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SPECIAL REPORT: THE GOLDEN HOUR

Saving an amputee: EMS rescuers race the clock after a freak accident

The Honda Accord barreled east on Sunset Point Road at 90 miles per hour. An ambulance crew saw it swerving in and out of traffic, and the driver joked: "There goes our next trauma alert.'' Less than a mile away, Krista Hyde sat outside chatting with a friend, smoking a Parliament Light. "The hugest boom I've ever heard'' sent her running toward the road. In the early morning darkness, she saw the Honda "teeter-tottering" down the sidewalk, first on its two left wheels and then on its two right. It smashed through a concrete mailbox and knocked down two power poles, then went airborne, spewing sparks before flipping into a wooded lot between two homes. Hyde ran toward the battered car and called 911 on her cellphone. As she talked to the dispatcher, someone got out of the car and ran. Seconds later, Hyde heard a woman scream. She ran back up Main Street toward McMullen-Booth Road and found the woman kneeling next to an injured man. He lay on his left side, curled in a fetal position. The woman rubbed his head and told him he would be okay. "I just looked down,'' Hyde said, "and I saw this dark puddle of blood and white intestines."

• • •

Andrew Hall, 19, had graduated from Hudson High in Pasco County the previous spring and was thinking about going to nursing school. For now, he was working at a call center and picking up shifts at a Clearwater restaurant. Hall had cerebral palsy and as a boy wore leg braces and sometimes needed a walker or a wheelchair. But the determined young man had devoted much of his life to strengthening his muscles so he could walk without assistance. On the morning of April 20, he was standing outside his apartment, waiting for a friend. Then came the car and the noise and the horrible impact. At 1:03 a.m. Krista Hyde dialed 911, and the clock started ticking on Andrew Hall's Golden Hour.

1:03 a.m.

The "Golden Hour'' defines the crucial link between speed and survival. The sooner a badly injured patient gets to a trauma center, the better.

The concept is based on data compiled by the French military in World War I. The late R Adams Cowley, a U.S. Army surgeon who founded the nation's first civilian shock trauma unit, turned it into a guiding principle of emergency medicine.

"There is a Golden Hour between life and death,'' Cowley said. "If you are critically injured, you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later — but something has happened in your body that is irreparable."

In Hall's case, it would take four medics just to keep him from dying right there on the sidewalk. But even as rescuers proceeded methodically through their assigned tasks, not one of them thought he stood a chance.

• • •

Deputy Chief Tom Dundon was on duty at Fire Station 52 in downtown Safety Harbor, seven-tenths of a mile from the scene. Dispatch said there had been a vehicle crash and someone had been ejected.

Dundon hopped into his Suburban, flicked on the emergency lights and headed west on Main Street. On his way, the call was updated: One patient had an amputated limb.

Approaching Oak Avenue, Dundon found the road blocked by a power pole. The street lights were out, so it was very dark. He got out of his SUV and kept going.

"What am I going to see here?" Dundon thought. "How bad is it?"

He assigned an engine crew to check on the two men from the 2007 Honda. One was trapped.

It was not Dundon's job to treat anyone. It was to evaluate the scene, make sure that it was safe for rescuers to move about — there were live wires down — and to evaluate the victims. Who needed help immediately? Who could wait?

Next, to his left, Dundon came upon a leg. He did not stop. About 24 feet beyond, Hall lay twisted on the sidewalk. His chest rose and fell ever so slightly. He was groaning.

Dundon reached for his radio.

"Command to dispatch. Trauma alert. One red. Air transport upgrade."

1:10 a.m.

The call that sent Dundon to the crash scene came as the Sunstar Paramedics ambulance was still heading west on Sunset Point Road, away from Safety Harbor, where the same road is called Main Street. On board, paramedic Damon Butts was about to call in a report about the speeding car, the one about which his partner, EMT Jeremy Tinter, had joked maybe 45 seconds earlier. Before Butts could act, dispatch came on the radio: "Motor vehicle accident with ejection, Oak and Main."

"Dude, that's our car," Butts said.

