Dr. Jeffrey Burns - Origins and Evolution of Critical Care at Boston Children’s Hospital

Why is everybody here? I don't understand. Well, it's my job that I'm Kevin Churchwell, I'm President, Chief Operating Officer, and EPP of Health Affairs at Boston Children's Hospital, and I'm recovering pediatric critical care specialists. And my job here is to welcome everybody to really a truly a great day and a celebration, part of our hundred and fiftieth celebration. And a history lesson that Jeff will lead us through. We're here to celebrate our past, present, and future. And truly how we help develop a clinical discipline, pediatric critical care. I mean, if you really don't know or wouldn't know how this all started, but for a period of time, critical, critical, critical, ill kids were taken care of and you would describe it in an ICU setting by the resident staff at one point and the attending, wherever, whoever the attending was. And that's how this all started at one point. But they were individuals to realize that there was a need for expertise in the care of the critical ill child, the critical child, the surgical critical care child, the cardiac critical care child, the medical critical care child. And they were responsible for the development of this discipline. Now, I had a chance to actually train here and then leave here. So I had a view of sort of how the nation viewed the development of this discipline. So if you go to the West Coast, they'll, they'll, they're individuals that claim that they developed it. Right? So you've got the kit and youth and his groups claiming. If you go to the Delaware Valley, you've got jacked down, you've got Mark Rogers, chop, DC, and Johns Hopkins, and how they claimed it. If you ever, if you ever knew Jack Downs, who was sort of like one of the Godfathers of this discipline, and ever had a lunch or a dinner with him and you were a resident or a fellow, he always asked these penetrated questions. He asked this one question and the question was, what was your job as a critical care specialist? And we as fellow would always fumble through it. And his whole point was your job was to make sure you were, you were maximizing Oxygen Deliver. But on the East Coast, we claim the creation of this discipline. And here are really some of the really, and I apologize for saying, some of the giants in the field that thought through what it took what it meant to take care of the child with a critical illness. And it's really exciting, but they're here today. I'm sure Jeff you'll introduce all of them as we go through. So I just want to welcome everybody and thank you for being here. And I'll turn it over to Jeff. Can I share a quick story of how I first met Kevin. He and I were residents together and we were in the University Department in September of 1989. And there were three of us. It was Rick Saladino, Kevin and I was about 2 a.m. We were being overrun. It was very busy. And I was working with a patient and I was trying to get an IV into this patient and I couldn't. I had to go out to my senior, Dr. Kevin's first, well, who might haven't met and say, I need your help. He came in the room and I noticed that he put the child's arm down a little longer for gravity. He receded the turn a kit and up popped the cephalic vein as big as Brookline Avenue. And now I'm looking at Kevin. I'm thinking, okay, here it comes. The senior resident's going to say, what are you doing? And instead his eyes looked down and he said, put it in. And under his guidance, I put it in. And I thought, what a generous thing to do, what a collegial thing to do. And that's who the president and CEO of our hospital is. But I stand before you today as chair of the ICU governance committee. And I confess this is one of the most interesting but difficult stories I've ever had to try to put together. Because it's a story of us and how we have cared for critically ill children. Right now there are 107 children who are ill in our hospital. Over 98% of them are going to live. They're going to go home and they're going to have a life and they're going to do great things. And in large part is because of the people who are here today. Sandy and Kevin are here this morning, but as I'll call them the founders are here. And as we go through the story, I'm going to try to explain each of their roles because each played a significant part that advanced the care that we provide. I also want to acknowledge all the people who helped me put this together. But as Fred loved Joy knows from writing several books about the history of our hospital, I have the unfortunate task of excluding large swaths of things that you people told me about. And Miranda warning, especially poor our colleagues who are here today, near the end of the presentation, I'm likely going to have to be moving very quickly over all the great things that you're doing. But I'm going to leave it to one of the house staff that are here to summarize your good works 30 years from now. And I have to begin here. This is the last audience that I need to say this to. But we live in to multiple times. But we are all fortunate to focus on what really matters. And what