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
Surviving a Self-Inflicted Gunshot Wound with Dr. Bryce Potter
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In this compelling episode of Flatline to Lifeline, Dr. Bill Long welcomes his longtime colleague Dr. Bryce Potter, a remarkable specialist with dual MD and DMD degrees, to explore how specialized training and innovative systems change patient outcomes.
Dr. Potter represents a rare breed of medical professionals - at the time of his practice, he was one of only twelve people in the United States with his particular combination of training. This unique background allowed him to handle complex head and neck trauma cases that would typically require multiple specialists working in sequence. Together, Drs. Long and Potter revolutionized trauma care by breaking down the territorial barriers between medical specialties to create a truly patient-centered approach.
The heart of this episode examines a fascinating case study of a 70-year-old man who survived a self-inflicted gunshot wound to the head. The bullet became lodged in his frontal sinus, creating a complex medical challenge that required innovative thinking and surgical expertise. The doctors discuss the critical decision-making process that took place, including the consideration of multiple surgical approaches and the necessity of having a "Plan B" when initial strategies prove impossible.
Most striking is their candid conversation about the psychological aspects of trauma medicine - how physicians respond differently to extreme stress, the dangers of perseveration and task fixation, and why some doctors struggle to adapt when faced with unexpected complications. This rare glimpse into the mindset of elite trauma specialists reveals why adaptability may be the most crucial skill in trauma care of critically injured patients and life-threatening emergency surgery.
Whether you're a medical professional seeking insights into trauma care or simply fascinated by remarkable human stories, this episode offers profound lessons about the systems and approaches that make unexpected survival outcomes possible.
Listen now to hear the full story of this amazing 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.
Special Guest Bio:
Dr. Bryce Potter, MD, DMD, is a board-certified surgeon in both Oral Surgery and ENT (Ear, Nose, and Throat). He earned his dental degree from the University of Oregon Dental School and also received his medical degree and completed his ENT residency at the University of Washington School of Medicine. He gained extensive trauma experience at Harborview Medical Center in Seattle and co-founded Head and Neck Surgical Associates in Portland, Oregon.
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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
Introduction to Flatline to Lifeline
Speaker 1Welcome to Flatline to Lifeline with Dr Bill Long. For three seasons, this podcast has explored unexpected survival outcomes and how Dr Long and his team of trailblazing nurses and doctors began to replicate these unexpected outcomes by applying available technology and available principles in new and profound ways. The pursuit of these unexpected outcomes became a mission for Dr Long's team over his 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 approach trauma care, because when the need is greatest for the patient, saving time saves lives. Need is greatest for the patient. Saving time saves lives. We have a special episode today.
Meeting Dr. Bryce Potter, MD, DMD
Speaker 1Dr Long has brought in another longtime colleague and friend, dr Bryce Potter, md, dmd. Welcome to the show, dr Potter, thank you. And obviously, dr Long, how are we doing today? Perfect, fantastic. So, dr Potter, the first thing that stands out is you have the MD and the DMV, so you are both a medical doctor and a dentist, board certified in both, which is very impressive. You graduated from the University of Oregon Dental School and then you went into the US Navy. Can you give me a quick background on that? How does that work? I don't even think of dentists when I think of the Navy.
Speaker 2I was a dentist in the Navy and during Vietnam and the highest ranking officer in a fire base camp was a dental officer, Because there are two things that keep a guy out of combat dental infection or abdominal problem. So the dental officer actually was the highest ranking officer, Wasn't in control, but highest ranking officer Russo. Spent two years there and then went on with training.
Speaker 1Just out of curiosity I have to ask, because I enjoy watching documentaries and movies about wartime things. Why would an impacted tooth keep a soldier off the battlefield?
Speaker 2It's not an impacted tooth, it's a dental infection.
Speaker 1Oh, dental infection Okay.
Speaker 2Dental infection and abdominal problems are the two most significant items that keep a man out of combat.
Speaker 1Okay, we talk about abdominal problems like a dysentery type of thing.
Speaker 2Yeah, or appendix or any abdominal problem like that.
Speaker 1And then, after leaving the US Navy, what did the rest of your career look like?
Speaker 2Well, I went to Westfield, Massachusetts, did an internship at a cancer hospital and then subsequently, I went to the University of Oregon and completed my oral maxillofacial residency three years of it and did the fourth year at the University of Washington, which had a combined program, so that I completed my dental degree and completed my medical degree. After that, I did a year of general surgery and three years of head and neck surgery. Subsequently, I came back to Portland and met Bill through Emanuel Hospital, where we both had interests in trauma.
Speaker 1Okay, so obviously, with the highest respect, you're an odd bird in that. I assume there's not a lot of MD DMDs out there.
Speaker 2There were 12 people at that time in the United States.
Speaker 1Yeah, a dozen in the country. Okay, so yes, odd bird.
Speaker 2My son is another odd bird because he was with us for a while and he's a dentist, MD, plastic surgeon, not a head and neck surgeon.
Speaker 1Oh, he had to one-up you. He went for the three, went for the triple threat.
Speaker 2Because of managed health care, I thought plastic surgery in the long run would allow him to do fee-for-service. So things were headed in the wrong direction in medicine.
The Unique Working Relationship
Speaker 1Okay, we've definitely had that discussion a couple of times, where the bureaucracy and the accountants, so to speak, begin making medical decisions because their tentacles go a little bit too far. So we've definitely looked into that. Dr Long, I want to go back to you here for a second because you guys have a unique relationship. As you told me, dr Potter was actually in private practice but he was volunteering time at the hospital in Portland, at Emanuel, with you for these specific cases. Can you give me just a quick overview of how that working relationship started, your friendship, things like that, and that'll give us a basis we go into the actual case study today.
