From Just a Pinched Ear?
Aaron Engstrom watched his rambunctious son, Carter, and a pack of his nephews run laughing through the house, bouncing off one another like bumper cars. They'd stuffed pillows inside their shirts and were "belly bashing."October mornings like this, with ice forming in the shallows of the Yellowstone River and the trees changing and the laughter inside the house -- that's why he moved back to the area where he'd grown up and settled in the small town of Sidney, Montana.
A few months earlier, Aaron and his wife, Annie, had left Bellingham, Washington, where he'd been taking pre-med classes and working as a tech at a busy Level II trauma center. Seeing the long hours doctors put in and looking ahead to years of school, he began to have second thoughts about his career. So when an opportunity to enter a new radiology program at the Sidney Health Center opened, he jumped at it.
Aaron smiled at the boys roughhousing in the living room. A thump to Carter's pillowed belly sent him tumbling backward into the corner of the maple TV stand. Carter covered his ear with his hand and cried.
"You okay, buddy?" Aaron asked, checking him over. There was no break in the skin. Carter, his eyes still full of tears, nodded, rubbed the sting away, tucked the pillow back in his shirt and ran off after his cousins.
But the fall had done more than pinch Carter's ear. The blow against the corner of the stand had sent a shock through his skull and ruptured the middle meningeal artery, which runs near the surface of the brain just below the dura, its lining. Nothing but a small red mark on his ear showed outside, but inside, Carter was bleeding and the trapped blood was compressing his brain.
At bedtime Aaron and Annie noticed their son looked groggy. Just a busy day, they thought. Dressed in red and blue Superman pajamas, he stumbled going to bed. "My ear hurts," he told them. As Annie tucked him in, she suggested that he turn over and sleep on his other side, then kissed him goodnight.
Just before dawn the Engstroms were awakened by piercing screams. They rushed to Carter's room and tried to soothe him. He was talking and lucid and eventually stopped crying. But when the two returned to their bedroom, Annie heard a small cry. They ran back and found Carter unconscious -- and they couldn't wake him.
Aaron carried his son into their room and laid him on the apple-green duvet on their bed. He discovered that Carter had wet himself. As he changed the boy's pants, Carter's arms and legs flopped like a rubber doll's.
Aaron checked his son's eyes. Lifting one lid, he saw that the pupil was fully dilated and not responding to light. Frantic, he pulled back the other lid; the pupil was completely contracted. Uneven pupil dilation is a sign of a life-threatening head injury. "We gotta go to the hospital now," he said.
Running Out of Time
At large hospitals, emergency rooms are open around the clock. Generally, at smaller hospitals, personnel are on an "on-call status" after-hours. It takes time to gather a medical team. Carter didn't have much time.That morning, however, the Sidney Health Center happened to have a fully staffed emergency room. When Aaron rushed through the doors with Carter in his arms, Dr. Edward L. Pierce immediately took the boy into a medical bay. Confirming the uneven pupil dilation, Pierce ordered a CT scan. The CT suite staff -- the very team Aaron worked with -- was on hand at that hour. When they completed the scan, they gave Aaron the images, and with a trembling hand he put them up on the light board.
His legs buckled. The scans showed a large gray shadow -- a massive hemorrhage inside the skull. Aaron had seen patterns like this before -- and the outcome had never been good. With colleagues gathered around him, he wept.
In the emergency room, medical personnel were frantically working to stabilize Carter. There was no brain surgeon in Sidney. The closest Montana hospital able to treat brain trauma was in Billings, 250 miles to the southwest. They called for an air ambulance, but with the plane more than an hour away, Carter might not make it.
Carter's life functions were rapidly deteriorating. Nurses intubated the child, using a hand bag to force air into his lungs to keep him alive until the plane arrived.
Then a return call came from Billings. Doctors there felt that given the severity of Carter's injury, he'd be better off flying to Denver, where there was a neurosurgical center with a pediatric intensivist. Denver was 550 miles distant. Billings would send a medically equipped plane for the trip.
