When four-year-old Caltong Liu arrived by ambulance at Stanford Hospital's emergency department, his medical condition was dire. While riding his bicycle down a Sunnyvale sidewalk, Caltong had been hit by a car and pinned between the vehicle and a tree. The impact broke his ribs in 14 places, collapsed one lung and left a host of other injuries.
"The entire front wall of his chest was completely crushed," said Rachael Callcut, MD, the pediatric trauma surgeon who treated Caltong in the emergency department. "He was having a great deal of difficulty breathing."
When he arrived soon after the accident on April 14, 2012, a team of about 12 pediatric trauma specialists quickly worked to stabilize Caltong. Nearby, physicians treated his father, Yuming Liu, also hit by the car but less hurt.
The first challenge was helping Caltong breathe. His ribs were broken in so many places that his chest wall did not expand when he tried to inhale, and both lungs were badly bruised.
"With that much bruising, the lungs become very heavy, wet and hard to inflate," Callcut said. A pediatric respiratory therapist helped re-inflate Caltong's collapsed left lung and put him on a respirator to ensure he got enough oxygen. The team also transfused blood and gave medications for his wavering blood pressure.
It took nearly an hour to stabilize Caltong enough for a CT scan that showed the full extent of his injuries. In addition to the rib fractures, there were two breaks in his jaw. The bone around his right eye, one vertebra, his right collarbone and his left hip also broke, for a total of 20 fractures in 17 bones. He had a small brain bleed, his liver and spleen were bruised, and a bad burn encircled his lower left leg.
The fact that Caltong made it through the first precarious minutes in Stanford's Emergency Department and progressed to a full recovery at Lucile Packard Children's Hospital is a testament to the skill of the Stanford/Packard Children's pediatric trauma team and their seamless integration with the wide spectrum of pediatric specialists at Packard Children's.
"In his first hour, if he had been at a lot of other hospitals, he would not have survived," Callcut said.
But he was alive and, after the first touch-and-go hour, was stable enough to move to the pediatric intensive care unit at Packard Children's. "He received a very high level of expertise in a short period of time," Callcut said. "That can really change someone's outcome."
Four-year-old Caltong Liu had arrived in the Stanford Hospital Emergency Department barely able to breathe. Now, a few hours after a car accident crushed his chest and left him with 20 bone fractures, the little boy had been transferred to the pediatric intensive care unit at Lucile Packard Children's Hospital.
Caltong was in a fragile state – on a respirator, sedated and heavily bandaged – when his parents, mom Chunhui Li and dad Yuming Liu, first glimpsed their son in the PICU. They hadn't seen the hard work of the pediatric trauma team in the Emergency Department; Yuming, who was also in the accident, had been receiving treatment for his broken leg, and it took police a few hours to call Chunhui to the hospital.
"The first night in the hospital, we were very unsure if he could walk or talk again," Chunhui said. At first, no one could predict the lasting effect of Caltong's injuries. But with expert care from a dozen different specialties and a few days of careful management, the physicians were soon confident Caltong could recover.
"He was very lucky that he didn't have any significant injuries to his vital organs," said pediatric intensivist Felice Su, MD, who cared for Caltong. His brain and heart were fine, and his lungs were supported by the respirator. "Kids have an ability to recover pretty impressively," Su said.
Still, problems remained. The biggest risk was taking Caltong off the respirator, a necessary milestone before discharge from the PICU. If the pain from Caltong's 14 rib fractures was too intense when he inhaled on his own, he might require so much pain medication that it would hamper his tenuous breathing.
The respiratory, anesthesia and plastic surgery teams collaborated to devise a unique solution. Caltong needed a skin graft to repair a deep burn on his left leg. After the surgery, while still in the operating room, the anesthesiologists injected a painkiller into the epidural space around Caltong's ribcage. Giving the drug directly to the injured area provided good pain relief with less medication, and thus less risk of interfering with breathing. Then, still in the operating room, the respiratory therapy team carefully transitioned Caltong to breathing on his own.
"The OR was the safest place to extubate him," Su said. "Having so many specialty teams who were able to co-ordinate Caltong's care in a global way was really important. It's an amazing strength of Packard."
Four-year-old Caltong Liu was scared to stand up.
"He would just say 'I cannot,'" said mom Chunhui Li. "We didn't know if it was physically cannot or emotionally cannot. He was trying very hard, but he would shake and could not balance."
Ten days earlier, a car accident crushed Caltong's chest, collapsed one lung and left him struggling to breathe. Packard Children’s pediatric trauma experts stabilized him in the Stanford Emergency Department, then coordinated with dozens of specialists to monitor his brain, lungs, broken bones and other injuries during a week in the pediatric intensive care unit at Lucile Packard Children's Hospital.
Now, in a non-intensive care room at Packard Children's, Caltong was beginning his rehabilitation. But even getting out of bed was difficult. Unable to fully understand why his body would not cooperate, Caltong needed care that took both his injuries and his young age into account.
Chunhui and her husband, Yuming Liu, appreciated the gentle and flexible approach of Packard Children's staff. If Caltong's physical therapist visited his hospital room when he was too tired for any exercises, the therapist showed Chunhui and Yuming what to try later.
"Little patients sometimes cannot follow orders," Chunhui said. "If you push them more, they may be very strong and say 'No.' Here, the nurses and therapists work with the parents instead."
"We really elicit parents' help," agreed nurse practitioner Raji Koppolu, who cared for Caltong. "We want to make sure they're participating in their child's care as much as possible."
Yuming and Chunhui were also grateful for the detailed updates doctors gave on Caltong's recovery. "That made us feel very comfortable no matter what happened," Chunhui said. Gradually, Caltong got on his feet again, motivated to walk to the hospital school for new books.
Packard Children's staff looked out for the whole family's wellbeing. A social worker helped them navigate unfamiliar processes such as obtaining medical leave from work, finding counseling to deal with the shock of the accident and enlisting a Mandarin-speaking interpreter to convey medical information in the family's native language.
"At first, we didn't even know what we needed," Chunhui said. "But we didn't have to struggle by ourselves." Such well-coordinated care is a unique benefit of a top-notch pediatric academic hospital, Koppolu said.
The final result? Now, five months past his accident, Caltong is almost completely healed and his physical and cognitive development are both normal. Recent milestones for his family include the July birth of his baby brother, Jonathan; Caltong's fifth birthday; his first day of kindergarten; and his return to the energetic outdoor play he loves.
These happy events could hardly be more welcome to Chunhui and Yuming, who had to face the nightmare of wondering if their son would ever recover. "He's a very active boy, very talkative," Yuming said with pride. Added Chunhui, "From somewhere, we got him back."