Takeaway
A continued focus on collaborative problem-solving can improve healthcare professionals’ practice. Adaptability, creativity, and leadership are essential to excellent patient care, especially during emergencies.
Lifelong learning in clinical excellence | October 7, 2026 | 2 min read
By Thomas Cox, MD, Washington University
When our fetal surgery program was still a new collaboration at our institution, we received a referral for an 18-year-old parturient at 34 weeks estimated gestational age who was carrying a baby with a large fibrosarcoma in his chest that was compressing the airway, lungs, heart, and major vessels leaving the heart. The mass was felt to be incompatible with life without an ex-utero intrapartum treatment (EXIT) procedure. Fetal surgery programs are by design multi-disciplinary collaborations involving physicians and nurses from many subspecialties, including surgery, anesthesiology, obstetrics, and neonatology. As our multi-disciplinary team was still in the early stages of preparation, there was a concerning decrease in fetal activity necessitating an emergency EXIT procedure within a few hours.
Though the team attempted to maintain uteroplacental circulation in the early stages of the EXIT procedure, the separation of the placenta resulted in massive blood loss and hemodynamic instability, necessitating the early delivery of the newborn. The newborn was taken to an adjacent operating room for resuscitation and massive transfusion following cardiac arrest and subsequent debulking of the mass. As a facilitator and objective observer of this procedure, I witnessed an impressive example of improvisation and collaboration during a medical crisis.
This procedure wouldn’t have been possible a generation ago without advances in the understanding of fetal development and uteroplacental circulation, and technological innovations in medical practice. These advances have expanded the scope of EXIT procedures beyond airway stabilization procedures to include other life-saving procedures such repair of congenital diaphragmatic hernias and life-changing procedures such repair of myelomeningoceles.
There are growing efforts in medical training programs and real world practice to have physicians and nurses learn to better communicate and collaborate as equal members of a team where each member contributes to the planning of complex patient care. The above EXIT procedure is illustrative of the highest level of creative collaboration, especially in an area of medicine where innovation and expansion of practice is still occurring.
On reflection, I feel my colleagues demonstrated some of the key features that are necessary to optimize the care of patients in novel and complex areas of clinical practice including:
1. Adaptability
The evolving series of life-threatening events necessitated the team to quickly change course and alter their original plan.
2. Creativity
There was no precedent or established template for this EXIT procedure so team members were required to improvise utilizing each person’s clinical expertise.
3. Collaboration
The success of this procedure resulted from optimal communication and a clear understanding of each team member’s role in the care of the mother and child.
4. Leadership
The leaders of each subspecialty section had the trust and respect of their colleagues, giving each the ability to lead effectively and efficiently.
If you’d like to read more about this patient encounter, you can read the report here:
“Massive Fetal Transfusion During an Emergency Ex Utero Intrapartum Treatment for a Congenital Infantile Fibrosarcoma: A Case Report”
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.