Christmas.

A few days before the holiday, the 52-year-old was resting after a racquetball game at the Bellingham Athletic Club (Bellingham, Wash.). Moments later, he blacked out - the victim of sudden cardiac arrest (SCA).

Fortunately, Bellingham owned an automatic external defibrillator (AED). A club employee used the device to save Biciunas' life.

David Cardone, the owner of the Memorial Athletic Club & Aquatic Center in Houston and president of THRSA (a Texas club association), shares a similar story. Last June, a 37-year-old member with no history of heart problems suffered cardiac arrest while walking on a treadmill. Before the paramedics even arrived, the club came to his rescue with its AED.

Today, the member - who, as it turned out, had a severe blockage in one of his arteries - still frequents the club. "He believes in exercise a little bit more," Cardone says. "He exercised regularly at the time, but because he had no heart incident, he had no reason to go to a cardiologist, or they might have found that blockage."

Both of these stories have happy endings. They are the exceptions. Few people survive sudden cardiac arrest, one of the leading causes of death among American adults.

CPR alone won't save an SCA victim, according to Christian Cary, product manager for Heartstream Operations, Agilent's Seattle-based AED business unit. CPR is mainly intended to keep oxygenated blood flowing to the brain, he points out. Yes, it is part of SCA treatment, but it won't stop the quivering of the heart associated with sudden cardiac arrest. Only a defibrillator will.

An AED treats SCA by supplying an electrical current to the heart. But treatment must be swift. Brain death can result in four to six minutes.

An Immediate Response
Since reaction time is so critical, only 5 percent of SCA victims survive.

"A lot of people think that calling 911 is enough because the paramedics show up with a defibrillator to treat [the victim]," says Lynda Goodrich, marketing manager for allied and commercial markets at Medtronic Physio-Control, an AED manufacturer. "But every one minute of delay is a 10 percent decrease in the chance of survivability from sudden cardiac arrest. So calling 911, when the typical response time is 10 minutes - you can quickly figure out those odds."

While pre-existing heart disease is a common cause of SCA, many victims have never had any heart problems. Sudden cardiac arrest hits without warning, and it can happen to anyone, regardless of age. The average victim, however, is 65. As people grow older, the chance of SCA becomes greater - a point worth considering in an industry where baby boomers represent a major market segment.

An aging membership base was a reason why WellBridge, a Denver-based chain, added AEDs to its 46 clubs.

"One of, if not the fastest-growing segments in almost every one of our markets is the 45 and 50-on-up age group," says Art Curtis, WellBridge's COO. "And as you are dealing more and more with older adults, the chances of having to deal with coronary events within a club become increasingly greater and greater and greater. And so it just seems to make sense that we should have these things available in our clubs to serve and protect our members."

Still, WellBridge is in the minority. Few clubs have accepted AEDs as a means of protecting and serving members. In an October 1999 survey of 273 member clubs, IHRSA found that only 16 percent of respondents had an AED installed. And while 26 percent were planning to purchase a defibrillator, 58 percent were not.

A similar survey presented at the November meeting of the American Heart Association (AHA) reported similar results. A study of 122 Ohio fitness clubs revealed that only 3 percent of respondents owned a defibrillator, according to lead researcher Kyle J. McInnis, Ph.D., director of research at the Rippe Lifestyle Institute (Shrewsbury, Mass.) and associate professor of exercise physiology at the University of Massachusetts in Boston.

The study not only found that most clubs were unprepared for sudden cardiac arrest, it discovered that 28 percent of the clubs never even screened members for cardiac problems, as outlined by the 1998 AHA Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities. The study also claimed that 92 percent did not conduct quarterly emergency response drills, and nearly 60 percent had no written medical emergency response plans. Dr. McInnis finds this worrisome, especially since 17 percent of the clubs reported a cardiovascular emergency within the past five years.

Pam Stoike, health and fitness manager at Courts Plus Health and Fitness Centre in Elmhurst, Ill., knows firsthand the importance of having an AED ready when cardiovascular emergencies arise. In the early '90s, before AED technology was available to clubs, her facility witnessed three people suffer SCA. All three instances occurred within a four-month period. All three resulted in fatalities.

