Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 LA City FD and LA County FD no longer allow pediatric intubations based upon these studies. _____ From: texasems-l [mailto:texasems-l ] On Behalf Of Alan Lambert Sent: Thursday, October 19, 2006 8:53 AM To: Paramedicine ; EMS_Research ; EMS-L@...; NEMSMA ; texasems-l Subject: Prehospital intubation Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 As I recall those were rather skewed studies though. >>> " Bledsoe, DO " 10/19/2006 9:31 AM >>> LA City FD and LA County FD no longer allow pediatric intubations based upon these studies. _____ From: texasems-l [mailto:texasems-l ] On Behalf Of Alan Lambert Sent: Thursday, October 19, 2006 8:53 AM To: Paramedicine ; EMS_Research ; EMS-L@...; NEMSMA ; texasems-l Subject: Prehospital intubation Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 I make a suggestion that you review the ins and outs of HOW to read these research papers and how to glean factual information out of them and determine if the study really has efficacy. Who was included in the study? How severe were the patients and would they have likely had a negative outcome anyway? What were the exclusion criteria? How many patients were in the study? Etc. There is a whole laundry list of questions you need to ask yourself as you critically review the ENTIRE study before making judgments on changing protocols. And you can't simply read the summary or outcomes statements. I have personally read studies where if you just read that, the authors of the study still slanted the results to say what they wanted them to say. But when you read the entire study, there was a glitch - for instance, not enough patients in the study to be valid and if ONE patient had responded differently, it would change the whole outcome of the study. That is just one example. The other issues surround if the results are actually really statistically significant - not just that they SAY they are. And another thought is have the results been validated with other studies with the same inclusion/exclusion criteria etc, - in other words, have the same results be properly produced in other studies? There is a terrific section at the end of Chapter one of the new PHTLS textbook about reviewing research that may be helpful. What is sad, however, is that it appears that the textbook authors then later on jump on the bandwagon and seem to draw conclusions from those studies in their literature, but if you go review those studies yourself, you might not draw the same conclusions if you review the ENTIRE study. I think you really should critically review those studies to which you are referring. I think you will find that there are gaps in the research. For instance, on the studies done in CA about intubation of head injury patients, I couldn't find any information about the inclusion criteria regarding the patients situation or condition PRIOR to intubation. However, if the head injury was severe enough to be intubated, we know that the mortality rate on those patients is significantly high anyway. There is no information really in the study to reflect that those patients were really salvageable from the start. That is just one example. Lee , chime in here because I know you critically reviewed those intubations studies recently. Anyway, those are just my thoughts. But be cautious. Making snap judgments based on just the Results and conclusions or a review are not a good idea. Now that EMS and emergency care as a whole is moving toward more research based decisions on standard of care, we all need to learn how to review the material for ourselves to come to our OWN conclusions. Trust no one, not even me. But make sound decisions only after thorough review of the entire study, or you might make a serious mistake. Jane Hill -------------- Original message from " Alan Lambert " : -------------- Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 Jane spoke volumes here. I am all in favor of research based medicine, and consider anecdotal evidence to be useless. Before you consider utilizing a study to define your protocols, be critical of the study WHERE it was performed, HOW it was performed, and how they extrapolated their opinion from it. Mike Hatfield FF/EMT-P www.canyonlakefire-ems.org " Ubi concordia, ibi victoria " Re: Prehospital intubation I make a suggestion that you review the ins and outs of HOW to read these research papers and how to glean factual information out of them and determine if the study really has efficacy. Who was included in the study? How severe were the patients and would they have likely had a negative outcome anyway? What were the exclusion criteria? How many patients were in the study? Etc. There is a whole laundry list of questions you need to ask yourself as you critically review the ENTIRE study before making judgments on changing protocols. And you can't simply read the summary or outcomes statements. I have personally read studies where if you just read that, the authors of the study still slanted the results to say what they wanted them to say. But when you read the entire study, there was a glitch - for instance, not enough patients in the study to be valid and if ONE patient had responded differently, it would change the whole outcome of the study. That is just one example. The other issues surround if the results are actually really statistically significant - not just that they SAY they are. And another thought is have the results been validated with other studies with the same inclusion/exclusion criteria etc, - in other words, have the same results be properly produced in other studies? There is a terrific section at the end of Chapter one of the new PHTLS textbook about reviewing research that may be helpful. What is sad, however, is that it appears that the textbook authors then later on jump on the bandwagon and seem to draw conclusions from those studies in their literature, but if you go review those studies yourself, you might not draw the same conclusions if you review the ENTIRE study. I think you really should critically review those studies to which you are referring. I think you will find that there are gaps in the research. For instance, on the studies done in CA about intubation of head injury patients, I couldn't find any information about the inclusion criteria regarding the patients situation or condition PRIOR to intubation. However, if the head injury was severe enough to be intubated, we know that the mortality rate on those patients is significantly high anyway. There is no information really in the study to reflect that those patients were really salvageable from the start. That is just one example. Lee , chime in here because I know you critically reviewed those intubations studies