Untitled photograph, New Orleans (2013), by Tatum Shaw, from the series "Wonderland Trail"
Dept. of Critical Care
By Peter Andrey Smith
Dr. Norman McSwain (1938-2015)
In the spring of 1862, at the Battle of Shiloh, Confederate general Albert Sidney Johnston was shot in the leg, apparently by one of his own soldiers, while sitting atop Fire-Eater, his thoroughbred. The bullet grazed an artery behind Johnston’s knee. Owing to some nerve damage in his leg, it seems that he did not realize the extent of his injury until it was too late. Shortly after the commander dismounted and his staff removed his blood-filled riding boot, Johnston exsanguinated in a crimson slick, with an unused tourniquet in his pocket. Military surgeons believed the device would have saved his life.
In the ensuing years, tourniquets fell out of favor with doctors and became known as a means of last resort—at best. Until recently, conventional wisdom held that applying a tourniquet only identified the point of amputation; most professionals thought hemorrhage was better controlled by putting direct pressure on a wound. (Problem is, sometimes the bleeding never stops.) It was one of General Johnston’s descendants, a trauma surgeon in New Orleans named Norman McSwain, who helped reopen the debate, crusading for the reevaluation of the tourniquet as a valuable lifesaving tool. In 2006, as the U.S. military began issuing tourniquets again, McSwain took his advocacy further, issuing a call for their widespread use in civilian trauma care.
Last April, I went to see Dr. McSwain at his office on the eighth floor of Tulane University School of Medicine, just west of the French Quarter. It was decorated with certificates and medals, grip-and-grin photographs, a pair of bubbling fish tanks, and a couple of colorful woven Cherokee blankets hanging on the wall. A spry seventy-eight-year-old, he wore one of his customary turtlenecks, with a bear claw necklace dangling to his sternum.
I had hoped our meeting would lay the groundwork for an in-the-wards look at a paradox: Despite the increasing lethality and possession of weapons and the escalating frequency of gunshot wounds, many cities, including New Orleans, had observed an overall drop in homicides. There are many factors and possible explanations, but I was starting to believe that McSwain had a hand in this apparent success story. He seemed inclined to accept that assertion, attributing the declining mortality rates to the work of medics and his surgical staff. “Our ego tells us that it’s because we get better at taking care of gunshot wounds,” he told me.
Not long after my visit, in July, Dr. McSwain suffered a fatal stroke, and we quietly lost an outspoken pioneer of modern medicine.
Norman McSwain had a signature greeting. When he met paramedics, surgical residents, nearly anyone on his trauma unit, he would pose a question: “What have you done for the good of mankind today?” It must have been what McSwain was asking himself on the morning of December 14, 2012, not long after a lone gunman’s AR-15 jammed and the gunfire finally ceased, and the country learned that twenty kids and six adults in Newtown, Connecticut, had died inside Sandy Hook Elementary School. For decades, Dr. McSwain had personally cared for hundreds of victims of gunshots. As politicians and pundits argued about the root cause of the shooting, McSwain wondered about the medical response: Why didn’t more victims survive? The day after Sandy Hook, as Tulane’s hospital hummed and beeped around him, he picked up his telephone and called Lenworth Jacobs, a colleague and fellow surgeon. “Why,” McSwain asked, “do we not have something better?”
McSwain saw penetrating gunshot wounds almost daily in New Orleans. All the evidence he could find suggested that fatalities could be reduced if first responders and bystanders stabilized victims and prevented them from going into shock. McSwain channeled his frustration into action and, in late 2013, he and Jacobs convened a brain trust of surgeons who agreed to make bleeding control—or B-Con—a household name. They pored over medical records and found that, all too often, a short delay in B-Con meant patients with otherwise treatable injuries nonetheless bled to death. McSwain argued passionately for teaching bleeding control to as many people as possible: “teachers and garbage people and golfers, and cops and firemen—anyone.” He knew the response might even transcend the country’s ideological divisions. “Gun control is arguable, it’s political, so many reasons to fight about gun control,” he said. “Stopping hemorrhage is not fighting. It’s motherhood and apple pie.”
McSwain often told people that he was determined to remain active in the three S’s: “Sex, Scotch, and surgery.” He had flown Piper airplanes and remained a hunter into old age. Born and raised in rural Albertville, Alabama, he once told a reporter with New Orleans Magazine that “you can learn a lot listening to the hill-country folks.” He said, “It is good to be a hillbilly or a redneck sometimes. I happen to be both.” Perhaps this was false modesty to mask his immense pride—his curriculum vitae swelled to 111 pages. More than likely, it was his way of coming off as folksy while intensely voicing his opinions.
Over the years, Dr. McSwain established emergency medical services where there were none, first in the state of Kansas and then in New Orleans. He designed training courses and wrote the bible—Prehospital Trauma Life Support, first published in 1986—for how paramedics should treat patients before they arrive at the hospital; the quality of care received in the critical sixty-minute period following an injury, known as the Golden Hour, often decides a victim’s fate. He invented the McSwain dart, a large-bore needle that keeps patients with severe chest injuries alive, and he crusaded against overloading a patient with IV fluids, favoring rapid evacuation and the transfusion of blood.
Rational, empathetic, and completely devoted to trauma care, McSwain once rushed out of his little house on Bourbon Street with a roll of paper towels to aid a stabbing victim. His expertise was unparalleled; he is the only doctor who has ever received all five major trauma awards from the American College of Surgeons. He never retired from teaching or from the trauma ward. The courses he developed have educated millions worldwide and have, as his colleague Dr. Jacobs put it, “saved more people than you can imagine.”
In the months after Dr. McSwain’s passing, I heard stories about bleeding-control kits sent to public schools and tourniquets being installed at airports. The Red Cross updated its first-aid guidelines to include them, and, late last year, the White House announced an initiative to make B-Con a kind of contemporary “Stop, Drop, and Roll.”
I think of McSwain each time debate erupts in the wake of public shootings. As I dug into his correspondence on a listserv for trauma surgeons, I found dozens of posts remembering him as someone who cared equally for patients and paramedics-in-training. A couple of surgeons even wondered if his unique blend of unassuming practicality persisted in the afterlife. What have you done for the good of mankind today? If the question arose, one colleague wrote, “St. Peter—and his Boss—were very well pleased with Norm’s answer.”
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