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.

Criminalizing Medical Errors

Criminalizing Medical Errors

By Mike McEvoy

Example scenario: While treating a 31-year-old heart failure patient, a paramedic mistakenly pushes 4 milligrams of intravenous norepinephrine instead of the intended lookalike vial of 1 milligram of bumetanide (Bumex®). The patient immediately develops a supraventricular tachycardia, becomes hypertensive, and deteriorates into ventricular fibrillation. Resuscitative efforts are unsuccessful; the patient is pronounced dead on arrival at the ED. After learning of the error from local media accounts, the district attorney launches a criminal investigation. A grand jury returns a felony indictment against the paramedic involved in the error.

Every medical provider fears making an error that harms a patient. The possibility of criminal prosecution adds to those fears — loss of personal freedom, property, certification or licensure, and potential loss of livelihood. Today, with increasing frequency, human errors in health care are being criminalized. The results may have far reaching consequences on the practice of medicine, nursing and EMS.

While the public and our legal system seek to blame and punish people who make fatal mistakes, health care experts and advocates believe that criminal prosecution of medical providers ultimately does far more harm than good. Such actions, they argue, will ultimately drive practitioners to stop reporting errors, and discourage recruitment and retention of a profession already in short supply.

The fact of the matter is that a fatal medication or procedural error could happen to any nurse, paramedic, EMT or physician. How then, should these tragic circumstances be dealt with? What leads society to criminalize medical mistakes? What role can you and I play in affecting how medical errors are managed?

Medicine is not the only profession susceptible to criminal indictments for mistakes. In September 2006, two U.S. pilots flying an executive jet clipped the wings of a commercial airplane over Brazil. The resulting crash was the worst aviation accident in the history of Brazil and killed all 154 people aboard the 737 airliner.
Criminal charges were later filed against the U.S. pilots involved(1). Like health care authorities, aviation safety experts commented that the charges would have a "chilling effect … on getting people to come forward and admit mistakes. We need to focus not on putting people behind bars, but rather on finding out what went wrong and why, and then to prevent its reoccurrence." (Kenneth Quinn, Flight Safety Foundation).

'Criminal human error'
History illuminates when and how safety experts and the criminal justice system arrived at their present day impasse. Attorney David Marx, writing in The Just Culture Community News and Views newsletter(2), calls this juncture the "birth of criminal human error." Marx traces the birth in the U.S. to a 1952 Supreme Court decision in the case of Morissette v. United States, 342 U.S. 246.

In December 1948, while deer hunting on an abandoned air force bombing range, Morissette salvaged 3 tons of abandoned bomb scrap metal. He did this in full view during broad daylight believing it was abandoned, and did not think he was stealing.

When the government charged him with theft, his attorneys argued for dismissal on the grounds that there was no evil or criminal intent, which they believed the law required(3). Justice Jackson, writing for the court, described a paradigm shift in defining the word "criminal," which until that time typically conjured up images of evil intent or intent to cause harm.
Jackson described how the industrial revolution had introduced powerful, complex machines with potential to cause significant harm not previously possible except by the hands of man or animal. He pointed out that automobiles became an instrument by which human behavior could inflict major damage. With the industrial revolution, vast harm became able to be caused from great distances. In response, legislatures started criminalizing acts where "evil intent" was no longer a necessary element. Criminal negligence was born.

Since the industrial revolution, many types of human error have been criminalized, especially where public health or welfare is at stake. Marx points out that today's convicted criminals are not all folks with "evil intent," but include those who breach a duty to others that our government labels "criminal." The Clean Water Act makes polluting waterways criminal. People who leave a child or pet in an unattended vehicle during hot summer months are likely to face criminal charges.

Unavoidable events
Considering the potential scope of actions that could expose any one of us to prosecution, statistics demonstrate a predictable randomness that would pronounce such events unavoidable. The only question is which one of us it will happen to next. And when egregious harm befalls an innocent victim, human nature is to react to the seriousness of the outcome. What firefighter is not happy to see criminal charges brought against an arsonist? What medic is not pleased to see a drunk driver marched off to jail?

