Saving Heroes – Oregon Trauma System and William Long III, MD

It’s a privilege that physicians we know and work with are involved in life-saving events on a daily basis. Perhaps none more so than Bill Long, the Director of the Level 1 Trauma Center at Emanuel Hospital (Legacy) in Portland, OR.  CLICK HERE to read how Dr. Long created the only American College of Surgeons Committee on Trauma (ACSCOT) Verified Level I Trauma Center in the Pacific Northwest.

When a case involves the shooting of a police officer it deservedly gets extra attention.  A recent The case involving  a police officer from coastal Oregon is a textbook case involving the effectiveness of the Oregon Trauma System and the professionals involved. (Dr. Long is credited as the architect of the OTS)

The following information is not designed to rehash the myriad accounts being covered in the mainstream media, but rather a glimpse into a multi-organizational trauma system that worked flawlessly to save an officer’s life.

What follows is a rough time-line of the treatment of the officer followed several questions answered directly by Dr. Long.

January 2011 – Coastal Oregon

2257

Policeman gets shot in small coastal town, normally 2 hours away from Portland.
2258 Policeman called into his precinct, and told them he was shot twice in the abdomen
2259 Another policeman on scene, held pressure on patient’s entrance wound.
2300 Ambulance dispatched.
2315 Ambulance on scene. Jeff Creff, EMT, puts REACH, an EMS helicopter based in Corvallis, on standby; Jeff’s wife, Trish, also an EMT intubates patient after Pat Ganz, EMT  starts IV.
2318 Ambulance leaves scene
2332 Ambulance arrives at level 4 trauma center.  Blood pressure barely palpable.
2337 In Hospital ED.  No BP,  HR 132. 

Emergency Physician:  Zach Dembitsky

2338 Large bore IV inserted. Blood gas drawn,  IV fluids wide open
2343 UNCROSSMATCHED blood started (3 units)  BP rises to 134.  Hospitalist (Bob Oksenholt, cardiologist and pulmonologist) and Mike Egan, MD (attending surgeon with naval medical training) arrive to help out.  Decision made to not try to operate patient but transfer.  REACH called.
0001 REACH arrives, patient loaded into helicopter.  (HOT LOAD)
0005 REACH departs for Portland.  REACH paramedics:  Jeff Turner and Kenny Nealy
0005 – 0050 Flight to Portland (Emanuel Hospital– Level 1 trauma center)
0050 Patient taken directly to OR.   Rapid assessment, torso roll to look for additional bullet wounds
0052 Ext. Jug, IV by cardiac/trauma anesthesiologist, blood draw for baseline labs & clotting profile  (Hct 34  INR 1.6  Plts. 150   Fibrinogen 105)
0053 Ancef & tetanus by nurse ABG  pH 7.2   PaO2  478   PaCO2  53   Base deficit -10.  Insertion of Foley catheter with thermister
0100 Laparotomy started 3 units of UNCROSSMATCHED blood, 2 units of FFP, 2 platelet packs, 2 units of Cryo started
0100 – 0200 Damage control surgery with: clamping and ligating of the shredded left external iliac vein stapling of small bowel with 6 holes and one hole in left colon packing of pelvis Massive transfusion Policy (MTP) activated.  No use of pressors.  Total crystalloid: 15 liters
TRNs (trauma resuscitation nurses) are responsible for providing all the blood products in a set ratio, drawing labs and ABGs every 15 to 30 minutes to track trends in the patient’s coagulation status, Hematocrit, and blood gases, including acid base balance.  They have to replace the amount of blood that was lost, being lost as the blood pressure improves, and will be lost from damage control surgery and postoperative oozing.  The coordination of the lab, blood bank, and delivery and infusion of products determines the severity of coagulopathy in a massive transfusion case. 

The anesthesiologist supports the heart function, sometimes with inotropes and pressors, but mainly through ion controls of potassium and calcium and pH, in addition to managing the anesthetic and ventilation.

