When the emergency call came on the evening of Oct. 19, doctors on Stanford’s pediatric trauma team realized the case heading their way could hardly be worse. Ten-year-old Elijah Olivas was being helicoptered from Central California to Stanford’s emergency department after having been thrown from a moving car. He had serious head injuries, and his right hand had been severed at the wrist.
The team immediately began planning how to save Elijah’s hand — and his life.
“We knew that when Elijah arrived, we’d need to get him to the operating room as quickly as possible but also as safely as possible,” said orthopedic surgeon Garet Comer, MD, one of several-dozen experts from the Level 1-certified pediatric trauma team at Stanford Medicine who cared for Elijah.
“Elijah had a potentially life-threatening cranial injury, and we had to ensure that there were no other life-threatening bodily injuries before taking him to the operating room,” said pediatric neurosurgeon Samuel Cheshier, MD, PhD. “It was incredibly important because being thrown from a car could have caused a severe bowel or aortic injury, for instance.”
Two operating rooms
While Elijah was en route, the pediatric neurosurgery and trauma teams gathered in the emergency department. Down the hall, the staff of the Ford Family Surgery Center at Lucile Packard Children’s Hospital Stanford reserved two operating rooms, one for Elijah’s amputated hand and the other for the rest of his body. And a member of the team called Elijah’s parents, Jason and Maria Olivas, to reassure them that they would get regular updates on Elijah’s condition as they made the four-hour drive from their Santa Maria, California, home. (The couple had not been in the car accident that hurt Elijah; however, their older son, Jason Jr., was in the car and suffered minor injuries.)
As soon as Elijah’s helicopter touched down around 10 p.m., his hand was whisked to one operating room at Packard Children’s to be washed. While waiting for Elijah to be cleared for surgery, Comer and his orthopedic surgery team identified important structures on the hand to prepare it for reattachment.
Meanwhile, in the emergency department, Cheshier, an assistant professor of neurosurgery, got his first look at Elijah’s head injury. The skull was fractured in several places. Cerebrospinal fluid was leaking slowly from a tear in the membrane around his brain and blood was accumulating in the space around his brain. The trauma team used a series of X-rays and CT scans to catalog Elijah’s other injuries: facial fractures near his left eye; a broken jaw; several missing teeth; a fracture in his right humerus bone, in the upper arm above where his hand had come off; a few fractured vertebrae; two breaks in his collarbone; and a break in his pelvis. None were critical enough to take precedence over surgery to reattach his hand, which had the best chance of success if it began without delay.
“Within a matter of minutes, he had clearance to proceed to the OR,” said Comer, a clinical instructor of orthopedic surgery. “It was very impressive how everybody came together.”
After Elijah arrived in his operating room, Cheshier placed a pressure monitor in his head to warn the surgeons if his brain hemorrhage began to endanger his brain. If this happened, the neurosurgery team was prepared to perform a craniotomy, in which they would surgically remove part of his skull to relieve the pressure, while the orthopedic surgeons worked on his hand. Elijah’s condition throughout his surgeries was closely monitored by Michael Chen, MD, clinical associate professor of anesthesiology, perioperative and pain medicine, and his team. Because of Elijah’s facial fractures, the ophthalmology, otolaryngology and plastic surgery teams consulted on his case in the operating room, too.
By the time the pressure monitor was in place, near midnight, Comer’s team had Elijah’s hand ready. They brought it from the other operating room to begin the delicate process of reconnecting it to Elijah’s arm, fitting together first his bones, then the tendons, then — with the help of a few blood vessel grafts — the veins, nerves and arteries. Finally, after nine hours of surgery, the team closed the skin. They also set Elijah’s broken humerus.
Early signs are promising
Early signs for Elijah’s hand reattachment looked good: When Comer gently squeezed Elijah’s fingernails, he could see the nailbeds blanch and refill, a clue that the reconnected arteries and veins were working.
After that, surgeon Karl Sylvester, MD, medical director of the hospital’s pediatric trauma program and associate professor of surgery, performed a bronchoscopy to check on Elijah’s airways, and inserted a chest tube to drain fluid from his lungs. Then, still under anesthesia, Elijah was taken to get another CT scan of his brain. The CT showed an expanding hemorrhage, and pressure in his brain was increasing, so Cheshier’s neurosurgery team took Elijah back to the operating room for a craniotomy. They evacuated blood, repaired his large skull fracture and fixed the leak of cerebrospinal fluid from his brain.
“Elijah was very fortunate that Stanford has all the technical know-how and physical resources to coordinate a successful response to his life-threatening injuries,” Cheshier said. “Not many hospitals can handle this level of trauma in a pediatric patient.”
When Elijah finally went to his room in the pediatric intensive care unit around 5 p.m. on Oct. 20, the medical team reassured Jason and Maria that their son’s surgeries had gone as well as anyone could have hoped. “They also gave us updates along the way, which was awesome,” Jason said. Still, he and Maria were worried and fatigued, having stayed up ever since they arrived at Packard Children’s at 3:45 a.m. It wasn’t until Elijah was brought out of his medically-induced coma a few days later that his parents said they breathed a true sigh of relief.
“Elijah woke up yelling, ‘What happened? Why am I in the hospital?’” Jason said. “It was a good sign for us.” Feeling around in his mouth, Elijah demanded to know why the Tooth Fairy was falling down on the job. “He said, ‘I wanna get paid, I’m missing some teeth! Somebody owes me some money!’” said Jason, remembering his joy at this evidence that his son was still himself.
Elijah stayed at Packard Children’s until Nov.16, turning 11 along the way, then moved to a rehabilitation center in Los Angeles to get more help with regaining function in his hand. He finally went home to Santa Maria on Jan. 22. He’s now being homeschooled, working to rehabilitate his hand — which has regained some movement — and adjusting to the long-term effects of the accident, including hearing loss from nerve damage. Comer is monitoring Elijah’s progress in cooperation with his hometown occupational therapists.
The Olivas family said it will always be grateful for both the lifesaving medical care and the empathy they experienced during Elijah’s stay at Packard Children’s.
“If we were taking a walk on the floor or eating in the cafeteria and we saw a member of Elijah’s care team, they’d always remember us and say, ‘Hey, Mr. and Mrs. Olivas, this is what’s going on,’” Jason said. “They gave us regular updates every time we saw them, even if we weren’t at Elijah’s bedside. Everybody really cared — we could tell. We are so thankful.”
- Erin Digitale
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