Ace844

Hope this helps, ACE844

Hi Everyone, I saw this and wasn't quite sure where to post it...but since it is related to some of the other topics here and it's abit long I figured it warranted it's own "post". It's an interesting read...and I'm curious to hear what others think... you can get the articles and more here:: http://www.jephc.com/ (2004; Volume 2 : Issue 3-4 Article Number: 990092 Mental health and mental illness in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making by: Ramon Shaban) ABSTRACT This paper is the first in a series that heralds a study examining paramedic accounts and constructs of judgment and decision-making (JDM) of mental health and mental illness. Providing an introduction and background to the evolving study, the paper will establish a warrant for the research and scope of the research agenda and methods of inquiry. Keywords clinical judgment; clinical judgement; decision-making; mental health; paramedic practice Background to the Research The provision of appropriate mental health services for Australians is an urgent national health priority. The National Mental Health Report 2000 cites that almost one in five (18%) Australians suffers from a mental disorder, and that 3% of the total population live with a serious psychiatric disorder at any one point in time.1 Fundamental changes to health-care policy in Australia and around the world have led to an increase in the extent to which emergency personnel come into contact with patients experiencing mental health problems.2,3 The launch of the National Mental Health Policy by the Australian Health Ministers in 1992 provided the stimulus for significant changes to psychiatric services within the Australian health-care system.4 Mainstreaming of services was a central feature of these changes, shifting the provision of traditional psychiatric care from dedicated institutions to integration and co-location with mainstream general health services and community settings. Such changes to mental health service delivery have been problematic for health-care workers across many disciplines. The decentralisation of mental heath services has resulted in increased attendance at emergency departments and to emergency medical services by patients with mental health problems, something well documented in Australia and around the world.2,4,5 Some facilities have reported a 10-fold increase of the number of patients presenting to the Emergency Department (ED) with mental health problems in 10 years.6 Health care workers from a variety of disciplines have reported perceiving themselves as lacking the skills and expertise to provide appropriate care and treatment to this client group.1,4,5,7,8 Such events and factors have meant that health-care workers, particularly community health and emergency personnel, are increasingly required to manage a variety of patients mental health problems, often complex and chronic in nature.1-4, 6 In Queensland, legislation has recently undergone major revision in line with national and international reform in the provision of mental health services. The Mental Health Act 2000 (Qld) (MHA)9 is, broadly speaking, the major legislative instrument regulating involuntary treatment and protection of people who have mental illnesses in Queensland. The MHA provides for the involuntary assessment, treatment, and protection of persons experiencing a mental illness while at the same time safeguarding their rights. While the MHA focuses on the aspects of mental illness that cannot be dealt with in other legislation, it does not specifically provide for voluntary treatment of mental illness. Voluntary treatment of mental illness is regarded in the same way as treatment for any other illness, with the protection of rights secured by other legislation. The MHA has been drafted to comply with the National Standards for Mental Health Services (1997), the United Nations Principles for the Protection of People with Mental Illness and for the Improvement of Mental Health Care (1997), and a model mental health legislation agreed to by all Australian states and territories. The MHA also reflects contemporary clinical practice, international, national, and state policy directions, and broad community expectations. An important aim of the MHA is to reduce the stigma associated with mental illness. The MHA provides for the involuntary assessment, treatment, and protection of persons (whether adults or minors) who have mental illness while at the same time safeguarding their rights. Emergency provisions under the MHA exist for police officers, paramedics, and psychiatrists. Pursuant to section 33(1) of the MHA, a paramedic (or a police officer) may make an emergency examination order for involuntary admission where the officer ‘reasonably believes’ that: (a) a person has a mental illness; and ( because of the person’s illness there is an imminent risk of significant physical harm being sustained by the person or someone else; and © proceeding under Division 2 (Justice’s examination order) would cause dangerous delay and significantly increase the risk and harm to the person or someone else; and (d) there is no less restrictive way of ensuring the person is assessed.9 The MHA defines mental illness as ‘a condition characterised by a clinically significant disturbance of thought, mood, perception or memory’. The MHA further defines ‘belief’ as a ‘reasonable belief’, which is characterised as a ‘belief on grounds that are reasonable in the circumstances’. An emergency examination order is dependent on the belief of the paramedic that the patient meets all of the criteria set out in section 33(1) of the MHA. The emergency examination order made by a paramedic or police officer is critically informed by a determination, or a judgment of the paramedic or police officer, that satisfies the criteria for involuntary admission. In the event that an individual does not satisfy the criteria for involuntary assessment, the provisions of the MHA do not apply. The Research Problem Paramedics are required to undertake rigorous, thorough, and complete assessment of their patients, often in difficult or emergency situations. Paramedic assessment of mental status is essential in determining the appropriate treatment for patients presenting with a mental illness. The introduction of new Queensland mental health legislation precipitated widespread industrial concern within the Queensland Ambulance Service (QAS) regarding the ability of paramedics to comply with explicit legislative requirements, citing poor education in mental illness and assessment techniques. The QAS prepared and distributed an in-service education program on the new MHA, which was designed primarily to orientate paramedics to the administrative functions of the MHA to meet their statutory and professional obligations. Its introduction was problematic. Paramedics expressed concern voiced through the union about the quality of existing education of its members and the ability of paramedics to satisfy legislative requirements owing to limited education and training in mental illness historically. Paramedics at the time expressed concern for their preparedness to manage mental illness in practice given the prevailing policy frameworks and contexts. The introduction of this education program signalled the existence of other issues in this context, and provided an opportunity to examine the relationship between theory and practice in paramedics’ judgment and decision-making (JDM). Importantly, it has highlighted the dearth of knowledge and research, substantiated by a literature search, about paramedic knowledge, judgment, and clinical decision-making in the context of mental health, mental illness, and mental health assessments. Six key themes are discussed that establish the warrant and justification for the research. 1. Industrial Relations and Action The introduction of new legislation governing the practice of paramedics of the Queensland Ambulance Service (QAS) has precipitated significant industry concern about the ability of paramedics to satisfy legislative requirements citing insufficient education and training in mental illness. These concerns are mirrored in the related literature that examines mental health assessment and management practices in medicine, nursing, and the allied health professions. The related literature of studies into the nursing and medical professions illustrates that generally the recognition and care of mental illness is limited.2-5, 7, 8 This literature demonstrates the problematic nature of knowledge, recognition, and management of mental illness by health-care professionals, and that further education and training of such professionals is required. To date there has been no published study found that specifically examined paramedic mental health knowledge, judgment, and decision-making practices nationally or internationally. 2. Statutory and Legislative Obligations The style and working provisions of the various mental health Acts worldwide have attracted intense criticism in the international literature. In particular, the major area of concern relates to the conditions in which clinical judgments that precipitate involuntary assessments are made. Holdsworth and Dodgson10 report that the Mental Health Act (2004) (UK) seriously impairs the clinical reasoning practices of individuals who act under provisions of the legislation in clinical or practical settings. Stating that the use of criteria that are based on frequentist statistical analysis excludes the ability of the clinician to use information idiosyncratic to the individual in making clinical judgments, Holdsworth and Dodgson10 argue that legislation of this nature over-values statistical frequency of clinical risk assessment and under-values idiosyncratic qualitative information, which is much more difficult to explicate, represent, or qualify. The use of objective statistical frequency assessments in determining clinical risk without concomitant weight or consideration to idiosyncratic qualitative judgments has been strongly criticised.11 The workings of Australian mental health Acts are yet to be examined in the published literature and will be examined in detail in this study. 3. Paramedic Clinical Practice and Clinical Practice Policy In order to improve clinical practice and clinical governance, the QAS has published a clinical practice manual consisting of a series of clinical guidelines, protocols, and flowcharts, including one for the management of ‘psychiatric emergencies’. The protocol is designed to provide paramedics with a guide to managing patients who are suffering a ‘psychiatric emergency’. In simple terms, the protocol requires that all paramedics transport their patients who they suspect suffer from a ‘psychiatric emergency‘ to definitive medical care. This policy, and its workings, is at odds with provisions of the MHA, which require paramedics to take action based on ‘reasonable beliefs in such circumstances’. The workings of this discrepancy in terms of conflict in judgment by paramedics in practices are of interest to this study. Shaban and colleagues12,13 suggest that the protocol is problematically constructed, narrow in the breadth of psychotic disorders, not reflective of the spectrum of mental illnesses, heavily biased towards a small percentage of psychotic disorders, and has significant limitations in view of the context and challenges presented to paramedics in the emergency care setting. The protocol will be the subject of further analysis in the continuing study. Anecdotally, the majority of cases reported by paramedics relating specifically to psychiatric emergency are those where there exists unacceptable risk of suicide, self-harm, or harm to others. No definition for ‘psychiatric’ is provided in the wider context of mental illness. It is suggested that lack of characterisation of the category limits or biases the use of it in the field. The term ‘psychiatric’ is narrow and may only reflect states of psychosis or serious psychiatric states (e.g. suicide) rather than broader mental health conditions encountered by paramedics that are more prevalent in the community. The generic classification of mental illness and mental disorders by paramedics as ‘psychiatric’ is problematic, particularly as it relates to conventional and contemporary definitions of mental illness. No other category exists to which mental illness other than that which is ‘psychiatric’ could be applied. 4. Paramedic Education and Training Programs Accredited paramedic and ambulance officer education and training programs are relatively new.12,13 The practice of paramedics and ambulance officers on a state, national, and international level may be characterised as a craft or guild. With the exception of a recent in-service undergraduate degree, all ambulance education programs are of a competency-based training (CBT) nature. CBT, an extension of competency-based education based on behavioural learning theory, focuses primarily on demonstrated outcomes rather than inputs. It is concerned with what someone may be expected to do, rather than on what actual learning processes occur.14 The capacity of paramedics with either CBT or Diploma based qualifications to conduct complex cognitive assessments, such as mental health assessments, has not been examined. Shaban and colleagues12,13 suggest that in, in principle, the level of existing ambulance qualifications does not adequately prepare paramedics to make clinical judgments in contexts outside those they have learned, and may be of limited relevance in complex or uncertain environments and ecologies. In view of this, even more problematic is the notion that paramedics are performing tasks that may or may not lead them to a ‘belief’ that someone is mentally ill when in fact the characteristics or assumptions that determine it to be ‘belief’ have not been described or examined. Patel, Arocha, and Kaufman15 argue that the concept of ‘belief’ is justified and is based on knowledge explicitly formulated in symbolic forms. These symbolic forms or ‘beliefs’ of paramedics surrounding mental health, mental illness, and mental health assessments have not been examined in the published research. The widespread systemic and profound negative stereotyping of mental illness within the community is well documented nationally and internationally.16 An analysis of QAS education, training, and professional development materials used from 1991 to 2003 12,13 reported an absence of explicit education and training in mental health assessment practices, clinical judgment, and decision-making. Analysis of this information, which included training materials, curricula, syllabi, clinical practice policies, and education records, suggests that ambulance officers and paramedics are not trained in comprehensive mental health assessment practice or clinical judgment and decision-making as it relates to mental health. The QAS Clinical Practice Manual (2003)17 provides a list of cues that officers should look for when managing someone with a ‘psychiatric emergency’. However, it does not detail declarative judgment processes as to how to conduct the assessment or how judgments would, should, or could be formed. 5. National and International Trends in Mental Health Care The National Mental Health Report 2000 recommends increased participation of a wide range of health, welfare, and disability professionals and organisations in the provision of services to people with mental disorders.1 Further, the report calls for increased knowledge and understanding of mental health and mental disorders for all health-care professionals, an awareness of additional needs with increased co-ordination of services provided to consumers and carers, and increased community interest and involvement in mental health issues. In order to contribute to and participate in the national mental health reform agenda, paramedics must be provided with comprehensive education and training opportunities with particular focus on judgment and classification, and management of mental disorders within appropriate professional practice, policy, and legislative frameworks. The role or potential role, impact, and influence of paramedics in the wider mental health agenda have not been examined in the published literature nationally or internationally in this context. 6. The Literature The largest body of research located in support of JDM relating to mental illness is limited to the professions of medicine, nursing, and police. While much research has been undertaken to investigate mental health assessment practices in the domain of psychiatry, research into practices in the ambulance or paramedic setting is limited. Few studies were found from other health-care disciplines (such as multi-disciplinary technical services) with no studies relating to the specific research problem of this study. Studies of paramedic JDM in cases of mental illness or psychiatric emergency referrals are rare. A search of the national and international literature sourced ten articles that examined paramedic JDM. All the articles found related to the examination of paramedic JDM as it related to cardiac arrest, trauma, triage, or decision to transport patients to definitive medical care. No articles were located that examined the JDM practices of paramedics in the domain of mental health, mental illness, or mental health assessments. The literature and theories on judgment and decision-making are as extensive as they are controversial. The fragmented nature of studies to date within the general health disciplines addressing aspects of clinical judgment process has not yet resulted in a comprehensive understanding of the phenomena18 or a suitable universal model or theoretical framework. Studies have traditionally followed or engaged one particular JDM paradigm or philosophy exclusively. Few, if any, have sought to view or examine JDM in more than one paradigm, which is a recent and growing criticism of the current body of research.18 Much of the work to date has applied descriptive approaches, such as information processing theory, in an attempt to contribute greater understanding of how judgments are made. In doing so, these studies, in the main, have provided greater insight into the cognitive process involved, particularly with respect to assessment practices. However, the ecological validity of many of these studies has been questioned,19-21 particularly with the criticism that they have focused on the representativeness of the judgment tasks presented.18 Many JDM studies have occurred in contexts and ecologies away from the clinical setting and therefore do not induce the same cognitive effect commensurate with the context.18,19 Conversely, some studies have focused primarily or exclusively on the accuracy or quality of the judgment or judgment process. To date, these studies have focused on judgment error in particular disciplines, largely the operations and management sciences.11 A major criticism of these studies, that are normative in nature, is that they negate to value of context, ecology, and interaction in examining the JDM processes.18, 22, 23 Other authors have criticised the methods by which risk, uncertainty, and stress have been quantified, arguing that no matter how quantified, the full effect of such factors can never fully be understood outside the context of the individual.24, 25 Sources of judgment errors in other contexts and disciplines need to be examined and explored. The use of prescriptive approaches, which attempt to improve JDM and help individuals to make better judgments, has also been criticised as a single paradigm of inquiry.18,22 Used considerably in teaching or instruction contexts and intervention studies, prescriptive models have been used to help individuals make better judgments and improve the quality of both the judgment and decision-making process. However, most studies have worked only within the prescriptive paradigm, resulting in significant limitations on the value of their findings in other contexts and paradigms.26 Further, a number of studies have attempted to improve JDM in the absence of any normative or descriptive data or constructs, and have failed because of a lack of understanding of the judgment process or the quality of a good judgments.18,22 It is clear that there are differing and competing accounts of judgment and decision-making in the literature and in research. In considering this study, it is apparent that none of the theories, philosophies and accounts of JDM individually are sufficient to address the specific research problems. There exists a dearth of judgment research in paramedic practice. A thorough literature review failed to locate research that examines the mental health assessment practices of paramedics. Given the recency of paramedic practice and pre-hospital care as a recognised discipline in healthcare, this omission is not unexpected.12, 27 There is a paucity of published work on critical thinking and clinical reasoning in this setting, which could suggest that the value of these skills are not yet fully appreciated in the field of pre-hospital care.12, 27 The few studies that have been conducted have examined JDM as it related to specific cases and instances (particularly cardiac arrest and trauma) and have worked within one particular JDM paradigm or theoretical construct, such as normative or prescriptive theory. These studies, as discussed earlier, are significantly problematic and have significant limitations due to study design or philosophical context. No article could be located that addresses either generally or specifically paramedic JDM practices with respect to mental illness, mental health, and mental health assessments, despite a growing warrant for this research. The absence of published research examining paramedic practice to achieve more accurate judgments (or indeed JDM at all) in the context of mental illness and mental health has meant that the impact of significant changes to practices precipitated by the MHA and trends in mental health care have occurred unexamined. The complexity of clinical situations faced by paramedics, where for example multiple contexts exists with significant levels of uncertainty, risk, and time criticality, most of which make clinical judgment process difficult has not been examined. The identification of strategies to support a more effective judgment processes a challenge has not been attempted.18 Summary and Future Considerations The rapid change in paramedic practice and ambulance care over the last decade has precipitated a number of challenges to the profession to ensure the sufficiency of professional practice standards, education and training programs, clinical standards, and policy for ensuring quality practice and accountability in the field. This paper has presented the background and warrant for of an ongoing study into one important area of paramedic practice: the management of the mentally ill. At issue in this ongoing study and warrant for research is the preparedness of the role of paramedic and the ambulance profession to recognise, assess, and manage mental illness in everyday practice. This research provides for a unique opportunity to examine the relationship between theory and practice in paramedics’ judgment and decision-making JDM in the context of mental illness and mental health assessment. Acknowledgments The author would like to acknowledge and thank Mr Jim Higgins, Commissioner QAS, and Dr Richard Bonham, Medical Director QAS for their approval and support of this research. I would also like to acknowledge and thank Associate Professor Claire Wyatt-Smith and Professor Joy Cumming for their supervision and support, and Mr Jason Emmett for his editorial review of this manuscript. References 1. Commonwealth Department of Health and Aged Care: The National Mental Health Report 2000: Changes in Australia's Mental Health Services under the First National Mental Health Plan of the National Mental Health Strategy 1993-1998. In. Canberra; 2000. 2. Wand T, Happell B: The mental health nurse: contributing to improved outcomes for patients in the emergency department. Accident and Emergency Nursing 2001, 9:166-176. 3. Green G: Emergency psychiatric assessments: do outcomes match priorities? International Journal of Health Quality Assurance 1999, 12(7):309-313. 4. Sharrock J, Happell B: The role of the psychiatric consultation-liaison nurse in the general hospital. Australian Journal of Advanced Nursing 2000, 18(1):34-39. 5. Salkovkis P, Storer D, Atha C, Warwick HMC: Psychiatric morbidity in an accident and emergency department - Characteristics of patients at presentation and one month follow-up. British Journal of Psychiatry 1990, 10:1-8. 6. Kalucy R, Thomas L, Lia B, Slattery T, Noris D: Managing increased demand for mental health services in a public hospital emergency department: A trial of 'Hospital-in-the-Home' for mental health consumers. International Journal of Mental Health Nursing 2004, 13:275-281. 7. Anstee BH: Psychiatry in the casualty department. British Journal of Psychiatry 1972, 120(625-629). 8. Bell G, Hindley N, Rajiyah G, Rosser R: Screening for psychiatric morbidity in an accident and emergency department. Archives of Emergency Medicine 1990, 7:154-162. 9. Mental Health Act (Qld). In. Brisbane, Australia: Queensland Government; 2000: 339. 10. Holdsworth N, Dodgson G: Could a new Mental Health Act distort clinical judgment? A Bayesian justification of naturalistic reasoning about risk. Journal of Mental Health 2003, 15(5):451-462. 11. Vincent C (ed.): Clinical risk management: Enhancing patient safety. London: British Medical Journal Books; 2001. 12. Shaban RZ: Mental health assessments in paramedic practice. In: B. Barlett. F. Bryer & R. Roebuck (Eds), Educating: Weaving Research into Practice. Brisbane: School of Cognition, Language and Special Education, Griffith University 13. Shaban RZ, Wyatt-Smith CM, Cumming J: Uncertainty, error and risk in human clinical judgment: Introductory theoretical frameworks in paramedic practice. Journal of Emergency Primary Health Care 2004, 2(1-2). 14. CCH Australia: Managing training and development. Canberra: CCH Australia Limited; 2004. 15. Patel VL, Arocha JF, Kaufman DR: Expertise and tacit knowledge in medicine. In: Tacit knowledge in professional practice. Edited by Sternberg RJ, Horvath JA. London: Lawrence Erlbaum Associates; 1999. 16. Fontaine KL, Fletcher JS: Mental health nursing. Sydney: Addison Wesley; 1999. 17. Queensland Ambulance Service: Clinical Practice Manual. Brisbane: Department of Emergency Services, Queensland Government; 2004. 18. Thompson C, Dowding D: Clinical decision making and judgement in nursing. London: Churchill Livingstone; 2002. 19. Gordon M: Strategies in probabilistic concept attainment: A study of nursing diagnosis. Doctoral Dissertation. Massachusetts: Boston University; 1972. 20. Greenwood J, King M: Some surprising similarities in the clinical reasoning of 'expert' and 'novice' orthopaedic nurses: Report of a study using verbal protocols and protocol analyses. Journal of Advanced Nursing 1995, 22:907-913. 21. Tanner CA, Benner P, Chelsa C, Gordon DR: Diagnostic reasoning strategies of nurses and nursing students. Nursing Research 1987, 36(6):358-363. 22. Hamm RM, Scheid DC, Smith WR, Tape TG: Opportunities for applying psychological theory to improve medical decision making: Two case histories. In: Decision making in health care: theories, psychology and applications. Edited by Chapman GB, Sonnenberg FA. Cambridge: Cambridge University Press; 2000. 23. Cooksey RW: Judgment analysis: Theory, methods and applications. Sydney: Academic Press; 1995. 24. Hammond KR: Human judgment and social policy: Irreducible uncertainty, inevitable error, unavoidable justice. London: Oxford University Press; 1996. 25. Hammond KR: Judgments under stress. New York: Oxford University Press; 2000. 26. Chapman GB, Elstein AS: Cognitive processes and biases in medical decision making. In: Decision making in health care: theories, psychology and applications. Edited by Chapman GB, Sonnenberg FA. Cambridge: Cambridge University Press; 2000. 27. Lord B: Book review: 'Clinical reasoning in the health professions'. Journal of Prehospital Emergency Primary Health Care 2003, 1(3-4). This article was peer reviewed for the Journal of Emergency Primary Health Care Vol.2 (3-4) 2004 Author Disclosure The author has no financial, personal or honorary affiliations with any commercial organization directly involved or discussed in this study. Comments on this Article Hope this helps, ACE844

