Steady travels from the travails of trauma

Trauma and critical-care providers at UCH helped patient regain her life, inch by inch
February 15th, 2017

In the Hollywood fictions often used to portray health care, heroic providers swoop into operating rooms and labor feverishly to rescue patients teetering on the brink of life and death. Hours pass under the lights of the OR. Beads of sweat pop on the furrowed brows of concentrating surgeons. At last, a turning point comes. The patient will make it. The exhausted providers finish up, turning from the operating table to strip off scrubs and stride to the waiting room to give anxious loved ones the news they have been longing for: The patient will live.

The scenario rarely, if ever, captures the reality of medicine and surgery. As the science fiction writer Arthur C. Clarke once put it, “The truth, as always, will be far stranger.”

Trauma providers at UCH saved Virginia Ficco with a sequence of surgeries to repair massive internal injuries she suffered in a 2014 car crash.

The case of Virginia Ficco illustrates the uncertain terrain where the gravely ill and injured and those who care for them dwell. In that world, there is no clearly defined moment at which the patient inches toward life or retreats toward death. Instead, the patient hovers in twilight, while providers make clinical choices, do their best to carry them out, then watch and wait.

“My job is to be constantly worried about the next potentially life-ending problem,” said Erik Peltz, DO, assistant director of Trauma and Acute Care Surgery (TACS) at UCHealth University of Colorado Hospital.

Peltz was one of a team of providers who cared for Ficco after she was involved in an April 2014 car crash. She suffered devastating abdominal injuries coupled with severe cardiac and respiratory problems.

After Ficco arrived at UCH, Peltz put her risk of death at 60 to 70 percent. Far from rescuing her with a single procedure, the trauma team performed a series of surgeries, never certain of success, but hopeful that each individual procedure and subsequent round of critical care would eventually lead to recovery.

“What we did at first was damage control surgery,” Peltz said. “We knew that everything would have to go perfectly for her to have a chance of survival.”

Ruin on the road

Many helping hands pulled Ficco, now 72, from the edge of death. She’d gone with her church group to Chinle, Arizona, and was returning to her home in Ouray, Colorado with a couple who were friends. Snow was falling as they approached Cortez on Highway 160. Ficco, in the backseat, saw a double-cab pickup coming the opposite way, clearly sliding out of control on the snow-covered road.

“I knew we were going to be hit,” she recalled. The pick-up hit the driver’s side of the car and flipped over. Ficco’s seatbelt may have saved her, but it also nearly killed her, as the impact crushed it into her abdomen. She was intermittently conscious as first responders got her out of the car and rushed her to Southwest Memorial Hospital in Cortez. Her husband eventually joined her, along with son Michael from Denver and daughter Marybeth, who flew in from Boston.

Surgeons at Southwest Memorial stabilized Ficco by removing the midsection of her large intestine, repairing lacerations to her small intestine, and reconnecting the remaining sections. Peltz credits the hospital for its initial lifesaving steps, but Ficco’s severe injuries eventually led to cardiac and respiratory issues that the providers there couldn’t stabilize.

Air-lifted to UCH, Ficco arrived in grave condition. On Easter Sunday, a nurse in the Emergency Department noticed redness on the left side of Ficco’s abdomen, asked her daughter about it, and decided to notify the attending physician about the sign of potential infection.

One saving step

The Trauma and Acute Care Surgery and Burn Surgery teams on the helipad at UCH about a year ago.

It was a lifesaving call. Maria Albuja-Cruz, MD, the attending TACS physician, opened Ficco’s abdomen and found the connective repairs to her large intestine had fallen apart. She also had a “significant” hernia, Albuja-Cruz said, with part of the intestine protruding through the abdominal wall that was damaged in the accident. Albuja-Cruz spent the next several hours cleaning out infection, removing Ficco’s colon, as well as several feet of small intestine that had died, and making other repairs that she could.

Albuja-Cruz’s prompt response had saved Ficco’s life. The damage was far too extensive for a single repair, however. Ficco’s abdomen had to remain open, covered with plastic dressing. In intensive care, she breathed through a ventilator. The question was what to do next. The damage to the digestive system wasn’t the only thing to consider. Ficco’s cardiac and respiratory systems were close to failing, and she’d sustained a brain contusion in the crash.

“To sew all of her intestines back together at once would have caused an insult so great that she would not have made it,” Peltz said.

The TACS team decided to give Ficco 24 to 48 hours in critical care. If she survived that, they would perform another surgery to begin the process of stitching her together. If that one went well, they would proceed to the next, closing the wounds sequentially. It was an agonizing approach, but her repair and recovery required small steps. It would be, Peltz told Ficco’s family, “a jagged course.”

The journey back ultimately required five separate surgeries, carefully spaced to allow Ficco time to recover from each one. Peltz and his team used biologic mesh to help the separated muscles and tissues of the abdominal wall heal back together naturally. Ficco was no more than fitfully conscious for much of the ordeal. She learned only later from Marybeth the “tremendous trust” the entire team built from the start with the family.

“From the get-go they were realistic,” Ficco said. “They were neither wildly encouraging nor grimly pessimistic.” As time went on, Ficco’s family began accompanying the provider team on rounds, each time gaining a better understanding of her progress and the challenges that remained.

“We were always treated with dignity and respect,” Ficco said.

A turning point of sorts came after the fourth surgery. During rounds, Ficco recalls the team deciding that things were continuing to go well and discussing what to work on next. Ficco piped up, saying nothing would happen until they figured out how to fix her nausea. For Marybeth, the comment signaled for the first time that her mother had moved out of the shadow between life and death.

“We understood that things were finally going in the right direction,” Ficco said.

Long road back

She eventually moved from the ICU to the inpatient Rehabilitation Medicine Unit at UCH, then on to outpatient physical and occupational therapy. Ficco had been in good physical shape at the time of the accident – a fact that probably helped her to survive – but the process was more arduous than she could have anticipated.

“I’d been told before I left the ICU that I could anticipate two to three days of rehab for every day I spent in the hospital,” Ficco said. “It was really more like two to three weeks for every day.”

She’d lost all function on her left side, but made a trip back to her home in Ouray in August and to Boston in September. “I’m a woman of some determination,” she said, but her body reminded her repeatedly in the months after her discharge that it needed much more time to make up the lost ground.

“If I walked 20 steps, it was a victory,” Ficco said.

She and her husband realized that the injuries made living in Ouray impossible. Marybeth searched the internet for apartments near UCH, which eventually led to one on the edge of the Anschutz Medical Campus. In a strange recrossing of paths, Albuja-Cruz had occupied the unit they moved into.

Ficco speaks at the Jan. 28 Hearts of All Ages event, which raised funds for the trauma and burn teams at UCH. (Photo credit: Brooks Canaday.)

Today, Ficco estimates she’s physically 85 percent of where she’d been before the accident. She still struggles at times with fatigue and balance. She made several trips to the emergency department because of blockages from the colostomy she underwent as part of the intestinal repairs, but an endoscopic procedure at UCH has cleared that up, she said.

Peltz noted that the series of surgeries means that Ficco “will have lifelong anatomic issues,” an appraisal she acknowledges.

“With that amount of injury, my body won’t bounce all the way back,” Ficco said. But a person meeting her for the first time wouldn’t guess how far she’s come since the disaster in 2014. She walks and talks with confidence and says she’s satisfied with the state of her health.

“If I never have another surgery, it’s okay with me,” Ficco said. That’s no reflection on the team at UCH who saved her life, she added.

“I got nothing but amazing individual attention and care,” she said.