Doing Research in Emergency and Acute Care

Making Order Out of Chaos

Michael P. Wilson, Kama Z. Guluma, Stephen R. Hayden

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781118643471
• Edition: 1
• Topic: Medicine
• Subtopic: Emergency Medicine & Critical Care

A practical guide to understanding and navigating the unique challenges faced by physicians and other professionals who wish to undertake research in the ED or other acute care setting.

Focusing on the hyper-acute and acute care environment and fulfilling two closely-related needs:

1) the need for even seasoned researchers to understand the specific logistics and issues of doing research in the ED; and 2) the need to educate clinically active physicians in research methodology.

This new text is not designed to be a complex, encyclopedic resource, but instead a concise, easy-to-read resource designed to convey key "need-to-know" information within a comprehensive framework. Aimed at the busy brain, either as a sit-down read or as a selectively-read reference guide to fill in knowledge gaps, chapters are short, compartmentalized, and are used strategically throughout the text in order to introduce and frame concepts. This format makes it easy - and even entertaining - for the research novice to integrate and absorb completely new (and typically dry) material.

The textbook addresses aspects of feasibility, efficiency, ethics, statistics, safety, logistics, and collaboration in acute research. Overall, it grants access for the seasoned researcher seeking to learn about acute research to empathically integrate learning points into his or her knowledge base.

As the ED is the primary setting for hyper-acute and acute care, and therefore a prime site for related clinical trial recruitment and interventions, the book presents specific logistical research challenges that researchers from any discipline, including physicians, research nurse coordinators, study monitors, or industry partners, need to understand in order to succeed.

PART 1
Getting ready: Preparing for your research study

CHAPTER 1
Aspects of research specific to acute care

Jarrod M. Mosier¹ and Peter Rosen²

¹ Department of Emergency Medicine, University of Arizona, USA

² Emergency Medicine, Harvard University Medical School, USA

Responsibility of the academic physician

The power to save lives, and the knowledge which forms that power, is a sacred art entrusted to every physician. One can debate about whether knowledge is discovered or invented (we think it may be both), but regardless of the means of acquisition, new knowledge falls into the realm of research and, thus, of the book that you are holding. It is the responsibility of the academic physician to uncover and disseminate this knowledge. Enthusiastic young physicians commonly enter academic medicine after inspiration in seeing their accomplished mentors’ body of work, only to find it frustrating that it is not easy and that it may not be possible to hit the ground running smoothly.

Indeed, many young physicians are both puzzled and dissuaded by the responsibilities faced in academic medicine. They are often willing to participate in the dissemination of knowledge, especially when this involves synthesizing others’ research, giving a lecture or supervising residents and students in the clinical setting. When it comes to research and storage (i.e., the preservation of that knowledge through articles, books, etc.) many find these areas too difficult or discouraging. Both research and storage are activities that can be learned and become easier with experience. However, neither is a customary part of the student or resident curriculum and both are, therefore, very intimidating to the young physician. This chapter reflects on research as an academic responsibility for acute care and Emergency Medicine (EM) physicians and, hopefully, will give some clues on how to make it less painful and intimidating for the inspired academic physician.

Asking the right questions

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The first research effort of one of the second author in medical school was an effort to produce an animal model of emphysema in rats. This was studied by building the rat a helmet with a one-way valve that it had to breathe against. The theory was that the increased pulmonary pressures would produce emphysema, but the experiment was a dismal failure. The only thing derived from the experience was an unswerving hatred of rats, which bit frequently and painfully as they were put into their helmets. The net result was that it was twenty years before the author tried any more animal research, and never again with rats.

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One of the areas of intimidation is the thought that the best research (i.e., the research most likely to be funded, recognized, rewarded, and acknowledged with promotion) involves basic science. While this is partially true, it is also true that basic science is not the only form of research that is useful, funded, or desirable. Clinical and translational science is concerned with the improved quality of the practice of medicine based on evidence, and the acquisition of that evidence is of critical importance. It has become increasingly evident that the best practice of clinical medicine is based on posing the right questions (see, for example, Chapter 3). The answers to those questions are dependent both upon the quality of data that create the evidence as well as how long the evidence can be relied upon. For example, in the presence of abdominal pain, last year’s pregnancy test result, no matter how well performed, is not going to help with sorting out the etiology of this year’s pain. Similarly, in the presence of chest pain, how long is last year’s negative stress test result helpful and, moreover, does it matter which stress test was performed?

Yet we are taught that we must obtain certain tests to be complete, thorough, or prudent, but no one gives any information on how long information lasts to be useful, nor what to do if the test is negative when only a positive test has any useful meaning. Thus, while the basic science questions regarding the best assay for determining pregnancy or detecting at-risk myocardium while stressed are of interest, a clinical scientist is most interested in the clinical questions that guide the practice of emergency medicine. (See, for example, Chapter 4, “Evidence-based medicine: Finding the knowledge gap.”)

Challenges with acute care research

How then should one commence a research project in acute care? There are many challenges to carrying out research in acute care settings, whether it is prehospital research, the emergency department (ED), or the intensive care unit (ICU). Some considerations include major hurdles such as:

• Consent: How are you going to obtain informed consent on the subjects of your study? If you want to carry out a study on resuscitation related measures, how are you expected to truly obtain informed consent when they are in respiratory distress, cardiac arrest, or are altered? Are you going to be there night and day to enroll and obtain consent from these participants?
• Where are you going to do this study? It may seem like an easy question to answer, but let us say you want to carry out a study on prehospital intubations with a new device. Are you going to put the device on every ambulance? If you want to carry out a study in the emergency department regarding a new device for an emergent procedure, where are you going to keep it? Are all the patients requiring that procedure going to go to the same place, or are they going to be spread out all over your 60 bed emergency department?
• Specialists: If you want to carry out a study with a new therapy in acute coronary syndrome, you are going to have to get buy-in from the cardiologists. Our time with these patients in the emergency department is limited, so obtaining agreements to participate from admitting services and specialists is very important and can be incredibly challenging based on your relationships with those services.
• Outcomes: What are the outcomes of your study going to be and how are you going to show that your limited time with this patient population made a difference in those outcomes?
• Blinding: How will you keep the participants and raters in your experiment blinded to their true treatment condition?
• Funding: The answer to many of the questions above is to have resources in place, but resources require funding. How and where will you obtain funding, which is increasingly harder to obtain?

Where do I start?

The initial responsibility is to define a question that needs examination. This can come from any source of inspiration, but the most useful way to begin is to think about a question from your clinical practice for which you do not know the answer. In fact, the less you know about the answer the better. If you do not know anything about the question, then any data you derive in the examination of the question will be interesting. If any data are interesting, you will be less likely to bias the results in trying to find a particular answer (see, for example, Chapter 10).

Think about cases you have seen in the emergency department. Your question may come from an observation of a dogmatic clinical practice that you do not understand the need to perform. For illustrative purposes, we will use the example of cricoid pressure during intubation. No matter how ma...

Table of contents

• Cover
• Title page
• Table of Contents
• List of contributors
• PART 1: Getting ready: Preparing for your research study
• PART 2: Getting it done: Doing your research study
• PART 3: Getting it out there: Analyzing and publishing your study
• Glossary
• Index
• End User License Agreement