ROXANA: Already Home
This Two-Year-Old Bounces Back Fast
Four days after a highly-complicated open heart surgery laid open her chest, little Roxana sat smiling on the foot of her bed,
perched on the rail like a bird, or maybe a hungry squirrel, looking very content as she ate a handful of sausage and bread. She
had just been cuddled between her father and mother, and right now life could not be any better.
Roxana is a quiet and shy two-year-old who can flash a killer
smile that hangs like a half moon beneath two deep brown pools for eyes.
Four days ago on the first full day of surgery for the "Flight For Life" medical team at The Institute of Cardiovascular Disease at the Clinic Fundeni in Bucharest, Romania, she was the first of three cases the American and Romanian team did together. The operation gave her mother and father renewed hope for Roxana to have a healthy and long life. But on Tuesday morning, going under the knife, they were anxious as her life hung somewhat in the balance.
Roxana was born with a highly complicated heart defect, which are
actually two separate defects that are connected. She was diagnosed with an
atrial septal defect (ASD) as well as a ventricular septal defect (VSD). It means there
is a hole in the wall between her two upper heart chambers, the atria, and there is
another hole in the wall between her two lower heart chambers, the ventricles. Of
the two major pumping functions performed by the heart, to push old blood to the
lungs for oxygen, and to then push new blood coming back from the lungs out to
the body for circulation, both of Roxana's functions were severely compromised.
When both the ASD and VSD conditions exist together, it is then called an atrial
ventricular canal (AVC). In some cases of AVC there is often a defect in the mitral valve. For two years now Roxana's heart has kept her alive despite these two major defects.
But now her body has grown to the size that her heart will not be able to
continue under this load for much longer without other parts of her body, major life-supporting organs,
getting damaged from not having enough oxygen and enough blood pressure.
Before surgery on Tuesday, Roxana was in her mother's arms in
their room on the pediatric ward. But then it was time; the moment had arrived.
Her mother, Doina, carried Roxana upstairs to surgery herself, walking alongside
the nurses and then up to the sixth floor where, for a few moments outside the
surgical suite, they paused together in a side room. Then the surgical nurses
came to prepare Roxana for surgery, to start the anesthetic process.
Roxana started to cry when she got the
first shot in the thigh, near the hip, but very quickly
she was sleepy. As the nurses carried Roxana away through
the open surgery door, Doina took one last fearful glance
to her child and started to cry. It would be many long
hours before she would touch her baby again, and the
anxiety was evident in her face and in her body language.
Even though Roxana was about to get the very best medical
care available anywhere in the world today, from a world-renowned
heart surgeon and at no charge whatsoever thanks to the charity
organization Gift Of Life International, these facts fade deep
into the background in the face of a parent's natural fears.
Once inside the surgical suite, the process moved quickly.
Anesthetic doctors and nurses positioned Roxana and started intravenous
lines and breathing tubes, along with all the external devices and
monitors that will give Dr. Pierantonio Russo and the surgical team
vital biological and statistical information in real-time telemetry
throughout the operation. Roxana, already deeply asleep, was
unaware of the bustling activity surrounding her. An endotracheal
tube was placed in her mouth and throat to protect her airway and
assist to assist breathing during the operation. A Foley catheter
and a central venous line were installed, and her tiny chest was
prepared for the coming incision.
A swabbing of Betadine solution was painted on her from waist
to chin by a nurse using a brush that was a rolled up wad of gauze held clamped in
hemostats, and the wet glazing shined in the bright lights. Outside the
surgery door, Dr. Russo was just finishing his twenty-minute scrubbing
of each hand before putting on the sterile gowns, his fiber optic
lighting system with head lamp that sits atop his head like a crown,
and gloves that go half-way up the forearm.
Once the surgical team surrounded the table, it was
only minutes before Roxana's tiny heart was clearly visible to
everyone. It beats and beats and beats and beats like a flashing
red light. Slowly, the function of circulating oxygenated blood
was transferred from her own little pump to the low-slung
artificial heart and lung machine run by perfusionist Jim
Weber, who sat about two feet behind Dr. Russo on a stool
beside the pump, much like a farmer sitting on a milking
stool behind a cow. But instead of white milk, the clear
plastic tubing is filled with bright red blood flowing
from the child to the machine and then back again.
