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One day at a time

| Monday, May 29, 2006

Dr. Barbara Gaines, a pediatric surgeon at Children's Hospital of Pittsburgh, rises before dawn. No time for breakfast on this cool April morning. Instead, she catches a few quiet moments with 8-month-old son Thomson before leaving for work.

It's a short trip from her home in Squirrel Hill to the hospital in Oakland, where she directs the hospital's Benedum Pediatric Trauma Program.

At the hospital she touches base with Dr. Justin Boccardo, a third-year general surgery resident who is wrapping up a 30-hour shift.

He insists he isn't tired. "You don't feel it till you stop," he says.

Children's is the destination for some of the region's sickest youngsters, and for kids who need medical care their local hospitals can't provide. Its trauma center -- one of just three Level I pediatric trauma centers in the state -- treats infants, children and teens who have been seriously injured or who require emergency surgery.

It's been a hectic night in the trauma center, Boccardo says -- a barrage of bicycle accidents, skateboard mishaps, go-cart crashes.

But as Gaines comes on duty, the center is quiet.

It is 6:30 a.m.

Gaines catches up with on-call trauma team members as they gather near the 10th-floor nurse's station. It's primarily a pre- and post-surgery floor. Many of last night's trauma patients have been brought here.

In addition to Boccardo, a chief resident, a second-year resident, two fellows and two interns are on hand to assist with morning rounds.

Gaines, 41, will serve as today's "rounder," or doctor on call. She'll look in on last night's trauma cases; she'll visit children scheduled for surgery; she'll respond to any emergency that may come up.

It's tough to say what the day will bring, says Gaines. "Typical" doesn't exist in this place. Still, she says she can't imagine any other job.

"I think all of us who are pediatric specialists do it because we love kids," she says. "We like to feel we're a part of allowing a child to have a normal, happy, healthy life."

Full house

Rounds will take some time. There isn't an empty bed on the floor.

"Not one," says Joyce Gardner, trauma coordinator. "We've had to put them wherever we could find space."

The team moves quietly, deliberately, down the hall. Room by room, Gaines checks vitals signs, reviews test results and performs general patient assessments.

Room by room, she greets weary parents. Some are napping on bedside recliners. Others haven't slept at all.

In a corner room at the end of the hall, Michael Brown, 3, lies quietly. The boy was transported from Knox, Clarion County, to Children's Hospital yesterday after his go-cart crashed. Last evening doctors repaired a hole in his small intestine.

He's had a lousy night, says Holly Brown, his mother.

Gaines taps lightly on the door before entering. Team members gather around Michael's bed. Gaines checks the boy's small incision for any sign of bleeding or infection.

"How's your tummy feeling?" she asks.

Michael makes a face.

"He's been in a lot of pain," says his mother.

Gaines nods, looking down at her patient. She pats his arm.

"We're going to get you through this," she assures Michael. "But we're going to have to take it one day at a time."

Holly Brown isn't sure her son will climb into another go-cart. But he's escaped life-threatening injury, and she'll hold on to that.

"He's a tough nut," she says. "He'll be OK."

Near the nurse's station, Gaines and company look in on Joseph Sherba Jr., 14, of Scott Township. He's scheduled for an appendectomy later this morning.

It is 8:30 a.m.

With 10th-floor rounds complete, trauma team members scatter, each to his own shift duties. If they are needed, pagers will summon them to the emergency room.

Gaines heads to the sixth floor for rounds in the intensive care units.

She takes the stairs. Elevators are too slow, she says. "We've all become masters at finding the shortest way from point A to point B."

Intensive care

In the Pediatric Intensive Care Unit, beds are arranged around the nurse's station. It's strangely quiet, almost hushed.

A nurse checks vital signs on Sam King, 6, who lies motionless in the third bed from the door. Tammy Brown, of Steubenville, Ohio, sits on a stool next to her son.

She's keeping a vigil. Sam is in a coma.

A car hit him, says Tammy Brown, as he played with a cousin two days ago. The boy was thrown up over the hood and into the windshield. He was airlifted to Children's.

Once he was admitted, a scan revealed Sam had suffered brain injury. As a result, he wasn't responding appropriately to his environment.

Doctors inserted a wire into the boy's brain to monitor swelling. Intravenous sedation keeps him still, decreasing unnecessary brain activity.

"Trauma cases are especially hard on families," says Gaines. "Their otherwise normal life is shattered by something completely unexpected, something they're not prepared for."