But Carter almost certainly didn't have that much time.
In a room a hundred yards away, Dr. Edward P. Bergin was unaware of the battle to save Carter being fought in the ER. He was preparing for his first scheduled surgery of the morning, a routine gallbladder operation. A scrubbed staff and a fully prepared operating table were waiting for him.
Just then a phone rang. It was Pierce calling from the ER. He had a critically ill patient. He wanted to know if Bergin could drill burr holes in the skull of a three-year-old boy.
Bergin felt himself tighten up. As a general surgeon he was the "turn-to guy," the doctor they called when other doctors needed something done beyond their realm of expertise; but this was a request for brain surgery, an area in which he had limited training -- and no neurosurgical tools on hand. Bergin also knew if Pierce was asking him, he was the only option left.
He hung up the phone and looked at his crew. Brain surgery was novel for them as well. But with no alternatives, you fall back on frontier medicine. You improvise; you do what is needed. Telling the anesthetist to hold the gallbladder patient, Bergin, in his teal-colored scrubs, hurried to the ER.
When he pulled back the curtains to the emergency room bay, Bergin saw a child who had regressed into flexor posturing -- arms bent inward, hands clenched into fists -- a sign of severe brain injury. Nurses were still bagging air into his lungs. The main thing Carter had going was his youth -- and strong little heart.
Bergin looked at the parents. "I'm sorry," he said, "but I have to try and do something or your son's not going to make it."
The Engstroms put themselves and their son in his hands.
Back in the brilliantly lit, tiled operating room, Bergin scrambled his team to gather an array of tools and prepare the boy for emergency surgery. As he rescrubbed, he searched his memory for anything he'd ever read about this operation. Then he made a quick decision. He'd call for help. He asked the staff to find a neurosurgeon somewhere, anywhere, who could walk him through the procedure. He'd use a speakerphone in the operating room.
A Long-Distance Guide
Neurosurgeon David VanSickle was assisting in an operation at the Children's Hospital in Denver when his pager went off. From the description, he realized how desperate the doctor's patient was. VanSickle agreed to help. Leaving the primary neurosurgeon to finish the surgery, he found a quiet spot, clear of distractions, and prepared to guide Bergin's hands long-distance.The speakerphone was on the wall of the OR not far from the operating table. Listening to the spectral voice that issued from it, Bergin began. First, cutting through skin and muscle tissue on the shaved left side of Carter's head, he exposed the skull and prepared to enter the delicate world inside. Guided by the CT scan and VanSickle's advice, Bergin estimated the clot's location by measuring with the width of his fingers. But he could not be certain until the holes were drilled.
Hospitals equipped for neurosurgery have specially designed instruments, some with drills fitted with footplates and guards to prevent penetrating the dura and the brain. Bergin would be working with a standard orthopedic drill, an electrically powered stainless steel apparatus about the size of a hair dryer used more frequently on bone spurs and shoulders than skulls. He had to be careful not to go too deep and risk irreparable damage or death.
The moment had come, however. Bergin took the drill and bored into the bone. His goal was to cut two one-centimeter-wide holes, and then check his position with the clot. With only his sight and the feel of the drill in his hands, he needed to go just far enough to pass through the skull without puncturing the dura, and not a millimeter more.
It took five minutes to drill two vertical holes above Carter's ear. The crucial step was done.
VanSickle then instructed Bergin to cut the bone between each hole, connecting them like a connect-the-dots puzzle. This would create a two-centimeter-wide window between the holes and allow Bergin to look inside the skull, find the hemorrhaged clot and remove it. If things worked well, they would be near the clot's location. If not, he would have to drill new holes until he found the hemorrhage.
Bergin looked at his tools. He had nothing that would allow him to cut through the bone while protecting the brain beneath. Forced to improvise again, he selected an instrument used to file bone spurs and carefully sawed away the bone between each hole.