Speaker 3I saw this in Baltimore and we had a plastic and dental surgeon, plastic surgeon, rural surgeon, ent surgeon Palms Wilhelmsen, and he tried to set up a separate department so that you can do everything in the face needed to be done with his training. He was successful at one private hospital but never could bring it to fruition at the University of Maryland. When I saw that, my father well said. Well, I knew him well. My father was a surgeon in Maryland and he used to have haunts down for dinner.
Speaker 3I heard the discussions of all the problems that were developing in medicine. So when I came out here and started putting the trauma program together, I had to contend with all these people who were privileged by the medical staff the hospital medical staff to do their specialty. And then there became a territorial fight over who would basically fix a trimalar fracture, which is where your zygoma is a bone that connects almost your ear to your cheek, and a zygomatic fracture. You had ophthalmologists wanted to do it, you had ENT want to do it, oral surgery wanted to do it and plasticologists wanted to do it. You had ENT wanted to do it, oral surgery wanted to do it and plastic surgery wanted to do it. And this territoriality meant that no one got any real experience with it, and so to try to form a call schedule, the hospital couldn't afford to pay for an oral surgeon to be on call, an ENT surgeon to be on call, a plastic surgeon to be on call and an ophthalmologist would be on call for one type of injury.
Speaker 1What year is this Like? 1983, 1986? 83, 84. 83, 84. Okay, so we still have this. Let's call back to season one, where we go. 911 is not universally available at this point. Cell phones are just coming in and they're three feet long and have a battery case the size of a Volkswagen that you have to drag around. Mobile calling is not a thing. I think we colloquially referred to it as the dark ages in medicine in the early 80s. You have all these people kind of clamoring over their ability to do a job, but there's no teamwork involved and you end up in this scenario where it seems like you're looking for a unicorn. You're looking for that odd bird that can do all the things that you need but is not willing to be, doesn't want to be, territorial. Is that kind of where you were leading that?
Speaker 3Exactly. Plus Bryce, because of his ENT background, could do a tracheostomy. So ophthalmology didn't do tracheostomies. No oral surgeon was doing tracheostomy. Ent could be doing it and plastic surgeons rarely did it. And emergency surgical airway is important in trauma. Based on skills, he could do one in two and a half minutes. Other people would take an hour because they're used to doing electives type of stuff where there's no time burden on them. They could spend three hours doing one procedure but no one would ever say boo about it. But in trauma, as we've talked over and over again, speed is of the essence. So when I first met Bryce he was the Hans Wilhelmsen of the West Coast. I had nobody like that at UC San Diego had that kind of training. So I recognized when Bryce was out of town I couldn't put him on call 24 hours a day, seven days a week. When he was out of town it took four different specialists to cover what he could do by himself.
Speaker 1You had a ringer on your team. Okay, that's high praise, Dr Potter, and I'll go back to something we said offline. How did this come about that you had your own private practice but you were brought in the headhunter is the wrong word, but you're brought in as this offsite guy to come in and you volunteered. And I think you said something again before we started where you said you were over-trained or over-qualified. Please tell me.
Challenges in Trauma Care Systems
Speaker 2With my background I could do essentially everything in the head and neck. I could do plastics, ENT, dentistry, oral surgery. So all the other specialties were lacking a certain component. They either lacked dental or they lacked medical. So my ability to do all that was perfect. And when I got there at Emanuel there were about four or five different specialists doing head and neck trauma call and, with all due respect, they were doing a very good job, and so the neurosurgeons demanded that I do any facial trauma that involved a fracture of the skull, and so all of a sudden I got all the trauma, and it wasn't that I was after it. They forced the hospital's hands so that I got it all, and when Bill came in then it was a done deal.
Speaker 3I realized that we couldn't ask Bryce to take call 24-7, 24 hours a day, seven days a week. I had to have somebody with similar credentials, had to have somebody with similar credentials. So then we began a nationwide search to find somebody who had the training of a potter and had the personality of a potter that was not going to be intimidated by trauma. And you have to remember, given these other specialties, elective surgery and office practice was a higher priority for them than taking care of the trauma patient. So a number of them that we were paying to take call if they were busy doing another surgery they weren't available. That's where they made their money, and so we had to create a team of people, or at least two or more people like Potter, to be able to provide comprehensive care and timely care. That was the important distinction I want to make there.
Speaker 1Yeah, I think it's vital that we do that, because we've highlighted the fact that both of you have incredible backgrounds in training, but I think the unique nature of it is every single person that you've brought in every time that we've talked about this cross-discipline intersectionality that is needed so that the highest performing doctors as I hear you talk about it are the ones who are the most highly adaptable, the ones that can cross over from one specialty into another to have a wider swath of things that they can cover and deal with. And that's why you're saying that it took four different people to fill the shoes of what Dr Potter.
Speaker 2Let me just point out that Bill says I wasn't on call 24-7, 365. That's not quite true, because it covered the ER as well as the trauma program. So I covered a manual for plastic surgery, oral surgery, ent, pediatric airway, all by myself, and I had residents affiliated because they wanted to be on my service from the university. So we ran a department of resident training as well, and then we subsequently added two fellowships, one in cancer ablation and one in pre-flat management.
Speaker 1Wow, you're covering a lot of ground there. The sticky part that I heard there was it sounded like you signed a contract with Uncle Bill. That was very casual and a handshake, and then he exploited you.
