New York City`s Resuscitation Debate: COVID and Cardiac Arrest

In recent weeks, New York City has seen a significant increase in cardiac arrests, and an even higher spike in prehospital pronouncements. According to the New York City Fire Dept., in-home death pronouncements increased by 400% from late March through early April.

To safeguard providers and to conserve essential EMS resources in response to the COVID-19 pandemic, officials have been investigating alterations to the city's and state's resuscitation protocols.

On March 31, the New York City Regional Emergency Medical Services Council (REMSCO), an agency whose mission is to improve and coordinate emergency medical services in New York City, issued an update to the city's cardiac arrest protocol. Advisory 2020-8 stated that “No adult non-traumatic or blunt traumatic cardiac arrest is to be transported to a hospital with manual or mechanical compression in progress without either return of spontaneous circulation (ROSC) or a direct order from a medical control physician, unless there is imminent physical danger to the EMS provider on the scene.”

One reason for the change was the dramatic increase in general and cardiac arrest call volume in New York City, according to FDNY dispatch statistics. This protocol update led to far more cardiac arrest patients being pronounced dead at home—one factor in the spike reflected in the statistics quoted by FDNY, Mayor Bill DeBlasio and the media.

Following suit, on April 17, the New York State Department of Health (DOH) issued a new cardiac arrest standard of care guideline intended to “protect the health and safety of EMS providers by limiting their exposure, conserve resources, and ensure optimal use of equipment to save the greatest number of lives’’ during the COVID-19 pandemic. The DOH’s new cardiac arrest algorithm (incorporated into REMSCO Advisory 2020-10 issued the same day) called for termination of resuscitation efforts immediately if an AED did not advise or if an ALS cardiac monitor did not display a shockable rhythm in non-EMS witnessed cardiac arrest patients.

EMS Responds to the Changes

As a result of these protocol adjustments, EMS providers and the public pushed back. As Oren Barzilay, head of the FDNY union representing EMTs and paramedics, told the New York Post, “They’re not giving people a second chance to live anymore…Our job is to bring patients back to life. This guideline takes that away from us.”

Perhaps as a result of this pressure, on April 18, FDNY issued Office of Medical Affairs (OMA) Directive 2020-13, clarifying for New York City's 9-1-1 responding units that they should continue to operate under the previously released OMA directive 2020-002A, which called for 20 minutes of BLS and/or ALS treatment of cardiac arrest patients prior to a decision to terminate resuscitative efforts in the field.

On April 22, according to the Post, the New York State DOH followed suit with a similar about-face on their new cardiac arrest guideline: “This guidance, proposed by physician leaders of the EMS Regional Medical Control Systems and the State Advisory Council—in accordance with American Heart Association guidance and based on standards recommended by the American College of Emergency Physicians and adopted in multiple other states—was issued April 17, 2020 at the recommendation of the Bureau of Emergency Medical Services, and reflected ‎nationally recognized minimum standards…However, they don’t reflect New York’s standards and for that reason DOH Commissioner Dr. Howard Zucker has ordered them to be rescinded.”

These protocol updates are being amended as of the time of this writing, and are likely to continue to change.

A Closer Look at the Numbers

Where does all this back-and-forth leave the EMS provider working on the city’s streets? The COVID-19 pandemic is a complex and multifactorial matter of geography, perception and call type. For this reason, swift reactions and sweeping protocol changes, while well-intentioned, can often prove shortsighted and potentially harmful.

For one reason, we must remember that while many of these “new” cardiac arrest patients’ deaths are related to COVID-19, not all of them are. Many patients are simply waiting longer to call 9-1-1—or in extreme cases, not calling at all. Multiple EMS agencies in the New York City area are reporting significant decreases to the number of STEMI (and other non-COVID-19 related) patients calling 9-1-1 compared to the same period last year.

Similarly, interventional cardiologists are reporting significant declines in STEMI patients presenting at their facilities. Clinicians say it will be important to study the impact COVID-19 has on patients with non-COVID-19 emergent conditions given what seems to be a reluctance to call 9-1-1 or seek other emergency medical treatment during the pandemic for fear of getting infected while seeking care.

While FDNY has seen its highest EMS call volume since 9/11, many geographies and agencies are seeing precipitous declines (estimated in several cities as more than 30%). In addition to the fear of being taken to the hospital, another theory for the decline is that people are altruistically trying to avoid burdening the 9-1-1 system during the pandemic.

Another popular theory is based on public health information provided as the pandemic broke. Several announcements in March instructed people to avoid 9-1-1 and hospitals altogether, except in a “life threatening emergency.” These public service announcements are now being reconsidered in light of the ways in which COVID-19 has presented in many patients, with a steep and rapid dropoff in lung function. A final factor to consider related to the drop in 9-1-1 calls is the increase in the adoption of telehealth consultations during COVID-19, another interesting variable to study in the coming weeks and months.

Consequences of Inconsistent Messaging

Like so many components of New York City, EMS is a complex web of authorities with varying degrees of responsibility. For prehospital patient care operations, there are state, regional and city-level agencies that normally function relatively harmoniously for the benefit of all New Yorkers.

But in extraordinary times, fissures can appear as one agency makes a change it deems necessary, which can have downstream (or upstream) effects on others. The situation here is further complicated by the tremendous attention that EMS has received in the media surrounding the COVID-19 pandemic.

There are no immediate or easy answers. But when considering reactionary policy changes in light of current (and temporary) circumstances, it’s important to keep in mind the broader consequences, and the resulting confusion to those on the ground—the EMTs and paramedics who are already stressed and stretched thin, and simply want to do what’s right for their patients.

Joshua D. Hartman, MBA, NRP, is senior vice president of the Cardiovascular and Public Safety divisions at HMP, the parent company of EMS World. He is an active paramedic in New York City and New Jersey.