Rob Fowler was born in New Brunswick, on the eastern coast of Canada, a province known for its warm, easy-going atmosphere blended with a history steeped in the great traditions of the sea, with a fishing industry concentrated on Atlantic Salmon, Scallops, and Lobster.  His mother was a schoolteacher and father an engineering technician.  Since eighty-three percent of New Brunswick is forested, it wasn’t out of the ordinary that Rob’s father purchased a plot of land in a rural area.  What was unusual, though, is that his father proceeded to design and build his own house, with his own muscle, from start to finish, for his new family.  He cleared the land, felled trees, processed the trees into lumber at the local sawmill, poured the concrete foundation, and saw the project through to the installation of the very last shingle on the roof. 

It was in this atmosphere that Rob learned his first lesson from his parents:  If you start a project, see it through to the end.  Completing tasks were a matter of family pride.  If you encountered a problem, hard work and resourceful thinking were paramount to overcoming it.  These were characteristics engrained in Rob from an early age. 

Rob naturally favored math and science in school and was the first in his family to go to college, matriculating at McGill University in Montreal.  He soon found himself drawn to medicine, as an extension of the biology, chemistry, and physics that he loved.  At McGill, his world started to broaden, exposed to people from different part of Canada and to different ideas and aspirations.  He settled on Internal Medicine as a specialty and found himself at the University of Toronto, grinding through the stress, scut-work, and nights on call. 

“Probably by my third year, I knew that the ICU would factor into my career, in some capacity.  But I was also thinking, I still have an interest in general surgery and anesthesiology, so my fourth year in residency I did mostly general surgery, anesthesia, and burn unit; a range of non-internal medicine rotations.  It was a terrific year.”  With these electives behind him, his desire for critical care medicine was cemented in place. 

“I would never have believed, growing up as a kid, that I would end up doing critical care in California, at Stanford.  I had a mentor at the University of Toronto that had trained there and felt the multidisciplinary approach to critical care was a little bit different (at Stanford) and they had had terrific experiences there before they came back to Canada.  I started critical care but with a heavy anesthesia-related twist.  I had a wonderful experience in Northern California.  I started getting interested in what would be a bit of an academic career in addition to critical care through exposure to people there who were doing clinical research and asking questions like how something might be done differently or done better, and how would you investigate whether that’s the case, and what would be the methodologies they would use in determining something better or not better.  And that led to me doing a master’s in clinical epidemiology afterwards.  I then came back to Canada in 2002, and I’ve been at Sunnybrook Hospital in Toronto ever since, mostly focused on critical care and clinical research.” 

In the United States, ICUs are mostly staffed by pulmonologists.  In Canada, it’s different.  “In Canada, like New Zealand and Australia, ICUs are staffed by folks that have a background in anesthesia, medicine, general surgery, trauma surgery, and emergency medicine, for example.  And everybody will do two or three years of training in ICU on top of their base specialty.  In addition, ICUs in Canada aren’t typically divided into medical ICUs, surgical ICUs, trauma ICUs.  They are much more commonly combined, and the departments are interdisciplinary.  In Germany, for instance, most ICUs are staffed by anesthesiologists.  There aren’t any internal medicine-based doctors, like in the US.”  Fowler states this heavily influenced his reasoning to take anesthesia rotations in his last year of internal medicine residency. 

Fowler felt his world broadening and in a way his parents couldn’t fathom.  They were born, grew up, and lived their entire lives in the same small, rural area of New Brunswick.  To them, leaving an area where you had put down your roots was unthinkable.  Fowler followed his own path however, going from New Brunswick to McGill in Montreal and then on to Stanford, California, and then to the most populous city in Canada, Toronto.  Although he didn’t know it, he was eventually going international, and a case at Sunnybrook Hospital was about to light the fuse.

“One night I was on call and an infectious disease colleague called me and asked if I would accept a transfer from another hospital who had evolving respiratory failure.”  The patient’s mother had just come back from Hong Kong, became ill, and died ten days later.  “Then her kids began to get sick with a respiratory illness. Over the next few days, one was admitted to another hospital and had been intubated, and one was in the emergency room of another hospital looking like they needed to be intubated,” said Fowler.