They turned back and soon came upon a sheriff's deputy with, Butts said, a "ghost-white look on his face."

"There's your patient," said the deputy, pointing. "And there's his leg over there."

• • •

In a macabre sense, Hall caught a break that night.

The crash did not neatly slice off his leg, as if it had been cut with a sharp knife; rather, the impact ripped it from his body. The former would almost certainly have led to massive bleeding from severed arteries and death within minutes.

Some of the time, so would the latter.

But the body has a natural defense in which ripped arteries will close up on their own, stanching the flow of blood.

"The artery . . . has a lining of muscle around it," explained Dr. Nicholas Price, a trauma surgeon at Bayfront Medical Center in St. Petersburg. "When it's torn off completely, it will just constrict down. The body has the ability to do that and it will form a clot, and if the blood pressure is low enough, the clot will hold it for short period of time. So that's why you have to get them to the hospital fast."

This phenomenon, called "vasoconstriction,'' benefited Hall, whose injuries included a torn femoral artery, a major vessel roughly the width of his thumb. And it explains the most surprising fact of the crash scene: Despite Hall's gaping wound, there was less blood than medics expected.

Still, Hall had lost a significant amount. His left leg alone contained maybe a fifth of his total supply. But he was still breathing.

There was still a chance.

1:11 a.m.

The alarm sounded at the Bayflite base at St. Joseph's Hospital in Tampa, awakening paramedic Dean Chester. Next came the voice of a dispatcher from the Bayflite control center atop Bayfront hospital.

"Bayflite 3. Scene call, Safety Harbor. All crews respond."

Chester, flight nurse Candace Bradley and Bayflite pilot Amund Moe jumped from their beds.

"Bayflite 3, all crews copy," Chester responded.

He opened a refrigerator, removed two units of O-negative blood and put them inside a small white Coleman cooler with a red top, the kind you might use to take a six-pack to a Bucs tailgate party.

Chester and the rest of the crew climbed into Bayflite 3, a twin-engine helicopter stuffed with emergency medical gear.

Thirteen minutes of Hall's Golden Hour had elapsed as Bayflite 3 lifted off into the warm spring night.

1:16 a.m.

As the Bayflite crew scrambled, Butts, the Sunstar medic, "heard a loud gasping breath come out of Hall."

This was not Butts' first amputation — he recalls "a couple fingers, a hand, an arm at the elbow and a leg at the knee'' — but it was the worst he had seen "of someone still alive.''

This man, he thought, "shouldn't be alive.''

Butts kept Hall's neck and spine stable while Tinter went to the ambulance to prepare a monitor and an intubation kit.

Safety Harbor Truck 53 arrived from its station 3 1/2 miles north on McMullen-Booth about 1:12 a.m. Among the crew were lead paramedic Mike Pounds and fire EMT Holly Warkenthien, who was driving. She flipped on an emergency spotlight, then went to the ambulance to hang two IV bags filled with sodium chloride solution.

Dundon, the scene commander, walked over to the Truck 53 captain.

"I need Mike here," Dundon said.

Pounds walked up, his airway bag and trauma box in hand. He helped the Sunstar medics roll Hall onto a backboard.

Together they gently lifted him onto a stretcher and wheeled him to the ambulance about 10 feet away.

• • •

Inside, Butts used a bag valve mask to pump oxygen into Hall's lungs as Tinter hooked him up to a monitor.

The medics performed their ABCs:

Make sure the patient's Airway is clear.

Make sure he is Breathing.

Make sure blood is Circulating.

For all of Hall's terrible injuries — and they included far more than the severed leg — the medical equation at this point was simple: keep Hall breathing so his heart would keep pumping and oxygen would continue to flow to his brain.

Hall was breathing, assisted by Butts, so A and B were okay for the moment.

Circulation was the problem. Hall was going into shock, a condition that Dr. Cowley once called "a momentary pause in the act of death."

When someone loses a lot of blood, the body reacts by cutting the supply to the extremities. It sends what blood there is to the brain and other vital organs.

