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ACSM'S Health & Fitness Journal:
doi: 10.1249/01.FIT.0000414742.57332.b5
COLUMNS: The Legal Aspects

Code Blue: Member Down

Abbott, Anthony A. Ed.D., FACSM, FNSCA

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Anthony A. Abbott, Ed.D., FACSM, FNSCA, is president of Fitness Institute International. He was a commanding officer of an Apollo Recovery Team and the Florida Director of the Physical Fitness Institute of America that helped develop the exercise program for NASA and Apollo missions. He is an ACSM Health/Fitness Specialist, ACSM Clinical Exercise Specialist, and an NSCA-CPT*D and CSCS*D. Dr. Abbott is frequently retained as an expert witness in fitness facility litigations.

Disclosure: The author declares no conflict of interest and does not have any financial disclosures.

“Code blue: member down.” As a fitness instructor or personal trainer, these words repeated over the public address system will get your heart racing like that of the client with whom you are working. With very few exceptions, in-house trainers and independent contractors are expected to respond to emergencies along with other facility staff members. Frequently, because of the higher expectations of personal trainers, these personnel are relied on to deliver the emergency response necessary to affect a successful rescue.

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Ideally, fitness instructors and personal trainers should possess formal education in exercise science from an accredited university or a vocational school and, in addition, should be certified by a professional association with credible standards in the fitness industry. The wise, concerned, and conscientious instructor or trainer also will carry liability insurance as well as be skilled in the delivery of first aid and cardiopulmonary resuscitation (CPR), to include automated external defibrillators (AEDs). Although precautionary measures, these could be critical considerations. A lack of the above insurance and credentials may reflect professional irresponsibility.

Although instructors and trainers typically are certified in CPR, most do not have certification in first aid, and a substantial percentage do not carry liability insurance. Of those with CPR, most are certified in adult CPR only, and this often occurs without training in AEDs. It would appear that, for many facility instructors and trainers, a commitment to the safety of their clients is lacking. The number one priority or duty of any fitness facility and its staff should be the health and safety of its members.

There are obvious reasons why instructors and trainers should be capable of providing first aid. From minor cuts to major lacerations, simple contusions to severe concussions, heat cramps to heat stroke, mild hypoglycemia to insulin shock, professional instructors and trainers should be able to help respond to these emergencies (5). Notwithstanding the importance of such emergencies, this article will address the most serious concern likely to confront the instructor or trainer, a cardiovascular complication. Whether a severe myocardial infarction (MI) or a sudden cardiac arrest (SCA), the question is whether a facility’s staff is prepared to make the difference between life and death.

The fact is that medical complications caused by exercise are a reality; and of greatest concern are cardiovascular complications. It has been well documented that coronary incidents transiently are increased with vigorous exercise in comparison with everyday spontaneous events. One study estimated that the possibility of a coronary incident leading to death during vigorous exercise was seven times greater than during more sedentary activities (14). Another study estimated that, for those with coronary artery disease, the risk of an SCA during vigorous exercise may increase as high as 100-fold (7).

For those free of coronary artery disease, the relative risk of exercise is extremely low. Unfortunately, coronary artery disease is very prevalent among older sedentary individuals, many of whom are now joining fitness facilities and availing themselves of group exercise classes and personal training services. In fact, nearly 1:4 U.S. adults has some form of cardiovascular disease (18). During deposition of a brain-death case, the executive director of a well-known fitness facility chain stated that they anticipated one cardiovascular complication for every 100,000 hours of exercise among their membership (6). Although this probably is an overestimation of the risk, it does reflect a serious concern, especially when you consider that many larger facilities average well more than 100,000 exercise-hours per year.

As previously indicated, cardiovascular complications within the fitness facility typically take the form of an MI or an SCA. In either case, the facility staff must respond with emergency cardiac care. Such care requires appropriate training and equipment.

