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
The Hard Place to Die: Saving a Cop with a Hole in His Skull
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A police officer is shot point-blank in the face during a routine traffic stop, the .38 caliber bullet severing his internal carotid artery at the base of his skull. Most wouldn't survive this catastrophic injury, but at Emanuel Hospital—a place Dr. Bryce Potter describes as "a hard place to die"—something remarkable happens.
Dr. Bill Long is joined by Dr. Bryce Potter, an oral and maxillofacial surgeon, as they take us through the harrowing case, revealing how innovative thinking saved this officer's life. When trauma surgeon Dr. John Zelko found himself literally holding back torrential bleeding with his finger, he made the crucial decision to call for help—an act that Dr. Long emphasizes is vital but sometimes prevented by ego in medical settings.
The solution? Dr. Potter improvised with bone wax and a muscle flap to permanently seal an un-repairable artery. Meanwhile, the team implemented their groundbreaking massive transfusion protocol, replacing the officer's entire blood volume multiple times during surgery using four specialized trauma nurses simultaneously administering blood components.
What truly sets this team apart is their philosophy of immediate intervention. "The patient is never more healthy than when they first present," Dr. Potter explains, challenging the standard practice of delaying facial fracture repairs. Their approach of immediate tracheostomy and fracture reduction not only stopped bleeding but dramatically shortened hospital stays and improved outcomes.
The police officer not only survived but eventually returned to active duty, despite the inevitable stroke. He had a permanent left hemiplegia resulting from the right carotid artery transection, and he underwent months of intensive rehabilitation. He is now confined to a wheelchair but is able to communicate orally with his devoted wife and family. His wife has worked out the logistics of transporting him in a vehicle to wherever they need and want to go. This case exemplifies how medical innovation comes not just from technology but from the willingness to challenge established protocols based on observed outcomes.
Join us to discover how these pioneering trauma techniques continue to influence trauma care of critically injured patients and why, sometimes, the most important medical tool is simply refusing to give up on a patient others might consider beyond saving.
To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.
Follow us on X @DrLongPodcast
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. They did this by applying available technology and principles in new and profound ways. The pursuit of these unexpected survivals 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 to adopt the life-saving techniques and approaches to trauma care that we discuss, because when the need is greatest for the patient, saving time saves lives. Thank you for joining us again on Flatline to Lifeline with Dr Bill Long. My name is Will Oman. I'm your host Today. We have the luxury and the pleasure of having Dr Long, as always, but his former colleague and friend, dr Bryce Potter is with us again. Hello, dr Potter, dr Long, hello. So you guys are both doing well today. Thank you again for joining us.
Speaker 1We discussed an impacted bullet in our previous episode from a self-inflicted gunshot wound, and today we're going to go into another case study about a gunshot wound. This one, unfortunately, was a police officer that was fired on at point like rain and, as I have done many times, spoiler alert this gentleman survived Because, as Dr Potter said and we're going to probably repeat several times during this episode the hospital where Dr Long and Dr Potter were in residence for trauma. It was a hard place to die. I love that imagery you come there and you're beat up, and that's a place where it is very difficult for you to expire. So again, thank you both for being here. Let's get right into it. Who wants to start?
Police Officer Shot at Point-Blank Range
Speaker 2I can start and Bryce can fill in. I was called later on, just like he was. So this 33-year-old policeman had stopped a speeding person and was talking through the window when all of a sudden the driver pulls out a .38 caliber handgun and shoots him in the face and we say point blank range. And the muzzle up wasn't against his cheek, but the muzzle was basically about two feet away from the officer when he fired it. The bullet went underneath of his right eyeball socket to the bone called the maxilla, skirted underneath that to the base of the skull where the internal coronary artery comes up to go into the brain through the skull. That was the entrance of the serforamen in the skull base. That was the entrance of the foramen in the skull base. Where that artery goes and severs it, the bullet exits from behind his ear. It's called the mastoid
Speaker 2process. So EMTs got to the scene very early and they transfer him directly to our operating room as per our protocol, and the trauma surgeon on call was John Zelko, a Denver General Hospital trained surgeon who did a lot of trauma at Denver General, and he was now faced with this person who was torrential bleeding from behind his ear, gunshot wound going to underneath of his skull. He didn't know quite what to do, so he's operating on the neck, thinking he could basically clamp the internal carotid artery or the external common artery to slow the bleeding down, the torrential bleeding down. And so while he's doing that, he had the good sense to call for help. So he called Bryce and he called me. I was in the hospital doing something else. Bryce was called in, I think from his office, so Bryce can take it from there when he arrived.
