Most physicians will tell you unequivocally that being a doctor isn’t anything like what television or the movies make it out to be. Diagnosing a rare infectious disease is not an everyday occurrence, performing a lifesaving procedure on a stricken colleague is extremely uncommon, and shouting “stat!” will usually elicit a chorus of amused chuckles. Their work, they’ll say, is not valiant or daring or even exciting on most days. In the hospital and at the clinic, they’re just doing what they’re trained to do—and that does not a hero make. After asking some of Denver’s Top Doctors to tell us about their most successful days as physicians, however, we’re inclined to disagree. The men and women of this city’s medical community might not break out the cape often, but when crises do happen, they are ready to save the day.
Coaxing new life while cheating death.
Friday, February 10, 2012, 8 a.m. to 10:10 a.m.
The labor and delivery deck at Saint Joseph’s Hospital in Uptown has long been one of the busiest such services in Denver. Each year, nearly 4,000 infants are born within the walls of the Baby Place, a 14-suite unit designed to feel more like a destination spa than a medical center. Although the slate tile, soft color palette, and wall art set a serene tone, “L&D,” in hospital parlance, is always bustling.
The morning of February 10, 2012, was no different. The typical hum of activity—nurses in blue scrubs flitting between rooms, white-coated doctors reviewing charts in the hallway, the occasional labor pain–induced scream escaping from an open door—met Dr. Joyce Gottesfeld as she came on for her 8 a.m. shift. Like any other day, a roster full of patients in varying stages of labor awaited the obstetrician-gynecologist. Gottesfeld checked the charts of each, including a spritely brown-haired, brown-eyed 33-year-old who was having her first child. C. Smith was only about five centimeters dilated after having been admitted the previous evening to be induced. As Gottesfeld began visiting each of her eight patients that morning, Smith was getting an epidural from the anesthesiologist.
When Gottesfeld finally laid eyes on Smith, her husband, A. Smith, and Smith’s mother, things were looking up. Although the patient mentioned she was uncomfortable and feeling tremendous pressure, Gottesfeld assured her that was good news—Smith was fully dilated and nearly ready to deliver. Except for some minor decelerations in the baby’s heart rate—usually attributed to the epidural—labor was proceeding beautifully. The doctor said she was going to check on another patient while the nurses set up the room and that she would be back shortly.
Gottesfeld could not have known just how quickly she would be paged back to Smith’s suite—or that what would happen next would be unlike anything she’d ever experienced in her 16-year-long career.
10:11 a.m. to 10:30 a.m.
“Down tones” is doctor-speak for when a baby’s heart rate slows dangerously during labor. When that happens—which is not uncommon—the baby isn’t getting enough oxygen. Nurses paged Gottesfeld back to Smith’s suite for that exact reason. Changing the mother’s position or putting her on oxygen can sometimes resolve these decelerations—but in Smith’s case the typical solutions weren’t working. Gottesfeld couldn’t believe it: 10 minutes ago this was an easy delivery in the making; now we’re talking a crash C-section.
At least, that’s what she thought was happening until Smith went pale, said she felt sick, and began to vomit. By the time they got her to the labor and delivery operating room (OR) to do the emergency
C-section, Smith was frothing at the mouth and having a seizure. Seconds later she had no pulse.
There’s a not-so-short list of pregnancy-related conditions that can be life threatening for mom and/or baby: placental abruption, preeclampsia, uterine rupture, postpartum hemorrhage. At the top of the list, though, is a little-understood yet catastrophic complication called amniotic fluid embolus (AFE).
Amniotic fluid embolus occurs when some of the material from the fetus inexplicably enters the maternal bloodstream. Although not completely understood, researchers believe AFE causes two phases of life-threatening complications. In the initial phase, fetal contents enter the mother’s heart and lungs, resulting in obstruction of blood flow into the lungs and problems with oxygen absorption. A reaction similar to anaphylaxis (an allergic reaction) can take place, causing high pressure in the arteries leading to the lungs. Cardiogenic shock, a condition where the heart isn’t strong enough to pump the blood the body needs, can also take place. In the second phase, something called disseminated intravascular coagulation, or DIC, occurs. This complication, which happens in 83 percent of AFE cases, causes the body to consume all of its blood-clotting factors, leading to uncontrollable bleeding.
AFE only occurs in 1 out of 20,000 deliveries (about 200 times annually in the United States), but recent studies suggest at least 30 percent of the time it is fatal for the mother, and only about 15 percent of women who do survive are neurologically intact. Neonatal mortality rates are directly related to how quickly doctors can deliver the baby after the mother goes into cardiac arrest.
