Pinnacle 2021 Quick Take: The EMS contrarian - Ditch the dogma and get real
Bryan Bledsoe: “EMS must be fixed with bulldozers not tweezers”
Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P, delivered an insightful and to-the-point presentation at the opening plenary session at the Pinnacle EMS Leadership Forum. Bledsoe, a clinician with a reputation for saying some of the most audacious things that EMS leaders don’t want to hear, but often need to hear, opined about the future of the profession and covered several hot topics.
Bledsoe got his start in EMS in 1974 as an EMT, paramedic and EMS instructor in Fort Worth, Texas. He then went on to medical school at the University of North Texas, earning his doctorate of osteopathic medicine. Over the years, Bledsoe has called into question numerous EMS practices and gained a reputation as an EMS myth buster. His myth buster series, originally published in EMS World, questioned such practices as therapeutic hypothermia, MAST Pants, public utility models, red lights and sirens, and system status management to name a few.
Applying his focus onto today’s elephants in the EMS room, Bledsoe noted he aims to challenge dogma and encourage critical thought, self-review and science. Following are the current myths Bledsoe tackled and top takeaways.
1. Lights and siren response
Bledsoe acknowledged that red lights and sirens are an emotional issue. As current peer-reviewed research by Jarvis, et. al. outlines, there is no evidence of improved outcomes; only increased risks for EMS providers and the motoring public when using red lights and sirens. Other than a response time in less than 4 minutes in the case of cardiac arrest, there is no association between response time and outcomes.
2. Medical helicopters
Bledsoe identified that nearly 1,000 medical helicopters are operating in the U.S., mostly owned and operated by private equity companies. He noted there is no significant evidence of benefit and that most operations are out of the patient's network. He acknowledged that when the surprise and balance billing legislation comes into effect, there may well be a 30-40% decline in revenues, which in turn may see the aircraft owners reducing the number of aircraft and available jobs.
First, do no harm
Despite extensive research finding lights and siren use makes little difference in patient outcomes, and in fact causes harm to patients, providers and the public, too many continue to respond hot
3. ALS first response
Bledsoe opined paramedic ALS first response is contrary to the prevailing science and is primarily prompted by response time dogma and the need to justify services. He acknowledges that there are time-sensitive, ALS-centric calls, such as cardiac arrest, polytrauma and anaphylaxis, but these are few. He identified that in the case of trauma, the best EMS treatment is “gas and diesel” to transport the patient to the hospital as quickly as possible as the life-saving intervention is solely in the hands of surgeons.
4. Mobile stroke units
Bledsoe maintains that mobile stroke units are devices “in search of an indication” and a tool to maintain captive patient flow. He suggested that such units often favor affluent neighborhoods, when many stroke patients come from lower socio-economic and underserved neighborhoods. The technical setup of stroke units also requires significant maintenance, upkeep and crewing, and is expensive and unnecessary.
5. Too many paramedics
“No matter how you slice or dice it,” Bledsoe noted, “we have too many paramedics – Seattle has it right!” He maintains that unnecessary skills and procedures are being performed to justify higher transport coding. Bledsoe believes that most EMS providers should be educated to EMT level with an expanded skill set such as analgesia, anti-emetics, nebulized beta-agonists, EpiPen and glucose administration.
Bledsoe also mirrored a theme common in multiple Pinnacle sessions, in that he believes our workforce is disenchanted, underpaid and overworked, with a limited ability to use their skills and knowledge, with limited options for growth and now with increased risk of violence. While this may be hard to read in some quarters, Bledsoe pulled no punches throughout his session, which merits further discussion, and in some cases, rebuttal.
6. Mechanical CPR devices
The case for mechanical CPR devices in Bledsoe’s view is not strong and he contends that there is no evidence of benefit. The real problem, he notes is that CPR is started and continued (with transportation) for patients who do not stand to benefit from further resuscitative efforts. He challenged the room to conduct a cost-benefit and lifesaving assessment of purchasing one mechanical CPR device or up to 12 AEDs at approximately the same price.
7. ECMO and transfusion
Bledsoe acknowledged ECMO is an important medical device, just not a prehospital strategy, and while there may be an overall benefit for selected patients, it is an expensive option. He offered that current dispatch systems do not immediately identify who may benefit from ECMO.
Moving onto transfusion, he identified the logistics of blood management in the field is problematic, with potential product shortages once a program is put into place. He noted that prehospital crystalloids are of limited benefit and most studies have looked primarily at plasma, although no civilian studies have demonstrated the benefit.
Research analysis: ‘ECMO is a useful tool but not a magic bullet’
Two studies from the University of Minnesota examine early ECMO and the chain of survival
Bulldozers not tweezers
In summary, Bledsoe believes that EMS has evolved into an unsustainable system in which we are trying to solve other problems while sometimes abandoning our primary role. His concerns for our level of funding, maintenance of the skills we currently possess and how we deliver EMS education in the future are a challenge we must immediately overcome.
Dr. Bledsoe believes that “EMS must be fixed with bulldozers, not tweezers.” He may be right. His firebrand session received tumultuous applause from those in the room and the halls were filled with acknowledging nods of his message and points. As the self-proclaimed EMS contrarian, his views challenging opinions and practice provided food for thought both in the room, on accompanying social media and now hopefully via this article.
What do you think?
That was Dr. Bledsoe’s view, perhaps deliberately provocative, but we would love to hear your views, warts and all! Share your responses in the comments below or by contacting us at firstname.lastname@example.org.
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