Studies
This is where the guiding hand of experience comes in handy, hence my questions.
I may have a few years on the road but I can make no claim to being a good researcher regardless of my on-road experience. I have read plenty of papers but I can't honestly say I have dug into the archives in a while to find them myself. Fortunately there a plenty of MICA types who are good researchers and have seen fit to share their efforts around the branches.
Also, regardless of the the amount of literature you read, it's very hard for an undergrad to gauge the state of the art, or the academic environment with which the articles should be contextualized. The effect that particular papers have had on the field, is a good example. Which are more important than the others, which are taken more seriously, how they have changed thinking, to what extent they have changed thinking and how long it took.
In pre-hospital (actual work in service) it is no easier to gauge prevailing consensus if in fact there is one on any given subject. This has always been part of the problem. Papers say one thing but front up to an Ed and more often than not you will see ED types doing one thing, ICU types going a different track and surgeons locked into their own habitat. It's certainly my experience to see aggressive fluid resus on trauma pts from ED docs often in situations where I believed the evidence said to do something else.
The reality is you do your update days at school and absorb the attached rationales and facts. When a new guideline is introduced it often also comes with background referencing but you have enough on your plate just digesting and memorising the new guideline and using it as well as reading all the attached notes and explanations. It doesn't mean you just parrot your practice to the cookbook recipe of the CPG but time constraints and other priorities demand your attention as well.
All of that is next to impossible without the wisdom and benefit of experience in the field.
It's not so clear cut. I have to follow the guidelines that have been established by our medical directors after their own interpretation and consensus on the evidence. But even this can vary from service to service, state to state. There are some general agreements and fluids in penetrating trauma is not a bad example. Even then however the ED docs at trauma centres like the Alfred will still infuse volume expander's supplemented by blood products for such patients whilst the surgeons/anesthetists will pour in Aramine for BP management on the table during ops despite this being a serious no-no in the field (based on pre-hospital evidence). Qualification comes in when you consider the component of the health system where such approaches apply. Certain studies may well look at ED management of problems and have no regard for the pre-hospital component. Other studies again may seem to be directed toward pre-hospital but look at outcomes or findings after the interventions of the ED, surgical and ICU areas with just the starting point of pre-hospital considered. So the study may not be relevant to evidence that will change pre-hospital practice.
The point is I guess when looking for the studies isolate those that deal specifically with EMS practice and outcomes to the door of the ED from those that mix everybody's input into an outcome on discharge. Alternately studies, like our RSI trial, were designed to show that a discharge outcome changed when only the pre-hospital component of management was altered in a very specific patient cohort. The ED's and ICU's etc tackled the Pt's the same way they always do but we inducted a tube and paralysed or did just the basics. There was one or the other. Randomised, double blinded, controlled trials.
The study design and choice of outcome was specifically intended to isolate and validate only the pre-hospital component.
In this case a very surprising revelation was demonstrated. RSI in these pt groups clearly made a difference to outcome in (using reliable and established study methodology) and in real terms. This was all the more surprising since their had been prior trials that produced a converse result - eg San Diego 1994 and Seattle in about 2002 ( I think).
Does AV facilitate journal access for it's employees? I realize there are plenty of free resources but the best ones cost money, and uni pays for that access. Does it continue into employment in some way?
To be honest I'm not sure. I'll check for you. (goes to show how much direct research I have done myself recently).
EDIT: Bickell WH, Wall MJ, Pepe PE, et al, "Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injury." N Engl J Med, 331:1105-1109, October 1994. Was this the article you were talking about? It's the closest one I can find.
Unless I'm mistaken you are spot on. See you are better at researching than you thought you were.
I don't know if I have been any help. I'll ask around and dig up some studies for you. I'll see if I can narrow down some of your specific questions a little better. Anyway two hours late home tonight after a pt threw about five different rhythms in the space of fifteen minutes. Finally a real MICA job!!!!
(He got better by the way)
Cheers
MM
