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bobdina
07-27-2009, 07:40 PM
Airman fights for job after surgery mishap

By Michael Hoffman - Staff writer
Posted : Monday Jul 27, 2009 15:40:44 EDT

Airman 1st Class Colton Read looked up from his hospital bed into the face of his wife. A tube down his throat kept him from talking.

Fighting back tears, Jessica Read told her 20-year-old husband that doctors had amputated his right leg above the knee and now they needed to take his left leg, too, to save his life. And all because of a mistake during his gallbladder surgery.

Read’s lips turned white. He started to cry. He reached for a pen and paper on the tray in front of him.

“AF???” he wrote.

Airman 1st Class Colton Read, whose bicep is tattooed with the Air Force logo, wanted to know if he could stay in the service he’d wanted to join since boyhood.

“He told me that after 9/11 that this is what he wanted to do,” Jessica Read recalled. “When we are at a baseball game or an Air Force event and the national anthem plays or a flyover occurs, he says he gets chills every time.”

The Air Force that Read loves, and graduated high school early to join, had nearly killed him — and his first concern was whether it would keep him.

Now, the service is trying to find out what went wrong. Four investigations are underway. Air Force Chief of Staff Gen. Norton Schwartz is receiving updates on Read. A two-star general flew to visit the airman and his family in the hospital.

Air Force Secretary Michael Donley sent his thoughts and prayers to the family and pledged the service will make sure Read “receives the necessary medical care and that he and his family receive the services and support they require throughout the recovery process and beyond.”
The fateful day

Read was nervous before he drove with his wife to David Grant Medical Center at Travis Air Force Base, Calif., to have the laparoscopic gallbladder surgery. Two Air Force doctors had recommended the elective surgery to stop the stomach pain Read was suffering. And if he didn’t opt for the elective surgery, he wouldn’t be deployed.

Read did what all good sons do: He called his mom for advice.

“I said, ‘Don’t be nervous. It is routine. They go in — snip, snip — and usually you go home the same day. You don’t want a diseased organ in your body. It will run you down,’” recalled Shelley Miller-Read, who lives in Ohio. “He said ‘OK,’ went back to the doctor and got it scheduled.”

Read was wheeled into the operating room at 9 a.m. July 9. An hour later, Jessica Read saw a nurse run out: “We need blood, now.”

Jessica Read recalled what she says she was told: A resident had punctured Read’s aortic artery, which is near the gallbladder, with one of four ports that had been inserted into his abdomen. The resident hadn’t even removed the gallbladder. The resident and the chief surgeon, Maj. Kullada Pichakron, who was observing, raced to clamp his artery and sew it up in time to save his life. At 11 a.m., Pichakron brought Jessica Read into the operating room to explain that Read was alive but the artery was leaking. A vascular specialist was needed to properly repair the valve, but the specialist at David Grant had separated from the Air Force eight days earlier. The replacement wasn’t scheduled to arrive until Aug. 5.

Dr. Michael Hines, Jessica Read’s uncle who is a surgeon in Texas, credited the doctors with saving Read’s life after the aorta was punctured.

“A mistake was made, but it is a tribute to those doctors that Colton is still alive,” Hines said.

During the discussion, Jessica Read looked down at her husband’s feet. They were blue

“They rushed me out of the operating room after I noticed,” she said.

The two main arteries carrying blood to Read’s legs were clogged with clotted blood. As time ticked by, the tissue and muscles in Read’s legs began to die.

“Anytime you lose blood supply to any tissue in the body, that tissue will die,” said Dr. Tim Gardner, a heart surgeon and former president of the American Heart Association. “Once blood is blocked from the legs, the legs go pretty fast.”

Jessica Read said that at 2:30 p.m., Pichakron and two unidentified medical center officials came to tell her they decided to transfer her husband by helicopter to University of California Davis Medical Center, some 40 miles north.

The three explained Read’s legs could go without blood six hours before being permanently damaged. More than five hours had already passed. And because of unexplained delays in transportation, it would be four more hours before the emergency surgery would be conducted.

Hines questioned why Read’s doctors didn’t do more to monitor the circulation to Read’s legs.

“Not having blood flow to your legs for nine hours is like having a truck lie on top of your legs for nine hours,” Hines said. “They are going to die.”

