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The Good, The Bad & The Ugly of EMS Research. Definitions Research: careful, systematic, patient study and investigation in some field of knowledge, undertaken.

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Presentation on theme: "The Good, The Bad & The Ugly of EMS Research. Definitions Research: careful, systematic, patient study and investigation in some field of knowledge, undertaken."— Presentation transcript:

1 The Good, The Bad & The Ugly of EMS Research

2 Definitions Research: careful, systematic, patient study and investigation in some field of knowledge, undertaken to discover or establish facts or principles.

3 Definitions Science: The state or fact of knowing; knowledge. Systematized knowledge derived from observation, study, and experimentation carried on in order to determine the nature or principles of what is being studied. Science: The state or fact of knowing; knowledge. Systematized knowledge derived from observation, study, and experimentation carried on in order to determine the nature or principles of what is being studied.

4 Is EMS Art or Science? The knowledge of EMS is science. The way it is applied is art. Excellent EMTs know the science of EMS and use the art of EMS to apply the science.

5 Art or Science? Some health practices are more about art than science. Chiropractic, for example, has little science and a lot of art. Some health practices are more about art than science. Chiropractic, for example, has little science and a lot of art.

6 Art or Science? Neurology today has a great deal of science and little art.

7 Art or Science? When you have a life threatening illness or injury, would you seek out a health care provider whose practice was more art or more science?

8 Art or Science? EMS is the safety net of society. We are often the first to provide care to the injured and the infirm. Our practices must be based on science.

9 But we must apply them with art!

10 Research Most medical research is based on the application of the scientific method.

11 The Scientific Method The scientific method is the process by which scientists, collectively and over time, endeavor to construct an accurate (that is, reliable, consistent and non-arbitrary) representation of the world.

12 The Scientific Method Steps: 1.Observe some aspect of the universe 2.Invent a tentative description, called a hypothesis, that is consistent with what you observed. 3.Use the hypothesis to make predictions. 4.Test those predictions by experiments or further observation and modify the hypothesis in the light of your results. 5.Repeat steps 3 and 4 until there are no discrepancies between theory and experiment and/or observation. Steps: 1.Observe some aspect of the universe 2.Invent a tentative description, called a hypothesis, that is consistent with what you observed. 3.Use the hypothesis to make predictions. 4.Test those predictions by experiments or further observation and modify the hypothesis in the light of your results. 5.Repeat steps 3 and 4 until there are no discrepancies between theory and experiment and/or observation.

13 The Scientific Method Hypothesis: groundwork, foundation supposition; an unproven theory.

14 The Scientific Method

15 The great advantage of the scientific method is that it is unprejudiced: One does not have to believe a given researcher, one can redo the experiment and determine whether his or her results are true or false. The conclusions will hold irrespective of the state of mind, or the religious persuasion, or the state of consciousness of the investigator and/or the subject of the investigation. Faith, defined as a belief that is not based on logical proof or material evidence, does not determine whether a scientific theory is adopted or discarded. The great advantage of the scientific method is that it is unprejudiced: One does not have to believe a given researcher, one can redo the experiment and determine whether his or her results are true or false. The conclusions will hold irrespective of the state of mind, or the religious persuasion, or the state of consciousness of the investigator and/or the subject of the investigation. Faith, defined as a belief that is not based on logical proof or material evidence, does not determine whether a scientific theory is adopted or discarded.

16 The Scientific Method A theory is accepted not based on the prestige or convincing powers of the proponent, but on the results obtained through observations and/or experiments which anyone can reproduce. The results obtained using the scientific method are repeatable. A theory is accepted not based on the prestige or convincing powers of the proponent, but on the results obtained through observations and/or experiments which anyone can reproduce. The results obtained using the scientific method are repeatable.

17 The Scientific Method There are many types of “pseudoscientific” theories which seem based on a mantle of apparent experimental evidence but that, when examined closely, are nothing but statements of faith.

18 The Scientific Method “Faith is believing what you know ain’t so.” Mark Twain, 1894 “Following the Equator”

19 Science versus Pseudoscience How to tell the difference: Anecdotes do not make a science. Scientific language does not make a science. Bold statements do not make claims true. Heresy does not equal correctness. Reversal of the burden of proof. Rumors do not equal reality. How to tell the difference: Anecdotes do not make a science. Scientific language does not make a science. Bold statements do not make claims true. Heresy does not equal correctness. Reversal of the burden of proof. Rumors do not equal reality.

