Luchtmacht

Airman 1st Class Colton Read was in the intensive care unit, unconscious. Jessica Read was on the telephone with a master sergeant from her husband’s unit. She was so upset the senior NCO could barely make out what she was saying. It had something to do with Read’s gallbladder operation. Something had gone horribly wrong, Jessica Read managed to say. The master sergeant rushed to David Grant Medical Center at Travis Air Force Base, Calif. Read had lost almost two-thirds of his blood and his legs were blue. At least a dozen doctors and nurses crowded around him. He received ultrasounds and an angiogram. He was moved from the intensive care unit to a radiology suite, then back to the ICU. Hours went by before Read was transferred to the University of California-Davis Medical Center, some 40 miles north. There, doctors amputated his legs to save his life. “My husband almost died … because someone took eight and a half hours to get him to U.C. Davis,” Jessica Read later told Air Force investigators. “I’d like to see how they would feel if it was their son or their husband or wife because there was no compassion whatsoever.” The investigation Jessica Read was one of 54 witnesses interviewed by the investigators in an effort to detail the events that unfolded July 9, the day that her husband chose to have the laparoscopic surgery so he could deploy. Maj. Gen. Winfield Scott, then commander of the 18th Air Force, which oversees Travis, ordered what is called a commander-directed investigation. A colonel, assisted by a lieutenant colonel and two majors, conducted the investigation in about two weeks, from July 24 to Aug. 6. Lt. Gen. Robert Allardice, the 18th’s current commander, approved the findings Sept. 8 and has determined no disciplinary action or punishment is warranted under the Uniform Code of Military Justice, said Capt. Shilo Weir, a spokeswoman for the command. Weir confirmed the two surgeons involved are still on active duty but would not say if they were still at David Grant or where they might be assigned, citing privacy concerns. Col. Lee Payne, commander of David Grant, defended his staff to investigators. “I am proud of my people, and I am proud of the work that we do here,” he said. “In the middle of this, what is a horrible, horrible outcome for Airman Read and his family, we understand that, but I want, in the aggregate, to show people that this hospital has been, I think, focused in the right direction and we will learn from this and grow from it, but it is part of the whole institution. I don’t think this is a bad institution.” Air Force Times obtained a heavily redacted copy of the investigators’ report through a Freedom of Information Act request. In it are gripping details of what happened to Read from the time he entered pre-op at 6:50 a.m. until he arrived by helicopter at U.C. Davis at 5:17 p.m. The Reads, who now live in San Antonio, received the report in November. Jessica Read made clear in her interview with investigators how angry she is with the surgeons. “Are [the doctors] going to keep their licenses and keep practicing? Whoever made that bonehead decision to keep him there, what’s going to happen?” she said. “It was their pride that kept them from sending him somewhere else because they thought they could fix him … so then they finally send him somewhere else. Somebody’s pride took my husband’s legs.” The couple has hired Darrell Keith, a medical malpractice attorney based in Fort Worth, Texas. Keith did not respond to telephone or e-mail requests for comment. In a December interview, Keith told Air Force Times that he is conducting his own investigation because he “strongly” disagrees with the investigators’ findings. He described the Air Force report as inadequate and incomplete because the interviews with the doctors at David Grant were not detailed and the civilian surgeon at the university hospital was not interviewed. The civilian surgeon declined to be interviewed by the investigators, according to Keith. Read, however, would have turned over his medical records from the university hospital if the investigators had asked for them, Keith said. “The U.C. Davis hospital records relating to Colton are critical to understanding what happened,” Keith said. “It is glaringly incomplete without that investigation. Also, the statements that they took were woefully inadequate of the doctors and health care providers involved [at David Grant] to determine what happened and to determine if there was any criminal misconduct.” The purpose of a commander-directed investigation, Weir said, is to gather, analyze and record relevant information and identify possible problems within a command. “The purpose of this CDI, however, was to collect and present a releasable record [to Airman Read] of the facts surrounding the medical incident for accountability and identification of issues of command concern, not to provide conclusions, opinions or recommendations,” Weir said. “The report illustrates the care that Airman Read received and shows that Air Force medical personnel were consistently engaged in the diagnosis, treatment and medical care of Airman Read from the moment he arrived at [David Grant] to the time he was airlifted to U.C. Davis.” Any conclusions or recommendations would come from three medical investigations, protected by federal law and not for review even to the patient or the doctors, Weir said. The investigations — a root cause analysis, a quality of care