Dr. Disaster

When the world is falling to pieces, emergency doctor Paul Pepe makes order from chaos

Another colleague commandeers 54 school buses from Bossier City. They are initially blocked at security checkpoints. Then FEMA tries to stop them from loading people onto stretchers which have been tied to bench seats by a DMAT team with experience in rescuing people after train derailments.

"They said they weren't sure it was safe," Swienton says. He overrules them.

By mid-morning, the place is almost empty. In 24 hours, they will get more than 2,000 patients out of the airport to better-equipped facilities.

Pepe confers with Dr. Kurt Kleinschmidt in the Parkland ER. UT Southwestern faculty members are present at all times in the ER.
Pepe confers with Dr. Kurt Kleinschmidt in the Parkland ER. UT Southwestern faculty members are present at all times in the ER.

Of the "expectants," only six die in the airport.

As people are rescued, many are funneled to Dallas, where more than 12,500 people are seen by nurses or doctors in the aftermath of Katrina and its sister storm Rita. (Pepe's team at Parkland would treat most of the survivors of the bus explosion and fire that killed 23 nursing home evacuees.)

U.S. Surgeon General Richard Carmona, also an emergency physician, praises the surge capacity centers at Reunion and the Dallas Convention Center. On November 1 in Washington, D.C., in fact, Carmona will present Pepe with the American College of Emergency Physicians' annual Award for Outstanding Contributions in emergency medical services.

The response of state and federal agencies stinks, but Pepe and his EM doctors experience their finest hour. It is the accumulation of all Pepe has been doing in a career that has mirrored the rapid evolution of emergency medicine.

When the 1976 class of interns showed up for their first day on the intensive care unit at the University of Washington in Seattle, Dr. Len Hudson noticed one character with bushy black hair wearing fatigues covered with pockets and a name tag that said, "Rick Fortune, star intern," instead of his real name, Paul Pepe. It was a goof on soap opera medicine; in reality, interns are the bottom of the food chain, the people who get stool samples. Pepe swears he took the name tag off before seeing patients. The gag was the first of many.

"Paul was a very talented and very unique individual," says Hudson, "but he also had this frenetic energy."

Pepe may have driven some of the faculty crazy, but they appreciated his intensity. He'd just graduated from medical school at the University of California-San Francisco. The son and grandson of doctors, Pepe grew up on the opposite coast, in Connecticut. His mother's father entered the U.S. at Ellis Island, went to medical school and then returned to the island to provide medical care for immigrants. His father is 83 and still performs surgery. Two uncles and a brother are also doctors.

"My mom would say you shouldn't be a doctor just because people in the family are," Pepe says. "It's more than a career." But his father's and grandfather's dedication to public service prompted Pepe to choose medicine over music. An accomplished keyboardist--though unable to read music--Pepe organized fellow interns for performances spoofing the house staff, complete with clever lyrics.

Intending to specialize in critical care, Pepe got involved with Seattle's ground-breaking "Medic One," the first true paramedic program in the United States. Based on a system in Belfast, Northern Ireland, paramedics in a custom-designed van would race to the scene of a cardiac arrest to administer CPR; sometimes residents rode along. Under the leadership of Dr. Mike Copass, another mentor, who pushed CPR training for all citizens, Medic One prompted 60 Minutes in 1974 to call Seattle "the best place to have a heart attack." The chance of survival for people with ventricular fibrillation--lethal in 240 seconds--improved dramatically if someone performed CPR. When that occurred, ER docs sent the patient home neurologically intact 43 percent of the time.

"I was out on the street with the medics, watching them raise people from the dead," Pepe says. "I saw that pretty routinely."

Today, an emergency room visit is about as universal as medicine gets: Your kid breaks his arm, Mom gets banged up in a car accident or Dad has a heart attack. The ER treats all comers. With the television show ER now a staple, it's easy to forget the current system of emergency care in the United States is less than 40 years old.

Changes began with a landmark report titled "Accidental Death and Disability: The Neglected Disease of Modern Society," published in 1966, which lambasted the inconsistent emergency care provided in U.S. hospitals. There were no paramedics, and CPR, introduced in the late '50s, was rarely done.

Most people in need of urgent care were transported to hospitals by funeral homes in hearses--the only vehicles where people could lie flat--then treated by whichever doctor was on call. After the Vietnam War, in which the helicopter increased survival rates, techniques used by combat medics started to be used on civilians. The concept of the "golden hour"--the 60 minutes when intervention could save a life--shifted the emphasis to providing medical care at the scene.

Emergency 911 phone service was first implemented in 1968 but took a long time to spread; as late as 1987, only 50 percent of the country was covered by the 911 system. Emergency medicine didn't become a board-certified specialty until 1979.

But there's a shortage of board-certified EM doctors today. There are an estimated 4,000 ERs in the U.S.; in 2003, patients made 114 million visits to them. Of those, only 10 percent were classified by the Centers for Disease Control as "non-urgent."

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