Ellison C. Pierce, Jr., MD, affectionately known to so many as “Jeep,” was the cornerstone of the conception and evolution of anesthesia patient safety. His passing on April 3, 2011, at age 82 was a tremendous loss to everyone involved with anesthesia in particular and heath care in general. Patients as well as providers perpetually owe Dr. Pierce a great debt of gratitude, for Jeep Pierce was the pioneering patient safety leader. He made a huge difference in the safety of health care for everyone. A true visionary, he saw what needed to be seen and said what needed to be said. He was on a perpetual mission to prevent patients from being injured or killed by anesthesia care. When he embarked on that mission, he did not know that the impact would extend far beyond the specialty to which he devoted his life.

While he had experienced close calls in the OR like all anesthesiologists, Dr. Pierce did not describe being directly involved in a serious anesthesia accident. However, we have an interesting revelation on one source of Dr. Pierce’s passion for safety from a recollection of Robert H. Bode, MD. Dr. Bode, a long-time, close associate of Dr. Pierce and former vice chairman to Dr. Pierce at the New England Deaconess Hospital in Boston (and currently affiliated with New England Baptist Hospital and associate professor of Anesthesia at Boston University School of Medicine) spoke at the memorial service held at the historic Trinity Church in downtown Boston. He told of how, during the times covered by Dr. Pierce’s early and middle career, the most grievous anesthesia errors causing catastrophic outcomes included unrecognized esophageal intubations and disconnections from the breathing apparatus. Dr. Pierce witnessed the impact of such an occurrence first hand. It involved the 18-year old daughter of one of his friends. She arrested and died during anesthesia for dental surgery after an accidental esophageal intubation, which was not recognized until it was too late. From the way Jeep told that story on a few occasions, it surely was one of several stimuli that provoked him to work toward preventing all such tragic anesthetic accidents. And because he was so dedicated to anesthesiology, he pursued this quest with all of his vigor and dogged persistence because he knew it was the most important thing that he could do for our specialty. Fortunately for all of us, he also had the wisdom and significant political savvy to achieve great progress.

Early “Primitive” Days

Raised in North Carolina, educated at the University of Virginia and Duke University School of Medicine, Dr. Pierce retained part of a southern accent in spite of his decades in Boston. This was clearly audible as Dr. Pierce elegantly outlined his personal history in his memorable 1995 Rovenstine Lecture at the American Society of Anesthesiologists Annual Meeting.1 He recounted how he first gave anesthesia as a resident in July 1954, when the equipment and practices were primitive by today’s standards. Cyclopropane was often used with an IV started only after induction, although thiopental was common and sometimes also used as a maintenance infusion. Tonsillectomy was done with open drop ether and no endotracheal tube. Rectal drug administration was employed and, also, spinals were very common—including for upper abdominal procedures. Intubation was relatively uncommon, and mask anesthesia was even used for thyroidectomy. Controversy raged about the newly introduced class of drugs, muscle relaxants, and prolonged blocks requiring postoperative hand ventilation in the newly created entity called the “recovery room” were not uncommon. Intraoperative monitoring was a blood pressure cuff and perhaps a precordial stethoscope. An ECG monitor was rarely available. There were no blood gas measurements. Introduction of the brand new copper kettle vaporizer led to an epidemic of ether overdoses. Intraoperative cardiac arrests from a variety of causes were not unusual. When a patient died on the table, the family was simply told that the patient just could not tolerate the anesthesia—“too bad.” Estimates of mortality caused solely by anesthesia care ranged from 1 to 12 per 10,000 cases. It was this environment that first inspired Dr. Pierce’s awareness that anesthesia care could actually be more threatening to patients than their underlying surgical pathology. He noted that he agreed with his longtime friend, Dr. William K. Hamilton of UC San Francisco, that “anesthetic deaths” were most likely 90% due to human error.

Dr. Pierce recounted in the Rovenstine lecture¹ his early interest in anesthesia accidents: “In 1962, I became interested in anesthesia patient safety. I had joined Leroy Vandam at the Peter Bent Brigham Hospital as de facto vice chairman. In his inimitable way, one day he assigned me the subject, ‘anesthesia accidents,’ to be given as a resident’s lecture. I still have notes in my files from that talk, which began as a collection of anesthesia mishaps that I knew about personally.” He often repeated his sad disbelief regarding how many patients he heard about from all over the country who were injured or killed by unrecognized esophageal intubations. In the 1970s, when he was chair of Anesthesia at the New England Deaconess Hospital, Dr. Pierce’s interest in safety deepened further when his department was 1 of 4 recruited for the initial landmark studies by Jeffrey B. Cooper, PhD, of the Massachusetts General Hospital and Harvard on the analysis of anesthesia “critical incidents.” Thus, the stage was set for a key coincidence that helped start Dr. Pierce on a path which ultimately birthed a movement permanently changing anesthesia practice and, in fact, all of health care.

