Every year, dozens of research studies relevant to the EMS profession are published. Some lead to new treatments, while others prove accepted therapies may not be effective. Others simply open our eyes to new ideas and challenges, even if the results are ambiguous.
Here are five research studies from 2015 that every EMS leader and paramedic chief needs to read. These articles might change the way you think about what we do and how we do it.
1. Is continuous chest compression CPR effective?
Nichol, Graham, et al. "Trial of continuous or interrupted chest compressions during CPR." New England Journal of Medicine 373.23 (2015): 2203-2214.
This study made my list for what it reported and its scale. Performing research in EMS is not easy. With an uncontrolled environment, and so many factors to take into account, randomized control trials (where a treatment is compared to a control or placebo) are often difficult to conduct and prohibitively expensive.
The research team trained EMS providers across 147 agencies in eight different sites on two different protocols. One protocol was standard CPR, 30 compressions to 2 ventilations, with just a five second or less pause for breaths. The other protocol involved continuous compressions, with asynchronous positive-pressure breaths every ten seconds. Each agency switched protocols periodically throughout the 4 years of the study.
At the conclusion of the study, more than 20,000 patients were included in the analysis: 12,653 in the continuous compression group, and 11,058 in the 30 to 2 group. The researchers looked at different outcomes, including both survival-to-discharge and neurological status.
What they found was that the two groups had very similar survival rates — 9 percent in the continuous compression group, and 9.7 percent in the control group — a difference that was not statistically significant.
This finding may come as a surprise after previous studies indicated that continuous compressions resulted in higher survival rates. However, the authors point out several reasons for these differences. For one, many of those earlier studies compared survival rates before and after initiation of new protocols. In those cases, the improved survival rates may have been due to other treatment changes that were happening at the same time, or simply due to a renewed focus on chest compressions. It’s often the case in EMS that we change several aspects of a protocol, and then attribute improvements in outcome to one of those changes without knowing for sure if it was the one that made the difference.
This study is a reminder that we should sometimes be cautious before jumping on the bandwagon of new treatments or trends in EMS. One local agency near me recently spent a lot of effort training hundreds of EMS providers on continuous compressions with ventilations, while perhaps just emphasizing the importance of minimizing pauses with the previous 30 compression to 2 ventilation protocol would have been just as effective.
At the same time, we can’t write off continuous compressions. This study only tested continuous compressions with positive pressure ventilation. It did not look at other potential solutions, such as compressions with passive ventilation, such as a non-rebreather mask, or with no supplemental oxygen.
2. Do the patient’s race and sex impact care?
Govindarajan, Prasanthi, et al. "Race and Sex Disparities in Prehospital Recognition of Acute Stroke." Academic Emergency Medicine 22.3 (2015): 264-272.
Researchers in California tried to determine if a patient’s race or sex was associated with an EMS provider’s ability to recognize a stroke.
This study had several limitations — it was retrospective, meaning the authors looked at EMS and hospital records after the fact. To determine whether or not EMS correctly recognized the stroke, for example, researchers used the primary impression field from the patient care report. The amount of training paramedics received on completing this field in the PCR was not described.
For example, a patient with altered mental status, a headache and one-sided weakness could have a primary impression of any of those three complaints. Listing altered mental status for a patient with acute stroke signs would not have been considered incorrect nor would it necessarily mean that the stroke wasn’t recognized or the hospital wasn’t alerted in advance. This is why documenting stroke scales and hospital notifications are so critical to quality improvement and research.
That being said, the results of this study should not be ignored. The authors found that EMS providers were less likely to recognize strokes in females than in males, and in Asians and Hispanics compared to whites.
To be clear the results of this study do not mean that EMS providers are sexist or racist. It could mean that there is bias among providers, but it could also mean that stroke symptoms present differently, or that communication barriers exist. What’s important is that we further study the disparities and acknowledge that gender and cultural differences impact the care we provide every day.
