historical trauma: i have no disclosures could we …...was deflected by the flames’ derek morris...

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Historical Trauma:Could We Do better?

Douglas J.E. Schuerer, M.D.

Director of Trauma

Barnes-Jewish Hospital

Professor of Surgery

Washington University School of Medicine

Department of Surgery

Section of Acute Critical Care Surgery

• I have no disclosures



MVC or Electrocution?



Is this a fall or an MVC?



Penetrating or Blunt Injury?



Current Trauma Care

• The “Golden Hour” is important in current trauma care.

• Getting patients to the appropriate level trauma center in the shortest time is integral in all treatment decisions in the field.

• Reassessment and treatment is started in the field and continuously reevaluated.

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Trauma Centers



ATLS

• ATLS is basic set of tools for all providers.• Airway

• Breathing

• Circulation

• Disability

• Exposure

• Secondary Survey



SO…

• Now we will examine a few historical cases to see if thing may have been different today.

• Most data presented are facts obtained from the literature. Some personal communication is included as well as other unpublished data.

• I tried to avoid the “conspiracy theories.”



Brittanie Cecil



Brittanie Cecil

• 13 year old eight grader

• At Columbus Blue Jackets game on March 16, 2002

• Went with dad as birthday present (March 20)

• Columbus Blue Jackets vs. Calgary Flames



Brittanie Cecil

• CBJ player Espen Knutsen shot at the net but it was deflected by the Flames’ Derek Morris

• Puck went over the glass and into the crowd

• Brittanie was struck on the forehead or temple area

• Hockey shots travel up to 100 mph

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Brittanie Cecil

• Her head snapped back suddenly.

• She walked out of the arena with a towel held to her head.

• She seemed “disoriented.”



Brittanie Cecil

• She was taken to Children’s hospital in Columbus on Saturday night.

• She remained awake through Monday morning

• She died Monday night after being declared “brain dead.”



Brittanie Cecil

• What happened here?

• Could anything have been done?

• What about prevention?



Brittanie Cecil

• Initially she probably had a concussion.

• This can explain her initial findings

• If worse injury, bleeding can occur and have IPH or SAH

• Symptoms are headache, memory loss, dizziness.

• Can have long term affects as well – especially with multiple repetitive injuries



Concussion



Brittanie Cecil

• But concussions do not kill!

• What happened?

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Brittanie Cecil

• A post was done…

• She had an injury to the vertebral artery.

• It runs along the spine in the neck to the brain.

• She had an intimal flap or injury to the vessel from the flexion and extension of her spine.



Vertebral Artery



Vertebral Injury



Intimal Flap



Brittanie Cecil

• The vertebral artery injury caused the vessel to clot off.

• That clot propagated into the Circle of Willis in the brain.



Brittanie Cecil

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Brittanie Cecil

• She had no flow to her brain.

• This left her brain dead.

• The family donated her organs.



Brittanie Cecil

• What could we do better?

• Diagnose the injury:

• High index of suspicion with a flexion/ extension injury of this type

• Modern CT imaging can provide accurate angiograms of the vertebral artery and diagnose this injury.



Diagnosis BCVI



EAST Guidelines



EAST Guidelines



Brittanie Cecil


• Treat the problem:

• Options include:

• Heparin

• Aspirin

• Coumadin

• Stenting

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Brittanie Cecil


• Prevention:

• Preventing injuries is the key to trauma care.

• NHL teams now all have nets around the end of the arenas in addition to the glass shields.



Ralph Dale Earnhardt, Sr

• Born: April 29, 1951

• Loved cars

• Started racing in 1973 and NASCAR in 1975

• “The Intimidator” as he raced faster and closer to other cars than most.



The Race

• February 18, 2001.

• Fourth turn in the final lap of the Daytona 500

• DES’s care clipped the front of sterling Matin’s, sending him counter clockwise.

• He turned hard right and was “t-boned” by Ken Schraeder



The Accident



The Crash

• He had on an open faced helmet – the only driver in NASCAR without one.

• He did not use a HANS (head and neck support) device – not required at the time.

