Making Hamburger of Sacred Cows:

A former EMT, paramedic and paramedic instructor, as well as a physician with more than 30 years' experience in prehospital systems and emergency medicine, Bryan Bledsoe, MD, has become known as somewhat of an EMS maverick. Among his famous challenges to well-established "sacred cows" have been examining the clinical need for MAST pants, analyzing the effectiveness of system status management (SSM), scrutinizing the economics of public-utility model (PUM) EMS and questioning the science behind critical incident stress management (CISM). In the last several years, if there has been a debate raging in EMS, chances are that Bledsoe has been at the center of the storm.

For this month's column, Bledsoe took time from his busy schedule to discuss his views on assorted topics in today's EMS environment. In addition to his clinical and administrative work, Bledsoe is an educator who has coauthored numerous EMS textbooks, including Paramedic Care: Principles & Practice; Paramedic Emergency Care; Prehospital Emergency Pharmacology and Anatomy and Physiology for Emergency Care. He is also a frequent contributor to various EMS journals and a presenter at EMS conferences. Although he has done significant work on various aspects of EMS systems, Bledsoe's primary research interests are in the area of utilizing evidence-based medicine and outcome studies to improve EMS practices. Whether you agree with his position on any given subject, it cannot be denied that Bledsoe is a dedicated advocate of prehospital medicine and a strong supporter of those who serve in EMS.

How do you see your role in EMS?

As a textbook author, I need to stay abreast of the science and translate it into a form that the EMS student can use. That is a significant responsibility in a time when we do not have a national standard curriculum. As a researcher, I must search for the evidence supporting what we do. In the near future, Medicare and the insurance companies will only pay for what we can document makes a difference in the patient's care and outcome. Finally, as an EMS physician, I serve as a mentor but also a buffer between other EMS physicians and field providers. My heart is still that of a field paramedic.

In the past few years, you've exposed a number of EMS "myths." While some other renowned industry figures, as well as some field providers, have disagreed with your views, the resulting debates have spurred greater assessment of these topics and in a few instances led to widespread changes in practices. In your opinion, what are the top "myths" that remain untested and need to be challenged?

Several years ago I was in a rut and had dinner with a good friend, the late Jim Page. He challenged me to take on some controversy. I remember him saying that both EMS and I were ready for that. He pointed out the problems with CISM, PUMs and SSM. So I researched these and wrote the EMS myths series. Most editors would not touch them, but Nancy Perry, editor of EMS Magazine, did, and I'm forever in her debt for taking the risk.

Of the eight myths published in EMS Magazine, the only one on which I was off-base was the role of fibrinolytics in stroke. While the evidence there remains shaky at best, there appears to be a limited role for using fibrinolytics in stroke-but not to the degree the American Heart Association suggests.

The series resulted in a lot of e-mail and letters. They were about 90% supportive, with the other 10% stating that I was either crazy or "had an axe to grind." Interestingly, almost all of the negative letters were from people who had strong emotional or financial ties to the myths in question and would not look at the process from a nonemotional point of view.

As we look back today, most agencies have dropped CISM, and even the CISM zealots are abandoning debriefing for the resiliency-based model. The overuse of medical helicopters has now come into the forefront of the popular press after a number of accidents. I am interviewed nearly weekly on this topic by media outlets, and now the National Transportation Safety Board and the National Association of State Medical Directors are looking critically at this important but highly overused part of EMS. The PUMs continue to decline as the governmental agencies take over (Fort Worth, TX, and Kansas City, MO, have joined Charlotte, NC, in running ambulance operations themselves instead of using contractors). More services (especially in Canada) are seeing that SSM is all smoke and mirrors. There are other myths waiting to be exposed, such as medical priority dispatch and some of the so-called "standard of care" technology being pushed on EMS by medical equipment manufacturers. Perhaps we can find time to write about these in the future.

As an EMS educator and medical director, what is your opinion of the first and second drafts of the National EMS Scope of Practice Model?

I have followed the documents closely and have not been pleased by either draft. They are political. The authors have tried to make them evidence-based, but we still don't know enough about EMS to make a perfect document. The second draft places a ceiling on care and limits the role of the local medical director. This is especially true in states like Texas and Florida, where the scope of practice is determined by the medical director. EMS is becoming more sophisticated, and I think the days are coming to an end where you can stay proficient in two areas (such as firefighting and EMS). If we carefully examine other models (Canada, Australia, England), we see that successful EMS systems are a part of the healthcare system and not public safety.

You recently penned an opinion that well-meaning entities are adversely affecting EMS by offering educational scholarships in other allied health fields, such as nursing, and increasing the shortage of paramedics. Considering the comparatively lower salaries of EMS providers across the country, it seems difficult to fault those who would leave the field for a better paycheck. Given these challenges, what do you think it will take to ensure the future of EMS?

I don't fault those for leaving; I left myself. However, giving scholarships to leave EMS for nursing or medicine further promotes the image of EMS as a trade and not a profession. I've gone into ambulance stations in Canada and Australia and seen paramedics older than me-and I just turned 50-who love their work, have been at the same station for 30 years and lament their impending retirements. What's the difference? The governments there have recognized that EMS is just as important as police and fire operations. In fact, one could argue that EMS is more important than fire suppression, because modern building codes and fire protection and suppression systems have significantly reduced the number of responses a fire department makes. These countries tie EMS to their healthcare systems and require significant education for EMTs and paramedics. They pay them what they're worth. Here, we continue to pump out 21-year-old paramedics from 700-hour courses, which floods the market. We must do several things:

1. Increase educational standards. Do away with the minimum-length courses and promote the degree-model programs (AAS at the least).
2. Separate ourselves from the public-safety model, for EMS will always be a stepchild in most fire department operations.
3. Lobby for a national oversight agency that's a part of the healthcare system and not Homeland Security, NHTSA or the Department of Transportation.
4. Require a certain amount of experience before moving from EMT to paramedic and from paramedic to CCT. Now people do it in less than a year and never really learn how to take care of people.
5. Promote evidence-based practice.