From hotline to surgery – How CHOC guided a family through an emergency during COVID-19

As the parent of a child with gastrointestinal issues, Kris wasn’t immediately concerned when her son Nolan complained of a stomachache while they were watching TV together. When his pain quickly got worse and Nolan started to vomit, Kris knew it was time to call CHOC.

“With COVID-19 going on, I didn’t know if the pediatrician’s office or emergency room was the best place to bring him. I didn’t want to take a spot in the waiting room from someone who needed it more than us,” Kris said.

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Nolan with his mom Kris

Luckily, Kris had noticed on social media that CHOC had implemented a COVID-19 hotline staffed by a team of registered nurses. She called the hotline for advice on where to safely seek care for her son during the pandemic.

“As the parent of an immunocompromised child, I knew CHOC could help,” Kris says. “A nurse took our call, and within a few minutes we were on a Zoom video call with a doctor. She gave us very clear parameters of what to watch for and when to call back. Nolan’s symptoms got worse, and when we called back, we were immediately patched through to a video call with a pediatrician.”

Dr. Lori Openshaw, a CHOC Children’s pediatrician, spoke with Kris and Nolan via video chat. After taking a medical history, Dr. Openshaw was able to walk Kris through doing an abdominal examination on Nolan, while the physician closely observed via video. With Kris’ help, Dr. Openshaw better understood the location and intensity of Nolan’s pain, and what might be causing his symptoms.

“Dr. Openshaw told me exactly what to do. She told me where to push on his stomach and where not to push. She paid attention to Nolan’s facial expressions during the exam,” Kris says.

Dr. Openshaw highly suspected that Nolan may have appendicitis and needed an urgent surgical evaluation. She directed Nolan and his mom to get to the Julia and George Argyros Emergency Department at CHOC Children’s Hospital quickly.

“By the time we got to CHOC, they were ready for us,” Kris says. “Dr. Openshaw had called the emergency department and told them we were coming. She gave us instructions to wait in the car at valet, and a staff member would come to the car and ask for our name. It was clear that everyone from valet to security was following protocol implemented to keep people as safe as possible during this pandemic.”

Nolan’s room in the emergency department was ready and waiting for him. He and his mom noted how everyone in the emergency department, and the medical unit to which he was admitted overnight, was calm and collected, which in turn helped them feel calm during a stressful health emergency.

Although Nolan has been a patient at CHOC many times before, he and Kris noticed that a few things were different about this trip to CHOC. To protect the health of patients, families, doctors, nurses and staff during the pandemic, CHOC had implemented a variety of safety measures. Kris and Nolan noticed that everyone underwent a health screening before entering the hospital, people wore masks (and more protective equipment when necessary), social distancing measures were in place with people staying 6 feet apart whenever possible, and additional cleaning measures were carried out on top of CHOC’s already stringent cleaning practices.

“Seeing people go above and beyond to keep patients safe, healthy and comfortable during this time is what makes CHOC so different and so special,” Kris says.

Testing confirmed Nolan did indeed have appendicitis, and his surgery was scheduled for the next morning with  Dr. Mustafa Kabeer, a pediatric general and thoracic surgeon. Surgery was a success.

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Nolan was in good spirits while recovering from surgery.

Nolan appreciated that staff made him feel as comfortable as possible during his stay.

“CHOC sees you as a person, not just a patient,” Nolan says. “Everyone explained to me what would happen and what medicine I would get. They made it easy for me to understand what was going on, which made the process feel smooth.”

Having a hospitalized child during a pandemic isn’t something Kris envisioned, but she knew Nolan was in good hands.

“It gave me peace of mind that there was consistency in protocols from each area of the hospital that we interacted with,” Kris says. “Everything was well thought out, and it was clear that everyone had bought into the changes being implemented throughout the hospital.”

Kris noticed that staff were reminding each other of changes in protocol, which further reassured her that the hospital was a safe place.

“Hearing nurses and other staff remind each other of things – whether that be a change in protocol, or where an item had been moved to – reassured me that the decisions CHOC had made to keep people safe were being upheld throughout the hospital.”

Nolan shares in his mom’s appreciation for CHOC.

“You never want to be sick, but if you’re going to be sick, you want to be sick at CHOC,” he says.

Nolan only had to stay at CHOC one night after surgery for observation and went home the next day. Dr. Openshaw, although not Nolan’s primary pediatrician, called several times to check up on him after surgery.