The artificial heart and lung machine is
complex, but on a simple level it does two things: it takes
blood from the right atria through a tube to the machine,
where a filter removes the C02 and replaces it with oxygen,
and the pump's second duty is to cool the blood - and then
later warm it back up again. Early in the process of
heart bypass the blood is cooled in a process called cardiopledgia,
which chills blood so that it will also cool the heart tissue when
it returns to the body, reducing damage and also slowing the heart
until it stops. Nearing the end of bypass, the blood is warmed in
the pump so that it will warm the heart and help it start beating again.
Roxana's surgery requires that she go on bypass at some point, which
means her heart will be stopped.
Deftly Dr. Russo and Fundeni surgeon Dr. Andrei Iosifescu, who assisted Russo, opened Roxana's upper heart wall to reach the septum, the wall that separates the left atria from the right atria. Here they repaired the hole that allowed blood from both left and right atria to mingle, when it should be never mingle but always be separated. Then they repaired the hole in the septum between the two ventricles, the larger chambers that make up the bottom left and right side of the heart. They checked the mitral valve, and then closed up the heart wall again.
Throughout the process, a constant
dialogue between Russo and Weber confirms the
pressure and flow of blood from the bypass
machine to the heart and body, and at what
temperature the blood is running, and how many
elapsed minutes the heart has been "cross clamped"
from circulating blood on its own. Russo would like
to limit the bypass to a certain number of minutes.
The running commentary helps everyone
keep track of the progress. Every few minutes Weber
is handed the latest blood gas results.
He reads the entire slip of paper
first, a small strip like a cash register
receipt, then shouts out the levels for
the number of red blood cells present,
the bicarbonate level, and any other measurements
that fall outside a certain range.
If it weren't for
the green gowns and spilled blood,
and the background beeping and humming
of monitors and pumps, the verbal
exchange between
surgeon and perfusionist might
sound something
like stock traders shouting
and confirming trades.
With the heart wall closed, the cross
clamp was removed and the responsibility
for pumping blood and oxygen was transferred back
from the bypass pump to Roxana's freshly-sewn heart.
As the blood warms the heart tissue, the electrical
impulses flashing from her central nervous system -
the signals that tell the heart muscle to contract
and relax - once again took command. Her heart started
beating again on its own, without having to be jump-started
by the defibrillation paddles. This is always a good sign,
and the team was relieved as the small heart started
twitching and jumping in the center of the
retracted incision.
Before closing her chest, Russo and Iosifescu checked all the sutures, confirmed the flow through the vessels and the pressure, checked for any last minute discoveries, and then began pulling the layers of pericardium and muscle back together with tuck after tuck of ever-so-fine suture. When they are finished there are two more children waiting for surgery today, but right now the discussion is a review of everything that just took place inside Roxana's chest, as Dr. Russo played the role of both surgeon and medical professor for the Romanian residents and interns observing the procedure.
Roxana, now stable and her chest closed with two drainage tubes in place under a large
gauze bandage, was prepared for transfer to the intensive care recovery room that is one
floor beneath surgery. The surgery had started around 9:00 am, and it was now a few minutes after noon and she was in the recovery room, very stable but still quite anesthetized. Protocols for her medications and recovery steps to bring her out of the anesthesia were discussed, and Dr. Russo examined her and left orders for her revival.
By 5:00pm Roxana was waking up
and calling out a muffled "Mama!" around the
plastic passageway in her throat. The tube,
which allowed for breathing support from the
ventilator, was removed. Roxana was thirsty and
wanted water. By 7:00pm she was not only talking,
but she was quite animated and wanting water,
always water, and she wanted to get up and go
to the bathroom. Only two-years-old, she was
already potty trained and didn't understand
that the Foley catheter would take care of
that for her.
