Joe Kozina's life is devoted to death, particularly when it happens suddenly, in public, with people around to see it take place. Particularly when there's a chance it may not be permanent.
With a zeal that is almost evangelical, the Sacramento, Calif., cardiologist has been urging stores, stadiums and other places where people converge to equip themselves with a sophisticated piece of medical equipment called an automated defibrillator. The newest of these devices is so easy to use, he says, that even novice rescuers can deliver a life-saving jolt of electricity to victims of cardiac arrest.
As part of his crusade for "public access defibrillation," Kozina has helped the American Heart Association lobby for a California law that would protect ordinary people from lawsuits if they decided to grab one of these machines, read the directions and zap somebody's haywire heart in an emergency.
Their bill, however, died in a committee as abruptly as a coronary case, the victim of what proponents said was a lethal bit of 11th-hour lobbying by trial lawyers opposed to laws limiting lawsuits.
This dispute over a machine that many people can barely pronounce is only one of many taking place in statehouses and city halls across the country. The American Heart Association, a network of activists like Kozina and a trio of big manufacturers are leading a broad push to put a potent tool for surviving one of the nation's most common forms of death into the hands of everyday people.
In the last six months, 11 states have passed laws allowing lay people to use a defibrillator, and 10 others are considering similar legislation. The laws generally would protect nonprofessionals from lawsuits if they decided to defibrillate someone who looked like they needed it.
"Four months ago it seemed like an exotic topic," said Richard Cauchi, who tracks medical trends for the National Conference of State Legislatures. "Now it seems like one of the hot topics in health care."
Yet in many places the machines are triggering philosophical hand wringing and political infighting over to what degree the masses should be able to freely wield such powerful medical technology, and whether distributing them widely is worth the cost. A dozen states prohibit lay people from using the machines, and several others require training that proponents say is not only unnecessary but prohibitive to the point of costing lives.
Many insurance companies won't pay for them if a heart patient wants one for home and won't extend coverage to businesses that want them for their workers.
The latest generation of supposedly idiot-proof defibrillators cost about $3,000 and weigh five pounds. Unlike their bigger manually operated cousins, these devices are designed to diagnose the victim's distress and automatically decide whether a shock is needed. Some have only a single button.
The simplicity and portability of these devices are already changing the dynamics of public safety by turning up in Seattle police cars, Las Vegas casinos, golf courses, shopping malls, commercial airlines and even amusement parks such as Disneyland.
The laptop-sized defibrillators have even become a fashionable acquisition of the cardiac-prone affluent. "I heard about someone the other day who bought one for his home and one for his yacht," said Shelly Cohen, a spokeswoman for Physio-Control Corp., a Redmond, Wash., defibrillator manufacturer.
Defibrillator advocates claim that the new defibrillators are easier than performing cardiopulmonary resuscitation.
Some critics insist that the automated devices are not 100 percent foolproof and could, theoretically, actually give people a heart attack. Proponents say the machines are more likely not to shock people who really need it, rather than the reverse.
If lawyers have an interest in fighting liability protections, manufacturers have a stake in blanketing the country with the devices. The industry is largely dominated by Physio-Control; SurVivaLink Corp. of Minneapolis; and Heartstream Inc. of Seattle, which was recently acquired by the Hewlett-Packard Co.
The big manufacturers also are financing various pilot projects around the country and routinely issue news releases announcing dramatic rescues with their particular brands. Kozina gets his machines at a discount from SurVivaLink, and both the company and Kozina helped the heart association lobby for the legislation.
Right now the industry is focusing on getting the nation's 260,000 police cars to carry defibrillators, and to make them as de rigueur as fire extinguishers in places where there are concentrations of people.
The market's ultimate potential is so big that it defies estimate, said Ben Andrew, medical technology analyst with Vector Securities International in Deer Park, Ill. He said portable defibrillator sales went from about $25 million in 1996 to nearly double that last year, and should hit $100 million next year.
In an effort to assuage liability anxiety, Physio-Control even promises to indemnify anybody who buys its devices. The industry is also promoting the idea that it may be more legally hazardous not to have a defibrillator on the premises. A court ordered Lufthansa last year to pay $2.75 million for failing to provide timely medical care to a man who had a heart attack aboard a flight, and United Airlines this year said it would add defibrillators to its planes after it was sued in a similar case.
Yet for each defibrillator put in an airplane or police car, somebody has to assume responsibility for using it. Many police shy away from performing such things as CPR.
"I don't think you want to lose sight of a primary purpose of the police officer, which is to catch a perpetrator or to prevent a crime," said Jim Pasco, executive director of the Fraternal Order of Police. "We don't want to be the all-around handyman."
Some critics say there is no evidence that putting a defibrillator in every police car -- or in every building, for that matter -- is worth the cost.
"There's a bandwagon mentality that is driving this issue," grumbled Dr. Arthur Kellerman of Emory University in Atlanta. "We have a general fascination in American medicine that if something is neat and works and does great stuff, it ought to be promoted without regard to the costs or the trade-offs."
The devices require maintenance and can be misused, said Kellerman, and patients who are defibrillated need a whole range of medical treatment to aid their recovery.
He said there is little good scientific evidence that peppering a community with defibrillators works. For every successful increase in survival rates in cities such as Seattle and Rochester, Minn., where defibrillators were put in police cars, there are places such as Cincinnati and Memphis, where the impact was negligible.
The American Heart Association is planning to begin a definitive study later this year. It intends to distribute defibrillators to 300 stores, health clubs, trailer parks and other places, then compare the impact with survival rates in 300 comparable places without defibrillators.
Kellerman and other skeptics say the association should wait for the study results before promoting defibrillator deployment, which he said saps money from other programs, such as heart disease prevention. Proponents say the devices are so effective that getting them out into the mainstream is only common sense.
"How many studies were done on the safety of fire extinguishers?" Kozina said.
The fire extinguisher analogy is one that defibrillator devotees reach for repeatedly. The industry would like nothing better than to make defibrillators a fixture in the home, where nearly 80 percent of heart attacks occur.
"I can guess in five to 10 years you will probably be able to buy one of these things at Wal-Marts," said Kevin O'Grady, western sales manager for SurVivaLink.
Critics, though, point out that studies done in Seattle of defibrillators placed in homes found that some people weren't able to collect themselves in time to save a loved one. Still, scientists are already working on the next generation of even more user-friendly defibrillators, including cheap disposable devices and lightweight models that could be worn like a vest. Others would automatically dial 911.
University of Arizona Dr. Terence D. Valenzuela said he believes widespread home use of defibrillators is imminent. He is so sold on the devices that he bought one for himself.
"I trained my kids to use it when they were 8 and 9 1/2 ," he said. "I'm perfectly confident they can employ it."