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Ever Ready

August 12, 2002

Mark Miester
tulanian@tulane.edu
Michael DeMocker

The first thing you notice about Norman McSwain is the bear claw dangling around his neck. A gift from a friend more than 30 years ago, the distinctive talisman is a fitting symbol for McSwain, epitomizing both his rugged, adventurous spirit and his respect for nature and affinity for Native American artifacts and imagery. Both his Tulane University Medical School office and his French Quarter residence--which bears the sobriquet Tsa-La-Gi, Cherokee for medicine man--are decorated with art of the Plains Indians.

Maybe it's just coincidence that McSwain at times sounds like another well-known trauma surgeon with an Indian nickname: M*A*S*H's "Hawkeye" Pierce. "I don't go to a lot of movies," he quips. "I'd rather do other things. Like drink. You've heard of the three S's of surgeons? Surgery, sex and scotch. If it keeps you from one or the other, it's a waste of time."

McSwain may come off like a typical good old boy, but don't let his waggishness fool you. He's also one of the country's foremost experts on trauma care. He's published more than 300 articles, 24 books and book revisions, and 93 book chapters on trauma care. He serves on the editorial boards and national committees of countless journals and medical societies. He's the inventor of the McSwain dart, a patented device that enables paramedics to relieve pressure around the lungs.

In addition to directing the trauma program at Tulane Medical School, he serves as trauma director of Charity Hospital in New Orleans, which holds the elite designation as a level-one trauma center. McSwain is the only physician to receive all three awards presented by the American College of Surgeons for outstanding accomplishments in the field of trauma. McSwain's greatest contribution to trauma care, however, is not as a surgeon but as a revolutionary.

McSwain is the founder of Pre-Hospital Trauma Life Support (PHTLS), a nationally recognized protocol for the pre- hospital care of trauma patients. PHTLS revolutionized emergency medical service (EMS), shifting the focus of emergency medical technicians (EMTs) and paramedics from treating discrete injuries at an accident scene to treating the patient as a system. Since its introduction in 1983, more than 300,000 emergency health professionals in 26 countries have completed the PHTLS training course. More significant, however, is the number of lives saved.

A 1997 study by Jameel Ali of the University of Toronto showed that the survival rate of of trauma patients increased by more than 5 percent after the introduction of PHTLS. "Norman is more than the godfather, he's the founding father of EMS," says Dawne Orgeron, EMS administrator for the city of New Orleans. "There is not anybody who has given more to the profession of EMS or who had done more to elevate it as a profession than Norman McSwain."

"He's a visionary," adds Jim Paturas, coordinator of the office of emergency preparedness for the Yale New Haven Health System and a co-developer of PHTLS. "But more important than that, he's a person. He has always been able to get past his position and stature in the health-care arena and realize that you as an individual are as important to the process as he is."

ACTS OF GOD AND NEGLIGENCE

On a warm May morning, I meet McSwain at his house, a two-story Creole cottage on a residential stretch of Bourbon Street near Esplanade Avenue. His 24-hour shift on trauma call at Charity ended at 7 a.m., and he greets me still decked out in scrubs. A convention of motorcycle enthusiasts meeting in New Orleans had made it a long night for McSwain. In the early morning hours, a motorcyclist struck and killed a pedestrian trying to cross Washington Avenue.

About 30 minutes later, a biker from Knoxville, Tenn., lost control of his Harley and plunged off an elevated section of Interstate 10. McSwain pours a cup of coffee in his kitchen. "I don't ride bikes on the street," he says. "I think competing with a 3,000 pound piece of steel going 60 miles an hour is an unfair advantage to somebody that has no protection." What caused the accidents? "These weren't accidents," he says. "An accident is an act of God. These were collisions. They're acts of negligence."

McSwain's house is an extension of his personality. There are souvenirs of University of Alabama football coach Paul "Bear" Bryant. There is a collection of antique medical instruments. There is his aforementioned collection of Native American art. There's a breakfast nook decorated with all but six of the posters from the New Orleans Jazz & Heritage Festival (McSwain has served as the festival's medical director since 1985). There's a sign by his bar, "Beware of Pickpockets and Loose Women--New Orleans Police Department" (McSwain has served as the department's police surgeon since 1979).

There's a Jacuzzi room and pool table. There's his home office, decorated from baseboard to molding with photos, certificates, diplomas and awards. ("The 'I love me room,'" he explains. "Everybody's gotta have one.") Most surgeons' homes look as if they were torn from the pages of Architectural Digest. McSwain's looks as if it were torn from Playboy, or at least GQ. McSwain is a maverick, a cowboy in the Wild West of medical specialties: trauma.

