Level 1 Designation Reflects Pediatric Surgery Excellence

Cortez Nelson shares a moment with his Children's Hospital ICU nurses
Cortez Nelson shares a moment with his "ICU angels" eight months after life-saving surgery. (l-r), Melissa Guess, RN, Lauren Galante, RN, and Eva Walder, RN.

It was nearly midnight on the evening of December 10, 2015, when his pager sounded, alerting Keith Oldham, MD, to get to the Children's Hospital of Wisconsin (Children's) Emergency Department as soon as possible. Dr. Oldham, surgeon-in-chief and the Marie Z. Uihlein Chair in Pediatric Surgery at Children's and professor of surgery (pediatric surgery) at the Medical College of Wisconsin, expected to be faced with the heartbreaking task of declaring the death of a young patient; instead, to his surprise and delight, he discovered the teenager, a gunshot victim, had rallied and was fighting hard to stay alive.

The young man had been shot at close range as the target of a robbery, with extensive damage to his lower right torso and upper thigh. He had lost a considerable amount of blood with ongoing CPR on arrival and was minutes away from succumbing to his injuries. The Children's trauma response team already was in action, but it was clear that an emergency operation was needed. More than 90 units of blood were administered and a second team of anesthesiologists, led by Eric Walbergh, MD, was called in. The patient underwent two laparotomies (a surgical incision into the abdominal cavity for diagnosis or in preparation for surgery) and eventual amputation of his right leg mid-thigh. Following hours of grueling surgery, the teen was wheeled to the Intensive Care Unit – where he would remain through the end of January before being transferred to a private room. On February 12, 2016 – 21 surgeries and more than 200 visitors later – he finally was able to return home.

Given the severity of his injuries, Cortez Nelson was fortunate to survive. He received an exemplary standard of care at Children's, reflecting the hospital's prestigious recent verification as a Level 1 Children's Surgery Center by the American College of Surgeons (ACS), the highest level of distinction for hospitals that perform surgeries – ranging from standard procedures to the most complex – in newborns, children and teens. It undoubtedly saved his life.

Research has shown there are fewer complications, better survival and shorter hospital stays when children undergo surgery in hospitals with expert resources for pediatric patients. The ACS Children's Surgery Verification Quality Improvement Program provides the nation's first and only multispecialty standards for children's surgical care, and is helping families compare the services of hospitals that perform children's surgeries.

Children's is one of six centers nationwide that agreed to be part of the ACS's verification pilot program, which included an on-site review by experts from across the country. The Level I status achieved by Children's and its Surgicenter requires 24/7 staffing by pediatric specialists, including surgeons, anesthesiologists (optimal anesthesia and airway management in infants and children require specific training and skills), diagnostic and interventional radiologists, emergency medicine physicians and critical care specialists; a Level IV neonatal intensive care unit (the highest level of critical care available for newborns); a transport service; and research and data collection for benchmarking outcomes.

ACS Level I Designation

  • Performs complex and noncomplex surgical procedures in newborns and children of all ages, including those with the most severe health conditions and birth defects
  • Staffed 24/7 with credentialed pediatric specialists
  • Includes a transport system
  • Has a Level IV neonatal intensive care unit (NICU), the highest level of critical care for newborns

Perhaps not so coincidentally, Dr. Oldham led the Task Force for Children's Surgical Care that developed the new standards between 2012–2015, supported by the ACS and the Children’s Hospital Association. "In over 30 years of practice as a physician, I had seen situations where care was sometimes not what you would seek for your own child," he says. The members of the Task Force – who represented key disciplines and perspectives – recognized how the verification of resources for trauma centers had improved trauma care, and they wanted to pursue a similar course for children's surgery. Their work culminated in the ACS's publication in 2015 of Optimal Resources for Children's Surgical Care.

Results from the pilot program were announced in May 2016. "The focus of the effort was to develop optimal resource standards that result in improved outcomes," remarks Dr. Oldham. "While children's surgical care is often excellent at hospitals across the country, the quality and resulting outcomes can be inconsistent." The results underscored that families in Wisconsin are fortunate to have access to one of the best children's hospitals in the country.

Dr. Oldham notes that the goal of the verification process is to see that every child in the US receives appropriate care at a hospital that is equipped to support medical, emotional and social needs of the child and family. "This process is meant to help families make the best decisions for their children and help ensure that complex procedures are being done at hospitals properly equipped and staffed to manage this level of care for children."

Keith Oldham, MDDr. Oldham, whose specialty is general and thoracic surgery in infants and children, joined MCW in 1998 from Duke University Medical Center, where he served seven years as chief of pediatric surgery.

His MCW team now includes 10 pediatric surgeons, six physician assistants, a variety of nursing staff (employed by Children's), four PhD scientists whose primary research includes endothelial cell biology and microvascular tissue injury, and a host of students, trainees and others.

