Flatline to Lifeline With Dr. Long

Case Study of a Self-Inflicted Gunshot Wound to the Heart in a Very Rural Setting

This episode includes a discussion of a mathematical description of the severity of the three worst injuries in a trauma patient, the Injury Severity Score, developed by Susan Baker at Johns Hopkins Hospital and Bill Long when he was a fellow at the Maryland Shock Trauma Center in Baltimore. This score was further refined by adding physiological variables such as systolic blood pressure, heart rate, respiratory rate and the Glasgow Coma Score (a neurological scoring system developed in Scotland) to become the Trauma Score (TS). The combination of these two scoring systems became the revised Trauma Score or RTS, from which the patient probability of survival could be calculated. This was the first objective mathematical system that allowed comparison of trauma patient outcomes by trauma centers and by trauma surgeons.

This episode describes a woman in a rural community with only a 24 bed hospital in rural Washington state, no general surgeon living in the community, no cat scanner, a very limited blood bank, and a family practitioner covering the Emergency Room. The path of the bullet went through the right ventricle of her heart and thoracic spinal cord, making her paraplegic. The family practitioner recognized immediately that this patient
was dying, and he needed help. He called the MSTT. We responded and were in the
air within 30 minutes. We asked the family practitioner to move the patient to the operating room and prep her chest and abdomen with an antiseptic solution before we arrived. The patient’s heart stopped beating as we landed in our helicopter. 

What follows is a step-by-step description of the steps we took to revive this patient, stabilize her, and take her to our trauma center. She survived, but remained paraplegic. We did this resuscitative surgery and suture of the two holes in her heart with the family practitioner as my first assistant and the local nurse anesthetist. This was the first time he and his staff had ever seen the chest opened. 

We also discuss how some cardiac surgical principles can be adapted to achieve a satisfactory outcome for this patient in a rural hospital with very limited resources.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.

Follow us on Twitter @DrLongPodcast

Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2025

This episode, packed with an edge-of-your-seat medical scenario and compelling discussions, will encourage you to envision a world where there's always a glimmer of hope, even in the face of failure. Dr. Long brings his 50-year medical journey to life as he delves into the intricacies of board certification and surgical training.

We tackle leadership's pivotal role in high-stress medical situations and the importance of adaptability and teamwork. Dr. Long describes blood components and their vital importance in trauma care, using the real-life case study of a head-on collision victim. Plus, we navigate the complexity of compound fractures, organ failures, and dialysis.

Yet, even with skilled medical professionals and advanced technology, we learn that mistakes can still be made. We dissect an unforgettable case study that tested the team's morale and the delicate balance of life and death. This episode is not just about trauma care, but also about the lessons learned from mistakes and the necessity of experience and training.

Medical Clarifications: 

There are four major components of whole fresh blood: water, red blood cells, plasma containing the bulk of clotting factors, and platelets. Banked blood is stored as components for the following: packed red blood cells, fresh frozen plasma which contains 90% of the clotting factors, and Cryoprecipitate which has 10% of the clotting factors, and lastly platelets, which initiate clotting and maintain clotting.

 Most clotting factors are made in the liver. They are stored as fresh frozen plasma separately in the blood bank. Cryoprecipitate is also stored separately and has a longer shelf life. Platelets, like red blood cells and white blood cells, are made in the bone marrow. Platelets are not frozen and have a time limited shelf life. This is the reason why rural hospitals don’t have platelets packs which could waste because the demand for platelets is very low.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.

Follow us on Twitter @DrLongPodcast

Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2025

Welcome to season two of Flatline to Lifeline!  Join us in this episode for a conversation about the events that changed the way some emergency treatments can be approached, somewhat akin to improving the performance of a football team. We explore the concept of the Golden Hour and how medical teams can prioritize the decisions and surgical and critical care of every critically injured trauma patient. In our experience, these changes resulted in lower mortality rates and provided unexpected survival.

We also discuss a game-changing innovation: The Mobile Surgical Transport Team (MSTT). This episode and the next six episodes show how this innovation brought some of the critical components of an ACSCOT level one trauma center to remote and resource scarce regions in the Pacific NW. Our discussion takes a deep dive into complex challenges of rural trauma surgical care, with limited surgical team experience with complex traumatic injuries, a limited blood bank, and surgical equipment usually not available at many rural hospitals staffed with only an emergency physician and occasionally a general surgeon. 

The Advanced Trauma Life Support Course recommends for rural hospitals and staff to stabilize and transfer to a trauma center. Some critically injured trauma patients cannot be stabilized without more advanced resources and training. This led us to think of ways we could bring some of our level one resources to a rural hospital calling for help and help them to stabilize the patient there before transporting the patient to a trauma center. 

