Flatline to Lifeline With Dr. Long
Consider a world where increasing survival rates in patients typically deemed dead on arrival could be the norm. Is dead actually dead? Is it an assumption or a fact? In Flatline to Lifeline we explore the very real potential for survival within the medical field of trauma and near-death experiences.
During his 50-year career, Dr. Long and his team radically altered the approach to trauma care by applying simple principles in profound ways. We hope to educate the general public and inspire medical practices worldwide to acknowledge and adopt these life-saving approaches to trauma care, because when the need is greatest for the patient, saving time saves lives.
Flatline to Lifeline With Dr. Long
Trapped in the Blizzard: Learning Ramifications of the Mount Hood Climbing Disaster
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Join us for a gripping recap of the 1986 Mount Hood disaster on Flatline to Lifeline. Listen as Dr. Bill Long takes us through the bone-chilling events, describing the blizzard that ensnared a group of high school students and faculty, turning an annual expedition into a catastrophe. Dr. Long recounts his experience from the initial awareness at the hospital to the moment the urgency of the situation shattered the calm, drawing in the media and escalating public expectations.
Discover the unique physiological challenges presented by accidental hypothermia, like hypovolemic shock, and the critical need to maintain circulation in these dire circumstances. You'll hear about the innovative and heroic methods employed by Dr. Long and his team, including the groundbreaking use of cardiopulmonary bypass equipment under extreme conditions, and how these techniques turned what seemed like a hopeless situation into multiple saves.
As the narrative progresses, you'll grasp the full scope of the rescue efforts and the collaborative spirit that defined the Portland medical community's response. Through harrowing accounts of specific rescues and the strategic decisions made under immense pressure, you'll understand the profound impact of these actions on patient survival. Dr. Long's storytelling not only highlights the logistical and medical hurdles faced but also emphasizes the ethical considerations and the unwavering dedication required in trauma care. Tune in for a powerful exploration of life-saving strategies and medical advancements that continue to inspire and educate.
Read more about the Mount Hood climbing disaster here. You can learn about the book that one student's mother wrote entitled, The Mountain Never Cries, and check out another recount of the event in the book, Code 1244.
To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.
Follow us on Twitter @DrLongPodcast
Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast
© Flatline to Lifeline 2025
Welcome to Flatline to Lifeline with Dr Bill Long. This podcast explores the very real potential for survival within the medical field of trauma. My name is Will Oman. Dr Long is both my uncle and a hero to many in the state of Oregon and beyond for radically altering the approach and adaptation to trauma care by applying simple principles in profound ways. Here we will discuss the innovations and adaptations that Dr Long and his team of nurses and surgeons employed. He did this over his almost 50-year career. The near-death experiences that we discuss here showcase the ability to achieve and to repeat unexpected survival outcomes. Patients that would normally be deemed dead on arrival are now being treated with techniques previously only available within an operating room. We hope to educate those listening from any walk of life and to inspire those within the medical profession to consider and adopt the life-saving techniques and approach to trauma care, because when the need is greatest for the patient profession to consider and adopt the life-saving techniques and approach to trauma care Because when the need is greatest for the patient, saving time saves lives Dr Long is here, as always. How are you, uncle Bill? Just fine, bill, thank you.
Speaker 1All right, so we are going to discuss something today that is pretty heavy topic work. We're going to discuss the 1986 Mount Hood disaster and how you and your team and several hospitals in Portland, oregon, were involved in the treatment of the people brought down the mountain those days, the people brought down the mountain those days. So in season one actually, we had our first real wilderness rescue. It was on Mount Adams and it dealt with a young woman who was hiking down Mount Adams and another climbing party was coming up and a boulder dislodged, rolled down and she basically got hit in the back by what I referred to as a Volkswagen and we went through the whole scenario of what a rescue team looks like and the travel time and all those things and she actually made a recovery. I only referenced that to reference the fact that wilderness rescues are something you had been a part of and your team started to employ, with deep hypothermic states and how to both rewarm a body but then how to adapt and adjust and to cool a body in order to perform in a bloodless field. So it is both the mathematical principle of getting the core temperature up and down as needed per the situation. Even on Wikipedia it states that this Mount Hood disaster to this day remains the second deadliest alpine accident in North American history, only to a 1981 avalanche on Mount Rainier that killed 11 people. It's also particularly heavy as a father that seven of the nine Mount Hood victims were teenagers from a private school that had decided to ascend that day.
Speaker 1It was a well-intentioned trip. It was something that was done annually. There were all sorts of there were good intentions behind it, people trained for it, they had professional guides and yet still this happened. The cursory background of how bad it was, people who were very familiar with Mount Hood in various articles, some of them summoning Mount Hood 400 plus times, said that the weather that day was singularly the worst they had ever seen, with winds topping 100 miles an hour on that specific day and four feet of snow dropping in a 24-hour period causing a whiteout. So what occurred from start to finish was just a catastrophic perfect storm, if you will, and I don't say that to be glib.
Speaker 2So from that little bit of information, so from that little bit of information, dr Long, since you were involved in this, I'll let you go from here when to begin. Basically, we weren't aware of any of this as it was happening until the TVs in the hospital and people were coming up to me from within the hospital saying you need to get on TV because there's been a disaster on Mount Hood and there's a climbing party that's missing. There's a blizzard up there and there's no one that can get. You can't see anything, you can't fly helicopters, you can't get land ambulances up there, you can't get climbers. Up there, in the middle of a blizzard was a complete whiteout. So that gave us. That was two days. While all this was happening.