20 Science versus Pseudoscience How to tell the difference: Failures are rationalized. Use of emotive words and false analogies. Ad ignorantiam reasoning (if you can’t disprove a claim, it must be true). Ad hominem or tu quoque statements. Overreliance on authorities. Circular reasoning. Reductio ad absurdum reasoning. How to tell the difference: Failures are rationalized. Use of emotive words and false analogies. Ad ignorantiam reasoning (if you can’t disprove a claim, it must be true). Ad hominem or tu quoque statements. Overreliance on authorities. Circular reasoning. Reductio ad absurdum reasoning.

21 The Scientific Method Enzyte has to work….after all, Bob is smiling!

22 The Scientific Method

23 Pseudoscience is still a major part of our culture. Many practitioners resort to pseudoscience and other anecdotal practices.

24 The Scientific Method Typically uses terms and images to appear “scientific”.

25 The Scientific Method Reliance on “names” and anecdotes. Dr. Greg Cynaumon? Physician? Psychologist? Nutritionist? Chiropractor? Master’s and Doctorate in psychology from Sierra University (known diploma mill).

26 The Scientific Method No clinical evidence CortiSlim works. No information about contents (natural or herbal). Dr. Talcott fringe nutritionist with loose affiliations with University of Utah. One of the largest scams in recent history. FDA issued a cease and desist order and fined Talbot and Cynamoun. No clinical evidence CortiSlim works. No information about contents (natural or herbal). Dr. Talcott fringe nutritionist with loose affiliations with University of Utah. One of the largest scams in recent history. FDA issued a cease and desist order and fined Talbot and Cynamoun.

27 Use of the Scientific Method in EMS Observation: During a discussion you and your coworkers bring up the idea that there are more psychiatric emergencies when the moon is full. Hypothesis: Psychiatric emergencies are more common when the lunar cycle is in the full moon phase. Observation: During a discussion you and your coworkers bring up the idea that there are more psychiatric emergencies when the moon is full. Hypothesis: Psychiatric emergencies are more common when the lunar cycle is in the full moon phase.

28 Use of the Scientific Method in EMS Prediction: You predict that there will be more EMS calls for psychiatric emergencies when the moon is full as compared to other times of the month.

29 Use of the Scientific Method in EMS Testing: You set up an experimental protocol to test your hypothesis. For this you: Determine you will conduct the study for a year. Determine when a full moon is scheduled to appear. Determine that you will declare two days before and two days after the full moon a five- day “full moon period.” Testing: You set up an experimental protocol to test your hypothesis. For this you: Determine you will conduct the study for a year. Determine when a full moon is scheduled to appear. Determine that you will declare two days before and two days after the full moon a five- day “full moon period.”

30 Use of the Scientific Method in EMS For this you: Define what a psychiatric emergency will be. Gather information over the course of the year that includes the date of all psychiatric emergency patients. When the data has been gathered for the period previously determined, you determine: 1. How many psychiatric patients were there? 2. How many were treated during the full moon periods? For this you: Define what a psychiatric emergency will be. Gather information over the course of the year that includes the date of all psychiatric emergency patients. When the data has been gathered for the period previously determined, you determine: 1. How many psychiatric patients were there? 2. How many were treated during the full moon periods?

31 Use of the Scientific Method in EMS For this you: Analyze the data based on the number of emergencies that arose during full moon periods and compare to the number of emergencies during the other periods. Perform any statistical tests necessary to understand the data. For this you: Analyze the data based on the number of emergencies that arose during full moon periods and compare to the number of emergencies during the other periods. Perform any statistical tests necessary to understand the data.

32 Use of the Scientific Method in EMS Results: Full Moon Period Days=65 Other Period Days = 300 Total Days = 365 Ψ patients = 10 Ψ patients = 74 Total Ψ patients = 84 Total Patients = 2,105 Total Patients = 9,300 Total Patients = 11,315

33 Use of the Scientific Method in EMS Results: Your study finds: During full moon period 0.5% of patients were Ψ patients. During other period 0.8% of patients were Ψ patients. During the entire study period 0.7% of patients were Ψ patients. Results: Your study finds: During full moon period 0.5% of patients were Ψ patients. During other period 0.8% of patients were Ψ patients. During the entire study period 0.7% of patients were Ψ patients.

