Making the Most of Life and Limb Threatening Injuries in a Remote Rural Setting by Mobilizing Local and Regional Resources to Obtain an Unexpected Survivor

Penetrating Trauma (.22 rifle bullet at close range) with injury to left common iliac artery & vein with initial stabilization by emergency physician in a very rural hospital in Lakeview, Oregon 

Josh, a 16 y.o. boy, was going to hunt squirrels with his .22 rifle.  He drove his car to a ranch outside of Lakeview, Oregon, a small rural town where Lakeview District Hospital has a 24-bed capacity and provided emergency medical services with nurses and a family physician on call. On this particular hunting day, Josh parked his car at the gate of the road leading to a ranch house about ½ mile away. As he pulled the rifle barrel from the trunk of his car, the rifle discharged. The bullet entered the left lower quadrant of his abdomen, almost severing his left common iliac artery and vein. He collapsed at the scene. The rancher’s wife noted an empty car and went to investigate. She found Josh lying on the ground holding his abdomen and blood oozing between his fingers. She called 911 immediately. 

The ambulance arrived on the scene about 15 minutes later, and the crew took Josh to the Lake District Hospital’s emergency room, where Dr. Bob Bomengen, an Emergency Physician was on call. Bob saw that Josh was in extremis from prolonged hemorrhagic shock, and he needed an operation to control the bleeding. Lake District Hospital had a limited blood bank, so Bob requested donors from the citizens of Lakeview to come and donate whole fresh blood to replace the blood that had been lost and to help correct the coagulopathy associated with prolonged shock. The townspeople responded and donated their blood which hospital emergency staff transfused into the patient and the patient stabilized. 

Meanwhile, Bob asked for help by asking the hospital operator to call Ken Tuttle to come and assist in the damage assessment and to repair the bullet penetrated left iliac blood vessels. Ken Tuttle, MD, a general surgeon who trained at Stanford University Medical Center, was based in Klamath Falls, Oregon (96 miles away from Lakeview or a drive of 1 hour and 49 minutes). He also asked the operator to call Emanuel Hospital to come with vascular grafts and sutures to restore blood flow to the now ischemic left leg.

Jon Hill took the call at Emanuel. He activated the Mobile Surgical Transport Team (MSTT) and Life Flight to provide helicopter transport. Meanwhile, Ken Tuttle went from his home to Merle West Medical Center to get vascular instruments to take with him in his car. He called the Oregon State Police (OSP) to give him a police escort on the two-lane highway connecting Klamath Falls with Lakeview. By the time the OSP arrived at Merle West, Ken had started driving to Lakeview. He drove at “flank speed” hoping to arrive in time to save a life and a limb for Josh. Ken arrived at Lakeview District Hospital and went straight to the operating room to join Bob Bomengen. 

 The MSTT and Jon Hill arrived to help the situation. Jon assisted Ken in sewing the Gortex vascular graft to span the gap in the resected common iliac artery. These anastomoses did not leak. Peripheral arterial pulses were restored after intra-arterial clots were removed with embolectomy catheters. The patient came back in the ONG helicopter with Jon and the MSTT.

 On arrival at the Emanuel helipad, the MSTT took Josh straight to the trauma OR where Jon performed lower leg fasciotomies for compartment syndrome, caused by the prolonged ischemia. The patient also began to get a return of muscle function and sensation in his leg. We transferred him to RIO for gradual mobilization of his leg and walking with assistance. Six months after this episode, he was back to normal activity. 16 years later, a phone call to the Lakeview District Hospital Clinic confirmed that Josh was living a normal life.

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