The Strength of Rural Health: Kevin’s Story

The story of Kevin’s injury and incredible recovery started with finding the perfect Christmas gift for his wife Andrea. The couple's home in Gunnison was in dire need of new flooring and in October of 2022 Kevin found the perfect flooring at the right price. Kevin tried to work out an installation schedule where the work would happen while Andrea was away – he really wanted to have her walk into a house with brand new floors – but the installers were running ahead of schedule and wanted to move the installation up to November. Kevin shared the great news with Andrea, they started making plans. They decided that Kevin would replace the baseboards and window trim to save them a little money.

On November 19, 2022, Kevin planned to spend the day working on his part of the project, not knowing that in just a few seconds his life was going to change forever. He was using a nail gun to speed up the process and things were going well until the nail gun jammed. Kevin thought the gun was out of nails and turned it around to take a quick look. He had the gun pointed toward him when he heard it go off and felt a puff of air. His first thought was, “Great, it’s working again,” and he reached for the next board. When he did, he felt his shirt stick. There was no pain, but he put the nail gun down and turned around to Andrea. He saw her eyes get big and she told him to get into the car because they were going to the emergency department - now.

Neither of them really understood the severity of what had just happened. They just knew that they needed to get him checked and have a medical professional remove the nail. They walked into the emergency department together. Andrea noted the time - it was 1:19 p.m. - then went to the window and told the unit coordinator what happened. For Kevin and Andrea, that was when things became a bit of a blur.

The emergency department was busy that day. Everyone had their hands full with two patients experiencing mental health crises. The emergency department tech on shift happened to be up near the front window and heard Andrea tell the unit coordinator that Kevin had shot himself in the chest with a nail gun. He very calmly put the procedures into motion that would save Kevin’s life. He got a wheelchair, took Kevin to the trauma bay and called a rapid response.

Amelia, one of the registered nurses working that day, had been supporting a patient who had a minor cut on the hand. When she heard the rapid response called, she stepped away and was the first person to respond. At first, she thought Kevin was having a heart attack, but then she saw the nail that was still in his chest.

Not far behind Amelia were emergency department nurse, Stephanie, and Dr. Megan Trzaskoma, the emergency physician on shift that day. Both had heard Kevin and Andrea tell the unit coordinator that he had a nail in his chest, but neither were expecting it to be as serious as it turned out to be.

The team quickly began assessing Kevin, who was still conscious although he was very lightheaded and starting to fade. Kevin kept telling Stephanie that he was very tired and wanted her to give him something to sleep. They both kept talking to him while they did their work, encouraging him to stay awake. They were struggling to get a blood pressure for him, and he was getting less and less responsive.

Stephanie said that it is unusual for someone to walk in on their own with an injury as severe as Kevin’s, and it changes the experience for the team.

“When dealing with a severe trauma like Kevin’s, it’s almost scarier to watch the person slowly go from walking and talking to unconscious,” Stephanie said.

In a trauma situation, there is a lot that happens at once. The actions of the clinical team involved look like chaos from the outside but are precise and well-organized procedures that the emergency department team move through like clockwork. For the team, things begin with a feeling of that chaos, but they quickly step into a rhythm. For every person in the room that day, Dr. Trzaskoma’s calm presence and incredible leadership was invaluable.

When Dr. Trzaskoma saw that the nurses were struggling to get a blood pressure, she immediately made the call to intubate. Some of the Gunnison Valley Health Paramedics team happened to be in the emergency department when Kevin came in and one of them stepped in to assist and do the intubation procedure. She also used the bedside ultrasound to take a first look at his heart. That was when she saw that the nail had gone all the way through Kevin’s sternum and into the right ventricle of his heart. The situation was incredibly serious, but during the first scan Dr. Trzaskoma didn’t see much fluid around his heart.

For Amelia and Stephanie, Kevin had lost consciousness, and they were unable to find a pulse. Stephanie immediately moved to begin CPR but stopped herself. Kevin still had the nail in his chest, and they wouldn’t be able to follow their typical procedures. Dr. Trzaskoma repeated the ultrasound and saw that things had gotten much worse, very quickly. The nail was causing fluid to collect around Kevin’s heart, which creates pressure, so the heart is unable to beat.

