Anything But Routine: Responders Answer Unprecedented Evisceration Call

 

 
 
 

Wayne M. Zygowicz, BA, EMT-P | From the July 2008 Issue | Saturday, July 26, 2008


At first the call sounded routine -- auto versus pedestrian accident. But everyone involved in the case, from veteran paramedics to seasoned trauma physicians, said it was the ˙call of a career,Ó a case that bordered on an act of God.

No one can remember a traumatic incident, like the one involving Victor Soto, having such a positive outcome. A heroic team effort saved the 20-year-old lawn-care worker after a freak accident left him clinging to life.

Incident Response

It was 1300 hours in October 2007 when communication specialists Sandy Vale and Lynda Sandoval received reports of an auto accident with a young male trapped under the vehicle. They quickly triaged the call using the medical priority dispatch system (MPDS) and alertedLittleton (Colo.) Fire Rescue -- a fire department of 130 crossed-trained, dual-role firefighter/paramedics and EMT-basics -- to respond.

An ALS engine company and medic unit fromLittleton's Firehouse 15 was quickly en route. A truck company with lifting tools was also dispatched. In just four minutes, Engine 15 and Medic 15 were on scene.

The accident scene was remarkable: a large, steel traffic pole was snapped off at its base, and traffic lights were smashed on the pavement. A paraplegic driver, operating a specially equipped van with hand controls, had lost control of his vehicle and hit the pole squarely at its base. The van then crossed five lanes of traffic before tearing through a fence in a residential neighborhood where Soto was running a weed trimmer in the backyard. The van struck Soto, dragged him across the yard under the vehicle before slamming into the house and pinning him face-up. He was in critical condition, moaning and uttering words in Spanish, whenLittleton crews reached him.

Lt. Knutsen and Paramedic Smith were the first to reach the unstable vehicle that had its left front tire resting on a landscape timber. They found Soto semiconscious and in terrible pain. Soto had visible tire tracks across his chest and abdomen, and his skin color was poor. He was having difficulty breathing and lay in a pool of blood under the vehicle.

The lifting tools from the truck company were still minutes from the scene as the ˙golden hourÓ of trauma quickly ticked away. Knowing he had to act fast, Lt. Knutsen crawled into a small void under the van. He noted that Soto wasn't physically entangled with the vehicle and could be moved out through the small opening. With the help of firefighters Kendra Keeley and Tim Urban, Soto was carefully extricated from under the van as the crew provided spinal precautions with a cervical collar and manual stabilization.

A rapid trauma assessment quickly revealed his injuries were stunning: Soto's eviscerated abdominal organs had been forced out of a fist-sized hole in the lower right quadrant of his back. His organs were exposed and contaminated with leaves, grass and dirt. His left upper arm was fractured. But Soto was responsive to verbal stimulation and had an adequate airway and a strong, rapid pulse. To protect the organs from further injury, the crew elected to pad and not spineboard the patient. Soto was stabilized on the ambulance cot in a left lateral recumbent position and quickly moved toLittleton's medic unit for transport. The total scene time was 5:26 minutes.

En route, a detailed assessment showed little evidence of head trauma or spinal injury. The patient was conscious, and had good sensation and movement in all of his extremities. His abdominal organs were quickly decontaminated by hand, irrigated and covered with wet, sterile trauma dressings. High-flow oxygen was administered, two large bore IVs were established, and two sets of vitals were taken during the nine-minute ride to theHealthONESwedishMedicalCenter, a Level 1 trauma center inEnglewood,Colo.

Lt. Knutsen's radio message to the hospital was calm and to the point, requesting ˙trauma-team activationÓ for an evisceration. Soto kept going in and out of consciousness as Lt. Knutsen, fluent in Spanish, attempted to communicate with him. ˙We're going to save your life,Ó Knutsen repeated while he provided care and tried to keep Soto from slipping into unconsciousness.

Life in the ED

Still semiconscious, Soto was met by emergency physician, David Rosenberg, trauma surgeon, Burt Katubig, and a team of nurses, specialists and technicians. Amazingly, Soto arrived at the hospital just 19 minutes after the first call for help was placed to 9-1-1.

