Saving Lives and Limbs

Flatline to Lifeline With Dr. Long

Case Study: Temporizing Balloon Angioplasty and Embolectomy for a Blunt Trauma Thrombosed Left Common Iliac Artery at a Rural Level 3 Trauma Center
A 36 year-old lady and her husband from New York were vacationing on the northern Oregon Coast when an oncoming car crashed into their car and their car went off the highway into a deep ditch. This happened during a coastal storm with high winds and rain. Coastal EMS had difficulty getting to the accident scene and needed a tow truck to extract the car from the ditch to enable removal of the occupants. The lady passenger was wearing a seatbelt, which ruptured her abdominal wall, causing her ruptured sigmoid colon to herniate through the wound in the left lower quadrant of her abdomen. The compression of her abdomen by the seatbelt damaged her left common iliac artery, causing almost no blood flow to her left leg.

This MSTT anecdote is presented not only to save a life, but also to save a limb. Time to save the limb was a major consideration for the rural surgeon who did not have much vascular surgery experience, nor did the rural hospital have vascular embolectomy catheters. Two to three hours for no blood flow to her extremity could result in muscle death, requiring an amputation. In a coastal storm in Oregon, roads may be blocked by fallen trees, markedly prolonging land ambulance drives from the coast to Portland. Ed Duret, the coastal general surgeon made the correct call for help to reperfuse (reestablish blood flow to) her leg. The MSTT responded promptly.

The Emanuel Trauma surgeon on call, Seth Izenberg, with the MSTT flew by fixed wing aircraft to an airport near Columbia Memorial Hospital (CMH) near the mouth of the Columbia River, about 90 miles away from Portland. Seth had both a burn fellowship and combat trauma experience in Iraq. Seth brought with him embolectomy vascular catheters which are not balloon angioplasty catheters with balloons strong enough to dilate a calcified diseased artery, severely obstructed by a plaque or a fresh clot. Embolectomy catheters remove soft blood clots in an artery. For this patient, Seth had the presence of mind to use the embolectomy catheter to dilate this patient’s common iliac artery to restore partial blood flow to her leg and to remove blood clots that had migrated from her injured artery. This procedure bought her leg time and the MSTT team brought her back to Emanuel Hospital, where the trauma surgeons addressed her ruptured abdominal wall and large bowel.

After the initial intervention, intravenous anticoagulation prevented further clots from being formed in her injured artery. The vascular surgeon’s decision not to repair her artery immediately because of fecal contamination of her abdominal cavity from the ruptured sigmoid colon was prudent, as a synthetic vascular graft could get infected. They sewed in a prosthetic graft a few weeks later.

With physical therapy and rehabilitation, she became ambulatory and we made plans to transfer her back to a level one trauma center in Albany, New York, her hometown.

She made a complete recovery and returned to her job as the director of the electrical power systems for the state of New York. She realized that the early decisions made on her care made this all possible. A year later, we invited her to come to our annual trauma conference and she came and gave a very moving speech about the need for trauma centers with experienced personnel who can save lives and reduce disability.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.

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Producer: Esther McDonald

Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2024

Chapters

1. Saving Lives and Limbs (00:00:00)

2. Saving Lives and Limbs (00:00:03)

3. Treatment for Limb-Threatening Injury (00:12:25)

4. Saving Lives and Limbs in Surgery (00:24:33)

5. Cost-Effective Care's Impact on Healthcare (00:40:49)