Speaker 2Meanwhile, the parents and the families and friends of these climbers, of the kids and members of the faculty of the school, were basically arriving in the parking lot of Timberline Lodge, which sits around 7,000 feet above sea level, two-thirds of the way up of the mountain, and waiting to hear what's going to happen.
Speaker 2So ABC, cbs and NBC had their news trucks park in the parking lot of the Timberline Lodge and they started basically talking about this developing drama. And part of that development was what should you do if you found these people and at that point they consulted hypothermic experts around the country and had them say their piece on national television. And one of them was a guy that was well-known in hypothermia circles For those who read that kind of literature, it was Murray Hamlet. He had headed up the Army research program at Natick Massachusetts and he was well-known because hypothermia is a major issue with wartime, especially in cold climates. So that's why the Army was interested in it and Murray basically said on national television you're not dead until you're warm and dead. And with that statement it raised the expectation among all the listeners, especially the people in Portland and on the mountain who are waiting to hear what was going to happen. Who and how is going to rewarm these people in an effort before we declare them dead. That set off the situation. So in the meantime….
Speaker 1So the gauntlet….
Speaker 2Sorry to interrupt, so the gauntlet has been thrown down to the national media at that point basically, I wouldn't say a gauntlet, but an expectation was created based on the military experience, that we should try to warm these people until they're warm and dead. You have to understand that the military, even in ice, cold climates, don't have cardiopulmonary bypass equipment, which has been a major topic of what we're doing this season is talking about the use of this equipment.
Speaker 1Can I back up just a moment in the setting of this? I back up just a moment, right um, in the setting of this. So we had discussed that this was a, this was a, a school kind of field trip, so to speak. Right um, something prepared for um it was. It was a trip that had that was done annually, and the reason Mount Hood um is chosen is because it's accessible Very much like you said, offline.
Speaker 1Mount Fuji in Japan, outside of Tokyo, I mean, it's a glaciated peak, it's nearby a metropolitan area, but you can ostensibly just walk to the top, get to the top, enjoy the view and walk back down. It doesn't take a great deal of expertise to ascend and descend. Unfortunately, the weather that day was the curveball, and then not only are they stuck, but you're finding out about this, and then an expectation, as you said, has been relayed to not only the families but to the population worldwide that had access to that broadcast, that somebody had to do something in order to assess and treat what was going on. So you were given an expectation of treatment, so to speak.
Speaker 2It was a noun. It wasn't basically in the textbooks that you're dead until warm and dead. I mean, as I say, the Army was interested because of the issues that comes about with combat in very, very cold environments and, as I say, murray Hamlet was basically the person in charge of the Army Research Institute of Environmental Medicine in Natick, massachusetts, and Murray is a highly respected guy. So basically, when that happened, we thought, well, people are going to expect we're going to have to try to rewarm these people whether they're frozen or not frozen I mean there were no parameters set for this. Frozen, I mean there were no parameters set for this.
Speaker 2Fortunately, because of our previous experience with dealing with ice cold patients who had profound hypothermia or immersion hypothermia in Portland, we had some idea of what it would take to rewarm them. And John Hill and I, who had trained in San Diego University of California, san Diego, and learned how to do deep hypothermic circulatory arrest for elective thoracic cases where you have to replace the entire upper thoracic aorta and you had to do it in a bloodless field, you deliberately cooled patients on bypass to around 20 to 25 degrees centigrade so you could turn off the pump, the bypass pump, have no circulation and you could operate in a bloodless field and replace the arteries and the connections of the arteries going to the brain and to to the rest of the body. And so when john hill and I started practicing here in portland and we started seeing these hypothermic patients coming in, we didn't see any hypothermic patients in san diego, I didn't see it. University of maryland, I didn't see it. In boston, I didn't see it.
Hypothermia Treatment and Rescue Efforts
Speaker 2In sc, where I trained. I mean. So then you have to adapt to what is being brought to you and attempt to see whether or not you're going to try to revive them. And so we asked the question. I said if you could do this deliberately, electively to people and cool them down to that lower temperature, what can you do for these people who have been exposed to hypothermia on a mountaintop, for example?
Speaker 1Ostensibly they're pre-cooled for you.
Speaker 2Yes, but the difference is, without going into too much physiological detail, people who undergo elective surgery are usually what we call normal bulimic. They have a normal circulating blood volume. Are usually what we call normal bulimic. They have a normal circulating blood volume. People who are profoundly hypothermic from accidental exposure, like in cold environments, not immersion, like you're up to your neck in ice-cold water, like the sailors who drowned in the Sea of Murmansk in World War II when their ship got torpedoed. So the question comes then how would you sit there and try to rewarm these people? Because a hypothermic patient, it takes a while to get them that cold and they lose blood volume, water from their vascular system into the surrounding tissues. They urinate more because the kidneys are not reabsorbing the water from their urine as they make it and so constantly it's called hypovolemic. They can be in shock from fluid loss into the environment and into the tissues, just like we described if they've been bled to death. So that was a key factor the hypothermia causes hypovolemic shock.
Speaker 2So now you're working on a dehydrated patient that you're going to try to rewarm, and there are many mechanisms to rewarm. You can rewarm them by heated air, by you breathe in. You can have basically hot packs placed in their armpits and their groins. You can do hot towels or hot blankets and put on top of them. You can do some people even do immersion to rewarm them. But that is not applicable for people who are basically have almost become ice cubes and a lot of their tissues are frozen or near frozen. And you have to have a circulation that is going to bring warmth that you put into the blood that's going to the rest of her body, into the tissues, and to be able to revitalize the cells that are dying from a lack of oxygen, lack of blood flow, lack of nutrients such as glucose. You have to sit there and have a circulation that's able to do that, and these people are already beginning with a circulation that's impaired by a lack of blood volume.
