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
Down but Not Completely Out: A High School Boxing Champion's Brush with Traumatic Brain Death
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Every second counts when a young boxing champion collapses unconscious in the ring. With his brain hemorrhaging and pressure building inside his skull, his life hangs by a thread. This is the story of a race against time, innovative medical thinking, and the power of teamwork in trauma care.
Dr. Long takes us deep inside the intricate architecture of the human brain and its protective systems. We learn how the scalp, skull, dura, and meninges form layers of protection, but also create confined spaces where even small amounts of bleeding—as little as a shot glass worth—can trigger catastrophic pressure increases. When this happens, the brain has nowhere to go except through the small opening at its base, a life-threatening condition called brain stem herniation.
The young boxer's journey from ringside collapse to complete recovery showcases revolutionary approaches to trauma care. Rather than following conventional protocols, the trauma team performed resuscitation measures directly in the CAT scanner—saving precious minutes. Most dramatically, surgeons kept the patient's skull open for five days, allowing his swollen brain room to expand while they monitored intracranial pressure with exquisite precision.
Beyond the medical details, this episode reveals the challenging human dynamics of trauma care. Dr. Long shares how he learned to bring together specialists with different training backgrounds to function as a cohesive team. He explains why doctors respond differently under extreme pressure and the most adaptive approach to navigating trauma care.
The boxer's story ends with a complete recovery—college graduation, marriage, children—though wisely, he never returned to the ring. This remarkable outcome demonstrates why Dr. Long's guiding principle remains: when the need is greatest for the patient, saving time saves lives.
Listen now to hear the full story of this remarkable recovery. If you found this episode helpful, please subscribe to our show and leave us a review.
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
Technical Director: Lindsey Kealey, of PAWsitive Choices
Editing and Post Production: Adam Scott of Atamu Media Productions
© Flatline to Lifeline 2025
Welcome to Flatline to Lifeline with Dr Bill Long. For three seasons, this podcast has explored unexpected survival outcomes within the trauma field and how Dr Long and his trauma team of nurses and doctors began to replicate these outcomes by applying available technology and in new and profound ways over Dr Long's almost 50-year career. We hope to educate those listening from any walk of life and to inspire those in the medical profession to consider and adopt the life-saving techniques and approaches to trauma care that we share here, because when the need is greatest for the patient, saving time saves lives. Welcome to Season 4, episode 2 of Flatline to Lifeline with Dr Bill Long. Dr Long, how are we doing today?
Speaker 2Very well, William. Thank you Excellent.
Speaker 1Our first episode of this season, we had a roundtable discussion with our producer and our organizer, both of which, lindsay and Esther, are both friends.
Speaker 1Of course, we talked around patient advocacy, being a patient and even being a doctor, and what those tense moments are like inside the room when the doctor's making rounds. Lindsay brought up the amazing nature of what human touch can do in a very stressful situation. Dr Long, you spoke about bedside technique and the things that were disarming to the patient and helpful in those times. When the doctor hits the door, there's nothing really positive waiting for him on the other side of that door, and when the doctor comes in for the family or patient, you're looking for answers. But a lot of times what happens is you end up getting confused or you get that very short amount of time that the doctor has because they have other responsibilities patients, and so just talk through some options and tips and tricks to establish that human connection and, instead of just a name, you become a person and you have a relationship with those medical providers. Uncle Bill, would you say that would be a pretty good summary of what we discussed.
Speaker 2Uncle Bill Walsh, I think you've done it very well, thank you.
Speaker 1Is there anything you want to piggyback off of last episode that you had to share?
Speaker 2Uncle Bill Walsh no, not this time, but when we get talking about these cases in the future, especially the one today, it raises a whole different level of ability to communicate adequately, in this case with a head injury patient. You don't communicate very well with them. They're either in a induced coma or come up on the injury.
Speaker 1Okay, just on average, since we're really going to go into a teaching format this season. This is going to be exciting for me because for a long time it's been you talking about things and I catch a Latin root word here and there. I'm excited because I get to go to class. Today we've got a story about a young high school male boxing champion and he basically fell into a coma after a boxing fight, after a match.
Speaker 2In the match. In the match he got hit and went down in the match. In the match he got hit. He went down on the canvas in the match 100.
A Young Boxer's Traumatic Brain Injury
Speaker 1We have an apollo creed, yvonne drago situation here. He hits the mat and then he's not moving. Obviously it's a different recovery. Spoiler alert this young man, he does survive, but the scare factor here is really important. So we're going to head right into brain trauma. We'll probably bunny trail into a couple of other things here, but, dr Long, take it away. I think we should start with just tell me how the brain is protected by the skull, like all the different layers.
Speaker 2It is interesting about the support of the brain, especially by the arterial and venous circulation, for example, the scalp on your head basically behind your ears, above your neck and above your eyebrows, is fed by two frontal arteries one coming from each side of the nose, a branch of the external carotid artery going off in front of the ear, called the pre superficial temporal artery. Two branches coming from behind the ear, from the same external carotid artery going to the back of the ear, the posterior auricular artery, and there's two coming up in the neck feeding that. So the scalp gets fed, but basically by arterial blood flow coming from four different directions.
Speaker 1So you've got four arteries that are feeding the blood flow.
Speaker 2There's at least four arteries on each side of the brain. Remember, the brain is divided into two halves.
Speaker 1Right, so it's four and four. So now we have eight different arteries feeding blood. So just as a reminder to all the parents at home, when your kid catches a stray table corner or is perhaps like my children jumping on a trampoline at night and deciding to do it closed eyes and then one stabs the other with a tooth, any forehead bleed. It bleeds excessively because of all that blood flow.
