Out-of-hospital resuscitation research: Rationale and strategies for controlled clinical trials

CONCEPTS

CPR emergency medical services resuscitation

Out-of-Hospital Resuscitation Research: Rationale and Strategies for Controlled Clinical Trials Fromthe Qty of Houston EmergencyMedical Services; and the Departments of Medicine, Surgery, and Pediatrics, Baylor Collegeof Medicine, Houston, Texas.

Paul E Pepe, MD, FACEP

Receivedfor publication September26, 1991. Revision receivedAugust 6, 1992. Accepted for publication August 19, 1992. Presentedat the Methodology in CardiacArrest Research symposium in Chicago,April 1991.

There is no better place to test life-saving resuscitation interventions than in the prehospital setting, Patients rarely survive cardiac arrest if resuscitation techniques have failed before leaving the scene. Also, paramedics are usually very experienced in key initial resuscitative techniques, and they routinely operate under strict paramilitary protocol, resulting in better study compliance. In addition, the large study populations that are derived from emergency medical services (EMS) systems lead to faster study completion and statistically stronger data. Most important, by reinforcing standardized care, rigidly scrutinized trials improve patient care, regardless of the effect of the study intervention. The success of productive EMS research centers requires routine communication between hospital and EMS administrators and their medical directors, designation of mutually acceptable data collectors who guarantee confidentiality, reciprocal exchange of study data provided as educational seminars to the hospitals, commitments to support the budget requests of an EMS program and appropriate system modifications, inclusion of EMS personnel in study design from the very beginning, prospective education of the medical community and media before protocol implementation, an authoritative grassroots medical director, and a paramedic supervisor system. [Pepe PE: Out-of-hospital resuscitation research: Rationale and strategies for controlled clinical trials. Ann EmergMedJanuary 1993;22:17-23.] INTRODUCTION Two and a half decades ago, when Uncle Harry suddenly collapsed, we said, "Uncle Harry had a massive coronary," and we went to his funeral. At that time, the potential reversibility of this sudden death syndrome, the number one cause of death in the United States, was not widely recognized, l In the late 1960s, several academic clinicians brought their scientific investigations of heart disease into the prehospital setting.2, 3 Not only did this research even-

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tually demonstrate the reversibility of out-of-hospital sudden death, it also led to the widespread development of sophisticated paramedic traimng programs and ubiquitious emergency medical services (EMS) systems. 1-3 With early provision of basic CPR by bystanders, followed soon by defibrillation, long-term survival rates in some EMS systems have now exceeded 50°£ for witnessed collapses associated with ventricular fibril]ation. 4 Considering that 0Ut-of-hospital sudden death is the first symptom in 25% of Americans with coronary artery disease and that, without intervention, it usually is fatal within four to five minutes, 1 these first out-of-hospital research efforts have made an obvious Empact, both scientifically and clinically. Today, those EMS systems that demonstrate life-saving capabilities continue to use prehospital investigations for improving performance. Research data not only guide the development of medical and operational policies and procedures but also generate better quality assurance because of the additional scrutiny and standardization that accompany scientific investigauons. OBSTACLES TO OUT-OF-HOSPITAL RESEARCH

Unfortunately, the early successes of pioneer research programs have not been reproduced in other venues. 2.5 Although resuscitation research was the original basis of EMS. the critical premise of establishing scientific mvestigauons to improve patient care was soon misplaced The focuses of most EMS programs have become response umes, procurement of equipment, certification of EMS personnel, and "protocol" development. Ironically, there have been very few controlled trials to validate the many treatment protocols that EMS systems now offer.3 Even the scientific medical community has hesitated to attempt prehospital care research. This reluctance, in part. stems from a mentality that prehospital care providers are "nonphysicians" and therefore unlikely to execute scientific studies. Also, the logistics of providing and accurately documenting care rendered outside of a hospital are constrained. Furthermore, true informed consent is unfeasible, 6 and because patients are taken to different hospitals, study compliance may be difficult to ensure. Even when the key role of out-of-hospital research is well accepted by the medical community, there are political roadblocks that may obstruct success, including hospital and EMS administrators, unions, the media, and the occasional "loose cannon." Most important, the EMS personnel who execute the protocol can constitute the biggest obstacle. The most common obstruction, however, is the access to in-hospital outcome data. Staff physicians

