This article was produced in partnership with The Public’s Radio, which is a member of the ProPublica Local Reporting Network. It was co-published with the Boston Globe.

CUMBERLAND, R.I. — When Rena Fleury collapsed in the stands during her son’s high school football game last August, there was reason to be hopeful.

At 45, she was on the young side for a cardiac arrest, which improved her odds of surviving. And she was in a public place, which, studies show, also increased her chances. Plus, she was in Cumberland, a “heart safe” community where emergency medical personnel are among the most highly trained in the state.

But despite four 911 emergency calls from people in the stands, two nearby automated external defibrillators and bystanders who tried to help, Fleury didn’t make it.

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The 911 call takers failed to recognize that Fleury was having a cardiac arrest. And they failed to provide CPR instructions over the phone.

A review of EMS dispatch logs and interviews with first responders showed that Fleury didn’t receive CPR for the first few minutes after she collapsed, perhaps for up to five minutes. Every minute delay in performing CPR on people in cardiac arrest decreases their chances of survival as much as 10%, according to the American Heart Association.

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The case haunts Dr. Heather Rybasack-Smith, medical director of Cumberland EMS, who helped perform CPR and supervised the emergency medical team’s response to the call. She testified about the case before the state House Committee on Health, Education and Welfare in March.

“No less than four people called 911. Four people,” she told state lawmakers, without mentioning Fleury by name.

“Unfortunately, the system completely failed this woman. This cardiac arrest went completely unrecognized by the bystanders, by her family and most importantly by the 911 operator who took the call.”

Rybasack-Smith and her colleagues in the emergency medical community wrote a series of articles in the May issue of the Rhode Island Medical Journal, which was devoted to out-of-hospital cardiac arrests. The issue includes new data showing that Rhode Island’s rate of bystander CPR — which one author described as “abysmal” — is well below that of other states that track it.

Fleury’s death once again raises troubling questions about whether failures in Rhode Island’s 911 system are costing lives, an investigation by The Public’s Radio and ProPublica has found.

In March, the news organizations reported on the death last year of a 6-month-old baby in Warwick after a Rhode Island 911 call taker failed to give CPR instructions to the family.

In every other New England state, as well as in Pennsylvania and New Jersey, among others, 911 calls for cardiac arrests and other medical emergencies are handled by certified emergency medical dispatchers, or EMDs. Their training includes following carefully scripted instructions — which one medical dispatch expert likened to a pilot’s preflight checklist — to talk a caller or bystander through performing CPR. But there is no federal mandate for these protocols and no central tracking of which states have adopted them.

After the story, Col. James M. Manni, Rhode Island State Police superintendent, recommended that all of the state’s 911 call takers be certified to provide emergency medical instructions over the phone before first responders arrive. The training, he said, would cost about $170,000.

But since next year’s state budget is still under discussion, it is unclear if money will be allocated to pay for it.

“Somebody Call 911”

On the day she died, Fleury and her fiance, Kevin White, had an early dinner before the game at their usual Friday night spot, PJ’s Pub.

Fleury, an office manager, and White, a software engineer, had met online several years earlier and soon became inseparable. They were both divorced with children in their late teens and 20s from previous marriages. And they were enjoying a new freedom and spontaneity. Sometimes they’d go into New York City for the day just to get pizza and shop.

They were living together at Fleury’s house in Woonsocket with her sons and the two cats they’d adopted. And the couple were planning a small destination wedding in Jamaica, followed by a big reception.

Kevin White and Rena Fleury were planning a small destination wedding and a big reception. (Lynn Arditi/The Public’s Radio)

In the car on the way to the game, White turned to his bride-to-be and told her how pretty she looked; her burgundy lipstick matched her blouse perfectly.

As they walked into the stadium, the couple ran into the football coach’s mother, who congratulated them on their engagement. “And of course, Rena’s telling her all about the wedding,” White recalled. And they’re “laughing and talking all the way into the stadium.”

Fleury’s youngest son, Emmanuel Gomes, was the star running back for Woonsocket High School, and she rarely missed a game. On this evening, the game was to raise money for the Woonsocket Villa Novans’ injury fund.