Gottesfeld, anesthesiologist Dr. Bruce Lowry, obstetricians Drs. Gerald Zarlengo and Lynette Vialet, and a host of other physicians and nurses knew they had less than five minutes to deliver Smith’s baby. At the same time, they had to save the infant’s mother. A Code Blue had been called over the hospital’s PA system seconds after Smith’s heart stopped. In response, a line of nurses, physician’s assistants, and residents formed to take their turns at two exhausting minutes each of chest compressions before going right back to the end of the queue. Lowry intubated Smith and Gottesfeld began cutting her way into the patient’s uterus. “I can tell you, as a physician, you’re just stunned,” Gottesfeld says. “I was trained for this. I knew what it was. It could’ve been a heart attack or a massive stroke, but it was probably an AFE. And you’re just kind of dazed.”
Less than five minutes later, Gottesfeld delivered a blue and unresponsive nine-pound baby girl, who was immediately intubated. Shortly thereafter, the baby was taken to the neonatal intensive care unit (NICU), where she was placed on a mechanical ventilator and her body temperature cooled to help her brain recover from the lack of oxygen. For the time being, the baby was in serious but stable condition.
The same could not be said of her mother. No one knows why an amniotic fluid embolus happens—there’s no way to predict who might get an AFE—but the doctors at Saint Joseph did know the delivery of the 33-year-old’s baby was only the beginning.
10:31 a.m. until 11:50 a.m.
The next three overhead pages that went out were for a cardiac anesthesiologist, a cardiothoracic surgeon, and a massive blood transfusion protocol. These are not common requests from L&D—so when they do come from the second floor, everyone in the hospital pays attention because it’s clear that something has gone terribly wrong on a floor where things shouldn’t take a tragic turn.
Dr. Peter Hession, a young cardiac anesthesiologist just eight months out of his fellowship, didn’t immediately think AFE when he heard the page he had to respond to. It was high on his list of possible diagnoses, but he’d never actually seen one before.
Fortunately for Smith, Dr. Kevin Miller was more familiar with AFE. A longtime cardiothoracic surgeon, Miller was in the main OR on the first floor just minutes from putting his own patient on bypass when the page for his services squawked overhead. With an anesthetized patient on his table, Miller couldn’t just leave—but when residents from L&D came to beg the doctor to come upstairs, Miller made the decision to leave his patient in the care of other physicians and took some of his team and another heart-lung machine to the second floor.
Saint Joseph’s blood bank received the third call to arms: Smith was going to need a lot of blood and blood products—quickly. The bank readied and sent up eight units of packed red blood cells, and kept them coming.
When Miller got upstairs there were 25 to 30 people in the L&D OR. It was, he thought, a remarkably well-controlled chaos. It had been nearly an hour, but the code team was still in line doing CPR. Although the patient was not responding, doctors were still attempting resuscitation efforts like defibrillation, epinephrine, and amiodarone. Coolers of blood were arriving. People were running back and forth from the OR to the pharmacy and the lab. Hession was getting a transesophageal echocardiogram to confirm the heart was in fact stunned from an AFE and not something else. The patient had begun to bleed from everywhere—the C-section incision, her uterus, the IV sites, her nose, and her mouth. Miller knew he needed to get the woman hooked up to the heart-lung machine posthaste.
To do that, Miller would normally attach the machine through a patient’s aorta, but that procedure requires a sternotomy—a huge incision in the middle of the chest. Smith was already bleeding too much to handle a major surgery; instead, Miller placed the heart-lung machine tubes, called cannulas, into the femoral artery in her leg.
Miller turned the machine on. After an hour and 15 minutes, the chest compressions finally stopped and the OR went quiet. Smith’s heart and lungs didn’t have to struggle to function any longer—the machine was doing all the work. It would simply take time for the organs to recover on their own. Her out-of-control bleeding was now the primary problem.
Early afternoon through late evening
The normal human body contains a little more than five liters of blood. Smith was bleeding so badly that if doctors and nurses had stopped giving her blood products for even a short amount of time, she would’ve died. But blood is a precious—and limited—resource. The blood bank at Saint Joseph only has about 150 units of blood and 120 units of frozen blood products at any given time. Smith was quickly depleting the hospital’s stores. Doctors needed to slow her bleeding.
Gottesfeld reopened Smith and tried to staunch the bleeding in the uterus; the procedure had little effect. Around 2 p.m., they decided to move her to the intensive care unit (ICU), where they would continue their efforts. But after just minutes there, they knew more aggressive treatment was necessary. They took her to the interventional radiology lab to try a procedure called a uterine artery embolization, which they hoped would lessen her bleeding by manually clogging some of the vessels that go to the uterus.
