Dr. Disaster

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

There is a reason why Paul Pepe became a doctor, and not in some relatively tame specialty such as dermatology. Or radiology. But the high-stress field of emergency medicine--where he is an innovator, a pioneer, one of the nation's foremost experts. At 55, he is chairman of emergency medical services at UT Southwestern and, by extension, director of the famous Parkland Hospital ER--which round the clock staples and stitches the casualties of one of America's most violent cities.

But his choice of career all goes back to a summer day at the beach near his grandfather's house in Milford, Connecticut, when Pepe was 11 years old.

He remembers playing, then stopping to watch some men use a car to pull a boat ashore. He hears a sudden, high-pitched twang--time stops.

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.
Swienton, a colonel in the Texas Medical Rangers, called an Air Force general for help during Katrina. He had to find a way to cut through the red tape and get casualties out of the New Orleans airport.
Mark Graham
Swienton, a colonel in the Texas Medical Rangers, called an Air Force general for help during Katrina. He had to find a way to cut through the red tape and get casualties out of the New Orleans airport.
Dr. Mike Proctor of Homeland Security and Swienton had to face down FEMA to evacuate patients from the airport in New Orleans.
Mark Graham
Dr. Mike Proctor of Homeland Security and Swienton had to face down FEMA to evacuate patients from the airport in New Orleans.
Dr. Ray Fowler directed the medical set-up of "surge capacity" facilities at Reunion Arena and the Dallas Convention Center, which screened 12,500 Katrina and Rita evacuees.
Dr. Ray Fowler directed the medical set-up of "surge capacity" facilities at Reunion Arena and the Dallas Convention Center, which screened 12,500 Katrina and Rita evacuees.
Dr. Pepe talks with Dr. Brent Treichler, a fellow ER doctor, outside the entrance to the Parkland ER--which treats an average of 300 people a day.
Dr. Pepe talks with Dr. Brent Treichler, a fellow ER doctor, outside the entrance to the Parkland ER--which treats an average of 300 people a day.
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.

Then no pain, just falling to the ground in shock. An awareness that something bad has happened. He looks down, sees a gaping red hole in his leg.

Blood gushes onto the sand. People gather over him, horror in their eyes.

He gasps out his address. A man, the boat owner, wraps a towel around his leg, then scoops him up and drives him home.

His mother sees the wound--muscle and sinew hanging from bone--and screams. Neighbors hover around him nervously.

"I'm going to die," he thinks.

Then the doctor--his father--arrives from his office 20 minutes away. He walks in, and instantly the vibration changes. Chaos lines up; loose ends fall into place.

His father looks into his eyes, smiling calmly. "Hi," he says. Paul has seen that expression before--at a bad car accident, with one of the victims screaming in pain.

But his father never gets flustered. He just takes control.

Speaking in warm, low tones, the doctor pulls off the towel and examines the leg. He hears the story: A rope snapped, hurling a foot-long anchor into Paul's leg. One of the iron prongs ripped the flesh from his shin, front to back.

The doctor instantly computes the cause, the result, the prognosis.

"We can take care of this," he says. "You're going to be OK."

"So I'm not going to die?" Paul says.

"Nope."


A freak accident, a swift, rational, cool response--the qualities Paul Pepe saw in his father, a family doctor--would inspire him to become a doctor himself and sustain him through 30 years of practicing emergency medicine.

At Southwestern, where he's been for five years, Pepe has taken the fledgling EM residency training program at Parkland and put it on the map. With another emergency medicine expert, Dr. Ray Swienton, a colonel in the Texas Medical Rangers, part of the Texas State Guard, he has also founded a national disaster medical training course created in response to September 11. Faculty at Southwestern and the Medical College of Georgia got together in 2002 and devised a family of courses in Basic and Advanced Disaster Life Support, which have now been adopted by the American Medical Association. The goal: a uniform, interdisciplinary and "all-hazards" approach that allows an ICU nurse in Seattle to work with a police officer in Chicago and a paramedic from Dallas.

In three years, Southwestern's faculty has trained 75,000 health-care providers in disaster medicine.

Pepe calls his approach to emergency medicine the "chain of survival." It's also the title of a 1991 treatise he co-wrote for the American Heart Association--and it begins with bystander response to a medical emergency, continues with the dispatcher's instructions, treatment by paramedics and delivery to the ER. It ends when the patient is treated and released by emergency physicians or admitted to the hospital for further care by specialists. At each step, research is ongoing to improve outcomes.

