Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Surviving the Next Shift – Part II

Continuing from Part I of the discussion about what we need to do to go home safely at the end of our shifts.

On Surviving the Next Shift, Brad Buck, Matt Fults, and Dr. Chris Russi D.O. are joined by Eric Dickinson (author, police officer, EMT, and author of the article Tactics to Survive Your Next Shift) and Art Hsieh (of EMS1.com and author of the article On self defense and being a medic).

When is the scene safe?

The scene is NEVER safe.

Scene safety is just another EMS myth.

What can we do to make the scene more safe?

Awareness of the environment.

Anyone who has been violent can should be expected to be violent again.

If you are an abused spouse and you want to believe that your abuser really loves you because they say they really love you with the same sincerity that they say they will never hit you again – that is your fault. Wake up and call 911.

If you are EMS and you believe some violent person who says I won’t do that again, with even more sincerity than a drunk saying he won’t drink again – it is your fault when you get attacked, again. Wake up and call for police right away.

The best predictor of violence is a history of violence.

The best protection from violence is not a weapon, not body armor, but awareness.


Image credit. Alex is so fond of ultraviolence, he even attacks his droogies.

The best protection from violence is not a weapon, not body armor, but awareness.

Weapons can be used against you. If you are not an expert with the weapon, expect to be donating your weapon to the violent person.

Body armor slows you down. The police will be using body armor to protect themselves from the weapons you gave to the violent people.

The most dangerous weapon is whatever can hurt you, that you don’t think can hurt you.

Your pen can be used to kill you. Do you get signatures from violent people? If you do, you are asking to be hurt.

You carry a knife. Do you know where it is? You should probably leave it where it is, but do you know what part(s) of you equipment includes a knife?

One of the weapons mentioned is the monitor, because of its size. The older monitors had the defib paddles and these can be great for stopping someone dead in their tracks. Hit the charge button and most people will not come any closer. My boss was left alone with a prisoner, but thought the police were still behind him. When the prisoner came after him and he realized that he was about to have some quality cellmate time, he grabbed the paddles, pressed charge, and said, Come and get it. Defib pads probably do not have the same effect.

There is also the possibility of oxygen therapy. A portable oxygen bottle can be swung very effectively in a confined space. Most regulators can provide a good grip, but even a two-handed grip can allow you to do enough damage to allow you to get away.

Our goal is to be as violent as necessary for anyone attacking us to change their minds and let us go. The police would much rather have us out of the way before they come in with weapons drawn. We will probably be back after the violent people have been disarmed and cuffed. Somebody has to patch up their injuries.

Do not play with the emergency panic button on your radio, or on the radio of someone from another agency on scene. I used to work with some clowns who would stand beside you and get their thrill for the day by pressing that emergency button on our portable radios. Since we work in EMS, nobody takes this seriously and there was never any punishment. Boys will be boys was the attitude. That is fine – after they have left EMS for the exciting world of fast food order fulfillment.

Another thing that is mentioned is the foolishness of medical command permission requirements for EMS.

 

A treatment for a true emergency should never require medical command permission.

 

If we get into a situation where we feel the need to use violence, we probably did something wrong.

Go listen to the podcast.

If you do not believe me about the knives in our equipment, here are two examples –


Image credit. For BLS (and ALS), an OB (OBstetrical) kit has a scalpel, which is a knife.


Image credit. For ALS, many cric (crichothyrotomy) kits contain scalpels.

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Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part III

ResearchBlogging.org

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the rest of the excellent material at these sites.

This paper is discussed in Prehospital administration of IV fluids to trauma patients: EMS Research Episode 5.

This is also discussed by Dr. Chris Russi in the podcast Russi’s Research Review – Episode Two (Fluid Administration in Traumatic Injury Patients).

Continuing from Part I and Part II.

The 5 most common EMS procedures as documented in the NTDB (National Trauma Data Bank®) are listed in this table.


Click on images to make them larger.
 

In Part II, I explained the problems with the NTDB claiming that only 49.3% of trauma patients had IV fluids starts documented. While that should raise questions, looking at the data on the rest of the top 5 procedures makes the questions even more obvious.

Looking at the abridged Table 1 that I included in Part II, to show the problem with the number of IVs documented, unit12medic recognized the problems with the rest of the data. I changed the abridged Table 1 only changing what I underlined. I removed the underlining from the IV fluids and added underlining to the other procedures that are documented with unrealistic frequency.

Only 8.1% had spinal immobilization?

IV (IntraVenous) starts were over 6 times more common than spinal immobilization for these trauma patients?