• His harness was modified for his comfort.



The Crash

• His car hit the wall at 150-180 mph.

• EMS was at the scene immediately.

• Oxygen while he was cut out of the car.

• Pulseless the entire time.

• CPR until the hospital 1 mile away.

• 16:54 to hospital, 17:16 pronounced dead at age 49.

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Cause of Death

• Abrasion on chin and dent in steering wheel from hitting it.

• 8 fractured ribs and a fractured sternum.

• Basilar skull fracture at foramen magnum.

• Possible blunt cardiac injury or carotid injury as well.



What about today?

• No doubt that he would have died from this once the accident had occurred.

• So, the key to this case is the injury prevention efforts.



What about today?

• Although it was an devastating impact, a full helmet with chin guard may have helped avoid the injury to his skull base.

• The HANS device is now required for all drivers in the NASCAR Winston Cup, Craftsman Truck Series and Busch Series.

• Another note – over 50% of traffic accidents happen within 5 miles of home, he was less than 1 mile from the finish.



What about today?

• EMS response time could not be better.

• The trauma center was one mile away

• There is little utility for continued CPR in a blunt trauma victim unless they lose their pulse in front of you.



President Andrew Jackson

• Born: March 15, 1767

• Service started in the Revolutionary War at age 13.

• He and his brother became prisoners of war.



Jackson

• Revolutionary War• Was slashed by British officer while prisoner and left with scars on his

left hand and head.

• He and his brother got smallpox, his brother died.

• He was an orphan due to the war at age 14.

• War of 1812• Won the Creek War

• Won the Battle of New Orleans

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Jackson

• Seventh President, 1828

• Renewed the “Democratic” party

• Opponent called him a “jackass”

• He used it as his symbol in the campaign



Jackson



Jackson - Attacks

• Robert Randolph struck the President in Virginia because

Jackson had dismissed him from the Navy.

• The president was fine.

• He did not press charges.



Jackson

• On 1/30/85 he became the first President to have an assassination attempt.

• Richard Lawrence fired twice at him with two different guns at close range.

• Both misfired.



The Duels

• Jackson married a divorcee.

• Because of the timing of the marriage, there was question of his wife’s honor.

• This was a sore point and led to 13 duels over his wife’s honor.



The Duels

• Two important ones.

• May 30, 1806 – Charles Dickinson

• Only man Jackson killed in a duel

• Dickinson goaded into angering Jackson by Jackson’s political opponents.

• He was a good shot.

• Duel over horse-racing debt and an insult to his wife.

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Duel 1

• Jackson allowed Dickinson to shoot first, knowing him to be an excellent shot.

• While Dickinson reloaded, Jackson shot.

• Jackson had been hit in the chest.

• Shattered two ribs.

• Bullet close to the heart and never removed.

• Jackson suffered profuse bleeding.

• One month was needed for him to ambulate.



Duel 2

• 9/4/1813

• Duel with 2 brothers, Jesse and Thomas Benton

• Might have been just a “gunfight.”

• One brother hit him in the left humerus.

• The other hit him in the let shoulder, nearly destroying it.

• Both slugs stayed in.



Aftermath

• Both slugs caused osteomyelitis of the bones.

• The wound drained constantly for decades.

• Handkerchiefs were used as daily dressings to catch the pus.

• He coughed up blood regularly after the first duel.

• Had to change his shirt often due to the odor.



Health Issues

• Had bowel issues his whole life.

• He believed in “bleeding,” calomel and laxatives to keep him healthy.

• Used “sugar of lead” for queasy stomach.

• He might have had both mercury and lead poisoning as a result.



Health Issues

• December 1821 – Chronic lung abscesses.

• Recurrent pneumonia and hemorrhage.

• Possible BOOP form chronic infections.

• Might have also had tuberculosis

• 1825 – series of severe hemorrhages.

• He recovered despite continued “bleedings.”

• 1832- his arm worsened.



Health Issues

• Bullet removed with no anesthesia.

• Had likely chronic osteomyelitis causing sweats and chills daily.

