An American hero - Dr. David Boyd and emergency health care.

• Author: Glastris, Paul
• Position: Life and Death in the Emergency Room, part 2

Dr. David Boyd pours the evening's fourth cup of coffee in his cluttered, windowless Washington office. Talking about is years in government, he says, "The thing about being a bureaucrat, a maverick bureaucrat, is that if you have reasonably good enough argument and balls enough to stick with it, you can win a lot of battles." Putting the urn back in the coffee machine, he says, "The thing is, nobody ever tries." It's a lesson he learned from experience In the early seventies, Dr. Boyd turned in his surgeon's scrubs for a bureaucrat's suit, and quickly rose to the directorship of something called Emergency Medical Services (EMS), a division of the department of Health, Education and Welfare HEW). You may not have heard of Boyd, or MS, but you probably take for granted the changes he and his agency brought about. The division existed only from 1974 to 1981, when the Reagan administration pulled its plug by turning its funding into block grants to state governments. But in those years, Boyd orchestrated a revolution in emergency medical care. In the course of it, he convinced some of his colleagues he was "egomaniac," "despot," "visionary"' and "pain in the ass." Yet the changes he helped bring about were so sweeping that, in the words of former co-worker Dr. John Otten, Boyd has probably "been responsible for saving many more thousands of lives than anyone in the medical profession today."

How Boyd turned his federal program into a catalyst for positive change, instead of another government boondoggle, is a story in itself. The program was meant to give states and municipalities "assistance and encouragement" otherwise known as the pork barrel-for projects like improving ambulance services and training volunteer firemen in new medical techniques. What kept the division from fulfilling its destiny as yet another do-nothing agency was, by all accounts, Boyd. Now, thanks in large part to him, hospital emergency rooms have been revamped and staffed with a new breed of specially trained emergency physicians. Almost half a million ambulance personnel have been trained in basic and advanced life support. Well-equipped paramedic vans are now a familiar sight as they fly down city streets. Victims of severe heart attacks, burns, poisonings, and serious injuries, people whose lives were once written off, are being saved by the thousands. In short, high quality emergency service has become an expected government function, the "third public force" after fire and police protection.

These were not small achievements. As Dr. Mark Vasu, an expert in emergency cardiology explains, "Prior to Dave's program, there was virtually no training, no standards, no 'system' of emergency care in this country:' Hospital emergency rooms were notorious as the dumping ground for inept physicians. The nation's ambulance drivers were so untrained that few knew how to put an IV into a bleeding patient.

But there's a disturbing story in the one key reform Boyd failed to implement. This, as described in the first part of this article (November 1985) was his "trauma systems" concept. In a nutshell, Boyd proposed setting up super-equipped "trauma centers" in selected hospitals, to which the most serious trauma patients ("trauma" is an umbrella term for injury) would be taken automatically. This mandatory diversion of patients away from less well-equipped emergency rooms, Boyd believed, would lead to dramatic improvements in emergency care.

Boyd had strong evidence to support that belief. Unfortunately, thousands of Americans continue to die every year of perfectly treatable injuries because he couldn't get his trauma system installed nationwide. It wasn't for lack of effort. "He had a ferocious intensity, an evangelical fervor-the success of the program was more important to him than his own career," recalls James Page, a California fire chief and publisher of JEMS, a trade magazine for paramedics. Dr. Michael Rhodes, a government EMS adviser in Pennsylvania, agrees: "Dave could have walked out of government and onto the staff of any medical school in the country'" But he spent too many years in the bureaucracy, and his medical skills dulled. Now Boyd makes his living as a private "EMS adviser" with a small Washington consulting firm.

What killed the nationwide trauma system Boyd envisioned was opposition from the nation's medical establishment. The great irony is that a good deal of the opposition grew out of the innovations of David Boyd. Doctors and hospital administrators, who a decade or two before probably would not have worried about emergency care came to perceive the idea as a threat to their power, prestige, and pocketbooks. That Boyd did his job, in a sense too well, is only one of the ironies of this story. To understand how all this happened, we need to examine some history.

MASH factor

The trauma center idea comes from the U.S. Army. In World War II, soldiers injured in battle were taken first to battalion aid stations, then to hospitals well behind the battle lines. This often caused 12-hour delays in getting them to surgery. In Korea, the U.S. Army Medical Corps decided this wasn't good enough. Instead, they transported the wounded, often by helicopter, to nearby Mobile Army Surgical Hospitals, now universally known as MASH units. There, surgical teams were ready to operate 24 hours a day. This reduced the waiting time by two-thirds. And since sewing up and caring for the wounded was the only medicine MASH doctors and their staffs practiced, their skills and teamwork were honed to near perfection. As a result, the mortality rate for wounded soldiers in Korea was half what it had been in World War II.

It would take years, however, before the lesson of the MASH unitswas learned in America. For the medical community at home, it was business as usual. The federal government did nothing during this period to change the pattern of emergency care, and it confined its involvement in medical matters to a few areas. It subsidized a massive hospital construction program-the origin of our chronic oversupply of beds. Congress also poured research money into medical schools, stimulating the production of a greater number of highly trained specialists. Moreover, there was a decline in the number of general practitioners entering the work-force. The old-style family doctor, though not exactly a vanishing breed, was getting considerably harder to find.

Consequently, by the 1960s, more and more people were showing up in hospital emergency rooms (ERs), looking for the physician care they otherwise couldn't find. The ERs weren't much of a substitute. Hospitals devoted scant resources to them since administrators believed the ER was a drain on revenues. Few ERs had physicians staffing them around the clock, and many doctors who worked the ER beat had reputations, even among their peers, for incompetence. "The ER was a terrible place to work," recalls Dr. Stan Zidlow, head of emergency medicine at Chicago's Northwest Community Hospital. "We called it 'the pit.' "

All those...