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Index The
Present State of EMS Research |
Beginning of EMS ResearchDuring the late 1960’s, a growing number of EMS organizations around the world recognized that their ambulance services required advancement.34-38 Improvements in these systems were generally implemented without undergoing unbiased evaluation. For example, in 1966 an editorial in the British Medical Journal suggested that patients were dying of suffocation because ambulance service personnel were inadequately trained in airway management.34 EMS systems responded by introducing airway interventions formerly reserved for the hospital emergency department directly into the field setting. The prevailing attitude was that if an intervention was useful and effective in the hospital then it would be similarly useful in the prehospital environment. However, study results from one particular environment do not necessarily translate successfully to other environments and may not apply to other populations. Studies of efficacy (i.e., does something work under ideal conditions) do not necessarily indicate effectiveness (i.e., does it work in the real world). Interventions that work in the emergency department might not work in the ambulance, interventions that work in an ambulance might not work in a helicopter, and interventions that work in a moderately busy suburban EMS system may not work in an overburdened urban system. While it makes intuitive sense to take the emergency department to the patient, the compressed time frame for patient evaluation, the lack of many medical technologies such as x-rays, and the limited training of EMS professionals sometimes alter the risk-benefit ratio.39 The earliest scientific analyses of EMS practices were limited in scope and methodology. Only three EMS-related randomized, controlled clinical trials were published before 1980.40-42 The remaining published studies were observational, descriptive, or retrospective in nature. Many studies were designed simply to demonstrate that certain hospital interventions, such as inserting a peripheral intravenous line or performing defibrillation, could be extended to the prehospital environment.30,43 Often the results indicated that the intervention could be applied in the field but gave no clue as to whether the patient benefited. For example, the early studies of the pneumatic anti-shock garment (PASG) and the esophageal obturator airway (EOA) observed physiologic responses such as increased blood pressure but did not evaluate the relationship of the physiologic changes to patient outcome.44,45 The science of EMS has been criticized for providing insufficient evidence to support many of its practices. In 1989, Ronald Stewart advised that EMS must begin to prove itself through research.46 Nearly a decade later, Michael Callaham repeated the sentiment and observed, “It is possible to document exactly how much scientific support there is for the efficacy of our present scope of EMS practice, and it is impressively deficient.”27 Progress towards a scientific foundation for EMS practices is slow, in part due to the inherent difficulties in performing research in the field, but also because of the lack of research infrastructure in EMS systems and the absence of funded researchers working in this field. Thousands of people dedicated to improving prehospital care including physicians from a variety of specialties, EMS providers, allied health professionals, public leaders, and even the lay public have been working both individually and through myriad professional organizations toward creating that scientific basis. Most research accomplished to date within EMS has been conducted on shoestring budgets using volunteer labor, surplus supplies, and in kind contributions from hospitals, medical schools, and EMS agencies. |