• Died June 8, 1945 at age 78 of tuberculosis, “dropsy” (edema), and heart failure.

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What about today?

• Smallpox

• Vaccinations in present day have eliminated this.

• Assassination attempts

• Secret Service much more proactive to avoid this today.

• Bowels

• Would likely have had treatment for IBD with medications or diet changes, not heavy metals



What about today?

• Duels

• Injury prevention is a key for trauma centers.

• “Gunfights” still occur today.

• Weapons today are likely more deadly.



What about today?

• Treatment

• Would be taken to a trauma center.

• Likely thoracotomy for the “profuse bleeding” with lung resection and bullet removal.

• Would treat the anemia with blood transfusion, not blood letting.

• Would ambulate soon post-op, not keep in bed for a month.



Early Bullets and Gangrene



Gangrene

• Bacterial infection of the wounds from the musket balls.

• No antibiotics to treat the wounds.

• Took soldiers out of action, so it was effective even without killing them.

• Bullets mushroom to cause more damage.

• Rules of war do not allow hollow point weapons now.



What about today?

• Treatment

• If he had been originally treated non-operatively for his chest, he might have VATS or thoracotomy for the empyema he developed.

• Operative repair of the humerus fracture.

• Anesthesia for bullet removal.

• Antibiotics for the TB

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What about today?

• Likely negative pressure wound therapy for the chronic open draining wound after debridement.

• Diuretics would have helped his heart failure near the end of his life as well.

• Avoid heavy metal poisoning.



The Red Baron

• Born May 2, 1892

• Manfred Albrecht von Richthofen

• Rich Prussian parents born in what is now Poland.

• Hunter and sportsman.

• Started as a scout



The Red Baron

• Became the most successful flying ace of World War I, with 80 confirmed air combat victories.

• Started as a pilot in 1915.

• Not the best flyer, used his plane as a platform to fire the guns.

• Observed a set of “maxims” while flying, perhaps the first “checklists” for safety.

• Painted his plane red, thus his famous nickname.

• Downed 22 British planes in April 1917.



The Red Baron – his Flight Team



The Red Baron - Injury

• On July 6, 1917, he was hit by gunfire and sustained a serious head wound.

• He was shot by Captain Donald Cunnell, who was killed a few days later.

• The Baron was grounded until October 1917.

• He had permanent effects, though, with post-flight nausea and headaches, as well as a change in temperament.



The Red Baron – The Last Mission

• His superiors asked him to retire in 1918, he refused.

• April 21, 1918. the Red Baron broke form formation to chase a Canadian Sopwith Camel.

• They flew very low and almost crashed into trees.

• The Red Baron, focusing on the chase found he was being shot at by ground gun units.

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The Red Baron – The Last Mission• It is unclear if he was shot

by a ground troop or by one other planes in the

area.

• There is debate whether

he crashed, but he probably managed a

sloppy landing.

• He died shortly after

landing around 11a.m.

• The plane was demolished

by souvenir seekers.



The Red Baron - Autopsy

• He was found still clutching his wheel.

• Poorly done autopsy, but he clearly was shot through the chest and great vessels, thus bleeding out.

• Facial trauma as well.



What about today?

• Even if he did land the plane, surviving a trans-mediastinal GSW in 2009 is hard, let alone in 1917.

• No anesthesia, no chest tubes, no ICUs, no antibiotics.

• Field hospitals were really lacking.

• If he lost pulses at the scene today, he still would have virtually no chance at survival.



What about today?

• The real question is did the head injury lead to his death?

• So once again, injury prevention would have helped by not putting this man in an unsafe position.

• His choices during his last combat were unsound in regards to the rules he usually followed.



What about today?

• It seems he had Post-Concussive Syndrome (PCS).

• Today, brain injured patients are evaluated for PT/ OT/ and Speech to clearly identify even slight problems with cognition.

• PCS affects a person’s ability to adapt.

• Also could have suffered from Combat Fatigue (CF).



What about today?

• Using today’s U.S. Air Force classification system, several authors have determined that the Red Baron would have not been allowed back in the air.