Since we have been debating the various methods of c-spine and LSB/spinal immoboilization here for some time, and this is the most recent related discussion I have decided to post this study here for your info. Any one have any thoughts or opinions??? Hope this helps, ACE844

In short, seek professional psych attention/help...

Here's an interesting study which looks at a population of pateints which we have all encountered in our profession...Any opinions, or thoughts..? Outcomes of interfacility critical care adult patient transport: a systematic review Eddy Fan1, Russell D MacDonald2, 3, Neill KJ Adhikari4, Damon C Scales4, Randy S Wax5, Thomas E Stewart6 and Niall D Ferguson7 1Fellow, Interdepartmental Division of Critical Care Medicine, University of Toronto, 399 Bathurst Street, F2-150, Toronto, Ontario, M5T 2S8, Canada 2Assistant Professor, Division of Emergency Medicine, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada 3Medical Director, Research Program, Ontario Air Ambulance, 20 Carlson Court, Suite 400, Toronto, Ontario, M9W 7K6, Canada 4Instructor, Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Rm B7-08, Toronto, Ontario, M4N 3M5, Canada 5Assistant Professor, Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 1818, Toronto, Ontario, M5G 1X5, Canada 6Associate Professor, Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, Mount Sinai Hospital and University Health Network, University of Toronto, 600 University Avenue, Suite 1818, Toronto, Ontario, M5G 1X5, Canada 7Assistant Professor, Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada Critical Care 2006, 10:R6 doi:10.1186/cc3924 The electronic version of this article is the complete one and can be found online at: http://ccforum.com/content/10/1/R6 Received 22 August 2005 Revisions requested 2 October 2005 Revisions received 24 October 2005 Accepted 31 October 2005 Published 1 December 2005 © 2005 Fan et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. -------------------------------------------------------------------------------- Outline Abstract Introduction We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients. Methods We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined. Results Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies. Conclusion Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults. Regionalization of care and the requirement for specialized resources result in the frequent need for interfacility transport of critically ill patients [1-3]. Although some of these patients may derive significant benefit from such a transfer, they may also be at considerable risk of transport-related morbidity and mortality [4-12]. The decision to initiate the interfacility transport of a critically ill patient must, therefore, be taken carefully. The impact of specific pre-transport and transport-related factors on morbidity and mortality are not well established, however, limiting the ability of clinicians to target particular patients where additional resources and care during transportation might be beneficial. For example, if high-risk patients could be reliably identified, they could undergo additional pre-transport resuscitation [13,14] and/or be accompanied by specially trained transport personnel with additional equipment in order to anticipate and reduce transport-associated risks [15-21]. Several professional societies have developed guidelines for the inter- and intrafacility transport of critically ill patients [22-25]; however, these guidelines focus primarily on general principles (for example, pre-transport stabilization, minimum transport equipment and medications) and the composition of the transport team, rather than risk stratification. Understanding which patients are most at risk while undergoing interfacility transport and the types of events that occur would be an important step in patient preparation and aligning resources (such as equipment and personnel) at the sending and receiving sites as well as during transportation. To this end, we conducted a systematic review of the literature to determine the adverse events associated with interfacility transport of mechanically ventilated adult patients, along with important pre-transport and transport-related prognostic factors. Identification of trials Our objective was to identify all relevant published clinical studies describing the incidence and predictors of adverse events in mechanically ventilated adults undergoing interfacility transport. We chose to study only intubated and mechanically ventilated patients in order to capture a well-defined group of critically ill patients with significant severity of illness. A priori, we defined adverse events related to transportation as those that occurred during interfacility transport and up to 24 hours after arrival at the destination. A computerized MEDLINE (1966 to 10 January 2005) search was conducted using the following medical subject headings: 'transportation of patients', 'intubation, intratracheal', and 'respiration, artificial'. In addition, we searched the databases CENTRAL (first quarter 2005), EMBASE (1980 to 10 January 2005), CINAHL (1982 to 10 January 2005), HEALTHSTAR (1975 to 10 January 2005), and Web of Science (1945 to 10 January 2005) using the keywords: 'transport', 'ventilation', and 'intubation'. No language restrictions were applied. Bibliographies of all selected articles and review articles [26,27] on interfacility patient transport were examined for other relevant studies. This strategy was performed iteratively, until no new clinical trial citations were found on review of the reference lists of retrieved articles. Full details of the searches are available upon request. Study selection and data abstraction/analysis The following selection criteria were used to identify published studies for inclusion in our analysis: clinical trial or cohort study or case-series (study design); all patients intubated and mechanically ventilated, and aged ≥ 18 years (study population); and interfacility transport (for example, from one health care facility to another health care facility). Interfacility transports between two sites of the same institution were included if the means of transportation involved air or ground ambulance. Two reviewers (EF and RDM) independently applied the selection criteria and abstracted the data using standardized forms. The reviewers abstracted data on description of the cohort, methods, adverse events/outcomes, and transport-related interventions. We report descriptive data from individual trials as mean ± standard deviation, unless otherwise stated. Because of the paucity of studies and the heterogeneity in study populations and reported outcomes, we did not conduct a meta-analysis. Outline Results Table 1 Characteristics of included studies Table 2 Transport characteristics of included studies Table 3 Results of included studies The combined computerized and bibliographic literature search yielded 599 potentially relevant studies, of which 24 articles were identified for more detailed review (Figure 1). Only five studies satisfied our inclusion criteria [28-32]. There was moderate initial agreement between reviewers for study inclusion (raw agreement = 0.80, chance-corrected agreement κ = 0.65 ± 0.16); all disagreements were resolved by consensus. The five included studies (Tables 1 and 2) enrolled 245 critically ill patients (median 15; range 8 to 146) with a wide variety of diagnoses. All were case-series, two of which were prospective. The most common indication for interfacility transport was the need for investigations and/or specialist care not available at the referring institution (three studies, 220 patients) [28,29,31,32]. The results of the included studies are summarized in Table 3. Pre-transport characteristics Only 1 study reported severity of illness (Sepsis-related Organ Failure Assessment (SOFA) [33] score of 10 ± 3) prior to transport [31]. Another study reported pre-transport arterial blood gas results from transported burn patients [28]. The other three studies provided little data on pre-transport status that would be useful in standardizing comparisons across patient groups. Transport characteristics Modalities used for interfacility transport included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in 3 studies (220 patients) [28,31,32]. In one study, 14 patients (21%) were transported in the prone position because of life-threatening hypoxemia [31]. Death during transport was rare (n = 1) [32]. No other adverse events or significant therapeutic interventions during transport were reported in any of the included studies. Post-transport characteristics One study (not the same one that described pre-transport characteristics) reported severity of illness on arrival and outcomes following interfacility transport (mean Acute Physiology and Chronic Health Evaluation (APACHE) II [34] score of 17 ± 6; intensive care unit mortality 30%) [29]. The burn study reported the incidence of respiratory alkalosis on arrival (in 19%) and the survival rate to burn unit discharge (71%) [28]. The presence or absence of post-transport adverse events was not reported in the other three included studies. Table 4 Barriers to transport research and recommendations for future studies The main finding of this systematic review is the paucity of studies examining adverse events and their associated risk factors in critically ill patients undergoing interfacility transport. The few published studies suggest that significant mortality or morbidity associated with interfacility transport of intubated adult patients is uncommon; however, there are significant limitations to the available data. First, the estimation of the incidence of adverse events is unreliable because all studies were case series (the majority of which were retrospective) that enrolled few transported patients. Second, associations between pre-transport variables and adverse outcomes could not be determined, both because pre-transport status was poorly documented, and because studies lacked standard definitions and methods for ascertaining adverse events. Finally, many studies only examined immediate or short-term adverse events (for example, during transport or on arrival), even though it is possible that later adverse events may also be associated with important transport-related factors (for example, barotrauma from exposure to high ventilatory pressures during transport may go unrecognized for several hours). A number of factors may have contributed to the low morbidity of interfacility transport documented in this review. These include the possibility that some patients who were less severely ill were intubated and ventilated solely to facilitate safe transportation, thereby lowering the overall acuity of illness and likelihood of adverse events. The extent to which this practice occurred was not reported in any of the included studies. In addition, the composition of the transport teams may have had an influence. In three of the five included studies, the transport teams included a physician; in two of these the physician was a specialist (a burn surgeon and an intensivist). In addition, a nurse accompanied the patient in all four studies that reported transport team composition. Interfacility transport is increasingly becoming the jurisdiction of highly trained and specialized transport personnel [35-38], with at least one paediatric study demonstrating significantly decreased morbidity associated with the use of such teams [36]. Professional guidelines have suggested that transport of unstable critically ill adults should be accompanied by either a physician or a nurse, preferably with additional training and experience in transport medicine [22]. The results of our review may not have been the same if more data were available from transports without such individuals. Although transport methods, distance, and time differ in intra-hospital transfers, the risks and types of adverse events for the patient may be similar to those undergoing inter-hospital transport [24,39,40]. Several studies of intra-hospital transfers of critically ill patients have reported transport-related complications [39-42]. In a recent study [42], 191 incidents related to intra-hospital transport were identified over a six year period. The majority of adverse events centered on patient-staff management issues and equipment problems that culminated in serious complications in 31% of reported incidents, including major physiological deterioration in 15% and death in 2% [42]. This relatively high rate of adverse events among reported incidents when intrafacility transport is subjected to close scrutiny further calls into question the validity of the results of our review. It seems likely that the potential for adverse events is significantly higher during air transport between two hospitals than on a trip to another department within the same hospital such as the radiology department. Alternatively, a possible explanation is that patients undergoing intra-hospital transports are sicker and/or the personnel associated with these transports are less experienced than inter-hospital transport teams. Finally, we acknowledge that a limitation to the generalizability of our results is the restriction of our review to intubated and ventilated patients undergoing interfacility transport. In our attempt to identify and study a well-defined population of critically ill patients, we may have missed other patients at risk for adverse events during interfacility transport. The lack of informative clinical studies evaluating the interfacility transport of critically ill patients is likely related to a variety of barriers in conducting research in this setting (Table 4). Clearly, deciding if patients will undergo interfacility transport by randomization is infeasible and unethical. Therefore, we believe that a multi-center, prospective observational cohort study is the methodology best suited to address the important questions raised by our review in this rapidly growing field of transit care medicine. In the design of such a study, attention would need to be paid to developing and validating consistent definitions for adverse events. In addition, extensive collaboration between the critical care and transport teams would be essential. Conclusion Few data document the risks of interfacility transport. Until more robust risk assessment tools become available, common sense and physiological rationale will continue to guide the risk/benefit assessment of interfacility transport for individual patients. We believe that more research is required to document the prevalence of adverse events in critically ill patients during transport, and to elucidate the associated patient- and transport-related risk factors. Such research could form the basis of new strategies to optimize patient safety. In addition, better identification of patients at risk may allow for more efficient and effective alignment of transport-related resources, such as specialist retrieval teams and enhanced pre-transfer stabilization. Key messages • Few data exist regarding the mortality, morbidity, and/or risk factors associated with these outcomes in intubated and mechanically ventilated adult patients undergoing interfacility transport. • Further prospective study is required to define the risks and benefits of interfacility transfer in this patient population. • Such information is important for the planning and allocation of resources related to transporting critically ill adults. Competing interests The authors declare that they have no competing interests. Authors' contributions EF, RDM, DCS, TES, and NDF conceived the study. All authors contributed to the study design and interpretation of the data. EF and RDM performed the literature search and abstracted the data. EF wrote the first draft of the manuscript, which was then revised for intellectually important content by all authors. All authors read and approved the final manuscript. Ace844

