Life and death in the emergency room - includes article on Dr. John West - part 1

Washington Monthly, Nov, 1985 by Paul Glastris

With the city and county governments paralyzed by the medical community's obstinance, the people of Cook County must look to the state if they want their emergency medical system reformed. But the state has its own problems. Since the mid-seventies the staff of the state's Emergency Medical Services (EMS) agency has shrunk from 50 people to 19. The reason for the drop, one EMS official says, is a decrease in federal funding and the perception among state public health administrators that emergency service is not a very high priority.

Fear and favor

The man behind that federal EMS grant program also happens to be the man who designed the EMS system for the state of Illinois: Dr. David Boyd. In the early seventies, boyd, then chief resident at Cook County Hospital's trauma unit, helped persuade Governor Richard Ogilvie to institute the nation's first coordinated, statewide system of emergency medical care. The program, interestingly, was financed with seed money that Boyd--like Ogilvie, a Republican-- requested from the Nixon administration. Boyd's "systems approach' to emergency care--which involves paramedic training, regional radio communications, a network of state-designated trauma centers, and a trauma "registry' for monitoring and evaluating hospital performance--is still considered one of the great innovations in the field. As Illinois's first EMS director, Boyd soon gained widespread attention and testified before Congress on the need for a nationwide system of emergency care. From 1974 to 1981 he headed a new federal EMS program at the Department of Health, Education and Welfare. During those years Boyd allocated some $300 million in federal grants to states and localities to set up EMS systems.

Boyd failed, however, to convince Illinois officials to adopt triage protocols, probably the most important aspect of the systems approach. Without these guidelines, paramedics cannot route trauma victims to the right hospital with enough speed, leaving Chicago's emergency system a vast, sophisticated machine that is never switched on.

One reason the EMS office hasn't followed Boyd's lead is fear. Doctors, administrators, and trustees at Illinois hospitals who oppose reform have the power to pull strings at City Hall and in the state capital. Health officials in Illinois and in other states say that colleagues who have pushed for reforms, such as trauma center designation and triage protocols, have found themselves looking for work. "If I do my job the way you and I think I ought to do my job,' one Illinois EMS official confides, "I don't have a job.'

Boyd's grant money gave EMS advocates a much-needed push. So in 1981, when the Reagan administration folded the federal program into less well defined preventive medicine block grants, much of the cause's momentum disappeared. What has happened in Illinois seems typical of what has happened across the country. In many areas, trauma care has stopped improving; elsewhere it's actually getting worse. Says Mike Williams, former EMS director for Orange County, California: "I've seen some good systems that with federal money were on the verge of designating trauma centers decompose, and others that have just gone into a silent mode.' Since no one gathers data on this subject, no one can say if individual impressions such as this are generally true. But one GAO study last year found that after the Reagan administration pulled the plug on Boyd's program in 1981, funding for EMS dropped in ten out of eleven states surveyed. The states, it seems, have not picked up the ball.