About 30 minutes into the game, Emmanuel ran 60 yards for a touchdown. People in the visitors’ stands cheered and leaped to their feet.

“Yay, a touchdown!” Fleury shouted.

Then White thought maybe she’d spoken too soon.

“Oh shit,” he said, “they flew a flag.”

“It’s still a touchdown!” Fleury said.

White’s eyes were glued to the field. He said three, maybe four seconds passed. Then he turned to his right and saw Fleury slumped over on the bench.

“I’m like, Babe!”

“I have the phone in my hand, but I’m like in shock. I said: Somebody call 911!”

Rhode Island Lag

The chances of surviving a cardiac arrest outside of a hospital in the United States average about 1 in 10, according to the nonprofit Cardiac Arrest Registry to Enhance Survival, or CARES, which collects data from 911 dispatch centers, EMS agencies and hospitals encompassing about 40% of the nation’s population (Rhode Island does not participate in CARES).

In Rhode Island, the odds are worse. Dr. Nick Asselin, an emergency medicine physician and faculty member at Brown University’s medical school, examined data from more than 500 cardiac arrests over 19 months during 2015-17 from three hospitals affiliated with Lifespan, the state’s largest health network. His preliminary findings show that Rhode Island’s survival rate for out-of-hospital cardiac arrests is 7.6% — or 1 in 13.

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The difference, Asselin said, is what happens before a patient gets to the hospital.

“The battle for this is really won and lost in the field,” Asselin said. “So if a patient is in cardiac arrest not receiving CPR, even the best pre-hospital care and the best hospital care won’t effect a good outcome for them.”

Outcomes vary widely across the country. King County, home to Seattle, is a national model for prehospital cardiac care. Nearly 70% of people who experienced a cardiac arrest outside of a hospital in 2017 received bystander CPR. That’s two to three times higher than most other parts of the country. King County’s bystander CPR rate has risen from 53% in 2004.

Not surprisingly, the survival rate for out-of-hospital cardiac arrests in King County in 2017 was about 21%, double the CARES national average rate of 10.4%.

And the survival rate for out-of-hospital cardiac arrests that were witnessed by someone else is even higher. In Seattle and King County, in situations where the patient’s heart was able to be shocked back into a normal rhythm, the survival rate in 2017 was 56%.

CPR training is part of the reason. Rhode Island is one of 38 states and the District of Columbia that mandate CPR training in high school. King County goes further, funding CPR training for adults, including residents of low-income communities, which studies show tend to have lower bystander response rates. About 80% of adults in King County are now trained in CPR.

King County also spends about $112,000 a year to help communities buy automated external defibrillators, or AEDs. And the county maintains a database of all AEDs that is accessible to 911 dispatchers.

In Texas, the Dallas/Ft. Worth International Airport introduced the first interactive kiosks where people can learn to perform CPR on mannequins. There are now more than 30 Hands-Only CPR Training Kiosks in cities around the country, as part of a partnership between the American Heart Association and the Anthem Foundation, the philanthropic arm of Anthem Inc. None are in Rhode Island.

And the emergency medical system in Allegheny County, Pennsylvania, uses a cellphone app, Pulse Point, that maps the locations of all AEDs so first responders can find them in an emergency. The app, which is funded by a three-year grant, can be downloaded for free by residents certified in CPR. These residents can then sign up to get alerts from the 911 center about the locations of possible cardiac arrests, so they can respond if they’re nearby.

Rhode Island currently has no statewide registry of AEDs. Cumberland created its own local registry, but EMS officials haven’t found a way to provide the information to the state’s 911 emergency center, the first point of contact for all 911 calls in the state, so it can be used to help callers.

In 2018, about 900 people in Rhode Island experienced a cardiac arrest outside of a hospital, but only about 22% — roughly 200 people — received CPR from a bystander, according to data from the state Department of Health. And not all of those people survived.

By comparison, the average rate of bystander CPR for jurisdictions that participate in CARES — whose members are required to log EMS data into special software that is then used to analyze and improve performance — is about 40%.

The single most effective way to improve the chances of surviving a cardiac arrest outside of a hospital, experts say, is to train 911 call takers to give CPR instructions over the phone.

