A simple hello has never meant more to Saraswati Kache, MD, critical care pediatrician and medical director of the Lucile Packard Children’s Hospital Stanford Pediatric Critical Care Transport Services. It came from Bryar Phelps, 4, who is alive today thanks to a complex life support machine and an exceptional transport team that kept him stable during multiple legs of a trip from Reno, Nevada to Packard Children’s. If it wasn’t for the quick, clear actions of the transport team, everyone agrees Bryar would not be here today.
On June 11, 2019, Bryar suffered a crushing accident across his neck and chest from a double axel cargo trailer carrying 3,000 pounds. He was taken by ambulance to a hospital near his home in Dayton, NV, then flown to Renown Children’s Hospital in Reno, NV. Despite their expert care and best efforts, they were losing ground with Bryar. His trachea was severely torn in two places and his right lung was completely collapsed, with the left highly compromised, making it nearly impossible to keep oxygen in his lungs. Instead, it escaped through the tracheal tears into other parts of his body, threatening organ failure. He needed the highest level of life support available—extracorporeal membrane oxygenation or ECMO. It’s equipment that acts as a heart-lung bypass machine, which oxygenates the blood and then pumps it back into the patient’s body. Renown didn’t have an ECMO machine—only about 310 pediatric hospitals worldwide do—so they called Packard Children’s.
“Despite doing a wonderful job keeping him alive, the team at Renown did not possess the technology needed to oxygenate Bryar,” says Justin Sleasman, MS, CCP, FPP, ECMO Perfusionist with Packard Children’s—a Gold level Extracorporeal Life Support Organization (ELSO) Center. “He needed ECMO to survive, and to establish a path to recovery.”
When the Packard Children’s transport team arrived, Bryar was nearly unrecognizable as a child. The critical care team, led by Dr. Kache, consisted of a critical care transport nurse, a respiratory care transport therapist, an ECMO perfusionist, and a contracted pilot and flight nurse.
“The air from the tracheal tears was escaping into surrounding tissue, so he went into respiratory failure. The tissues around his neck and head were ballooning up,” says Michelle Fernandez, RN, Transport Specialist. “Once on ECMO, we started seeing dramatic changes. His color changed and he looked like a little boy again.”
Six legs, six patient transfers. That’s what it took to get Bryar from Renown to Packard Children’s pediatric intensive care unit (PICU). The first three legs were spent getting the transport team on an ambulance to the airport, then flying to the Reno airport and riding in an ambulance to the hospital. The Renown surgical team had Bryar on the operating room table, ready to work side-by-side with the transport team to place cannulas (thin tubes) into large vessels in his neck, and hook him up to ECMO.
Then, the three-step process was reversed to bring Bryar to Packard Children’s, with six extra steps to transfer him from one gurney to the next. With air transports, space is a premium. You have to think about where each person will sit and where to put every piece of equipment. There’s a long list of equipment and parts, including oxygen tanks, ventilators and the ECMO machine. Plus, you have to be careful not to dislodge patient tubes—Bryar had five chest tubes and three other tubes helping drain air that seeped into his tissues.
“It’s not as simple as lifting the patient. Lines can get tangled, chest tubes need to be held,” says Sean Casey, Respiratory Therapist, Transport Specialist. “Everything has to move in a coordinated fashion, it’s an incredibly orchestrated effort.”
ECMO transports are rare—Packard Children’s has completed just three or four in the last few years. That’s because ECMO is used only in the most severe cases of respiratory failure, cardiac failure or severe sepsis.
“Ours is a veteran transport team that truly supports each other, and the result was vanguard care from the moment we placed Bryar on ECMO in Reno to the moment we transferred him to Packard Children’s,” Justin concludes.
What makes this transport so unique is that it was the first time the team partnered with an outside hospital to place the patient on ECMO. Usually, it is in place when the team arrives.
“While I was standing on the plane in Reno, it hit me just how much teamwork it takes to make such a fragile transfer happen,” Dr. Kache says. “I was holding the ECMO cannulas and endotracheal tube while the pilot held the gurney in place on the plane and four paramedics, two flight nurses, a transport nurse, an ECMO perfusionist and a respiratory therapist were on the ground holding chest tubes and multiple other tubes in place. I was struck by the precision of it all—especially when you consider the ambulance gurney is on the ground at 3 ft and the airplane is 10 ft up.”
Bryar stayed in the PICU at Packard Children’s for a month. To allow his trachea to heal on its own, he remained on ECMO for 10 days. His mom, Amanda Phelps, stayed at his bedside the entire time.
“If Bryar wasn’t transferred so expertly to Stanford that day, I would not have him standing in front of me,” says Amanda. “Not one person said, ‘I don’t think he will make it.’ They never let me think I would lose him. He’s alive today because everybody worked together and gave 100 percent.”
That simple, ‘Hi’ from Bryar not only signified that he survived, but that his brain was functioning normally. Every time Dr. Kache visited Bryar in his room she hoped he would speak. It didn’t happen during his monthlong stay at Packard Children’s, due to the trauma he endured and the medications he required.
“Amanda brought Bryar back to the PICU for a visit a few days after he was transferred to a regular floor. We were all standing around giving him high fives,” Dr. Kache says. “I looked right at him and he locked eyes with me and said, ‘Hi.’ It was an incredible moment that brought his journey full circle.”
It’s astounding that Bryar is alive today, talking and living his life of playing outside, catching lizards and running through the sprinkler with his four siblings, Ckayden, 14, Domennick, 9, Harley, 6, and Ophelia, 1. Amanda and her husband, Jarad, credit Bryar’s feisty, happy nature with helping him survive the accident. “When Bryar said, ‘Hi’ to Dr. Kache, that was his first word off the ventilator,” Amanda says. “We are blown away that he survived. Packard Children’s is why he’s here today, but it certainly helped that he’s a push-through kind of kid.”
