Dr. Disaster

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

Building relationships in Houston turned him into a "true public servant," Pepe says. And he learned to use the media. At the scene of a car wreck, he'd point out that the driver had been killed, but a baby lived because it was strapped in a car seat. Everything was a teaching opportunity.

In the late '80s, Houston went through a business bust, forcing the EMS to do more with less. "We didn't have enough ambulances," Pepe says. His idea: to train all the firefighters as paramedics. "We ran it [EMS] at an incredibly lower cost. It was an incredibly well-oiled machine. Because I imposed that work on them, they weren't happy. But others realized it would end up saving the fire department."

By 1996, when Pepe left Houston to serve as emergency medical director for Pennsylvania at the request of then-Governor Tom Ridge, Houston's survival rate after cardiac arrest was the highest among major metropolitan areas.

Mark Graham
Dr. Ray Swienton shares a story with faculty member Dr. Dale Simmons at UT Southwestern.
Mark Graham
Dr. Ray Swienton shares a story with faculty member Dr. Dale Simmons at UT Southwestern.

Possibly the most famous emergency room in the world is Parkland's, the ER where doctors struggled to save the life of President John F. Kennedy in 1963.

Designated a Level One Trauma Center, Parkland not only treats members of the "gun-and-knife club," it serves as a medical safety net for the poor and uninsured. Anywhere from 250 to 300 people seek treatment on an average day.

Triage means the walking wounded often must wait for hours. Parkland's ER is the butt of an old joke: "If I'm unconscious and bleeding, take me to Parkland. If I'm talking and walking, take me anywhere else."

After leaving Pennsylvania, Pepe came to Dallas to direct Southwestern's emergency medicine department and head Parkland's ER, which has been significantly shaped by Dr. Jim Atkins. Tall and now balding, with a beatific smile, Atkins was a freshman medical student at Parkland on the day Kennedy was shot.

A cardiologist and chief of internal medicine at Southwestern in 1971, Atkins began pushing to upgrade Parkland's ER. He beefed up staffing and established the "BioTel" system with which doctors could talk to dispatchers and paramedics by radio. He initiated the use of defibrillators on Dallas fire trucks and trained paramedics to use them. In 1976, Atkins talked Southwestern into hiring Ron Anderson to run the emergency department. Now Parkland CEO, Anderson was instrumental in wooing Pepe to Dallas in 2000.

Atkins says several events came together in 1974 that radically changed emergency medicine. The National Academy of Science released two breakthrough studies on trauma and cardiac arrest. The NAS recommended that hospitals create dedicated trauma centers and that defibrillators should be placed on all ambulances. Federal money to train paramedics was made available.

By 1979, Dallas and its suburbs had EMS services. "The transition went so fast," says Atkins, "our problem was logistics. We had trouble getting radios, ambulances, defibrillators. The department of health was running around the state putting radio antennas on top of every hospital as fast as they could." They couldn't train paramedics quickly enough.

It paid off in lives saved. Atkins says that, in one year, mortality rates for gunshot wounds fell from 35 to 23 percent, and for stab wounds from 7 to 1.6 percent.

Being an emergency physician often meant improvising. After the crash of Delta 191, Atkins realized that rescuers were getting cut by scraps of metal from the airplane. At 1 a.m., Atkins had to locate 750 doses of tetanus vaccine to inoculate everyone. (That crash revealed that most area rescue agencies were on different radio frequencies. By the next disaster, they had synchronized their radios.) After a twister devastated Wichita Falls, ambulance tires were being punctured by debris; they had to buy tires to keep them running. "I've often said there are two disaster books," Atkins says. "You need the manual of plans and the Yellow Pages."

Atkins got to know Pepe during the '80s, when he was still in Houston and Atkins was medical director for the city of Dallas. They'd run into each other in Austin while lobbying for state laws affecting emergency medical care. "He has a lot of energy and enthusiasm," Atkins says. "And that becomes very important in the type of leadership position he has."

As late as 1990, there were no board-certified emergency physicians at Parkland. The ER was staffed by Southwestern residents doing rotations in internal medicine and surgery. Faculty doctors were on call, not on site.

Southwestern's first effort to create an emergency medicine residency program in the early '90s failed. "We were naïve in what it took," Atkins says. "We didn't put enough resources into it, and we were turned down" by accreditation authorities. The next proposal was approved, and in 1996, faculty was hired and interns were accepted. But within the larger institution, the EM program got little recognition. That changed when Pepe arrived. With 40 faculty members and 60 residents and fellows, Southwestern's program is now one of the most competitive in the country, attracting 500 applicants for next year's 16 residency slots.

One reason is the hot-shot faculty. Anderson says Pepe started recruiting people who were double-boarded in emergency medicine and another specialty.

Dr. Jane Wigginton, one of the first EM residents, started her training in 1997. Pepe recruited her to stay on as faculty. "He is a wonderful diagnostician and has an incredibly inquisitive mind that really pushes research," says Wigginton, who spent a week in Louisiana during Katrina. "I think that's what we needed: someone with charisma who would also be a big patient advocate." When she had trouble with a patient in the ER, Pepe would show up in scrubs to help.

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