To the Editor.
—In their article, Dr Lombardi and colleagues1 examined out-of-hospital cardiac arrest survival in New York City and found a dismal 1.4% overall rate. This well-designed study clearly documents a breakdown in the American Heart Association's "chain of survival," including delays in early access, initiation of cardiopulmonary resuscitation (CPR), time to defibrillation, and time to advanced life support.2 However, even when the survival analysis focused on patients with an optimal prognosis (such as those with a witnessed arrest in whom the presenting cardiac rhythm was ventricular fibrillation and bystanders provided CPR within 4 minutes), the observed survival was still far below the survival reported by other emergency medical services (EMS) systems.2 Lombardi et al rejected the notion that the low survival rates may be related to EMS system performance. Indeed, they speculated that there were "certain sociodemographic features common to victims of cardiac arrest in
Bickell WH. Emergency Medical Services: Factors Associated With Poor Survival. JAMA. 1994;272(20):1573. doi:10.1001/jama.1994.03520200029016