Written by Dr. Thomas N. Told
“The rule of the artery is supreme”, is a widely quoted axiom attributed to Andrew Taylor Still MD, DO the founder of Osteopathic Medicine as he explained one of four key tenants of our uniquely American profession. Though Dr. Still never wrote or uttered those exact words he did say;” the rule of the artery is absolute, universal, and must not be obstructed.” In my nearly a half century of practicing medicine including half those years in medical education, I have come to respect the devastating effects of arterial occlusion whether it be in the heart, brain, lungs, gut, or peripheral vascular system resulting from disease or human causes. In practice we watched diligently the constrictive tourniquet inflation times in surgery making sure they did not pass a certain threshold, or monitored closely circulation after application of casts and splints which could obstruct circulation causing devastating nerve injury and contractures. In the ER we rushed to medically open occluded vessels in the brain and heart to curb the devastating effects of extended thrombotic occlusion times. The after effects of uncontrolled disease-caused occlusions are generally accepted and excused as expected complications, but ill effects from occlusion with a tourniquet have not been well received by the medical profession or public, so few tourniquets were ever applied until recently when evidence from battle wounds proved their application safe and effective. Conventional wisdom for physicians and first responders in the last century was to only apply a total occlusive vascular tourniquet when the chance of death from exsanguination was eminent, and preserving life was more important than the continued viability of the injured limb.
Dr. Dennis Kinder, who would join us on the Parker campus to become RVU’s Director of the Medical Clinic including IM Residency faculty, would ask me to join him as we faced that very decision years before while covering our Northwest Colorado emergency room. Dr. Kinder recounted our experience recently while visiting Dean David Park at the Montana College of Osteopathic Medicine in Billings, Montana. Dr. Park was so impressed by the story we felt it valuable enough to share with all of you on the RVU Blog.
Here in bold italicized print is Dr. Kinder’s recollection of the event as he related it to Dr. Park, and I will follow with my comments and recollections including interesting background information surrounding that event given all participants involved were patients of ours at Craig Medical Center.
Dr. Dennis Kinder’s Recollections:
“I was fresh out of residency training in internal medicine and was working a weekend shift in the emergency room in rural northwest Colorado. The weekend shift started Friday at 6 pm and ended Monday at 6 am. Our general surgeon was out of town and this always made me feel a bit apprehensive. My trauma training was mostly in medical school, and I was ATLS certified.
The work over this weekend had been routine. I saw kids with otitis media, adults with urinary tract infections and assorted minor lacerations. That morning the ambulance was called out for multiple gunshot victims. This shouldn’t be happening in our small town. I hadn’t taken care of someone with a gunshot wound since medical school and at that time it was a whole trauma team consisting of multiple surgeons, residents, medical students, and nurses. I knew I was going to need help, especially since our surgeon was out of town. I was on call for our practice, but Dr. Told was always available 24 hours a day, 7 days a week, and 365 days a year. I was hoping he was close by.
Dr. Told had been practicing for over 20 years in the area and was always happy to teach or lend a hand. Luckily, he was close by and was able to come right over. Unfortunately, one victim was shot in the neck and died at the scene. The second was a man that was shot through the biceps above the antecubital fossae. He had a major arterial bleed. EMS on the scene applied a tourniquet and packed the wound with good hemostasis. A couple large bore IVs were started in the other arm. He was transported to the ER
The great thing about Dr. Told was that he had an amazing ability to figure things out, even if he had never run across the situation before. It didn’t have to be in the textbook either. Our gentlemen’s arm was not doing well with the tourniquet. It looked like we could save him, but his arm was in danger. Dr. Told unpacked the wound and explored the suspected area of the arterial bleed, his brachial artery. A large chunk of his biceps was missing, and nerves, arteries, and veins were laid before us like an anatomy dissection. We slowly released the tourniquet and blood nearly hit the ceiling. We tightened the tourniquet again and Dr. Told continued to explore until he found the severed artery and clamped it with a vascular clamp. As soon as the artery was clamped, our patient regained a radial pulse and color returned to his hand through collateral circulation. It was a miracle seeing his arm come back to life. We rigged up his arm with the vascular clamp taped down, covered with gauze, and protected with a shield we devised from a Styrofoam cup. We wrapped the whole thing with an ACE bandage.
