The Call Doctor Story - Part 1
The history of Call Doctor - The idea and evolution of the Call Doctor concept - Part One in a series
By Doctor Gresham Bayne

Chapter One - The Beginning:

The shrill scream of the long-range pager broke my snooze in front of the television at the University of California School of Medicine's call room for LifeFlight physicians. The Celtics were losing a play-off game (again) and I was bored stiff. LifeFlight helicopter physicians are required to be on the pad ready to load in five minutes, so we had to spend week-ends at the Medical Center waiting for 911 calls. This one seemed stupid, in that we were flying to downtown San Diego (about three minutes) to pick up someone injured in an industrial accident. Generally, ground transportation would be used when that close to the trauma centers in town, but for some reason, the helo team was dispatched.

Fifteen minutes later I found myself forty feet above the Alouette helicopter parked in the street, at the top of a fireman's ladder with my gloved right hand inserted into the buttocks of a dying man. I could feel his pelvic bones and its heart-shaped ring where the impaled tine of a giant fertilizer-mixing machine was hung up. I had already amputated his right leg above the knee with a pair of bandage scissors, quickly dissecting the shards of crushed femur that had only moments before constituted his thighbone. The firemen had made a two-purchase pulley and were pulling him off his perch...a six inch pipe made to rotate its affixed metal tines to mix fertilizer, but this time having caught the cuff of the workman's trousers, it had wrapped his right leg three times around the pipe and inserted his flattened foot into the remains of his right thigh. His left leg, with an open fracture exposing the two bones of his shin, hang uselessly below us dripping the remaining red blood cells he might have into the fertilizer below.

Roberto was barely alive, having no pulses and moaning gently with an occasional Hispanic phrase. Good thing people in profound shock really don't experience pain, because there was no time for anesthesia, nor did we have any. My problem now was, as the firemen were grunting with the strain of hoisting him, the ten-inch "T" shaped tine was hooked inside his abdomen on the pelvic ring.

Feeling blindly, and trying not to slip off the slanted metal chute to the concrete slab two stories below, I finally managed to spin his skewered body around and disengage his pelvis. As expected, the compression effect of the wrapping of his lower torso and leg around the six-inch pipe release, Roberto lost all signs of life and hemorrhaged out of the torn femoral artery in his leg.

Fortunately, that day I was flying with perhaps the most experienced and wisest flight nurse in the country. Phil Moomjean, currently Flight Nurse Director of Critical Air Medicine, the largest private air ambulance company in America, was my teammate, and he had the foresight (since the fire Scene Commander would only allow one of us up to the precarious perch) to fly back to UCSD and bring four units of universal donor blood.

The firemen, using the advanced training and discipline so rarely needed, but so critical in times like this, lowered Roberto's lifeless body down in a Stokes stretcher to the street where Phil began pumping blood back into him all the way to the operating room some eight to twelve minutes away.

Chapter Two - The Idea:

That was in 1984. Today, Roberto walks on his healed left leg, a hindquarter prosthesis, and crutches. He is quite wealthy having recovered millions in the lawsuit brought by his attorney, Patrick Fregas (now serving ten years in jail with two San Diego Superior court judges convicted of taking his bribes). I still have guilt about the fleeting thought I had during the resuscitation that he was probably illegal and was going to cost the taxpayer a fortune in rehab; turns out he was a naturalized American working his way through school and spoke fluent English when he wasn't in hemorrhagic shock.

What I remember most about this flight was the inappropriate credit I got for "saving his life." This was the most obvious decision I think I have ever made in decades of emergency medicine: he was about to die unless we could get him extracted from the horrific attachment he had made in the mixing machine. Any fool would have known that, and being the only doctor on scene, it was appropriate I perform the logistics, for which no real training, including three years of general surgery residency at the world's largest military hospital and an emergency residency at Georgetown, could have prepared me. The more serious most medical decisions are, the more obvious the right answers become. This was my first realization that the simplistic dream I had been formulating, that of bringing emergency care into the home, was more complicated than I thought.

The real hero of Roberto's survival is "the system." By that, I mean a system involving complex machines (helicopters), communications (the multi-million dollar dispatching center created by UCSD), trained personnel (although Phil Moomjean RN is definitely a cut above any clinicians I have ever met, and is the person most responsible for Roberto's survival), and the entrepreneur/organizers who trained them (Dr. Bill Baxt as Founder of UCSD LifeFlight fought all sorts of political battles to bring helicopter medical evacuations, long in use in other major cities, to San Diego).

What if the helicopter had needed to refuel before going back to the Medical Center for blood? What if Phil Moomjean had not had the training and experience to suggest on his own that, given a prolonged extrication and the obvious massive blood loss, maybe he could go get some blood to save twelve minutes on the "time to initial transfusion" in that first "golden hour?" What if the pilots had not been trained and ready, the doctor's kits hadn't had the right sized gloves, the flight kits hadn't had metal (and bone) cutting scissors? What if there was no way to communicate with the dispatch center to get the blood to the flight deck so they could "scoop and haul?" The list goes on.

