Q&A: Bryan Bledsoe, DO, FACEP

   This month, we speak to Bryan E. Bledsoe, DO, FACEP, a noted emergency physician and author of numerous EMS textbooks, including Paramedic Care: Principles & Practice, Paramedic Emergency Care and others. He is a frequent speaker at EMS conferences and contributor to EMS publications. He is a clinical professor of emergency medicine in the Department of Emergency Medicine at the University of Nevada School of Medicine and in the Department of Emergency Medicine at University Medical Center in Las Vegas. His website is www.bryanbledsoe.com. Dr. Bledsoe spoke on hypertensive emergencies and ophthalmological emergencies at the 2010 EMS World Expo. Here we discuss some specifics of those presentations with him.

The first of your presentations concerns hypertensive emergencies. What should people know about this class?

   There's a lot of misunderstanding about when to treat hypertension, and the way we treat it in the field has changed quite a bit. The first thing we cover is the pathophysiology of hypertension, with emphasis that it is a chronic disease. And it's something we see a lot in emergency medicine and EMS, but that doesn't mean it necessarily has to be treated. We go through a pretty good description of current recommendations from the heart and stroke associations about when and how to treat it.

   The take-home part of this talk probably is that with 90% of these cases, you're not going to do anything. The remaining 10% or so need to be stratified for care. But with a problem like high blood pressure, giving a onetime treatment to make the blood pressure look better can actually be counterproductive, or even dangerous for the patient. Of the chronic conditions we encounter, high blood pressure is something that needs to be addressed a little differently, and people in emergency medicine are so oriented toward seeing something and fixing it, it takes kind of a change in the way we think.

So it's something that's overtreated now?

   Yeah, it is. In the last 10 years, we've found people were coming into emergency departments with elevated blood pressures without any other symptoms, and we were giving them drugs that were sometimes causing more complications than benefits. Now that we've started to become more aggressive about treating stroke, maintenance of blood pressure is important, because a decrease in blood pressure in a stroke patient can sometimes worsen the problem.

   It's something we find every day. We have people sign into the ED all the time because their blood pressure is elevated, sometimes horribly elevated, but if they don't have end-organ changes, we don't necessarily need to put them on potent medications that could make us put them in the ICU.

Your other talk is on ophthalmological emergencies. What does that cover?

   In EMS we just don't get all that much training in that area. There are a lot of things paramedics can recognize, and with the eyes there are things that may not seem so bad until you get an exam, but can actually be eye-threatening lesions or injuries.

   The goal is to get people to recognize not only common eye emergencies, but also the uncommon ones that can result in identifying a lesion or condition that requires care in the emergency department that can save the eye. I've seen cases where hyphema, or blood in the anterior chamber of the eye, was missed. When you see something like that, it should increase your index of suspicion for more serious lesions.

   We'll also review the anatomy and physiology and common conditions of the eye, just to give people a more detailed update than they can get in textbooks.

Beyond the show, you've been a vocal critic of the overuse of air resources in EMS. Do you see things improving there?

   I think the number of flights is slowly going down, and field providers are starting to recognize the resource has sometimes been overused. I think the big area of abuse now is interfacility transfers. In Las Vegas, I routinely get helicopter patients flown in from out of the area who could easily have come by ground. We've concentrated pretty well on EMS, and it's starting to react, but in terms of the interfacility stuff, which is out of EMS' control, we're seeing a lot of it.

   I think you're seeing more scrutiny from insurance companies and more scrutiny on paramedics for calling helicopters. There's been a push also to tie Medicare reimbursements for helicopter transports to the level of safety provided. Who knows how that will turn out, but we're getting the interest now--the federal government is getting interested, and the insurance companies have gotten interested. The word is out.

   The mainstream press has picked it up as well. I was interviewed for an article about it for the July issue of Popular Mechanics, and have spoken quite a few times with local reporters. So the public is starting to question it. I'll be curious to see what kind of reaction the Popular Mechanics story has, because they have a pretty extensive readership.

   Nobody wants to get rid of these resources. We just want them to be used appropriately.