Abstract:
An atrial defibrillator includes a portable, non-implantable housing, a pair of defibrillator pads, a shock generator, and an analyzer. The pads are applied to the outside of a patient&#39;s body, and the shock generator delivers a shock to the patient via the pads. The analyzer receives a cardiac signal from the patient, determines from the signal whether the patient is experiencing atrial fibrillation, and enables the shock generator if the patient is experiencing atrial fibrillation. Unlike conventional external atrial defibrillators, such an atrial defibrillator can be used by a layperson in the comfort of a patient&#39;s own home. Furthermore, such a defibrillator does not cause the surgery-related problems associated with implantable atrial defibrillators. Moreover, because the patient can choose when to receive a shock, such a defibrillator is less likely to surprise and embarrass the patient than automatic implantable defibrillators are.

Description:
TECHNICAL FIELD 
   The invention relates generally to medical devices, and more particularly to an external atrial defibrillator and method for terminating atrial fibrillation. 
   BACKGROUND OF THE INVENTION 
   Atrial fibrillation (AF), which lay persons know as heart palpitations, is a commonly occurring cardiac arrhythmia. Generally, an AF episode is not life threatening, and the patient is functional during the episode. Some patients, however, feel under the weather, feel dizzy, or even lose consciousness during an AF episode. Nevertheless, even in the most severe cases, AF episodes without secondary sequelae and lasting less than 48 hours are thought to have no long-term adverse effects on a patient&#39;s health. Conversely, among other consequences, episodes lasting 48 hours or longer increase a patient&#39;s risk of stroke. Therefore, a patient&#39;s physician usually instructs him/her to seek medical treatment if an AF episode does not spontaneously terminate within 24 hours. This gives the patient sufficient time to actually receive treatment within the 48-hour safety window. 
   Referring to  FIGS. 1 and 2 , AF is characterized by irregularly distributed R—R intervals in a patient&#39;s electrocardiogram.  FIG. 1  is portion of a patient&#39;s electrocardiogram that includes one R—R interval. The electrocardiogram includes P, Q, R, S, and T waves, and the R—R interval is defined as the interval between the upper peaks of adjacent R waves.  FIG. 2  is a plot of the respective lengths of a patient&#39;s R—R intervals during an AF episode. In the electrocardiogram of a patient having a normal heart rhythm, the lengths of adjacent R—R intervals differ from one another by no more than a few milliseconds (ms), and thus are approximately equal. Therefore, during a period of normal heart rhythm, the plotted lengths of the R—R intervals would lie on or near the dashed line  10  in a normal distribution pattern. But during an AF episode, the plotted lengths of the R—R intervals differ significantly and randomly from one another. Therefore, during an AF episode, the plotted lengths  12  of the R—R intervals lie in a random distribution pattern with the appearance of a “bee swarm”. 
   There are several preventative and termination treatments available to patients with AF. Preventative treatments such as anti-arrhythmic drug therapy help prevent AF episodes from occurring, and termination treatments such as cardioversion terminate AF episodes once they have begun. As discussed below, some of these treatments are often expensive and/or inconvenient. 
   An external atrial defibrillator is a device that a cardiologist uses to apply one or more cardioverting electrical pulses, i.e., shocks, to the patient in order to terminate an AF episode. As discussed above, the cardiologist instructs his patient to notify the cardiologist&#39;s office if an AF episode lasts more than 24 hours. The cardiologist then admits the patient to the hospital on an in-patient or out-patient basis. While in the hospital, the patient is anesthetized and is shocked one or more times until the AF episode terminates. Unfortunately, this procedure costs approximately $1000–$5000 per session depending upon the procedure location within the hospital, and thus is relatively expensive. In addition, this procedure is burdensome to the patient for a number of reasons. For example, he/she often misses at least a day of work to undergo cardioversion. Furthermore, because the lingering effects of the anesthesia render him/her temporarily unfit to drive, the patient must find someone to drive him/her home from the hospital after the procedure. Because many AF patients require this procedure several times per year, the cumulative costs and burdens associated with this procedure can be quite substantial. 