In Dallas, the benefits are direct: Parkland-trained emergency physicians go on to staff local ERs. Citizens learn CPR and how to use automatic defibrillators. Paramedics get state-of-the-art training. And research keeps the ER on medicine's cutting edge. Pepe has brought in millions of dollars in research grants related to studies in clinical emergency medicine. "Here in Dallas under Dr. Pepe, we are truly in the forefront of watching turbulent winds of change sweeping across this field," says Dr. Ray Fowler, assistant professor and co-director of EMS/Disaster Medicine at Southwestern. "He sees things on the highest level. People who come to know Paul find that very exciting. Emergency medicine faculty come here now because there is an opportunity to participate in very important missions under Paul's guidance."

Fowler points to Farmers Branch. Under Pepe's leadership, the city's paramedics keep more than 30 percent of people who suffer cardiac arrests alive long enough to reach the hospital.

Pepe's methods have generated controversy, however. Some accuse him of being a showboater who cultivates media attention, who loves rubbing shoulders with high-profile people; he met his wife, a TV producer, after giving life-saving treatment to an injured dog on camera.

"Paul's a peculiar character and probably misunderstood," says Parkland CEO Ron Anderson, who once ran the ER. "He's about pragmatism."

And if that means doing TV in the morning to emphasize injury prevention during Halloween trick-or-treating or meeting with a politician who can sponsor legislation, Pepe will make time.

"Some people are turned off by his grandstanding and playing to the media," says one of his mentors, Dr. Len Hudson, professor of medicine at the University of Washington. "But I've been impressed that he uses it pretty well--to accomplish something."


It is Wednesday, August 31, 2005, and Pepe is about to embark on a mission that will test everything he's learned about emergency medicine. Louisiana authorities have summoned him and Dr. Ray Swienton to the Hurricane Katrina command center in Baton Rouge, 50 miles from the scene of America's biggest natural catastrophe.

At 5 foot 7, with a salt-and-pepper beard and a slightly roly-poly shape, Pepe looks more like Santa Claus' little brother than the fast-talking, speed-walking adrenaline junkie he really is. He constantly jokes about his diminutive size: "I'm a giant compared to some children." Pepe is always smiling and has a high puns-per-minute index, which results in groaners like this: "What do you call a lady of the evening who likes Italian food? A pasta-tute!"

But his philosophy of medicine is down to earth. "Every person in the ER should be treated the way you'd want a member of your family treated," he says. And the tools he carries are the trappings of high-pressure work. Pepe totes three cell phones, a Blackberry and a pager--and one of them is always going off. He has the premier emergency medicine experts in the world on speed-dial.

It is the day after the levees broke in New Orleans, releasing Hurricane Katrina's floodwaters into the poorest neighborhoods. In Dallas, Southwestern faculty members, led by Dr. Fowler, are setting up "surge capacity" medical facilities to treat casualties.

Though tales of horror and bedlam are being beamed out of the ruined city, Pepe wants to be in the thick of it. "I felt Katrina was going to be the biggest medical disaster in United States history," he says. "We had a lot to learn from this. I didn't want to be on the sidelines."

When Pepe and Swienton arrive in Baton Rouge, they snag one of the last rental cars and make their way to the Katrina command center.

The center buzzes with local, state and federal officials. Behind glass in another room, CNN and other media outlets train cameras on the activity. But for several hours the two docs stand around, feeling awkward and unnecessary. "Why are we here?" Pepe wonders.

Pulled into a meeting with top leaders of Louisiana's emergency response team, they realize the bustle hides barely contained chaos. "A health-care disaster is evolving before your eyes," someone tells Swienton. Sick and dying people are trapped in hospitals, nursing facilities, on the tops of their homes.

When Pepe and Swienton ask basic questions, though, they get wildly different answers. The New Orleans International Airport is in a state of anarchy. No, it's under control. Hundreds of people are stranded on an overpass. No, they've been rescued.

Communications have broken down. Land lines aren't functioning, and cell phone circuits are jammed. Nothing is working but Blackberries--and those intermittently.

In the absence of facts, no one can make decisions. The chain of command seems to have collapsed.

Needing hard information, someone sends a helicopter to the airport to bring back several nurses, who describe disintegrating conditions. While Swienton works to set up a surge capacity facility in an abandoned Kmart, Pepe is dispatched to New Orleans by helicopter for reconnaissance. Pepe also wants to find the head of the city's EMS. She and her team have disappeared.

Then the media start reporting that people are taking potshots at rescuers. Going in under fire doesn't bother Pepe; he's waded into numerous volatile situations during his career, but the pilots don't want to risk it. A couple of heavily armed state troopers agree to drive Pepe there--after making sure he can use a weapon if necessary.

