By Karen Leach

It's 9:15 p.m., and Ed Racht, MD, is dripping wet as he climbs into the driver's seat of the white Suburban, marked "Austin/Travis County EMS Medical Director."

Racht's clothes had achieved a soggy state of saturation an hour before, when he held an umbrella over two paramedics on Seventh Street as they examined a hit-and-run victim. Since then, he's evaluated the driver of a car that rammed into the concrete wall on a dangerous part of I-35, on the lower level just north of 38-1/2 Street.

Now, with the latest patient packaged and tucked into the ambulance for a fast ride to Brackenridge Hospital, Racht is ready to head home and dry off.

He wipes the water off his forehead and back across his hair as he settles himself behind the wheel. He talks for a moment about the injured man, noting that the hospital will run drug-and-alcohol tests and check for the possibility of a seizure, because there doesn't seem to be any reason for the accident. "His blood sugar is okay," Racht says as he shakes his head. Since low blood sugar can make a person appear intoxicated, medical personnel often check a patient's blood sugar to rule it out as a possible accident cause.

Changing gears, he turns to his passenger and says, "In a weird way, being out in the rain is pretty refreshing." His face lights with a grin. "In what other job could you run around in the middle of the Interstate at night in the rain?"

Does he think he has the coolest job in the world? "Oh, yeah. Absolutely." The man is completely sincere.

As medical director of the Austin/Travis County Emergency Medical Services System, Racht oversees the quality of medical care given by seventeen hundred providers in thirty-eight different agencies, including the Austin/Travis County EMS, Austin Fire Department, fifteen Travis County fire departments, STAR Flight, Travis County Park Rangers, LCRA Park Rangers, Travis County Tactical Medics, Aviation Police and a network of private corporation response teams. He is the liaison between the out-of-hospital emergency medical system and the Austin medical community.

According to Richard Herrington, executive director for Austin/Travis County EMS, Racht is one reason that the system is considered a model, cited among the five best EMS systems in the United States. Racht himself was named Texas Medical Director of the Year in 1999 and was featured in the Journal of Emergency Medical Services as "A New Breed of Medical Director."

"The best thing we've done here in the last six years is hire Ed Racht," Herrington states unequivocally. "Austin EMS has always been good. With Ed Racht, we're very good."

Driving back to EMS headquarters, Racht explains why, despite his executive position, he spends at least one night a week in the field.

"There is an important professional reason for riding out with the paramedics," he explains. "There is a big difference between medical care in theory and medical care in the field. I learn what things are working, what's not working. And when someone turns to me in a meeting and says, 'You have no idea how hard it is out there,' I can say, 'Oh yes I do.'"

In the field, Racht participates fully in each call, carrying equipment and stretchers, helping to move patients, answering questions and evaluating patients. And, sometimes, standing back and letting the paramedics do their jobs while he holds an umbrella to keep the rain off them.

"He calls the people who work with him his 'paramedic partners,'" says Kathryn Perkins, chief, Bureau of Emergency Management for the Texas Department of Health. "The other medical directors I know call them 'my paramedics' or 'the paramedics who work for me.' With Ed, the feeling is partnership. They work under his license, but he trusts them to give good medical care and to get with him if they need his input."

Racht says that he sees the paramedics as his colleagues, much as he would view other physicians if he were in a group practice. "We all have the same mission. I don't like the concept that someone works for me. We all work together, trying to make something happen."

As chair of the Governor's EMS and Trauma Advisory Council, Racht works closely with Perkins. "He could call me up and say, 'I need you to do this and I need you to do that.' But he doesn't do that. When I started working with him, it became very clear, very quick that what we'd have is a partnership," she says.

Perkins notes that the committee isn't an easy bunch of people to work with; the previous committee was disbanded because the dissension was so great that little was being accomplished.

"These are mostly young guys, very Type A personalities. They want to get on the scene, take charge, get things done and get off the scene. In the environment of policy and regulation making, it doesn't work that way," she says.

Racht is an exception. "He approaches things with an organized, calm manner, and lets people have their say," says Perkins. With Racht's guidance, the group is learning how to reach consensus.

"One of the most divisive issues has been on recertification of EMS personnel. Physicians want it one way, EMS wants it another way, fire departments want it yet another way," says Perkins.

The issue had been argued over for years, with a lot of verbal head-butting. According to Perkins, Racht steered the committee to an options plan that lets each entity choose from a selection of methods the plan that best fits that agency.

"I don't think we're going to be revisiting that issue for awhile. When he stepped up to the state role, Texas was fortunate. I don't know how I got so lucky," she says.