An example of a defibrillator that is placed in public areas. Fleury died despite four 911 emergency calls from people in the stands, two nearby automated external defibrillators and bystanders who tried to help. (Kayana Szymczak, special to ProPublica)

Dr. Michael C. Kurz, an associate professor of emergency medicine at the University of Alabama at Birmingham and chair of the American Heart Association’s Telephone CPR Task Force, said that getting 911 call takers to consistently provide telephone CPR involves more than a one-time training.

To be effective, he said, EMS systems have to gather data and monitor performance. Such programs cost money and are often mandated by state law or regulation.

“It is significantly less expensive than building fire stations,” Kurz said, “or putting more ambulances on the street or frankly mass-training citizens.”

Jason Rhodes, the state Department of Health’s chief of emergency medical services, agrees that Rhode Island can do better.

“If we are able to double our bystander CPR rates from 1 in 4 to 2 in 4,” Rhodes said, “we think we’ll be able to save at least 100 more people in the state” each year.

The state Department of Public Safety is preparing to provide its 911 call takers with emergency medical dispatch training if the legislature provides funding to do so in next year’s budget. “If and when the funding is approved, the training would begin as soon as possible,” Laura Meade Kirk, a spokeswoman for the department, said in an email last week.

“Oh My God, Is She OK?”

After Fleury collapsed in the football stands, the first person to respond was Jonathan DePault, the father of another player, who was seated a few rows back.

“There was people saying, ‘Oh my god, is she OK?’” he recalled.

A former volunteer firefighter and EMT-Cardiac (his EMT-Cardiac license expired in 2009), DePault knelt next to Fleury.

“She was not conscious,” DePault said, “or she was in and out of consciousness.”

Initially, DePault said he thought she might be having a seizure. So he took off his sweatshirt and tucked it underneath her head. Then he checked her neck for a pulse and said he detected one.

“I was trying to talk to her and reassure her that everything was OK,” DePault said.

Kayla Cullerton, an assistant athletic trainer, was on the field when she heard the coach’s mother in the stands shouting for her. She jumped the fence and ran into the stands.

Fleury was lying not quite flat on her back between the bleachers, Cullerton said, while a man who said he was an EMT (later identified as DePault) held Fleury’s head.

“He was holding her head up and said she was seizing,” Cullerton said. “He kept saying he had a pulse.”

DePault would later say that he didn’t immediately start CPR on Fleury because “you can only do CPR if there is no pulse.” That runs counter to the American Heart Association’s CPR guidelines, revised in 2000, which recommend that no pulse check be done before bystanders begin chest compressions on a person who is unconscious, because a pulse check is “unreliable.”

DePault said he is familiar with the AHA guidelines but he relied on his professional training. “CPR needs to happen immediately, I get that,’’ he said. “But it could be the lady just passed out or slipped off the stands and banged her head. ... To me, there has to be some kind of assessment.”

Cullerton rubbed the knuckles of her fist into Fleury’s chest — a practice known as sternum rubs — to try to wake her.

“She was reacting to the rubs; her eyes were moving a little bit,” Cullerton said. “So I kept asking [DePault] if he had a pulse.”

Cullerton felt Fleury’s wrist for a pulse. Nothing.

At some point, she said, DePault told her, “I don’t have a pulse.”

Then they pulled Fleury out from between the bleachers onto the middle steps and began CPR. A police officer ran to find an AED while they took turns doing chest compressions. But when the AED arrived, it indicated the rhythm of Fleury’s heart wouldn’t respond to a shock.

Down on the field, Mark Levesque, the athletic trainer for both the Woonsocket and Cumberland High Schools’ football teams, was watching the game when he spotted a fire truck pull up near the concession stands. Levesque is also a paramedic and brings a portable AED to every game.

Mark Levesque, an athletic trainer for high school football teams who is also a paramedic and brings an automated external defibrillator to every game, shown at the stadium where Fleury collapsed. (Lynn Arditi/The Public’s Radio)

Levesque didn’t immediately think his help was needed. He figured someone had a medical problem at the concession stand, and he turned his attention back to his players.

A few minutes later, a rescue truck pulled up near the end zone. Levesque looked up into the stands and saw firefighter EMTs performing CPR.

If he’d known it was a cardiac arrest, he said, he would have come sooner.

