Treating trauma: supporting families when the unthinkable happens

One patient’s story of surviving a terrible accident and his road to recovery.

For one Bay Area family, this holiday season brought a very real sense of gratitude, more so than any other before. “It was a holiday like no other with the gratitude that our son is still with us and is doing well,” said Debra Scott, whose teenager suffered a severe boating accident earlier this fall.

When 15-year-old Francesco Adamo returned home from Lucile Packard Children’s Hospital Stanford on the weekend before Thanksgiving, his entire medical team felt a surge of gratitude, too.

“To recover from injuries like those Francesco sustained takes an extraordinary level of not only motivation and resilience, but patience as well,” said his pediatric physical therapist, Jon-Erik Pena, PT, DPT.

A family outing turns tragic

October 28 was supposed to be a fun experience for Francesco, who goes by the nickname Chicco (“Kee-koh”) and his dad, Dr. Filippo Adamo. Father and son took their dog and set out for a kayak excursion on the Marina Lagoon in San Mateo, Calif. Chicco was struck by a motor boat and knocked unconscious.

“I was in shock,” said Adamo. “I just expected that I would see Chicco jump from the water, but he didn’t.” His father swam to him, but Chicco was unresponsive to his father’s voice.  Someone had called an ambulance and he was brought to Stanford’s Emergency Department, the only Level 1 pediatric trauma center on the peninsula.

The pediatric trauma team was called to action. Trauma surgeons David Spain, MD and Stephen Shew, MD, led the emergency response to resuscitate Chicco and assess his most urgent needs.

Prioritizing the most critical treatment

“Chicco had large, complex lacerations across his back, chest and head, all deep injuries involving his lungs, spine and the base of brain,” said Shew. The trauma team’s first priorities included life-threatening lung injuries. Trapped air was compressing one lung, hindering Chicco’s breathing and pushing against his heart. Chicco had lost a significant amount of blood, and his blood pressure was dangerously low; required continuous resuscitation with donated blood products. “We had serious concerns for the neurological implications from his head wounds, including possible brain swelling, hemorrhaging and permanent brain injury,” recalled Shew. “Once the immediate life-threatening concerns were addressed, our team of specialists could focus on his other injuries.”

Those specialists numbered in the dozens, including trauma, orthopedic and neurosurgeons, anesthesiologists, critical care physicians and surgical staff.

Chief of pediatric neurosurgery, Gerald Grant, MD, and his team performed the emergent repair of Chicco’s open depressed skull fracture. “I felt like I was back in the military operating theater in Iraq since Chicco’s injuries were so severe,” said Grant. In a patient with multiple traumatic injuries, several teams often need to operate simultaneously to stabilize multiple organ systems and get the patient out of the operating room as soon as possible, Grant said.

Chicco’s injuries included fractures in all the ribs on his left side, several rib fractures on the right and multiple spinal fractures. Furthermore, because Chicco had been submerged in lagoon water, his wounds were at the highest level of infection risk.

“This definitely wasn’t a case you see every day,” said Shew. “But it’s exactly what we are trained for. When every second and every decision can impact the outcome, we have an extraordinary team of experts here who work simultaneously to triage the most critical areas of care.”

Thanks to their collective expertise, the team worked to save his lungs, brain and spine, and treat extensive soft tissue damage and multiple musculoskeletal injuries.

The family, coming to terms

When Adamo arrived in the emergency department, he was struck by the care shown by the staff.

“From the moment I arrived, they offered me dry clothes and the updates from the OR, telling me about the surgeons involved and reassuring me that the environment in the operating room felt calm and under control,” he said. “That was really important to me, just making it possible to wait.”

After about four hours in surgery, Chicco was moved to the pediatric intensive care unit in critical condition. He remained there for one week.

Chicco’s mother, Debra Scott, was traveling out of the country on business when the accident occurred and received the news by phone.

“It’s the phone call that you never want to get as a parent,” said Scott. “It was devastating and very frightening, not knowing if what I was being told by my family over the phone was for my protection, because I was so far away. The not knowing was very difficult. I just got on the first flight I could.”

When Scott saw her son for the first time in the ICU, he was on a ventilator with all sorts of tubing connected to his body. “My knees buckled,” she said. "You just don’t ever think you will see your child in that state.”

Chicco had very limited capacity to communicate, sometimes responding to requests to move his fingers or blink his eyes. “All of this was incredibly concerning and overwhelming,” said Scott. But learning every day from the care teams about Chicco’s care plan helped her to come to terms with what had happened to her son.