“Dr. Openshaw’s care and follow-up made us feel comfortable and assured,” Kris says.

Today, Nolan is back at home, getting reacclimated to distance learning while his school is closed – he’s also learning how to cook and do laundry before he heads off to college in the fall.

Kris is happy to have this health scare behind them, but grateful she knew who to call when her son was sick.

“CHOC has always known what is best for my child. No matter what is going on around us – even a pandemic – doing what’s best for my child will always be CHOC’s priority,” Kris says. “I knew the only place I would trust information from during this time was CHOC. The fact that they had set up a COVID-19 hotline for parents was just another sign that they are always three steps ahead in every situation.”

Get more information on Coronavirus (COVID-19)

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The Appendix: 5 Common Questions

More than 700 kids are treated for appendicitis at CHOC Children’s every year. The appendectomy is one of the most commonly performed surgeries in the world. But just what is the appendix, and why does it send so many people to the emergency room with stomach pain?

Dr. Peter Yu, CHOC Children’s pediatric general and thoracic surgeon, explains everything you’ve ever wondered about the appendix, and more.

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Dr. Peter Yu, pediatric general and thoracic surgeon at CHOC Children’s

 

  1. What does the appendix do?

The appendix is a small, finger-like projection that sticks out of the large intestine, located in the right side of the abdomen. It weighs about as much as an earthworm. In fact, its old-fashioned name is vermiform appendix, which means worm-like, Dr. Yu explains.

Everyone’s appendix is different. Some are long, some are short and stubby. But one thing they all have in common is that they are not necessary for a happy, healthy life.

“We are not sure if the appendix has a purpose. Some doctors don’t believe it does anything,” Dr. Yu says. “Some think it plays a role in the development of the immune system, and some believe it harbors ‘good bacteria’ that helps intestinal health. The bottom line, though, is that appendicitis is common, and patients do extremely well after removal of their appendix.”

  1. What causes appendicitis?

Bacteria naturally live in the large intestine and flow in and out of the appendix. Sometimes, the opening to the appendix gets blocked. Either constipation, a hard piece of stool called a “fecalith,” or enlarged lymph nodes cause these blockages.

The blockage traps the bacteria inside where it festers and multiplies. This leads to inflammation of the organ. If left untreated, the appendix can burst, releasing the infectious bacteria into the body.

Symptoms of a Burst or Inflamed Appendix

What are signs of appendicitis?

  • sudden severe pain
  • pain that starts near the belly button and moves to the lower abdomen on the right side
  • fever, nausea or vomiting

To diagnose appendicitis, the Julia and George Argyros Emergency Department at CHOC Children’s Hospital will check your child’s blood for signs of an infection and will do an ultrasound of the abdomen. While many hospitals use a CT scan to diagnose appendicitis, CHOC radiologists and sonographers have the training and experience to make a diagnosis using ultrasound, in order to minimize your child’s exposure to radiation. If the ultrasound is inconclusive, the radiologist may conduct a CT scan.

  1. How does the surgeon remove the appendix?

The surgeon will perform a procedure called a laparoscopic appendectomy to remove the appendix. A pediatric anesthesiologist will put your child to sleep using general anesthesia. The procedure takes about 30 minutes, though CHOC’s pediatric general surgeons can remove the organ in less than 10 minutes if needed.

During surgery, three tiny incisions are made on the abdomen. Carbon dioxide is blown into the belly to create a dome, giving the surgeon room to work. Small surgical tools are inserted in two of the incisions and a laparoscopic camera is inserted in the third. The appendix is identified, stapled or tied off, and removed.

The surgeon closes the incisions with surgical glue and dissolvable strips. In most cases, children will stay in the hospital for one day before the doctor discharges them. They should have no heavy activity or sports for two weeks after surgery and can usually return to school quickly, often even the next day.

  1. What do you do with the appendix after you take it out?

Pathologists then inspect the removed appendix in the pathology department under a microscope. This inspection is important because it will confirm the diagnosis of appendicitis and rule out other conditions such as ulcerative colitis, Crohn’s disease and carcinoid. Your surgeon will update you with the results during your follow-up appointment.

  1. What if my appendix bursts?

“Fortunately, perforated appendicitis is less common than non-perforated appendicitis, but it can happen,” Dr. Yu says. “For some, the appendix can burst quickly, and for others it does not burst at all. There are many factors that a surgeon will consider before deciding whether to operate immediately, or to wait.”

