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.
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.”
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.”
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.”
Lizette Lough, experiencing a seemingly normal pregnancy, was making final preparations to welcome her first baby, when her water unexpectedly broke at 33 weeks. She was rushed to San Antonio Regional Hospital in Upland, close to home, where her son Landon was born early on May 3, 2016.
After a few days in the hospital, Lizette and her husband Sean noticed the baby had not made a bowel movement. Tests revealed that Landon had an obstruction in his intestine. His physician recommended Landon be transferred immediately to CHOC for an emergency surgery with Dr. Peter Yu, a pediatric general and thoracic surgeon.
“My husband and I lost it,” Lizette says. “Our baby was only three days old and weighed about 4 pounds. The thought of surgery was beyond frightening.”
Upon arrival at CHOC, the Loughs were immediately made to feel at home by the staff, who helped them find a nearby hotel. Dr. Yu explained every scenario of the complex surgery in a compassionate and confident manner, the Loughs recall.
“Landon was in stable condition when he arrived at CHOC, and I’m very pleased that our expert transport team was able to get him here quickly and safely. If there had been a delay in transfer, Landon could have become very sick and it’s very possible that more of his intestine could have died. If that would’ve happened, he may not have had enough bowel to adequately digest food, which can be incompatible with life,” Dr. Yu says.
Landon was diagnosed with jejunal atresia, a rare condition – approximately 1 in 5,000 births – in which the small intestine is incompletely developed, leading to one or more gaps, or blockages, in the intestinal tract.
Lizette had gone through the required genetic tests prior to Landon’s birth, and jejunal atresia – often diagnosed prenatally – was not detected.
Additionally, Landon had malrotation of his intestines, which failed to coil in the proper position in the abdomen. This led to twisting of his bowel. If surgery had been delayed for longer, Landon could have died.
Landon’s surgery involved making an incision on his abdomen, examining the entire length of his intestine and untwisting it, removing the dead bowel, stitching together his small intestine, and performing a Ladd’s procedure. A Ladd’s procedure places the intestines back into the abdomen in a safe configuration to prevent future twisting of the bowel.
Sean, who works as a law enforcement officer, recalls how traumatic this was for his family. “I’m used to working in stressful situations, but this was a different kind of stress,” he says. “We were so happy that our baby had a successful surgery and that he was better. However, we were still waiting for him to have his first bowel movement. We were trying to stay positive.”
After his first bowel movement indicated that his intestines were recovering well, and spending about a month in CHOC’s surgical NICU, Landon was finally able to go home with his family.
“It takes a team to successfully care for sick babies and complex patients,” Dr. Yu explains. “Landon would not have had the excellent outcome that he had without our wonderful neonatologists, experienced and skilled pediatric anesthesiologists, Melissa Powell, our dedicated surgical neonatal nurse practitioner, and the outstanding NICU nurses who have dedicated their lives to taking care of newborn babies such as Landon and countless others. Together, we have the only dedicated surgical NICU in the area, with a special focus on taking care of newborns with surgical problems.”
Thanks to the expert multidisciplinary care provided at CHOC, today Landon is a happy baby, meeting all his milestones. The Loughs are enjoying their brave little boy, and look forward to his first birthday next month.
“Dr. Yu and the nurses in the NICU were so empathetic and amazing. They saw us through so much throughout our stay and we will forever be thankful,” Lizette says.
You want to know your child who needs surgery is in the best hands. Kids’ bodies are completely different inside, and pediatric specialists know the difference. Pediatric anesthesiologists at CHOC Children’s, who lead your child’s surgery team, have compiled a list of questions commonly asked before surgery. Any question about your child is a good question. If there is ever anything you do not understand, ask your child’s surgery team. They are there to help.
Am I allowed to be with my child before surgery? If so, for how long?
Before surgery, you and your child will be taken to the pre-operative unit, or “pre-op.” A nurse will review the information needed to safely perform the child’s procedure. The surgeon and the anesthesiologist will evaluate your child and answer any questions you have. You will be asked to sign any necessary paperwork and then accompany the child to the operating room doors. After another hug and kiss, the team will assume care of your child.