Speaker 1Can I interrupt real quick and ask you a question? My question is this You're talking about the carotid artery. I think there's probably two arteries that the general public knows about. You probably hear about the carotid artery and the seminal, the one on the leg. I'll ask Dr Potter this how many blood vessels are actually located in the head properly?
Speaker 3There are two main ones that go into the skull. One's the carotid artery.
Speaker 1There's a left and a right.
Speaker 3There's a carotid artery on each side, so you've got two arteries on each side, for a total of four.
Speaker 1Okay, and then the branches of those veins are infinite.
Speaker 3External. They're external. We're talking about what goes internal.
Speaker 1Okay, so there's four main blood supplies internally.
Speaker 3And they all join together in what's called a circle of willis and they feed the brain.
Speaker 2Basically, the willis is arteries connected, the internal parotid arteries with the occipital arteries from the brain. Basically, the willis is arteries connected, the internal carotid arteries with the occipital arteries from the back and there's a circle around it. So it's probably a protective mechanism. The circle is the arteries go around the medulla oblongata, which is at the base of the brain, before it goes down to a huge foramen to go into the spinal cord.
Speaker 1The medulla oblongata being the lizard brain.
Speaker 2Correct. I don't know which lizard you're talking about, but I'll ride with that.
Speaker 1That's the gecko from Gecko. All right, so we'll move on now. So we've got this person in a traffic stop. We've got the police officer, muzzles about two feet away through the window, shoots the guy, severs the carotid artery exits behind the right ear. We've established that there are four different arteries feeding to the brain. It's bilateral, so there's one each side. All right, here comes the dynamic doctor of maxillofacial surgery, Dr Potter. Take it away from here.
Speaker 3This is an injury that very few people survive from when you have a complete transection of the carotid artery. Not a lot of people survive that injury and the problem was when I got a call and it was from Dr Zelko, so I knew it was a bad case because he's very competent. So I go in there and I say what's going on. He says scrub immediately and get in here. And he has his hand up in the neck area. So I scrub and come in here and he says come over here. So I walk over to his side and he says put your finger up here. And I said what's going on? And he said that's a crowded artery when it comes out of the skull and there's no remnants of the crowded artery that we can sew to, we can't repair it. And he says your case, see ya.
Speaker 1So not only is that deeply and darkly comedic. Then he said hey, put your hand right here, I got to go. But the sentence that we just casually went over there is yeah, we can't sew that carotid artery back together. That seems like a very final statement. It is just like we can't do this. It's one of the main blood supplies. You say that not people survive. It seems why you're the dutch boy with your finger in the dam.
Speaker 3You literally have your finger in a guy's skull stopping bleeding if you can't stop the bleeding, he's going to die, and the carotid artery is a major vessel to the brain, and so when there's nothing to get a hold of, clamp up or so, and you just have a finger, as you say, in the dam, you have a major problem, and this is not covered in any textbook. There's no manual that tells you what to do, and that's why I say trauma surgeons have to be able to think on their feet. So I'm in a mess, to say the least, and I asked for some oxycell, which is a component that helps stop bleeding, and I pushed that up into the hole, and then I took bone wax and forced it up into the hole and held it for about 15 to 20 minutes and after checking it, it had indeed stopped the bleeding, and you never know when it's going to come back.
Speaker 1So what is bone wax?
Speaker 3It's just a wax. When you look at it, it's a component of wax, but it's malleable, so you can manipulate it. You don't have to heat it up with your hands. You can manipulate it around.
Speaker 1Okay, so it's like silly putty.
Speaker 2Yes, Okay, but it's sterile.