Doina and Roxana were reunited after Roxana was stabilized in the recovery
intensive care unit. Doina had to wear a hat, coat and mask as part of the hospital's policy
to help prevent post-operative infections, but she obviously didn't care. To see and touch her baby again,
she would have worn a boat anchor and dragged it up the stairs. Parents are allowed only a few minutes with their
children in ICU, unlike many American hospitals where family spends a great deal of time at the bedside. So
Diona's moments in ICU were brief. Relieved that the stress of the day was finished, that
her little daughter was not only repaired but doing so fantastically well with recovery,
she broke down - but only for a minute, and some of it had to be from joy.
By 8:00pm Roxana was doing so well that she was
making the Romanian and American nurses laugh and play with her.
She kept saying something in Romanian that made the nurses laugh.
Asked for a translation
to English for the "Flight For Life" nurses who don't speak
Romanian, the Romanians laughed and said, "she keeps asking for a hammer!"
It wasn't clear what, or maybe who, she wanted to hit with it,
but that was part of what made it so funny. Children can be
the same the world over, in Romania as well as in Missouri
where the "Flight For Life" nurses work in the pediatric
intensive care unit at University Hospital. To see a child
like Roxana doing so well only hours after such serious
surgery, and to know that she has a healthy and functioning
heart after two years of not knowing if she was even going
to have a tomorrow, is enough to bring a tear of joy to the
eyes of even the most seasoned nurses.
By 9:00pm Roxana was very stable,
had been awake from the drugs and was now allowed
to go back to sleep on her own, not under the influence
of anesthesia, and she was sleeping with a tiny stuffed
animal on the bed. The orange stuffed toy Tiger, the familiar mascot
of Missouri University, mysteriously appeared on each
bed when the children came out of surgery.
As the long day wound down, Roxana
slept calmly in her bed undisturbed by the noise
of the day's third surgery being wheeled into ICU.
Six nurses, two pediatricians, two surgeons, and
two anesthesiologists gathered around these three
beds, attending to the every need of babies whose
chests were spread wide open only a few hours ago.
Exhausted parents stood, or sat slumped against
the wall, in the hallway where there is no
furniture at the end of a long corridor. The
heart team had now been on their feet, beside
the operating table in two small suites, or
here in ICU, since early this morning. But
up here at the top of the hospital a window was
swung wide open in the ward and a warm breeze
filled the air. A magnificent late sunset
painted the Bucharest skyline where tonight
these three children sleep with something
they have never had, not since birth: a fully
functional and healthy heart, and the hope of
a longer and happier life.
By the following Monday, Roxana was doing so
well that talk started about when she would be allowed
to go home. Her mother and father don't hesitate to
pick her up and hold her as they always have, kissing her
and cuddling her and holding her close. In the United
States she would have gone home on Monday night. But in
Romania, it is the custom to keep children in the
hospital for a longer time. Unlike America, where
insurance companies dictate length of hospital stay and try to force
the patient out of the hospital at the first opportunity, in Romania they
are not restricted by such corporate limitations. It is in the best
interest of the children to be near the doctors and to be seen every day,
and so they stay.
If anything is going to go wrong after open-heart surgery, it will usually happen
in the fourteen days afterwards. Many of these children have traveled from remote regions for
the "Flight For Life" team, so they will stay here under the close eyes of pediatricians.
Roxana, who defies all expectations by bouncing back so quickly after such a serious event,
will be the first child to go home. And when she does the family and neighbors who will see
her as vibrant and healthy and happy as she is today will find it hard to imagine what her
small body has gone through since Tuesday. The only thing that can been seen on Roxana's
face now is the smile of a happy and healthy child, and just the highest tip of her chest
incision showed above her pajama collar hinting at what she may have endured.
Roxana is truly one of the very lucky ones. The statistics
are alarming: according to Dr. Russo's
estimates, there will be approximately 350 new children who will
require life-saving heart surgery this year in Bucharest alone.
In the United States, there are 5,270 heart surgeons. Of that
group, only 216 are listed as performing surgery on children
and adults. Of that number, only 42 specialize in pediatric
cardiothoracic surgery. Of those 42, one of them spent this
week in Bucharest, putting his fingers deep inside the hearts
of Roxana and the other babies, and sharing his expertise with Romanian surgeons and intensive care nurses who care as deeply
as he does for these smiling, loving children's faces, the ones
with eyes as deep as pools and whose hearts are filled with love.
Photographs and story by Donald R. Winslow
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