July 2018 Outcome Edition

July 2018

EMS, RESEARCH, AND THE MEDICAL LITERATURE EMS INSTRUCTOR OR DYNAMITE EDUCATOR… THE CHOICE IS YOURS!

The Outcome Edition

Table of Contents 6 Decoding the myth of resiliency in Emergency Medical Services It seems like every day there is another story on first responder fatigue, poor resiliency and stress.

Has the job gotten that bad that no one can survive it anymore? Or does the problem lie within us?

10 Lift Different. Stop Injuries.

Lifting patients is the most dangerous task EMS providers will perform during a typical shift. In fact, 90% of sprains and strains are from patient lifts according to a recent study by NIOSH. Binder Lift is the simple answer to this complicated problem.

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EMS Instructor or Dynamite Educator… The Choice Is Yours!

How educators can leave a legacy of quality patient care .

20 WHEN THERE IS NO HELP COMING When bleeding from an artery, you can lose nearly your entire blood volume in just minutes. You must rely on yourself and those around you to act in those important first few minutes.

23 EMS, RESEARCH, AND THE MEDICAL LITERATURE How can EMTs help to save even more lives, and make a great second income? We proudly present our Outcome Ambassador Program!

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Our Industry Needs Your Help Welcome to The Outcome Edition, a medical journal dedicated to improving outcomes in medicine. Focusing on outcomes is important and we need your help to do this. The Outcome Edition needs your insight to support EMS providers' health, medical education, and leadership.

For those of you who are focused on improving outcomes, we’re here to tell your story, share your insights, and introduce you to the industry's latest innovation. In our experience, many, if not most, professionals working in EMS have valuable experience that the industry needs to hear. We believe that your personal experience holds the key to elevating outcomes around the world.

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In this issue we have articles that focus on EMS Health and Resiliency, Education, and Research. Industry leaders have used their incredibly valuable time and energy to share their insight with us and the world.

Please take the time to deeply consider their generous contributions. And when you have a moment, consider what you could share with our readers to elevate the industry.

Here is to your continuing success!

Dana Friesen Publisher The Outcome Edition Summit Sciences Group

Decoding the Myth of Resiliency in Emergency Medical Services

By Bryan Fass It seems like every day there is another story on first responder fatigue, poor resiliency and stress. Has the job gotten that bad that no one can survive it anymore? Or does the problem lie within us?

I will argue that much of the problem lies with us. Let me explain.

There is no arguing that in the past call volumes were not nearly what they are today.

EMT’s had to do a lot more with a lot less yet it was, for the most part, a career that people retired from. This begs the question; were previous generations tougher and more resilient than today's current cadre of EMT’s or are they just different?

Allow me to draw some parallels.

The EMS Diet: In the past, we can argue that life moved at a slower pace, this was reflected in the limited options for going out and purchasing food. Meals were often planned and eaten at the base or at a sit-down restaurant. Of course, call volume and transport times have also affected this however back then there was not a convenience store on every corner with an endless array of nothing healthy.

Our nutrition has changed so much and so quickly that first responders are simply not eating a balanced diet of healthy natural foods. Foods that allow the body to heal, repair, recover and grow. Instead many first responders have fallen into the processed, fast food, sugar-laden and chemical filled world we now live in.

Did you realize that in 1977 when fat became evil and sugar became good there was an almost immediate spike on obesity, cancer and many of the diseases we treat today? (1) 6

EMERGENCY MANAGEMENT EMS AND HOSPITAL LEADERSHIP SAFETY TRAINING RISK MANAGEMENT TRAINING peter.dworsky@outcomesolutions.org (732) 620-3563

Further, we can look at a simple study that shows what happened when we became a carbohydrate (added sugars) rich diet and not a balanced diet with few refined oils, meats or processed foods. The bottom line is that food should heal and not harm; what we eat harms us.

Fit for duty: There is no debate that we have become a very sedentary country. Gym class is gone in many schools and with the advent of technology we spend an increasing amount of time sitting, usually with a screen in our face. This presents two distinct problems.

We are creatures of motion not meant to be sedentary or to take on the shape of a chair.

Previous generations were not tied to a screen. As more and more jobs, hobbies and past times become sedentary we have seen the predictable, yet preventable, shift in first responder fitness, wellness and I will argue physical resiliency.

EMS is a 100% physical job, an argument that I have made many times before. No matter how much we throw engineered solutions at the problem we still have to move the patient. We still have to be able to lift and move our gear. Having written and validated over a dozen EMS physical abilities tests plus administering over 5000 tests, it's truly chilling to see how deconditioned and immobile the current generation of first responders has become.

