5.David King — Direct (Part 1)

DAVID KING: David King, K-I-N-G.

DAVID KING: Good morning, ma'am.

DAVID KING: I'm a trauma and acute care surgeon at the Massachusetts General Hospital.

DAVID KING: I have a bachelor's degree in biology from the University of Tampa, my medical doctorate's from the University of Miami. I did my residency and fellowship training in general surgery, trauma surgery and surgical critical care, divided in pieces between the Beth Israel Deaconess here in town and University of Miami and Jackson Memorial Medical Center and the Ryder Trauma Center.

DAVID KING: So as a -- I'm a member of the division of trauma emergency surgery and surgical critical care. My job is to care for the acutely injured and acutely ill, those with surgical diseases. That includes all aspects of emergency surgery for any of those conditions. And then as an intensive care physician, we take those patients, we operate on and follow them throughout their entire hospital course.

DAVID KING: I'm an assistant professor of surgery at the Harvard Medical School.

DAVID KING: I do. I've been in the United States Army for 14 years.

DAVID KING: My primary duties in the military are to take care of wounded soldiers -- sailors, Marines and airmen -- but also in accordance with the Geneva Convention, to take care of anyone injured on the battlefield whether they be enemy, host nation, national. Anybody who's injured.

DAVID KING: Yes, ma'am, I have.

DAVID KING: I was deployed to Iraq as part of Operation Enduring Freedom -- pardon -- Operation Iraqi Freedom and in Afghanistan as part of Operation Enduring Freedom. I was also deployed to Haiti on a humanitarian mission after the earthquake.

DAVID KING: Yes, ma'am, I am.

DAVID KING: Over the course of my entire training and military experience and civilian experience as a trauma surgeon in general, hundreds for certain, perhaps even a thousand or more for certain.

DAVID KING: Yes, ma'am, I did.

DAVID KING: Well, on my way to the hospital I really had no idea what was happening. I just knew that some circumstance, I had no idea, arose that likely would require my expertise and the expertise of our entire team there. No one works in a vacuum at a hospital like that or anywhere in town. And when I arrived in the emergency department, I arrived just as the first wave of casualties had shown up. And I looked across the patients and I knew immediately without anyone really having to tell me exactly what the wounding mechanism was and what had happened. Of course, not the details. But as I looked across the injured patients in a few instants, in just a few moments, the pattern of injuries was fairly predictable and stereotypical for injuries that I'd seen hundreds and thousands of times caused by explosive devices.

DAVID KING: So the -- sadly, the type of wounds that we see from explosive devices that are placed on the ground is fairly typical. It involves blast and fragmentation injury primarily to both lower extremities, and depending on how big the blast is, that blast and fragmentation injury can extend higher and higher on the torso. This was the pattern that was really fairly obvious from the doorway, meaning without even really laying hands on the patients, any surgeon with similar experience, and even some surgeons without similar experience, quite honestly, who have read peer-reviewed literature would be able to identify this fairly characteristic pattern of injury.

DAVID KING: That's correct.

DAVID KING: Right.

DAVID KING: Yes. So as I said, this is a judgment made in an instant looking over all the patients within my line of sight when I first arrived.

DAVID KING: You know, I don't exactly recall. Certainly that's findable information. I know for certain how many I looked at. I don't know how many were in the ED at that instant, the moment I arrived.

DAVID KING: I personally looked over three.

DAVID KING: In that very moment, I personally examined three.

DAVID KING: Yes, ma'am. My cursory examination of those three patients, and one in particular who I deemed at that very moment to be extremely critical, confirmed my initial observation that these were injuries and patterns of injuries consistent with an improvised explosive device.

DAVID KING: It was traumatic amputations of the lower extremities with burn blast and fragmentation wounding that was worse towards the lower half of the body and improved as it -- as the examination went towards the upper end of the body, which is fairly characteristic.

DAVID KING: Yes, ma'am.

DAVID KING: So we use the term "traumatic amputation" to -- so the term "amputation," of course, means the loss of part of a distal limb, right? So that can be an arm or leg. It can be any appendage, actually. It can be an ear, nose, whatever. And we characterize a wound as a traumatic amputation even though -- so some of them are very easy. So if the wounding mechanism has caused the limb to be completely severed, as they say, the medical student can figure that terminology out, but when the injury causes the extremity to become mangled, which is fairly common in this kind of wounding mechanism, it's inherently sometimes obvious that that mangled extremity cannot be salvaged and so we would call that -- we'd use the terminology of "traumatic amputation" or "near traumatic amputation" as an initial diagnosis. Now, you never know for sure whether an extremity can be salvaged or not until you're in the operating room and you can see the details. But it's not an unreasonable term to describe many of the wounded limbs.

