On Aug. 31, Dan Dillard, pastor of the Grace Reformed Presbyterian Church in Bend, was riding home on his motorcycle on Bear Creek Road when an oncoming car turned without seeing him. The Ford Mustang broadsided Dillard's Harley Davidson, which was traveling about 45 mph at the time. Dillard was thrown off the bike, suffering multiple life-threatening injuries.
Seeing the extent of the injuries, bystanders and local residents knelt beside Dillard and prayed.
Dillard, 60, was taken to St. Charles Bend with slim odds of survival. His case may be one of the more complex cases ever treated at the hospital.
And while he must still make significant progress to survive, his care has been a model of cooperation and coordination among multiple surgeons and specialists, with hundreds of nurses, technicians and support staff, and the use of a cutting-edge medical procedure never before performed in Central Oregon.
“We're not out of the woods yet, but there's a glimmer of light there,” said Dr. Andy Higgins, the surgeon coordinating Dillard's care. “He's given me enough glimmers to keep pushing hard.”
Dillard's wife, Sharon, is an arts and music teacher at Eastmont Community School. She was in the middle of the school's open house when she received call from police chaplain Jim Crowley about the accident. Crowley drove Sharon to the hospital where doctors had a grim prognosis.
“They didn't expect him to make it,” she said. “He had so many wounds. His pelvis was shattered; his aorta had a tear in it.”
He had a fractured neck, a broken clavicle, broken ribs and a punctured lung. His wounds were so extensive he was in danger of bleeding out. At times, the staff couldn't even obtain a blood pressure reading.
“He was bleeding to death,” said Higgins, the surgeon on call that night. “Within the first 24 hours, we completely replaced his blood volume.”
The transfusions stabilized his condition and allowed doctors to take a closer look at his injuries with a CT scan. The scan showed just how badly his pelvis was broken and confirmed the aortic tear that doctors suspected from an initial X-ray.
The aorta is the main artery descending from the heart, supplying blood to the rest of the body. Ruptures, generally occurring in vehicular accidents or falls, are fatal in 75 to 90 percent of cases. In some individuals, however, the tissue surrounding the aorta stays intact, keeping the patient from immediately bleeding to death.
There was no guarantee the rupture would stay that way. An increase in blood pressure or other problems could cause that tissue to give way at any moment. Still, Dillard had more pressing issues that needed to be addressed first.
The CT scan showed the arteries in his pelvis were bleeding heavily. Higgins called in an interventional radiologist, Dr. Pat Brown, to create an artificial blood clot in the arteries. The clot is formed with a gel foam delivered via a guide wire and catheter inserted through other blood vessels and directed to the spot of the bleeding.
But as they were ready to take Dillard in for the procedure, a 45-year-old woman arrived at the hospital with a heart attack requiring a cardiac catheterization to clear the blockage. The same team was required for both procedures, and the woman's case took precedence. So Higgins and the other doctors had to continue to keep Dillard alive as they waited for the cath team to finish.
With the arterial bleeding shut off, doctors then turned to the blood leaking from his damaged veins. Those couldn't be blocked off in the same way, so they took Dillard into surgery to determine what could be done with his open wounds. He had an open fracture, meaning the bone was exposed through the skin, a complication that is fatal in 50 percent of cases. They stopped much of the bleeding but couldn't continue with the operation much longer for fear of complications. They packed the wound tight with gauze and sponges, hoping to create enough pressure to halt the rest of the bleeding.
Within 24 hours, they took Dillard into surgery again, unpacked the gauze and found a new complication. When the pelvis shattered, the pelvic ring broke in two places and a sharp bone spur had shifted position and punctured his bladder. They called in Dr. Brian O'Hollaren, a urologist with Bend Urology, to repair the bladder. Higgins trimmed the shard smooth, and inserted several sheets of a biomedical pig skin to protect the bladder from further damage. It was as much as they could get done at the time.
Recently arrived surgeon
Dillard's aorta was still ruptured, and Higgins called in Dr. Wayne Nelson, a vascular surgeon with Bend Memorial Clinical and medical director of vascular surgery at the hospital. Nelson had arrived in town in July, recruited by both institutions for precisely such cases.
Aortic ruptures have traditionally been repaired with open surgical procedures, where the chest is cut open, the aorta clamped, the damaged portion cut out and replaced with a synthetic graft. Even in ideal situations it's a risky procedure that many patient won't survive.
“In a critically ill patient, that's fatal most of the time,” Nelson said.
In the past, most such patients would be flown to Portland, where if they survived the trip, the rupture could be repaired. Last year alone, St. Charles sent 25 aortic ruptures over the mountains, including eight in January 2012 alone.
Nelson has been fellowship-trained in a new way of repairing damaged aorta, using a wire and mesh stent that can be delivered via a catheter through two small needle holes in the groin, much in same way that cardiologists clear blockage in heart arteries using a balloon catheter.
The procedure, known as thoracic endovascular aortic repair or TEVAR, had never been done in Bend before, but Nelson had done more than 100 in his training at the University of Texas.
He had been called in early on the case, as soon as X-rays suggested Dillard might have an aortic rupture. But the TEVAR procedure requires giving the patient blood thinners, and doctors first had to get Dillard to stop bleeding.
Nelson was able to use the CT scan and ultrasound images to measure the size and position of the rupture and to determine which stent graft would fit best. He performed his calculation, readied the equipment, had his staff on stand-by and waited.