Hi all, Since there are a number of us here who regularly "cite," and post journal articles. I thought it may be helpful to those who don't know how how, or have never been taught to have a refrence to see how, or if it is applicable to them.. Also, I wanted to post a way for you to "evaluate" what you are reading... Please select the type of article that you are appraising below: Therapy Question- A question concerning the effectiveness of a treatment or preventative measure Diagnosis Question - A question concerning the ability of a test to predict the likelihood of a disease Prognosis Question - A question concerning outcome of a patient with a particular condition Harm Question - A question concerning the likelihood of a therapeutic intervention to cause harm ________________________________________________________________________________ _____________________ Appraising Relevant Overview or Meta-Analysis To appraise a systematic overview, there is a series of questions that you must answer. First of all, was the study valid? Did the overview address a focused clinical question? Were the criteria used to select articles for inclusion clearly stated and appropriate? Is it likely that important relevant studies were missed by the search strategies employed? Was the validity of the included studies appraised? Were the validity criteria used appropriate to the nature of the clinical question? Were the assessments of the studies with respect to inclusion criteria reproducible? Were the results similar from study to study? If heterogeneity was present, was it clinically significant? After thinking about the above questions, Is there a FATAL flaw in the study? If there is, then toss this study and go onto the next one. If not, continue the appraisal. -------------------------------------------------------------------------------- What were the results? Were the results reported in the form that you need to apply them to your practice? i.e. relative risk or odds ratio for therapy, likelihood ratio for diagnosis, etc. If not, is data given which allows you to calculate the needed parameters from the reported results? Were the results pooled, and were the confidence intervals sufficiently narrow to eliminate ambiguity? Appraising Relevant Therapy Studies To appraise a study, there is a series of questions you must answer. First of all, was the study valid? Was the study randomized? Was follow-up complete and adequate and were all patients kept in the groups to which they were assigned? Was the study blinded? Aside from the intervention(s) being studied, were the patients treated identically in the different groups? Were the groups similar at the start of the study? After thinking about the above questions, Is there a FATAL flaw in the study? If there is, then toss this study and go onto the next one. If not, continue the appraisal. -------------------------------------------------------------------------------- What were the results? Did the study CLEARLY show harm or benefit? Were confidence intervals reported and was the entire interval on one side or the other of the HARM-BENEFIT line? If no confidence intervals, were P values reported and were they less then .05 -------------------------------------------------------------------------------- Are the results applicable to my patients? Were all clinically important outcomes reported? Were absolute risk data reported for dichotomous outcomes ? What was the number needed to treat for the important dichotomous outcomes? Number needed to treat calculator Are the overall results clinically significant? Would these results apply to my patients? Did the treatment cause harm which might outweigh the benefit for my patient(s)? -------------------------------------------------------------------------------- Overall: Does this study answer the original clinical question and is the answer meaningful? -------------------------------------------------------------------------------- If this study is does not answer the original question or if the answer is not meaningful after the above appraisal, then toss out the study and proceed to the next one Appraising Relevant Diagnosis Studies To appraise a study, there is a series of questions you must answer. First of all, was the study valid? Was there an independent comparison with an acceptable " Gold Standard " Did the study population involve an appropriate spectrum of disease? Were subjects without disease clinically symptomatic? Was the gold standard test performed on all patients who underwent the diagnostic test in question? Were the methods described in sufficient detail to permit duplication? After thinking about the above questions, Is there a FATAL flaw in the study? If there is, then toss this study and go onto the next one. If not, continue the appraisal. -------------------------------------------------------------------------------- What were the results? What are the likelihood ratios(s)? likelihood ratio calculator -------------------------------------------------------------------------------- Are the results applicable to my patients? Did the disease spectrum in the study population reflect that of the patients for whom I might need this test? Are there other reasons that this test might perform differently in my patient population? Can the accuracy reported for this test be achieved in my practice setting? Will the results effect my management of my patients? Bayes Theorem nomogram (you must have entered figures into calculator above) Do the benefits of this test justify the costs, risks, and inconvenience to my patients? -------------------------------------------------------------------------------- Overall: Does this study answer the original clinical question and is the answer meaningful? -------------------------------------------------------------------------------- If this study is does not answer the original question or if the answer is not meaningful after the above appraisal, then toss out the study and proceed to the next one. Appraising Relevant Prognosis Studies To appraise a study, there is a series of questions you must answer. First of all, was the study valid? Was there a representative sample of patients as a well-defined point in the course of the disease? Was the follow-up sufficiently long and complete? Were the outcomes well-defined and unambiguously measurable? Were important prognostic factors identified and were their effects on relevant outcomes reported? After thinking about the above questions, Is there a FATAL flaw in the study? If there is, then toss this study and go onto the next one. If not, continue the appraisal. -------------------------------------------------------------------------------- What were the results? How large is the likelihood of the outcomes in a specified period of time? Are confidence intervals reported? -------------------------------------------------------------------------------- Are the results applicable to my patients? Was the study population sufficiently similar to my own? Do the results help to identify which of my patients will most benefit from specific therapies? Do the results allow me to tell my patients what they want to know? -------------------------------------------------------------------------------- Overall: Does this study answer the original clinical question and is the answer meaningful? -------------------------------------------------------------------------------- If this study is does not answer the original question or if the answer is not meaningful after the above appraisal, then toss out the study and proceed to the next one. Appraising Relevant Studies on Harm To appraise a study, there is a series of questions you must answer. First of all, was the study valid? Were the comparison groups similar with respect to factors which could forseeably influence outcome? Were outcomes and exposures measured in the same way in all groups? Was follow-up sufficiently long and complete? Did exposure precede the appearance of the symptoms in question? For medicines, is there a dose-response relationship with respect to the symptoms in question? After thinking about the above questions, Is there a FATAL flaw in the study? If there is, then toss this study and go onto the next one. If not, continue the appraisal. -------------------------------------------------------------------------------- What were the results? How large is the Relative Risk (RR) or Odds Ratio (OR) of the measured outcomes in the exposed group? Are confidence intervals given for the Relative risk or Odds ratio? -------------------------------------------------------------------------------- Are the results applicable to my patients? Is the magnitude of the risk sufficiently large to obviate the need for work-up of other causes of symptoms? Is my patient at particular risk for a bad outcome from this exposure? Do I need to stop the exposure? -------------------------------------------------------------------------------- Overall: Does this study answer the original clinical question and is the answer meaningful? -------------------------------------------------------------------------------- If this study is does not answer the original question or if the answer is not meaningful after the above appraisal, then toss out the study and proceed to the next one. Definitions:: - A - Absolute risk and its reduction This is the percentage of subjects in any group or sub-group that experiences a discrete bad outcome such as death or admission to the hospital. An efficacious therapy serves to reduce that risk. For example, if 15% of the placebo group died and 10% of the treatment group died, the absolute reduction in the risk of death is 5%. Accuracy The proportion of all test results (positives and negatives) which agreed with the gold standard. Applicability (also called external validity, generalizability, relevance) This is the degree to which the results of an observation, study, or review are likely to hold true in your practice setting. For a detailed discussion, click HERE. -------------------------------------------------------------------------------- - B - Bayes' Theorem This is a simple formula that says that if a particular test result is twice as likely to occur in patients with a disease, condition, or injury than in patients without, then, it is twice as likely that the patient with the result being tested for actually has the disease as compared to any randomly selected similar patient who has not been tested. If you don't like thinking about things like this, just use the nomogram in the users guides or the calculator on the diagnosis appraisal page. Bias This is any factor which might change the results of a study from what they would have been if that factor were NOT present. The direction of bias may be unpredictable. For example, giving a team a ten point advantage might seem to give that side an advantage but some teams actually play much better when they have to come from behind! The validity of a study is integrally related to the likelihood that the results have been biased by factors extraneous to the study design. Blinding The "masking" or concealment from study subjects, caregivers, or others involved in the study of any detail(s) of the study which could introduce Bias. For example, not telling patients or doctors which patient gets placebo or actual drug; or not telling radiologists the clinical assessment of patients whose films they are reading. -------------------------------------------------------------------------------- - C - Case-control study This might be considered a randomized controlled trial played backwards. People who get sick or have a bad outcome are identified and "matched" with people who did better. Then, the effects of the therapy or harmful exposure which might have been administered at the start of the trial are evaluated. In other words, you first find the people who did poorly and then look at the therapy or exposure and compare it to people who didn't get the therapy. Needless to say, this is a crude way of doing a study. When the effect of interest is HARM, this may actually be the only ethical way of doing the study. Case report This includes single case reports and published case series'. These are searchable as a separate category in the MEDLINE database C.A.T. see critically appraised topic Clinical significance Results are clinically significant when they make enough difference to you and your patient to justify changing your way of doing things. For example, a drug which is found in a megatrial of 50,000 adults with acute asthma to increase FEV1 by only 0.5% (P value<.0001) has failed this test of significance. Cochrane Collaboration An international organized effort to organize all existing clinical studies into systematic reviews easily accessible to practicing clinicians and to otherwise facilitate the process of bringing clinical evidence to bear on decision making in patient care. Cohort study Also called a "prospective observational study", this design follows a group of patients, called a "cohort", over time to determine general outcome as well as the outcomes of different subgroups. Cointervention A therapy or other ancillary treatment which is NOT under investigation which is given to study patients. Confidence intervals An interval around an observed parameter such as relative risk which is guaranteed to include the true value to some level of confidence (usually 95%). That level of confidence is only justified to the extent that bias is absent from the study. A well known election poll advertises itself "this poll is accurate to within 2 percentage points 99% of the time." This is a way of saying, in language aimed at voters (perhaps a skewed sample from the standpoint of IQ) that the 99% CI around the reported percentages is + 2. Controlled clinical trial Any study which compares two groups by virtue of different therapies or exposures fulfills this definition. Critical appraisal The process of assessing and interpreting evidence systematically considering its validity, results, and relevance. For more information, consult the User's Guides. Critically appraised topic (C.A.T.) A 1 or 2 page summary of a search and critical appraisal of the literature related to a focused clinical question. This summary should be kept in an easily accessible place so that it can be used to help make clinical decisions. -------------------------------------------------------------------------------- - D - Dichotomous outcome Any outcome measure in which there are only two possibilities, like dead/alive, admitted/discharged, graduated/sent to glue factory. Beware of potentially fake dichotomous outcome reports such as "improved/ not improved", particularly when derived from continuous outcome measures. For example, if I define a 10 point or greater increase in peak expiratory flow in a study of acute asthma as "improved", I may show what looks like a tremendous benefit when the results were clinically insignificant. This is lesson 2a in "How To Lie With Statistics." Double blind A single blind study means that someone (patient or physician) does not know what is going on. Double blind means that at least two people (patient and physician) don't know what's going on. Triple blind might mean that the paper is written before the results are tabulated. The whole point is to prevent bias. -------------------------------------------------------------------------------- - E - Effect size The difference in measured outcomes attributed to a therapeutic intervention. This term is encountered in meta-analyses when different studies have measured different things. For example, results of an asthma study which measured FEV1 could be combined with those of another study which measured return visits to the ED using a statistically derived generic effect size. Do you prefer skiing or red wine? Effectiveness I buy a BMW which test drives miraculously on the dealer’s special runway. I then find that the roads in the area where I live have all been closed. This is a breakdown of effectiveness. See efficacy. Efficacy The BMW I have selected for a test drive blows all four tires, stalls out and crashes on the dealer’s special runway. I spend two days in the hospital. This is a breakdown in efficacy. See effectiveness. Event rate This is a term for absolute risk. Exposure Anything you can be exposed to: a drug, a surgical procedure, time, sexual harassment, rounds, even a diagnostic test. Most commonly encountered in therapy, prognosis or harm studies where the EFFECT of an "exposure" is the subject of the study. External validity See applicability. -------------------------------------------------------------------------------- - F -(empty) -------------------------------------------------------------------------------- - G - Generalizability See applicability. Gold standard No longer relevant in the realm of high finance from whence it originated, this term gained new life when it was decided that it should refer to a reference standard for evaluation of a diagnostic test. For the purposes of a study, the "gold standard" test is assumed to have 100% sensitivity and specificity. This may well constitute an exaggerated estimate of the reference test. Choice of the "gold standard" must therefore be evaluated in appraising a diagnosis study. -------------------------------------------------------------------------------- - H - Harm-Benefit Line On a graph of outcomes, this line divides results favoring therapy from results favoring the control. Heterogeneity Also called "homogeneity" but having nothing to do with sexual preference, this term is used to designate a statistical test used to determine whether results from a set of independently performed studies on a particular question are similar enough to make statistical pooling valid. Are the apples sufficiently red and the oranges sufficiently green to be able to add them up and report the total number of "orpples"? As in other matters, statistical tests do not guarantee clinical relevance. Homogeneity See heterogeneity. -------------------------------------------------------------------------------- - I - Incidence The rate at which an event occurs in a defined population over time. To be distinguished from prevalence. Intention-to-treat Intentions... that with which the path to hell is lined. Patients assigned to a particular treatment group by the study protocol should be retained in that group for the purpose of analysis of the study results no matter what happens. Patients redefined or dropped from a study early on as a result of protocol violations unlikely to create bias may validly be considered exceptions to this rule. Internal validity See validity. -------------------------------------------------------------------------------- - J - (empty) -------------------------------------------------------------------------------- - K - (empty) -------------------------------------------------------------------------------- - L - Likelihood Ratio An operator defined as the percentage of patients positive by gold standard for a particular disease, condition or injury who have a particular test result divided by the percentage of patients without the problem who have that same test result. A likelihood ratio of two means that the test result in question is twice as likely to come a patient with the problem as it is from a patient without the problem. The LR may be derived from reported sensitivity and specificity or from a clear understanding of the above definition. To see how the LR is used, see Bayes‘ Theorem; to actually use it, see the nomogram. To see how the Likelihood Ratio is generated, use the calculator -------------------------------------------------------------------------------- - M - Meta-analysis A review of a focused clinical question following rigorous methodological criteria and employing statistical techniques to combine data from independently performed studies on that question. To learn more, see the User’s Guide. -------------------------------------------------------------------------------- - N - Nomogram for Likelihood Ratio Null hypothesis What do you do when you want others to be maximally impressed with what you do? You DECREASE EXPECTATIONS, then what you do accomplish looks even better! The null hypothesis is the assumption that there is no difference between the groups and that the treatment you are studying has no effect. Any difference in outcome actually observed between the groups is then evaluated in relationship to the "zero expectation" hypothesis. Number needed to treat (NNT) The number of patients who must receive a particular therapy for one to benefit. You might tell a patient that an NNT of 10 means that the chance that he/she will benefit in this way from the treatment is 1 in 10. To calculate NNT use the calculator. -------------------------------------------------------------------------------- - O - Observational study Any study of therapy, prevention or harm in which the exposure is not assigned to the individual subject by the investigator(s). A synonym is "non-experimental"; examples are case-control and cohort studies. Odds ratio The odds of an event, understood best by those who enjoy wagers, is the number of times it occurred (a) divided by the number of times it didn’t (, or a/b. This contrasts with the probability of an event which is the number of times it occurred divided by the number of times it could have occurred, or a/a+b. The odds ratio is the ratio of the odds of an event in one group divided by the odds in another group. When the event rate or absolute risk in the control group is small (less than 20% or so), then the odds ratio is very close to the relative risk. -------------------------------------------------------------------------------- - P - Placebo The thing you give a study subject who has been assigned to the control group to make them think they are getting the treatment you are studying. Point estimate The exact result that has been observed in a study. The confidence interval tells you the range within which the result is likely to lie. Post-test probability The likelihood that your patient has the disease, condition or injury you are testing for at the moment the result of the test you (or someone) ordered is delivered to you. To calculate it you need the pretest probability or prevalence and also the likelihood ratio for the test in question. To do this, you could use Bayes theorem or, if you are lazy (and practical), use the nomogram. Pre-test probability At the point you order a diagnostic test, you already have some idea of how likely your patient is to have the disease, condition or injury in question. You think of this as small, medium or large. "Pretest probability" means putting a number on the estimate you have already made. A difference of 10% in either direction will not change the effect of the diagnostic test. Putting the number on your clinical estimate will, however, allow you to determine what the test result means, should you want to know. This is also called prevalence. Prevalence The proportion of people in a defined group who have a disease, condition or injury. In the context of diagnosis, this is also called "pre-test probability." To be distinguished from incidence. Prospective study Any study done forwards in time. This is particularly important in studies on therapy, prognosis or harm, where retrospective studies make hidden biases very likely. Publication bias A possible bias which can effect systematic overviews to the extent that studies on the question at hand with conflicting results may not have been published. P value The probability that the difference(s) observed between two or more groups in a study would occurred if there were no differences between the groups other than those created by random selection. The assumption underlying the p-value is the null hypothesis. Power The chance that an experimental study will correctly observe a statistically significant difference between the study groups. This may be considered the "sensitivity" of the study trial itself for detecting a difference when it is there. -------------------------------------------------------------------------------- - Q - (empty) -------------------------------------------------------------------------------- - R - Randomization A technique which gives every patient an equal chance of winding up in any particular arm of a controlled clinical trial. Randomized Controlled Trial A controlled clinical trial in which the study groups are created through randomization. Relative risk and its reduction The probability of an event in one group divided by the probability of the same event in another group. Generally the event is a bad one and the rate in the therapy group (when it is a therapy study) is in the numerator. When a benefit has been observed, this ratio is less than one. Subtracting the ratio from one gives the relative risk reduction, which is the percentage by which the risk in the control group has been reduced by the therapy. Reliability Sometimes used loosely, this actually refers to the reproducibility of a measurement procedure. It is NOT the same as validity or applicability of a study. Retrospective study Any study in which the outcomes have already occurred before the study has begun. Risk factor Any aspect of an individual’s life, behavior or inheritance which increases the likelihood of a disease, condition or injury. -------------------------------------------------------------------------------- - S - Sensitivity The probability that a patient with a disease, condition or injury will test positive by a particular test for the problem. Sensitivity analysis An analytical procedure to determine how the results of a study would change if the facts were different or different studies included. This is chiefly important in meta-analysis or complex techniques such as decision analysis and cost-effectiveness analysis. Specificity The probability that patients without a particular disease, condition or injury will test negative for the problem by a particular test. Statistical power see Power Statistical significance A measure of how confidently an observed difference between two or more groups can be attributed to the study interventions. The p value is the most commonly encountered way of reporting statistical significance. The methods assume that the study is free of bias. Clinical significance is entirely independent from statistical significance. Stratified randomization A way of ensuring that the different groups in an experimental trial are balanced with respect to important factors which could effect outcome. Spectrum In a diagnosis study, the range of clinical presentations and of relevant disease advancement exhibited by the subjects included in the study. Systematic overview A formal review of a focused clinical question based on a comprehensive search strategy and structured critical appraisal. -------------------------------------------------------------------------------- - T - Threshold Probabilities The level of suspicion at which your clinical decision changes -------------------------------------------------------------------------------- - U - User's Guide A guide to using literature that was developed by the evidence based medicine group from McMaster University in Canada. For further information, please click on McMaster link on main menu. Utility Particularly for a diagnostic test, this is a measure of whether the patient is truly better off as a result of the test. A test could have high sensitivity, specificity and good likelihood ratios and still have low utility if it is very invasive or poses other risks or inconvenience to the patient. It belongs under the section of a diagnostic review. -------------------------------------------------------------------------------- - V - Validity The degree to which the results of a study are likely to be true, believable and free of bias. This is entirely independent of the precision of the results (p value) and does not predict the of the results to your patients. For a detailed discussion of validity, Literature Class Validity Importance Applicability All Therapy Diagnosis Harm Prognosis Overview Decision Analysis Practice Guideline Utilization Review Outcome Analysis -------------------------------------------------------------------------------- - W - (empty) -------------------------------------------------------------------------------- - X - (empty) -------------------------------------------------------------------------------- - Y - (empty) -------------------------------------------------------------------------------- - Z - (empty) -------------------------------------------------------------------------------- Here are some articles to also read about this!!:: 1) Oxman AD, Sackett DL, Guyatt GH. Users' guides to the medical literature. I. How to get started. JAMA 1993; 270: 2093-2095. 2) Guyatt GH, Sackett DL and Cook DJ. Users' guides to the medical literature. II. How to use an article about therapy or prevention. A. Are the results of the study valid? JAMA 1993; 270:2598-2601. 3) Guyatt GH, Sackett DL and Cook DJ. Users' guides to the medical literature. II. How to use an article about therapy or prevention. B. What were the results and will they help me in caring for my patients? JAMA 1994; 271:59- 63. 4) Jaeschke R, Guyatt G and Sackett DL. Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. Are the results of the study valid? JAMA 1994; 271 (5):389-391. 5) Jaeschke R, Gordon H, Guyatt G & Sackett DL. Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. what are the results and will they help me in caring for my patients? JAMA 1994; 271:703-707. 6) Levine M, Walter S, Lee H, Haines T, Holbrook A & Moyer V. Users'guides to the medical literature. IV. How to use an article about harm. JAMA 1994; 271 (20):1615-1619. 7) Laupacis A, Wells G, Richardson S , Tugwell P. Users' guides to the medical literature. V. How to use an article about prognosis. JAMA 1994; 272:234-237. Richardson WS , Detsky AS. Users' guides to the medical literature. VII. How to use a Clinical Decision Analysis. A. Are the results of the study valid? JAMA 1995; 273 (16):1292-1295. 9) Richardson WS, Detsky AS. Users' guides to the medical literature. VII. How to use a Clinical Decision Analysis. B. What are the results and will they help me in caring for my patients? JAMA 1995; 273 (20):1610-1613. 10) Guyatt GH, Naylor CD, Juniper E et al. Users' guides to the medical literature. XII. How to use articles about health-related quality of life. Evidence-Based Medicine Working Group. JAMA 1997; 277 (15):1232-1237. 11) Oxman AD, Cook DJ, Guyatt GH. Users guide to medical literature. VI. How to use an overview. JAMA 1994; 272:1367-71. 12) Wilson MC, Hayward RS, Tunis SR, Bass EB, Guyatt GH. Users guide to medical literature VIII How to use clinical practice guidelines (A). Are the recommendations valid. JAMA 1995; 274:570-4. 13) Wilson MC, Hayward RS, Tunis SR, Bass EB, Guyatt GH. Users guide to medical literature VIII. How to use clinical practice guidelines (. What are the recommendations and will they help you in caring for your patient? JAMA 1995; 274:1630-2 14) Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook RJ. Users guide to medical literature IX. A method for grading health care recomendations. JAMA 1995; 274:1800-4 15) Naylor CD , Guyatt GH. Users guide to medical literature X. How to use an article reporting variations in the outcomes of health services. JAMA 1996; 275:554-8. 16) Naylor CD , Guyatt GH. Users guide to medical literature XI. How to use an article about a clinical utilization review. JAMA 1996; 275:1435-9 17) Drummond MF, Richardson WS, OBrien BJ, Levine M and Heyland D. Users guide to medical literature XIII. How to use an article on economic analysis of clinical practice: A. Are the results of the study valid? JAMA 1997; 277:1552-1557. 1 OBrien BJ, Heyland D, Richardson WS, Levine M , Drummond MF . Users guide to medical literature XIII How to use an article on economic analysis of clinical practice: B. What are the results and will they help me in caring for my patients? JAMA 1997; 277:1802-1806 19) Dans AL, Dans LF, Guyatt GH, Richarson S. Users guide to medical literature XIV. How to decide on the applicability of clinical trial results to your patient. JAMA 1998; 27; 279:545-9 20) Richardson S, Wilson M, Guyatt GH, Cook DJ, Nishikawa J. Users guide to medical literature XV. How to use an article about disease probability for differential diagnosis. JAMA 1999; 281:1214-9. 21) Guyatt GH, Sinclair J, Cook DJ, Glasziou P. Users guide to medical literature XVI. How to use a treatment recommendation. JAMA 1999; 281:1836-43. 22) Barratt A, Irwig L, Glasziou P, et.al. Users guide to medical literature XVII How to use guidelines and recommendations about screening. JAMA 1999; 281:2029 23) Randolph AG, Haynes RB, Wyatt JC, Cook DJ, Guyatt GH. Users guide to medical literature XVIII How to use an article evaluating the clinical impact of a computer-based clinical decision support system. JAMA 1999; 282: 67- 74. Hope this helps, ACE844

