Report: Defibrillator Used Too Late in Texas Teen Girl`s Death in July

The 12-year-old collapsed on the steps of a water coaster at NRH2O on July 14. She was declared dead more than an hour later. But she might have lived if she had been shocked with defibrillators within four to six minutes of her collapse, experts and studies say.

The water park has two of the devices, which send an electric shock through the heart. They were stored at the opposite end of the 7 1/2-acre park in the first aid office and the administration office. Paramedics used their own defibrillators some 20 minutes after Sarah collapsed -- far too late to save her.

"If there was any chance to bring her back, it would have been with defibrillation," said Dr. Harry Lever of the Cleveland Clinic Heart Center in Ohio. He is a leading expert in hypertrophic cardiomyopathy, the condition that led to Sarah's death.

For each minute that passed after her collapse without defibrillation, Sarah lost 10 percent of her chance to survive, Lever said.

An incident report obtained from the park states that a lifeguard at the Green Extreme was notified of Sarah's fall at about 10:45 a.m. She announced a medical emergency over the radio and cleared Sarah's airway.

The report does not state what time the park's emergency medical technician, Jennifer Kettner, got to Sarah. When she arrived, Kettner, of North Richland Hills, asked for an oxygen tank. An off-duty nurse who was helping told Kettner that she could not find a pulse.

Kettner asked for an automated external defibrillator. The report does not specify what time she asked for it, only that the device, which was 180 yards away, got to the scene at 10:51 a.m., the same time that the paramedics arrived.

Kettner could not be reached to comment.

"The reality is, there has to be an assessment done," said Richard Torres, an assistant city manager who oversees NRH2O along with the city parks and recreation division. "She's up on a tower, and there are lines of people everywhere. This is a large park with thousands of people and one EMT. For all we know the EMT didn't even get to her for several minutes."

Although paramedics got to the park three minutes after the 911 call, they didn't make contact with Sarah for another three minutes, according to reports.

Sarah had already been down for at least six minutes, and paramedics did not use defibrillation right away, said Dr. Roy Yamada, medical director of emergency medical services with the North Richland Hills Fire Department. They used cardiopulmonary resuscitation first to get her blood flowing, but her heart had completely stopped. Quivering or fibrillation of the heart must be present for the device to work.

Medics gave her an IV and epinephrine to make the heart quiver, he said.

The paramedics could not have known Sarah had hypertrophic cardiomyopathy. Epinephrine can make it worse, Lever said.

About 21 minutes had passed before medics administered the first shock, according to reports from both NRH2O and paramedics.

"If she was down next to the first aid center where they had the AEDs, it may have been different," Yamada said. "But in a tower like that where they're on the second floor and they don't have the equipment up there ... and then with the heart being enlarged.

"It's unfortunate, but they tried. They worked their hearts out for her."

Park staff is trained

The off-duty nurse and water park staff administered CPR, but chest compressions and assisted breaths alone are not as effective as CPR with an AED, according to two studies published in the New England Journal of Medicine in August.

One study found that 14 percent of people with cardiac arrest survive with only CPR by trained volunteers. But about 23 percent survive with early defibrillation and CPR combined.

"It was the only chance she had," said Lisa Salberg, president of the Hypertrophic Cardiomyopathy Association, a nonprofit support and advocacy group based in New Jersey. "In all likelihood, they would have resuscitated her."

The second study, conducted in Canada, shows that trained bystanders could increase survival rates after cardiac arrest with CPR and early defibrillation because paramedics often arrive too late.

AEDs are now common in public places and businesses. Dallas/Fort Worth Airport has one at every checkpoint. American Airlines carries the devices on planes and trains flight attendants to use them. Some cities, including North Richland Hills, stock AEDs in all public buildings. The HeartStart Home Defibrillator is available with a prescription.

Most states, including Texas, have "Good Samaritan" laws that protect the average person from liability if they come to the rescue of a person in distress with an AED.

The NRH2O water park, unlike a passer-by, has a responsibility to care for anyone hurt on site, said Ellen Pryor, a tort expert and law professor at Southern Methodist University's Dedman Law School in Dallas.

By adding AEDs to its inventory, the park has a responsibility to use the equipment appropriately, she said.

"The water park is not an average person," she said. "If someone is drowning or hurting in your pool or on your property, you have a duty of care. ... The more tools you have when you're under a duty of care, the more you've got know about what to do with them."

At NRH2O, the 200 members of the water park's staff are trained to operate AEDs and to conduct CPR, said Paulette Hartman, North Richland Hills city spokeswoman.

About 50 employees, including lifeguards, and one emergency medical technician are at the park at all times, said NRH2O Operations Coordinator Frank Perez.

The park's two AEDs are checked daily. Workers get training updates monthly on either AEDs, CPR or administering oxygen. Updates for lifeguards include aquatic training, he said.

"We're going above and beyond by having two AEDs," he said.

The park had tried in the past to store one of the AEDs at the Green Extreme tower for easier access, Perez said. But the machines got too hot and malfunctioned.

Instead, one is kept in the first aid office and the other in the park's administration office, both at the front of the park near the entrance.

Sarah's death was the first cardiac arrest in the park's 10-year history. The AEDs have never been used, Hartman said.

"The staff at the water park and the paramedics did everything they could to save this little girl," she said.

Odds against her

The odds may have been against Sarah. She was on the second story of a seven-story water coaster. The AEDs were 180 yards away. And no one expected a 12-year-old girl's heart to stop.

"When you hear of a 12-year-old going down, you don't think of cardiac arrest," Yamada said. "You think of heat exhaustion, you think of falling. You never think she's going to have a cardiac arrest."

Sarah was one of about 450,000 people who die of sudden cardiac arrest in the United States each year. Forty-seven percent of the deaths occur outside a hospital, according to another study in the New England Journal of Medicine. Only about 5 percent of people who experience cardiac arrest outside a hospital survive.

But Lever contends that defibrillation within minutes of a collapse could mean a normal life for a person with hypertrophic cardiomyopathy.

"This is one of those cases that makes you feel really bad," he said.

When seconds count

Sarah Friend, a 12-year-old from North Richland Hills, collapsed at NRH2O and died July 14. Doctors attributed her death to a previously undetected heart condition.

Some medical experts say that she may have been saved if the staff had used automated external defibrillators, stored at the park, within four to six minutes of her collapse.

About 10:45 a.m. A lifeguard at the Green Extreme at NRH2O learns that a girl has collapsed.

10:48 a.m. Dispatchers notify the Fire Department.

10:49 a.m. Laura Friend gets a call saying that her daughter has collapsed.

10:51 a.m. Paramedics arrive at the scene.

10:54 a.m. Paramedics make contact with the girl.

10:56 a.m. Paramedics start to monitor her heart.

11:06 a.m. Defibrillator is used, but paramedics cannot revive her.

12:14 p.m. Sarah is pronounced dead at North Hills Hospital.

SOURCES: NRH2O incident report, North Richland Hills public safety reports, Friend family

Hypertrophic cardiomyopathy

The disease causes the heart to thicken and can fatally disrupt the flow of blood.

The most common genetic heart disease, hypertrophic cardiomyopathy is underdiagnosed. It occurs in about one in 500 people and is more common than cystic fibrosis and muscular dystrophy. For some people, sudden death is the first sign.

Symptoms include palpitations, shortness of breath, dizziness, passing out and chest pains. The disease is diagnosed with an echocardiogram, an ultrasound scan of the heart.