In the first part of this series I chronicled how the challenges posed by the distance and isolation of our community and rural hospital led our town and medical staff to create a functioning air ambulance service. This service would help us defeat that great enemy of all trauma patients: time to definitive care. It is also notable that our first and most memorable transport originated in the most isolated and challenging area of our county in terms of ease of travel and communications.
Even today, with improvements in satellite assisted communications and increased cellular towers, there still exist significant communication dead spots throughout the region known as Browns Park. Another complicating variable at the time was the mechanism of injury. The lifesaving actions taken by the family and first responders set up a series of hemodynamic and pathophysiologic processes that obscured the correct diagnosis upon reaching the hospital. That process would put the child’s life in peril days later, and required the services of our newly minted air ambulance system to save life and limb.
A Memorable Flight to Save a Young Life
Our story starts at the end of a crisp October day, in a valley nestled between the Cold Springs and Diamond mountains and bisected by the Green River as it makes its way to the confluence with the Colorado River. For centuries this valley was a gathering spot for Native Americans, mountain men, trappers, ranchers and even outlaws, all of whom admired not only its natural beauty and serenity, but also enjoyed its complete isolation from the outside world. Early settlers called the valley Brown’s Hole, named after a French-Canadian fur trapper who lived there in the early 1800’s. However, John Wesley Powell, an American geologist, U.S. Army soldier, and explorer, recorded this unique valley as Browns Park in his journal shortly after beginning his historic river exploration in Wyoming in 1869, and that name has stuck to the present day.
In one of the several ranch houses located in Browns Park, the evening meal had just finished and an eight-year-old girl, who we’ll call Annie, was helping her mother with the dishes. Annie’s job was to dry the dishes one by one as they came out of the dish pan and then put them away. At one point, she carefully picked up a large butcher knife with a sharp thin blade, worn that way from years of sharpening. The handle was oak, smooth and well-polished from generations of family cooks using it to cut bacon and other fatty meats, which had permeated the wood’s open grain and given it a well-worn shine. However, that fat-finished handle had made the knife a bit slippery, especially when it was wet.
The family’s carving knives occupied a spot on the wall, housed in a square wooden case with a long and thin horizontal slot at the top. The case had an open front in the middle to display the blades while the points were protected in a closed section at the bottom. It was a bit of a reach for the little girl to put the knife in the case, but if she pinched the knife handle between her thumb and forefingers with the blade pointing down while standing on her tiptoes, she could get the point of the blade into the slot and allow it to drop into place inside the wooden case. She had executed this maneuver many times before, but this night, either because she was tired or feeling rushed to get the dishes done, she did not lift the knife point quite high enough to align it with the slot. When she released the knife, it plunged downward point first, deep into the outside of her thigh. Blood immediately shot out of the entry site and was forceful enough to spray across the floor.
Annie’s startled but quick-thinking mother immediately removed the knife and attempted to stop the hemorrhaging with her hand. Her equally surprised father sprang into action and grabbed a dish towel to apply pressure over the wound. At first it took most of his strength to control the bleeding while his wife used their phone – one of the few telephones in the area – to call the ambulance in Maybell, a small town some 60 miles southeast. Little did Annie’s dad know that he would have to maintain manual pressure on the wound until help arrived an hour and a half later. And no one could have ever imagined that his life-saving maneuver, along with the later actions of the first responders, would set up a series natural clotting and healing mechanisms that would, unfortunately, mask the true extent of the original injury and alter the care delivered to Annie at the hospital.
After fielding the call from Annie’s panicked mother, the Maybell volunteer ambulance crew responded in record time, navigating the narrow, winding road to Browns Park in the dark. Caution was always the watch word on this road at night because the road had a soft and unforgiving sandy shoulder with steep sides that had rolled many a vehicle. This was also open range and frequented by critters of all sizes that constantly crossed from one side of the road to the other looking for food and water. The ambulance crew had made numerous trips before this one to pick up motorcyclists and unlucky motorists that had collided with large ruminates both wild and domestic in the dark.
Following previously set protocols, the crew communicated with the hospital in Craig and relayed all of the details they had obtained from the mother before they passed into one of many communication dead zones on the route. To the emergency room (ER) personnel, myself included, the details of this call sounded potentially fatal if not corrected, so we alerted our surgery crew and anesthesia to set up and stand by. I also contacted my partner, Raymond G. Witham, MD, who at that time had been the hospital’s surgeon for more than 20 years.