   An internal atrial defibrillator is a device that is implanted within a patient&#39;s body and that applies one or more cardioverting electrical shocks directly to the patient&#39;s heart in order to terminate an AF episode. A manual model, such as the InControl Metrix, allows the patient to shock himself when he wishes to terminate an AF episode. In one known device, the patient initiates a shock by using a magnet to toggle a subcutaneous switch. Unfortunately, the implant surgery may cause discomfort to the patient, and complications such as infection may arise following surgery. Furthermore, additional surgeries can be required to replace the batteries or to repair or replace a defective unit. Alternatively, the internal defibrillator may include circuitry that detects an AF episode and automatically shocks the patient to terminate it. Unfortunately, in addition to the problems described above for the manual model, the automatic model may embarrass the patient. For example, a defibrillator shock affects not only the heart muscle, but often contracts most, if not all, of the voluntary muscles in the patient&#39;s thorax. Unfortunately, these contractions often cause the patient to “jump” uncontrollably. Therefore because the patient has no control over when the defibrillator delivers the shock, the shock, and thus this potentially embarrassing side effect, may occur during work or a social occasion. 
   Therefore, what is needed is an external atrial defibrillator that a patient or caretaker can use safely in the patient&#39;s own home. 
   SUMMARY OF THE INVENTION 
   In one aspect of the invention, an atrial defibrillator includes a pair of defibrillator pads, a shock generator, and an analyzer. The pads are applied to the outside of a patient&#39;s body, and the shock generator delivers a shock to the patient via the pads. The analyzer receives a cardiac signal from the patient, determines from the signal whether the patient is experiencing atrial fibrillation, and enables the shock generator if the patient is experiencing atrial fibrillation. 
   Unlike conventional external atrial defibrillators, such an atrial defibrillator can be used by a layperson in the comfort of a patient&#39;s own home. Furthermore, such a defibrillator does not cause the surgery-related problems associated with implantable atrial defibrillators. Moreover, because the patient can choose when to receive a shock, such a defibrillator is less likely to embarrass the patient than automatic implantable defibrillators are. 

   
     BRIEF DESCRIPTION OF THE DRAWINGS 
       FIG. 1  is portion of a patient&#39;s electrocardiogram that includes an R—R interval. 
       FIG. 2  is a plot of an R—R-interval distribution for a patient experiencing an AF episode. 
       FIG. 3  is a diagram of an atrial defibrillator according to an embodiment of the invention, and a patient connected to the defibrillator. 
       FIG. 4  is a schematic block diagram of the atrial defibrillator of  FIG. 3  according to an embodiment of the invention. 
       FIG. 5  is a plot of an R—R-interval distribution for a patient experiencing premature ventricular contractions (PVC). 
       FIG. 6  is a portion of an electrocardiogram for a patient experiencing Ashman&#39;s phenomenon. 
       FIG. 7  is a flow diagram of an atrial-defibrillation procedure that incorporates the atrial defibrillator of  FIG. 3  according to an embodiment of the invention. 
   

   DESCRIPTION OF THE INVENTION 
     FIG. 3  is a block diagram of an atrial defibrillator  20  according to an embodiment of the invention, and a patient  22  connected thereto. The defibrillator  20  includes a portable shock/analyze unit  24  for generating an atrial-defibrillation (ADF) shock, and includes electrode pads  26  and  28  for delivering the ADF shock to the patient  22 . (The pad  26  is in dashed line to indicate that it is coupled to the patent&#39;s back.) The unit  24  includes a control panel  30 , which allows an operator (not shown) to input commands such as a shock command to the unit  24 , and includes an identification verifier  32 , which prevents the unit  24  from generating a shock if the operator is unauthorized to operate the unit. The pads  26  and  28  are coupled to the unit  24  via wires  34  and  36 , respectively, are attached to the patient  22  with a conventional adhesive, and include a conventional contact gel that enhances the electrical conductivity between the pads and the patient&#39;s skin. Although an anterior-posterior placement of the pads  26  and  28  is shown and is believed to be the most effective placement for terminating an AF episode, one can use the shock unit  24  with other pad placements as well. 