We had to overcome logistical and legal requirements to create this system. Examples include: malpractice Insurance covering our surgeons for care rendered at the rural hospital, medical licenses for the MSTT surgeon operating at a hospital in another state, and emergency surgical privileges to be granted and on file by the rural hospital. All this had to be done before we provided the MSTT service. We credentialed the Emanuel trauma surgeons whose personality, skills, and knowledge would be conducive to working with rural hospital personnel in a collaborative way.

We conclude this episode with a discussion about trauma care provided by surgeons board certified in their specialty, but who may not have the skills and knowledge to perform high quality trauma care with the MSTT and at our trauma center when the patient is transferred there. We focus on the importance of teamwork, especially when all the trauma team members are under severe stress from knowing the patient is in danger of dying if rapid and effective care is not provided competently.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.
You can also learn more about Susan Baker's book, The Injury Fact Book, here.
Follow us on Twitter @DrLongPodcast

Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2025

Motor Vehicle Crash (Pickup Truck vs. Telephone Pole)

This accident happened in the Fall of 1983. At the time of impact, the restrained teenage female driver’s upper torso moved forward and hit the steering wheel. The transformer crashed through the roof, hit her in the mid back, and crushed her liver. She was in shock at the scene from blood loss. EMTs extricated her from the pickup and transported her to Emanuel.

She arrived in the Trauma Operating Room with a barely palpable blood pressure and a distended abdomen. The trauma anesthesiologist intubated her, while we did an exploratory laparotomy as other trauma team members inserted large bore IV catheters and started massive transfusions.

 On opening her abdomen, large amounts of dark blood flowed out the incision. Her liver had large cracks in the hepatic capsule of both the right and left lobes of the liver. Large gauze packs were placed under her liver and around the spleen to temporarily slow the bleeding until we had a chance to assess her injuries. The spleen was uninjured, as were the kidneys. There was little other choice but to reinforce the packs with more packs and compress the liver fragments together. We left her abdominal incision open and created a silo to avoid abdominal compartment syndrome. 

We planned to change the packs every 4 days to see if the liver could recover and “knit” together with time. Her blood pressure stabilized. Her kidney function declined, and we started hemodialysis once the blood urea nitrogen exceeded 80 mg/dl (normal 6-24 mg/dl). Her liver failed as her hepatic enzymes and total bilirubin exceeded 30 mg/dl (normal 1.5).

She became septic. As her jaundice and renal failure progressed, her serial abdominal Cat Scans without contrast showed no normal liver anatomy. Questions arose whether she had a survivable liver injury. A biopsy of her liver revealed “ghost” cells. Another question arose whether she was a candidate for a live transplant? Oregon and Seattle had yet to do a successful adult liver transplant by 1983.

We called Tom Starzl, the pioneer of liver transplant in the USA, and asked his opinion. He said, “Wait it out and she will recover.” And we did and she made a full recovery, got married, and had two kids. This patient displayed the amazing ability of the liver to regenerate, something that few organs can do.

Medical Clarifications:
1. The liver gets 25% of the cardiac output for a patient at rest.
2. The spleen is the organ that makes the most antibodies.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.

Follow us on Twitter @DrLongPodcast

Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2025

Motorcycle Crash in Oregon Coast Mountains Resulting in Paraplegia and Prolonged Immersion in Near Freezing Water and Death From Severe Hypothermia

This young man, riding his motorcycle on trails in the Coastal mountains during the wintertime, lost traction and rolled down a steep hill, hit a tree, became paraplegic, and landed in a mountain lake with ice forming on it. No one witnessed the accident. He was able to grab a tree branch to hold his head and neck above the water level, and to breathe. He was unable to climb out of the water. He had no head injury. 

His friends began to search for him and found him 1.5 hours later. He was unconscious from the cold. They extracted him from the water, found him unresponsive, and started CPR. They called for rescue, but it took another 1.5 hours for EMTs to get him to a clearing to enable Life Flight to land and pick him up to take him to Emanuel Hospital. By the time the patient arrived at Emanuel, the prehospital time was over 4 hours. The patient had no signs of life; his pupils were fixed and dilated, and the ECG was flatline.

The Trauma anesthesiologist intubated his trachea, while the Trauma team and I cannulated his right femoral artery and left femoral vein and initiated CPB. His core body temperature was 24 degrees Centigrade. His arms were folded across his chest, and too stiff to place by his sides.