protocols are practice guidelines and minimums, not the end all be all last word...but alas lets try to keep this on topic..this has been discussed elsewhere here well the "protocol" bit anyway

Unfortunately in my area we have a regular gathering of the "Protocol gestapo," whom by their own consensus have reached the conclusion that a fall or any "trauma which potential involves spinal injury" is all the "Mechanisim", one needs and all of those who have this get a board and collar. This is far from an educated, knowledgeable, or progressive approach. Sadly, although if one should choose not to board, they run the very real risk of losing thier job, house, car, etc....& so on...So, on the flip side and despite multiple attempts by colleagues, EMCAB here refuses to acknowledge the practice reality, so we are stuck with potentially causing our patients harm, to lower our litigous risk...sad but true.. out here, ACE844

Hi All, With the abundance of so many of our professional "coleagues" from the grate abyss to our north, i decided to look into some of their literature and saw this article which at this time of year may be useful.. http://www.caep.ca/004.cjem-jcmu/004-00.cj...005/v76.378.htm

CHANGES IN PHYSICAL EXAMINATION CAUSED BY USE OF SPINAL IMMOBILIZATION. March JA, Ausband SC, Brown LH. Prehosp Emerg Care 2002 Oct-Dec;6(4):421-4. BACKGROUND: The standard of care for patients following blunt trauma includes midline palpation of vertebrae to rule out fractures. Previous studies have demonstrated that spinal immobilization does cause discomfort. OBJECTIVE: To determine whether spinal immobilization causes changes in physical exam findings over time. METHODS: This was a single-blinded, prospective study at a tertiary care university teaching hospital. Twenty healthy volunteers without previous back pain or injuries, 13 male and seven female, were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation. RESULTS: Three patients had point tenderness of cervical vertebrae within 40 minutes. Five patients developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1-1), in contrast to 4 (range 1-9) at 60 minutes, p < 0.05. CONCLUSION: This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations. THE EFFECT OF SPINAL IMMOBILIZATION ON HEALTHY VOLUNTEERS. Chan D, et al. Ann Emerg Med 1994 Jan;23(1):48-51. STUDY OBJECTIVE: To determine the effects of standard spinal immobilization on a group of healthy volunteers with respect to induced pain and discomfort. DESIGN: Prospective study. SETTING: University teaching hospital. TYPE OF PARTICIPANTS: Twenty-one healthy volunteers with no history of back disease. INTERVENTIONS: Subjects were placed in standard backboard immobilization for a 30-minute period. Number and severity of immediate and delayed symptoms were determined. MEASUREMENTS AND MAIN RESULTS: One hundred percent of subjects developed pain within the immediate observation period. Occipital headache and sacral, lumbar, and mandibular pain were the most frequent symptoms. Fifty-five percent of subjects graded their symptoms as moderate to severe. Twenty-nine percent of subjects developed additional symptoms over the next 48 hours. CONCLUSION: Standard spinal immobilization may be a cause of pain in an otherwise healthy subject. COMMENT: Yet another reason to get that patient off that backboard as soon as you can. 2005; Volume 3 : Issue 3 Article Number: CC930130 Spinal Immobilisation in Prehospital Trauma Patient Ayan Sen Keywords cochrane corner hot topic; spinal immobilisation; spinal injury; trauma Indications for prehospital spinal immobilization have changed dramatically over the history of modern Emergency Medical Systems.1 Prehospital practice currently comprises immobilization of essentially all patients with any potential for spinal injury based on mechanism of injury.1 Cost-effective care of trauma patients has advanced significantly, and numerous studies examining indications for spine radiographs in trauma patients have been published.2-7 The findings of these studies universally support the use of clinical criteria to determine the need for spinal radiographs. They also support the presumption that without symptoms and physical findings associated with spinal injury, no significant spinal injury exists. Spinal immobilization on a rigid backboard is not without complications. Besides the direct cost of the equipment, there are also significant effects on patient comfort and the cost of Emergency evaluation. Respiratory compromise due to the strapping techniques used and pressure complications from rigid immobilization have been reported.8,9 Head and back pain is a nearly universal complication of prolonged rigid spinal immobilization and can alter Emergency department presentation and evaluation, necessitating radiographs that might have been avoided by omitting spinal immobilization in asymptomatic patients.10-11Data SourceThe Cochrane Library 2005, Issue 1.Search TermsPrehospital Search Filter Version - 1.0 12Spine, spinal, cervix, cervic*, lumbar, thorac*, neck, whiplash, immobil*, stabili*, stable, collar, backboard, back-board, splint*, board*, strap*Search ResultsProtocolsNoneSystematic ReviewsKwan I, Bunn F, and Roberts I, on behalf of the WHO Pre-Hospital Trauma Care Steering Committee. Spinal immobilization for trauma patients. The Cochrane Database of Systematic Reviews, Date of Most Recent Substantive Amendment: 22 January 2001.Clinical TrialsNoneCommentaryThe authors of the systematic review did not find any randomized controlled trials (RCTs) quantifying the effect of spinal immobilization in trauma patients, and the possible adverse effects of its application. Therefore, the effects on mortality, neurological injury, spinal stability and adverse effects in this cohort of patients remain uncertain. Domeier11 conducted a study in 2002 to evaluate five pre-hospital clinical criteria-altered mental status, neurological deficit, spine pain or tenderness, evidence of intoxication, or suspected extremity fracture-the absence of which identified 94.9% of pre-hospital trauma patients without a significant spine injury. Hauswald and Braude13 in their review of literature mention that it is now clear that immobilization subjects most patients to expensive, painful, and potentially harmful treatment for little, if any, benefit. Low-risk patients can be safely cleared clinically, even by individuals who are not physicians. March et al14 reported that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. Studies done on healthy volunteers have shown that the vacuum splint is more comfortable than long spinal boards with no loss of stability. Randomized controlled trials and large prospective studies are needed in trauma patients to validate the decision criteria for spinal immobilization in trauma patients with high risk of spinal injury.The Bottom LineThe Cochrane review conducted in 2001 did not find any randomized trials on pre-hospital spinal board immobilization but numerous reports, reviews and studies highlight use of clinical criteria along with mechanism of injury necessitating future RCTs for level 1 evidence.15 This Article should be cited as: Sen A. Spinal Immobilisation in Prehospital Trauma Patients. Journal of Emergency Primary Health Care [serial on the Internet]. 2005;3(3): Item No. CC990130. Available from: http://www.jephc.com/full_article.cfm?content_id=261 Padded vs unpadded spine board for cervical spine immobilization R Walton, JF DeSalvo, AA Ernst and A Shahane Department of Medicine, Louisiana State University, New Orleans, USA. OBJECTIVES: To determine whether padding the long spine board improves patient comfort, affects cervical spine (c-spine) immobilization, or increases sacral transcutaneous O2 tension. METHODS: A prospective randomized, controlled crossover study of healthy volunteers was conducted over a two-week period. Participants included 30 volunteers with no previous history of c-spine injury or disease. The subjects were randomized to either padded or unpadded long spine board immobilization with serial measurements of discomfort (using a visual analog scale) and transcutaneous tissue O2 tension obtained at zero and 30 minutes. Measurements of ability to flex, extend, rotate, and laterally bend the c-spine were made using a goniometer. The subjects then returned a minimum of three days later to complete the opposite half of the study (padded vs unpadded boards). RESULTS: Subject discomfort was significantly reduced in the padded group compared with the unpadded group (p = 0.024). There was no significant difference in flexion (p = 0.410), extension (p = 0.231), rotation (p = 0.891), or lateral bending (p = 0.230) for the two groups. There was no significant difference in the actual drop in sacral transcutaneous O2 tension from time zero to 30 minutes for the padded and the unpadded groups (mean drop = 14.8% +/- 17.5% vs 12.2% +/- 16.8%, respectively; p = 0.906). CONCLUSION: Adding closed-cell foam padding to a long spine board significantly improves comfort without compromising c-spine immobilization. Sacral tissue oxygenation does not appear affected by such padding for healthy volunteers. Backboard versus mattress splint immobilization: a comparison of symptoms generated. Chan D, Goldberg RM, Mason J, Chan L. Department of Emergency Medicine, University of Southern California Medical Center, Los Angeles 90033-1084, USA. The study objective was to compare spinal immobilization techniques to a vacuum mattress-splint (VMS) with respect to the incidence of symptoms generated by the immobilization process. We used a prospective, cross-over study in a university hospital setting. Participants consisted of 37 healthy volunteers without history of back pain or spinal disease. Interventions consisted of two phases. In Phase I, subjects were randomly assigned to be immobilized on either a wooden backboard or a mattress-splint for 30 min. The incidence and severity of any symptoms generated by the immobilization process were recorded. In Phase II, the two groups were again tested after a 2-week washout period, with the method of immobilization being reversed. Symptoms and severity were again recorded. Pain symptoms were confined to four anatomic sites: Occipital prominence, lumbosacral spine, scapulae, and cervical spine. After adjusting for the effect of order of exposure, subjects were 3.08 times more likely to have symptoms when immobilized on a backboard than when immobilized on the VMS. They were 7.88 times more likely to complain of occipital pain and 4.27 times more likely to complain of lumbosacral pain. Severity of occipital and lumbosacral pain was also significantly greater during backboard immobilization. We conclude that, when compared to a VMS, standard backboard immobilization appears to be associated with an increased incidence of symptoms in general and an increased incidence and severity of occipital and lumbosacral pain in particular.

I used to feel the same about that, until I went to a progressive medic program that acutally taught[>gasp<]..MEDICINE.. :shock: who'd have thunk it possible!?!? :shock: :!: :wink: 8) :arrow: ..But back on track, please check the literature posted, and the links below, the studies will point out the more than likely reasons why this occurred. More often than not as "rid," asserted in his original post, the patient recieved no "benefit" from the board and could have been "ruled out" clinically, as you saw the "doc" do first hand. Furtheremore, the board is for transport, extrication, and in rare cases confirmed Fx stabilization ONLY, not for long term "in-house" use... Hope this helps, ACE844

Hi All, For more “Studies and info on and related to this subject for those interested which have been previously discussed here:: http://www.emtcity.com/phpBB2/viewtopic.php?t=3116 http://www.emtcity.com/phpBB2/viewtopic.php?t=2820 http://www.emtcity.com/phpBB2/viewtopic.php?t=1740 http://www.emtcity.com/phpBB2/viewtopic.php?t=2570 http://www.emtcity.com/phpBB2/viewtopic.php?t=2499 http://www.emtcity.com/phpBB2/viewtopic.php?t=2025 http://www.emtcity.com/phpBB2/viewtopic.php?t=319 http://www.emtcity.com/phpBB2/viewtopic.php?t=1405 out here, Ace844

"Rid," The bold portion of the study above is where i begin to take issue with it's efficacy. It was merely a review of H&P and the chart as opposed to a controlled clinical study, big difference between the 2 IMHLO...Although on the totherside of this there are a number of "clinical" trials which came to a similar conclusion, although personally, it certainly wasn't a "landmark" paper..Food for thought. For more “Studies and info on and related to this subject for those interested which have been previously discussed here:: http://www.emtcity.com/phpBB2/viewtopic.php?t=3116 http://www.emtcity.com/phpBB2/viewtopic.php?t=2820 http://www.emtcity.com/phpBB2/viewtopic.php?t=1740 http://www.emtcity.com/phpBB2/viewtopic.php?t=2570 http://www.emtcity.com/phpBB2/viewtopic.php?t=2499 http://www.emtcity.com/phpBB2/viewtopic.php?t=2025 http://www.emtcity.com/phpBB2/viewtopic.php?t=319 http://www.emtcity.com/phpBB2/viewtopic.php?t=1405 For those that are interested, here are more studies for you all to look at and learn from...:: http://www.ispub.com/ostia/index.php?xmlFi...2/spinestab.xml http://www.nata.org/jat/readers/archives/4...50-40-3-162.pdf. http://www.pubmedcentral.nih.gov/articlere...gi?artid=233172 http://www.spineuniverse.com/pdf/traumaguide/1.pdf. http://www.hartwellmedical.com/clinical.html http://pdm.medicine.wisc.edu/20-1%20PDFs/Kwan.pdf. http://www.geocities.com/rcrmced/AbsArt_fi...ne_Immobil.html http://www.charlydmiller.com/RA/alltiedup3.html http://www.fernoeducation.it/news/ACEP%20ABSTRACT.pdf. http://www.caep.ca/004.cjem-jcmu/004-00.cj...001/v31-031.htm ...http://www.paramedicpractitioner.com/C-Spine%20Rule%20out_files/frame.htm#slide0016.htm , http://www.caep.ca/004.cjem-jcmu/004-00.cj...001/v31-031.htm://http://www.paramedicpractitioner.co...v31-031.htm://http://www.paramedicpractitioner.co...v31-031.htm://http://www.paramedicpractitioner.co...v31-031.htm , http://www.naemsp.org/Position%20Papers/ClinGdeSpine.html ://http://www.paramedicpractitioner.co...Spine.html http://www.aafp.org/afp/20040615/tips/17.html http://www.ohri.ca/programs/clinical_epide...Summary0211.pdf http://www.jephc.com/full_article.cfm?content_id=261 References 1. Mahadevan S, Mower WR, Hoffman JR, Peeples N, Goldberg X, Sonner R. Interrater reliability of cervical spine injury criteria in patients with blunt trauma. Ann Emerg Med 1998;31:197-201. 2. Graham ID, Stiell IG, Laupacis A, O'Connor AM, Wells GA. Emergency physicians' attitudes toward and use of clinical decision rules for radiography. Acad Emerg Med 1998;5:134-40. 3. Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhauer MA, et al. Variation in emergency department use of cervical spine radiography for alert, stable trauma patients. CMAJ 1997;156:1537-44. 1. Bachulis BL, Long WB, Hynes GD, et al: Clinical indications for cervical spine radiographs in the traumatized patient. Ann Surgery 1987;153:473Ã477. 2. Bressler MJ, Rich GH: Occult cervical spine fracture in an ambulatory patient. Ann Emerg Med 1982;11:440Ã442. 3. Burgess AR, Poka A: Musculoskeletal trauma. Emerg Med Clin N Amer 1984;2:871Ã882. 4. Cadoux CG, White JD, Hedberg MC: High- yield roentgenographic criteria for cervical spine injuries. Ann Emerg Med 1987;16:738Ã742. 5. Chilton J, Dagi TF: Acute cervical spine injuries. Am J Emerg Med 1985;3:340Ã351. 6. Dagi TF: The exclusion of cervical spine injury. Am J Emerg Med 1988;6:312Ã313. Editorial 7. Deutsch DS: The evaluation and immediate care of the patient with spinal trauma. RI Med J 1980; 63:265Ã269. 8. Fischer RP: Cervical radiographic evaluation of alert patients following blunt trauma. Ann Emerg Med 1984;13:905Ã907. 9. Herkowitz HN, Rothman RH: Subacute instability of the cervical spine. Spine 1986;9:348Ã357. 10.Holdsworth F: Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg 1970;52A:1534Ã1551. 11.Jaffe DM, Binns H, Redkowski MA, et al: Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med 1987;16:270Ã276. 12.Kaplan D: Spine problems in emergency department patients: Does every patient need an X-ray? J Emerg Med 1985;2:257Ã263. 13.Kassel EE, Cooper PW, Rubenstein JD: Radiology of spinal traumaÑpractical experience in a trauma unit. J Can Assoc Radiol 1983;34:189Ã203. 14.Knopp RK: Evaluation of the cervical spine: Unresolved issues. Ann Emerg Med 1987;16:1Ã27. Editorial. 15.Korres DS, Katsaros A, Pantazopoulos T, et al: Double or multiple level fractures of the spine. Injury 1981;13:147Ã152. 16.Lee C, Rogers LF, Woodring JH, et al: Fractures of the craniovertebral junction associated with other fractures of the spine: Overlooked entity? AJNR 1984;5:775Ã781. 17.McArdle CB, Wright JW, Prevost WJ, et al: MR imaging of the acutely injured patient with cervical traction. Radiology 1986;159:273Ã274. 18.Mace SE: Emergency evaluation of cervical spine injuries: CT versus plain radiographs. Ann Emerg Med 1985;14:973Ã975. 19.Miller MD, Gehweiler JA, Martinez S: Significant new observations on cervical spine trauma. Am J Roentgenol 1978;130:659Ã663. 20.Montana MA, Richardson ML, Kilcoyne RF, et al: CT of sacral injury. Radiology 1986;161:499Ã503. 21.Ordog GJ: Missed cervical spine fractures. Ann Emerg Med 1987;16:726Ã727. Letter to the editor. 22.Perdue P: Urgent priorities in severe trauma: Life-threatening head and spinal injuries. RN 1981;44:36Ã41,102. 23.Podolsky S, Baraff LJ, Simon RR, et al: Efficacy of cervical spine immobilization methods. J Trauma 1983;23:461Ã465. 24.Ravichandran G: Missed orthopaedic injuries in the resuscitation room. J Royal Coll Surg Edinb 1984;29:126. Letter to the editor. 25.Reid DC, Henderson R, Saboe L, et al: Etiology and clinical course of missed spine fractures. J Trauma 1987;27:980Ã986. 26.Ringingberg BJ, Urdaneta LF, Midthun MA: Rational ordering of cervical spine radiographs following trauma. Ann Emerg Med 1988;17:792Ã812. 27.Rosen P: On the evaluation of the traumatized cervical spine. J Emerg Med 1985;3:409Ã410. Editorial. 28.Scher AT: Unrecognised fractures and dislocations of the cervical spine. Paraplegia 1981;19:25Ã30. 29.Shaffer MA, Doris PE: Limitation of the cross table lateral view in detecting cervical spine injuries: A retrospective analysis. Ann Emerg Med 1981;10:508à 513. 30.Slack CM: The spine in sports. Compr Ther 1980;6:68Ã74. 31.Streitwiesser DR, Knoop R, Wales LR, et al: Accuracy of standard radiographic views in detecting cervical spine fractures. Ann Emerg Med 1983;12:538Ã542. 32.Sumachai AP: Missed cervical spine fractures. Ann Emerg Med 1987;16:726Ã727. 33.Suomalainen O, Kettunen K, Saari T: Computed tomography of spinal and pelvic fractures. Ann Chir Gynaecol 1983;72:337Ã341. 34.Tator CH, Ekong CE, Rowed DW, et al: Spinal injuries due to hockey. Can J Neurol Sci 1984;11:34Ã41. 35.Vines FS: The significance of Ã’occultÓ fractures of the cervical spine. Am J Roentgenol Redium Ther Nucl Med 1969;107:493Ã504. 36.Wales LR, Knoop RK, Morishima MS: Recommendations for evaluation of the acutely injured cervical spine: A clinical radiologic algorithm. Ann Emerg Med 1980;9:422Ã428. 37.Walter J, Doris PE, Shaffer MA: Clinical presentation of patients with acute cervical spine injury. Ann Emergy Med 1984;13:512Ã515. 38.Webb SB, Berzins E, Wingardner TS, et al: Spinal cord injury: Epidemiologic implications, costs and patterns of care in 85 patients. Arch Phys Med Rehabilitation 1979;60:335Ã340. 39.White AA 3d, Panjabi MM, Posner I, et al: Spinal stability: Evaluation and treatment. Instr Course Lect 1981;30:457-483. 40.Woodring JH, Lee C, Jenkins K: Spinal fractures in blunt chest trauma. J Trauma 1988;28:789Ã793." out here, Ace844