• Treatment may be with medicine or therapy.

• Mild traumatic brain injury usually recover in 3-6 months, moderate 1 year or more.

• New studies are using MRI to see the changes of mild brain injury not present on CT.

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William McKinley



William McKinley

• On September 6, 1901,

President McKinley and his wife were visiting Buffalo

for the Pan-American

Exhibition.



McKinley

• Leon Czolgosz was a 28 year-old anarchist who believed in “complete individual liberty”

• While in line to shake the President’s hand, shortly after 4 p.m., Czolgosz pulled out a .32 caliber short-barreled Johnson revolver and shot McKinley twice.



McKinley

• One shot caused a

non-penetrating flesh wound.

• One ripped through

his stomach.



McKinley

• Dr. Matthew Mann – a gynecologist with no gunshot victim experience – performed an operation to attempt to remove the bullet.

• Dr. Roswell Park – a respected surgeon- came later, but after many mistakes had already been made.

• Some excerpts from the bulletin of the case:

Remember – McKinley was a big man.



McKinley

• 9/6: 7 p.m. – One bullet glanced of the breast bone, the

other penetrated the abdomen five inches below the left nipple. The abdomen was entered through the line of the

bullet and it was noted that the stomach was entered. The

front wall of the stomach was closed as was the posterior stomach. No bullet was found.

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McKinley

• 10:40 p.m. - Resting comfortably. 100.4 F

• 9/7 6:00 a.m.- The President had a good night. 102 F

• 9:00 a.m. – Pulse 146

• 6:30 p.m. – Pulse 130, 102.5 F

• 9/8 9 a.m. – Pulse 132, 102.8 F, His mind is clear.



McKinley

• 9/9 9:20 a.m. - The President’s condition is becoming more and more satisfactory.

• 9/10 9 a.m. - The President’s condition is eminently satisfactory to his physicians.

• 10:30 p.m. – The condition is unchanged. A piece of his coat that was removed caused a slight irritation of the tissues and a few stitches were removed. Start pure beef juice.



McKinley

• 9/11 9 a.m. – His condition this morning is excellent, 100.2 F.

• 10 p.m. - Blood count corroborates absence of blood poisoning.

• 9/12 8:30 p.m. – The President’s condition is not so good. Excretion has not started. Pulse 128.



McKinley

• 9/13 12:05 – All unfavorable symptoms have improved. 100.2 F.

• 2:50 a.m. The president’s condition is very serious and gives rise to the gravest apprehension. His heart does not respond properly to stimulation. 100 F

• 9:00 a.m. – Somewhat improved.



McKinley

• 4 p.m. – He is only slightly improved.

• 5:35 p.m. – The President’s physicians report that his condition is grave at this hour. He is suffering from extreme prostration. He responds poorly to stimulation.

• 6:30 p.m. – Condition is most serious



McKinley

• 9:30 p.m. – The president is dying.

• 9/14 2:15 a.m. – The President is dead.

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McKinley - Autopsy

• Both stomach holes closed by stitches… but tissue around them was gangrenous.

• Upper pole kidney damage.

• Gangrenous bullet track through the pancreas.

• No bullet was found.

• “No sign of peritonitis”



McKinley

• There are reports of dissent among the treating physicians, and Dr. Park wanted to re-look at the abdomen when McKinley was worse.

• Politics prevailed and nothing else was done.



Well…

• Today we certainly have trained trauma surgeons to care for such wounds, and trauma care is part of every surgical residency – Gynecology does not do much trauma.

• Antibiotics would help as he certainly seemed to develop a wound infection.

• Resuscitation is better now – he had a high heart rate for days.



McKinley

• I certainly think we would have found all of his injuries.

• If patients get worse, second look laparotomy is mandated.

• He would almost definitely have lived with a similar injury today.



McKinley

• And one more thing…

• Exhibited in the building next to McKinley when he was shot… a new invention… the x-ray machine.

• If only they had a x-ray to help identify where the bullet went…



General George Patton

• Born: November 11, 1885

• Went to VMI, then West Point.

