Banks Wood was born on a Tuesday and went home with his parents, Chelsea and Matt, on Thursday. At eight-pounds, fourteen-ounces, he was a big baby and seemed perfect in every way. But soon after they got home, his parents started to worry. "Things just didn't seem right. His spit-up was a suspicious yellow color and he was crazy lethargic. But we're first-time parents, so we thought, 'What do we know?'," Chelsea recalls. When he hadn't improved by Friday, they went to their pediatrician. "He gave us some things to watch for and said to call him if nothing had changed by Saturday or Sunday."

Back at home, they checked in with friends and family who had children of their own. "I was texting them about how tired he was, and everyone kept saying that's normal and the spit-up is just what babies do," says Chelsea. "But we couldn't stop thinking that something was off." Saturday afternoon Banks' spit-up turned green, and their pediatrician called the Medical University of South Carolina (MUSC) for an emergency consult, where he spoke with Carrie Busch, MD, a pediatric emergency medicine physician, who recommended Banks come in to the emergency department (ED) immediately.

"An infant with green vomit is a surgical emergency until proven otherwise," says Lucas McDuffie, MD, pediatric surgeon at MUSC Children's Health. "Time is absolutely of the essence because green vomit potentially represents a condition called malrotation with mid-gut volvulus, where the intestines are twisted and their blood supply is cut off. This can be catastrophic - they can lose their entire small intestine which can result in death. Even if we are able to save part of the intestine, they can have life-long problems from a shortened gut because they can't absorb nutrients from food anymore," says McDuffie.

Chelsea vividly remembers getting the call from their pediatrician. "He said, 'MUSC deals with a lot of scary stuff and they said to come in right now.' It was terrifying. We just jumped up with Banks and went." Meanwhile, the MUSC emergency staff notified Jeanne Hill, MD, the pediatric radiologist on call, and McDuffie, who was the on-call pediatric surgeon that day. The radiology technician waited in the lobby for Chelsea and Matt to arrive. "This kind of thing is a total team effort," says McDuffie. "Dr. Hill, did the upper-GI test right away, and as soon as she saw his intestine was twisted, we got him into surgery. It all happened within 45 minutes."

The ED was the last place Chelsea and Matt imagined spending their first Saturday evening with Banks. "Dr. McDuffie told us what could happen and that things were going to move fast. We were just freaking out. We couldn't believe we were signing anesthesia papers for our four-day-old baby," says Chelsea. The next couple of hours seemed to stretch on and on as they waited for word on how things had gone. "We were just pacing and crying, but everyone was so comforting. The nurse hugged us and rubbed my back. She even went all over the hospital looking for a breast-milk pump for me. It just meant so much to us."

Fortunately, Banks' surgery was a best-case scenario. When McDuffie untwisted his intestine, blood flow returned and no areas needed to be removed. He did a procedure to prevent it from twisting again and closed the abdominal incision without any complications. "It was essential to his good outcome that his parents brought him into the ED at MUSC where he could get the right test quickly, get the right kind of surgical care immediately, and be taken care of by an expert pediatric anesthesiologist during surgery" says McDuffie. "It went really smoothly. It was emblematic of the kind of teamwork that exists here at MUSC - as well as the collective expertise that's only available at a pediatric center like the Shawn Jenkins Children's Hospital."

Banks was transferred to the neonatal intensive care unit (NICU) where he spent the next twelve days recovering. Chelsea and Matt rarely left his side and joined the care team for daily rounds where they could ask questions and hear how Banks was progressing. The experience gave them a new perspective on parenting. "Walking around MUSC and seeing kids with cancer and in wheelchairs, it just changed how I thought so much," says Matt. "Even with a best-case scenario, I could never have imagined how hard it is to go through something like this. There's one room in the NICU with Happy Thanksgiving and Merry Christmas up on the walls - I just can't imagine what it's like for those parents who are there for months."

While intestinal malrotation is relatively rare, being the only major referral center for pediatric emergencies in the state of South Carolina means MUSC sees more cases. Unfortunately, because it is uncommon and many facilities lack pediatric-specific expertise, the diagnosis can get missed. "Too often we see kids who've been to multiple EDs before they get the right test. By the time they get to us, they've lost some or all of their intestine. If they do live, their whole life and future has changed," says McDuffie. "It's extremely gratifying when you can fix the problem before it gets worse. Banks is now good to go and will have a long, healthy life. There's a saying in pediatric surgery that, 'You don't just save a life - you save a lifetime'. For him, that's really true."

Progressnotes Spring 2021