Sunday, September 03, 2000

Luck, chance and modern medicine save man


New surgery proves a life-saver

By Tim Bonfield
The Cincinnati Enquirer

        Many west-side residents know Jack Torbeck.

        He was among the builders of Western Bowl in 1958. He and his partners also built more than 3,000 homes over the years, mostly in Delhi and Green townships and west Price Hill.

Jack Torbeck
Jack Torbeck
        But only a few people realize how fortunate the retired builder is to be alive after being severely injured Aug. 9 in a car wreck on Hamilton Avenue in College Hill.

        The broadside impact took a terrible toll on the 72-year-old man. Mr. Torbeck's spleen, liver and lungs were damaged. The crash shattered his ribs and broke his shoulder blade, pelvis and ankle. A blow to the head caused bleeding in his brain.

        Worst of all, the force of the crash was so intense it fractured his aorta, the main blood vessel leading from his heart. More than 80 percent of those who suffer such an injury bleed to death before an ambulance can reach the scene. And nearly 80 percent of those who live long enough to reach a hospital die within 24 hours.

        But Mr. Torbeck survived. Doctors say Mr. Torbeck is alive thanks to luck, medical heroes who recognized the severity of the situation and a piece of experimental medical technology — an aortic stent graft device — that may help other Tristate trauma victims in years to come.

        In fact, doctors at University Hospital say only five other medical centers in the world have reported performing the procedure that saved Mr. Torbeck.

        Here's Mr. Torbeck's story:

        10:55 p.m. Aug 9, College Hill: On his way home to Delhi Township, Mr. Torbeck starts to make a left turn from Hollywood Avenue onto southbound Hamilton Avenue.

        A car driving north on Hamilton slams into the driver's side of Mr. Torbeck's Chevy Blazer. Mr. Torbeck's body is smashed against the crumpling steel, plastic and glass of the SUV's door.

        10:56 p.m.: A 911 call comes via cell phone from a man who was driving north on Hamilton Avenue. “There's a bad accident,” the caller says. “I just pulled up and this guy is bleeding all over the place.”

        11 p.m.: Cincinnati Fire Department Engine 51 is the first of six fire department vehicles, seven Cincinnati police cruisers and at least one police car from North College Hill to arrive.

        Rescue crews find Mr. Torbeck conscious, bleeding and moaning in pain. It takes about 40 minutes for rescuers to cut through the wreckage and get Mr. Torbeck on an ambulance headed for University Hospital.

        The people in the other car,19-year-old Jesse Gatliff of North College Hill and a 17-year-old female passenger, are taken to Mercy Franciscan Hospital-Mount Airy, where they are treated and released.

        11:55 p.m.: The University Hospital trauma team goes to work. About 30 people are involved in performing exams, opening Mr. Torbeck's airway, starting IV medications, taking X-rays and CT scans, connecting him to a ventilator and performing a variety of surgeries.

        A chest X-ray and CT scan reveal the first hints of what turns out to be Mr. Torbeck's most life-threatening injury — a fractured aorta.

        UC trauma doctors see this kind of injury about a dozen times a year, nearly always from crashes. The injury occurs because of the body's structure; the aorta, which can be wider than a garden hose, emerges from the top of the heart then bends like a candy cane to feed the lower parts of the body.

        While the heart and the arched part of the aorta are suspended in the chest loosely enough to move with the impact of a sudden blow, the straight, descending part of the aorta is firmly strapped to tissues along the spine.

        Slam the chest hard enough and the aorta's walls, which are thicker and stiffer than most other blood vessels, can fracture like a bone.

        Without surgery, people with this injury can hang on 36-48 hours. But they can die at any minute.

        At about this point, Dr. Johannigman calls in two specialists: Dr. John Howington, a thoracic surgeon on-duty at the trauma center, and Dr. John Edwards, an on-call vascular surgeon.

        1 a.m., Aug. 10: While the trauma team works on Mr. Torbeck, police re-route traffic, investigating the scene and trying to notify Mr. Torbeck's family.

        :Mr. Torbeck's wife, Mary Claire, isn't home. She's on her way back from a 10-day pilgrimage to Fatima, Portugal, a holy site for Catholics who believe the Virgin Mary appeared there in 1917 and that miracles had been performed there.