It appeared to be working. Gottesfeld thought they might have turned the corner—until she looked at Smith’s leg. “I’m the gynecologist, but I don’t think this looks right,” Gottesfeld said to her colleagues. Cold and mottled, the patient’s leg was dying: The large tubes from the heart-lung machine were impeding blood flow in Smith’s small artery.
For the second time that day, Miller was stat paged—this time to the radiology department. “I thought about putting the machine into her other leg,” Miller says, “but I was afraid she was already going to lose the first leg. She was still really bleeding but I knew I had to cut her open; I had to do a sternotomy and connect it to her aorta.”
That became the plan. Miller cracked her sternum and placed the heart-lung machine tubes directly into Smith’s heart. At the same time, Gottesfeld had made the decision to do a hysterectomy, and the vascular surgeons would have to repair the artery in Smith’s leg and do a limb-saving surgery called a fasciotomy. All four surgeries happened simultaneously in Saint Joseph’s main OR. More than once during the approximately seven-hour-long surgery, Gottesfeld brought Smith’s husband into the OR to say goodbye. His wife—no matter what they did and no matter that they’d given her more than 200 units of blood—was still bleeding.
Just after midnight, February 11
After hours in the OR, doctors brought Smith to the ICU. They were still putting in blood as fast as they could, and it was coming back out just as quickly. The key to winning the battle against the bleeding caused by DIC is time. Doctors had to keep Smith supplied with blood until her body began to once again produce its own clotting factors, which would slow—and ultimately stop—the bleeding. But that wasn’t happening yet. Smith had received intermittent anesthesia—she had no conscious awareness of what was happening to need it consistently—and it began to concern Hession that she wasn’t at all responsive. He knew the prognosis was becoming more and more grim. Miller agreed. Doctors once again brought Smith’s husband in to say goodbye.
By 2 a.m., the doctors began to discuss whether they’d reached the point of futile care. “We were burning valuable resources,” Miller says. “The blood bank was calling and saying, ‘We’re down to the last units of platelets in town.’ She had endured more than an hour of CPR. We had no idea if her brain and kidneys and other organs had been damaged. We began to wonder if she was even recoverable.”
Miller went into Smith’s ICU room—they were still giving her blood—and walked around her bed. He examined her. He held her hand. He adjusted one of the tubes.
And then she opened her eyes.
“She looked at me,” Miller says. “I knew then we couldn’t stop. She was there. Her brain was there. I was amazed and encouraged. That’s all that it took.”
Gottesfeld brought Smith’s husband and mother back up to the ICU, this time to say hello.
Over the next several hours, Smith began to equilibrate, her bleeding slowed slightly, and knowing his patient was doing well on the heart-lung machine, Miller finally took a nap.
The next 48 hours
The rest of the day on February 11, Smith was kept under anesthesia and remained on the heart-lung machine, which would give her body time to recover. As the day wore on, she required less and less blood.
The next day, Sunday, Miller saw that Smith’s heart and lungs were recovering. That afternoon, Hession, Miller, and a team of vascular and general surgeons took Smith back to the OR, where they removed the heart-lung machine, stopped some bleeding in her belly, performed a follow-up procedure on her leg, washed the excess blood from her abdomen, and took her back to the ICU. She improved. Her heart and lungs were working on their own. Her kidneys, liver, and intestines were functioning well. She was still sedated and intubated, and she was still getting some of the 270 total units of blood products she’d ultimately receive—but her body was experiencing an extraordinary recovery.
A palpable pulse of energy shook Saint Joseph Hospital on Wednesday when doctors extubated Smith. For six days, everyone who had been involved—directly or indirectly—had been starved for any morsel of information about her progress. The tiniest updates had rippled through the hospital; the possibility that Smith was going to be able to talk was as heartening as finding out days before that her infant daughter had recovered from her nightmarish entry into the world.
Not long after the tube came out of her throat, Smith did indeed begin to talk—and she had a pressing question: “Are we still in network?” In her drug-induced haze, she thought her husband had taken her to a hospital in another city—and she was worried that their insurance would not cover her medical expenses. A sad commentary on the state of America’s health-care system? Maybe. More important, it was a clear sign to the doctors that Smith was neurologically intact.
Then she wanted to know about the baby, who Gottesfeld immediately—and against hospital rules—brought up to see her mother. “I think they could have sold tickets to the one-way show up to the ICU,” A. Smith says. “Our daughter became the princess of Saint Joe’s.”
Fourteen days after the birth of her daughter, Smith left Saint Joseph. She was still nursing major incisions in her abdomen, chest, and leg; she was on an array of antibiotics and painkillers; and she had a newborn to care for at a time when she felt like she might not ever be able to care for herself again.
