Every year out-of-hospital ventricular fibrillation cardiac arrests kill hundreds of thousands of people worldwide, often striking those without obvious high-risk conditions or symptoms.1 The fundamental strategy to improve survival is to reduce the time interval from collapse to defibrillation, as the likelihood of survival decreases on average about 5–10% for each minute that elapses without defibrillator treatment. The traditional deployment model is to equip specific emergency medical services (EMS) professionals, who are activated to respond with a defibrillator and deliver the potential life-saving shock. In most communities, the average interval from the emergency call to EMS defibrillator care exceeds 8 min, an interval that results in less than a quarter of patients surviving. In many communities the survival rate is in the single digits. Early bystander cardiopulmonary resuscitation, expert EMS care and comprehensive hospital management have an integral life-saving role, but the effectiveness of these links is undermined by delays in defibrillation.

Thus the development of the automated external defibrillator (AED)—which can assess the cardiac rhythm and correctly deliver a shock to the fibrillating heart—holds great promise. An AED enables almost anyone to save a life so long as the rescuer has ready access to an AED. The approach was rigorously evaluated in the public setting more than a decade ago, with results indicating that public access defibrillation (PAD) can double survival.2 A subsequent trial in the home setting did not demonstrate survival benefit, in part because the event rate was substantially lower than anticipated, making robust comparative evaluation challenging.3 Nevertheless, when the AED was used in the home, survival was favourable. Fundamentally, earlier defibrillation regardless of the setting provides for a real opportunity to improve survival.

When the results of the landmark PAD trial were presented more than a decade ago, one vision for the present day would have the majority of public-setting arrests treated by AEDs applied by a variety of persons—police, security and most especially laypersons. One might even envision that some minority of home-setting arrests would be treated by this strategy.

On paper, community translation of this approach would seem like a high-traction, achievable strategy to reduce mortality. In practice however, the strategy appears to have made modest inroads in many communities. Deakin et al4 describe the role of PAD in Hampshire. Of 1035 cardiac arrests, only 44 (4.25%) in 34 different locations involved the caller knowing an AED was present at the scene and only 18 (1.7%) had an AED applied before trained personnel arrived. The authors cite similar modest public access AED experiences from other communities around the world. Even in proactive communities where public-access AEDs are programmatically supported by EMS, AED involvement has not achieved visionary goals.5 No doubt, public access AED programmes have saved lives, but as the Deakin study highlights the current strategy has enabled only modest progress.

So what can be done to realise the lifesaving promise of the AED? We are faced with an unpredictable condition where specific high-risk locations (such as exercise facilities, airports and other transportation centres, shopping centres, casinos and dialysis centres) account for only a minority of events. Certainly a worthwhile approach is to continue to identify higher-risk locations and strategically deploy AEDs. This approach will save lives but is unlikely to transform resuscitation in a way that changes the perception that cardiac arrest is a life-ending tragedy for most. Emerging strategies leverage technologies to map AEDs, enlist social networks, and ultimately engineer more coordinated and quicker community AED response. These approaches deserve evaluation and may ultimately provide benefit, though initial evaluations suggest that such strategies in their current form may have limited impact.6–8

A complementary approach would be to consider the AED as a ubiquitous public safety device that should be available in almost every setting. Currently the cost of the AED and the lack of public appreciation of cardiac arrest prevent such a model of widespread, personal AED deployment. But let's consider fire prevention as an imperfect analogy. Many homes and businesses are equipped with smoke alarms and fire extinguishers even though the risk that a given structure will catch fire is exceptionally small. The fire extinguisher is not engineered to replace professional firefighting equipment, but rather intended as a practical intervention that may successfully treat the fire in its early stages. In combination, the cost of residential smoke alarms and extinguisher might be $100–200. Most persons accept this approach as a reasonable investment.

The materials to manufacture a personal AED are available and could support this type of competitive pricing. Yet AED convention—driven in part by safety concerns and regulation—introduces substantial expense so that AEDs typically cost at least $1000. Could we consider a different paradigm that might enable a low-cost AED that would have a more limited scope of therapy and less rigorous performance standards? What would be the consequence if a ‘cheap’ personal AED was engineered to provide only a single shock and would tolerate a 2% critical-failure rate?

Again we turn to the fire prevention analogy to begin the discussion about downstream consequences; the smoke alarm and fire extinguisher enable early treatment but do not prevent professional response from the fire department. Similarly in cardiac arrest, layperson AED use does not prevent EMS response so that standard care is still operational. Indeed EMS routinely has an active role in patients treated by layperson AED.5 Thus, the deployment of a ‘cheap’ personal AED with these distinct operating specifications would have a high likelihood to improve care, and a small chance that the patient receives the status quo standard of care when there is a critical AED failure. If we consider the current status of community resuscitation—which is the greater shortcoming: a cheap AED that suffers a 2% failure rate but could ‘change the rules’ and truly accelerate AED dissemination, and in turn enable a much broader reach of early defibrillation, while still providing for the status quo under the worst case scenario…. or the current strategy that realises the AED promise for only a handful using near-perfect technology that routinely outdistances the clinical requirements of the single-shock, layperson AED resuscitation.5

Of course this perspective is naïve. For example, many laypersons are not familiar with cardiac arrest or the role of the AED. For those unaware, the AED is an irrelevant technology, regardless of pricing. Fortunately, efforts aimed at education are growing given advances in communication and more systematic inclusion of AED in traditional training curriculums. This low-cost economic model may not appeal to industry stakeholders. The cheap technology could ultimately undermine the current pricing structure that enables manufacturers to remain commercially successful.

But we need to have these conversations, turn convention upside down and test innovative strategies that can take advantage of what we know: early defibrillation saves lives. As the Deakin investigation demonstrates, we are a long way from comprehensively applying this knowledge. We can be thankful for the handful who are saved with early defibrillation, but we should be troubled by the many who are denied the benefit. Collectively, we need to strive to deliver this proven treatment. If we are successful, the next decade will bring a fuller realisation of the AED's lifesaving promise.