Speaker 2That becomes important because everybody saw one of the Kevin Costner movies. Basically, a guy gets scalped by the Indians in that movie. I just explained why you can bleed to death when somebody rips your scalp off, because they're basically pulling up on your hair and then cutting off all the blood supply and you got four arteries that are going to be bleeding. We have several survivors of young women got scalped by a machine and they can survive. You've been coming from 300 miles away, so it's a different physiology that you're dealing with, but you have to understand the anatomy to know how to fix it.
Speaker 1I'm just curious now what type of machine scalps a person so I can stay away from those?
Speaker 2In Eastern Oregon. They do a lot of the irrigation and they have irrigation equipment driven by a water pump and high pressure that not only turns the wheels of the irrigating system circling around but also drives the sprinkling system. Gating system circling around but also drives the sprinkling system. The winching of his gears all which are metal pulled her hair off of her head and scalp off her head including one ear.
Speaker 1So that was wonderful. You know what. That's enough. I'll just stay away from things with like blades, scissors and suction all at the same time. I'm not going out and buying Willa's infomercial flow bees to do a haircut. All right, we have eight arteries going to the brain. There's a significant amount of blood flow just to the scalp. I apologize, you have got to brain. Yeah, sorry, I'm a student. You're the teacher. Please continue.
Speaker 2The next layer is the bony scalp. The bone of the skull is not round like many people say. It looks a little bit like a rugby football. Shapes can vary enormously, but you have a circle of bone that doesn't expand or contract. The bone is fused together shortly after infancy and there's no room for expansions.
Speaker 1Unless, exactly as you said, if the human head, if the skull does in fact look like, does in fact look like a rugby ball. I'm a little concerned that now all I'm going to think of when I think of people's skulls is Jane Curtin and. Dan Aykroyd and the kind of tone heads, because my dome with looking like a rugby ball. It's not a good look, but I get what you're saying Slightly oblong.
Speaker 2Inside the skull, the bone is a network of little arteries, not as big as the ones that fed the scalp Underneath it. Between the arteries and the bone there's what's called the dura. The dura is a layer of fibrous tissue relatively about one millimeter thick that helps cover between the brain and the skulls itself, and so if the bone of the skull breaks and lacerates one of the arteries that are basically attached to the skull, you could get bleeding in that space called the epidural space.
Speaker 1Okay, so you have the skull bone and the dura is above that.
Speaker 2Underneath of it.
Speaker 1The dura is underneath, so we use the word superficial.
Speaker 2We use the word superficial meaning near to the surface. Okay, so there's layers that we have to go down through. Dura is one significant layer underneath of the bony skull.
Understanding Brain Anatomy and Protection
Speaker 2Then there's another layer on the surface of the brain called the meninges. So there's two potential spaces there is the epidural space and then below the dura there's another space between that and the meninges, not a very big space until bleeding occurs. You have a complex of easily veins, small arterial blood vessels in that layer. That's the subdural space, arterial blood vessels in that layer, that's the subdural space. And so either accumulation of blood in a tight chamber, like a skull, which cannot expand, can cause changes in the pressure inside the skull itself. So if you add fluid to a balloon or something like that, or inflate a tire, you're increasing the pressure inside the tire by pounds per square inch. It's not as much different inside the brain. When you're bleeding under the skull. Between these layers you are basically increasing the pounds of square inch of pressure inside the brain, which then takes a spongy organ like the brain and compresses it, and there's no room for the brain to go, except for a hole, anatomical hole, at the base of the skull where the spinal cord emerges from the brain and goes down through the spine, all the spines to your tailbone practically. So that's the issue People have to understand. You're not losing a lot of blood in the brain, normally with blunt trauma, but you're losing enough blood to sit there and cause a change in the pressure.
Speaker 2As the pressure mounts inside the skull, it compresses the spongy part of the brain which has a different blood supply and that basically reduces what's called the perfusion pressure or the blood flow through that part of the brain that's being compressed. And there's a formula that we calculate and measure very carefully for seriously in your brain injuries and what is basically is the cerebral perfusion pressure is equal to the mean arterial pressure of our main body blood system minus what's called the intracranial pressure. The intracranial pressure rises as the blood accumulates in either of those two layers epidural or subdural hematomas and as it rises there it begins to push the brain down to that hole. That's where vaginal oblongata, it's where you control your blood pressure, your heart rate, your respiratory rate, all your key elements. That keeps you alive. Okay, that's called herniation of the brain. You get a hernia groin, you get a hernia in the skull.
Speaker 1Okay, can I break in with a question here? Yes, scallop, then to the skull, then to the dura, then to the epidural, okay, and then you have the meninges and these spaces. But there seems to be a consistency with how the body is designed, that important pieces organs specifically, but even muscle groups all have a sac, a casing, a protective layer that when that specific body part is hurt and it starts to bleed, its initial thing it's the body's defense mechanism. Perhaps that the bleeding will be localized because of these protective sacs. Is that kind of the intent?
Speaker 2It probably was not what it was designed to do. Yes, that's right, you can get a bruise of your arm. Arm and the skin will hold that bruise. But as it expands, the skin gets tighter and it can get so tight that the blood flow to that area of the skin. Over the bruise there's an adequate blood flow.
Speaker 1Okay, so now we're talking about basically elasticity and what kind of, like you said, palace persuadings can that protective sack or holding space can it maintain? In the case of this young boxer, essentially what we think happened was that, through repeated head traumas and punches that he had taken, that there was potentially a slow bleed within the brain that was increasing pressure to get to this point that something very acute and obvious happened. What I keep thinking of when you talk about this pressure different, but I think the analogy is as you fill up a water balloon.