Speaker 1This is in direct contrast to that first girl from season one, where being packed in the snow actually improved her situation Right, because, as you described it, I believe, as she was rewarmed, she kind of opened up like a flower, like her hands across her chest, things like that, like a flower, like her hands across her chest, things like that. Or the young boy who was found face down in the river, who it was a gradual freezing, as opposed to this, which is shock where it's happened so quickly that you, as you said, become dehydrated and go into this position where the fluids just aren't there.
Speaker 2Right, you know, the girl that you talked about in the first season was a girl who, basically, was hit by the rock coming down the mountain that broke almost all of her ribs in her back. Well, the spinous processes along her spine, without paralyzing her, broke her pelvis and so she had hemorrhagic shock, in addition to the shock associated with her falling temperatures, as she was exposed at around 7,000 or 8,000 feet up on Mount Adams. So it was, if you want to call it, a perfect storm of both trauma, where blood loss has occurred, and fluid loss is occurring because of the hypothermia. Different magnitude of difference the people, the girls and boys and adults that were involved in the Mount Hood disaster, were not injured, gotcha.
Speaker 1Okay. So in this particular case, you know we're dealing with these young kids, high school age kids, most of them about 15 years old, a couple of school representatives and some experienced guides, and you know the guides. As this blizzard comes in, they go up the mountain. I guess against best protocol. I guess against best protocol. So, per what I've read, the day begins approximately 3 am in the morning and it was forecasted that weather was going to be pretty bad. There was a storm coming.
Speaker 1The leader from the school decided, in the face of that weather report, that he felt like they could get up and back safely before the storm hit. Because, as you have said multiple times, this is considered by an experienced climber. This is considered a walk-up. You still need tools. It's still over a glacier, there's still crevasses and dangers involved. You need crampons and things to get to the actual summit, but for all intents and purposes, this is a very mild hiking experience. To get to a summit, right, right. And so what happens is that they get up to or near the top of what is referred to on this mountain as the hog's back and a whiteout occurs, the winds pick up, the snow comes in and visibility drops to within 30 or 40 feet and then continues to degrade from there. Um, in the, in the initial party there were 20 people and you know, at various, at various intervals, uh, between, uh, well, two people turned back pretty early on Um, another two, another two people turned back a little bit later, but you have the core group with the guides still on the mountain and the head of the school was still pressing forward. Now, one of the things that happened I mean, this is still happens to this day is there's a memorial service at that school commemorating and and doing a memoriam for that tragedy, because the school still exists today.
Speaker 1Nonetheless. What happens is these people get trapped and through the experience of the two guides, they figure out okay, we need to protect what we can. At 103 miles an hour, as I've read, that's considered a category two hurricane, and just from exposure in both temperature and wind, your best bet right there is to create an ice cave, and one of the guys does this. Creates an ice cave very quickly, about within an hour. But that cave, area-wise, would have fit normally about six people, and at that point they were fitting. There were 13 people inside, so their breath, their body heat was actually melting the inside of the cave, turning it into ice, um, instead of instead of snow, and also, you know, creating kind of a pool of ice-cold water at the bottom of the cave, creating more hypothermic conditions. Three people had gone outside of the cave for reasons, probably to relieve themselves or something else, and were able to never get back in. This was a tragedy from start to finish. All could have been avoided simply by not going up that day.
Speaker 1The historical perspective of it there's been books written about it. You can find this in our show notes. One is called Code 1244, but it doesn't really go into what you're going to talk about, which is the medical aspect of this. It talks about the rescue efforts, which were phenomenal as far as the amount of work and hours put in by volunteers, getting in army specialists, helicopters, all of it just to locate these people to begin with. And there were actually, and there were, two survivors.
Rescuing Hypothermic Victims
Speaker 1And this goes to a point that you've made several times about hypothermic states, that the younger the person is, the better off they are at withstanding these hypothermic shock situations. Uh, far better than the adults, because the adults, aside from those who were able to get out or go seek help, uh, all of the adults that didn't turn back or seek help. They perished. There were two survivors One was a 17 year old girl and one was a 15 year old boy, if I'm not mistaken. But back to your back to your statement that goes out to the major news networks. The army expert says that they're, they're not, they're not dead until they're warm and dead, and so that places an expectation. And now we'll switch it over to how you were brought into this. What exactly happened, what were the mechanics of it?
Speaker 2I was going to say. We were watching television, like a lot of other people in Oregon at that time, and I was at the hospital. John Hill and I were both at the hospital and neither one of us had surgery scheduled at that particular time and we became aware of what was happening. So at this point in time, john Hill and I were not recognized by the local community as having any knowledge about hypothermia, accidental hypothermia, how to treat it. Cameron Bangs an emergency physician here in Portland. He was the local expert on moderate rewarming of hypothermic patients and because of that I asked him to come to Emanuel and see if we got any.
Speaker 2Who had gone outside of the snow cave to relieve themselves, couldn't get back in and died of hypothermia and froze basically outside the entrance to the snow cave. Their bodies were covered over with snow. To the snow cave, their bodies were covered over with snow. So when the weather cleared, helicopters were circulating around the mountain trying to see if there was any evidence of anything. No flag, no, nothing whatever. And there was a Sergeant Harder who worked with one of the recovery teams and he basically guessed that they would be somewhere southwest of the hogsback, based on when this blizzard came and where, where they might be at that time, on potentially coming down the mountain and, uh he, he focused them on that and they found the first three bodies outside the snow cave but still did not know where the snow cave was. They brought the bodies down and put them in body bags because they were quote frozen.