Speaker 2He tried to, but I was a willing participant. But the thing was I had a full-time coverage of the ER, plus I had a full-time private practice.
Speaker 1So you were exploited by choice? Yes, okay, I like it. I like that.
Speaker 3You had something to add, dr Moore. I think the other part about it is that when I came to San Diego to Emmanuel Hospital, and having seen the arcane issues of trying to get a trauma service going at a university such as UC San Diego and the same thing previously at Shock Trauma in Baltimore, I went to the administration and I said your medical staff can privilege these guys any way that they want. I want to be able to control the call schedule. You can get somebody privileges and they're automatically assented with their own trauma call, but I can't rely on them to show up on time or to do the right thing. I want total control of every specialist that I say when they can take trial or not. Because they don't play well in the sandbox with others, they don't take trauma call.
Self-Inflicted Gunshot Wound Case
Speaker 3So the next step was that we basically we offered everybody an opportunity for an exclusive contract to do all the head and neck trauma exclusive. No one else A group practice of one or two people can't do that. So no one applied. So then I went to Bryce and I said can we help you find somebody who will help you to make this a reality? And that's what we did, and so we gave them the exclusive right to do all head and neck trauma. I don't think you could do that at a university. There are too many competing subspecialists. But we did it out of necessity because we wanted a reliable call schedule.
Speaker 1This leads me back to this conversation where you say that there and you said you overheard your dad and another doctor talking, so obviously this goes back into your more formative years that there is a problem in the way these cases are being managed, at least insofar as the benefit to the individual patient.
Speaker 1We've taglined this for four seasons now. Saving time saves lives and it's an overly simplified premise. But it's factual that you've established that you have to stop the bleeding and you have to stop what's going to kill you first, and it's a very measured approach that the patient is a number one on the priority schedule. But yet when you talk about the system of medicine itself, there is a dichotomous change where it is the system that is more important than the patient. That is what I hear, and you said this last time in one of the episodes that your techniques and your team is only as good as the system that is running your techniques and your team. Is that correct? Have I quoted you correctly on that? Yes, so what you were designing in the historical perspective? I don't want to sound like I know it all.
Speaker 1but season one was the idea of an Army sealed hospital being brought into an urban environment. Season two you talk about taking that sealed hospital back out into the field on either helicopter or fixed wing. And then that was season three is developing it to the fixed wing model where you take it out and help those lower levels center. You had something to add here, dr Long.
Speaker 3I just want to make this emphasis, especially for doctors and nurses that are listening to this podcast. The health care gives the right to have privileges, but I demanded, as trauma and medical director, when I first came to Emanuel I had the right to say who takes call. I did nothing with their privilege. They could retain their privileges.
Speaker 3That's a medical staff situation. But if they couldn't play as part of a team and they couldn't be reliable when they're supposed to be on call and they couldn't be found, I didn't want them on the call schedule. And that's how that one factor working with the administration allowed all this to evolve from there, and I guess the fulcrum of all this was head and neck surgery. Because of all the different specialties arguing over who's going to fix the trimelular fracture, and neither one of them. There weren't enough many patients that could sit there and provide any expertise. If you're one of five specialists taking calls simultaneously, it doesn't work.
Speaker 2And I think the other big thing that complicates head and neck trauma is the lower jaw, upper jaw, the teeth, because plastic surgery, ent head and neck could not deal with jaw fractures very well and, matter of fact, the National Society of ENT recommended that ENT people do not do tooth-bearing fractures, that ENT people do not do tooth-bearing fractures. So all of a sudden that whole area was difficult for fine people who could treat it and when I came along and would cover the trauma, those doctors were very happy to just stay in their office and make money while I was in the hospital operating on no pays. So an area that reimbursement is for. Initially Dr Long was able to correct that. But why would you want to go treat a patient in the ER when you can treat a patient in your office who has insurance Self-selects?
Speaker 1out, so that again, that's the polar opposites being pulled. You have the system which is designed to. You have to run a business, you have to make money, so you have that. And it's a competing interest against the patient's life, because no system could ever be set up for the one% chance and have that be the overarching principle for how all the other people are treated, because you're devoting too many resources to it. The unexpected outcomes Because, as you just said, it's easier to bill on a person with insurance who is coming into your office than down in the ER under an emergency situation.
Speaker 1So I just hear this from the outside as a fiscal problem as opposed to a medical error problem. The fiscal just seeps over into the medical and then the patient doesn't have as many chances and the doctors are painted into a corner of what you're allowed to do. Am I hearing this kind of correctly?
Speaker 2Yes, that's an unfortunate problem. It is going to be single-payer health care because they're not going to be able to afford to take care of all these problems that appear. And with what Medicare pays you will not get somebody to train to the level that I have, or my son is trained, or Dr Longestrain. That just won't happen with government reimbursement.
Speaker 1I guess from that statement alone I wonder, as the future or potential patient, that there are very few people like you out there who are doing things for the benefit of the patient that they haven't met yet.
Speaker 2I had to do dentistry so I could afford to do medicine.
Speaker 1Oh wow, dentistry so I can afford to do medicine, oh wow.
Speaker 2Dentistry paid me enough that I could go and do non-pays of poor-paying medical patients.
Surgical Approaches for Bullet Removal
Speaker 1Gotcha. Okay, that makes a lot more sense. So can we transition right here into the actual case study? You guys good with that? Perfect, Okay. Now, Dr Potter, this is not one that you actually worked on, but you are here as a guest because Dr Wong wants you to get into the intricacies of this particular surgery, so I guess I'll just set the tone. Unfortunately, this is a 70-year-old man in rural southwest Washington who attempted suicide, and it happened to be a .38 caliber bullet and, as the notes say, it went into the right side of his forehead and the supraorbital cavity. What is the supraorbital cavity?