Speaker 2You don't put something sterile. I became aware of bone wax when I learned how to do heart surgery. I never had used it before in my life. And when you do a sternotomy and you split the sternum with a saw vertically from the top of your sternum all the way vertically down to what's called the xiphoid process and you part the sternum so you can take a good look at the heart bone marrow will bleed. It's relatively low-pressure bleeding. But to stop the bleeding continuously obscure everything you're trying to look at on the heart, you put bone wax on the surface of the marrow and wedge it in and that stops the bleeding from the bone marrow. So it's just a temporary plug. It's a temporary plug.
Speaker 1That's fantastic Because, as Dr Potter said, you know, in I alluded to last episode, you guys are the medical version of a SEAL team and you come in there and you have all this training. He says it's not in the textbook and you go yeah, most of the emergencies that we deal with in lights there really isn't a textbook. And it's how adaptable are we and how well trained are we.
Speaker 2You're using the metaphor of a SEAL team, which basically talks about an animal that can live in both salt and fresh water. So what we're?
Speaker 1going to talk about is sealing the bleeding from a bone. For you people that hardly know, dr Long is a master of puns, many of them poor, but all of them clever. So, yes, I was referring to the military arm of the United States, marines in the Navy. He is talking about aquatic mammals that circulate around the San Diego area and are hunted by sharks. Moving on back to another group of mammals, the humans, in this case one that is bleeding to death and and Dr Potter is saving with a bone wax, silly putty temporary blood dam. And let's keep going here.
Speaker 3Actually, Well, what we have to do is cover the bone wax so that it's bolstered from below. So there's a muscle called the sternum estroid that is in the area. I borrowed a pedicle from that and transferred that over to bolster the bone wax. In other words, I was able to close the wound on the way out. So it just wasn't bone wax over a hole. The hole was stopped and then I had to address the carotid artery down below. Once we made sure that was secure and the base of the brain was secure, the case was over. It would have been nice to have been able to re-enast the most the carotid artery, but it was severed at the base of the brain in such a fashion that there were no remnants of the carotid artery visible. The blood was just coming out of a hole.
Speaker 1Okay, so we're still in temporary sick state, correct?
Speaker 3No, this is going to be permanent.
Dr. Potter Takes Over Critical Case
Speaker 1This is going to be permanent. Okay, so the bone wax at this point has gone from temporary to permanent Correct and you have bolstered it by moving the muscle, the sternocleidomastoid. A portion of it, a portion of it, okay. And how do you seal it or attach it? Because the way I'm hearing it, it seems like propping a door under a doorknob as extra security to keep the door from opening. So it sounds like that's what you're doing.
Speaker 3Yeah, that's a good analogy.
Speaker 1Okay, so you're just basically just blocking the plug. Yes, okay.
Speaker 3Blocking the hole, okay, and then reinforce it.
Speaker 2So just to emphasize the sternocleidomastoid, you can see on a person with a relatively thin neck, it's a large muscle that goes down from what's called the angle of the mandible down to the sternum and that helps you to turn your head, but it's not essential for neck movement. You can take a part of it and swing it around like he did and push it underneath his skull, but it's a long muscle it's about 8 to 12 inches long at least, and so you can disconnect it and then use that as he talked about, push it in place with his finger and to the base of the skull. You'll be able to support that and stop the bleeding. But you have to also remember, even though the circle of Willis is there, you can clonus off with atherosclerosis portion of the circle of Willis, but you have the other three arteries in your brain basically still able to compensate somewhat, but that's when you're not bleeding. But when you're bleeding you think you have it stopped on one plate inside the brain, but you don't.
Speaker 2You have to sit there and realize that this person's going to lose 80% of the blood supply to the right middle cerebral artery, to the right frontal artery and then to the circle of the willows, and so that's going to lead to a stroke. So while we're thinking about this, the only way to potentially prevent this stroke would be operate on immediately what used to be called a superior temporal artery shunt. You take down the superior temporal artery, which is a branch of the external carotid artery from the front of the ear, and you go through a craniotomy and you sew that to the middle cerebral artery and you basically bypass the obstructed internal carotid artery that you just sealed off. Opus is not too complex.
Speaker 3But that was not electively for atherosclerotic and the.
