The End of the Beginning

     Raymond Fowler, MD, has been involved in EMS as an educator, medical supervisor and political advocate for more than three decades. He currently serves as co-chief of the EMS, Disaster Medicine and Homeland Security section at the University of Texas Southwestern Medical Center and chief of EMS operations for the Dallas-area BioTel system. In addition to serving as president of the Georgia College of Emergency Physicians and as a member since 1980 of the Georgia EMS Advisory Council, he was also the second elected national president of the National Association of EMS Physicians and a cofounder and senior faculty for the NAEMSP's National EMS Medical Directors Course.

     Fowler was the original national BTLS program director and helped found the EMS State of the Sciences Conference, better known as the Gathering of Eagles. He has been named EMS Medical Director of the Year by the state of Texas and received the NAEMSP's prestigious Keith Neely Outstanding Contribution to EMS Award. In 2005, when 40,000 Hurricane Katrina evacuees fled to the Dallas Convention Center, Fowler led the team that arranged their medical care. He and dozens of physician colleagues created a temporary hospital. He once again led the team to establish the evacuee medical surge facility operation at the Dallas Convention Center for Hurricane Gustav, when it made landfall in August 2008. At the time this article was written, he was part of the team monitoring the prospect for landfall of Hurricane Ike.

     As principal investigator for multiple studies and author of many book chapters and significant papers in EMS and emergency medicine journals, Fowler has a unique perspective on EMS and the changes, clinical and otherwise, that may impact the field.

As a physician, you have a unique place in the world of EMS. Focusing on lessons learned, what do you see as a future direction for our field?

     I believe we are at the end of the beginning of the greatest time in EMS. We are entering a new era. We're already into a golden era of EMS; EMS providers are finally receiving the respect they so richly deserve through their hard work in adverse environments. Additionally, there are EMS staffing crises in many parts of this country. The natural effect of this is that as EMS providers are scarce, their salaries will rise. This is bringing about, finally, the improvement of wages for EMS providers, and thank goodness. We have come to expect knowledge, productivity and good clinical sense from our EMS providers, and only now are they being remunerated fairly. I am pleased to finally see them getting the attention they're due.

     Next year there will be an important effort taking place all across the EMS industry: an attempt to place prehospital emergency medicine into medical subspecialty status. Those of us who oversee EMS practices know this is long overdue. With the publication of the fourth edition of Prehospital Systems and Medical Oversight, we will be laying out a foundation that will describe those essential elements of clinical EMS medicine practice. From this foundation, we can step forward to hold ourselves out as partners to all the other medical specialties and subspecialties.

     The scientific underpinnings of EMS have never been broader. Take, for example, the evaluation of the chest pain patient. EMS providers now take a history, assess the nature of the chest pain, apply and interpret 12-lead EKGs, communicate with medical control, apply appropriate therapies and insert these patients into STEMI systems. Another example is the utilization of waveform capnography. Capnography is a window into the status of the airway, the flow of air and the actual metabolic status of the patient. The understanding of the entire tide [Author's note: Fowler prefers the term tidal—i.e., throughout the entire tide of the breath moving—as opposed to end-tidal] is so critical that I have urged manufacturers to develop algorithms much like the 12-lead EKGs have.