Patent Publication Number: US-11642541-B1

Title: System for multiple defibrillation therapies

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. application Ser. No. 15/788,704, filed Oct. 19, 2017, which claims the benefit of U.S. Provisional Patent Application Ser. No. 62/410,290, filed on Oct. 19, 2016, the contents of which are herein incorporated by reference in their entirety. 
    
    
     BACKGROUND 
     Double sequential defibrillation (DSD) or simultaneous/near simultaneous defibrillation is a treatment protocol that is growing in use and popularity to treat patients suffering from cardiac arrest. For a patient in ventricular fibrillation, and especially for a patient suffering from refractory ventricular fibrillation, the use of DSD or simultaneous defibrillation may be an effective treatment in helping restore the patient&#39;s normal heart rhythm. Conventionally, DSD has been performed as a last ditch effort to try and save the life of a patient suffering a difficult-to-terminate cardiac arrhythmia. The administration of DSD has been haphazard, poorly timed, and uncoordinated. Typically, DSD or simultaneous defibrillation is administered using two separate and distinct defibrillators, such as two monitor/defibrillators (sometimes referred to as manual defibrillators), or two automated external defibrillators (AEDs), or a monitor/defibrillator and an AED Human rescuers manually time the two (or more) defibrillation shocks to be delivered to the patient at the correct time but the time precision with which the shocks must be delivered for effective treatment is likely greater that what can be achieved manually. 
     Relying on human ability and/or judgement to administer shocks from two separate defibrillators in a coordinated manner is an imperfect system that results in questionable therapy outcomes due to improper shock delivery timing. Improper timing of the shock delivery can potentially lengthen the amount of time a patient experiences cardiac arrest with ventricular fibrillation or can potentially cause fatal additional arrhythmias to the patient&#39;s heart (for example, inducing ventricular fibrillation while attempting to treat atrial fibrillation). 
     DSD and simultaneous defibrillation is becoming more widely adopted for patients suffering from cardiac arrest. The art would benefit from systems and/or methods for assisting in proper delivery of such therapies with precise timing control and reproducible timing of multiple shock deliveries. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG.  1    is a diagram of a scene where an external defibrillator is used to save the life of a person according to embodiments. 
         FIG.  2    is a table listing two main types of the external defibrillator shown in  FIG.  1   , and who they might be used by. 
         FIG.  3    is a functional block diagram showing components of an external defibrillator, such as the one shown in  FIG.  1   . 
         FIG.  4    is an example system for delivering multiple defibrillation therapies. 
         FIG.  5    is a further example system for delivering multiple defibrillation therapies. 
         FIG.  6    is yet another example system for delivering multiple defibrillation therapies. 
         FIG.  7    is an example circuit diagram of a modifier for use with a system for delivering multiple defibrillation therapies. 
         FIG.  8    is another example circuit diagram of a modifier for use with a system for delivering multiple defibrillation therapies. 
         FIG.  9    is an example process for administering multiple defibrillation therapies. 
         FIG.  10    is an example flow chart showing administration of multiple defibrillation therapies. 
         FIG.  11    shows example hardware for intertwining wires. 
         FIG.  12    is another example of hardware for intertwining wires. 
         FIG.  13    is yet another example hardware for intertwined wires. 
     
    
    
     SUMMARY 
     An example medical device can include a therapy module that is configured to output an energy delivery, such as a defibrillation shock. The medical device can also include sync mode circuitry that is coupled to the therapy module and configured to receive a generated artifact. The generated artifact can be indicative of a first energy delivery and the sync mode circuitry can generate an instruction for the therapy module to discharge a second energy delivery from the therapy module. In an example embodiment, the generated artifact can be substantially similar to a patient physiological parameter. In a further example embodiment, the generated artifact can be an electromagnetic artifact. 
     In another example, the electromagnetic artifact can be generated by the first energy delivery from another medical device and the electromagnetic artifact is included in the first energy delivery. 
     In a further example, a first electrode can be electrically connected to the therapy module by a first wire and a second electrode can be connected to another device by a second wire. The first and second wire can be at least partially intertwined such that the electromagnetic artifact is received by the first wire from the second wire. In another example embodiment, an electrocardiogram wire can be coupled to the sync mode circuitry and a second electrode can be connected to another device by a second wire. The electrocardiogram wire and the second wire can be at least partially intertwined such that the electromagnetic artifact is received by the electrocardiogram wire from the second wire. 
     In another example, a modifier can be included. The modifier can be configured to receive at least a portion of the first energy delivery and to generate the artifact in response to the first energy delivery. The generated artifact can be transmitted by the modifier and received by the sync mode circuitry. In an example embodiment, the modifier can be discrete from the medical device. In a further example embodiment, the modifier can be passive and configured to be energized by an induction power transfer from the first energy delivery, the energized modifier can output the generated artifact having one or more predetermined artifact characteristics. In another example embodiment, the modifier can be an active modifier and configured to be energized by an induction power transfer from the first energy delivery, the energized modifier can output the generated artifact having one or more artifact characteristics. In a further example, the one or more artifact characteristics can be selected from a plurality of artifact characteristics. Further, the plurality of artifact characteristics can be based on the first energy delivery. 
     An example dual sequential defibrillation system can include a first defibrillator and a second defibrillator. The first defibrillator can include a first therapy module that is configured to output a first energy delivery. The discharge of the first energy delivery can generate an artifact. The second defibrillator can include a second therapy module that is configured to output a second energy delivery, and sync mode circuitry that is coupled to the second therapy module. The sync mode circuitry can be configured to receive the generated artifact from the first therapy module and also configured to generate an instruction for the second therapy module to discharge the second energy delivery based at least in part on the received generated artifact from the first therapy module. In another example embodiment, the sync mode circuitry can include a delay module configured to determine a delay of one or more of the instruction or the output of the second energy delivery relative to the receiving the generated artifact. Example delays can include 100-150 milliseconds and 600 milliseconds. 
     In a further example embodiment, the sync mode circuitry can include an artifact sync mode that is configured to specifically detect the generated artifact and generate the instruction based on the detected artifact. 