Speaker 2American College of Neurosurgeons felt that this was not the results of people doing this operation was not successful. We had no one at Emmanuel Neurosurgeon who was trained in doing that procedure. I called the university and I talked to the professor. He said by the time I can get down there with my team, the person's already going to have a stroke. You're going to have to ride it out. It'll be too late by the time I get there. So now then we're dealing with a guy who's going to have a stroke where I can be able to move the right side of his body from this injury, but he's alive.
Speaker 3The other thing to remember that what Bill was talking about is a person that has a reduced blood flow. He does have a blood flow from the carotid artery and, supplemented with this other technique, this gentleman had no blood flow from the carotid artery and so by the time anybody got there it was going to be too late. I don't think there was really an option to bypass the carotid artery with this injury and people that have arthrosclerosis. Their artery is narrowed slowly over time so they're able to adapt and build blood supply from other areas. Where you have an abrupt cessation of the bleeding, where it's totally cut off, it's real hard to improve on that.
Speaker 1Okay, so the cumulative hardening and thinning of the arteries is easier to absorb than the acute nature of it.
Speaker 3Right.
Speaker 1Okay, whew, this is pretty heavy stuff. So you've taken a temporary solution and made it more permanent. You're reestablishing the baseline. The guy is certainly alive, but there is more to do. So I guess, take me through the next steps, dr Long.
Speaker 2So again I want to emphasize that the reason why we made the oral maxillofacial surgeons the team leader for all things related to the skull base and below. Neurosurgeons took everything that came through the base of the skull and I can remember learning in anatomy class all the apertures and foraminae with the blood vessels and the nerves going in and outside the brain. But I never used that because I wasn't a neurosurgeon and I didn't operate on the base of the skull Potter's group. With his training he knew every bump on the surface of the base of the skull. He knew where every aperture is and what went through it and that knowledge determines how well a person is going to do in an emergency or even in elective circumstances. You've got to know the anatomy.
Speaker 1I can't even fathom what it would be like to memorize the roadmap of the veins in the brain and just be able to conceptualize. That's as foreign to me as exploring the outer galaxy. But the closest I can come is trying to trying to memorize. He's called the thomas guide. It used to be. This huge binder is like 250 pages thick.
Speaker 3It was all the maps of the freeways and roads in la and that's what I'm imagining you is memorizing that textbook so you know every single road in the entire los angeles system I went through a year of anatomy in dental school and then, when I went to medical school, I went through essentially another year of anatomy and even though I was a student, I became an assistant instructor in head and neck anatomy while I was in medical school. So I had a lot of training in that area and when you focus so much on that area, it's secondhand knowledge.
Speaker 1And this goes along. This is a very credible point to any type of learning, especially rote memory. I use it with kids all the time. I say let's simplify the complicated, let's take all the variables and limit them and just do one thing. And then when you do one thing and you know what it is, you can practice that and become excellent at it. And then when you become excellent at a very basic skill, it gives you the freedom to adapt. You can say I don't like this situation, I have to do something different and adjust. So everything you're saying, I may not understand the words, but I understand the premise.
Speaker 3You have to give Zilko credit because he was there at the time and was able to stop the bleeding enough. I was not in the hospital but called in from outside my office, which is 20 minutes away. So it was probably 30 to 40 minutes before I arrived at the operating room and Zelko essentially stopped the bleeding with his finger and tying off a carotid artery until I got there.
Speaker 2That's amazing, the key thing to remember from Zelko and I want to emphasize this point Zelko with all of his training. He was an excellent general surgeon and had a lot of basketball training at Denver General and so on. He knew when to call for help.
Speaker 1That has been a theme.
Speaker 2Some people's ego will never call for help. In some hospital situations, the help you call for won't come. This is the issue and that's what we tried to build into our trauma system the willingness to admit that you were in something over your head and call for help, and when somebody would come and help you.
Speaker 1Now that has been a theme. The humility of the experts plays a huge role in whether the patient is appropriately taken care of. Sometimes you just you run out of bandwidth and important to ask for help as we continue this, as far as I recall in your retelling he is stabilized. Dr Potter has bolstered and stopped the bleeding. Where do we go from here, dr Lowe?