   In operation, the shock/analyze unit  24  analyzes the patient&#39;s heart rhythm, determines whether the patient  22  is experiencing an AF episode, and generates an ADF shock in response to the operator&#39;s command if the patient  22  is experiencing an AF episode and other conditions are met. The unit  24  receives a cardiac signal such as an electrocardiogram from the patient  22  via the pads  26  and  28  or by other conventional means. The unit  24  analyzes the cardiac signal to determine whether the patient is experiencing an AF episode. If the patient is experiencing an AF episode, then the identification verifier  32  determines whether the operator is authorized to shock the patient  22 . If the operator is authorized, the unit  24  generates an ADF shock in response to the operator entering a shock command via the panel  30 . As discussed below in conjunction with  FIGS. 4 and 5 , the verifier  32  checks the operator&#39;s authorization primarily for safety reasons. For example, in one embodiment the verifier  32  prevents the patient  22  from shocking himself/herself. After generating the ADF shock, the unit  24  analyzes the cardiac signal again to determine whether the AF episode has terminated, informs the operator and patient of the analysis results, and suggests further treatment options if the AF episode has not terminated. Conversely, if the patient  22  is not experiencing an AF episode or if the operator is unauthorized to operate the defibrillator  20 , then the unit  24  does not generate an ADF shock regardless of the commands that the operator enters via the panel  30 . 
   The atrial defibrillator  20  provides many advantages over prior atrial defibrillators. Unlike conventional external defibrillators, the portability and analysis capability of the shock/analyze unit  24  make the defibrillator  20  ideal for use by laypersons outside of the hospital and doctor&#39;s office. Therefore, the defibrillator  20  significantly reduces the costs and inconveniences associated with conventional external cardioversion techniques, and may even be a convenient alternative to anti-arrhythmic drug therapy for some patients. Furthermore, unlike implantable atrial defibrillators, the defibrillator  20  has no surgery-related risks and allows the patient  22  to receive an ADF shock at a time and place of his/her own choosing. 
   Although one embodiment of the defibrillator  20  is discussed for example purposes, the inventors contemplate other embodiments. For example, the unit  24  may lack the non-patient operator verifier  32  so that the patient  22  can shock himself/herself should the diagnostic algorithm allow. 
     FIG. 4  is a schematic block diagram of the shock/analyze unit  24  of  FIG. 3  according to an embodiment of the invention. In addition to the control panel  30  and the identification verifier  32 , the unit  24  includes a shock-generator circuit  40 , an analyze/synchronize circuit  42 , a memory  44 , and a communicator  46 . 
   In operation, the circuit  42  first analyzes the cardiac signal from the patient  22  via the pads  26  and  28  ( FIG. 3 ) to determine if the patient is experiencing an AF episode. If the patient  22  is not experiencing an AF episode, then the circuit  42  informs the patient and operator via the communicator  46 —which may be a visual display or a speech synthesizer—and the unit  24  delivers no ADF shocks. If the patient is experiencing an AF episode, the circuit  42  informs the patient and operator via the communicator  46 , enables the circuit  40 , and synchronizes the circuit  40  such that it generates the ADF shock during a desired portion of the cardiac signal. Thus, even if the operator enters a shock command via the control panel  30 , the circuit  42  delays the circuit  40  from generating the ADF shock until the occurrence of the desired portion of the cardiac signal. After the ADF shock, the circuit  42  analyzes the cardiac signal to determine if the AF episode has terminated. If it has, the circuit  42  informs the patient and operator via the communicator  46  and disables the circuit  40  from generating more ADF pulses. If the AF episode has not terminated, the circuit  42  informs the patient and operator and allows the circuit  40  to generate another ADF shock if the patient so desires. But as discussed below, the circuit  42  may disable the circuit  40  after the patient has received a predetermined maximum number of ADF shocks. 
   Still referring to  FIG. 4 , the design and operation of the shock-generator circuit  40  and the analyze/synchronize circuit  42  are discussed in more detail. 