Dr. Trzaskoma knew that they had to drain the fluid and that she needed more resources. She called in the on-call surgeon and anesthesiologist to assist and called for a massive transfusion protocol. While she waited for additional support to arrive, Dr. Trzaskoma started trying to drain fluid from around Kevin’s heart. The team quickly discovered they didn’t have the exact needle they needed, but after some trial and error they were able to remove enough fluid that they found a pulse and it seemed like Kevin was stabilizing.

In the hospital’s lab, Jill was the only one working that Saturday. When the initial rapid response was called, Jill responded and was providing blood, doing all the testing and all the matching that comes with the procedure. When the call was made for the massive transfusion protocol, Jill contacted their pathologist and the lab director. Tina, the Gunnison Valley Health lab director, immediately made her way to the hospital to support Jill and the emergency department team.

At Gunnison Valley Health, the lab maintains a stock of blood and frozen plasma. The stock is larger than you may see at a critical access hospital of the same size but knowing that the Gunnison Valley Health hospital is hours away from the nearest large trauma center, all lab procedures, including the amount of blood on hand, are considered.

Knowing that Kevin needed a level of care beyond what Gunnison Valley Health can provide, the emergency department team had begun the arrangements for a transfer. CareFlight of the Rockies was called and was enroute from Grand Junction. Additionally, Dr. Trzaskoma was in contact with the thoracic surgeon at St. Mary’s Medical Center. The goal was to stabilize Kevin enough to take the flight to St. Mary’s where their surgery team would be waiting.

It didn’t take long after draining some of the fluid for Kevin’s condition to worsen and the fluid to fill back in and for him to become hypotensive. General surgeon, Dr. Andrew Salim, anesthesiologist, Dr. Matt Kaufmann, and nurses from the operating room had arrived and the thoracic surgeon recommended that they do a pericardial window to drain some of the fluid. The procedure involves cutting a small opening in the chest and removing a small part of the sac surrounding the heart so excess fluid can be removed.

Amelia remembers the blood pouring out of Kevin’s chest during the procedure. With Kevin decompensating in front of them, Dr. Trzaskoma and Dr. Salim making the call to perform a thoracotomy to access his chest cavity and heart. The procedure is serious and something that isn’t performed regularly in Gunnison Valley Health’s emergency department; in fact, if one has ever been performed there, it was so long ago that no one can remember.

For Amelia, one of the things that will stay with her forever is that a few days earlier, a group from the emergency department had gotten the thoracotomy kit out and discovered that it needed some repair.

“I don’t remember why we started talking about thoracotomies, but someone said they had never seen the kit,” Amelia said. “We got the kit out and one of the physicians explained how it was used. We also did a little repair to get it in working order and ready in case it was needed. It was a strange coincidence.”

While the emergency department team was opening Kevin’s chest, the lab team was working swiftly to try and keep up with the demand for blood. As the emergency department team kept asking for more and more blood and the lab watched their supply of whole blood dwindle, Jill was thawing frozen plasma.

“The machine used to safely thaw plasma uses hot water,” Jill explained. “The more units you thaw, the slower the process becomes which is incredibly stressful for everyone involved in the care of a trauma patient.”

Jill continued to work on getting Kevin the blood products he needed and fortunately, CareFlight of the Rockies arrived with plasma as well.

When they opened his chest, Dr. Trzaskoma and Dr. Salim worked to remove the nail and stitch the hole, but quickly ran into problems.

As Dr. Salim and the surgical team closed the initial hole, they noticed that he also began to bleed from each needle hole. Kevin was still losing blood, and his persistent bleeding indicated he also needed the coagulation factors in the frozen plasma that would allow him to form clots more normally.

The team was working to repair the damage to his heart all while giving him blood products and continuing resuscitation efforts, hoping they could minimize the damage to his brain and organs. By this time, the team was manually squeezing Kevin’s heart to move the blood through his body. They had to do this frequently enough to keep him alive, but also had to balance that with time needed to work on closing the holes.

“At one point I was massaging his heart and there was no blood in it at all,” Dr. Trzaskoma said. “That’s how severe the blood loss was. We were struggling to give the transfusions fast enough to keep up.”