Time began to heal her physical wounds. Except for a small infection in her leg and some fluid buildup in her pelvic area, Smith had remarkably few complications considering the extent of her medical crisis. The emotional wounds, however, were harder to deal with. Smith and her husband were both struggling—but in different ways.
Smith missed many of her daughter’s “firsts”—her first feeding, her first diaper change, her first noises, her umbilical cord falling off. She couldn’t care for her daughter without help for many months—and when that time did come it was a very dark day for the new mother. “I felt sad and helpless and, most of all, I felt wronged,” she says. “I kept thinking that I’ll never know what it feels like to give birth or hold my newborn child—because I can’t have another child.”
While Smith battled those thoughts, her husband wrestled with something not unlike post-traumatic stress disorder. He had watched his lifeless daughter be delivered and seen his wife nearly die. He made medical decisions he wasn’t prepared for. Then he had to say goodbye to Smith—more than once. And when they finally got home, he had to care for two people instead of one.
By midsummer, though, Smith was well enough for a mini vacation to Crested Butte, where the family took a hike and where the baby sat up by herself for the first time. Smith says she remembers the day later that summer when she told her husband, “I feel strong.”
Today, a year and a half after that fateful February day, the family is doing well. The scars—physical and emotional—are still there, but they’re fading. The memories, however, are vivid. Smith tells the story about the first time she remembers—really remembers—seeing her daughter. Smith was still in the ICU, but she had left her room to have lunch with her husband and the baby. “She was big and beautiful and felt like a little stranger to me,” Smith says. “I remember thinking in that moment, I went through all of this and you look just like your dad.”
The Top Docs
Thoracic and Cardiac Surgery
GeralD V. Zarlengo
Obstetrics and Gynecology
The Widow Maker
A doctor’s heart stops in his own ER.
Enduring an early-morning meeting. Going to the gym. Folding laundry. Taking a shower. These are the little tasks that make up most of our days. We take them for granted because we think we’ll be doing them all over again tomorrow. So, Andy and Kerry Ziller, Denverites who’d been married for 22 years, could’ve been forgiven for their casual approach to a Wednesday morning in April 2012. “I remember we had spent some time online that morning trying to find a replacement for the rubber stopper on our salt shaker,” Andy says. “Really just mundane stuff…until it just came out of the blue.”
And by “it,” he means the pain.
He wasn’t short of breath. The ache was not radiating down his left arm. But located right in the center of his chest was an agonizing spasm. Kerry was upstairs folding laundry, so, thinking it was just a panic attack, Andy tried to relax.
He walked around. He got a drink of water. He laid down.
Kerry isn’t sure why she stopped what she was doing mid-task—she thinks maybe she was hungry and ready to grab lunch up the street at Modmarket—but when she came downstairs she could tell immediately that something was wrong with her 54-year-old husband. He was sweaty and couldn’t get comfortable. “I told him we should just go get it checked out at the ER,” Kerry says. “But I guess I didn’t really think it would be anything because I grabbed a bottle of water, a granola bar, and the New York Times crossword puzzle to have in the waiting room.”
As the Zillers drove north on Colorado Boulevard toward the ER at Rose Medical Center, Andy, who initially said they should just go on to lunch, became less and less reluctant about seeing a doctor. The pain was getting worse. So bad, in fact, that Andy called his friend, emergency room doctor Donald Lefkowits, who was working that day. “I called Don and said, ‘I’m coming in,’?” Andy says. “?‘I think it’s probably just anxiety, but I’m having chest pain.’?”
Rose Medical Center’s ER sees an average of 110 patients each day—but Andy Ziller was no average patient. Andy, or more formally, Dr. Andrew Ziller, had been an ER doc at Rose for the previous 20 years and was the president of the medical staff.
The text from Lefkowits came through to Andy’s iPhone just seconds after they had finished talking. The Zillers were still a mile or two away. It read: Bed 2 is waiting. Just walk right in.
Andy didn’t have to walk very far once Kerry turned into the small ER parking lot: It was a quiet day in the emergency department, so Lefkowits had decided to meet Andy outside. Andy got out of the car and the longtime colleagues entered the ER together. Within minutes, a tech had hooked up the electrocardiogram (EKG) to Andy, who snuck a peek at the reading as it rolled off the machine. Before Lefkowits could look at the EKG himself, Andy knew it was bad.
He had recognized what doctors often call “tombstones”: EKG readings that portend a massive heart attack. Lefkowits told Andy he was calling a cardiac alert—the emergency protocol for managing a heart attack across multiple hospital departments—a fact that made Andy think to himself: You’re not telling me anything I don’t know, and, yeah, you’d better be calling a cardiac alert.