     In another example embodiment, a first electrode can be connected to the first therapy module and a second electrode can be connected to the second therapy module and coupled to the sync mode circuitry. A first wire of the first electrode can be intertwined with a second wire of the second electrode and the generated artifact can be transmitted through the first wire of the first electrode and received by the second wire of the second electrode. 
     In a further example embodiment, a first electrode can be connected to the first therapy module via a first wire and an electrocardiogram lead can be connected to the second defibrillator and coupled to the sync mode circuitry. The first wire and the electrocardiogram lead can be at least partially intertwined such that the generated artifact is received by the electrocardiogram lead from the first wire during the discharge of the first energy delivery. 
     In another example embodiment, a modifier device can be included. The modifier device can be configured to generate the generated artifact and to transmit the generated artifact to the second defibrillator in response to the discharge of the first energy delivery. 
     In a further example embodiment, the sync mode circuitry can be further configured for the administration of a dual sequential defibrillation therapy. 
     In another example embodiment, the first defibrillator can include sync mode circuitry. The sync mode circuitry of the first defibrillator and the sync mode circuitry of the second defibrillator can be synced to one or more characteristics of an ECG signal. The sync mode circuities can also be configured to generate instructions such that the first energy delivery and the second energy delivery occur substantially simultaneously. 
     DETAILED DESCRIPTION 
     Described herein are methods and systems for controlling multiple defibrillation therapies, such as dual sequential defibrillation (DSD) and simultaneous defibrillation. DSD is the administration of multiple defibrillation therapies, or energy deliveries, the administration of each timed relative to one or more preceding administrations. Simultaneous defibrillation is the administration of multiple defibrillations, or energy deliveries, substantially concurrently. The administration of multiple defibrillations and/or energy therapies has been shown to assist with correcting an abnormal heart rhythm of a patient, including ventricular fibrillation, atrial fibrillation, and other rhythms considered shockable by a clinician. The systems and methods described below provide a controlled, adjustable and repeatable means for delivery of such defibrillation therapies so as to assist in the correction of an abnormal heart rhythm.  FIGS.  1 - 3    explain a general overview of defibrillation therapy using a single defibrillator or therapy module for sake of simplifying the general explanation.  FIGS.  4 - 10    relate specifically to DSD and/or simultaneous defibrillation using two or more therapy modules and/or defibrillators. 
       FIG.  1    is a diagram of a defibrillation scene in which a patient is receiving defibrillation therapy from a single external defibrillator  100 . The person  82  is lying on his or her back and could be a patient in a hospital, or someone found unconscious, and then turned to be on their back. The person  82  is experiencing a cardiac arrhythmia in his or her heart  85 , which could be Ventricular Fibrillation (VF) for example. 
     A portable external defibrillator  100  has been brought close to the person  82 . At least two defibrillation electrodes  104 ,  108  are usually provided with an external defibrillator  100 , and are sometimes called electrodes  104 ,  108 . The electrodes  104 ,  108  are coupled with the external defibrillator  100  via respective electrode leads  105 ,  109 . A rescuer (not shown) has attached electrodes  104 ,  108  to the skin of person  82  and actuates the defibrillator  100  to administer a brief, strong electric pulse  111  via electrodes  104 ,  108  through the body of person  82 . Pulse  111 , also known as a defibrillation shock, goes also through heart  85 , in an attempt to remove the shockable arrhythmia (for example VF) and allowing the natural rhythm of the heart to resume, for saving the life of the person  82 . 
     The defibrillator  100  can be one of different types, each with different sets of features and capabilities. The set of capabilities of the defibrillator  100  is determined by planning who would use it, and the training those rescuers would be likely to have. Examples are now described. 
       FIG.  2    is a table listing two main types of external defibrillators, and their primary users. A first type of defibrillator  100  is generally called a defibrillator-monitor because it is typically formed as a single defibrillation unit in combination with a patient monitor. A defibrillator-monitor is sometimes called monitor-defibrillator. A defibrillator-monitor is intended to be used by persons in the medical professions, such as doctors, nurses, paramedics, emergency medical technicians, etc. and often requires technical training on its operation. Such a defibrillator-monitor is intended to be used in a pre-hospital or hospital scenario. 
     As a defibrillator, the device can be one of different varieties, or even versatile enough to be able to switch among different modes that individually correspond to the device varieties. One variety is that of an automated defibrillator, which can determine whether a shock is needed and, if so, charge a therapy module of the device to a predetermined energy level and instruct and/or prompt the user to administer the shock. Some AEDs are also able to deliver the shock automatically to a person detected to be in a shockable rhythm, rather than wait for the user to press a button to deliver the shock. Another variety is that of a manual defibrillator where the user determines the need and controls administering the shock. 
     As a patient monitor, the device has features additional to what is minimally needed for mere operation as a defibrillator. These features can be for monitoring physiological indicators of a person in an emergency scenario. These physiological indicators are typically monitored as signals. For example, these signals can include a person&#39;s ECG (electrocardiogram) signal or impedance between two electrodes. Additionally, these signals can relate to the person&#39;s temperature, non-invasive blood pressure (NIBP), arterial oxygen saturation/pulse oximetry (SpO2), the concentration or partial pressure of carbon dioxide in the respiratory gases, known as capnography, and so on. These signals can be further stored and/or transmitted as patient data. 
     A second type of external defibrillator  100  is generally called an AED, which stands for “Automated External Defibrillator”. An AED typically automatically makes the shock/no shock determination on whether to deliver defibrillation therapy to the patient. Indeed, it can sense enough physiological conditions of the person  82  via only the shown defibrillation electrodes  104 ,  108  of  FIG.  1   . In its present embodiments, an AED can either administer the shock automatically, or instruct the user to do so, e.g. by pushing a button. Being of a much simpler construction, an AED typically costs much less than a defibrillator-monitor. As such, hospitals, for example, may deploy AEDs at its various floors, in case the more expensive defibrillator-monitor is more critically being deployed at an Intensive Care Unit or other emergency situation of greater or prior need, and so on. 