Shock left Hall's skin pale and cool. But it allowed his heart to pump just hard enough to keep his brain alive. Hall's low blood pressure was another reason why he didn't bleed more: His heart wasn't pumping hard enough to push out much blood.

To boost Hall's pressure, Pounds needed the two IV bags Warkenthien had prepared.

Gingerly, he picked up Hall's left arm, which was broken in six places. He used a tourniquet to find a vein, then inserted an IV line. He repeated the process on the right arm.

Tinter took over bagging Hall so Butts could try to get a breathing tube down his throat. Butts placed his thumbs on both sides of Hall's jaw and pressed down. Hall's mouth was clenched so tightly Butts could not get it open.

Butts went back to bagging Hall.

The medics examined the wound that stretched from Hall's groin to the top of his hip and around to his lower back.

"All I can see is a lot of muscle, a lot of tissue," Pounds said. "There was a lot of dirt and leaves on the wound."

Pounds carefully picked out some of the leaves. Normally, he would have tried to clean the wound using a sterile solution. But this risked dilating the torn arteries that had fortuitously closed.

The wound was still just "trickling'' blood "like a really thick Kool-Aid," so Pounds left it as is.

He still needed to bandage the area. He grabbed an absorbent dressing, tucked one end under Hall's buttock and simply laid the rest on top of what remained of Hall's pelvis.

The medics cut off Hall's shirt, looking for other injuries. They checked for a pulse in Hall's right foot to make sure that a major vessel had not broken in the right leg.

Nothing else required immediate attention, but one task remained.

• • •

Pounds turned to Warkenthien.

"Holly, why don't you go get the leg so we can send it with him?"

"As far as our training goes, there was nothing that we were going to do with the leg," Pounds explained later. "Basically we sent it with him to complete the patient and to get it off the scene."

Warkenthien and Tinter walked over to Hall's leg and knelt beside it.

The force of the impact had been so severe that Hall's entire pair of jeans had been pulled from his body and were still on the leg. So was a brown Kenneth Cole dress shoe.

The medics considered how to proceed.

"There was absolutely no form or structure to this leg," Warkenthien said. "It had been devastated."

Warkenthien rolled up the slack in the jeans, tightening the denim firmly around the leg. She then lifted it onto a yellow blanket Tinter had unfolded, the kind used to cover dead bodies at accident scenes. They rolled up the slack in the blanket, pulling it stiff against the leg.

"I dealt with it pretty reverently,'' Warkenthien said, though she knew it would be of no further use to her patient.

Carrying the rolled up blanket with two hands — it was much heavier than she expected — she walked back to the ambulance, past wide-eyed sheriff's deputies. Tinter helped her place the leg on the outside edge of the backboard next to Hall's right leg.

Bayflite was minutes away.

"Back me up,'' Butts said. "We're ready to go."

Rescuers had been working on Hall for 8 1/2 minutes. At 1:20 a.m., the ambulance drove the short distance back to McMullen-Booth, where a Clearwater fire crew had used strobe lights to create a landing zone in the northbound lanes.

1:26 a.m.

Hall was more than a third of the way through his Golden Hour when Bayflite 3 landed.

Chester and Bradley, the Bayflite medics, climbed into the Sunstar ambulance. Five medics now jammed the ambulance bay, all of them attending Hall. Butts described the scene inside as "controlled chaos,'' which raises the question: How did so many people from three different departments coordinate their work?

The short answer, according to Safety Harbor's Dundon: "Repetition and training.''

The basics of trauma treatment don't change much from scene to scene: Stabilize the spine, mind the ABCs, clean and bandage wounds. One step leads almost automatically to the next.

"Formulaic,'' said Dundon, "is how we are. …We try to approach every scene, minor to severe, in the same manner so we don't have to think about it that much. We just know what we have to do."

• • •

"Hey, can you hear me?" Chester, the Bayflite medic, asked Hall.

Hall's eyes were open, but he did not respond.

Trained to deal with horrible sights, emergency responders say they take with them "flash images" of traumatic scenes: the blue lips of a drowned child, the screams of accident victims trapped in burning wreckage.

Chester remembers Hall's eyes.