As he rewarmed with CPB, his pupils began to react, and his ECG showed signs of electrical activity. He had a marked lactic acidosis from anoxia, and high levels of carbon dioxide in the blood, both of which we corrected with CPB. As his core body temperature reached 34 degrees Centigrade and above, he developed bradycardia, then sinus rhythm, and then had a palpable pulse. As we were using CPB, his oxygen saturation monitors were normal. He began to breathe, spontaneously move his upper extremities, and make urine. We rewarmed and supported his cardiopulmonary function to practically normal, before we weaned him from CPB.

Then we took him to the CAT Scanner for a trauma workup and found only the distracted thoracic vertebral fracture/dislocation causing the paraplegia. His lungs were clear, meaning he had not drowned, nor did he have pulmonary contusions. A spine surgeon reduced his fracture dislocation and did a posterior and lateral stabilization.

He awoke and followed commands. After extubation, he was cognitively intact, according to family and friends. We transferred him to the Rehabilitation Institute of Oregon for spinal cord rehab.

Cold water immersion is different from drowning because the patient does not inhale water. However, sudden very cold-water immersion can cause very rapid profound hypothermia and even cardiac arrest. During WW2, American sailors jumping from cargo ships torpedoed by Nazi submarines in the Arctic Ocean had less than six minutes to be rescued before they succumbed from the cold. This patient recovered from cardiac arrest after at least four hours of gradual profound hypothermia.

Medical Clarification:
1. The liver has the largest glycogen stores for an organ in the body.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.

Follow us on Twitter @DrLongPodcast

Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2025

Survival of Salt Water and Sand Aspiration

This middle-aged woman drove her SUV to a beach on the Oregon coast to watch the ocean in a winter storm. She parked her vehicle on the beach, about 100 yards from the surf. A “sneaker” wave, much larger than usual, swept up the beach and washed her under her SUV and trapped her there. She inhaled sand and salt water, causing acute respiratory distress. Bystanders pulled her from underneath her car and tried first aid, to no avail.

 Someone called 911. Rural EMTs arrived 10 min. later, and were unable to insert an airway because of thick sand in her mouth and throat. They transported her to Tillamook General Hospital (TGH) where an emergency physician managed to clear most of the sand from her mouth and throat, and see well enough to insert an endotracheal tube in her trachea, so that she could get assisted breathing and oxygen. 

The weather precluded the Life Flight EMS helicopter from flying to Tillamook to transport her to Portland. TGH loaded her into a land ambulance to take her to Emanuel Hospital, a trip that normally would take about one hour, but under bad weather, the trip would take at least 1.5 hours. En route, her oxygen saturation monitor showed decreasing oxygen saturations, and she became bradycardic. EMTs tried to suction her endotracheal tube (ETT), but sand clogged their suction catheters. The EMTs decided to remove her ETT, and bag valve mask her for the rest of the journey. She lost all vital signs during the last 30 min. of her journey. 

Fortunately, the TGH emergency physician called the Emanuel Hospital trauma surgeon, and told him of what happened. That information enabled the Emanuel Trauma Team to call a Cardiothoracic surgeon, who in turn called in a perfusionist to prime the portable CPB machine. EMTs took her directly to the Trauma operating room, where the trauma anesthesiologist was able to clear sand from her hypopharynx and insert an ETT and start to ventilate her. Concurrently, I was the cardiothoracic surgeon who cannulated left common femoral artery and vein and initiated cardiopulmonary partial bypass, which can provide her needs for organ and tissue perfusion and oxygen, and remove carbon dioxide, even if her lungs were filled with sand and saltwater. 

Once we had her heart working, we were now faced with the problems of how to remove the sand from all her major airways, so that she could breathe with no airway obstructions. I was trained at UCSD Hospital by James Harrell, eminent pulmonologist and bronchoscopist, in both flexible and rigid bronchoscopy. There was too much sand in the trachea to even attempt flexible bronchoscopy, and removal of sand with biopsy forceps. We asked the anesthesiologist to insert a smaller ETT so that I could insert a large rigid bronchoscope and we set up a trachea-bronchial irrigation and suction system to remove the sand in her main airways. We were able to do this.

A portable chest x-ray showed evidence of sand crystals still lining the smaller airways, beyond the reach of the rigid bronchoscope and irrigation system. Worried about sand obstruction of the small airways, we opted to transfer her on CPB to the ICU where we placed her in the prone position and used a percussion device to see if we move sand from the smaller airways to the larger airways where we could suction it out. Two days later, her pulmonary function and oxygen exchange was near normal, and we were able to stop the CPB and extubate her. We discharged her home three days later. She survived neurologically intact and with no pulmonary dysfunction. We searched the medical literature to see if there were similar cases of sand and saltwater aspiration and found none.

To learn more, look for Dr. Long’s upcoming book, Flatline to Lifeline.