We called the limb preservation unit in Denver and made arrangements for transport by helicopter. A young ER resident came with the air crew and told us that they couldn’t transport our patient with that “hemostat” clamped on his artery and the rest of our apparatus. We explained to him that if the vascular clamp was removed, that his radial pulse would be lost, and the hand would become cyanotic then ischemic. He proceeded to unclamp the device, then saw for himself what we told him. He put everything back the way we had it and took our patient to Denver. They were able to save his arm and he regained partial use of his hand.”
Dr. Tom Told’s Recollections:
I too maintain a vivid memory of the events from that day, for this traumatic and tragic episode would transpire close to my home including a disturbing encounter with the soon to be alleged shooter the day before by a member of my family. Here is my recollection of that encounter and other details that would came to light after the shooting.
I had just climbed up on the top of my camp trailer that weekend morning to get it ready for the upcoming elk hunt when I heard the unmistakable sound of gun shots from a high powered rife coming from just down the street. Within minutes’ sirens converged on a house that was just out of my sight. That house was occupied by an elderly widower who was eccentric, reclusive, and the man we suspected the day before of flagging down my daughter-in- law who was visiting us along with my son and our grandkids from Utah. That man accused my daughter-in-law of running him off the road the previous week. When she protested by saying she just arrived in town a day ago he countered by saying he had her license plate number tacked to his wall and he was sure it was her. (We would learn the following day in the ER from police that this man had hundreds of license numbers tacked on his walls.) Shaken she sped off to our house to report the incident. We immediately returned to the location, but the man was gone. Now hearing the shots in the vicinity of the elderly widower’s house not far from where my daughter-in-law had encountered an angry elderly man the thought crossed my mind that there might be a connection between this event and the one yesterday? That question would be answered in the next few minutes when my beeper erupted with an urgent message to come to the ER Stat.
Being just a few blocks from the ER I dropped everything and made the trip to the hospital in just under 3 minutes on my bicycle. I knew Dr. Kinder was on call and would not have urgently summoned me unless there was something very wrong that required my assistance. The Kinders had been a great addition to our medical community in the short time they had been in Craig. Dr. Dennis Kinder and his wife Pamela an MD neurologist had joined us at the Craig Medical Center following graduation from their residencies at the University of Utah the summer before, and were building very busy Internal medicine and neurology practices which included taking call at the hospital. Cool under pressure, Dr. Kinder could be counted on to handle most any situation that confronted him, so I instinctively knew there would be challenges awaiting me at the ER if he asked for help.
I found the ER in state of controlled chaos caring for a middle aged patient I recognizes as having taught all our clinic employees Western Line Dancing at our last year’s Christmas party. He was laying on the treatment gurney pale, weak, but slowly responding to Dr. Kinders resuscitative efforts. His right arm was dressed in a bulky compressive dressing that was showing a few areas of fresh blood staining beginning to seep through fresh bandages. The tourniquet was in place above the dressing high on the arm and tightened to achieve nearly complete hemostasis.
Obtaining a history from law enforcement as we worked, we learned that our patient and his fiancé occupied the house across the street from the shooter. They were in the process of loading a small trailer to move to another location when the elderly man appeared on the porch and ordered them to move the trailer or he would shoot them. When they ignored him and the woman returned from the car to the house leaving our patient by the driver’s side door with his back to the old man, only served to further enraged him. Suddenly in a flurry of expletives he whirled and stormed back into his house emerging a short time later carrying a loaded 30 caliber deer rifle. Without warning he fired the first shot at our patient just as he was turning in the direction of the shooters front porch. That first shot was wide missing our patient’s torso, but struck him in the middle of the right arm tearing out a large chunk of his Biceps, and producing profuse bleeding. Seeking quick cover, the wounded man jumped behind the wheel of his car, and proceeded to start the car with his good left arm which was awkward slowing him down. Hearing the shot his fiancé rushed out of the house to the car, and seeing her boyfriend bleeding in the front seat entered the passenger side door crawling across the console to reach him. The second shot blew out the driver’s side window and missed hitting the man’s head and neck, but struck his fiancé in her neck instantly killing her. Law enforcement quickly surrounded the house, and subdued the man who was still raving incoherently from what appeared to be an acute psychotic episode.