After years of learning to confront emergencies, improvising whenever necessary, not much can rattle Pepe. Like his father, Pepe has the ability to remain calm under the worst conditions, to impose order on disorder, to think on his feet. He surrounds himself with like-minded people.

A colleague calls him a "trailblazer with a machete" who brings in people with unique skills to set up the infrastructure. Within a few hours, Pepe and members of his hand-picked emergency medicine faculty--dubbed the Katrina Medical Relief Team--are in the eye of chaos.


The Louisiana state trooper turns his squad car onto Magazine Street, shutting off the lights as he rolls to a stop. Pepe and the two troopers are plunged into darkness. They've reached New Orleans, black and eerily silent.

From his spot in the back seat, Pepe reckons that the ruined city looks like a scene from the Apocalypse. As they move in deeper, the streets appear more like Escape From New York: creepy shadows, fires burning in the distance, flooded houses, people moving like wraiths. An occasional yell. The crackle of gunshots.

It is just before midnight on Thursday, September 1. The state trooper guides Pepe through the haunted city. He drives them to the Poydras Center, through deep water, amid swimming rats, and to the gates of City Hall. They make it to the flooded Charity Hospital, where the power is down, patients are on ventilators powered by generators and the staff is running out of fuel, food and water. Doctors have to post guards with weapons to keep out desperate civilians.

What Pepe sees when they get to the Superdome is a sea of people camped out in their own stinking filth, like refugees from a Third World country. He will never forget these sights, sounds and smells.

On Friday, when Pepe makes it to the New Orleans airport, he encounters an even bigger nightmare.

He can hear the thwop-thwop of helicopters taking off and landing on the tarmac every few minutes. Ambulances are unloading the sick and dying from nursing homes and hospitals. Healthy people fleeing the flood are crammed in the hallways; later estimates put the crowd at 10,000. The airport reeks of feces and urine and sweat and mildew and rotting garbage.

Medical tents have been set up inside the sweltering D concourse near the gates, where Pepe finds one of his newest faculty members from Southwestern, Dr. Kelly Klein. A feisty, down-to-earth New Yorker who's done a fellowship in disaster medicine, Klein belongs to a federal "DMAT"--Disaster Medical Assistance Team--that arrived in New Orleans earlier in the week.

An exhausted Klein is doing triage among very sick, mostly elderly people. Triage means "sort," and it's a fundamental of emergency medicine. Doctors must separate patients into those who can wait for treatment, those who need immediate attention and the dead or dying. Many of these patients are stoic, but others moan, cry or plead for help.

Those Klein has black-tagged "expectant"--expected to die--are being placed in the downstairs baggage area and given only "comfort care," such as morphine. Though people are crammed so tight it's difficult to walk among them, here it is oddly quiet.

People who share the same nursing home are holding hands, sometimes praying. Klein recalls that there were more than 110 expectants--people with IVs, Foley catheters in their urethras, diapers that need to be changed. Few have medical records or medications with them. Some are no longer responding. Some are dead.

Klein tells Pepe that they ran out of gloves and most other supplies within 24 hours of the first patients arriving at the airport. They hadn't anticipated so many extremely ill people. They had so few resources that early on, Klein's team is forced to make a decision: They will not do CPR, intubate or practice any other advanced life support. It is necessary in these conditions, but it goes against their training. Then doctors must take old people off stretchers and out of wheelchairs, lying them on the floor, to bring in new arrivals. And the sick just keep coming.

Pepe is horrified; the scene looks like the aftermath of a military battle. He picks his way through the chaos to ask how he can help. Pepe can see that Klein and the other "young champions" are struggling with their anger at how the elderly and dying patients are being treated--and how little they are able to do.

He also senses paranoia among some doctors as more evacuees, some armed, flood into the airport. They are scrounging for food and water, crapping and urinating on floors. A nurse gets stabbed. There is no evacuation plan and no chain of command. Klein tells Pepe people need to be triaged to buses or helicopters, not stacked up like cordwood. The chaos is costing lives.

A Louisiana state official will later wonder out loud if Pepe has been cloned--for the next few days it seems as if he is everywhere.

Riding with state troopers, Pepe finds pockets of stranded people and relays the information back to Baton Rouge. He learns that the New Orleans EMS squad has been rescued by the fire department and is camped out at a nursing home in Gretna. And from the command center he talks to faculty members in Dallas, who are setting up the "surge capacity" facilities at Reunion Arena and the Convention Center. He grabs only a few hours of sleep a day, either in a dorm at LSU or on the floor of the office in Baton Rouge.