The solution is radically simple. Test all your employees at hire and annually after that.

Fit for duty is not a luxury, it’s a down right necessity as fit employees get hurt less then unfit first responders. Give them access to fitness equipment and teach them how to manage the aches and pains of the job, something I personally have been fighting to change for over a decade in EMS. How can we expect EMT’s to remain resilient and with risk averse behaviors when 8

by the design the system breaks them down? From an operational perspective it is far cheaper to keep an employee healthy and on the job to retirement then to constantly hire new employees that will only stay for a few years.

It’s far less expensive to have a fit employee that is free from injury than to pay for the claim when they have an MI on duty, a CVA, a MSI or an MVC. It is far easier on an operation to invest in an EMT’s education before they have substance abuse issues, poor health, PTSD, anger issues, risky behavior or worse. It is up to us as a profession to teach new and incumbent responders how to survive the job.

Stop rushing new employees through haphazard training just to get them on the street, this is the true definition of insanity.

Instead teach them how to be fit for duty, teach them how to employ sleep hygiene strategies, teach them how to eat in the field, make them experts at safe patient handling and equipment use. Educate them about risk in EMS, the root cause of injuries, exposures, slips and assaults before they hit the street.

Resource: Injury Free University by Fit Responder www.fitresponder.com 1. National Center for Health Statistics (US). Health, United States, 2008: With Special Feature on the Health of Young Adults. Hyattsville (MD): National Center for Health Statistics (US); 2009 Mar. Chartbook

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Lift Different. Stop Injuries.

Lifting patients is the most dangerous task EMS providers will perform during a typical shift. In fact, 90% of sprains and strains are from patient lifts according to a recent study by NIOSH. This sobering statistic represents 89,100 EMS providers who visited an ED between 2010 and 2014. Because of the prevalence of powered stretchers that can self-load into an ambulance, the majority of these injuries happened when lifting the patient from the ground or transferring to a hospital bed.

Unfortunately, published studies provide statistics, but none provide answers to why the lifting related injury rate is so much higher in EMS than any other industry. Knowing where most injuries are happening – lifting the patient from the ground – does little good if it isn’t clear why they are happening. The answer is simpler than one might think: handles.

It is impossible for caregivers to effectively team lift or use proper lifting ergonomics without having handles to grasp. Unfortunately, humans don’t come with handles. But you can bring your own. The Binder Lift’s 19 to 25 handles give caregivers something to grasp when lifting patients. With the Binder Lift, caregivers can share the load of the patient with their partners. They can also all lift with their legs while keeping the patient’s weight close to their body.

The Binder Lift’s torso wrap design is also very comfortable and secure for the patient.

When crews have access to the Binder Lift, they no longer must use sheets, blankets, or soft stretchers - which are dangerous when used for lifting. The Binder Lift has been proven to prevent lifting related injuries and increase patient comfort and outcome. Now, any department in the USA can experience the Binder Lift difference by setting up a free field trial. It’s time to Lift Different and Stop Injuries. W W W. B I N D E R L I F T . C O M / F R E E - T R I A L

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Lift Different. Stop Injuries.

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Try One FREE. Call, Email, or Visit our Website 855.239.5438 • Info@BinderLift.com • www.BinderLift.com/free-trial

The Outcome Edition

EMS Instructor or Dynamite Educator…

The Choice Is Yours!

Richard A. “Doc” Clinchy, PhD, EMT-P By way of introduction and background, I will be renewing my paramedic license in Florida once again this year. By the time this renewal expires, I will have held an EMS license or certification of some sort for fifty years. Teaching of prehospital care started back in 1971…and first aid before that. If you are an EMS educator your value to quality prehospital care can never be over-estimated. If you are responsible for education of prehospital care personnel, those who are educators working for you cannot ever be undervalued. When running programs in South Florida over thirty years ago, I was very excited when I signed my first of book contract. I was proud of that accomplishment because I’d be “leaving something behind.” A friend and one of my instructors, a wise paramedic with Miami-Dade Fire Rescue, asked me, “How many EMTs have you educated?”

My response was I wasn’t sure but over 1,000. He went on to ask, “How many paramedics?” My response was that in whole or in part over 500 and thousands who had participated in my conference presentations. His reply was something to the effect those students were my real legacy…not a book in a library. I share that only because that’s what teaching is all about…the legacy of the delivery of quality patient care.

