As indicated in the previous Legal Aspects column, the primary reason for litigations against fitness facilities, in which a member has died, is a cardiac arrest that is often complicated by the lack of an effective emergency response plan and the lack of an automated external defibrillator (AED). In this article, we will look at the likely causes of cardiac arrest in facilities and how such incidents can be reduced, describe appropriate emergency responses, and review a variety of actual death and brain death cases that might have been avoided if handled in a professional manner.
There have been many articles written on the benefits and risks of exercise and the incidence of cardiovascular complications in both normal and high-risk populations. Although the opinions regarding the benefits of exercise can sometimes be quite extreme, there seems to be a general consensus that the benefits greatly exceed the risks. However, there also exists the understanding that certain precautions should be taken before, during, and after exercise.
CAUSES OF CARDIAC ARREST
All be it rare, pathophysiological evidence suggests that exercise, especially vigorous exercise, may precipitate a myocardial infarction or sudden cardiac arrest (SCA) in persons with documented or latent cardiovascular disease (6). Vigorous exercise increases myocardial oxygen consumption while shortening diastole (and consequent) coronary artery perfusion time. This in turn may evoke exercise-induced myocardial ischemia and predispose one to ectopic activity and perhaps a fatal arrhythmia.
Lack of an adequate warm-up prevents blood vessels from having adequate time to properly dilate and supply working muscles and the heart with oxygen, thereby resulting in a rapid rise of blood pressure and, possibly, myocardial ischemia. When firefighters free of known heart disease were involved with strenuous exercise without a warm-up, several displayed abnormal electrocardiogram changes attributed to inadequate myocardial oxygenation (3). Whereas this is not good for the normal healthy individual, it can be dangerous for one who already has coronary artery disease. For these high-risk individuals, this rapid rise in both heart rate and blood pressure can lead to insufficient myocardial oxygenation that can trigger abnormal heart rhythms.
Lack of an adequate cooldown can lead to decreased venous return and subsequent blood pooling in the lower extremities secondary to abrupt cessation of exercise. This venous blood pooling gives rise to a rapid drop in blood pressure and the insufficient delivery of oxygen to the brain that may result in dizziness or fainting. In addition, this lesser amount of blood being returned to the heart causes a decrease in cardiac output that in turn may prevent adequate oxygenation of myocardium and set the stage for life-threatening arrhythmias. This post-exercise period is the time during which the exerciser is most vulnerable to arrhythmias (2).
The absence of a gradual cooldown after exercise may affect cardiac function adversely because of a relatively high concentration of catecholamines (epinephrine and norepinephrine) produced by the adrenal glands and also released from certain nerve fibers in the body. This catecholamine excess may cause myocardial irritability that could trigger ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. Continuation of mild exercise during the recovery or cooldown phase allows higher catecholamine levels to subside and return to near resting levels within only a few minutes, thereby blunting their potentially deleterious effects on cardiac function (7).
Recognizing that overly vigorous exercise slightly increases the risk of cardiovascular complications, especially for high-risk individuals, it is incumbent on facilities and trainers to provide not only warnings about the dangers of overexercise but also ample instruction to members and clients about how to establish appropriate intensities and volume of exercise. Orientations should be provided to all facility members before their being allowed access to equipment and classes. In addition, members should be educated about the signs and symptoms of heart attack and how to respond accordingly.
Members and clients must be advised about the importance of warm-up and provided with specific guidance on how to initiate an exercise program, including those activities that are best suited for their needs. They should be trained how to increase exercise intensity gradually, allow for an adequate warm-up period, and determine when they have achieved an acceptable level of intensity to meet their fitness goals.
Likewise, members and clients also must be advised about the importance of cooldown and informed that most of the few cardiac events that occur with exercise usually do so after exercise not during exercise (5). They must understand how activities should decrease in intensity for a sufficient period to allow continued skeletal muscle massaging of the venous system, an action that aids in the return of blood to the heart. Heart rate guidelines can be provided that enable members to know that they have cooled down appropriately.
Ultimately, prevention can be achieved through the normal “steps to success,” as outlined in a previous column. Simply practice STEPS, which stands for screening, testing, evaluating, programming, and supervising. When members or clients are screened through comprehensive health appraisals, tested through fitness profiling, evaluated through analysis of health appraisals and fitness profiles, programmed based on their levels of health and fitness, and supervised with attentive detail to the safety of their programs, they should not only achieve success but do so without cardiovascular incident.