     AEDs, however, can also be used by people who are not in the medical profession. More particularly, an AED can be used by many professional first responders, such as the police, firefighters, emergency medical personnel, etc. AEDs are often found in public locations especially those locations that tend to host large numbers of people. Such AEDs are often operated by rescuers with first-aid training or by a good Samaritan who has no training on the device at all AEDs increasingly can supply instructions to whoever is using them and anticipate this wide variety of skill levels of its users. 
     AEDs are thus particularly useful because clinical response time is very critical when responding to someone suffering VF. Indeed, the people who are able to first reach the VF sufferer may not be and are often not in the medical professions. 
     There are additional types of external defibrillators that are not listed in  FIG.  2   . For example, a hybrid defibrillator can have aspects of an AED and also of a defibrillator-monitor. A usual such aspect is additional ECG monitoring capability among others. 
       FIG.  3    is a diagram showing components of an external defibrillator  300  made according to embodiments. These components can be, for example, in the external defibrillator  100  of  FIG.  1   . Additionally, the components of  FIG.  3    can be provided in a housing  301 , which can also be known as a casing  301 . The external defibrillator  300  is intended for use by a user  380 , who is the rescuer. The defibrillator  300  typically includes a defibrillation port  310 , such as a socket in the housing  301 . The defibrillation port  310  includes nodes  314 ,  318 . The defibrillation electrodes  304 ,  308 , which can be similar to the electrodes  104 ,  108 , can be connected to the defibrillation port  310  so as to make an electrical connection with the nodes  314 ,  318 , respectively. It is also possible that electrodes can be connected continuously to the defibrillation port  310 , etc. Either way, the defibrillation port  310  can be used for guiding an electrical charge that has been stored in the defibrillator  300  to the person  82  through the electrodes. 
     If the defibrillator  300  is a defibrillator-monitor, as was described with reference to an example discussed in  FIG.  2   , then it will typically also have an ECG port  319  in housing  301 , for plugging in ECG leads  309 . ECG leads  309  can help sense an ECG signal, e.g. a 12-lead signal, or from a different number of leads. Moreover, a defibrillator-monitor could have additional ports (not shown), and another component  325  structured to filter the ECG signal, e.g., apply at least one filter to the signal so as to remove chest compression artifacts resulting from chest compressions being delivered to the person  82 . The defibrillator  300  shown in  FIG.  3    also includes a measurement circuit  320  that receives patient physiological signal(s) from the ECG port  319 , and also from other ports, if provided. These physiological signals are sensed, and information about them is rendered by the circuit  320  as data, or other signals, etc. 
     If the defibrillator  300  is an AED, it may lack an ECG port  319 . The measurement circuit  320  can obtain physiological signals through nodes  314 ,  318  instead, when defibrillation electrodes  304 ,  308  are attached to person  82 . In these examples, a patient&#39;s ECG signal can be sensed as a voltage difference between the electrodes  304 ,  308 . Further, impedance values sensed between the electrodes  304 ,  308  can detect, among other things, whether these electrodes  304 ,  308  have been inadvertently disconnected from the person. 
     The defibrillator  300  also includes a processor  330  that may be implemented in any number of ways. Such ways include, by way of example and not limitation, digital and/or analog processors such as microprocessors and digital-signal processors (DSPs); controllers such as microcontrollers; software running in a machine; programmable circuits such as Field Programmable Gate Arrays (FPGAs), Field-Programmable Analog Arrays (FPAAs), Programmable Logic Devices (PLDs), Application Specific Integrated Circuits (ASICs), any combination of one or more of these, and so on. 
     The processor  330  can include a number of modules. One such module is a detection module  332 , which senses outputs of measurement circuit  320 . Detection module  332  can include a VF detector. Thus, the person&#39;s sensed ECG can be used to determine whether the person is experiencing VF. Another such module in the processor  330  is an advice module  334 , which arrives at advice based on output(s) of the detection module  332 . Advice module  334  can include a Shock Advisory Algorithm, implement decision rules, and so on. The advice can be to shock, to not shock, to administer other forms of therapy, and so on. If the advice is to shock, some external defibrillator embodiments merely report the shock recommendation to the user, and prompt them to do it. Other embodiments further execute the advice, by administering the shock. If the advice is to administer CPR, the defibrillator  300  may further issue prompts for it, and so on. The processor  330  can include additional modules, such as the module  336 , for other functions. In addition, if another component  325  is indeed provided, it may be operated in part by the processor  330 , etc. 
     Defibrillator  300  optionally further includes a memory  338 , which can work together with the processor  330 . The memory  338  may be implemented in any number of ways. Such ways include, by way of example and not of limitation, nonvolatile memories (NVM), read-only memories (ROM), random access memories (RAM), any combination of these, and so on. The memory  338 , if provided, can include programs for the processor  330 , and so on. The programs can be operational for the inherent needs of the processor  330 , and can also include protocols and ways that decisions can be made by the advice module  334 . In addition, the memory  338  can store prompts for the user  380  and patient data, as needed. 
     The defibrillator  300  may also include a power source  340 . To enable portability of the defibrillator  300 , the power source  340  typically includes a battery. Such a battery can be implemented as a battery pack, which may be rechargeable or not. Sometimes, a combination is used, of rechargeable and non-rechargeable battery packs. Other embodiments of power source  340  can include AC power override that allows a rescuer to use AC power when such a source exists, but rely on the battery power if AC power is unavailable. In some embodiments, the power source  340  is controlled by the processor  330 . The defibrillator  300  additionally includes an energy storage module  350 . The module  350  is where some electrical energy is stored, when preparing the device for sudden discharge to administer defibrillation shock therapy to the patient. The module  350  can be charged from the power source  340  to the desired amount of energy, as controlled by the processor  330 . In typical implementations, the module  350  includes one or more capacitors  352  that charge and help store the energy for later discharge, and so on. 