A paramedic, Stoike knew an AED might have saved lives. So when the technology became available, she successfully pushed to purchase defibrillators. Courts Plus added an AED in 1996 and has had one ever since. And while Courts Plus has never used a defibrillator, Stoike is glad that the technology is nearby.

"Better to have it and not need it, then to need it and not have it," she says.

Why don't more operators share Stoike's opinion? Well, for one thing, there is no industry standard compelling clubs to invest in AEDs.

IHRSA neither advocates nor condemns AED usage. In a briefing paper titled Defibrillators (AEDs) in Health Clubs, the association states, "After a significant amount of research, IHRSA has concluded that there is not a legal standard of care that requires that automated external defibrillators (AEDs) be in all fitness centers. However, the association does not discourage health club operators from installing AEDs in their facilities."

That being said, IHRSA recognizes that AED laws are evolving and plans to keep a close eye on the issue, according to Helen Durkin, director of policy. For now, the association does have its own safety standards for member clubs. Specifically, IHRSA expects clubs to be able to respond quickly to any foreseeable emergency.

Toward that end, the club must have an appropriate emergency plan which can be executed by qualified personnel in a timely manner. Furthermore, a club must offer a pre-activity screening appropriate to the exercises that a member will perform.

AED proponents feel that this isn't enough - that a comprehensive safety plan must include a defibrillator. Courts Plus has implemented such a plan, which is practiced through ongoing training and mock emergencies where employees are expected to save a "member" (actually, a special mannequin) by calling 911, starting CPR and using a defibrillator.

This may sound elaborate, but, in reality, defibrillators are extremely simple to learn and operate. Furthermore, CPR classes frequently include AED training.

"It's actually easier to learn than CPR," claims Goodrich of Medtronic Physio-Control. "The machines guide you through the process. They analyze the patient, and tell you if a shock is needed or not."

Cardone verifies the simplicity of AEDs, citing his experience with the 37-year-old SCA victim.

"We put the pads on the guy, and I didn't even expect for his heart to be stopped, but sure enough [the AED] said, `Stand clear, ready to administer shock,' and all I had to do was push a button," he recalls. "It shocked him, and within 10 seconds, we could feel his pulse coming back." The AED also stored all of the information about the victim's heart rhythms, which the attending cardiologist downloaded for analysis at the hospital.

Training Requirements
Still, IHRSA believes that there is some risk associated with AED usage. In its briefing paper, it writes, "[U]ntrained rescuers may not know how to recognize the signs of SCA, and they may not use an AED safely, posing some danger of electric shock to themselves and others. Also, untrained rescuers probably would not know how to respond to the victim if the AED prompts `no shock indicated.'"

The briefing paper also points out the challenges of defibrillator education and purchase, noting that "AED training requirements vary by state." In addition, the paper explains that, under FDA regulations and various state laws, "only doctors or people authorized by doctors (via a prescription) may buy and operate AEDs."

This can complicate matters, particularly for clubs with multiple locations. Curtis can attest to that. WellBridge has facilities in 15 states.

"Frankly, it's unfortunate in some ways because it makes it a lot harder for a company like ours that operates around the country to put one of these programs in place," Curtis says.

Before a club can even worry about training, however, it must first invest in an AED - another point of contention. While AEDs have dropped in price over the years (the figure often quoted is $3,000 - or the price of a treadmill, as AED proponents put it), some clubs balk at the cost.

IHRSA's Durkin explains it like this: Obviously, everyone agrees that $3,000 is a small price to pay to save a life; however, "the margins in this business are not great." So an AED may not find space on a club's shopping list.

"I'm an operator trying to decide what's going to bring someone in the door," Durkin says. "And probably I'm going to be better off spending money on a treadmill. Most people aren't going to base their decision on whether or not there is an AED."

Durkin also points out that the $3,000 figure may be misleading. Defibrillators only have value if they are spaced three minutes apart, she claims. Therefore, a larger club may end up buying more than one.

