“Where’s the evidence?”
Every so often you have one of those moments as an educator where you say “Wow, someone really gets it!” I had one of those moments today and I think it reflects the ways in which we’re trying to create of next generation of paramedics who not only can do great care but also think very hard about how and why they do that great care.
We’re emphasizing thoughtful paramedicine in our paramedic program with the idea of nurturing excellent clinical judgment and so in the first week of class I presented one of my favorite topics, evidence based medicine and using the literature in EMS. The primary focus of this seminar is on understanding the basic principles of evidence-based medicine (ask a question, query the literature, critique the literature, and integrate the evidence with your experience into your practice of EMS). We also discuss some basic statistics (the only number you need to know is “5”) and describe the various types of manuscripts published in the EMS literature.
As part of our work to develop critical thinking skills, we are also introducing Enquiry Based Learning (EBL) and, more specifically, Problem Based Learning (PBL) into our curriculum. Although this practice is common in other fields of medical education, it’s pretty new in EMS and so today I ran a demonstration PBL for the class. For those of you who aren’t familiar with PBLs, our approach is basically to develop a clinical scenario broken into lots of little sections and after a small group reads each section, the participants come up with a list of things they don’t know about the content of that section, ask questions, assign the questions to the participants, and then the group separates, and each person researches his or her question. The group then comes back together and presents the answers to the questions. Highly effective and a great way to not only learn how to know what you don’t know but also how to learn the things you realize you don’t know. Since this was a demonstration, we ran through the scenario and then I answered the questions as if I were all of the participants (one of the advantages of writing the case is you know all the answers).
So anyway. The case was a cardiac arrest and one of the sections described the induction of therapeutic hypothermia (TH) upon arrival in the emergency department. The group realized it didn’t know much about TH and so that became one of the questions. When I subsequently answered the question, the discussion then arose about prehospital induction and, since it was an opportunity to do some teaching, we talked about that as well.
Rapidly approaching me was a “wow” moment. I’m talking about the current state of the prehospital TH induction literature and what it takes to get TH done in an ambulance when one of the students looks at me and says…
”If the evidence supports starting it before 8 hours, where is the evidence that starting it even sooner is better?”
OK, it’s probably pretty obvious to anyone who has taken care of a post-resuscitation patient in the back of an ambulance that you’re kind of, you know, BUSY and one more task load is painful to consider if it doesn’t actually make a difference. But “Where’s the evidence?!?”
Now, when I went through my paramedic class in ’93-94, we would never have asked that question. First of all, what we were learning was from the national standard curriculum and was therefore clearly the gospel of EMS and second, and perhaps more importantly, we never really considered that you could question the source of what you were being taught and that you could wonder if an intervention had actually been shown to make a difference.
But this is exactly what we’re trying to foster in our class and frankly in our state. EMS has advanced to the point that we need to, as a practice of medicine, really start figuring out what it is that we don’t know. Many of our practices are not based on evidence from any studies, let alone EMS studies. The true EMS research literature is thin (but rapidly growing).
Some EMS providers rely on their protocols to absolutely guide care; unfortunately, the complexity of our assessment and intervention tools and skills are now approaching the complexity of our patients and our ability to really, really hurt people with what we do has never been higher. Protocols alone do not provide the “protocol medic” with the ability to really care for these patients. For example. knowing that furosemide does not provide an immediate benefit in acute CHF, that it is only useful in the 50% of patients in acute CHF who are actually total body fluid overloaded, and that it dramatically increases mortality in the two big mimics of CHF (COPD exacerbation and Pneumonia / Pulmonary Sepsis), the thinking medic will elect not to push this medication until it is absolutely clear that the patient is in cardiogenic pulmonary edema and is total body fluid overloaded. The “protocol medic” however may say “Hmm, my ‘Respiratory Distress’ protocol says I can give lasix nitro, CPAP, Duonebs, and methylprednisolone to this patient. I think I’ll do all of them since I’m not sure what’s going on” with little benefit to anyone from the furosemide and the potential for significant harm to many patients.
Conversely, we also have the ability to do great good for our most ill patients. Being able to diagnose an ST elevation MI (STEMI) in the field, pre-activate the cath lab, and get the patient into cardiac catheterization sooner does reduce mortality. Being able to provide non-invasive ventilation to patients with acute cardiogenic pulmonary edema (CHF) does improve outcomes. But we wouldn’t have these tools if a dedicated (rabidly fanatical?) cadre of field personnel, physicians, and researches hadn’t questioned the basic principles of traditional EMS techniques.
Getting back to the “wow” moment, it was really great to have a student look at me as I talked about exciting potential visions of the future and jerk me back to earth with “Where’s the evidence?” We do need to look to the future but we also need to make sure that what we do lets us perform our fundamental life stabilizing skills in ways that we know make a difference without burying us in care that may not make a difference at all. Therefore, to all of you providers out there who ask every day “Can we do this better?” I give you my utmost support and appreciation. To those answering that question, we, and even more importantly, our patients, owe you an immeasurable debt.
Stay safe, ask questions, and remember, we help people.