Speaker 2It gets heavier, gets preppy and ultimately, pops.
Speaker 2When you talk about herniation, as I was talking about before, you can have a tire covered, the inner tube covered by what I call hard rubber. But if that hard rubber breaks, the inner tube, which is also rubber but very thin wall, bulges out and that makes it more prone to rupture or break, especially if something sharp punctures it. But that is similar to the brain. Those soft layers or these layers underneath of the skull is basically can't get it to hold it a little bit, but the brain has to go somewhere and the brain, as it's swelling and the pressure rises, tries to go down through the base of the skull. And that's what killed you.
Speaker 1Yeah, we like to keep the head above that.
Speaker 2Okay. So getting back to this kid, he was basically an amateur boxer, quite successful. He was from southern oregon high school kids in boxing matches wear helmets, basically cushioned helmets, to avoid listen, the contact helmets like you see in the olympics and junior. So in the women's boxing association they wear helmets. Correct Men don't Generally not.
Speaker 1Now we're back to the high school, unless you're talking about this lot.
Speaker 2So this kid is practicing in his home environment. He's got an uncle and his father and they spar with him and he's hopefully wearing a helmet at the time. They hit him one time. He got hit and was stunned a little bit. Then they and he's hopefully wearing a helmet at the time they hit him one time. He got hit and he was stunned a little bit and they stopped and he recovered from that. About a week later he got hit again Again. He was stunned and recovered Remember there's no brain injury protocol back in the mid-18, mid-1980s, 1990s let's just call it the 1880s he recovered and acted normal.
Speaker 2So everybody assumed that everything was okay. Then he comes to Portland. He goes to the state championship fights which are in a ring about a mile and a half from Emanuel Hospital. So he's in there helmeted boxing away. He gets hit, basically probably on the forehead we're not quite sure he goes down basically probably on the forehead. We're not quite sure he goes down. They usually have an emt at the fights. Just like we put a doctor at the when they had the automobile races in portland, we have an emt basically at the worst racing event so that there's some medical care immediately available when somebody can get, potentially get hurt. So he goes down the m, jumps into the ring and notices he is not responding to voice commanding and he doesn't respond to when you pinch somebody. That's called a painful stimulation, doesn't respond to that and he's got a dilated pupil. He realizes that he's got as we have taught EMTs he's got a brain hemorrhage going on and he needs to be seen immediately. I got to stop here.
Speaker 1I got to stop here. We're uncomfortable with the word hemorrhage. Medically speaking, what is the definition of hemorrhage Bleeding? Okay, we're always bleeding. You're saying that you're bleeding externally?
Speaker 2There's bleeding. What did you say? Where you cut yourself as bleeding external, there's internal bleeding, Okay, and you can bleed almost in any body cavity. You can bleed within the eye. It can bleed within the middle ear, just inside your skull. You can bleed from the chest cavity. You put six liters of your entire blood volume in one side of one lung cavity or the other. You can bleed into the pericardium, which we talked about which is the protective sac of the heart.
Speaker 2That sacs around the heart and there is the abdomen. The abdomen can hold your entire blood volume. If you bleed from a ruptured spleen or ruptured liver, our organs got a major blood supply, such as our kidney and you have the pelvis, which helps supports where the legs or the femurs insert into the pelvis so you can walk.
Speaker 2That's a cavity also covered by a membrane called the peritoneum. So there are similarities in each area of the body, somewhat similar to the brain. The pelvis, for example, doesn't move unless the bones are really broken. The concept is similar. And then you go down into the extremities arms and the legs and you have an investing fascia around the muscles. That is what you see when you're looking at somebody who's very well-toned. They have what's called the weightlifters, call it definition, and if you've been watching the Olympics, all those athletes have great definition, except maybe the shot putters and the wrestlers.
Speaker 1Right yeah, the amazing difference in body types of athletes depending upon their events is crazy. We've got a high jumper versus a shot putter, okay. So let's go back to the sponsor. He's knocked out. He is most definitely wrong because he failed all of the tests. So what were the next parts of the story?
Speaker 2This is a race against time, because when the pupil, one or more pupils are dilating, which is associated for the intracranial pressure, not from direct injury to the eye, but they're dilating because the nerves are being compressed by the blood, accumulating blood at the base of the brain, so on.
Speaker 1Okay, when that happens, you're going to start to get an alcohol it's an understating, so you're talking about correct food was inside the cranium, the base of the skull, and you're bleeding and the brain is nowhere to go. As the pressure is accumulating and it reminds you, the fluid is then pushing the softer, lighter tissue of the brain down through the base of the skull. That's the process occurring. Okay, so we're just adding gradual aggression?
Speaker 2okay, but he's got nowhere to escape as I say, it's a race against time. You've got to relieve the pressure. As I say, it's a race against time. You've got to relieve the pressure it was stop the bleeding. Yes, we've got to stop the bleeding, yeah, but it's major to the patient because they're the ones who are basically herniating, potentially herniating from the brain, and when the brain herniates, your chances of survival are very low.
Speaker 1Okay, so now I have to ask on a volume question. So you mentioned the bloodure body cavity, your central abdomen cavity, you got the perineal side, you got all these different places where blood can exceed, like you hold the entirety of your body's blood in your lungs or in your abdominal cavity. But what volume? Of what volume of blood? Not, naturally speaking, but it's just bleeding into the gradient that would create enough preference to create a very dire situation.