DAVID KING: Yes, ma'am.

DAVID KING: One patient in particular had a fairly horrific limb injury with significant ongoing blood loss who I thought was going to die in front of me.

DAVID KING: You know, it's easy and it's difficult to answer. The difficult part is if you ask me to characterize, for example, a certain blood pressure of, I would say, someone who is about to die, or a certain pulse rate or something, although those seem like objective numbers, sometimes they're not very predictable of what a patient's outcome might be. However, more important than a set of absolute numbers is the interpretation of the visualization of injuries from an experienced eye. And for an experienced surgeon, it's very easy to tell who has lost almost all of their blood, not because their blood pressure is low, because everybody's blood pressure was low who was injured, but because they're pale and clammy and losing consciousness and their sensorium is altered, a variety of less quantifiable numbers. And it doesn't honestly even take an experienced physician. Some -- you can -- most people can look at another human being who's hurt and figure out who is dying and who is not dying.

DAVID KING: Sure. Sensorium is just a way to describe mental status. So if you're awake and alert and can balance your checkbook and do long division and so on, I would say your sensorium is largely -- largely -- intact, but when you don't know your own name or can't answer simple questions like where are you or what happened, we would consider that an altered sensorium or altered sense of consciousness as tends to happen with ongoing or significant blood loss in this case.

DAVID KING: So, again, largely the same set and characteristic pattern of injury. It's -- and it was a recurring theme not just for me but I mean really around town for all the other trauma centers and physicians caring for these patients. This predictable, identifiable pattern of lower extremity blast amputation with multiple fragmentation, it was sadly the theme of the day and is entirely characteristic.

DAVID KING: So for any patient with this characteristic type of injury, the dominant preventible cause of death is exsanguination. Exsanguination is just a term that means rapid blood loss. And you have a -- every human has a finite amount of circulating blood volume in their bodies. And generally you tolerate moderate amounts of blood loss very well, right? You donate a unit of blood at the Red Cross and you go home, have some orange juice, you're okay. And your body has plenty of compensatory mechanisms that make that okay for you. At some point, though, your compensatory mechanism starts to tip. So it may be safe to donate a unit of blood, but what about two or three or five, and at some point you have nothing left to give. Well, the same is true for patients who are bleeding. You can sustain some injury, any injury, and you can lose a little bit of blood. And although it may be scary, perhaps your life is never threatened. But as that blood loss continues, you lose more and more of the finite amount of volume, of this blood resource that you have, and at some point you no longer have enough to sustain your own life and you will die.

DAVID KING: So generically speaking, yes. So the average 70 kilogram adult has approximately five liters of blood in their body understanding that there's variability for height and weight and body mass index and so on. But approximately. The average adult approximately has five liters of blood.

DAVID KING: Not just yes, but an enthusiastic yes. In fact, on the military side we've even changed the way we used to -- we approach injuries like this. Traditionally, people are taught -- and probably not just physicians. Laypeople are taught the ABCs of people being injured: airway, breathing and circulation. And very early on, on the battlefield, you recognize that something may be more important than A, and that's H, which is hemorrhage control. So for someone who sustains this kind of traumatic injury, the most important maneuver is to stop the blood loss first.

DAVID KING: So it depends on where you're bleeding. So patients who are bleeding from an extremity injury, like these types of lower extremity blast injuries, there's a few ways to intervene. The simplest is the one that's most reflexive. So you cut yourself, you put your hand on it, right? So that's applying direct pressure. That's fairly intuitive for most small wounds and almost everyone knows how to do that. And, of course, as wounds get bigger and more dramatic with more and more blood loss, you need to escalate the aggressiveness of hemorrhage control, or bleeding control, and that can be really as simple as putting your hand into and on a much bigger wound to compress it or applying a tourniquet around the limb as a very -- more definitive hemorrhage control maneuver if the wound is so devastating that you can't just put your hand on it and apply pressure.