34 Use of the Scientific Method in EMS Results: Your study finds: The incidence of Ψ patients during the full moon period was 0.15 patients per day. The incidence of Ψ patients during the other moon phases was 0.25 patients per day. The incidence of Ψ patients overall was 0.23 patients per day. Results: Your study finds: The incidence of Ψ patients during the full moon period was 0.15 patients per day. The incidence of Ψ patients during the other moon phases was 0.25 patients per day. The incidence of Ψ patients overall was 0.23 patients per day.

35 Use of the Scientific Method in EMS Psych patients are less common during the full moon. HYPOTHESIS DISSPROVED! Psych patients are less common during the full moon. HYPOTHESIS DISSPROVED!

36 Use of the Scientific Method in EMS Revise hypothesis: New hypothesis: Psychiatric emergencies are no more frequent during full moon lunar phases than during other lunar phases. HYPOTHESIS ACCURATE. Report findings. Paper should be detailed enough that anybody can follow it and repeat your experiment. Repeat study to determine whether findings can be repeated. Revise hypothesis: New hypothesis: Psychiatric emergencies are no more frequent during full moon lunar phases than during other lunar phases. HYPOTHESIS ACCURATE. Report findings. Paper should be detailed enough that anybody can follow it and repeat your experiment. Repeat study to determine whether findings can be repeated.

37 EMS Research The more valid a study, the closer it is to the truth!

38 EMS Research Bias: A mental leaning or inclination; partiality; prejudice; bent. The more a study design adheres to the scientific method, the less chance for bias to affect the outcomes. Bias: A mental leaning or inclination; partiality; prejudice; bent. The more a study design adheres to the scientific method, the less chance for bias to affect the outcomes.

39 EMS Research Types of biases: Selection bias Volunteer bias (tends to favor the treatment group) Nonrespondent bias Group not homogeneous Measurement bias Instrument bias Insensitive measure bias Expectation bias Recall bias (people remember positive events rather than negative events) Attention bias (aware of participation) Types of biases: Selection bias Volunteer bias (tends to favor the treatment group) Nonrespondent bias Group not homogeneous Measurement bias Instrument bias Insensitive measure bias Expectation bias Recall bias (people remember positive events rather than negative events) Attention bias (aware of participation)

40 EMS Research Types of biases: Intervention bias Contamination bias Compliance bias Withdrawal bias Proficiency bias Publication bias Cherry picking (mainly retrospective studies) Trashcan bias Types of biases: Intervention bias Contamination bias Compliance bias Withdrawal bias Proficiency bias Publication bias Cherry picking (mainly retrospective studies) Trashcan bias

41 EMS Research Avoiding bias: Randomize subjects Prospective design Blind subjects and researchers Contract to publish irregardless of findings Admit conflicts of interest Use null hypothesis Avoiding bias: Randomize subjects Prospective design Blind subjects and researchers Contract to publish irregardless of findings Admit conflicts of interest Use null hypothesis

42 EMS Research Bias (sometimes flat deception) has been a common practice in medicine and EMS. Quackery and bias still permeates many aspects of modern healthcare.

43 EMS Research Validity: Whether the study measures what it was supposed to measure. Validity refers to the appropriateness of the interpretation of the results of a study. External Validity: The extent and appropriateness of the generalizability of results. Internal Validity: The basic minimum control, measure, analysis and procedures necessary to make results interpretable. Validity: Whether the study measures what it was supposed to measure. Validity refers to the appropriateness of the interpretation of the results of a study. External Validity: The extent and appropriateness of the generalizability of results. Internal Validity: The basic minimum control, measure, analysis and procedures necessary to make results interpretable.

44 EMS Research Constant: A characteristic or condition that is the same for all individuals in a study. Variable: A characteristic that takes on different values or conditions for different individuals. Dependent Variable: the variable being affected or assumed to be affected my the independent variable. Independent Variables: the variables that affects (or is assumed to affect) the dependent variable under study. Experimental Variable: at least one independent variable being manipulated by the researcher. Constant: A characteristic or condition that is the same for all individuals in a study. Variable: A characteristic that takes on different values or conditions for different individuals. Dependent Variable: the variable being affected or assumed to be affected my the independent variable. Independent Variables: the variables that affects (or is assumed to affect) the dependent variable under study. Experimental Variable: at least one independent variable being manipulated by the researcher.