recently. Anyway, those are just my thoughts. But be cautious. Making snap judgments based on just the Results and conclusions or a review are not a good idea. Now that EMS and emergency care as a whole is moving toward more research based decisions on standard of care, we all need to learn how to review the material for ourselves to come to our OWN conclusions. Trust no one, not even me. But make sound decisions only after thorough review of the entire study, or you might make a serious mistake. Jane Hill -------------- Original message from " Alan Lambert " <alambert (AT) brgov (DOT) <mailto:alambert%40brgov.com> com>: -------------- Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 There has been some criticism of the San Diego studies on adults. The Gauche-Hill study on pediatric intubations was a prospective randomized trial. There have been similar studies with the same results. Paramedics, at least in southern California, do not do enough pediatric intubations to remain current in the practice. That is an issue we all must face. A BVM provides as good or better results that ETI. One missed unrecognized esophageal intubation (UEI) equals 1 dead child. There are many who believe that stopping prehospital pediatric intubations will not affect outcomes and may actually improve them. Since there is no evidence that pediatric ETI is better, it would be sad to think that one child died from paramedics performing a skill not necessary. It is an emotional issue. There is still a strong push in some areas to remove all intubation skills from prehospital care. I am not among those who believe that to be beneficial. I have to admit that the pediatric literature is pretty convincing though. _____ From: texasems-l [mailto:texasems-l ] On Behalf Of Rinard Sent: Thursday, October 19, 2006 9:37 AM To: texasems-l Subject: RE: Prehospital intubation As I recall those were rather skewed studies though. >>> " Bledsoe, DO " <bbledsoe (AT) earthlink (DOT) <mailto:bbledsoe%40earthlink.net> net> 10/19/2006 9:31 AM >>> LA City FD and LA County FD no longer allow pediatric intubations based upon these studies. _____ From: texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com [mailto:texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com] On Behalf Of Alan Lambert Sent: Thursday, October 19, 2006 8:53 AM To: Paramedicine@ <mailto:Paramedicine%40yahoogroups.com> yahoogroups.com; EMS_Research@ <mailto:EMS_Research%40yahoogroups.com> yahoogroups.com; EMS-L (AT) ems-l (DOT) <mailto:EMS-L%40ems-l.org> org; NEMSMA (AT) yahoogroups (DOT) <mailto:NEMSMA%40yahoogroups.com> com; texasems-l@yahoogro <mailto:texasems-l%40yahoogroups.com> ups.com Subject: Prehospital intubation Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 I am giving a talk on this very topic-how to interpret research-at the Texas EMS conference. Again, many of the RSI and adult studies were problematic. The pediatric studies are very strong. Attend the lecture and learn about the various types of research. A New England Journal of Medicine article carries more weight than one published in the Journal of Irreproducible Results. Interestingly, I have given this same lecture several times before. The only people who show are educators and administrators. Every paramedic needs to learn how to access and review scientific literature. BEB _____ From: texasems-l [mailto:texasems-l ] On Behalf Of Hatfield Sent: Thursday, October 19, 2006 10:00 AM To: texasems-l Subject: RE: Prehospital intubation Jane spoke volumes here. I am all in favor of research based medicine, and consider anecdotal evidence to be useless. Before you consider utilizing a study to define your protocols, be critical of the study WHERE it was performed, HOW it was performed, and how they extrapolated their opinion from it. Mike Hatfield FF/EMT-P www.canyonlakefire-ems.org " Ubi concordia, ibi victoria " Re: Prehospital intubation I make a suggestion that you review the ins and outs of HOW to read these research papers and how to glean factual information out of them and determine if the study really has efficacy. Who was included in the study? How severe were the patients and would they have likely had a negative outcome anyway? What were the exclusion criteria? How many patients were in the study? Etc. There is a whole laundry list of questions you need to ask yourself as you critically review the ENTIRE study before making judgments on changing protocols. And you can't simply read the summary or outcomes statements. I have personally read studies where if you just read that, the authors of the study still slanted the results to say what they wanted them to say. But when you read the entire study, there was a glitch - for instance, not enough patients in the study to be valid and if ONE patient had responded differently, it would change the whole outcome of the study. That is just one example. The other issues surround if the results are actually really statistically significant - not just that they SAY they are. And another thought is have the results been validated with other studies with the same inclusion/exclusion criteria etc, - in other words, have the same results be properly produced in other studies? There is a terrific section at the end of Chapter one of the new PHTLS textbook about reviewing research that may be helpful. What is sad, however, is that it appears that the textbook authors then later on jump on the bandwagon and seem to draw conclusions from those studies in their literature, but if you go review those studies yourself, you might not draw the same conclusions if you review the ENTIRE study. I think you really should critically review those studies to which you are referring. I think you will find that there are gaps in the research. For instance, on the studies done in CA about intubation of head injury patients, I couldn't find any information about the inclusion criteria regarding the patients situation or condition PRIOR to intubation. However, if the head injury was severe enough to be intubated, we know that the mortality rate on those patients is significantly high anyway. There is no information really in the study to reflect that those patients were really salvageable from the start. That is just one example. Lee , chime in here because I know you critically reviewed those intubations studies recently. Anyway, those are just my thoughts. But be cautious. Making snap judgments based on just the Results and conclusions or a review are not a good idea. Now that EMS and emergency care as a whole is moving toward more research based decisions on standard of care, we all need to learn how to review the material for ourselves to come to our OWN conclusions. Trust no one, not even me. But make sound decisions only