The previous Legal Aspects column addressed emergency response plans and outlined in detail the components of such plans and how the professional facility should handle emergencies to include cardiovascular complications. The number one priority of any fitness facility must be the health and safety of its membership, and to that end, this precedence is reflected in the comprehensive design of its emergency response plan, along with the commitment to effectively execute that plan as written.
Emergency responses frequently will require the use of equipment, such as first aid kits, and, in the case of cardiovascular complications, the use of oxygen and AEDs. However, it must be remembered that emergency equipment alone does not save lives but may, in fact, offer a false sense of security (1). Equipment must be backed up with appropriate staffing of personnel who sufficiently are trained in how to deploy and use such equipment.
In light of the above, staff and instructors must maintain their first aid and cardiopulmonary resuscitation (CPR)/AED certifications and be tested periodically to ensure that they are retaining their skills. Therefore, crisis and emergency plans must be practiced and rehearsed with regularity. Ideally, mock emergency drills should be conducted at least on a quarterly basis if not more often; and some of these drills/rehearsals should be undertaken on an unannounced basis. The emergency response plan, to include rehearsals, should be evaluated by facility risk managers, legal advisors, and medical providers to ensure that timely and effective procedures are being followed and modified when needed (4).
The following death or brain death cases are a small sampling of litigations in which this author has been retained as an expert witness. They are presented to highlight the unnecessary cardiovascular incidents that could have been avoided with appropriate precautionary measures and appropriate emergency responses.
Mangell v. Scandinavian
During the height of an aerobic dance class, Marteen Mangell was notified by a facility employee that he had a phone call in the lobby. He left the class, stood by the phone, most likely had blood pooling, and went into SCA. There was no discernible emergency plan, and the staff did not know CPR. After much confusion, emergency medical services (EMS/911) finally was called and delayed CPR was administered by members.
No orientation or instruction had been given to class members about the concept of blood pooling and the importance of cooldown. The class leader did not feel that it was her responsibility to ensure that all participants received a cooldown before being allowed to leave class. Education of class members, coupled with responsible control of the class by the instructor, could have likely avoided this SCA. In addition, the lack of a well-rehearsed emergency plan conducted by staffers qualified in CPR likely added to this disastrous outcome.
Alix v. Bally’s Health & Fitness
During the end of an aerobic step class, Raymond Alix experienced an SCA. Confusion led to a delay in notifying EMS/911, and the class instructor, not recognizing a cardiac arrest or knowing CPR, just cradled Mr. Alix in her arms. Class members, who had taken CPR classes elsewhere, recognized the need for CPR and tried to intervene and assist; however, the manager on duty, who had arrived at the scene, forbade their intervention for fear that it might increase Bally’s liability.
Again, there was no comprehensive well-rehearsed emergency response plan, and instructor personnel were not qualified in CPR. Mr. Alix had not been screened properly nor had he received any instruction in the concept of cooldown. The manager’s refusal to allow members to provide CPR added to this tragic outcome.
Hooi v. Q Club
Poh Saik Hooi was working out on a step machine when he experienced a cardiac arrest. It is not known how long he was down before being discovered because staff did not have visual access to his location. Staff did not provide CPR but deferred to two members who identified themselves as nurses. Although Mr. Hooi was evidencing obvious agonal breathing and turning cyanotic, the nurses never provided CPR. Once EMS/911 was called, their response was very rapid; however, because of unknown downtime and failure to provide CPR, Mr. Hooi experienced severe neurological damage resulting in brain death.
A probable contribution to this tragedy was the fact that staffers on duty lacked the ability to observe an area on the gym floor and, therefore, could not see a member go down, thereby affecting an immediate response. Again, staff members were not well qualified in CPR and deferred to nurses who also were unable to recognize a cardiac arrest and provide effective CPR. This tendency to defer to medical personnel has been noted to have led to disastrous results in a number of cases because such personnel were not capable of providing an appropriate emergency response to include CPR.
Lunoff v. Corpus Christi Athletic Club
In the middle of a workout on a step machine, Humberto Lunoff decided to speak with his wife who was on a treadmill. Without cooling down, he got off the stepper, stood by his wife at the treadmill, and began an extended conversation. Blood pooling evidently led to his SCA to which club staff responded. There was a delay in calling EMS/911, and staff failed to administer CPR but rather deferred to a member who was a physician. The physician did not understand basic CPR procedures, and Mr. Lunoff died.
Neither Mr. Lunoff nor his wife had been instructed on the concept of blood pooling and the importance of a cooldown. Again, a written emergency response plan and subsequent training to include drills could not be verified. There was a delay in identifying a cardiac arrest and the need for immediate notification of EMS. Although a staff member was evidently CPR certified, he was unable to provide effective CPR and discern that the physician also was not capable of providing an appropriate emergency response. It is the obvious responsibility of staff to provide CPR in the case of a cardiac arrest and only to defer to medical personnel if they can do the job equally well or better.
