Miracles We Have Seen

by Harley Rotbart

  Karen was transferred to the operating table, as the staff got ready for an emergency surgery and the pediatrics team readied for the arrival of her premature baby. Every second counted, and the teams worked in concert to expedite this critical delivery. We worked against the sickening knowledge that such a large uterine rupture was unlikely to be survivable for her baby and, even if survivable, unlikelier still to result in a child who was neurologically intact. A baby’s brain function depends on sufficient oxygen being delivered through an intact and in-place umbilical cord connected to the placenta. As soon as the surgical drapes were placed to frame Karen’s abdomen, an incision was made from her pubic bone to beneath her breasts, revealing a free-floating infant with only its head remaining inside the uterus. The rest of the baby’s body protruded into the abdominal cavity through the massive tear in the uterus. The cord was clamped and cut and the baby girl was handed off to awaiting pediatricians, floppy but miraculously very much alive.

  No one could believe it but the placenta accreta, which now posed an imminent threat to Karen’s life, had saved her baby with its tenacious grip on the uterus in spite of the rupture. The placenta had deeply invaded the wall of the uterus, tightly anchoring itself. Under just about any other circumstance with a uterine rupture of this size, the placenta would have ripped completely away from the uterus, leaving the fetus floating helplessly in the abdominal cavity, without blood supply or oxygen. Invasion of the placenta into the uterus is a dreaded obstetric complication, one typically seen with prior caesarean section scars. It is associated with massive blood loss and usually requires removal of the uterus with the placenta after delivery of the infant to save the mother’s life. In Karen’s case she had no caesarean scar on her uterus, only the procedures to remove her fibroids and decrease blood supply. The likelihood of her having a placenta accreta was low and in this case this dangerous abnormal placental growth was the only thing that saved her infant’s life. The baby was, as it turned out, saved by the very placental abnormality that initially announced her presence and put her mother’s life at risk. One life-threatening complication of pregnancy, the placenta accreta, rescued both mother and baby from another life-threatening complication of pregnancy, a ruptured uterus.

  Incredibly, Karen underwent an uncomplicated hysterectomy to remove both her uterus and the invasive placenta. In spite of massive blood loss, she was moved from the intensive care unit to the regular postpartum floor the day after her surgery. Now, more than a year-and-a-half later, Karen is completely recovered from her ordeal and joyously watching her absolutely perfect baby girl thrive as she discovers the world around her.

  Periodically Karen will send pictures of her miracle baby. They serve as moving reminders that sometimes everything conspires to make the impossible possible.

  Date of event: EARLY 2000s

  Exploding Blood Cells

  Philip L. Glick, MD, MBA

  A fourteen-year-old boy from a dairy farm in the rural part of the Northeast was admitted to our intensive care unit (ICU) with a serious condition called hemolytic uremic syndrome (HUS). This illness is usually caused by certain types of bacteria in food, but has also been linked to swimming in contaminated lake water, which was the suspected source in this child’s case. HUS begins with the gradual bursting of red blood cells, causing anemia. The debris from the burst cells can clog the kidneys and cause them to fail. Other organs of the body are less commonly affected. The prognosis for the typical case of HUS in a child is excellent. However this was, in no way, a typical case.

  This boy developed kidney failure, the most common serious complication of the disease; however, he was quite stable for several days in the ICU. Our surgical service was consulted because of the possible need for dialysis should his kidney function deteriorate further. Dialysis involves hooking up a filtering machine to the patient’s blood vessels through a catheter tube and running the patient’s entire blood circulation through the machine to clear the toxins, returning “clean” blood back to the patient. Removing toxins is a normal function of the kidneys, but with kidney failure, toxins accumulate and, without dialysis, these can be very dangerous.

  After another stable day, the child’s kidney function gradually deteriorated further and we made the decision to mobilize the surgical team and take him to the operating room at 12:30 am for placement of a dialysis catheter, rather than waiting until a more “normal” hour and risking further decline in his kidney function. He remained quite stable as we rolled him in, and we anticipated a very routine procedure. As we were obtaining consent for surgery from the parents, the boy’s heart monitor suddenly showed that he had developed a very abnormal heartbeat pattern, the type caused by excessive levels of potassium in the blood. There could be only one explanation for such high levels of potassium so suddenly: a massive explosion of the child’s red blood cells (which contain high levels of potassium). Whereas his HUS had caused a more gradual destruction of blood cells up until that point, the illness now had taken a potentially lethal turn with simultaneous bursting of millions of blood cells.

  As a result of the destruction of so many red blood cells all at once, there weren’t enough left to sufficiently carry oxygen to the vital parts of the body, including the brain. This profound anemia forced the child’s heart to overwork trying to get too few cells to too many places in the body. Adding to the crisis was the excessive potassium from the burst cells. Potassium, in high levels, is extremely toxic to the heart. The child suddenly went into cardiac arrest on the operating room table, and we instantly began cardiopulmonary resuscitation (CPR). But we knew this child would very likely die unless we did something dramatic—immediately—to save his heart and brain.

