EDITORIALS

not to provide any data regarding the effects of time differences (or similarities) on patient outcome.

A critical issue raised by this study concerns the accuracy of times collected and used in prehospital research. The times used by Hoekstra et al were recorded by advanced cardiac life support crew members either during the arrest or "immediately thereafter;" synchronization of timepieces was not addressed. The accuracy of these times must be considered suspect. Our own research 2 as well as that of Spaite and colleagues shows that times documented by paramedics on trip reports vary significantly from the actual times of occurrence as determined from real-time audio recordings.

Accurate determination of prehospital event times is a fundamental issue which, if not carefully addressed and answered with stringent precision, will prohibit the conduction of valid EMS research and will continue to leave EMS open to attack from those skeptical of its value. We agree with Spaite that the "ability to evaluate accurately prehospital time intervals in a standardized fashion" is crucial to determining the impact of EMS operations on outcomes. His report validating the use of on-scene observers to more precisely document system event times and, even more so, his development of a model template for analyzing the various components of an EMS response represent major advances in EMS research. 3

Still, there is much more work to be done. First, we must develop cost-effective methods to accurately determine prehospital event times that are feasible for use in high-volume services. It is likely that on-scene observers would be prohibitively costly unless reliable sampling methods are developed. Cummins, 4 and more recently Bradley, 5 have reported that audio recordings are accurate but labor intensive. Perhaps the answer will lie in "computerized timecards" that medics will "punch" to effect real-time data entry; these could be integrated with patient monitoring modules such as ECG, noninvasive sphygmomanometry, and pulse oximetry as well as with the system's dispatch center.

Next, consensus must be reached regarding a standardized terminology and reporting format, akin to the Utstein style developed for cardiac arrests. 6 This will not only promote greater understanding and communication among EMS researchers but also facilitate the conduction of multicenter trials--essential for generating sufficient power to answer the tough questions that must be asked.

Finally, we must use these newly created tools to rigorously evaluate all aspects of EMS. Just as an auto maker knows the time required for each step along the assembly line, so should we in EMS know the time required for each prehospital intervention. Just as a

general adeptly deploys various troops to most effectively execute the mission, so must we learn which "troops" should be deployed when and with how rapid a response for each of our different "missions." What is the cost in patient outcome for the time spent in the field for taking a history, conducting an examination, starting an IV line, or administering dextrose? Where are the bargains? Where are the white elephants?

The challenge now faces EMS researchers to enter the trenches of prehospital care--armed.with a simple (but synchronized) clock and with standardized terminology--to rigorously study the issue of time in EMS. Time is the currency of every prehospital encounter. For the sake of our patients, we must learn how to spend it wisely.

As the Romans once said, "Tempusfugit!" Vincent N Mosesso, Jr, MD Division of Emergency Medicine Department of Medicine University of Pittsburgh 1. Maio RF: EMS Systems: Opening the 'black box" (editorial). Ann Emerg Med 1993;22:730-731.

2. Mosesso VN, Sullivan MP, Davis EA, et al: Times of EMS interventions as document- ed on trip reports versus on-scene audio recordings (abstract). Ann Emerg Med 1993;22:920.

3. Spaite DW, Valenzuala TO, Meislin HW, et al: Prospective validation of a new model for evaluating emergency medical services systems by in-field observation of specific time intervals in prehospital care. Ann Emerg Med 1993;22:638-645.

4. Cummins RO, Austin O Jr, Graves JR, et al: An innovative approach to medical con- trol: Semiautomatic defibrillators with solid-state memory modules for recording car- diac arrest events. Ann Emerg Med 1988;17:818-824.

5. Bradley K: Use of a cassette recorder for data collection in prehospital cardiac arrest research. Ann Emerg Med 1993;22:80-83.

6. Cummins R0, Chamberlain DA, Abrarnson NS, et al: Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein style. Ann Emerg Med 1991;20:861-874.

Retooling the Medical Army See related article, p 1280. Pity the military. For years, moneys flowed into the defense budget as a necessity for America to keep up with Russian military strength. The continuous threat of global warfare fueled an unprecedented military buildup. The Gulf War showcased the awesome power and sophistication of the modern technology of war.

But we live in amazing times where changes are sweeping. Russia is now almost a Third World country, and the threat of truly global warfare seems so diminished that the Department of Defense has found its budget slashed and under increasing scrutiny. Money is a central issue, and there is increasing demand that dollars be spent wisely. Military personnel, once trained for battle, now find their roles changing to better fit the current national needs. Can you teach an old dog new tricks?

Eyes are now cast on the medical establishment. Medical spending is more than three times that of the

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EDITORIALS

military and employs twice as many personnel. 1 The fee-for-service era fueled a tremendous buildup that, too, has awesome power and sophisticated technology. But the facts are clear. The house of medicine that was built in the last few decades is geared toward illness, not wellness. In 1993, only 3% of the health care budget was spent on public health. The role of the house of medicine is shifting toward prevention. Can we do that?

The article by Dunn et al in this issue of Annals is a case in point. Reviewing emergency department visits for childhood injury in a rural setting, the authors found that simple actions and readily available safety devices could have prevented injury or reduced the severity of injury in 27% of cases. However, only 3% of the cases recorded any injury prevention instruction to patients or their families prior to discharge. The number of preventable cases is most certainly underestimated as the authors focused only on such prevention strategies by the patient as seatbelts for automobile crashes and helmets for bicycle-related injuries. Environmental factors such as lack of bike lanes and sidewalks, poor road maintenance and signage, and inadequate lighting often cause the injury-creating event and also are amenable to intervention. This is especially true in rural environments.

What is clear from the paper is that a steady stream of injured patients flows through the ED, and the army of health care providers within it is poorly equipped to wage the war of prevention. No wonder--traditional medical training is geared toward diagnosis, therapy, and treatment with little instruction on prevention strategies or how safety devices work. Emergency physicians will educate the patient as to how a prescribed medication works, but may be unable to describe the proper fit of a seatbelt or strategies to prevent scald injuries in the home. It simply has not been a requirement of the job.

Why focus educational efforts only on injured patients? Injuries are predictable by age, sex, occupation, and time of year. Assessment of risk factors for disease is an integral part of the physician-patient interaction and a thorough evaluation. Patients who are found to be at risk for a particular injury can receive counseling, education, or referral to additional resources such as home health nurses, social services, and community organizations.

To redefine a role demands the resources to fulfill it. Injury prevention information must be integrated into training programs for medical students, nurses, emergency medical technicians, and physicians. After- care instructions for cause of injury can provide useful information for both medical professionals and patients. Educational videos can be shown in waiting rooms, providing patients and their families practical advice

and insight. Educational displays can be situated throughout the ED and used as a teaching tool as patients flow through the department. Monthly prevention themes can coincide with injuries from boating and motorcycle and bicycle use. Custom- designed programs can target the common injuries in each community.

It is time to take a critical look at what the role of an ED is in today's health care systems. Without a doubt, we can no longer sit passively waiting for the next injured patient to enter our domain. The challenge to change is ours.

Ricardo Martinez, MD, FACEP Trauma Services Stanford University Hospital Stanford, Cafifomia 1. "The Coming Health Care Shake Out." Fortune May 17, 1993, p 70-75.

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