Finally, with the window successfully created, Bergin looked in on the dura -- the tough, fibrous membrane that wraps the brain. Relief filled him. He had drilled directly above the clot. They would be able to remove it through this aperture.
Now the neurosurgeon directed Bergin as he and his team began to remove pieces of clotted blood. Using forceps and suction, they scooped the mass from the hole, but as the clotted blood came free, Bergin's nerves tightened. "There's fresh arterial blood," he told VanSickle.
Because more of the heart's pumping force is behind it, an arterial bleed applies greater pressure on the brain and it can be harder to stop. It was a nerve-racking moment. Yet, in calm voices, the two doctors conferred on a plan of action. To slow the leak, Bergin selected a common adhesive sponge called Gelfoam.
"Use it," VanSickle told him. They both hoped it would work.
Taking small forceps, about the size of eyebrow tweezers, Bergin inserted the sponge into the area and pushed it against the pulsing artery. He held pressure on the ruptured vessel, and hoped the sponge would adhere and seal the leak.
After a few moments, Bergin carefully relieved pressure, watching the point where the sponge was lodged. "The flow is slowing," he said.
"Tell me what the dura looks like," VanSickle asked. The dura's appearance would indicate what was happening to the brain. The brain's covering, VanSickle explained, should be lax, not tense and under pressure, not bulging like a balloon somewhere.
Bergin looked at the dura. It pulsated regularly, appearing soft and relaxed.
"That's a good sign," VanSickle responded. The pulsating meant blood and oxygen were entering the brain. The soft, lax appearance meant pressure had been alleviated. Bergin's efforts seemed to be working.
There was still the long flight to Denver. Worried that jostling during the flight might restart the bleeding, VanSickle advised Bergin to insert a drain through a separate incision in the scalp near where the clot had been. If the sponge patch broke, the drain would give the medical crew a way to draw blood to prevent another hemorrhage.
Working carefully, Bergin positioned the drain. Forty minutes after he first entered Carter's skull, he closed the incision and prepared the boy for transport. Only minutes after Bergin finished, the Denver plane touched down in Sidney, and an ambulance took Carter to the airport.
"You Do What You Have to Do"
Three hours later, Denver neurosurgeons, led by Dr. Charles Wilkinson, enlarged the window made by Bergin and examined the area. All major bleeding had stopped, and Carter's stressed brain was already shifting back to normal.Denver surgeons enlarged the incision, removed some bone and remaining portions of the clot, and cauterized the artery that was torn. They then made a small incision in the dura to see if there was deeper damage -- there was not. They finished cleaning the area and removed the Gelfoam sponge. Finally they replaced the bone with titanium plates and screws, closed up and sent Carter to the recovery room.
Because the trauma to the child's brain had been so severe, doctors told the Engstroms that his recovery could take months. There was the possibility of permanent damage. Aaron and Annie simply rejoiced that their son was alive.
That night Annie slept in Carter's room in the pediatric intensive care unit. Monitors beeped constantly. Tubes ran into him and out of him. He wore a neck brace. It was the first time Annie had seen the bright red, swollen stitches on his half-shaved head.
The next morning Carter was able to get off his breathing apparatus. Annie squeezed his hand. He didn't open his eyes or move. "Mommy's here," she said. She heard something that sounded like, "Yep."
"Mommy loves you," she told him.
"I love you too, Mommy," he said.
A CT scan revealed that the hematoma was gone and the brain appeared undamaged. The doctors took intravenous lines out of his legs and moved him to a medium care unit.
Five days later, after walking on his own in physical therapy, Carter rode to the elevator in one of the little wagons used to transport children in the hospital. The Denver doctors had decided he could go home.
Today Dr. Bergin is still at work in Sidney. Most of his surgeries are planned. "But when you're up to your elbows in alligators and help is miles away, you do what you have to do," he says. That's frontier -- Montana -- medicine. And watching their son once again tear through the house, playing with his cousins, Aaron and Annie Engstrom know that was just fine.