Debunking new myths in EMS
Dr. Bryan Bledsoe spoke about six new EMS myths at a session at EMS World Expo
By Drew Johnson
Eight years ago, Dr. Bryan Bledsoe wrote a series of articles for EMS magazine that critically examined eight myths and urban legends in EMS.
Bledsoe, a professor of emergency medicine and director of prehospital and disaster medicine at the University of Nevada School of Medicine, briefly revisited those eight myths, and did his best to debunk six more in a session at EMS World Expo in Las Vegas today.
"There are many things we do that may not be efficacious," he said. "This is just the state of the science; EMS is old enough that it's time to start questioning these things.
What practices have limited or no scientific support?
This time around, Bledsoe picked six new sacred cows to tip over:
Merit badge courses
Bledsoe argued that, for providers above a certain level of education (like doctors, nurses, and perhaps paramedics), these courses serve little to no purpose. Rather than providing a tangible education benefit for medics, merit badge courses serve only as a revenue stream for the organizations that sponsor them (like the American Heart Association).
The biggest problem he has with them, though, is not that they make money, but that they aren't scientifically proven to improve care. Bledsoe cited numerous studies showing that these types of certifications do not improve outcomes.
He did stress that in some cases (like for initial education), the courses made sense. But for many, they are a waste of time and money.
The use of epinephrine in cardiac arrest
Epinephrine has long been a mainstay in cardiac arrest resuscitation, Bledsoe said. He admitted that it does increase heart reate, contractility, cardiac and cerebral blood flow. The question, though, is whether it improves survival?
Bledsoe sited two studies – one done by a medical team in Australia, one by a team in Singapore – showing that, compared to a placebo, epinephrine did little to improve results on discharge. In fact, patients who received the placebo had better neurological recovery outcomes than those who got the epinephrine.
Home AEDs save lives
Certainly, Bledsoe admits, AEDs are associated with improved resuscitation rates. Though this is the case, it is more likely the location of the AED that accounts for patient survival than its presence.
For example – AEDs are often used successfully to save patients in crowded locations like shopping malls, airports, and casinos, where they are prominently displayed and, more importantly, there is likely to be trained personell nearby who know how to use the device.
But the success of public AEDs doesn't translate to private locations. Studies show that AEDs save few lives in residential units. Why is this?
Bledsoe contends that it's a combination of factors. First, people may purchase an AED and put it somewhere in their home, then promptly forget where they stored it. When the time comes to use the device, they aren't able to locate it.
Second, residents may have an emotional attachment to the person their supposed to be saving. It would likely be more traumatic and difficult to use the device on someone you know than a stranger in an airport.
Is medical dispatch effective at detecting high-acuity calls?
To answer this question, Bledsoe pointed to a San Francisco Fire Department study that examined how dispatchers where allocating ALS care.
What the study found is that the triage schemes used by the dispatch were good at determining who's not sick, but pretty miserable at determining who actually is sick.
More often than not, dispatch was sending a lot of resources on calls that got little benefit. Another study — this one done by an English hospital — showed that fewer than half of stroke victims were identified with phone triage
If you get there in 8 mins 59 seconds you'll live!
There are a range of factors that affect how soon an ambulance reaches a patient. Among them are: traffic conditions, road conditions, vehicle conditions, and the skill of the driver. Trying to account for all of these is a fool's game.
Regardless, the myth that reaching your patient in under nine minutes will ensure resuscitation is totally wrong, Bledsoe argued. In fact, he cited research showing that the duration most highly correlated with patient survival is four minutes.
The implications for this are huge. Consider how many medics die unnecessarily in ambulance crashes and helicopter crashes because they raced recklessly to a scene. The solution is not to strive endlessly for reduced response times, Bledsoe argued, but rather to train paramedics and EMTs who can provide better care.
The benefit of prehospital IVs
To cap off his list of new EMS myths and urban legends, Bledsoe looked at the efficacy of prehospital IVs. What he found was unsurprising: a large Chinese study where half of the group received prehospital fluids via IV and half didn't had a predictable outcome: the mortality rate for both groups was the same.
What EMS myths and urban legends do you think do more harm than good to the industry? Leave your thoughts in the comments section below.