Dr. Kinder’s account chronicled accurately the resuscitative efforts to save this patient by first responders in the field and the team at the ER. Some may have questioned then my decision to remove the tourniquet and explore the wound for the bleeder when I arrived, but I felt it was as important to attempt to save the arm right along with saving the patient. In my opinion given the extended time it would take for a helicopter to make the round trip from Denver over the Continental Divide to Craig and stop to refuel in route often coming and going consumed precious hours well beyond the limits to allow a tourniquet bound arm to survive the prolonged ischemia. In addition, the extensive damage wrought to the tissues of the right arm by the bullet including the severing of a main artery would shorten the time of viability even more.
There were further challenges that arose when we explored the wound with the tourniquet loosened and circulation restored. The friable injured tissue made using suture to close any open vessels very problematic. The suture when tightened would cut through the traumatized tissue effortlessly just as a wire cheese cutter slices through soft cheese. I finally resorted to atraumatic vascular clamps to control major bleeding. Thin jawed vascular clamps were designed to cross clamp vessels with minimum trauma. They seemed to work better than suture, because we could be more precise in the placement avoiding entrapment of nerves, or further traumatizing the severed vessel walls. A relatively healthy blood vessel wall makes a later anastomosis more successful. The use of standard hemostats crushes the vessel walls effectively killing them.
We were not sure what would happen when I clamped the injured Brachial Artery. Would the arm go pale and pulseless, or would there be enough collateral circulation around the clamped vessel? Would the collateral circulation be strong enough to cause troublesome back bleeding from the distal severed part? Thankfully Dr. Kinder and I were impressed when I closed the clamp on the vessel. To our relief the arm quickly gained color and the pulses returned weak, but palpable in the wrist. I was prepared for back bleeding from the distal end of the severed vessel but it was minimal. We taped and bandaged the clamp in place while providing an easy access window to periodically check it the vessel viability while in flight. We continued to manage his blood pressure with fluid and blood as we prepared him for the flight back.
I was aware that there may be push back from the transport team when they realized a vascular clamp was under our makeshift shield and indeed that was the case. I will never forget the reaction of the ER resident who was on the transport when he quickly viewed the x-rays of the bandaged arm for the first time. Seeing the unmistakable outline of a metallic object he abruptly froze and his eyes widened in surprise causing him to almost drop the film as if it were red hot. In an equally surprised voice he blurted out “WHAT IS THAT”? It’s a vascular clamp on the artery I explained; do you want to take it off? Oh no he said, but I am not sure we can fly with it. Then I said, I don’t know how you are going to get him back if you cannot fly with it, and I would strongly advise leaving it in place because we know that sutures will not hold. Well as Dr. Kinder explained, a phone call and a quick opening and closing of the vascular clamp by the resident convinced the Denver folks that we knew what we were doing…. so the transport was on and came off without a hitch.
I would never have our vascular clamp returned by the receiving hospital in Denver to the chagrin of our hospital administrator. Understandably our patient never returned to Craig after he recovered citing too many strong memories. I would hear later from the family of the girl that was killed that the limb salvage surgeon in Denver had told our patient he was lucky to have had us stabilize him, because what we did that day to bolster collateral circulation by instituting measures that did not overly traumatize the severed Brachial artery allowed the limb salvage team to successfully graft the artery and save his arm. To this day when I reflect on our actions that very memorable Fall day I am inspired once again by the wisdom of Dr. Still’s words of long ago for they are even more appropriate in medicine today because; “The rule of the artery is absolute, universal, and must not be obstructed.” Whether it is trauma, skin grafting, wound care, transplantation, or just restoration of normal body mechanics virtually every bodily function depends on the existence of an adequate circulation of oxygenated arterial blood, and that is why in nature the Rule of the Artery Does Indeed Reign Supreme.