A network of care and support

As Chicco’s condition stabilized, his infection risks fell but he continued to require complex multidisciplinary care. Pediatric orthopedic surgeon, John Vorhies, MD, assisted by trauma surgeon Thomas Weiser, MD, performed a six hour operation to stabilize Chicco’s fractures. Chicco’s right arm was fractured and his chest wall had been severely crushed. His multiple rib fractures were impairing his ability to breathe without a ventilator. Dr. Vorhies felt that reconstructing Chicco’s fractured ribs with titanium plates and screws would offer him the best long-term functional outcome by helping him come off the ventilator sooner and easing his pain during recovery. The approach was successful. Soon after the surgery, Chicco was taken off the ventilator, a major milestone in being able to move out of intensive care.

Drs. John Vorhies and Tomas Weiser with Francesco at Lucile Packard Children's Hospital Stanford in Palo Alto, CA

Along with the various specialists treating his injuries, the pain management team carefully managed the medications needed to keep Chicco as comfortable as possible. Nursing staff at the bedside were responsible for being with Chicco around the clock to recognize and interpret any changes of his condition and to respond quickly with any modifications needed.

“The coordination of care across all the teams in the ICU is so essential, especially in a case like Chicco’s,” said Lindsey Rasmussen, MD, pediatric intensivist and the trauma team liaison in the pediatric intensive care unit. “We tried to strike a balance with keeping the family informed but mitigating what could be an overwhelming amount of information.”

The family’s mental and emotional health received expert attention, too. “Families can be in different emotional states following a crisis,” said Stanford Children’s Health psychologist Michelle Brown, PhD. “From the mental health care perspective, we try to work both with the patient and their family members individually and together to help assess their reactions to the trauma and respond accordingly.”

Brown notes that the team of mental health care providers in the hospital helps to prepare families for the potential impacts of a traumatic event, particularly after they leave the hospital and transition to life back home. This includes education on signs and symptoms of post-traumatic stress disorder, skills to regulate emotional distress and resources for follow-up care if needed.

The network of family support is critical to the overall recovery for the patient and family, according social worker Sasha Trinkaus, MSW, who followed Chicco’s case. Along with nurses, social workers and psychologists, Child Life Specialists help patients and families understand their injuries and the path that the lies ahead.

“It’s vital to care for the whole family when their loved one is in the hospital,” said Trinkaus. “And it goes beyond what’s happening on any given day. As care teams we discuss how to help families transition after they are out of the hospital. They’ve just experienced this massive disruption and we try to support them so they can move forward.”

Chicco and his parents remember many of their care team members very fondly, particularly Sasha, pointing out how much they appreciated his daily check-ins. Chicco said he felt like a friend.

Recovery

With lots of support and his own determination, Chicco’s recovery accelerated, impressing his family and his care team. Physical and occupational therapists played a major role in helping Chicco regain enough strength and mobility to leave the hospital.

“It took a lot of guts from the patient,” said pediatric physical therapist Pena. “Because Francesco sustained multiple injuries to different parts of his body, any amount of movement could put stress on his healing wounds and tissues. That made participating in physical therapy uncomfortable and challenging. Despite this, he came in ready to give it his all and to do whatever was required to bounce back.”

Chicco doesn’t remember much of his time in the hospital, in part due to the pain medications he required. He does remember more from his recovery process.

“At first I could barely walk. My legs were really weak and I could hardly move my arms. When I could stand, it wasn’t for very long,” he said. “It was pretty rough and scary. Slowly, with the help of the therapists, I started first in my room, walking there. Then I would try to make it to a window on the floor. Just seeing outdoors meant a lot and was a kind of motivation for me.”

Since leaving the hospital, his physical therapy has continued. The damage to his muscles will require long-term rehabilitation; he is currently working with physical therapy twice a week, and completing a home exercise program twice a day. It will all help him regain mobility, strength and any endurance lost during his prolonged recovery.

Chicco returned to school part-time this January, and will gradually progress toward attending full-time as he builds back his strength. He has his sights set on returning to playing soccer. “My soccer coaches visited me in the hospital and it helped me to focus on getting back to playing again,” he said.

The experience also gave him some food for thought of a future in medicine. “After this I am considering a medical career,” he said. “I want to be able to help someone like they helped me.”

Chicco’s parents are hopeful that he’ll have a full recovery and a healthy life. “What the doctors have done here is given us the best chance at that,” said Scott. “That, combined with Chicco’s efforts, has been really powerful. I watch him every day go through the struggle and pain. He’s a fighter.”