Content warning: The following article contains descriptions of amputation (explicit), blood (gore, minor), and death/dying.
In this ongoing series, Dr. Thomas N. Told, Dean of RVUCOM, shares his thoughts and experiences as a family medicine physician of more than 35 years. Each new entry will be that of a timely issue in the world of medicine, viewed through the lens of an experienced osteopathic physician and an advocate for improving healthcare services for all, especially those in rural and underserved areas.
I have come to understand through the years that there are events in the lives of all of us which occupy unique pockets in our memory. Interestingly, the details of those experiences can be recalled just as freshly and vividly as the moment in which they were experienced, even decades later. Usually, these types of experiences are linked to an outpouring of extreme emotional exertion coupled with other strong modifiers such as fear, pain, extreme physical effort, life-threatening situations, or profound joy and happiness. Simplistically, I have reasoned it as the body’s way of allowing us to continue to review some of the unresolved high points and low points in those experiences so as to reach some resolution or closure before that event can be filed comfortably away in the deeper parts of our minds.
Though it has been many years, there is one event in my life as a physician that continues to stand apart from all the others in that way. It was an event that deeply touched our entire Moffat County Emergency Medical Services system, and was of such a traumatic nature – followed by an equally tragic outcome – that any mention of “the auger” would bring a shiver to one’s core and the instant recollection of that experience for years to come. Here, for the first time, are my reflections on that night that tested an entire emergency medical response team’s skill and resolve to never give up.
After a busy day in the clinic, I reported to my 72-hour weekend shift at the emergency room a bit behind schedule. Unfortunately for me, this meant I would have to skip supper with my family, but I was confident that I could catch up with them and give them a big hug at a slower time during that weekend.
I had just changed into my scrubs when an urgent call came in from the Colorado State Patrol Dispatch. In a somewhat excited and almost breathless tone, the dispatcher said a doctor needed to go to the sawmill to remove a man’s foot that was caught in an auger. She didn’t know more than that but said she would relay more details as they came in. In an effort to speed up that process, the Sheriff’s Department was dispatching a deputy to pick me up at the hospital and immediately rush me and any necessary equipment to the scene.
I thought it was a strange request, for they were not the kind to panic like that. This also didn’t make much sense, because we had just purchased thousands of dollars of specialized equipment to remove cars from around people. I could not understand why they needed me at the scene to remove a man’s foot from an auger when, with that new equipment, it would be a simple task to cut mechanisms on both sides of the victim and remove the trapped appendage. However, the responders at the scene remained steadfast in their request to have a doctor come in, in spite of my probing questions to the contrary. I also sensed an urgency in the tone of this communication that I had never experienced before. There was something clearly wrong and the lack of detail around the incident worried me. I assured them I was on my way.
I quickly gathered my equipment: a “Ready to Go” sterile wrapped, ER surgical tray which included the largest portable surgical procedural pack our hospital had in stock. Having little knowledge of what awaited me, I included bottles of local anesthetics, syringes, gloves, sterile dressings, antiseptic prep swabs to clean and dress the wounds, and some IV pain medication. I would rely on the ambulances to supply the intravenous access and fluids, more dressings if required, and other emergency support equipment such as Military Anti-Shock Trousers, or MAST Pants, which were the hottest shock/trauma device of the period for trauma stabilization but are no longer used today.
Just as I had finished gathering my equipment, the deputy appeared at the emergency room door. We traveled through town at speeds I never thought possible and arrived at the sawmill south of town in mere minutes. I was surprised to see that all the emergency vehicles were not centered around the buildings where the giant power saws were located. Instead, the fire trucks and ambulances were centered around a large black, steel cube of a building located roughly 50 yards to the west of the mill.
The building was a 12- to 15-foot square box that had been turned on its side, giving the impression of a diamond-shaped building. That huge structure was hoisted on legs that were 15-20 feet off the ground to allow dump trucks to pass underneath. The bottom of the walls pointed downward, forming a V-shaped trough which contained a large auger the size of a telephone pole with welded blades in a perfect Archimedes spiral. It was designed to move shavings to a hopper at the opposite end to then be delivered onto the trucks waiting below.
The top of the walls pointed upward and formed a pointed gable so that, within the chamber, there were no level surfaces to trap the wood shavings it stored. The walls at each end [KP1] were flat and attached to a large conveyer belt system that shuttled wood shavings up an incline from the sawmill to an opening at the top of the black steel box. The hopper system was located on the side opposite from the opening and was fed by the auger to dispense a measured amount of shavings in each load. Every surface within this giant storage chamber was designed to deliver shavings from the top right and down to the trough with the auger. The steep angled sides, polished smooth from years of use, made standing above the auger or walking inside the chamber nearly impossible.
“He’s up there, doc,” a fireman shouted as I exited the patrol car. I looked up at a small, spindly metal ladder which was attached to the front of the building alongside the conveyer belt system. It led to the service platform for the belts and motors that ran the auger and the conveyer belt transport system. On that perch stood two other firemen in front of a very small, almost cave-like entrance that led into the chamber.