• Broke both arms in football tryouts.

• Was in World War I at a young age

• Participated in the 1912 Olympics –modern pentathlon

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Patton

• Learned more about tanks.

• On September 26, 1918, he lead a six man attack on German machine guns. He was shot in the left leg and was saved by the only other survivor, his orderly.



Patton

• He recovered from his injuries.

• In 1931, while commanding in Hawaii he wrote a defense plan anticipating an air raid against Pearl Harbor, not really used ten years later.



Patton

• Slapped a soldier in 1943 at a hospital when the soldier said he was there for “his nerves.”

• Lost his command but got it back later

• Saved thousands during the Battle of the Bulge



His Health

• Suffered many auto and horse accidents during his life.

• Some say that is why he was aggressive, mean at times, but very intelligent and effective.

• Sound like a trauma surgeon?

• Or CTE?



The Accident – 12/9/1945

• Was riding with no seatbelt in back seat of car going to hunt

• At RR crossing, car was hit by a large Army truck, likely low speed

• He was thrown forward, but the others in the car were fine



Patton’s Care

• Large bloody gash on his forehead from striking the privacy window – likely a hyper-flexion injury. He had trouble breathing.

• The local field hospital was bypassed and he was taken to the Army hospital that had AN x-ray machine.

• He could not move his fingers, still had numbness and tingling.

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Patton’s Care

• X-rays showed that the 3rd and 4th

vertebrae were fractured/ dislocated.

• All American neurosurgeons had been sent home or to the Pacific.

• Hugh Cairns, FRCS, RAMC, from Great Britain was called in but in took days to get there form Heidelberg.



Patton’s Care

• Crutchfield tongs were used in the meantime.

• Morphine was used for pain, caused by the tongs slipping.

• Penicillin, 1500 ml of plasma and 300 ml of whole blood in the first 10 hours



Patton’s Care

• When Cairns arrived, he determined the spinal cord was partially transected, with an incomplete C5 lesion and a dislocation at C4.

• Motion still in right hand and knee, Cairns was hopeful for recovery of function.

• Ordered traction using zygomatic hooks.



Patton’s Care

• Glen Spurling from the U.S. was summoned from Lexington, Ky. He was not hopeful for recovery.

• Initially showed improvement, Patton was able to eat, talk and regained some motor function in his extremities.

• Plan formulated to send him home.

• On December 20, he had an acute, hour long episode of shortness of breath.



Patton’s Care

• One lung filled with fluid.

• He recovered, but plans to home were suspended.

• He felt better the next morning.

• At 5:50 pm he became acutely SOB, unresponsive, and died.

• Likely a pulmonary embolus



What about today?

• Soldier who was slapped…

• He actually had malaria, which is easily prophylaxed

today.

• He might have also had other diagnosis:

• CF – Combat Fatigue

• PTSD

• These are well recognized in today’s military –

American Sniper

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What about today?

• Multiple Concussions

• Patton fell from horses and was in multiple auto accidents

• Some feel the multiple head injuries caused post-concussive syndrome

• May be why he was so easily agitated and angered his superiors and others (like the Russians) all the time.

• CTE and NFL and other sports



What about today?

• No seat belt

• Injury prevention efforts have improved seat belt compliance.

• He was in the back seat, and many adults still do not wear seat belts in that position.

• Primary seat belt law is needed in this state (MO) to improve compliance and save lives.



What about today?

• Triage

• He went past a field hospital to a better staffed hospital with an X-ray.

• This may have been appropriate triage, but only if the transport did not worsen his spinal cord injury.

• Higher level trauma centers are better equipped to deal with spinal injuries.



What about today?

• Laceration and Bleeding• He got antibiotics, appropriate choice at the time.

• He got whole blood and plasma

• This was ahead of his time

• Blood banks went to component use to ease storage of products

• We all have MTP now to recreate whole blood

• Some centers have followed military lead and are using Low Titer Type O whole blood for MTP.



What about today?

• Care

• He certainly would have had an emergent CT scan and likely MRI.

