Thursday, July 10, 2008

Reading Emergency Medical Services Literature

Reading Emergency Medical Services Literature

By Jim Upchurch

It is important to have a basic understanding of research study prior to interpreting research articles and abstracts. Dr. Jim Upchurch and Jeri D. Pullum illustrate the significance of scrutinizing EMS research articles.

Introduction
Emergency Medical Services (EMS) literature is the printed word concerning EMS. This includes articles, books, computer software and WebPages. The literature can be divided into two broad categories: research literature and non-research literature. Both serve an important purpose. Research literature helps to direct the practice of EMS by showing us what works and what doesn’t. The non-research literature may also change our EMS practice through the spread of information concerning various topics in EMS. These topics can be educational, personal opinion, survey data, etc. The article you are currently reading is non-research literature with the intent to describe two categories of EMS literature and offer an approach to effective reading.

EMS is a broad field dealing with the medical care provided for patients who become suddenly ill or injured. The field includes both out-of-hospital and in-hospital emergency healthcare providers. There are publications devoted entirely to EMS, such as JEMS and Prehospital Emergency Care, and there are general medical journals that regularly print articles about EMS. Until the past decade, virtually everything that was considered literature was in print form: books, magazines, journals and newspapers. A growing source for literature is the Internet. Readers must apply the same critical reading skills to Internet sources as they do to print sources.

Those who know the literature gain a better understanding of the field and can use that information to continually improve their out-of-hospital medical practice.

Research Literature
According to Webster, research is the careful, systematic study and investigation in some field of knowledge, undertaken to discover or establish facts or principles. Our interest is in the field of medicine. Articles published on medical research can be thought of as a snapshot of the medical topic being investigated. This snapshot gives us one view of a problem. Sometimes that single view is so powerful as to change our patient approach through just one study. One example is the investigation of penetrating chest trauma and treatment with the Military Anti-Shock Trousers (MAST), now often referred to as the Pneumatic Anti-Shock Garment (PASG). This study was done in Houston, Texas, several years ago, and clearly demonstrated that patients who were shot or stabbed in the chest died more often when MAST were applied than when they were not. This one study has changed the way we treat penetrating chest trauma in the field. However, the benefit of MAST or PASG in other situations remains unanswered due to a lack of research. It often takes several research projects or snapshots to give us a good picture of the subject under investigation.

What is EMS research literature? Research articles are generally published in medical journals that are issued several times a year. This helps to distribute the results of medical research faster than waiting for textbooks to be released or updated. Prehospital Emergency Care is currently the only medical journal dedicated to out-of-hospital medicine. EMS research articles are also found in the Annals of Emergency Medicine and occasionally in other medical journals. EMS research occupies a very small space in the overall field of medical research. Other research not specifically EMS also can impact out-of-hospital practice. The ongoing research in the treatment of heart disease is one major example.

So, what is a ‘good’ research article? It is one that gives us a true snapshot of the subject studied. The first step toward finding these articles is to look in a refereed medical journal. The author(s) published in these journals must work their way into the journal by passing one or more in-depth reviews of their article. The reviews are performed by one or more experts on the research subject contained in the article. It can take a year or longer before the article is accepted for publication. Journals that require a review process will identify this fact inside their journal. Prehospital Emergency Care and Annals of Emergency Medicine are two examples of refereed medical journals. After obtaining an article to read (or perhaps, one provided by your medical director), how do you get the most from your reading? First, you will need access to a dictionary (English and medical). It is important to look up words that are unfamiliar; otherwise, an important message from the article may be lost. A terminology gap can exist between what the author writes and the reader’s word memory bank. Dictionaries help close the gap. Other useful tools may include medical texts, drug references, etc. Next, it is helpful to understand how a research article is put together. In general, research articles are divided in to the Study Objective or Introduction, Methods, Results, Discussion and Conclusion. All but the Discussion is briefly covered at the beginning of an article. This is called the Abstract. The remainder of the research article discusses all divisions in detail.

The Study Objective or Introduction contains the research question. This part of the article should clearly describe what is being studied. Background information and a discussion of related studies (literature review) may also be provided here.

Methods is a description of how the study was conducted. Retrospective and prospective methods are frequently used. Retrospective studies use previous patient contacts to look for answers to the study objective. This is accomplished by reviewing medical records from a hospital or ambulance or from a database like the trauma registry. A prospective study is set up before patient contact. An example is the MAST study mentioned earlier. MAST was applied on one day but not the next. Patient response to treatment with and without MAST was documented in a prospective manner.

The Results section describes the data collected by the researchers and whether it meant anything. By time you get to this point in the article, you should have a fair understanding of what the researchers are looking for. Statistics help determine if the results of the study were real or due to outside influences. This is called statistical significance. There are different statistical tests used to calculate statistical significance. The selected test method should be identified along with the results. Statistical significance is important but does not guarantee clinical significance. Clinical significance is whether the study shows an impact on patients. The authors should identify the clinical significance they found.

The Discussion should be straightforward and review the study up to this point. Look for a description of the limitations of the study. This is a clue that the author(s) are trying to present a true picture of their findings.

Finally, the Conclusion should contain the author(s) response to the Study Objective based on the research. This may be included in the Discussion.

Non-research Literature
Non-research literature can take many forms: reporting on practices in the field, product reviews, announcements of new procedures, or feature stories on unusual or noteworthy people, agencies or events.

A critical reader can gain much valuable information from these articles. Product reviews help readers make informed decisions about purchases. Reporting on practices in the field helps readers stay up-to-date and helps determine whether practices in their own areas need updating. Feature stories can provide motivational material or can spawn ideas of how to adapt innovations to improve local EMS services.

