Like the crew of a hulking ship at sea crashing through the waves, paramedics toil daily in the communities in which we work. We provide assistance to the people we serve in an effort to keep the whole proverbial ship from sinking. We do one job, one call at a time, while the unseen and unheard skipper barks out orders that flow down the chain of command for us to follow. Never questioning; always doing; ours is not to reason why; et cetera, et cetera. Or, at least, that is how it once was.

Today, throughout all areas of EMS practice, paramedics have begun to question the hows and whys of what we do. It is a necessary and inevitable process of growth to question the status quo. And, as a profession, we are clearly in that rebellious adolescent phase. But, as we question our masters and ourselves, questions are being raised about us, too. What is the value of the work we do? How do we justify our wages and the costs of providing our service to fiscally challenged municipal, county, regional or provincial managers and others who hold the purse strings? Some professions need only to resort to allegory and hyperbole and proclaim, “Babies will die; insurance rates will rise!” and the public eats it up and hands over the chequebook. A profession like ours, on the other hand, seems always to need to justify its existence through business case models and statistical analysis to please the bean counters.

The entire medical community in recent years has begun to move towards evidence-based practice. That is, it has started to revise treatments and medical protocols to match data arrived at through clinical trials or studies. What impact does this have on EMS? Should we evolve our practice to embrace these studies and to incorporate their outcomes into our daily practice, or should we resist the urge to jump on the research bandwagon? Should we actively participate in field trials and prospective studies? Is there any justification to the obvious increase in energy and workload that conducting a study in the prehospital setting demands? And are we, as a collective of medical practitioners, morally or ethically bound to perform such research studies?

We are presumably in this profession to help others; to intervene in times of crisis and misfortune on a micro scale; to help individuals and communities when things go wrong—heart attacks, car accidents, train wrecks—from the smallest personal misfortune, to natural disasters, to calamities on a national and global scale. But it all starts with a desire to help. We study, learn and grow as students, then practitioners, and then perhaps, as mentors and as teachers. But without knowing the value of the things we do—from the smallest procedure to the most invasive—what value is our work to anyone at all?

Research is the road we must travel to answer that question. Whether we participate or not, research is and will continue to be conducted in our field. One can perform an Internet search on the term “EMS Research” and Google will return 976,000 hits. Most do not specifically link to studies, but this vast number of hits is an indication of the relevance of the question, if not the terminology searched. But, while research as an idea is good, not all studies are good research. And that is perhaps what paramedics should be most concerned with. As I stated earlier, bean counters try to account for every penny spent. Bad research perhaps postulates bad questions. Or worse, supplies bad answers. A well-constructed study, on the other hand, designed by EMS researchers and performed by paramedics is likely to be more relevant. In the December EMS Chiefs of Canada newsletter, Dr. Laurie Morrison, Director of the Prehospital and Transport Medicine Research Program at the University of Toronto Department of Medicine writes, “A successful trial design is one that has had constructive, creative and timely input from the service and the provider.” In other words, for a study to be most relevant, paramedics must be involved.

Prominent EMS physician and prolific author Dr. Bryan Bledsoe from Texas told me, “EMS research is the only way for the profession to evolve. It takes more work—but the paramedics, the patient and the system benefit.” He went on to say, “… like all things, you have to take good research along with the bad. The OPALS study is a pain in the ass—but the best EMS study ever done, providing information that can be taken to the politicians and accountants that shows that EMS does make a difference and paramedics and EMS are worthy. EMS research is a natural part of the evolution of the profession and must be embraced.”

Many paramedics may be loathe to embrace this notion, however. Much of this attitude is perhaps based on a declining labour environment in their service district and the perception that management somehow derives benefits from these studies that can somehow be used against the paramedic workforce. Or, the other argument, which is somewhat more valid, is that we are so busy and run down, with no time to get even a brief lunch break during the day that we shouldn’t even consider participating in any studies until these other matters are resolved. To these arguments, Dr. Bledsoe replies with an example of a hot EMS issue — “If the unions would get with the base hospitals and study system status management in a purely objective format they can prove that it is not what managers think it is.”

By raising the model of System Status Management (SSM), Dr. Bledsoe shows us the multi-faceted nature of research in EMS. There is research that studies systems and operations, such as SSM, and there is clinical research studying procedures and interventions and their efficacies, such as the study entitled, “Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial,” by Gausche et al, published in JAMA, June 28, 2000. The conclusion of which, excerpted from Medline is, “… that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.”

But, in what context are these studies being designed and conducted? And, more significantly, how will such conclusions be received and interpreted by the aforementioned bean counters that we all fear? If the EMS profession allows itself to be left out of the design and implementation of these studies, then we expose ourselves to the risk of letting others arrive at the conclusions that will drive our practice. I am not a paramedic that likes to live vicariously through the experiences of others. I like to get out there and get my hands dirty. I like to taste the grit of life and all its offerings. This applies to my clinical practice as an Advanced Care Paramedic as surely as it does my personal life and love of motorcycling and other hobbies. To quote Dr. Bledsoe further, if we do find ourselves sitting on the sidelines, paramedics “will lose the opportunity to have a voice in the future of EMS, as the studies will continue with or without your support.”

Noted Canadian EMS proponent and commentator, Dr. Martin McNamara, says, “Few people who have never done the work can truly appreciate the full aspects of a paramedic’s work. By the same token, few people, particularly research people, can truly appreciate all that goes into being a good paramedic.” He goes on, “What this leads to is the fact that if paramedics leave their research and research questions to outsiders, these people will ask research questions framed by their own experiences and with their own agendas in mind. Much like letting others negotiate your wages and conditions of work, the power is out of your hands… you are pawns. The research will dictate the job.”

As paramedics, we find ourselves adrift on an unsettled sea. The question becomes do we allow our paths to be steered unknowingly and misguided through the fog, headlong into the swiftly approaching iceberg, or do we take control of the helm and head for open waters that, though uncharted, may prove more valuable for the promise of the discovery they undoubtedly will yield to us and all whom we serve?