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and, subsequently, hospital administrators are wary of outside government interventions and quality assurance programs. Therefore, when researchers want to review charts or visit patients to determine neurologic outcome; hospitals may View these outsiders as either a regulatory agency (eg, the municipal EMS) or a Competing enterprise (eg, private ambulance service). Likewise, EMS administrators often are reluctant to provide information. Understandably, they may be apprehensive of being viewed negatively if their EMS program iS found to have a low survival rate. Another disconcerting problem is the unexpected loose cannon the disenfranchised individual (eg, decertified paramedic; union official, Or community physician) Who anonymously calls the media or city council member stating that the paramedics are "killing people on Thursdays and Fridays," They Use inflammatory phrases like "using the citizens as guinea pigs" in an attempt to generate negative publicity. On occasion, the roadblock may be an overly conservative institutional review board that is concerned about the issue Of informed consent. All of these problems can Create a reluctance to implement EMS research. CLEAR RATIONALE FOR OUT-OF-HosPITAL

RESEARCH There iS clear rationale for mandatoryEMS research. Although patients may not be found with potentially reversible ventricular fibrillation by the time rescuers arrive, it still constitutes the primarY precipitating event leading to sudden death and occurs in as many as 300,000 persons annually in the United States.2,4, 7-9 Regardless of age, most cases of reversible cardiac arrest occur in the out-of-hospital setting, and recent studies have reconfirmed the value of resuscitative efforts for out-of-hospital patients presenting with other cardiac rhythms 8-10 Despite low survival rates, such efforts contribute significantly to overall survival statistics because of the sheer vOlume of such patients. 8 Furthermore, whether basic CPR, defibrillation, or thrombolysis, the earliest possible intervention always has been associated with a better outcome.2,4, *1 In fact with the exception of monitored arrests and cases of persistent ventricular fibrillation, patients who fail to achieve on-scene restoration of spontaneous circulation within 25 minutes of paramedi c arrival (using standard advanced cardiac life support techniques) do not survive.2,12,13 Therefore, interventional trials that are conducted in another venue or do not account for prehospitai actions may prove fruitless. This philosophy also applies in certain types of trauma. >-16

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Although paramedics and emergency medical technicians maynot be "physician-scientists," ironically, the "uncontrolled" prehospital research environment has advantages overthe in-hospital environment. Most paramedic programs are paramilitary in nature, especially fire department programs, Protocols usually are followed meticulously In addition, the "scope of practice" relative to physicians tends to be more focused toward resuscitation protocols. In turn, compliance often is far better than that achieved by hospital-based emergency care personnel, lz In the hospital, unless they have a personal stake, multiple rotating physicianswith many different approaches to patient care can easily forget (or ignore) the study protocol because it is 0nly one of dozens of simultaneous issues that they must confront daily. In addition, in current EMS systems, physiciansrarely initiate the key resuscitation interventions. In contrast, certain EMS personnel may respond to as manyas 25 to 30 cardiac arrests a month, a level of experience (and resulting consistency) that is hard to match, is Potential for Better Study Design With the prehospital arena, a larger number of patients can be studied because all of the patients from the entire EMS catchment can be included,is This leads to faster study completion, better statistical power, and greater productivity In resuscitation research, large study populations often will be essential to delineate the effects of study interventions within certain subpopulations (such as the various subgroups of cerebral performancescores) and to avoid the quandary of type II statistical errors. 19-23 Larger study groups and subsequent faster study completions also ensure better historical control by eliminating the effectsof other evolving system variables. Although out-of-hospital research will, in turn, involve multiple receivingfacilities (and presumably less control), most ofthe key variables known today to affect outcome are determined or implemented long before hospital arrival.12,13 Studies Improve Patient Outcome Perhaps the most important rationale for conducting out-of-hospital researchis the "Hawthorne effect." This re@plied concept borrowed from industry management studies infers that by simply implementing a study, one will observe improved outcomes in both study and control groups because of the closer scrutiny and reinforcement of standardized performance. A classic example was the first controlledprospective investigation of the prehospital application of the pneumatic antishock garment. A 50% survival rate had been projected for the control group using the prestudy survival rates being observed for those meetingthe planned entry criteria. Within two months of