   In one embodiment, the shock-generator circuit  40  is conventional and includes a power supply  48 , shock source  50 , sensor  52 , timer  54 , controller  56 , counter  58 , and pad coupler  60 . The supply  48  charges the shock source  50 , and in the absence of another power supply, provides power to the other circuitry of the shock/analyze unit  24 . When the pad coupler  60  couples the source  50  to the wires  34  and  36 , the shock source  50 , which is a capacitor bank in one embodiment, discharges to generate an ADF shock pulse. The sensor  52  provides a sensor signal to the timer  54  when the pulse decays to a predetermined level. The timer  54  provides a pulse timing signal to the controller  54 . The controller  56  activates the pad coupler  60  to generate an ADF pulse, deactivates the pad coupler  58  to terminate an ADF pulse, and may reverse the polarity of the coupler  58  to reverse the polarity of a biphasic or multiphasic ADF pulse. The counter  58  increments or decrements by one each time the controller  56  activates the pad coupler  58  to generate a new ADF pulse. 
   In operation, when it receives respective enable signals from the identification verifier  32 , the analyzer  44 , and the counter  58 , the shock controller  56  activates the pad coupler  60  in response to a shock command from the control panel  30 . The active coupler  60  couples the shock source  50  to the pads  26  and  28 , and thus the energy stored in the source  50  discharges into the patient  22  ( FIG. 3 ). This transfer of energy constitutes the ADF pulse. The sensor  52  monitors the ADF pulse, and, when it decays to a predetermined level, the sensor  52  signals the timer  54 . The timer  54  waits a predetermined time after receiving the sensor signal, and then provides a timing signal to the controller  56 . If the controller  56  is programmed to generate a uniphasic ADF pulse, then the controller  56  deactivates the pulse coupler  60 , which uncouples the shock source  50  from the pads  26  and  28  to terminate the pulse. If, on the other hand, the controller  56  is programmed to generate a biphasic ADF pulse, then the controller  56  causes the pulse coupler  60  to reverse the polarity of the connection between the shock source  50  and the pads  26  and  28 . The sensor  52  then monitors this reversed-polarity portion of the pulse, and, when this portion of the pulse decays to a predetermined level, the sensor  52  again signals the timer  54 . The timer  54  waits a predetermined time after receiving the sensor signal and then provides another timing signal to the controller  56 , which deactivates the pulse coupler  60  to terminate the biphasic ADF pulse. Although the shock controller  56  is described as generating uniphasic or biphasic ADF pulses, the shock controller  56  can also generate multiphasic ADF pulses in a similar manner. 
   As is known, the ADF pulses generated by the shock-generator circuit  40  can have a wide range of voltage and energy levels. For example, the energy levels of ADF pulses are typically within a range of approximately 70–400 Joules (J). Because AF episodes are difficult to terminate with one ADF pulse, particularly with a lower-energy pulse, in one embodiment the circuit  40  generates each ADF pulse having an energy of at least 200 J. This reduces the chance that the patient will require multiple ADF pulses to terminate an AF episode. Typically, multiple pulses are more uncomfortable to a patient than a single pulse, even if the single pulse has a higher energy level than each of the multiple pulses. Therefore, terminating an AF episode in only one pulse significantly reduces the patient&#39;s discomfort. 
   Shock-generator circuits such as the shock-generator circuit  40  are discussed in many references including U.S. Pat. No. 5,735,879 to Gliner et al. for “Electrotherapy Method for External Defibrillators”, which is incorporated by reference. 
   Still referring to  FIG. 4 , as discussed above, the analyze/synchronize circuit  42  analyzes a cardiac signal to determine if the patient  22  is experiencing an AF episode, and if so, enables the shock-generator circuit  40  and synchronizes the generation of the ADF pulse to the cardiac signal. If, on the other hand, the patient is not experiencing an AF episode or has received the maximum number of ADF pulses allowed, the circuit  42  may disable the circuit  40  from generating another ADF shock. 