Am I allowed to be with my child while anesthesia is being given?
You child’s safety is our biggest priority. Having a parent in the operating room can distract the team’s focus away from your child. To ensure the safest environment possible for your child, you will be taken to the waiting room.
Will my child have pain when getting an IV?
Depending on the child’s age and planned procedure, we may start an IV in the pre-op unit. An IV is a small plastic tube inserted into the vein and used to deliver medication. Depending on the age of your child, a small amount of anti-anxiety medicine may be given orally before placement of the IV. The staff will also use special numbing medicine to reduce the discomfort of IV insertion. A child life specialist will provide age-appropriate distractions such as books, games, or bubbles to aid in the process.
What kind of anesthesia will my child be given?
Anesthesia is broken down into three main categories: General, Regional, and Local.
General anesthesia makes and keeps a person completely unconscious (or “asleep”) during the operation. It can be administered through an IV, or by inhaling an anesthesia gas delivered by mask.
Regional anesthesia is when a drug is injected near the spinal cord, numbing a large area of the body. An example is an epidural. It is often combined with general anesthesia in kids and used for pain control after the surgery.
Local anesthesia numbs a small, specific area of the body- for example, a foot, hand or patch of skin. It can be given as a shot, spray or ointment. Local anesthesia is often used to reduce the pain after surgery.
The anesthesia your child receives is tailored to their needs and depends on factors including:
The type of surgery
The location of the surgery (hospital, outpatient surgery center or doctor’s office)
How long the surgery will take
Current and previous medical condition
Previous reactions to anesthesia (in your child or family members)
Medications your child is currently taking
Age, height and weight
No matter which type of anesthesia your child receives, your anesthesiologist will be available before, during and after the operation to monitor the medications your child receives and ensure they are receiving the right amounts.
Will my child be sedated before anesthesia is given?
Your child may receive medication to help them remain calm and feel sleepy before the procedure or surgery. This medication is usually given by mouth and before starting the IV. Many children are curious about the operating room and prefer to experience falling asleep in the OR, so they skip the sedative.
Will my child still have an IV in or be hooked up to any monitors or equipment after surgery is over?
Your child will usually wake up with their IV in place. This is helpful as additional medications are sometimes needed to treat pain or nausea. Your child will also wake up with several monitors that help the anesthesiologists and nurses monitor your child’s recovery from anesthesia. These monitor blood pressure, heart rate and oxygen levels. As your child recovers from anesthesia, the IV and monitors will be removed.
How long will it take my child to fully wake up from general anesthesia?
The anesthesiologist will begin to “wake up” your child after the surgery is completed. This amount of time varies from child to child and is dependent on their medical history and type of surgery performed. This can take up to an hour, and most children wake up in the recovery room (also referred to as the post anesthesia care unit, or PACU) in a shorter amount of time. Full recovery can take up to several hours.
How soon after the surgery can I see my child?
After the surgery is completed, the surgeon will speak with you in the Tidwell Procedure Center lobby. It may take an additional 20 to 30 minutes for the nursing staff and anesthesiologist to recover your child from anesthesia before having you enter the recovery room (PACU).
How soon after the surgery can my child eat, drink, go to school, or drive [if you have a teen]?
If your child is going home after surgery, the nurse will offer your child a snack and drink in the recovery room. No driving for teens the day of surgery. The surgeon will provide a school note if time off is required. If a hospital stay is required, and depending on the procedure, the surgeon will order the appropriate diet.
How soon after the surgery can my child go home?
Children usually spend 30-90 minutes in the recovery room. Patients heading home will be provided a discharge plan. This plan may include instructions on how to take care of the operative site, what medications to take, what your child should eat that day, and what activities the child may participate in. It will also have instructions on what to look out for and when to call the doctor. Download a copy of the discharge questions worksheet.
You will receive a phone call from a CHOC nurse within 72 hours of the patient’s discharge from the hospital. Our nurse will ask about how the child is feeling and will be able to answer any additional questions you may have.
Having surgery at a hospital can be a scary thought for children and parents, alike. Knowing what to expect can help alleviate fear and anxiety. The photos below highlight some key aspects of the patient and family journey through the Tidwell Procedure Center at CHOC Children’s Hospital.