But Pepe's biggest successes come from "his guys," doctors like Klein and Swienton, as well as Dr. Mike Proctor, senior medical advisor for U.S. Homeland Security's Office of Domestic Preparedness. They've been given a mandate to get people the hell out of the New Orleans airport.

At midnight on Saturday, Pepe manages to get a call through to Swienton, who sounds depressed. He can't break through the logjam. Doctors are arguing in the halls. A few seem on the verge of psychotic breakdowns. The leader in charge of transportation has no evacuation plan but has tried to throw Swienton and Proctor out of the airport for usurping his role.

"If they evacuate everybody," he asks a flabbergasted Swienton, "what are all my DMAT people going to do?"

But by 7:30 a.m. on Sunday morning, when Pepe calls again, Swienton and Proctor have broken through the gridlock. Swienton, an Air Force veteran, has made contact with a three-star general, who sends planes into the airport despite the lack of landing lights or air control, putting one down every 15 minutes. FEMA and EMS officials try to stop them from loading people, Swienton says, because "they hadn't been medically screened." Absurd. He and Proctor turn to air marshals for help, and people start flying out. Another friend knows Al Gore; the former vice president brings in two airplanes and flies 300 patients to Tennessee.

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.

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."

Clearly the need is there. But outside big cities, almost half of the physicians working in ERs are moonlighting family practitioners and specialists in other fields who may know little about trauma. Trained to recognize and respond quickly to life-threatening conditions, emergency physicians must have a broad grasp of many disciplines and the temperament to deliver quality care under pressure.

Pepe still follows his father's example. "We maintain low tones," he says. "We're caring. We tell you what we're going to do. We understand the creature comforts. Anything you can do to decrease apprehension is medically important."

In Seattle, Pepe simply wanted to be the best hands-on doctor in the world. He thought research and publishing was for laboratory docs. There were no emergency medicine journals, because little research was being done in the field.

But after working on a pioneering study of pulmonary critical care--hanging out all hours in the emergency room to identify patients, get families' permission and enroll them in the study--Pepe was hooked.

One of Pepe's first research projects was published in the prestigious New England Journal of Medicine. Board-certified in three specialties, Pepe has since published more than 400 papers; some have changed the way emergency medicine is practiced.

"He's been innovative and done some of the very difficult studies out in the field," Hudson says. For example, "there wasn't a consensus whether they should do stabilization in the field before they drove to the medical center or they should scoop and run." (The answer: It depends. When people are bleeding to death internally, it's "scoop and tube." Pepe moved the "golden hour" to a half-hour for blunt injuries and a quarter-hour for penetrating injuries.)

Pepe evolved into a scientist willing to question preconceived notions, committed to the idea of strengthening "the chain of survival."

In 1982, Pepe applied for a job running a critical care unit at a Houston hospital. Because of his experience in Seattle, he was offered a job as director of the city's EMS; recent legislation required cities with emergency medical services to have a physician supervising paramedics.

Pepe looked at Houston's survival rates for cardiac arrest. "They were essentially zero," Pepe says. "They had no enhanced 911 system. No one was doing CPR. There was no formal emergency training going on at the time, and no one was interested in it."

So of course he took the job.


When her overnight photographer ran the video of the pickup truck wreck, Linda Pepe knew she'd put it on the weekend news. Paramedics had saved the driver's life, and then someone noticed his badly injured Doberman on the side of the road. Onlookers were begging someone to do something. Linda watched as a young doctor who'd been riding with the paramedics ran an IV through a paw and resuscitated the dog, which was then rushed to a vet clinic. "Well, I knew the basics," said the doctor on camera.

"What a neat guy," she thought. In 1983, Linda was weekend news producer at KTRK-TV. Though Paul Pepe had only been in Houston a few months, her photographers knew him well. There were only 150 paramedics serving the entire city of Houston, and most nights Paul would be onboard an ambulance, observing while they worked, patting them on the back and, if necessary, quietly suggesting alternative ways to handle the patient.

Linda called Paul to get a few more details. Paul agreed to talk for something in return: He wanted Houstonians to learn CPR, and nobody wanted to write about it. Linda agreed to help him get publicity.

A few weeks later, Linda was listening to the police scanner and heard a report that seven or eight people had been shot at a restaurant, a big event even in Houston, which then had the highest murder rate in the country.