They were open and "tracking," he said. "I felt bad for this … child with this devastating injury. He was conscious, aware."

Bradley, the Bayflite nurse, gave Hall an amnestic drug, standard in cases of severe trauma.

"(We) didn't want this kid to remember this," Chester said.

Next, Bradley administered a medication that would temporarily paralyze Hall. Its purpose is two-fold: to keep patients from thrashing about and to surrender their breathing to trained professionals.

The medicine relaxed Hall's jaw, which Butts had been unable to pry open. Chester put a tube down Hall's throat, then started pumping oxygen into his lungs.

Drugs administered, it was time to go.

The medics transferred Hall to the helicopter. Despite all their efforts, said Pounds, "I thought I would be reading about him passing away at the hospital.''

When Bayflite 3 took off, Hall's Golden Hour was down to 22 minutes.

1:41 a.m.

Flying south toward St. Petersburg, Chester continued to pump oxygen, while Bradley took the two bags of blood from the Coleman cooler and hooked them up to the IV lines that Pounds had inserted.

The helicopter took 10 minutes to cover the 16 miles from McMullen-Booth to the roof of Bayfront Medical Center.

A Bayflite dispatcher opened the elevator that would take Hall down seven floors to the trauma room, using a key that ensured there would be no stops along the way. Two minutes after landing, Hall was whisked into Trauma Room 1. Dr. Price, the surgeon, was waiting.

The medics had raced the Golden Hour, and with 10 minutes to spare, they had won.

1:53 a.m.

A technologically advanced society had thrown everything it had into the effort to get Hall to Bayfront: an intricate 911 system, a team of skilled medics and technicians, advanced lifesaving equipment, a $4-million helicopter and a $15 Coleman cooler.

But beating the clock did not guarantee Hall's survival. It just improved his odds. In Price's opinion, Hall's were not very good.

Price has been a trauma surgeon for 20 years, and Hall's was "one of the more devastating injuries" he had ever seen.

He gave Hall about a 5 percent chance.

"I thought he'd die on the operating table, that's what I thought," Price said. "When I saw this wound, I knew immediately we had to . . . get control of the hemorrhage because he had torn off his leg and half of his pelvis and muscles and torn all the arteries."

In the trauma room, Price first inserted a larger line into Hall to carry more blood, more quickly.

He removed the dressing that Pounds had applied at the scene.

The IV solution that Pounds had administered and the two units of blood Hall had received on Bayflite had achieved the intended effect. His blood pressure was up.

But now, Price said, "Blood was just pouring out. So I immediately shoved packing in there, just pushed them in and applied pressure."

In the operating room, Price started by clamping off the smaller veins and arteries.

"It's like you follow where the blood's coming from, you know?"

Hall was bleeding heavily deep inside his pelvis.

"He had torn his pelvis, so I picked up the pelvic bone, all the muscle, and it was down deep in a hole, and the blood was just flowing out," Price recalled. "And that's when I realized that we had to do a little more exposure. That was when it was a little hairy."

"Suck here, pull here'' Price ordered emergency technicians, who used a suction device to clear blood from the wound and retractors to pull back damaged tissue. "Give me a clamp.''

Then Price spotted "the big bleeder."

"It was a deep iliac vein — one of his iliacs — or a vein off of his lumbar spine," Price recalled.

He clamped it off. Surgery lasted 90 minutes.

By sunrise, Hall had gone through eight units of blood at Bayfront — plus the two Bradley gave him during the flight. It amounted to a full-body transfusion, the first of two Hall would receive over the next 48 hours.

But Price said the efforts of Butts, Pounds, Chester and all the others had paid off.

"Another 20, 30 minutes, I don't think he would have made it."

Postscript

• Hall spent 34 days in intensive care. He will spend his 20th birthday Thursday at Bayfront, where he is now undergoing physical therapy. He has already endured seven surgeries to repair his shattered pelvis and arm and a dislocated right knee with major tendon damage, clean infections and graft skin at the wound site. In one of his first conversations with family members, he said he plans to walk again with the help of a prosthetic limb.