Speaker 2cavity. What is the supraorbital cavity? I don't know that there is a supraorbital cavity, but it was right above the orbit, and so you have the frontal sinus and the orbit, and our F-point sinus surround this area.
Speaker 1Okay, so roughly. This is just right above his eye socket.
Speaker 2I think he shot himself right there.
Speaker 1Oh, just upward angle.
Speaker 2Yeah, okay he put it right above his nose and right over his right eye.
Speaker 1Okay, and there was no exit wound. No, the bullet was lodged in the frontal sinus area. Just a crazy shift. I can't get over what would happen. You're so in despair that you put a gun to your head, you pull the trigger and then there's no exit wound. And this guy had the presence of mind, right after he attempted to kill himself, to call 911 before he passed out. So he went from ending his life to saving his life probably in a matter of seconds what seconds?
Speaker 3because emts had to come to his rural home, basically north of longview washington, which is further down the columbia river. What?
Speaker 1I'm just talking about. I'm just talking about his emotional state. I'm just talking about how. I'm just talking about his emotional state. I'm just talking about how the human condition he went from complete despair and total give up to nah, that didn't work. I'm going to give it, I'm going to, I'm going to call these guys. They'll help. That, to me, is a shocking switch in the human condition.
Speaker 3Some people do something and they regret immediately what they did.
Speaker 1I would assume a bullet lodged in your head would do that to you. Yeah, so, that being said, there's a long drive. Rural and EMTs arrive, and I will let the dynamic duo of dual-trained doctors take it away.
Speaker 2My experience is people that try and commit suicide with firearms that aren't successful regret doing it and rarely do it a second time, and I think it makes their life more valuable to them if they live through it.
Speaker 1The other thing you notice about this guy that shot himself.
Speaker 2he had an elevated blood alcohol level and so I'm sure that affects the decision making.
Speaker 1I would only assume so. As it says, emts arrived. We don't have a real time frame on it, but we're going to assume, since it's rural and it takes 30 minutes later to arrive at Emanuel, so it's at least 30 minutes out to him. Is that fair?
Speaker 3A rural EMT took him to the nearest hospital, which was in Longview, washington. At that time there was no trauma system in Oregon or in Washington to speak of, so he was at a real emergency department, okay, and they realized that this was he's got an unconscious patient with a gunshot wound to the head, right above his eyebrow, next to his nose, where's the entrance wound and they realized they didn't have any neurosurgeons on staff. They couldn't handle it. So they called and we would take the patient. Of course we accept the patient.
Speaker 3They transferred him by helicopter to a manual, so all this takes time. It's basically a half an hour for that injury. You have to remember, though, that it affects the size of the pupil, that kind of wound. So he has a not basically a poorly active reactive pupil on the right side, where this next, where his eye lies, and they didn't know whether or not he was bleeding within the head or not. Fortunately, they decided to do a lot of x-rays or CAT scans and waste more time with that. They transferred him immediately. We took him to our CAT scan and got the information more time with that. They transferred him immediately. We took him to our CAT scan and got the information In the show notes it'll show pictures of the path of bullet took to his skull from the front and going to the frontal bone and a little bit into the brain, with bullet fragments in the brain and bone fragments in the brain.
Speaker 3And then we went to the operating room to see what we could do. The question came up was with this pupil that's slightly dilated and not reacting, how will we best approach this? And so normally this would not be necessarily a neurosurgical crisis because there was no blood forming within the brain itself. There might be a few bone fragments and bullet fragments in the frontal part of his brain, but this was a problem a bullet lodged in a sinus where sinuses are known to cause infection. Bryce can go into more details on that, but the bullet should be removed and basically the issue of the sinus infection be addressed before it becomes a problem.
Speaker 1So I have a question here Now. Did you receive this patient? Were you on call when this patient?
Speaker 3arrived. I don't remember because I do all the quality assurance and so this case was so unusual. Well, same from all the x-rays and CAT scans and the forum, the discussion for our quality assurance committee. That's where I got all the x-rays and CAT scans and form, the discussion for our quality assurance committee, and that's where I got all the pictures from.
Speaker 1Okay, so timeline-wise, let's say, gun goes to the head, he shoots himself, he calls 911. We assume, or I'm assuming, about 30 minutes at least to get to him. I'm probably assuming another 15 to 30 minutes on scene as they're treating him and getting him to the local hospital at least, and then 30 minute transport to you before you guys get him into the ct. So the golden hour has passed, but you keep describing this in a way that it doesn't seem like there's a great deal of blood, like it looks at me. I hear you talking about the patient and you're talking about the orbital bone and the right eye is slugger. When I think of somebody committing suicide, putting a gun to their head, I think of something more dramatic, more explosive I don't hear you talking about. There's not a lot of blood loss there? It's just because of the impacted bullet, or is it just because of the location?
Speaker 3the sinuses don't bleed heavily. No, there was no massive bleeding externally. I want to emphasize that point of it. They didn't do a CAT scan at the Longview Hospital.
Speaker 1Right, they did the CT.
Speaker 3That means that they would have to have a CAT scanner immediately available and a CAT scan tech to be able to do the procedure. That would easily take 30 minutes, maybe longer, if they have to call a CAT scan tech in to come in and do the scans.
Speaker 2Okay.
Speaker 3So they saw that they had no idea what was going on inside the brain and they realized if he was bleeding in the brain, what would they do with it? Nothing. So that's why they made an amazing decision to transfer the patient immediately to a place where we could do something immediately if we had to.
