One year ago today, a speeding car lost control and struck a group of people awaiting a bus. Several, including eight-months-pregnant Stephanie Johnson, were rushed to the busy Level I trauma center at University Hospital, where a team of doctors, nurses, and technicians worked frantically to save them. As Johnson’s pulse stopped and her baby’s dropped, the hospital staff was faced with a crucial decision – and there was no time to think.
“That day started off busy,” said trauma nurse Matt Lozano. “At 7:30 we had our first Level 1 Alpha come in.” A Level 1 Alpha is the highest-urgency classification possible for trauma. It’s a case that’s serious enough to mobilize multiple specialty teams – anesthesiology, blood bank, respiratory therapy, pharmacy, X-ray and social work.
“Before 11 o’clock we had received five Level 1 Alphas,” Lozano said.
And that was just the warmup.
11:07 a.m.: The intersection of Zarzamora and Culebra is a busy, multi-lane crossroads. The weather that morning was clear and warm. Stephanie Johnson, eight months pregnant, was waiting for her bus alongside several other commuters when a speeding car hit an embankment and went airborne, slamming into Johnson and the others. Horrified witnesses called 911.
MEDCOM, a regional trauma coordination center, began coordinating patient transfers for multiple injuries. Estimated time of arrival for the first patient was three minutes. Cassie Rubio, a physicians assistant in the trauma department, immediately called Dr. Deborah Mueller, the trauma surgeon in charge. Mueller was finishing a surgery in the operating room upstairs. The team received the morning’s next Level 1 Alpha activation, with a five-minute ETA for a badly injured pregnant patient: Stephanie Johnson. Instead of five minutes, she arrived in two.
11:37 a.m.: Patient arrives.
Rubio, Lozano and a phalanx of multi-specialty trauma doctors, nurses, and staff were already at work in the Trauma Resuscitation Unit. It normally holds four patient beds. That morning, there were already six patients there, and two were Level 1 Alpha. Johnson made seven. When she arrived, she didn’t look good.
“She was gray,” Rubio said.
“Her eyes were huge,” Lozano said. “I thought, ‘This patient is going to die.’”
Mueller rounded the corner and saw a full and very busy room. She did a quick assessment.
11:40 a.m.: “I immediately recognized that I needed to call for help,” she said. She messaged Dr. Douglas Pokorny, a second-year trauma and surgical critical care fellow: “Several level 1 now.”
“When trauma needs reinforcements, we call it ‘loading the boat.’”
That particular boat was getting very full. It was crowded with doctors, residents, nurses, techs, and first responders. Rubio was with the group around the head of Johnson’s bed, talking to her and trying to get a response. Mueller checked Johnson’s femoral pulse, high on the top of her thigh. But then she stepped back.
“It’s kind of like I’m a conductor,” she said. “I don’t really get to play an instrument here.”
11:41 a.m.: The team intubated Johnson. The obstetrics team arrived.
11:44 a.m.: Dr. Lauren Javernick, a second-year OB resident, was monitoring the baby’s heart rate, then in the normal, 140-beats-per-minute range. At the same moment, the trauma team got another Level 1 Alpha alert – another critically injured patient was on the way.
The stakes were skyrocketing by the second.
11:45 a.m.: Dr. Georgia McRoy, a third-year emergency medicine resident, was doing an assessment on Johnson when the mother’s heart stopped. McRoy went on autopilot and started CPR.
Trauma nurse Amber Hicks, one week back from maternity leave, entered the room as McRoy started chest compressions.
11:46 a.m.: The fetal heart rate dropped to a dangerously low range of 80 bpm.
Pokorny yelled, “I need a combo tray and a thoracotomy tray! Somebody get me a knife! We are going to do a C-section and a thoracotomy.”
One team member said, ‘We need to go to OR.’” Pokorny said, “We don’t have time.”
Normally this would be where the team made the call to save either mother or baby.
“The normal teaching is to try to get mom back, and if you don’t get mom back in four minutes you save the baby,” Pokorny said. “We had enough people that we could do multiple things, and I already had evidence that he [the baby] was in trouble.”
Hicks said, “You never say, ‘I want to save the baby over the mom,’ but at that point, the baby had a pulse.”
Pokorny turned to Mueller and said, “Both?”
“Both!” she said.
11:47 a.m.: The team administered epinephrine to Johnson to help with bleeding control.
Lozano handed a blade to Pokorny so he could make the incision for the C-section. He made a fast decision to do a horizontal, not vertical, cut. “If her liver is exploded and I open her up on the midline, she bleeds out and she dies,” he said.