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study implementation, however, preliminary data indicated that survival rates were approximately 65% in both study and control groups. 22 After six months, they had increased to approximately 70% in the pneumatic antishock garment group, a 40% improvement over prestudy survival rates. Such a historically controlled analysis might have suggested a clear benefit of pneumatic antishock garment application, but this simplistic conclusion was placed in proper perspective by a concomitant survival rate of more than 75% in the control population (a 50% improvement over the prestudy rate). The survival rates significantly improved for the pneumatic antishock garment group, yet they improved despite a relative disadvantage compared with controls. This not only is a clear example of the Hawthorne effect, but it also emphasizes the need for randomized, controlled studies and rapid study completion. In this example, other key variables in the system also had been affected by implementation of a new, rigidly controlled patient care protocol (eg, direct transport to a trauma center, shorter scene times, and more aggressive prehospital airway management). ~6,22 Also, as time on the learning curve passed, even better protocol compliance was achieved. After the first six months of study, despite a probable adverse effect of the pneumatic antishock garment (in the context of this particular study), even the patients receiving the device had a much better chance of surviving, simply because a study protocol had been implemented and strictly enforced. Because the researchers are scrutinizing the protocol closely, related patient care is improved universally This concept is an important observation, not only to justify studies to the institutional review board, the media, and skeptics-at-large but also because it is the main reason why an EMS system should be research oriented, i In essence, research is the ultimate form of continuous quality improvement, both academically and clinically This same concept was most recently and elegantly demonstrated in the Seattle study of prehospital thrombolytic intervention for myocardial infarction, ll FACTORS THAT AFFECT SUCCESSFUL OUT-OF HOSPITAL RESEARCH

The EMS systems that have been effectivein providing sound scientific data generally have been centralized systems (usually a single organization, most often the municipal fire department, administers the entire emergency response system) that have taken into account all of the patients in their jurisdiction.4,Tjl,17Ag,21, 23-27 Also, one

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typically finds a readily identifiable academic physician who not only provides intensive medical training and direction but also has clear operational control of EMS. 3,14,28 Under such singular medical direction, patient care becomes m o r e standardized, resulting in better controlled studies.2S, 25,26 This is one of the more subtle (and often poorly appreciated) elements for achieving both clinical and research success in EMS. EMS medical directors who view responsibility for the EMS just as they would a personal medical practice are apt to provide routine on-scene evaluation and participation, both in-hospital and out-ofhospital.3,28, 29 This combined clinical and supervisory role facilitates a medical director's ability to elucidate any specific flaws or shortcomings in the EMS providers' clinical care as well as any activities that may affect study protocols.3,28, 29 In the area of trauma research, this concept is especially applicable to in-hospital care because most of the study patients (or, in some cases, all of the study patients) are brought to one facility--the regional trauma center. 14,15,23 Even if the protocol is followed closely in the prehospital arena, compliance (and even the definitive patient care affecting outcome) may be less controlled inside the hospital for the reasons discussed previously In systems where such research has been reasonably successful, the EMS medical director not only oversees the prehospital arena but also is a supervising physician in the major receiving facility, m o s t often, a public receiving facility 15,16,18,24-2r Baseline Survival Considerations and the EMS Infrastructure If a resuscitation study is to be well designed, c~values and statistical power should be determined prospectively Therefore, before the study, existing outcome data should be taken into account. In a system where there is negligible survivorship for cardiac arrest, a comparison of control and study group survival rates will lead to less-thanmeaningful results (eg, 1% versus 2%). This issue becomes more pertinent when certain pharmacologic or mechanical interventions are to be tested. These generally are implemented in the subpopulation of patients who are much less likely to survive, namely, those who do not respond immediately (with restoration of pulse) to initial countershocks and/or intubation. 19 Therefore, overall survival rates will have to be substantial and subpopulation outcome must be taken into account before the development of such studies, particularly when considering degrees of neurologic outcome. Another key element to success in EMS research is the paramedic system. In systems in which successful research projects have been generated, the paramedics not only