As Charity Hospital's associate director of trauma, McSwain marshals a team of surgeons, residents, nurses and technicians that on a nightly basis scoops bullets out of bodies and sutures organs penetrated in accidents, punctured in fights and pierced in falls. About 70 percent of the patients he sees are blunt trauma--like motorcycle collisions--and about 30 percent are penetrative trauma--bullet and stab wounds. In the so-called Golden Hour--the crucial 60 minutes following a traumatic injury that often determines whether a patient lives or dies--nobody is better than McSwain. 

"I'd never wish for someone to be shot," McSwain told The Learning Channel when he was profiled in its "Code Blue" series, "but if someone is shot, I hope it's when I'm on trauma call." What makes McSwain unique among surgeons, besides his sartorial fondness for turtlenecks and snakeskin cowboy boots, is his selfless dedication not only to trauma surgery but to the whole of EMS. McSwain may be the only surgeon in America who also maintains his certification as a street paramedic.

Ken Bouvier, a New Orleans paramedic who serves on the board of the National Association of EMTs, recalls a call he got to assist a man in the French Quarter who had been stabbed in an attempted robbery. "I arrived there and here's Dr. McSwain outside with just a pair of shorts on and a roll of Scott paper towels trying to control the bleeding," Bouvier says. "He heard the commotion and was already rendering care when I got there."

As police surgeon for the New Orleans Police Department, McSwain personally provides care for every officer seriously injured in the line of duty. If a cop goes down, McSwain is at the scene in minutes and, more often than not, performing surgery minutes later. He performs his police surgeon duties without pay, his only compensation the use of a police car. "It gives me better access to emergencies," McSwain says.

Probably the best-known example of McSwain's dedication to out-of-hospital emergency care occurred in New Orleans a number of years ago. A boy's legs had been crushed under a train and his life was hanging in the balance. McSwain got the call. "An EMT or a paramedic would not have been enough to keep that child alive," says Orgeron. "He performed surgery lying on his stomach underneath a train to save that kid's life. That young man has to be in his early 20s, and Norman still keeps in touch." According to those around him, devotion to his patients and decisiveness of action define McSwain.

"You always know when you've spent enough time on something because Norman will just stand up and say, 'All right. Let's go,'" says Will Chapleau, PHTLS chair of the National Association of EMTs. "That's a Normanism. He brings it to a head and says, 'Let's do it.'"

PORTRAIT OF THE SURGEON AS A YOUNG CUB SCOUT

McSwain's rugged exterior is a product of his upbringing. Born in the small mountain town of Albertville, Ala., in 1937, McSwain says he knew he wanted to be a surgeon from the age of 8. "I was at a physician's office, and he was giving me my Cub Scout physical. I knew at that time it's what I wanted to do." McSwain's dream took him first to the University of the South in Sewanee, Tenn., where he majored in biology, and then to the University of Alabama, where he earned his MD in surgery in 1963.

After a surgical internship in North Carolina and a stint in the Air Force, McSwain in 1969 became chief resident in surgery at Atlanta's Grady Memorial Hospital. It was an appointment that would change his life. "Grady is a hospital almost exactly like Charity," he says of the New Orleans hospital where he spends most of his working hours. "It's almost the same size and has the same kind of training program. We did a lot of trauma there. We did an awful lot of trauma there."

Gunshot and stabbing victims were a nightly occurrence at Grady. McSwain doesn't remember his first gunshot wound, but he vividly recalls one particular evening at Grady. When he went off duty at 7 a.m., there were 10 gunshot victims still waiting to be operated on. McSwain says he learned early on to avoid getting involved in the lives of his patients, many of whom are less than forthcoming about the circumstances surrounding their injuries. Stories often don't add up, and the truth is often elusive. Grady taught McSwain to stop trying to fill in the blanks and to just do his job.

His experience at Grady also taught McSwain a lot about himself. "I recognized how much I enjoyed taking care of trauma patients," he says. "After I finished my training, I worked in private practice for a couple of years and I recognized how much I hated not taking care of the trauma patients. That's when I started looking around for an academic position." That search landed him first in Kansas. In 1973 he became director of emergency medical training for University of Kansas Medical Center.

He established the state's first emergency medical service and created the state's first course for EMT training coordinators. In 1977, McSwain joined Tulane as associate professor of surgery and director of the trauma program. He was instrumen- tal in obtaining a U.S. Department of Transportation grant to establish the state's first paramedic program. The program was coordinated through the School of Medicine's Department of Surgery, and McSwain became the first medical director for the state bureau of EMS. Since then, he's remained one of the nation's--and the world's--foremost figures in emergency medicine and trauma care. 