As soon as that cut was made, McRoy stepped back. Dr. David Bittenbinder, a first-year trauma fellow, used another blade to make the horizontal cut between two ribs. He opened up the space between Johnson’s ribs with a retractor to reach her heart. A broken rib had punctured it, and blood had filled the pericardium, the sac that surrounds the heart. The pressure was choking off the heartbeat. Bittenbinder nicked open the sac with the blade, releasing much of the blood suffocating her heart.
11:48 a.m.: After Pokorny’s initial incision, Javernik stepped in to complete the delivery, cutting open Johnson’s uterus. In less than a minute she was handing the baby to McRoy. She set the infant on the bed at his mother’s feet – still attached by the umbilical cord – and rhythmically compressed his tiny chest with her fingertips.
“He was the grayest baby I had ever seen,” McRoy said. “I knew he was dead, so I just started CPR.”
Hicks said, “One patient turned into two patients that were both coding.”
It probably took another 30 to 40 seconds to get the clamps and cut the cord. McRoy handed the baby to Hicks, who moved the baby to the warmer. McRoy, joined by members of the pediatric transport team, kept working to save him.
11:49 a.m.: Pokorny cleared out the rest of the blood in Johnson’s pericardium, working out a heavy clot that had formed inside of it.
Bittenbinder took her heart in his hand and massaged it three times. It began to beat on its own. The mother came back to life.
“We scooped the clot out of the chest and it was time to go to the OR,” Pokorny said. They covered her chest but left the retractor in place, keeping the heart exposed for the short trip from trauma to the OR.
“It’s super useful to be able to see if the heart stops again,” Bittenbinder said.
11:50 a.m.: Johnson was rushed up to the OR for further surgery. The neonatal intensive care team arrived to take over baby Ethan’s care. OB fellow Dr. Alejandro Peña was able to intubate him. Dr. Amy Quinn, NICU assistant medical director, put a line in the infant’s umbilical cord. They gave him saline and medication.
“Once he was stable-ish and had a little bit better heartbeat, we transported him up to NICU,” Hicks said.
There were other doctors and nurses and staff and patients in the bay, and more were coming. But for the team working on those patients, what had been a handful of hectic minutes expanded and slowed until the image of mother and child was etched permanently in each their minds.
“I looked up and I couldn’t believe that hardly any time had passed,” Rubio said. “Time was really compressed.”
McRoy sat down. “My hands were just shaking,” she said. “She was 28 and I’m 28.”
Hicks was all nurse as she helped get baby Ethan to the NICU. When she walked back to the elevators, she became a mother with her own tiny baby at home, and she cried.
“He was blue, he didn’t have a great pulse, he had been receiving cardiac drugs,” she said. “I just delivered this baby that I don’t think is going to live, and – how do we tell Stephanie?”
Pokorny had gone to the OR with Johnson.
“After the operating room, I went straight to the NICU to check on Ethan,” he said. “It was really seeing him alive that kind of let me have that moment” to decompress from the tense scene. “Even at that, for two or three days I replayed everything in my head.”
Defying the odds
It was a dramatic and unusual case where the odds were strongly against mother and child.
The survival rate for blunt traumatic cardiac arrest is 1 percent to 2 percent. For babies delivered by C-section after the mother has died or is dying after blunt trauma, the survival rate is unknown. But it’s only 20 percent to 30 percent in non-trauma situations for babies delivered by C-section from dying mothers.
Johnson was awake by the next day and began a speedy recovery despite multiple painful injuries and a cardiac arrest that few survive. The NICU team gave Ethan a transfusion and cooled his body temperature, which can help reduce brain injury. The practice is to keep the body several degrees cooler than normal temperatures for three days. Only after slowly warming the patient can the medical team get a good read on how he was doing. The entire team kept close tabs on the progress of mother and child.
“We were ecstatic when we learned that Ethan was warmed and doing well,” Hicks said.
Along with the incredible personal journey the physicians and staff took with Johnson and her baby, they were also transformed as a team.
They have a heightened awareness when a pregnant patient comes into trauma and are using the event to examine what went right and what could be improved.
“The group of us that were involved that day, we certainly have a bond,” Pokorny said.
“Because of this, we’re going to do mock drills with Trauma, ER, OB, and us,” Quinn said.
They also did a multi-team presentation at the May 2019 trauma conference held by the Southwest Texas Regional Advisory Council. Johnson and baby Ethan, who at nine months was hitting all his developmental milestones, were special guests. Both patients got to meet the first responders who first cared for them that fateful day, and everyone was delighted to see their progress. They crowded around the baby and took lots of photos, and he seemed to enjoy the exchange as much as they did.
“Every time we said his name in the talk, he cried out,” Pokorny said. “He’s a happy little baby.”