after thorough review of the entire study, or you might make a serious mistake. Jane Hill -------------- Original message from " Alan Lambert " <alambert (AT) brgov (DOT) <mailto:alambert%40brgov.com> com>: -------------- Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 For my particular purpose I am looking at how the studies influence EMS operational decisions. I am looking for real examples where the understanding or lack of understanding of research has been a factor in making decisions that affect the field provider. The validity of the studies is another debate in itself. AJL ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of Bledsoe, DO Sent: Thursday, October 19, 2006 10:27 AM To: texasems-l Subject: RE: Prehospital intubation I am giving a talk on this very topic-how to interpret research-at the Texas EMS conference. Again, many of the RSI and adult studies were problematic. The pediatric studies are very strong. Attend the lecture and learn about the various types of research. A New England Journal of Medicine article carries more weight than one published in the Journal of Irreproducible Results. Interestingly, I have given this same lecture several times before. The only people who show are educators and administrators. Every paramedic needs to learn how to access and review scientific literature. BEB Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 I am attempting to find out exactly how services are using research to influence their protocols/policies. I have a problem with some of the studies that I provided. What I am looking for are examples of services that have made decisions based on this research and how much of an effort they used to interpret it. Did they simply read the conclusions? Did they find other studies that were able to reproduce the results? AJL ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of je.hill@... Sent: Thursday, October 19, 2006 9:50 AM To: texasems-l Subject: Re: Prehospital intubation I make a suggestion that you review the ins and outs of HOW to read these research papers and how to glean factual information out of them and determine if the study really has efficacy. Who was included in the study? How severe were the patients and would they have likely had a negative outcome anyway? What were the exclusion criteria? How many patients were in the study? Etc. There is a whole laundry list of questions you need to ask yourself as you critically review the ENTIRE study before making judgments on changing protocols. And you can't simply read the summary or outcomes statements. I have personally read studies where if you just read that, the authors of the study still slanted the results to say what they wanted them to say. But when you read the entire study, there was a glitch - for instance, not enough patients in the study to be valid and if ONE patient had responded differently, it would change the whole outcome of the study. That i s just one example. The other issues surround if the results are actually really statistically significant - not just that they SAY they are. And another thought is have the results been validated with other studies with the same inclusion/exclusion criteria etc, - in other words, have the same results be properly produced in other studies? There is a terrific section at the end of Chapter one of the new PHTLS textbook about reviewing research that may be helpful. What is sad, however, is that it appears that the textbook authors then later on jump on the bandwagon and seem to draw conclusions from those studies in their literature, but if you go review those studies yourself, you might not draw the same conclusions if you review the ENTIRE study. I think you really should critically review those studies to which you are referring. I think you will find that there are gaps in the research. For instance, on the studies done in CA about intubation of head injury patients, I couldn't find any information about the inclusion criteria regarding the patients situation or condition PRIOR to intubation. However, if the head injury was severe enough to be intubated, we know that the mortality rate on those patients is significantly high anyway. There is no information really in the study to reflect that those patients were really salvageable from the start. That is just one example. Lee , chime in here because I know you critically reviewed those intubations studies recently. Anyway, those are just my thoughts. But be cautious. Making snap judgments based on just the Results and conclusions or a review are not a good idea. Now that EMS and emergency care as a whole is moving toward more research based decisions on standard of care, we all need to learn how to review the material for ourselves to come to our OWN conclusions. Trust no one, not even me. But make sound decisions only after thorough review of the entire study, or you might make a serious mistake. Jane Hill Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 I agree with you completely. I am attempting to show the average field level provider how research (properly or improperly done) can affect EMS at the field provider level. I am looking for real life examples - the recent AHA changes are a little too easy I am looking for more controversial subject's ie prehospital intubations, but any other examples would also work. AJL ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of je.hill@... Sent: Thursday, October 19, 2006 9:50 AM To: texasems-l Subject: Re: Prehospital intubation I make a suggestion that you review the ins and outs of HOW to read these research papers and how to glean factual information out of them and determine if the study really has efficacy. Who was included in the study? How severe were the patients and would they have likely had a negative outcome anyway? What were the exclusion criteria? How many patients were in the study? Etc. There is a whole laundry list of questions you need to ask yourself as you critically review the ENTIRE study before making judgments on changing protocols. And you can't simply read the summary or outcomes statements. I have personally read studies where if you just read that, the authors of the study still slanted the results to say what they wanted them to say. But when you read the entire study, there was a glitch - for instance, not enough patients in the study to be valid and if ONE patient had responded differently, it would change the whole outcome of the study. That i s just one example. The other issues surround if the results are actually really statistically significant - not just that they SAY they are. And another thought is have the results been validated with other studies with the same inclusion/exclusion criteria etc, - in other words, have the same results