EMERGENCY FORUM
Research in Emergency Medical Services Lawrence Rose, MD Hyattsville, Maryland
Rose L: Research in emergency medical services. JACEP 8"197-199, May, 1979.
emergency medical services, research
INTRODUCTION
Academic medicine in t h i s country has often been described as r e s t i n g on the t h r e e e q u a l l y i m p o r t a n t legs of teaching, service, and research. The problem t r o u b l i n g us in the N a t i o n a l Center for H e a l t h Services Research (NCHSR) is w h e t h e r the r e s e a r c h leg is long enough and strong enough to c a r r y its share of the e m e r g e n c y medical services (EMS) load. We also wonder w h e t h e r a categorical p r o g r a m of E M S r e s e a r c h can and should grow to m a t c h t h e i n c r e a s i n g burdens t h a t are being placed on the t e a c h i n g and service legs. These concerns are especially t i m e l y s i n c e t h e E M S A m e n d m e n t s will expire in 1979 and there is some controversy about w h e t h e r the legislation as a whole, a n d p a r t i c u l a r l y the r e s e a r c h p r o g r a m authorized under Section 1205, should be continued. HISTORY
The E M S Systems Act of 1973 e s t a b l i s h e d a t h r e e - y e a r federal p r o g r a m to assist and encourage the d e v e l o p m e n t of comprehensive e m e r g e n c y medical services systems. In 1976 the p r o g r a m was extended for t h r e e more years. The Act is u n u s u a l in its d e t a i l e d specification of each of the e l e m e n t s needed in a regional system. The guidance and technical assistance provided by the Division of EMS in the B u r e a u of Medical Services, H e a l t h Services A d m i n i s t r a t i o n , have added f u r t h e r r e f i n e m e n t s to the m a n d a t e d model. A u t h o r i z a t i o n for a p r o g r a m in EMS r e s e a r c h was included in both the 1973 and 1976 legislation. Responsibility for a d m i n i s t e r i n g this r e s e a r c h section was assigned, to the NCHSR, an agency in the Office of A s s i s t a n t S e c r e t a r y for Health, DHEW. The objectives of the EMS r e s e a r c h p r o g r a m were presented at the U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medicine (UA/EM) m e e t i n g in 1977 t o g e t h e r w i t h a description of the w e a k n e s s e s in proposals t h a t h a d been received. The EMS Systems Act is based on the a s s u m p t i o n t h a t a nationwide network of coordinated s y s t e m s will provide effective and efficient emergency medical care. The prima~y a i m of the research p r o g r a m has been to provide methods for t e s t i n g this assumption. ! CRITICISMS OF RESEARCH
M e m b e r s of the S u r v e y and I n v e s t i g a t i o n s staff of the House of RepresentaFrom the National Center for Health Services Research, Office of the Assistant Secretary for Health, DePartment of Health, Education~~nd Welfare, Washington, D.C. Opinions expressed are those of the auther and do not necessarily reflect the views of the Public Health Service. Presented at the University Association for Emergency Medicine Annual Meeting in San Francisco, May, 1978, . •~Address for reprints: Lawrence Rose; MD, Medical Officer, National Center for Health Services Research, Center Building, Room 8-27, 3700 East-West Highway, Hyattsville, Maryland 20782 J~P
8:5 (May) 1979
JACEP
197/43
tives C o m m i t t e e on A p p r o p r i a t i o n s h a v e e x a m i n e d various a s p e c t s of the m a n a g e m e n t of the E M S prog r a m this y e a r and were very critical of a n u m b e r of activities, including the EMS research program. They considered the research to be too theoretical and longterm, not focused on the i m m e d i a t e needs of the EMS program. These auditors a s s e r t e d t h a t the g r a n t reviewers were too concerned about e l e m e n t s of the research design and t h a t they did not a p p r e c i a t e t h e importance of the problems to be studied. It was held t h a t applications from EMS officials were too often rejected because of design weaknesses, since these a p p l i c a n t s were not "professional researchers." We t a k e all such c r i t i c i s m s a b o u t the focus of EMS r e s e a r c h very seriously, p a r t i c u l a r l y w h e n t h e y question the relevance of the research to real-world problems. A l t h o u g h N C H S R is located in close geographic p r o x i m i t y to the EMS "lead agency" (The Division of EMS, H e a l t h Services A d m i n i s t r a t i o n ) , we are at a considerable organizational distance from them, and therefore we are at r i s k of developing an ivorytower m e n t a l i t y . To minimize this possibility, N C H S R has r e p e a t e d l y and aggressively solicited ideas from a wide v a r i e t y of persons k n o w l e d g e a b l e in the field of EMS concerning the kinds of problems t h a t the research p r o g r a m should be e x a m i n i n g . We recognize t h a t m a n y of the i m p o r t a n t problems faced by EMS systems are not y e t included in the r e s e a r c h portfolio. In some cases, this m a y be because r e s e a r c h e r s have not been i m a g i n a t i v e or perceptive enough to identify ways of exploring these questions t h r o u g h systematic investigations, or p e r h a p s because no one has n o m i n a t e d t h e m as subjects for research. For w h a t e v e r reason, new research topics, as well as better study methods, are in g r e a t demand.
