An American hero - Dr. David Boyd and emergency health care.

Dr. David Boyd pours the evening's fourth cup of coffee in his cluttered, windowless Washington office. Talking about is years in government, he says, "The thing about being a bureaucrat, a maverick bureaucrat, is that if you have reasonably good enough argument and balls enough to stick with it, you can win a lot of battles." Putting the urn back in the coffee machine, he says, "The thing is, nobody ever tries." It's a lesson he learned from experience In the early seventies, Dr. Boyd turned in his surgeon's scrubs for a bureaucrat's suit, and quickly rose to the directorship of something called Emergency Medical Services (EMS), a division of the department of Health, Education and Welfare HEW). You may not have heard of Boyd, or MS, but you probably take for granted the changes he and his agency brought about. The division existed only from 1974 to 1981, when the Reagan administration pulled its plug by turning its funding into block grants to state governments. But in those years, Boyd orchestrated a revolution in emergency medical care. In the course of it, he convinced some of his colleagues he was "egomaniac," "despot," "visionary"' and "pain in the ass." Yet the changes he helped bring about were so sweeping that, in the words of former co-worker Dr. John Otten, Boyd has probably "been responsible for saving many more thousands of lives than anyone in the medical profession today."

How Boyd turned his federal program into a catalyst for positive change, instead of another government boondoggle, is a story in itself. The program was meant to give states and municipalities "assistance and encouragement" otherwise known as the pork barrel-for projects like improving ambulance services and training volunteer firemen in new medical techniques. What kept the division from fulfilling its destiny as yet another do-nothing agency was, by all accounts, Boyd. Now, thanks in large part to him, hospital emergency rooms have been revamped and staffed with a new breed of specially trained emergency physicians. Almost half a million ambulance personnel have been trained in basic and advanced life support. Well-equipped paramedic vans are now a familiar sight as they fly down city streets. Victims of severe heart attacks, burns, poisonings, and serious injuries, people whose lives were once written off, are being saved by the thousands. In short, high quality emergency service has become an expected government function, the "third public force" after fire and police protection.

These were not small achievements. As Dr. Mark Vasu, an expert in emergency cardiology explains, "Prior to Dave's program, there was virtually no training, no standards, no 'system' of emergency care in this country:' Hospital emergency rooms were notorious as the dumping ground for inept physicians. The nation's ambulance drivers were so untrained that few knew how to put an IV into a bleeding patient.

But there's a disturbing story in the one key reform Boyd failed to implement. This, as described in the first part of this article (November 1985) was his "trauma systems" concept. In a nutshell, Boyd proposed setting up super-equipped "trauma centers" in selected hospitals, to which the most serious trauma patients ("trauma" is an umbrella term for injury) would be taken automatically. This mandatory diversion of patients away from less well-equipped emergency rooms, Boyd believed, would lead to dramatic improvements in emergency care.

Boyd had strong evidence to support that belief. Unfortunately, thousands of Americans continue to die every year of perfectly treatable injuries because he couldn't get his trauma system installed nationwide. It wasn't for lack of effort. "He had a ferocious intensity, an evangelical fervor-the success of the program was more important to him than his own career," recalls James Page, a California fire chief and publisher of JEMS, a trade magazine for paramedics. Dr. Michael Rhodes, a government EMS adviser in Pennsylvania, agrees: "Dave could have walked out of government and onto the staff of any medical school in the country'" But he spent too many years in the bureaucracy, and his medical skills dulled. Now Boyd makes his living as a private "EMS adviser" with a small Washington consulting firm.

What killed the nationwide trauma system Boyd envisioned was opposition from the nation's medical establishment. The great irony is that a good deal of the opposition grew out of the innovations of David Boyd. Doctors and hospital administrators, who a decade or two before probably would not have worried about emergency care came to perceive the idea as a threat to their power, prestige, and pocketbooks. That Boyd did his job, in a sense too well, is only one of the ironies of this story. To understand how all this happened, we need to examine some history.

