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Law and Ethics in AED Use

Luiz Henrique Horta Hargreaves, MD

Brazilian Society of Emergency Medicine

   First of all I would like to say that is a pleasure to contribute with so important Congress and I would like to say thanks for the organizers of this event.

   In Brazil, the National Congress represents the Legislative and is formed by the House of Representatives with 513 representatives (deputies) and Federal Senate with 81 senators.

   The most common way to elaborate a law, is by a Law Project in a process namely Legislative Process which a Representative presents the topics that should be appreciated by their colleagues. In this process, some legislative consultants have the responsibility to analyze the legislatives and technical aspects of the Law Project and they can suggest some modifications that can be accept or not by the Representative.

   The Defibrillation Law Project was elaborated by Deputy Ursicino Queiroz, a physician from Bahia state, in 1999 and it is namely Law Project nº 1503 /1999. This law project was modified by Deputy Eduardo Seabra in 2000 and now it is namely Substitution of Law Project 1503/1999. This Law Project is actually in Family and Security Social Commission (that includes Health projects) which was approved and it is waiting the considerations of the deputy responsible for this project in this Commission (a physician and ex-governor of Rio Grande do Norte state).


   · Art. 1 - The teaching institutions in health area , in any level, will obligatory include in their disciplines , emergency procedures, including defibrillation training (AED) for immediate care in cardiac arrest

   Comments: This is an important article of this law project because in Brazil there are only few Medicine and Nursery Schools that have in fact emergency disciplines which all students learn and can practice RCP procedures. We intend with this article, that all medical, nursery and other health students can get access to emergency training facilities following the guidelines of ILCOR (including BLS, ACLS, PALS courses) and trauma guidelines of American College of Emergency Physicians and American College of Surgeons.

   · Art. 2 - Obligation to have AEDs, available, accessive, ready and in good conditions:

I - Sites of residences, work, shopping, tourism with concentration/circulation rate per day of 100 or more people
   Proposition: We propose an other substitution for the Law Project (this substitution do not delay the legislative process) including airports, maritime ports, rail stations (including subways (underground) stations), bus stations and change the concentration rate for 1000 or more per day, but 100 per day in Theme Parks, Rural Hotels, Spas and other locals which the ALS system is not efficient (response > 8 minutes).

II - Police vehicles used in Patrol round
   Proposition: We propose to include Fire and Rescue vehicles, ambulances and other Prehospital services instead of all police vehicles.
   Comments: In Brazil we have not paramedics or EMTs as in USA. The Preshospital System in Brazil is different for each state. In São Paulo, all response units for public emergencies are from Fire Department (First Responders, Nurses and Physicians in a two tiered system according the Dispatch Physician) or 192 Medical Service that work with a two tiered system (including physicians) too. There are some other private medical ambulance companies that are responsible for in home emergencies (a non-tiered system with physicians).This system is similar in Paraná, Minas Gerais and other states with little modifications. In Rio de Janeiro, the most response calls are from Fire Department with physicians in ACLS ambulances but only for public emergencies (emergency situations with people in streets and public places). In Brasilia there are not physicians in Fire Department ambulances and they have only one non-tiered system and sometimes they can ask for support by their hospital physicians or by other hospitals and public services. The response time for emergencies in Brazil in general is not good and the reason why we think that is not a good idea that all police cars have an AED is because Brazil is a country with almost 5,000 counties with almost 180,000,000 population. So, if it is not possible in this moment that a law can obligate all police cars are equipped with AEDs (costs and training problems) we could approve a law that would not be effective. We believe that if we get that all ambulances, rescue and Fire vehicles have an AED with a trained team, we will get good results in mortality reduction, but for other countries could be an excellent proposition that all emergency vehicles, including police , have an AED with trained teams. A Health Ministry Regulation recently established guidelines for Prehospital Response which is determined that all Prehospital teams should be directed by a physician including Medical Dispatch.

III - Aircrafts with capacity to 100 passengers or more, used in regular or not commercial flights of national airlines
   Proposition: We propose to include ships , boats and trains .In Brazil the most popular transportation system is by buses and cars, but in general the capacity of buses transportation do not exceed 40 or 50 passengers and it will not practical that all buses have an AED. In emergency situations, some important highways have an ALS system that has AEDs and conventional defibrillators operated by physicians. In others highways , interstate and federal ways, Highway Patrol has rescue and ambulance vehicles that will be equipped with AEDs. Our proposition for include ships and boats, is because in North of Brazil , Amazonas River, is very common this kind of transportation with boats carrying almost 100 or 150 passengers in long trips across wild places with little or none medical resources, besides Cruise Ships in our litoral.

