Drone-Based Automatic External Defibrillators for Sudden Death? Do We Need More Courage or More Serenity?

The Serenity Prayer asks for the courage to change what can be changed, the serenity to accept what cannot be changed, and the wisdom to know the difference. Medicine demands large doses of all three. The greatest difficulty is deciding when the times call for more courage or more serenity. Some of our problems seem so intractable that we stop expecting progress during our professional lifetimes. Occasionally, however, advances completely unrelated to medicine give us cause to reconsider the comfort of our serenity-courage balance. Out-of-hospital cardiac arrest is one of medicine’s most vexing public health problems. Decades of research have failed to reveal any test that is sufficiently accurate to identify people who will have a sudden cardiac arrest (SCA) before the catastrophic event occurs. Huge research efforts have been expended to identify best resuscitation practices at the time of the SCA event (eg, how many inches of chest compression, at what rate, and with what ventilation strategy; airway management; and what adjuvant drug therapies) and best treatment practices in the hours and days following (including targeted temperature management and early coronary angiography). Community-wide emergency medical service (EMS) systems have been created to deliver interventions to SCA patients with a goal of arriving within 8 minutes of the 9-1-1 call at least 90% of the time. However, despite improvements in prehospital systems of care and bystander resuscitative efforts, absolute survival for out-of-hospital SCA has remained at or below 10%.1–3 Glimmers of the possibility of much higher survival rates have appeared in the form of observational reports of automatic external defibrillator (AED) use. The first AED was approved by the US Food and Drug Administration in 1998. Early work showed that when SCAs occurred in well-populated public spaces with an AED close at hand and a shock was delivered by bystanders, 30-day survival rates reached 40% (airplane) to 74% (casino, shock within 3 minutes).4,5 The PAD trial (Public Access Defibrillator; a test of best-case static AED coverage) compared the use of AEDs plus cardiopulmonary resuscitation with cardiopulmonary resuscitation alone in 993 “community units” (shopping malls, recreational areas, hotels).6 The AED intervention arm was intended to deliver an AED to a cardiac arrest scene within 3 minutes. Fourteen percent of the 107 subjects with definite cardiac arrest survived to hospital discharge in the cardiopulmonary resuscitation–only arm compared with 23% of the 128 in the cardiopulmonary resuscitation plus AED arm. However, even with such encouraging proof of concept, the potential of rapid AED use has proven surprisingly difficult to generalize to the community level, and bystander defibrillation rates have remained low.1,2,7 The 2 current options for getting an AED to the site of a cardiac arrest in a timely fashion are placing static AEDs in strategic (largely public) locations, which requires bystanders to find and retrieve the devices, and getting first responders to bring Drone-Based Automatic External Defibrillators for Sudden Death?