C o m m i s s i o n m o n i t o r s p r o d u c t - r e l a t e d injuries. Par. t h e r m o r e , N C H S R , u n d e r its g e n e r a l r e s e a r c h au. thority, conducts studies of the relationships betwee~ E M S systems and other activities t h a t are intended t0 improve the organization, financing, and delivery of h e a l t h care. The EMS r e s e a r c h funds should concea. t r a t e on a c q u i r i n g i n f o r m a t i o n t h a t is not g a t h e r e d t h r o u g h o t h e r programs, being 3) Research funds m u s t be used efficiently. Un. less research is conducted in accordance with accepted p r i n c i p l e s of s t u d y d e s i g n a n d d a t a a n a l y s i s , it is prone to result in erroneous or m i s l e a d i n g informa. tion. A research p l a n m u s t contain sufficient detail to p e r m i t the study to be replicated as necessary to con. firm the results; it m u s t consider the applicability of its findings to other t i m e s and other communities. Research topics m u s t be selected because the results are likely to be useful to p l a n n e r s and decision-makers and because the r e s u l t s will be forthcoming in time to be applicable. 4) Research in E M S m u s t account for problems a n d p r e s s u r e s e x t e r n a l to t h e EMS systems. These systems are being introduced as discrete, categorical activities, b u t t h e i r c o n t i n u a n c e is dependent on con. cerns such as t h e i r role in r u r a l h e a l t h care systems, t h e i r functions as sources of p r i m a r y care, their ira. pact on cost-containment policies, and their relation. ships to other r e g i o n a l i z a t i o n strategies. An EMS research p r o g r a m should not become so parochial that it focuses e x c l u s i v e l y on t h e d a y - t o - d a y p r o b l e m s of m a n a g e r s who are c o n c e n t r a t i n g on the establishment of a n a t i o n a l n e t w o r k of special-purpose systems. ROLE FOR EDUCATORS This Association should become more involved in designing EMS research p r o g r a m s and in conducting the studies. UA/EM m e m b e r s a r e involved in training the people who will be responsible for providing effective and efficient e m e r g e n c y care. Your students will soon be asked about how medical control should be m a i n t a i n e d , how c l i n i c a l a l g o r i t h m s should be designed and used, how t r a n s f e r protocols should be iraplemented, how hospitals should be categorized, and s i m i l a r questions directly affecting t h e i r professional roles, their financial status, and t h e i r public responsibilities. F u r t h e r m o r e , t h e y will be a s k e d to address such problems in the context of growing n a t i o n a l concern over the rising costs of h e a l t h care and the possibility of some form of r a t i o n i n g of h e a l t h services. There are b e t t e r reasons for including research in an e m e r g e n c y medicine c u r r i c u l u m t h a n m e r e l y prod u c i n g l i s t s of p u b l i c a t i o n s t h a t p r o m o t e t h e acceptance of e m e r g e n c y medicine a s an academic discipline. Research in EMS can improve the delivery of services and the q u a l i t y of teaching, not as by-products - - as is often the case in biomedical research - - but as the goal of the studies. R a t h e r t h a n a s s u m i n g t h a t exposure to research methods is a v a l u a b l e but unmeasu r e a b l e benefit in a u n i v e r s i g y - b a s e d t e a c h i n g program, a n d r a t h e r t h a n a c c e p t i n g the c o n v e n t i o n a l wisdom t h a t p a t i e n t care is b e t t e r in a t e a c h i n g institution, we can use EMS r e s e a r c h both to l e a r n more about r e s e a c h m e t h o d s a n d d i r e c t l y to m o n i t o r and improve t e a c h i n g and p a t i e n t care. The field of E M S r e s e a r c h includes both biomedical and clinical a r e a s b u t its most c h a l l e n g i n g and significant topics are in the a r e n a of h e a l t h services r e s e a r c h - - s t u d i e s of t h e o r g a n i z a t i o n , financing,