be properly produced in other studies? There is a terrific section at the end of Chapter one of the new PHTLS textbook about reviewing research that may be helpful. What is sad, however, is that it appears that the textbook authors then later on jump on the bandwagon and seem to draw conclusions from those studies in their literature, but if you go review those studies yourself, you might not draw the same conclusions if you review the ENTIRE study. I think you really should critically review those studies to which you are referring. I think you will find that there are gaps in the research. For instance, on the studies done in CA about intubation of head injury patients, I couldn't find any information about the inclusion criteria regarding the patients situation or condition PRIOR to intubation. However, if the head injury was severe enough to be intubated, we know that the mortality rate on those patients is significantly high anyway. There is no information really in the study to reflect that those patients were really salvageable from the start. That is just one example. Lee , chime in here because I know you critically reviewed those intubations studies recently. Anyway, those are just my thoughts. But be cautious. Making snap judgments based on just the Results and conclusions or a review are not a good idea. Now that EMS and emergency care as a whole is moving toward more research based decisions on standard of care, we all need to learn how to review the material for ourselves to come to our OWN conclusions. Trust no one, not even me. But make sound decisions only after thorough review of the entire study, or you might make a serious mistake. Jane Hill -------------- Original message from " Alan Lambert " <alambert@... <mailto:alambert%40brgov.com> >: -------------- Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 Understood. Now THAT I don't have. LOL Jane Hill --------- Re: Prehospital intubation I make a suggestion that you review the ins and outs of HOW to read these research papers and how to glean factual information out of them and determine if the study really has efficacy. Who was included in the study? How severe were the patients and would they have likely had a negative outcome anyway? What were the exclusion criteria? How many patients were in the study? Etc. There is a whole laundry list of questions you need to ask yourself as you critically review the ENTIRE study before making judgments on changing protocols. And you can't simply read the summary or outcomes statements. I have personally read studies where if you just read that, the authors of the study still slanted the results to say what they wanted them to say. But when you read the entire study, there was a glitch - for instance, not enough patients in the study to be valid and if ONE patient had responded differently, it would change the whole outcome of the study. That i s just one example. The other issues surround if the results are actually really statistically significant - not just that they SAY they are. And another thought is have the results been validated with other studies with the same inclusion/exclusion criteria etc, - in other words, have the same results be properly produced in other studies? There is a terrific section at the end of Chapter one of the new PHTLS textbook about reviewing research that may be helpful. What is sad, however, is that it appears that the textbook authors then later on jump on the bandwagon and seem to draw conclusions from those studies in their literature, but if you go review those studies yourself, you might not draw the same conclusions if you review the ENTIRE study. I think you really should critically review those studies to which you are referring. I think you will find that there are gaps in the research. For instance, on the studies done in CA about intubation of head injury patients, I couldn't find any information about the inclusion criteria regarding the patients situation or condition PRIOR to intubation. However, if the head injury was severe enough to be intubated, we know that the mortality rate on those patients is significantly high anyway. There is no information really in the study to reflect that those patients were really salvageable from the start. That is just one example. Lee , chime in here because I know you critically reviewed those intubations studies recently. Anyway, those are just my thoughts. But be cautious. Making snap judgments based on just the Results and conclusions or a review are not a good idea. Now that EMS and emergency care as a whole is moving toward more research based decisions on standard of care, we all need to learn how to review the material for ourselves to come to our OWN conclusions. Trust no one, not even me. But make sound decisions only after thorough review of the entire study, or you might make a serious mistake. Jane Hill -------------- Original message from " Alan Lambert " <alambert@... <mailto:alambert%40brgov.com> >: -------------- Over the last few years there have been several studies questioning the effectiveness of prehospital intubation. Particularly the studies done by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for references of EMS providers who have modified their protocols/standards for prehospital intubation recently using these studies as a reason. If you know of a service that has done this or is contemplating this please let me know. Thanks, AJL Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 Well, you could take the Mattox/Pepe study on PASG. That resulted in lots of folks throwing them out, although the study was rather limited in its scope, and measured only patients in an urban area with Level I trauma center within close range. I'm not a great fan of PASG, but I also think that the study was of very limited application. People extrapolated much more from it than was warranted, I believe. Another study that has influenced what we do in the field is, IIRC, another Mattox study on the use of fluid resuscitation. That study and probably some others (I don't have the references--sorry) caused a significant change in practices. Now we don't overload our trauma patients with fluids as we formerly did. Studies done by the American Society of Anesthesia have resulted in waveform capnography being the gold standard for monitoring in the OR, and that has spread to EMS even faster than it has to ER practice. For those who are not familiar with those studies, ASA has studied closed cases for many years with the cooperation of insurance carriers, and it has determined that when waveform capnography is used, undetected esophageal intubations drop to zero. The studies involving paramedic practice did not measure either the amount of kind of training