Speaker 2That's going to be around 30 to 50 cc's of blood.
Speaker 1Okay If we were putting that in a cooking bag, that's two ounces made. That's a shot glass of blood. So now we have a shot glass of blood that just got emptied into your salt inappropriately and now you're sliding for your life Because that two ounces of blood went to the wrong salt. It's phenomenal when you think about just that little bit. It's a shot glass and now, all of a sudden, words like, or phrases like, your brain's getting pushed through the bottom of your skull. That's a big deal.
Speaker 2Remember there's two types of bleeding. I'm talking about Epidural bleeding, which is arterial driven, much higher pressure and blood can accumulate faster because of the arterial pressure.
Racing Against Time: Emergency Response
Speaker 2Then you have venous bleeding, which is usuallyial-driven, much higher pressure and blood can accumulate faster because of the arterial pressure. Then you have venous bleeding, which is usually subdural, below this fibrous layer that covers the brain. That's between another layer of the brain which is called the meninges. It could put a lot more blood but it's under less pressure. That can accumulate up to 300 milliliters of blood in that area. Sometimes you could replace an older person who has brain that's shrunken somewhat because of age. You can put almost 500 cc's of blood into an area. But I'm going to say you have to weigh a lot of the things that sit there and you have realized these pressure gradients and what can affect them and how you're going to approach it. But the real issue is again, it's a race against time to prevent neurological damage from lack of blood flow going to the brain. Ultimately to prevent herniation. Herniation is the ultimate disaster that you want to avoid. Okay.
Speaker 1So now from this stage he's not moving, dilated pupils, non-reactives, no voice or pain stimulation. And then they call you guys and you said this is about a mile and a half away or a mile away from Emmanuel. So this is as close to that fake scenario where I said, if you're going to have an awful and traumatic accident, have it in the parking lot of the level five trauma center. So this is pretty close.
Speaker 2So it happened to be on that day Linda Irwin, who came after she finished her surgical training at Oregon Health Science University, joined us. We were talking about saving time saves lives and she realized the urgency of the situation. So, instead of asking the emts to go directly to the operate room, because she knew that the neurosurgeons won't operate without a cat scan, that became the standard of care. You don't operate without a cat scan, especially for trauma. In the old, they used to do a burr hole and then they made you get a CAT scan if there was one available.
Speaker 1Burr hole just means you're drilling a hole in the cranium, In the skull. That's right in the skull.
Speaker 2About a 3 to 5 to 8 millimeters in diameter. If it's an epidural, the blood squirts out and it relieves some of the pressure. But remember, it could still be bleeding even though you've relieved the pressure Because you haven't stopped the bleeding. You haven't sewn anything up yet.
Speaker 1You're just giving it a space to go to protect the brain for a small period of time while you do the other work. Yeah, okay, yeah.
Speaker 2Okay. So the EMTs bring them, take them right straight to our trauma CAT scanner where the anesthetist, trauma anesthesiologist what I do along with the trauma surgeon and immediately intubate the patient, put in some IVs and folic catheter, drain the urine looking for adequacy of renal function, and then they put them in the CAT scanner and get these images that shows that he's got blood accumulating in the frontal part of the frontal lobe of his brain, where he took the hit no fracture to the bone, so the pressure is directly to the throat.
Speaker 2To the front, so it's pushing the brain backwards and potentially downward. That would accumulate. But he didn't have any skull fractures which made this unusual. Following the CAT scan, the neurosurgeon had arrived. For our protocol, we called them as soon as we got somebody coming in who has the signs and symptoms of a severe brain injury and so if they're at home they can go directly to their scanner that they have at home LinkedIn to our scanner we have at the hospital and look at the images there. Or he can look at them if he's got a portable viewer in his car and he can be looking at it while he's coming in to the emergency department. So we took him straight to the operating room. And again, in how we organize for somebody who has an acute brain injury and potentially dying from it, we do the prepping and draping for the neurosurgeon because we know he has to come in and change clothes and then come to the operating room, scrub and then work. And we're trying to save time, to save lives. So we basically undress the patient, put the catheters in if necessary, prep, shave the skull in case their anticipation is going to want to do a craniotomy or a burr hole. We prep it with antibiotic solution and then drape it. Antibiotic solution and then drape it and all the neurosurgeon has to come in now and make an incision, do the burr hole or do a craniotomy or take out our whole section of bone called a craniectomy.
Speaker 2Okay, and craniectomy was done during World War II for people with severe penetrating trauma to the head. It was disparaged for a while. Ray Grew brought it back from the Korean War. He was one of our neurosurgeons who was in the Korean War. He brought that back and it was picked up over time by other neurosurgeons. As they saw it was effective in keeping the swollen brain from being under too much pressure. So when you're new or a part of the skull, the swollen brain can just like underneath the skin. The swollen brain can, if you want to call it, herniate into that area and relieve the pressure.
Five Days with an Open Skull
Speaker 2So anyway, he does a great craniotomy removes the epidural hematoma, the brain swells into the hole that he's made in the skull. He saves parts of the skull bone that are removed and puts that into our bone bank. So in case we need it later on to close the skull, we have bone. We don't have to put an artificial bone in. We have the patient's own bone to do this.
Speaker 2So the brain continues to swell from the injury. The craniotomy removes more bone so the edges of the skull don't compress or lacerate the brain as it swells, gotcha. Lacerate the brain as it swells, gotcha. So after it gets that swelling out, it looks a little bit like one of those cauliflower heads of the people on Star Wars. He puts a burr hole in the opposite side and puts a catheter through the brain into what's called the ventricle, which is a fluid-containing chamber, just like in the heart, the ventricle inside the brain, inside the hemisphere of either the right or the left part of the brain, and there's a ventricle there and you can put a catheter in and drain off fluid to reduce the pressure inside the skull, inside the brain.