“I was ready to do it as soon as it became the pressing issue,” he said. “So when the time was right, and not a second later, we took him to the operating room.”
Nelson inserted a guidewire into the femoral artery in Dillard's groin.
“I carefully advanced the catheter up into the area where the injury was and we navigated that area and put a wire beyond the injury, so I had a rail or a system to work over that was away from where the injury was,” he said. “So you can imagine that was tenuous.”
Nelson then snaked the stent graft into position and pulled a rip cord on the unit to get it to deploy. When there's a rupture high in the aorta, there's always a danger that the left subclavian artery, which supplies blood to the left arm, can be covered up by the graft. But Nelson was able to deploy the graft in an ideal position, effectively sealing it to the aortic wall, covering the rupture, but maintaining access to the subclavian artery.
Dillard will have to be monitored regularly both over the short term and the long term to make sure the graft remains sealed to the wall and isn't allowing blood to leak between the graft and the aortic wall. While use of such a graft is still relatively new, early results show the procedure has fewer complications and better survival data than open procedures, at least for the short term.
Although the grafts can cost upwards of $20,000, the overall cost of the procedure is lower than open surgery, and in the absence of other problems, results in shorter hospital stays. Nelson has been doing similar non-emergency repairs of aortic aneurysms at the hospital.
After the procedure, Nelson came out and showed Sharon images on his iPhone of her husband's aorta before and after the procedure.
“It looked absolutely perfect,” she said. “He was like a kid in a candy store. He was so excited when he came out and this turned out better than we had hoped for.”
Higgins said an open procedure would have been difficult for Dillard to survive.
“To be able to do that in Central Oregon was great,” he said. “To be able to do that percutaneously (through a needle puncture) was fabulous.”
With the aortic rupture no longer a concern, doctors shifted their focus to the pelvic fracture and the open wound. Dr. Anthony Hinz, an orthopedic surgeon with The Center, was called in to repair the pelvic ring and put the bone shard back in its original position.
“It's pretty hard to move these fragments without anchoring with something like an orthopedic implant,” Hinz said. “The problem with that is it's in the middle of this wound, which has now go some bacteria.”
Dillard had developed a staph infection as well as a vancomycin-resistant enterococci infection, or VRE. The enterococci bacteria are naturally found in the intestinal tract, but some strains can become resistant to vancomycin, a commonly used antibiotic, making them harder to treat.
St. Charles officials say the hospital has had several isolated cases of VRE in the past and have set protocols to isolate the patient and prevent spread to others at the hospital. Those protocols include limiting who can enter the patient's room, requiring gloves and gowns, followed by handwashing, and doing a heavy-duty cleanup of operating rooms after the patient's surgery.
Dillard's strain of VRE is a particularly resistant one, and doctors worried the infection might be too much to overcome. They have had to go in repeatedly to clean out the wound, including cutting away tissue that has died to lack of blood flow.
Hinz won't be able to fix the pelvis with plates and screws until the infection clears.
“I was actually a little bit more concerned the day before that the infection was going to be our demise,” Higgins said Thursday morning. “But last night's appearance down there looked a little better.”
By Thursday, his white blood cell count and temperature had dropped, suggesting the body was making progress against the infection. Higgins said a plastic surgeon, Dr. Adam Angelis, will likely have to move muscle tissue to the wound in the pelvis, after which the fracture can be fixed.
“Then he has a very long road to rehab and recovery,” Higgins said.
Dillard continues to do well, he said, because he was fit and healthy before his accident. Sharon said her husband had gone for a five-hour hike in Smith Rock State Park only the day before. His lungs and kidneys continue to function well, which has been key to keeping Dillard improving.
“If he hadn't been very healthy, I don't think we would be talking now,” Higgins said.
Dillard's has been one of the most complex cases Higgins has seen in nearly 20 years as a surgeon.
“This is probably the most amount of time, energy and work I've devoted to a single individual that I can recall,” he said. It's a case he caught only because he happened to be the surgeon on call the day of the accident. He has been assisted by specialists in critical care, orthopedics, neurology, urology, plastic surgery and radiology, all from different practices across town.
Even Nelson's presence here in Bend was the result of cooperation between BMC and St. Charles, which only a few years ago had been bitter rivals. As part of the contract signed with Nelson, the hospital is building a new hybrid surgical suite that will allow doctors to perform the type of through-the-artery procedures as well as open surgeries in the same room, with state-of-the-art equipment.
According to Karen Doolan, director of cardiovascular services at St. Charles, each year some 300 Central Oregonians have non-emergency vascular procedures done outside of the area. Once the new hybrid operating room is completed in February or March, those cases can be done here.
Hinz said it's not unusual for trauma cases to require the work of a number of different specialists.
“It's hard to have high-speed collisions that don't injure more than one organ system,” he said. “That's the aspect about trauma care that becomes both rewarding and challenging, getting everybody coordinate to have him or her do their part in helping somebody that is critically injured like Mr. Dillard.”
Meanwhile, Sharon Dillard and her 7-year-old son, Joseph, are taking great comfort in the prayers and support of church members here and across the country. A webpage to update friends had nearly 10,000 hits as of Wednesday, many from Presbyterian pastors and congregations that Dillard has reached out to in the past.
“St. Charles has been phenomenal,” Sharon said. “The ICU nurses are so educated and so professional and so caring, it gives me a lot of peace .”