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Facing fears and risks

Ahmed and Mohamed are, together, one in 10 million. Of every 100,000 live births, only one will be a set of conjoined twins (and about one in 200 identical twin births). Of those, less than 2 percent arrive as craniopagus twins, with fused skulls and shared cranial blood vessels that make separation a remote possibility.

A pair of Guatemalan craniopagus twins, Maria Teresa and Maria de Jesus Alvarez, were successfully separated in August 2002 at UCLA Medical Center, and were home by February 2003.

There have been cases of such twins living into adulthood, such as Lori and Reba Schappell of Reading, Pa. Another famous set of twins joined at the skull, Laleh and Ladan Bijani of Iran, made headlines worldwide in July 2003 when they opted to be the first-ever adult craniopagus twins to undergo separation. But after a 53-hour operation, the 29-year-old twins died of blood-loss complications.

The deaths of the Bijani twins shook the nurses at Medical City last summer, reminding them of the peril the Ibrahim twins faced. “When you have the Iranian twins in the back of your mind, you’re thinking the worst,” admitted Angie Buckmeier, RN, nurse coordinator for child patients at the Dallas Craniofacial Center within Medical City.

The high-risk surgery was in the planning stages from the day the boys were born in a town 500 miles south of Cairo. Pediatric experts invited pioneering craniofacial surgeon Kenneth Salyer, MD, chairman of Medical City Dallas Hospital’s International Craniofacial Institute, to examine the twins for possible separation. The earlier the twins were separated, the better their chances for a normal life.

At 6 months of age, Mohamed and Ahmed were flown to the United States for extensive MRIs and CAT scans in Dallas. The results showed the boys had independent brain function, but the intertwined cranial vascular structures, including the crucial saggital sinus vein, would be the neurosurgeons’ greatest challenge. Specialists examined the test results as well as a detailed model configuration of their cranial structures, determining it would be much more difficult than the Alvarez twins’ separation. Some doubted whether the boys could be separated.

Even with the long odds and the potentially devastating outcome, nearly every nurse in the pediatric ward volunteered to work with the twins, Buckmeier said. She narrowed the volunteer list and selected a team of 20 to 30 nurses who would tend to the boys in the year and a half they would spend in tests and surgical preparations.

Mohamed and Ahmed spent most of their preoperative days with two Egyptian nurses, Wafaa Dardir and Naglaa Mahmoud, who came over with the entourage of physicians and caregivers from the University of Cairo hospital. The boys had to wear special jackets to prevent bedsores because they were confined to lying on their backs most of their waking hours.

Greenwood and Ruby became two of the Medical City nurses closest to the boys, which may be attributable to their own twinhood. Both felt an early affinity for the Ibrahim twins and think the feeling is mutual.

“Of course,” Greenwood said, with a laugh.

Greenwood brought mirrors into the room, so the boys could look at each other. Ruby chuckles at how Mohamed kept trying to take her pager and cell phone off her uniform with his feet.

The nurses helped the boys through the pain, discomfort and monotony of hospitalization, as well as through a precursory operation in April 2003 to implant five tissue expanders (silicone air balloons) into their skull and thighs to develop excess skin for later grafting.

As the separation surgery neared, the fate of the twins began to consume more of the nurses’ personal lives. Buckmeier recalls how her 8-year-old son took a heightened interest in the twins after they arrived in Dallas.

“He was very curious and concerned for them,” Buckmeier said. “He asked for the year and half that they were waiting, ‘Have they had surgery yet?’ ”

In the weeks leading up to the operation, the hospital arranged for group prayer services for the separation team. “We had the peace of knowing we had that support and by having that prayer meeting as a group, we were all focused on the same desire and outcome,” Buckmeier said.

A stunning day

In early October, the boys were transferred to the Children’s Medical Center Dallas, where neurosurgeons opted to have the surgery. Although just 10 miles down U.S. Highway 75 from Medical City, the nurses who would stay behind steeled themselves for the chance the Egyptian twins might not return.

Doggett, meanwhile, assembled her best team of OR nurses from NTHC with those from Medical City and Children’s Medical Center. They expected it would be the most difficult and harrowing job of their careers, and if that weren’t enough pressure, Doggett had to replace two nurses who left the hospital since the tissue expansion surgery.

“Management gave me free rein to do what I needed to do,” Doggett said.