LIMITS TO THE RESEARCH PROGRAM There are several constraints t h a t affect an expanded E M S research agenda: 1) It seems obvious t h a t research funds a r e intended to produce research results; they are n o t subs t i t u t e s or s u p p l e m e n t s for service funds. Congress h a s made it clear t h a t comprehensive regional E M S systems are needed, and h a s specified the 15 compon e n t s t h a t m u s t be included in these systems if t h e y are to be eligible for federal support. The Division of E M S h a s developed regulations, guidelines, a n d reporting procedures to insure t h a t EMS systems p u r s u e the e n t i r e r a n g e of required activities. The E M S research p r o g r a m should not be considered an a l t e r n a tive source of federal funds for regions t h a t are u n a b l e or u n w i l l i n g to e s t a b l i s h comprehensive programs, nor should it evolve into a m e c h a n i s m for p a y i n g bonuses to good systems. 2) Research in EMS should not try to s u b s t i t u t e for, nor duplicate, other activities. M a n y of the operat i o n a l p r o b l e m s faced by g r a n t e e s can be r e s o l v e d a d e q u a t e l y t h r o u g h the advice, consultation, and educational efforts of the Division of EMS. Solutions to problems of t h i s n a t u r e do not require formal and exp e n s i v e r e s e a r c h methods. Moreover, m a n y of t h e questions t h a t trouble EMS systems a r e being studied t h r o u g h o t h e r research programs: m a n y of the clinical studies of the N a t i o n a l I n s t i t u t e s of H e a l t h are di rected at patients with central nervous injuries, t r a u m a , b u r n s , ' s t r o k e , m y o c a r d i a l infarction, etc; the D e p a r t m e n t of T r a n s p o r t a t i o n i n v e s t i g a t e s h i g h w a y accident victims; and the C o n s u m e r Product Safety
44/I 98
JACEP
8:5 (May) 1979
s a n a g e m e n t , a n d e v a l u a t i o n of h e a l t h care. F o r example, biomedical r e s e a r c h m a y focus on c h a n g e s in ~ayofibril c o n t r a c t i l i t y and c l i n i c a l s t u d i e s m a y describe t h e e x t e n t o f m u s c l e d a m a g e f o l l o w i n g a ~ayocardial infarction, b u t h e a l t h services r e s e a r c h ~aight test a model to improve diagnostic accuracy or examine the effectiveness of c a r d i o p u l m o n a r y resusciration training. Biomedical r e s e a r c h m i g h t c o m p a r e topical antibiotic agents for burns, b u t h e a l t h services research m i g h t study the value of a l g o r i t h m s in proriding better i n i t i a l resuscitation, s t a b i l i z a t i o n and referral. It seems to me t h a t the k i n d of E M S r e s e a r c h which can be considered a subset of h e a l t h services research is more directly concerned with the k i n d s of problems for which e m e r g e n c y medicine p r a c t i t i o n e r s at all professional levels are being called on to provide advice or solutions.
Involvement in r e s e a r c h activities offers your students an o p p o r t u n i t y to acquire experience in r e s e a r c h methods, l e a r n s o m e t h i n g about appropriate study designs, and e v a l u a t e the adequacy o f . d a t a sources. If you are able to introduce t h e m to h e a l t h services research topics, you can t e a c h t h e m how to e x a m i n e issues t h a t directly affect t h e i r own futures. CONCLUSION The question of w h e t h e r EMS research continues as an identifiable p r o g r a m will probably be a n s w e r e d on the basis of "who needs it." It seems clear t h a t research should be helpful to EMS s y s t e m m a n a g e r s , administrators, and policymakers. The issue of w h e t h e r t h i s r e s e a r c h s h o u l d a l s o be u s e f u l to educators m u s t also be considered.