        A neighbor tells police Mr. Torbeck's oldest son, John, 46, lives in Covedale. John alerts his brother, Chris, 39, and three sisters, Cathy Ray, 44, Annie Kroth, 41, and Mary Schulcz, 38, all of whom live in Greater Cincinnati.

        As the siblings rush to University Hospital none are aware how important their presence will become.

        7:59 a.m.: It takes several hours in intensive care to get Mr. Torbeck stable enough to survive the next diagnostic step, an angiogram to pinpoint damage to the aorta.

        Standard treatment for a fractured aorta involves opening the chest, clamping off the aorta, then stitching in a length of artificial tubing to replace the damaged section. But doctors agree the surgery is extremely risky for Mr. Torbeck — medical records reveal he barely survived a coronary bypass nearly two years ago.

        Instead, they turn to Dr. Edwards, an expert in placing stents to prop open clogged arteries. Stents eliminate the need for open chest surgery and have become a popular alternative to coronary bypasses, as well as surgery in other parts of the body. But this application is highly experimental.

        The aortic stent graft device, made by a unit of Medtronic Inc., is a self-expanding wire mesh tube covered with a layer of Dacron fabric. The device, under study in a multicenter clinical trial, is designed to push outward with enough force to seal the damaged area and stick to the aorta's walls, so there is no need for sutures.

        UC is not one of the medical centers in Medtronic's trial. But about a month before, Dr. Edwards won compassionate use permission to install an experimental stent in a patient.

        Medtronic generally ships three stents per case, one to fit the estimated diameter of the patient's aorta, plus one bigger and one smaller — just in case.

        One of the devices was a close enough fit for Mr. Torbeck.

        Armed with the knowledge that the procedure is possible, the next step is talking with the family.

        10 a.m.: Doctors show the family images of Mr. Torbeck's damaged aorta and lay out the options.

        Even with the stent approach, the risks are high. Pushing the folded stent into the curved part of the aorta means putting considerable pressure on an already damaged vessel.

        Also, once deployed, the self-expanding stent cannot be retracted or repositioned. This procedure has to work right the first time.

        Because Mr. Torbeck is unconscious, informed consent is required. Mrs. Torbeck can't be reached, so it falls to the children to decide their father's fate.

        Even with the parts on hand and the family's approval, the experimental procedure still requires emergency approval from the U.S. Food and Drug Administration. In a world choked with red tape, this approval is obtained with a single phone call.

        1:50 p.m. The two-hour stent graft procedure begins. A surgical team led by Dr. Edwards inches a catheter carrying the folded stent from Mr. Torbeck's groin to his aorta. The doctors watch their progress through two video monitors.

        When the catheter reaches the critical curve, it gets stuck. The doctors push a little harder. Nothing. The tip is snagged on the back wall of the aorta.

        At this point, the entire surgical team holds its breath. Pushing too hard will cause the catheter to rip through the artery, killing Mr. Torbeck.

        Finally, the device pops free and slides around the curve.

        8 p.m., Cincinnati/Northern Kentucky International Airport: Mary Claire Torbeck is unaware of what is happening to her husband. But she knows something is wrong when her son John is waiting at the gate.

        Seeing her husband in intensive care is a shock. Mr. Torbeck is on a ventilator and is not speaking. The extent of the damage is still not certain.

        Aug. 23: Mr. Torbeck moves to a step-down unit. Even now, he drifts in and out of consciousness. Sometimes he squeezes his wife's hand.

        After days of non-committal comments, Dr. Johannigman is “cautiously optimistic” that Mr. Torbeck will recover. The brain damage appears minimal.

        Aug. 30: Mr. Torbeck's lung strength now accounts for 85 percent of his own breathing, but he remains on a ventilator and semi-conscious from heavy pain medication.

        Doctors still speak about the case with awe.

        “So many things had to go just right,” Dr. Edwards says.

        Sept. 2: Mr. Torbeck is now at Drake Center, a long-term rehabilitation center in Hartwell. At Drake, Mr. Torbeck will be weaned off the ventilator and endure several weeks, perhaps months, of physical rehabilitation.

        “We still have a long road to go. But there will be a complete recovery,” Mrs. Torbeck says.

        Too many coincidences kept her husband alive for Mrs. Torbeck to chalk it up to pure chance.

        She traveled to Fatima to see a place where miracles are believed to have occurred. She wound up coming home to one.

       



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