The helicopter was scheduled to take off 20 minutes after the conversation. Medical personnel, though, didn’t carry Read onto the helicopter for nearly two hours, at 4:23 p.m.

Neither Jessica Read nor the rest of Read’s family has received an explanation from the Air Force why it took three hours to transport Read to UC Davis.

“It almost feels to me that my husband’s life was not important to them because why did it take so long, and why did he arrive here in the condition that he did,” Jessica Read said. “They didn’t feel the urgency, it seemed.”

Air Force officials refused to discuss events leading to the amputation of Read’s legs and declined an Air Force Times request for an interview with Pichakron. The Air Force would confirm only that Pichakron has been a general surgeon at David Grant for the last four years. She had been a resident at the Travis hospital from 2001 to 2005.

Jessica Read arrived at UC Davis shortly after 5:30 p.m., 10 minutes after her husband. She made a 45-minute drive with two members of Read’s unit, the 9th Intelligence Squadron at Beale Air Force Base, Calif. In the 9th Squadron, Read analyzed the full-motion video fed back from MQ-1 Predators and MQ-9 Reapers flying over Iraq and Afghanistan.

“He loved working with the guys who are out there fighting every day,” said Airman 1st Class James Lowe, assigned to the 9th squadron with Read.

As soon as Jessica Read walked into UC Davis, she received a sobering report about her husband’s condition.

“The surgeon was real with us and he said, ‘Things don’t look good,’” Jessica Read recalled. “‘There is a real chance your husband might not survive.’”

Read was immediately rushed into surgery. His aortic artery was repaired and blood flow restored to his legs. But his legs swelled under the pressure of the returning blood, and circulation stopped at his knees because the tissue below had died.

“The only thing that has kept my husband alive is the fact that he is young and that he has a good heart, good lungs and good kidney,” she said.

Doctors removed Read’s right leg above the knee at 2:40 a.m. July 10. By then, Read’s kidneys had started to slow down and were worrying doctors.

When Read woke up that afternoon, his wife told him what had happened. By that time, Read’s parents had flown to California — his mother from Chillicothe, Ohio, outside of Columbus, and his father, Steve Read, from the Dallas-Fort Worth area. They all cried together.

“If you can imagine sitting there not knowing if your child is alive or dead because you don’t know his status. It was the most unbearable thing I have ever went through in my life,” Read-Miller said.

Airman Read’s family then had to explain to him that doctors would amputate his left leg above the knee and more of his right leg up to the thigh.

Said Jessica Read: “I was scared out of my mind. ... I didn’t know whether he was going to come back.”
Fighting the good fight

Almost three weeks after what should have been minor surgery, Read is still fighting for his life. On July 23, he was listed in critical but stable condition. Jessica Read made it clear the possibility that her husband could still die is very real.

As late as July 20, doctors removed even more tissue from Read’s right leg. His left leg has been sealed and is healing. Family members are afraid, though, doctors will have to amputate his right leg up to the hip, ending his chance to walk with prosthetics.

Now, Read’s family is focused solely on Read’s recovery, but they can’t help but think about the mistakes made at David Grant Medical Center.

Air Force policy requires a patient to sign a release form before a resident takes part in a surgery. Jessica Read said she didn’t remember her husband signing that release form.

The Air Force has launched four investigations into Read’s surgery — including three medical investigations and one Command Directed Investigation ordered by 18th Air Force Commander Maj. Gen. Winfield Scott III.

The Air Force did not respond to why Scott ordered the investigation, but 18th Air Force is the war-fighting component of Air Mobility Command and Travis is an AMC base.

The three ongoing medical investigations are a root cause analysis, a quality of care review and a medical incident investigation. The individuals involved in Read’s surgery will have their roles examined in the quality of care review, which is reported to the Air Force Surgeon General’s Quality Office.

The medical incident investigation started July 20 and is done by a team of external experts who will have full access to personnel, records and investigations — ongoing or complete. The final report is briefed to the assistant surgeon general, health care operations.

This is only the second medical incident investigation this year. It is the 118th completed in the Air Force since 1998.

This isn’t the first time David Grant Medical Center has faced scrutiny for a routine surgery gone wrong. Staff Sgt. Dean Witt, 25, died in 2003 during an appendectomy. Another airman, Christopher White, died in 2002 during a shoulder surgery.

