Handling apparent asystole and the AHA's approach to the exchange of ideas

Years ago, I think in 1994, I noticed a question in Currents in Emergency Cardiac Care (an AHA-published newsletter for caregivers, apparently since defunct) about shocking apparent asystole (flatline). The answer was that you shouldn't do it. My interest was piqued because not even a hint of a rationale was given in the answer. I decided to look into the matter.

Shocking apparent asystole was first strongly discouraged in the 1992 ACLS Guidelines, based on the rationale that shocks caused a "parasympathetic storm" which would lessen the chance of a natural pacemaker  restoring a cardiac rhythm. I found that the references cited as supportive in the Guidelines did not actually support this hypothesis. I raised this and other objections in a manuscript to Currents. After several months, I learned from the then-editor Mary Newman that the editorial board had accepted the manuscript, which they planned to publish along with a reply from an ECC Committee member. After a few more months, I learned that the reply had been deemed unacceptable for publication by the editorial board and that the author had apologized to the board; the result was that neither the reply nor my original manuscript was published. Ms. Newman was kind enough to supply me with a copy of the reply, and it was clear to me why it had been ruled unacceptable for publication: it was personal, vitriolic--and perhaps most importantly, did not address any of the issues I had raised.

Later, I submitted essentially the same manuscript to the American Journal of Emergency Medicine as an editorial; it was initially rejected on the basis of one reviewer's comments. Based on a brief excerpt from the comments that the editor shared with me, I strongly suspected that the reviewer was the same physician who had gone ballistic in his response to my submission to Currents. (I belatedly noticed that he was on the editorial board of AJEM.) I believe that he should have recused himself, and that not doing so represented a breach of prevailing standards for peer review. I called the AJEM editor, who acknowledged problems with the review and agreed to publish my manuscript as a letter: Stewart JA. Questions remain about shocking asystole. Am J Emerg Med. 1996 May;14(3):337-8.

More later (perhaps).