At the time, there was only one negative pressure room in the ICU and the ventilation system in that room was broken.  Engineering told him they could fix it in the morning, but Fowler explained it couldn’t wait.  The system was fixed, and the patient was admitted but continued to deteriorate over the next several days.  To Fowler, the disease was infectious and clearly transmissible.  It was also the beginning of his experience with highly transmissible infectious diseases. 

“And so, my boss said, well, you’ve got the (epidemiology) training, make use of it and decide what you’re going to do with the patient in the back hall who is hypoxic.  The only way we seemed to be able to keep the patient’s oxygenation up is to have them on high frequency oscillatory ventilation.”   Mechanical ventilation often provides 12-20 breaths per minute delivered in an average ventilatory volume of 450-500 cc’s, but tailored of course, to individual circumstances.  With high frequency oscillatory ventilation, the ventilatory rate can be 200-300 breaths a minute delivered in extremely small volume oscillations.  Although it was keeping the patient alive, the downside was increasing exposure to this unknown pathogen to the staff, and the nursing and respiratory therapy teams were getting increasingly nervous about transmissibility.  In fact, nosocomial amplification was indeed occurring at the hospital and began to trickle outside the doors of the institution, as staff began to come down with respiratory symptoms despite their best isolation efforts.  As it did so, hospitals in Toronto began canceling elective surgical cases and assumed only the business of admitting patients.  Some hospitals became quarantined and were taken out of the loop altogether.   Through these efforts and other public health initiatives combined with a high index of suspicion for the disease, cases started to slow, and the epidemic began to fade. 

Through knowledge of the SARS outbreak in China, which he had been following, coupled with a high index of suspicion, Fowler assumed the patient had SARS, or Severe Acute Respiratory Syndrome, and this patient’s mother had just returned from Hong Kong, with a respiratory illness no less, and had subsequently died.  “There was great interest from WHO and CDC, and eventually the NIH, in what was happening at Sunnybrook.  We didn’t know it was SARS but we assumed it was.”  It wasn’t until viral sequencing studies could be done in the next few weeks that proved Toronto was under assault by the corona virus that caused SARS.  Patient zero occurred in November 2002 in Guangdong, China.  The epidemic was responsible for around 8000 cases worldwide in twenty-nine different countries around the world, including twenty-nine cases in the United States.  Age was a dominant factor in SARS, with half the fatalities occurring in patients sixty years and older.  Though he was learning on the go, eventually, by applying his epidemiology training and through better containment policies at Sunnybrook, the epidemic was able to be contained. 

“It’s very common to overestimate bad outcomes at the beginning of these outbreaks, because you only know about the patients that are really sick.  Those that are less sick, you may not pick up in surveillance.  You often get a skewed view of the outcomes.  So, there was a push to try to get that part right.  And I was, at that point, one of the only people with clinical epidemiology training in critical care medicine in the city.”  Fowler was very careful to describe the characteristics of the illness, what treatments each patient got, and what their clinical outcomes were not only in an attempt to accurately characterize the Toronto outbreak but to help determine just how dangerous this could be for North America, and possibly the world. 

“So, coming out of the SARS experience, which consumed us for most of the year, was the idea that these things (outbreaks) were going to happen and we should be prepared for them to some degree.  You need to describe the patients you are seeing with a common case definition that you can then apply to other hospitals in Toronto, or Los Angeles, or Singapore, and be able to then help build data among public health organizations, whether nationally, or internationally, like WHO or CDC, and make decisions on what the rest of the world should be doing, including how to treat these patients and what resources are going to be needed.  This is much more important than just doing a case series of five patients who died with SARS.  With SARS, I became more educated on the importance of trying to apply sound, observational research methods to outbreak investigation.  That was my first interaction with CDC, NIH, and WHO because they were very interested in what the experience was like.  There was very limited experimentation from a clinical trial perspective during SARS because people were just too overwhelmed with the outbreak and caring for patients to set that up.  If you want a lesson of the failings of that experience, it was that.  If you are not prepared to deal with something like this, you’re not going to learn much from it.”