EMERGE N CY M E D I C I N E FOUNDATION A gift to the E m e r g e n c y M e d i c i n e F o u n d a t i o n in t r i b u t e to s o m e o n e you wish to h o n o r will a d v a n c e r e s e a r c h a n d e d u c a t i o n in e m e r g e n c y medicine. Y o u r t h o u g h t fulness will be a p p r o p r i a t e l y a c k n o w l e d g e d . EMERGENCY MEDICINE FOUNDATION 3900 C a p i t a l City Blvd., L a n s i n g , M i c h i g a n 48906
8:5 (May) 1979
JACEP
199/45
Research in Emergency Medical Services Lawrence Rose, MD Hyattsville, Maryland
Rose L: Research in emergency medical services. JACEP 8"197-199, May, 1979.
emergency medical services, research
INTRODUCTION
Academic medicine in t h i s country has often been described as r e s t i n g on the t h r e e e q u a l l y i m p o r t a n t legs of teaching, service, and research. The problem t r o u b l i n g us in the N a t i o n a l Center for H e a l t h Services Research (NCHSR) is w h e t h e r the r e s e a r c h leg is long enough and strong enough to c a r r y its share of the e m e r g e n c y medical services (EMS) load. We also wonder w h e t h e r a categorical p r o g r a m of E M S r e s e a r c h can and should grow to m a t c h t h e i n c r e a s i n g burdens t h a t are being placed on the t e a c h i n g and service legs. These concerns are especially t i m e l y s i n c e t h e E M S A m e n d m e n t s will expire in 1979 and there is some controversy about w h e t h e r the legislation as a whole, a n d p a r t i c u l a r l y the r e s e a r c h p r o g r a m authorized under Section 1205, should be continued. HISTORY
The E M S Systems Act of 1973 e s t a b l i s h e d a t h r e e - y e a r federal p r o g r a m to assist and encourage the d e v e l o p m e n t of comprehensive e m e r g e n c y medical services systems. In 1976 the p r o g r a m was extended for t h r e e more years. The Act is u n u s u a l in its d e t a i l e d specification of each of the e l e m e n t s needed in a regional system. The guidance and technical assistance provided by the Division of EMS in the B u r e a u of Medical Services, H e a l t h Services A d m i n i s t r a t i o n , have added f u r t h e r r e f i n e m e n t s to the m a n d a t e d model. A u t h o r i z a t i o n for a p r o g r a m in EMS r e s e a r c h was included in both the 1973 and 1976 legislation. Responsibility for a d m i n i s t e r i n g this r e s e a r c h section was assigned, to the NCHSR, an agency in the Office of A s s i s t a n t S e c r e t a r y for Health, DHEW. The objectives of the EMS r e s e a r c h p r o g r a m were presented at the U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medicine (UA/EM) m e e t i n g in 1977 t o g e t h e r w i t h a description of the w e a k n e s s e s in proposals t h a t h a d been received. The EMS Systems Act is based on the a s s u m p t i o n t h a t a nationwide network of coordinated s y s t e m s will provide effective and efficient emergency medical care. The prima~y a i m of the research p r o g r a m has been to provide methods for t e s t i n g this assumption. ! CRITICISMS OF RESEARCH
M e m b e r s of the S u r v e y and I n v e s t i g a t i o n s staff of the House of RepresentaFrom the National Center for Health Services Research, Office of the Assistant Secretary for Health, DePartment of Health, Education~~nd Welfare, Washington, D.C. Opinions expressed are those of the auther and do not necessarily reflect the views of the Public Health Service. Presented at the University Association for Emergency Medicine Annual Meeting in San Francisco, May, 1978, . •~Address for reprints: Lawrence Rose; MD, Medical Officer, National Center for Health Services Research, Center Building, Room 8-27, 3700 East-West Highway, Hyattsville, Maryland 20782 J~P
8:5 (May) 1979
JACEP
197/43
tives C o m m i t t e e on A p p r o p r i a t i o n s h a v e e x a m i n e d various a s p e c t s of the m a n a g e m e n t of the E M S prog r a m this y e a r and were very critical of a n u m b e r of activities, including the EMS research program. They considered the research to be too theoretical and longterm, not focused on the i m m e d i a t e needs of the EMS program. These auditors a s s e r t e d t h a t the g r a n t reviewers were too concerned about e l e m e n t s of the research design and t h a t they did not a p p r e c i a t e t h e importance of the problems to be studied. It was held t h a t applications from EMS officials were too often rejected because of design weaknesses, since these a p p l i c a n t s were not "professional researchers." We t a k e all such c r i t i c i s m s a b o u t the focus of EMS r e s e a r c h very seriously, p a r t i c u l a r l y w h e n t h e y question the relevance of the research to real-world problems. A l t h o u g h N C H S R is located in close geographic p r o x i m i t y to the EMS "lead agency" (The Division of EMS, H e a l t h Services A d m i n i s t r a t i o n ) , we are at a considerable organizational distance from them, and therefore we are at r i s k of developing an ivorytower m e n t a l i t y . To minimize this possibility, N C H S R has r e p e a t e d l y and aggressively solicited ideas from a wide v a r i e t y of persons k n o w l e d g e a b l e in the field of EMS concerning the kinds of problems t h a t the research p r o g r a m should be e x a m i n i n g . We recognize t h a t m a n y of the i m p o r t a n t problems faced by EMS systems are not y e t included in the r e s e a r c h portfolio. In some cases, this m a y be because r e s e a r c h e r s have not been i m a g i n a t i v e or perceptive enough to identify ways of exploring these questions t h r o u g h systematic investigations, or p e r h a p s because no one has n o m i n a t e d t h e m as subjects for research. For w h a t e v e r reason, new research topics, as well as better study methods, are in g r e a t demand.