If I were to recreate the capacity to treat emergencies in the home, and thereby be able to do most anything else short of major surgery, I definitely would need some equipment.

Chapter Three - The Equipment:

March 3, 1985 "Big Bertha" rolled off our production line in Chula Vista. We picked the Ford Econoline 350 extended van because the engine block could be supplied by local parts in virtually every civilized city in the world. To provide power to the $50,000 of medical machines in the back cargo area, we cut out the bottom of the van and welded in new structural supports around a side-mounted, 6kw Onan generator. A potable sink provided a place to wash hands and discard hasmat fluids into a gray water tank underneath. Being a mobile darkroom, the van was able to support X-ray processing from films taken with a portable X-ray machine weighing 195 pounds and wheeled in on a $1500 dolly. To mount the X-ray film processor, we had to buy our own metal machine shop and invent a "Jacob's vise" type of arrangement to customize a gimbaled surface upon which the three vats of liquids (including picric acid) used in X-ray processing would remain level at all times.

Nothing worked. With Big Bertha proudly parked in my driveway, I was able to trouble shoot after each of the first 250 housecalls showed where the problems were. The first X-ray machine was so heavy (the minXRay had not been invented yet) the metal tracks and electric lift mechanism we invented to get it out of the van were constant problems. The first EKG machine ran off 9-volt batteries using a heat stylus, which quickly deteriorated in the arid internal van environment during San Diego summers.

The first chemistry analyzer, the Seralyzer made by Becton Dickinson, had an idiosyncrasy that even their corporate engineers could not solve. Keeping the calibrations of the delicate instrument required about six hours of testing using expensive reagents and controls for each of the some 16 lab tests we could do. The machine received power from a shore power cable plugged into my garage, or transferred over to the van generator. Whenever the transfer occurred, or we lost power for even a microsecond, all stored information on calibration and controls was instantly lost. One day, I went out to drive the van on a housecall, and my seven year old son had unplugged the shore power cable to make room for his basketball game in the driveway!

Despite all the technical difficulties (Big Bertha has caught on fire twice!), the essential lesson was driven home: I could drive the van to a patient's house and perform almost all of the tests an emergency room physician does for about one-tenth of the cost. The real lesson, however, were the patient responses.

From 1985-1987, we let it be known (having no advertising budget) that we would be able to make housecalls 24 hours a day, 7 days a week, in Point Loma, my little community. "We" included Dr. Kirk Raeber, perhaps the most admired emergency physician in San Diego, who is still practicing in the emergency room at Scripps, Chula Vista. Kirk had succeed me as Chairman of the Emergency Department at Balboa Naval Hospital and won the "Stitt Award," given by the residents of all specialties to the physician who contributed most to their teaching and education. I had tried to win that award for over three years unsuccessfully, so having Kirk agree to cover 'port and starboard' (Navy slang for covering when I wasn't able), was a real privilege.

My family generously contributed $50,000 to match a local engineer's contribution to build the first van, (along with some $300,000 in donated engineering), and I promised Kirk I would pay him $25 an hour when on call, whether he had to make housecalls or not. Exercising my fledgling business acumen, I had neglected to think that my hourly wage being on call for LifeFlight was about $18 an hour. The result was it cost me about $7 an hour to moonlight in my LifeFlight capacity, while Kirk was home in bed or tending to his ranch!

After the first six months we had seen very few patients, mostly through word of mouth at the Point Loma Presbyterian Church (Presbyterians have always been risk-takers), and Kirk refused his $22,000 first paycheck for being on call. His rationale was that he didn't do anything. My rationale was that his association and support was invaluable, that a deal was a deal even if only on a handshake, and that some day the issue of trust was sure to raise its head. The latter comment was to be prophetic.

Chapter Four - The First Patients:

The first real patient (other than family and assorted friends who soon learned our house was a good place to get medical care), was Clare Tavares, after whom Claremont, a section of San Diego, was named. I had met this distinguished patron of the arts in La Jolla, through the USCD Foundation, and she loved the idea of knowing a doctor who made housecalls. Around the time I first thought the van was finally reliable, she fell at home on the top of Mt. Soledad. Parking the van in her steep driveway convinced me all the hours engineering our Jacob's vise for the X-ray processor were worth it. The exam suggested a pelvic fracture, especially since I was able to see exactly where, how far, and upon what hard surface, she had fallen. The X-rays confirmed a Type I, non-displace fracture of a pelvic bone, and the lab tests proved no bleeding (often a serious complication of such injuries) or kidney damage had occurred. I placed her on bedrest in her elegant home, gave her some strong pain pills, arranged for supportive care through her myriad of social contacts, and left her quite delighted to be CallDoc #1.