Massive Transfusion Protocol and Blood Loss
Speaker 2I want to emphasize that while all this was going on, we have a massive transfusion protocol. This guy had lost at least two blood volumes while we were giving that, and so the massive transfusion policy is to recreate whole fresh blood through stored components is to recreate whole fresh blood through stored components. You're giving a set ratio of red blood cells, plasma bonding factors, platelets and all in an effort to minimize the bleeding and to keep up with bleeding as it's happening and to replace what's been lost and to anticipate what's going to be lost in the future. So this guy had essentially three exchange blood transfusions of his entire body from external sources to keep him alive. Without that, this patient would have been deader than money's goat.
Speaker 1I assume that you're also using the bypass machine during all of this? No, you're not Okay. So explain to me the idiot layman, how this gentleman gets shot in the face and he loses all of his blood almost twice over. You put the excess in because you've done the formula where you have to take what is lost, what is current, and then what he's going to lose in the future, and you overloaded him.
Speaker 3Two anesthesiologists one to have the patient sleep and monitor that and the second anesthesiologist to keep up with the blood loss. So you have one person that is like a pump but is doing it manually and they're giving them blood. But there are also other components that they have to be given. Just besides old blood, they need platelets and other ingredients just to help you with the problem. So it's a massive resuscitation protocol that takes a couple people, ie anesthesiologists, to control that portion of the bleeding.
Speaker 1The only reason I understand this even is because in season one, Dr Long explained to me the four components of blood therapy and the replacements and all these things. I'm following along for anybody who's just joining in these four components. It's not like they just have a vat of O negative sitting around and they just pour it into you. We have to reconstruct the actual blood. Dr Long, you had something to add.
Speaker 2So this is. This happened. This patient arrived before we had developed the portable cardiopulmonary bypass machine. Okay, and so to get to take a standard, you have to call a perfusionist, and we set up the machine we talked about before and all of a sudden it's for a standard cardiopulmonary bypass machine. But it really wasn't needed.
Speaker 2So, with the massive transfusion protocol, even with two anesthesiologists doing it, we had trained what's called trauma resuscitation nurses, who came from the ER, or and the ICU, how to do massive transfusion, and that was their sole job. There were four of them, basically pumping blood in through one into the right arm, one into the left arm, through their veins and the leg and in order to give the volume of blood to keep up with what's been lost, what was going to be lost, and so on. You have to do this in order to maintain what we call hemostasis, so that there's no organ failure from the lack of blood flow going to the vital organs. Without that, you get behind, and when you get behind, the organs begin to fail. So the whole object is you don't want organs to fail. You have to give them what they need to be able to continue to function if this patient is to survive.
Speaker 3You say bleeding is an antis anesthetic or anesthesia problem, because if it wasn't, they would never give me a knife I love it when you deal with people who are who are experts in their field.
Speaker 1There's always there's a strange hint of dark humor that comes in all All right.
Speaker 2If he didn't have the dark humor, you could not do this.
Speaker 1Absolutely no. You have to have a thick skin.
Speaker 2That's right, cause you have to be able to laugh and cry at the same time, sometimes because it's the futility of what you're trying to overcome, and the lack of knowledge, and by other people who, if they're not trained to help you, you're you're racially all alone.
Speaker 1I heard it like this, as far as these situations go, from a player who is much smarter than me and much better, and he basically just said people with expertise have to go into this place where they disassociate. And his simple version is you have to have an excellent capability and a terrible memory. That's the only way you're going to survive.
Speaker 2I want to basically add an addendum to that. I talked about this in one of the earlier podcasts. There was a problem that came up when I was a medical student and I was on a TB ward at that time and the guy started bleeding from what's called the veins of rasps and a huge tuberculous cavity in his lung and the blood was pouring out of his mouth and he was almost drowning in his own blood. That issue I remember. The resident and thoracic surgeon came by when we called him staff to come help us and he didn't know what to do except watch the patient die. And that case haunted me for years. It wasn't until I got the UC, san Diego, and I was thinking about how could you prevent this guy from exsanguinating from his lung, bleeding out, bleeding out, okay? And so I thought about this and thought about this.
