how to do prehospital research

SMACC DublinMarius Rehn@DrRehnNorwegian Air Ambulance FoundationLondon´s Air AmbulanceUniversity of Stavanger

How to do pre-hospital research

Painfully complicated; Publications Practical work; Lonely Hard work: Clinical-Academical

Patient pathophysiology-strategies of care Care: Influence outcome the most

Evidence-based: PH-practice Critically appraising our practice: Improvement/harm/cost-effectiveness

Cannot extrapolate in-hospital evidence-field Pre-hospital environment: Kit, diagnostic, crew

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7 Deaths per year (millions)

Injury HIV/AIDS, TB and Malaria

Figure 1:

The scale of the problem Injury deaths compared to other leading causes of mortality.

The magnitude and causes of injuriesEvery day the lives of over 15 000 people are cut short as a result of an injury. Among

the causes of injury are acts of violence against others or oneself, road traffic crashes,

burns, drowning, falls, and poisonings. The deaths caused by injuries have an

immeasurable impact on the families and communities affected, whose lives are often

changed irrevocably by these tragedies.

Injuries and violence have been neglected from the global health agenda for many

years, despite being predictable and largely preventable. Evidence from many

countries shows that dramatic successes in preventing injuries and violence can be

achieved through concerted efforts that involve, but are not limited to, the health

sector. The international community needs to work with governments and civil society

around the world to implement these proven measures and reduce the unnecessary

loss of life that occurs each day as a result of injuries and violence.

Injuries are a global public health problem About 5.8 million people die each year as a result of injuries. This accounts for 10%

of the world’s deaths, 32% more than the number of fatalities that result from malaria,

tuberculosis, and HIV/AIDS combined (see Figure 1).

Approximately a quarter of the 5.8 million deaths from injuries are the result of suicide

and homicide, while road traffic injuries account for another quarter. Other main causes

of death from injuries are falls, drowning, burns, poisoning and war (see Figure 2).

Every 5 seconds

someone in the world dies as a result of

an injury

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Injuries and violence: The facts. WHO; 2010

10% deaths PH-research is underfunded Quality of evidence is weak How can you contribute? Components

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Transfusionpaperwork

Golden hour box™

4 emergency units of O Rh negative packed red blood cells

Sealed by blood bank

Maintain steady state temperature of 2-4C for 48-72 hours

Data logger

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Unit of packedred blood cells

Battery pack

Blood warmergiving set

Blood giving set

3-way tap and 50 ml syringefor intraosseous administration

Patient

Blood warmerheating element

Blood giving set

Relevant - patient oriented questions “So what” filter

Hospital - Street Test: Feasibility and impact on outcome

PH: injuries evolving, classic features; “fully established disease” Indications/contraindications Diagnostic test accuracy

Before embark: Recent and seminal pieces Systemic review: identification, data extraction, quality appraisal, meta-analysis

Crux: Study methodology Hierarchy of evidence: Expert opinion-RCT Aim high: not dismiss Case series: High volume Observational studies: Causation / Association

RCT: Systematic skewness Not impossible Solid framework: Funding, data collection, experienced researcher, commitment PH-cancer care: Systematic hard work Increase level of evidence

Statistical models Observational: Regression Not feasible: Mathematicians Statisticians Selective publication: positive studies Negative studies

Science lead to change: Communicated SMACC: FOAM vs conservative scientific establishment Editorial peer review + Unmoderated debate Merge science with education; Twitter

Clinician, relevant hypotheses, designer of research methods, analyser of data, interpreter of results, current literature, decent writer - communicator of science, 140 characters Fascinating, vital, never completely mastered

Evidence-based medicine Preserve limited resources Seek evidence it is lacking Dichotomy Know and Do Quest: Critical care without walls