R Adams Cowley (July 25, 1917, Layton, Utah—October 27, 1991, Baltimore, Maryland) was an American traumatologist and surgeon who is considered a pioneer in emergency medicine and the treatment of life-threatening shock following severe traumatic injury. Called the "father of modern trauma medicine", Cowley first observed what he later called the "Golden Hour" while working as a war surgeon in post-World War II Europe. He noticed that trauma patients who were treated immediately and aggressively had a better chance of survival, especially when the doctors and nurses were specially trained in trauma medicine, than those whose treatment was slow or delayed.
This observation eventually led him to found the Shock Trauma Center at the University of Maryland Hospital in 1962 with a grant from the US Army. When it was established, about 40% of critically injured accident victims survived; by the time he retired in 1989, that percentage had increased to 90%. The Maryland Institute for Emergency Medicine (later the Maryland Institute for Emergency Medical Services Systems, or MIEMSS) grew from the trauma center in the early 1970s and made Maryland the first in the nation to have a statewide EMS system. A 1986 study showed that Maryland had an accident survival rate 2.5 times higher than the national average. The Shock Trauma Center was a model for trauma units, which spread across the country as the impact became clear, numbering 165 centers by 1985.
In addition to the Shock Trauma Center and MIEMSS, Cowley pioneered emergency medicine as its own area of study, the use of helicopters to quickly transport accident victims to the hospital best suited to treat them, and the concept of trauma as a disease. He was a thoracic and cardiovascular surgeon and was one of the first to perform open-heart surgery, and was head and professor of the Division of Thoracic and Cardiovascular Surgery at the University of Maryland. He also contributed to research in hyperbaric oxygen treatment, blood composition theory, and medical devices.
Early life and education Cowley was born in Layton, Utah, on July 25, 1917, to pharmacist William Wallace Cowley and Alta Louise Adams. His father was the first in his family to graduate from college and founded Kowley Drugs in 1919 with his brothers-in-law Spencer Adams and E. G. King. Adams and King later sold their share to Cowley, whose family managed the store until it was bought by Safeway in 1980. R Adams Cowley's maternal grandfather, Rufus Adams, was a merchant, banker, and Utah state senator (1921-1924). Adams told Cowley's mother that, if she named her son after him, he would give her a "wicker baby carriage;" she got as far as writing the first letter before changing her mind. As such, his name birth name is R Adams Cowley, with no period after the R.
Raised Mormon, Cowley was one of five sons; his brothers Stanford, Bill, Kermit, and Hal all pursued careers in pharmacy. In a 1982 interview, he referred to himself as "just a country boy" who broke wild horses in his childhood. He graduated from Davis High School, where he played football and did track and javelin. He told Sun Magazine that he was suspended from Davis five times, and was later expelled from University of Utah, where he was studying on a pre-med track, for playing poker. He finished his degree in 1940, graduating eighth in his class despite the interruption.
Cowley moved to Baltimore to study medicine at the University of Maryland but nearly dropped out due to homesickness. He was drafted into the Army Students Training Program, which paid for his room, board, and tuition, and graduated in 1944. He started training in general surgery at Maryland and spent six weeks at Valley Forge Hospital in Phoenixville, Pennsylvania for additional training. He was commissioned a second lieutenant in the US Army Medical Corps in 1944 and did special officer's training in San Antonio. He was sent first to France, then to Germany, as a military surgeon in the aftermath of World War II. He worked with the 98th Field Hospital in Munich and later Allgemeines Krankenhaus in Vienna. He took note of the speed and accuracy with which European surgeons worked and improved his own skills by modeling them. When he returned to the US, he completed his residency at University of Maryland, then moved to University of Michigan to train in thoracic surgery for two years.
Career
While in the army, Cowley observed that the survival of a trauma patient was dictated by how quickly and aggressively they were treated in the 60 minutes following their injury. He dubbed this the "Golden Hour", a now widely-observed theory that focuses on preventing shock from irreparably damaging the organs by stressing the cruciality of "speed as well as skill in operating procedures." After finishing his training at University of Michigan, Cowley returned to the University of Maryland to teach and do research. By the mid-1950s, he was chair of University of Maryland Hospital's thoracic surgery division, and the chief heart and lung surgeon by 1960. While serving as director of the Cardiopulmonary Lab (1951-1962), he concluded that animals have different responses to shock and that the "approach to shock needed to be multidisciplinary" and had to be tested on humans in situ. He began lobbying for the establishment of a trauma center, claiming that a traditional emergency room was not sufficient in skill, time, or equipment to handle traumatic injuries. In 1958, the US Army awarded him a $100,000 contract to study shock in humans; he used the grant to start the first clinical shock trauma center in the country, which officially opened as part of the University of Maryland Hospital in 1962.