THE PREHISTORY OF PHTLS

In 1970, when McSwain was a resident at Grady in Atlanta, he took on the largely voluntary position of medical director of the Sports Car Club of America. McSwain didn't have any skills that particularly suited him for the job, but he was a perfect fit. An avid sportsman with an appetite for adventure, McSwain spends his free time scuba diving, dirt biking and piloting his own plane for kicks. The excitement of the speedway and the challenge of providing trauma care under extreme conditions excited the young surgeon.

Over a two- year period, he visited most of the major sportscar tracks and became race medical physician at speedways across the South, including Daytona International. At the time, medical care at speedways was primitive. For his first race, he carted his equipment to the track in the trunk of his MG. By the next season, he had built a trackside hospital equipped for almost any situation. Leveraging his experience, he developed a program called Crash and Burn School to teach track medical personnel to better manage crashes during races.

The principles McSwain incorporated into Crash and Burn School would provide the blueprint for PHTLS. As a certified paramedic, McSwain was unsatisfied with the quality of care typically provided by EMTs. Too much time was wasted at the trauma scene, he thought, and too many unnecessary procedures were performed. "Pre-hospital care was terrible," McSwain says of the era. "So I started in Atlanta and then in Kansas developing educational systems for EMTs. Prior to that, they had no educational training."

McSwain was among the first in the nation to take the American Heart Association's Advanced Cardiac Life Support (ACLS) course, and he became convinced that the American Trauma Society should develop such a course for trauma care. At the same time, Deke Faringdon, an orthopaedic surgeon based in Nebraska, had worked with the American College of Surgeons to develop what he called the Advanced Trauma Life Support (ATLS) course, a program for emergency room physicians and technicians.

The American College of Surgeons eventually picked up the course but balked at the idea of offering the course to lowly EMTs. "The College of Surgeons made the decision that they were in the business of training physicians and so they would not allow non-physicians to take the course," McSwain says. "So I went to them and said, 'Hey, if you're not going to let non-physicians take the ATLS, will you at least sponsor a course based on ATLS?' They said yes."

In 1981, McSwain started working on a brand new course for paramedics and EMTs. Up until that time, EMTs had treated the injuries of trauma patients as discrete injuries. "If there was an injury to the upper extremity, you dealt with that," explains Paturas. "If there was a head injury, you dealt with that, rather than realizing the potential complications of having all those at once." That paradigm wasted precious time and often ignored the larger issue of the patient's overall health.

PHTLS advocated instead transporting the patient to the hospital immediately after the airway was established and fractures stabilized. It stressed treating the patient as a whole in terms of multisystem trauma. The goal was "salvagability"--getting the patient to the operating room as soon as possible. Four national pilot courses in PHTLS were offered in 1982, including one at Tulane.

In 1984 the program went nationwide. As McSwain explains it, PHTLS combines the Department of Transportation's EMT training program--the standard certification program for EMTs--with the American College of Surgeon's ATLS course. "It's basically a continuing education course," McSwain says. "EMTs take it over a weekend after they've already been certified in whatever EMT level they're certified in."

MARS NEEDS EMTS

McSwain's latest work in the field of trauma care has been out of this world-literally. Since April, McSwain has been traveling to Houston two days a week as he works on an emergency medical program for the National Aeronautics and Space Administration. McSwain is writing a guide to instruct astronauts--most of whom have no medical training--in the basics of emergency medical care in space. "Crew medical officers are not physicians," McSwain explains. "The training they've traditionally gotten is about equivalent to a basic ambulance attendant."

McSwain's program is one designed specifically for space, one that dispenses with skills and procedures that don't apply in a zero-gravity environment. "Microgravity brings a lot of physiological and physics changes, so these have to be taken into account," McSwain says. While teaching astronauts to administer medical care in space at first seems a far cry from teaching EMTs to administer care to an accident victim on the side of the road, McSwain says they're not so far apart.

"We're training non-physicians to work in space," he says. "Because you're training somebody with non-medical experience in how to do those tasks, you use the same text books." Seeing as he's trained emergency medical personnel in 26 countries around the world, it's only fitting that he's tweaking PHTLS to bring it to, perhaps one day, Mars. Would you go into space if NASA asked you? "Oh, absolutely," he says instinctively, before adding, "but they won't. I'm too old to go into space."

He says this with a glint in his eye, and you're left with the unmistakable impression that a ride on the space shuttle, if offered, may yet loom on this cowboy's horizon.

Mark Miester is an editor in university publications and a regular contributor to Tulanian. He may be reached by e-mail at mark@tulane.edu.

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