Still this doesn't solve the oncotic pressure gradient that remains present..

IIRC, I understand that premise, yet in a patient who is HYPERvolemic, there is little NTG action in achieving EUvolemia, unless of course you are considering the increase of Renal perfusion as a benefit to increased preload, from NTG admin...then perhaps, but I'm not quite sure I agree with your assertion.. You can learn more about this here:: http://www.emtcity.com/phpBB2/viewtopic.php?t=2639 , http://www.emtcity.com/phpBB2/viewtopic.php?t=2496.. hope this helps, Ace844

Hi All, While doing some research for a response to another thread I found this study which has some great points and infa-structure realted things to this discussion. If you're interested, look here::: Memphis EMS assessment '05

Can you please clarify for me how NTG causes failure pt's to be euvoluemic? Also, what's CRT? out here, Ace844

Doing Justice the Southie Beantown way!! Cheers to texas who has an expresslane to their Deathrow, while others have stopped the death penalty all together! :cheers: :)/ :thumbleft: :occasion5: out here, Ace844 [stream:9b5b925623]www.amfp.org/boondock/sounds/codes.wav[/stream:9b5b925623]

For those who are interested, they can be seen here::: http://www.osageind.com/who_is.htm out here, Ace844

First off, I am not advocating taking away of EMT-B, they have their place, and they fill a need in the EMS system. As long as we have different levels of providers, non-standard and un equal education standards we will have this problem. At some point someone is going to have to “stand up†and say, look, these are the minimum standards, and if you don’t like it..too bad..you’re outta luck. Your patient’s and families, etc.. deserve X amount of top notch pre-hospital care and the providers should have Y amount of education to address this. Remember, a lot of the success of this is “HOWâ€, the message is delivered as opposed to “What,†that message actually is. Well, here’s what I think should happen to a service who is seriously considering doing this. In business there is a long held principle that you need to sometimes outlay capital in the short term to increase efficiency and profitability. So here is what I’d recommend. Since most EMS companies/systems aren’t profitable or grossly so, one needs to identify the problem areas that are affecting that and re-address/fix them. I think that if an organization were to say hire or bring into it an accountant, a lawyer, and a professional, capable, experienced management/employment consultant and make the scale of their salaries dependent on success, they would have the motivation to “fix†the issue. That being said, the overall management and organization would need to support these measures as well as understand them. Once the finances/management are straightened out there, there should be an increase in available funds. Take these funds and apply them to further the goals you have set forth to improve the organization, and training to improve it. Depending on how much of a capital shortfall, you have, would then dictate what actions the organization would need to decide on how best to address this. The key here is not to throw large amounts of money at the problem without justification and accountability for the expenditures. I wasn’t speaking specifically about AMR or any other company, so the answer would be dependent on how important improvement in care, service, efficiency, and management, is to them. I worked under the assumption that since an organization was considering this issue, that they were serious and being proactive to bring about this change… See my responses above Now some say you need to “start with the providers outside of the organization.†I disagree. I think that if you have a solid philosophy, good teamwork, and management, as well as a solid well defined plan over a period of time as well as various ways to allow the implementation of this plan. It will create an environment for success and provide you a solid platform to grow from. I’m in no way advocating an over night change, but a gradual, progressive, measured change. In the mean time as I said you would need to institute a minimum hiring/qualification requirement, but this should happen after you have your own organizational foundation in place as aforementioned. In that transitional period in between, you would need to decide, what is an acceptable compromise and minimums prospective employees need to meet as mentioned in my last post. As fort the local/regional/National issue. If an organization were to seriously take these measures, and provide clear benchmarks, for their measure of success, or even accept that as time goes on and the overall plan is implemented, then the success of the change would speak for itself. It would influence and get noticed locally for its success, compel competitors to “keep upâ€, and if done properly, garner the attention and imitate the “wish†for change via example at the other levels… Hope this helps, Ace844

"Dust," Your right...silly me, I'd hate to provide people with information from which they stand to benefit and learn from... I'm sure there is no one here who learned anything from my post. Although I am also quite sure that the majority of people here haven't the slightest clue what their medical director does, how he could help with this problem, or even what he was meant to handle...If you don't like it..scroll on past, but there may be others who could utilize that info to their benefit. So why not support the attempt at education, as you claim to be a proponent of it? Or aren't you? Perhaps you just enjoy throwing insults and being part of the problem rather than offering a viable solution to it.. :wink: :roll: :shock: :!: :arrow: out here, Ace844

I'm kind of surprised at the lack of response to this thread...what with all of the medical einsteins we have here and soapbox philosophers proclaiming how we need this and that (myself included) but a surprisingly small number have the gumption to actually post solutions....Here's your chance...lets hear it folks!!