45 Levels of Evidence

46 Center for Evidence-Based Medicine (Oxford) Ia. Meta-analysis of RCTs Ib. One RCT. IIa. Controlled trial without randomisation. IIb. One other type of quasi-experimental study. III. Descriptive studies, such as comparative studies, correlation studies, and case-control studies. IV. Expert committee reports or opinions, or clinical experience of respected authorities or both. Center for Evidence-Based Medicine (Oxford) Ia. Meta-analysis of RCTs Ib. One RCT. IIa. Controlled trial without randomisation. IIb. One other type of quasi-experimental study. III. Descriptive studies, such as comparative studies, correlation studies, and case-control studies. IV. Expert committee reports or opinions, or clinical experience of respected authorities or both.

47 Levels of Evidence American Heart Association 1. Positive randomized controlled trials. 2. Neutral randomized controlled trials. 3. Prospective, non-randomized controlled trials. 4. Retrospective, non-randomized controlled trials 5. Case series (no control group) 6. Animal studies 7. Extrapolations 8. Rational conjecture (common sense) American Heart Association 1. Positive randomized controlled trials. 2. Neutral randomized controlled trials. 3. Prospective, non-randomized controlled trials. 4. Retrospective, non-randomized controlled trials 5. Case series (no control group) 6. Animal studies 7. Extrapolations 8. Rational conjecture (common sense)

48 Study Designs Randomized Controlled Trial (RCT): A group of patients are randomized into an experimental group and a control group. These groups are followed up for the variables/outcomes of interest. RCTs most closely approximate the scientific method and are the most valid of studies. Randomized Controlled Trial (RCT): A group of patients are randomized into an experimental group and a control group. These groups are followed up for the variables/outcomes of interest. RCTs most closely approximate the scientific method and are the most valid of studies.

49 Randomized Controlled Trial

50 EMS Research Houston MAST Study: Constant: All patients with abdominal trauma with hypotension transported by the HFD to Ben Taub Hospital. Dependent Variable: survival from trauma. Independent Variables: age, sex, location of injury, transport time, etc. Experimental Variable: Application or non- application of the MAST. Houston MAST Study: Constant: All patients with abdominal trauma with hypotension transported by the HFD to Ben Taub Hospital. Dependent Variable: survival from trauma. Independent Variables: age, sex, location of injury, transport time, etc. Experimental Variable: Application or non- application of the MAST.

51 Example Mattox KL, Bickell B, Pepe PE, Burch J, Feliciano D. Prospective MAST study in 911 patients. J. Trauma. 1989;29:1104-12 911 trauma patients > 15 years of age with systolic BP < 90 mmHg were randomized by alternate day assignment. All transported by HFD to Ben Taub hospital trauma center. Experimental variable: MAST or no-MAST Dependent variable: survival from trauma Mattox KL, Bickell B, Pepe PE, Burch J, Feliciano D. Prospective MAST study in 911 patients. J. Trauma. 1989;29:1104-12 911 trauma patients > 15 years of age with systolic BP < 90 mmHg were randomized by alternate day assignment. All transported by HFD to Ben Taub hospital trauma center. Experimental variable: MAST or no-MAST Dependent variable: survival from trauma

52 Example Independent variables: etiology, age, race, sex, location of injury, trauma scores, injury severity scores. Scores revealed the two groups to be statistically identically matched. Findings: Mortality rate 31% in the MAST group and 25% in the non-MAST group. Difference statistically significant. Independent variables: etiology, age, race, sex, location of injury, trauma scores, injury severity scores. Scores revealed the two groups to be statistically identically matched. Findings: Mortality rate 31% in the MAST group and 25% in the non-MAST group. Difference statistically significant.

53 Double Blind Study

54 A double blind study is one in which neither the patient nor the physician knows whether the patient is receiving the treatment of interest or the control treatment. It is a type of RCT. A double blind study is one in which neither the patient nor the physician knows whether the patient is receiving the treatment of interest or the control treatment. It is a type of RCT.

55 Double Blind Study

56 Bracken MB, Shephard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. NEJM 1990;322(20):1405-11 Patients with spinal cord injury randomized by computer to receive methyprednisolone, naloxone, or placebo. Researchers and patients did not know which drug was which (prepared in pharmacy) Bracken MB, Shephard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. NEJM 1990;322(20):1405-11 Patients with spinal cord injury randomized by computer to receive methyprednisolone, naloxone, or placebo. Researchers and patients did not know which drug was which (prepared in pharmacy)

57 Quasi-Experimental Studies Quasi-experimental studies use intact groups of subjects rather than assigning subjects to groups at random.

