It has been well established that habitual physical activity reduces coronary heart disease events; however, vigorous activity also can acutely and transiently increase the risk of acute myocardial infarction (AMI) and sudden cardiac death (SCD) in susceptible persons (1). This incidence of both AMI and SCD is most frequently found in those who are habitually inactive and the elderly.
Regarding physical inactivity, an onset study cited in ACSM’s Guidelines for Exercise Testing and Prescription noted “the risk of AMI during or immediately following vigorous intensity exercise was 50 times higher for the habitually sedentary compared to individuals who exercised vigorously for 1-hour sessions five or more days per week” (2). Also noted in the same text is that SCD is higher in middle-aged and older adults than younger individuals because of the higher prevalence of cardiovascular disease in the elderly. In addition, it is the elderly who are joining fitness facilities in greater numbers than ever before.
The International Health, Racquet and Sportsclub Association (IHRSA) publishes an annual “Health Club Consumer Report.” The 2017 report indicated that “nearly one out of four health club members are 55 and older and membership among Boomers and the Silent Generation (typically born between 1925 and 1942) has increased by 5% since 2012” (3). Because IHRSA’s mission is to promote, grow, and protect the health club industry, it is incumbent upon them to ensure that their membership recognizes this higher risk population and those actions that must be taken to protect them. Such actions include health screening, proper supervision, and the availability of an effective emergency response plan (ERP), the lack of which has precipitated numerous litigations.
Over the years, IHRSA has publicized a standard that states “The club will respond in a timely manner to any reasonably foreseeable emergency event that threatens the health and safety of its patrons. Toward this end, the club will have an appropriate emergency plan that can be executed by qualified personnel in a timely manner” (4). With an aging membership, this need for a comprehensive and well-rehearsed ERP executed by qualified personnel has become more important than ever before.
In a like manner, ACSM’s Health/Fitness Facility Standards and Guidelines text lists a number of standards for risk management and emergency policies. The first standard reads: “Facility operators must have written emergency response policies and procedures, which shall be reviewed regularly and physically rehearsed at least twice annually. These policies shall enable staff to respond to basic first-aid situations and emergency events in an appropriate and timely manner” (5).
Similarly, the National Strength and Conditioning Association’s Strength & Conditioning Professional Standards and Guidelines publication reads: “Strength and conditioning professionals must develop a written, venue-specific emergency response plan to deal with incidents such as injuries, lightning strikes, and reasonably foreseeable untoward events (cardiovascular complications) within each facility. The plan must be posted at strategic areas within each facility and practiced at least quarterly” (6). It also should be noted that the standard requires that ERPs be initially evaluated by facility risk managers, legal advisors, medical providers, and/or off-premise emergency response agencies and that plans be modified as necessary at regular intervals.
It is interesting to observe that ACSM and NSCA have different stated standards regarding how often ERPs should be physically rehearsed. In fact, the frequency of rehearsals should not be a locked-in number, but must vary depending upon the type of facility, number of staff, and turnover of personnel. Emergency plans must be rehearsed with a frequency that ensures that not only will all personnel have the opportunity to participate in drills on both an announced and unannounced basis but more importantly that they will be able to respond rapidly and effectively.
A comprehensive ERP includes the availability of a first aid kit, cardiopulmonary resuscitation (CPR) materials, and an automated external defibrillator (AED). However, it must be remembered that emergency equipment alone does not save lives but may, in fact, offer a false sense of security (7). Equipment must be backed up with appropriate staffing of personnel who are well trained in how to deploy and use such equipment. To this end, staff, instructors, and trainers must maintain their first aid and CPR/AED certifications and be periodically tested to ensure that they are retaining their skills.
The question is, “Are staff, instructors, and trainers throughout the fitness industry maintaining their first aid and CPR/AED certifications as well as retaining their skills?” The answer is a resounding “no.” This should not be a surprise considering the fact that studies have shown that some fitness instructors and personal trainers within the industry also have demonstrated a limited knowledge base in exercise science that may prevent them from working safely and effectively with their members and clients.
