The End of the Beginning

     Raymond Fowler, MD, has been involved in EMS as an educator, medical supervisor and political advocate for more than three decades. He currently serves as co-chief of the EMS, Disaster Medicine and Homeland Security section at the University of Texas Southwestern Medical Center and chief of EMS operations for the Dallas-area BioTel system. In addition to serving as president of the Georgia College of Emergency Physicians and as a member since 1980 of the Georgia EMS Advisory Council, he was also the second elected national president of the National Association of EMS Physicians and a cofounder and senior faculty for the NAEMSP's National EMS Medical Directors Course.

     Fowler was the original national BTLS program director and helped found the EMS State of the Sciences Conference, better known as the Gathering of Eagles. He has been named EMS Medical Director of the Year by the state of Texas and received the NAEMSP's prestigious Keith Neely Outstanding Contribution to EMS Award. In 2005, when 40,000 Hurricane Katrina evacuees fled to the Dallas Convention Center, Fowler led the team that arranged their medical care. He and dozens of physician colleagues created a temporary hospital. He once again led the team to establish the evacuee medical surge facility operation at the Dallas Convention Center for Hurricane Gustav, when it made landfall in August 2008. At the time this article was written, he was part of the team monitoring the prospect for landfall of Hurricane Ike.

     As principal investigator for multiple studies and author of many book chapters and significant papers in EMS and emergency medicine journals, Fowler has a unique perspective on EMS and the changes, clinical and otherwise, that may impact the field.

As a physician, you have a unique place in the world of EMS. Focusing on lessons learned, what do you see as a future direction for our field?

     I believe we are at the end of the beginning of the greatest time in EMS. We are entering a new era. We're already into a golden era of EMS; EMS providers are finally receiving the respect they so richly deserve through their hard work in adverse environments. Additionally, there are EMS staffing crises in many parts of this country. The natural effect of this is that as EMS providers are scarce, their salaries will rise. This is bringing about, finally, the improvement of wages for EMS providers, and thank goodness. We have come to expect knowledge, productivity and good clinical sense from our EMS providers, and only now are they being remunerated fairly. I am pleased to finally see them getting the attention they're due.

     Next year there will be an important effort taking place all across the EMS industry: an attempt to place prehospital emergency medicine into medical subspecialty status. Those of us who oversee EMS practices know this is long overdue. With the publication of the fourth edition of Prehospital Systems and Medical Oversight, we will be laying out a foundation that will describe those essential elements of clinical EMS medicine practice. From this foundation, we can step forward to hold ourselves out as partners to all the other medical specialties and subspecialties.

     The scientific underpinnings of EMS have never been broader. Take, for example, the evaluation of the chest pain patient. EMS providers now take a history, assess the nature of the chest pain, apply and interpret 12-lead EKGs, communicate with medical control, apply appropriate therapies and insert these patients into STEMI systems. Another example is the utilization of waveform capnography. Capnography is a window into the status of the airway, the flow of air and the actual metabolic status of the patient. The understanding of the entire tide [Author's note: Fowler prefers the term tidal—i.e., throughout the entire tide of the breath moving—as opposed to end-tidal] is so critical that I have urged manufacturers to develop algorithms much like the 12-lead EKGs have.

     The utilization of CPAP in the field is another clear indicator that advances in medicine can decrease morbidity and mortality in our patients. It's clear that the problem of ventilator-acquired pneumonia (VAP) is important in our patients. Routine intubation practice has been questioned in some settings. Perhaps, as data becomes available about the risk of illness or death due to VAP, we can possibly avoid intubating some patients, especially in the nonsterile prehospital environment. I recognize this may be contentious, but we need to think of the patient first, and I believe CPAP can be a good option, in some cases, as opposed to intubation.

You were recently dubbed a "Hero of Emergency Medicine" by ACEP. Can you tell us what an award like this means?

     There were many awardees, including my boss, Paul Pepe, and many other providers in many states. I am humbled to join a group of people whom the college has decided have been of significant service. This comes in my 30th year of practice in EMS, and it allows me to reflect on this time—dealing with the politics and realities and still getting many important, formative things accomplished. It's also a reminder that I've chosen this field for life. I will keep working in the ER until I have to tell the nurse next to me to tend to me as well as the patient. Emergency medicine requires the evaluation and management of all areas of medicine, from pediatric to geriatric, from cardiology to orthopedics, from the wilderness all the way to rehab.

What's the biggest enemy to EMS moving forward?

     Complacency. In this era we all, especially field providers, must recognize the gravity of the roles we occupy in patient management. Failure to do so would be an embarrassing throwback to substandard clinical practice.

     There are three great risks in EMS:

• Airway management—We now have all the devices we need to know that our patients' airways are being managed appropriately. Thus, we can never justify an unrecognized esophageal intubation with an ET tube.
• Unsafe driving practices—If a UPS or FedEx driver can get packages safely to customers, we can do likewise in delivering our patients to appropriate medical facilities. We can never justify unsafe driving practices that may harm a provider, a provider's partner, citizens, etc.
• The nontransported patient—This patient interaction represents a crossroads in EMS: exhausted personnel seeing a patient they believe is nonemergent and does not require transport. Perhaps there's even an EMS provider who would lead a patient into making a transport decision that's not in the patient's best interests. There's intense pressure placed on EMS responders today by the growing public health need in the out-of-hospital environment—9-1-1 is so successful that our customers call for a lot of things outside the scope of normal operations. One example is the chronic patient who runs out of pain medication and calls 9-1-1 a dozen times in a few-month period. While treating pain is important, the better approach would involve having the patient involved in a program for pain management and not requiring a 9-1-1 response. Examples abound of uses of EMS that make our systems more expensive and put units out of service when truly life-threatening calls may go unattended.

Raphael M. Barishansky, MPH, EMT-B, is program chief of Public Health Emergency Preparedness for the Prince George's County (MD) Health Department, and a member of EMS Magazine's editorial advisory board. Reach him at rbarishansky@gmail.com.