Eight minutes after Andy walked into the ER, his heart stopped.
Although he could barely believe what was happening to his friend, Lefkowits delivered a precordial thump—essentially a carefully aimed blow to the chest—to try to interrupt Andy’s ventricular fibrillation, an abnormal heart rhythm. Then they tried to shock him—but the machine didn’t fire. A tech began CPR while cardiologist Dr. Vijay Subbarao, who had responded to the cardiac alert, connected what ended up being a missing adapter. It took two shocks to convert Andy’s heart back to a normal rhythm. Seeing the alarm on Lefkowits’ face, one of his colleagues offered to intubate Andy. “I could have done it,” Lefkowits says. “I’ve done it a million times but I just kept saying, ‘No way, no way, this can’t be happening.’?”
A coronary angiogram—a test that uses dye and special X-rays to see the heart’s arteries—administered by Subbarao showed that Andy’s heart was experiencing a worst-case scenario. Although there was only one clog in his heart, the left anterior descending artery was completely blocked at the most critical juncture. Most people know this particular occlusion as the “widow maker.”
Using the angiogram as a guide, interventional cardiologist Dr. Michael Wahl threaded a catheter through Andy’s groin and up into his heart, where he expanded a small balloon to open the blockage and then placed a stent to keep the artery open permanently. It had taken less than 45 minutes from “door to balloon,” an important time frame that quantifies how long it takes from the time a patient enters the hospital until the obstruction is opened in the cath lab and blood is flowing. The national standard is 90 minutes or less.
After the procedure, Andy’s heart was weak—only squeezing at a little more than half its typical strength—but it appeared the muscle was mostly undamaged. Once the obstruction was removed, his heart began to recover. That left only one unknown: how Andy’s brain had fared.
To make sure they saved as many brain cells as they could, Dr. Michael Schwartz, the ICU attending, conferenced with Lefkowits and Subbarao to determine if therapeutic hypothermia might be a reasonable course of action. Therapeutic hypothermia—a treatment that brings a patient’s body temperature down to about 91.4 degrees—has been shown to improve neurological outcomes after cardiac arrest. “He was out long enough after he arrested,” Lefkowits explains, “that we all thought hypothermia was warranted. But that was hard for us because it takes 24 hours of keeping a patient sedated, and we just wanted to see Andy wake up and be Andy.”
Watching her husband be “cooled” by a special jacket and be deprived of blankets and clothing was difficult for Kerry. “I just kept asking them if we could at least put a sheet on him,” she says. The answer, of course, was no—but Kerry knew there was a medical method to what seemed like madness. And that was evident Friday morning when doctors allowed Andy to wake up.
“My first conscious thought was that I was at home in bed,” Andy says, “and as I reached out to touch my wife who would normally be sleeping next to me I hit the bar of the hospital bed. And then the memory hit me: Oh yeah, I had a heart attack.”
Andy was still intubated when he first awoke so he couldn’t talk, but he motioned for a piece of paper to write on. The first word he wrote: “Stent?” The second thing he wanted to know was his ejection fraction, which is medical terminology for how well the heart is squeezing blood. And lastly, he wanted someone to call Kerry and tell her that he loved her. “Andy was very dialed in,” Schwartz says. “He was ‘all there,’ and it was very cool to see.”
Two days later, Andy walked out of the hospital through his own ER, having escaped death in the very same building in which he had been born. About six weeks later, he was back at Rose for his normal shifts. Today, the doctor has no lingering effects from the heart attack. “We take great care of everyone,” Schwartz says. “We apply the same level of care to a homeless guy, a board member, or a colleague. But Andy is loved here, and he really did ride on that wave of love.”
The Top Docs
Dr. Andrew Ziller
Dr. Vijay Subbarao
Dr. Donald J. Lefkowits
Dr. Michael D. Schwartz
Critical Care Medicine
Bacteria living in the most innocuous place almost end a young life.
Parents have gut feelings about their kids. They know when the house has suddenly become too quiet. They can hear a middle-of-the-night cry before it comes. And they’re able to tell when what looks like a run-of-the-mill cold is something much more sinister.
