Meet the EMS Myth Buster

Known as the EMS “contrarian,” Bryan Bledsoe believes EMS protocols and practices should be based on evidence-based medicine instead of tradition, profit motive or anecdotal evidence. Over the years, he has called into question numerous EMS practices, ranging from the frequent use of helicopters to what he considers an overemphasis on intubation.

Bledsoe got his start in EMS in 1974 as an EMT in Fort Worth, TX. Soon after, he became a paramedic and EMS instructor. Later, he earned his DO (Doctor of Osteopathic Medicine) from the University of North Texas. He is board-certified in emergency medicine.
Bledsoe is the author of numerous EMS textbooks, and a frequent contributor to EMS publications and presenter at EMS conferences. Today, he is a professor of emergency medicine at the University of Nevada School of Medicine, an attending emergency physician at University Medical Center in Las Vegas and medical director for MedicWest Ambulance in Las Vegas.
The following excerpted interview can be found in its entirety on the Best Practices in Emergency Services website at www.emergencybestpractics.com.

How did you come to be known as the EMS contrarian?

It was over dinner with Jim Page in Queensland, Australia, in 2003. I was lamenting the fact that I was doing all of these conference talks on shock and other straightforward medical topics. He suggested that I’d been doing this long enough to challenge some of the more controversial issues such as critical incident stress management.

Critical incident stress management wasn’t based on any science. It didn’t help responders recover from an incident, but it had become ingrained in the culture. We did a lot of things in EMS in the ’70s and ’80s that somebody thought was a good idea—but there was no evidence that they worked. We came up with a list of eight myths of EMS, which were published in EMS Magazine in 2003. And that’s how it started.

What are some of the practices that are being done now that are not based on medical evidence?
Helicopters are being vastly overused. Most people being transported don’t benefit, yet it’s the most rapidly growing segment of EMS. It’s all about profit and less about medical need. Another thing that is controversial is paramedics’ use of endotracheal tubes. We are going from anecdotal to empiric evidence, and the transition is painful.

What do you see as the most pressing issue facing EMS today?

One is paramedic education. It is so brief compared to other allied health professions. Everybody in EMS wants respect, but they don’t want to put in the time to get the necessary education to catch up with other professions.In this country, a person can become a paramedic very quickly. In other countries, it’s a more arduous process.

What new myths are on your radar?

We have all quickly embraced cooling therapy, or therapeutic hypothermia. However, several recent studies have shown it doesn’t matter if you cool the patient in the prehospital setting or in the emergency department. The outcomes are about the same.

There is also controversy about whether oxygen should be delivered routinely. There is quite a bit of research showing high quantities of oxygen are bad. That is one of the things that goes so far against what is conventional wisdom that it’s hard for people to accept.

As far as medical care is concerned, is there anything EMS is not doing that it should be?
Getting paramedics to be more adept at recognizing real serious disease processes such as sepsis. Sepsis, a potentially fatal blood infection, is a big thing for hospitals. We have to get antibiotics started quickly. Getting these people identified in the prehospital setting could help get treatment started earlier.

In Las Vegas, we’re studying whether paramedics can identify sepsis—and once they do, to begin fluids and do a lab test called a lactate test. For services that have a long transport time, there might be a role in giving the initial dose of antibiotic, since there is a relationship between the time the first dose of antibiotics is given and outcomes. It would be very strictly directed and done under protocol.

How do you see EMS continuing to evolve in the coming years?

I think it’s going to take on a greater role in healthcare. In general, fewer physicians are going into primary care. The emergency departments are overloaded. Primary care physician access is limited. EMS will become the ultimate safety net—we are going to be making determinations if patients need to go to an emergency department or to a lower level of care, such as a clinic or treated by paramedic practitioners and left on scene. This current model of everybody who calls an ambulance gets taken to a hospital is not sustainable from a hospital or an EMS standpoint.

Jennifer Goodwin is associate editor of the monthly newsletter Best Practices in Emergency Services.