Follow us on Twitter @DrLongPodcast

© Flatline to Lifeline 2025

Pediatric Cold Fresh Water Drowning in a Portland Metro Area Case Study Summary

This 4-year-old boy got away from his mother and disappeared near an area where Johnson Creek meanders and drains the foot hills of the Cascade mountains in Clackamas County on its way to the Willamette River. 

This happened during the winter time. While the mother looked frantically for her son, a Metro bus driver in Clackamas County was showing her son the bus route when he noticed a small body floating down the creek. She stopped the bus, and her son pulled the boy, floating face down, from the creek and started CPR while his mother called 911. A land ambulance arrived 10 minutes later, continued CPR, and took the boy directly to the Trauma OR at Emanuel Hospital, where a cardiopulmonary bypass machine and cardiothoracic surgeon were waiting. This boy had no signs of life and his ECG was flatline. The prehospital time was over 1 ½ hours.

Because of previous successful experiences with cold fresh water drowning, we asked the trauma anesthesiologist to intubate the patient while we performed a median sternotomy to cannulate the child’s right atrium and ascending aorta to initiate cardiopulmonary bypass (CPB) with oxygen and to rewarm the patient. After 10 minutes, the boy’s pupils went from fixed and dilated to reactive, and heart began to beat. Gradually his heart recovered and we no longer needed inotropic support. (We don’t use cardiovascular constrictor drugs as the CPB would perfuse all the organs and tissues without them.)   

His abdomen became very taut from all the intraabdominal organ swelling. The anesthesiologist decompressed with a nasogastric tube inserted into the boy’s stomach and removed the swallowed water, while we made an abdominal silo to decompress the abdomen.

He recovered quickly. We closed his chest and weaned him off CPB in 4 hours. We were able to extubate him two days later, as he was breathing spontaneously, moving all limbs, and following simple commands.

We were concerned about anoxic brain damage. We asked a pediatric neurologist to evaluate the boy. We obtained an EEG which showed normal brain activity, and an MRI scan which showed normal brain anatomy. 

After a few more days, before we sent him to pediatric rehabilitation, he was walking in the hallways holding his mother’s hand. One month later, the report came back that physically he had no disabilities and he was only one year behind his peer group intellectually.

Take home message: With the development of portable ECMO and CPB machines that are easily primed and readily available to meet all the patient’s oxygen and perfusion needs, the ability to rapidly provide this support system may change the outcomes of pediatric drowning victims.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.

Follow us on Twitter @DrLongPodcast
Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2025

Rural Trauma Road Traffic Accident in SW Washington State Case Study

This young man was the sole occupant in a car at an intersection, when his car was “t-boned” by another vehicle with a drunk driver. The accident was witnessed by other drivers who called on their cell phones to get help. Rural EMTs are mostly volunteers who work and have to be called in. The EMTs arrive at the scene approximately 30 minutes after the accident. The patient was trapped in his vehicle. The EMTs needed the Jaws of Life to extricate from the vehicle, at least another 30 minutes. Upon extrication, the patient lost pulses and consciousness. The EMTs start a peripheral IV, do CPR and give intravenously cardiac resuscitation drugs, resulting in a slow return of vital signs. They transport the patient to the nearest hospital, Columbia Memorial Hospital (CMH) with surgical capability in Astoria, Oregon, a fifteen minute transport from scene to hospital. 

The patient has another cardiac arrest as he arrives in the emergency department. The surgeon on call happened to be a retired academic general and trauma surgeon who inserts more IVs, gives two units of type specific blood, and inserts two chest tubes, with return of the patient’s vital signs. What to do next?  Stabilize then transfer vs. transfer the patient and stabilize at the trauma center where all advanced technology is immediately at hand? This is a classic example of making decisions that save time to save lives, even though it goes against what is recommended by trauma experts.

This situation now poses a major dilemma. The Advanced Trauma Life Support Course advocated that a rural trauma patient should be stabilized before being transferred. 
For a rural hospital with limited resources, trauma experience, and blood bank, providing immediate surgery is not possible, the OR nursing staff, surgeon, anesthetist has to be called in, causing another 30 minutes (minimum) in delay of operative care. This patient having had two episodes of loss of vital signs, is at risk for having a 3rd episode of loss of vital signs at the rural hospital while waiting for the rural OR team to respond and be ready to do surgery at the rural hospital. The other dilemma is the capability of the rural blood bank and coagulation lab to provide massive transfusion if, upon opening the abdomen, the surgeon encounters massive bleeding from an injury.