   In one embodiment, the analyze/synchronize circuit  42  determines whether the patient is experiencing an AF episode by analyzing the differences between the R—R intervals in the patient&#39;s electrocardiogram ( FIG. 1 ). Specifically, the circuit  42  samples a plurality of consecutive R—R intervals, computes the respective differences between the length of each sampled R—R interval and the lengths of the adjacent R—R intervals, and determines that the patient is experiencing an AF episode if at least a predetermined number of these differences equals or exceeds a predetermined difference threshold. For example, suppose the number of samples is 20, the difference threshold is 40 ms, and the predetermined number is 5. Therefore, the circuit  42  detects an AF episode if 5 or more of the R—R-interval differences equal or exceed 40 ms. Alternatively, the circuit  42  may repeat this procedure for multiple groups of sampled R—R intervals and detect AF if the predetermined number of differences within each group equals or exceeds the predetermined difference threshold. For example, suppose there are 10 groups of 20 samples each. Therefore, the circuit  42  detects an AF episode if 5 or more of the R—R-interval differences within each group equal or exceed 40 ms. Circuits and techniques for performing such an R—R interval analysis are well known, and, therefore, are omitted for clarity. 
   In another embodiment, to increase diagnostic specificity, the analyze/synchronize circuit  42  determines whether the patient is experiencing an AF episode by analyzing the R—R intervals as discussed above and by analyzing the QRS signals of the patient&#39;s electrocardiogram. Referring to  FIG. 1 , a QRS signal is a combination of the Q, R, and S waves. During an AF episode, the patient&#39;s QRS signals typically have a normal shape. Therefore, the circuit  42  samples several of the QRS signals from the patient&#39;s electrocardiogram and compares each of their shapes to a normal QRS shape that is stored in the memory  44 . (The normal QRS shape is the shape of a QRS signal that was previously sampled and stored while the patient was experiencing a normal heart rhythm.) If the respective differences between the shapes of the sampled QRS signals and the shape of the normal sinus rhythm QRS signal are all less than a predetermined QRS difference, then the circuit  42  determines that the sampled QRS signals are normal. Therefore, if the sampled QRS signals are normal and the R—R-interval analysis indicates an AF episode as discussed above, then the circuit  42  determines that the patient is experiencing an AF episode. If, however, the shapes of at least a predetermined number of the sampled QRS signals differ from the shape of the normal QRS signal by at least the predetermined QRS difference, then the circuit  42  determines that the sampled QRS signals are abnormal. Therefore, if the sampled QRS signals are abnormal, then the circuit  42  determines that the patient is not experiencing an AF episode regardless of the results of the R—R-interval analysis. Furthermore, because abnormal QRS signals may indicate a serious arrhythmia such as ventricular fibrillation (VF), the circuit  42  informs the operator and patient to seek prompt medical attention for the patient. Alternatively, the shock/analyze unit  24 , upon identification of VF, may revert to a standard AED for VF. Circuits and techniques for comparing the shapes of QRS signals are well known, and, therefore, are omitted for clarity. 
   In yet another embodiment, the analyze/synchronize circuit  42  determines whether the patient is experiencing an AF episode by first determining the patient&#39;s heart rate and then performing either of the AF detection techniques discussed above. Typically, the heart rate of a patient experiencing an AF episode is in a range of approximately 40–200 beats per minute. Therefore, if the circuit  42  determines that the patient&#39;s heart rate is within this range, it proceeds with one of the AF-detection techniques as discussed above. Conversely, if the circuit  42  determines that the patient&#39;s heart rate is outside of this range, it informs the patient and operator that the patient is not experiencing an AF episode, and thus disables the shock-generator circuit  40  for atrial cardioversion. Circuits and techniques for determining a patient&#39;s heart rate are well known, and, therefore, are omitted for clarity. 