  There was only one “something” that might work: an invasive and potentially dangerous technique called extracorporeal membrane oxygenation, or ECMO. ECMO does for the heart and lungs what dialysis does for the kidneys. It siphons all the blood from the body into a machine that puts oxygen into the blood and removes carbon dioxide, as a normally functioning heart and the lungs do with each breath we take. This child’s failed heart was unable to get sufficient blood to his lungs, and ECMO was our only option.

  While the team was still performing CPR, I ran out to find the parents and explain, as quickly and completely as I could, how our plans for a routine dialysis catheter insertion had changed to an emergent lifesaving and high-risk ECMO procedure. I cautioned the boy’s parents that ECMO itself can cause brain damage because of the removal and replacement of the child’s entire blood pool, the blood thinners required to keep the blood flowing smoothly through the machine, and the potential disruptions of blood flow to the brain that any step of the procedure can cause.

  There are some miracles that seem to occur because circumstances are just right for a miracle, a perfect “alignment of the stars” that allows for an astonishing outcome. Heart failure as a complication of HUS is very rare and often fatal. Had this child’s massive explosion of red blood cells occurred at home, in an ambulance, in a small community hospital, or even in a different part of our tertiary care children’s hospital, he would likely have died. Instead, his life-threatening, instantaneous deterioration developed before our eyes, on the operating room table, as we were preparing him for a much more routine surgical procedure. The ICU team with an ECMO machine was only a few steps away, the veins into which we were going to have to insert the ECMO catheters had already been scrubbed with iodine in preparation for the dial-ysis catheter insertion, and the surgical team was already in place in the wee early hours of the morning. It was as if this boy’s body “waited for the right minute” to give out.

  We finished the procedure at 3:00 am and brought the child to the ICU. At 6:30 am, as my team made rounds, we found him awake and alert, but I was a little concerned that he might have been somewhat dulled in his responses to my questions. Had his cardiac arrest, prolonged CPR, or ECMO caused neurologic damage? At 8:30 that morning,
I found Mom at the bedside and asked her what she thought of his condition—specifically, his speech, thought processes, level of awareness, etc. She couldn’t figure out what I was concerned about—he’s perfect, she said, completely normal.

  “Never was a rocket scientist, never will be, but he’s exactly who he was before; my boy, the love of my life!” With a big hug and tears in both of our eyes she said, “Thank you, Dr. Glick, and thank your team. Bless you!”

  She and I couldn’t have been more grateful for the miracle of this boy’s extraordinary timing.

  Date of event: April 2015

  Right Where She Needed to Be

  Matthew Old, MD

  As a head and neck cancer surgeon, my patients are typically referred to me by physicians of many different specialties; patients don’t typically seek me out on their own. One day, however, a young woman working at our cancer hospital stopped me in the hallway and asked me for my opinion about her symptoms. This self-referral could not have been more appropriate or timely, and it may well have saved her life.

  Elli was a college freshman interning at our cancer center. Her position was not initially supposed to be on our surgery floor, but just before starting her job she was reassigned here. I had spoken with Elli many times on the phone through her work as a liaison with the families of our patients, but I had never before met her face-to-face.

  Elli told me an incredible story of symptoms lasting more than five years: dizziness, lightheadedness, intermittent face swelling, and periods of vision and hearing “blackouts.” She saw numerous doctors over that long period of time, each with a different, but reassuring, theory about what was causing her symptoms: iron deficiency, hormone changes, anxiety, recurring upper respiratory infections, and chronic tonsillitis. She received antibiotics, iron pills, and steroids to treat a variety of possible ailments suggested by the doctors. She even had her tonsils taken out. Nothing helped. She had to give up high school basketball because it made the symptoms worse, but then they began occurring during normal daily activities as well. She would fall asleep with her head to the side and wake up with stroke-like symptoms—imbalance, dizziness, nausea, and weakness. She told me she suspected something bad was happening, and then was sure of it when she felt a lump in her neck.

  When I examined Elli’s mouth, I was very disturbed to find that the back of her throat wasn’t symmetric. The tissues on one side of her throat were displaced off to the side and bulging into her neck space. I ordered a CAT scan (a special kind of X-ray) and what we saw floored us—a large, baseball-size tumor at the base of her skull was totally surrounding her right carotid artery. One nerve to her tongue and voice box was already compromised by the tumor, paralyzing half of her tongue and one of her vocal cords. Carotid arteries, one on each side of the neck, provide the major source of blood, and therefore oxygen, to our brains. Elli’s tumor was so large it was not only stealing blood from her carotid artery, but also compressing the artery itself. Through a series of scans I determined the tumor was cutting off the blood flow to her brain, causing all of her symptoms for the past several years. If it continued to grow, she would almost certainly have a stroke and, possibly, lose her life. When I informed Elli about the tumor, she said she was relieved she had an answer to everything she was experiencing and that she was not “crazy” and didn’t have an anxiety disorder. On the other hand, her family was devastated, learning that suddenly her life was in a precarious balance, particularly with what she was about to face.