Kari and Brian Hinkel experienced what many people call a parent’s intuition this past January 1 when their five-month-old daughter, Keona, seemed crabby, was sleeping more than usual, and wasn’t eating well. To anyone else, these symptoms probably would’ve seemed less than alarming—and Kari admits she initially thought Keona had a head cold that was making her sluggish and making it difficult for her to breathe and breast-feed at the same time. She and Brian tried a few things: They put some saline solution in Keona’s nose, spoon-fed her some milk, and took a warm shower with her to see if the humidity would loosen her congestion. But less than 24 hours after her first symptoms, their daughter seemed to be getting worse. Kari knew something was wrong. The pretty, blue-eyed infant seemed like she wanted to eat, but couldn’t suck hard enough to breast-feed; she was becoming dehydrated; and she could barely keep her eyes open. They went to see the pediatrician, who told them to go to the ER.
At Sky Ridge Medical Center, ER docs asked the Hinkels patient history questions, took a look at Keona, and ran a few tests. They agreed that something wasn’t right, but they weren’t sure what it was. Then, without warning, Keona stopped breathing.
Sky Ridge physicians swiftly intubated the baby and then made the decision to fly her via helicopter to Rocky Mountain Hospital for Children (RMHC) at Presbyterian/St. Luke’s Medical Center in Uptown. In a state of shock, the Hinkels drove from Highlands Ranch to be with Keona in the ICU. Doctors at RMHC began a broad workup on the five-month-old, who was becoming weaker by the hour. Her eyes weren’t opening at all and she wasn’t moving.
Doctors did an EEG and an MRI. They considered poisoning, seizures, and infections. But it wasn’t until one of the RMHC pediatric intensive care physicians, Dr. Jennifer Snow, consulted Dr. Benjamin Ross, a neurologist with special qualifications in child neurology, that a diagnosis began to take shape.
“I brought up infant botulism,” Ross says. “There’s a book of weird, rare diseases that it’s my job to know about—but I’ve actually seen infant botulism before. And this fit.” Common symptoms of this relatively uncommon paralytic illness—it’s seen about 90 times annually in the United States—are constipation, poor feeding, ptosis (eyelid droop), poor muscle tone, and lethargy. Infant botulism is caused when children younger than one consume spores of the botulinum bacterium, which are most often found in poorly oxygenated soil as well as in a household product nearly everyone has in the pantry: honey.
When children and adults get food-borne botulism, the result is usually a bout of unpleasant—but eminently survivable—food poisoning. But when an infant ingests the spores of Clostridium botulinum, the bacteria colonize a baby’s immature large intestine and produce a toxin that blocks the link between nerves and muscles. Essentially, the toxin creates a paralysis that begins at the head and moves its way down the body, sometimes causing babies to stop breathing. The fact that many physicians have never seen a case of infant botulism—which can be a contributing factor in a slow diagnosis—makes this a life-threatening situation.
In Keona’s case, the illness moved quickly—and she was fortunate her parents had followed their instincts. After all, there’s no better place to stop breathing than an emergency room. She was also lucky that Ross had seen infant botulism before. But that didn’t mean Keona would get better right away. Not only is the illness difficult to diagnose, it’s also challenging to confirm—and it’s even trickier to secure the medication needed to treat it.
For this part of the tag-team effort, Ross called upon RMHC infectious disease doctor Wendi Drummond. “It’s not a benign undertaking to diagnose and treat infant botulism,” Drummond says. “The treatment costs $45,000, there’s only one place we can get the antitoxin, and because there is a limited quantity of the medication, we have to be able to reasonably ‘prove’ we have the correct diagnosis before we can secure it.”
Lab results to verify infant botulism can take as long as a week. Clearly, that time frame was not ideal for a five-month-old on life support. She needed the antitoxin as soon as possible. Instead of waiting, Drummond set out to anecdotally confirm that Keona had somehow been exposed to botulism bacteria spores. “The patient history is critical in this situation,” Drummond explains. “I had to interview the baby’s mom.”
That, of course, is not an easy undertaking when a mother is as traumatized as 28-year-old Kari Hinkel had every right to be. But after asking Kari to think about what the family had done in previous weeks; what she had cooked for dinner; and whether she kept honey in the pantry, Drummond thought she had a plausible exposure scenario. The family had recently used honey to sweeten tea and Kari had also used it in a recipe just days before. It was possible Keona had somehow licked an errantly sticky finger.
Dr. Drummond hoped the information would be enough to acquire BabyBIG, the antitoxin, from the only place it was available: the California Department of Public Health Services’ Infant Botulism Treatment and Prevention Program.
After a lot of paperwork and several in-depth phone calls—all of which took her nearly five hours to complete on the morning of January 4—Drummond had guaranteed that Keona would be getting the drug she needed. The medication arrived via commercial jet about seven hours later and was infused into Keona’s IV just two hours after that. Less than 48 hours after receiving BabyBIG, Keona began to move her legs and then her arms.
