On the front lines in the ER and in the field
It was a day meant for fun and sun in Stage Harbor. But, suddenly, the boat outing turned into tragedy. The vessel’s propellers accidentally ran over both legs of a 27-year-old woman swimming by its side.
Fortunately, one of the first responders was a trained Emergency Medical Technician working that day for the harbormaster.
“He was smart enough to put tourniquets on both legs as soon as he arrived at the scene,” recalled Cape Cod Hospital emergency department physician Jake Crowell, MD.
Minutes later, rapid response paramedics arrived. They immediately administered life-saving IVs and worked to stabilize the grievously injured woman’s wounds, while trying to control her pain.
Their ambulance raced to Cape Cod Hospital’s Emergency Center in Hyannis, where doctors and nurses sped into action.
Fortunately the woman survived. As many as 50 people a year die from similar propeller accidents, according to the U.S. Coast Guard.
Dr. Crowell, uniquely, experiences these life-saving events year-round. He’s not only an emergency room physician at Cape Cod Hospital, but also a member of the Dennis Fire and Rescue Department, frequently responding to car crashes, fires and other life-and-death events.
He also serves as one of two Affiliate Hospital Medical Directors who work in conjunction with Cape & Islands Emergency Medical Services (CIEMSS), the organization that is the liaison between Cape Cod Healthcare and 20 fire/rescue departments on the Cape.
A graduate of the University of Massachusetts Medical School, he grew up as part of the firefighter’s world. His father, grandfather and uncle all were members of the Dennis Fire Department.
“My experience in the field gives me huge respect and appreciation for the work done by the paramedics and EMTs,” Dr. Crowell said. “I describe them as the underbelly of Cape Cod’s healthcare system. They may not hold the glitz and glamor of interventional cardiologists or even emergency room doctors, but their training and ability provide the initial stabilization and diagnoses that are indispensable to our success once the patient reaches the hospital. They truly are an extension of the emergency room.”
Despite this, Dr. Crowell observes that many Cape Codders aren’t even aware that the same rescuer who fights a fire will be the first responder diagnosing a heart attack.
“They go unnoted and often unrecognized,'” he said.
Dr. Crowell has watched with some amazement how the role of a firefighter on Cape Cod has grown in sophistication.
“During my grandfather’s career, they pretty much just transported patients in the back of a vehicle similar to a hearse. That was only two generations ago. Now, an ambulance is equipped to be an emergency room, and paramedics undergo years of classroom and hospital training. ”
In a typical year, more than 125,000 ambulances arrive at the emergency rooms at Falmouth Hospital and Cape Cod Hospital. The majority are transporting patients with non-life-threatening issues – from seniors who may be dehydrated to a growing number of people suffering from behavioral health issues.
“At least a quarter of EMS calls involve patients whose pre-hospital care at their home and in the ambulance make a huge difference; receiving care that once would have occurred only upon reaching the emergency room,” Dr. Crowell explained.
The most significant area is cardiac care, he noted.
“It could be 30 minutes from Chatham and close to an hour from Provincetown before a patient reaches us in Hyannis. That time frame could mean the difference between life and death.”
Even in the summer when the Cape’s population triples and even quadruples with visitors and second homeowners, response times are not compromised, observed Dr. Crowell. One of the reasons for this is a sophisticated mutual aid system that can dispatch ambulances and even boats from neighboring towns in a virtual instant.
As Dr. Crowell looks back over three generations of his own family’s experience as firefighters and lifesavers, he pinpoints the Vietnam War as a turning point.
“Today’s paramedics and EMTs benefit from the advanced training that medics experienced on the battlefield and that has continually improved to this day,” he explained. “This ranges from airway management to fluid resuscitation to treating traumatic blood loss. Paramedics have incorporated all this knowledge.”
The techniques used to save the woman injured in the Chatham boating accident benefited from battlefield experience, for example.
Another game changer has been technology.