Dr. Witham had focused extensively on surgery during his generalist training at Presbyterian/St. Luke’s Hospital in Denver before entering practice in Craig, Colorado in the mid 1950’s. Though technically a Family Physician, he primarily performed surgery at our hospital. Many of the prominent surgeons in Colorado at that time had been Dr. Witham’s classmates during their internship years and he enjoyed much support amongst the state’s surgical community. In the operating room, Dr. Witham was indeed a skilled and experienced surgeon who was always measured and cool under fire. He was a great teacher and wonderful mentor to me, and just the person I would want by my side in a potentially serious trauma situation like this.
Upon reaching the ranch house, the ambulance crew reported in by telephone with the good news that the father’s efforts to stop the bleeding using just his hands and a towel as a pressure bandage were partially successful. The bleeding had slowed to a trickle when released, but if left unattended it would gradually pick up again. This was also a time in medicine when tourniquets were viewed as last resort measures, and thus were not considered in this situation. For the trip back, the first responders instead applied a full leg air splint and inflated it to max, thereby mirroring the father’s manual pressure to control the bleeding.
Once Annie had been transported to the ER, we carefully deflated the air splint and exposed the wound. We had expected it to begin bleeding immediately, but it didn’t. Gentle exploration of the small one-inch wound also elicited no bleeding and circulation appeared to be intact to the foot and toes. The small wound was closed and a bulky gaze dressing was applied with a bias-cut stockinet to provide some gentle pressure. All of us in the ER were deeply puzzled by this event, because nothing seemed to add up. In light of our concerns, we admitted Annie for several days of observation before discharging her to return to Browns Park.
“What had we just witnessed?” I thought to myself. All of the history we had taken and the mechanism of injury had pointed to a major vessel injury, but the course after admission did not support that premise. We certainly didn’t need to explore the wound when it was not actively bleeding and appeared stable. I couldn’t keep from myself thinking about the rule I had learned as an intern: the more accurate the preoperative diagnosis the more successful the surgery will be. In this case, we had little to go on and certainly no firm diagnosis, so we decided it was best to wait and observe. We never expected at the time that the answers to all our questions would become all too abundantly clear a week after discharge, when Annie returned to our office for a recheck.
During that recheck visit, Annie’s mother said that after discharge, her daughter had returned home and resumed normal activity. Annie appeared to be totally fine, but just the day before this visit, they had both noticed a small lump on the inside of her thigh located opposite from the knife’s entry point, which was on the outside part of the thigh. The lump was not painful, but curiously enough, it had a definite weak pulse. Dr. Witham’s evaluation determined that this was a hematoma caused by a small active bleeding vessel that had not completely clotted off. He had only seen one other hematoma like this in his practice and it required exploration and ligation. Since we were not certain of our diagnosis, we both agreed it would be best to explore the lump and ligate the offending vessel in the controlled setting of the operating room (OR).
In the OR, we carefully dissected through the tissue to the level of the lump, which appeared to be encapsulated in the surrounding muscle. When we spread that muscle layer apart in search of the hematoma, blood immediately sprayed out of the wound with enough force to nearly hit the operating light. Instinctively, I pushed through the drapes to where I had determined the femoral artery pressure point would be, and that thankfully slowed and then stopped the bleeding. However, each time I released pressure, blood would well up rapidly and obscure the bleeding site. We cut down on the femoral artery upstream of the bleeding site and cross clamped it with a small spring-loaded vascular clamp. For the next hour, we earnestly tried to identify the bleeding source, but each time we released the clamp, blood would immediately well up faster than our suction could keep up with. The rule I had learned as an intern was true, and we were failing to correct this problem because we had failed to make an accurate pre-op diagnosis. It was now abundantly clear that we had a lacerated femoral artery with no good way to correct it.
In a measured and steady tone, Dr. Witham said, “Tom, I think it’s time we used that air ambulance of yours. I’m going to call Denver and explain our situation, and let them know you are coming. We will dress our operative site with a thick absorbent dressing while leaving you clean access to the vascular clamp. Every 30 minutes or so, with your sterile and gloved hand, I want you to gradually release the clamp on the artery without removing it and let the foot pink up for a time, and then close the clamp again. It will, of course, bleed into the bandage, but reinforce the dressing if you need to. We will send a generous supply of blood with you to give to the patient when you feel she needs it. While you are getting that going we will call in donors and collect an ample supply of blood to send with you for the trip.”
