“EMS is wild and imperfect. Just like our patients. It’s dangerous and a little mad and possibly contagious…patients don’t come to us… we go to them, and where and how we find them, well, that, too, is part of the story. once in the field, we should expect no help.” – Kevin Hazzard
Well, it is EMS fellowship interview season again, and every year after the lovely encounter with very well qualified candidates, I am left wondering if they have achieved a good return on their investment of time and money coming to visit us. Did they really get a good idea of the important aspects of our program, or will they just have to make an educated guess about whether they would be happy spending a year or more with us?
The first time I saw the Thumper performing CPR on a patient I thought “well, that makes sense.” Since then we have seen other devices, most notably the Zoll AutoPulse and the Physio-Control LUCAS. It was disappointing to many in 2005 when the AutoPulse trial was halted early due to harm. 1 Although four-hour survival was similar between groups, the hospital discharge survival rate in the manual CPR group was 9.9% compared to 5.8% in the mechanical CPR group. Many hypotheses were proposed to explain the results, which included Hawthorne effect, prolonged device deployment time, and enrollment bias. Last month, the results of the LUCAS in Cardiac Arrest (LINC) trial were published in JAMA, breathing new life into the mechanical vs manual CPR debate. 2
The short answer to this question is NO. Since the landmark post-arrest, therapeutic hypothermia studies published in 2002, 1,2 extensive efforts have been made to ensure our post-arrest patients are cooled… and cooled fast. It only seemed logical to extend this revolutionary treatment into the field and have paramedics begin the cooling in the field. New EMS protocols were developed around the country to incorporate hypothermia into cardiac arrest management and well received by paramedics and EMTs. But a recent JAMA publication calls this now into question. 3
To provide a resource for evidence-based Emergency Medical education, this list of must-read landmark articles was created to supplement the Emergency Medicine (EM) internship year of training. There are 52 articles so that one article can be read at leisure each week of the year. I searched national databases and polled faculty at the University of Washington to identify articles that faculty would expect any EM resident to be familiar with or that they felt were practice-changing in EM. Articles were selected for the final list based on the quality of study design, sample size, and relevance for EM residents.
The faculty and fellows of the UCSF EMS/Disaster Fellowship Program met monthly over the past 2 years to to write a study guide for for the EMS Medical Board exam based on the National Association of EMS Physician’s (NAEMSP) seminal textbook Emergency Medical Services: Clinical Practice and Systems Oversight [Amazon link] (Kendall Hunt Publishers, David C Cone, Robert E O’Connor and Raymond L Fowler, Series Editors, 2009). We condensed approximately 1,800 pages into 69 pages with a simple format: summary of material and take home messages to help improve our EMS system. (more…)