     The defibrillator  300  can also include a discharge circuit  355 . The discharge circuit  355  can be controlled to permit the energy stored in the module  350  for discharge to the nodes  314 ,  318 , and thus also to the defibrillation electrodes  304 ,  308 . The discharge circuit  355  can include one or more switches  357 . Those switches can be made in a number of ways, such as by an H-bridge, and so on, or other desirable configurations. 
     The defibrillator  300  further includes a user interface  370  for the user  380 . For example, the interface  370  may include a screen to display what is detected and measured, provide visual feedback to the rescuer for their resuscitation attempts, and so on. The interface  370  may also include a speaker to issue voice prompts or otherwise audibly interact with the user and may additionally include various controls, such as pushbuttons, keyboards, and so on, as needed or desired. In addition, the discharge circuit  355  can be controlled by the processor  330 , or directly by the user  380  through the user interface  370 . 
     The defibrillator  300  can optionally include other components. For example, a communication module  390  may be provided for communicating with other machines. Such communication can be performed wirelessly, or via wire, or by infrared communication, and so on. This way, data can be communicated, such as patient data, incident information, therapy attempted, CPR performance, and the like. Another feature of a defibrillator can be CPR-prompting in which prompts are issued to the user, visual or by sound or otherwise, so that the user can administer CPR and/or receive feedback/instructions regarding the administration of CPR and/or delivery of shock therapy to the patient. 
     To synchronize, or otherwise coordinate timing of, multiple defibrillators to deliver simultaneous and/or sequential defibrillation, an artifact generated by one defibrillator during an energy delivery can be used to cause another defibrillator, similarly attached to the patient, to also administer an energy delivery to the same patient. The artifact, as described herein, can be an electromagnetic electrocardiogram (ECG) artifact that is generated by, or caused to be generated by, the energy delivery of one, or an initial, defibrillation by a defibrillator. The defibrillators can be inductively coupled, such as by intertwining various leads or wires of a second defibrillator with an electrode wire of the first defibrillator, and/or through the use of a modifier that is inductively coupled to both defibrillators. The other defibrillator(s) attached to the patient can be operated in a synchronized cardioversion mode (sync mode) that is capable of detecting the ECG artifact that is received via the inductive coupling of the other defibrillator(s) with the defibrillator administering an energy delivery. Various current defibrillators, defibrillator/monitors and/or AEDs already include a sync mode capable of administering an energy delivery in response to one or more characteristics of a patient&#39;s ECG. The generated artifact can substantially mimic one of the one or more characteristics that the defibrillation device is monitoring for a sync mode and/or the artifact can have one or more ECG characteristics that cause the sync mode of the defibrillation device to administer an energy delivery. 
       FIG.  4    shows an example system  400  for delivering multiple defibrillation therapies. The system  400  includes a pair of defibrillators  410  and  420  that include therapy modules  412 ,  422  that output an energy delivery to a patient through the electrode pairs  452 ,  454  and  462 ,  464 . In the example shown, a first defibrillator  410  includes a therapy module  412  that is connected to electrode  452  by a wire  432  and to electrode  454  by wire  434 . Energy delivery by the therapy module  412  through the electrodes  452 ,  454  can be manually or automatically initiated, or triggered. A second defibrillator  420  includes a therapy module  422  that is connected to electrode  462  by a wire  442  and to electrode  464  by wire  444 . Additionally, the second defibrillator  420  includes a sync mode circuitry  424  that is connected to the therapy module  422 . The sync module  424  can receive patient physiological data, such as from the electrodes  462 ,  464 , and/or other patient physiological sensors, monitoring sources, equipment and/or other data sources. The sync mode circuitry  424  can monitor certain patient physiological parameters and/or generate an instruction and/or output to cause the therapy module  422  to discharge an energy delivery. In the system  400 , the discharge of an energy delivery by the first defibrillator generates an artifact, such as an electromagnetic signal, that can be received, or detected, by the sync mode circuitry  424  of the second defibrillator  420 . The second defibrillator  420  can receive the generated artifact through the electrodes  462 ,  464  connected thereto. In response to receiving the artifact, the sync mode circuitry  424  can generate the instructions to cause the therapy module  422  to also discharge an energy delivery. 
     In the example system  400  shown in  FIG.  4   , the artifact can be generated by and/or transmitted through the intertwining of one of the electrode wires, such as  434 , of the first defibrillator  410  with one of the electrode wires, such as  444 , of the second defibrillator  420 . The intertwined portion  470  of the electrode wires  434 ,  444  are inductively coupled and/or can act as a rudimentary transformer. In this manner, an energy delivery discharged by the therapy module  412  of the first defibrillator  412  can induce a current in the electrode wire  444  of the second defibrillator. This induced current is, at least in part, the generated artifact in this example embodiment and can be received by one or more of the therapy module  422  and the sync mode circuitry  424  of the second defibrillator  420 . In response to receiving and/or detecting the generated artifact, the sync mode circuitry  424  can output an instruction to the therapy module  422  to discharge, or output, an energy delivery. 
     The electrodes  452 ,  454 , connected to the first defibrillator  410 , and the electrodes  462 ,  464 , connected to the second defibrillator  420 , can be arranged such that one of the electrode pairs,  452 ,  454  or  462 ,  464  are located anterior-posterior (AP) on the patient and the other is located anterior-lateral (AL). In the AP arrangement, one pair of the electrodes is placed so that one electrode of the pair is located anterior the patient&#39;s heart and the other electrode of the pair is located posterior the patient&#39;s heart. Similarly, in the AL arrangement, one pair of electrodes is placed so that one electrode of the pair is located anterior the patient&#39;s heart and the other electrode of the pair is located lateral the patient&#39;s heart. For example, in the AP/AL arrangement, one pair of electrodes  452 ,  454  are arranged in the AP configuration and the other pair of electrodes,  462 ,  464 , are arranged in the AL configuration. The intertwined wires of each of the defibrillators  410 ,  420  can be such that the wire  434  is connected to an AP electrode  454  and the wire  444  is connected to an AL electrode  464 , i.e. AP/AL inductive coupling. Alternative inductive couplings can include AL/AP, AL/AL and/or AP/AP, in which one wire of one electrode pair of the first arrangement, AL or AP, is intertwined with one wire of the other electrode pair of the second arrangement, AL or AP. Other DSD and/or simultaneous defibrillation appropriate inductive couplings between the two defibrillators  410 ,  420  are possible such that the generated artifact can be generated/caused by one defibrillator  410  and received by the other defibrillator  420 . 
