ISSUE 26 - April 2003
The newsletter of the Joint ASA/JRCALC Clinical Effectiveness Committee
In this Issue:
§ ASA/JRCALC Regional CHD Seminars
§ National Morphine Workshop
§ Cardiac Arrest Dataset
§ Pre-hospital research – the end is nigh??
§ Star of Life - the EMS symbol
§ ASA Research Database
Introductory message from the NCEP Manager
Mark E Cooke
BMedSci(Hons), MSc, SRPara
Spring is now upon us, and I for one am enjoying the lighter nights and warmer weather.
It makes such a change from the dreary winter weather!
The first quarter of the year has been very busy and productive for the Clinical Effectiveness Committee and already behind us are a number of seminars, workshops and conferences. I have been able to meet many of you at these events and I am looking forward to future seminars and AMBEX where I will be available to discuss any clinical issues.
I am delighted to announce that Lucy Evans, formerly of the Two Shires Ambulance Trust, is now contracted to the ASA and is leading on the development of the AMI/Chest Pain Audit and the development of the Cardiac Arrest Dataset.
These were held at Chippenham, London, Leicester and Bolton and were useful to provide an update on developments regarding the AMI/Chest Pain Audit. Other important issues discussed included thrombolysis, morphine, and the Cardiac Arrest Dataset. We were also pleased to announce two further regional workshops to develop the Cardiac Arrest Dataset and details of those events are noted below.
Emerging themes from these one-day seminars included the request for national guidance for the use of morphine, more ASA seminars and nationally agreed datasets for audit.
A national morphine workshop was held in London on Friday 14 March in response to feedback from the ASA/JRCALC seminars, and also to satisfy the requirements of the Medicines Control Agency (MCA). The aim of this well-attended workshop was to develop a nationally agreed core of information to collect regarding the use of morphine and also to develop upon existing practice to develop standardised guidance and operating procedures for ambulance services to use. Draft information will soon be sent out to trusts for consultation, with introduction anticipated in the near future.
Two regional workshops are being held on Thursday 3 April in Leeds and Friday 4 April in London. These workshops, led and facilitated by Lucy Evans, look at the national requirements of the Cardiac Arrest Dataset. These two workshops will develop an agreed core dataset and establish how this information is to be collected and reported.
This is a very worrying prospect for all us with an interest in pre-hospital research. Recent European legislation from Brussels states that any research involving treatment of patients will be illegal from April 2004 if strict and, quite frankly, impossible consenting arrangements are not in place.
This human rights legislation basically states that patients can only be recruited into research studies if they are capable of giving legal consent to participation in a clinical trial. For patients to give informed consent, there is a requirement for the individual to be in of a normal psychological state, to have written information regarding the study, to have time to understand the implications of the study and to provide signed consent. If these criteria are not met, the patient’s legal representative should be present to undertake this on the patient’s behalf.
In real terms, this means that patients who are in cardiac arrest, traumatised or in pain might be excluded from pre-hospital research. This includes cohorts of patients required for research into cardiac arrest and patients who have chest pains.
So, while we are encouraged to practice Evidence Based Medicine (EBM), which is based upon sound research methodology, how can we develop best practice and develop upon existing practice to provide patients with the most clinically appropriate and effective health care?
Randomised Controlled Trials, often considered to be the ‘gold standard’ of research might well become a thing of the past unless there is a ‘U’ turn of this legislation.
Further and more detailed information is available from the ASA via email [email protected] or Candour readers may find these references of interest:
Editorial. Implications of the EU directive on clinical trials for emergency medicine. BMJ 2002 (18 May);324:1169-70
Sterz F, Singer EA, Bottiger B, Chamberlain DA, Baskett P, Bossaert L, Steen P. A serious threat to evidence based resuscitation within the European Union. Resuscitation 53(2002): 237-238
Just as physicians have the Caduceus, emergency medical service personnel have the Star of Life.
Designed by Leo R. Schwartz, Chief of the EMS Branch, National Highway Traffic Safety Administration (NHTSA), the ‘Star of Life’ was created after the American National Red Cross complained in 1973 that they objected to the common use of an Omaha orange cross on a square background of reflective white which clearly imitated the Red Cross symbol.
The NHTSA investigated and felt the complaint was justified and the newly designed, six barred cross, was adapted from the Medical Identification Symbol of the American Medical Association.
Each of the bars of the blue Star of Life represents the six system functions of emergency medical services, as below:
The snake and staff in the centre of the symbol portray the staff of Asclepius who, according to Greek mythology, was the son of Apollo (god of light, truth and prophecy).
Supposedly, Asclepius learned the art of healing from the centaur Cheron; but Zeus - king of the gods, was fearful that because of Asclepius’ knowledge, all men might be rendered immortal. Rather than have this occur, Zeus killed Asclepius with a thunderbolt.
Later, Asclepius was worshipped as a god and people slept in his temples, as it was rumored that he effected cures and prescribed remedies to the sick during their dreams. Eventually, Zeus restored Asclepius to life, making him a god.
Asclepius was usually shown in a standing position, dressed in a long cloak, holding a staff with a serpent coiled around it. The staff has since come to represent medicine's only symbol.
In the Caduceus, used by physicians and the Military Medical Corps, the staff is winged and has two serpents intertwined. Although the staff does not have relevance to medicine in its origin, it represents the magic wand of the Greek deity, Hermes, messenger of the gods.
The staff with the single serpent is the symbol for medicine and health and the winged staff is the symbol for peace. The staff with the single serpent represents the time when Asclepius had a very difficult patient that he could not cure, so he consulted a snake for advice and the patient survived. The snake had coiled around Asclepius' staff in order to be head to head with him as an equal when talking.
The winged staff came about when Mercury saw two serpents fighting, and unable to stop them any other way, placed his staff between them causing them to coil up his winged staff.
The Bible, in Numbers 21:9, makes reference to a serpent on a staff: “Moses accordingly made a bronze serpent and mounted it on a pole and whenever anyone who had been bitten by a serpent looked at the bronze serpent, he recovered.”
Are you currently conducting any research or have recently completed a research study that is related to pre-hospital care?
If so then please let us know so we can establish an Ambulance Service Association Research Database.
Of particular interest is research of:
· Public Placement AED schemes
· First Responder Schemes
· Pre-hospital Thrombolysis
· Pre-hospital Analgesia
· Interpretation of 12-lead ECGs
There is probably much valuable research that has been undertaken that has not yet been published and it is likely that there is much research work in progress that we don’t about. The database will allow you to see who is doing what type of research and will be a valuable tool to those who:
· Are conducting similar research studies
· Are searching for research studies
· Are wanting to compare research methodologies/findings
· Want a testing ground for publication
It is also hoped that such a database will be a valuable tool to stimulate and encourage interest in pre-hospital research.
I will also be happy to provide assistance or guidance to people interested conducting pre-hospital research. Please don’t hesitate to contact me via email at the Association via [email protected] to provide information for the database or to make enquiries