If your surgeon decides to wait, then treatment can include antibiotics, placement of a drain in the abdomen, and nutrition through an IV if needed. Most patients improve in several days, after which the doctor discharges them. Your surgeon will then schedule your child for an interval appendectomy, which is removal of the appendix 8-12 weeks later. This gives the body time to recover from the infection and inflammation, making surgery safer and less complicated.

The CHOC Emergency Department, equipped to treat appendicitis 24 hours a day, with pediatric surgeons ready for all situations is mainly for kids and teens.

Learn more about appendicitis in kids and teens

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An Unexpected Case of Appendicitis: Jordan’s Story

Six-year-old Jordan was enjoying a fun break with his family in Big Bear, Calif. when he started complaining of stomach pains one afternoon. He had no chronic conditions or other symptoms, so his family didn’t immediately think it was anything serious. They assumed it might be a stomach virus, and never imagined that he would need to undergo surgery at CHOC Children’s a mere 24 hours later.

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When Jordan complained of stomach pains while on vacation with his family, they never imagined he’d undergo surgery a mere 24 hours later.

Late that night Jordan was in tremendous pain, so his parents took him to an emergency room near their resort. Two local physicians ruled out anything serious. They told Jordan’s parents it was likely just constipation or gas, and sent Jordan home.

“We were wary of the diagnosis received and being vigilant, we cut our family vacation short and rushed home so we could be closer to CHOC if his condition worsened,” says Jordan’s mom, Emma.

His pain became unbearable overnight.

“We knew his pain was abnormal and didn’t want to take any more chances at any local hospital. I wanted to know my son was in a place that specializes in kids.”

An accurate and timely diagnosis at CHOC

Testing in the ED immediately revealed that Jordan had a unique case of appendicitis with ileo-colic intussusception (a condition where part of the intestine folds into itself, like a collapsing telescope), and would undergo surgery that same day.

“Appendicitis is the most common reason for abdominal surgery in children. Pediatric surgeons at CHOC saw over 700 cases of appendicitis last year,” says Dr. Peter Yu, a pediatric general and thoracic surgeon at CHOC. “Many of these patients first come through the emergency department, meaning our ED staff is well-versed in both classic and non-traditional symptoms of appendicitis, and very unlikely to miss a diagnosis. Also, when we discover unusual variations associated with common childhood illnesses, such as ileocolic intussusception with acute appendicitis, the pediatric surgeons here are prepared to deal with it.”

Surgery at a Place Designed Just for Kids

Receiving a correct diagnosis faster meant that Jordan was on his way to surgery before his symptoms worsened.

“Jordan’s parents made a good decision in bringing him straight to CHOC,” says Dr. Yu. “If they had gone to an ‘adult’ hospital first, they would likely have been transferred to CHOC for surgery anyway.  This can be costly, delays care, and can be a huge inconvenience for families.”

Learning that your child needs surgery can be scary for parents to hear. But thanks to Jordan’s parents’ decision to bring him to a hospital that only treats kids, Jordan was under the care of pediatric-trained specialists using equipment that’s made just for kids.

CHOC has pediatric surgeons on call 24/7, meaning there is always a pediatric-trained specialist ready to treat your child, no matter what time of day or night your child needs surgery.

“These events are extremely stressful as a parent because while we are still digesting the diagnosis, we need to ensure we make sound decisions in a short amount of time,” says Emma. “Dr. Yu was patient and very thorough, and I knew there was no one else I would rather have care for my son.  He was in excellent hands. We were probably his last surgery of the day but he made us feel like we were his first.

After making the decision to return to CHOC for Jordan’s correct diagnosis and surgery, their son was not only in the hands of a pediatric surgeon, but a pediatric anesthesiologist as well.

“Although, an appendectomy is one of the less invasive surgeries a child can undergo, as a parent you’re still very much concerned of the potential issues that could arise from going under anesthesia,” Emma recalls. “Knowing he was under the care of an anesthesiologist who specializes in children was a great comfort to my husband and me. After we met with his surgery team, we knew he was in the best hands possible.”

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Jordan and his pediatric surgeon., Dr. Peter Yu.

Healing faster in an environment just for kids

Jordan sailed through surgery with flying colors. His appendectomy was done via a single incision hidden in his belly button, meaning he will have minimal to no scarring after surgery. His intussusception self-resolved and needed no additional surgical intervention.

After surgery, Jordan only needed to stay at CHOC for one night for observation, but he had so much fun that he would have stayed even longer if he could have, Emma recalls.