Troia v. Scandinavian
In the middle of a workout on an exercycle, Giuseppe Troia decided to weigh himself on a set of scales located on the gym floor. He got off the exercycle and stood on the scales at which time he experienced a cardiac arrest. The staffer who responded did not recognize agonal breathing as an obvious indication of cardiac arrest but rather interpreted this irregular gasping as an obstructed airway. Therefore, he proceeded to give Mr. Troia the Heimlich maneuver. CPR was never administered, and the call for EMS/911 was delayed. Again, there was no comprehensive written emergency plan that was practiced and rehearsed.
Mr. Troia had not received instruction on the concept of blood pooling and the importance of cooling down such as should have been done before dismounting the exercycle and weighing himself. Staff members had not been trained effectively in CPR nor had they had to participate in any emergency response drill. Again, the lack of a comprehensive written emergency response plan and a commitment to ensure its rapid enactment most likely contributed to this member’s death.
Vernon v. Sportrooms
Immediately after finishing a racquetball match, Harold Vernon returned to the facility’s locker room where he began experiencing chest pain and other symptoms of a myocardial infarction. A staff member who had been advised of Mr. Vernon’s discomfort went to the locker room with an oxygen bottle and mask. Unfortunately, the staffer had received no instruction on oxygen administration and was unaware that the bottle was empty. Shortly after the mask attached to the empty bottle was placed on Mr. Vernon, he went into cardiac arrest. After the actual arrest, EMS/911 finally was alerted. No CPR was provided nor was there a written emergency response plan or requirements for the CPR certification of staff.
Depositions of members and Mr. Vernon’s racquetball partner revealed that there was no orientation for members or discussion of the concept of blood pooling and the need for cooldown. Mr. Vernon’s abrupt cessation of physical activity after an hour of racquetball may have led to venous blood pooling and his myocardial infarction. Failure to call 911 immediately, coupled with a lack of CPR, resulted in a delayed emergency response and the unavailability of the artificial circulation of blood.
VanDusen v. Bally’s Health & Fitness
Similar to the previous scenario, immediately after completing a game of racquetball, Lance VanDusen and his partner sat down outside the court for a short break. Within a couple of minutes, he experienced an SCA. A staff member arrived on the scene, and noting his condition, left to call EMS/911. The manager on duty failed to come on the scene, coordinate the in-house emergency response, and have a staffer initiate CPR. In fact, when CPR was initiated, it was delayed and administered by a nonemployee. There was no availability of an AED despite the published position statement by ACSM and the American Heart Association recommending emergency response procedures and AEDs in fitness facilities.
Again, there was no evidence that Mr. VanDusen, his racquetball partner, or members had received any instruction on the concept of blood pooling and the importance of cooling down after a vigorous activity such as racquetball. Although requested during discovery, a comprehensive written emergency response plan was not produced. In addition, management’s lack of coordination of an emergency response to include an employee’s initiation of CPR, coupled with the lack of an AED, demonstrated a lack of concern for members’ welfare.
Hoffman v. LA Fitness National
Stephen Hoffman was working out on a treadmill when he decided to stop suddenly and join his daughter who was sitting by the facility’s pool. He sat down in a chair by the pool where he then experienced a cardiac arrest. Although EMS/911 was called, agonal breathing was not recognized as indicative of cardiac arrest needing CPR but was rather misinterpreted as just difficulty in breathing. Consequently, CPR was not provided nor was there the availability of an AED. Again, in addition to the lack of a detailed emergency plan, staff members qualified in CPR were not available.
During discovery, it was apparent that members such as Mr. Hoffman and his daughter had not received instruction on the concept of blood pooling and the importance of a cooldown. Because of lack of training, staff members were unable to recognize a cardiac arrest and respond accordingly. Again, although the rationale for AEDs had been fairly well established at this time, there was no effort on the part of LA Fitness National to require the purchasing of AEDs or the training of staff on how to deploy them.
The number one precedence of any fitness facility must be the health and safety of its membership, and that priority is reflected in the screening process of members, the thoroughness of their orientation, the safety of program design, attentive supervision of physical activities, and the comprehensive design of its emergency response plan and the commitment to execute that plan effectively as written. Although relatively rare, cardiovascular incidents among those with latent cardiovascular disease are inevitable in an environment where people engage in vigorous exercise. How a facility anticipates, prevents, and responds to these unexpected but foreseeable events literally can mean the difference between a member’s life and death.