‘Beyond emergency surgery’ – Lifesaving neurosurgery couldn’t have happened without communication, teamwork

A Virginia couple attributes their little boy’s survival to divine intervention – that when the worst happened, a mother’s instinct pushed her to act, which got them to the right doctors with the needed skills and the experience to know when to bypass typical procedure.

“It was a miracle to get him into the hands of people who really could perform a miracle,” said Elissa Shahan.

Shahan; her husband, Nick Shahan; and their two children, Skyler, 3; and Sander, 1, were visiting family in the Myrtle Beach area over the Labor Day holiday last year. Monday, Sept. 6, started off as a normal relaxing vacation day. Elissa Shahan was making eggs for breakfast when Sander, strapped into his booster seat, jerked himself backward and crashed to the floor, hitting his head.

Elissa and Nick immediately checked him out. A self-described overprotective mother with their first, she knew to check whether his pupils responded to light. They did, and Sander stopped crying after a few minutes. Elissa Shahan called a couple of medical providers, but she couldn’t get into a pediatrician’s office because they weren’t regular patients, and the emergency department that she called warned they were overwhelmingly busy. In any case, Sander seemed to be OK.

Sander's parents didn’t know that the fall had sheared an artery. Blood was pumping into the space between his skull and the outer covering of his brain, steadily pushing his brain into a smaller and smaller space. Called an epidural hematoma, this type of injury can easily be fatal, said Ramin Eskandari, M.D., chief of pediatric neurosurgery at MUSC Children’s Health.

“That type of epidural is the kind that can kill people. That's the stuff where everything is fine … fine ... fine … and then suddenly they die,” he said.

The family finished breakfast and headed to the pool.

Race to the ER

Nick Shahan has photos of that morning, of Sander splashing around in the pool in his water wings. The family enjoyed the morning, then mom put Sander down for a nap.

“It was nap time – and I never let him nap with us. But for some reason I let him nap next to us, and he threw up a little. And that made me a little nervous,” Elissa Shahan said.

 

The parents cleaned him up and put him back down. About 45 minutes later, as they headed in to give Skyler lunch, Sander threw up again, she said. He also seemed oddly sleepy – not just naptime sleepy, but something different. And his body had gone “noodly,” Nick Shahan said.

Elissa Shahan knew it was time to head to a hospital. Panicking now, she raced with Sander to Conway Medical Center. The staff there rushed her inside and immediately scanned Sander’s head.

Back at the house with their daughter and the dog, Nick Shahan got a call from a nurse a half-hour later. His wife was too hysterical to talk, the nurse said, but his son needed to be sent to a medical facility that could handle his injury.

A helicopter was on its way to pick up Sander and bring him to MUSC Shawn Jenkins Children’s Hospital in Charleston.

Diagnosis

Matthew Moake, M.D., Ph.D., was the attending physician in the Pediatric Emergency Department that afternoon. The ED commonly receives calls from other hospitals and pediatricians’ offices and then triages potential patients based on information the referring doctors can provide as well as any scans they may have. Most – but not all – hospitals in South Carolina participate in an image sharing system so that doctors can send CT or MRI images to outside hospitals.

The doctors in Conway had told Moake they had an infant with a brain bleed. Yet when he pulled up the images, he was stunned. The injury was far worse – and far more urgent – than he had expected. He immediately called Eskandari, who was on call but not in the hospital.

Because Eskandari wasn’t near a computer, he couldn’t see the scans. Moake began describing them, including a measurement of the bleed. The bleed was so large, Moake said, that Eskandari at first thought Moake must be measuring front-to-back instead of side-to-side.

Assured of the accuracy of the measurement, Moake said Eskandari’s reaction was essentially the same as his had been – unpublishable. Moake then photographed the scans and texted the pictures to Eskandari.

 

“It was one of the biggest, if not the biggest, epidural hematomas I’ve ever seen,” Eskandari said.

Sander would need surgery immediately upon arriving at MUSC Children’s Health, Eskandari said. Every second mattered at that point.

Ghost patient

It takes a lot of people and a lot of teamwork to make an operating room jump into action – far more than simply a surgeon who’s willing and able. To begin with, a doctor can’t just walk in, claim an OR and start grabbing supplies. Everything – every medication, every set of sterile blue drapes, every set of scalpels, not to mention the reservation of an OR – must be associated with a medical record number: in other words, an actual patient.

But technically, Eskandari didn’t yet have a patient.

 

The usual procedure is for a transferring trauma patient to be triaged through the Emergency Department, at which time a patient record would be created and supplies could be ordered. But Eskandari wanted Sander to be brought directly from the helipad to the operating room, bypassing the Emergency Department.

There’s good reason that patients, even patients who you know will need surgery, are triaged in a standardized manner, Moake said. This ensures that nothing is missed and gives the doctors here a chance to stabilize the patient, conduct a physical exam or do additional scans.

And the unfortunate truth is that parents aren’t always honest about how a child was injured. If the injury happened differently than how parents say it did, there could be additional injuries lurking undetected. It would be disastrous if Eskandari started operating on a child’s brain without anyone realizing that the child was also bleeding in the abdomen, for example.

In this case, though, the doctors felt confident that the images they were seeing from Conway Medical Center and the parents’ description of the incident matched up.

“With the low odds of there being anything else, and the very real chance that this kid wasn’t going to make it from the injury we knew he had, it made sense to go ahead and address it right away,” Moake said.

Moake spent the rest of his shift communicating with both the flight team and teams within the hospital to clear the way for the surgery.