MASH factor

The trauma center idea comes from the U.S. Army. In World War II, soldiers injured in battle were taken first to battalion aid stations, then to hospitals well behind the battle lines. This often caused 12-hour delays in getting them to surgery. In Korea, the U.S. Army Medical Corps decided this wasn't good enough. Instead, they transported the wounded, often by helicopter, to nearby Mobile Army Surgical Hospitals, now universally known as MASH units. There, surgical teams were ready to operate 24 hours a day. This reduced the waiting time by two-thirds. And since sewing up and caring for the wounded was the only medicine MASH doctors and their staffs practiced, their skills and teamwork were honed to near perfection. As a result, the mortality rate for wounded soldiers in Korea was half what it had been in World War II.

It would take years, however, before the lesson of the MASH unitswas learned in America. For the medical community at home, it was business as usual. The federal government did nothing during this period to change the pattern of emergency care, and it confined its involvement in medical matters to a few areas. It subsidized a massive hospital construction program-the origin of our chronic oversupply of beds. Congress also poured research money into medical schools, stimulating the production of a greater number of highly trained specialists. Moreover, there was a decline in the number of general practitioners entering the work-force. The old-style family doctor, though not exactly a vanishing breed, was getting considerably harder to find.

Consequently, by the 1960s, more and more people were showing up in hospital emergency rooms (ERs), looking for the physician care they otherwise couldn't find. The ERs weren't much of a substitute. Hospitals devoted scant resources to them since administrators believed the ER was a drain on revenues. Few ERs had physicians staffing them around the clock, and many doctors who worked the ER beat had reputations, even among their peers, for incompetence. "The ER was a terrible place to work," recalls Dr. Stan Zidlow, head of emergency medicine at Chicago's Northwest Community Hospital. "We called it 'the pit.' "

All those non-emergency patients flooding into ERs soon helped focus America's attention on the scandalously poor care available to patients with real emergencies. The number of Americans who died each year on the nation's streets and highways roughly equaled the number that eventually died in Vietnam. Street violence was also on the rise and accounted for an increasing number of emergency cases. But the comparison with Vietnam is instructive, because with the Army's superior emergency medical systems, a soldier shot in Vietnam stood a statistically better chance of surviving than a civilian shot on an average American street corner To get some idea of how primitive emergency services in this country were, consider this statistic from an influential 1966 study: half of the vehicles being used as ambulances were operated by morticians--the ultimate conflict of interest.

It took some time, but gradually this demand conjured suppliers.Groups of doctors, scattered around the country, began to see real profit potential in ERs. Forming partnerships, they contracted with hospital administrators to take over the headache of having to staff and operate their ERs. With more and more Americans using ERs like doctors' offices, the partnerships eventually blossomed into corporations, and the physicians who owned them became rich.

Meanwhile, other physicians were experimenting with ways of delivering needed services beyond the hospital. A few doctors in the early sixties realized that firemen, equipped with the newly created tools of cardiopulmonary resuscitation (CPR), could be trained to defibrilate heart-attack victims in the street and keep them alive long enough to get them to a hospital. Elsewhere, reform-minded physicians were training nurses in their local communities to treat problem pregnancies and accidental poisonings in the field.

These efforts were far-flung and controversial. Many physicians disliked mere nurses and firemen performing medical procedures hitherto reserved for doctors. But the benefits were undeniable, and considerable positive press resulted. The federal government itself got involved in 1966 when Lyndon Johnson sent Congress his Traffic Safety Act, which eventually pumped millions into state governments through the Department of Transportation for the purpose of developing uniform highway safety programs. Some states began putting EMS offices in their health departments and writing basic standards for ambulances and personnel training.