Yet to effectively deal with errors, particularly medical errors, we need to suppress our natural reactions and try to ignore outcomes during the time it takes to analyze the circumstances that led to the error.

The greater question, as it pertains to medical providers, is why human error has become not only a violation of rules and regulations, but a criminal act when it threatens the safety of citizens. Are prosecutors becoming overzealous? Are lawyers running out of control? Are our elected officials so frustrated that they’ve turned to criminal law to protect society? Or is it perhaps the systems we designed and manage that are heading us in this direction? Probably no single one of these explanations accounts entirely for where we are today, but several will determine where we go in the future.

No one of us is perfect. As human beings, we are destined to make mistakes. The Just Culture Organization, working to improve patient safety, believes that medical systems often fail to recognize human beings have not one, but two "intentions" related to anything we do. But while we acknowledge human intention toward the outcome, we frequently overlook human intention toward the action or behavior that leads to the outcome.

Undoubtedly, few medical providers intend to hurt their patients — the outcomes. But what about their intentions toward their actions? Did the paramedic in our opening scenario consciously disregard what he knew to be a significant and unjustifiable risk to his patient? If he did, the Just Culture model would call that behavior "reckless" and that is precisely the question they believe should be applied when considering criminal charges in medical errors.

The belief that punishment or criminal charges are unjustified merely because a health care provider did not intend to cause harm flies in the face of accountability, our legal system and good patient safety.

Provider's intentions
When investigating medical errors, our systems must carefully weigh the provider's intentions toward their behavior for recklessness. Regularly, we need to look for risky behavior and coach providers to straighten up and fly right.

Reckless behavior, on the other hand, should be punished. Yes, you read that correctly: some behaviors need to be punished. Perhaps our failure to consistently address reckless practices has prompted attorneys, prosecutors and legislators to take up our slack themselves.

A highly intoxicated partygoer who chooses to drive themselves home does not intend to strike and kill a pedestrian. But when such an incident happens, the courts will likely find the behavior — driving drunk — was intended, and consciously disregarded a significant risk to others.
Recklessness that harms others is criminal, and society sends the guilty to jail. Health care providers should not enjoy special exemption from the rules that govern the rest of society.
Our regulatory systems need to do a better job of dealing with providers who aren't living up to professional standards. Using the criminal justice system to accomplish this should rarely be necessary.

Speaking at the Society of Critical Care Medicine's 2007 Congress in Orlando, Lucian Leape, a Harvard physician and founder of the National Patient Safety Foundation, told the audience that problem health care providers are not bad people but, "our friends and colleagues whose performance poses a potential threat to patient safety.

Our failure to insure that all of our colleagues are competent and safe is ethically indefensible, and we have to do something about it." Dr. Leape continued, "We are the only ones capable of judging and taking action with our peers. We have to take the responsibility."

Equally important are our safety systems. Many error investigation models, the Just Cause model included, see two inputs for every adverse outcome: the system we design around the provider and the behavioral choices they make within that system.

Some systems facilitate risky behaviors; others fail to implement safeguards to reduce risks. In 1998, a Denver nurse was indicted for criminally negligent homicide in the death of a newborn from a dose of penicillin. The Institute for Safe Medication Practices (ISMP) investigating the case found more than 50 deficiencies in the hospital medication-use system contributed to the error(4). Had any one of them been corrected, the error would not have reached the infant.

Protecting patients, providers
Safety systems are critical to protect patients and providers. Too often, safety nets are lacking or non-existent. Human beings will continue to make mistakes. System operators, administrators, manufacturers and regulators own responsibility for the environment of care.

When two drugs are packaged in lookalike vials, the department has an obligation to prevent potential errors. While we often focus on individuals involved in errors, the fire service and EMS community collectively are responsible to gather and analyze near miss reports and feedback from the streets to improve patient safety. Without strides in meeting that obligation, future criminal focus may well take aim at chiefs, administrators, medical directors and system operators.

The increasing trend toward criminalizing medical errors is very likely to discourage health care providers from reporting errors, hurt recruitment and retention, and bring important patient safety initiatives to a screeching halt. EMS providers, like our physician and nursing colleagues, need to step forward and take a more proactive role in how medical errors are managed.
We need to look for risky behavior before they result in errors, and consider whether recklessness contributed to errors that do occur. We must begin to hold our systems accountable for their contributions to errors in the environment of care.