Riding around Austin in the rain, Racht is the Medical Director with a capital M and a capital D, talking about setting standards, working toward consensus, and the importance of professional give-and-take to good patient care. But he's also a man delighted with his city.

"Look at that view," he says, pointing northward on Congress Avenue toward the lights of the city. "I love this town. It's a wonderful city. And it's the best city-no it's the best community-in the country to get sick or injured in."

As the lightning flashes and the rain pours down in sheets, Racht says, "I really like this kind of weather. Why? I have no idea." He seems content to cruise the streets, admiring his adopted home, until something exciting happens. He admits that he shares that adrenaline-junkie spirit that drives most emergency personnel.

"When I was a resident, working in the emergency room, I told my dad, 'That's kind of odd, to like this stuff.' He told me, 'You don't have to like people getting sick or injured. But it's okay to say, 'If there's gonna be an event, let it happen on my shift,'" Racht says.

As he talks, the radio dispatcher orders Medic 6, an ambulance unit, to go to the accident on I-35. "MD-1 going with 6," he says quietly into his microphone. He turns on the lights and sirens and says, "Yowzer."

Unlike many EMS systems, Austin/Travis County EMS doesn't encourage its drivers to "run hot" to every scene, meaning with full lights and sirens. Only Priority One and Priority Two calls, those involving potentially life-threatening conditions, merit the lights and sirens. This reduces the odds that emergency vehicles will get into an accident. In its entire history, the agency has had only two fatal accidents, both involving civilian drivers who were drunk.

As a part of the Academy training process, all new paramedics spend three days completing an Emergency Vehicle Operators Course, according to agency Executive Director Herrington. "They are taught the value of control versus speed," he says.

Racht drives with a combination of speed and caution as he heads for the scene. At each intersection, he makes eye contact with the other drivers, checking to be sure that they see him and yield the right of way before he moves on through. To the uninitiated, it seems almost too cautious, until Racht notes, "It's my biggest fear of mortality. There are a lot of ways to leave the world. I don't want it to be in an emergency vehicle at an intersection."

The STAR Flight (Shock/Trauma Air Rescue helicopter) program shares this concern with safety. It is one of the few medical air transport systems in the country that has never had an accident. On the helicopter, if any one member of the flight crew determines that the conditions of flight or landing are too dangerous, the helicopter turns back. That eliminates much of the "macho pilot" attitude that resulted in numerous helicopter crashes in other cities in the nineteen-eighties.

According to Racht, safety is the foremost concern. "We train everyone to look out for number one. If something happens to you, you become a patient, and you can't help anyone else," he says. "If the 911 call is a violent scene, EMS and fire won't come in until police are there to protect the provider."

Since police, firefighters and paramedics often show up at the same scenes, clearly defined roles have been established. At a vehicle crash, fire department personnel are in charge of securing the scene, often using their large engines to create a barrier between rescue workers and traffic. In the case of a rescue operation, they are in charge of bringing the victims out of danger. Once there is access to the patient, EMS assumes responsibility for medical care. Police officers on the scene deal with legal and criminal issues.

Sometimes, the decisions on the scene are difficult. When you're trained to save lives, deciding not to do it, because it would mean putting your own life at risk, can be gut-wrenching. "When I watch them on the scene, it's unbelievable to me that, day in and day out, they make those decisions," says Racht.

The ability to come onto a scene of chaos and calmly restore order is a talent, he adds. "You have to be born with the capacity. Skill and training refine it, and working with mentors as you come up through training."

Part of that talent is a specific response to adrenaline. In many people, adrenaline is a jolt to the system that can make them less effective at making decisions. In others, that same jolt of adrenaline supercharges the part of the brain involved in decision-making and judgment. It allows the person to be calm, deliberate and decisive, to quickly evaluate a changing scene and move surely to still the chaos.

The world of emergency medicine (and emergency services of all kinds) is heavily populated with people who show tendencies toward Attention Deficit Hyperactivity Disorder. While these folks often have trouble concentrating and sitting still in less demanding situations, they are among the ones most likely to react calmly and decisively to that rush of adrenaline.

"I've never been diagnosed as ADHD," says Racht, "but I'm right there knocking on that door."

Still, he says, ninety percent of EMS calls are not life-threatening. "Most of our job is not saving a life, but helping people figure out what to do next."

A bumpy road to medical school

Racht, who grew up in Florida, didn't always dream of being a physician. He first became interested in the idea in high school, when he worked at a hospital, cleaning respiratory therapy equipment. One day, when the hospital was short-staffed, Racht was asked to help with a treatment. He showed an aptitude for it, and over the next two years, he often helped with patient care. That experience taught him the satisfaction of helping people in a very personal, direct way.