“Person Unresponsive”

The initial 911 call was for “person unresponsive with possible seizure activity,” said Rybasack-Smith. She and Cumberland EMS Director John Pliakas had been working at a festival and were driving back to the station headquarters when the first 911 call blared over their radio.

A cardiac arrest is caused by an electrical problem in the heart; the shaking that sometimes occurs at the onset can be mistaken for a seizure. In Rhode Island, emergency calls for people in cardiac arrest often initially get reported as seizures, according to a sampling of EMS call logs reviewed by The Public’s Radio.

Rhode Island law bars the public — even the family of someone who was the subject of a 911 call — from accessing 911 records without the caller’s “written consent” or a court order. And in Fleury’s case, the callers’ identities are not known.

But doctors who were able to obtain the recordings from the 911 center as part of a review of emergency services say that in none of the calls did the 911 operators direct anyone to perform CPR.

It took about seven minutes from the time of the first 911 calls, at 7:32 p.m., for the firefighters, who are certified EMTs, to arrive at the field, according to EMS logs. The football game was still in progress, so first responders had to skirt the perimeter of the field to reach the visitors’ stands.

Rybasack-Smith said she and the EMS director reached Fleury just behind the ambulance crew, which arrived nine minutes after the first call. A second paramedic crew arrived shortly after, she said, bringing the total number of emergency staff on scene to nine.

They took turns performing chest compressions on Fleury. They gave her medication. And they shocked her heart multiple times (her heart at this point did have a shockable rhythm).

“We were really trying everything,” Rybasack-Smith said, “to get her heart back into a normal rhythm.”

But Fleury’s heart never managed to beat again on its own. She was later pronounced dead at Landmark Medical Center.

“She was so young and she really had so many things going for her,” Rybasack-Smith said. “And so you just never know what might have been if somebody had started CPR right away.”

A House bill, sponsored by state Rep. Mia A. Ackerman, D-Cumberland, would require that at least one 911 operator trained in telephone CPR be on call at all times at the Rhode Island 911 call center to “coach” someone calling about a cardiac arrest until a rescue unit arrives.

But the bill, introduced on behalf of the Rhode Island Chapter of the American College of Emergency Physicians, has been put on hold, Ackerman said, since Manni, the state police superintendent, recommended improved training for all 911 call takers.

“I have to respect that he is a man of his word and things are going to change,” Ackerman said. “And if I don’t see any movement, if it’s just a lot of talk, then I’m going to put the bill back in again” when the next legislative session begins in January.

Manni has asked Gov. Gina Raimondo to have all 34 telecommunicators and eight supervisors in the 911 emergency center certified in emergency medical dispatch.

“I support his recommendation,” Raimondo, a Democrat, said last March, “and we’ll be working with the legislature to secure the additional funding.”

The legislature typically adjourns in late June.

These days, White lives alone in a tidy rental apartment he shares with his and Rena’s two cats, Big Daddy (named after the rapper Big Daddy Kane) and Sugar Mama.

White with photos of him and his late fiancee, Fleury. (Lynn Arditi/The Public’s Radio)

One evening last January, White sat on his living room couch, Big Daddy curled up on his lap, as he flipped through a small photo album. There was a photo from New Year’s Eve in Georgia with his sister. And one from Mexico last July, where he proposed. And another with Rena showing off her big diamond engagement ring.

Rena’s daughter, Daneta, 29, made albums of her mother for each member of the family. White keeps his in a locked safe in his office.

“It’s hard for me to even look at her pictures,” he said. “I miss her so much. She was my everything.”

Their wedding reception was supposed to be this coming Saturday. Fleury, he said, was so organized, she had everything booked.

“I just feel so cheated.”

Lynn Arditi is a health reporter for The Public’s Radio in Providence, Rhode Island. Email her at [email protected] and follow her on Twitter at @LynnArditi. Do you work in emergency medical response in Rhode Island? Help us investigate. We want to know what concerns Rhode Island’s emergency medical technicians (EMTs), paramedics, emergency physicians, 911 telecommunicators and dispatchers have about the state’s emergency system and how it could better serve Rhode Islanders. Here’s how to contact us confidentially: Leave a voicemail at 401-213-9187

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