Welcome to CHOC Children’s Hospital – a hospital for children and teens, only. When a child requires surgery, his needs are different than an adult. CHOC has specialized in pediatric surgery since we welcomed our first patient in 1964. Today, our nationally recognized surgeons perform the latest procedures using equipment customized to pediatric patients, from newborns to adolescents.
After checking in at our first floor lobby, surgical patients and their families are directed to our Tidwell Procedure Center, which includes seven operating rooms, five procedure rooms and two cardiac catheterization labs. The Center boasts leading-edge technology and safety features, as well as a calm, healing environment. Here’s the Center’s bright, colorful lobby, featuring natural light, bubble columns and interesting artwork. There’s also a family room and playroom.
We want our patients and their siblings to still have the opportunity to act like kids while facing the adult issues of surgery. In addition to a playroom in the lobby, we have an area for play, stocked with books and toys in pre-op. Dedicated child life specialists help normalize the experience by making the environment less strange. Providing distraction and developmentally appropriate education, child life specialists are important members of the surgical team.
Child life specialists are at the bedside to provide developmentally appropriate education. Patients are able to see pictures of the operating rooms on iPads, which helps to limit stress and anxiety without the use of medication.
Before heading into the operating room, patients stop at what is affectionately called the “kissing spot.” Here’s where they can say “see you later” to their loved ones before “taking a nap” for surgery.
Child life specialists escort patients into the operating rooms and to provide distraction and emotional support while pediatric anesthesiologists and other staff members prepare patients for surgery.
Following surgery, patients recover in our PACU (post anesthesia care unit). As soon as the patient is stabilized, parents/legal guardians are escorted into the area. During this time, patients need as much rest as possible to help their bodies heal and give pain medication time to take effect. The environment is kept calm and quiet. From here, the patient will either be taken to a hospital room, or discharged home.
Our physicians, nurses and staff are dedicated to getting kids better and back to their normal activities as quickly as possible. Patients and families are our partners in this effort; knowing what to expect before, during and after surgery can make a big difference on the experience and recovery. For more information, visit www.choc.org/surgery.
By Dr. Peter T. Yu, pediatric general and thoracic surgeon at CHOC Children’s
5:00 a.m.: Alarm rings. I hit snooze once, for an additional 9 minutes of peace. Then it is time to get up and at ’em. In the dark, I attempt to avoid injuring myself on the various toys that are strewn about the house–one of the hazards that comes with raising young children. I start the coffee maker, brush my teeth, shave, get dressed and kiss my slumbering family good-bye. Then it is off to swim practice.
7 a.m.: Swim practice is over. Fatigued but happy, I shower and joke with the teammates on my masters swim team. I am grateful for my health and momentarily enjoy the small personal accomplishment of having completed my workout for the day.
7:30 a.m.: After navigating moderate traffic and enjoying NPR, I arrive at CHOC. I meet with the very kind family of my first patient, a 5-year-old boy who is having inguinal hernia/hydrocele surgery today. In children, an inguinal hernia is a small, congenital opening in the groin that allows communication between the abdomen and the scrotum in boys and the labia in girls. Thus, things like fluid, fat, omentum or intestines can pass through this opening, creating a bulge and sometimes causing pain. A hydrocele is related to an inguinal hernia and is due to fluid that has passed from the abdomen, through the opening, and into the scrotum. Inguinal hernias occur in about 1-5 percent of all children. Hernia and hydrocele surgery are routine operations for all pediatric general and thoracic surgeons and, as expected, the operation goes smoothly.
9:00 a.m.: For my second operation of the day, Dr. Mustafa Kabeer, a fellow pediatric general and thoracic surgeon, and I perform a minimally invasive Nuss procedure on a teen athlete. This patient, who hopes to earn a college scholarship, has pectus excavatum or sunken chest, the most common congenital chest wall abnormality in children. For many, this is far more than a cosmetic problem. Using small incisions that will ultimately be well-hidden in this patient’s armpits, we are able to insert a metal bar between his heart and his chest wall that helps to pop the sternum out into normal position. This bar will stay in place for three years, before it is removed in an outpatient procedure. Our operation today took only 2 small incisions and 45 minutes of operating time. We prefer the minimally invasive Nuss procedure to the older, more invasive Ravitch procedure since it achieves a wonderful outcome with less pain, minimal blood loss and only tiny, hidden scars.