Speaker 1Gotcha.
Speaker 2And you can also measure the pressure in the brain through that catheter. That's called the intracranial pressure. Having that number and the mean arterial pressure that you measure with an arterial pressure monitor or blood pressure cuff, you can subtract from the mean arterial pressure the intracranial pressure, and then you have the actual pressure of the blood still able to go through the brain. That's called the cerebral perfusion pressure. So these formulas become important not only in diagnosing and treating the patient but also preventing the patient from getting worse Gotcha.
Speaker 2So with that information, over the next five days his brain was so swollen we were trying everything possible to keep the brain from further herniating and we basically had the patient's open skull with a herniated brain in the operating room with a surgeon basically titrating drugs that would affect the cerebral perfusion pressure, the mean arterial pressure, in order to get an optimal pressure for the brain to get blood flow. And so we took turns about 12 hours each, taking 12 hours apiece, to sit there and maintain that, so that you had direct response, because this is a critical injury, in order to stay on top of it. So I want to emphasize he didn't lose much blood, but he did develop a lot of pressure from the swelling of his brain and you kept him with. You kept him with, technically, his skull open for five days.
Speaker 1How long can you keep somebody out of his his sterile environment? You know he run massive risk of infection whatever it is, and you're not able to keep him alive for five days. How long can you keep somebody out of a sterile environment? You run massive risk of infection whenever anything's open, but how long could you potentially keep a person in that status where you're trying to avoid the swelling?
Speaker 2You want to protect the brain from infection now that it's open. We have a system similar across the country that you take from cadavers, dead people. You take the dura off that and you can freeze it and store that and use that to cover the brain temporarily and cover that with a sterile dressing. Sometimes they can have weeks of having a skull with the brain sticking out of it before it begins to reduce enough to be able to sit there. The brain will slowly, as a swelling drop goes away, the brain will slowly withdraw back inside the skull cavity. At that time the neurosurgeon can take the bone from the bone bank and then screw the bone with plates to the other parts of the skull and stabilize that fragment and then you have reconstituted essentially the bone in his skull Using his own bone.
Speaker 2He gradually woke up. It became normal again and he was still ventilated and we weaned him off the ventilator. If I began to follow commands, move all four extremities and then we could get him sitting up in a chair. We took the tube out of his windpipe and waited a day or so for the swelling in the back of his throat from the tube in his windpipe to go down and then he began eating and we transferred him to rehabilitation, from where he made a complete recovery. He went on to graduate from college this is a high school, so he graduated from college but he never boxed again.
Speaker 2Linda came from an environment where she didn't believe in going direct to the operating room, didn't believe in saving time saves lives. She became a believer in this one case and I admired her for the fact that she realized that going direct to OR was not going to accomplish anything without the CAT scans. So we resuscitated him in the CAT scanner, which is highly unusual. You resuscitated him in the CAT scanner, which is highly unusual. You resuscitated him in the CAT scanner, but an attractor tube put the catheters in the CAT scanner before sliding him into the chamber. Wow, I didn't know that was an option.
Speaker 1Yeah. So my background, we all know, is sports. So when I'm watching the Olympics, things like that, you see somebody make a crazy move every now. And then I happen to'm watching the Olympics, things like that you see somebody make a crazy move every now. And then I happen to be watching the badminton game and it's shocking how fast that shuttlecock moves. But this one guy he's returning a serve and managed to hit a ball backwards behind his head as a good returning serve and I thought, wow, that's an amazing shot. I slowed it down, I rewatched it a couple of times and I'm like thought, wow, that's an amazing shot. I slowed it down, I rewatched it a couple of times and I'm like, dude, how is that? Even an offset?
Speaker 1What in your brain said I'm going to go ahead and move this way at the bulk and it can only happen over an extreme number of reps that are done in a very fundamental way. And then it allows you the freedom. Because you're so comfortable doing the simple thing. It allows you the freedom to just go. I have to react. That's almost how I'm envisioning the fact that you're seeing a lot of these trauma scenarios where you're fully prepped, you know what to do in all these different scenarios, but they're all so unique that you have to come in with an open frame of mind and go. You know what? We're going to resuscitate this guy in the CAT scanner today Just because there's no other option. This is the option. That's fantastic.
Speaker 2Yeah, the other option takes too long.
Speaker 1And you go, really, because this is how I see the world, sometimes unfortunately, through the game of baseball, but I look at it and I go baseball. One of the things it has to it is the most variables of any game that is played. That's why it's so difficult and you go. How do you make this game easy when it's so difficult? You limit the variables. What is so difficult, you limit the variance and you go down to okay, we have all the options, but really we need to focus on two. Like you're saying, we can help him while he's in the CAT scanner, resuscitate him, or we can wait and let him die.
Speaker 2You pick. Yes, it's. An interesting thing is that many trauma centers, as they got going, the general surgeon would do a trauma fellowship and it's been two to three years taking care of trauma patients, but many of them were critical care fellowships as opposed to operative techniques. Can you explain about those when you think of how specialization evolved? Neurosurgeons have their own border for certification. They have their own ways of assessing knowledge and competency in that area, but how much do they know outside of their area?
Speaker 2That gets us into the compartmentalization of medicine within the American medical system coach like Steve Kerr, who only played as a guard, could understand the dynamics of what it means to be a center or a power forward.