Speaker 1Because they recognized they had a limitation, that they could only go so far, and then they were delaying. You know Okay.
Speaker 3So the reason why we're presenting this case is not because he was bleeding to death inside the brain or bleeding externally, losing a lot of blood. It's because it could have been, but how would you know until you are able to sit there and make the diagnosis and then do the appropriate treatment?
Speaker 1Yeah, that's why Dr Potter is here.
Speaker 3That's right. Bryce will tell you what the dangers are having a bullet lodged in the frontal sinus. It's not a sterile environment, right.
Speaker 2Correct Bullet has to come out.
Speaker 1Has to be a road. Is that simply because of the location?
Speaker 2You don't want to leave a bullet unless you absolutely can't get it out, because it is going to cause problems on down the road at some point. So if you left this bullet where it was, it would have gotten infected, involved his brain, his eye, and could be a lethal consequence of this gun show.
Speaker 1Okay. So you watch old West movies and you always see the doctor digging in there with the pliers or the forceps to pull out a lead slug. I've actually heard conflicting reports that sometimes the removal of the impacted item the bullet is actually more problematic. I assume it's a case-to-case basis because it's a foreign body that's in you, so that's never good, but we like Teddy Roosevelt. Teddy Roosevelt survived an assassination attempt and gave a speech with a bullet still locked to them. Can you explain to me what the protocol is for removing something? Where does it? Where do you cross over into this? Absolutely?
Speaker 2I think that your Wild West movies were, with all due respect, old-time approach and now, with CAT scans and MRIs, we're able to determine where the bullet is and what type of destruction it has done. So this case involves not only removing the bullet, but removing all the bullet fragments and, if necessary, repairing the dura if it's lacerated the dura. So there's not only the fact that the bullet needs to be removed, but you need to take care of the damage caused by the bullet.
Speaker 1Right, yeah, because we haven't even talked about what the impact is on the brain.
Speaker 2I don't think this case had a lot of brain damage.
Speaker 1Is it just because of the nature of the curvature of these bones, where in certain places it's just incredibly strong? Just because of the way it's constructed?
Speaker 2I suspect it's more due to the bullet round they used. Obviously, it wasn't one of the higher .38 caliber bullets, so I think the bullets were strong enough that they slowed it down.
Speaker 1Okay, so this was not a 38 special, this was a 38 unspecial that didn't do the job.
Speaker 2They have what's called a plus B now, which has more power and would have gone further. Ah, okay, you can have a lot of trauma to the face and eye without having brain damage?
Speaker 3Okay, so I think, from a historical point of view, what you're talking about from cowboy movies, which are in Hollywood, Hieronymus Ronschweig basically did a woodcut of basically penetrating wounds about 100 years after the Battle of Crecy, which is the time bullets were first used in Europe in wartime, and what year would this be around? Roughly in the early 1300s. Oh, that's it Okay, and he found basically that probing for bullets could cause more bleeding, sometimes fatal bleeding Frequently. It was unsuccessful and introduced infection.
Speaker 1Remember, they didn't have septics in those days, we're just talking about the technology leap and the antibiotics and things like that.
Speaker 3So a few years later, quite a few years later, there's a movie that came out with Russell Crowe, captain Commander about a Frick basically fighting the battle with the French in the Pacific and the ship's doctor gets shot in the abdomen just below the rib cage. They got a scene in there where the ship's assistant to the doctor is trying to remove the bullet which lies underneath of rib, while the doctor is guiding him using a mirror and a candle. Come on, people are influenced by what they see in the movies.
Speaker 1For sure I'm not asking to be made fun of. I'm telling you what the layperson sees is visual imagery. Sees is visual imagery. And yeah, it makes sense that a dude in 1300 england or 1850 tombstone, arizona, whatever you need you're just digging in there with a butter knife. Yeah, you're going to cause some damage if you have no antibiotics. That's not helpful either. Okay, I get that, that's not a far putt. Let's go back into this now and I want to hear you guys talk about what this was and then what the procedure was to not only go from a status assessment to actually now we have something in place and we're going to go to work, because I want to hear how you two wizards pulled this off.
Speaker 2They tried to remove the bullet, ie going through the wound, and were unsuccessful. In my opinion, retrospectively, looking at the x-rays and everything, there are two approaches to the bullet. One is you come through the frontal sinus and you'll see that the frontal sinus actually the back wall of the frontal sinus, is blown out and you could achieve two things you could remove the bullet, deal with the fractures of the back wall and repair any localized brain damage to a wound that way, and the other way that it was eventually used is a craniotomy and come through that way. Both ways give you access to the bullet.
Speaker 1Okay, and which did you ultimately go with?
Speaker 3They tried first to go through the sinus and they could not get it because they had to push the eye down in order to be able to get into the back wall of the sinus to be able to make an assessment. Bryce doesn't recall who did it. I don't recall.
Speaker 2I think they went through the orbit. I don't think.
Speaker 3They were trying to go through the orbit.
Speaker 2I agree.
Speaker 3I don't think they went into the sinus, but you gotta I mean you gotta push the eyeball aside or push it down in order to get into the back wall of the orbit, the. The orbit has thin bone in the back which holds it, holds the eye, and thick bone all around the eye to protect the eye socket. Correct me if I'm wrong. On facial anatomy, that's right, miracle, and but that a lot of people don't understand the anatomy. The anatomy is the key to understand what you're about to do and how you're going to get there. To understand what you're about to do and how you're going to get there.