C o m m i s s i o n m o n i t o r s p r o d u c t - r e l a t e d injuries. Par. t h e r m o r e , N C H S R , u n d e r its g e n e r a l r e s e a r c h au. thority, conducts studies of the relationships betwee~ E M S systems and other activities t h a t are intended t0 improve the organization, financing, and delivery of h e a l t h care. The EMS r e s e a r c h funds should concea. t r a t e on a c q u i r i n g i n f o r m a t i o n t h a t is not g a t h e r e d t h r o u g h o t h e r programs, being 3) Research funds m u s t be used efficiently. Un. less research is conducted in accordance with accepted p r i n c i p l e s of s t u d y d e s i g n a n d d a t a a n a l y s i s , it is prone to result in erroneous or m i s l e a d i n g informa. tion. A research p l a n m u s t contain sufficient detail to p e r m i t the study to be replicated as necessary to con. firm the results; it m u s t consider the applicability of its findings to other t i m e s and other communities. Research topics m u s t be selected because the results are likely to be useful to p l a n n e r s and decision-makers and because the r e s u l t s will be forthcoming in time to be applicable. 4) Research in E M S m u s t account for problems a n d p r e s s u r e s e x t e r n a l to t h e EMS systems. These systems are being introduced as discrete, categorical activities, b u t t h e i r c o n t i n u a n c e is dependent on con. cerns such as t h e i r role in r u r a l h e a l t h care systems, t h e i r functions as sources of p r i m a r y care, their ira. pact on cost-containment policies, and their relation. ships to other r e g i o n a l i z a t i o n strategies. An EMS research p r o g r a m should not become so parochial that it focuses e x c l u s i v e l y on t h e d a y - t o - d a y p r o b l e m s of m a n a g e r s who are c o n c e n t r a t i n g on the establishment of a n a t i o n a l n e t w o r k of special-purpose systems. ROLE FOR EDUCATORS This Association should become more involved in designing EMS research p r o g r a m s and in conducting the studies. UA/EM m e m b e r s a r e involved in training the people who will be responsible for providing effective and efficient e m e r g e n c y care. Your students will soon be asked about how medical control should be m a i n t a i n e d , how c l i n i c a l a l g o r i t h m s should be designed and used, how t r a n s f e r protocols should be iraplemented, how hospitals should be categorized, and s i m i l a r questions directly affecting t h e i r professional roles, their financial status, and t h e i r public responsibilities. F u r t h e r m o r e , t h e y will be a s k e d to address such problems in the context of growing n a t i o n a l concern over the rising costs of h e a l t h care and the possibility of some form of r a t i o n i n g of h e a l t h services. There are b e t t e r reasons for including research in an e m e r g e n c y medicine c u r r i c u l u m t h a n m e r e l y prod u c i n g l i s t s of p u b l i c a t i o n s t h a t p r o m o t e t h e acceptance of e m e r g e n c y medicine a s an academic discipline. Research in EMS can improve the delivery of services and the q u a l i t y of teaching, not as by-products - - as is often the case in biomedical research - - but as the goal of the studies. R a t h e r t h a n a s s u m i n g t h a t exposure to research methods is a v a l u a b l e but unmeasu r e a b l e benefit in a u n i v e r s i g y - b a s e d t e a c h i n g program, a n d r a t h e r t h a n a c c e p t i n g the c o n v e n t i o n a l wisdom t h a t p a t i e n t care is b e t t e r in a t e a c h i n g institution, we can use EMS r e s e a r c h both to l e a r n more about r e s e a c h m e t h o d s a n d d i r e c t l y to m o n i t o r and improve t e a c h i n g and p a t i e n t care. The field of E M S r e s e a r c h includes both biomedical and clinical a r e a s b u t its most c h a l l e n g i n g and significant topics are in the a r e n a of h e a l t h services r e s e a r c h - - s t u d i e s of t h e o r g a n i z a t i o n , financing,
