Presented at EMS World Expo: New and Improved Myths of EMS

Eight years ago, EMS World published a series of articles that critically examined eight myths and urban legends of EMS. The author was invited to speak at the 2011 EMS World Expo in Las Vegas to see how accurate he was with his predictions and to make a few new ones -- poking holes into things that some consider sacred in EMS.

And if a review of his old predictions and debunking is an indication, Dr. Bryan Bledsoe might be right on his new positions.

"We spend a lot of money on trying things that are new and may not be efficacious," Bledsoe said.

Use of military anti-shock trousers (MAST) is at the top of his list of items that were thought to be a good idea when first embraced, but no longer have worthwhile benefits, Bledsoe said.

Second in his myth busting was recombinant tissue plasminogen activator (tPA) for stroke patients. In 2003, he wrote that it was not the standard of care, even though it was a Class I recommendation, meaning "if you don't use it, you'll be sued."

During the conference this week, he said the first person he ever gave the drug to got well, but the results are still mixed on whether it's worthwhile.

In 2003, Bledsoe said critical incident stress management was "a bad idea." This week he said it is probably the myth that he was most wrong about.

"It developed a cult following," he said, noting that he originally dismissed it, calling instead for "simple psychological first aid."

"It turns out it's very good as long as you don't do anything bad," he said.

Back in 2003, Bledsoe said giving steroids for acute spinal cord injuries was a useless treatment and recommended they be taken off the trucks and returned to the pharmacy.

That opinion proved accurate.

"It was based on flawed studies," he said. "It showed no demonstrable benefit.”

Another myth Bledsoe busted was that speed and lights and sirens made for better patient outcomes. It was an issue back in 2003 and it is today as well, he said.

It's that same mentality that spawned the medical helicopter craze , he said -- get people to the hospital faster -- another one of his eight myths.

Additionally, in 2001 the federal government changed its rules on reimbursement, meaning they would pay for the helicopter ride and that lead to a proliferation of helicopters to the point of absurdity, Bledsoe said.

Those in EMS are often enamored with gadgets and gizmos that don't make a whole lot of difference in patient outcomes, and helicopters fall into that category, he said.

He also didn't shy away from tackling some of the modern controversies as well, such as cardiac drugs, therapeutic hypothermia, and home automatic external defibrillators. In all, he had six new "myths" that he challenged the EMS universe to prop up.

He took on what he called "merit badge courses" that people collect just to say they have them.

While some do some good, they do not represent standards of care. They're too short and often don't cover enough to really impart the needed skills.

"It's hard to learn how to treat trauma in a weekend," he said, declaring most of the courses a waste of money.

Bledsoe also tilted against cardiac drugs, pointing out the huge list of drugs once administered during any cardiac arrest that have now been taking out of protocols, with really one remaining - epinephrine.

Despite some evidence of short-term survival rates, patients who receive epinephrine do not survive long-term any more than those who do not.

All the effects epinephrine is supposed to create could be had with as much effectiveness if the provider simply placed it under the patient's head to elevate it, Bledsoe said.

Home automatic external defibrillators were also on Bledsoe's hit list. He said they don't work primarily for two reasons: first is they're never available when they should be and locations are generally not known in times of true emergencies. Secondarily, spouses and loved ones become paralyzed and unable to remember where they are or even how to use them when they are most needed. The science just doesn't support their value.

Bledsoe also skewered dispatch centers and their employees' ability to accurately determine the medical acuity of calls.

He used a study of the San Francisco Fire Department that showed dispatchers didn't do a very good job of being able to tell who was really sick, or badly hurt with much accuracy.

A British study of telephone triage revealed much the same results.

He said the accuracy of their triage was "no better than a coin toss."

Response times were also on his list. He busted the myth of improved outcomes if the ambulance reaches the patient in 8 minutes 59 seconds. He said there is no correlation between quick response times and positive outcomes.

A better way of treating patients is to have providers who are well trained and practice good medicine. Just getting their fast doesn't make for better outcomes, he said.

Bledsoe also said he sees no value in most field IVs. Studies have shown that patients who get IVs have no better outcomes than those who don't except in cases of patients who are hypotensive and those who have suffered trauma.

"There are things that just don't make sense," Bledsoe said.