review and a medical incident investigation — have been concluded, she said. The operation Read, who analyzed full-motion video from MQ-1 Predators and MQ-9 Reapers flying over Iraq and Afghanistan, decided to follow the advice of Air Force surgeons to have his gallbladder removed to stop his stomach pain. If he didn’t opt for the elective surgery, he wouldn’t be deployed. Then 20, Read went into David Grant early in the morning as an outpatient. In fiscal 2009, the doctors at David Grant — the Air Force’s largest hospital on the West Coast — saw 303,707 outpatients and performed 2,724 surgeries, delivered 503 babies, cared for 5,025 inpatients and treated 21,641 emergency room patients. By 6:50 a.m., Read was being prepped for surgery, one performed through four small tubes or ports inserted into his abdominal wall. Less than two hours later, the surgeons — a male resident with the rank of captain and the female attending staff surgeon with the rank of major — started their work. Their names are redacted in the report. The surgery went wrong immediately. The resident started to insert the first port with a 7-inch surgical tool, called a trocar, by applying “firm and continuous pressure” but did not see or feel the instrument go into the abdominal wall. “I asked if I was applying enough pressure, and [the attending surgeon] said to keep applying firm and gentle pressure and rotate it,” he told investigators. The attending surgeon then became “concerned about how quickly the trocar went into the abdomen and the amount of pressure [the resident surgeon] was applying … and told [him] to stop,” according to the report. She took over and noticed blood in Read’s abdominal cavity, but both doctors noted “no large or sustained accumulation of blood,” the report states. “Both presumed the bleeding was coming from a source somewhere in the connective tissue that attaches the intestines to the abdominal wall.” The attending surgeon continued to look for the source of the bleeding, inserting four more ports into Read’s abdomen. Eight to 10 minutes later, she still could not find a “definitive bleeding source,” according to the report. By this time, the attending surgeon decided to cut open Read to look for the bleeding source and called for additional surgeons and anesthesiologists. As the surgeons worked, the anesthesia staff began pumping blood products, intravenous fluids and medication into Read to stabilize his blood pressure. Read continued to bleed. Staff members rushed to get O-negative blood, the universal donor. They did not know Read’s blood type because blood-typing is not a standard pre-operative test for the laparoscopic gallbladder surgery, according to the report. By this time, Jessica Read returned to the hospital from the base exchange, where she had gone to pass some time. She walked by the operating room on her way from the elevator to the waiting room. “A nurse runs out and was like, ‘We need blood now,’ and she rounds the corner and she says, ‘We can’t wait for that cross type,’” Jessica Read told investigators. A few minutes later, an anesthesiologist found Jessica Read and asked for her husband’s military identification card. “I said, ‘Why do you need his ID card?’ And he said, ‘Well, there was a little problem during the surgery. He lost a little more blood than we thought he would, but everything’s OK,’” Jessica Read said, “because at that point, I started to cry, I was really upset. And he was like, ‘But everything’s OK; he’s doing great, ma’am, everything’s fine. I just need his ID card to see what blood type he is.’” Unlike an older version of the military ID, however, Read’s ID did not include his blood type. The anesthesia staff ended up giving Read 3 liters of IV fluids, three units of packed red blood cells, one unit of fresh frozen plasma and 1 liter of colloid, which is a special IV fluid that contains proteins to help maintain the density of a patient’s blood plasma. The surgeons continued their search for the source of the bleeding. With Read’s abdomen open, they could see a “large contained collection of blood/bleeding located at the back of the abdominal cavity” that indicated injury to an artery or vein, the report states. As described to investigators by one of the doctors, the injury looked like a blood-filled balloon 5 to 7 inches long and 3 to 5 inches wide. Staff members suctioned 2½ liters of blood, about half the body’s blood volume, from Read’s abdomen. As the seconds ticked by, doctors determined the trocar had nicked Read’s aorta, the body’s largest artery. There was a 9- to 11-millimeter laceration to the lower section of the aorta, just above the point where it splits into two common iliac arteries that take blood to the legs. The attending surgeon repaired the aorta with sutures. At 10:42 a.m., more than an hour after the surgery started, the attending surgeon removed the clamp to test her repair and noticed a “little bit” of continued bleeding, according to the report. She added more sutures and noted “measurable blood flow with a pulse in both common iliac arteries,” according to the report. “The repair appeared hemostatic [the bleeding stopped],” the surgeon told investigators. “I opted to leave the patient open … with the intent on bringing him back to the operating room another day to reassess the abdomen, address his gallbladder issues and close him later.” Read’s abdomen was packed with gauze and temporarily sealed with a vacuum dressing. At 11:07 a.m., the