Early in the fall of 1985, a dramatic event occurred, which pointed out both the power and the risk of such an undertaking. Judge _______ is a retired San Diego judge (known for refusing to issue speeding fines in the year Governor Ronald Reagan was stopped while speeding but did not get ticketed), and, as a survivor of the Bataan Death March, a true Member of the Greatest Generation. Late one night, with the van conspicuously parked in my driveway, his wife awoke me banging on the front door. "Can you come quickly, he's fallen unconscious in the shower, PLEASE!"

We hopped in the van and saved her the one block walk down the alley to his home. He had passed out in the shower, was now awake, but had an alarming history of chest pain. The 12-lead EKG (probably the first ever taken in history in such circumstances) suggested an acute cardiac event, so I gave him nitroglycerin and called 911. He, indeed, turned out to have ischemic heart disease, but is probably out gardening in his beautiful Point Loma yard as I write this today. But how differently this could have turned out.

What responsibility did I hold in representing to the public, even passively by letting it be known what this van could do, that I could do EKG exams and such in the privacy of your home? How serious is the public's antipathy to hospitals and emergency rooms, especially 911 ambulances, such that they would avoid the obvious decision to call 911 and run up the street to bang on my door? What if the EKG machine didn't work? What if my nitroglycerin was out of date (nitroglycerin tablets tend to decay and become worthless in six months with exposure to sunlight)? What if I wasn't board-certified in emergency medicine and was just some general practitioner with an iconoclastic bias?

Clearly, some lines needed to be drawn.

My most unforgettable patient was Capt. Sigmund Alfred Bobczynski, skipper of the USS "Archerfish" and the man who fired the six torpedoes that sank the Japanese aircraft carrier "Shinano", the largest ship ever sailed in history till that time. Capt. Bobscynski had seven children, all of whom contributed to the origination of Call Doctor. Bob, the oldest son, built the first four vans with his brother Tom and still has the machine shop where he invented all sorts of solutions to technical problems during the early years. Jane, the eldest daughter, took pictures of the van and early patients, which are used in promotional materials to this day. Michelle created the first logo, constructed presentations, advised in all things graphic, and along with her equally talented husband Glenn helped sorting out many computer problems on the basic Mac computer we used to type up the first health records.

So many people ask why I gave up a lucrative career in emergency medicine or surgery. The answer lies somewhere in what my relationship with the Bobczynskis became. Capt. Bobczynski was, like my Dad, the strong WWII veteran and leader of men. Yet, for sixteen years I took care of him, mostly at home, during one medical crisis after another, watching him gradually succumb to the ravages of disease. Usually, for some reason, he would have a crisis on a national vacation day.

One Christmas morning, his wife Jane called me at home (the doctor-patient relationship in a housecall practice quickly ramps up to an intimacy best documented by the doctor's decision to give out their home phone number) saying he was having severe abdominal pain. I left my wife and small kids unwrapping presents and drove the van the one mile to his house. Feeling a painful, pulsate mass in his upper abdomen, I quickly called 911 and the vascular surgeon (Dr. Brent Eastman, now head of the Scripps medical groups), asking him to meet the ambulance in the emergency room. A ruptured abdominal aneurysm can kill in seconds and my original diagnosis was that he was "dissecting," or about to rupture. The excellent Scripps surgeons and staff met me in the ambulance at the front door and immediately took him straight to the CAT scanner, showing a large aneurysm that fortunately was not about to rupture. Three days later he came home, after it became clear to all of us that he had had a small heart attack, masquerading as an aneurysm about to pop. The value of being in that ambulance with my ability to give the surgeons a credible history would have been inestimable, had he truly been rupturing. As it turned out, the only sequelae of the heart attack was the frequent dangerous heartbeats he had had for years stopped: he must have infarcted an irritable center in his heart that might have caused him to fibrillate in the future.

Two years later, on a routine follow up visit to "The Captain," I asked him if he had had any angina pains recently. "Nope," said the stoical war hero. Overhearing us in the kitchen, his wife Jane shouted out "That's not true! You woke up last night with chest pain... remember?" This variant of chest pain, called Prinzmetal's angina, is a very alarming sign, and prompted by the life-saving comments of his wife, I was able to admit him and arrange for his quadruple bypass four days later.

Many further years and exciting housecalls later, I made my last call to The Captain. His heart failing, lungs compromised, and now in total kidney failure, he lay weakly on his deathbed. The seven children and Jane were in various stages getting to the house upon my recommendation that "the time is near." As I knelt by his bed for the last time, this crusty old sailor, this huge man of history who sank the largest warship ever sailed, this devout Catholic who feared nothing, including death, had beckoned me closer to hear his weakened whisper: "You did a good job" was all he said.

It was not the first time I have cried at the bedside, nor the last I hope. What kind of nobility does it take, such that a man thinks to reward his physician with a compliment from his deathbed? What depth of relationship is attainable between a doctor and patient? What kind of a practice have we created that can reduce an ER doctor, who once cut off a man's leg without either anesthesia or emotion, to a blubbering hulk at the bedside?

I wasn't much better at the funeral.