 

Eskandari drew upon another case to make the plan to treat Sander immediately upon arrival. Back in 2017, a 4-year-old girl named Annie Nichols slipped in her garage and fell, hitting her head. She, too, was flown to MUSC Children’s Health. Stephen Kalhorn, M.D., was on call that day, and he had the hospital admitting team create a dummy medical record number so he could prep the operating room and be ready the instant she arrived. Eskandari, who took over Annie’s care the following day, made a mental note of Kalhorn’s time-saving trick for extreme cases. But as many surgeries as he does every year, he never needed to go to such extremes to prepare for surgery – until Sander’s case. He credits the admitting team for helping to get the ball rolling.

Of course, Eskandari wasn’t alone in the OR. He had already called Tracy Wester, M.D., the on-call anesthesiologist. By coincidence, Wester had also been the anesthesiologist in Annie’s case. As soon as Eskandari told her what was happening, she knew what they needed to do.

Prepping for surgery typically takes place in a specific step-by-step order, to ensure that no steps are skipped and to protect the sterility of the equipment. But in this case, Eskandari said, “It was all going to happen at one time because every one to two minutes saved here or there was lifesaving.”

 

For instance, equipment usually isn’t unpackaged until the OR doors close, to protect sterility. But there was such urgency to this case that Eskandari made an exception.

“We're going to have everything open; we’re going to have the drill bits on the drill; we’re going to have two sets of everything so we’re not switching things up,” he told the team.

“We do emergency surgeries not infrequently,” he said. “Everyone is on point; everything’s done right. This was beyond emergency. This was ‘We have to have everything ready so when he rolls into the room, we shave his head and cut his scalp.’”

Wester’s only ask: That she have a minute to check Sander’s breathing tube before anyone else did anything, because breathing tubes can sometimes shift in transport.

The team was ready – now they only needed a patient.

Surgery

 

As soon as the transport team landed, Wester was on her way to meet them.

“The breathing tube was exactly in place, so Dr. Eskandari could start prepping while I inserted an arterial line. We had all the drugs we needed; we had all the equipment we needed, and it went as smooth as a dream,” she said.

Because of the simultaneous nature of their prep, the team threw blue drapes over Wester so she could insert the line while the surgical team prepared for the first cut.

While Wester concentrated on the ABCs – airway, breathing, circulation – continuously scanning the monitors and listening for any change in the pulse oximeter, the surgical team began work.

Within about five minutes, the team had removed part of the skull. With the artery continuing to pump out blood, the hematoma had doubled in size by the time Sander arrived in surgery.

Eskandari knew the artery was severed, but the question was: Where?

He removed as much of the pooled blood as he could and then searched for the source of the bleeding, even as more blood continued to fill the cavity. Unable to find the source, Eskandari had to remove more of the skull to get a better view. Finally, he tracked down the cut and repaired the blood vessel. Once that vessel was taken care of, he carefully checked to ensure there was no other source of bleeding. Satisfied on that count, the team reassembled the bones – somewhat like a jigsaw puzzle – and attached them to the skull using absorbable implants.

Sander hadn’t suffered any seizures, and because young brains can bounce back quickly, Eskandari was optimistic about the outcome. He called Sander’s parents to let them know the surgery went well.

The longest drive

When Nick Shahan got that first phone call from the nurse at Conway Medical Center telling him what was happening with Sander, he fell to pieces for a minute. But he quickly went into “father mode,” he said. He needed to get his family safely to Charleston. So he packed up their things, including Skyler and the dog, waited for his wife to return from the local hospital with the RV, and took the steering wheel for the 100-mile trek to Charleston.

“It was the longest, worst drive of our lives,” Elissa Shahan said.

Nick Shahan managed to stay cool on the outside – he was driving, plus he didn’t want to scare Skyler. But inside, he was worried. The couple had been told that Sander would be out of surgery by the time they got to Charleston. They just didn’t know what the news would be.

“I was either going there to help my son with recovery or I'm going there to pick up my 1-year-old son to bring him back to Virginia to bury him,” he said.

 

The couple got the call from Eskandari when they were almost to the hospital. Things were looking good.

Finally in Charleston, they met with Eskandari in person.

“Maybe it’s because he’s a father; maybe he’s just a good person, but his bedside manner was just amazing,” Elissa Shahan said. “He sat us down and talked – straight shooting, but as a parent wants to hear it.”

Sander wasn’t completely out of the woods, Eskandari warned. Another MRI was still scheduled to check whether the bleeding had truly stopped.

The family checked into a nearby hotel, exhausted, around 10 p.m. In the middle of the night, they got a call. The MRI was beautiful – not only had the bleeding stopped, but Sander’s brain had unsqueezed itself and was occupying its usual position.

“The next day when he put the scans next to each other, it was like it never happened,” Elissa Shahan said.

Recovery

Sander arrived at the MUSC Shawn Jenkins Children’s Hospital on a Monday. That Thursday, he and his family returned to Myrtle Beach. After a few more days of rest, the family went home to Virginia on Tuesday, just a week and a day after the accident.

He had a couple of follow-up scans at a hospital system near his home, and everything looks good, his parents said.

 

That’s the thing about young brains, Eskandari explained. They don’t tolerate fast changes, but they also recover quickly if those changes are dealt with.

He pointed to the communication among the staff from so many different departments, as well as the flight crew and the referring doctors, as a key reason why he was able to pull off the surgery.

Moake agreed.

“One of the things I like about being at MUSC is that we’re a large enough center that we have everything, from a specialty standpoint, but we’re a small enough center still that we know each other by name,” he said. “We have each other's cell phone numbers. Attendings can talk to attendings and get things done. Ramin said, ‘Every second matters. I need this OR fast.’ And we did it.”

Elissa Shahan, on the other hand, still needs a little time to recover emotionally.

“Every time he falls, I still cringe. I know he’s not made of glass. I know he’s a boy,” she said. She joked that she intends to follow him to college.

"He's our little miracle baby."