When Linda and her photographer arrived at the scene, it was mobbed by ambulances and two helicopters. Pepe was in the middle of the pandemonium, triaging. "He was very calm, very polite and soft-spoken, very instructive," Linda says. "Even in that kind of environment, I've never seen him ruffled."

Several weeks later, Linda helped Paul promote a major event: More than 5,000 people gathered at the Astrodome to learn CPR. At her advice, Paul held it on a Sunday to get maximum TV exposure. It was so successful, Pepe did two CPR mega-trainings per year, one for adults and one for children.

They didn't start dating until four years later, after each ended long-term relationships. "We'd go out to eat and then respond to ambulance calls," Linda says. "I'd start out in the passenger seat, he'd turn on the siren, and I'd end up on the floor. We'd go to fires and shootings. I got to see this guy in action. It made me fall for him."

Linda and Paul got married in Greece in 1990. They now have two children.

In Houston, Pepe says he learned how to deal with political turf wars. "There were fire chiefs and paramedics and other people who think they know how to do things better than you," Pepe says. "In the EMS system, the big problems were ego, financial issues or laziness."

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.


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.

Wigginton and Pepe did a study on child drowning victims, showing that 70 percent of those who received immediate CPR or mouth-to-mouth resuscitation came out "neuro-intact." All of the children who had to wait for treatment suffered some kind of neurological damage. It was practical research illustrating the importance of civilians knowing how to do CPR.


On a recent day, Pepe starts work at 5 or 6 a.m., doing an early shoot with Channel 11 on Halloween safety. He meets with head nurses at shift change, then bounces through Parkland's ER touching base with nurses, residents and paramedics ("Anything I can do to help you?"). The ER is still crowded from the previous night's patients. Paramedics are transporting a woman in labor on a gurney. To Pepe, it looks like an average crowd. It's busy but not chaotic. People tell Pepe "hi" with big smiles. (His number one requirement when hiring: "good citizenship.")

Mid-morning, he confers with the Secret Service in preparation for Vice President Dick Cheney's visit and then heads downtown for a meeting of the Dallas City Council's transportation committee, where he pulls out his laptop to answer e-mail and finishes a PowerPoint presentation while awaiting his spot on the agenda.

Then it's up and out on the streets, checking out paramedic response to a car accident in Oak Cliff. One of the victims has hit his head on the windshield but doesn't want to go to the hospital. Pepe persuades the guy to get it checked out.

Back in the ER, a shaken nurse tells Pepe about a patient she just released to police custody. He'd allegedly shot and killed someone, then was brought to the ER where his own wounds were treated. They'd saved a killer's life.

Business as usual.

But as "Katrita" vividly demonstrated, emergency medicine is evolving in ways not anticipated 30 years ago. A sub-specialty called disaster medicine has emerged in response to September 11 and other threats: sarin gas on a Tokyo train, bombs on a London subway, an avian flu pandemic and "weapons of mass effect" such as toxic chemical releases and suitcase nukes. Another sub-specialty: tactical physicians, doctors who accompany SWAT teams and FBI agents on operations. In a homeland security project conceived by Pepe called GEMSS (government emergency medical security services), Southwestern has a surgeon serving as a "SWAT doc."

As Rita barreled up the Gulf of Mexico, Pepe and members of his team went back to Baton Rouge and New Orleans to "resolve disputes" that would affect emergency medical efforts. Pepe later made a formal presentation to the White House Medical Unit. "Me being a glass-is-half-full guy, we could classify this as the most amazing rescue in U.S. history," Pepe says of Katrina.

Most of the lessons reinforced by Katrina are being taught in the disaster life support courses:

··· Medical technology has many limitations when the power fails or equipment doesn't work.

··· A means of foolproof communications is needed when cell networks are jammed.

··· Well-meaning but superfluous volunteers and donations must be managed.

··· Doctors need security in chaotic situations where patients or their loved ones may be armed.

··· In the midst of a big disaster, there are a lot of little disasters, like an outbreak of dysentery at Reunion Arena that required rigid enforcement of hand-washing.

"There will always be new obstacles," Pepe says. "Instead of being upset, you just do the best you can. What I hope is that people understand there are risks and benefits to everything we do. I hope the public gets to learn that we all are vulnerable and need to help each other."

But the biggest lesson, Pepe says, is that it can happen here. For all the hype about homeland security and combating terror, resources haven't been directed to the hospitals. Pepe wants to make sure Dallas is ready.

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1 comments
strakedavis
strakedavis

I've seen a lot of different things going on in <a href="http://rcnd.com">Dallas. Radiology</a> there tends to be extensive and brutal.

 
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