DAVID KING: So that's a different classification of bleeding that is extremely problematic. So limb bleeding, so that is a wound below the shoulder -- or pardon me, below the groin -- are the types of wounds that we characterize as tourniquetable. So wherever the bleeding is, you can apply -- there's enough space to apply the tourniquet above that wound and control the blood loss. Now, where your limbs meet your torso, so in the groin or in the axilla, in the armpits, bleeding injuries in those sites cause tremendous bleeding and there's no way to wrap a tourniquet around that injury. So it's higher than you could wrap a belt or a tourniquet around your limb. It's truly in the groin. So we call those wounds by definition junctional wounds. They occur at the junction between a limb and your torso. Junctional wounds are, by definition, non-tourniquetable, so you cannot put a tourniquet on them. It's the biomechanics, it's physically impossible, and they're extremely challenging to control. And usually the way hemorrhage is controlled for those wounds is with direct pressure with your hand or with wound packing. There's a variety of ways, of materials you can pack into the wound to help stop bleeding. And although not entirely popular in the civilian world, in the military side there are some devices that are used to help control junctional bleeding but they haven't quite made their way into the civilian world. The real solution for junctional hemorrhage is an operation. You need a surgeon for that kind of devastating wound.

DAVID KING: So the science on blood loss and death is extraordinarily solid. The research that's been done on hemorrhage and resuscitation, that is, bleeding and control of bleeding, is extensive particularly in the past 14 years of warfare. Dare I say, it is almost impossible to bleed to death instantaneously. It is a long gray scale, right? Let me give you -- may I give an example?

DAVID KING: So if you sustain a very small injury, a very small cut and the blood loss from that cut is what you might consider minor in your own mind. You say, "Gee, that's not bleeding that much." But you don't do anything about it. And suppose it's bleeding at a rate of 100 cc's per minute, but you do nothing. You have five liters of blood. So over a period of many minutes or half an hour, 45 minutes, although that bleeding is slow, eventually you will run out of blood and you will die. If you have a more severe injury where you're bleeding at one liter per minute from perhaps a much bigger wound, you only have five liters of blood and so you'll bleed to death in less than five minutes. So this is the spectrum that I mean. You can -- patients bleed to death from minor injuries all the time, they just do so over a more extended period. And naturally these are sometimes patients who sustain an injury far away from medical care, nobody knows what to do, or they're alone and can't intervene to help themselves. There are a variety of circumstances you can think of where someone might have a minor injury and bleed to death slowly over a long period of time. And so that's the long gray scale. Blood loss does not result in instantaneous death with rare, rare exceptions that you could maybe conceive of some bizarre circumstance. But speaking in solid scientific generalities, blood -- death from blood loss does not occur instantaneously.

DAVID KING: Oh, absolutely not. It's just beginning. So, you know, this -- taking care of trauma patients who are bleeding is not a one-shot deal. Losing all your blood volume and then stopping the blood loss itself is its own set of additional injury, of physiological insult. So your body is not meant to do that. So we can stop the blood loss and I can even give you blood back, right? I can transfuse you many -- as much as you need or as much as I want. I can give you lots and lots of blood back to replace what you lost, but that blood you're getting back is not yours. It's donated blood; it's bank blood. It's not the same thing. It's not half -- or even a quarter as good as your own blood. And doing that -- we do that because there is no other good way right now. I would love to be able to transfuse you your own blood. It's just not possible in 2015. And so giving you back that blood and subjecting you to the stress of an operation, or in the case of these patients, no one rarely had a single operation, right? We do many operations over the course of an extended period. And that surgical insult on top of surgical insult and physiologic stress and more and more blood transfusions, and every time we do another operation and give you another unit of blood to replace that which you lost, it's more stress to your body. And those insults keep piling up and up and up. And every time you do that, it makes your body more subject to risk of infection, organ failure, kidney failure, heart failure, lung failure, and so on and so on.