But getting to medical school wasn't easy, despite his high intelligence and natural talent. "I started college as pre-med from day one, but I wasn't pre-med after mid-terms. I got a big F in inorganic chemistry."

It was a shattering experience, and he spent the remainder of his freshman year studying psychology and the social sciences.

"But it just didn't click, and I got back in and made an A in chemistry," he says. "It was one of the best things that ever happened to me, flunking chemistry. It instantly made me the underdog and I worked super-duper hard to keep my grades as high as I could to overcome that whole thing.

"It became the central theme of my medical school essays: 'Let me tell you what I've done since.' It was the focus of my interviews. It became one of my biggest assets," he says. His comeback so impressed admissions officials that he earned acceptance to seven different schools, a rare achievement.

"It taught me that the video is more important than the slide. If you look at a single event and not the big picture, you're likely to miss an opportunity to see the good. It was a good life lesson for me," he says. "And it made me commit to being well-rounded. I wanted to enjoy as much of school as I could."

Racht admits that being well-rounded is sometimes a struggle "Time management is a big dark side for me," he says. "Sometimes I feel that I don't spend enough time at home and, at the same time, I feel that I don't spend enough time at work. If something big happens, I'd rather they call me in the middle of the night to tell me, rather than to learn about it the next day." He's not a big sleeper, averaging five or six hours a night, though some nights three or four hours is all he gets. He uses the hours when his family is asleep to feed his workaholic tendencies without sacrificing family time.

"Two or three times a year, I have a Sunday that I kind of sleep all the way through."

Besides his full-time medical director duties, Racht has co-authored dozens of professional papers on emergency medical systems, emergency cardiac care and pre-hospital medical treatment. He volunteered with a program to train EMS personnel in Russia, and is active with both the local chapter of the American Heart Association and the national organization, too. He was named Regional Volunteer of the Year for the Capital Area District of the Heart Association and has served on local and state boards for the organization.

Racht's wife of ten years, Cheryl Piche Racht, is a critical care nurse, though since the birth of their first son four years ago and twins (one boy, one girl) two years ago, she's been a stay-at-home mom.

"She's a wonderful mom," Racht says of the woman he calls "Queen Cheryl the Great."

"I hope I'm a great dad. Though the first time your four-and-half-year-old says 'damn it' you kind of wonder," he says ruefully.

When his older son, Harrison, was a toddler, Racht taught him to say "I love you" in sign language. Each night, Racht repeats the sign as many times as Harrison has years. "He's taught it to his younger brother and sister, which is kind of cool," says Racht with obvious pride.

Racht is a big practical joker, and says his wife is a pretty good sport about it all. She sometimes turns the tables on him.

Once Racht brought home a teaching skeleton, strapped into the passenger seat of his wife's car. Because it was raining, he decided to leave the skeleton there overnight.

As he was preparing for bed, he glanced out the window and saw his wife bringing the skeleton in. Unbeknownst to her, Racht watched as she dressed it in his hat and shirt and set it at the kitchen table with a cup of coffee.

"She knew that I usually get up in the middle of the night to get a snack, and she thought I'd freak, seeing the skeleton there when I turned on the light."

But Racht didn't get up that night. The next morning, he told his wife about the skeleton in the car, and that it was very old, very expensive, and very fragile, and shouldn't be moved or exposed to rain. While he was dressing, he watched out the bedroom window as she stealthily returned the skeleton to the car.

The joker in Racht gets a certain amount of satisfaction from the couple's initials: he's ER and she's CPR.

Creating excellence

At one stop during that rainy Tuesday night, paramedic Juan Hinojosa pulls Racht aside to seek professional guidance. He describes a situation to Racht and then asks if he did the right thing.

"That is one of the ultimate compliments a paramedic partner can pay you: To come up to you and tell you what he did and ask, 'Did I do it right?' It means that he trusts you to listen, to understand and not to say, 'You did what?!!' It's a very healthy thing in the medical community to constantly worry that you're doing the right thing," Racht says.

Deciding on medical standards is a task that Racht takes seriously, and he believes that consensus is crucial.

"You can't take a vote on medical care," he says. He's been known to tell committees that they will stay right there in that room until they reach consensus.

Only once in his tenure with the Governor's Council has a vote not been unanimous.

"And that one time, the physician who had proposed the measure, which had been approved, brought it back to the council because he felt that consensus was more important than getting his way," says Racht. After further discussion, the council modified the decision and reached full consensus. For a bunch of Type A adrenaline junkies, that's not just an achievement, it's a miracle.