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have intensive medical direction and training but also become extremely experienced by virtue of dispatch deployment strategies (eg, tiered advanced/basic life support response and transport systems).<14,30-32 Most important, the motivation of the paramedics and other EMS personnel can be the key factor in the success of a scientific study If they come to view a new protocol as simply a new set of duties with which to contend, study execution can flounder in terms of both motivation and protocol compliance.29, 33 If there is one lesson to be learned, it is that the study executors (eg, the EMS personnel) must be involved with the study design from the very beginning. 29 Then, it becomes their study In fact, they will often make excellent suggestions, especially with regard to logistical considerations. Furthermore, it is vital to provide them with continuous feedback and communication, especially in the form of routine follow-up meetings. These should be held regularly to clarify protocol issues and refresh the motivation of the EMS personnel. Study compliance and patient recruitment can be associated with the frequency of such meetings. Clinical Supervisor System Another consideration in the development of an out-of-hospital research program is a clinical supervisor system, especially in a large city where it is harder to supervise directly all of the patient care providers on a routine basis. 34 The supervisors respond to the scenes and ensure that proper procedures are followed (or provide them if necessary). By closely interacting with a smaller cadre of experienced paramedical supervisors, EMS medical directors can have a 24-hour, on-site quality assurance mechanism. They can focus on cases of concern such as cardiac arrest or major trauma situations. As a result of encountering many more of these cases than the average paramedic, their skills and judgment are further enhanced. In turn, the medical director develops absolute trust because of their expertise, and they provide an excellent mechanism for implementing a feasibility trial or perhaps a study protocol that involves a controversial drug or procedure, is Ethical Considerations and the Risk of Complications The issue of consent appears to surface most often when the risk-benefit ratio is not as clear, such as in the use of a new drug with possible adverse effects. Regardless of ethical considerations, if a complication does occur, paramedics want to have a medicolegal safety valve. More important, they also want to be able to quickly determine any options that could immediately help the patient. This concern means that they need a physician not only to contact immediately but also who they trust. Therefore, this responsibility should not be delegated randomly to a

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base station physician who is not involved routinely with the individual EMS personnel. With regard to the consent issue, proper informed consent cannot be obtained because of the time restraints involved in care of the critically injured or ill patient. 6 Resuscitation of the critically ill or injured is a situation in which the patient has few alternatives and seconds literally count. Therefore, ethically, this not only makes waiver of informed consent plausible, but, as is the case with any other critical emergency, also necessitates a unique type of "implied consent." This concept is quite valid when the researchers, in good faith, are trying to provide their patients with either the standard of care or an improvement over that standard. Furthermore, in resuscitation reseamh most proposed complications are less foreboding in someone who has no option other than death. Nevertheless, the researchers always must be patient advocates first. Prospective announcements of the plan to public officials and the media are a good practice as are assurances of fair randomization for all concerned. As long as the study is carefully designed, carefully discussed, carefully executed, and carefully monitored and scrutinized for safety, the patients' best interests are served. As with any medical act, it is the overall faith in the physician(s) that best determines the outcome of a consent process. Nevertheless, it always is a wise practice to use and nurture relations with the institutional review board, even with noninterventional studies. In addition, a new research team should build a "track record" and start with less controversial trials before they attempt bolder areas of investigation. 22,35 Obstacles to Data Collection The introduction of new or special forms for the purposes of a particular study usually results in less compliance, both in-hospital and prehospital. Therefore, data collection that is made on a day-to-day basis should be modified as needed for cardiac arrest as well as other studies. Accordingly, future development of new patient record forms should include data points required and/or recommended for a cardiac arrest data base or trauma regist® 36 Dealing With Political Roadblocks A way of dealing with the politics of hospital data collection is to have one-onone meetings with each of the medical directors and administrators of the EMS program and the individual hospitals in the system. At these meetings, data collectors who will maintain confidentiality and who are acceptable to both groups should be designated. In addition, the medical director and/or EMS researchers should try to j0m the staffs of all of the main hospitals within the EMS catchment area and routinely provide research and educa-