I'm going to be speaking about today is largely the work of physicians and nurses respiratory therapists and others who have advanced care of the critically old child. But it begins, of course, and ends with what really matters, what happens to our patients and their families. So where did it begin? As I first framed this, I thought, well, it's the story of when did these ICU's open up. And as you'll see, it began really with the opening up of the cardiac intensive care unit. And this morning, I'm going to be speaking about the development of the cardiac intensive care unit, the medical surgical intensive care unit, the medical intensive care unit, the neonatal intensive care unit, which has made such great contributions to this hospital was described earlier this summer. My focus is on the development of these three. And at that time in 1972, it was a roughly a 10 bed unit. And what is today? Farley five. There was a smaller NICU on Farley seven. And at that time, it was the ICU's were about 5% as we can see of the hospital capacity. In 1980, there was a big change. There was opening as well here of what is known as the multi-disciplinary ICU, as well as the CICU went to 18 beds, what was called pavilion five and six. Or what is today where the GPU is and where the CTSU is. The next big change came, of course, in 205 when we were moved into the current South building. And at that time, the total ICU beds were about 23% of our capacity. With the opening of the medical ICU, now to its full capacity in 2018 at 22 beds, where it currently, about 26% of our 405 active beds. And when hail opens, ICU capacity will be roughly 32%. But as I quickly realized, that's not really the story of caring for ill children at this hospital. As we'll hear, Fred Lovejoy and the work that was established beginning in 1955 was one of the first investments by the hospital in a discrete program designed to promote care of ill children. This was followed by the opening of the emergency department and emergency medicine as a discipline by Gary in 1986. Level one, Prama Center in 1994. The introduction of the crib care transport team that will describe and many of the transport nurses are here today. The introduction of the Berlin Heart and the Vascular Assist device and service in 2005, critical care could now literally be extended outside of the ICU with this device. And of course, the opening of the home ventilation program in 2007, going beyond the walls of the ICU and following children into their home who were technology dependent. Mobile ECMO, you have another extension of our ability to provide critical care. Our transport nurses basically shoot ICU care to any child all throughout the Northeast United States and bring them back, expertly. But with the introduction of mobile ECMO, we are now truly extending the capabilities of our ICs to any point in the US. And yesterday or two days ago, I believe there was the eighth or ninth mobile ECMO that was performed. And of course, there have been collaboration such as the surgical critical care collaboration. So who provides this care? I had the benefit of interviewing Dr. Castanada when he was here several years ago. And I said to him, Dr. Castanada, what was it that drove you to increasingly repair, congenital heart patient said earlier and earlier age? What was the impetus? Was it you and several others who had the idea or was it the growth of technology? What drove it? And he looked at me and this video is on Open Pediatrics and he looked at me kind of quizzically and he says, no one does this by themselves. It's a chain. And the chain has to work together. Everyone, everything works okay if all parts of the chain are okay. If one fails, the whole thing fails. We are all dependent on one another. One thing we did here was to create an environment where everybody was recognized as equal. So I list here all the people in that chain, all of you basically. I have said this many times before, but then I know I speak for my critical care colleagues. There's nothing better than to successfully care for a critically ill child and see them go home and to have the opportunity for a life. But I never feel like I did this by myself. Everyone here plays a part of that chain. But if the chain begins with one first indispensable link, it is with our nursing staff. As Dr. Castanada said to me that day, the nurses are intensive care. We are blessed to have not just a competent professional nursing staff that's able to care for patients in all of our 107 beds. We are blessed with truly one of the premier nursing programs in pediatrics in the world. I've had the opportunity to travel to more than a few hospitals in the last five years all around the world. And when I walk in, one of the first questions they ask me is, how do you recruit and retain and grow your nursing staff? Well, this is due to the leadership really of Patty Hickey. Since 2004, she has been responsible for the nursing care in our four ICUs. And that has led to four beacon awards. These are the highest awards that are bestowed upon nursing excellence in any clinical environment. And they've been bestowed on not one of our