How the ‘Death lab’ evolved into a modern trauma system
Remembering shock pioneer, R Adams Cowley, 30-years after his death
Standing in their signature pink scrubs, the trauma resuscitation team waits on the helipad at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in downtown Baltimore. Car horns, sirens and the incoming medevac can be heard in the distance as the team prepares. The vibrations and wind from the rotor blades become more intense as the aircraft comes into view. Finally, the wheels touch down on the pad and the flight crew signals it is safe for the trauma team to approach. This dedicated team of technicians, nurses and doctors knows this routine too well.
The Primary Adult Resource Center is named after R Adams Cowley, MD, a highly regarded and visionary cardio-thoracic surgeon who died Oct. 27, 1991, after dedicating his career to advance the study of trauma medicine in Maryland.
“What Dr. Cowley did was emphasize the need for and begin to develop a system that funneled [patients] to the most appropriate place to continue their care [emphasizing trauma],” Maryland Institute for Emergency Medical Services Systems Executive Director, Ted Delbridge, MD, MPH, said.
'Give them to Cowley'
Cowley was born and raised in Utah and received his medical degree from the University of Maryland in 1944. He was sent to Europe as a military surgeon in 1946. Cowley spent that time working in the operating rooms of Army field hospitals. He was amazed at the speed at which some surgeons could operate.
Cowley once called shock “a momentary pause in the act of death,” a process that – once set in motion – was irreversible. Cowley’s goal was to make it reversible. With an Army award grant of $100,000 to study shock, he developed the first clinical shock trauma unit in the nation. The original unit consisted of two beds.
By 1960, Cowley’s team was trained and the equipment was in place.
“Dr. Cowley begged the hospital for space ... beds he could control to study shock,” Associate Professor of Shock Trauma Center and Attending David Gens, MD, said. “They gave him two beds. He needed referrals. So, when patients in ICUs that were sick and weren’t expected to survive, they would say ‘Give them to Cowley.’”
As these patients slowly came in, many dying, the two-bed unit expanded to four and got the label the “death lab.” Cowley and his staff were able to save some of these patients, getting them through the critical phase and then returning them to their own physicians for treatment.
As Cowley’s program advanced, a theory that EMS clinicians still reference today known as the golden hour emerged.
Cowley explained in an early interview, “there is a golden hour between life and death. If you are critically injured, you have less than 60 minutes to survive. You might die right then; it may be three days or two weeks later, but something has happened in your body that is irreparable.”
This is still standard practice today, according to Thomas Scalea, MD, physician-in-chief of the R Adams Cowley Shock Trauma Center.
“When a patient is brought to shock trauma either by ambulance or helicopter, they are immediately brought to the trauma resuscitation unit. Here, patients are rapidly assessed by a team of professionals who are exclusively trained in trauma care,” Scalea wrote. “We believe that if you or a loved one is injured, your best chance for survival is to have care within the first hour of injury. We refer to this as the golden hour.”
Research analysis: ‘ECMO is a useful tool but not a magic bullet’
Two studies from the University of Minnesota examine early ECMO and the chain of survival
During the 1960s, it was common for patients to be transported to the closest hospital in vehicles that were not appropriately equipped or staffed for the patient’s injuries. Cowley wanted to change that, and he did.
Maryland established the first statewide EMS system and has become a model worldwide.
First medevac transport accepted
In 1968, Cowley negotiated to have patients transported by military helicopter to get patients to the shock trauma unit more quickly. After discussion with the Maryland State Police, the first medevac helicopter transport occurred on Mar. 19, 1970, after the opening of the five-story, 32-bed center for the study of trauma.
“It took about three weeks before we got our first call because it was all new all over the state,” retired Maryland State Police Lt. Colonel Gary Moore said. “That particular morning in 1970, [TFC] Paul [Benson] and I were the duty crew and landed on the highway, picked that patient up and took him down to the trauma center. That patient did live.”
This mission by the Maryland State Police formally opened their doors to the world of emergency medical services. The mission marked the first time a civilian agency transported a critically injured trauma patient from a scene by medevac helicopter. This had never been done before outside of a military setting, Ron Snyder, public information officer for the Maryland State Police, wrote in a press release.
Over the past 50 years, the Maryland State Police Aviation Command has transported 150,000 patients and completed over 180,000 missions. Snyder wrote, the Aviation Command currently has a fleet of 10 helicopters that are assigned to seven locations in Allegany, Frederick, Baltimore, Prince George’s, St. Mary’s, Talbot and Wicomico counties.