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tional seminars for each hospital. By becoming part of "the family" in each facility, the EMS researchers become less of a threat. Likewise, EMS administrators should receive support wherever appropriate from the research group in budget requests that will help to improve the EMS system. In elucidating low survival rates, the EMS researcher can be seen as an outside expert who can also exonerate the paramedics and EMS administration and implicate the lack of proper support for the EMS system. Therefore, resuscitation research can be a key mechanism to achieving better fiscal support. 5 In terms of union opposition, if the rank-and-file paramedic is included in the design and development of the study from the very beginning and if feedback is continually supplied, these problems are less apt to surface. When feedback demonstrates that the investigation is helping people, even the least sophisticated of EMS personnel becomes motivated. Saving lives is their job, and nowhere does one find a more dedicated group of individuals. Furthermore, in successful EMS systems, union members and EMS researchers have joined together to nurture research activities, a9 The more sophisticated union personnel have capitalized on the long-term investment, knowing that what has saved and will continue to enhance the budgets, salaries, and benefits provided to prehospital care providers is the perception of their educational level and aptitudes. Once they have risen to the level where they are educating the medical community by performing sophisticated scientific projects, the esteem for these special public safety personnel eventually translates into further tangible support. On the other hand, unions that have stood in the path of such progress have lost sight of their main mission--to save lives. Financial Reimbursement Most investigators, although sympathetic to the concept of rewarding those who recruit the patients, do not provide direct cash incentives. Even in funded studies, it gives the appearance of proprietary interest. Funds would be better allocated as uniformly distributed educational benefits to the EMS personnel (eg, books, conference registration fees) or even new equipment that would benefit patients. Positive Reinforcement One of the most rewarding activities that EMS researchers can offer is to arrange to bring the paramedics and other EMS personnel to the patients that they had resuscitated succesfull?~ Not only does it reinforce that the cardiac arrest resuscitation was a worthwhile thing to do, but sometimes it becomes a very useful public relations event for the research team. VV'nen EMS

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research is associated with a rewarding feeling, it motivates future efforts. The successful use by the EMS personnel of a new device appeals to the media as well as the public-atlarge and sets the tone for future research projects. Also, such follow-up visits allow the investigators to obtain both objective and subjective analyses of the patientg outcome. Documentation of return to work or, on occasion, an improved physical status can be determined more easily Even with a residual neurologic or physical disability, the family's sense of satisfaction with the outcome h d p s to provide additional perspective on the meaning of a successful outcome. Above all, this activity is immensely rewarding for most families, who usually want an opportunity to thank the rescuers. Media and Public Relations W h e n a potentially controversial study is planned, it is beneficial to meet prospectively with various media. This helps to preempt the loose cannons described earlier. Simply stated, if a disenfranchised individual decides to call the various media as a "whistle blower," the issue is no longer "news." In turn, the media are less likely to pursue the matter. If possible, meetings should be conducted on a "one-on-one" basis with each of the local news organizations; news conferences can be held later. During the meetings, keep the details simple; when explaining the rationale for a "control" group, let them know that you would have no probIems having yourself or a family member "randomized" if necessary Above all, tell them about the Hawthorne effect. These strategies also should apply to public officials responsible for the EMS program. SUMMARY