Speaker 2And the chief flight nurse, pat Pat Roberg, of the Life Flight Helicopter Program, which is managed by Emanuel Hospital, then called me from the parking lot and said what am I going to do with these three students put in body bags? So, based on what I had heard from Murray and other hypothermia experts who were still saying on national television about the number one priority, which is try and rewarm them, I told her we were going to try to rewarm the three students and transport them without anybody doing any treatment of any kind, from the time that they leave the the Mount Hood parking lot to the time they arrive at Emanuel, because there's nothing that they could do externally when we believe that they need to be rewarmed internally. So Life Flight Helicopter can only carry one patient at that time and the Oregon National Guard had a Huey on standby in the parking lot and they could bring the other two to a manual as well. We happen to have three cardiopulmonary bypass machines two portable, which we had just started developing that program, and the third is standard cardiopulmonary bypass for elective and somewhat emergency cardiac surgery.
Speaker 2We basically knew there were going to be others going to be found. So at that point I called the other Portland cardiothoracic surgeon who did heart surgery in the five Portland hospitals that did it Emanuel, good Samaritan, Oregon Health Science University, province Portland and Province St Vincent and asked them I said would you be willing to try to give any, make an effort to try to rewarm them with bypass technology? And I said we'll be willing to give you our protocol for what we've learned so far in rewarming very cold patients.
Speaker 1So at this point you've already called Cameron Bangs and asked for his knowledge and we've discussed many times over that the medical community is very averse to asking for help. But you're doing it actively. But you're doing it actively and then you actively make another call to grab the five other hospitals in the Portland area to say, hey, do you have any interest? Do you want to take on some of these patients? Because it's not going to be just these three, they're going to be more, these three.
Speaker 2You know they're going to be more and we've been given a mandate, so to speak that we need to do this and you're also willing to share expertise to these guys about what you've been doing, right? Right, because, as I say, none of those hospitals had any interest in doing deep hypothermia from environmental exposure and so this would be something new for them. But they had the technology, just like we had the technology to rewarm these patients if they would only try. So I asked and they said they would be willing to try and they would accept some of the patients, because Emmanuel couldn't take nine patients. We had trouble just with dealing with three. Right. So, having that, then we basically looked at the support that we had within Emmanuel. We had basically still there trauma ICU nurses or nurses who participated in our previous efforts to rewarn patients with cardiopulmonary bypass. We had two perfusions immediately available to man one standard cardiopulmonary bypass machine used for open heart surgery and two portable cardiopulmonary bypass machines made by the CR Bard Company, who also developed long catheters to put in the artery and vein to help get the circulation started. So when the first patient arrived, we took the patient directly to the operating room, arrived at a manual, we had all the necessary staff and equipment and John Hill took the first patient and cannulated the femoral artery and vein and with cut down, since he was so cold and his arms were frozen across his chest, and so the possibility of doing a median sternotomy or open the chest to expose the heart was impossible, and so we put that patient on bypass and started bypass to rewarm him. At the same time, we drew a lot of blood to get a blood analysis to see where his blood was in terms of plotting, where his blood was in terms of the blood count, such as what's called the hematocrit, how much was the percentage of the red blood cells in the sample that we took. We also added a serum ammonia level to see whether or not how much protein catabolism was occurring because of this prolonged period of exposure with no calories and no fluids. And so, under our protocol, we roamed the patient with one and a half degrees every 10 to 15 minutes, starting with the patient's folic catheter temperature measuring 21 degrees centigrade, and we put myocardial temperature probes into the calf of the cannulated leg so we know when and if the tissues in that leg were going to become the same temperature of the central organs such as the brain, heart, lungs, kidneys and liver. So we're trying to do this systematically and scientifically to show that we're not.
Speaker 2So we had information that we could use to make an adjustments as we needed to on the resuscitation of these patients. The anesthesiologist wanted to intubate the patient but there was no. We tried to explain to him there was no need, since cardiopulmonary bypass was already supplying all the oxygen and removing the carbon dioxide in the patient's blood. So we didn't need to have an anesthesiologist intubate the patient and do ventilation. That's what the cardiopulmonary bypass machine does and the patient's mouth was frozen shut anyway. So you know, oral tracheal intubation was not possible and we couldn't do a tracheostomy at that time because of potential for bleeding.
Speaker 2So we noticed that the initial hematocrit was 54%. 40% is normal. So that means he was very dehydrated. He needed more IV fluids than we anticipated and he became increasingly swollen in the face from edema or water settling leaving his vascular supply, the capillaries, into the surrounding tissues and his face was becoming swollen. And the same thing was once he warmed up enough.
Speaker 2We were able to do a median sonotomy and pericardiotomy to look at the heart, which did recover some of that activity, such as refined ventricular fibrillation, but it didn't respond to defibrillation, even after the myocardial temperature probe reached 35 degrees centigrade, which you normally in open heart surgery. You should be able to defibrillate. A person at that temperature should be able to defibrillate a person at that temperature. So the heart became more edematous and as it got more edematous it became stiffer and then it began to have small what's called small petechial hemorrhages, where a lack of platelets circulated into the patient's blood. And it got so stiff that we couldn't do any more and we withdrew therapy and sent him to the laboratory for a pathologist to take a look at his serum. Potassium was rose from a normal of four point mil equivalents per liter up to 12 mil equivalents per liter and did not respond to alkalizing agents when, when you say that he didn't respond to these alkalizing agents and such you're, you're basically saying that that he's passed as well.