the paramedics in the system has received, nor did they take into consideration the adjuncts to airway management that we now have. I don't quarrel with the changes that were made. If paramedics cannot intubate in that system, then it's better that they not try it. But to say that the results of that study apply to the paramedics in systems where they are better trained is a stretch. Recently some services have eliminated endotracheal intubation from their protocols, in favor of Combitubes. I have no quarrel with that in services where medics are not able to keep up their intubation skills. As a matter of fact, I think the Combitube ought to be used by Basic EMTs routinely when advanced practitioners are not readily available. But the Combitube won't work on pediatrics. There are other devices, such as the LMA and the Cobra PLA that come in pedi sizes, and one wonders whether or not the use of one of those devices wouldn't be better than simply going to nothing but BVM ventilation. However, no one can quarrel with a service that emphasizes ventilation over intubation. Ventilation is the standard, not intubation. So whatever achieves that goal in the best way is what ought to be done. These are some examples of study driven changes that have occurred that I'm aware of. Gene G. > > I agree with you completely. I am attempting to show the average field > level provider how research (properly or improperly done) can affect EMS > at the field provider level. I am looking for real life examples - the > recent AHA changes are a little too easy I am looking for more > controversial subject's ie prehospital intubations, but any other > examples would also work. > > AJL > > ____________ ________ ________ _ > > From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On > Behalf Of je.hill@.... > Sent: Thursday, October 19, 2006 9:50 AM > To: texasems-l@yahoogrotexasem > Subject: Re: Prehospital intubation > > I make a suggestion that you review the ins and outs of HOW to read > these research papers and how to glean factual information out of them > and determine if the study really has efficacy. Who was included in the > study? How severe were the patients and would they have likely had a > negative outcome anyway? What were the exclusion criteria? How many > patients were in the study? Etc. There is a whole laundry list of > questions you need to ask yourself as you critically review the ENTIRE > study before making judgments on changing protocols. And you can't > simply read the summary or outcomes statements. I have personally read > studies where if you just read that, the authors of the study still > slanted the results to say what they wanted them to say. But when you > read the entire study, there was a glitch - for instance, not enough > patients in the study to be valid and if ONE patient had responded > differently, it would change the whole outcome of the study. That i s > just one example. > The other issues surround if the results are actually really > statistically significant - not just that they SAY they are. And another > thought is have the results been validated with other studies with the > same inclusion/exclusion criteria etc, - in other words, have the same > results be properly produced in other studies? There is a terrific > section at the end of Chapter one of the new PHTLS textbook about > reviewing research that may be helpful. What is sad, however, is that it > appears that the textbook authors then later on jump on the bandwagon > and seem to draw conclusions from those studies in their literature, but > if you go review those studies yourself, you might not draw the same > conclusions if you review the ENTIRE study. > > I think you really should critically review those studies to which you > are referring. I think you will find that there are gaps in the > research. For instance, on the studies done in CA about intubation of > head injury patients, I couldn't find any information about the > inclusion criteria regarding the patients situation or condition PRIOR > to intubation. However, if the head injury was severe enough to be > intubated, we know that the mortality rate on those patients is > significantly high anyway. There is no information really in the study > to reflect that those patients were really salvageable from the start. > That is just one example. Lee , chime in here because I know > you critically reviewed those intubations studies recently. > > Anyway, those are just my thoughts. But be cautious. Making snap > judgments based on just the Results and conclusions or a review are not > a good idea. Now that EMS and emergency care as a whole is moving toward > more research based decisions on standard of care, we all need to learn > how to review the material for ourselves to come to our OWN conclusions. > Trust no one, not even me. But make sound decisions only after thorough > review of the entire study, or you might make a serious mistake. > > Jane Hill > > ------------ ------------<wbr>-- Original message fr<alambert@... > <mailto:alambert%mailto:alam> >: ------------: - > > Over the last few years there have been several studies questioning the > effectiveness of prehospital intubation. Particularly the studies done > by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for > references of EMS providers who have modified their protocols/standards > for prehospital intubation recently using these studies as a reason. If > you know of a service that has done this or is contemplating this please > let me know. > > Thanks, > > AJL > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 2006 Report Share Posted October 19, 2006 Dr. B, Did the study compare EMT-Ps vs. Nurses? Or did the study only compare the physicians vs. non-physicians? The abstract only paints a picture of the latter. The reason I ask, is that while the airway training may be similar, the skill set experience can be very different between flight nurses and flight medics. EMT-Ps joining a flight program typically have a minimum number of years of field medic experience that includes intubating patients; however, it is not typically the career-long experience of RNs. Often, RNs do not have the same experience in intubating patients (especially in austere conditions) throughout their career that their flight medics usually bring to the table prior to employment as flight medics. I would like to have seen the success percentages listed by physician, nurses, and medics...not just docs vs. non-docs. Grouping the nurses and medics together may have unfairly skewed the results for the nurses or the medics. Just my initial reaction to the abstract; anyone else raise the same question? ----- Original Message ----- >> I make a suggestion that you review the ins and outs