Surgeons remove blow dart that entered girl’s nose, lodged in skull

Patient Stories |

09/21/2023

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A freak accident requires collaboration among adult and pediatric surgeons to safely loosen a 3-inch dart without piercing a vital artery. “There is no standard operating procedure for something like this. It was completely unique … a rare, critical scenario.”

By Maureen Gilmer, IU Health senior writer, mgilmer1@iuhealth.org

A freak accident brought together specialists from Riley Children’s Health and IU Health Methodist Hospital to save the life of a little girl last month.

One wrong move, one bad decision, and 7-year-old Olivia might not have been doing cartwheels in the lower level of the Riley Outpatient Center this week.

Olivia sitting in chair smiling and laughing

Olivia, her two older brothers and parents Phillip and Jessica (who asked that their last name not be used) returned to Riley on Tuesday evening to meet with the doctors who saved her life after she was injured by a blow dart at a friend’s house in northwestern Indiana.

The nearly 3-inch-long dart pushed through her nostril and embedded in a bone at the base of her skull. A tiny portion of the dart could be seen protruding from the girl’s nose, but Olivia’s mom, a nurse, knew better than to attempt to pull it out.

That could have been disastrous, risking damage to nerves and arteries and potentially uncontrolled bleeding, doctors said.

With any kind of penetrating object, Riley pediatric neurosurgeon Dr. Laurie Ackerman said, never try to pull it out yourself. It must be done in a controlled environment.

Instead, after Jessica arrived on the scene, she took her daughter straight to the emergency department at a nearby hospital in northwestern Indiana.

ANSWERING THE CALL

Dr. Ackerman, interim division chair for pediatric neurosurgery at Riley, was on call that Saturday night in early August when doctors at the other hospital requested a consult on Olivia’s care, providing X-rays of the dart lodged in Olivia’s skull.

Viewing the scans while she talked with the emergency team there, Dr. Ackerman could see the dart was piercing a bone in front of the spinal cord at the bottom of the skull, something you don’t see very often, she said.

“The hospital did a wonderful job of stabilizing her, getting pictures that we needed and giving us the opportunity to prepare on this end.”

That preparation included a huddle with multiple providers here, as they looked at the images and discussed the best approach to treatment.

“We have a very deep bench here,” Dr. Ackerman said of the Riley and IU Health teams. “We have people with specialty expertise to handle about anything that rolls in the door.”

Olivia was transferred to Riley via LifeLine ambulance, arriving shortly after 11 p.m., her mom recalls.

Dr. Ackerman and Dr. Matthew Partain, a pediatric otolaryngologist (ear, nose and throat), were there when she arrived, as were members of the operating room team and radiologists.

Olivia was “incredibly calm,” Dr. Ackerman recalls. “She was one of the coolest customers I’ve met in the emergency department.”

That’s not the Olivia her parents know and love. Jessica and Phillip said their daughter typically is unnerved by hospitals and medical care in general.

“We knew something was up because she doesn’t act that way,” her dad said, admitting that he was a mess himself. “She’s not calm for medical stuff.”

Yet, she was aware of what had happened and open with the medical team about what she was feeling, Dr. Partain said.

“When they arrived at Riley, we had everyone ready to triage and make sure she was stable enough to go through a couple more tests and get things ready for the operating room,” he said.

DINNER MUST WAIT

IU Health neurosurgeon Dr. Mitesh Shah, interim chair for the Department of Neurosurgery, was not on call that Saturday night and had plans to go out to dinner.

When Dr. Ackerman contacted him and explained Olivia’s case, he quickly realized his evening was about to change.

In 30 years as a neurosurgeon, this was something he’d never seen. In fact, he didn’t even know what a blow dart looked like. (Blowguns are legal in Indiana.)

“When I got the call, I knew that based on the location of the dart, this was not something that a community hospital could handle,” Dr. Shah said, noting the tip of the dart was so close to the vertebral artery, she could die if it pierced the blood vessel.

“Once we got over the shock and awe of what we saw on the images, we decided about the strategy. It not only was embedded in the bone … it had traversed the covering of the brain and was sitting in spinal fluid. Fortunately, the brain stem wasn’t affected and the nerve it was adjacent to (which moves the tongue) wasn’t affected.”

The plan was to engage ENT specialists to work through the nose to remove portions of bone, thereby loosening the dart.

“We had to organize a team in the middle of the night that had expertise in managing the specialized equipment we needed,” Dr. Shah said.

Dr. Partain explained that the team had a space of 2 centimeters (about ¾ of an inch) across to work with. “If there’s anything hiding around corners, we have angled instruments to see where we’re operating. It’s important for us to visualize everything completely and know we’re able to get our instruments safely back where we needed to operate.”

“RARE, CRITICAL SCENARIO”

Dr. Satyan Sreenath, an ENT rhinologist and skull-based surgeon at Methodist and Riley, was part of that team called in to operate on Olivia.

He recalls going into a Zen-like state on his drive to Riley in the early hours of Sunday morning.

“There is no standard operating procedure for something like this,” Dr. Sreenath said. “It was completely unique … a rare, critical scenario.”

The team of surgeons put their heads together to figure out, “how do we utilize our known techniques to be able to handle this unknown territory.”

The team prepared to do brain surgery through the nose, inserting a tiny camera, drill and other instruments that would enable them to remove a small portion of bone to loosen the dart, while at the same time keeping it from shifting and lacerating the vertebral artery.

“In the old days, we used to take off half the skull and retract the brain to be able to get to that area in the center of the head,” Dr. Sreenath said. “Endoscopic skull-based surgery laid the foundation for a lot of our modern collaborative neurosurgical and ENT surgical approaches.”

“GREAT RELIEF”

As surgery got underway, he said, “Dr. Partain and I are very cognizant of – how do we minimize damage to other structures in the sinus cavity to be able to loosen this projectile? We’re trying to save this little girl’s life, but in the back of your head these are things that are also important.”

Olivia’s parents were anxiously awaiting word during the operation, and part of that time Jessica remembers talking to her daughter, even though she was in another room.

“Right before Dr. Ackerman came out to tell us that they got the dart, I started talking to (Olivia) and reminded her that she was strong and she had a lot of life left and she needed to come back and see her brothers and do this and that,” Jessica said.

Her daughter would later tell her that she saw her great grandmother, who died a few months ago, while she was sedated.

“She was holding my hand, but you guys couldn’t see her because I was asleep,” Olivia told her parents.

Surgery lasted several hours through the night, but Olivia did well and was moved to the pediatric intensive care unit to recover at about 6 in the morning.

BACK TO GYMNASTICS AND SCHOOL

For a situation that could have gone “six different ways,” Dr. Sreenath said, seeing how well Olivia is doing today is “the greatest relief.”

Olivia, who spent much of Tuesday’s reunion at Riley chasing her brothers around the room and doing cartwheels on command, seems none the worse for her experience. She is back in school, participating in gymnastics and playing with her friends.

Her parents, though, are still recovering from the trauma.

“God forbid anybody has to go through something like that,” Jessica said. “These doctors are absolutely phenomenal. They listened, they communicated, they knew their job. Honestly, I’m kind of in love with all of them because they’re great,” she added.

“We couldn’t do anything but place all of our trust that they were going to save her, and they did.”

Photos submitted and by Mike Dickbernd, IU Health visual journalist, mdickbernd@iuhealth.org