“Reality” TV Hits Home

The ABC television program 20/20 aired on April 22, 1982, a segment called “The Deep Sleep: 6,000 Will Die or Suffer Brain Damage.” The announcer opened with “If you are going to go into anesthesia, you are going on a long trip and you should not do it, if you can avoid it in any way. General anesthesia is safe most of the time, but there are dangers from human error, carelessness, and a critical shortage of anesthesiologists. This year, 6,000 patients will die or suffer brain damage.” After scenes of patients who had experienced anesthesia mishaps, the program stated, “The people you have just seen are tragic victims of a danger they never knew existed—mistakes in administering anesthesia.” They showed a patient who was left in a coma after the anesthesiologist mistakenly turned off the oxygen rather than the nitrous oxide at the end of an anesthetic. Later, one of the hosts was told that, “There is a hospital in New York City where there are 2 anesthesia people covering 5 operating rooms.” He appeared incredulous and asked, “How do they do it?” The reply: “Well, they run quickly and pray a lot.” Public attention and reaction were significant, just compounding the already extant “malpractice crisis” in anesthesia practice. Dr. Pierce thought about protecting patients first, doctors second. That was a potentially risky political move but he didn’t hesitate. He just did the right thing.

Dr. Pierce related, “The 20/20 program was a watershed for anesthesia patient safety endeavors. At the time, I was first vice president of the American Society of Anesthesiologists (ASA) and decided to establish a new ASA committee, the Committee on Patient Safety and Risk Management . . . . never before had the concept of patient safety been so specifically addressed by our specialty society.”¹ This appears to have been the first use in this context of the now ubiquitous term “patient safety.”

ISPAMM and APSF

Soon after, Dr. Pierce helped organize and host an unprecedented and important gathering—the International Symposium on Preventable Anesthesia Mortality and Morbidity in Boston. Strongly stimulated by that energetic assemblage, Dr. Pierce conceived of the idea of the Anesthesia Patient Safety Foundation (APSF). Through his charisma, political know-how, patience, and persistence, he created and was the first president of the organization that has been the beacon for patient safety in anesthesia and far beyond.

Through APSF and his many connections in the world of medicine, Dr. Pierce’s vision was moved forward to become what is now a global movement to prevent needless injuries and deaths from errors both human and system-induced. He was an attractor, someone we all wanted to help to accomplish his goals. When he assembled the nimble independent team that would build the APSF, he was inclusive and strategic. Beyond anesthesiologists, the original Board of Directors included lawyers, pharmaceutical and device manufacturers, a biomedical engineer, risk managers, nurse anesthetists, malpractice insurers, and representatives from the Food and Drug Administration, the Joint Commission, the American College of Surgeons, and the American Medical Association. As Dr. Pierce noted, such diversity of stakeholders certainly was not possible in the structured environment of the ASA at that time. He knew just how far he could go, just what kinds of people together were needed to do the job.

Dr. Pierce wasn’t the one with all the detailed ideas. Yet, he instantly could spot a good one. And, he made the person who had it feel like a genius. He was generous and sincere with his praise; yet he wasn’t looking for it himself (but he received a lot of it, including many recognitions of his pioneering efforts). He was happy and satisfied in himself to see the good work being done—the APSF Newsletter informing and educating the entire community of anesthesia professionals, the research grants program supporting patient safety research for the first time ever and yielding some truly groundbreaking insight and innovation, the catalysis of new technologies, the development of high-fidelity mannequin-based simulation and teamwork training (focused both on human error analysis and crisis resource management), and the innumerable special projects that came from APSF during these past 26 years—all the result of an organization that was built from Dr. Pierce’s astute sense of people, diplomacy, and timing. Further, as immediate past president of the ASA in 1985, Dr. Pierce participated in the creation of the ASA Closed Claims Project that persuaded several malpractice insurance companies to open their files for analysis of what caused anesthesia accidents. In subsequent years, that project yielded several important studies contributing directly to safety improvements.

Visionary Success

While the exact statistics can be (and are) debated, there is widespread recognition that anesthesia care, particularly in the USA but also throughout the developed world, has become much safer for the patient over the last 26 years. Contributing to this dramatic improvement have been many factors, including especially the practice standards and protocols started at Harvard and expanded by the ASA that Dr. Pierce supported so strongly, but all of the factors together relate back to the original drive by Dr. Pierce to implement the simple idea that is the APSF’s vision: “that no patient shall be harmed by anesthesia.”

In his Rovenstine lecture,¹ Dr. Pierce emphasized how extremely proud he was of the fact that at the 1995 ASA meeting, there were 139 scientific papers presented in the section featuring patient safety, and that a mere 10 years previously, the topic existed nowhere on the program. Building to a conclusion, he characteristically exhorted, “Patient safety is not a fad. It is not a preoccupation of the past. It is not an objective that has been fulfilled or a reflection of a problem that has been solved. Patient safety is an ongoing necessity. It must be sustained by research, training, and daily application in the workplace.” He was very concerned that production pressures and cost concerns “could easily undo many of the gains that we cherish so highly,” but he concluded his epic and riveting presentation with, “Patient safety is truly the framework of modern anesthetic practice, and we must redouble efforts to keep it strong and growing.”