A study at Florida Atlantic University revealed that when fitness facility instructors throughout the State of Florida were administered a nationally validated survey test examining their knowledge base in exercise science and safety issues, they scored significantly below that of a control group of ACSM certified Health/Fitness Instructors (33% vs. 83%). Very disturbing was the fact that facility instructor personnel scored no higher than facility members who also were administered the same survey test (8).
A similar study at UCLA revealed that formal education and not experience, among personal trainers throughout the Los Angeles area, was the most significant factor correlating with a sound knowledge base that included an understanding of exercise safety. The study concluded that formal education in exercise science coupled with certification from either ACSM or NSCA were strong predictors of a personal trainer’s knowledge base of his or her field of expertise, whereas years of experience without formal education did not correlate with a sound knowledge base (9).
Again, it has been recognized that just because a fitness instructor or personal trainer is certified does not mean that he or she is qualified (10). This inconsistency applies not only to their lack of knowledge and skills related to exercise instruction and training but also to their inability to respond to emergencies. Explicit medical emergency policies dictate that sufficient staff members are certified in first aid; however, it is well known that the majority of fitness instructors and personal trainers lack training and certification in first aid although they do possess CPR/AED certification (11).
This actuality (CPR/AED certification) is based upon the fact that most instructor/trainer certification programs require that candidates possess CPR/AED certification. Notwithstanding this fact that most instructors/trainers are CPR/AED certified, this does not correspond with their being qualified to administer CPR and deploy an AED.
This author has been retained as an expert witness in more than 40 death cases within fitness facilities, primarily as a result of an inappropriate emergency response to AMI and SCA. The most obvious failure has been the inability of staff to recognize an AMI and an SCA and how to respond accordingly. It is noteworthy that during depositions, most instructors/trainers, although CPR/AED certified, were unable to explain the difference between an AMI and an SCA, a concept which is always discussed in CPR student workbooks and training manuals.
For example, a current case in which this author is involved, a personal trainer, with a National Commission for Certifying Agencies (NCCA) accredited certification, conducted a high-intensity interval training class in which a first-time, visiting participant with diabetes was exposed to an obvious vigorous activity without a proper cool-down. Upon completion of the class, the participant experienced classic symptoms of an AMI: pain, pressure, and tightness in the chest. Rather than calling 911 or emergency medical services (EMS), the trainer explained that the pain was due to muscle cramping and, therefore, provided stretching exercises for the chest.
After half an hour of stretching and although still experiencing chest discomfort with some dizziness, the participant was allowed to drive home wherein after feeling worse, he drove himself to a hospital at which time he was diagnosed with an AMI. He underwent angioplasty with stent placement (anterior descending artery); however, because of the delay in receiving medical treatment and consequent myocardial damage, he developed congestive heart failure (ejection fraction 28%), required an implantable cardioverter defibrillator, and has become a candidate for a heart transplantation.
Student workbooks, like the American Heart Association’s Heartsaver CPR/AED book, outline symptoms (discomfort or pain in the chest, uncomfortable feeling in one or both arms, the neck, the jaw, or the back between the shoulder blades) that the victim of an AMI typically experiences and emphasize the urgent need to activate the EMS system. In addition, this book explains that the longer a person with a heart attack goes without treatment, the greater the possible damage to heart muscle and occurrence of a lethal heart rhythm (SCA) (12).
In addition to instruction on recognizing an AMI provided by the American Heart Association (AHA) and the American Red Cross (ARC), textbooks made available to candidates for fitness instructor and personal trainer certification programs typically address this same concern. For example, NSCA’s Essentials of Personal Training highlights the Personal Trainer’s Response to Cardiovascular Complications and reads, “When a mild to moderate MI is suspected (tightness of the chest, radiating pain, etc.), activation of the EMS system is essential” (13, p. 621). It then goes on to discuss concepts of emergency cardiovascular care that a rescuer should provide.