There is no better place to test life-saving resuscitative interventions than in the prehospital setting. Out-of-hospital clinical resuscitation research will provide academic credibility to the evolving field of emergency medicine, perhaps more than any other field of study. 3r Therefore, the pitfalls and obstacles, particularly those addressed in this discussion, must be anticipated and appropriately obviated by prospective, cooperative efforts and education of all key community leaders. REFERENCES 1. Emergency Cardiac Care Committee, American Heart Association: Standards and guidelines for cardiopulmanary resuscitation (CPR)and emergency cardiac care (ECC). JAMA 1986;255:2841 ~2857. 2. Pepe PE: The past, present, and future of emergency medical services. PrehospDisasMad 1989;14:47-49. 3. Pepe PE, Bonnin M J, Mattex KL: Regulating the scope of EMS. PrehespDisasMad 1990;5:59-63.

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4. Cummins RO, Ornate JP, Thies WH, et at: State-of-the-art review---Improving survival from sudden cardiac arrest: The "chain ef survival" concept: A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation1991;83:1832-1847. 5. Becker LB, Ostrander MP, Barrett J, et ah Survival from cardiopulmanary resuscitation in a large metropolitan area: Where are the survivors? Ann EmergMad1991;20:355-361. 6. Abramson NS, Safar P: Brain Resuscitation Clinical Trial II Study Group: Deferred consent: Use in clinical resuscitation research. Ann EmergMed1990;19:781-784. 7. Levine RL, Pepe PE, Fromm RE, et al: Prospective evidence af a circadian rhythm for out-ofhospital cardiac arrest. JAMA 1992;267:2935-2937. 8. Pope PE, Levine RL, Fremm RE, et ah Cardiac arrest presenting with rhythms other than ventricular fibrillation: Contribution of resuscitation efforts toward total survivorship. Crit Care Mad 1993 (in press). 9. Pepa PE: Current standard and future directions of advanced cardioputmonary resuscitation, in Vincent JL (ed): Updatein Emergencyand Intensive Care.Berlin, Springer-Veriag, 1990, p 565585. 10. Bannin M J, Pope PE, Clark PS: Survival prognosis for the eldedy following out-offhespital cardiac arrest (abstract]. Ann EmergMad 1989;t8:469. 11. Weaver WD, Cergueira M, Hallstrom AP, et al: Results of the Myocardial Infarction Triage and Intervention (MITI) trial. Presented at the annual meeting of the American College of Cardiology in Dallas, April 1992. 12. Bonnin M J, Pope PE, Clark PS: Key role of prehospital resuscitation in survival from out-off hospital cardiac arrest labstract). Ann EmergMad 1990;19:466. 13. Ke/larmann AL, Staves DR, Hackman BB: In-hospital resuscitation following unsuccessful prehespita/advanced cardiac life support: "Heroic efforts" er an exercise in futility? Ann Emerg Mad1988;17:589-594. 14. Pepe PE, Copass MK: Prehespital care, in Moore EE (ed): AmericanCollegeof Surgeons Committeeon Trauma.EarlyCareof the Injured.Toronto, BC Decker, Inc, t990, p 34-55. 15. Capass MK, Oreskovich MR, Bladergroen MR, et al: Prehospital cardiopulmonary resuscitation of the critically injured patient, Am J Surg1984;148:20-26. 16. Durham LA, Richardson RJ, Wall M J, et al: Emergency canter thoracetomy: Fmpactof prehospital resuscitation. J Trauma1992;32:775-779. 17. Maningas PA, Mattox KL, Pepe PE, at a h Hypertonic saline-daxtran solutions for the prehospital management of traumatic hypotensian. Am J Surg1989;157:528-534. 18. Pepe PE: Ccntrolred studies in the prehaspital satting: A viable, important venue for clinical research. PrahospDisas Med 1990;5:285-288. 19. Brown CG, Martin DR. Pepe PE, et ah Standard versus high-dose epinephrine in out-off hospital cardiac arrest--A controlled clinical trial. NEng/JMed1992;327:1051-1055. 20. Safar P: Cerebral resuscitation after cardiac arrest: Summaries and suggestions. Am J Emerg Mad 1983;2:198-214. 21. Bickell WH, Pepe PE, Wyatt CH, et ah The effect of anti-shock garments on patients with penetrating abdominal injuries. Ann EmergMad 1987;16:659-658. 22. Papa PE, Bickell WH, Mattox KL: The effect af anti-shock garments on prehaspital survival: The need for controlled clinical studies. J Wer/dAssecEmergDisas Mad 1987;3:40-45. 23. Papa PE, Bass RR, Mattox KL: Clinical trials af the pneumatic antisheck garment in the urban prehospital setting. Ann EmergMad 1986;15:1407-1410. 24. Weaver we, Cobb LA, Cepass MK, et ah Vantricular fibrillatien--A comparative trial using 175-J end 320-J shocks. NEnglJMed1982;307:1101-IlOg. 25. Haynes RE, Chinn TL, Copass MK, et ah Comparison of bretylium tosylate and lidocaine in management af out-of-hospital ventticular fibrillation: A randomized clinical trial. Am J Cardiol 1981 ;48:353-356. 26. Mattox KL, Maningas PA, Moore EE, et al: Prehespita[ hypertonic saline/dextran infusion for post-traumatic hypotensian--The USA multi-center trial. Ann Surg1991;213:482-491. 27. Stueven HA, Thompson B, Aprahamian C, et al: The effectiveness of calcium chloride in refractory electromechanical dissociation. Ann EmergMed 1985;14:026-629. 28. Pepe PE, Stewart RD: Role of the physician in the prehospital setting. Ann EmergMad 1986;15:1480-1483.