If you ask any EMS educator what they are being paid, most will simply tell you their hourly rate or salary. When you look at the true cost of teaching a classroom full of aspiring EMTs or paramedics, it’s well beyond that: Instructor’s salary; students’ compensation by their department for each hour they sit in the classroom…sometimes involving overtime; the cost to the department or service to cover the student’s shifts, student’s paid-time off to attend classes, etc. It’s even more compensation per hour for the instructor if it’s a conference educational session where travel, lodging, honorarium, and per diem come into play.

Good education is not cheap!

Let’s first address two terms… “Training” and “Education.” Taxonomy of learning theory talks about training focusing on skills…the “protocol paramedic” versus the paramedic who knows exactly why s/ he is doing what s/he is doing. Education, on the other hand is comprehensive. It is achieved by a complex approach to learning and an understanding of the reasons behind what prehospital care providers should or should not do. It also embodies teaching students an understanding of the pathophysiology of a patient’s condition versus just making decisions based on what’s shown on a monitor or memorized from a protocol 12

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The Outcome Edition

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manual, e.g. see this, then do this, but never really understanding why.

What’s contained in this brief article began as an all-day workshop for EMS Educators at the Wisconsin EMS conference many years ago.

Nothing an educator does is unimportant…the teacher is on stage each and every time he/she is in front of a class. How you sound, how you look, my favorite…clothes on the outside reflect the mood on the inside. The true educator can never ever be over-prepared.

Preparation reduces nervousness, usually resulting from lack of preparation. Being thoroughly prepared puts the educator in a mind-set where s/he is relaxed and in command.

Sitting while teaching is disrespectful of your students…stand-up, walk around, make eye contact with every student you are teaching…they will be far more engaged and will learn more.

The Chevy Vega did not last too long in the marketplace but the mnemonic VEGA is an important one for educators…Voice, E-ye Contact, G-estures, A-ttitude.

Get all those wrapped up in a teacherpackage and there is an effective educator.

Arena preparation is critical to effective teaching…not the arenas in which gladiators battled. The teacher’s classroom is the arena in which s/he fights to help students learn and learn well. What’s the seating arrangement?

Can everyone see? Are they situated in a way that the teacher can get up close and personal? Traditional classroom set-ups

prevent close interaction. So, why not rearrange a classroom in a U- or modified U-shape. What’s the lighting like? Can they see their own notes? Away from this article, look up Knowles’ Model of Human Learning. Adults essentially teach themselves and will learn based on need and intrinsic factors. The teacher is merely the catalyst. If you do it right, they will learn.

Adult learners almost inherently have test anxiety and many have been away from formal education for a very long time. Tell students what they’re expected to know. Do not create testing situations or questions to trick students. Teachers who produce students achieving high test results are not “easy graders” and will not “look bad.” Instead these teachers are truly educating if all their students become confident and competent.

Little things will push an adult learner off the rails and rarely do we consider these little things. Don’t mark “-20%” on a test score. Mark it “80%! Well done”. As kids, when we did badly in school, there were red marks everywhere on our test papers. Throw away the red pencils and mark everything in black or blue instead.

As an educator, how well do you know your students? Do you know their names and remember them? If not, get them to wear name tags that you can read and have a tent card in front of them with their name in big letters until the day you can look every student in the eye and address them by name. What do you know about them? At the beginning of a class, have each student introduce

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The Outcome Edition

him/herself and tell everyone a bit about them…more than just “why are you here?” Learn their backgrounds and take notes. At my age, I have many life-long friends who are former students. They are running EMS systems, Chief officers at Fire Departments, one is a State EMS Director, many are now physicians, and they all remember those who were their real teachers.

Almost all EMS education is geared to a standard curriculum of some sort but it need not be canned. If you truly know your students, you’ll know what they need to be taught and, in fact, they can tell you and, in so doing, modify the curriculum.

If you negotiate student-directed lesson plans the students will remain more engaged.

In the adult learning setting, have students practice using information immediately.

Be creative using skills demonstrations, role playing, simulations, games…adults learn by doing. Adult learners who are not actively involved in learning will be lost. Start entry-level EMS students with “Mega-Codes”. Not the nail biting, tear inducing, terror situations of ACLS in the 1970s and 80s but situations where students become cognizant of the “patient” and develop “situational awareness” of what things look, feel, and smell like. Have students practice skills in a darkened room and see how much better they become.