     The generated artifact can be an induced electromagnetic artifact having artifact characteristic, such as a current, electromagnetic signal properties and/or other electromagnetic characteristics. For example, the induced current can have a magnitude that exceeds a threshold, such as a preset threshold, that causes the sync mode circuitry  424  to output an instruction to the therapy module  422 . In another example, the generated artifact can be an electromagnetic signal that has one or more signal properties that cause the sync mode circuitry  424  to output the instruction to the therapy module  422 . In a further example, the generated artifact can substantially mimic a patient physiological characteristic, such as a QRS complex or other physiological parameter that causes the sync mode circuitry  424  to generate the instructions. By substantially mimicking a patient physiological parameter that causes a sync mode of a defibrillator to output an energy delivery, the DSD and/or simultaneous defibrillation can be effected using one or more systems that generate an artifact with a defibrillator having a suitable sync mode and/or sync mode circuitry. 
     The sync mode circuitry  424  can also include a delay in the generated instructions. The delay can cause the therapy module  422  and/or the sync mode circuitry to delay a set period of time before triggering, or outputting, the energy delivery from the therapy module  422 . The delay duration can be set by a user or automatically by the defibrillator  420  and/or the sync mode circuitry  424 . The delay can be selected from one or more predetermined delays or can be a custom set delay that can also be based on physiological data of a patient, to which the defibrillator  420  and/or other physiological sensors and/or monitors are attached. The various physiological data can be sensed and/or received by the defibrillator  420 , the sync mode circuitry  424  and/or other components and/or systems for use in determining a delay to include in the generated instructions. In example embodiments, the delay can be between 0.1 and 20 milliseconds and/or between 100 and 150 milliseconds. The length of the delay can be based on clinical testing that indicates a preferred delay duration for administering the second energy delivery subsequent to a prior energy delivery. 
     Alternatively, the sync mode circuitry  424  can be coupled to a timing control unit and/or another module, circuit, mode or other timing source/control, to calculate, implement and/or time the delay. As described above, the calculated delay can be included in the instructions that the therapy module  422  receives. Alternatively, the timing control unit can delay the reception and/or transmission of the instructions by/to the therapy module  422 . In a further example, the timing control unit can be integrated with one or more of the sync mode circuitry  424  and/or the therapy module  422 . 
     The wires  434 ,  444  of the electrodes  454  and  464  can be manually intertwined by a user or can come pre-intertwined for use in DSD and/or simultaneous defibrillation therapies. In the embodiment in which a user manually intertwines the wires  434  and  444 , one or more of the defibrillators  410 ,  420  can provide instructions regarding the intertwining, such as a procedure for intertwining the wires  434  and  444 , the number of times the wires  434  and  444  are intertwined and/or other characteristics of the intertwined portion  470  required and/or desired for administration of a DSD and/or simultaneous defibrillation therapy. Alternatively, one or more devices and/or systems can be used to assist with the proper intertwining of the electrode wire for use with the administration of a DSD and/or simultaneous/near simultaneous defibrillation therapy. 
       FIG.  5    illustrates another example system  500  for administering multi-defibrillation therapies. The system  500  includes defibrillators  510  and  520  that output energy deliveries to a patient. The first defibrillator  510  can include a therapy module  512  that can output an energy delivery to a patient through electrodes  552 ,  554  that are coupled to the therapy module  512  via wires  532 ,  534 . The second defibrillator  520  can include sync mode circuitry  524  coupled to a therapy module  522  that can output an energy delivery to a patient through electrodes  562 ,  564  that are coupled to the therapy module  522  via wires  542 ,  544 . Similar to the system  400  of  FIG.  4   , the sync mode circuitry  524  of the second defibrillator  522  can generate instructions to cause the therapy module  522  to output an energy delivery in response to receiving and/or detecting an artifact caused by an output of an energy delivery by the therapy module  512  of the first defibrillator  510 . 
     In the example system  500  of  FIG.  5   , the second defibrillator  510  also includes electrocardiogram (ECG) electrodes  582 ,  584  coupled, via ECG leads  581 ,  583 , to the sync mode circuitry  524 . The ECG electrodes  582 ,  584  can gather patient physiological data that the defibrillator  520 , or subcomponents/subsystems thereof, can analyze and/or use for various defibrillator functions, including outputting the physiological data for a user. The sync mode circuitry  524  can monitor the patient physiological data acquired via ECG electrodes  582 ,  583  to cause the sync mode circuitry  524  to output an instruction to the therapy module  522  to output an energy delivery. In an example embodiment, the ECG data can include a patient&#39;s heart rhythm and the sync mode circuitry  524  can output the instruction in response to an abnormal heart rhythm or detection of a QRS complex. 
     In the example system  500 , the wire  534  of the first defibrillator  510  can be intertwined with the ECG lead  583 , along an intertwined portion  572 , to cause the artifact to be generated and/or transmitted by an energy delivery from the therapy module  512  of the first defibrillator  510 . The generated artifact can be transmitted to the sync mode circuitry  524  of the second defibrillator  520  via the ECG lead  583 . The received generated artifact can cause the sync mode circuitry  524  to generate an instruction to the therapy module  522  to output an energy delivery. Similarly, to the system  400  of  FIG.  4   , the energy delivery by the therapy module  522  can include a delay to space the energy delivery relative to the energy delivery of the therapy module  512  of the first defibrillator  510 . 