of HOW to read >> these research papers and how to glean factual information out of them >> and determine if the study really has efficacy. Who was included in the >> study? How severe were the patients and would they have likely had a >> negative outcome anyway? What were the exclusion criteria? How many >> patients were in the study? Etc. There is a whole laundry list of >> questions you need to ask yourself as you critically review the ENTIRE >> study before making judgments on changing protocols. And you can't >> simply read the summary or outcomes statements. I have personally read >> studies where if you just read that, the authors of the study still >> slanted the results to say what they wanted them to say. But when you >> read the entire study, there was a glitch - for instance, not enough >> patients in the study to be valid and if ONE patient had responded >> differently, it would change the whole outcome of the study. That i s >> just one example. >> The other issues surround if the results are actually really >> statistically significant - not just that they SAY they are. And another >> thought is have the results been validated with other studies with the >> same inclusion/exclusion criteria etc, - in other words, have the same >> results be properly produced in other studies? There is a terrific >> section at the end of Chapter one of the new PHTLS textbook about >> reviewing research that may be helpful. What is sad, however, is that it >> appears that the textbook authors then later on jump on the bandwagon >> and seem to draw conclusions from those studies in their literature, but >> if you go review those studies yourself, you might not draw the same >> conclusions if you review the ENTIRE study. >> >> I think you really should critically review those studies to which you >> are referring. I think you will find that there are gaps in the >> research. For instance, on the studies done in CA about intubation of >> head injury patients, I couldn't find any information about the >> inclusion criteria regarding the patients situation or condition PRIOR >> to intubation. However, if the head injury was severe enough to be >> intubated, we know that the mortality rate on those patients is >> significantly high anyway. There is no information really in the study >> to reflect that those patients were really salvageable from the start. >> That is just one example. Lee , chime in here because I know >> you critically reviewed those intubations studies recently. >> >> Anyway, those are just my thoughts. But be cautious. Making snap >> judgments based on just the Results and conclusions or a review are not >> a good idea. Now that EMS and emergency care as a whole is moving toward >> more research based decisions on standard of care, we all need to learn >> how to review the material for ourselves to come to our OWN conclusions. >> Trust no one, not even me. But make sound decisions only after thorough >> review of the entire study, or you might make a serious mistake. >> >> Jane Hill >> >> ------------ ------------<wbr>-- Original message fr<alambert@... >> <mailto:alambert%mailto:alam> >: ------------: - >> >> Over the last few years there have been several studies questioning the >> effectiveness of prehospital intubation. Particularly the studies done >> by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for >> references of EMS providers who have modified their protocols/standards >> for prehospital intubation recently using these studies as a reason. If >> you know of a service that has done this or is contemplating this please >> let me know. >> >> Thanks, >> >> AJL >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 20, 2006 Report Share Posted October 20, 2006 It compared: Second year EM residents Third year EM residents Flight nurses Flight medics Flight nurses had better success rates than paramedics. Gene, the Mattox/Pepe MAST study was repeated by Chang with the same results. The Cochrane Review of the Mattox and Chang studies leaves little doubt. _____ From: texasems-l [mailto:texasems-l ] On Behalf Of W. Graham Sent: Friday, October 20, 2006 12:52 AM To: texasems-l Subject: Re: Prehospital intubation Dr. B, Did the study compare EMT-Ps vs. Nurses? Or did the study only compare the physicians vs. non-physicians? The abstract only paints a picture of the latter. The reason I ask, is that while the airway training may be similar, the skill set experience can be very different between flight nurses and flight medics. EMT-Ps joining a flight program typically have a minimum number of years of field medic experience that includes intubating patients; however, it is not typically the career-long experience of RNs. Often, RNs do not have the same experience in intubating patients (especially in austere conditions) throughout their career that their flight medics usually bring to the table prior to employment as flight medics. I would like to have seen the success percentages listed by physician, nurses, and medics...not just docs vs. non-docs. Grouping the nurses and medics together may have unfairly skewed the results for the nurses or the medics. Just my initial reaction to the abstract; anyone else raise the same question? ----- Original Message ----- >> I make a suggestion that you review the ins and outs of HOW to read >> these research papers and how to glean factual information out of them >> and determine if the study really has efficacy. Who was included in the >> study? How severe were the patients and would they have likely had a >> negative outcome anyway? What were the exclusion criteria? How many >> patients were in the study? Etc. There is a whole laundry list of >> questions you need to ask yourself as you critically review the ENTIRE >> study before making judgments on changing protocols. And you can't >> simply read the summary or outcomes statements. I have personally read >> studies where if you just read that, the authors of the study still >> slanted the results to say what they wanted them to say. But when you >> read the entire study, there was a glitch - for instance, not enough >> patients in the study to be valid and if ONE patient had responded >> differently, it would change the whole outcome of the study. That i s >> just one example. >> The other issues surround if the results are actually really >> statistically significant - not just that they SAY they are. And another >> thought is have the results been validated with other studies with the >> same inclusion/exclusion criteria etc, - in other words, have the same >> results be properly produced in other studies? There is a terrific >> section at the end of Chapter one of the new PHTLS textbook about >> reviewing research that may be helpful. What is