˙At first, we thought we had the wrong patient,Ó stated Katubig, when Soto was wheeled into the emergency room. ˙His abdomen was flat, and the sheets were white with no evidence of blood.Ó They quickly realized Soto's small and large intestines were eviscerated out his lower back -- not his abdomen. ˙We continued to communicate with the young man and provide him comfort medication as we reduced his evisceration.Ó

In 20 minutes, Soto's abdominal organs were repacked, dressings applied, and the humerus fracture was reduced and splinted. He was rolled on his back, administered induction medication, intubated and moved to the operating room (OR) after X-rays and blood work. Katubig told the paramedics, ˙Call your supervisor and get permission to go to the operating room with your patient.Ó (SwedishMedicalCenter physicians encourage paramedics to follow their patients into the OR. This ˙teamÓ approach provides a unique learning experience for EMTs and paramedics to track patient progress and outcome.)

Soto was then moved emergently to the OR with a team of doctors, nurses and fiveLittleton firefighters following behind. Looking for injuries, the surgeons opened Soto's abdomen and began a four-quadrant exploration of his organs. Each piece of the small and large intestine was examined, and the damaged pieces were removed in a re-section process.

The organs were continually irrigated during surgery, revealing leaves and other debris. The surgeons removed the badly damaged spleen and discovered that Soto's diaphragm had also been torn in half, which allowed his lacerated liver, still attached and functioning, to be relocated into his chest cavity by the force of the accident. They also discovered that Soto had sustained multiple rib and spinal fractures and a collapsed right lung.

His abdominal cavity was left open and covered with aBogota bag. This specialized covering allows the incision to remain open for up to a week so doctors can monitor the organs for bleeding, swelling and signs of infection.

Soto was taken back to the OR on several other occasions for post-surgical evaluation of his wounds. Other segments of small intestine were removed, and his organs and abdominal cavity irrigated. The surgeons later repaired his left humerus fracture with internal fixation. He was given IV antibiotics and moved to intensive care for observation.

Road to Recovery

After two weeks of intensive care in critical condition, Soto was transferred to inpatient rehabilitation for multi- systems trauma. He had survived this extraordinary event and was working hard to regain his life. Members of his trauma team -- EMTs, paramedics, nurses and surgeons -- visited him in the hospital during his rehabilitation.

Like many survivors of traumatic events, Soto remembers little of the incident or the people who saved his life. However, he was happy to meet each rescuer and sensed they were now special people in his life. He now faces many days of physical therapy. He will have to adjust to the weakness in his right lower back muscles and may develop scoliosis as he ages. His multiple rib and spinal fractures may also complicate his long recovery.

Bowel obstructions and infections are common in these injuries. But Soto has shown tremendous progress in a very short time with few complications. He suffered a mild traumatic brain injury and was being evaluated for cognitive deficits using Spanish, his primary language.

˙This is a rare injury that no one [here] has ever seen before,Ó stresses Katubig. ˙There are some key lessons to be learned.Littleton paramedics remained extremely calm. That calmness allowed them to make great patient-care decisions. Their choice not to lie this man flat on a backboard avoided severe damage to his organs. They continuously communicated with the patient during his transport, kept him calm, provided him a position of comfort and rapidly transported him to a trauma center.Ó

Forty-four days after Soto was injured, he was ready to go home. A well-attended press conference highlighted his unbelievable story and recovery.Littleton firefighters, nurses, doctors and rehabilitation therapists were in attendance, along with Soto's family. The soft-spoken young man credits his survival to his rescue team and believes his survival is ˙a miracle.Ó

No similar case could be found after an extensive search of the existing medical literature. The skills of talented paramedics, nurses and doctors played a substantial role in saving Soto's life, as did ˙Lady Luck.Ó

Learn more fromWayne Zygowiczat the EMS Today Conference & Expo, March 2Ï6 in Baltimore.




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Related Topics: Patient Care, Medical Emergencies, Trauma, Jems Case of the Month

 
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Wayne M. Zygowicz, BA, EMT-PWayne Zygowicz is a 30 year veteran of the fire service and currently holds the rank of EMS Chief with Littleton (Colorado) Fire Rescue. Wayne is a member of the editorial board of Journal of Emergency Medicine Services (JEMS) magazine, a writer and a nationally known speaker on fire and EMS topics.

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