We did not have a blood bank in Craig at that time, and instead relied on a system of walk in blood donors whose blood types and antibodies were well known to us. When their blood type was needed they would come to the hospital day or night and donate their blood if it matched the patients. With cases in urgent need for blood, most of our physicians would donate a unit of blood to their patients if they had a compatible match. Using walk in donors is totally unthinkable now-a-days, but at the time it was the best our community could do and it worked out well. Before long, I had three units of compatible blood, which was more than enough for the trip, but acted as a buffer if we had more unforeseen bleeding complications.
On the airplane, our OR circulating nurse assumed the role of the flight nurse and I occupied the seat most near the affected leg, making sure I had enough room to access the clamp and bandaged wound. All of our gear and monitoring equipment were loaded onto the plane, which took off on a chilly morning flight over the Rocky Mountains. Throughout the trip the OR nurse and I went through the routine that Dr. Witham had suggested, releasing the clamp and allowing the foot to pink up, then closing off the vessel and reinforcing the dressing to keep it clean. When vital signs dipped, we administered blood in measured quantities to bring them back to normal.
As we cleared the last snow dusted peak of the Continental Divide and began our decent into Stapleton Airport, the pilot turned back to me and said, “Hey doc, this is a pretty serious thing, right? I’m going to call the tower and tell them we are a Life Guard Flight and they need to get us down as quick as possible.” I readily agreed because we did not want to keep this routine up any longer that we had to.
I could see the airport off in the distance through the side window of the airplane, and two layers of large commercial aircraft circling above the airport in their respective landing patterns waiting to land. Our pilot made the call. “Denver Tower this is Life Guard, November 65 Romeo requesting priority to land”. Without hesitation, Denver tower replied, “Affirmative 65 Romeo we have your ambulance waiting at Combs Aviation.” What followed would be a sight that has stayed with me to this very day.
It was as if I were watching a well-rehearsed water ballet where the participants were airplanes rather than swimmers. The circling aircraft lifted up almost in unison to positions high above the airport, making a clear path below them for us to land. Our humble, rural air ambulance and its precious cargo touched down, rolling past the giant aircraft parked on the ground and right up to the waiting ambulance.
When we arrived, the hospital was ready for us. Annie and I were shuttled right up to surgery where Dr. Tom Early, the vascular surgeon, was waiting. The preoperative routine and debriefing went quickly and smoothly. Without further delay, Annie and I were back in surgery. However, we were not out of the woods yet, for though the geography may have been different the problem remained the same. We again struggled to identify the illusive bleeding site from what clearly had to be from the femoral artery.
Finally, after more than an hour of tediously dissecting out a large portion of the artery, we found it. The knife had entered the vessel low and though the side and then passed through the lumen of the artery to the other side forming two flap-like wounds. Over time, this facilitated the formation of a pseudo aneurysm that had allowed for continued flow of blood, as well as a bleeding site nearly impossible to detect from a classic surgical approach.
At one point during the surgery, a young surgical resident poked his head in the door and said, “what happened? Heard a hick town general practitioner in Craig tried to fix a femoral hernia, and instead got into the femoral artery?” The OR went completely silent as all eyes settled on me. The resident also sensed that his comment had not received the reaction he had intended. I certainly was not offended and was actually a bit amused at his comment, so I kept silent. In a measured voice, almost identical to Dr. Witham’s tone earlier that morning, Dr. Early said, “No, this was a very interesting and quite frankly challenging case. This little girl suffered an unusual knife wound to her femoral artery a week or so ago, and if it weren’t for her family physician, Dr. Told, who is standing right here next to me, she may have lost her leg and possibly her life.” The resident replied with an awkward “Oh,” and quickly retreated back out the door.
The artery was successfully repaired, and following a brief hospital stay, life returned to normal for our little patient. Years later, she won the title of Moffat County Rodeo Queen. As a member of the Moffat County Sheriff’s Posse, I also participated in the opening ceremony of the rodeo and escorted her royal court onto the field for the opening introductions. As I sat astride my horse behind the queen, who was seated tall in her saddle and flanked by her two attendants on their horses with banners waving in the breeze. all of the memories of that heroic event and plane ride years before came flooding back to me. I sat just a little taller in my saddle knowing that all of the efforts that we as an entire medical community had put into our now retired rural air ambulance service had been worth every effort and sacrifice.