     Similar to the example system of  FIG.  4   , the placement of the electrodes  552 ,  554 ,  562 ,  564  and the ECG electrodes  582 ,  584  can have an effect on the inductive coupling of the defibrillators  510 ,  520 . In the example system  500 , one of the ECG electrodes  582 ,  584  can be a right arm (RA) electrode and the other ECG electrode can be a right leg electrode. The intertwining of the wire  534  and a RA or RL electrode is done to assist with preventing the second defibrillator  520  from administering an inadvertent energy delivery that is an energy delivery not triggered by the artifact caused by the first defibrillator  510 . The inadvertent energy delivery can happen if an ECG signal of a patient, as detected via one or more ECG electrodes  582 ,  584 , would otherwise cause a sync mode, or sync mode circuitry  524 , of the second defibrillator  520  to inadvertently trigger the second defibrillator  520  to administer an energy delivery. In an example embodiment in which the ECG electrodes  582 ,  584  are affixed to a patient, the placement of the RA and RL electrodes can be reversed to prevent inadvertent triggering of an energy delivery. For example, if the wire  534  is intertwined with RA ECG electrode  582 , then the RA ECG electrode  582  should then be placed where the RL ECG electrode  584  would otherwise go and the RL ECG electrode  584  should be placed where the RA ECG electrode  582  would have been placed. In a further example embodiment, the ECG electrodes  582 ,  584  may not be placed on a patient and instead both are connected to a conductive medium, such as a wire or resistor. To effect proper DSD and/or simultaneous defibrillation, the ECG lead intertwined with the wire  534  needs to be the ECG lead from which synchronization can be performed using the sync mode, or sync mode circuitry  524 , of the defibrillator  520 . Alternatively, other ECG leads can be inductively coupled with a wire of an electrode to effect the proper synchronization for administration of a DSD and/or simultaneous defibrillation. 
       FIG.  6    illustrates yet another example system  600  for administering multiple defibrillation therapies, such as DSD and/or simultaneous defibrillation. The example system  600  includes defibrillators  610 ,  620  that can output one or more energy deliveries to a patient to which the defibrillators  610 ,  620  are attached. A first defibrillator  610  can include a therapy module  612  that is coupled to an optional artifact generator  616 . The therapy module  612  can be coupled to electrodes  652 ,  654  via wires  632 ,  634  to output an energy delivery to a patient. A second defibrillator  620  can include a therapy module  622  and sync mode circuitry  624  that includes an optional delay  625 . The therapy module  622  can be coupled to electrodes  662 ,  664  via wires  642 ,  644  to output an energy delivery to a patient. An energy discharge by the therapy module  612  of the first defibrillator  610  can cause an artifact to be generated and/or transmitted to the sync mode circuitry  624  of the second defibrillator  620  to cause the sync mode circuitry  624  to generate instructions to cause the therapy module  622  to output an energy delivery, similar to the above described systems. 
     A modifier  670  can be inductively coupled between the wire  634  and wire  644  to generate and/or transmit an artifact. The modifier  670  can be a separate element that can be attached or inductively coupled to the wires  634  and  644  and as such, could be retrofit to existing defibrillators. In an example embodiment, the wires  634  and  644  can be wrapped about one or more portions of the modifier  670  to induce and/or receive a current and/or artifact transmitted through or form the modifier  670 . Alternatively, one or more of the wires  634 ,  644  can include the modifier  670 . Further, the modifier  670 , while shown in  FIG.  6   , can be used with other DSD and/or simultaneous defibrillation therapy systems, such as those shown in  FIGS.  4  and  5   , to assist with the inductive coupling necessary to transmit and/or generate the artifact. 
     The first defibrillator  610  can include the optional artifact generator  616  coupled to the therapy module  612 . The artifact generator  616  can generate an electromagnetic artifact that can be included in the energy delivery output of the therapy module  612 . The electromagnetic artifact can include one or more electromagnetic characteristics that can cause the sync mode circuitry  624 , therapy module  622  and/or second defibrillator  620  to cause the output of an energy delivery by the therapy module  622  of the second defibrillator  620 . The artifact generated by the artifact generator  616 , and subsequently discharged with the energy delivery by the therapy module  612 , can be passed directly through, or modified by, the modifier  670  to transmit the generated artifact to the wire  644 . 
     The modifier  670  can include the ability to wave shape the artifact, such as a signal, that is transmitted through or generated by the modifier  670 . Waveshaping the artifact can include widening the artifact duration, modifying the amplitude of the artifact, and/or delaying the transmission of the artifact. Waveshaping can assist the administration of DSD and/or simultaneous defibrillation as the artifact generated by the first defibrillator  610  may not be ideally shaped, ideally delayed, or have ideal characteristics, to cause the sync mode, or sync mode circuitry  624 , of the second defibrillator  620  to administer an energy delivery in response to the artifact, in a desired manner. The modifier  670  can assist with forming and/or modifying the artifact to cause the second defibrillator  620  to administer an energy delivery as desired in response to the artifact. 
     The modifier  670  can be a passive or active modifier. In the passive form, the modifier  670  can include circuitry that is inductively coupled to the wire  634  to receive the artifact and transmit the artifact “as is” or modified to the wire  644 . The passive circuitry of the modifier  670  can modify the artifact in a predetermined manner as determined by the passive circuitry. Example passive circuitry can filter the artifact such that the artifact has certain electromagnetic properties or can modify the artifact to alter one or more electromagnetic characteristics of the artifact in a known and/or predetermined manner as determined by the passive circuitry and its properties. 
     In the active form, the modifier  670  can include a powered circuit that generates and/or modifies the artifact and that can derive power from the inductively coupled wire  634 . Alternatively, the modifier  670  can include a power source contained within, such as a battery, or can derive power from another source, such as an external power source connected to the modifier  670 . Using the powered circuitry, the artifact output and/or transmitted by the modifier  670  can have consistent electromagnetic properties. These electromagnetic properties can be further selectable and/or modifiable. In this way, the artifact can act as a form of data transmission to cause the sync mode circuitry  624  to respond in a known and/or desired manner to receiving the artifact from the modifier  670 . 