In a recent death case, a facility member was exercising on a treadmill when he experienced physical distress with symptoms characteristic of an AMI. When staff members were made aware of his discomfort, they failed to recognize the nature of his symptoms but rather escorted him to an air-conditioned break room to cool down and neglected to contact EMS. While in the break room, he suffered an SCA that was mistaken for a seizure; and therefore, he was not provided with CPR nor was an available AED deployed until paramedics arrived on the scene.
This inability to recognize an SCA has been a constant issue in the majority of death cases in which this author has been retained. Although the AHA and ARC manuals outline the signs indicative of a cardiac arrest, why are instructors and trainers typically unable to meet this challenge and save lives? The answer is that obviously their CPR training was inadequate.
It is not uncommon for instructors and trainers to undergo cursory, perfunctory, and hurried CPR/AED instruction. This shortcoming, coupled with the fact that instructors and trainers rarely receive ongoing training and evaluation through drills and rehearsals, results in certified but unqualified CPR responders. Couple this with the fact that CPR/AED awareness and skills deteriorate very rapidly after initial training, it is no wonder that potential rescuers fail to recognize and appropriately respond to SCA.
The retention of CPR/AED information and skills is short-lived. A study reported in PubMed and published in the European Resuscitation Journal reflected that adults who participated in both Heartsaver and visual self-instruction (VSI) programs experienced significant performance decline in their CPR skills after a post-training interval of only 2 months. Interestingly, the VSI program produced retention performance at least as good as that seen with traditional Heartsaver training (14). Of extreme concern was the fact that CPR skill retention for both groups declined on some measures to the level of untrained controls.
Insight Instructional Media reviewed 19 published studies on CPR/AED skill retention, all of which reflected that these skills were lost very rapidly. The investigators determined that, on average, 66% of subjects were unable to pass a skills test 3 months after their instructor-lead training program. After 1 year, 90% of subjects failed skill testing based on national CPR and AED standards (15).
Based upon these disturbing studies, the question that naturally arises is “how often should staff, fitness instructors, and personal trainers practice?” We know that the average CPR/AED certification card expires after 2 years, and most people do nothing to maintain their skills until they renew their CPR cards. Unfortunately, this author’s experience has been that far too many instructors and trainers do not take CPR/AED skill retention very seriously.
Most EMS professionals are required to complete skill refreshers every 90 days to keep their skills honed and current. A hands-on skill session every 90 days would seem prudent for instructors and trainers as well in that they work in an environment with the foreseeability of needing CPR/AED responder skills. Maintaining these skills is part of an instructor’s and a trainer’s job responsibility as much as their ability to provide safe and effective exercise programming. The fact remains that possessing these skills is a certification and job requirement.
Again, these studies reinforce the concept that frequent CPR/AED training and rehearsals become of paramount importance if facility staff, instructors, and trainers are going to be able to respond effectively to cardiovascular events. As stated numerous times in previous articles, the prime concern of any fitness facility must be the health and safety of its users, and that priority is reflected in the comprehensive design of its ERP and the commitment to effectively execute that plan as written.
A most important component of ongoing training is to address this common issue of failing to recognize the signs of cardiac arrest. So often, SCA victims are mistaken to be having a seizure because of their abnormal breathing pattern. Abnormal breathing is frequently observed as agonal gasps and is a sign of cardiac arrest. As described in AHA and ARC student workbooks, agonal breathing may be present in the first few minutes after an SCA.
These workbooks highlight the concept of agonal breathing with a “cautionary” note stating “A person who gasps usually looks like he is drawing air in very quickly. The mouth may be open and the jaw, head, or neck may move with gasps. Gasps may appear forceful or weak. Some time may pass between gasps because they usually happen at a slow rate. The gasp may sound like a snort, snore, or groan. Gasping is not normal breathing. It is a sign of cardiac arrest” (16). Consequently, it requires immediate CPR followed with a rapid deployment of an AED.