surgery finally came to an end. Read had lost an estimated 3½ liters of blood — the average man has about 5 liters of blood — but was in stable condition. After the surgery, a colonel acting as the hospital’s deputy commander told investigators that Read’s surgeon was “clearly, visibly shaken by the events.” “We asked how she was, how the other staff members were and if there was anything that we could do,” the colonel said. The waiting Two doctors went to the waiting room at 11:15 a.m. to update Jessica Read. Back in the operating room, a registered nurse could not find a pulse in Read’s feet and noticed his toes were white. A surgical technician with the rank of staff sergeant examined Read with a Doppler, an instrument that uses high-frequency sound waves to translate blood flow into sound, but also could not detect a pulse in his feet and found them “very cold to touch,” according to the CDI. “When we went to go turn him,” the technician told investigators, “I saw a bruise on the back of his right leg. It was a purplish color, and I had said that it didn’t look right.” Still concerned, the staff sergeant touched Read’s feet again, “then I touched up a little higher to see exactly how cold because it was just weird. But I’ve been in trauma situations overseas and that’s why I did it. And I made the comment that it was unusually cool. … Everyone is a jumbled mess with the exception of a few.” One after another, staff members checked Read’s feet and legs, looking for a pulse. One doctor found a faint pulse in his left foot. Another had trouble finding a pulse in the femoral arteries in the groin area and upper portions of the legs. Even with an ultrasound, the doctors had difficulty finding a pulse. Finally, a staff member found “continuous, non-pulsatile flow” in the femoral arteries with the Doppler. The staff members attributed Read’s weak pulse to the blood loss or the medication to boost his blood pressure. When the attending surgeon returned to the operating room from talking to Jessica Read, “no member of the OR staff told her about a possible change in [Colton Read’s] lower extremity pulse exams,” according to the report. “His whole body was white,” the surgeon said. “And that would have to do with the fact that he had lost an estimated three and a half liters of blood volume, which is almost 60 to 65 percent of his blood volume.” At 11:25 a.m., Read was taken to the intensive care unit in critical but stable condition and Jessica Read was allowed to see him. “I went back and he was asleep,” she told investigators. “He didn’t look great, no one does after surgery, but they assured me everything was OK, and I was like, ‘All right.’” Read’s vital signs improved in the ICU, but staff members there had trouble finding a pulse in his legs, which some described as being “cool, pale and mottled,” the report states. Doctors became concerned there was a complication from the aortic repair and requested a bedside ultrasound for Read. The technical sergeant conducting the exam could not see Read’s aorta or his pelvic and leg arteries because of his open abdomen, so she called on her boss — a female radiologist with the rank of major — for help. When the radiologist arrived, she too could not see the aorta. An exam of his iliac and femoral arteries showed sluggish, low velocity, non-pulsatile flow, suggesting abnormal blood flow in both legs caused by blood clots nearly blocking the arteries and a separation of the layers in the aortic wall that fills with blood and causes a blockage, according to the CDI. “I said, ‘This is totally abnormal,’” the radiologist told investigators. “Your normal blood vessel, when you look at it on ultrasound, the lumen is black. … His vessel is gray. It has little speckles all throughout it.” By 12:30 p.m., the doctor had finished the ultrasound and reported that neither leg appeared to be getting blood. The decision After the radiologist’s pronouncement, the doctors, including Col. (Dr.) Thomas Dye, then the medical surgical operations squadron commander with the 60th Medical Group at David Grant, began debating whether to transfer Read to the university hospital or continue treating him at David Grant. “Ultimately, the group decided that if they could treat [Read] at [David Grant], they would treat him there,” according to the report. The doctors ordered an angiogram, a special X-ray exam that uses dye injected into the arterial system. After being briefed on Read’s condition, the doctor who was going to perform the angiogram suggested moving Read to a hospital with a vascular surgeon on staff. The other doctors countered by requesting the doctor to perform an urgent angiogram to see if the problem was treatable. The doctor agreed. During this time, about 12:45 p.m., doctors brought Read out of sedation to examine him. “He began to move his head, his neck, his arms,” one of the anesthesiologists, a major, told investigators. “I asked him to open his eyes, and although he could not open his eyes, he tried to open his eyes. His eyebrows raised, but his eyelids did not open.” Read could move his arms but couldn’t squeeze the doctor’s hands or hold up one or two fingers, the doctor said. “We asked him to move his legs and his feet and his toes. He didn’t. We gave him a painful stimulus to his foot to see if he would move his toe. He did not, either of his feet or his legs,” the anesthesiologist told investigators. Jessica Read too had noticed her husband’s feet looked blue