Why Evidence Based EMS?
By: Arthur Hsieh

Evidence-based  medicine (EBM) refers to making medical decisions based on evidence gained  from the scientific method. While that may seem to be common sense, it may  come as a surprise that EBM has only really come into practice since the  late-twentieth century. For most of recorded history, most of medical  practice was based on common sense, anecdotal evidence ("what I did worked,  therefore it must work for all who try it"), and sheer guesswork. The  concept of conducting structured, clinical trials where new interventions  could be tested in a controlled setting began in the 1930s with evaluations  done on medications such as streptomycin. An explosion of new drugs being  developed in the 1950s raised concern about uncontrolled application of use  and untoward outcomes; the Thalidomide disaster of 1962 changed the way the  medical community viewed the importance of conducting well designed studies  of new medical treatments. By the mid 1980s and early 90s efforts to create  the infrastructure to conduct uniform approaches to research, analysis and  review paved the way for how modern medicine develops today.

How does  this history relate to EMS? For those of us who began our careers in the  late 70s and early 80s we were caught in the transition of medicine from  more of an "art" to more of a "science". As an EMT student, I was told how  critical MAST pants were to preserving blood pressure; how crucial it was to  place the hypotensive patient in full trendelenburg position; and how  essential it was to clear the obstructed airway of the unconscious choking  patient before performing chest compressions, at a 5:1 ratio and at 80 beats  per minute. As a paramedic student, sodium bicarbonate was as primary a  cardiac arrest drug as epinephrine was; that three stacked shocks was really  needed; that two large bore IVs running wide open and advanced airway  control was established prior to the transport of the critical trauma  patient; that rotating tourniquets and aminophylline drips were critical  interventions in CHF.  I remember how each of these interventions was  "really important" and even "life saving"!

Flash forward to today.  Each one of these techniques or interventions have either been refuted or at  least modified, based upon research and evidence. In many of these cases,  not only were they ineffective, they were downright harmful to the patient!  The procedure may have been exciting to perform, and made good common sense,  it didn't help the patient. This is the key point, and emphasizes one of the  main precepts of medical ethics: Primum non nocere, or First, Do No  Harm. as a prehospital care provider, you are duty bound to ensure that your  practices do no harm to your patients. There are several ways to do  this:

- Keep up with the research. You don't need to be a rocket  scientist to review the studies and come to your own conclusions. Scholarly  journals like Prehospital Emergency Care, Annals of Emergency Medicine  and Academic Emergency Medicine are sources for EMS studies. 
- Participate in online communities to trade ideas,  discuss hot topics and review what other agencies are doing in their EMS  systems.
- Provide input into your own medical protocols. Often, the  science can outpace the development of local protocols. You can help by  providing input during public comment periods or attending meetings where  protocols being designed.
- Consider doing research. It doesn't  have to be a big, NIH-sponsord clinical trial. It might be a new device that  your department wants to try out. Ask questions like, how will this  contribute to my patent's well-being? How can I measure that benefit? DOes  the benefit outweigh the cost?

We will be talking more about EBM and  how the research can improve your practice in future articles. For now, stay  safe, care for your patient, and provide the best care you  can.