DAVID KING: Yes. So nothing is for free here, right? Once upon a time we used to treat -- we used to treat trauma more -- pardon the analogy, more like a marathon. You had an injury, we took you to the operating room and we just worked on it and fixed everything all at once until every last little bit was squared away. We recognize now that that's generally a poor approach to trauma care. Instead, what we do is on the first operation, we fix only that which is absolutely essential and lifesaving, and then we bring you to the ICU and let you recover for a period of time. Sometimes that's a few hours, sometimes it's a few days. Then we go back and do a little more surgery and fix a few more things, and then we give you a break and let you recover. And by doing this, as opposed to one big operation, doing many, many small ones, we spread out the stress of surgery. So instead of putting an elephant on your back all at once, we put smaller things on you. Smaller amounts of stress allow you to recover from that stress, and we go back. Now, we do that because the science suggests this is the best way to have living patients at the end, right? So there's a survival benefit. It's called staged surgery, to staging surgery like this, abbreviating surgery. But each of those operations comes with its own set of risks, right? Every time you go to sleep -- I don't want to scare anybody away from surgery. You need surgery. But it's not for free. Every single time you go to sleep, even before the surgeon starts operating, there's a risk you might never wake up. You could have a heart attack or stroke or a giant blood clot. And all of this has nothing to do with the operation, per se, it's just the process of going to sleep for whatever operation it is that you're going to have. And having breathing tubes put in and back out and put in and back out for every operation has also its own set of attendant risks. So we do it because we have to but it's not for free, and we know that going in.

DAVID KING: No, limb salvage is definitely not for free. Limb salvage is a catch-all trauma term for describing the staged approach to trying to avoid an amputation, right? So what I said at the beginning is you can look at some patients who don't have a -- sort of a clean amputation where obviously you know that is not possible to successfully reattach a limb. Many patients have a mangled extremity. And on a cursory exam, you could think to yourself there's no way to -- there's no way that's going to survive. There's no way I could fix that. But you never know for certain until you get to the operating room. And sometimes when you get to the operating room you occasionally will be surprised and you'll say, "Gee, that looked bad downstairs in the emergency department but now that the patient is asleep and I can dissect and see blood vessels and these nerves and these muscles, maybe, you know, if I fix this blood vessel and move this nerve this way and put a muscle in between there, you know, maybe we won't have to amputate this limb." And so largely we take that approach, if you can. We'll go through some extraordinary measures to try to take what is a badly injured limb and make some surgical maneuvers to try to salvage it, to try to bring it back to a usable limb. Sometimes that's successful, often it's not. But just because something's not successful every now and again doesn't mean you shouldn't try every time when you think it's appropriate.

DAVID KING: So to repeat the theme here, nothing is for free. So if I thought that one limb was potentially salvageable by restoring, say, blood flow to the -- distal to the injured part of the limb -- so if the blood vessel is severed, I need to restore that blood flow, I wouldn't necessarily hesitate to harvest or borrow -- borrow -- steal a vein from your opposite leg to bring it over to the injured leg so I can sew it in to restore blood flow to the injured leg to try to salvage it. Now, your -- the donor limb, right, the leg where you would borrow or take that vein from to use to try to salvage the other limb, well, that vein is there for a reason, right? Your body has evolved in a way that most of your arteries and veins have a purpose. They do something for you. And so we try to take veins that we think will have the least amount of impact on the donor limb, recognizing that they're there for a reason. So the very simplest example of taking vein from a good leg and bringing it to an injured leg is that removing that vein requires a big incision. That big incision causes pain and suffering and that incision can get infected which causes a chronic wound which needs a skin graft and debridement. That's just a single example of all the things that can go wrong when -- for a procedure that just rolls off your tongue like, "Sure, we just harvested a vein." Well, yeah, it's easy to say as long as it's not your leg that you're harvesting the vein from. Then it's easy to say. But when it's your limb, all of a sudden you recognize it's not so easy just saying, "I borrowed the vein." There's a whole litany of complications that can come from that: Like I said, infection and wound breakdown and clots. The list is long. Importantly, though, for patients with this kind of injury, unfortunately you're often borrowing a vein from the lesser injured limb to bring to the more injured limb, right, to try to salvage it. So it's very different than the -- than a diabetic who needs blood flow restored to their foot because they can't walk and get cramps. Now you're -- and you're talking about one limb that might be normal, so you take a vein out of a normal limb. Now you're talking about a threatened limb, one you're trying to salvage, and you're going to take a vein from another limb that also has blast and fragmentation but perhaps isn't as bad as the other. So now you're gambling that this vein which, in a healthy person they may tolerate very well not having anymore, that vein that you just removed may end up being critical to the lesser injured limb surviving. So all I'm trying to say is it's not for free and it's a little bit of the shell game, moving risk from one side to the other and trying to do the right thing to optimize the best outcome, which is limb salvage.