Since the early 1970’s, the University of Maryland Shock Trauma Center and Maryland’s integrated emergency medical services system grew into a network of trauma centers, specialty hospitals and medevac services that earned them a worldwide reputation as the leaders in trauma care.
In the 1980s, MSP Aviation Command replaced the smaller Jet Ranger aircrafts with the procurement of the AS365 Dauphin helicopters, which provided additional enhancement for the fleet, such increased speed, added safety and the ability to accommodate two patients. The program advanced again in 2013 when the fleet transitioned to the AgustaWestland AW139 helicopters, according to Snyder.
“It’s not just the helicopter, but the helicopter and all that comes with it,” Sam Galvagno, DO, PhD, said. “In our case, MSP Aviation Command has some of the best trained and best equipped paramedics in the world. MSP paramedics are trained to perform a variety of advanced airway techniques as well as other techniques.”
Dr. Galvagno is a professor at the University of Maryland Department of Anesthesiology and Program in Trauma. He also serves as the medical director for the Multi Trauma Critical Care Unit and deputy medical director for Shock Trauma’s GO-TEAM, a specialized component of Maryland’s statewide emergency medical system composed of an attending physician and a certified registered nurse anesthetist.
Galvagno added that aviation command paramedics will soon be able to transfuse whole blood for patients with severe bleeding.
Center continues to advance
In 1989, an eight-story, state-of-the-art trauma center opened and was named after Cowley. The center combined the highest level of patient care and teaching with research, leading to advances in therapy for the critically injured. This institute also focuses on trauma presentation, injury control and public policy as a way of saving lives. Most importantly, thousands of trauma victims are alive today and are a living testimony to his dedicated work.
Critical injuries are sustained from car and motorcycle crashes, falls and violent crimes, according to Scalea, and “97% of those patients survive because of the intricate, complex care that is provided here at the Shock Trauma Center.”
“Organized chaos ... that’s what Shock Trauma is,” Gens said. “Everyone has a background in trauma. It is a small hospital within a large academic center ... that goes back to the beginning.”
The R Adams Cowley Shock Trauma Center is Maryland’s primary adult resource center for trauma patients in the state of Maryland and serves more than 7,000 critically ill and severely injured people annually from the Maryland; Delaware; Virginia; Washington, D.C.; Pennsylvania and West Virginia areas each year, Galvagno said.
“Additionally, due to the expertise in the Shock Trauma Center (i.e., ECMO), we have received patients from all over the country,” Galvagno, said. “Our center has treated more than 200,000 patients to date. We also receive patients from the entire region in need of advanced lung rescue, patient who require hyperbaric oxygen therapy, and just about any form of shock that requires prompt stabilization.”
Galvagno added with the success and high survival rate of the Trauma Resuscitation Unit (TRU), a medical unit known as the Critical Care Resuscitation Unit (CCRU) was added and can manage the full spectrum of adult critical illness, ranging from severe heart failure to obstetric emergencies.
The CCRU is “a truly unique unit at Shock Trauma,” Galvagno said.
Honoring a legend
Cowley demanded loyalty, dedication, skill and hard work. He demanded it of those who worked for him. He demanded it of himself. He never gave up the vision that he believed in. Nothing was impossible to him. He wanted the critically ill and injured to survive and he moved mountains to make it possible. Cowley wanted the very best of the citizens of Maryland.
The Baltimore Sun called Cowley an already superior cardiac surgeon involved in early open-heart operations – one of the first to recognize that emergency medicine should be a separate medical discipline, demanding doctors, nurses and paramedics trained in the needs of people with multiple, massive injuries.
“He was rough, tough and no BS,” Gens said. “He was straightforward with no pleasantries. Tough. Tough. Tough. But, good. That’s how he built the trauma center.”
Cowley, 74, died at his home in Baltimore. He was buried at Arlington National Cemetery.
After Cowley’s death, his papers, awards and memorabilia were requested by and donated to the University of Utah Marriott Library, where he was named one of “Utah’s Heroes,” according to the “New York Times.”
“He was rough and gruff, and he got it done. I don’t know too many people that could have got it done,” Gens said. “He set up a field program, a hospital entity and a research program.”
“Prior to his work, most of these [shock] patients would expire in emergency departments and nobody knew quite why. Dr. Cowley studied these patients closely with the most technologically advanced methods available to him at the time,” Galvagno said. “In doing so, he was able to identify patterns and stages of shock, which led to a series of interventions aimed at reversing this process. This was truly revolutionary work at the time.”