   Referring to  FIGS. 4 ,  5 , and  6 , in still another embodiment, the analyze/synchronize circuit  42  distinguishes between AF and other arrhythmias that the above-described AF-detection techniques may erroneously interpret as an AF episode.  FIG. 5  is a plot of an R—R-interval distribution for a patient experiencing premature ventricular contractions (PVC). Like AF, the lengths of adjacent R—R intervals of a patient experiencing PVC can differ significantly. But unlike AF, the R—R-interval distribution for PVC lies primarily within three distribution regions  70 ,  72 , and  74 . Therefore, if the circuit  42  detects such a distribution pattern, it determines that the patient is not experiencing an AF episode even if the above-described R—R-interval analysis or combined R—R-interval/QRS analysis indicates otherwise.  FIG. 6  is an electrocardiogram of a patient experiencing Ashman&#39;s phenomenon, which is characterized by a wider-than-normal QRS signal  76  that follows an Ashman sequence. An Ashman sequence includes a shorter-than-normal R—R interval  78 , a normal QRS signal  80 , and a longer-than-normal R—R interval  82  (only a portion of which is shown in  FIG. 6 ). Because Ashman&#39;s phenomenon affects the QRS signals but not the R—R intervals, it is only a concern when the circuit  42  uses the combined R—R-interval/QRS analysis described above. Therefore, if the R—R-interval portion of the analysis indicates an AF episode but the QRS portion of the analysis indicates no AF episode, the circuit  42  determines whether the abnormal QRS signals follow respective Ashman sequences. If this is the case, then the circuit  42  determines that the patient is experiencing an AF episode regardless of the results of the QRS portion of the analysis. Circuits and techniques for detecting Ashman&#39;s sequences are well-known, and, therefore, are omitted for clarity. 
   Still referring to  FIG. 4 , in one embodiment, the analyze/synchronize circuit  42  synchronizes the generation of the ADF pulse to the rising edge of an R wave. Such synchronization reduces the chance that the ADF pulse will induce other more serious arrhythmia such as VF. Circuits and techniques for performing such synchronization are well-known, and, therefore, are omitted for clarity. 
   In another embodiment, the analyze/synchronize circuit  42  synchronizes the generation of the ADF pulse to the rising edge of an R wave that follows a normal or long R—R interval. This is because synchronizing an ADF pulse to an R wave that follows a short R—R interval increases the chances that the pulse will cause the patient to experience a more serious arrhythmia such as VF. A circuit and technique for performing such synchronization are discussed in U.S. Pat. No. 5,207,219 to Adams et al., which is incorporated by reference. 
   Still referring to  FIG. 4 , after the shock-generator circuit  40  generates the ADF pulse, the analyze/synchronize circuit  42  uses techniques similar to the AF-detection techniques discussed above to determine whether the AF episode has terminated. In one embodiment, the circuit  42  analyzes the differences between the R—R intervals in the patient&#39;s post-shock electrocardiogram and determines that the AF episode has terminated if at least a predetermined number of these differences is less than a predetermined difference threshold. For example, suppose that the number of samples is 20, and the difference threshold is 40 ms, and the predetermined number is 15. Therefore, the circuit  42  detects termination of the AF episode if at least 15 of the R—R-interval differences are less than 40 ms. In another embodiment, the circuit  42  also compares the post-shock QRS signals with the stored normal QRS signal. The circuit  42  detects that the AF episode has terminated if the post-shock QRS signals match the normal QRS signal and the results of the R—R-interval analysis indicate termination of the AF episode. 
   Although the shock/analyze unit  24  is described in conjunction with  FIG. 4  as including a number of functional circuit blocks, the unit  24  may instead include one or more processors that are programmed to perform the functions of these circuit blocks. 
     FIG. 7  is a flow diagram of an atrial defibrillation procedure that incorporates the atrial defibrillator  20  of  FIG. 3  according to an embodiment of the invention. 
   Referring to block  90 , the operator activates the defibrillator  20  and attaches the pads  26  and  28  to the patient&#39;s body ( FIG. 3 ). 
   Referring to blocks  92  and  94 , the defibrillator  20  analyzes the patient&#39;s cardiac signal and determines whether the patient is experiencing an AF episode as discussed above in conjunction with  FIGS. 4 ,  5 , and  6 . Referring to blocks  96  and  98 , if the patient is not experiencing an AF episode, then the defibrillator  20  informs the patient and operator and instructs the operator to remove the pads  26  and  28  from the patient. 
