We have all seen the headlines on the EMS trade journal social media sites on cardiac arrest survival statistics, STEMI statistics such as time to first 12-lead and door to balloon times, but what percentage of EMS care does this make up? We are also plagued by articles on the consequences of hyperoxia and the use of backboards, topics we have had arguably sufficient data on for years. I think we are caught in the midst of a serious EMS research conundrum where most of our efforts are focused on measuring what is easy to measure. When you combine this with the fact that the profession of emergency medical services (outside of physician medical oversight) has very few trained researchers, it creates a significant issue for the future of our profession.
In the grand scheme of the current climate of healthcare, we are looking for care that is valuable, that is cost effective, and that improves patient outcomes. So far, EMS has failed to prove this empirically through research. We have a lot of data on cardiac arrest, STEMI, and stroke, which as a rough estimate make up approximately 3% of our calls. But how do we justify the importance of the care we provide for the other 97%? EMS leaders are largely focused on EMS 3.0, but we have yet to prove that the care we have been providing since EMS 1.0 has proved any value. We are close to having the data from the PARAMEDIC2 study, but again, that will just provide us more data on cardiac arrest. Albeit an extremely important topic where EMS arguably makes a substantial difference in the potential outcomes for patients, it is only a small part of what we do.
Let me present you with a common problem EMS treats that we have very little data for. Given the current opioid crisis, the idea of whether or not we should be using opioids for pre-hospital pain relief has been a hot topic of discussion. Do the patients we provide opioids to in the field benefit from that care? One of the most common presenting complaints to emergency departments in the United States is abdominal pain, often accompanied by complaints like nausea. Anecdotally, the pain relief and anti-emetics we provide in the field reduce that patient’s overall care, reduce the time spent in the ED before the patient is comfortable and able to receive advanced diagnostics such as imaging. Ultimately, this improves not only their outcomes, but experience of care, one of the Institute for Healthcare Improvement’s triple aim goals. On top of that, reduced time spent in the ED before a diagnosis is made may also improve ED throughput and reduce ED wait times for other patients. A search of the literature on PubMed and Google Scholar reveal very little data to support any of our interventions in these cases.
The idea of a randomized controlled trial to explore the benefits of EMS pain management and anti-emetic treatment for patients who present with abdominal pain would provide some important data that may support or refute current practice and may provide us insight into how to improve treatment and patient outcomes. The issue here is that supporting a trial like this is complicated and would require a principle investigator knowledgeable in conducting the study, a statistician with the knowledge to perform the right statistical analyses involved from the very
beginning, and the proper controls in place to appropriately analyze the data. Furthermore, it would have to be generalizable to the EMS system at large to provide useful and meaningful data.
Here is where we reach the EMS research conundrum. One of the key issues here is that ability to generalize this to the EMS system at large. As the old adage goes, when you have seen one EMS system, you have seen one EMS system. A single center trial in a large urban area where all patients are within minutes of a fully capable tertiary care center is hardly generalizable to a rural area of a frontier state with a two-hour ground transport to a critical access hospital. Another issue is information sharing. Most EMS systems currently lack the ability to share information between EMS agencies and the hospitals we transport to, or the data we do get is disjointed and hard to use for study. Hopefully in the coming years with more widespread use of ePCR/HER systems and things like HL7 interfaces we will be able to overcome this variable. Another old adage applies here as well, garbage in is garbage out. The data we provide to systems like NEMSIS or our ePCR software is often incomplete or largely subjective making it hard to produce valid results. Finally, we lack the personnel in research positions to provide us with this valuable data that are academically trained to do clinical research. This falls outside the variables of a 30-day outcome for cardiac arrest patients whether or not they were treated with epinephrine (an obvious and intentional oversimplification of a lot of the current literature).
It is my hope that EMS can begin to start incorporating better research into our profession. If we want to advance EMS as a profession, it is a requirement. We must abandon our discussion of high flow oxygen and backboards (things we have sufficient data for) and focus our efforts on supporting and refuting our current practices, and on taking EMS in future directions. Having adequate research will be key to the future of clinical care, reimbursement, and how we are viewed by the rest of the healthcare industry.
Tom Latosek, MS, NRP, CCP-C
Tom is a practicing paramedic and EMS educator who is interested in EMS research, and advancing the profession of EMS through education. Tom has practiced in a variety of EMS clinical settings and teaches a variety of courses for a healthcare education company. Tom holds an MS in neuroscience and a bachelor’s degree in biology and psychology and is currently a first-year medical student.