Good thing I skipped supper, I thought. I have never been too keen on heights and now I had a large audience watching the doc do what he clearly disliked most: climbing spindly and slippery ladders to even just change a light bulb at home. I resolved to remain calm and in control no matter how hard it would be and having an empty stomach would be one less thing to worry about.
Without looking down, I ascended the ladder to the landing and entered the chamber. The firemen had secured one of their ladders from the chamber door to the trough so that it sat right over the auger; this ensured that unsecured ladders would not slide in all directions on the angled polished surfaces. In the glow of flashlight beams, I noticed a wooden ladder that sat near the auger at an odd angle, as if it had been thrown there by some force. It seemed out of place in the surroundings. A fireman shined a light in my direction and in the sweep of his beam, my eye caught the upper torso of a teenage boy buried in shavings to his mid chest. The track of his lower body appeared to lay right in line with the auger, and, curiously, one of his shoes with a foot still in it was positioned next to his shoulder above the shavings, the toe pointed toward his ear.
The teenage boy was exhausted and barely responsive, but EMTs reported he was gradually regaining consciousness as the IV fluids began to do their work. I quickly positioned myself against the slippery walls next to the boy and went to work assessing him, while obtaining what history I could from one of the mill workers who had joined the firemen.
He said that the boy had been fine at lunchtime, but then no one could recall seeing him for the rest of the afternoon. The boy usually checked the conveyer system that fed into the auger building to see if sticks or pieces of wood were slowing the progression of the shavings from the mill.
That day, the auger had become partly clogged, as it often did, and for reasons the boy could never tell us or anyone at the mill could explain, he did not shut off the motor to the auger before going into the chamber. It appeared that he had lowered the wooden ladder into the chamber to a spot right over the active auger, then descended to remove the clog. The auger must have jerked or sprung into motion when a clog or piece of wood was removed. This then caused the legs of the wooden ladder to slide into the mechanism, pitching both the boy and the ladder up the side of the chamber. Unable to maintain traction on those well-polished sides, he slid down right into an active auger.
My blood ran cold thinking of the auger trapping his leg and progressively drawing in the rest of his body like a giant snake devouring its prey. This process continued until the resistance became so great that the rubber drive belts on the motor burned off the pulleys, stopping the auger’s progression at about his belt line. While in indescribable pain, the boy must have found himself completely trapped and probably spent the next six hours pounding on the angled sides of the auger building in an attempt to summon help that finally arrived near quitting time.
Only the resilience and resolve of youth could endure such an insult and survive as he did. I knew instinctively that, even with the strongest of individuals, time was not on our side, and his stamina and vital life functions were fading fast. We needed to free him as quickly as possible and move him to the hospital.
The firemen and I worked systematically, like archeologists uncovering an extremely valuable artifact. We quickly (but very carefully) removed the piles of wood shavings that covered the injured parts of his body. Blood-soaked or spotted shavings heralded the site of a potential injury and signaled us to slow down and be more meticulous and gentler. While standing in piles of dry shavings, I knew why the fire department had not wanted to cut the auger in pieces and remove him as I had suggested: one stray spark or torch flame would have turned the shavings bin below into a fatal conflagration in seconds. The shavings were far easier to remove from injured flesh than sawdust would have been, so our process proceeded quickly and soon we had all of the boy’s injuries exposed and identified.
Somehow, his left foot and leg had slipped between the auger blades unharmed, but the thigh was not as fortunate. The auger blade had slashed through the thigh, crushing the femur and delivering the lower leg up next to his shoulder at a grotesque angle. The leg had remained attached by a large bundle of muscles that had once made up the lateral muscular complex of the outer thigh and hip but were now twisted. The spiral blades had continued up to the pelvis where they clamped down like a large rotating hemostat, almost slashing through the pelvis and restricting blood flow to the left leg where they had stopped. It still amazes me to this day that the femoral vascular complex had not been severed.
The upper edge of the auger had begun to cut through his suprapubic area, but by some miracle had not entered the peritoneum, located under the macerated rectus muscle and fascia and which remained visible and still intact. The boy’s mid chest and throat were marked with abrasions where the auger blades had almost completed their path. The belts had burned off just at the right moment, I recall thinking. Maybe by luck or through a higher power, good fortune was on our side that day.
I asked the first responders and firemen to form a ring around the patient and then had them shine their lights down to form makeshift operating light. It was difficult for some of the firemen to maintain even footing, but the “operating light” worked quite well. I handed the surgical tray to the fireman closest to me, asking him to hold it level and lower it when I needed an instrument. During this time, the injured boy seemed to be losing consciousness and reacted only occasionally to what I was doing. I explored the area around the amputation site, then clamped and tied bleeders while isolating and infiltrating the large, twisted mass of muscle to divide it free from the leg. I had feared that the femoral vessels in the leg stump, which lay under the auger blade, would begin bleeding when we moved him, but mercifully they never did.