This academic surgeon reasoned that the Life Flight helicopter waiting on the rural hospital’s helipad could have this patient on the OR table at Emanuel in less time than the surgeon could start surgery at CMH. He chose the latter, and transferred the patient by helicopter to Emanuel. He took the precaution of sending two units of blood with the transfer team. On arrival in the Trauma OR at Emanuel, the patient had another cardiac arrest, and was revived with massive transfusions of blood and blood products and surgical control (splenectomy) of bleeding from a shattered spleen.

The patient did well, as other less significant injuries were addressed. He was transferred to Rehabilitation, then home. He completed college, went to Seminary School and became a pastor.

Medical Clarifications:
1. On the surfaces of bones (periosteum) are small arteries which contribute to the amount of bleeding which cause a significant amount of blood from fracture sites.
2. For a transfusion consisting of 1 unit of packed red blood cells, 1 unit of fresh frozen plasma, and one liter of saline or Ringers lactate, it gives you a total of two liters.
3. The ACSCOT and ACEP white paper states that resuscitation of blunt trauma patients in cardiac arrest in the prehospital time period is futile, not when the patient arrives in the ED in cardiac arrest.
4. The prehospital time was at least one hour. 

© Flatline to Lifeline 2025

Mt. Adams Rescue

A college climbing party was descending from the summit. An estimated 400 pound boulder broke free from ice and rolled down the mountain striking a 19 y.o. girl on the back, breaking ribs, thoracic spines, and shattering  her pelvis. She was conscious, and moving her limbs. She showed signs of impending shock from blood loss from her injuries 

An emergency physician and his climbing party were ascending the mountain and witnessed the accident. They went over to where she was, and applied first aid and tried to keep her warm with blankets. She needed to be evacuated by air, as an altitude response to altitude of 7,000 feet on a mountain would take too long.

This incident happened on a Sunday. The nearest Army national guard helicopter mountain rescue team was in Yakima 70 miles away. To activate a rescue by a national guard unit on the weekend requires permission from the Pentagon, which gave permission 1 ½ hours later. The time to arrive on scene, hover to load the patient into the helicopter took 2 more hours. Transport to Emanuel hospital took another hour. 

She was essentially dead on arrival at the helipad. No signs of life; pupils fixed and dilated, no respirations, no palpable pulses; flat line on the ECG monitor. 4 ½ hours of prehospital care time.  The trauma team took her directly to the Trauma operating room. The trauma surgeon on call happened to be Jon Hill, a cardiothoracic surgeon and trauma surgeon with experience in profound hypothermia and hemorrhagic shock.

The trauma team stayed with her in the operating room, until her heart regained vigor, her contused lungs were exchanging oxygen for carbon dioxide, her coagulopathy was correcting, and she was no long actively bleeding. At that point Jon transferred her care to WBL, as Jon had multiple elective cardiac surgeries to perform that day. When she was stable enough, we took her to the cat scanner and scanned Brain, Chest, Abdomen, and Pelvis. The brain scan was normal. The chest scan showed a recurrence of a clotted left hemothorax and multiple rib fractures. The pelvic scan showed a shattered pelvis.

She had 1 ½ liters of blood under the skin of her back, where the impact of the boulder caused a shear injury of the back, separating the skin from the muscles of the back. We drained that. Her estimated and measured blood loss from all her injuries were at least 8 gallons of blood (normal adult blood volume is 1.25 gallons). From tissue destruction of her back and buttock muscles, she developed acute renal failure and needed hemodialysis for the next two months. She developed liver failure from the shock and sepsis from a depressed immune system. A repeat Brain scan showed she had several small brain hemorrhages, but none required surgery. 

Over the next 3 to 4 months, we kept the multiple specialists involved in her care, focused and following our protocols. She did not develop antibiotic resistance, because we restricted the antibiotics to two, and did not need nor use an antifungal antibiotic, as was the custom for many critically ill patients in trauma centers.  

Her family lives in the Seattle area. We transferred her to Harborview Medical Center where plastic surgeon Nick Vetter revised the surgical incisions that needed revision.

This young woman beat all the odds against surviving. She made a full recovery from 5 organ failures, got married (Nick Vetter, the Emanuel trauma nurses and I attended her wedding), and she was able to return to snow skiing and has a full time job.

Gradual hypothermia associated with shock from blood loss is somewhat protected from organ failure and cardiac standstill. Gradual rewarming with organ support such as hemodialysis can be lifesaving.

Look for Dr. Long’s upcoming book, Flatline to Lifeline. Follow us on Twitter @DrLongPodcast

© Flatline to Lifeline 2025

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.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.

Follow us on Twitter @DrLongPodcast

Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast
 

© Flatline to Lifeline 2025