  Our team concluded the tumor had to be removed—but the surgery we would need to perform was very complicated and risky, and could itself cause a stroke. To make matters worse, it was not only the carotid artery that was at risk due to the tumor—the nerves controlling her face, tongue, throat, and voice box were also at risk due to the location of the tumor. These are rare surgeries but I had training in them and had performed them previously, so I was confident and optimistic. However, due to the high stakes and severity of her symptoms, it was nerve-racking and stressful for all of us.

  What ensued next is among the finest examples of collaborative surgery I have ever been privileged to be a part of. It took seventeen hours for our extraordinary team of three different surgeons to dissect, pry apart, tease away, and finally remove the entire tumor from Elli’s neck and base of skull. The surgery was harrowing; if we tilted her head to one side or the other, her vital signs would change—blood pressure and pulse would drop—because we were altering the blood flow to her brain through her severely narrowed carotid artery. During the procedure we realized we couldn’t save the nerves to her vocal cords and tongue. We successfully preserved her hearing and the nerves to her face so she wouldn’t have a droop. Even after surgery, we still held our breath as we noticed her lower left leg was paralyzed—but, thankfully, it is slowly recovering. Elli was left with a slightly raspy voice, weakness on the right side of her tongue, and a temporary limp. But she survived with intact hearing, no facial droop and, most importantly, without suffering a major stroke or other devastating complication. We were all relieved she pulled through it, but I credit this mostly to her resolve and determination to overcome obstacles.

  To look at her today, you would have no idea what Elli has been through. Her recovery should have taken more than a year, but she returned to work two months after surgery to a surprise standing ovation from the entire staff of the surgery floor. She now uses her experiences to help our other hospitalized patients and families get through difficult times dealing with cancer and surgery. Not long after, Elli returned to college, a pre-med major, hoping to be a children’s cancer doctor someday.

  We now know Elli’s tumor was a vagal paraganglioma, a very rare tumor occurring in less than one in every five million people. She, of course, had no way of knowing she had a rare paraganglioma when she stopped me in the hallway. She had heard about lymphomas, a different kind of tumor that can occur in the neck, and she was worried that’s what she had. Elli also had no way of knowing that during my training as a head and neck surgeon, my mentor was an expert in this very type of highly specialized paraganglioma surgery and taught me to become expert in that procedure as well.

  There are a lot of other hospitals in town where Elli could have worked. In our hospital, there are many doctors on many different floors including many even on our surgical floor—innumerable other white-coated colleagues Elli could have asked for help. But Elli chose to work in our hospital where she asked me. Only because I worked on the same floor as she did—the floor she had been switched to at the last minute before starting her internship. As a result, an almost certain stroke was prevented just in time, and her life may have been saved as well.

  Call this a case of good luck: being right where she needed to be, right when she needed to be there; doing the right job, with all the right people working beside her. Or call it serendipity, the alignment of all the stars to result in a wonderful outcome. Or call it a miracle. She and her family do, and so do I.

  Date of event:1999

  When Sister Bernie

  Prays for You

  Claudette Dalton, MD

  I met Sister Bernie Kenny in the late 1990s when I organized a medical team from our university medical center to go to the mountains of southwest Virginia to help with a weekend dental and medical clinic. Sister Bernie is a Catholic nun who ran an organization called the St. Mary’s Health Wagon. This group of dedicated nurses drove around the Appalachian region near the town of Wise, in southwestern Virginia, to provide basic medical and follow-up care to the residents of the area. Geographically, this area is the “tail” of Virginia, sitting between West Virginia, Tennessee, and Kentucky. Coal mining, logging, and railroads are the main industries, but these are largely played out and dwindling along with the region. Consequently, most of the remaining population is uninsured, unemployed, and poor. They also have some of the highest rates of chronic diseases, cancer, and drug abuse in the state. />
  Sister Bernie also knew that there was almost no dental care in this area. So she asked a nonprofit organization called Remote Area Medical (RAM) clinic to help provide a free, once-a-year dental clinic. RAM, based in Knoxville, Tennessee, worked with the Virginia Dental Association to provide dental care over a hot summer weekend in an unused airplane hangar at the Lonesome Pine Airport just outside of Wise. Unfortunately, many of the patients were too ill with diabetes, hypertension, or heart disease to safely have dental work done. So, in planning for the next year, Sister Bernie called me to put together a medical team to complement the dental efforts.

  I’m proud to say we had no trouble finding medical volunteers to spend a steamy, muddy July weekend in a remote, deserted airplane hangar more than six hours away from my home base in Charlottesville. The generosity of this extraordinary group of doctors and nurses from all over Virginia and beyond has become legendary and their work continues each summer now for the past sixteen years. But that first year, I had no idea what supplies and services we would need, where we would house and feed the team, how we would transport them and how we would follow up on patients. In the midst of this planning chaos, I got another call from Sister Bernie, now just two weeks before the event.

  “Do you know,” she asked, “where we could get a mammogram van for the event?”

  I replied that, as an anesthesiologist, I knew nothing about mammogram vans and I didn’t think I had the time or expertise to help her. We were in enough tumult just trying to get a medical team to Wise.