She takes a minute to visit with Sam's mother. She tells her doctors are hopeful the boy will respond quickly to the medication and the pressure on his brain will drop. Until then, Tammy Brown will sit and wait.

So, too, will the family of Ethan Morrison.

Ethan -- in one of the unit's isolation rooms -- is the lone survivor of an April 13 auto accident that killed his father, Spencer Morrison, 37, and siblings Garret and Alaina, both 4.

Ethan was admitted with a depressed skull fracture, a broken thigh bone and multiple facial fractures. The 4-year-old may need to undergo additional surgery at some point, says Gaines.

He was awake earlier, but Ethan is sleeping now. Stephanie Bias, his aunt, rocks in a rocking chair near his bed. Balloons and stuffed animals decorate every inch of available space in the room.

"He's looking great," Gaines says with a smile. "He's really doing very well."

Over the next week or two, she says, doctors will watch closely for any sign of infection.

"We don't like infection," Gaines tells Bias. "But we're realists. And I can almost guarantee before he leaves here, he'll develop some kind of infection."

Littlest patients

The doctor winds her way out of the PICU and into the Neonatal Intensive Care Unit. The room is dotted with incubators, each with a tiny baby inside. Nurses travel back and forth from a central station, their infant charges no bigger than loaves of bread.

Jessica Scott, of Eighty Four, rocks 5-day-old Dominic. He is her first child, born on Easter Sunday at St. Clair Hospital, in Pittsburgh's South Hills. Two days later, Scott and her husband, Matthew, were told their son has Hirschsprung's disease.

The Scotts had never heard of it. Online, they read about a condition resulting in chronic constipation because the intestines do not work properly. The disease is caused by an absence of nerve cells in the bowel wall.

Treatment requires surgery.

"It's like your world comes crashing down," Scott says. "You're expecting to come home, and the next thing you know, you're in an ambulance heading to Children's."

Dominic is scheduled for a colon resection this afternoon. During the surgery, Gaines will remove the affected bowel and join the healthy bowel segments.

"This is a tough one for parents," she says after talking with the Scotts. "This disease is not diagnosed prenatally. So they're expecting a normal baby."

Near the nurse's station, Liam Alexander Hunter starts to fuss. Gaines crosses the room to take a look. Born last night at Excela Health Westmoreland Hospital, in Greensburg, Liam has an imperforate anus -- the absence of a normal anal opening.

Derek Hunter, of Irwin, looks down at his son. The baby's mother, Amy Smith, is still in Greensburg. He wishes she could be here.

"She's freaking out," Hunter tells Gaines.

The doctor explains that Liam probably will need a colostomy, surgery that will let his body's waste drain into a bag though an opening in the abdominal wall.

In two or three months, the baby will undergo reconstruction and creation of a neo-anus. When that has fully healed -- in another two or three months -- doctors likely will be able to reverse the colostomy and get rid of the bag.

Hunter wants to know if his son will be able to lead a normal life.

"Most likely," says Gaines. "But it may be that he won't be exactly like the child sitting next to him. On the other hand, who knows what's going on with that child?"

Out in the hall, her pager beeps. Fourteen-year-old Joseph Sherba is ready to have his appendix removed.

It is 10 a.m.

In surgery

In the operating room, senior fellow Dr. Gretchen Purcell guides a laparascope -- an optical isntrument complete with video camera -- into Joseph's abdomen.

Gaines watches and directs Purcell's movements. Soon a white, worm-like appendix comes into view on color monitors suspended above the operating table.

Purcell gently staples off the inflamed appendix, bags it, and pulls it back through the small incision in the abdomen. Stitches close the incision.

Gaines tracks Mary Sherba, Joseph's mother, to the parents' waiting room. She's leaning against the wall, eyes closed. She's been up all night.

The surgeon tells her the operation went without a hitch; her son probably will be discharged tomorrow.

Sherba smiles. She doesn't like hospitals, she says.

Feeling "hypoglycemic," Gaines grabs a quick sandwich from the hospital's Pop Stop and retreats to her office to catch up on paperwork.

It is 11 a.m.

The doctor is back in her office after a return visit to the 10th floor. Nearly seven hours have passed without a summons to the emergency room.

Thank God, says Gaines. There will be too many of those calls once summer rolls around, when kids are out of school and spending more time outdoors.

"You can easily tell without looking at the thermometer that the weather is getting warmer," she says.

Still, the day is young.