Speaker 3So they tried to go in for them, for I mean, as they through, basically going underneath the eyelid and go pushing the eye down and then try to get to. For that he couldn't do it. So then we had to go to plan B and get the neurosurgeon involved to do a, an incision along where his hairline is over his right eye, pull the scalp down over his eyebrow to expose and take out a piece of bone called a craniectomy and then basically forage into there and then remove the bullet that way, and that's how it was done. Bryce comments.
Speaker 2Well, I think if you look at where the bullet is actually extending up into the frontal sinus and when you take the bullet out, you have to obliterate the frontal sinus coming from that approach, and you may have to obliterate it even if you come through the sinus. But it's interesting that and I'm looking at this in retrospect that his right eye had vision and when that got done operating, he has no vision in that right eye anymore. So I think their approach caused some problems. If I had this case I would have gone right through the frontal sinus.
Speaker 1Can I ask a question right here? Okay, so when you're saying going right in through the frontal sinus, does that mean like backing it up the way it came in?
Speaker 2No.
Speaker 1Okay.
Speaker 2Similar to the craniotomy. You would have to raise a similar flap and then you go into the frontal sinus.
Speaker 3You don't go inside the skull, you have to cut the bone way over the bullet.
Speaker 2Yeah, it's sitting up at the frontal sinus there, see that.
Handling Stress in Critical Situations
Speaker 3Whatever, all the back wall.
Speaker 2You just take the back wall out and you can just reach the bullet.
Speaker 1Either way, I love how casually you're just talking about this. I've listened to Dr Long so many times talking about we just moved the heart to the side. I'm just putting my hands and I just moved it to the side a little bit and then I got this one thing done and then I just pushed it back into the pericardial sac. You just got to cut out that bone.
Speaker 3As a heart surgeon former heart surgeon, I had trauma surgeon I can tell you that I saw a number of people who had been shot and the bullet was still in the heart muscle and they were alive and recovered. And the question is do you go in and remove that bullet or not? And some of them have been in there for years and you're like where's that bullet? On the next day they come in for another reason. There's this guy and they've got a bullet basically in the heart and you say how did that happen? Then they tell you the story of how they got shot. Usually it's with a .22, because the velocity of an average .22 bullet is not very high. If it's a .22 long bullet then it's got a lot more powder and it can go through and through the heart. So you have to know your firearms a little bit.
Speaker 1So, with all of the different complications and the different choices that you can make procedurally, dr Potter, you said you would have gone in through the front of the sinus Because, like I read the notes, the right eye even though the impact, even though the bullet entered right near his right eye, as you said, he still had vision. There was still reactiveness, the pupil was sluggish but it was still reacting. And then, post-surgery, you said he had lost all vision in that right eye.
Speaker 2Right.
Speaker 1Did the eyesight?
Speaker 2All the ophthalmologists confirmed that the patient had a right eye blind and had a sudden injury.
Speaker 1Okay.
Speaker 3So the ophthalmologist that was on call was actually this was in the early days was a resident and busy doing something else, and so there was a delay. And then we did not have a visual acuity test done prior to him going into surgery to try to remove the bullet. That was against our practice. We emphasize these things because people need to be aware of it. Not everything works perfectly in medicine. Who should be on call? What is the caliber of person being on call to make the decisions that will help? And again going back to this, the person in charge of the approach of this patient was a rural maxillofacial surgeon, because they had the most knowledge of all the injuries to the skull and the skull bones and that final sign fracture is related to a skull bone.
Speaker 3So they were in charge and when they couldn't get through, to get to the bullet.
Speaker 2That's when you called the neurosurgeons in to do the craniectomy gotcha the one thing you have to realize is this patient may have gone on to blindness whether or not they explored the orbit from the compression of the bullet, so I'm not saying the surgery caused it. No one knows for sure what caused the blindness.
Speaker 1That makes sense. You can't attribute all consequences to a mistake. Sometimes those are just things that they regress to the meat.
Speaker 2Overall, you have to say that the surgery was very successful because the guy's alive got discharged, tried to commit suicide and lost vision in his right eye, but it's a huge plus that he walked out of the hospital vision in his right eye, but it's a huge plus.
Speaker 1And he walked out of the hospital. Absolutely. It's incredible when you just think about what should have occurred. It befuddles me that the guy is still walking the earth today.
Speaker 3Now he would be 110, so probably not so during my career. An algorithm, basically, is a yes-no type of situation. How do you do a procedure? What are the steps you should go through? And these are the most recommended steps you should go through. Now then trauma algorithms are a little bit different. Suppose you have to do a procedure with a set period of time where the patient would die and you run into problems. You can't do the procedure called for. What is plan B? There are very few algorithms ever written on plan B and plan C. When you're running into problems or causing complications with the algorithm and algorithms were the hotspots from 1960s, mid 1960s to the mid 1980s and then you see just linear algorithms since then and all of a sudden, we did everything that's going to go well at every step of the diagnosis and treatment. So that was the thing that we emphasize. If something was not working or you're having great difficulty and you're losing time to save lives. What is plan B? And a lot of people don't have a plan B, right, bryce?
Speaker 2I think you have to be able to think under your feet and make decisions in trauma. It's not like a case you can plan in advance, before you go into surgery, what Bill is saying when you get there, it takes a trauma surgeon or special training to be able to adapt to the situation. You don't know exactly what you're going to deal with until you get there what you're going to deal with until you get there.
Speaker 1I love that because at least in my realm, in sports, I can at least be empathetic or alongside that ceiling, because when you have training and expertise in a certain field, you just see things different and you understand what needs to be done.