Speaker 1Okay, now that you're in the sports room, I have to chime in. So there is a compartmentalization that is currently existing within professional sports and it trickles down into youth as well. To your statement, steve Kerr, playing the game as a guard, how does he understand where the center needs to be? So I'll bring it to baseball and go well, the general consensus is that the best managerial candidate is a former catcher. Reason being he has a full view of the field, he knows how to control a pitcher, he knows how to control a pitching staff, but he literally sees the game in front of him.
Speaker 2The left fielder has no board certification. The shortstop has no board certification saying that they're the experts in that area. But to get a group of different specialists in medicine to work together, you have to be able to have some knowledge and understanding of their language and what they do. One of the things I started this at UC San Diego. I scrubbed with every neurosurgeon and orthopedic surgeon, vascular surgeon, to get to know their language and how they thought and by helping them. Basically I didn't tell them, but I was learning from them how they viewed the world. And once you understand their language and how they view the world, it's easier to have a way of communicating. You get them to work with you, as opposed to saying I take priority over everybody else and I have to go first.
Speaker 1You can't do that in medicine but a lot of people try that when you talk about the departmentalization, like I'm saying, the catcher is the ideal guy. A lot of people are being taught their specific portion of the game. So the outfielders only know outs, the infielders only know in, only know outs, the infielders only know innings. This happens in football a lot, where plays and offenses get so complicated that a wide receiver knows that when the play call is made he's just triggering to the code word for his route three. He's got four different possibilities to run, based on where the defense is, but he has no idea what the blocking scheme is doing, where the running backs are and what the other receivers are doing. When he's in space you always hear the wide receiver cream of donning going give me the ball. There's a reason he didn't get the ball every single time.
Speaker 1Without the understanding of how the whole offensive system works, we have a problem. So to bring it back to medicine if you don't have a broad scope understanding of the different principal specialties, if you only understand the specific specialty neurotrauma, how can you understand all the things that go on with the lungs, the kidneys, anything like that? So you have to have the soul view. So bring it back. The catcher tends to be that guy. You scrubbed in with all sorts of people with the intention of getting that broad knowledge, so you knew where all the pieces had to be simultaneous. That's when you're playing quarterback, when you truly know where everybody supposed to be and you're adapting. That's where you're giving individual care. Is that accurate?
Speaker 2That's right. The quarterback, by tradition, is the play caller and so when you get into a huddle and you have the offensive tackles and the guards in the center and the ends and the backs, he calls a play and he doesn't have a round table discussion. The play is going to be, and they all accept that, right or wrong. You only have so many minutes in the huddle.
Speaker 1You're saying that the doctors rarely have a quarterback.
Speaker 2It's unusual because so many of them in elective medicine. When you're a neurosurgeon, in the operating room you are the quarterback. You tell the nurses and the assistants anesthesiologists what to do to help you do your operation. Same thing for every other specialist. Now you put all these specialists on one patient. Who is going to decide the priority?
Speaker 1Okay. Now you have five quarterbacks in the same room.
Speaker 2You can't go in there and start bossing around a specialist, because they'll go crazy. They have to know that you know their language and you understand them. And you've made an effort by working with them, learning their system and talking with them, going to their conferences, going to their CQI, you become one of them. They look upon you not as an adversary or a contrarian. They look upon you as a person who's trying to help to make the patient better.
Speaker 1Nice.
Speaker 2And it's hard for a lot of people because you have to subject your will to the collective will of somebody who can lead the team. But there's a lot of people who are given the title of trauma leader who can't do it.
Speaker 1You think that's a problem of ability to delegate, or do you think?
Speaker 2it's just a nature of control.
Building Effective Medical Teams
Speaker 2What you're trying to have of a neurosurgeon, a stress surgeon, abdominal surgeon, orthoped surgeon, abdominal surgeon, orthopedics all working simultaneously on the patient. Anesthesiologist is trying to keep the patient asleep during that period of time, which they do extremely well. There's a time when the patient loses too much blood and somebody has to say stop what you're doing, compress what you have to do to stop the bleeding. We need to catch up with blood volume during transfusion. Or something happens in one body cavity where somebody is working takes priority over the others and you ask them can you hold off what you're doing while we get this matter straightened out?
Speaker 2once it's straightened out, we can go back doing concurrent surgery.
Speaker 1Okay, so obviously you with your pit crew and all that goes on there, you had this plane, you had a system and a hierarchy and then, ultimately, the buck stopped there. In a normal scenario, in your training, what did you see that led you to get to that place? Because, obviously, like I was playing board game with my kids and my wife last night and I did something, I gave a clue and everybody was like everybody thought it was the wrong clue or it was illegal and there's nothing in the rule book that says. But then it was voted on that moving forward, you were not going to accept that type of clue. It was like that's how rules are made Generally you show up at the airport, you get the sign at TSA.
Speaker 1The one that gets me is the one that says no chainsaws allowed on the plane. That's only there, because someone did bring a chainsaw at some point and then they had to make a rule at some point. And then they had to make a rule In your scenario. You watched enough surgeries, you watched enough things go wrong where the integral parties are in there and nobody calls stop or nobody says I'm the guy who says this Because you have high-flying specialists sitting in there and they're all the alpha. So how do you get to this place and what got you to establish the protocols that you did?
Speaker 2It's very difficult starting off in the adult world. When we got eventually, we dealt the adults first and then did the pediatrician second. There weren't that many of the pediatricians and pediatric surgical specialists involved, but there were few but they were very vocal.