The Hinkels spent five weeks in the hospital. Keona was on a ventilator for 22 days before her body was strong enough to breathe on its own. The toxin that coursed through her system reverted her muscle tone back to that of a newborn. But after physical therapy, Keona began rolling over, sitting up, and, earlier this summer, crawling. She will celebrate her first birthday this month.
The Top Docs
Dr. Benjamin A. Ross
Dr. Wendi Drummond
Pediatric Infectious Disease
A day at the lake ends at the Denver Clinic for Extremities at Risk.
The Front Range isn’t particularly well-known for its lake culture, but on a sunny day in August 2003, 10-year-old Jaime Culley was enjoying a carefree day on Boyd Lake near Loveland. She, her friend, and Jaime’s dad, who was driving, were zipping across the lake on their Jet Ski, heading back from the lake’s tubing area. It was the quintessential end-of-summer day for a kid who was excited about her upcoming birthday and the first day of sixth grade.
As the trio skimmed the surface, their faces wet from spray, the Jet Ski encountered a heavy wake and a gust of wind. The unexpected jolt caused Jaime to lose her balance, and she quickly found herself taking a swim. Jaime had been carrying the group’s inner tube as they crossed the water. When she fell backward, the tube and the rope attached to it came with her. Jaime’s dad realized his daughter had come off the watercraft and let go of the gas. What none of them comprehended, though, was that Jaime’s hand had become tightly tangled in the rope, which was attached to the Jet Ski at the other end. Before anyone could grasp the situation, the forward momentum of the Jet Ski pulled the rope taut—and with it came Jaime’s left hand, which was completely severed at the wrist.
It was a devastating injury, one that the team of physicians at Loveland’s McKee Medical Center was not equipped to repair. Their recommended course of action was to clean the wound and leave Jaime with a stump. But a nurse had seen a poster for a program she thought might be worth checking into first: the Denver Clinic for Extremities at Risk.
The name is a mouthful, but the Presbyterian/St. Luke’s Medical Center–based team of medical professionals has been managing diseases and conditions that place people at risk of losing a hand, foot, leg, or finger for 27 years. It is one of the few clinics of its kind in the country, and people from all over come to see its doctors for limb-threatening diseases like bone cancer or after accidents involving lawn mowers, chain saws, snowblowers, gas explosions, military injuries, and, like Jaime, ugly encounters with ropes.
Dr. William Brown, a plastic surgeon who’s been with the Extremities at Risk team since 1991, met Jaime shortly after she arrived in Denver via air ambulance. Certified in hand surgery and self-taught in microsurgery, about 30 percent of Brown’s patient load sees him not for cosmetic purposes but for reconstructive procedures. “Jaime was medically stable when she reached us,” Brown says, “but she had a significant injury, a life-changing injury. I was limited in what I could do for her, but I believe any replant you can do in a child is worth doing.” That meant Brown wanted to try to reattach Jaime’s hand. Fortunately, the “part,” as Brown calls it, had not sunk to the bottom of Boyd Lake and had instead remained lodged in the inner tube roping. Jaime’s hand had traveled with her to Denver.
During a six-hour surgery that same day, Brown did what he could for Jaime. He attached bones with pins; he re-established blood flow by repairing arteries and veins; and he hooked up as many tendons and nerves as he could. Although he was doing his best to ensure the operation was successful, Brown knew this would not be Jaime’s only surgery. “She was not ever going to have full range of motion,” Brown says. “But with some tendon transfers and nerve grafts at a later date, I thought we could give her a good helper hand.”
This month marks the 10-year anniversary of that day on the lake for Jaime. In that time she has endured five major surgeries, a handful of smaller procedures, and a lot of physical therapy. Her left hand is not normal, but she has better-than-expected function, which she learned how to use well enough to do all the things she ever wanted to do. Her thumb doesn’t function as well as she’d like; her fingers can’t extend as well as they retract; and she cannot bend them at the outermost knuckles or move them independently. “I never really let it stop me,” she says. “I just kept playing like kids do.”
Of course, Jaime remembers the accident well. She recalls her father holding it together admirably in the moment—flagging down a nearby patrol boat for help—but then falling apart later on. She remembers seeing the mangled mess that was her arm. And she remembers that she didn’t feel much pain. She also remembers exactly what she thought when she first realized her hand was gone. “I was getting ready to go into the sixth grade,” she says, “and I remember immediately worrying about how I was going to have to learn how to write with my right hand because I had been left-handed.”
Today, Jaime calls Brown when she has concerns about her hand. But most of the time, she doesn’t think about it. She’s busy being a psychology student at Colorado State University. She’s considering nursing school after graduation and maybe training to be a flight nurse. “If I could make someone else feel better in a situation similar to mine,” she says, “I think that would feel really good.”