     The sync mode circuitry  624  can include a delay  625  that can calculate and/or implement a delay in the output of the energy delivery by the therapy module  622  of the second defibrillator  620 . The delay can be included in the instructions generated by the sync mode circuitry  624 , can delay the transmission/reception of the instructions and/or otherwise delay the output of the energy delivery. The delay can be calculated, such as based on one or more physiological parameters/characteristics of the patient, or can be predetermined, such as selected from one or more delays/delay durations. The delay  625  can be selected to assist with the efficacy of the sequential defibrillations, or energy deliveries, in a DSD therapy. The energy deliveries can require a minimum and/or maximum delay between the energy deliveries in order to have maximum effect in correcting the abnormal heart rhythm. 
     While the above described systems, such as those shown in  FIGS.  4 - 6   , are shown to include two defibrillators, the systems described systems can include additional defibrillators that are coupled together to, or otherwise, receive the generated artifact to cause the output of additional energy deliveries. Alternatively, the described systems can be implemented in a single device that can include multiple therapy modules to output the multiple defibrillation therapies. 
     Additionally, the sync mode circuitry, such as shown and described in the above examples, can be implemented in different forms and/or states. For example, the sync mode circuitry can be a stand-alone, or separate, module of/in the defibrillator(s) or can be included as part of the processor, such as instructions which are executed by the processor. Alternatively, the sync mode circuitry can be a sub-module of module switching circuitry for defibrillators and/or device that include such capabilities. Further, the various functions of the sync mode circuitry described can be implemented using one or more components and/or systems of a medical device, such as a defibrillator, defibrillator/monitor and/or an AED 
       FIG.  7    is a diagram of an example passive modifier circuit  700 . The modifier circuit  700  is a passive circuit that is inductively coupled to two defibrillators, such as shown in the system of  FIG.  6   . The modifier circuit  700  includes an input  710  that is inductively coupled to a first defibrillator. To inductively couple the defibrillator, the input  710  can include an inductor and/or the input  710  can be wrapped about an output of the defibrillator. The inductive coupling of the modifier circuit  700  and a defibrillator induces a current in the modifier circuit  700 . The induced current then flows through a modifier section  720  that can modify the current flow through the modifier circuit  700 . In the example shown, the modifier section  720  includes a diode bridge electrically connected in parallel with a capacitor. The current then passes to the output  730  of the modifier circuit  700 . Much like the input  710 , the output  730  is inductively coupled to a defibrillator. The defibrillator coupled to the output  730  is different and/or separate from the defibrillator coupled to the input  710 . The output  730  transmits and/or generates the artifact that will be received by the inductively coupled defibrillator to cause an output of an energy delivery from the inductively coupled defibrillator. 
       FIG.  8    is a diagram of an example active modifier circuit  800 . The active modifier circuit  800  includes an input  810  that is inductively coupled to a first defibrillator and an output  830  that is inductively coupled to a second defibrillator. An energy delivery by the first defibrillator can generate, or cause the modifier circuit  800  to generate, an artifact that is then transmitted through the inductive coupling, to the second defibrillator. An active modifier  820  section of the active modifier circuit  800  can modify and/or generate the artifact. The active modifier  820  can include resistors, capacitors, multivibrators and/or other circuit elements to modify and/or generate the artifact that is received by the second defibrillator. Power for the active modifier circuit  800  can be derived from the inductive coupling of the active modifier circuit  800  and the first defibrillator and/or the active modifier circuit  800  can include an internal, or external, power source  812 , such as a battery. 
       FIG.  9    illustrates an example process  900  for administering multiple defibrillation therapies. The process  900  includes detecting a shockable heart rhythm at  902 . A shockable heart rhythm can include a patient experiencing ventricular fibrillation (VF) or atrial fibrillation (AF), for example. The systems described above can be used to administer DSD and/or simultaneous defibrillation therapies to assist with correcting a heart rhythm of a patient, such as one experiencing VF or AF. 
     At  904 , the decision to administer DSD or simultaneous shocks is made. If the decision is made to administer DSD and/or simultaneous shock therapy, one or more defibrillators connected to a patient are set to one or more sync modes at  906 . In an example embodiment, one defibrillation, the defibrillator providing the initial shock, or energy delivery, is not required to be set to a sync mode as the discharge of the energy causes the other defibrillator(s), set in a sync mode, to administer a sequential defibrillation. In another example, the defibrillators can all be set to a sync mode such that the defibrillators can administer a sequential or simultaneous defibrillation therapy. 
     At  908 , optionally, an ECG segment can be detected. The detected ECG segment can be a particular ECG segment that the process  900  is waiting and/or looking for. This detected ECG segment can be used in other elements of the process  900  and/or to time the various elements of the process  900 . 
     At  910 , a decision to delay the second shock is made. If no delay is desired and/or indicated, such as by the detected ECG segment, then the shocks from the defibrillators is delivery substantially simultaneously at  912 . 
     If a delay is desired and/or required, then an optional timing relationship can be determined at  914 . The timing relationship can be calculated and/or selected to include a delay for delivering the second, or subsequent, shock after the first, or prior, shock. The delay can space the shocks to assist with the effectiveness of the administration of the defibrillation therapy. 
     At  916 , the sequential shocks are administered. If the optional timing relationship was determined at  914 , then the sequential shocks are administered according to the timing relationship. If no timing relationship is determined and/or required, then the shocks proceed substantially sequentially, with a subsequent shock following the one administered prior shock. While no timing relationship may have been determined at  914 , one or more of the defibrillators administering the subsequent shock can include hardware to cause a delay in the administration of the subsequent shock. 
       FIG.  10    is an example flow chart  1000  showing administration of multiple defibrillation therapies for use with a patient experiencing atrial fibrillation. At  1002 , the atrial fibrillation of the patient is detected. To administer the DSD or simultaneous defibrillation therapy, two options can be used to set a delay, either a calculation of the delay or selection of a delay. The defibrillation device can include a specific DSD sync mode that can detect the artifact and introduce an appropriate delay for safe and effective DSD and/or simultaneous defibrillation therapy administration. The specific DSD sync mode can be implemented with hardware, software or a combination thereof. The DSD sync mode can include routines that assist with preventing the administration of the sequential energy delivery at an inappropriate time, such as during a T-wave of the patient. 