As with the research article, critical reading is important to gain the most from the non-research article. Although there is nothing wrong with reading for entertainment, the critical reader can improve comprehension through guided reading. You can perform a self-review of the information you read by answering the following questions.

Who wrote the article? The critical reader should check the writer’s credentials. The credentials should support the notion that he or she has some knowledge of the topic under discussion. For example, an article on surgical airways written by a social worker probably should not carry much weight (unless the social worker is also a paramedic, R.N. or M.D.). However, that same social worker writing an article on critical incident stress is more likely to be useful. Also, the critical reader will pay attention to the credentials of other sources the writer is using for information. All this helps the reader shape an opinion about the article. Many feature stories are project reports and are often submitted by someone involved in the project. There is nothing inherently wrong with this practice, but without the strict scientific standards that are required of research articles, some writers involved in the project may paint a biased “rosy” picture. The critical reader should be suspicious if the writer fails to acknowledge any adverse circumstances, results or features.

What is the writer’s perspective? A physician may have a different view of the subject than an emergency medical technician, nurse or non-medical author. Medical professionals are not the only people who can write about EMS; people with many different backgrounds can offer great insight into various EMS topics. But their perspective is bound to be different.

What is the article’s perspective? Does the writer presents various points of view? Obviously, an article about a controversy in the field should include all viewpoints. This consideration applies to other topics as well. A product review should note poor features of the product, as well as the good features, indicating an unbiased evaluation. Critical readers can gain valuable insight from weighing opposing viewpoints for themselves or from understanding what does or does not work.

What are the credentials of the source: the journal, magazine, newspaper or Web site? The critical reader should find out how long the source has been operating and who publishes it. A critical reader can get a good sense of the tone of the source by evaluating its contents over time. Web sites, in particular, can come and go in the blink of an eye. That does not mean that a new magazine or web site is automatically suspect, but the critical reader realizes that such sources have not had time to establish a reputation. Publishers can range from professional organizations, industry groups with specific special interests, educational institutions, or communications organizations. The publisher’s philosophy influences the types of information published and exerts at least some editorial control.

Does the author describe reading objectives and resources used in their work? You should be informed early on what it is you will gain by spending the time to read the author’s creation. Resources utilized by the author should be recorded in the offering.

Does the information apply to you? The reader should consider both how well the information applies to his or her particular situation and the age of the information. The reader should look carefully at how the reported situation is both similar to and different from his or her own experience. Further, the reader must evaluate whether the information is dated or if it still applies.

Does the author use correct grammar and spelling (yes grammar!)? If the text does not flow well it may be the result of poor sentence structure and/or spelling. A writer who does not take the time to use correct grammar and spelling may not have taken the time to develop good content. And speaking of content, the ideas presented should flow in a logical manner.

Now, where do we find these articles? JEMS and EMS Magazine are major contributors to the written word on EMS. The articles are generally well written by experienced writers and provide useful information. Other sources include various web sites, Fire based journals, Search and Rescue journals, and occasionally medical journals other than Prehospital Emergency Care or Annals of Emergency Medicine.

Summary
With the information overload provided by the Internet and the many publications that address EMS, it is important to develop a sense of what is worth your valuable reading time and to get the most from what you do read. The reader who can keep an open mind but remain skeptical has the most to gain from regular and studied reading of the EMS literature. Hopefully this introduction will point you in the right direction. So read!

References
Rowntree D. Statistics Without Tears: A Primer for Non-Mathematicians. New York: Charles Scribner’s Sons; 1981.

Cuddy PG, Elenbaas RM, Elenbaas JK: Evaluating the medical literature. Part I: abstract, introduction, methods. Ann Emerg Med. 1983; 12:549-555.

Elenbaas JK Cuddy PG, Elenbaas RM: Evaluating the medical literature. Part III: results and discussion. Ann Emerg Med. 1983; 12:679-686.

Huck SW. Reading Statistics and Research, 2nd ed. New York: Addison Wesley Longman; 2000.

Merriam-Webster’s Collegiate Dictionary. Springfield, MA: Merriam-Webster, Inc. 1999; 995.

CO-AUTHOR
Jeri D. Pullum. Jeri has spent the past 15 years working with rural EMS providers, primarily on training projects for the Critical Illness and Trauma Foundation. She has designed, produced and authored numerous interactive computer-based training programs and contributes substantially to both the development of grant projects and in overseeing their completion. Using her background in print journalism and bachelor’s degree in journalism from the University of Montana, Jeri writes and edits scripts, training materials, proposals, reports and newsletters. She was an editor for a daily newspaper and worked for several years for a video production company. Jeri has a master’s degree in distance education and instructional technology. You can contact her at jpullum@bresnan.net.

Jim Upchurch MD, MA, NREMT practices in Montana and is board certified in Family Practice with added qualification in Geriatrics. He has a master’s degree in education and human development and is licensed as a paramedic. Dr. Upchurch is a ‘Legacy’ member of the American College of Emergency Physicians. Since 1985 his practice has focused on emergency medicine and EMS while providing the full spectrum of care required in a rural/frontier environment. He provides medical direction for BLS and ALS EMS systems, including critical care interfacility transport; and for the Incident Medical Specialist Program, USDA Forest Service, Northern Region. Dr. Upchurch has served as American Heart Association ACLS Regional and National faculty for Montana and currently represents Montana on the Council of State EMS Medical Directors of the National Association of State EMS Officials. Contact him via e-mail at upchurch@mcn.net.

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