As the red blood cells and eventually the thawed plasma flowed into Kevin’s veins, the surgical team realized that blood wasn’t the only thing in limited supply. Since elective heart surgeries are not performed at our critical access hospital, the specialized pre-made sutures needed to repair a heart were not stocked and readily available. Instead, between all these resuscitative motions, Dr. Salim had to create his own pledgets. With the plasma transfusions being administered, Dr. Salim was able to successfully use the pledgets to patch the holes.

But even once the holes were physically closed and finally no longer bleeding, Kevin’s massive overall blood loss had taken its toll, leaving him unstable and requiring continued resuscitative efforts.

All this care played out for hours and the team was at the end of what they were able to do for Kevin.

“We couldn’t get him stable enough to make the flight to St. Mary’s,” Dr. Trzaskoma said. “I was getting support from the thoracic surgeon, but we were running out of options.”

When the time came for a call to be made about continuing rescue efforts, Dr. Trzaskoma asked the team and not a single person, including herself, wanted to stop.

“No one wanted to give up, but after several hours we had reached the point where there was very little left for us to try,” Dr. Trzaskoma said. “I talked to the surgeon in Grand Junction again and was given what I knew was the last option before I had to make the call to stop.”

The team did the things suggested by the surgeon at St. Mary’s and that last minute play was the one that finally took. The team got the bleeding under control and stabilized Kevin enough to try the flight to Grand Junction. No one knew if Kevin would survive the trip to St. Mary’s or if his brain function was intact, but it was the only chance he had.

Andrea was waiting with her and Kevin’s kids and the team called her in to see Kevin and say goodbye. When she talked to him and squeezed his hand, the team saw his foot move. There was a palpable wave of relief to see him react. He was not out of the woods by any means, but it was a small bit of hope.

The team quickly jumped back into action to prepare Kevin for the flight to St. Mary’s. The lab was able to provide CareFlight of the Rockies with extra plasma and the team got Kevin on the gurney. The flight would be well over an hour, and no one knew if he would survive the trip.

After hours of care at Gunnison Valley Health, Kevin lifted off with CareFlight of the Rockies and the emergency department team was left to clean up and take care of the next person. They still had the two patients experiencing mental health crises in need of care and others had come through their doors with other serious injuries and illnesses.

“There were many people from different areas of the health system involved in Kevin’s care and the entire team was incredible. Every person involved worked tirelessly to provide the care that Kevin needed, but a lot of the reason that Kevin is alive is because of his strength and constitution,” Dr. Trzaskoma said.

For Andrea, she was left to take the longest drive of her life to meet Kevin at St. Mary's Medical Center. She had no idea what she would find when she arrived, but she knew she had to be there for Kevin.

“I left the hospital before the helicopter took off,” Andrea recalled. “I got to my house to pack a couple of things right as the helicopter flew overhead. I see that helicopter all the time and don’t really notice it. It is so different when you know a person you love is on board and you have no idea if they are still alive. I will never look at that helicopter flying over my house the same way.”

Kevin did survive his flight and the thoracic surgery team at St. Mary’s were able to repair the holes in his heart. Kevin woke up after the surgery but was disoriented in pain and needed to be sedated throughout the night. The next day the team at St. Mary’s was able to extubate and Kevin was alert, talking and had made it through without major damage to his brain and organs.

Kevin’s story is miraculous. It felt like all the pieces aligned perfectly to keep him alive. The team that was there that day were all the right people who had the right skills and made the right calls to keep Kevin alive long enough to get him to the higher level of care that he needed.

Beyond that, Kevin’s story is a story of rural healthcare and its unique strength.

There were nearly 20 people involved in Kevin’s care that day, and those people were supported by colleagues from Gunnison Valley Health, other Western Slope hospitals and local law enforcement. From the mobile crisis clinician who came to support the family; to the paramedics who supported in the emergency department; to the law enforcement officers who arrived in the emergency department to help with the mental health patients; to the lab tech from Montrose Regional Health who drove through a construction zone to deliver more blood products so the Gunnison hospital would be prepared to treat other patients; to the CareFlight crew who were there for hours supporting and waiting for a transfer that may not happen; to the staff at St. Mary’s Medical Center who shared their expertise. All these people came together because a patient and their family needed help. In those moments we are one interconnected rural healthcare team who work together to save lives - that is the strength of rural healthcare.