• The Pinellas County Sheriff's Office criminal investigation continues. The two occupants of the Honda, Joshua West and Douglas Ziegler, refused to tell authorities who was driving that morning. On Aug. 11, the official crash report named West as the driver and estimated he was going 90 mph per hour in a 25 mph zone. Officials have also said West may have been intoxicated. Results from blood tests are pending. No charges have yet been filed. In the meantime, West was sentenced to 13 months in prison for violating his probation on unrelated drug charges. West is the man Krista Hyde saw running from the Honda Accord.

• R Adams Cowley, "the father of trauma medicine,'' is buried at Arlington National Cemetery. A quotation from Abraham Lincoln is inscribed on his grave, and from the past it pays tribute to those who rushed to Hall's aid on April 20:

"Next to creating a life, the finest thing a man can do is save one."

Rita Farlow can be reached at farlow@sptimes.com or (727) 445-4157. Michael A. Moscardini can be reached at mmoscardini@sptimes.com or (727) 445-4151. Douglas A. Clifford can be reached at dclifford@sptimes.com or (727) 445-4177.

Life savers



Damon Butts

23, of Oldsmar; paramedic, 6 months with Sunstar

"I've run a lot of real bad trauma calls but that was probably one of the smoothest running ones I've ever had."

On working the April 20 crash scene



Jeremy Tinter

28, of St. Petersburg; EMT, 2 1/2 years with Sunstar

"When you see something like that, you take a split second to say 'Wow, you know, this is what we have' and then it's just, it's very automatic. You go into what you were trained to do."

On doing his job after discovering that Hall's leg was gone



Tom Dundon

44, of Safety Harbor; deputy chief/shift commander,
23 years with Safety Harbor Fire Department

"If we were betting men, we would have lost some money."

On whether Hall would live



Mike Pounds

39, of, Clearwater; firefighter/paramedic, 14 years with Safety Harbor Fire Department

"It was a great team effort from everyone involved, from Sunstar to us to Bayflite to the ER, the sheriff's department, trauma doctors. … Everything went in his direction."

On what it took to save Hall



Holly Warkenthien

39, of Palm Harbor; firefighter/EMT; 20 years with Safety Harbor Fire Department

"I didn't think it could be reattached … but it still needed to get (to the hospital) in a respectable manner."

On Hall's severed left leg



Dean Chester

44, of East Lake; flight paramedic, 8 years with Bayflite, 25 years with Largo Fire Department

"When we were coming in, we saw the lights and cop cars and ambulances and fire departments all over the place and we knew it was something pretty bad."

On arriving at the crash scene



Candace Bradley

45, of St. Petersburg; flight nurse; 21 years with Bayfront Medical Center, 3 years with Bayflite

"Studies have shown that the patients that will survive an injury, a traumatic injury … are patients that are brought within the first hour of injury to a hospital."

On the Golden Hour



Dr. Nicholas Price

56, of Tampa; trauma surgeon for 20 years, at Bayfront Medical Center since 2006

"He opened his eyes, responded, followed commands the next day and I, I about fainted."

On Hall, the day after the crash

About this story

The Times interviewed every first responder who directly cared for Hall on the morning of April 20 and the surgeon who treated him at Bayfront Medical Center. All spoke after Hall waived, in writing, his right to medical confidentiality.



Asked what he hoped readers would learn from his story, Hall said: "to savor and enjoy … every minute of every day in life … knowing that in a split second you can ... lose a leg, or lose your life. So just grab life by the horns, so to speak, and live life wholeheartedly."



Hall said he was grateful to all those who cared for him the morning of April 20 and over the past four months, as well as those who have sent him cards and held fundraisers in his honor.



"I can't express in words how thankful I am. I really don't take … one ounce of that for granted. I really don't, and I'm so thankful," Hall said.

The rescuers interviewed for this story go by different titles — such as paramedic and EMT — but in this story they are referred to collectively as medics.

Saving an amputee: EMS rescuers race the clock after a freak accident 08/21/09 [Last modified: Monday, August 24, 2009 2:15pm]

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