The thought of buying multiple defibrillators - let alone one - could discourage some club operators. On the other hand, under the right circumstances, an AED could be the greatest investment a club ever makes. Just ask Cathy Buckley, owner of the Bellingham, where Migo Biciunas is still exercising.

"[I]t was the best $3,000 I ever spent," she maintains. "And when he came in with his daughter, I think everybody was crying. She was crying. She [said], `If you hadn't had [the AED], I wouldn't have had my dad for Christmas.'"

Such an experience could easily justify a $3,000 price tag, but cost isn't the only obstacle that keeps clubs away from AEDs. Liability is also a concern. It shouldn't be, according to Goodrich. She says that state and federal laws protect AED users.

"Most all states have Good Samaritan legislation, and the federal government recently enacted the Cardiac Arrest Survival Act, which establishes additional user protections," she explains.

Durkin counters that the Good Samaritan laws are spotty, change very quickly and differ state to state. For example, Stoike says that Illinois passed an AED act last spring protecting defibrillator users under the Good Samaritan law, but Buckley claims that Washington's Samaritan laws become grayer when an employee is involved.

"A Good Samaritan law covers you just when you are a Good Samaritan - just a bystander, so to speak," Buckley explains. But when a worker uses an employer's AED, "the standards change somewhat. The Good Samaritan law does not stretch as far."

AEDs and Insurance Rates
While Good Samaritan laws generally protect people who own and use an AED, some clubs worry about owning an AED and not using it.

Ken Reinig, president of the Association Insurance Group in Lakewood, Colo., shares this scenario: A club has an AED. A member goes into sudden cardiac arrest at 5:30 in the morning. The only one around is a young aerobics instructor, and she doesn't get the AED because either a) she didn't know about it or b) she was too scared.

"[T]he liability issues with that club go skyrocketing because they have the device and did not use it," Reinig says.

For this reason, it's conceivable that an AED could increase your insurance rates. "Because you have the device on premises, your liability could go up," Reinig says. "You have raised the bar of expertise." And by raising that bar, you could also raise your rates.

If you do invest in an AED, Durkin recommends that you consult with your supplier and insurance agent to make sure you have appropriate coverage. Also, train staff adequately and conduct drills. Don't get caught in the same trap clubs fell into when they did PAR-Qs to impress members, yet didn't have the expertise to back the questionnaires up. They threw the PAR-Qs into drawers, forgot about them, and left themselves liable.

Given the industry's turnover rate, keeping staff trained can prove problematic, according to Reinig. Clubs with AEDs could end up with monthly - possibly even weekly - training sessions so employees will know how to use a device that, in Reinig's opinion, "will sit in a closet and gather dust."

Gather dust? Maybe. Then again, WellBridge has already saved two lives with its AEDs, reports Curtis.

A Minor Risk?
Still, there is no guarantee that clubs will ever find themselves in a situation where a defibrillator is necessary. This is why, more than likely, an AED won't have any effect on your insurance, claims Reinig.

Insurance companies base their rates on actuarial data - that is, on cases that they have lost. Since AED cases aren't piling up on their desks, insurers have no reason to adjust their rates - up or down.

"Insurance companies are too busy paying out a $50,000 claim because some idiot dropped a weight on his foot," Reinig says. "Worrying about somebody having [sudden cardiac arrest] is one of the minor risk management issues currently confronting a health club."

Reinig speaks from experience. He has been in the insurance business for 20 years, and he counts 1,500 clubs as customers. Yet he has only dealt with five cases where club members died of sudden cardiac arrest.

"It's not that big of an issue, is the bottom line," Reinig says. "In every single one of those [SCA] cases that involved fatalities, the health club was never held negligent anyway."

A recent court case in Florida supports this argument. A jury there found in favor of Q The Sports Club, which had been sued for not having oxygen or an AED on hand to aid a member. The defense argued that there were no regulations or industry standards requiring defibrillators at clubs.

To be fair, the verdict wasn't a clear-cut victory. As the result of a pretrial agreement, the plaintiff - who suffered permanent brain damage - received a $2.25 million settlement. Furthermore, the jury didn't reach a decision easily, according to Dr. McInnis, of the Rippe Institute.