ICUs, but all four. But equally impressive is how our nursing staff is really the engine for innovation that often comes to us later. And we lose track of where did that idea come from. Parent President at Procedures was really the impetus of our nursing college in 2005, Red Zone Distraction Prepractice in 2008, and soon coming to the operating rooms and other places throughout the hospital. The Nursing Science Fellowship developed in 2012. The Nursing Cammuote Tool in 2015, the NEST Coach, to provide support for those who are feeling moral distress. These are all innovations that have come out of the nursing program. And the science behind what they do could not be stronger. This is one example of the work that Patty and her colleagues have done over the past eight or nine years. And what their science showed was that nursing education experience is associated with lower mortality and that certification and nursing education are associated with fewer complications. These data are driving lessons that are used around the world. These data serve as the cut point for how we try to staff the ICUs. That is, Patty's data shows that if 20% or more of your nursing faculty have fewer than two years of experience, then some of your outcomes might not be as strong as you would like. And therefore, that is one key lesson that we try to pay attention to. In some, the nurses are the indispensable first link in the chain. And if there's an indispensable second link in the chain, it's our respiratory therapy and ECMO specialists. John Thompson, who is here today and is somewhere over to my left, there he is, was recruited from the Massachusetts General Hospital in 1981. And Dr. Love's Joyce books about Dr. Janeway and in comments from Dr. Nathus. One of the things that our hospital has been blessed with is to have the right person doing the right job at the right time. Dr. Janeway and probably recruited Dr. Nathus, who was at the time a private pediatrician in Greenfield, Massachusetts, and said, I think you're the one to develop and lead the Department of Cardiology. And in doing so, Dr. Nathus, perhaps somewhat and probably perhaps not, created one of the most world famous pediatric cardiology departments currently led by tall. So too, Bob Cron recruited John Thompson. And I told Bob, if you did nothing else, you selected the right person who led respiratory therapy at this institution for the next 38 years. The clinical service when John arrived into what our colleagues do today, Peter, and his colleagues do today, has grown immeasurably. But more importantly, it's the innovation that they have supported as a key link in the chain. As you'll hear, it's kind of shocking to me, the pulse-exametry did not exist and was not introduced in this hospital until 1982. But beyond that, they made possible the introduction of ECBEL, high frequency auditory ventilation. And as you'll hear, they supported Dr. David Wessel in the development of nitric oxide. And their achievements like our nursing colleagues are listed here. For the six-year-old row, we are an extracorpural-like support organization center of excellence. And that is because of the quiet, competent work of our respiratory therapy colleagues. And then there's one last group that I want to identify because there are many house staff here today. And one of the engines of innovation, certainly probably in any teaching hospital, but definitely in ours, is when a resident or a fellow asks you why? Why does this happen? And that drives more innovation than perhaps we realize. I cite here a study by Nikki Glazer that was reported in the New England Journal in 2001. Nikki was a resident with me in the old multidisciplinary ICU. I still remember what best space we're at. And we were caring for a young boy who presented at the age of six with new asset, DKA. By the time he got to us, he had critical cerebral brain swelling, and he died. And I can see now the look on Nikki's face when she said, why does this happen? Nikki and Nate Cooperman and several other members of Gary's University Department did this very meticulous study. It was still in the age when we thought that the normalization of deranged values was the thing to do. So these patients would come in with a low pH, and we had an amp of bicarbonate, and we would give an amp of bicarbonate. But as you'll hear, we knew from the work that Mike McManus and Kevin Church overdoing that that osmotic load couldn't be good for a brain under threat. We were normalizing values and we shouldn't, and this paper was a landmark study because it demonstrated that we should not be giving by carbonate to aggressively treat the acidosis that they present with, that we should not aggressively try to normalize values. It came from the work of a resident who saw a patient and asked why. So we're to begin, we do have to now go to 1972. But first to look back at the cardiovascular critical care here at children's. They of course were caring for critically ill children before the CIC was formed in 72. Dr. Gross's delegation of the Dr. Sartreosis in 1938 is well known. Perhaps a little less well known as the hospital archivist helped me