An internationally respected leader in prehospital care, Dr. Paul Pepe’s contribution to EMS spans more than three decades. While the depth and breadth of his work is unmatched, the bulk of his research—and passion—is in prehospital cardiac arrest and trauma resuscitation and prehospital care, most recently evaluating how estrogen can improve resuscitation rates with a team of prehospital care experts.
Renowned for his grass-roots, street-wise style in planning, implementing and overseeing a systems approach to saving lives—both operationally and through clinical trials—Pepe’s programs have resulted in some of the highest cardiac arrest and trauma survival rates in the world.
Pepe, a tenured full professor of medicine, surgery, pediatrics and public health, and Riggs Family Chair in Emergency Medicine at the University of Texas Southwestern Medical Center in Dallas, heads a ground-breaking academic emergency medicine program based at Parkland Hospital, the county emergency-trauma center.
Pepe sees himself more as a change agent, one who looks at a situation and tries to understand how it could be enhanced. This has been exemplified by his research and innovation regarding trauma and sudden-death cardiac arrest patients.
Most recently, Pepe has added to his long-standing portfolio in resuscitation medicine with new research on the role that sex hormones may play in outcomes.
Breathing New Life into Resuscitation
Pepe was one of the thought leaders who saw that patient outcomes could be significantly improved by creating specific facilities to treat specific problems. For example, many years ago, he thought that gathering a group of highly skilled specialists at a particular receiving hospital, specific for the purpose of treating stroke, would improve a patient’s chance of recovering.
“Here we are eight years later, and stroke centers have become mainstream. The Joint Commission on Accreditation for Hospitals now accredits them,” Pepe says.
Similarly, along with a close-knit group of colleagues across the nation, he has championed the cause of creating resuscitation centers with a cardiac-arrest focus.
“When you have a centralized receiving center for a particular emergency type, the care providers are more effective because they are used to doing it on a day-to-day basis,” he says. “We think the same concept holds true when treating cardiac arrest, because we know so many things that can affect the outcome are provided or continued in the hospitals.”
He is now using a similar approach to set up resuscitation centers. Facilities should use therapeutic hypothermia, be up-to-date on the latest standards of chest compression, and, of course, have quality controls in place.
“Quality has not been so good in either prehospital or in-hospital,” he says. “Weak links have been shown. Can they demonstrate quality CPR and chest compression in their own staff members? Are they actually monitoring this?”
Pepe insists that by measuring and monitoring quality, hospital performance will improve.
“Sometimes what we want from a hospital is to know that they have identified the problem, what they did to fix it, and what happened to make it better,” he says. “So we have to have the quality assurance and data collection component to measure it.”
Pepe admits that not every hospital has to be a designated cardiac resuscitation center. In fact, sometimes the fewer the centers, the better the data and individual experience at each center due to the higher volume of patients treated.
“To some extent, a smaller number of resuscitation centers makes it easier to collect and collate data. It’s more efficient if you only have to work with seven or eight places versus, say, three dozen,” he says.
Pepe has also spent three decades conducting major clinical trials that have achieved significant notoriety. Many of his research initiatives have successfully challenged sacred cows and opened up new avenues of investigation.
Pepe believes that the greatest gains in research can be made by getting groups of scientists together to tease out all of the important factors that can impact treatment. With an understanding of best practices, treatment protocols can be not only be standardized, but will also improve outcomes just by renewed focus and attention to details.
“Even if the intervention itself is not effective, when you start training people, focusing on the right treatment, and paying attention to quality assurance, you save lives,” he says.
This effect was recently seen in Dallas during the implementation of scientific studies for the NIH. “We were hoping to get the survival rates up 10–20 percent. They actually went up more than 50 percent in Dallas alone and 60 percent across the county. In some cities, the survival rate almost quadrupled,” says Pepe. “I’m a big advocate of conducting research studies because, just by doing them, you can produce and demonstrate a life-saving effect.”
Estrogen’s Role in Resuscitation
In more recent research, Pepe and his team of researchers have begun to demonstrate the powerful impact that sex hormones may have on resuscitation medicine.
“When I first came to UT Southwestern, one of my chief residents was looking at the concept that women have worse outcomes than men with heart attacks,” Pepe says. “That’s what the widely held opinion was at the time.”
But Pepe and that chief resident, Dr. Jane Wigginton, thought otherwise and set out to discover the real story. For example, it had been questioned that women may present with different symptoms, or that they may not be treated as aggressively, for various reasons.
In May 2000, at an annual meeting of the Society of Academic Emergency Medicine in San Francisco, Dr. Wigginton delivered a scientific presentation based on their research that demonstrated that women, though older on the average, actually had much better outcomes than men in out-of-hospital cardiopulmonary arrests.
“The cool part about dealing with cardiac arrest is that the diagnosis is easy and everyone gets the same therapy. Men and women both were shown to get the same kinds and same numbers of drugs for each protocol and the same length of treatment,” Pepe says. Differences in outcomes had to be explained some other way.
“At first, we thought it would be unlikely to be hormones because the average age of a woman who has a cardiac arrest is 69, so we expanded our study further until we got to 10,000 patients. Suddenly, we could study a very large number of women who were under the age of 50,” says Pepe. “It turned out that almost all of the differences between men and women were completely explained by the cohort of women under the age of 50; they had much better survival rates than the men.”
Dr. Wigginton is now leading researchers nationally in exploring resuscitative endocrinology (as she calls it), with the support of Pepe and world-famous resuscitation researcher, Dr. Ahamed Idris. Having demonstrated differences in outcomes in the laboratory by infusing estrogen for a myriad of critical conditions, from head injury to burns and other insults, they are leading the effort to eventually take estrogen infusion to the streets.
As a safe, inexpensive, and simple-to-use treatment, it may dramatically improve cardiac arrest survival arrests, head injury, and burns in both men and women.
A Collaborative Style
Such work has helped set national priorities in resuscitation research. Most notably, UT Southwestern Emergency Medicine and its affiliated 16 partner cities in the Dallas EMS System have been designated jointly as an NIH Center for Resuscitation Research, working with 10 other sites throughout North America. For this purpose, Pepe and his team are scheduled to conduct 10 or so federally funded clinical trials in cardiac arrest and trauma resuscitation over the next five to 10 years.
“What I think I contribute best is bringing the right group of people together, in the right milieu, to get the right scientific answers,” Pepe says. “This is done by gathering a critical mass of terrific thinkers and doers, who are oriented toward prehospital care.”
Pepe believes that the right prehospital care, including the proper resuscitation protocols, will not only significantly save lives—but also ICU costs. He has devoted his professional life to supporting the research efforts and advances that will continue to improve resuscitation protocols and strengthen prehospital care.
“Now many more people are not only surviving, but more importantly, in some study circumstances, almost everyone is waking up before they get to the hospital,” he says. “As a result, we are sparing people from going into the ICU on ventilators. An ounce of good prehospital care can save a ton of ICU care. That’s why I have spent—and will continue to spend—a lot of my focus and time in the prehospital arena.”