sad, however, is that it >> appears that the textbook authors then later on jump on the bandwagon >> and seem to draw conclusions from those studies in their literature, but >> if you go review those studies yourself, you might not draw the same >> conclusions if you review the ENTIRE study. >> >> I think you really should critically review those studies to which you >> are referring. I think you will find that there are gaps in the >> research. For instance, on the studies done in CA about intubation of >> head injury patients, I couldn't find any information about the >> inclusion criteria regarding the patients situation or condition PRIOR >> to intubation. However, if the head injury was severe enough to be >> intubated, we know that the mortality rate on those patients is >> significantly high anyway. There is no information really in the study >> to reflect that those patients were really salvageable from the start. >> That is just one example. Lee , chime in here because I know >> you critically reviewed those intubations studies recently. >> >> Anyway, those are just my thoughts. But be cautious. Making snap >> judgments based on just the Results and conclusions or a review are not >> a good idea. Now that EMS and emergency care as a whole is moving toward >> more research based decisions on standard of care, we all need to learn >> how to review the material for ourselves to come to our OWN conclusions. >> Trust no one, not even me. But make sound decisions only after thorough >> review of the entire study, or you might make a serious mistake. >> >> Jane Hill >> >> ------------ ------------<wbr>-- Original message fr<alambert (AT) brgov (DOT) <mailto:alambert%40brgov.ala> ala >> <mailto:alambert%mailto:alam> >: ------------: - >> >> Over the last few years there have been several studies questioning the >> effectiveness of prehospital intubation. Particularly the studies done >> by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for >> references of EMS providers who have modified their protocols/standards >> for prehospital intubation recently using these studies as a reason. If >> you know of a service that has done this or is contemplating this please >> let me know. >> >> Thanks, >> >> AJL >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 20, 2006 Report Share Posted October 20, 2006 Thanks for the clarification...point well taken. If the flight medics are not performing as well, how well are can our street medics be doing??? This is an important issue that I suspect our paramedics will overlook for fear of losing a skill in th toolbox. Hopefully it will be an impetus for further investigation and a training solution. Or...alternative, more effective means for prehospital airway management. BG Re: Prehospital intubation > > > > Dr. B, > > Did the study compare EMT-Ps vs. Nurses? Or did the study only compare the > physicians vs. non-physicians? The abstract only paints a picture of the > latter. The reason I ask, is that while the airway training may be > similar, > the skill set experience can be very different between flight nurses and > flight medics. EMT-Ps joining a flight program typically have a minimum > number of years of field medic experience that includes intubating > patients; > > however, it is not typically the career-long experience of RNs. Often, RNs > do not have the same experience in intubating patients (especially in > austere conditions) throughout their career that their flight medics > usually > > bring to the table prior to employment as flight medics. I would like to > have seen the success percentages listed by physician, nurses, and > medics...not just docs vs. non-docs. Grouping the nurses and medics > together may have unfairly skewed the results for the nurses or the > medics. > Just my initial reaction to the abstract; anyone else raise the same > question? > > > ----- Original Message ----- >> I make a suggestion that you review the > ins > and outs of HOW to read >>> these research papers and how to glean factual information out of them >>> and determine if the study really has efficacy. Who was included in the >>> study? How severe were the patients and would they have likely had a >>> negative outcome anyway? What were the exclusion criteria? How many >>> patients were in the study? Etc. There is a whole laundry list of >>> questions you need to ask yourself as you critically review the ENTIRE >>> study before making judgments on changing protocols. And you can't >>> simply read the summary or outcomes statements. I have personally read >>> studies where if you just read that, the authors of the study still >>> slanted the results to say what they wanted them to say. But when you >>> read the entire study, there was a glitch - for instance, not enough >>> patients in the study to be valid and if ONE patient had responded >>> differently, it would change the whole outcome of the study. That i s >>> just one example. >>> The other issues surround if the results are actually really >>> statistically significant - not just that they SAY they are. And another >>> thought is have the results been validated with other studies with the >>> same inclusion/exclusion criteria etc, - in other words, have the same >>> results be properly produced in other studies? There is a terrific >>> section at the end of Chapter one of the new PHTLS textbook about >>> reviewing research that may be helpful. What is sad, however, is that it >>> appears that the textbook authors then later on jump on the bandwagon >>> and seem to draw conclusions from those studies in their literature, but >>> if you go review those studies yourself, you might not draw the same >>> conclusions if you review the ENTIRE study. >>> >>> I think you really should critically review those studies to which you >>> are referring. I think you will find that there are gaps in the >>> research. For instance, on the studies done in CA about intubation of >>> head injury patients, I couldn't find any information about the >>> inclusion criteria regarding the patients situation or condition PRIOR >>> to intubation. However, if the head injury was severe enough to be >>> intubated, we know that the mortality rate on those patients is >>> significantly high anyway. There is no information really in the study >>> to reflect that those patients were really salvageable from the start. >>> That is just one example. Lee , chime in here because I know >>> you critically reviewed those intubations studies recently. >>> >>> Anyway, those are just my thoughts. But be cautious. Making snap >>> judgments based on just the Results and conclusions or a review are not >>> a good idea. Now that EMS and emergency care as a whole is moving toward >>> more research based decisions on standard