Speaker 2But we got them all in a room and said we're going to do things the Emanuel way. I know you trained at St Louis, you trained at Harvard, you trained at USC, you trained at Harborview. But we only have so many nurses and they can't do all your idiosyncrasies in a crisis. That's asking too much of the nurse to memorize what you do Now on the weekends. You might not even have a nurse who's ever seen something like this before. You have to have something where everybody knows what's coming, what you're doing individually for your private practice on one patient. You have to reduce that to sit there and understand. We work for the collective good and we had, we created a body of protocols for management of pediatric trauma and I had every surgical specialist and anesthesiologist sign it that they would follow this, knowing that if they didn't, it could be taken off the call schedule. And no one wanted to be taken off the call schedule.
Speaker 1So you simply had to put in a penalty.
Speaker 2But it's accepted in baseball and basketball. The coach can take you out of the game. Okay, and that's fair. In the middle of a crisis, I can't take a person out of the game.
Speaker 1No, no, you can't replace a team, so you have to preemptively set up all your checks and balances so that when it comes pressure, it's if A, then B, not there's a discussion.
Speaker 2Which tells me another thing. So you got to watch the psychological thing. People handle pressure in different ways. Wrote a chapter on this in our book Shock Trauma Manual, done with shock trauma in Baltimore Will perseverate, They'll see something and continue to try to do the same thing over and over again even though it's not working. Because the definition of insanity and there is a thing called task fixation somebody's trying to do a procedure, it's not working and they're having trouble and instead of the procedure should be done in five minutes and they're taking 15 minutes or they're still not getting it there. When they're causing complications. That's called task fixation and that's what a lot of people do. Under pressure they try to do something that's familiar to them because they can't handle the pressure.
Speaker 2A third group are screaming and shouting, blaming everybody around them.
Speaker 1The people who get locked in on the task fixation. They just get tunnel vision.
Speaker 2I found early on in medical school and surgical training that very few people, very few of the doctors, surgery sports. They may play golf, they may play tennis or something like that. It's in its own way, but a team sport is a whole different situation brought that up before that.
Speaker 1A lot of doctors do athletic pursuits that they generally do individual athletic pursuits if they do athletics at all.
Speaker 1We've done sports analogies many times because it's comfortable for me, but I do think it's culturally easy to understand Like we just see sports on TV that understanding of how to work as a team and to do your job really well. But only do your job. I would tell kids, if you're doing somebody else's job, who's doing yours? If you're grinding yourself into a pulp, then somebody has to come help you. Now they're not doing their job. So I can only imagine the difficulty in being in leadership, trying to get everybody on the same page, signing that document and having them all on board, with the consequence of hey, if you can't play by these rules, then we have to make a move.
Speaker 2Well, the main thing was trying to get to the administration of many hospitals, the nurse is a nurse, the doctor is a doctor. Many hospitals the nurse is a nurse, the doctor is a doctor, and you have to overcome that bias when trying to get them to understand the world we're living in and what we're trying to do for patients.
Speaker 2But, in an OR nurse, it is to have a heart surgeon. I was trained under three different heart surgeons, all very competent men. You had to do the heart operation exactly their way, otherwise they wouldn't teach you. When you think about this taking place in all other specialties, with one-on-one teaching, you have to learn their way. Then, when you're done and you're finished there, you can go out and make modifications. But think about the nurse who's trying to assist you in a very difficult high-tension operation and you're calling for instruments she's never heard from. You're asking her to do things she's never seen before. She's not engaged, she can't get engaged and she could be terrified. And if she gets terrified she gets paralyzed.
Speaker 2There's a lot of group psychologists and this is what made to me trauma fascinating. How can you take a disorganized, potentially disorganized great situation with a lot of egos involved and get them to subjugate their egos to look upon the success of the patient as a whole? And I studied a lot of books in industry Jack Welch ran General Motors and all these other people how do you influence people and get them to work with them? It's an art form, but in medicine it was extremely difficult because medicine is basically not quite a business like General Motors. You're not in any way like it. Each person is. You see what I mean.
Speaker 1No, you're dealing with any type of people who have reached the quote mountain. They've gone into elite status. When you go to school to become a doctor for as long as you do and then have to do your resident training and all that by the end of it. In your field you're an expert. You've gone from a 7,000 vocabulary to 23 000. So I find the same scenario when I get a bunch of coaches, especially guys that have played at the big league level for a considerable amount of time.
Speaker 1You're talking about experts and the way they see how things should be done, and it's all predicated by their own personal upbringing, their success levels in the game, how they saw it. And you get five, just three of those guys in the room and you want to talk about how to build a team, you're going to get three different opinions. You bring in a hundred coaches. They'll agree on principle, but it's kind of like the factioning of Protestant churches. It's hey, we agree on these three things, but then everything else you're doing is wrong. But the only three things that matter are the things we agree on, but we're going to spend all the time arguing about the stuff below it. That really doesn't. Do you find that happens with doctors too. Oh yeah, where it's like. Nobody will deny that saving time or stopping the bleeding is patient helpful, but yet how they do it is going to be off the charts different.
Handling Pressure in Medical Crises
Speaker 2It makes quality assurance Baseball, basketball, football it's all filmed. You've got films, basically, and you can see usually they'll have five filmers for the game, one for the line, one for the backs and one for the opponents, and they study these films to see where their weaknesses are. There is no film that's done in the operating room except on an individual operation, usually collectively scheduled. I watch a lot of those for famous wrestlers like Denton Cooley and others. I'm trying to understand what they were doing, how they were doing, how they moved their hands and all these things are important. But you have to recognize stress is what separates the men from the boys and how they handle stress.