Choppers and cutters

The greatest forward leaps in emergency care, however, came from physicians and others who had served in the Army and knew its advanced systems firsthand. Perhaps the most famous of these is Dr. R.A. Cowley of the University of Maryland. An Army surgeon in France during World War II, Cowley conducted research in the sixties for the U.S. government on the phenomenon of shock, the "cell suffocation" that results from the hemorrhaging caused by most serious injuries. Shock triggers wild oscillations in the body's biochemistry, which in turn can lead to organ failure and death. Cowley found the best way to save lives is to sew up a patient's wounds as fast as possible, before the effects of shock become disastrous. This explained why trauma death rates were so much lower for soldiers in Korea and Vietnam than for civilians back in the States.

Cowley had a vision of MASH-like trauma care for everyone in the state of Maryland. During the sixties he transformed his lab into one of the nation's first trauma centers, with its own blood bank, lab, operating room, and a crew of surgeons and support staff ready to operate 24 hours a day. He even got the Department of Transportation (DOT) to buy a squadron of helicopters, which he shared with the state police, some of whom he trained as paramedics. The helicopters could scoop up seriously injured individuals anywhere in the state and transport them to Cowley's operating table with remarkable speed. Cowley understood that to make such advanced care economically feasible, a trauma center had to have a minimum number of patients-a far larger number than the average hospital received. A steady stream of cases was also necessary to keep the staffs skills sharp.

But getting enough patients meant dispatching choppers and ambulances into zones traditionally covered by other hospitals. Cowley saw this as good medical practice; unfortunately, other Maryland doctors saw it as patient stealing. They spread a story among local ambulance personnel, most of whom were volunteer firemen, that Cowley wanted to replace them with his paramedic-policemen. Fierce territorial battles ensued. On one occasion, a state trooper found himself holding off a local ambulance crew at gunpoint while other troopers loaded a seriously injured patient into a helicopter.

Such clashes poisoned the political atmosphere and ruined for years Cowley's chances of realizing his dream of statewide trauma care. Throughout the late sixties, he battled just to keep the doors of his trauma center open. Nevertheless, his work attracted young surgical students who became his disciples and carried his ideas with them to other hospitals. One of these was David Boyd. Under Cowley, Boyd learned not only the medical aspects of trauma reform, but the political realities that work against it. When he left Maryland to finish his residency at another pioneering trauma center at Chicago's Cook County Hospital, he took with him Cowley's dream and a good idea of the political tools he'd need to achieve it.

Guns and money

Boyd didn't wait too long to begin his crusade While digging bullets out of the bellies of people i"knife and gun club" neighborhoods on Chicago's west side, the young surgeon saw an opportunity and seized it. During a political fight over staff cutbacks at his tax-supported hospital, Boyd managed to buttonhole the then-governor of Illinois, Richard Ogilvie. Boyd was lucky to find a willing listener Ogilvie was not only a Republican like Boyd but a World War II veteran whose life had been saved by Army surgeons. Boyd's ideas made sense to the governor and he liked the young surgeon's aggressive style He soon brought Boyd into his administration, diverted some DOT traffic safety dollars his way, and gave him a carte blanche to put together a statewide trauma system, Boyd's bureaucratic education was about to begin.

He was a quick study. Soon after taking the job, Boyd learned a valuable political lesson that few politicians seem to grasp: that sacrifice and commitment to a good idea can move people. During a routine budget battle in Springfield, a powerful state senator cut Boyd's entire budget. After pursuing the senator for days, Boyd finally cornered him in a restaurant, introduced himself as "Doctor" Boyd, and launched into a desperate lobbying effort. The senator, Boyd recalls, was impressed that Boyd had given up a surgeon's salary to become a state health bureaucrat. "He asked me what I made a year," Boyd says. "When I told him he said, 'You must really want this project bad: I said I did. He said, 'Shit, man, you got it,' and I was back in business." Self-mockingly, Boyd calls this the lesson of "Playing Jesus Christ."