Hi All, Here's my MD Director responsibilites follow up post and this may give insight as to how they could help with this problem. Check here:: http://www.acep.org/webportal/PracticeReso...calServices.htm , and here:: http://www.emedicine.com/emerg/topic716.htm Medical Direction of Prehospital Emergency Medical Services Taken from ACEP Policy This Policy Resource and Education Paper is an explication of the Policy Statement Medical Direction of Emergency Medical Services. Introduction All aspects of the organization and provision of basic (including first responder) and advanced life support emergency medical services (EMS), require the active involvement and participation of physicians. Furthermore, every prehospital service that provides any level of life support must have an identifiable physician medical director at the local, regional, or state level (or combination thereof) whose primary responsibility is to ensure quality patient care. Additional responsibilities include involvement with design, operation, evaluation and ongoing revision of the system including initial patient access, dispatch, prehospital care, and delivery to the emergency department. If medical direction is to be effective, the medical director must have official authority over patient care. The medical director, therefore, must have a well-defined position with respect to the other components of the EMS system; the responsibility to develop necessary medical policies and procedures; and the power to limit the activities of those under the medical director's supervision who deviate from the established clinical standards of care or do not meet training standards. Physician direction of prehospital emergency care may be accomplished through off-line and on-line medical direction using prospective, concurrent, and retrospective methods. Off-Line (Prospective and Retrospective) Medical Direction Off-line medical direction is the administrative promulgation and enforcement of accepted standards of prehospital care. Off-line medical direction can be accomplished through both prospective and retrospective methods. Prospective methods include, but are not limited to, training, testing, and certification of providers; protocol development; operational policy and procedures development; and legislative activities. Retrospective activities include, but are not limited to, medical audit and review of care, direction of remedial education, and limitation of patient care functions if needed. Various aspects of prospective and retrospective medical direction can be handled by committees functioning under the medical director with representation from appropriate medical and EMS personnel. On-Line (Concurrent) Medical Direction On-line medical direction is the medical direction provided directly to prehospital providers by the medical director or designee either on-scene or by direct voice communication. Ultimate authority and responsibility for concurrent medical direction rests with the medical director. Role of the EMS Medical Director The medical director should have authority over all clinical and patient care aspects of the EMS system or service, with the specific job description dictated by local needs. The job description should include, as a minimum, the following qualifications and responsibilities. Qualifications To optimize medical direction of all prehospital emergency medical services, these services should be managed by physicians who have demonstrated the following: Essential: License to practice medicine or osteopathy. Familiarity with the design and operation of prehospital EMS systems. Experience or training in the prehospital emergency care of the acutely ill or injured patient. Experience or training in medical direction of prehospital emergency units. Active participation in the ED management of the acutely ill or injured patient. Experience or training in the instruction of prehospital personnel. Experience or training in the EMS quality improvement process. Knowledge of EMS laws and regulations. Knowledge of EMS dispatch and communications. Knowledge of local mass casualty and disaster plans. Desirable: Board certification in emergency medicine. Responsibilities To optimize medical direction of all prehospital emergency medical services, physicians functioning as medical directors should, at a minimum: Serve as patient advocates in the EMS system. Set and ensure compliance with patient care standards including communications standards and dispatch and medical protocols. Develop and implement protocols and standing orders under which the prehospital care provider functions. Develop and implement the process for the provision of concurrent medical direction. Ensure the appropriateness of initial qualifications of prehospital personnel involved in patient care and dispatch. Ensure the qualifications of prehospital personnel involved in patient care and dispatch are maintained on an ongoing basis through education, testing, and credentialing. Develop and implement an effective quality improvement program for continuous system and patient care improvement. Promote EMS research. Maintain liaison with the medical community including, but not limited to, hospitals, emergency departments, physicians, prehospital providers, and nurses. Interact with regional, state, and local EMS authorities to ensure that standards, needs, and requirements are met and resource utilization is optimized. Arrange for coordination of activities such as mutual aid, disaster planning and management, and hazardous materials response. Promulgate public education and information on the prevention of emergencies. Maintain knowledge levels appropriate for an EMS medical director through continued education. Authority for Medical Direction Unless otherwise defined or limited by state or local requirements, the medical director must have authority over all clinical and patient care aspects of the EMS system including, but not limited to, the following: Recommend certification, recertification, and decertification of non-physician prehospital personnel to the appropriate certifying agency. Establish, implement, revise, and authorize system-wide protocols, policies, and procedures for all patient care activities from dispatch through triage, treatment, and transport. Establish criteria for level of initial emergency response (e.g., first responder, Basic EMT, EMT-Intermediate, Paramedic). Establish criteria for determining patient destination. Ensure the competency of personnel who provide concurrent medical direction to prehospital personnel including, but not limited to, physicians, EMTs, and nurses. Establish the procedures or protocols under which non-transport of patients may occur. Require education and testing to the level of proficiency approved for the following personnel within the EMS system: First Responders EMTs, all levels Nurses involved in prehospital care Dispatchers Educational coordinators On-line physicians Off-line physicians Implement and supervise an effective quality improvement program. The medical director shall have access to all relevant records needed to accomplish this task. Remove a provider from medical care duties for due cause, using an appropriate review and appeals mechanism. Set or approve hiring standards for personnel involved in patient care. Set or approve standards for equipment used in patient care. Obligations of the EMS System The EMS system has an obligation to provide the medical director with the resources and authority commensurate with the responsibilities outlined above, including:Compensation for the time required. Necessary material and personnel resources. Liability insurance for duties/actions performed by the medical director. A written agreement that delineates the medical director's authority and responsibilities and the EMS system's obligations. December 20, 2005 Medical Control Last Updated: June 9, 2005 AUTHOR INFORMATION Author: Eric Lavonas, MD, FACEP, Director, Medical Toxicology Hospital Services, Adjunct Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center Eric Lavonas, MD, FACEP, is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, North Carolina Medical Society, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society Editor(s): Robert M McNamara, MD, FAAEM, Professor of Emergency Medicine, Temple University; Chief, Department of Internal Medicine, Section of Emergency Medicine, Temple University Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Amin Antoine Kazzi, MD, Vice Chair, Associate Professor, Division of Emergency Medicine, University of California at Irvine Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Craig Feied, MD, FACEP, FAAEM, FACPh, Director, National Institute for Medical Informatics, Director, Federal Project ER One, Director of Informatics, Washington National Medical Center, Director, National Center for Emergency Medicine Informatics OVERVIEW Medical direction is the process by which a physician or, occasionally, group of physicians guide and oversee the patient care provided by an emergency medical services (EMS) system. Law requires medical direction for all advanced life support (ALS) service providers. Most states require basic life support (BLS) agencies to have a medical director as well. Medical direction from a physician is recommended for all EMS activities. EMS Medical Director/Administrators The role of an EMS medical director is far greater than merely lending the physician's name and license number to satisfy a legal requirement. The medical director is responsible for all aspects of care provided in the EMS system. In addition to writing protocols for prehospital care, the EMS medical director offers continuing education for EMS personnel, contributes expertise to the process of system planning and dispatch, reviews quality of care, supervises individuals providing on-line medical care, and solves problems. In most cases, the administrative chain of command in an EMS system is separate from the position of medical director. The EMS system administrators hire, fire, schedule, and promote employees; purchase and maintain equipment and supplies; and perform the hundreds of other tasks required to operate the EMS system. The EMS medical director must have a good working relationship with EMS system administrators. Ultimately, the medical director has the responsibility to certify and decertify EMS medical providers and decide what forms of prehospital care will be provided. Any physician who is seriously considering becoming an EMS medical director should, at minimum, read the American College of Emergency Physicians (ACEP) publication, "Medical Direction of Emergency Medical Services." This concise 80-page guide outlines the standards of responsibility and reviews national policies on EMS medical direction in more detail than is possible in this article. DEFINITION OF MEDICAL CONTROL Off-line medical control refers to all physician activities that prospectively and retrospectively are performed to improve quality of care in an EMS system. On-line medical control is the process through which an emergency physician guides prehospital care while it occurs. When most people think of medical control, they envision on-line medical control (eg, paramedics communicating with and receiving instructions from a physician in the ED). However, in order to maintain a quality EMS system, several hours of off-line medical control activity are necessary for every minute of on-line control. Off-Line Medical Control The medical director of an EMS system is responsible for off-line medical control actions, including the following: Development and implementation of protocols and standing orders Supervision of any initial and recertification training programs provided by the EMS agency Retrospective review of the care delivered (to ensure compliance with patient care standards) Liaison of activities between EMS professionals and others, including other physicians; ED personnel; and regional, state, and local EMS authorities Providing input on dispatch, mutual aid, disaster planning, and hazardous materials response activities General supervision of physicians who provide on-line medical control Acquiring and maintaining up-to-date knowledge of EMS issues Support of EMS research, where practical Problem solving Generally, an EMS system has one overall medical director for off-line activities and a group of physicians designated as the source of on-line medical control. On-Line Medical Control On-line medical control involves directing the care of a single patient. The on-line medical control physician evaluates information given by medics, makes decisions regarding immediate patient care, and gives appropriate orders. Medics and their patients benefit from having immediate access to an emergency physician for advice in difficult or unusual situations. In addition, the EMS medical director may use mandatory on-line physician authorization to maintain tight control of certain potentially dangerous prehospital treatment options (eg, prehospital thrombolytic administration). THE EMS MEDICAL DIRECTOR Qualifications of a Medical Director An EMS medical director must be a licensed physician with interest, experience, and knowledge in emergency medicine and prehospital care. It is extremely helpful if the medical director is a full-time, practicing, emergency physician at the lead hospital for the EMS system, with additional training and experience in EMS. When looking for a medical director, many emergency medicine physician groups may find a former paramedic and who maintains an enthusiasm for EMS. Although these are helpful qualifications, a medical director also must be knowledgeable in medical, administrative, and legal issues. However, this information is not taught in medical school or by direct EMS experience and may only partially be covered in an emergency medicine residency training program. Medical director courses, which are available through ACEP and the National Association of EMS Physicians, are a valuable experience. For those with a career commitment to EMS, 1-year fellowships are available. Duties of the Medical Director to the EMS System The medical director is responsible to the EMS system and the community for ensuring that prehospital care providers function at the highest possible level, given their available resources. Responsibilities of the medical director include the following: To actively participate in system design, personnel training and retraining, supervision, and quality improvement To ensure that appropriate standing orders and protocols are in place for prehospital care of common and foreseeable medical conditions, interfacility transfer, disaster response, and hazardous materials response To be responsible for general protocol to cover the unforeseen situations that inevitably arise Above all, to serve as a patient advocate Duties of the EMS System to the Medical Director Responsibilities of the EMS system include the following: To provide the medical director with the authority to enforce standards of care; this includes the authority to decertify individual EMS providers who fail to maintain training, patient care, or communications standards To provide administrative help because, without it, the medical director's role would be impossible owing to the amount of time this responsibility requires. To provide liability insurance for the physician's actions as the medical director Possibly, to compensate the physician for time spent working as medical director The medical director's duties, responsibilities, and authorities, as well as the EMS system's obligations, should be recorded in a written agreement. Individual Medical Director Versus the EMS Council Some EMS systems choose to provide off-line medical control through an EMS council or physician advisory board. This body usually consists of representatives from each hospital within the EMS system's coverage area. It often includes a representative from each EMS agency within the system. In this case, the chairman of the EMS council becomes the overall medical director for legal purposes; however, decisions about system design, protocols, and certification and decertification of EMS personnel are made by the entire committee. Advantages of an EMS Council By definition, an EMS council is less autocratic than an EMS system with a single medical director. Occasionally, an EMS council can buffer the EMS system from the politics that are inherent in competition between hospitals and companies. A system design decision (eg, designating a preferred receiving center for trauma, pediatrics, or burns) that seems to favor the single medical director's hospital may be perceived by personnel of other hospitals as being motivated by the medical director's proprietary interest. The same decision by an EMS council does not draw such criticism. Discipline of individual medics or agencies by a council may not seem as personally vindictive as when the same actions are taken by an individual medical director; therefore, the discipline may be better accepted when it is imposed by an EMS council. By distributing responsibilities among more people, an EMS council can sometimes accomplish more without overburdening any one individual, and a council may be able to devote more energy to planning improvements. If the EMS council includes senior paramedics, then a practical, experience-based standpoint is brought into each decision; however, such a point of view may be lacking in the decisions of a single medical director. Often, a given paramedic (ie, medic) or emergency medical technician (EMT) will work for 2 or more different EMS agencies. In these situations, it becomes difficult for the medics to follow one set of protocols. Regional protocols, as designed by regional EMS councils, are used to avoid this problem. Advantages of a Single Medical Director System Political and economic concerns can be detrimental to an EMS council; these concerns can make it impossible to serve as an impartial patient advocate. Sometimes, in a rush to be fair, the patient's interests take second place. This is particularly likely if hospitals or EMS agencies are in extreme economic competition. EMS councils rely on a consensus for action to transpire but usually only meet once a month. To quote Elbert Hubbard, "A committee is a thing, which takes a week to do what one good man can do in an hour." The administrative work involved in operating the council can divert energy from accomplishing the actual work at hand. Maintaining confidentiality is very difficult when an EMS council has to make difficult or high profile decisions. Although federal law tries to protect quality assurance activities from discovery in legal trials, in many states these statutes have been diluted to the point that records of quality assurance activities by an EMS council can be used in court against medics, EMS agencies, or the council. Once an EMS council is formed, it virtually is impossible to revert to a single medical director system. Politics and the Medical Director The absolute duty of the medical director is to serve as a patient advocate and protect the patient from politics and profit-making influences. Competing hospitals and EMS agencies often try to put pressure on the EMS system, especially when questions of patient destination and choice of EMS provider are involved. The EMS medical director must ensure that the patient's interests (eg, autonomy, best medical care) are of absolute priority when the standard operating procedures are devised. EMS councils often consist of people with strong personalities who tend to have difficulty receiving criticism; therefore, politics in an EMS system may be more volatile than in other organizations of similar size. Everyone involved makes life-or-death decisions; this increases the energy driving politics and consequences of ignoring a real problem. The medical director must be diligent to distinguish actual performance problems from personality conflicts and to address both in a way that protects the patients and the medics. Medicolegal Liability Fortunately, lawsuits against EMS medical directors remain uncommon; however, this will probably change. Losing a lawsuit is unlikely as long as reasonable written protocols exist, and medics complete frequent refresher training and testing on these protocols. Several studies have shown that the risk of being sued for involvement in an EMS system is many times less than the risk of being sued for involvement in regular clinical practice. The EMS system has an obligation to provide the medical director with appropriate liability insurance. PREHOSPITAL CARE PROTOCOLS EMS medical directors write prehospital care protocols (ie, standing orders) to instruct medics of the kind of care needed for patients in a wide variety of situations. This document provides the framework for all prehospital care, including assessment and management instructions for a variety of patient conditions, dosing and indications for medications, and specific instructions for occasions when the paramedic or EMT must call for advice and authorization from on-line medical control. While writing or revising prehospital care protocols, consider the following: Use previously established protocols Contact the medical directors of EMS systems in the area and request permission to review and copy their protocols. Read several different protocols and look for the subtle, but important, differences among them. Do not fix what is not broken If the EMS system already has an effective protocol in place, only incorporate changes when the benefit is clear. Avoid changing the same part of the protocol several times. Examples of this are as follows: The current protocol may still include the use of military antishock trousers (MAST) for hemorrhagic shock. Currently, solid evidence indicates that MAST are harmful, and no research supports a likely change to this conclusion. Therefore, the use of MAST should be removed from prehospital protocols. Based on active research, recommendations for fluid resuscitation in trauma are rapidly changing. Rather than modifying the fluid resuscitation protocol several times, it is usually wise to leave an acceptable current protocol in place until definite changes can be made. Write protocols for each level of certification If the EMS system includes providers with different levels of training, a protocol for each level of medic needs to be written. For example, the cardiac arrest protocol for different levels of medics should be written as follows: An EMT-Basic (EMT- should perform cardiopulmonary resuscitation (CPR), placement of oropharyngeal airway, and bag-valve-mask resuscitation. An EMT-Defibrillation (EMT-D) should perform the above protocol and apply a semiautomatic external defibrillator. An EMT-Intermediate (EMT-I) should perform the above protocol, start an IV line, and, perhaps, intubate or place a Combi-tube. An EMT-Paramedic (EMT-P) should perform the above protocol, intubate, and administer epinephrine and IV antiarrhythmics per advanced cardiac life support (ACLS) protocol. What works in the city may not work in the country Protocols that work well in urban areas often fail in rural areas (and vice versa). Volunteers staff many rural EMS systems; therefore, their time available for training often is less than if the staff was comprised of full-time medics. Lower call volumes offer rural medics fewer opportunities to apply their skills; thus, skill atrophy is a problem. Rural EMS systems have longer average transport times than urban EMS systems; this influences the effect of prehospital care. Comparison of rural and urban EMS protocols may create a paradox. For example, consider the following factors for whether to train EMT-Bs to intubate: In an urban area, paramedics may be full-time employees who transport up to 2500 emergency patients per year and who have access to full-time training personnel. These paramedics have many opportunities to intubate and have access to frequent refresher programs. In contrast, a rural volunteer EMT may transport an average of 100 patients per year and have few opportunities to maintain skills, which often decay when not frequently practiced. ALS in urban areas is often readily available and transport times are likely to be 10 minutes or less. However, rural EMTs may face average transport times of 30 minutes with no ALS back up. Intubation by an EMT is potentially advantageous over prolonged bag-valve-mask ventilation. Target your protocols to the skill of the medics involved When writing protocols, take into account the average and the lowest skill level of the medics in the EMS system. Provide medics with enough information about drugs, devices, and latitude to do their jobs effectively; however, do not allow potentially dangerous modalities unless all medics in the system can safely handle them. Resist expanding protocols until the entire group is ready to advance to the necessary level of competency. Avoid protocol sprawl Every skill, drug, or device in an EMS protocol requires initial training, memorization, and continuing training for EMS caregivers to remain proficient. In addition, purchase and resupply of equipment and medications costs money. Whenever