dig out that as of 1964, we had reported that we had used cardiopulmonary bypass on over a thousand patients, which surprised me that it was that prevalent at that time. But perhaps even more surprising is for many of you to learn that in the basement of Farley was a hyperbaric chamber. It was a two chambered device. The picture on your left shows the operating theater where the surgeons were operating on congenital lesion and on the your right is the decompression chamber that the clinicians would go in after the procedure. This was largely the work of Dr. Barnard and it was written up in the New England Journal and Peter Lang has told me that this was principally for lesions with hyperemia. These were patients that for various reasons they felt that bypass was not the best approach. What's also interesting is this JFK, Jackie Kennedy had a premature baby born on the Cape in 1963. This chamber was only six months old at the time. The baby was flown from the Cape to Boston Children's Hospital and was placed in this hyperbaric chamber. The baby was only born at 34 weeks, which today we would say is not even a concern. But at the time that was respiratory distress syndrome, Highland Memorand disease, this baby was placed in this chamber JFK was holding a vigil outside it and it was up to Dr. Nathus to tell him the next day that your baby's not going to survive. We're going to have to take the baby out of the chamber and the baby died here. This chamber existed until about 1970. But the story begins now in 1972. Roberta Williams is shown here with Dr. Nathus from a clipping from a globe. And Roberta Williams was a cardiologist, appointed medical director of this newly formed roughly 10 bed division 25, again on the fifth floor of what's currently the Farley building. Dr. Nathus and Dr. Castanada appointed her and she wrote me several times I've been bothering her. She's been filling me in with the details after an introduction from Jane and Peter Lang that she felt that she was probably appointed to serve as the continuity across the rotating chief surgical fellows who were rotating every six months. And she served in that role and worked with the surgical chief residents just one other surgical chief resident really taking care of the patients while she had yet another job. She was also the head of the imaging lab. So between doing the echoes and taking care of these patients and being on call every other night, I trust that some of our young faculty won't complain as much. Peter Lang joined her in 1975 and the challenges they faced in these first 10 years are really almost hard to imagine. This was before Paul Sox symmetry. This was before Prost-Aglandins. They were caring for children with minimal equipment. Roberta wrote that they were sharing transducers with the operating room. Dr. Gross kept the heart long bypass machine, she locked under key, obtained only by his nurse. And they were scrambling for resources as they formed this new unit. The first paper in critical care from the institution was this study by Peter Lang. And it was a landmark paper because it followed the first paper in the Lancet from Toronto, several years prior, where cardiologists in Toronto had used Prost-Aglandins for a child with pulmonary atreasia successfully so. And it seemingly opened up a new era. Peter however had the notion of caring for a child with an interrupted aortic arch that perhaps if he opened the duct, he could support systemic circulation as well. And so he and Dr. Natives, Dr. Castellan, others did. They had to bring the child to the cath lab and seat the infusion right at the opening of the the ductus. And as Peter and I were kind of talking this morning that may have not been the most optimal delivery mechanism since it was dissipated in a very short transit time. Nonetheless, the patient did well and it opened up the era of Prost-Aglandins at this institution. Prost-Aglandins are in the top 100 list of most essential medications in the World Health Organization. Prost-Aglandins are a standard part of the armamentarium of our transport nurses who very easily could use it today as one of the first key essential therapies for any child in New England who's born blue. These early years were also marked by some absolutely extraordinary and paradigm-changing work. It is difficult to overestimate how much the movement to repair children with congenital heart disease at an ever earlier age was up to that time if a child was born with congenital heart disease and was blue. But notion was they won't survive this surgery and anesthetic. If we attempt this in the newborn period, we will wait until the child gets older. This program had another idea and that is that these children should be repaired early in life. And these two papers by Dr. Norwood and Castaneda in the citations since that time gives you some sense of how important and landmark and paradigm-changing this work was. But I call your attention to the third study. Jane Newberger is with us this morning. And what she reports here in the New England Journal is clearly an outcome study. What she reported was that there was an inverse relationship between