LIMITS TO THE RESEARCH PROGRAM There are several constraints t h a t affect an expanded E M S research agenda: 1) It seems obvious t h a t research funds a r e intended to produce research results; they are n o t subs t i t u t e s or s u p p l e m e n t s for service funds. Congress h a s made it clear t h a t comprehensive regional E M S systems are needed, and h a s specified the 15 compon e n t s t h a t m u s t be included in these systems if t h e y are to be eligible for federal support. The Division of E M S h a s developed regulations, guidelines, a n d reporting procedures to insure t h a t EMS systems p u r s u e the e n t i r e r a n g e of required activities. The E M S research p r o g r a m should not be considered an a l t e r n a tive source of federal funds for regions t h a t are u n a b l e or u n w i l l i n g to e s t a b l i s h comprehensive programs, nor should it evolve into a m e c h a n i s m for p a y i n g bonuses to good systems. 2) Research in EMS should not try to s u b s t i t u t e for, nor duplicate, other activities. M a n y of the operat i o n a l p r o b l e m s faced by g r a n t e e s can be r e s o l v e d a d e q u a t e l y t h r o u g h the advice, consultation, and educational efforts of the Division of EMS. Solutions to problems of t h i s n a t u r e do not require formal and exp e n s i v e r e s e a r c h methods. Moreover, m a n y of t h e questions t h a t trouble EMS systems a r e being studied t h r o u g h o t h e r research programs: m a n y of the clinical studies of the N a t i o n a l I n s t i t u t e s of H e a l t h are di rected at patients with central nervous injuries, t r a u m a , b u r n s , ' s t r o k e , m y o c a r d i a l infarction, etc; the D e p a r t m e n t of T r a n s p o r t a t i o n i n v e s t i g a t e s h i g h w a y accident victims; and the C o n s u m e r Product Safety
44/I 98
JACEP
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s a n a g e m e n t , a n d e v a l u a t i o n of h e a l t h care. F o r example, biomedical r e s e a r c h m a y focus on c h a n g e s in ~ayofibril c o n t r a c t i l i t y and c l i n i c a l s t u d i e s m a y describe t h e e x t e n t o f m u s c l e d a m a g e f o l l o w i n g a ~ayocardial infarction, b u t h e a l t h services r e s e a r c h ~aight test a model to improve diagnostic accuracy or examine the effectiveness of c a r d i o p u l m o n a r y resusciration training. Biomedical r e s e a r c h m i g h t c o m p a r e topical antibiotic agents for burns, b u t h e a l t h services research m i g h t study the value of a l g o r i t h m s in proriding better i n i t i a l resuscitation, s t a b i l i z a t i o n and referral. It seems to me t h a t the k i n d of E M S r e s e a r c h which can be considered a subset of h e a l t h services research is more directly concerned with the k i n d s of problems for which e m e r g e n c y medicine p r a c t i t i o n e r s at all professional levels are being called on to provide advice or solutions.
Involvement in r e s e a r c h activities offers your students an o p p o r t u n i t y to acquire experience in r e s e a r c h methods, l e a r n s o m e t h i n g about appropriate study designs, and e v a l u a t e the adequacy o f . d a t a sources. If you are able to introduce t h e m to h e a l t h services research topics, you can t e a c h t h e m how to e x a m i n e issues t h a t directly affect t h e i r own futures. CONCLUSION The question of w h e t h e r EMS research continues as an identifiable p r o g r a m will probably be a n s w e r e d on the basis of "who needs it." It seems clear t h a t research should be helpful to EMS s y s t e m m a n a g e r s , administrators, and policymakers. The issue of w h e t h e r t h i s r e s e a r c h s h o u l d a l s o be u s e f u l to educators m u s t also be considered.
EMERGE N CY M E D I C I N E FOUNDATION A gift to the E m e r g e n c y M e d i c i n e F o u n d a t i o n in t r i b u t e to s o m e o n e you wish to h o n o r will a d v a n c e r e s e a r c h a n d e d u c a t i o n in e m e r g e n c y medicine. Y o u r t h o u g h t fulness will be a p p r o p r i a t e l y a c k n o w l e d g e d . EMERGENCY MEDICINE FOUNDATION 3900 C a p i t a l City Blvd., L a n s i n g , M i c h i g a n 48906
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