When an MI is suspected (tightness of the chest, radiating pain, etc.), activation of the emergency medical services (EMS) system is essential. In addition to making the member/client as comfortable as possible and keeping him or her as calm as possible, the staff ideally should immediately administer supplemental emergency oxygen. Although the use of emergency oxygen typically is viewed as falling under the purview of a medical fitness center, there are more fitness facilities recognizing the value of adding supplemental oxygen to their emergency response plan.

Why is supplemental oxygen so important during this type of medical emergency? Because lower levels of oxygen in the blood can contribute to cardiac arrest, a condition where the circulation of blood ceases. The fact is that any victim of a potentially life-threatening illness or injury, and this is without exception, should receive emergency medical oxygen. It has been estimated that oxygen administration may double a person’s chances of survival (4).

Another question commonly asked is whether oxygen can ever be harmful during a medical emergency? The answer is no. The administration of oxygen may improve the likelihood of a positive outcome. Emergency medical literature reflects that the immediate use of supplemental oxygen is important to victims of sudden life-threatening illness or injury. As was once thought, short-term oxygen does not suppress the respiratory drive in patients with chronic obstructive pulmonary disease and only becomes harmful with extended use.

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What about the fact that oxygen is considered a drug? Wouldn’t this mean that the administration of emergency oxygen requires a doctor’s prescription? Again, the answer is no. Although it is true that oxygen is a drug when it is given in concentrations beyond that found in the air we breath, such as when used for medical treatment, the Food and Drug Administration (FDA), the regulating agency for medical gases, has exempted the prescriptive requirement for emergency oxygen (8).

To qualify as nonprescriptive emergency oxygen, the delivery system must provide a minimum flow rate of 6 L · min−1 for a minimum time of 15 minutes. As stated by the FDA, anyone properly trained in oxygen administration can provide this emergency drug. The FDA and other concerned agencies have not determined and, therefore, specified what constitutes proper training. In fact, just reading the instructional manual on the administration of emergency oxygen is recognized as sufficient training.

Not only should rescuers be familiar with an oxygen delivery system’s instructional materials and directions but also they should undergo formal training. Such training is available by a number of organizations to include the American Red Cross and can be completed in just a few hours. When facilities fail to provide oxygen by properly trained personnel, it could mean missing an invaluable opportunity to help save a life.

Oxygen administration also is important with SCA when CPR is required. By including oxygen, the rescuer can provide the victim with an oxygen concentration well above that of normal air. This procedure is important and should follow the initiation of CPR and AED.

When SCA occurs within the fitness facility, the prognosis is poor unless the facility is equipped with an AED. In the United States, SCA strikes approximately 350,000 people each year outside of the hospital environment, and more than 95% die (10). Rapid defibrillation is the only definitive treatment.

Because of the unavoidable response time of paramedics, defibrillation by EMS personnel may be too late to provide successful resuscitation. Once blood stops circulating, as with ventricular fibrillation or pulseless ventricular tachycardia, every minute without defibrillation decreases the chances of survival by 7% to 10%. The only solution to this dilemma is the availability of an AED on the premises; one that can be applied immediately to the victim. Studies have noted that when defibrillation is applied within the first few minutes of an SCA, the chances of victim survival may be as high as 80% to 90% (11).

AEDs have been used effectively for more than 20 years and are credited with having saved thousands of lives. Michael Spezzano, former national health and fitness director for the YMCA of the United States and current editor and project coordinator of the YMCA’s technical assistance paper, reports that more than 100 YMCA members’ lives have been saved with AEDs (15). In fact, this author is aware of at least five of his former students who have saved lives with AEDs. As a result of the numerous lives saved by this timely application of defibrillation, AEDs represent an important breakthrough in the management of SCA.

Because of the proven success of AEDs, in 2000, the House of Representatives passed the Cardiac Arrest Survival Act that directed the Department of Health and Human Services to develop guidelines for placing AEDs in federal buildings nationwide. This legislative bill also established a “Good Samaritan” provision that protects individuals from liability issues in those states that have not already enacted such laws regarding AEDs (12). Representative Olson of the 112th Congress recently introduced the updated Cardiac Arrest Survival Act of 2011, which attempts to establish a nationally uniform baseline of protection from civil liability for persons who use AEDs in perceived medical emergencies (13). The latest version of this bill to clarify liability protections is on track for bipartisan approval.