When you are preparing to teach students pediatrics, invite all of the students with children to bring their kids to school with them. First, the children will enjoy 16

the adventure. Second, those who are parents, will find it easier to explain to their kids what they are learning and what their profession is all about. Finally, for those students who have no children of their own, they will begin to interact with children of all ages and sexes and not have to encounter their first pediatric patient “on the street.”

When it comes to evaluating performances, let the students do evaluations of themselves and their peers before you, the teacher, renders judgment.

If you have been involved in full scale exercises, you are familiar with the concept of the hot wash. Do hot washes with your students. It will let you know how you are doing because you’ll better understand how they are doing.

There is no avoiding death by PowerPoint but no one is forcing an educator to use every PowerPoint slide invented by man. Thin them out, supplement slides by having equipment that students can gets “hands on”. Educators need to learn to draw or find supplemental resources.

For example, you can show paramedic students a series of rhythm strip examples and hope rote memorization and recollection will enable them to recognize dysrhythmias in the real world. Or, the really well-prepared educator might have handouts that show the rhythm strip AND a diagram of the heart showing where conduction problems or ectopic foci might be occurring AND also listing what sort of signs and symptoms a patient might be experiencing. If the teacher starts the students’ learning in the classroom

with a solid grounding of anatomy and physiology, it is amazing how logical many patient presentations will become to them.

Do the lights need to be turned down to show PowerPoint images? If so, get new PowerPoint images or, better yet, make your own. The brain’s reticular activating system is what triggers our wake and sleep states. When the lights go down, the sleep state is triggered. Never, never, never read PowerPoint slides… they are an educational adjunct…the teacher is the educator, not an inanimate screen.

As a retired SCUBA Instructor, we used to say, “SCUBA skills can’t be learned on the deck of the boat.” Similarly, EMS skills cannot be taught by lecture.

Skills require hands-on activities and that requires a lot more thought and preparation by the teacher but it is well worth it.

Adults learn by using all of their senses and those who pursue EMS, Law Enforcement, and Fire Service professions…Public Safety as a whole… are typically more action oriented individuals. Teachers of these students need to be very creative to be effective.

Keep them active. Go beyond the minimums. Have them do research away from the class that cannot be found in whatever textbook they have been given.

When teaching EMS students, get them to learn mnemonics to help them quickly recall complex lists of things they need to be cognizant of such as S-A-M-PL-E, A-V-P-U, S-O-A-P, AEIOUTIPS, MUDPIES, SLUDGE… and many more.

These will be stored in their “mental rolodex” and will become second nature to the students once “on the street.” With this knowledge always at hand, it will instill both calm and complete control of medical situations without missing any important aspect of the assessment and documentation process.

If you’re teaching IV drip rates and medication administration, simplify the learning process by converting concentration drip rates to the face of a clock. 60 minutes in an hour…60 drops per ml in a minidrip IV administration set.

Compare the Rule of 9s to the Pillsbury Doughboy.

Add humor now and then…it breaks up what can become very tedious material and when it becomes tedious, retention deteriorates.

I have tried to jam many hours of discussion, examples and concepts into a very brief article. However, if I can be of any assistance to you with building your quality EMS education programs, feel free to contact me at drclinchy@gmail. com I’ll be delighted to lend a hand. As I implied at the opening, our legacy as EMS educators is to inspire outstanding prehospital care professionals who will consistently delivery nothing but superior patient care.

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The Outcome Edition

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The Outcome Edition

WHEN THERE IS NO HELP COMING

BY JIM MANSON You are sitting at your desk at work, and it has been a typical day so far. You are reading email and catching up from the weekend when you hear the commotion coming from down the hall. Was that a firecracker? Is that glass breaking? Now you hear screaming. You realize it’s gunfire and something terrible is happening. Someone is in the place you always considered to be a safe place and is creating carnage. People are calling for help, they are running, and the gunfire is getting closer to you. You witness your co-workers being wounded or killed. And soon the shooting stops and the aftermath is before you. A dozen of your friends in need, bleeding, some hemorrhaging to death. Do you know what to do?

needlessly from a hemorrhage that could have been stopped if someone would have been trained to do so. Simple wound packing, pressure, and tourniquet placement.

Easy to learn skills that can make the difference between life and death.

When bleeding from an artery, you can lose nearly your entire blood volume in just minutes. Quick and definitive action to control bleeding in the first few minutes is critical as shock and death can come very quickly. There is no help coming that will get to you in that amount of time! You must rely on yourself and those around you to act in those important first few minutes.