but didn’t receive any information from doctors. “Everyone was just kind of not telling me what was going on, like you kind of felt like there was something going on because there were so many people in there [in his room] but no one had said anything,” she said. At 1:20 p.m., staff members took Read for the angiogram. Again, two nurses in the radiology suite could not detect a pulse in Read’s feet and found his legs cold to the touch. The two doctors who conducted the angiogram confirmed the nurses’ findings. One of the doctors noted discoloration in both legs with a mottled appearance below the knees, “a definite demarcation,” according to the CDI. The angiogram found blood flowing into the left leg but not into the right leg and possible narrowing of the aorta or a clot near where the attending surgeon closed the artery. The doctor, however, could not provide a definitive diagnosis, according to the CDI. Again, the question of whether to transfer Read came up. One doctor told investigators she believed Read needed a vascular surgeon, a specialist that David Grant didn’t have at the time. Another doctor lobbied for Read to stay at the Air Force hospital if doctors there could treat him. An anesthesiologist assigned to Travis who also worked at the university hospital told investigators “there was a discussion about whether or not this was a fixable problem that we could do here [and] … someone said that they thought that maybe it was an aortic dissection, another person said ‘No, I don’t think that that is what we are really dealing with here, and if this is fixable we should go into the operating room and fix it now.’” Three doctors who overheard the discussion told investigators “it appears there was a disagreement” between at least two of the doctors about the next course of action for Read. By this time, more than four hours had passed since the resident nicked Read’s aorta. At 2:30 p.m., the doctors finally decided to move Read, setting off a flurry of activity to arrange for air ambulance and a bed and a doctor at the university hospital. The transfer Jessica Read learned about the transfer 15 minutes after the decision was made. Accompanying her was the master sergeant whom she had called and other members of her husband’s unit, the 9th Intelligence Squadron at Beale Air Force Base, Calif. According to a second lieutenant with the 9th, doctors told Jessica Read that a patient could lose his limbs if he goes without blood flow for about six hours, but they “were not concerned because [Read] had some blood flow so he had more than six hours.” When Jessica Read asked how long it would take to move her husband, doctors told her it was a 20-minute flight and a helicopter was on its way. “Col. Dye spoke with Jessica, apologizing for what had happened,” the second lieutenant told investigators. “He said they were doing what they could to correct the situation. He was very nice, however avoided answering any questions. It was obvious he did not know the full extent or story of what had happened and he did not want to comment on anything he was not sure of. He was mainly there, I think, to show his concern.” At 3:36 p.m., the helicopter and the aircrew began preparing to move Read, who was still in critical condition. Jessica Read and the master sergeant started driving to the university hospital. At 5 p.m., David Grant received a call from U.C. Davis: “The doctor is here waiting. Where is he?” The helicopter departed at 5:01 p.m. and landed 16 minutes later. After the civilian doctor assessed Read, he went to talk with Jessica Read. He was blunt, describing Read as “a very sick boy.” The doctor “plainly told me things don’t look good, and he was most likely not going to survive the surgery,” Jessica Read told investigators. “He said, ‘People don’t survive this.’” The master sergeant told investigators that he was shocked when he heard the doctor’s words. “Nobody gave any impression of exactly how sick Colton was at that point,” he told investigators. “There was never any sense of urgency, never any sense of ‘Hey, this guy might lose his legs or his life.’ That never came into anybody’s mindset until we got to U.C. Davis and we actually found out the truth.” Read went into surgery again. The university doctors repaired his aorta and restored blood flow to his legs. Under the pressure of the returning blood, Read’s legs swelled and circulation stopped at his knees because the tissue below had already died. At 2 a.m. July 10, doctors delivered somber news to Jessica Read. “They came out and said they were going to have to remove the bottom portion of his right leg, and it was removed by 2:45,” she told investigators. “He had a drain on the left leg and then Friday evening is when they took his left leg.” Now, Read’s left leg ends above the knee and his right leg at mid-thigh. He is still in the Air Force, promoted to senior airman in December. The service will not make any decision on Read's status until he finishes his recovery and rehabilitation at Brooke Army Medical Center in San Antonio, an Air Force spokeswoman told Air Force Times shortly after Read lost his legs. Jessica Read told investigators she often thinks about what she could have done differently. “The first red flag should have been when [the doctor] had told Colton … ‘You might be here overnight, you could be here as long as five days if I cut the wrong thing.’ That should have been my first red flag.” Read the entire report (55 pages)