Estimated blood loss: 10 liters, 5 liters on opening the abdomen

Replaced blood products :  20 units of PRBCs, 8 units of FFP, 8 platelet packs, 4 units of Cryoprecipitate.

Coagulation studies at end of surgery:  Hct 20   Plts 132   INR  1.7   Fibrinogen 145   Ionized calcium 1.8  MTP stopped.

0230 To Cat Scanner for torso survey.  No unexpected findings.
0300 To Trauma ICU for critical care.   Later in day: Fasciotomy for elevated compartment pressures in left leg.
1st Post-op Day US shows clots in right iliac vein, probably secondary to pelvic packing.  IVC filter placed via right int. jugular vein
2nd Post-op Day Re-exploration laparotomy, removal of packs, reanastomosis of stapled segments, colostomy, closure of abdomen…very little edema– surprising.

Note: For a copy of the time-motion study of this case, send me a note and I will have a copy forwarded to you.

1. If you had to boil down to key elements to saving the officer’s life…the things that had to be executed flawlessly, what were they?

  • Officer is able to call in, and activate system… fellow officer applies pressure to bleeding abdominal wound.
  • 18 min ambulance response time, with EMTs notifying EMS helicopter to be ready to launch.
  • EMTs aware of Level 4 trauma center’s limited capability and blood bank stocks.  This notification avoided a 30-minute delay later!!!
  • 3 min. scene time with intubation
  • 35 min. total pre-hospital time from the time of the injury.
  • Initial Hospital care in coastal town:

o   Adequate IV access with large bore IVs,  early use of UNCROSSMATCHED blood.

o   < 30 minutes of hospital assessment, resuscitation, and stabilization time —–no unnecessary studies, cat scans, etc.  Patient needs an OR!!!

o   Early launch of REACH helicopter enabling transport of patient as soon as resuscitation phase was over.

  • Direct to Operating Room with abdomen being prepped while additional IV lines are inserted.
  • Damage control surgery, with no major vascular repairs in a contaminated abdomen.
  • Aggressive coagulation factor replacement started BEFORE the individual coagulation factors drop to critical levels. (anticipation of a coagulopathy can help to avoid one)
  • Rapid coordinated operative care with two attendings and a resident…Antibiotics redosed as we did exchange transfusions.
  • Temperature control to avoid hypothermic coagulopathy.

2. What kind of time-lines were involved from the first response to ER to your team etc?

ONE HOUR damage control surgery.  We were fortunate that the external iliac artery and deep pelvic veins and arteries weren’t injured and bleeding excessively.
3. Anything other items you can think of that would make this somewhat of a case study on how it should be done for others in the industry.

“All in all, a fairly straightforward case.  The inter-hospital transfer logistics made it possible for the patient to arrive in better shape than he would have. Had the timeliness of each phase prior to arrival in Portland been prolonged, or they omitted some key steps, by not following ATLS protocols (Advanced Trauma Life Support), or they got bogged down by doing a laparotomy without enough blood products to prevent a serious coagulopathy, the outcomes might have been very different

Coastal Hospital has a competent surgeon, skilled in trauma, but he knows his local resources well, and what they can do and cannot do.  He made a key decision.  This case was a two attending case, and he didn’t have an adequate assistant.  Had the weather been better, we could have flown down our mobile surgical trauma team with 40 units of blood products and helped to stabilize the patient. “

4. A little background on the lead surgeon Seth Izenberg, MD

Seth Izenberg, MD

  • Harvard educated in Physics.  Brown University for medical school and surgery training.
  • Training in Burn Surgery at Harborview/University of Washington; fellowship with famous burn surgeon: Charles Baxter, MD. Burns and Trauma attending surgeon at University of South Alabama.
  • Currently a Colonel in US Army Reserves; Seth has been to Iraq/Afghanistan 3 times, and leaving for Afghanistan in a several weeks.
  • Deputy Sheriff with Clackamas County and member of SWAT.
  • Attending trauma surgeon with Emanuel for 10 years.  Associate Trauma Medical Director for ATLS & RTDC and Outreach to rural hospitals.
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