possible, remove treatment modalities that are out-of-date or no longer necessary from the protocol. Do not expand protocols beyond the level of a capable medic's competence. Query the receiving physicians about the patients' needs Solicit feedback from the emergency physicians who treat the patients being transported by the EMS agency. Determine prehospital conditions that the medics inappropriately are managing because of current protocols. Determine what the medics are doing that may make receiving physicians uncomfortable. Determine if medics are spending time on prehospital tasks that easily could wait until the patient's arrival. Involve EMS personnel in protocol development Ask medics for suggestions when writing the protocol. If the medical director is uncertain whether a protocol change is worth the required amount of time and money, a mock protocol should be written. After the medics have reviewed the mock protocol, have them make a copy of the patient's chart for whom they feel would have benefitted from the proposed treatment. This process gives the medical director an idea of how many times a new treatment will likely be used. It also acts as a check to evaluate if the medics are likely to inappropriately apply the treatment. Make on-line medical control mandatory in certain situations If a particular treatment decision has particularly high medical or medicolegal risk (eg, administration of prehospital thrombolytics, termination of resuscitative efforts in the field), consider requiring approval of the on-line medical control physician. In addition to providing guidance, oversight, and experience, this relieves the medics of some medicolegal responsibility. The process of establishing on-line medical control slows the delivery of care, prolongs scene time, and occupies a busy emergency physician for several minutes. Limit mandatory on-line medical control to those situations in which a physician's judgment is necessary. Decide in advance how to handle "Do not resuscitate orders" Situations in which medics are called to care for a patient who is dying of an incurable condition are volatile and emotionally charged. Morally, medics are bound to respect a patient's desires not to be resuscitated. Several states have adopted statutes that govern prehospital orders not to resuscitate. Incorporate the state statute into the protocol, if possible. If the state EMS codes do not address this situation, the medics need to be instructed through the protocols. A 1988 ACEP position statement provides guidance in this area. In general, if on-line medical control is available, instruct the medics to discuss each potential do-not-resuscitate (DNR) situation with the on-line physician. It often is helpful for the medics and/or the on-line medical director to discuss the situation with the patient's personal physician and family if this quickly can be accomplished. Written DNR orders generally should be honored as long as the identity of the patient is not in question and all involved agree. The decision not to attempt resuscitation does not include withholding fluids and oxygen when they are needed. Allow for variations from protocol No set of standing orders will provide the correct instructions for every situation that medics encounter. The simplest way to authorize medics to deviate from their protocols is to require the medic to contact the on-line medical control physician to discuss the situation and receive appropriate orders. The protocol also should permit medics to perform to their level of training in the event of communications failure. Include procedures for interfacility transfer Interfacility transfer requires different skills and behavior than prehospital emergency care. If the EMS agency provides this service, standing orders must address the important differences. In general, EMT-Bs can transport medically stable and spontaneously breathing patients who are on oxygen, including patients with tracheostomies. With minimal additional training, EMTs can be taught to maintain noncritical IV lines. The protocol clearly should state what types of IV the EMTs are allowed to supervise. Because EMT-Bs are not trained to restart IVs if pulled out, they should not accept a patient with life-sustaining IV fluids or medications unless accompanied by a paramedic or registered nurse (RN). It is suitable for an appropriately trained EMT-Ambulance (EMT-A) to transport patients who are on maintenance crystalloid with no more than 20 mEq/L potassium chloride (KCl). The addition of benign additives (eg, vitamins) does not pose a problem. Paramedics are capable of performing the wide range of ACLS skills, can titrate and restart IVs, and can manage much more unstable patients during interfacility transfer than EMTs. If many unstable cardiac patients are transported, the paramedics need to know how to run IV infusion pumps and should have additional training on drugs (eg, IV heparin, nitroglycerin, common vasopressors, paralytic medications). Occasionally, critically unstable patients need to be accompanied by an RN during transfer from a hospital. Under the federal Emergency Medical Treatment and Active Labor Act (EMTALA), the transferring hospital is legally responsible for providing an RN, respiratory therapist, or medical doctor to accompany the patient during transport in case an advanced level of care is needed. Legal considerations aside, this is expensive and inconvenient for the transferring hospital. Trusting the paramedics to effectively transfer the patient is highly tempting, even when the patient's needs are more complex than those the paramedics are trained to handle. The system's protocols should specify the situations in which paramedics may transport an unaccompanied patient and the situations that mandate a nurse to accompany the patient during transport. Patients who at least require an RN-paramedic team to assist in transport include the following: Patients with unstable vital signs at the time of transfer, with the possible exception of patients presenting with fresh trauma who have not yet been to the operating room Patients in advanced or preterm labor Seriously ill children younger than 6 years Patients likely to require intubation en route The medical director or on-line medical control physician should become involved in difficult cases. Paramedics are professionals and their judgment should be trusted; when paramedics are uncomfortable accepting a patient, that admission should be respected, even if it inconveniences the transferring hospital. Specify the procedure for medical control when a physician is on the scene Prehospital care protocols need to provide guidelines for the medics' actions when a physician is on the scene. Sometimes, on-scene physicians tend to interfere more than help. These situations must be handled with tact and diplomacy, but must not delay patient care. ACEP has chosen a clear and rational position on this issue. It is summarized in a 1984 position that states, "When an ALS squad, under medical direction, is requested...a doctor/patient relationship has been established between the patient and the physician providing medical direction. The paramedic is responsible for management of the patient and acts as an agent of medical direction unless the patient's physician is present (as would occur in a doctor's office)." If the patient's private physician is present and assumes responsibility for treatment, medics should defer to that private physician. If an intervening physician is present and on-line medical direction is possible, the intervening physician should speak directly with the on-line medical control physician to discuss the situation. The on-line physician has the option of entirely managing the case, working with the intervening physician, or allowing the intervening physician to assume responsibility. If an intervening physician is present and on-line medical control is not possible, ACEP states, "A paramedic...should relinquish responsibility for patient management, but if the treatment...differs from that outlined in local protocol, the physician should agree in advance to accompany the patient to the hospital...." QUALITY ASSURANCE AND PROBLEM SOLVING Medical directors have the responsibility to ensure that all care provided under their authority is of the best quality possible. Several actions are required to accomplish this goal, including the following: Routine Run Review by EMS Agency Leadership Someone within the EMS organization routinely should review all EMS run records for completeness. This person, usually the chief medic for the service, should perform the following: Maintain statistics on factors (eg, scene times, number of attempted IVs and intubations, number completed IVs and intubations, number of cardiac arrests managed for each medic in the system) Collect data to determine necessary areas of improvement for the entire service (ie, continuous quality improvement [CQI] data) Screen for problems that might otherwise be undetected (ie, quality assurance [QA]) Random and Focused Run Review by the Medical Director The medical director should review a reasonable percentage of EMS runs for the preceding month. If all runs cannot be reviewed, critical runs should be targeted (eg, runs in which ACLS drugs and advanced airway modalities were used, runs by problem medics). Additional runs for review should be selected by random sampling of those remaining. Provide written feedback for individual medics and identify patterns of behavior that need individual or group retraining. Maintain a file of each paramedic's feedback for future review, if needed. Soliciting Feedback from Receiving Physicians Emergency physicians (EPs) and administrators at all receiving hospitals in the EMS system's coverage area need to know whom to call with problems or questions about the service. The medical director should be introduced to colleagues at other hospitals, preferably during an ED or EP group meeting. This process should periodically be repeated to encourage open communication and feedback, which can prevent many interinstitutional problems and may quickly help identify problems with specific medics or situations. The medical director should meet with the administrative directors of hospitals in the area where the EMS system regularly operates (eg, coronary care staff for frequent interfacility transfers). Handling Problems No organization or person does the right thing every time. By its nature, EMS requires medics with incomplete knowledge of the situation to make complex life-or-death decisions very rapidly and during continuous distraction. It is a tribute to EMS professionals that, through dedication and training, they get things right the vast majority of the time. When mistakes happen, the challenge of the medical director is to decide the following: If, given the situation faced by the medics, the mistake is understandable If the mistake at hand indicates a need for further training If the mistake was simply a fluke If a specific medic or the entire service needs to be addressed about the mistake All possible information should be gathered before action is taken to handle a potential problem situation. Feedback should be collected from everyone involved, including the medics, physicians, and nurses at the receiving hospital and, perhaps, the patients and their families. Obtain run records, ED reports, and, when relevant, inpatient care records and autopsy records. Often, what initially appeared to be a dangerous mistake will turn out to be a reasonable decision based on the information available to the medic at the time. Situations That Always Require Intervention Unrecognized esophageal intubation Although an endotracheal tube (ETT) can become dislodged when the patient becomes agitated, it should not become displaced with simple movement of the patient. This occurs more often than many would imagine, and a response to this problem should be consistent. The director should meet with the paramedic involved to discuss the situation. If a pattern develops, refresher training for the individual paramedic or, perhaps, all paramedics in the service should be required. Colorimetric carbon dioxide detectors and esophageal intubation detectors are commercially available, inexpensive, and reasonably reliable. These could be added to the equipment list and protocols. If a specific paramedic has recurrent problems with unrecognized esophageal intubations, the paramedic should be decertified until the problem has been corrected. Inappropriate medical care and inappropriate withholding of medical care The medical director should conduct a thorough investigation. Policies should be revised, refresher training should be provided, or discipline of medics should be carried out, as appropriate. Injuries to patients Patient injuries usually occur because of the following 2 situations: Patients are dropped from the ambulance stretcher. Patients are injured during the application of restraints. These situations can typically be corrected with refresher training and written policies. Many ambulance stretchers are not designed to be in the up position when patients are rolled long distances. The EMS service may need to invest in new stretchers or require that stretchers are in a down position when rolling patients; the latter policy eventually will lead to back injuries among medics. Storm drain covers with inch-wide rectangular vents may potentially cause accidents. To reduce the chance that the EMS service and facility are sued over a patient injury, these storm drain covers need to be replaced with ones that will not trap stretcher wheels. Allegations of theft from patients This is a personnel matter, not a medical issue, and it should be handled by the administrative chain of command of the EMS system. Substance abuse among medics This problem requires action by the EMS system chain of command and medical director. The EMS agency must have personnel policies and procedures to address this situation. However, the medical director is responsible for appropriate use of all narcotic medications purchased by the EMS service under the drug enforcement agency (DEA) number of the medical director. The medical director's responsibilities in these situations include the following: Act as a patient advocate by protecting patients from the risk of a medic acting under an extension of the director's physician license while intoxicated. Act in the best interest of the patients and medic involved. Comply with legal requirements to report impaired medics to the state EMS licensing authority. Work with the EMS agency's attorney during every step to ensure that the medic is treated fairly and to protect the director and EMS agency from lawsuit. Realize that the potentially impaired health care professional is handled best by consulting with an expert in the areas of addiction to medicine and substance abuse. Carefully handle the process of confrontation. Be aware that most state medical societies are a valuable resource in these matters. TRAINING An EMS medical director should actively be involved in initial and recertification courses that are conducted by the agency. Generally, a training officer or course director will run the day-to-day mechanics of the program. The EMS medical director serves as the medical director for the course, helps arrange for lecturers, provides some direct instruction, and supervises testing. Many states require the medical director to personally certify, in writing, that each graduate of the training program clinically is prepared to practice prehospital care at the appropriate level of certification before the applicant is permitted to take the state EMT or paramedic examination. The EMS medical director also must coordinate a regular, ongoing, training program for medics. It is effective to combine programs of general interest with refresher training that is targeted at areas of potential improvement. The medical director should do some teaching, occasionally recruit outside instructors, and encourage medics within the service to develop areas of expertise for peer instruction. ON-LINE MEDICAL CONTROL In an ALS, paramedics and other EMT-As make 99% of the requests for advice and orders; however, EMT-Bs also require the advice of a physician. Therefore, providers at all levels of certification must have access to on-line medical control. On-line medical control must be available 24 hours a day, 365 days a year. The medical director designates a group of physicians to perform on-line medical control. Three basic ways to provide this service are as follows. The on-duty emergency physician at the lead hospital for the EMS service (ie, the resource hospital) can serve as on-line medical control. Alternatively, the on-duty emergency physician at the hospital that will receive the patient can be responsible for on-line medical control. Finally, medical control can be provided by a small group of physicians at a centralized location. In the third scenario, the medical control physician dedicates his full attention to this task and is not simultaneously responsible for patient care. This is practical in large EMS systems, and it is often coordinated with an emergency medicine residency program, such as exists in Pittsburgh and Milwaukee. Advantages and Disadvantages Advantages and disadvantages exist for each system. The first and third options of providing on-line medical control (mentioned above) use a smaller number of physicians, usually partners or residents of the medical director, which improves consistency and communication between the physicians. The second option, which is probably the most common nationwide, sacrifices consistency of medical control and makes it difficult to reach every medical control physician and disseminate changes to protocols. Paramedics may dislike the inconsistency of the orders they receive when service is provided according to option 2. However, the second method has advantages. Paramedics and emergency physicians receive immediate feedback since the medic, physician, and patient arrive at the same place at the same time. Also, with option 2, the receiving physician can hardly be dissatisfied with the orders given, and may change those orders based on the situation at the receiving hospital (eg, withholding an order for prehospital thrombolytics if the cardiologist and catheterization lab team already are in the hospital). Overall, the second method is the easiest to set up but the hardest to do well. Personnel Providing On-Line Medical control At a minimum, any physician providing on-line medical control must be skilled in emergency medicine and familiar with the equipment and capabilities of the EMS system and the paramedics' training and protocols. A short base station training course for physicians, especially those without prior EMS experience, will greatly improve the quality of medical control. However, it often is hard to get physicians to attend. One possible solution is to incorporate a brief training program into a regular ED or physician group meeting. Sometimes, nurses from the ED, physicians' assistants, or specially trained paramedics are permitted to provide on-line medical control. This is convenient in a busy ED, but medics prefer and patients may benefit from the physician's direct input. Of course, the designated on-line medical control physician is legally responsible for the orders given by others who are under his supervision. Communication with Physician Verses Other ED staff If the on-line medical control physicians feel that their time is taken unnecessarily by EMS calls, the medics may be speaking with the physician when physician guidance is not necessary. The first step to correct this problem is to ask medics to begin their call to the medical control hospital with the introduction of "report only" or "physician needed for orders." Any qualified ED staff member can take a report about a patient coming in. The physician is summoned only if the medic has a question or is requesting advice or orders for specific treatment changes. Emergency physicians at the receiving hospitals may be uncomfortable with this system at first but, in most cases, eventually prefer it. If this is already part of the system and physicians still feel that too much of their time is occupied with by EMS calls, one of two things is happening; either the medics lack the confidence to independently carry out protocol orders or the protocols and standing orders have been structured to require an on-line physician order for tasks that the paramedics should be able to independently initiate. These problems should be recognized and addressed by the off-line medical director. Forms of Communication Although most medical control conversations use EMS radios, telephones (ie, land-based, cellular) possess advantages in clarity and confidentiality. EMS professionals should be encouraged to use the phone whenever practical and use the EMS radio only when the telephone is not available. In the early days of EMS, medics in the field commonly transmitted cardiac rhythm strips via VHF radio for physician interpretation. This is time-consuming and the equipment often does not produce a readable strip at the receiving facility. Paramedics are trained to recognize and treat arrhythmias. Today, rhythm strips rarely are transmitted for off-site interpretation. However, obtaining a 12-lead prehospital ECG to transmit over cellular phone lines to a receiver in the ED has some advantages. Medical directors and EMS system administrators should carefully consider the cost (eg, equipment, airtime, training, increased scene time) and benefits (eg, more rapid administration of thrombolytics in the receiving hospital, possible prehospital thrombolytics) of such a system. Occasionally, questions arise about what was said and ordered during on-line medical control conversations. An accurate record of these conversations is useful in training, for quality assurance, and for medicolegal purposes. Tape recording, written record keeping, or both are used for this purpose. Tape recording is more accurate but more expensive than keeping a written record. However, tape recording medical control conversations can inexpensively be accomplished through the dispatch center, which may already have a multichannel tape recorder in use to record incoming calls and radio traffic. If this technology is not available, recording devices must be attached to all radio and telephone lines at the medical control hospital(s) that are used for this purpose. The EMS system also must establish a procedure to securely catalog and store tapes. Printing and distributing forms for written documentation of medical control conversations is easy, but this system has several shortfalls. It is difficult to simultaneously listen, analyze, and write down everything the medic says. On-line physicians tend to write less and think more. The result can be a very fragmented and incomplete record. Also, because of patient confidentiality concerns, the patient's name usually is not broadcasted over EMS communications systems. This creates a problem when trying to match the medical control record with a specific patient. As digital cellular technology gradually replaces VHF radio, concerns about eavesdropping should lessen. Cataloging and storing on-line medical control reports is a challenge, especially when the patient is not transported to the hospital or when the medical control facility and receiving hospital are not the same. Finally, many disputes and problems in on-line medical control arise from a misunderstanding between what the medic "knows" was said and what the physician "knows" was heard. A hastily scribbled record by the medical control physician almost never contains enough information to sort out the truth in these situations. In general, the tape-recorded systems are the better choice for most EMS systems. The start-up costs are small, although not negligible, when compared to the cost of gasoline, insurance, salary, and other operating costs of an EMS system. Although setting up a tape-recording system initially requires more work than printing and distributing forms, the amount of work saved in the long run far exceeds the amount invested. The off-line medical director may choose to review medical control records only when problems arise. However, random or focused reviews of medical control conversations are very useful for quality improvement and training purposes and a productive use of the medical director's time. BIBLIOGRAPHY Ossmann EW, Bartkus EA, Olinger ML: Prehospital pearls, pitfalls, and updates. Emerg Med Clin North Am 1997 May; 15(2): 283-301[Medline]. Storer DL, Dickinson ET III: Physician medical direction of EMS education programs: policy resource and education paper. American College of Emergency Physicians (ACEP) Emergency Medical Services (EMS) Committee, and the National Association of EMS Physicians (NAEMSP). Prehosp Emerg Care 1998 Apr-Jun; 2(2): 158-9[Medline]. Werman HA, ed: Medical Directory of Emergency Medical Services. American College of Emergency Physicians; 1993. NOTE: Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER Medical Control excerpt © Copyright 2005, eMedicine.com, Inc. Hope this helps, Ace844

