July 10, 2020, is a day Atheia Penafiel will never forget. Early that morning, she took her son, Alec, to his pediatrician’s office for a 15-month checkup and immunizations. As usual, he cried with each of the three shots he received, but the doctor said he was fine in all other respects. After the pediatrician left the room and Penafiel got Alec dressed to go, she turned to grab her car keys and within that split second, Alec fell off the exam table. Penafiel was horrified. She did not see how he fell, whether on his feet or head, but she was scared out of her wits that he might be seriously hurt. Frantically checking for bleeding, bumps or bruises, she found none.

“I debated whether to say something to the doctor but he seemed fine,” Penafiel says. “He was still crying, but I was thinking it was the shots.”

Back at their home in Frederick, Maryland, Alec slept on and off, and cried each time he woke up. He seemed to his mother to be progressively less responsive as the hours passed. At one point, she rolled Alec over and saw a painful expression on his face, his right eye was puffy and tightly shut, and he was drooling. Worse, she could not wake him up. Was he having a seizure?

Penafiel finally got her son to sit up, but then he vomited. She ran upstairs with Alec in her arms and called the pediatrician, who instructed her to call 911 right away. “They came really fast,” she says.

In the ambulance, Penafiel noticed that the emergency medical technicians (EMTs) were checking Alec’s right eye with a flashlight. They were concerned it was dilated and unreactive, an ominous sign — coupled with Alec’s fall, sleepiness and vomiting — of brain herniation and brainstem compression from an intracranial hemorrhage, a potentially fatal brain trauma.

Time was of the essence. The ambulance headed toward the nearest heliport in Frederick, because Alec would have to be airlifted to Johns Hopkins Children’s Center immediately. “I was in shock,” says his mother.

When they arrived at the Children’s Center after the 16-minute flight, she saw some 20 doctors and nurses waiting for Alec. They confirmed the EMTs’ observation regarding Alec’s right pupil, and while examining his head, they found a knot on the right side. They quickly ordered a CT scan, which revealed a very large, actively bleeding epidural hematoma caused by a fracture in the parietal bone that lacerated the middle meningeal artery in the head. The biggest concern was the increasing compression on Alec’s brain caused by the torn artery, and he was rushed to the operating room by pediatric neurosurgeon Alan Cohen and his team.

“We worked very quickly to do a craniotomy to open up the skull, remove the blood clot, stop the bleeding from the lacerated artery and repair the skull fracture,” says Cohen, who is director of the Division of Pediatric Neurosurgery at Johns Hopkins. “It’s a matter of speed in getting the clot out because ‘time is brain.’ As a level 1 pediatric trauma center, we rehearse this scenario and can do the surgery pretty quickly.”

Following the operation, Alec made a remarkable recovery. He woke up and his pupil normalized. Repeat CT scans showed resolution of the hematoma. After an uneventful five-day stay at the Children’s Center, he returned home, where Cohen expects him to make a full recovery.

As important as the treatment, Cohen stresses, were the mother’s observations of her son’s symptoms and reporting them quickly to the pediatrician, which made all the difference in the outcome. In such cases of head trauma, says Cohen, parents should be wary of the following persistent symptoms: crying and irritability, vomiting, and lethargy and seizures. In some cases, he says, children with an epidural hematoma can experience a lucid interval. Some pediatric neurologists call this the talk and die syndrome — a child cries because of an initial concussive impact to the brain, then improves, only to deteriorate further and become unresponsive as the expanding intracranial hematoma compresses the brain.

“These symptoms and signs can develop in a delayed fashion, so it is important to take all head injuries seriously,” says Cohen. “Alec had an enormous life-threatening epidural hematoma. Thanks to his mother’s quick thinking, he will survive to live a normal life.”