Speaker 2I was watching the Olympics last night with these gymnasts, female gymnasts. I was watching these young women basically on the balance beam, falling off and making a misstep or sliding off. One of them even landed on her crotch. You get unnerved by this and they get back up and try to complete their routine and they're wobbly and things like that. The same thing happens in surgery If somebody makes a mistake or a complication occurs. They can get unnerved.
Speaker 2It's easy to understand, but it's hard to recover. As the French would say, sang far. You get your cold blood back when you're not going to be subject to your own emotions surging to make all your movements coarse and you're thinking they're irrational. All this has to be taken into place. I've had to go in the operating room when the nurses call me and say this guy's screaming and shouting, he's out of control. You walk in and instead of sitting there making an accusation and say can I help you? The question who called you? All you say is I got a sense that things were not going well. I'm here to help. What can I do to help you? You change the polarity of the situation. That's fantastic.
Speaker 2It's as much psychological and emotional as it is technical.
Speaker 2Ultimately, we're always dealing with people. Nothing gets the blood boiling and all the hormones being released into the bloodstream at the same time as somebody bleeding to death in front of you, and even in the practice laboratories where we're teaching people how to settle up a vena cava that's been stabbed. Vena cava is one of the largest veins in the abdomen. When you hear it, it's one of the few veins where, if it's bleeding, you can actually hear it bleed. That's not a sign. Arterial blood goes. You hear that, but there is venous bleeding that can occur, that you can actually hear it. That is usually exsanguination. It's happening or about to end the patient's life.
Speaker 1Okay, now, because we're in class, I'm going to raise my hand. You know, I know what this word means For the rest of the public.
Speaker 2Exsanguination. Sanguination means losing all of your blood.
Speaker 1Sanguine means losing all of your blood. So we have you are bleeding out, exsanguination, bleeding out, got it? So if anyone hears the word exsanguine, you now know, and nothing dreads your viewers like standing in front of somebody who is bleeding out. I would hope, considering your profession.
Speaker 2You might read in the literature sometimes somebody has a sanguine personality.
Speaker 1Okay, so let's circle this back to the patient. You had his head open for five days. He didn't lose much blood, but he was in a dire situation. You've had to take off his scalp or remove part of his skull and just say, hang out for five days, we'll see the swelling it does. And then, ultimately, what does the recovery of this gentleman look like?
Speaker 2He graduated from college and had a good occupation, but he never boxed again. Got married and had a good occupation, but he never boxed again got married and had kids, so there's no long-term effect in this case.
Speaker 2No, for this particular case there's no long-term effect. Five years later I was eating at a restaurant in Portland with my wife and I recognized the boy's father, who was a surgeon I knew from Southern Oregon. I bought him a drink from our table, went over, shook hands and it was like old home week, it was like alumni meeting.
Speaker 1It's kind of like John Bill's thing where you're sitting at a restaurant.
Speaker 1That's got to be the most amazing feeling. As a doctor, you know that you helped a person. At no point do you come off as prideful, but I know that there is a person. You cried Every time you got to bring someone back or help them. That's a feather in your cap, even though you're not going to promote yourself. But what an incredible feeling to see that person you saw unconscious at death's doorstep and just to see them out and about in a normal scenario years later. How rewarding is that.
Patient Recovery and Emotional Aftermath
Speaker 2It is. But you have to recognize some people try to bury a bad memory. So if you go into this business expecting to be thankful and have a great chance of slapping you on the back and wanting you to meet their family and all this other stuff, it happens doesn't happen very often. One guy which we'll be talking about when we talk about heart injuries lacerated his right ventricle from a fractured sternum and had tamponade and I set it up and he survived, never saw him again. He turned out to be in Beaverton, which is a suburb of Portland. He was running the register for a grocery store and saw a colleague of mine, a pediatric emergency physician, in a scrub suit and said he knew me. The guy said yeah, I did the pediatric emergency and I did a lot of things together. He said I was dying and he saved my life and I said would you like to meet with him? He said no. So there you have it.
Speaker 1Memory is too painful.
Speaker 2He was thankful in a way, but why wouldn't he want to? I offered to have him come to my office and we would take pictures together and do all that. Some people try to bury a bad experience or an event deep in their subconscious, never to emerge again.
Speaker 1I can understand that you just don't want to go back to that place. Maybe it was too emotionally trying. So from this I guess our first episode where we had Lindsay and Astor coming in and talking, considering what Lindsay's going through right now with her husband Thomas, whatever the outcome may be, I think it's completely understandable from a patient or a patient advocate, family member perspective that don't want to revisit that emotional trauma and then maybe even the physical memories. I think the people that have the fuller lives are the ones that say yes, this happened and acknowledging, appreciating it because that's part of their journey. But I can completely understand that somebody just doesn't want that memory at all we'll see with Thomas, her husband, several years time soon.
Speaker 2everything works out well when he is regarded into his experience only with leukemia.
Speaker 1Life is hard and anybody who says otherwise is so-and-so. The human experience is difficult and aging is not full. In the time we're talking about these issues, I hope that just our enjoyment level of speaking to each other. But the people that listen in, I hope that they maybe glean something else of it. If it's medical, great. If it's not medical, that's fine too, but hopefully it just opens the conversation a little bit. People are more educated about what can happen, what preparations they can take, and that you're a special human being. But we see into the mind of a doctor and what he is dealing with as well. We want to thank you for joining us again on Flatline to Lifeline with Dr Bill Long. Join us again as we continue to look at specific regional traumas within the body and how Dr Long and his team came together and found a solution to the problem, because when the need is greatest for the patient, saving time saves lives. See you again soon.
