Letter to the editor regarding the irresponsibly written piece about the RI EMS Cardiac Arrest Protocol.

1. January 3, 2017
Beacon Communications
Dear Editor:
The article titled “30 minute CPR protocol raises issues “published in several of your publications on
December 28th
provides the reader with inaccurate and incomplete information.
Contrary to what was stated, there was “consultation over the protocols with the hospital community”.
The composite of the Ambulance Service Advisory Board (ASAB), which approved the 2017 RI Statewide
EMS Treatment Protocols, includes, but is not limited to representatives from the Hospital Association of
RI, the RI Chapter of the American College of Emergency Physicians, the RI Medical Society, the RI Chapter
of the American College of Surgeons, and the RI Chapter of the American Academy of Pediatrics. In
addition, Dr. Kenneth Williams, MD, FACEP (attending physician RIH ED) is a member of the ASAB and
serves as the Medical Consultant to the RI Department of Health, Center for Emergency Medical Services.
All full ASAB and subcommittee meetings are open to the public, with the exception of Medical Affairs
Committee meetings in which disciplinary complaints involving EMS providers are adjudicated.
Additionally, the Acute Ischemic Stroke Protocol was drafted by the RI Stroke Taskforce, chaired by Arshad
Iqbal, MD who is director of the Stroke Program at Kent Hospital (Dr. Dacey is the president and chief
operating officer of Kent Hospital). Membership on the RI Stroke Taskforce also includes representatives
from other RI hospitals.
The 2010 and 2015 Emergency Cardiac Care (ECC) Guidelines published by the American Heart Association
(ECC guidelines are published every 5 years) recognize and emphasize the importance of minimally
interrupted high quality cardiopulmonary resuscitation (CPR) and the timely delivery of defibrillation.
The inferior quality of CPR performed in a moving ambulance is documented in the medical literature.
Pauses in compressions, inadequate compression rate and depth, and failure to allow for chest recoil on
the upstroke of a chest compression all negatively affect the quality of CPR. All of these factors are
associated with patient movement and transportation. This is recognized in these guidelines which state
“Because of the difficulty in providing effective chest compressions while moving the patient during CPR,
the resuscitation should generally be conducted where the patient is found”. Performing on-scene
resuscitation is in alignment with this recommendation. Readers should also note that the non-trauma
related cardiac arrest never fell into the “scoop and run” category and that under the current (old) RI EMS
Cardiac Arrest Protocol, providers are not prohibited from providing 30 minutes (or greater) of CPR and
other resuscitative efforts on scene prior to transporting a patient in cardiac arrest.
Evidence suggests survival is 10 to 35 times more likely if return of spontaneous circulation (a sustained
pulse) is achieved in the field. In a study published in 2010 which examined data from 79 studies involving
142,740 out of hospital cardiac arrests (OHCA), the most powerful criterion associated with survival was
return of spontaneous circulation in the field.
Evidence also suggests that survival without neurologic disability is also possible following prolonged
resuscitation in the field. For example, after the Wake County EMS system (WCEMS) in North Carolina
changed their system protocols emphasizing high quality CPR and not moving the patient (EMS providers
in WCEMS initiate resuscitation in the field and do not transport the patient unless there is return of
spontaneous circulation i.e. a sustained pulse), the survival rate for cardiac arrest patients increased by

2. 48%. WCEMS researchers reviewed the data from 2,905 OHCA within the (WCEMS) system that occurred
after the protocol changes. They noted that the amount of time spent on-scene by EMS providers
attempting to resuscitate patients in cardiac arrest increased. The median duration of resuscitation
(DOR) was 38 minutes, with the median DOR for survival without neurological disability was 24 minutes.
The 90th percentile for survival without neurologic disability was 40 minutes. In a paper recently
published in the Journal of the American Heart Association, researchers analyzed the records of 17,238
patients with OHCA. For patients who survived without neurological disability, the critical time spent
performing CPR in the field for patients with heart rhythms possibly responsive to defibrillation was 35
minutes and 42 minutes for patients with no heart rhythm (ie. asystole aka “flatline”). The Salt Lake City
Fire Department recently published data following implementation of a multifaceted cardiac arrest
protocol which included several American Heart Association best practices for the resuscitation of
patients in cardiac arrest (all of which are emphasized in the new RI EMS cardiac arrest protocol). This
protocol also included a directive for on-scene resuscitation (versus early transport) to avoid interruptions
in CPR attributable to patient movement and transport. No upper time limit was given for the duration
of CPR in the field, but it was suggested that at least 30 minutes of CPR be performed on scene. Similar
to the results in the WCEMS system, implementation of the protocol in Salt Lake was associated with
improved survival without neurologic disability.
Additionally, research has also identified cases in which CPR performed for greater than 30 minutes in the
field may be beneficial. Some of the indicators used to identify these cases include the patient’s heart
rhythm, episodes of temporary response during resuscitation, and the amount of carbon dioxide which is
exhaled each time the patient is ventilated.
With regard to concerns attributed to a local fire chief related support in implementing the new cardiac
arrest protocol, the Rhode Island Department of Health’s Center for Emergency Medical Services (CEMS)
has provided multiple protocol updates for departmental EMS training officers, chiefs and EMS providers.
CEMS has also released a comprehensive slide set covering changes in the new protocols. These slides
are available to all RI EMS agencies and EMS providers. There is no specifically required education
regarding the language directing 30 minutes of CPR on scene in the 2017 Cardiac Arrest Protocol. It is
simply a directive to do CPR for 30 minutes on-scene. In most EMS services in RI, this likely no more 10-
15 minutes longer than the period of time now spent doing CPR on-scene. For reader clarification, CPR
is performed by two or more providers taking turns doing compressions in two minute cycles.
As stated above, the new stroke protocol was drafted by the RI Stroke Taskforce, chaired by Dr. Iqbal who
is director of the Stroke Program at a Kent Hospital, a facility that Dr. Dacey is the president and chief
operating officer. Contrary to what was stated in the article, the stroke protocol does not direct that all
stroke patients be transported to a comprehensive stroke center (CSC). This statement is inaccurate and
misleading to the reader. The protocol directs that patients with a high probability for having a stroke
related to clot in one of the large vessels of the brain (emergent large vessel occlusion) to be transported
to a (CSC). This is because these types of strokes usually require mechanical intervention in addition to
the administration of fibrinolytic (“clot busting”) medications. This type of mechanical intervention is only
available at a CSC. A stroke is the brain equivalent to a heart attack and as such, timely treatment is
required. In stroke, “time is brain” as “time is muscle” in a heart attack. Each minute that stroke passes,
approximately 2 million neurons are lost!

3. Your office was provided with all of the above information and supporting medical research prior to
publication of the article. We believe it was irresponsible and disservice to the lay public to not include
discussion of the rationale or the prevailing research related to development of the cardiac arrest
protocol. In the future, your paper should reach out to credible subject matter experts for comments on
such matters.
The biggest factors in the successful resuscitation of patients who experience out of hospital cardiac arrest
is the performance of bystander CPR and early use of an automated external defibrillator (AED). The
authors encourage readers to take the time to learn CPR and to know where public access defibrillators
are in their daily course of activities. Readers are also encouraged to learn the signs of stroke (FAST –
Facial droop, arm weakness, speech difficulties, and time).
John Pliakas
John Potvin
Both authors are members of the Rhode Island Ambulance Service Advisory Board.