“Jordan loved being at the hospital because he felt like he was the boss! Everyone was so attentive to him. Every person that we interacted with, from the nurses that cared for him and spoke in a way he would understand, to the volunteer in the play room that let Jordan teach him how to play chess, helped make CHOC a kid-friendly place. I know any fear of doctors, hospitals and surgery that Jordan had were all lessened because of this environment.”

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Jordan only had to spend one night in the hospital after his emergency surgery for appendicitis. In that time, he benefited from the generosity of a volunteer in one of the hospital’s play rooms, who let Jordan teach him how to play chess.

Jordan spent a few days resting at home and was back at school the following week.

“Dr. Yu helped get us through this high-stress situation with our son with the amount of professionalism and care you would ever want in a scary time. He is hands down one of the best. We’ll be forever grateful to Dr. Yu!” says Emma. “Now that I know how wonderful the emergency department and entire staff is at CHOC, I won’t take my kids anywhere else.”

Get answers to parents’ frequently asked questions about surgery

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Stomach Flu or Appendicitis? What Parents Should Know

Parents often mistake appendicitis for a bad stomachache. It can be particularly difficult to diagnose in younger children, who can’t adequately describe their pain. CHOC Children’s pediatric surgeon Dr. Troy Reyna, who says appendicitis is the most common reason for abdominal surgery in children, provides helpful insight for parents in the following Q & A.

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What is the appendix? 

The appendix is a small extension of the intestine usually the size and length of one’s little finger. The appendix finds its home in the right lower corner of the abdomen. It is attached to the cecum, which is the beginning of the large intestine.

What is appendicitis?    

It is thought that appendicitis starts as a result of obstruction either by swelling of the inner lining (mucosa) or by hard stool (fecalith). Once the obstruction starts, the appendix swells, resulting in pain that may start centrally and later migrate to the lower right abdomen. Anyone with an appendix can get appendicitis. Approximately 80,000 children in the United States suffer from it each year.

How do I know my child’s pain is related to appendicitis?

The pain with appendicitis may be vague in the beginning and be confused with the stomach flu. Generally, though, the flu will subside after 24 hours of slight bowel rest. In appendicitis, the pain will increase in intensity and often cause a child to become immobile, as movement can aggravate the pain. The location of the pain is usually midway between the navel and the right hip bone. Pain that persists and is associated with other symptoms, such as vomiting, decreased appetite, decreased frequency of stools or changes in mental status, requires prompt attention by a medical professional.

What will be done for my child?             

If your child is seen in a doctor’s office and his exam is mild, you will likely be advised on fluid management and told to follow up in 24 hours if no improvement is noted. If your child is seen in a pediatric emergency facility, such as the Julia and George Argyros Emergency Department at CHOC Children’s Hospital, he will likely receive an IV (intravenous) to get needed fluids, and get blood drawn for a lab study. He may also receive an abdominal ultrasound. If a diagnosis of appendicitis is considered, then a pediatric surgeon will be called to assess your child and address any questions or concerns you may have.

What kind of operation is involved?     

The operation for appendicitis is usually done with laparoscopy. One to three small incisions are made in the belly button and off to the side. Small plastic tubes are placed through the incisions. A camera is placed into the abdomen to visualize the appendix or look for the cause of the pain. The appendix is usually then stapled or tied off and removed. The small incisions are closed. If the appendix was not ruptured, your child can drink and eat as soon as it is safe and go home within 24 hours of surgery. If the appendix is ruptured, your child will need extra antibiotics for several days to treat the peritonitis and prevent further infection.

What if it is not appendicitis?   

The appendix is carefully inspected during the surgery. In about 15 to 20 percent of the time, the appendix is normal and another cause is discovered that will require surgery. The cause may be an anomaly of the gastrointestinal tract. In girls, the problem could also be related to the fallopian tubes or ovaries. Whatever the cause, it will be treated. After surgery, the pediatric surgeon will brief you thoroughly on details and expectations.

What can I expect after surgery?              

After your child is discharged from the hospital, there will be a short recuperation at home – approximately two to three days. He will be restricted from physical education for two to three weeks. He’ll need to be seen, for follow up, by his surgeon about two weeks after leaving the hospital. Within six weeks, your child should be able to resume normal activity.

Dr. Troy Reyna is a pediatric surgeon with CHOC Children’s Specialists. He is board certified in general and pediatric surgery. He can be reached at 714-364-4050.

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