Immediate Facial Fracture Repair Benefits
Speaker 2And then at San Diego, after I was learning to do heart surgery, jim Harrell, one of the pulmonologists there, one of the world's best people in doing knowing how to do bronchoscopy was going down looking inside the windpipe to learn how to treat the diseases or stop bleeding from that area. And we had a patient on his TB ward that did the same thing. Well, we had a potential plan. We put the endotracheal tube into the good lung and ventilated the good lung and let know and stop at the same time. Stop the bleeding from the bad lung until we could get time to get in, to do the psoricotomy and take out the part of the lung at the huge lung cavity from which it was bleeding. And so it took 30 years practically for the idea to come to formulation and be put to the test. So I'm saying these kind of cases haunt you, because there should be an answer to solve a problem, especially if it comes from a focal area within the body.
Speaker 1So this takes me back to a season one concept that we kept going on to, which is I want my doctor to try, and it takes effort to try. It takes no effort to quit, and you mentioned that time and time again in season one that you weren't okay with just letting the patient expire, and that speaks to Dr Potter's assessment that it was a hard place to die at your hospital.
Speaker 3Massive blood transfusion protocol and so when you got to point X in a case you knew you were in trouble, you would institute the massive transfusion protocol and I had multiple cases that I remember where we replaced the patient's blood three and four times of normal volume. During that resuscitation and before Bill instituted that, it was really difficult to keep up with the blood loss.
Speaker 1So, Uncle Bill, how did you develop this transfusion protocol?
Speaker 2At the University of Maryland, where I went to medical school, they had a chief of blood bank named Ben Dawson and we were talking to them about the problem of these people getting blood products sequentially, not concurrently. Remember, we talked about that before. So if you basically give three units of packed red blood cells and a half an hour later give two units of fresh frozen plasma and a half an hour later give some platelets, each one of them get diluted over time and so the effectiveness of what you've given goes away, because you have to have a certain resting level of these cells going through your body in order for the plotting to take place. And so we stopped the sequential, basically of one nurse trying to keep up with a massive transfusion, spiking bags, putting an IV and doing blood transfusion one unit at a time, whether it's fresh frozen plasma or red blood cells, and doing it with four nurses who could do it concurrently. It was the human version of a cardiopulmonary bypass machine which we evolved later.
Speaker 3But my experience between this place and another major hospital in Portland where I was doing a very large cancer case involving neurosurgery and myself. It was intracranial combined facial tumor removal and it took 11 hours and we did not have the massive transfusion protocol and the anesthesiologist said to me at the end of the case don't bring any more cases like this to our hospital, we cannot handle them. You shut down our whole ward and so you have to understand that without approach to be able to get a massive transfusion protocol when you're losing volumes of blood blood was unique to Armandio Wow.
Speaker 1The hospital literally said no.
Speaker 3Said don't bring any more cases like this to our facility, we cannot handle them.
Speaker 2It was people like Bryce and others that we were able to attract to come and want to do this that when the case was over if the patient died on the OR table we never left the operating room.
Speaker 2We got the nurses involved, all the people were in that room and we went to a case. It took an extra hour before we had the backup team already there providing coverage while we were locked up trying to figure out what we did right and what we did wrong. And unless you do that, the human memory basically shuts out the bad stuff and you rarely revisit it because it's too painful to revisit. But you've got to do it if you want to improve trauma care or any emergency care where they're having massive blood loss. It can happen in cancer. You walk into a huge hemangioma, which is a collection of arteries and veins, and all of a sudden you've got torrential bleeding and, as I told you before, it can happen in the venous system and when you have bleeding that you can hear in the venous system you've got major bleeding and it can happen.
Speaker 3And it can happen. There's another aspect of this that when patients came in with major facial trauma and associated injuries, we reduced the bones as soon as we could, because reducing the fractures stopped the bleeding, and so what we would do is we would perform a tracheostomy, insert a breathing tube and fix the facial fractures and then the doctors later on could come in and put the patient to sleep using the tracheostomy and not have to try and go through a bloody face or something to have it done, because the facial trauma was all taken care of, patient had an airway, and then they can concentrate on their area of expertise.
Speaker 1So you're literally doing your work and prepping for the next guy. Absolutely, that's phenomenal. You're doing two things at the same time and both of them are yielding positive results.
Speaker 3Yeah, most people don't fix facial trauma on the initial presentation. They wait five to 10 days. The patient is never more healthy than when they first present. After they get admitted to the hospital, they're never as healthy, as in that first 10 to 12 hours that's mean Seriously, that's a mind-blowing statement, but it's so obvious.