10:00 a.m.: As the anesthesiologist and the operating room staff prepare for my final case of the day, I walk over to the surgical neonatal intensive care unit and medical/surgical unit to make rounds and touch base with my team of excellent, experienced surgical nurse practitioners (NPs). Not a day goes by that I am not thankful for their contributions to the outstanding care of our surgical patients at CHOC. Currently, on the surgical floor, I have patients who have recently had appendectomies, a cholecystectomy (removal of the gallbladder), lysis of adhesions (cutting of intra-abdominal scar tissue) to treat a small bowel obstruction, port placement for chemotherapy, and a Nissen fundoplication for gastroesophageal reflux disease. In the NICU I have one baby with congenital diaphragmatic hernia whom I recently placed on ECMO (extracorporeal membrane oxygenation), state-of-the-art technology that supports the heart and lungs by taking over the heart’s pumping function and the lung’s oxygen exchange. A second patient of mine in the NICU is a baby who recently had esophageal atresia/tracheoesophageal fistula surgery to repair a congenital defect where the trachea, or windpipe, abnormally communicates with the esophagus, or food tube. Fortunately, all patients are doing well, I am able to address the questions of each of my patients and their parents, and the NPs and I come to a consensus on the plan of care for the day for each one.
10:30 a.m.: Once rounds are done, I head back to the operating room for my final case of the day, a thoracoscopic lung lobectomy. This is one of my most favorite operations and is my area of expertise. This 3-month-old patient was diagnosed prenatally when an ultrasound showed a congenital lung lesion, also known as a CPAM (congenital pulmonary airway malformation, formerly known as CCAM). This diagnosis is becoming more and more prevalent, occurring in about 1 in every 5,000 babies. Fortunately, more than 90 percent will be symptom-free during pregnancy and after birth, allowing pediatric general and thoracic surgeon such as myself to hold off on surgery until the infant is a few months old and better able to tolerate the stress of an operation. Even though infants with CPAMs may be asymptomatic, it is still recommended that these lesions be removed because they can often become infected and, in rare instances, may become a cancer later in life. The benefit of operating sometime during the first several months of life is that the CPAM has yet to become infected, making surgery easier and allowing for a minimally invasive removal. Thanks to the patient’s young age, the remaining portion of her healthy lung will grow in size and compensate for the removed lobe.
Thoracoscopic lung lobectomy is extremely technically challenging because the surgeon navigates major blood vessels such as the pulmonary artery and pulmonary vein, and operating time can vary from two to six hours depending on a patient’s particular anatomy. Fortunately, this little baby’s anatomy is favorable and I am able to complete the minimally invasive operation in about 2 hours with minimal blood loss and an excellent outcome. After surgery, I have the privilege of giving her parents good news, which is always the best part of my work day. I anticipate that she will have a two-day hospital stay with minimal pain and no complications, and her tiny scars will ultimately be unnoticeable by others (except for mom! Pediatric surgeons know that moms see everything J).
1:00 p.m.: I have a quick lunch with my NPs and Dr. David Gibbs, another pediatric general and thoracic surgeon at CHOC who is also the medical director of trauma. He has established the excellent trauma program we have here, the only trauma center in Orange County that is exclusively dedicated to children. We take a moment to enjoy each other’s company, get trusted input on current clinical situations, and catch our breaths from this very typical, fast-paced workday.
2:00 p.m.: I participate in a fetal counseling session. Given my special training in fetal surgery, I work closely with community perinatologists (also known as high-risk obstetricians or MFMs–maternal fetal medicine physicians) to counsel expectant mothers and fathers on what to expect when their baby has been diagnosed in utero with a condition that will require surgery.