We have the same feature on our stretchers in the US as well....It comes as a Standard option if you will!!

As a follow up post, to my which I forgot to add my input on the staffing issue. This is how I would address the issue. Posted in no particular order A.) Give a definitive timeline for the in house personnell to complete the trianing and come up to "standard. The timeline will be uniform and as many provisions as possible will be made to train them and to allow them to meet the expectation. B.) Bring in marketing professionals, the Medical director, management, and come to an agreement as to what the training, standards and minimal education is and must be. The service must fight the urge to be CHEAP while doing this C.) Make all ne whires/applicants meet the standard, education, and provide what additional training is needed for canidates who are exceptional but minimally/but educationally qualified... D.) Test the above applicants written, practical, oral interviews, then have them meet with the Md director, and go through the process he'd require to work/practice. Also, require a lifting test, drug test, physical etc...for those who pass the preceding, and are good canadtes E.) Once word gets out that you are a progressive provider/service, that you have progressive, professional work environment and pay well and also have great training the canadates will come to you!! Think King County medic one! 8) F.) As your services capabilities, education, and morale grow so will the desire to work there and be affiliated with them. By having a competent, educated workforce, who provides quality, professional care, will have no problems recouping the costs as facilities/contracts will see and hear a noticable difference in service. G.) All of the above will result in positive press, and force the competition to adapt and also raise their standards.. E.) Maintain, and purchase nice, effective, state of the art equipment. F.) The rest will take care of itsself with good management, marketing, MD Direction, and QA/QI... But it should be noted that it is clear from MD advocacy groups/professional associations how they may help...I will post this as a third follow up... Food for thought, Ace844