The Top Doc
Dr. William C. Brown
The Power of Observation
With one look, a Denver doc knew this much for sure: His patient needed surgery—immediately.
There’s a grossly callous phrase in medicine that nearly every doctor knows and uses in the company of other doctors: “circling the drain.” Used in context, it means that a patient is rapidly declining and, despite best efforts to save him, he may not live much longer. Sometimes, when the deterioration is related to old age or a longtime terminal illness, the body’s failure to thrive is normal, understandable, and even merciful. But when an otherwise healthy young man looks like he’s circling the drain—and for unknown reasons—that is anything but routine.
Dr. David Longcope, a colon and rectal surgeon at Rose Medical Center, remembers well walking into Jeff Lindquist’s room on March 20, 2008. The 38-year-old Fort Collins resident had just been transferred to Rose via ambulance after spending a week at another Colorado-based medical center. His breathing was rapid and shallow. He was jaundiced. He couldn’t move. He had searing pain in his abdomen. And he was in and out of consciousness.
The doctor had been called in to consult on the patient by colleague Dr. Jonathan P. Fishman, a gastroenterologist who knew a bit more about Lindquist’s case. Normally, Longcope would have spent time taking a patient history, running some tests, and discussing the case in detail with Fishman. Instead, Longcope took one long look and decided Lindquist didn’t have that kind of time. “I essentially had to walk up to him and his family,” Longcope says, “and say, ‘I know you don’t know me, but I need to operate on you. Now.’?”
Until a week before he ended up at Rose Medical Center, Jeff Lindquist had been a relatively active person who liked to play tennis, golf, ski, and goof around with his one-year-old daughter. He’d had some health issues; he was diagnosed with ulcerative colitis—an inflammatory disease of the large intestine—in the mid-’90s and had surgery related to that in 2003. A couple of years later, Lindquist was rediagnosed as actually having Crohn’s disease—not ulcerative colitis—by Fishman. The Denver gastroenterologist had put Lindquist on Remicade, a drug known to help with the symptoms of Crohn’s, which is an inflammation of the gastrointestinal tract that usually affects the small intestine. Lindquist had been doing well on the drug until one morning in March 2008, when the Fort Collins man bent down to pick up his daughter. “If felt like someone stabbed me in my back,” Lindquist says. “By noon that day I was doubled over in pain.” He went to the local urgent care center, where they told him to go to the hospital.
Lindquist says he doesn’t remember much after that. In fact, he has very little memory of the following six weeks. But he knows that he spent a week in the hospital, where doctors had trouble diagnosing his condition and were reluctant to do surgery, before his physician father had him transferred to Rose Medical Center.
Although the memory is hazy, Lindquist says he remembers seeing Fishman and recalls Longcope coming to see him. “I remember Dr. Fishman’s face,” Lindquist says. “He looked very serious. He and Dr. Longcope talked for a few minutes about 10 feet away from my bed. I couldn’t hear them. But then Dr. Longcope came over and said he was going to do surgery. And he was taking me right then.”
Within two hours, Longcope had his patient in the OR and began operating. What he found inside Lindquist was unlike anything he’d seen in 14 years of doing surgery. “There was two feet of black, dead, liquefied bowel,” the doctor says. “I’ve never seen that before, because a person is usually dead before that can happen.”
Longcope vacuumed out the dead intestine—likely the result of the bowel kinking on itself, which was what caused Lindquist’s stabbing pain—doing his best to clean out what he knew could be infection-causing material. He gave Lindquist a temporary small bowel stoma—a procedure in which the remaining healthy bowel is affixed to an incision in the abdomen and a tethered plastic bag serves as a reservoir for waste—which would allow his patient’s gastrointestinal tract to begin to recover. The surgery was successful, but Lindquist spent about a week in the ICU on a bevy of medications meant to stave off infection.
At home, the recovery was slow. Although Lindquist had to be treated for an infection postoperatively, he knows he was lucky. Lucky his dad moved him to Rose and fortunate that Fishman and Longcope were there. “Had I not gotten there when I did,” Lindquist says, “I wouldn’t have lived. Had the doctor waited to do surgery, I wouldn’t have lived.”
Five years later, Lindquist is still dealing with Crohn’s disease, but he is grateful for Longcope’s quick actions. “I think of those doctors a lot,” Lindquist says. “I think of them when I see my scars and when I can go skiing and, most important, when I see my son, who we were able to have because they saved my life.”
The Top Docs
Dr. David C. Longcope
Colon and Rectal Surgery
Dr. Jonathan P. Fishman