the age of repair and how the infants did on cognitive, auditory, and visual assessments later, after, long after the repair was done. It was important in its own right for its finding that the earlier repair, the better the child did have on important cognitive, visual, and auditory outcomes. That in itself is worthy of the New England Journal. But there is another lesson here for all of us. And I think this is one of the major lessons that I learned in preparing this. And that is that innovation is essential. Innovation is what drives us forward. But innovation in its own right is necessary but not sufficient. It must be coupled with meticulous, rigorous measurement and reporting of outcomes that really matter. And the heart center has led the way in doing that. And we haven't always been our best. We're great innovators, but we often couple it to such rigorous outcome measurement. And this did not happen on its own. As Dr. Casanadev reminds us, no, the surgery was one link on the chain. It couldn't occur without cardiac anesthesia. My colleague, Kristen Oedigard, described the evolution and development of the cardiac anesthesia service. But I will simply summarize it as this. Around this time, there was a rather widespread belief in medicine that infants do not feel pain. And premature infants in particular. And so it was not surprising at all to read reports where an infant underwent a procedure and had minimum to know analgesia to all of us now, that seems unbelievable. But the person who's arguably the most responsible for clearly demonstrating that this was not true that infants did feel pain and did have a stress response to surgery. And that that needed to be treated. If not for the humane reason, also for the reason to mitigate the stress response to allow a better outcome. Listen here is the work of Paul Hickey, who is here, right here in the audience, and is arguably the researcher who conclusively demonstrated improved the point that the stress response of an infant to surgery must be blinded for humane and for important outcome reasons. Well, now we're moving into approaching 1980. And around the late 70s, planning was underway to develop these two new units, so called division 85 and 86. Again, on what we would call now the GPU in pavilion 5 and the area right above it, which is the CTSU and the planning was for two 18 bed units. And as it is today, I am sure it was in years ago that there was only harmony and collegiality as the planning was underway to determine which departments would get beds and who would control them. But first to look back on what was building. A cardiac ICU as we had seen was underway and was developing. Now the goal was to develop an ICU really for all of the other patients, all of the medical patients, neurosciences patients, surgical patients, and oncology patients. And what were they building on? They were building on quite a bit. The care of these children did not at all begin with the formation of this unit in 1980. The work of Dr. Gamble in the early 20s extending through the 40s really created the field of understanding electrolyte constituency and the loss of electrolytes in the appropriate re-infusion up until his age, children died of diarrhea. And in large part because medicine was unsure of what rehydration fluid to most successfully administer these children. Dr. Gamble reversed that. Dr. Ladden pediatric surgery really developed the field. And you see this quote here from one of his former trainees. We were saving lives just by the virtue of the procedures that we were doing. The first epilepsy unit and seizure unit was developed in this hospital in the late 40s. The story of anesthesia as we described has been told with the emergence of an recruitment of Betty Lark, a certified nurse anesthetist in 1935, which made operations with Dr. Ladd possible. And of course the work of Dr. Farber and chemotherapy. And in the lower right there, the work of Dr. Dr. Drinker. The first application of mechanical ventilation on a patient in a hospital in the world. The pediatric and adult happened here in 1928 when Dr. Philip Drinker dragged a pretty large negative pressure generator over for an eight-year-old girl who had polio. And as it is today, they struggled with whether to apply it because they struggled with whether this was a reversible disorder or if they put her in the negative pressure chamber, she would become aruned. And they debated whether to use it and they decided to use it. She panked up right away and asked for an ice cream cone and had temporary benefit but died roughly three weeks later. But that ushered in the age of negative pressure generation, especially for the polio epidemics. So in the lower right corner is a five multichamber negative pressure unit that was again in the basement of the Farley building. This is a picture of that unit and nurses caring for children, four children with polio in 1955. And it's important to look back on the establishment of the Poison Center. As I said, it wasn't just the ICUs, the hospital made a deliberate effort to form a poison center in 1955. Staff first by Dr. Haggertey and then later by Fred