Until we manage to convince the public, our legal system and legislators that we take mistakes seriously, they will continue attempts to fix our problems themselves with legislation, regulations and criminal charges.

Far better outcomes could be had if we, the people who know health care, lead change from within. It's time to begin — we owe it to our patients and each other.

References:
1. ISMP Medication Safety Alert! Criminal prosecution of human error will likely have dangerous long-term consequences. 2007; 12(5):1-2.
2. The Just Culture Community News and Views. The Criminal Edition. Marx, D, Cassidy, KM. Eds. January/February 2007.
3. Morissette v United States, 342 U.S. 246 (1952)
4. ISMP Medication Safety Alert! Since when is it a crime to be human? 2006; 11(23):2.
________________________________________
Mike McEvoy is the EMS Coordinator for Saratoga County and the EMS Director on the Board of the New York State Association of Fire Chiefs. Formerly a forensic psychologist, he is a clinical specialist in Cardiac Surgery and teaches Critical Care Medicine at Albany Medical College. Mike is a paramedic for Clifton Park-Halfmoon Ambulance, chief medical officer for West Crescent Fire Department, past chair and current member of the New York State EMS Council. He is the fireEMS editor for Fire Engineering magazine and recently published a book titled "Straight Talk About Stress for Emergency Responders." Mike is a popular speaker at fire, EMS, and medical conferences and in his free time, is an avid hiker and winter mountain climber

SPMI Sr. Program Officer

The American Red Cross Tsunami Recovery Program (TRP) had been established to direct the organization’s response to the South Asia tsunami disaster. The TRP activities focus on integrated community recovery and preparedness interventions in tsunami affected countries in Asia and East Africa in collaboration with Red Cross and non-Red Cross partners. Please visit www.redcross.org/tsunamirelief

The Indonesia TRP Delegation operates from offices in Banda Aceh, Calang, Lamno. It also has liaison offices in Jakarta, and other areas in Aceh province in collaboration with the Indonesian Red Cross. The American Red Cross seeks dynamic individuals to fill the :

SPMI Sr. Program Officer

(Aceh - Banda Aceh)

Responsibilities:
Providing ongoing on- and off-site technical assistance to PMI and American Red Cross YRSH Program Manager
Providing technical assistance on school health programming
Assisting sites in implementing the program through on-site coaching, mentoring, trouble-shooting
Providing training and supervision in all components of management, program and administrative procedures
Discover partnering possibilities/opportunities for PMI with local government agencies for PMI to sustain Health and Nutrition promotion in the future also facilitate and support development of partnership
Identify training needs within PMI teams and support ARC instructional unit to develop, organize and facilitate relative trainings
Technical assistance in supporting PMI for program exit and document best practices and lesson learned for PMI ABDYA and Aceh Utara.
Creating a continual system of feedback, sharing and quality improvement of program interventions
Accessing and/or developing resources for program use (e.g., manuals, how-to Instructions, exemplars, etc.)
Liaison and networking with local GOs and NGOs
Technical Assistance to PMI to develop strategic partnerships to institutionalize Health Strategic Maintain and update Project database, ensure validity of data and good filling system
Responsible for monthly and quarterly report as well as weekly report
Assist Project Manager in Monitoring related to Program and finance status at field level
Whenever needed, represent Program Manager in events related to Program

Requirements:
Good interpersonal Skill.
Medical degree or related background and have experience in Nutrition and Health Promotion issues.
Minimum 3 years experience in managing programs, community development work, past experience in community based program is preferred
Minimum 2 years experience in school health program
Ability to train and manage staff
Excellent relational, administrative, written and oral communication skills
Proficiency in English (written and spoken)
Proficiency in computers especially MS office, capability in database program.
Ability to take initiative, think creatively and work collaboratively
Result oriented and make things happened
Able to work efficiently under time pressure.

Please submit your application and curriculum vitae to hr@amredcross.org

put Job title in Subject line.

Only applications in English and short listed candidates will be notified.