As I prepped the area to remove the leg, I suddenly felt metal objects hit my head, neck, and back. At first slowly and then more rapidly, the objects bounced down onto the auger blades in front of me. They were hemostats, scissors, scalpel blades, and handles. I turned to find the source and looked into the glassy eyes of the fireman-turned-surgical assistant just as his eyes rolled to the back of his head. The whole tray came crashing down with him. Apparently, he had locked his knees while standing on the angled surface of a hot, stuffy container. While watching the stressful site, he had fainted. My mind raced to consider another option to quickly resolve this new problem.
In that moment, I remembered that Steve, the new dentist renting the office below our clinic, had just joined the volunteer fire department. Several weeks ago, he had proudly shown me his new uniform and equipment which included a very shiny, sharp, and especially clean Buck knife. Steve happened to be standing right behind me, and I asked him for his knife. I cut through the large bundle of muscle as fast as I could and freed the leg. I handed the leg to Steve and turned back to the patient. We quickly applied a pressure bandage, expecting a lot of bleeding, but very little came. Being trapped for an extended period of time and the pressure of the auger had done its work to thrombose off major vessels, staving off major blood loss.
Almost immediately, my work was again interrupted by a loud thud and the clatter of a fire helmet hitting the metal wall of the chamber. Steve, my good dentist friend, had become dizzy and blacked out, still clinging tightly to the leg. We now had patient number three to tend to. What else could go wrong? I thought. Hopefully, the pending evacuation of all three patients would go more smoothly.
With our young patient free from the auger, we quickly applied the MAST pants to the unaffected leg and abdomen, which included the dressed amputation stump and pelvic area. This compartmentalized suit, similar to the G-suit that military pilot’s wear, inflates in sections and pushes blood that has pooled in the lower extremities and pelvis into the central circulation, improving blood pressure and profusion. However, there is a distinct downside to this technology: poorly circulating blood in the lower regions of the body during long periods of shock can become progressively more acidotic. When that acidotic blood is squeezed back into the circulation, it can cause all types of arrhythmias that are equally as fatal to patients as the trauma and shock. As we inflated the compartments of the MAST pants, our patient regained consciousness long enough for us to assure him he had been rescued.
A conventional Stokes Litter was too wide to fit through the small door of the chamber so a hastily fashioned blanket stretcher—with double the usual stretcher bearers to keep the blanket taut and level going up the short ladder—was used to transport the patient through the small door and onto the ambulance stretcher. The stretcher was quickly attached to the mechanical ladder and, with the help of an EMT and fireman, was gently lowered to the ground. Taking a moment to calm myself—the fear of heights about to kick in—I swallowed hard and climbed down the ladder.
Word had spread fast of the two firemen who had passed out, and it was not long before the diamond-shaped box was teaming with lights from EMTs and firemen seeking to help. Like us, they all struggled to remain upright and not slide down into the now-disabled auger.
After a whiff of strong-smelling salts and some fluids, my reluctant but brave surgical assistant began to come around. In this case, the slanted walls of the chamber were to our advantage: his legs had been positioned up the incline, keeping his head below his body and restoring much-needed blood to his brain. We packed shavings on the auger trough to make a level path to the escape ladder leading to the opening. With our help, the fireman made it out of the chamber. Steve, the dentist, was attended to in a similar fashion and gladly gave up the severed extremity that he had clung to. He was a bit embarrassed, but could now add the title of well-seasoned fireman to his list of skills.
As for our patient, whom I accompanied to the hospital, the first four hours in the operating room were spent with a dedicated team: the general surgeon and myself, as well as a cadre of valiant nurses and technicians. We all worked in earnest to reverse the damage hours of hemorrhage, hypotension, and massive trauma that this brave young man had endured.
We were running low on our supply of blood and resuscitative medications when, suddenly, all of the monitor indicator lines and digital values instantaneously dropped. Our patient had hit the dreaded wall when the body could no longer compensate for trauma endured. The wall, unmistakable to all physicians, is the point at which we know our efforts to restart any vital functions will be soundly rebuffed by the decisive flat line on the monitor.
Losing a patient is always a blow, but losing such a young life so needlessly was a huge blow to everyone in the EMS system—from the EMTs, firemen, and Sheriff’s deputies right up to the physicians and nurses. All of us carried that night in one of those unique pockets of our memories that I spoke of earlier, to be reflected on and revisited in private moments of introspection in our lives for years to come.
The greatest lesson I learned from that night was that, though I was uncomfortable with what I would find under the wood shavings, I was confident that our team would find a way to help our young patient. Learning to live and work with the discomfort that accompanies treating the unknowns of medicine is vital to a long and healthy career in the medical field. Discomfort does not need to be a negative feeling; it can be a positive motivator as it heightens active introspection of one’s abilities and the possible pitfalls that could derail one’s best efforts. In many ways, discomfort can inadvertently lead us to achieve excellence as we seek to overcome or lessen that feeling.
We cannot always be sure of the ultimate outcome of our efforts as we confront trauma and disease in the course of delivering care to our patients. However, we can rest assured that by not quitting, turning away, or complaining in these uncomfortable situations, we will gain valuable experience and confidence that will not only improve us on a personal level, but will be to the benefit of our patients, as well. In short, learn to be comfortable with being uncomfortable.