"Schools are really pretty safe," Gaines says. "But after 3 ... well, you just never know what might happen. Kids are quite enterprising."

Her pager beeps. Dominic is being prepped for his colon resection. It's a delicate procedure, says Gaines, one that may take more than four hours.

"Every once in awhile, you have to take a step back and say, 'My God, these parents have just given me permission to do something like that to their baby,'" she says, leaning forward in her chair. "The trust these people have put in me ... it's sort of awe-inspiring."

Gaines' pager beeps again. They're ready for her in the operating room.

It's 2 p.m.

Waiting for news

Jessica and Matthew Scott can't stand to sit. They walk for a bit, through downtown Oakland. Soon, though, the couple is back in the waiting room. They can't stay away from their son.

In the OR, Gaines asks the scrub tech to call Dominic's NICU nurse with an update.

"We know the family is thinking about us," she says. "I'd just like to let the family know we're thinking about them."

It is 3 p.m.

Jessica Scott walks the halls. Her baby's surgery is nearing the four-hour mark. What could be taking so long?

Finally, Gaines appears in the waiting room. The doctor has good news: a condition that sometimes can require three separate operations has been corrected with one.

Dominic, she says, will be fine.

It is 6:30 p.m.

Gaines' pager beeps. A patient she's seen earlier in the day needs an appendectomy.

Shortly after the laparoscopic operation, Gaines is called back to the OR for a procedure to correct pyloric stenosis, a condition that is causing a 1-month-old baby to vomit after every feeding.

The procedure is successful. The baby should be eating normally in a day or two, she says.

It is 8:30 p.m. as Gaines winds up her shift.

It's been a successful day, she says -- busy, but not "trauma busy." Those are the best days, she says.

The doctor is looking forward to visiting with her parents, Abner and Rosalyn Gaines. They've traveled from Rhode Island for the weekend. She's also eager to get home to her children Liliana, Bobby and Thomson.

"Most of my spare time is taken up by my family," she says, laughing. "My hobby list has gone by the wayside. When I'm not here, I'm Mom."

Gaines turns off the lights, closes her office door, and heads for home.

About the trauma program

Children's Hospital of Pittsburgh is the only accredited Level I Regional Resource Pediatric Trauma Center in Western Pennsylvania. Staff members within the hospital's Benedum Pediatric Trauma Program treat critically ill and injured children who come from central and western Pennsylvania, northern West Virginia and eastern Ohio. Some have come to the center from as far away as Buffalo, N.Y.

The trauma center's mission: to offer specialized medical care, to conduct research into pediatric trauma, and to prevent injuries by educating children and adults.

Last year, more than 18,500 patients were admitted to Children's overall, and the trauma team was called into action for 1,628 infants, children and teens who arrived in the hospital's emergency room. Trauma admissions at the hospital have increased 38 percent since 2000, a hospital spokesman said.

Dr. Barbara Gaines, a pediatric surgeon, serves as the program's director. She joined the hospital staff in 2000.

How are they doing?

Michael Brown was discharged from Children's Hospital April 25 after recovering from intestinal injuries sustained in a go-cart crash. After a follow-up exam in the hospital's outpatient office, Dr. Barbara Gaines, pediatric surgeon, reports the 3-year-old is "doing nicely."

Joseph Sherba was discharged April 22, the day after his appendectomy. The 14-year-old has returned to school and Gaines has cleared him to return to normal activities.

Sam King left the hospital on May 4, the day after his 7th birthday. After being hit by a car, doctors kept King in a coma to help ease brain trauma. The boy is "doing very well," a hospital spokesman says.

Dominic Scott was discharged April 28 after recovering from colon resection surgery. Gaines will follow his progress through office visits and e-mail correspondence with Jessica Scott, the infant's mother.

Liam Hunter went home May 14 after sufficient recovery from colostomy surgery. The infant -- born with an imperforate anus, or the absence of a normal anal opening -- awaits reconstruction and creation of a neo-anus. Baby Liam is "doing well at home," says a hospital spokesman.

Ethan Morrison left the hospital May 12. The 4-year-old was the lone survivor in an accident that killed his father, Spencer Morrison, and triplet siblings Garrett and Alaina. The boy was admitted with facial, skull and leg fractures, and underwent 12 hours of reconstructive surgery. Although Gaines had advised family members that an infection was likely, Ethan remained infection-free during his recovery.

SOURCE: Children's Hospital of Pittsburgh

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