Boyd's obvious commitment helped him rally support among the non-medical people involved in emergency care-firemen, policemen, and volunteers. Throughout the state he set up training seminars to teach them basic emergency medical techniques they could use in the field. "The prehospital people-and there were thousands of these people who were volunteers-were hungry for it," says Dr. Rhodes. "They didn't understand his big words, but they knew someone was paying attention to things that had been happening on the streets for a long time." The thousands who went through these seminars lent Boyd's program the kind of participatory enthusiasm that any campaign-political or otherwise-needs.

Gaining support from the medical community was far more difficult.

Many Illinois physicianspersonally disliked Boyd for papers he had published in medical journals charging, in essence, that physicians' ignorance of trauma medicine was killing people Boyd's solution-diverting the seriously injured away from conventional ERs and to a few designated trauma centers-angered them even more. Many ER physicians feared a loss of business and prestige if their hospitals weren't chosen as trauma centers. Many surgeons feared the opposite: if their hospitals were chosen, they'd have to give up weekend golf games and nights of sleep in order to keep the trauma centers ready 24 hours a day.

The physicians had plenty of power to obstruct changes they didn't like. Their "disinterested" and "expert" views on medically oriented political matters carried great weight with politicians, the press, and the public. Their jargon-filled objections could kill trauma reform proposals outright or send them through an endless maze of government committees and study groups.

The only effective counterattack, Boyd knew, was to get other physicians to speak out in favor of trauma reform. So Boyd toured the state, evangelizing about trauma centers and trying to gain physician-converts. It was slow going. Dr. John Otten, then chief of surgery at Peoria's St. Francis Hospital, recalls he became furious when Boyd spoke to a group of that city's medical providers. " 'By God,' I thought, 'I've been in practice, I've had good training, we don't need some resident from Chicago to tell us how to do it: And I stood up and told him so." On his way home from the meeting, Otten says he started thinking about what Boyd was saying. The next day, he called Boyd and asked how he could help. Soon, Otten was the EMS "medical adviser" to the Peoria area-an unpaid, time-consuming position-and his hospital, St. Francis, was the area's designated trauma center.

Otten and others like him-established surgeons, usually Republicans with unassailable reputations and memberships at the right country clubs-became Boyd's agents, his subversives. When they attacked physicians who opposed trauma reform in front of county councils and at meetings of local medical societies, people listened. "I never got anywhere," says Boyd "if I didn't have a local, credible surgeon in there, with blood on his shoes, to blow away the smoke, to stand up in front of everybody and say 'that's bullshit.'"

Boyd put his network of agents to good use. From 1970 to 1974 hebuilt his trauma network through a combination of behind-the-scenes politicking and publicity mongering. His DOT money went for innovations newspapers loved: new ambulances, radios to link them with hospitals, computers to monitor trauma center performance, and helicopters to transport patients from rural hospitals to trauma centers in the larger towns and cities. Most important, he picked trauma centers, and with the cooperation of the pre-hospital people, arranged for the seriously injured to be sent to them. By 1974, his coordinated statewide trauma system was up and running. And it worked. Traffic deaths in the Springfield area dropped by 30 percent. In the Peoria area, around Dr. Otten's trauma center, such deaths dropped by 50 percent.

Salad days

Boyd's innovations in trauma care were paralleled elsewhere in the country by advances in care for other problems: cardiac arrest, burns, poisonings, problem pregnancies, and so on. No reformers, however, had devised a system capable of handling all these at once. The expert consensus was that the only way to organize such a comprehensive system was on a regional basis, with neighboring municipalities pooling their resources. And the only way to get such an effort started, Boyd and other reformers realized, was with federal support.

The opportunity finally came after much lobbying and several pilot projects. In 1974, President Nixon signed a bill establishing the new EMS office in HEW to spread the gospel of "regional EMS systems" around the country. To run the program, he chose Boyd.