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29.WamkeWJ, Bonnin MJ: Direction and motivation of prehospital personnel to do research: Howto do it better. PrehospDisas Med 1992;7:79-83. 30.CurkaPA, PopePE,Ginger VF, et al: Computer-aided EMS priority dispatch! Ability of a computerizedtriage system to safely spare paramedics from responses not requiring advanced lifesupport(abstract).Ann EmergMed i991;20:446. 31.McManusWF, Tresch DD, Darin JC: An effective prehospital emergency system. J Trauma 1977;17:304-310. 32.CobbLA, AlvarezH, CopassMK: A rapid response system for out-of-hospital cardiac emergencies.MealClinNorthAm 1978;60:283-290. 33.HellerMB, Melton JB, Kapian RM, et al: Data collection by paramedics for prehospital research.AnnEmergMefl 1988;17:414-415.

The author thanks Nina Meher-Homji for preparation of the manuscript and Dr Lance Becker for organization of the excellent Methodology in Cardiac Arrest Research symposium. The author also thanks Drs Leonard D Hudson and C James Carrico for their mentorship in effecting clinical resuscitation research, as Well as the firefighters' local union president, Captain Wesley J Warnke, EMT-P, and the other Houston Fire Department EMS supervisors, paramedics, emergency medical technicians, first-responders, and dispatchers from the City of Houston EMS system for their tremendous contributions to the field of cardiac resuscitation research. Address for reprints:

Paul E Pep& MD, FACEP

34.PopePE,CurkaPA: Scenesupervision Of EMS, in Swor R (ed): QualityManagementin PrehospitalCare.Philadelphia, CV Mesby and Co, 1993, Chap 18.

City of Houston Center for Resuscitation and

35.MartinRR, Bickell WH, Pope PE, et al: Prospective evaluation Of preoperative fluid resuscitationin hypotensivepatients with penetrating truncal injury. J Trauma1992;33:354-362.

410 Bagby, Suite 300

36.CumminsR0, ChamberlainDA, Abramson NS, et al: Recommendedguidelines for uniform reportingof data from out-of-hospital cardiac arrest: The Utstein style. Ann EmergMed 1991;20:861-874.

Emergency Medical Services Houston, Texas 77002-1595

37.PetersdorfRG:The place of emergency medicine in the academic community. Ann Emerg Med1992;21:193-200.

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