The confluence of Dr. Oldham, the Children's trauma team, the pediatric critical care team, the pediatric anesthesiologists, the Froedtert Hospital vascular surgery team and numerous other healthcare providers in the early morning hours of December 11, 2015, undoubtedly saved the life of 17-year-old Cortez Nelson. A junior at Milwaukee Vincent High School, the 6'5" teen had just returned home from playing in his first basketball game of the season and was accompanying a friend on a short walk to a nearby convenience store. Two men jumped out at them from behind a building, brandishing weapons, and demanded their wallets and cell phones. Cortez was forced to the ground and although having surrendered his possessions, was shot. He got up and ran, but his leg gave out. His friend kept Cortez awake, got him back on the ground, and called out for help. After the police arrived he was transported to Children's; on the way there, Cortez says he saw an angel looking out for him. "I heard a voice tell me that it wasn’t my time to go yet," he shares.

His mother, Shalonda Walker, was resting at home when the mother of a friend banged on her door. "Cortez got shot," she yelled. It was 10:45 p.m. on December 10. Shalonda rushed to hospital with her sister; after word got out about the shooting, Cortez's friends camped out overnight in the hospital parking lot. "They told me he had nine holes in his intestines and one in his stomach, as well as heart and kidney damage," Shalonda recalls. "And they took off his leg in order to save his life."

For Cortez, the recuperation was a major challenge. "It was overwhelming to go from a star athlete to a handicapped amputee in like three seconds," he says. But the unwavering support of his friends – some of whom never stopped visiting him – and the outstanding care from the Children's nurses and physicians gave him the strength to persevere. Cortez is particularly grateful to his three ICU nurses, Eva Walder, RN, Lauren Galante, RN, and Melissa Guess, RN, whom he calls "my angels."

During his hospital stay, Cortez dropped half his weight – arriving home at a mere 99 pounds. His "Christmas present" in ICU, he shares, was "a sip of water."

Cortez still faces additional surgery on his leg to allow the prosthesis to fit more comfortably, but he's completed both occupational and physical therapy. "I'm adjusting to the new normal," he remarks. "My journey would have been so much harder without the great people at Children's. They treated me like family."

His mother continues to gush over the care Cortez received. "I am so grateful to the doctors for bringing back my baby. The fact that they never gave up on him gave me a lot of comfort," she adds. "They explained everything to me. And he had such wonderful caring nurses. Even the valet at the hospital was nice!"

Doctors, nurses, caregivers – even angels! Giving a life back to a critically injured pediatric patient takes the hard work of a talented and dedicated team, supported by the right tools and resources.

Pediatric surgery statistics

"Verification by the ACS as a Level 1 Children's Surgery Center validates that we have the people and resources necessary to provide the best care for young patients such as Cortez – and to generate the best of outcomes," according to Dr. Oldham.

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Pediatric Surgical Team Saves Baby Born Without Trachea

In spring 2016, a male infant was born in Wisconsin without a trachea. The condition, known as tracheal agenesis, is a rare birth defect (approximately 150 reported cases since 1900). Kathleen Dominguez, MD, FEL '14, pediatric surgeon at the Marshfield Clinic, conducted the initial surgery needed to stabilize the baby so that he could be transported to Children's Hospital of Wisconsin. Upon arrival, a team including neonatology, pediatric cardiothoracic surgery, pediatric surgery, pediatric otolaryngology and additional provider staff provided the surgical and clinical care needed to overcome the missing trachea.

Over the next three months, surgeons connected a section of the infant's esophagus to the lungs, creating an alternative airway leading to an opening at the base of the throat. Because the wall of the esophagus is floppy compared to the trachea's rigid structure, a rigid ringed sleeve made of ski jacket material was placed over and sewn to the esophagus to prevent the reconstructed airway from collapsing. The boy is now home and breathing without a ventilator and eventually will have his stomach reconnected to the remaining esophagus.

The baby is the oldest US survivor of tracheal agenesis; four people in Japan have survived for years after similar surgeries. "The teamwork, talent and wide-ranging expertise from our academic medical center were critical in this case," says John Densmore, MD, MCW associate professor of pediatric surgery.

Distinguished Pediatric Cardiac Surgeon Joins MCW

Viktor Hraska, MD, PhDViktor Hraska, MD, PhD, among the world's most distinguished experts in pediatric cardiac surgery, joined MCW in July 2016 as professor of surgery and division chief of congenital heart surgery. He also is medical director for cardiothoracic surgery at Children's Hospital of Wisconsin and The S. Bert Litwin Chair of Cardiothoracic Surgery at Children's. Further, he serves as surgical director of the Herma Heart Center and as a member of Children's Specialty Group, a joint venture between MCW and Children's.

Dr. Hraska is an accomplished pediatric cardiovascular surgeon with vast clinical, teaching and research expertise. He trained in Europe and at Boston Children's Hospital – completing residencies in anesthesia, cardiology, surgery and vascular surgery, and fellowships in cardiac surgery and pediatric cardiac surgery. Dr. Hraska regularly lectures worldwide on pediatric cardiac surgery topics and has published extensively.

The Children's Herma Heart Center team, which includes surgeons Michael Mitchell, MD, and Ronald Woods, MD, along with MCW faculty in disciplines such as anesthesia, critical care and cardiology, has led groundbreaking work that has produced some of the best outcomes in the world for pediatric heart surgery.

Dr. Hraska joins 10 other surgeons in providing a six-year integrated cardiothoracic surgery training program. MCW is one of the first in the country to offer an integrated program that provides a more streamlined approach than traditional surgery curricula.

– Greg Calhoun | Sara L. Wilkins

MCW Magazine: Clinical story

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