   Referring to blocks  100  and  102 , if the patient is experiencing an AF episode, then the defibrillator  20  “asks” the patient if he/she has waited for at least a specified waiting period since the onset of the AF episode. Such a waiting period allows the AF episode a chance to spontaneously terminate without the need for an ADF shock. In one embodiment, the waiting period is approximately 6 hours. The patient or the operator enters a “yes” or “no” response. If a “no” is entered, then the defibrillator  20  instructs the operator to remove the pads  26  and  28  (block  98 ) and to wait the remainder of the waiting period before using the defibrillator  20 . 
   Referring to block  104 , if the patient has waited for at least the specified waiting period, then the defibrillator asks him/her if there is another authorized person, i.e., the operator, available to administer the ADF shock. If the patient answers “no”, then, referring to blocks  106  and  98 , the defibrillator  20  informs the patient that he cannot shock himself and instructs the patient to remove the pads  26  and  28 . As discussed above, the patient is not allowed to shock himself for safety reasons. For example, there is a very small risk that an ADF pulse, even if properly synchronized to the cardiac signal, may cause the patient to experience VF. A patient is typically unconscious during a VF episode, which can lead to the patient&#39;s death. Therefore, if the ADF shock induces VF and no other person is present, then the patient, who will be unable to call for help, will die. The presence of an operator, however, allows the rare induction of VF to be promptly treated with the defibrillator  20  or a portable VF defibrillator (not shown) and allows the operator to call an ambulance and even administer cardiopulmonary resuscitation (CPR). For additional safety, the identification verifier  32  ( FIGS. 3 and 4 ) insures that only an authorized operator can initiate the ADF shock. For example, the verifier  32  may require the operator to enter a secret code or may scan a physical characteristic such as a fingerprint or retina and compare it to an image of the characteristic stored in the memory  44 . Or, the defibrillator  20  may include circuitry that determines whether the operator is attached to the pads  26  and  28 . If the operator is so attached, then the defibrillator  20  determines that the operator is actually the patient and is attempting to shock himself, and thus disables the shock-generator circuit  40 . 
   Referring to block  108 , if an authorized operator is present, then the defibrillator  20  informs him that he/she can initiate an ADF shock when the patient is ready. For example, the patient may want to delay the initiation of the shock for several hours so that he/she can take a sedative such as Valium and allow the sedative sufficient time to take effect. Once the patient is ready and the diagnostic algorithm is satisfied, the operator initiates the ADF shock by entering a shock command via the control panel  32  ( FIGS. 3 and 4 ). 
   Referring to block  110 , the defibrillator  20  waits for the operator to enter the shock command. Referring to blocks  112  and  114 , once the operator enters the shock command, the defibrillator  20  generates and delivers the shock to the patient and updates the shock counter  58  ( FIG. 4 ), which the defibrillator previously reset to an initial count value such as zero. 
   Referring to blocks  116  and  118 , the defibrillator  20  analyzes the post-shock cardiac signal from the patient and determines whether the AF episode has terminated. In one embodiment, the defibrillator  20  uses one or more of the AF-termination-detection procedures discussed above in conjunction with  FIGS. 4 ,  5 , and  6 . 
   Referring to blocks  96  and  98 , if the AF episode has terminated, then the defibrillator  20  informs the patient and operator and instructs the operator to remove the pads  26  and  28  from the patient. 
   Referring to block  120 , if the AF episode has not terminated, then the defibrillator  20  checks the shock counter  58  ( FIG. 4 ) to determine if more shocks are available for the present session. 
   Referring to block  122 , if there are no more shocks available in the present session, then the defibrillator  20  instructs the patient to call his cardiologist and wait a specified time before the next session. Next, referring to block  98 , the defibrillator  20  instructs the operator to remove the pads  26  and  28  from the patient. 
   Referring to block  124 , if there are more shocks available in the present session, then the defibrillator  20  asks the patient if he would like another shock. Referring to block  108 , if the patient answers “yes”, then the defibrillator instructs the operator to initiate the shock. Referring to block  98 , if the patient answers “no”, then the defibrillator instructs the operator to remove the pads  26  and  28  from the patient. 
   From the foregoing it will be appreciated that, although specific embodiments of the invention have been described herein for purposes of illustration, various modifications may be made without deviating from the spirit and scope of the invention.