58 Quasi-Experimental Studies Non-randomized controlled trial: 1 group receives intervention 1 group receives no-intervention (control) Subjects assigned to groups by methods other than randomization. Non-randomized controlled trial: 1 group receives intervention 1 group receives no-intervention (control) Subjects assigned to groups by methods other than randomization.

59 Cohort Studies A Cohort Study is a study in which patients who presently have a certain condition and/or receive a particular treatment are followed over time and compared with another group who are not affected by the condition under investigation.

60 Cohort Study

61 Cohort Studies Framingham Heart Study: People in Framingham, MA have been followed for over 50 years. Conducted by National Heart, Lung, and Blood Institute (NHLBI) and Boston University. 5,209 residents between 30 and 60 years of age initially enrolled. In 1971, 5,124 children (and their spouses) of the original cohort added. 500 minority members have been added. Framingham Heart Study: People in Framingham, MA have been followed for over 50 years. Conducted by National Heart, Lung, and Blood Institute (NHLBI) and Boston University. 5,209 residents between 30 and 60 years of age initially enrolled. In 1971, 5,124 children (and their spouses) of the original cohort added. 500 minority members have been added.

62 Cohort Studies Framingham Heart Study: Every two to four years, study participants are given extensive medical examinations including a medical history, blood tests and other sophisticated tests such as bone scans, eye exams and echocardiograms assessing multiple aspects of their current health status. Framingham Heart Study: Every two to four years, study participants are given extensive medical examinations including a medical history, blood tests and other sophisticated tests such as bone scans, eye exams and echocardiograms assessing multiple aspects of their current health status.

63 Cohort Studies Framingham Heart Study (results): Risk factors for heart disease identified. Better understanding of the effects of lifestyle. More than 1,000 papers published significantly adding to the knowledge base of heart disease. Study continues…. Framingham Heart Study (results): Risk factors for heart disease identified. Better understanding of the effects of lifestyle. More than 1,000 papers published significantly adding to the knowledge base of heart disease. Study continues….

64 Case-Control Studies Case Control Studies: Case control studies are studies in which patients who already have a certain condition are compared with people who do not.

65 Case-Control Studies

66 Case Series A case series is a report on a series of patients with an outcome of interest. No control group is involved.

67 Case Report A case report is a narrative report of an interesting case.

68 Historical Studies Historical studies are systematized searches for the facts and then using the information to describe, analyze, and interpret the past.

69 Historical Studies Bledsoe BE, Smith MG. Medical Helicopter Accidents in the United States: A 10-Year Review. J Trauma. 2004;56:1325-1329

70 Historical Studies Methods:Review of all air medical helicopter accidents in the US from 1997- 2002 from the NTSB database.

71

72

73

74 Systematic Reviews A summary of the medical literature that uses explicit methods to systematically search, critically appraise, and synthesize the world literature on a specific issue.

75 Systematic Reviews Bledsoe BE. Critical Incident Stress Management (CISM): Benefit or Risk for Emergency Services? Prehosp Emerg Care. 2003;7:272-279

76 Meta-Analysis A meta-analysis is a systematic review that uses quantitative methods to summarize the results.

77 Meta-Analysis

78 Meta-analysis of RCTs represents the highest level of scientific evidence. Allows for more objective appraisal of the evidence. Reduces the possibility of false negative results. Meta-analysis of RCTs represents the highest level of scientific evidence. Allows for more objective appraisal of the evidence. Reduces the possibility of false negative results.

79 Meta-Analysis van Emmerik AAP, Kamphuis JH, Hulsbosch AM, Emmelkamp PMG. Single-session debriefing after psychological trauma: a meta-analysis. Lancet. 2002;360:766-771

80 Meta-Analysis

81 Meta-Analysis (Observational Studies) Less valid than RCTs. Still valid in that it gives better information of the population as a whole. Many EMS interventions cannot be tested with an RCT as it might be unethical to withhold care from the control group. Less valid than RCTs. Still valid in that it gives better information of the population as a whole. Many EMS interventions cannot be tested with an RCT as it might be unethical to withhold care from the control group.