Speaker 1Your person was whole. Everything was working. They have a violent injury, yes, they're in distress, but their body health system is far better than it would be in recovery.
Speaker 3The healthiest they're going to be on their whole admission when they first present.
Speaker 1When you're talking about fixing the fractures. So we have the mandible and you have this orbital bone. You're just talking about resetting it.
Speaker 3Yes, we put in the breathing tube and then we can take the tube out of the mouth. That was put in initially for resuscitation and then we can reduce all the fractures and we have a technique where we put metal plates in stabilizes the lower jaw, upper jaw, and the patient does not have to be intubated through the nose or mouth again because they have a breathing tube and the net which facilitated return of the patient to the operating room for the rest of their care.
Speaker 1And so you say that you noticed that there was a significantly better outcome if you reset the fractures first. Was there any correlation? Did you notice that when you did this, like 50% more people tended to survive? Was there any sort of formula for that?
Speaker 3I don't think anybody looked at survival data from that standpoint, but we do know the patients left the hospital sooner. Everything was done and the breathing tube was put in. Because if you wait with a patient with a what's called a tube through the mouth, an oral endotracheal tube, for 10 days before you put it in the breathing tube at the neck, our patients were gone home or onto rehabilitation while other places were still having procedure steps.
Speaker 1Okay.
Speaker 2Saving time saves lives. But a lot of people didn't like tracheostomy and they felt it was unnecessary because as long as you could put a nasal tracheal tube in through your nose and slide it past the larynx into your trachea, it quote saved the patient in operation. But there's a thing called hygiene. A person who has a nasal tracheal tube in or an endotracheal can't swallow. They salivate like crazy and so you have all this pool of stuff accumulating in the back of the throat all the time, because salivary glands make about a half a liter of salivary saliva a day and when you're under stress it goes up. So a person can drown in their own saliva. Lying on their wreck with an endotracheal tube in, the nurses can frequently suction a lot of that out. But some of that saliva leaks around the endotracheal tube cuff and goes down into the trachea.
Speaker 2And what is the one place in your body that has the most disease-causing organisms? Bacteria your mouth. What is the one place in your body that has the most disease-causing organisms? The bacteria, your mouth. Yeah, so a human bite is worse than a dog bite? Maybe equal? Maybe equal.
Speaker 1So you went for a more invasive prey with the tracheostomy, but that was done with the forethought that it was going to yield more positive results on the back end.
Officer's Survival and Recovery
Speaker 3See, I don't consider that more invasive. I actually think it's more therapeutic when you get all those tubes out of the mouth and nose and you're able to fix the fractures that are there, immediately, reduce the bleeding so it doesn't on-go, and you're able to fix the fractures that are there, immediately, reduce the bleeding so it doesn't ongo and you don't have to worry about the facial area or cranial area, which gets treated all together. And having the breathing tube facilitates then return of the patient to the operating room for other procedures that orthopedics wants to do, cleanup work that general surgery wants to do. So it's a big plus for them.
Speaker 1Why isn't that standard operating procedure?
Speaker 3Because a lot of the procedures that are done by facial surgeons don't have tracheostomy experience or don't feel comfortable doing that.
Speaker 2I think the other thing is you observe what works and what doesn't work, and so in the early days of facial trauma there used to be a thing called basically putting wires in, to wire the teeth of the upper of the maxilla to the teeth of the lower so that you had occlusion and they don't have an inadequate bite once you take the wires out. But on the other hand, these people who have their teeth wired together, do they deal with what's called a mandibular fracture or maxillary fracture? If they vomit they can't open their mouth to get the vomit out, so they drown in their own vomit. I saw this happen three or four times. No one. You sit there and take somebody who's drowning in their own vomit and try to cut the wires to get their mouth open again so you can suck it out is an exercise in futility. So having seen that multiple times, it doesn't take three or four to realize maxillary mandibular fixation without a tracheostomy is not a good idea.