Lugjoy. And the work that they did is landmark. And the work that Dr. Lugjoy and his colleagues did persist today. This study reported in 1985 the value of QRsteration and predicting seizures of ventricular rhythms and overdose from Pricyclic antidepressants remains the gold standard today for bedside assessment. It is the most sensitive and specific means to rapidly determine is this patient at risk for seizures or ventricular dysrhythmias. This is all work that came from this program. What the multidisciplinary unit did form in 1980. Dr. Robert Cron who is here today was a point of the first chief of critical care. And in the first year he and Bob Pascucci worked I guess every other week before Mark Rockoff was refuted over from MGH. These three were trained in anesthesia and intensive care. They later started a fellowship in Pearl O'Rourke who is here today was the first fellow. Pearl like Kevin and I was trained in critical care in this program. And these four established an extraordinary relationship with the Department of Surgery. And what were the challenges they faced? Some was starting a new unit the 24-7 challenge of creating guidelines so that they had common pathways. Congenital Diapragmaticernia as it is today was one of the major challenges that they faced in patient care. But look at some of the disorders that they were dealing with. Rice syndrome, epical otitis, Adria-Myson toxicity, mass spas and following halethame, H. flu, meningitis, epical otitis, and percoditis. In the next 10 years, all of these would go away. The advent of vaccines made all of the homophilous influenza problems go away. By the time Kevin and I were fellows we rarely saw that. Adria-Myson toxicity, hard lessons were learned and avoided for the cardiacity from that. But these were problems that they faced. And in collaboration with our surgical colleagues, the first liver transplant patient who survived 1983. We've gone on to do several hundred now. The first ECMO patient in 1984, the first lung transplant patient in 1990. What is the first ECMO patient that deserves some special description? This was one of the first centers in the world to perform ECMO. At the time, it had been tested in adults and found to be not efficacious. Dr. Robert Bartlett, who trained here as a surgeon, was in Michigan and he had recently tried it on newborns with pulmonary persistent pulmonary hypertension. And it appeared that the technology had found a home in appropriately caring for these children. We were one of the second programs to develop an ECMO program. John Thompson working with Pearl, Bob Prome, Mark Scooch and others. And of course, Craig Lilahai and Dr. J. Vacanti cobbled together a circuit. The first circuit and probably had an endotracheal tube for the venous cannula. And on the, I'm seeing Pratema and Somal is eyes raising. And on the field, they had some clippers where they clipped out extra infusion ports if they weren't satisfied with the flow rate being generated from the endotracheal tube. Nowadays, it's hard to imagine, but John Picklestein's probably got his hair on top of his head at the thought of this. There was no bladder box. And so the blood is draining out of the venous outflow cannula down into the lower area via gravity. And today, we have a bladder with servo plates, which are detecting if it's the bladder's collapsing. There's insufficient venous return. Those plates servo together and they slow the roller pump so that we won't entrainer and the patient is treated in some way to improve outflow. There was no bladder box. And so they had to stand there, 24-7. And Pearl and Bob were speculating who it was. And they decided it was probably Craig. As Craig is, Craig Lilai is the only pregnant thing surgeon still here. And so he was on doubly the young guy who had to stand there and 24-7 used his hand to detect that the bladder was filling out equally or not. And their work reflected the populations that they were caring for. They were caring for critically ill children. So medical children, so some of the first descriptions of Hallithane for as status as Maddoxis, Mark Rockoffs, work in neurocritical care, based on his prior work in San Diego, led to some landmark papers, including this one with Kristen Outwater on apnea testing to confirm brain debt. It's only got 64 citations, but it is actually the basis for all brain debt testing in pediatrics and adults used throughout the world today. And we see here the enormous collaboration, notice the collaboration between Jay Vacanti, Craig, Dr. Ororke, Dr. Crome, on the care of the child with congenital diaphragm, di-fragmectchernia and ECMO. But if there is one landmark study from these years, it is this. It's the so-called play of the winter study. At the time, ECMO was clearly successful for congenital diaphragmectchernia. Whether it was successful for a newborn with persistent pulmonary hypertension was unclear. Studies in Michigan by Dr. Bartlett, the year before, had demonstrated that 12 patients who received ECMO had survived. When our colleagues here examined the local treatment and outcomes in the Harvard system, 13 patients in the year prior had presented newborns with persistent pulmonary hypertension of the newborn. 