After a severe vehicular accident left a 7-year-old boy with a devastating leg injury, his parents traveled from their home state to Duke in hopes of saving the limb.
“This was as bad as it can be,” says Jeffrey Marcus, MD, chief of plastic surgery in the Duke Division of Plastic, Maxillofacial, and Oral Surgery and chief of surgery at Duke Children’s Hospital & Health Center, who examined the patient. “The injury involved devascularization and massive injuries to his nerves, blood vessels, and arteries—a scenario that could likely result in amputation at any medical center.”
To treat the complex needs of this young patient, a multidisciplinary team was required to attend to his immediate needs and coordinate his care. Marcus credits Duke’s “hospital within a hospital structure” that enables seamless access to both adult and pediatric specialties. “We needed many different skill sets to care for this patient,” he says. “Vascular surgery, plastic surgery, specialized reconstructive microsurgery to reconnect nerves and move tissues, an accomplished PICU staff to deal with the boy’s trauma—it takes a tremendous infrastructure to do all of this in a coordinated fashion.”
In addition to Marcus, Jonathan Riboh, MD, sports medicine orthopaedic surgeon, stabilized the boy’s leg initially, cleaning his wounds to reduce the risk of infection and applying an external fixator to provide temporary stability while his blood vessels were reconnected. Leila Mureebe, MD, vascular surgeon, performed the procedure that saved the leg. Henry Rice, MD, pediatric surgeon, led the case from the general pediatric surgical perspective. Elizabeth Hubbard, MD, pediatric orthopaedic surgeon, performed limb lengthening and bone grafting procedures. Suhail Mithani, MD, hand surgeon and extremities reconstruction specialist, performed reconstructive procedures.
“You might think that being at a free-standing children’s hospital would be better in a case like this,” says Marcus, “but it was better for this patient to be here at Duke because all of these terrific surgeons were on call that night. Some of them care mostly for adults but we needed their specific skill for this child.”
Rice notes that many providers from the ED, PICU staff, and other departments came together to care for the patient. “Our system is really geared to work together as an interdisciplinary care team, which is essential for the care of children with complex injuries,” he says.
Duke Children’s Hospital & Health Center was one of the first centers designated as a Level 1 children’s surgical facility by the American College of Surgeons in late 2016—the highest level of certification for children’s hospital surgical programs. “This was an extensive process involving every aspect of patient care,” says Marcus. “We needed to make some changes within our infrastructure to show that we could take care of the most complex of situations—exactly this type of scenario,” he says. Rice adds that the designation process resulted in enhanced capacity for comprehensive interdisciplinary care and demonstrated Duke’s leadership in providing the safest and highest-quality specialized surgical care for children.
The team was able to save the boy’s leg, and although he required several surgeries and a long stay in the hospital, he recovered well from the initial trauma and stayed at Duke until treatment was complete. The Duke team connected the family with providers at a major medical center in their home state where he will receive ongoing care.
“This case demonstrates everything that we’re supposed to be doing and that we hope to be able to do, and sets us apart from every other center in North Carolina,” Marcus says.