     In an example in which the delay is selected, a predetermined delay can be selected at  1008 . The selected predetermined delay can be selected such that administration of the second shock is unlikely to occur during a T-wave of the patients ECG. Administration of a shock on the T-wave can cause the patient to go into ventricular fibrillation. To avoid this, the delay can be selected to increase the probability that the T-wave is avoided during administration of the second shock. In an example embodiment, the selected predetermined delay can be 600 milliseconds after the first shock. To sync the timing of each of the defibrillators, each of the defibrillators can be synced to an R-wave of the patient&#39;s ECG. This can then be used for simultaneous defibrillation or for timing the delay of the second shock relative to the administration of the first shock. 
     In an example in which the delay is calculated the patient&#39;s ECG can be analyzed to determine a Q-T duration of the patient at  1004 . The delay can then be calculated at  1006  such that the administration of second shock avoids the T-wave of the patient&#39;s ECG. The calculated delay can be customized to the patient and their current physiological parameters. 
     At  1010 , the first shock is administered and then a delay  1012  is waited and the second shock is administered at  1014  once the delay duration has expired. 
     In a further example, simultaneous defibrillation can be used to assist in correcting atrial fibrillation of the patient. In administering simultaneous defibrillation, no delay is required and the defibrillators are synced such that the shocks are administered substantially simultaneously. To sync the defibrillators, the patient&#39;s ECG can be analyzed and each of the defibrillators can be synced to administer shocks on an R-wave of the patient&#39;s ECG. 
       FIG.  11    illustrates an example system  1100  that includes a device that can be used to assist with intertwining wires for use with a DSD and/or simultaneous defibrillation system, such as those described above. The device includes a first part  1192  and a second part  1194 , both of which are shown substantially cylindrically shaped. The first part  1192  has a wire  1134  wrapped one or more times about the first part  1192 . One end of the wire  1134  is connected to a first defibrillator  1110  and the other end of the wire  1134  is connected to an electrode  1154 . The electrode  1154  is an electrode of an electrode pair that is connected to the first defibrillator  1110 . The second part  1194  has a wire  1134  wrapped one or more times about the second part  1194 . One end of the wire  1144  is connected to a second defibrillator  1120  and the other end of the wire  1144  is connected to an electrode  1164 . The electrode  1164  is an electrode of an electrode pair that is connected to the second defibrillator  1120 . The second part  1194  can include one or more features, such as the notches shown, to allow the wire  1144  to be wrapped around and extend from the second part  1194  as necessary and/or desired. With the wires  1134  and  1144  wrapped about the first and second parts  1192 ,  1194 , the second part  1194  can be inserted within the first part  1192 , as indicated by the arrow. The insertion of the wire  1144  wrapped second part  1194  into the wire  1134  wrapped first part  1192  creates a transformer, or transformer-like device, that inductively couples the wires  1134  and  1134 , allowing for the generation and/or transmission of a generated artifact from, or caused by, the first defibrillator  1110  to the second defibrillator  1120 . 
       FIG.  12    illustrates another example system  1200  that includes a device that can be used to assist with intertwining wires for use with a DSD and/or simultaneous defibrillation system, such as those described above. The device includes a first part  1292  and a second part  1294 , both of which are shown as substantially plate shaped. The first part  1292  and the second part  1294  are connected by a hinge  1296 , allowing the first part  1292  and second part  1294  to be folded over each other, such that the first part  1292  and the second part  1294  are substantially adjacent. A wire  1234 , connecting a first defibrillator  1210  to an electrode  1254 , can be wrapped about the first part  1292 . Similarly, a wire  1244 , connecting a second defibrillator  1220  to an electrode  1264 , can be wrapped about the second part  1294 . As discussed above, each of the electrodes  1254 ,  1264 , are one of a pair of electrodes that is connected to the first defibrillator  1210  and second defibrillator  1220 , respectively. With the wires  1234 ,  1244  wrapped about the first and second parts  1292 ,  1294 , the first part  1292  and second part  1294  can be folded, using the hinge  1296 , to place the first part  1292  substantially along the second part  1294 . Arranging the wire  1234  wrapped first part  1292  and the wire  1244  wrapped second part  1294  in such a manner forms a transformer, or transformer-like device, that inductively couples the wires  1234  and  1244 , allowing for the generation and/or transmission of a generated artifact, or caused by, the first defibrillator  1210  to the second defibrillator  1220 . 
       FIG.  13    illustrates an example system  1300  that includes a wire module  1302  for use with a DSD and/or simultaneous defibrillation system, such as those described previously. The wire module  1302  contains pre-intertwined wires and connections to connect the wire module  1302  to one or more defibrillators and/or electrodes. In the example shown, the wires module  1302  includes ports  1322  and  1324  to which electrodes can be attached and includes plugs  1312  and  1314  that can be connected to defibrillators. The plug  1312  can be electrically connected, through the wire module  1302 , to the port  1322  and the plug  1314  can be electrically connected, via the wire module  1302 , to the port  1324 . A first defibrillator and a first electrode can be connected to the plug  1312  and port  1322 , respectively, to couple the first electrode to the first defibrillator. Similarly, a second defibrillator and a second electrode can be connected to the plug  1314  and port  1324 , respectively, to couple the second electrode to the second defibrillator. As discussed above, the first and second electrodes are an electrode of an electrode pair that are connected to the first and second defibrillators. The inductive coupling to generate and/or transmit a generated artifact from, or caused by, the first defibrillator to the second defibrillator is facilitated by the intertwined and/or otherwise connected wires, within the wire module  1302 . 
     The above described systems and/or methods can be used to administer sequential and/or substantially simultaneous defibrillation therapies. The administration of such therapies can increase the effectiveness of defibrillation therapy administration in correcting one or more conditions of a patient&#39;s heart rhythm. 
     It will be appreciated that variants of the above-disclosed and other features and functions, or alternatives thereof, may be combined into many other different systems or applications. Other embodiments Various presently unforeseen or unanticipated alternatives, modifications, variations, or improvements therein may be subsequently made by those skilled in the art which are also intended to be encompassed by the following claims.