Speaker 1And I think that word adapt, or adaptability, is probably the most important thing in a high level, high tension situation, and it always brings me back to elite level soldier teams like the SEALs and things like that. And I look at you guys and you're both sitting there being very humble in one but, medically speaking, those dual trained, intersectional trained doctors who have multiple specialties. You guys are the special forces of the medical community who can walk into a terrifying situation, adapt to it and then, as you're treating treating be able to shift completely to another thing. That is now a grave danger for the patient I see it in sports all the time is that the people who are not just the most well trained, but the people who are calm and can process the information and basically take a horrifyingly complex situation and break it down into if A, then B, like this happened. Therefore, we do this.
Speaker 2You have to divorce yourself from the empathy that you have for the patient and deal with the problem. So you have to be able to know and, like I like to say, think on your feet about what the situation is and what you have to do at that moment, and so it becomes an academic challenge.
Speaker 1And so it becomes an academic challenge. I believe you Not to oversell my background, but in pitching the home plate is 17 inches wide but it's 60 feet 6 inches away from where you release the ball. So when I release the ball, if I miss the release point by one inch, that can cause over 20 inches of variation down at the plane. So my ability to replicate a certain movement correctly yields the positive result. But if I screw something up and I can identify it mid-motion, I can correct and do something different, and I feel like that's a very loose metaphor or similarly to what you guys are doing.
Speaker 2The other problem that you have is you're dealing not in inches, you're dealing in millimeters, and the other thing that you're dealing with is a patient who is alive and has blood pumping and all these problems that you have to control before you can actually do part of the procedure. So there are a lot of variables.
Speaker 1Again, I hear adaptability in my head ringing over and over, because I just see almost as a fly on the wall, or if I was watching a video of you guys doing these surgeries and Dr Long has hit it time and time again it's that these surgeries are happening at the same time. It's multiple people working at the same time who have checked ego at the door, dr Long.
Speaker 3I think the other thing that's hardly ever mentioned is how certain people handle stress, and when you have maximal stress this is a patient bleeding to death or having a complication that you may have created how do you get out of that particular situation? And there are certain reactions to stress which we wrote about years ago. One is perseveration. You keep doing the same thing over and over again, and I've seen this in baseball. The guy throws a pitch and the guy keeps hitting it foul and they keep throwing the same pitch. Why would he expect anything different? Because he's stressed out and no matter what the catcher's telling him to do, he throws the same pitch.
Speaker 1Yeah, it's almost a flight or fight mechanism.
Speaker 3Exactly, and the other one is alternation. They basically keep going back and forth, keep changing their mind, can't change their mind, and then they get a whole call for delay of the game. And then there's what's called task fixation, which is a form of perseveration. I've seen people try to do a cut down to get access to a vein in the arm or the leg and they're having difficulty, they're stressed out or they're causing damage when they're trying to expose the vein or the artery to put catheter in it. And you can't stop them because they're so task fixated and everything else is deteriorating and they're totally focused on getting that done. And that's why the baseball has coaches, that's why football has coaches.
Speaker 3But in medicine you don't have a coach sitting there watching a team of people working, and so we made Bryce and his partners coaches for the whole thing dealing with head and neck trauma, things that happen isolated in the brain, neurosurgery, but things are basically a combination of both. You want somebody there who can stay above the fray and make the right decisions. You got to get them out of the game. The pitching coach walks out and tries to talk to the pitcher. Calm them down Doesn't work. Take him out. You don't see that in medicine.
Speaker 1As a player. It would be depressing. It would be one of the most humbling and embarrassing things to be taken out in the middle of an inning defensively. I can't even imagine what that would feel like to a doctor who is a specialist, who isn't performing and then just gets tapped on the shoulder and says you're relieved.
Speaker 3Yeah, thank you. That's where I'm enamored with sports, because they seem to have identified the problem of high stress. And trauma surgery, especially under dire circumstances, is high stress. Some people can perform, some people can't, but once they get in there, they don't want anybody else to come in and help them. They get mad and there has to be somebody that says no, this is a little over your head, you need some help. I would get a call from the UOR, from the trauma circulating nurse, saying he's stuck, he can't get out of this situation, he's howling and screaming and carrying on. Can you come in and help?
Speaker 3I think you have to recognize what goes on and stress, because it happens in all these sports that we're talking about. It also happens in medicine, but the average doctor will say, no, I don't need any help. If they say that, then you got the wrong doctor in the operating room Because, remember, the trauma patient is not a private patient. The trauma patient came to you through a system. You've got to do the best you can for that patient, based on the fact that you have not had a preoperative consultation in your office, gone through all the pros and cons. You haven't done that. You have to give them the best of what you got to sit there and give them a chance for life.
Speaker 1These are just simply the facts. Right, as you stated the last episode, you know your techniques. They're only as good as the system that is in place. So if you have people fighting over who knows the most and not accepting help, then that is not a teamwork environment that you are trying to drive, for.
Speaker 2That's not patient first, that's ego first I think what dr long did was put together a highly trained group of specialists, probably better trained than most any other place in the United States, ie the world, for this type of business, and we were really specialists in that area, and most programs did not have the people with that type of training available, and so it makes a difference.
Speaker 1Well, I can only imagine that, not only having people who are trained, but people who are willing and that's the big thing is that we've talked about this time and time again, as Dr Long has described it, the pit crew approach and giving the nurses a voice and putting people to work at the same time, as opposed to in a linear fashion, one after the next, it seems like the best possible environment to be in a trauma situation.
The Value of Dual-Trained Specialists
Speaker 2As a patriot, I said about the trauma program under Long is that it was a hard place to die. About the trauma program under long is that it was a hard place to die. You couldn't just die because he could keep a dead person alive.