IV (Proposition) - Mass Gathering events with public concentration above 500 people.
   Comments: We propose AEDs for mass gathering events because is not unusual that is this situations we can find cardiac arrests, in special in small places with many people and difficult conditions for a good response time.

· Art. 3 - The AED operation that is not an exclusive medical act, to be used in cardiac arrest, is under the responsibility of:

   I- People who live in the referred community, established by members of this own community.
   II- Health area employees, security and other sites of work, shopping , tourism or leisure
   III- Police officers in their vehicles
   Proposition: We propose to include firefighters, rescuers, emergency technicians and everyone who have care responsibilities in EMS response according our proposition to article 2º which is linked here and for this reason we propose the exclusion of police officers in their vehicles except if they are rescuers as we see in Highway Patrol in rescue and ambulance vehicles.
   IV - Flight attendant in commercial aircrafts
   Proposition: We propose to include maritime crew and rail crew.
    V (Proposition) - Response teams responsible for emergency situations in mass gathering events
   §2-The exercise of this responsibility does not disauthorize medical actions that are on site

· Art. 4 - The DEAs should fulfill the following general requests:

   I- Facility of operation (can be used by emergency trained witness and trained lay people in medicine).
   II-Security of operation (Protection to operator as the victim).
   IV-Be ready and placed in good conditions and easy access.
   V-Minimal maintenance.
   VI-(Proposition) Technology - (AEDs should be at minimum biphasics)
   Comments: When you approve a new law, which new concepts and equipments will be an obligation for a society, we have to take care to avoid that people ,without the same commitment that we have with the life ,can take the advantage of this law and they can build very bad equipments and these equipments may be hazardous for use by population what will break the confidence of the society in AEDs. So, it is why we propose that these equipments should be at minimum biphasics, because nowadays, all good AEDs are biphasics with medical literature support.

· Art. 5 - The Health Ministry will regulate, in a maximum of 60 days time after publishing this law, the places where, obligatory, will need DEA, how many machines to be installed in each place, as well the institutions which will be officially certified to offer the mentioned training.

· Art. 6 - This law will be in force in 180 days counting on its publication.

   We believe that may be are there any other considerations and propositions that we can could do for this law, but at this time we think that with these propositions that we did, we hope that this law will be fundamental for mortality reduction in our country. We are working together with Brazilian Society of Cardiology, Brazilian Intensive Care Association, Brazilian Society of Internal Medicine and Brazilian Society of Emergency Medicine and recently we have the opportunity to take an orientation visit to USA invited by Trade Development Agency (TDA) with some Congressmen, Dr. Timerman (Interamerican Heart Foundation elected President) and represent ants of USA government which we knew successful Public Access of Defibrillation Programs, defibrillators manufactures and we meet important persons in PAD process, including Senator Gordon, besides a meeting in American Heart Association. We think that visit was very important for this process and we believe that until the end of this year we can get the approbation of this Law. In our legislative process, the next step is the Commission of Financial and Tributation, Commission of Constitution and Justice, Federal Senate and if are there none objections, the President of Republic can signed it. Until now, in all Commissions this law was analyzed, there were none objections and at now we are working together with our legislative consultants to modify the law project with our propositions without delay the process.

   SUMMARY: The necessity of a legislation about AEDs utilization by lay people is very known in many countries, therefore, there are few places which in fact, a public access defibrillation (PAD) has the support of a specific law. This presentation will discuss about a Brazilian Law Project of Defibrillation.
   RESUMO: A legislação quanto à utilização do DEA por pessoal não médico, tem sido motivo de discussão em diversos países, no entanto em poucos locais há de fato uma lei específica que trate do acesso público à desfibrilação.No Brasil, há um projeto de lei que está em adiantado processo de aprovação onde cria-se a obrigatoriedade da aquisição e treinamento de pessoal para utilização de DEAs dentro do conceito de acesso público à desfibrilação.Esta lei é o motivo maior de nossa apresentação, onde discutimos seus aspectos em geral
   SUMARIO: La legislación sobre la utilización de DAEs por personal que no trabaja en area de Salud ha sido tema de debate en diversos paises, pero sin embargo hay pocos locales donde existe en efectivo una ley especifica acerca del acceso publico a desfibrilación. En mi presentación voy a debater los aspectos en general de uno proyeto de ley que trata de este tema en Brasil.


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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
Dr. Raúl Bretal
Scientific Committee
Dr. Armando Pacher
Technical Committee - CETIFAC

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