Speaker 2Right. Metabolically we were too late. His cell or mitochondria were not functioning, so metabolically we were too late. So while we're dealing with this, we had two other patients that came in, brought by the Oregon National Guard. We experienced similar difficulties but we got similar measurements of the patient's metabolic derangements, because we felt that was important to understand where we were beginning with and as more patients started coming into the system, we could call the other hospital and say we were making these adjustments. You might want to consider doing that yourselves, okay?
Speaker 2So the next day the search and rescue team found the snow cave with two adults the two episcopal faculty and seven students, two of which showed minimal signs of life. I should mention, as you mentioned before, that the guide, after building the snow cave, and one of the students agreed to try to walk down to the mountain and let everybody know what was happening. They were so disoriented by the whiteout of the snow and the blizzard that they did not go down the mountain to Timberline Lodge. They ended up Mount Hood Meadows, about a mile away from where Timberline Lodge is. So that gave you an idea of the visibility that was taking place and the logistics of trying, the difficulty of logistics of trying to find these people. So, but they eventually found the other snow cave and uh, and then we arranged for them to basically have these, uh, distributed these patients to the various hospitals in portland that do that, do heart surgery. And uh, we let the disaster management group at the mount hood parking lot let them decide which patient went where. We had no idea about how that would be selected. There is supposed to be a decene management director, usually run by the Clackamas County Sheriff, who would make those kind of decisions. But we did get the agreement that we would try to revive all people found in the snow cave, and that was an important logistical problem.
Speaker 2So there were two patients who are barely alive when the snow cave was uncovered, giles Thompson and Britton Clark, and that's spelled B-R-I-T-T-O-N. Britton Clark, not Brinton. Okay, both were. Both were near the mouth of the snow cave, while the others were clustered on top of one another at the other end of the snow cave. That became a major discussion factor, because did they get more oxygen preferences, since they were near the mouth of the opening which had been closed over with snow, versus the others who were packed on top of one another and they died as asphyxia in the back of the snow cave. That that was never, never really resolved. So giles was transported to province portland hospital and britain came to emmanuel. The other patients were distributed to the others.
Speaker 2As we talked about uh at the other hospital, one one of the patient had clots or gels in the venous system which clogged the cardiopulmonary bypass oxygenator, making further efforts futile. The other two died on bypass and were declared dead. One was declared dead at ohsu, britain. The one that came to us, an 18 year old junior, came directly to the operating room in a manual where all the nursing physicians and surgical staff who participated in the resuscitation uh the day before never went home and stayed to await the arrival and anybody else who might be sent to Emmanuel. That tells you professionalism. They could have said my shift is over and gone home, but they stayed because they wanted to be part of resuscitation.
Speaker 1And that speaks to your team and its mission that the patient's life has value right.
Speaker 2So john and I have made an agreement that, uh, he would cannulate britain while I would oversee the team members effort to resuscitate her. We've talked about that before. The pit crew boss never put changes a tire but refuels the vehicle where he's like. He makes sure that all the team is working effectively. And it's so important in trauma where you might have a neurosurgeon or a maxillofacial the tire but refuels the vehicle. He makes sure that all the team is working effectively. And it's so important in trauma where you might have a neurosurgeon or a maxillofacial surgeon, chest surgeon, abdominal surgeon, orthopedic surgeon all operating simultaneously. One person doing surgery themselves doesn't have the field perspective to sit there and see what all the other people are doing and, of course, direct the team, all the team members.
Reviving Hypothermic Patient With CPR
Speaker 2So that was my role and while John did the technical part of it, and as we transferred from the helicopter gurney to the OR table, we took care not to jostle her because the potential cause of ventricular fibrillation, which is a known complication of profound hypothermia, you jostle them, rough them up or moving them, jerk them around a little bit and all of a sudden their heart could be breathing at a sinus, bradycardia, slow heart rate, around 40. Now then would become fibrillation. Now you have an almost frozen chest wall. You're trying to put shock through to defibrillate the heart. So her face through to defibrillate the heart. So her face. Basically she was not moving any limbs, her arms were basically frozen across her chest. Her chest wall was not moving, no palpable pulsals, no sign of a heart rate. Her face was flushed. The nasal ally were barely moving and the only objective sign that she was breathing was when you put a glass slide under her nostrils and we noticed an intermittent fogging of the glass slide. That means her exhaled air coming out through her nose was basically slightly fogging the glass slide. Her pupils are dilated, not reactive to light. Her arms were folded across her chest, too stiff to move aside, to expose her chest. She did not respond to any verbal or painful stimuli.
Speaker 2So john, candulated, uh, both groins and because we learned something from the previous guy who which we'll talk, which we talked about, who lost a leg, because we can't, we put both the venous cannula, arterial cannula, in the same lower extremity and uh, basically, uh put in the long venous cannula first and pushed that up as far as the right atrium and when he took the stylet out of the cannula. No blood came out. That shows you how dehydrated Britton was. No blood came out of the venous cannula. So then he basically put the arterial cannula in the left common femoral artery and then he did get some blood back and uh, it wasn't, it was barely a pulsatile. But we used that blood for the laboratory sampling to find out where we were with the metabolic status of that particular patient so she has blood and but it's ostensibly it's not flowing because it's either frozen or she's so dehydrated that it's just non-existent right and the heart's not not beating successfully.