From Springfield to Washington-it was a great American success story. But after moving to Washington, Boyd realized that not only would he have to cover a good deal more territory, he'd also have to play by a different set of rules. Fearing the program would be too much of an intervention in state and municipal affairs, the Nixon administration circumscribed Boyd's power. He could no longer run around designating trauma centers at will. Boyd could only provide "assistance and encouragement," in the form of federal dollars to health department bureaucrats, who were to push reforms themselves. In Illinois, Boyd had built his system by fiat; as a federal bureaucrat, he was supposed to act more like a midwife.

It was a fine Republican idea to limit the power of the division,but it ignored the fact that state health bureaucracies weren't peopled with David Boyds. The average health bureaucrat was a more mild-mannered sort; eager, certainly, for federal money, but terrified of risking his job by pushing reforms that powerful medical interests opposed. "Health officers like to regulate and maintain and study," says Boyd. Instead of joining the cause, health officers were "more comfortable monitoring bacteria levels in restaurant salad dressing."

The federal officials at HEW assigned to serve as Boyd's regionalrepresentatives were similarly worthless. "He got a few good ones and some real turkeys," recalls an official who had to work under them. "These guys were all former venereal disease investigators. . .one of them was a hopeless drunk, others were lazy, one was a pathological Liar. It was a really bizarre group. So that's the kind of resources Dave had when he came to Washington. The only way he could get rid of them was if they retired."

Knowing he couldn't trust his subordinates, Boyd devised many clever ways of circumventing them. One was to leave Washington almost as soon as he arrived. For months, Boyd jetted around the country, dropping in on state and local health bureaucrats to meet them face to face and offer them federal grants. This gave Boyd a chance to identify local schemers as well. He recalls a dinner meeting at which he asked a group of local health planners roughly how much their EMS feasibility studies would cost. He was taken aback when one of them quoted an exact figure. "It's no mystery why," said the planner, obviously misjudging Boyd. "That figure is next year's operating budget for my department." Boyd made sure the planner never saw a cent of his federal funds.

Frustrating the greedy was one way Boyd kept his program from turning into another federal failure; another was not burying his vision in piles of undecipherable regulations. Rather than write some kind of "EMS manual," Boyd, with a team of experts in tow, presented his ideas orally at "EMS workshops" around the country. If, at the end of the workshop, the bureaucrats and medical providers in attendance still didn't understand exactly what a trauma center was, Boyd would buy them tickets to Peoria to tour Dr. Otten's facility. "It was beautiful," recalls James Page, who was one of Boyd's frequent guest speakers. "A junket? It was unheard of. What you're supposed to do is put together volumes of dry technical material that no one can read."

These workshops weren't bland information seminars; they were more like revival meetings. Boyd gave fire and brimstone speeches about how poor training, worn out ideas, and a lack of coordination were killing people. His solutions-radio communications, training, trauma centers-comprised the gospel. Simply gathering in one room bureaucrats, hospitals administrators, physicians, nurses, and firemen from all the neighboring municipalities was a small revolution in itself. These people, most of whom probably had never met, suddenly were told they were members of the same EMS community and that federal money wouldn't magically transform emergency care without a considerable amount of voluntary effort on their part.

Boyd's challenge frequently worked. Voluntary effort, especiallyfrom the prehospital people, fueled the EMS program. Boyd formalized their participation by making sure prehospital professionals, not just doctors and hospital administrators, had seats on policy-making "EMS advisory councils." Those prehospital representatives often brought associates with them. "If some hospital administrator, or whoever, stood up at a local EMS council meeting and tried to stop [a reform] ," explains Michael Rhodes, "there would be 16 ambulance volunteers standing up, telling him why it was the other way."

