Death From Profound Hypothermia and Hemorrhagic Shock

Mt. Adams Rescue

A college climbing party was descending from the summit. An estimated 400 pound boulder broke free from ice and rolled down the mountain striking a 19 y.o. girl on the back, breaking ribs, thoracic spines, and shattering  her pelvis. She was conscious, and moving her limbs. She showed signs of impending shock from blood loss from her injuries 

An emergency physician and his climbing party were ascending the mountain and witnessed the accident. They went over to where she was, and applied first aid and tried to keep her warm with blankets. She needed to be evacuated by air, as an altitude response to altitude of 7,000 feet on a mountain would take too long.

This incident happened on a Sunday. The nearest Army national guard helicopter mountain rescue team was in Yakima 70 miles away. To activate a rescue by a national guard unit on the weekend requires permission from the Pentagon, which gave permission 1 ½ hours later. The time to arrive on scene, hover to load the patient into the helicopter took 2 more hours. Transport to Emanuel hospital took another hour. 

She was essentially dead on arrival at the helipad. No signs of life; pupils fixed and dilated, no respirations, no palpable pulses; flat line on the ECG monitor. 4 ½ hours of prehospital care time.  The trauma team took her directly to the Trauma operating room. The trauma surgeon on call happened to be Jon Hill, a cardiothoracic surgeon and trauma surgeon with experience in profound hypothermia and hemorrhagic shock.

The trauma team stayed with her in the operating room, until her heart regained vigor, her contused lungs were exchanging oxygen for carbon dioxide, her coagulopathy was correcting, and she was no long actively bleeding. At that point Jon transferred her care to WBL, as Jon had multiple elective cardiac surgeries to perform that day. When she was stable enough, we took her to the cat scanner and scanned Brain, Chest, Abdomen, and Pelvis. The brain scan was normal. The chest scan showed a recurrence of a clotted left hemothorax and multiple rib fractures. The pelvic scan showed a shattered pelvis.

She had 1 ½ liters of blood under the skin of her back, where the impact of the boulder caused a shear injury of the back, separating the skin from the muscles of the back. We drained that. Her estimated and measured blood loss from all her injuries were at least 8 gallons of blood (normal adult blood volume is 1.25 gallons). From tissue destruction of her back and buttock muscles, she developed acute renal failure and needed hemodialysis for the next two months. She developed liver failure from the shock and sepsis from a depressed immune system. A repeat Brain scan showed she had several small brain hemorrhages, but none required surgery. 

Over the next 3 to 4 months, we kept the multiple specialists involved in her care, focused and following our protocols. She did not develop antibiotic resistance, because we restricted the antibiotics to two, and did not need nor use an antifungal antibiotic, as was the custom for many critically ill patients in trauma centers.  

Her family lives in the Seattle area. We transferred her to Harborview Medical Center where plastic surgeon Nick Vetter revised the surgical incisions that needed revision.

This young woman beat all the odds against surviving. She made a full recovery from 5 organ failures, got married (Nick Vetter, the Emanuel trauma nurses and I attended her wedding), and she was able to return to snow skiing and has a full time job.

Gradual hypothermia associated with shock from blood loss is somewhat protected from organ failure and cardiac standstill. Gradual rewarming with organ support such as hemodialysis can be lifesaving.

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