AEDs are safe, simple, reliable, and relatively inexpensive. Considering that the cost of an AED is comparable to that of a piece of gym equipment ($1,500 to $2,000), it really is inexcusable that all facilities do not have them as part of their emergency response. With the availability of AED instruction through the American Heart Association (AHA), American Red Cross, National Safety Council, and equipment manufacturers, the cost of training also is very reasonable.

Likewise, emergency oxygen systems can be purchased for a few hundred dollars; and as with AEDs, the training is not overly time consuming or expensive. Emergency oxygen coupled with an AED provides a winning combination that will improve greatly the chances of survival during a cardiovascular complication.

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Some fitness facility managers will argue that the use of an AED may increase a facility’s exposure to litigation because it is a medical device and, therefore, they will be held to a higher standard of care. In reality, the opposite is the case. In the August 2002 issue of Best Review, a respected insurance industry publication, the following was stated, “The need for defibrillators outweighs potential liability. Not only do the lifesaving benefits of a well-conducted automatic defibrillator program outweigh the potential downside, but unnecessary failure to provide such a program in the event of sudden cardiac arrest is becoming a liability concern” (17).

Regarding this above concern of being held to a higher standard of care, we might ask the question whether the fitness industry needs to be held to higher standards? Having served as an expert witness in 25 death/brain-death cases, this author can attest to the fact that, in every case, the facility involved was found to be lacking an appropriate emergency response and, in which most of the cases, AEDs were not available. In light of surveys documenting the poor preparedness of facilities to handle cardiovascular emergencies, it would appear that standards need to be upgraded (16). The really important question to ask is “does the availability of oxygen and AEDs help save lives?” The answer to this question is a resounding yes.

Although the American College of Sports Medicine (ACSM) through its ACSM’s Health/Fitness Facility Standards and Guidelines book does promulgate a standard for the incorporation of a public access defibrillation (PAD) program within a facility’s emergency response, ACSM legally cannot mandate such a standard for the fitness industry (1). However, as the standard of care regarding AEDs in fitness facilities continues to evolve, courts will look to professional associations like ACSM to determine the degree of care that responsible fitness facility management should use during emergencies.

However, when it comes to delivering emergency care, we should not only look to professional associations like ACSM for setting the standards but also to those organizations that specialize in emergency response — the AHA, the American Red Cross, and the National Safety Council. When we think of cardiovascular complications requiring emergency care and/or CPR, we primarily think of the AHA.

For the past 20 years, the AHA has recommended PAD to include the use of AEDs within fitness facilities. As far back as 1994, the AHA manual of Basic Life Support for Healthcare Providers stated that “because of the intrinsic simplicity of AEDs, a markedly expanded range of individuals can now be trained to provide early defibrillation, including … and supervisory personnel at exercise facilities” (2).

The AHA’s promotion of PAD has been relentless to the extent that, in 2002, ACSM cooperated with the AHA in advancing a joint position statement on Automated External Defibrillators in Health/Fitness Facilities (3). This statement urged health and fitness facilities to implement a PAD program to minimize the time between SCA recognition and successful defibrillation. These two associations have recommended that all fitness facilities have AEDs as long as facilities have memberships more than 2,500, service the elderly, service those with medical conditions or are located in areas where EMS response would preclude defibrillating a victim within 5 minutes.

As stated earlier, the standard of care regarding AEDs in fitness facilities is evolving. In the 2006 death case of Tringali versus LA Fitness, the jury returned a verdict against the fitness facility for not having an AED (20). In 2008, a Cook County Circuit Court in Maryland ruled that a Bally’s facility’s refusal to maintain an AED demonstrated intentional indifference to the welfare of its patrons and, therefore, rose to the level of gross negligence (9). A request for summary judgment was dismissed, especially in view of the fact that an internal study conducted by Bally’s revealed that an SCA was a foreseeable event during vigorous exercise. The study documented that the Bally’s chain averaged 35 deaths every year because of cardiac events.

