OUR CARE
Six-year-old shot in the heart defies survival odds
From left to right: Sharnae Phagan, MSN, RN, TNS; Erin Rogala, RN, BSN, CFRN, TCRN, TNS; Marion Henry, MD, MPH; Lindsay Jaeger, MD
There was no advance warning from emergency medical services that a gravely injured child was en route to the University of Chicago Medicine Comer Children’s Hospital emergency department (ED), the only level 1 pediatric trauma center on the South Side of Chicago. A man literally carried the 6-year-old through the front door of the ED, explaining that the boy had been shot inside his home.
The trauma alert page went out, and within minutes dozens of people responded. “When we activate our trauma cascade, people from all disciplines trained at the highest level show up to the trauma bay,” said Alisa McQueen, MD, pediatric emergency physician and Program Director, Pediatric Residency Training. Pediatric emergency physicians and nurses arrived, along with pediatric and adult trauma surgeons, an anesthesiologist, a radiology technician, a pharmacist, the social work team, and chaplains. A child life specialist was also there to coach the child through the emergency medical care to minimize psychological trauma. Also present was a violence recovery specialist to support the boy’s family and connect them with resources to mitigate the effects of the acute stress of a violent injury.
Jerome* had a single gunshot wound to his left upper back. He was barely breathing and in shock, likely due to cardiac tamponade, or blood in the pericardium that prevented his heart from expanding fully and beating properly. The chest X-ray showed a bullet on the right side of his heart and blood in the left chest. The team started a blood transfusion and placed a tube to drain the blood from the left chest. With the child minutes away from death, pediatric surgeon Mark Slidell, MD, MPH, rushed him to the operating room and called the pediatric cardiothoracic surgery team to help, along with a surgeon from the adult trauma surgery team, Andrew Benjamin, MD.
About 20% of trauma patients at Comer Children’s have been injured by a gun or from stabbing, an incidence of violent injuries that is one of the highest in the country for children. “The penetrating trauma rate at most pediatric trauma centers is closer to 3%, so we are dramatically different here,” said McQueen.
But the volume of penetrating trauma is even greater at UChicago Medicine’s adult level 1 trauma center. “Our adult trauma service has extensive training and capabilities in treating gunshot victims, and we are fortunate at Comer Children’s to have a close collaboration with them,” said pediatric surgeon Marion Henry, MD, MPH, Medical Director of Pediatric Trauma. “Our trauma patients benefit from the expertise of pediatric surgeons working alongside the adult trauma surgeons, who have broad expertise in managing multiple traumatic injuries.”
Slidell opened Jerome’s chest and then the pericardium to evacuate the blood, which briefly improved the boy’s heart rate and blood pressure. Slidell removed the bullet from the right-hand side in the pericardium and found the bullet hole in the worst possible place — in the left atrium on the back wall of the heart. “This is a very difficult location to access and repair,” said the physician. “Lifting up the heart to repair it kinked off the blood that was trying to exit or enter the heart, and the child’s blood pressure would plummet. I couldn’t repair the hole and keep him alive at the same time.”
So Slidell did the only thing he could — he put his finger in the hole in Jerome’s heart to stop the bleeding while waiting for pediatric cardiothoracic surgeon Narutoshi Hibino, MD, PhD, to arrive and put Jerome on cardiopulmonary bypass. Hibino was astonished to find Slidell holding the boy’s heart in his hand with his finger in the bullet hole, a position he held for 20 minutes. As Hibino was putting Jerome on cardiac bypass, the boy’s heart briefly stopped, necessitating open-chest CPR.
“The hole was large and very difficult to repair,” said Hibino. “Any air that would be sucked into the hole would have gone to the brain and the boy would be brain dead. He was also at risk of dying from a myocardial infarction because the hole was very close to the coronary artery. Adding to the complexity, the hole was close to the mitral valve, which made controlling the blood flow difficult.” Maintaining cardiopulmonary bypass in such unusual conditions was also very challenging, said Hibino. “Without the amazing teamwork to manage the rapid placement on bypass, the boy would not have survived.”
Hibino repaired the hole and temporarily closed the chest to allow the edema in Jerome’s lung and abdomen to resolve. He also placed cardiac pacing wires to manage potential abnormal heart rhythms. Nancy Ghanayem, MD, Chief of the Section of Pediatric Critical Care, was also in the operating room to be prepared to deliver the care Jerome would need in the pediatric intensive care unit. The child was stable enough to be removed from cardiac bypass at the end of the surgery, and two days later, Hibino closed his chest. Remarkably, Jerome walked out of the hospital eight days later.
“That he survived a gunshot wound to the heart is extraordinary enough, but, astonishingly, Jerome’s neurological function, lung function and cardiac function were all fine,” said McQueen. Added Slidell: “This patient’s care is right up against the edges of what any pediatric trauma center would ever be capable of. The only reason this child’s life was saved was because of the tremendous expertise of the multidisciplinary team and because everyone stepped up and performed with their A-plus game.”
That preparedness to deliver extraordinary treatment is hardly accidental, said McQueen. “We run trauma simulations each month where we rehearse various scenarios of blunt or penetrating trauma with the entire team — emergency physicians, surgeons, other specialists and nurses,” she said. “We use real equipment and practice in the trauma bay, not in an artificial simulation center, which is uncommon. The entire team learns to seamlessly communicate with each other and develop a muscle memory for the split-second responses they must deliver. Consequently, the orchestration in real life is perfect.”
Although the “40 heroes who did everything right” were responsible for saving Jerome’s life, much more needs to be done to combat the “very real and sad reality of gun violence in our community,” said McQueen. An active area of research among pediatric and adult trauma faculty is to develop strategies to prevent gun violence. “We are investigating the root cause of gun violence and developing interventions that will drive down the incidence of these horrific injuries,” she said.
Comer Children’s also collaborates with multiple community groups to decrease rates of traumatic injury in children. “We participate in community outreach and educate parents in our clinics on how to prevent other injuries through the use of car seats, seat belts and making sure bookshelves are properly secured, for example,” said Henry. “We also need to make sure parents understand the risks of having guns in the home and the safe way to store guns. We are working with community groups on the best ways to prevent these violent injuries, as well.”
The violence intervention program Healing Hurt People – Chicago helps teens who are victims of violent injury heal psychologically through intensive case management and counseling. Through greater access to education, employment and mental health, teens are less likely to retaliate and get re-injured. And the Recovery and Empowerment After Community Trauma (REACT) Program provides support and trauma-focused therapy to pediatric and adult trauma patients and their families.
Comer Children’s faculty are also engaged in research to evaluate whether bullets that remain in the soft tissue in children create a hazardous lead burden. “The standard of care is to leave bullets or fragments in the body if they are not causing damage to a vessel, organ or nerve,” explained McQueen. “What we don’t know is how much lead from a bullet left in a five-year-old will be absorbed by that child’s body over time.” The trauma team is collecting baseline lead levels on all children who have been shot and tracking lead levels over time. “It may be that we need to treat kids differently, because the burden of lead in a child whose brain is still developing has different consequences than the burden of lead in adults,” she said.