Boyd's cleverest end run around the establishment also involved tapping voluntary effort, this time from physicians. It was really a variation on what he had done in Illinois. He required that to be eligible for federal grant money, the health department had to find a local physician, preferably a surgeon, to volunteer his time as the department's "EMS medical adviser.'" It was to these physicians that he preached the most-often over drinks at some local tavern during his numerous trips into the field. The more committed to reform they became, the more Boyd delegated to them-and not to the bureaucrats-the responsibility for the project. These physician-operatives became known in the trade as "Boyd's mafia." The best of them Boyd promoted to federal posts as "regional advisers," supplanting the regulars from HEW

Getting physicians involved wasn't just a matter of political expediency; it was essential to saving lives. What had kept emergency care so primitive was an almost total lack of communication between doctors in the ERs and ambulance people in the field. Boyd's program, for the first time, integrated the two. His medical advisers established radio hookups between hospitals and ambulances, trained ambulance crews, designed their procedures, and reviewed their cases. By convincing doctors to look over the shoulders of ambulance and paramedic crews, Boyd and his cohorts integrated prehospital care into the physicians' sphere of activity. This made for both better on-site care and a new spirit of cooperation among the various parties involved in treating the sick and the hurt.

Boyd spent the early years of his program setting all this in motion. After 1976, he began concentrating on what had always been his ultimate goal: creating a system of trauma centers for the entire nation, The word went out to his operatives to start pushing their EMS departments to designate trauma centers and implement "triage protocols" the rules instructing ambulances to take seriously injured patients directly to trauma centers, even if it meant bypassing normal ERs closer to the scene of the injury. Tuning in 

But great changes were underway in American medicine that would make the designation of trauma centers and the adoption of protocols more and more difficult. The trend toward increasing utilization of the emergency room continued, and, if anything, the pace of change quickened because of Boyd's medical army. Through their efforts, more seriously sick and injured patients were being kept alive long enough to get them to hospital ERs. ER doctors thus had to improve their critical care skills to cope with the additional cases they were receiving. New procedures were developed, and Boyd was instrumental here as well. Millions of dollars from his program went to the nation's medical schools for courses in emergency medicine. Better skills brought greater credibility. And prestige inevitably brought with it a greater sense of group consciousness for the ER physicians. They saw themselves as having common, well-defined interests. The American College of Emergency Physicians (ACEP), which had only been founded in 1968, won official recognition in 1979 from the American Board of Medical Specialties, giving it the hallmark of respectability.

A new consciousness of the economics of emergency care also arose.

Hospital administratorsfinally realized the importance of the ER. They spent huge sums throughout the seventies on new medical devices and hired more ER physicians to use them. The ER came to be considered a prime source of revenue. Hospitals competed, each trying to outdo the other in the lavishness of its ER. "We stopped calling them 'rooms,' " says one ER physician. "They became emergency departments. The ER was no longer 'the pit' but the hospital's 'window to the community."

Predictably, hospital administrators and ER physicians didn't want anyone, especially government, meddling with their new source of income They weren't about to sit back and watch as ambulances carrying seriously injured and potentially lucrative patients bypassed their hospitals for the trauma center down the street. The possible loss of revenue was bad enough; the public relations damage would be intolerable. The average patient, they believed, would surely prefer to take his non-emergency problems to a hospital with a trauma center than to one without. So if the trauma center idea couldn't be stopped outright, they decided, it had to be modified so that every hospital that wished to could be designated as a trauma center Otherwise, they feared, the economic results could be dire. But Boyd knew that too many trauma centers was almost as senseless as none at all. Without the volume of patients that comes with centralization, no hospital could afford to keep surgeons, staff, and operating rooms ready 24 hours a day. The temptation to cut corners on care would be overwhelming. Without patient volume, too, surgeons and operating crews couldn't keep their skills honed. The result would be second-rate care at all hospitals. Boyd let regional EMS bureaucrats know that if they compromised like this with their hospitals and with the public's health, they could forget about federal EMS funds.

This, of course, infuriated ER doctors and hospital administrators. Soon, lawyers and lobbyists for ACEP and the hospital associations were swarming around Washington and state capitals in an attempt to override Boyd's authority. In Pennsylvania, for instance, hospitals slowed the designation process with a lawsuit charging that Boyd's trauma system concept, by diverting patients to government-selected hospitals, resulted in "restraint of trade." The charge didn't hold up in court. But lobbyists picked up where the lawyers left off. This pressure-from doctors and hospitals-backed up with massive PAC contributions, killed pro-trauma center efforts in the Pennsylvania legislature.

