Medical research made easy


CarolinaFireJournal - Doug Edenburn, NREMT-P
Doug Edenburn, NREMT-P
04/21/2013 -

There can be little doubt that evidence based medicine is here to stay. EMS has seen a number of treatments and gadgets added to its bag of tricks in the past decade or so thanks to this concept. Conversely, more than a few treatments have fallen victim to the unforgiving standards of evidence based practice. At its core, evidence-based medicine requires that clinicians make treatment decisions consistent with sound scientific support. Scientific evidence is demonstrated through a variety of research methods, the results of which are most commonly presented in the form of research papers published in academic journals. The ability to read and interpret these papers is foundational to one’s ability to practice evidence-based medicine. While most any physician is at least reasonably adept doing so, many EMS providers remain ignorant. Fortunately, assessing medical research at a basic level is not a difficult skill to master — further, this basic understanding is sufficient to glean much information with which EMS providers may enhance their practice.

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Types of Medical Research

In order to properly read and interpret research, one must first understand the basic types of papers that are to be found. The first distinction among types of research concerns its data’s source. When research is undertaken on data gathered by the study itself, it is called primary research. Secondary research is that which is composed of data already collected by other studies. Secondary research will be some type of review. Primary research will fall into one of three categories: basic or experimental research, clinical research and epidemiological research.

Basic research

Basic research may best be described as the classic science experiment. In basic research, one or more independent variables is manipulated, and its effects on a dependent variable observed and described. Suppose that an experiment was designed to examine the relationship between diet and weight in laboratory animals. A number of animals might be fed a variety of foods for a period of time and their weights measured and recorded. In this case, the dependent variable is the weight of the animal — that is, it is expected to be a result of its diet, the independent variable. The design of an experiment is prescribed in such a manner that it may be repeated by others with high fidelity.

Basic research as applied specifically to medicine often examines the properties of drugs or is used in the development of diagnostic tests. Every drug in the EMS provider’s bag started out as a chemical whose properties were examined in the most basic form, through experimentation. While tests performed on laboratory animals fall into the category of basic research, human research does not. Such research falls into the category of clinical research.

Clinical Research

Clinical trials may be the most recognized variety of medical research. In clinical research, the effects of a therapy such as a medication, medical device, or procedure are studied on a population of humans. Drug trials are a classic example of clinical research. These trials are highly regulated and carefully designed to achieve accurate results. Researchers must first assemble, or enroll, a group of participants as analogous as possible. Then, therapies — or the lack thereof, such as placebos — are randomly assigned to individuals. Ideally, study participants and researchers are unaware of who receives which therapy. This process is known as blinding, and helps eliminate one source of bias. In the realm of EMS, clinical research is used to test and prove therapies. Some, such as Continuous Positive Airway Pressure (CPAP) and therapeutic hypothermia, are introduced as a result. Others, such as the routine use of atropine in asystolic arrest, are not proven effective and are discarded.

Epidemiological Research

Simple Steps Toward Evaluating Medical Research
  1. Is the paper from a credible source?
  2. Is the subject of the research applicable to the practice of EMS? 
  3. Is the design of the study appropriate to answer the question being asked? 
  4. Are variables controlled closely enough to ensure reliability of results? 
  5. How conclusive are the results? 
  6. Are the conclusions logical? 
  7. What alternative explanations exist for results? 
  8. How does the paper impact the body of evidence that already exists? 
  9. To what degree may the paper be biased? 
  10. Are changes in current practice called for? If so, what are they?

Epidemiological research attempts to study the distribution of various pathologies across varying segments of a population. Race, gender, geography, economic status, and a host of other factors may play into the incidence or severity of disease. These risk factors can be discovered and hopefully mitigated through epidemiological research. Such research is common in the public health arena, but it is also vital for EMS providers. Epidemiological research discovered a link between the incidence of asthma and a patient’s economic status. The astute provider can use such information in formulating a differential diagnosis of a respiratory patient.

Secondary Research

As mentioned earlier, secondary research is that which is conducted on data gathered by other research. Secondary research papers are common in the literature and may be thought of as a review. In a review, researchers attempt to gather the body of evidence that exists on a particular subject, summarize it, and draw some sort of conclusion. Reviews are valuable pieces of research, as they render potentially large volumes of information more easily processed. Studies conducted on registry data, such as a hospital’s trauma registry, often fall into the category of secondary research as well.

Research Paper Formatting

Armed with a basic understanding of the types of research available, the EMS provider should next consider the layout of a typical paper. Fortunately, this is a simple proposition, and a basic assessment of these parts reveals much. The following paragraphs detail what those pieces are, and what an EMS provider should look for in each.

Title and Abstract

The first section of any research paper is the title. In theory, the title of a paper should clearly describe what the paper examines. In an episode of the EMS Research podcast, Dr. Keith Wesley warns readers to beware titles that he calls “headlines.” These titles may be misleading, as they are more designed to attract attention. Fortunately, readers need not look far to find truth behind the marquee. Immediately following the title — and name of author(s) — is the paper’s abstract. The abstract is essentially a summary. The paper’s writer breaks down what may be pages and pages of information into a handful of sentences. An abstract is extremely useful to the reader. An abstract only takes a few seconds to read and understand. After reading it, an EMS provider can make a better decision about whether or not the paper is worth his or her time and effort. While the abstract is important and useful, it is no substitute for reading the entire paper. If a reader believes that the research presented may be applicable to his or her practice, a short summary will not suffice. Professionalism dictates that the paper be interpreted, and this cannot be done from an abstract.