Speaker 2I mean, remember, we did not have sinus rhythm, we did not have normal heart rate, she, her heart was we would think would be stiff, based on what we had seen with the other three patients and she's non-responsive to any stimuli, right, right.
Speaker 1So this would indicate, as we say in the intro, essentially she's dead, dead on arrival.
Speaker 2She's clinically dead, okay.
Speaker 2Okay, now, when we got the EKG leads on her, you have to remember the leads are going on to a very ice, cold skin and so the electrical transmission of her heartbeat to her body, to her skin, to the electrodes on her skin to measure the EKG is barely readable Right and consequently we basically had a nodal bradycardia where only the atrial ventricular node was beating and that was around about 30 beats per minute and she had no blood pressure, nothing.
Speaker 2So once we did got the cannulas in and the artery in the vein and we put her to the pump tube and we started slow pre reperfusion of her body with fluid. We've given her iv fluids, including blood and blood, other blood products such as fresh frozen plasma, cryoprecipitate platelets to sit there and get her blood clotting starting back to normal, because platelets in basically a very cold patient, platelets will accumulate in the frozen extremities which have, especially if they have, frostbite, and in the lungs. Wherever there's a cold interface between a blood vessel and the atmosphere, that's where platelets will accumulate. So she had a relatively loss of platelets in those areas, but not to the rest of the body, probably too much information.
Speaker 1It's definitely not too much information. I mean, it's highly technical, but it's important to understand for the, for the listening public, whether they be a lay person or a medical professional, that this is the. This is the profound level of complexity that you're dealing with, while the layperson isn't going to understand some of the lingo. The fact that you're listing, time after time after time, a new complication or a new procedure or a new attempt. It deals with how hard this is. And let me just go back to the fact that this girl is clinically dead and you're still doing more, and it begs the question. It begs the question not what the on-air mandate was. They're warm and dead.
Speaker 1It speaks more to try or not try, and we've said this time and time again. It takes no energy to quit. Quitting is easy, but yet you and your team keep trying and you in the supervisory role, looking down and making sure everything's coordinated. This stems and flows from you. This team, this pit crew, was born. It was an idea that you implemented and, even though you won't give yourself credit for it, you're still. Your team is still actively pursuing saving the life of somebody who's dead, and that's incredible in its own right.
Speaker 2Well, put it in a slightly different perspective, if you're a Star Wars fan, yoda tells Luke Skywalker do or not do so. It's the same message, try or not try. And that's the difference. And if it can be brought out in Star Wars, why couldn't it be done in the operating room for these people? So while this was going on, while Jadon was preoccupied getting the cannulas in the anesthesiologist a very experienced anesthesiologist he tried to insert a nasal tracheal tube, since he couldn't open the mouth because that was frozen and the nasal tracheal tube was about the size of my little finger in thickness. And when you push it through the nostrils, the mucosa of the lining of her nose is very friable and edematous and it's scraped off and she started bleeding. As we were rewarming her torrentially from the nose, we took the tube out, packed her nose with gelatin gauze to tamponade the bleeding.
Speaker 2But this is what happens. You know, in any type of desperate circumstances, people get an idea that they want to help and, for all the best motivations, it's the wrong thing what they do. And, as I say, I watched this last week, this last weekend, when the Ravens fell apart, their football team lost poise and what the game plan was and they just deteriorated. I mean, it was a shock to everybody watching it, but it was a totally different situation. But they made major mistakes. And this is what happens when people want to do something, do not really know what to do, but they want to do something, to sit there and help the situation. It's a natural human situation, but that's why the pit crew boss has to be there. You have to stop this impulsivity that can lead to patient harm. If you believe in first do no harm, you try to prevent people from doing harm when they're trying to do it for what they think is the right reason.
Speaker 1Good actions and good intentions are very, very different.
Speaker 2Right. So he didn't realize that all endothelial mucosa in profoundly hypothermic patients, even putting a nasogastric tube down into the stomach, are a demoness and friable pain for accidental hypothermia. I've seen people who almost bleed to death from somebody putting a nasogastric tube in the stomach to drain the stomach and all of a sudden they get bleeding from the stomach. You'd have to do a major operation to stop that, sometimes all right. So as britain began to re, began to rewarm, her distal extremities lost their power. They were basically like not quite ice, but they were white. There was no sign of anything, there's just white. As her core temperature rose above 28 degrees Fahrenheit or centigrade, she began to move her arms outwardly, sometimes akin to a tulip bulb opening its petals. I mean, you had to be there to watch it. At that point her teeth were unclenched and the anesthesiologist was able then to do an oral tracheal intubation. Her legs lost their rigidity and the nurse was able to basically abduct her thighs to put a folic catheter and thermistor into her urinary bladder. The initial temperature was 23 degrees centigrade. So this is down at the level where you could do circulatory arrest, you know for deep hypothermic circulatory rest. All right, her heart rate rose from sinus bradycardia 34 per minute to 80 and then to 100. She developed a palpable femoral pulse in the non-cannulated extremity. She began to breathe spontaneously, at which point the anesthesiologist started, inhaled anesthetic and increased the temperature of the inhaled air. So now then, we're warming her internally through cardiopulmonary bypass and now we're rewarming her from basically provide a heated air going into the lungs. We're not putting hot packs on her groin, not putting hot packs on her skin, because her skin has not warmed up yet. If you do that too soon, there is no circulation bringing blood, oxygen and glucose to the tissues and the skin will die.