Boyd was able to pull off a few victories where his agents commanded enough power. While the rest of Pennsylvania languished, Dr. Michael Rhodes developed an exemplary system in the Allentown region that cut preventable death rates by 33 percent. R.A. Cowley used Boyd's grant money to build Maryland's into possibly the best statewide system in the country. EMS reformers in Orange County, California battled lawyers and lobbyists from ACEP and the Hospital Council of Southern California for almost two years before they could install a trauma system. Once in place, Orange County's system cut the preventable death rate for non-head-injured auto accident victims from 73 percent to 9 percent. For every Orange County, though, there were a dozen communities where officials either lost the battle outright or buckled under the pressure and sent trauma proposals back for further "study:'

The final blow to the movement came in 1981, when the Reagan administration folded Boyd's EMS funding into block grants paid directly to the states, no strings attached. This has slowed the trauma care movement considerably. Instead of going to regional EMS offices, federal money now goes to state health departments, where the bureaucrats are free to spend it on less controversial projects. "Instead of funding EMS," explains Dr. Mark Vasu of the way things now work in his home state of Michigan, "they make the decision to get rid of rats in Detroit:' As Michigan went, so went the nation. A 1984 GAO report found that funding for EMS dropped after 1981 in ten out of eleven states surveyed.

With Boyd out of government, the money available for EMS no longer comes with his strict standards. EMS bureaucrats have rid themselves of their troublesome medical advisers-Boyd's network has disintegrated. Without these hard-driving physicians, the bureaucrats are once more prone to make the kind of compromises they never got away with under the Boyd regime. In states such as Florida, Pennsylvania, and even Illinois, "trauma centers" have popped up like so many pizza parlors.

Boyd has ample reason for his pessimism. Studies suggest that between 10,000 and 20,000 Americans still die every year of serious but treatable injuries because a nationwide trauma system isn't in place.

That hospitals and doctors resist change out of a fear of losing money and prestige is obscene. What's more, even their fear of lost business is probably unjustified. Boyd and other reformers have insisted for years that seriously injured patients are only a small fraction of trauma patients-about 5 percent. Diverting these patients to specialized trauma centers, they claim, would be an insignificant sacrifice of revenue for non-trauma centers, especially considering the lives that would be saved. Concern about a public relations debacle, Boyd believes, is equally unfounded. A recent study of the economic impact of Orange County's trauma system suggests Boyd is right on both counts. The study found no significant drop in admissions in those Orange County ERs that were not designated trauma centers.

David Boyd's quest for emergency medical reform was abruptly foreshortened by the Reagan administration. Yet, while the current state of affairs is distressing, the story of Boyd and his program is not without a hopeful lesson. That is, in short, government does have a proper role in our lives. Without the power of position and money that Boyd wielded as a federal bureaucrat, it is hard to imagine where emergency care would be today-and how many more preventable deaths would have occurred. Are there many better instances of government promoting the general good over that of narrow interests? And Boyd himself showed that passion and a good idea can go a long way toward overcoming the seemingly intractable problems of bureaucracy and greed. The federal EMS program should have become a model for all kinds of other federal initiatives. But for the moment, it's been largely forgotten.

Trauma reform is too good an idea to disappear altogether. Currently, in offices scattered around Washington, a few committed officials are plotting the movement's comeback. They have plenty of ideas: proposals for trauma research money, new national trauma care standards for hospitals, and legislation to enforce those standards. Of course, the lobbies aren't going to sit back and let all this happen: To defeat the doctors and hospitals will require a massive effort by the government, and then only with a shrewd maverick bureaucrat leading the offensive. Someone should see if David Boyd is available.