Dear Editor,

We thank Mr. McEachen for his comments on receiving patients with vital signs absent from paramedics.^{Reference McEachen1} He correctly points out that paramedics carry a higher risk of exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) due to their work in uncontrolled settings without access to some of the “protected code blue” approaches that have been developed in the hospital setting.^{Reference McIsaac, Wax and Long2} Expanding on his point, most paramedics in Canada are not capable of administering paralytics during intubation or performing rapid-sequence intubation, which is advocated for airway management of coronavirus disease (COVID-19) patients.^{Reference Kovacs, Sowers, Campbell, French and Atkinson3,Reference Cheung, Ho, Cheng, Cham and Lam4} Additionally, basic life support paramedics have even fewer airway tools available and are unable to intubate, again resulting in a higher exposure risk during cardiopulmonary resuscitation.

We are in agreement with Mr. McEachen's suggestion that base hospitals and paramedic services should strictly follow termination of resuscitation protocols during a pandemic to reduce unnecessary risks during transport. Furthermore, if a health care system becomes overwhelmed with a lack of critical care resources, termination of resuscitation protocols should be promptly updated to follow local guidelines surrounding candidacy for critical care interventions.

The purpose of our paper is to provide recommendations about how emergency departments (EDs) should receive patients during COVID-19, presuming that termination of resuscitation has not occurred in the field.^{Reference Nolan, Chartier, Verbeek, Huyer and Mazurik5} Our discussion was intentionally focused on how EDs can prepare for these patients with considerations to reduce exposure to other patients and staff in ED hallways as resuscitation is ongoing. We intentionally did not discuss considerations for field pronouncements by base hospital physicians as we felt it was beyond the scope of our paper.

A calculated approach to the risk and benefits of continued resuscitation and transport is crucial to ensure the safety of all health care workers during the COVID-19 pandemic. We believe that base hospitals, paramedic services, and EDs should work collaboratively to find solutions that fit their unique system's needs. We hope our paper can provide some guidance and considerations to ensure the safety for all health care workers.