Is there any place where this is the way EMS does things?

8.1% had needle decompression, but only 4.4% were hypotensive?

Is there any reason to assume that a patient who is not hypotensive will improve by having a large needle stuck in his chest?

Chest decompression is almost 3 times more common than intubation in these trauma patients?

More than one in every 12 1/2 trauma patients had chest decompression.

MAST application is 3 1/2 times more common than spinal immobilization?


Click on images to make them larger.

When broken down by procedure among those who did not have an IV start documented vs. those who did have an IV start documented, things become even more odd. The authors claim to have adjusted for all of these variables, but the difference in rate of application goes from small to what appears to be inexplicably huge. I can’t explain this except if the data do not reflect reality.

A total of 776,734 patients with complete prehospital procedure files were identified from the 1,466,887 total patients in the National Trauma Data Bank.[1]

Multivariable logistic regression was used to examine the relationship between prehospital IV and mortality in the 311,071 patients with complete data.[1]

1,466,887 total NTDB patients.

776,734 patients with complete prehospital procedure files (53% of 1,466,887).

311,071 patients with complete data (40% of 776,734 and 21% of 1,466,887).

What would result in such a dramatic difference between MAST with an IV Start and MAST without an IV Start?

53.4% is 281 times more common than 0.19%. What could possibly explain this? Differences in protocols?

Even though the authors concluded that IV Starts produced worse outcomes, the procedure most strongly correlated with IV Starts was determined to have produced a protective effect. Most IV Start patients had MAST applied, while less than one fifth of one percent of the No IV Start patients had MAST applied.

Intubation (OR 1.57) and spinal immobilization (OR 1.42) were found to increase the odds of death by much more than IV Starts (OR 1.11) were increasing the odds of death.

If these numbers were valid, the increased odds of death should result in strongly worded warning letters on the hazards of spinal immobilization and intubation of trauma patients.

The less frequent the procedure/condition, the larger the calculated increased risk of death. This also means that the larger the calculated increased risk of death, the larger the confidence interval.

With the unbelievably low rate of spinal immobilization, which is more likely the opposite of what is recorded, should we trust any of the numbers from the NTDB?

If we cannot trust any of the numbers from the NTDB, we must doubt the least frequent numbers.

We did not adjust for cardiopulmonary resuscitation because the data on cardiopulmonary resuscitation appeared to be biologically implausible:[1]

 

I read this and thought that they were going to explain that compressions of the chest are pointless, when there is no blood in the vessels to circulate. And this is true.

I thought that they might also explain that compressions of the chest are pointless, when there is a complete obstruction to circulation. And this is true with arrests due to pulmonary embolus or cardiac tamponade.

But that was not their point.
 

the mean systolic blood pressure of penetrating trauma patients who received cardiopulmonary resuscitation was 118 mmHg.[1]

 

That is higher than my blood pressure.

I am pretty sure that the AHA (American Heart Association) does not want anybody using CPR (CardioPulmonary Resuscitation) on people with good blood pressures. CPR is for people with no blood pressure (or for children with extremely low blood pressures).

Does this give us a hint about the reliability of the information used?

I think so.

Regardless of the problems with the data in this study, we still have no evidence that giving fluids to patients before bleeding is controlled improves outcomes.

Regardless of the problems with the data in this study, we still have no evidence that giving fluids to patients before bleeding is controlled is safe.

I generally agree with the conclusion, that fluids should not be given (I would add – before bleeding is controlled), but I do not think that this study provides valid evidence to support that conclusion.

I am adding the article below to Part I. This is the reporting by Medscape. This was not put on line after I wrote about it, but I missed it when I originally wrote this. Medscape is a web site edited by doctors, but even they did not seem to notice the flaws of this study.

From Medscape Medical News
Prehospital IV Fluids May Be Harmful for Trauma Victims
Medscape
Laurie Barclay, MD
January 20, 2011
Article

Footnotes:

[1] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis.
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
Ann Surg. 2010 Dec 20. [Epub ahead of print]
PMID: 21178760 [PubMed – as supplied by publisher]

Full Text in PDF format from www.medicalscg.

Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, & Chang DC (2010). Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of surgery PMID: 21178760

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Do Gold Standards Exist

The most recent Standing Orders podcast, “A Hot Potato” The Future of Pre-hospital Airway Management, covers a topic that can fill up several podcasts – airway management/intubation.

At 9 1/2 minutes into the podcast Dr. Keith Wesley makes a statement about Gold Standards that is worth a bunch of podcasts itself.