3. Can stroke scales be more sophisticated?
Katz, Brian S., et al. "Design and Validation of a Prehospital Scale to Predict Stroke Severity Cincinnati Prehospital Stroke Severity Scale." Stroke 46.6 (2015): 1508-1512.
I picked a second stroke study because it points to the promise of prehospital research and the potential to improve care. I also think stroke is a condition that is often overlooked for the more dramatic patients, such as trauma, cardiac arrest and heart attack victims.
New stroke treatments have led experts to question whether there might be ways for EMS providers to distinguish large-vessel occlusions (LVO), which are strokes that impact the major vessels in the brain, from other ischemic strokes. LVO patients seem to have better outcomes if they receive timely endovascular therapy (mechanical retrieval of the clot), not just medical treatment (such as administration of tpa to dissolve the clot). If prehospital providers could identify patients with LVO, they might be able to triage them to the most appropriate care, potentially a facility that provided mechanical interventions for stroke.
It makes sense that researchers from Cincinnati tackled this topic, as the Cincinnati Prehospital Stroke Scale is well known and the most commonly used stroke scale in EMS. They are not the first ones to address this issue. In 2014 a group of researchers in Spain published the RACE (Rapid Arterial Occlusion Evaluation) scale.
The validation of the Cincinnati Prehospital Stroke Severity Scale (CPSSS) was performed retrospectively, meaning the researchers looked at a previously existing data set to see if their scale could have identified the patients who were given a score of 15 or more on the National Institutes of Health Stroke Scale (NIHSS), which has a high correlation with severe strokes and LVO.
The CPSSS consists of just a few items:
- Conjugate gaze deviation (2 points).
- Incorrectly answers questions about age or month and does not follow commands (1 point).
The EMS White paper
That started it all
The EMS White paper was published in 1966 by the National Academy of Sciences as the paper "Accidental Death and Disability: The Neglected Disease of Modern Society" It was noted that the state of emergency care was rather poor in the early sixties. Many new EMTs wonder how our system evolved to where it is today. This page is going to go back in time to review the state of EMS in the early sixties. You can read the original paper here.
The EMS White Paper states that in 1965 there were 52,000,000 accidental injuries. Of these accidental injuries there were 107,000 killed, 10,000,000+ disabled and 400,000 permanently impaired. The estimated costs were $18 billion (this is $117 billion in 2008 dollars).
There were 49,000 motor vehicle crashes resulting in death or about 24.9 per 100,000 people in 1965. In 2006 there were 44,700 motor vehicle crashes resulting in death but since the population of the United States has increased from 1965 to 2006, the actual incidental rate has dropped to 14.2 per 100,000. Source (US Census) (warning, opens a new window)
The EMS White Paper identified that in 1965 there was a need to inform the public of these statistics. The Paper also identified that most people did not have basic first aid training. Those who do have some basic training had little to no training for cardio pulmonary resuscitation, childbirth and other life saving techniques. This includes police departments, fire departments and many ambulance services.
To address these problems the EMS White Paper said there was a need to create government and pseudo-government agencies such as community councils such as red cross to teach first aid, a National Council on Accident Prevention and a National institute of Trauma
The lay public did not understand the magnitude of the problem. Accidents were the leading cause of deaths between ages 1 and 37 and accidents were the 4th leading cause overall of death. 70% of motor vehicle crash deaths occurred in rural areas (with populations under 2500). There are more deaths per year from motor vehicle accidents than died in the entire Korean War.
What is the solution to this problem? The answer is "Accident prevention." Prevention is the long-term solution to this problem. Education is the key to prevention (as evidenced by reduced injury rates).
The state of emergency first aid and medical care in 1965 identified some additional problem areas. There was a general lack of on-scene medical care. Most medical care began at the emergency room. In fact, in 1965 a severely injured patient had a higher survival rate on the battle field than on a US highway because there were properly trained medical personal on the battlefield. Medical personal on the battle field were directly responsible for a dramatic reduction in battlefield deaths. In World War I 8% of battlefield injuries resulted in death. By World War II this had dropped to 4.5%. In the Korean War this was 2.5% and in Vietnam (as of 1965) this was 2%. The EMS White Paper recommended mandatory first aid training for all people beyond the 5th grade.
