Teamwork in the Department of Pediatrics and Adolescent Medicine
How an interdisciplinary team at the Department of Pediatrics and Adolescent Medicine in Erlangen fought for the life of premature baby David – and won against all the odds
Some patients’ stories are nothing short of a miracle. However, it is only rarely that the life of a patient is saved thanks to as many people as in this case: 16 physicians and nursing staff from the Department of Pediatrics and Adolescent Medicine (director: Prof. Dr. Joachim Wölfle) from Uniklinikum Erlangen gathered around little David and his parents, his twin sister Adele and his big brother Lev for a group photo. It was touch-and-go whether David would make it: He was born with a congenital heart defect much too early, in the 29th week of pregnancy, and only weighing 1,200 grams. He only survived thanks to the resolute determination of an interdisciplinary and interprofessional team at the Department of Pediatrics and Adolescent Medicine in Erlangen. “In my 25 years working as a doctor, I have never before experienced such an extraordinary interdisciplinary team effort,” enthuses Prof. Dr. Heiko Reutter, head of Neonatology and Pediatric Intensive Care Medicine at Uniklinikum Erlangen. Karolina G., David’s mother, adds: “The doctors and nursing staff are true heroes in this story. They are like angels without wings.”
It was during the pregnancy that doctors realized that little David would require an operation on his heart shortly after his birth. Ultrasound scans led to the diagnosis of a transposition of the great arteries (TGA) in David, but not in his twin sister. In this congenital heart defect, the two main arteries leaving the heart, i.e. the aorta and the pulmonary artery, are reversed. That means that the pulmonary circulation that enriches the blood with oxygen and the main circulation system that provides oxygen to the body are completely separate, instead of being connected like normal. As a result, the heart pumps oxygen-rich blood into the lung and oxygen-poor blood into the body, which leads to the organs receiving an insufficient supply of oxygen and, if the condition is not operated on, to death. “TGA can generally be treated well. In 95 percent of cases, this heart defect can be treated with a heart catheter followed by corrective surgery shortly after birth,” explains Prof. Dr. Sven Dittrich, head of the Department of Pediatric Cardiology and speaker of the Pediatric Heart Center at Uniklinikum Erlangen. “The prognosis for David was therefore actually very positive.”
Dramatic home birth
However, life had different plans for David and his sister Adele: In the 29th week of pregnancy – much too early – Karolina G. suddenly started to have contractions: “I felt an urge to push, but I didn’t feel any pain. Perhaps my mind just didn’t want to accept that it was actually happening,” she describes. I was alone at home with my older son Lev when the contractions started. My husband was away on business. I dialed for an ambulance.” By the time the paramedics arrived, David and Adele were already born: Karolina G. gave birth to the twins all alone, with just the help of her first son. “I held the towel for Mummy,” says six-year old Lev with obvious pride. From this point on, David was fighting for his life. “He didn’t cry,” the 31 year old mother remembers. No wonder: Due to his congenital heart defect, his heart couldn’t provide enough oxygen to his little body.
Once the paramedics had reanimated the premature baby, they took the twins to a hospital, from which they were both transferred to the Department of Neonatology at Uniklinikum Erlangen on the very day they were born. Upon arriving at the intensive care unit, little David, who only weighed 1,200 grams, was connected to a ventilator to keep him stable. “The situation is both complex and challenging,” recognized the neonatal specialist Prof. Reutter, and consulted with colleagues from pediatric cardiology, pediatric cardiac surgery and pediatric surgery.
“Without the operation he will die.”
“Normally, a newborn with TGA would immediately receive surgery to place an emergency heart catheter, more explicitly we would perform a Rashkind procedure and then later in the Department of Pediatric Cardiac Surgery an arterial switch operation,” explains the pediatric cardiologist Prof. Dittrich. During this minimally invasive procedure, a small natural opening between the two heart atria is enlarged using a balloon catheter. This allows the heart to pump oxygen-rich blood into the body and oxygen-poor blood to the lung, stabilizing the patient’s circulation until corrective surgery can be performed. The arterial switch operation then permanently corrects the position of the major arteries. Prof. Dittrich explains the challenging situation as follows: “It is not possible to simply conduct heart catheter surgery on a child that only weighs 1,200 grams, let alone an arterial switch operation. At that point, our Rashkind balloon was larger than his heart. We therefore planned to stretch the tiny hole in the atrial septum using a mini balloon, bearing in mind that the whole heart was no larger than the size of a cherry.” “TGA in a extremely premature baby is one of the worst prognoses a child can have.” Prof. Reutter continued: “We knew that an operation would be risky, but without it, David would definitely die.”
Finally, the team of specialists decided, together with the parents, that they wanted to give David this chance. Less than 24 hours after the emergency home birth, Prof. Dittrich conducted the first heart catheter surgery using a mini balloon. The operation was a success and the premature baby’s circulation stabilized. However, the relief after this initial success was short-lived. Shortly after surgery, David’s bowel became inflamed. That is not unusual for children with a congenital heart defect. If there is a lack of oxygen in the bowel, the risk of inflammation rises,” explains Prof. Dr. Manuel Besendörfer, Head of the Department of Pediatric Cardiac Surgery at Uniklinikum Erlangen, who provided the premature baby with an artificial bowel sphincter before his live-saving heart operation. By performing a classical Rashkind procedure several weeks later, pediatric cardiologist Prof. Dittrich ensured that David’s body was able to keep growing until he had a sufficient volume of blood for the corrective operation on his heart. “It was a miracle that David was still alive at all at this point,” says Karolina G.
The big day
13 weeks after his birth, it was finally time: David weighed roughly 2,300 grams and was finally big and strong enough for the life-saving heart surgery. “We prepared carefully for the operation. For example, very small instruments are required for operating on such a small heart,” explains Dr. Ariawan Purbojo, deputy head of Pediatric Cardiac Surgery department at the Department of Cardiac Surgery (director: Prof. Dr. Oliver Dewald) at Uniklinikum Erlangen and David’s surgeon. “You might think that operating on a small heart would be quicker. Quite the opposite is the case, however: the suture is much finer. Everything has to be stitched much more carefully than usual.” The surgery was successful: David’s heart now works the way it should. For Karolina G and her family, a weight lifted off their shoulders on the day of the operation: “Until then, we were left hanging between hope and despair. After the operation, we were finally able to breathe again.”
Little David remained for roughly another two weeks in the Neonatology ward for monitoring. “Our nursing staff nursed him tenderly back to health and took amazing care of him,” praised Prof. Reutter. “The child also survived due to the great job done by our nursing staff!” The Neonatology Department and the whole team agree: “We are confident that David has a good chance of living an entirely normal life.” Karolina G. is endlessly grateful: “Words just cannot describe what I feel today when I hold him in my arms. It is unbelievable that he is alive after all that he has gone through. I am so proud of him,” she says. “Cases like David’s are very rare. He had a very special medical history, and benefited from an extremely unusual interdisciplinary and interprofessional collaboration between doctors and nursing staff from the Departments of Neonatology, Pediatric Cardiology, Pediatric Cardiac Surgery, Pediatric Surgery, Anesthesiology and Cardiac Technology. This was only possible here in Erlangen,” summarizes Prof. Dittrich. Almost four months after the twins’ emergency birth, David can finally be discharged – his parents, his big brother Lev and his twin sister Adele can hardly wait.
Further information:
Press office Uniklinikum Erlangen
Phone: + 49 9131 85 36102
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