The center started as a two-bed research unit and was referred to by skeptics as the "death lab." Cowley championed the trauma response ideology of "treat first, diagnose later," insisting that patients in emergency rooms died from shock while waiting for doctors to diagnose them. This, coupled with pushback from hospitals and doctors who felt that their patients were being taken away, made the center controversial. Cowley himself was labeled as "arrogant, determined, stubborn, [and] difficult to get along with," a reputation Marvin Mandel referenced affectionately in his eulogy at Cowley's funeral in 1991. Still, Cowley remained undeterred, and the center grew incrementally to 32 beds before the end of the decade. Construction on a new federally-funded facility, including a donated high-pressure chamber in the basement and a dedicated biochemistry lab, was completed in 1969. The same year, after extensive negotiations, the first medevac transport to the trauma center by the Maryland State Police was completed using the helipad on the hospital roof. This allowed not only for a shorter travel time, but also for communication between the pilot and/or onboard physician and the trauma center, giving the trauma team the opportunity and information needed to prepare for the patient's arrival. In the late 1980s, Cowley helped select the type of helicopters he wanted for the medevac fleet. He chose the 365N-1 Dauphin II because it was nearly nine minutes faster on average than Bell Textron's models.
In 1971, State Legislature Clerk Jim Mause was brought to the trauma center in critical condition after a car accident. His successful recovery caught the attention of Mause's friend and colleague Marvin Mandel, the state governor, who met with Cowley to discuss the center. In 1973, Mandel signed an executive order that financially split the trauma center from the medical school, meaning it would receive funding directly from the government rather than receiving a small share of the University of Maryland's federal monies, a decision that drew criticism from the university. This order turned the trauma center into the Maryland Institute for Emergency Medicine and established the Division of Emergency Medical Services; Cowley was made director of both. They were combined in 1977 to create the Maryland Institute for Emergency Medical Services Systems (MIEMSS), making Maryland the first to have a statewide EMS system. It wasn't until 1979, nearly 20 years after the center opened, that anyone "believed that trauma centers made a difference," according to Donald Trunkey. By 1985, Cowley's trauma center ideology had taken hold enough that there were 165 trauma centers in the United States. In 1982, Cowley started the Mid-Atlantic Council, which "allow[ed] movement of trauma cases across eight state lines so patients in any of the cooperating jurisdictions [could] be taken as quickly as possible to the most appropriate center."
The Shock Trauma Center started offering interdisciplinary emergency training on a large scale, including the 1976 Inner Harbor Disaster Exercise, wherein "local police, aviation officials, doctors, hospital crews and others from various emergency agencies" spent three hours working together to identify shortfalls and to prepare for actual emergencies. The training was held during the USA Bicentennial Emergency Medical Services and Traumatology Conference and Exhibition. By 1980, the center had expanded to 54 beds and launched a bachelor's degree in emergency health services, and in December 1985 broke ground on a $45 million, eight-story building. The new, 138-bed building was opened in February 1989, and was officially renamed the R Adams Cowley Shock Trauma Center in May.Baltimore Sun, May 1, 1989. The center had its own rooftop helipad and space designed specifically for recovery and rehabilitation. Cowley retired as director in mid-May 1989 after nearly 30 years. He accepted a role as director at the Mathias National Center for the Study of Trauma and Emergency Medical Services, which had been established by Congress at University of Maryland in 1987 after receiving approval from President Reagan the year before. The Study Center focused on providing information about "trauma prevention, injury control[,] public policy," and national disaster plans for medical teams globally. Cowley also served as a special adviser to Governor William Donald Schaefer.
Between the center opening in 1962 and a 1971 article in The Evening Sun, the unit's "applied research" led the staff to the realization that many of the head trauma deaths they encountered were not due to head injuries but to "metabolic problems triggered by the head injur[ies]." The clinicians were then able to bring the death rate down from 67% to 22% in less than ten years. At the time of his retirement in 1989, the "survival rate of critically injured accident victims" had risen from 40% in 1962 to nearly 90%. A 1986 study reported that Maryland's accident survival rate was more than 2.5 times higher than the national average. In 1991, at the time of Cowley's death, the Echelons of Care network consisted of 49 hospitals with 24-hour ERs, 20 specialty referral centers, and 10 area trauma centers, as well as 450 ambulances and a fleet of medevac helicopters. Marvin Mandel shared in his eulogy of Cowley that detractors of his methods were quickly silenced by the results.
In addition to all of his clinical work, Cowley was also a professor of thoracic and cardiovascular surgery at University of Maryland (1960-1991) and a clinical professor of medicine at Pennsylvania State University (1980-1991).
Other notable research In addition to his work developing emergency medicine, Cowley also contributed to the fields of hyperbaric oxygen treatment, blood composition theory, medical devices, and thoracic and cardiovascular surgery. He was among the first surgeons to perform open-heart surgery and, in 1956, helped design a surgical clamp with John M. Allen called the Cowley-Allen Clamp. He worked on the prototype transistorized pacemaker used by Dwight D. Eisenhower, as well as on artificial blood vessels and heart valves, and self-balancing electronic monitoring systems.