82 Meta-Analysis (Observational Studies) Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF. Helicopter transport of trauma patients: a meta-analysis. J Trauma. 2006;60:1257-1266 Observational meta-analysis examining validated trauma scoring systems in trauma patients transported from the scene to a trauma center. Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF. Helicopter transport of trauma patients: a meta-analysis. J Trauma. 2006;60:1257-1266 Observational meta-analysis examining validated trauma scoring systems in trauma patients transported from the scene to a trauma center.

83

84 Meta-Analysis (Observational Studies) Conclusions: 2 out of 3 trauma patients transported from the scene to a trauma center have minor injuries based on validated trauma scoring criteria. 1 out of 4 patients transported are discharged from the emergency department. Conclusions: 2 out of 3 trauma patients transported from the scene to a trauma center have minor injuries based on validated trauma scoring criteria. 1 out of 4 patients transported are discharged from the emergency department.

85 Animal Studies Animal studies provide insight into biology. For ethical reasons, some studies cannot be carried out on humans. Computer modeling are replacing many animal studies. Animal studies provide insight into biology. For ethical reasons, some studies cannot be carried out on humans. Computer modeling are replacing many animal studies.

86 Expert Opinion Expert opinions can take various forms: Systematic reviews Narrative reviews Pure opinion pieces Expert opinions can take various forms: Systematic reviews Narrative reviews Pure opinion pieces

87

88 Rational Conjecture Lowest level of scientific validity. But, overall very important. “You don’t have to run a Chi-Square test on common sense”

89

90 Journals Not all journals are the same. Impact rating: Cites Articles Readership Not all journals are the same. Impact rating: Cites Articles Readership

91 Journals Journal Impact Rating (2005) NEJM44.016 Lancet23.407 JAMA23.332 Circulation11.632 BMJ9.052 Crit Care Med 5.077 Ann Emerg Med 2.782 Acad Emerg Med 1.789 J Trauma 1.722

92 Statistics Statistics are essential to any scientific analysis to eliminate bias and chance. “Torture numbers and they’ll confess to anything.” (Gregg Easterbrook) “Satan delights equally in statistics and in quoting scripture.... ” (H.G. Wells) “The average human has one breast and one testicle.” (Des McHale) Statistics are essential to any scientific analysis to eliminate bias and chance. “Torture numbers and they’ll confess to anything.” (Gregg Easterbrook) “Satan delights equally in statistics and in quoting scripture.... ” (H.G. Wells) “The average human has one breast and one testicle.” (Des McHale)

93 Summary EMS must be driven by science. Science is based upon quality research. EMS providers of the future must be able to understand, and in certain cases, conduct valid research. EMS must be driven by science. Science is based upon quality research. EMS providers of the future must be able to understand, and in certain cases, conduct valid research.

94 Summary Break Time

95 Good Gaucshe M, Lewis RJ, StrattonSJ, et al. Effect of Out-of- Hospital Pediatric Intubation on Survival and Neurologic Outcome: A Clinical Trial. JAMA. 2000;283:783-790

96 Good Methodology: RCT Randomization: By calendar day. Journal: JAMA Participants: 830 consecutive patients  12 years and weight < 40 kg Interventions: BVM only (odd days) N= 410 BVM then ETI (even days) N= 420 Methodology: RCT Randomization: By calendar day. Journal: JAMA Participants: 830 consecutive patients  12 years and weight < 40 kg Interventions: BVM only (odd days) N= 410 BVM then ETI (even days) N= 420 Outcome Measures: Survival to discharge Neurologic status at discharge Results: No improvement in survival or neurological outcome in either group.

97 Bad Timmerman S, Cardoso LF, Ramires JAF, Halperin H. Improved Hemodynamic Performance with a Novel Chest Compression Device During Treatment of in- hospital Cardiac Arrest. Resusc. 2004;61:273- 280

98 Bad Methodology: Case series Randomization: None. Journal: Resuscitation Participants: 31 terminally-ill, fresh dead Brazilians who failed 10 minutes of ACLS. Age 68  10 years Interventions: Swan-Ganz catheters placed Methodology: Case series Randomization: None. Journal: Resuscitation Participants: 31 terminally-ill, fresh dead Brazilians who failed 10 minutes of ACLS. Age 68  10 years Interventions: Swan-Ganz catheters placed Interventions: 90 seconds A-CPR (60 compressions / minute) followed by manual CPR (100 compressions / minute). No ventilations Subjects then intubated. Ventilated (12 / minute) Epinephrine given