• If he had some residual function, an operation would have likely been done on at least an urgent basis. (Would not wait days for a consult.)

• Steroids? Probably NOT as no one has been able to reproduce the one study that encouraged the use of high dose steroids in blunt spinal cord injuries.



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What about today?

• Early ambulation

• Deep vein thrombosis prophylaxis

• Possible IVC filter if DVT present

• Tilt tables

• Better operative techniques

• Better braces for non-operative management.



Ronald Reagan



Ronald Reagan

• March 30, 1981: Only 70 days after taking office, at 1425, Reagan exited the Hilton Hotel and approached his limo.

• As he waved to the crowd, he and three others were shot by John Hinkley, who was apparently trying to impress Jodi Foster.



Hinkley



The Shooting



The Shooting

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Shooting

• Reagan was hit by a bullet that ricocheted off his armor plated limo. (He did not know it at the time.)

• Also shot were Press Secretary James Brady, Secret Service Agent Timothy McCarthy, and a D.C. police officer, Thomas Delahanty.



Brady and McCarthy



Reagan

• He was pushed into the limo by the secret service and he felt pain in his rib.

• He said, “Get the … off, I think you’ve broken a rib.”

• Then he coughed up blood.

• The agent ordered the limo driver to go to George Washington Medical Center – 9 blocks away. This was against protocol that would have mandated he go back to White House.



Reagan

• He reported difficulty breathing.

• 1435: Arrival to ED – “I can’t catch my breath.”

• He fell to his knees and was carried to a trauma room.

• Extreme pain.

• Initial BP – 80/palp



Reagan

• Blood noted at face and mouth.

• O2 by mask, Fluid, 2 Units PRBCs started.

• President able to make jokes.

• Wound at 4th intercostal space, posterior axillary line.

• No breath sounds over left chest.

• Hct from 40 to 30 in 30 minutes.



Reagan

• Chest tube yielded 1200 ml of blood and continued at 200 – 300/ 15 minutes. –Total of 2275 in the E.D.

• There is some discrepancy here, with other reports of only 1200 to 1300 total.

• Most trauma texts now advise thoracotomy if more than 1500 ml at first and more than 200 an hour of bleeding.

• BP – 160/100 in 15 minutes.

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Reagan

• There are some who say a left subclavian line was attempted which led to the increased bleeding from the chest tube – so a trip to the O.R.

• In fact, most low velocity GSW’s to the chest do not require thoracotomy (90%)

• Did he really need the O.R?



Reagan

• Likely yes, but not from the lung injury but potentially from a subclavian vein injury – we will never know.

• It turns out it was a devastator bullet with lead azide-filled centers that would have required an operation to remove anyway.



Reagan

• 1458 CXR:



Reagan - OR

• President to the surgeon Dr. Benjamin Aaron, “Please tell me you’re a Republican.”

• Dr. Aaron, a liberal Democrat, “Today, Mr. President, we’re all Republicans.”



Reagan - OR

• Peritoneal lavage to exclude abdominal injuries.

• Left thoracotomy:

• 500 ml old blood

• Bleeding bullet track

• Difficulty locating bullet



Reagan - OR

• Bullet finally found and bleeding controlled.

• Operation

• 2 hours and 40 minutes

• EBL 3000 to 3500

• Transfused 8 units PRBC, 3 units FFP, 1 pack plts

• HCT 33 in the recovery room

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Reagan - Bullet



Reagan



Reagan - Recovery

• Recovery delayed by atelectasis, mucous plugging, and possible pneumonia

• He was never reintubated, but was bronchedtwice.

• He was discharged on 4/11/81, POD #12



Reagan



Reagan

• What would be different?

• Ambulance vs. limo

• Chest CT with angio would rule-out concern for cardiac wound

• Abdominal CT would replace DPL if stable

• Likely would have avoided emergent O.R.

• Would not have looked so long for the bullet during the case (avoid coagulopathy)

• MTP



Thank You

historical trauma: i have no disclosures could we …...was deflected by the flames’ derek morris...

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