Today, I meet with parents whose daughter has been prenatally diagnosed with congenital diaphragmatic hernia, or CDH. Simply put, CDH is a hole in the diaphragm, which is the muscle that divides the abdomen from the chest. The diaphragm helps us breathe, and a hole here allows things that are normally in the abdomen, such as the liver or intestines, to pass into the chest. Besides potentially compromising the intestine itself, this can also lead to small lungs (pulmonary hypoplasia) which may not be able to adequately oxygenate the body. Another severe consequence of CDH is pulmonary hypertension, which is abnormally high pressure in the blood vessels of the lungs. This is a problem because a newborn’s heart must work extra hard to pump blood into this abnormal high-pressure system, which can lead to heart failure and death if not appropriately treated.
I go over the diagnosis with mom and dad, and explain to them that, after birth, their baby will require a breathing tube and ventilator to support her small lungs. Special inhaled and intravenous medications will be used to decrease the high blood pressure in the blood vessels in the lungs and to help support her beating heart. If these measures are not enough, we will need to use ECMO. If ECMO is needed, I will perform a surgery to make an incision on her neck to access her carotid artery and jugular vein so that ECMO catheters can be placed.
Ultimately, once their daughter’s heart and lung condition has stabilized—which may take days to weeks after birth—I will repair the congenital diaphragmatic hernia. To do this, I will make an incision on the abdomen, move the intestines and liver from the chest back into the abdomen, and stitch the hole closed.
I am careful to be upfront and honest about the situation: CDH is a serious and frequently life-threatening condition and the national average for survival is approximately 65 percent. Their daughter will likely require a two to three month stay in our NICU and may need to go home with supplemental oxygen and special medications for a period of time. However, I’m able to reassure them as well. Nearly 90 percent of newborns that have this surgery at CHOC survive. At CHOC, we are fully equipped and have the expertise to handle any possible outcome, thanks in part to our surgical NICU, the only one of its kind of the west coast.
Mom and dad are tearful at the gravity of their daughter’s situation but they also express how grateful they are for the opportunity to learn more about CDH, have their questions answered, and leave feeling better prepared for the next steps. They know they can contact us at any time, day or night, and we will be there to address any problem and provide support. They also feel relieved that they will be surrounded by familiar, trusted faces when their daughter is born.
3:00 p.m.: I head back to my office with some precious time to complete some homework—yes, I said homework—and work on research projects. Believe it or not, I have gone back to school to get my Master of Public Health degree from Johns Hopkins University. This is feasible because I am able to complete the majority of my coursework online. I wanted to get this additional degree to gain knowledge and experience in outcomes research, a relatively new branch of public health research that seeks to understand the end results of particular health care practices and interventions. While pursuing this degree, I am simultaneously working on outcomes research projects with my research partner, Dr. Yigit Guner, another pediatric general and thoracic surgeon at CHOC. Together we are utilizing large national databases to create risk calculators that can help better predict CDH outcomes, as well as predictoutcomes in other neonatal diseases such as VACTERL (vertebral defects, anal atresia, cardiac defects, trachea-esophageal fistula, renal anomalies, and limb abnormalities).
6:00 p.m.: I head home for the day. En route, I call my mother who lives out-of-state to check in. My father recently passed away after a long struggle with illness and I just want to make sure she’s doing alright. She assures me that she is, and stubbornly resists my suggestions to have her move to Orange County. She is happy and comfortable in her home, which makes me happy as well, but I am concerned that I will be unable to adequately help her in the years to come should her health someday fail.
6:30 p.m.: I’m happy to be home with my family. It’s dinner time and I’m famished. I relish the chance to catch up on the day’s events with my wife and kids. I play with the kids for a bit and then it is time to help my oldest with homework. After that, my wife and I get all the kids ready for bed and tuck them in.
9:00 p.m.: My wife and I finally have a precious moment to ourselves. We watch a favorite TV show together and I barely make it to the end before falling asleep. It feels so good to lie in bed, with the cool night breeze filtering in through my bedroom window. I dream of my family, work and old friends. Tomorrow, I have clinic and then I will spend the remainder of the day and night in the hospital, as I am on call for any pediatric general, thoracic and trauma emergencies that come to CHOC. I feel so blessed to have the family that I have, and to be able to do the meaningful work that I do.