Just as with Witt and White, though, Read and his family can’t sue David Grant Medical Center or any of the Air Force doctors for their mistakes.

A 1950 Supreme Court decision, commonly known as the Feres Doctrine, bars military members from suing the government for medical malpractice.

Read’s family contacted Richard Gespirini, a retired Army lawyer, about their case. He had to turn them away.

“Until someone steps up and gets this changed in Congress, it won’t matter how gross the case is,” Gespirini said.

There is such a bill in the House right now — HR 1478, the Carmelo Rodriguez Military Medical Accountability Act of 2009. Sponsored by Rep. Maurice Hinchey, D-N.Y., the bill is named for the Marine sergeant who said military doctors repeatedly misdiagnosed his skin cancer. Rodriguez died in 2006.

HR 1478 could be voted on before the end of July in the House Judiciary Committee, but Gespirini isn’t optimistic.

“I wouldn’t get your hopes up. I have to turn away two or three cases a month,” he said. “But this is such a gross case, I did open a file on this case.”

On July 23, Maj. Gen. Bradley A. Heithold traveled from Lackland Air Force Base, Texas, where he is commander of the Air Force Intelligence, Surveillance and Reconnaissance Agency to UC Davis to visit Read and his family. Gen. Schwartz chose Heithold because Read’s unit falls under his command.

After the visit, Heithold issued a statement.

“I met this young man for the first time just a couple weeks before this incident, when I visited his squadron at Beale AFB. I was impressed then with his professional talent and his contributions to our mission in the fight. But today, sitting with him in the hospital, I was simply humbled by his courage. This young man exemplifies everything our Air Force stands for: integrity, excellence and devotion to service. He makes me incredibly proud to be an Airman.

“As I told Colton and his family today, the Air Force is remaining close at hand as he continues through his medical recovery, rehabilitation and reintegration. We’ve already taken steps to ensure they get the support they need. I also want to thank the communities around Beale and Travis AFBs for all of the support they have provided the Read family.”

Read’s unit has been there to support Jessica Read since the first surgery.

The 9th Intelligence Squadron assigned two family liaisons — Master Sgt. Aaron Dawson and Master Sgt. Larry Hancock — to help the 15 family members who have flown from across the country to be with Read.

Unit members have helped with a multitude of tasks, from making travel arrangements to delivering hot meals every day, Read-Miller said.

“In these tough times we rally together,” said Master Sgt. Carlos Chavez, Read’s first sergeant. “We want to be there to help Read and his family in any way we can.”

Regardless of the investigations’ outcome, Read wants to stay in the Air Force.

Each one of Read’s family member who spoke to Air Force Times related the story of how Read wrote “AF???”

Read’s father doesn’t see why his son couldn’t return to the Air Force.

“He is sitting down when he does his job,” Steve Read said. “He needs his eyes and his brain, and he has both of those.”

The service will not make any decisions on Read’s status until he is through recovery and rehabilitation, said Lt. Col. Jennifer Cassidy, an Air Force spokeswoman.

After that, Read’s case could go before a medical evaluation board that determines an airman’s fitness for duty if he can no longer perform military duties due to an injury of illness.

The medical evaluation board can rule two ways: a return to duty or a referral to a physical evaluation board. The physical evaluation board is made up of personnelists and medics at Air Force Personnel Command in San Antonio. They are the ones who rule if an airman should remain on active duty, be discharged or be medically retired. Any ruling by the Physical Evaluation Board can be appealed by an airman.

If an airman is medically retired, he will then go through the process of determining his disability rating by the Air Force and the Veterans Affairs Department.

Read’s family members said they think he deserves a chance to stay in the Air Force that he graduated from high school early to join.

“He didn’t choose to lose his legs from an Air Force doctor,” Jessica Read said. “So we think he should have the choice if he wants to stay in or not.”


http://www.airforcetimes.com/news/2009/07/airforce_colton_read_072709af/

nastyleg
07-27-2009, 08:03 PM
Fuck me...hope he wins his case and uses the Army as an example that a wounded warrior can go back to active duty and do his job....ie the man who returned to theater with an amputated leg.

Sixx
07-27-2009, 09:34 PM
I don't trust military doctors at all, I still have problems from a hernia operation done by them 10 years ago.