of care, we all need to learn >>> how to review the material for ourselves to come to our OWN conclusions. >>> Trust no one, not even me. But make sound decisions only after thorough >>> review of the entire study, or you might make a serious mistake. >>> >>> Jane Hill >>> >>> ------------ ------------<wbr>-- Original message fr<alambert (AT) brgov (DOT) > <mailto:alambert%40brgov.ala> ala >>> <mailto:alambert%mailto:alam> >: ------------: - >>> >>> Over the last few years there have been several studies questioning the >>> effectiveness of prehospital intubation. Particularly the studies done >>> by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for >>> references of EMS providers who have modified their protocols/standards >>> for prehospital intubation recently using these studies as a reason. If >>> you know of a service that has done this or is contemplating this please >>> let me know. >>> >>> Thanks, >>> >>> AJL >>> >>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 20, 2006 Report Share Posted October 20, 2006 What independent variables might have skewed this, if any? Adverse field conditions, difficult airways, availability of support personnel??? What type parameteric analysis was done? >>> " W. Graham " 10/20/2006 8:50 am >>> Thanks for the clarification...point well taken. If the flight medics are not performing as well, how well are can our street medics be doing??? This is an important issue that I suspect our paramedics will overlook for fear of losing a skill in th toolbox. Hopefully it will be an impetus for further investigation and a training solution. Or...alternative, more effective means for prehospital airway management. BG Re: Prehospital intubation > > > > Dr. B, > > Did the study compare EMT-Ps vs. Nurses? Or did the study only compare the > physicians vs. non-physicians? The abstract only paints a picture of the > latter. The reason I ask, is that while the airway training may be > similar, > the skill set experience can be very different between flight nurses and > flight medics. EMT-Ps joining a flight program typically have a minimum > number of years of field medic experience that includes intubating > patients; > > however, it is not typically the career-long experience of RNs. Often, RNs > do not have the same experience in intubating patients (especially in > austere conditions) throughout their career that their flight medics > usually > > bring to the table prior to employment as flight medics. I would like to > have seen the success percentages listed by physician, nurses, and > medics...not just docs vs. non-docs. Grouping the nurses and medics > together may have unfairly skewed the results for the nurses or the > medics. > Just my initial reaction to the abstract; anyone else raise the same > question? > > > ----- Original Message ----- >> I make a suggestion that you review the > ins > and outs of HOW to read >>> these research papers and how to glean factual information out of them >>> and determine if the study really has efficacy. Who was included in the >>> study? How severe were the patients and would they have likely had a >>> negative outcome anyway? What were the exclusion criteria? How many >>> patients were in the study? Etc. There is a whole laundry list of >>> questions you need to ask yourself as you critically review the ENTIRE >>> study before making judgments on changing protocols. And you can't >>> simply read the summary or outcomes statements. I have personally read >>> studies where if you just read that, the authors of the study still >>> slanted the results to say what they wanted them to say. But when you >>> read the entire study, there was a glitch - for instance, not enough >>> patients in the study to be valid and if ONE patient had responded >>> differently, it would change the whole outcome of the study. That i s >>> just one example. >>> The other issues surround if the results are actually really >>> statistically significant - not just that they SAY they are. And another >>> thought is have the results been validated with other studies with the >>> same inclusion/exclusion criteria etc, - in other words, have the same >>> results be properly produced in other studies? There is a terrific >>> section at the end of Chapter one of the new PHTLS textbook about >>> reviewing research that may be helpful. What is sad, however, is that it >>> appears that the textbook authors then later on jump on the bandwagon >>> and seem to draw conclusions from those studies in their literature, but >>> if you go review those studies yourself, you might not draw the same >>> conclusions if you review the ENTIRE study. >>> >>> I think you really should critically review those studies to which you >>> are referring. I think you will find that there are gaps in the >>> research. For instance, on the studies done in CA about intubation of >>> head injury patients, I couldn't find any information about the >>> inclusion criteria regarding the patients situation or condition PRIOR >>> to intubation. However, if the head injury was severe enough to be >>> intubated, we know that the mortality rate on those patients is >>> significantly high anyway. There is no information really in the study >>> to reflect that those patients were really salvageable from the start. >>> That is just one example. Lee , chime in here because I know >>> you critically reviewed those intubations studies recently. >>> >>> Anyway, those are just my thoughts. But be cautious. Making snap >>> judgments based on just the Results and conclusions or a review are not >>> a good idea. Now that EMS and emergency care as a whole is moving toward >>> more research based decisions on standard of care, we all need to learn >>> how to review the material for ourselves to come to our OWN conclusions. >>> Trust no one, not even me. But make sound decisions only after thorough >>> review of the entire study, or you might make a serious mistake. >>> >>> Jane Hill >>> >>> ------------ ------------<wbr>-- Original message fr<alambert (AT) brgov (DOT) > <mailto:alambert%40brgov.ala> ala >>> <mailto:alambert%mailto:alam> >: ------------: - >>> >>> Over the last few years there have been several studies questioning the >>> effectiveness of prehospital intubation. Particularly the studies done >>> by Drs. Wang and Yealy, Gauche, , Stockinger. I am looking for >>> references of EMS providers who have modified their protocols/standards >>> for prehospital intubation recently using these studies as a reason. If >>> you know of a service that has done this or is contemplating this please >>> let me know. >>> >>> Thanks, >>> >>> AJL >>> >>> Quote Link to comment Share on other sites More sharing options...
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