“As a physician, I point to the advent of the 12-lead EKG machine and its portability,” said Dr. Crowell. “This, by far, has revolutionized cardiac care in the back of the ambulance. It now allows paramedics to aggressively treat significant heart attacks that are identified by the EKG.
“We train paramedics to interpret the cardiac condition as well as use protocol-guided treatment while en route to the hospital, with the backup of real time direct from the doctor to paramedic on an as-needed basis. Paramedics are now empowered to activate the cardiac catheterization lab to fast track patients for immediate lifesaving procedures.”
This could save between 5 to 40 minutes, and that means less morbidity and fewer disabled patients, he noted.
Teamwork Across The Cape
A big part of Dr. Crowell’s role as liaison between Cape Cod Hospital, CIEMSS and fire departments from Barnstable east to Provincetown is to enhance the teamwork between the rescue departments and emergency room staff.
“Years ago, there was a disconnect between the parties, but that has diminished and even disappeared for the most part,” he observed. “One of the reasons for this is the integration of doctors and nurses in the sophisticated training programs every paramedic and EMT on the Cape must undergo.”
This not only applies to the hundreds of hours of clinical experiences across almost every department of the hospital that are required during initial certification, but also the mandatory continuing education refresher training programs conducted by Cape & Islands Emergency Medical Services. Many classes are taught by doctors and nurses – from EKG interpretation to delivering babies to burn treatments.
For Dr. Crowell, part of closing the gap between rescue squads and hospital staff is attributed to his own involvement on a town rescue squad.
“I not only understand what paramedics and EMTs experience on the ground and in the back of the ambulance, but I’m also able to share that experience with my peers in the hospital,” he said.
Today, paramedics are trained and empowered to perform intubations and administer sophisticated medications that in generations past would be within the sole purview of physicians.
That requires constant education, Dr. Crowell emphasized.
“Ultimately, all paramedics in the towns I am responsible for need my authorization to practice.
“My job is to adequately train and oversee the care of our paramedics to make sure they are providing the highest quality of pre-hospital care possible.”
That requires an imposing regimen for Dr. Crowell.
A typical month for him is the standard 16 shifts in the emergency department and up to five hours a month developing training lectures. Then there is the actual time needed to teach up to 20 training courses a year at the Cape & Islands EMS training facility. This doesn’t even account for the endless hours he works side-by-side with paramedics who must undergo up to 400 hours of on-the-job training at the hospital.
‘When they do their time in the emergency department, I get the opportunity to train them and talk with them about specific procedures on a case-by-case basis,” he said.
In addition, he will devote another four hours a month evaluating actual rescue cases through a quality assurance program. These will be reviewed by all parties involved – from first responders to hospital staff – with the goal of continuous improvement and remediation.
Part of His Life
On top of this, Dr. Crowell sits on the board of the Cape & Islands Emergency Medical Services and attends monthly meetings at the regional and state levels, representing both EMS and Cape Cod Healthcare.
His role and that of his counterpart at Falmouth Hospital, emergency medicine physician Ryan Bemis, MD, is particularly critical for a location like Cape Cod, Dr. Crowell explained.
“We are very decentralized on the Cape – unlike a big city hospital. There are 20 different fire and rescue departments here. It would be difficult, if not impossible for our hospitals to have a medical director tied to each one.
“That’s what makes the Cape & Islands EMS so critical. It serves as the coordinator for all training programs required for EMTs and paramedics year round. I can be the medical director for 15 departments as a result.”
All this while he continuously trades in physician garb for his firefighting and rescue equipment in Dennis.
Recently, while driving home from a shift in the emergency department at 1 a.m., Dr. Crowell heard an emergency call seeking additional EMS help for a cardiac arrest. Instead of going home to sleep, he veered to the house location where he encountered a man whose heart stopped due to a heroin overdose.
“I remember as a kid, my father, who is a banker, and my grandfather, would drop everything to go on a call. It was part of the fabric of our lives. They were always modest and understated about their roles – just like the hundreds of paramedics and EMTs I work with every day.
Ultimately, for me, it’s a privilege not only to be a doctor, but to service this wonderful community that raised me.”