The AHA and the ARC share a common policy in that student workbooks are to be provided in advance of classroom instruction. They are to be read before the classroom experience wherein the book information is reinforced with video, discussion, and practical training. Again, with instruction provided through both the reading of workbooks and the classroom training, it is perplexing why facility staff members fail to recognize agonal breathing as a sign of cardiac arrest. The only logical conclusion is that staff members are not receiving appropriate instruction.
Another concern as to why facility staff members may not recognize AMI and SCA and respond appropriately is based upon the critical concept of “denial.” The psychology of denial is founded on the victim’s tendency to deny the possibility that he or she may be having a heart attack, and this response of the victim may persuade a potential rescuer not to contact EMS. This denial of the serious nature of the symptoms of an AMI delays the activation of EMS and consequent treatment thereby increasing the risk of death. The fact is that denial is not limited to the victim.
This psychology of denial or the tendency of people involved in an emergency to downplay the serious nature of the presenting problem is a natural one that must be overcome to provide rapid intervention and maximize the victim’s chance of survival (17). Typically, facility staff, instructors, and trainers would rather that an unconscious member with abnormal breathing be experiencing a seizure versus an SCA to which they have to respond with CPR and AED deployment. This reluctance to respond but rather to deny also may be the result of a lack of confidence in their ability to affect a successful rescue.
This lack of confidence also explains why too often instructors and trainers defer to facility members who might possess rescue skills. In one case of an SCA, an instructor deferred to a nurse who just remained with the victim lying on his back with agonal gasping. In another case, certified instructors were providing effective two-person CPR on an SCA victim when they deferred to a nurse and doctor who then delayed the CPR effort and provided a single rescue technique utilizing an incorrect protocol. In another ongoing case, certified individuals capable of providing two-rescuer CPR to an SCA victim deferred to a nurse who continually interrupted her CPR effort and that with an incorrect protocol. It is the responsibility of facility staff to provide the CPR response unless they know that someone else can perform the effort more effectively.
Currently, the primary reason for litigations against fitness facilities, in which a member has died, is because of the lack of an effective ERP coupled with a lack of an AED. Most facility ERPs are typically limited in their scope and rarely rehearsed — without the availability of manikins and training AEDs. Without a comprehensive and well-rehearsed ERP executed by qualified personnel, facilities will continue to be embroiled in litigation. Prudent management of a fitness facility knows that it is not a matter of whether a medical emergency will occur, but rather when it will occur.
Accidents, injuries, and cardiovascular incidents are inevitable in an environment where people are competing against others as well as themselves and pushing their physical limits. How a facility handles these unexpected but foreseeable events can literally mean the difference between a member’s life and death (18). A properly trained staff frequently rehearsed in emergency procedures can respond to accidents, injuries, and cardiovascular events with confidence rather than confusion. Therefore, the elements of a well-designed ERP must be not only understood by facility management but also practiced by the entire staff. It stands to reason that a well-designed ERP is part and parcel of a facility’s risk management program (19) (see Figure).
The question posed at the outset of this article was “Are staff, instructors, and trainers throughout the fitness industry maintaining their first aid and CPR/AED certifications as well as retaining their skills?” Like before, the answer remains a resounding “no.” As previously discussed, most staff, instructors, and trainers fail to have first aid certification, and although the majority of personnel are CPR/AED certified, they typically receive abbreviated instruction in which their skills are not thoroughly tested. Couple the concern that skills rapidly deteriorate over time with the fact that ongoing training is limited to rare, and it is no wonder that CPR/AED responses are usually ineffective. True, instructors and trainers may be certified, but typically they are not qualified. Just being certified does not get the job done!
As an AHA Basic Life Support instructor trainer for more than 40 years, this author has become painfully aware that the typical CPR/AED certification required by fitness facilities is inadequate in preparing instructors and trainers how to respond in a timely and effective manner to cardiovascular complications such as a heart attack or cardiac arrest. This problem has been compounded by the fact that facilities have not provided the necessary rehearsals and drills to ensure that personnel are prepared to react appropriately. As with former articles, there are numerous cases that can be cited validating this serious problem within the fitness industry.
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