In 1965 ambulance services varied widely in capability. There was a lack of clinical data and no central reporting agency. What was found was that ambulance attendants had a wide variations in training. Many ambulance services used untested equipment that was too expensive. Ambulance services were not overseen by government agencies and volunteer agencies had almost no oversight.
50% of ambulance services in 1965 were provided by 12,000 morticians. The simple fact that hearses were better equipped to accommodate stretcher litters. Private ambulance services could not provide enroute care to the emergency room due to a lack of space in the transport vehicle and due to a lace of equipment an training.
In 1965 dispatching was poor and communications in some areas of the country did not exist. One notable exception was the city of Baltimore. To better use the limited resources available there should be a centralized facility to screen and route calls to units and to emergency rooms that can accept patients.
Medical training of ambulance attendants varied widely. Interns used to accompany ambulances but this practice was diminishing in 1965. There were no nationally accepted training standards for ambulance attendants. Currently there are nationally accepted standards for ambulance attendants. We call them emergency medical technicians. The National Highway Traffic and Safety Administration has developed a training curriculum for EMT's
The EMT White Paper identified that in 1965 there was no fixed definition of an ambulance. Most ambulances were based on a passenger vehicle (or a hearse) and were converted into an vehicle that could transport a patient. In 1966 the National Highway Traffic and Safety Administration set standards for ambulance construction.
Note: insert link to KKK spec when done.
Communications between the ambulance and the emergency room were very poor. It was easier to communicate with astronauts in orbit easier then with a responding ambulance. A better system of communication had to be developed. The EMS White Paper also identified a need for a nationally recognized and easy to remember phone number for civilians to call for services. In 1968 ATT announced that 9-1-1 would be the national emergency number The paper also indicated that more public phone were needed on the United States Highway system.
The EMS White Paper also addressed issues relating to hospitals and not to just accident prevention and ambulance response. In 1958 there were 18 million visits to emergency departments, in 1962 28.5 million and estimated to have 49.3 million in 1970. A 2008 report by the CDC shows that this trend has continued to increase.
In 2008 there were 119 million visits to emergency rooms. In 1965, emergency rooms were small. Often these "ER's" would only have a few beds. Only 7000 hospitals in 1965 reported to have dedicated emergency rooms in the United States.
Mass casualty events and natural disasters could overwhelm most emergency systems in 1965. This was due to poor planning on the part of local government.
The 1965 EMS White Paper made some specific recommendations to prevent accidental death. Accident prevention was on the top of the list. The paper recommended several prongs of attack on accident prevention. The first was to form a National Council on Accident Prevention. The second was to educate the lay public on basic first aid and to provide a nationally acceptable set of standard and a curriculum for training emergency responders.
The paper also recommended several items regarding ambulances. The first is that there should be a nationally acceptable standard for ambulance construction. In addition, ambulance services should have some sort of governmental oversight such as state wide certification. Local governments should be mandated to provide for emergency ambulance transport and have the funding made available to accomplish this feat.
Research was also recommended. Pilot studies for having doctors and more advanced medical personal on ambulances were to be conducted. To decrease response time, emergency transport by helicopter was to be studied.
Communications were a big issue in the paper and pilot studies were called for to designate emergency radio channels as well as to study centralized dispatching from central stations. Communication issues were so important that the paper called for the day-to-day use of voice communications.
Future research would be necessary to help reduce the risk of accidental death. Data needed to be collected to see if and where additional emergency departments were needed. Financial scoping studies should have been conducted to see if more studies were need. Centralized collection of trauma data was also to be established but by who and where was not discussed in the paper.
The EMS White Paper finally concludes that more research is required to establish legal medical oversight in death investigations and to increase the funding for trauma research.
How have we done since 1965?
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