The principle of no one is coming holds true in other emergency situations. Whether Unfortunately, this scenario has played out it’s a fire, tornado, flood, or earthquake numerous times in our communities resulting - essentially any situation that requires in the death, disability, and mental trauma immediate action, it is up to you to make for thousands of our friends and neighbors. those first few decisions that will save your And I don’t think we have seen the last of life. Also, it is dependent on us to have a it. But based on what we have learned from plan that ensures our safety and provides the US military experience on the battlefield for our basic needs during a protracted in Afghanistan and Iraq is that people die event. The larger the event, the less likely needlessly from blood loss because people we can rely on formal resources to help. just don’t know how to control bleeding.

We need to look no farther than Hurricane Katrina and the aftermath in Puerto Rico And it not just an active shooter problem. for examples of how having a plan for the Injuries that result in life-threatening first three to five days is essential. And as hemorrhage occur in many everyday many US states struggle with meeting their settings. Vehicle accidents, table saws, financial obligations, the Federal Emergency accidents, breaking of glass windows and Management Agency (FEMA) recently coffee tables, hiking and hunting accidents announced that it was creating a “disaster are just a few examples of situations deductible” system to push more of the of where injuries occur, and people die financial responsibility for disaster response

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back on individual states. Under President George H.W. Bush, FEMA declared 174 disasters, amounting to an average of 43.5 per year. Under Presidents Bill Clinton and George W. Bush, declarations rose substantially to 716 and 1,037 respectively, averaging 89.5 and 129.6 per year. Under President Barack Obama, declarations remained high with 854 total alerts being issued, or 106.8 on average per year. This is There is no help coming that likely a trend in federal disaster aid spending will get to you in that amount that is not sustainable and more financial responsibility for response will be placed back of time! on individual states. While some may argue that this is sound fiscal policy, it will create a greater burden on states and local communities to solve and fund their own disaster preparedness needs.

It’s time to take action. It’s time to lessen our dependence on the larger systems for help when our communities need it and time for our communities to stand together and take charge of their own future. Working in partnership with state and federal agencies and not depending on them puts our communities in a much better and sustainable position.

This is where the Outcome Project comes in. The Outcome Project is a boundary object whose purpose is to bring communities together - to be the entity to help break down barriers and silos so that we can achieve greater levels of preparedness and resilience than ever before. And to help fund those projects in ways that do not depend on the typical methods of grants and fundraising.

Get involved and bring the Outcome Project to your community. For more information visit www.theoutcomeproject.org

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Peak Performance For EMS Leaders www.summitsciences.com Summit Sciences is a full-service consulting firm which donates 100% of its fees to groups who are working to improve outcomes worldwide.

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EMS, RESEARCH, AND THE MEDICAL LITERATURE Peter T. Pons, M.D., F.A.C.E.P.

Past E.M.S. Medical Director

Professor Emeritus

Denver Paramedic Division

Department of Emergency Medicine

Denver Health

University of Colorado School of Medicine

Denver, Colorado

"The future of EMS is indelibly linked to the future of EMS research.

This reality provides EMS with its greatest opportunities, its greatest risks, and its greatest single need to depart from the ways of the past.”

Daniel W. Spaite, MD1 Emergency Medical Services (EMS), as a component of the healthcare delivery system, has engaged for some time in a conversation about how best to elevate the standing of the profession and its providers within the healthcare system. This has included discussion about the educational requirements to best function as an EMS provider, the most appropriate system in which to deliver emergency medical care, and the research base needed to support the practice.2 For over 50 years now, EMS data collection and research have been identified as critical components needed to document the efficacy of prehospital care and treatment.3 Unfortunately, the effectiveness of most EMS interventions and of EMS systems, in general, still has not been well established with appropriate outcome criteria.4-8 The rationale for many EMS interventions is based on in-hospital studies, and not on scientific investigation of their outof-hospital effectiveness. Much of the published “EMS” research has not been initiated or performed by EMS providers or agencies but rather by traditional medical

specialties such as cardiology, pediatrics, and trauma services.

Despite numerous calls for expanded research efforts, EMS research remains hampered for a number of reasons, not only in the United States but also worldwide. 9-17 These include: •

Lack of formalized research education for EMS providers and managers,

•

Underappreciation by many in EMS of the importance of research,

•

Inadequate preparation of EMS personnel to carry out research,

•

EMS data that often are not collected in a rigorous fashion that allows academic evaluation,

•

The lack of a formal, centralized group to drive EMS research,

•

The lack of linkages between existing EMS and hospital databases, and

• Randomized controlled trials are

difficult to conduct in the prehospital setting.