Well-Deserved Recognition

Among the numerous honors Dr. Pierce received, perhaps the most meaningful was his induction as an American into the prestigious Royal College of Anaesthetists in the UK. Also, he received a special citation from the Food and Drug Administration for his work, and received awards from the Royal Society of Medicine (UK), the American Medical Association, and the Russian Society of Anesthesiology. Dr. Pierce spoke on the topic of anesthesia safety across the US, as well as in Japan, Russia, and also various cities in Europe, South America, and Australia. He is known to anesthesia practitioners the world over for his appearances in safety and training films (many of which he helped produce) sponsored by the FDA, the ASA, and the APSF.

Dr. Robert K. Stoelting, MD, current president of the APSF, at Dr. Pierce’s memorial service, summarized several tributes he had received honoring Dr. Pierce, including one from E.S. “Rick” Siker, MD, the first APSF secretary and then executive director who commented, “I am comforted by the knowledge that he made an indelible mark on American medicine and that his contributions will never be forgotten.” Also, Mr. Michael Scott, the long-time ASA legal counsel added, “It was a privilege to work with Dr. Pierce on the formation of the APSF. As ASA counsel for many years I worked closely with a succession of dedicated, able leaders of the specialty, but none displayed the intense sense of singular mission at all hours of the day and night than did Dr. Pierce with respect to improving patient safety. He was truly an uncommon man.”

James F. English, MD, who succeeded Dr. Pierce as president of Anesthesia Associates of Massachusetts in 1998, spoke of his close friend and mentor at the memorial service. He lauded Dr. Pierce’s remarkable successes and continued, “Jeep didn’t accomplish all this by being a shrinking violet. He had a very strong and distinct personality. He knew how to get what he wanted, and one of his main tools was his skill in communicating. Jeep was very erudite and articulate and he reveled in being descriptive. For example, one of his pet peeves was false piety. When he encountered it, he relished using the word sanctimonious. . . . it would roll off his tongue, often preceded by an interesting adjective and always followed by a colorful noun.” Dr. English recounted one of his favorite stories of Jeep: “ A young doctor joined us who had all kinds of ideas about how Jeep’s beloved group and hospital could be improved. Jeep disagreed with every suggestion, at first politely but with increasing vehemence as this doctor persisted. A few times he even had to resort to his patented rebuke: ‘YOU CAIN’T DO THAYAT!’”

Dr. Pierce was also eulogized by Dr. Bob Bode, who shared illuminating personal insights: “Briefly, I would like to describe the Jeep Pierce I grew to love and respect. Jeep was impeccably honest, had a great sense of humor, and was a wonderful mentor to me and to many others. He treated everyone with dignity and respect, whether you were a senior physician, nurse anesthetist, anesthesia technician, orderly, or receptionist at the Prudential Towers. Jeep was also an iconoclast, a rebel of sorts, who basically did not care how others felt about him as long as he knew in his heart that he was doing the right thing…. Jeep was a great leader whose style was always deliberate and he often raised his voice for effect. He was a highly respected man, but many nurses at the Deaconess thought that he could be intimidating at times. Jeep would deny this.”

Dimensional Diversity

Despite his intensity about patient safety, Dr. Pierce was far from unidimensional. He had other loves as well—surely the most for his late wife, Elizabeth, and his children Chip and Wendy, and his 3 grandchildren. Also, in a social moment, he’d reveal his passion for large pipe organs and their magical music, including the one at Boston’s Trinity Church where his memorial service was held. He traveled the world to see the special ones. Functionally a “renaissance man,” he loved opera and architecture, too, but especially history. Winston Churchill was his hero; he read all he could about the great leader and statesman (and displayed a Churchill bust in the vestibule of his apartment, a gift from the APSF on his retirement as president). Dr. Pierce always had a delightful sense of humor and contagious laughter, and he was quick to help others, even when he himself might have been in need.

Passionate, persistent, patient, jovial, charming, and dedicated completely to a cause he believed in, he was an inspiration to all of us. Dr. English rightfully labeled him “transcendent” (“surpassing; extending or lying beyond the limits of normal experience”). Ellison C. Pierce, Jr., MD, was truly a “great man.” He has left anesthesia practice an order of magnitude safer and the world generally a better place. We do and will miss him enormously.

Dr. John Eichhorn, Professor of Anesthesiology at the University of Kentucky, was the founding editor of the APSF Newsletter and remains on the Editorial Board and serves as a senior consultant to the APSF Executive Committee. Dr. Jeffrey B Cooper, Director, Center for Medical Simulation and Professor of Anaesthesia, Harvard Medical School, Boston, MA, is Executive Vice President of the APSF and one of the founding members of the Executive Committee.

Reference

1. Pierce, EC. The 34th Rovenstine Lecture: 40 Years behind the Mask: Safety Revisited. Anesthesiology 1996;84:965-975.