Speaker 2So John put it at what we call a myocardial temperature probe, when we're doing a heart surgery and we're freezing the heart temporarily to operate, when it's not beating into the soft tissue of her left calf to measure the temperature differential from her extremity and the folic catheter thermistor left calf to measure the temperature differential from her extremity and the folic catheter thermistor. That's important because you have to have a way of knowing, as you're rewarming, that everything is rewarming uniformly. So if the bladder is rewarming faster than the extremity, then you're going to have a problem. That's why we don't use vasoconstrictors, we use vasodilators to sit there to try to get all the flow going to the extremity and we have the bypass machine pump doing the work of the heart that is still recovering from this major insult. So she stayed on the bypass machine until all the parameters were stable in the operating room and her metabolic and respiratory acidosis had returned to normal. We used the normograms that the professor at Scripps Institute of Oceanography had developed for us for poiklothermic seals and he took our data and made nomograms for humans and we would use that to sit there and get her uniformly rewarmed and correct her metabolic acidosis, which meant all the mitochondria and cells in her body were getting back to normal, not just in one organ but all the organsria and cells in her body were getting back to normal, not just in one organ but all the organs together.
Speaker 2Since we couldn't visualize her heart directly, we placed her on low-dose dobutamine, which is a strong inotropic drug to help the heart contract more forcibly and it also improves microcirculation because it causes a mild vasodilation of the small arteries and small veins.
Speaker 2We transferred her then on the portable bypass machine to the ICU where we support her until we could wean her from the dobetamine, the cardiopulmonary bypass machine and the ventilator. So once that happened, john was able to decannulate the right common femoral vein artery. After reopening the groin incision Then put what's called a purse string suture around where we put the cannulas in. Then as you pull the cannula out you tighten that down like you do with a purse string purse that has strings in it that closes the mouth of it so it wouldn't bleed. Then I sutured up the rest of the wound and this provided the seam estates from the vessels. Without need for additional sutures. She made a full recovery. The only complication of this experience was she developed what's called fat necrosis and the arch of her foot there's a little bit of fat and the arch of her foot there's a little bit of fat.
Speaker 1So the only lingering complication that she has is necrosis in the arch and heel of one foot. Yeah, that's amazing. So she's frozen to death. She's dead on arrival. You guys do everything possible through multiple different procedures, and you uniformly rewarm her from a fully non-responsive and dead status to she makes a full recovery with only with only an issue in one foot right she went on.
Speaker 2She went on intellectually. She went on to graduate from the organ episcopal school, play in the organ youth symphony, graduate from Stanford University Medical School, complete a residency in internal medicine and became the internal medicine residency director for a position she still holds Really.
Speaker 1Yes.
Speaker 2Hypothermia does affect the intellectual act of a person because the brain is a soft tissue organ like everything else. But she made a full recovery and that shows you that she was not limited in any way intellectually. From that, Giles had a different kind of course.
Speaker 1But that's amazing, that she goes from not only experiencing a horrific tragedy like this experiencing a horrific tragedy like this but then that presumably the gratitude that she probably had for all the work that your team did and that experience probably pushed her towards that field. But she's an acting physician now.
Speaker 2Well, her mother was a dermatologist, her father was a radiologist. Okay, so she was probably on course she was on course for that expectation. It would be the right choice, I think the right choice. She didn't have to go into surgery, but she chose internal medicine and did very well with it.
Speaker 1Unbelievable. But you said the other boy, giles. He had a different experience and I'm not putting the other hospital to tax on this.
Speaker 2But he had a different clinical course. He was slightly more awake and more mobile in the snow cave than she was. Some said he was making noises at the scene, his heart allegedly defibrillated during the transfer from the helicopter gurney to an OR table. We talked about that, before it can happen. He was successfully defibrillated and placed on advanced cardiac life support drugs, including vasopressors. He was rewarned with standard cardiopulmonary bypass machine, which is what they had, but to what temperature I don't know.
Speaker 2He had more signs of severe frostbite in his extremities. That may have affected his clinical course because he ended up having above-knee amputation and below-knee amputation in his lower extremities and he had to have what's called fasciotomies on his forearms to be able to do that. But Giles recovered intellectually. He basically ended up with prostheses for his lower legs, but he was able to resume snow skiing with his artificial limbs back again. I mean so that's just amazing. And his mother basically wrote a book about her experience with this tragedy. It gives a different impression of how things evolve from a survivor, from a mother's point of view. And again, it's just overwhelming when you consider how things turn out.
Cardiopulmonary Bypass in Hypothermia Treatment
Speaker 1It's incredible. I mean you're talking about two survivors out of a party of 20 that started. I mean multiple people turned back or or were able to get out at various times, but so many people, you know, losing their lives in this and that you and your team were instrumental in saving one of those lives and working tirelessly on patients who nothing could be done on, but yet you were still putting in the efforts and using those efforts as learning modules for what eventually was achieved with Britain. And obviously, the other young boy who lost, who lost both of his legs, um, you know that's a tragedy in its own right, but the fact that he still walks the earth today and actually skis the earth today is incredible, because the theme of this season has been the cpb, um and and the portable cpb.
Speaker 1We. You didn't have to really use the portable one onto a fixed-wing aircraft. You used the actual machine in-house, right, right, but there was a little bit of controversy within that because your techniques were not ones that were previously published. They were ones that you offered out to the other five hospitals in Portland. They were things that you had studied. But ultimately there are critics everywhere, but your patient had a full recovery, fully ambulatory, they're walking, talking, everything's good. She goes, she goes on to become a physician uh, no amputations whatsoever. You said there weren't many emergency physicians or trauma physicians that had experience, um, with rewarming profoundly hypothermic patients uh, that are that are caught in in dire need and avalanches or snowstorms, blizzards, with the exception of a Swiss man who you have mentioned before, anton Sedgiser, right, and you leaned on his knowledge, you and John specifically leaned on his knowledge to kind of give you a roadmap for what you were dealing with.