It is often tempting to read the abstract or summary of a published research paper and then make a decision as to whether or not the conclusions reported justify a change in current EMS practice.

Instead, it is essential that EMS as a medical profession and EMS personnel as healthcare providers read the entire original research paper and rigorously evaluate its quality and appropriateness to EMS practice.

a. It is important to look at the data tables and information given to determine whether or not the stated conclusions are, in fact, supported by the data.

6. Were both statistical and clinical significance considered?

a. While most, if not all, studies provide a determination of statistical significance, it is critical that clinical significance also be assessed. For example, if the study group Critical evaluation of a research paper or is large enough, a new medication may study requires that a number of questions decrease blood pressure by 2 mm Hg and be a statistically significant result, but is be answered every time a publication that clinically significant? is reviewed.18-21 These include the following: 7. Is the therapy feasible in your practice 1. Were patients randomized? If so, how? or setting? a. It is necessary to determine whether a. There should be a study group and a or not the intervention studied can control group and enough demographic reasonably be offered or delivered in your information supplied to determine individual EMS setting. whether or not they are similar. Every participant in the study should have an 8. Were all patients entered at the equal chance of being assigned to the one beginning of the study accounted for at group or the other. the end?

2. Were all relevant outcomes reported? a. Every study should provide a complete a. While most prehospital studies tend to accounting of the patients who were use death as the outcome measured, it is entered into the study and what happened important to determine if other outcomes to them during the study. Specific reasons for excluding patients should be were or should have been reported. documented.

3. Is the setting similar to yours?

The future of EMS, both as a medical a. Ideally, for an intervention to be discipline and as a financially sustainable adopted into daily practice, the setting medical endeavor, is dependent upon utilized in the study should be similar to demonstrating evidence of its value and the setting into which it will be adopted. benefit. EMS itself must contribute to the on-going expansion of the EMS 4. Are the patients similar to yours? knowledge base. This can only be accomplished by high quality research. a. Enough information about the study Every EMS-related study must be population should be provided to critically evaluated. All too often, the determine if the patients studied are first study reported in the literature is not similar to your patient population. the final word. It is long overdue that 5. Are the conclusions supported by the EMS educate its leaders and providers data? about the importance of research and the 24

appropriate methods of interpreting and evaluating the research, and accepts its responsibility for performing prehospital research.

REFERENCES: 1.

National Highway Traffic Safety Administration and the Health Resources and Services Administration, Maternal and Child Health Bureau. EMS Agenda for the Future. 1996.

2.

Committee on the Future of Emergency Care in the United States Health System. Institute of Medicine of the National Academies. Emergency Medical Services: At the Crossroads. National Academies Press, 2007.

3.

Gibson G. Congressional Briefing. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC1071958/ pdf/hsresearch00546-0045.pdf Accessed May 8, 2018 4.

Callaham M: Quantifying the scanty science of prehospital emergency care. Ann Emerg Med December 1997;30:785-790.] Joseph J. 5.

Osterwalder JJ. Insufficient quality of research on prehospital medical emergency care – where are the major problems and solutions? Swiss Med WKLY 2004;134:389 – 394.

6.

National Highway Traffic Safety Administration, Department of Transportation and the Maternal and Child Health Bureau. National EMS Research Agenda. Health Resources Services Administration, Department of Health and Human Services. 2001 7.

Sayre MR, White LJ, Brown LH, McHenry SD for the Implementation Symposium Participants.

National EMS Research Agenda: Proceedings of the Implementation Symposium. Acad Emerg Med 2003; 10:1100–1108 8.

Sayre MR, White LJ, Brown LH, McHenry SD for the National EMS Research Strategic Plan Writing Team The National EMS Research Strategic Plan. Prehosp Emerg Care 2005;9:255– 266 9.

Schmidt TA, Nelson M, Daya M, DeIorio NM, Griffiths D, Rosteck P. Emergency Medical Service Providers’ Attitudes and Experiences Regarding Enrolling Patients in Clinical Research Trials. Prehosp Emerg Care 2009;13:160–168 10.

Ripley E, Ramsey C, Prorock-Ernest A, Foco R, Luckett, Jr. S, Ornato JP. EMS Providers and Exception from Informed Consent Research: Benefits, Ethics, and Community Consultation.

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11.

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