Speaker 3The problem that you have to understand in order to reduce facial fractures. The number one item is reestablishing the occlusion how the teeth fit together and so that almost every fracture that gets treated has the upper and lower jaw wired together as fixation. When you want to come back and do another procedure, how are you going to put them to sleep? You have to try and pass a tube down through the nose or cut down and do a tracheostomy. If you do it initially, it expedites the patient's healing.
Speaker 1I guess that gives back to your point. They've never been healthier than when they came in.
Speaker 3The healthiest they're going to be.
Speaker 1It just. It makes so much sense, but you don't think about it All. Right Back to the case study. I already spoiled it. The guy survives and he is on the Emanuel Wall of Hope, which was created by Dr Long and his team as a visual representation of many of these cases that were near-death or store-death experiences, experiences, and the place that was hard to die at. There is now basically a memorial for all these stories.
Speaker 2Great. Dr Long, you wanted to add something. Well, I'm just saying to follow up. He survived this and went into rehabilitation. He was paralyzed on the right side of his body but he was able to communicate verbally with his wife. Once his tracheostomy tube was out, he was able to propel his wheelchair with his right foot and right arm, since the left side was one that was paralyzed. I should have said and frankly, in my experience I didn't think it was possible to control this type of bleeding, basilar skull bleeding but Bryce showed it could be done, and that's what you want to have around you when you're trying to do optimal trauma care is people like him who don't get intimidated by what can go wrong. You have an idea of what can be done and use common sense to get there.
Speaker 1You don't have to have a lot of confidence, and that confidence comes from the tree.
Speaker 2Yes, patient, 35 years later, is still alive.
Speaker 1That's amazing. He never got on a motorcycle again, but he did return to active duty as a police officer, correct? He didn't ride a motorcycle again.
Speaker 2That's right, okay, so the only thing that was amusing to the staff is his wife had a twin sister. Staff is his wife had a twin sister and when he still had his brain trauma the frontal lobe he had trouble distinguishing between the wife sister and his wife and the conversations got a little weird. But anyway, the nurses got a big kick out of it and they would come and tell me what was going on.
Speaker 1There's a dark humor against. That's a great comedic twist to this. I still find it shockingly like we both do so many of these stories and just me in my small brain, whatever. I'm thinking of this watching a movie and I see a guy rolled down his window in traffic. Stop cop peeks in, guy shoots head, there's an exit wound, we see blood and then 20 minutes later in the movie you see that same character with a bandage on walking around. You're like there's no way. There's no way that guy's still walking around. Apparently he went to your hospital I overuse this phrase, but that is frigging bananas. The guy literally had his head shot through it. He took it in the face and he's still walking around. That is crazy to me and just a testament to what you guys do. That's why you're elite and I know we're not sitting around here trying to bandy your reputations about and fill you up with ego, but what you do is an incredible thing and I don't think doctors are saying to us.
Speaker 2Brian Smith, phd. Bryce and I realized this was a unique situation. He had people being sent to him, residents and fellows being sent to him from all over the world learning how to do maxillofacial trauma, and they formed a relatively new society, the Society of Oral Maxillofacial Trauma. He can tell you a lot more about that, but I was impressed and so when we had an inspection by the oral surgeons who came to our hospital to evaluate as a part of the surveillance that the American College of Surgeons Committee on Trauma wants, I had certain professors and chairmen of departments at other university medical centers asking me. They saw what was happening here. They asked if they could get a job here, and that is your highest compliment.
Speaker 2But the end of the question Bryce would say. He says how are you going to take a guy who's 55 years of age, he wants to sit there and will he accept it A learning position with you underneath that situation, when he previously was chairman of the department? Answer is no. You can teach an old dog new tricks. It's been the age old question. And so why would you? Paul Cutler?
Episode Conclusion
Speaker 1you can teach an old dog new tricks, you just have to do it very slowly. A lot of patients, a lot of patients. Sorry, I just did an unintentional pun there, so let's close this out. Thank you both for being here. Another great episode, proving once again that there are doctors out there that are patient first, not system first, that they created a system for the patient to serve the patient, and we thank Dr Potter and Dr Long, as always. This concludes this episode. We hope you come back and join us for our next episode dealing with trauma and unexpected survivals, because, honestly, when the need is greatest for the patient, saving time saves lives. Thank you for joining us on Flatline to Lifeline with Dr Bill Long.