Speaker 1With all due respect no, I don't want to sound like I'm being overly effusive I never knew what my uncle did until we started doing this podcast and then a whole new world opened up and memories of me being eight years old, 12 years old, whatever. And then Uncle Bill walks in, he looks a little tired and he said I was just in surgery. And now I know what that surgery was. Oh, you were fixing somebody's eye who had a bullet impacted in their brain, got it. That's just phenomenally out of my comprehension level. So thank you both for what you do and what you did With that. Are there any other things about this case that you really feel need to come to light?
Speaker 2I just think it was a decision-making on the approach to the bullet and the outcome was fine, so everything got done well, I just think it was a decision-making on the approach to the bullet and the outcome was fine, so everything got done. Well, they just had an interim procedure that I don't think had much chance of succeeding.
Speaker 1But other than that, the outcome was good. Yeah, a self-inflicted gunshot wound and the guy walks away.
Speaker 3Yeah, I would say that's an excellent result. I think it's important though which we did mention that his right eye had what we call chemosis C-H-E-M-O-S-I-S, which is marked swelling of the surface of the right eyebrow, and the conjunctiva becomes quite edematous or filled with fluid, and so then that makes it less compressible or may be able to move in the socket, because the socket is a fixed orbit in which the eye is, and so if the eye is swelling you can't push one to one side without causing more and more damage. And it's not often that you see that, but when it's present, that chemosis is a hard thing to deal with, and usually you try to deal with that non-operably, and so on. Bryce comment.
Speaker 2That's correct. I think any approach through the orbit would just cause more chemosis and swelling of the eye. So the approach from above, either through the frontal sinus or the skull, was a way to come.
Speaker 1Okay, and you come to that only. I can only assume you come to that just because of years of training and just knowing what the consequences are for each successive action.
Speaker 2I think it's the background area. Like my ENT, oral surgery gives me a dual approach, the ability to have a dual approach. And head and neck trauma. That's the type of individual you need Somebody with a dental degree and a plastic surgery degree, or dental degree and a medical degree in otolaryngology. Ent, dual trained, dual specialties are invaluable.
Speaker 3I think the other thing Will is if somebody has done their gynecological training or surgical training at an elective hospital that does bring a little trauma gynecological training or surgical training at an elective hospital that does very little trauma.
Speaker 3They always have to sit there and take four years additional with you and be willing to accept that you're trying to show them a different approach than what they would normally do under elective circumstances. And I saw a number of people who applied for jobs who came out of those programs and they felt confident about what they were taught. But they were taught on non-trauma patients and you have to have that mindset, saying I am willing to learn a new way of doing things that is beyond what I was taught. And they will say I'm board certified. I said I don't care what you're at. It's a minimum qualification, board certification and a lot of it depends upon who you train with and what they expected of you and how much mentoring they did of you to get you through that training program so that you could handle some of the things that you're called upon to do.
Speaker 2Our fellowship program. We got a resident who had completed his oral surgery residency as a dental degree and completes a medical degree and then would spend an additional two years with us learning trauma and head and neck cancer. So those individuals were highly trained resident.
Speaker 1Dr Long has explained time and time again that this team was hand selected to come together to do incredible things. So I just hear you talking about just the importance of being able to bridge the gap between disciplines, because that just allows you that adaptability that we've talked about several times. With that, I think we've covered this and we thank you, dr Potter, for joining us. Dr Long, as always, bringing light to not only medical technique but the consequences of implementing systems that are not patient centric. Dr Long, you had something else you wanted to add to that.
Speaker 3I just want to say Bryce could join us for tomorrow's podcast.
Preview of Next Episode
Speaker 3We're dealing with a person that I never in my entire career would have thought would survive. He was a policeman, shot at point blank range with a 38 revolver Went underneath of his eye socket went across the base of his brain and severed his internal carotid artery as it entered into the skull and he was bleeding torrentially out of his cheek and the exit wound was behind his ear and the general trauma surgeon on call was trying to sit there and tie off his carotid artery but there's back bleeding from the other tie off his carotid artery but there's back bleeding from the other part of the carotid system and Bryce took some bone wax on his finger and pushed his finger through the hole underneath of his cheek into that and pushed the bone wax up against the internal carotid arteries that goes into the brain and stopped the bleeding. I have never seen that or read about anybody doing that, but he knows the basis of the skull like the back of his hand and he knew that this might work and it did. So that was going tomorrow.
Speaker 1I'm sorry. I don't mean to oversimplify this or be glib, but, dr Potter, what was just a strike to me is you went, dr Boyd, with the finger in the dam.
Speaker 2Not a problem, but you have to understand. When I walked into the room, the general surgeon had his finger up at the base of the skull and he says to me put your finger up here. I said what's the problem? He said he's back bleeding out of the chronic artery. Put your finger here. I do, and he says your case goodbye. And he walked out. Oh my Lord, I do, and he says your case goodbye.
Speaker 3I want bail oh my lord and it's true, I have seen that so often. He might drop on you hey, thanks for coming in.
Speaker 1See ya, that's awesome. What a great close. So we look forward to having Dr Potter again with us on the next episode. There's never a dull to having.
Speaker 3Dr Potter again with us on the next episode. There's never a dull moment with Dr.
Speaker 1Potter right Absolutely. Flatline to Lifeline strikes again. We hope you enjoyed this episode. To learn more about this case study and the history of the equipment, systems or medical design we have discussed and the strategies for life-saving, you can check out the show notes 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. A 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.
