I never thought about that much until I took part in an experiment with a certifying body. In a room full of doctorate level analysts, myself and four other designated SMEs (subject matter experts) were given a verbal patient scenario. We were asked to openly state at each step what we would do in that situation. It was amazing as to how each of us (different backgrounds and cities) answered relatively the same or readily agreed with a peer. We were of course told that we were picked because of our backgrounds of long term management of EMS and having worked as field paramedics. What struck me in this was that it took hours for us to walk through this process of a single patient contact so that the researchers could analyze how we used critical thinking to arrive at our conclusions... and just as I had been told many years ago, just how many data points and decisions occur in a matter of seconds.
That being said... We are products of how our axons, dendrites and synaptic clefts have developed. What we accept to be truth in training and experience subconsciously directs our critical thinking. This is the engine behind what we do. In a way, however, it is also our greatest flaw.
In taking my Six Sigma training, there was one quote that always stuck in my mind: "What you know is wrong." So many times this has been proven to be true when I look at data. That is a known fact... WRONG. I predict that... WRONG. This is the cause of... WRONG. And so it goes.
And our care and critical thinking is directed BY WHAT WE KNOW. That is why we have to look at data, studies and most of all "true outcomes" (in other words, it doesn't matter if you get a pulse back if the patient does not survive until discharge... Your definition of a save may not be exactly what the patient is looking for here).
My last post was a bunch of links to data, quasi-science and peer reviewed articles. Now, on the scale of validity, peer reviewed is always the best, but even those can suffer from flaws such as inadequate subjects in the test field. Manufacturer studies are always suspect as they may be tainted subconsciously to a desired outcome.
So how do we define "evidence-based." Sometimes that is just looking at real data. At other levels it must be peer-reviewed. It depends on how important it is to mortality and outcomes. In a nut shell, to be called evidence based, it has to address these points:
1) Is the data as clean as it can get?
2) Has bias been removed or at least accounted for?
3) Are the results convincing?
4) Can the data and results be replicated elsewhere?
5) What is the impact?
6) Is the resultant course of action more efficacious and safe than what we have today?
Now, let's look at some examples:
1) Did you know that the relationship between Epinephrine and cardiac outcome had never been studied until recent years? But we blindly want everyone to have Epi because it "saves lives."
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| MAST or PASG |
2) For years we added (what we are told) are precious minutes to trauma scenes by applying MAST (or Pneumatic Anti Shock Garment) to patients that were bleeding to death? Why? It worked to "save lives" in Vietnam so it had to work here. When someone finally decided to measure it, the results were not replicable. The time frames to surgery at MASH units was much shorter and transport was mostly by helicopter in Vietnam. Here, we saw it raised blood pressure and we gave it a big thumbs up. We at the same time prided ourselves on getting two 14 gauge IV lines and pouring liter after liter of fluid into trauma victims. There are plenty of buried bodies to prove that both concepts were wrong... which brings us to number three.
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| Vietnam Era Bell UH-1b Iroquois |
3) "We need intravenous therapy at levels lower than paramedic." Why? "It saves lives." At the services I have worked for during the last decade or so, we have all practiced fluid restrictive resuscitation in trauma. We have known that fluid in trauma has been de-emphasized. Read the opening statement at this link:
What does that tell you. It is the current scientific model. Large volumes of fluid simply hinder the bodies ability to compensate for shock. On top of this, with the advent of many nasal administered meds, the RAMPART study showing that IM Versed is faster than IV Versed in seizures, sublingual Zofran... well, you can see that we just don't have an increasing need for IV access in the field.
4) Some of the caregivers finishing the new AEMT program in Indiana desire adult EZ IO. I agree. It makes sense for those rare times when a drug route is needed and cannot be gained with an IV. But has anyone thought what happens if you do an EZ IO on a conscious patient without Lidocaine prior to the fluid push? You might find your patient in pretty intense pain. PRIMUM NON NOCERE! That said, I would say they need Lidocaine for the IO... but not Lidocaine for anything else. Why?
5) Look at the numerous studies on Lidocaine vs. Amiodarone. Fairly inconclusive as to which is better. Some minor arguments exist that the Vasopressin/Amiodarone combination has some additional numbers attached to it.... but, in all of this has anyone looked at the proarrhythmia issue? What is proarrhythmia? It is what happens sometimes about 24-72 hours after you give Lidocaine. Some patients return to their ventricular arrhythmia and cannot be converted easily. This happens less with Amiodarone... far less. So I would argue that this fact alone makes Amiodarone the better antiarrhythmic medication.
6) For years we pushed D50. Then along came a shortage and many of us had to switch to bags of D10. What did we learn? No combative wake ups. Less chance of necrosis. Less incidence of phlebitis. Less incidence of headache upon waking. BUT WE HAD TO BE FORCED BY A PROBLEM TO LOOK AT A DIFFERENT MECHANISM AND CHANGE.
Those are just a few examples... there is getting ready to be a ton of data collection starting on cervical immobilization. Why? Read up on internal decapitation by cervical collar application. Not pretty. Neurologists are already calling for change.
I understand that there are a large number of people who want to keep doing what they are doing now. The problem is that there have been issues nationwide with these skills producing outcomes or increasing numbers of complications due to low initial training hours or infrequent skills use.
I am not opposed to seeing any caregiver get any skill AS LONG AS THEY CAN THROW THE EVIDENCE BASED DATA ON THE TABLE. I want to make one very clear statement:
NONE OF US GET TO DO WHAT WE WANT TO DO IN THE BACK OF AN AMBULANCE JUST BECAUSE WE WANT TO DO IT.
Be very careful when you say your only reason is: "It saves lives."
In many ways, Indiana is ahead of the game. I talk to many EMS operations in a lot of places. Many wish they had what we have on the Paramedic level... local control of the medicine. I personally see many states with drastically stale and outdated protocols because they are on a state or regional protocol that is a lowest common denominator so that all can comply. We do not want that to occur. At the same time, the EMS Commission's charge is to build functional EMS systems. We cannot do this if we ignore evidence-based medicine. We have to start making all providers meet a test of need for a waiver to the rules. And most of all, we need evidence.
This entry could go on for ever, but it does not need to do so.
This train is leaving the station and hopefully it will never return.
What did the Conductor say in The Polar Express?
"The thing about trains... it doesn't matter where they're goin'.... what matters is whether or not you decide to get on."
In this case, we know where the train is going... focusing on outcomes produces better outcomes.
We function by what we believe. Don't you want to make sure you are believing the right thing?
Are you going to get on?
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