"In that case, there were a number of jurors who were confused on both sides of the argument about what is the standard of care," he says. "And I think that will become clearer in the next year or two."

Why will the standard become clearer? Because more studies will show that cardiac emergencies do occur in public facilities and that defibrillators save lives, answers Dr. McInnis.

Such studies already exist. AEDs at O'Hare International and Midway Airports have been credited with saving nine lives in 13 attempts, and research in the New England Journal of Medicine found that AED usage in 32 Las Vegas casinos saved 56 of 105 SCA victims.

If AEDs do become a standard of care for health clubs, insurance companies will react accordingly, says Reinig: "[AEDs] will become part of their application. It will say right on the application, `Do you have an AED device? What kind is it? Has your staff been certified in its use?'"

Questioning the Standard of Care
But the question remains - Should the standard of care ever reach that point? Durkin puts it this way: Defibrillators are only carried in approximately 80 percent of ambulances and 50 percent of fire-department vehicles that have the capabilities for basic and advanced lifesaving. So why, she asks, should AEDs be mandatory for health clubs? And, she adds, if clubs must install defibrillators, will parks have a defibrillator at every telephone pole to protect joggers?

Oddly enough, that may eventually happen. The AHA is supporting a PAD (public access defibrillation) program that encourages sites such as businesses, high-rise buildings, golf courses and sports stadiums to install AEDs. And researchers from the University of Chicago are placing defibrillators at Chicago-area museums, apartment buildings and shopping centers as part of a national study to see if community volunteers can save lives.

As studies like the one being conducted in Chicago build public awareness of defibrillators, it's possible that people will come to expect the devices in more places. Like health clubs.

"They will be demanding that standard of care and have higher expectations," believes Stoike of Courts Plus.

Reinig thinks that courts - not people - will be what ultimately pressure clubs to install AEDs. "It's only going to take one high-profile court case to make everybody panic," he says.

Taking Charge
Instead of leaving it up to the courts, Curtis would prefer to see clubs show initiative. "This is a good example of something where, as an industry, we should be...taking a position of responsibility rather than pushing it onto someone else to legislate it for us or create laws that require us to do these things," he says.

Rippe's Dr. McInnis believes that more AED studies could make defibrillators the standard of care for clubs. However, he explains that AEDs and preparatory plans aren't enough. He points out that exercise can trigger SCA in someone with pre-existing cardiac disease. Therefore, in addition to investing in AEDs, health clubs must also screen members.

"What we really want to do is identify those individuals whom we would deem at highest risk and then take appropriate action, including being prepared," Dr. McInnis points out.

Durkin agrees that fitness centers must be prepared for emergencies. But she adds that fitness centers encompass everything from unsupervised workout areas in apartments to hospital-based facilities. AHA's own fitness recommendations make it quite clear that different facilities deliver different services for different members. In other words, Durkin says, not all health clubs are equal and not all consumers require the same level of safety. That's why IHRSA objects to making AEDs mandatory for all clubs.


Heart Attacks and Sudden Cardiac Arrest

While the terms "sudden cardiac arrest" and "heart attack" are often used interchangeably, they are, in fact, two completely different things. Approximately 1.5 million Americans suffer heart attacks annually, compared to 225,000 who suffer sudden cardiac arrest (SCA).

A heart attack is caused by a reduction or stoppage of blood flow to the heart muscle. When this occurs, the muscle begins to die. A heart attack usually results from an obstruction - typically plaque. Signs of a heart attack include pain in the chest, arm, upper abdomen or jaw. Nausea and sweating are common. Patients often remain conscious.

Although a heart attack is not the same as sudden cardiac arrest, a heart attack can trigger SCA. Cardiac arrest is best described as an electrical malfunction to the heart, often associated with coronary heart disease. Victims lose consciousness. Other signs of SCA include loss of blood pressure and the absence of normal breathing.

Defibrillators are used to treat SCA. Every minute that goes by without treatment reduces a victim's chance of survival by 7 to 10 percent.

Sudden cardiac arrest and heart attacks aren't the same thing, but both can land you in a hospital bed, attached to a heart monitor - if you are lucky enough to survive.