Karen Leach has written about medical issues for more than twenty years, and confesses great admiration for adrenaline junkies who get their fixes by helping people in chaos.

Austin/Travis County EMS

OVERVIEW

• Operating Budget $24.6 Million
• Square Miles Served City of Austin and Travis County: 1,100
• Population Served Travis County: 842,000
• Number of Dispatches (2000-2001 Fiscal)
• Total 81,246
• City 67,865 (83.53%)
• County 13,381 (16.42%)

EMERGENCY SERVICES DIVISION

• Communication Medics 36
• Field Operation Paramedics 207
• Special Operations Rescue Paramedics 54
• Paramedic Ambulances 22
• Paramedic Rescue Ambulances 5
• Tactical Paramedic Ambulances 1
• Rescue Helicopter 1 to 2
• Rescue Support/Rehab Unit 1 (Seasonal or event specific)

SPECIAL EVENTS UNITS

• Bike Medics As needed up to 8
• Stand-by Ambulances As needed up to 9

To Fire or Not to Fire

When Austin EMS was created in 1976, a choice had to be made on the structure of the organization: should it be part of the Austin Fire Department, should it be hospital-based, or should it be a municipal "third service," i.e., an independent agency alongside fire and police?

A blue ribbon commission, which included neurosurgeon and lawyer Donald Patrick, MD, and Texas Monthly publisher Mike Levy, guided the decision toward the third-service model. There are many who would say that Patrick and Levy gave the decision a good hard shove in that direction. Levy, in particular, has been a vocal advocate for the third-service model, believing that it is key to excellence in the EMS system.

"The city has a philosophic comfort level with mediocrity. Don Patrick and I bullied the city into excellence," says Levy. Of the Austin/Travis County EMS Levy says, "Both quantitatively and qualitatively, it's the best in the country."

The system began with just thirty-two emergency medical technicians. Current Executive Director Richard Herrington and Assistant Director Gordon Bergh are the only two out of the original group still working with Austin EMS. Herrington was an emergency room technician at Brackenridge Hospital when the new service was begun, and was in the first training class.

"We started out with just EMTs, no advanced life support at all. We could do basic CPR, provide oxygen and first aid and that's all. We weren't allowed to give any drugs," says Herrington.

Within the year, the first paramedic in the system graduated from training, and each year the system added more. In 1996, Austin EMS began the transition to all paramedics, with all ambulance units able to provide advanced life support. In 1999, Austin EMS merged with Travis County EMS, and the system's service area now includes all of Travis County, including the City of Austin.

Despite the system's success, the controversy still rages over whether EMS should be a stand-alone system. Members of The Austin Association of Professional Firefighters (the local employee union), who believe that EMS should be part of the Austin Fire Department, fuel the debate. It's a turf battle based on job protection; currently, seventy percent of fire department responses are medical in nature. The union president even defined it clearly as a turf battle, with little bow to the public good.

Scott Toupin, president of the firefighters' union, wrote on the union's web site, "We can no longer wait for our command staff to protect our jobs-EMS is in direct competition with fire in every area except urban fire extinguishment."

The controversy has become even more heated because of staffing decisions on the new $525,000 Heavy Rescue Vehicle, which has been ordered but not yet delivered. The staffing plan calls for two paramedics on the team, along with several firefighters trained in rescue.

Union members have said that EMS staff on the truck would be "dead weight," despite the fact that Austin EMS has won the Texas State EMT Association Wilderness Rescue Competition at Garner State Park five times in the past ten years, consistently topping the performance of the Austin Fire Department, which also participates.

The union isn't getting any encouragement in their bid to take over EMS. Even Fire Chief Gary Warren thinks it's a bad idea. Neither City Manager Toby Futrell nor any city council member supports the idea. EMS management and the Austin/Travis County EMS Advisory Board think it's a really bad idea.

"In my opinion, we have conflicting missions," says EMS Executive Director Richard Herrington. "In fire department-based systems, being on the ambulance is a temporary way station in their careers. A lot of firefighters don't want to be paramedics. In Austin we have a system that focuses on patient care, that values experience and tenure in the medical setting."

As medical director, Racht is responsible for patient care given by both firefighters and paramedics. Despite the disagreements, both systems work together daily.

"We've always been able to emerge from debates with an understanding of where we are going," says Racht (his emphasis). "There's no fight on the scene over who's in charge. When the public needs us, they don't care whether the fire engine is silver and all the providers are naked. They just want to know that whoever is taking care of them knows what they are doing."

-Karen Leach