I keep hearing “The Gold Standard.” Well, as much as this may blow away our listeners, particularly those fresh out of training –

There are no Gold Standards.

If there were Gold Standards, then we would be practicing the same medicine that Hippocrates was practicing thousands of years ago.

The realities are that science changes. I don’t believe in Gold Standards. I think that assumes there are absolutes.

This episode of the Standing Orders podcast was recorded on Valentine’s Day. This was not the Valentine I had been hoping for. This could be even better than what I was hoping for.

Late edit – 03/03/11 – I changed the last sentence from, This could be better, to This could be even better than what I was hoping for. It was pointed out to me that the original wording could be interpreted as a negative comment about the podcast. My impression of the podcast is not at all negative.

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Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part II

ResearchBlogging.org

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the rest of the excellent material at these sites.

This paper is discussed in Prehospital administration of IV fluids to trauma patients: EMS Research Episode 5.

This is also discussed by Dr. Chris Russi in the podcast Russi’s Research Review – Episode Two (Fluid Administration in Traumatic Injury Patients).

As I pointed out in Part I, using placement of an IV (IntraVenous) line on a trauma patient as a surrogate for administration of IV fluids to maintain blood pressure, or to raise blood pressure, is a mistake. We do not know how much fluid was administered. I have often stated IVs on trauma patients and not given more than a few milliliters of fluid, which is an insignificant volume of fluid regardless of blood pressure. If I have given IV fluid, it has been because there is medication in the fluid – morphine (10 mg/ml) or fentanyl (50 mcg/ml). These are not significant amounts of fluid, but they are significant treatments.

The problem with this study is that the NTDB (National Trauma Data Bank®) does not produce information that appears to be accurate. The authors stated –
 

Patients without complete prehospital procedure information were excluded.[1]

 

This presumes that what they describe as complete prehospital procedure information is the same as accurate prehospital procedure information.

On the podcast, we all agreed that the data do not appear to reflect reality. I have worked in EMS for 20 years and I have worked in four of the five states with the largest number of EMS providers. California, New York, Pennsylvania, and I worked at a trauma center in New Jersey. The others on the podcast, Tom Bouthillet, Dr. Bill Toon, and Harry Mueller have similar, or more, experience.

Here are the numbers on the 5 most common EMS procedures as documented in the NTDB.


Click on images to make them larger.

Only 49.3% had IV fluids starts documented?

Researchers dream of randomizing things this evenly. However, this is an unusually low rate of IV starts for trauma patients. I have never seen a protocol that does not indicate that an IV should at least be attempted on trauma patients.

Study Protocol
During the prehospital phase, patients assigned to receive immediate fluid resuscitation were treated with a standard paramedical protocol1-3 that included endotracheal intubation and assisted ventilation with oxygen when appropriate, rapid transport to the emergency center, and insertion of two or more 14-gauge intravenous catheters in the upper extremities for rapid infusion of isotonic crystalloid (Ringer’s acetate solution) en route to the hospital. In accordance with recent recommendations, no patients were treated with antishock garments24.
[2]

 

Patients assigned to the delayed-resuscitation group were cared for in an identical manner with the exception that after the insertion of the intravenous catheters, the catheter lumens were covered with an infusion cap that was then flushed with 1 to 2 ml of 1 percent heparin in normal saline.[2]

 

Even the no fluids group in that study did have two 14 gauge IVs started. If we evaluated that study according to the criteria of the current study, both groups received IV fluids, since both had IVs started.

We know that is not true.

In the Bickell study,[2] we know which of the patients who had IVs started received fluids and we know how much fluid patients received.

In the current study, we assume that everyone who had an IV started received fluids and we do not seem to care how much fluid patients received.

Can this possibly answer a question about the influence of fluids on trauma?

It is also hypothesized that delays to start IVs could have been the cause of the bad outcomes.

How many medics delayed on scene to start an IV?

We don’t know.

How many medics started IVs on the move and did not delay transport?

We don’t know.

Should we even try to explain results that are based on bad data?

No.

To be continued in Part III.

Footnotes:

[1] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis.
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
Ann Surg. 2010 Dec 20. [Epub ahead of print]
PMID: 21178760 [PubMed – as supplied by publisher]

Full Text in PDF format from www.medicalscg

[2] Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.
Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL.
N Engl J Med. 1994 Oct 27;331(17):1105-9.
PMID: 7935634 [PubMed – indexed for MEDLINE]

Free Full Text from N Engl J Med. with link to Free Full Text PDF

Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, & Chang DC (2010). Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of surgery PMID: 21178760

Bickell, W., Wall, M., Pepe, P., Martin, R., Ginger, V., Allen, M., & Mattox, K. (1994). Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries New England Journal of Medicine, 331 (17), 1105-1109 DOI: 10.1056/NEJM199410273311701

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Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part I

ResearchBlogging.org

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the rest of the excellent material at these sites.