Introduction

Finding Medical Research
Given the extremely large number of scientific journals that exist today, locating relevant research can be challenging. There are, however a few sources that can help EMS providers get started.

First, trade magazines often highlight new research, and offer expert commentary. Online sources also provide a good starting point. The National Institutes of Health maintains PubMed (www.ncbi.nlm.nih.gov/pubmed/) which archives millions of citations of medical research. Many PubMed articles include links to publisher sites and full-text papers. Medscape (www.medscape.com) is another good source of documents. Many medical directors subscribe to individual journals and may help in procuring papers. Finally, public, college, and hospital libraries can obtain copies of many articles at no charge to users.

A paper’s introduction is responsible for familiarizing readers with the subject of the research conducted. In the introduction, researchers explain the current state of knowledge of the area concerned and often describe the need for the project in question. Finally, the introduction briefly explains how this particular research fills that void. EMS providers should examine a paper’s introduction to further determine its applicability to their practice. Does it sound like the question presented is valid? Should this paper be able to answer the question? These are key questions to ask when reading.

Methods

The methods section of a paper describes how the study was conducted. This is a two-part proposition. The method of collecting data will be described first. This is an important consideration for EMS providers reading a paper, as a wide range of conditions exist in the practice of pre-hospital medicine. Carefully considering the methods of data collection will help the reader determine to what degree the research may or may not apply to a particular situation. For instance, if a reader working in a busy metropolitan system were to consider research conducted in a rural area with extremely long transport times, the results may not apply.

The second part of the methods section will detail the statistical processes used to analyze data. This part of a paper has the potential to confound readers, as most EMS providers are not trained statisticians. Fortunately, a thorough understanding here is not required. Generally speaking, readers may assume that an article published in a reputable journal will be statistically valid — ensuring such is the responsibility of the publisher.

Results

After describing the methods used to collect and analyze data, a paper will then report the results of the research. In this section of the paper, authors objectively describe findings and explain their statistical significance — or lack thereof. While the results are what we’re all looking for in a paper, EMS providers should not stop there. Results must be interpreted by the reader, and considering the author’s perspective is the first step toward doing so. Interpretation of the results is not appropriate in this section — that will be done in the next two parts of the paper.

Discussion

In the discussion section, a paper’s author will compare the study’s results with what is currently known — or thought to be known — about the subject and then analyze its implications and limitations. Whether the research confirms or contradicts that which exists will be discussed, as will the findings’ clinical significance. It is important to keep in mind that even statistically significant findings may not have much clinical application. For an EMS provider reading a paper, this distinction is an important one, and the author’s opinion is a valuable piece of the equation. Generally speaking, researchers in EMS are also experts in its practice, so the author’s conclusions should be carefully considered by readers.

Discussion of a study’s limitations is another important factor for EMS providers to consider. Even well-designed and conducted studies are limited by the imperfect nature of medical research. If certain factors cannot be controlled for, they should be explained thoroughly. Such discussion will allow a reader to interpret findings correctly.

Conclusions

This section of a research paper takes into account all of the preceding information and attempts to summarize it and make recommendations. These recommendations could range from a change in clinical practice to a call for more research. Conclusions are more subjective than any other part of a research paper, as they require a reader to weigh all parts of the study and assign them relative value. Again, researchers tend to be experts in their field, and their conclusions should be carefully considered.

References

The end of a research paper lists all of the references used in its writing. While this is usually thought of as a necessary process to prevent plagiarism, EMS providers should consider references carefully. Is some of the research cited known to be flawed or invalid? If so, questions about the paper being read could exist. The references provided are a good source of further information on a topic as well. Virtually no clinical decisions may be made on the basis of only one paper. Thorough understanding requires that a reader consider all of the evidence available, and this section provides a great tool to find such evidence.

Acknowledgements

Medical research can be an expensive undertaking. As such, it must often be sponsored. In the acknowledgements section, a paper’s author should disclose what entities, if any, provided financial support. The ultimate goal here is to explain potential conflicts of interest. Suppose that a study determines a particular drug to be ineffective and harmful. If that study were sponsored by a competitor of the drug and conducted by that company’s employees, then readers should be suspect. Such information is not necessarily inaccurate, but the potential for bias must be considered.

Summing it all Up

Reading and interpreting medical research need not be a difficult task. Given an understanding of the types of research available and the general formats thereof, EMS providers should be capable of analyzing said research and drawing appropriate conclusions. While patient care protocols and procedures are determined by medical direction, it is no less important for EMTs and paramedics to understand research. By understanding, we are able play an active role in the advancement of care and the development of our profession. The perspective of an informed EMS provider is valuable to a medical director in prescribing treatment, and a sound understanding of current science is a vital first step in gaining that perspective.

Doug Edenburn is a paramedic from Concord, NC. He works full-time for Cabarrus County EMS and part-time for Medcenter Air. Edenburn is also an adjunct EMS instructor at Rowan-Cabarrus Community College in Salisbury, NC. Contact him at [email protected].For references used in this article, e-mail [email protected] with your request.
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