In light of the evolving standard of care, the Cook County court noted that much has happened in terms of the statutory law regarding AEDs nationwide. Whereas earlier cases cited by Bally’s in which courts held that facilities had no duty to maintain AEDs on their premises, the Cook County court recognized that the use of AEDs had become much more commonplace, bordering on a standard of practice in certain industries.

Unfortunately, many to most fitness facilities still lack a PAD program, as recommended by the AHA and ACSM. It appears that, although many municipalities may mandate that local fitness facilities provide AEDs and the training of staff to deploy such lifesaving devices, there exists only 11 states that currently mandate that all facilities be so equipped and trained (19). Sadly, some states require AEDs, but their deployment is optional.

As stated above, it is the goal of the AHA that victims of SCA be defibrillated within 5 minutes of onset. For this reason, the AHA recommends that AEDs be placed in locations where there is a reasonable probability of one SCA occurring every 5 years. Certainly, fitness facilities fall within this category.

To provide the gift of life as well as health to members and individual clients, fitness facilities and their staff should have the ready availability of AEDs and, ideally, even oxygen. This emergency equipment is essential if we are to give the victims of MI and SCA a fighting chance. Therefore, it stands to reason that fitness instructors and personal trainers should encourage the training for and the use of such equipment within their respective fitness facilities, if such practices are not already in place.

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References

1. American College of Sports Medicine. ACSM’s Health/Fitness Facility Standards and Guideline. 3rd ed. Champaign (IL): Human Kinetics; 2007.

2. American Heart Association. Basic Life Support for Healthcare Providers. Dallas (TX): American Heart Association; 1994.

3. American Heart Association 2002. Automated external defibrillators in health/fitness facilities, AHA/ACSM scientific statement. Circulation. 2002; 105: 1147–50.

4. American Red Cross. Oxygen Administration. St. Louis (MO): Mosby Lifeline; 1993.

5. Bates M., ed. 2008. Addressing Health and Safety Concerns, Health Fitness Management. 2nd ed. Champaign (IL): Human Kinetics.

6. Chai vs. Sports & Fitness Clubs of America, No. 98-16053 CA (05) (FL, Broward County Cir. Ct. August 2000).

7. Cobb LA, Weaver WD. Exercise: A risk for sudden death in patients with coronary heart disease. J. Am. Coll. Cardiol. 1986; 7: 215–9.

8. Food and Drug Administration, Docket 2003D-0165, Practice for Medical Gases.

9. Fowler vs. Bally Total Fitness, No. 07 L 12258, IL (MD, Cook County January 2008).

10. Gillum RF. Sudden coronary death in the United States. Am. Heart Assoc. Circ. 1989;79:756.

11. Ginsberg W. Prepare to be shocked: The evolving standard of care in treating sudden cardiac arrest. Am. J. Emerg. Med. 1998;16:315.

12. H. R. 2498, Cardiac Arrest Survival Act, 106th Congress, 2nd Session (2000).

13. H. R. 3511, Cardiac Arrest Survival Act of 2011, 112th Congress, 1st Session (November 2011).

14. Koplan JP. Cardiovascular deaths while running. JAMA. 1979; 242: 2578–9.

15. Larkin M. Should your facility have an AED? J Active Aging. May/June 2007.

16. McInnis K. Low compliance with national standards for cardiovascular emergency preparedness at health clubs. Chest. 2001; 120( 1): 283–8.

17. Relyea AT. Need for defibrillators outweighs potential liability, Best Review. August 2002, A. M. Best Company, Inc., Oldwick, NJ.

18. Schnirring L. Fitness Clubs Urged to Do Cardiac Screening. Physician & Sports Medicine, August 1998.

19. Steinbach P. Technology: Eleven states mandate AEDs though industry resistance remains, Athletic Business. March 2008.

20. Tringali vs. LA Fitness, No. 04-19840, CA (11) (FL, Broward County Cir. Ct. March 2006).

© 2012 American College of Sports Medicine

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