99 Bad Outcome Measures: CPP MAP Results: Usable blood pressures obtained in 16/31 patients (52%) Rosary or wake interrupted (25%) CPP: A-CPR: 20  12 M-CPR: 15  11 Outcome Measures: CPP MAP Results: Usable blood pressures obtained in 16/31 patients (52%) Rosary or wake interrupted (25%) CPP: A-CPR: 20  12 M-CPR: 15  11 PAP: A-CPR: 115  42 M-CPR: 153  28 Results: Increased CPP is related to increased chances of resuscitation. A-CPR improved CPP.

100 Ugly Everly GS, Flannery RB, Eyler V A. Critical Incident Stress Management (CISM): A Statistical Review of the Literature. Psych Quart. 2002;73:171- 182

101 Ugly Methodology: Meta- analysis? Randomization: None. Journal: Participants: Meta- analysis of 8 CISM investigations. Evaluation: Results pooled and Cohen’s d calculated Methodology: Meta- analysis? Randomization: None. Journal: Participants: Meta- analysis of 8 CISM investigations. Evaluation: Results pooled and Cohen’s d calculated Results: Significant effect size (Cohen’s d) of 3.11 showing a beneficial outcome from CISM. You can’t obtain a Cohen’s d without a control group!

102 Ugly STUDYCISMMEASURESPROBLEM Busuttil (1995)Used CISM to treat PTSD in British Air Force personnel. PTSD ScaleCISM is not a treatment for PTSD Flannery (1995)ASAPAssaults Questionnaire No mention of CISM in paper Flannery (1998)ASAPAssaults Questionnaire No mention of CISM in paper Flannery (1999)ASAPAssaults Questionnaire No mention of CISM in paper Richards (1999)Debriefing following bank robbery in NSW IESCISM provided at 10 0r 24 hours Mitchell (2000)CISM provided for volunteer firefighters with PTSD 3 years after a tornado Diagnostic interviewsCISM is not a treatment for PTSD Flannery (2000)ASAPAssaultsNo mention of CISM in paper Flannery (2000)ASAPAssaultsCISM mentioned

103 Good Wang HE, Kupas DF, Hostler D, Cooney R, Yealey DM, Lave JR. Procedural Experience with out- of-hospital endotrachela intubation. Crit Care Med. 2005;33:

104 Good Methodology: Analysis of administrative database Randomization: None Journal: Critical Care Medicine Participants: Records: 1,544,791 11,484 ETIs by 5,245 rescuers. Methodology: Analysis of administrative database Randomization: None Journal: Critical Care Medicine Participants: Records: 1,544,791 11,484 ETIs by 5,245 rescuers. Outcome Measures: Of 5,245 rescuers: 67% performed  2 ETIs. 39% performed 0 ETIs/ Mean ETIs = 1 Results: Out-of-hospital intubation is an uncommon event.

105 Bad Amatangelo M, Thomas SH, Harrison T, Wedel SK. Analysis of Patients Discharged from Receiving Hospitals within 24 Hours of Air Medical Transport. Air Med J. 1997;16:44-14

106 Bad Methodology: Retrospective review of flight records Randomization: None Journal: Air Medical Journal Participants: 945 flights 42 (4.4%) discharged less than 24 hours of transport. Methodology: Retrospective review of flight records Randomization: None Journal: Air Medical Journal Participants: 945 flights 42 (4.4%) discharged less than 24 hours of transport. Results: Patients met air transport criteria. A priori

107 Ugly Ohshige K, Kawakami C, Kubota K, Tochikubo O. A contingent valuation study of the appropriate user price for ambulance service. Acad Emerg Med. 2005;12:932-940

108 Ugly Methodology: Questionnaire survey Randomization: None Journal: Academic Emergency Medicine Participants: 3,363 ambulance service customers sent survey. 2,029 (60.3%) returned survey. Methodology: Questionnaire survey Randomization: None Journal: Academic Emergency Medicine Participants: 3,363 ambulance service customers sent survey. 2,029 (60.3%) returned survey. Results: Public inelastic (not concerned) about cost of ambulance service when case is an emergency. Public fairly elastic about price in nonserious situations. Thus, a ¥ 20,000 (US$ 190.00) user fee will reduce the number of nonemergency calls.


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