This is discussed in Prehospital administration of IV fluids to trauma patients: EMS Research Episode 5.

CONCLUSIONS: The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.[1]

That is the conclusion posted in the abstract available from PubMed. For many people, this may be all that they will read. Sometimes the full text is available for free, so a subscription is not required to read the full text. Even so, most people with access to the full article may not read it.

We expect the PubMed abstract to provide the important information.

In this case, we would be wrong.

This study does not look at Prehospital Intravenous Fluid Administration.

Prehospital IV Starts are Associated With Higher Mortality in Trauma Patients.

That would improve the accuracy of the title, but even that is not supportable.

We hypothesize that trauma patients receiving prehospital IV catheter placement (with or without IV fluids) have higher mortality than trauma patients who did not receive an IV or fluids.[1]

But that is not the way this is being reported in the media, including medical media.

The primary independent variable was defined as prehospital IV. The majority of patients with the word “intravenous” or “IV” in the prehospital procedure file of the NTDB were coded as having received “intravenous fluids.” However, there were many different terms reported along the “intravenous” continuum and we could not definitively differentiate IV fluid administration versus IV catheter placement alone. Therefore, we grouped both all patients under the heading of “pre-hospital IV”.[1]

The very next sentence is –

We performed a descriptive analysis of our dependent and independent variables, and we conducted an unadjusted analysis that included a comparison of mortality rates among all patients with versus without prehospital IV fluids.[1]

with versus without prehospital IV fluids.

They don’t even know which patients received fluids.

They don’t know anything about the amount of fluids that might have been given.

All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.

We know nothing about the dose of fluids.

Was it 10 ml/patient?

Was it 100 ml/patient?

Was it 1,000 ml/patient?

Was it 10,000 ml/patient?

Your guess is as good as mine.

Your guess is probably also as good as the guesses of the authors of this study.

How did the media report this?

Giving IV fluids on scene might raise death risk for trauma victims
Updated 1/10/2011 4:52 PM
By Alan Mozes, HealthDay
USA Today
Article

The above article is also published at Bloomberg Business Week.

IV fluids may not always be good for accident victims, study finds
January 04, 2011
By Thomas H. Maugh II
Los Angeles Times
Article

These articles do not contain any explanation that the researchers have no idea which patients received fluids or how much fluid. Dr. Haut was interviewed and presented his information as if the abstract were accurate and informative. It is neither.

A late entry – 03/01/11 is the reporting by Medscape. This was not put on line after I wrote about it, but I missed it when I originally wrote this. Medscape is a web site edited by doctors, but even they did not seem to notice the flaws of this study.

From Medscape Medical News
Prehospital IV Fluids May Be Harmful for Trauma Victims
Medscape
Laurie Barclay, MD
January 20, 2011
Article

What about on line sources?

Prehospital Intravenous Fluids May Harm Trauma Patients
Mortality highest in patients with penetrating injuries, hypotension, or severe head injury

Modern Medicine
Article

Prehospital Intravenous Fluids May Harm Trauma Patients
Doctors Lounge
Article

Prehospital IV fluid administration
IVTEAM
Article

These essentially repeat only the information in the abstract, or they repeat small parts of the information in the abstract.

Did anybody get it right?

Pre-hospital iv and increased mortality
RESUS.me
Article

Does Fluid Resuscitation Harm Trauma Patients?
Skeptical Scalpel
Article

And the podcast I mentioned at the beginning –

Prehospital administration of IV fluids to trauma patients: EMS Research Episode 5
EMS Research Podcast
Podcast

Late entry – 02/21/11 Also covered by Dr. Chris Russi in the podcast Russi’s Research Review – Episode Two (Fluid Administration in Traumatic Injury Patients).

Part II and Part III will explain some of the problems with the study and some of the things to look for when evaluating the merits of a study.

Footnotes:

[1] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis.
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
Ann Surg. 2010 Dec 20. [Epub ahead of print]
PMID: 21178760 [PubMed – as supplied by publisher]

Full Text in PDF format from www.medicalscg.

Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, & Chang DC (2010). Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of surgery PMID: 21178760

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EMS and Ethics – Part I

The most recent Standing Orders podcast, Consciously Incompetent: The Safe Non-Transport of EMS Patients, raises a lot of interesting questions about patients having the capacity to refuse. One topic that they touch on could fill up several podcasts. I will break this up into a bunch of posts. Ethics.

First a bunch of questions to think about.

Does EMS have any ethical obligations?

What are those ethical obligations?

Are those ethical obligations the same for every patient?

Are the ethical obligations the same for every care giver?

Is it ethical to throw EMS into situations with difficult decisions and expect them to make good ethical decisions without any preparations?

Is it ethical to follow SOPs (Standard Operating Procedures) if SOPs appear to present significant risk to the patient?

Is it ethical to follow protocols if the protocols appear to present significant risk to the patient?

Is it ethical to follow medical command orders if the medical command orders appear to present significant risk to the patient?

If we do what we believe is what is right for the patient, but violate SOPs/protocol/medical command orders, what protection is there for us?

Should we be punished for behaving ethically?

Does a potential patient surrender all rights to informed refusal of treatment and/or transport with the first sip of alcohol, first toke of marijuana, the first sip of coffee, et cetera?

If we refuse to comply with patient requests, what minimum standards do we need to satisfy before depriving a patient of their rights?

Is it ethical to coerce potential patients into refusing transport when the person does want transport and/or treatment?

Is it ethical to coerce potential patients into going to the hospital when the person does not want transport and/or treatment.

Is it ethical to refuse to honor a DNR (Do Not Resuscitate) order just because it is not an original DNR (or just because it is not an Out Of Hospital DNR in Pennsylvania)?

Is it ethical to honor a Living Will, when protocols state that EMS may not honor any document that is not an original DNR?

Is it ethical to require EMS to violate a DNR/Living Will/Advance Directive while contacting medical command for permission to honor the wishes of the patient/designated decision maker?

Is it ethical to prevent a patient from taking a sip of water, drinking a cup of water, smoking a cigarette, or anything else that we are told we must prohibit?

Is it ethical to follow orders to withhold pain medicine just because medical command refuses to give an order for pain medicine?

Is it ethical to follow orders to limit pain medicine just because medical command refuses to give an order for more pain medicine?

What is coercion?

Is it ethical for medical directors to coerce unethical behavior from EMS?

Is it ethical for anyone in the chain of command to coerce unethical behavior from EMS?

Is it ethical for any agency to coerce a medical director into authorizing dangerous paramedics to treat patients?

And plenty more . . .

What do you think?

Based on what?

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Comment on Is EMS Research Provincial by Dr. Russi

Also posted over at Paramedicine 101. Go check out the rest of what is posted there.

In response to Is EMS Research Provincial is this comment by Christopher S Russi

I am one of the co-hosts from a new podcast called Standing Orders (emsstandingorders.com) and I am the associate director for prehospital research at the Mayo Clinic.

The Standing Orders podcast looks sounds great. Only one episode, so far, but on a very important, too often ignored, topic – Sepsis.

We may think that we do not see much sepsis, or that we may not have much of an ability to affect the outcomes of septic patients, but their debut podcast should change our minds. Go listen.

I will write some more about the sepsis podcast. I look forward to more great podcasts from everyone at Standing Orders.

While I haven’t heard the entire podcast by Dr. Wesley, what you posted needs clarification. To answer your question about location of research and validity, it depends.

There are a few types of validity. Likely what Dr. Wesley is referring to is called external validity. Better understood in this way: can what was done via the methods be replicated in my current situation / system? Further, you have to understand the population where the intervention was delivered and the inclusion / exclusion criteria used for the subjects. As you can imagine, it is imperative that you read the methods section with a critical eye and consider the confounding variables taken or not taken into account.

These are important points and critical to understanding all research.

So while the location of the research has to be taken into consideration for comparison with your own environment, it does not mean that it serves as a litmus for throwing away data or considering it useless.

Exactly. While there may be important differences between the way EMS is provided in the US versus another country, there are plenty of differences even among the ways EMS is delivered in the US.

A well done study done in another country may be designed and carried out much better than similar studies done in the US.

I think that is part of what Dr. Wesley was getting at, just expressing it in passing during a podcast that covered a lot of different aspects of how to read EMS research. Reading EMS Research: EMS Research Episode 3

I am much more interested in the way the research was done, than I am in where the research was done. Sometimes the different levels of providers, in other places, can help us to learn something about the way EMS might be improved by better educating our providers, or the claims that doctors would not be able to intubate as well as paramedics, if they were working in the same environment.

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