Speaker 2Right Because, as I say, he had published a book called Emergency Surgery Think of his name of it and in his experience basically reviving people who are caught in avalanches in the Swiss mountains and who had fallen into the frozen tarns of Swiss lakes and because he had success from that and published it. That was like a beacon of what we should be looking at to see what was possible. So, intellectually, john and I reached a conclusion. Conclusion cardiopulmonary bypass could be an answer to profound accidental hypothermia, but the logistics have to be worked through, the physiology has to be worked through and the metabolic aspects have to be worked through in order to get a positive result. And that could only come with time and experience.
Speaker 1And, to that end, you actually ended up holding a conference to share this information and brought in experts I believe you said it was about four and a half months after the tragedy just to share these findings and what future protocols could be, so that it became extant knowledge as opposed to just something that you and your team were doing.
Speaker 2Well, I never. We had a resident who Mike Halti, from Oregon Health Science University. He wrote up a paper on the Mount Hood disaster, relating to the metabolic aspects of it and so that. But I never published it the whole, the whole story from the medical side of it, because there was so much acrimony and regarding who survived and who didn't survive, and I felt that the mental status of the people in Portland, especially the people involved, most intimately involved, was too fragile to sit there and have a scientific discussion about it.
Speaker 2And so now, all these years, later, all these years later I think it's since other people now want to talk about what we did accomplish. I think it's time to sit there and bring out some of these lessons that we learned.
Speaker 1I mean better late than never. I mean, ultimately, I get out of this a couple of things, some of which you have fed me, but as I sit and just kind of ruminate on this know one.
Speaker 1The question keeps coming up do you try or do you not try? You know, as you, as you said yoda, um, even though his, his actual quote was do or do not. There is no try. Yeah, um, you, you were actively in the process of doing something. It takes no energy to quit, which is amazing and laudable and falls directly in line with the Hippocratic Oath. And do no harm. To do nothing can be a harm, especially for this young girl Britton, for this young girl Britain. If you hadn't done anything in her clinically dead status, she doesn't go on to become a physician.
Speaker 1The next thing that comes up is that you know, with the critiques and the things that you experienced in the aftermath of this um, you know you had techniques that you used with cardiopulmonary bypass for rewarming. It doesn't justify that use over all other uses in all cases, you know, as we've gone through three seasons now, it's important to mention that, albeit the word anecdote or anecdotal does carry with it a negative connotation in the science world. That is what your whole principle was based around, in the sense that you were looking for unexpected outcomes and then wanting to repeat them and these singular experiences that are, quote, anecdotal. They speak to. How much you value the life of the patient. You have to treat them individually. You cannot treat them as a status quo. This is the procedure that will be followed, no matter what you have to deal with the problem that's presented in front of you, and so, for your case, you made the best decision possible, which was the CPB. It doesn't mean that it had to happen all across any deep hypothermic state.
Speaker 2Well, we knew how to use the CPB. That was the thing. It wasn't something sitting in a closet, it was something that we were using daily and all we did was basically apply to it, with the same technology on a different clinical situation, to try to get a positive outcome, and we did.
Speaker 1It's still amazing and, like we've said, you know, you can look this, you can look up, you know, anywhere from Wikipedia to the LA times to the Oregonian, you can find out more information about this. You know, 1986 Mount Hood disaster. We'll have links in the show notes. Um, but to to our knowledge, um, well, mine only because I'm, I'm, I'm in proximity to this case now, uh, because of your retelling, uh, but to your knowledge, this tragedy was the first recording and documentation of treating mass casualties suffering from freezing and profound accidental exposure hypothermia with cardiopulmonary bypass, and that in and of itself is groundbreaking and trendsetting. So again, check out the show notes for more links on that. There are YouTube documentaries on it. Very few of them actually touch on the medical side of this and what Dr Long and his team were able to accomplish and thank God you were able to accomplish it, especially for the life of that young girl. And thank you to the other team at the other Portland hospital for their efforts in saving the life of young Giles.
Speaker 2All the cardiac surgeons tried and that I mean that I was most excited about they tried doing something. They were not well connected but in the effort to try to save lives I was very pleased with that.
Speaker 1Tragedies are one of the most horrible, great things that can happen because people come out of the woodwork, are willing to do in the face of a tragedy are those simple reminders on a great scale that human lives matter. And you see, and you see, people come together over it. I mean, we see it all the time, uh, during a hurricane or a flood or a tsunami, or 9-11, um sports disasters, the DeMar Hamlin just horrific injury last year in football, all the way to this Mount Hood tragedy, and you watch these communities and people rally together. What's beautiful about it? And every time you talk with me I'm reminded that you were generating that environment within your own hospital and within your own team, that you were going to start from a place of humanity, and that, to me, is just that's priceless. We'll close with that.
Speaker 1We hope you enjoyed this episode. To learn more about this case study and the history of the equipment systems we have discussed and the strategies for life-saving techniques, you can check out the show notes, where we will have links, and Dr Long's upcoming book entitled Flatline to Lifeline. As we close, we remind you to imagine a world where dead isn't actually dead. We remind you that there are places and people who value the patient over the system. Flatline is not the end. A lifeline exists. Saving time saves lives. Thank you for joining us here on Flatline to Lifeline with Dr Bill Long. We'll see you again soon.