11 of them died, an 85 percent mortality rate with congenital therapy. And yet, there wasn't consensus within our institution as whether ECMO would be the solution. And so they developed a randomized controlled clinical trial. I distinctly remember driving in here as I did this morning. Now, is that the corner of Brookline Avenue and the Riverway, and I heard MPR come up on the hour, not local MPR news, coming out of Washington. In the lead story, Harvard's children's hospital announced today somewhat controversial study, the so-called ECMO study. Why was it controversial? It was designed with what's called adaptive randomization or so-called play of the winter. And what this meant was the statistician, not the clinicians, Dr. Lilla Hay or Rorck Crone, who are here today, did not know what the allocation would be. But the allocation scheme was driven by Dr. James, where a very senior respected statistician. And it basically means this. Initially, there is a 50-50 allocation scheme, as there normally would in any randomized clinical trial. But after a predetermined before the study starts, after a predetermined allocation, the allocation will start to skew towards the intervention that seems to be working best, the so-called play the winter. And in this case, in the first phase, it was 50-50. Ten received conventional therapy for those children died. The children who were receiving conventional therapy were in the NICU in Division 30, up on Farley 7. The children that were receiving the intervention were down on Pavillion 6, the CTSU. They were separated, but the nursing staff certainly knew what the different outcomes were, because down in Pavillion 6 and the first phase were allocated nine patients to receive ECMO, and they all survived. In phase two, another 20 patients were enrolled, and this is when play the winter kicked in. The next patient got ECMO and survived. Therefore, the next patient got ECMO and survived. The next patient who survived got ECMO. It kept skewing towards ECMO. At the end of the study, 19 of the 20 patients in phase two, all received ECMO and all survived. The study was stopped, and the authors concluded that ECMO was beneficial, more beneficial than conventional therapy in the treatment of PPHM. It also used something controversially known as the Zelen procedure, which basically meant that prior to enrollment, the patient was enrolled in the study and randomized before consent was obtained. Marvin Zelen was a respected researcher at the Harvard School of Public Health. This was imposed on our colleagues here by our own IRB as the way the consent should happen. So the patients were enrolled, they were enrolled and then randomized throughout a conventional or the intervention, which was ECMO. Only then were the patients and the parents of only the children randomized to ECMO approached. The parents of the children who were randomized to control did not get approached. They didn't know they were in a study. The feeling was that it would be less burdensome to those families to know that they weren't getting the intervention. This turned out to be the most lasting concern about this study and whether such a Zelen procedure for consent is adequate. But the story moves on with the introduction of the emergency department in 1986. Our very own front door was not organized in a formal way to care for critically old children who presented. Gary Fletcher was recruited from Children's Hospital of Philadelphia and established the field. Here is the seventh edition of a textbook that all of us as residents held on to. Indeed, one day I was presenting a patient to Gary and he very kindly looked down at me and said, Jeff, you might want to look at chapter two of my book, The Sceptic Appearing Infant. I knew that was very spilt out of saying I was clearly stumbling on the presentation of this patient. The work that came out of the emergency department and emergency medicine in the early years identifying infants and children at risk for bacteremia, established the field and made it a lot easier for us to know who we had to worry about and who we did not. Now we enter the 90s and we move into a remarkable period where Dave Wessel is recruited and Dave Wessel is recruited to be the medical director of the CIC starting in 1987. He is trained in probably anesthesia, critical care, cardiology that I leave out any. Dr. Wessel is currently the president and chief medical officer at DC Children's Hospital minister with us this morning. He was paired with Dr. Robert Trude who is here this morning. Dr. Trude is today the first chair and director of medical ethics or Harvard Medical School and arguably one of the most respected emphasis in the United States. Kevin and I had the privilege of working with them both and seeing how the units evolved somewhat differently but for reasons that made sense in terms of the problems that they were dealing with. Dave's challenges were managing newborn low cardiac output, the impact of mechanical ventilation especially after the Norwood procedure. The early trials on Syldena Phil and nitric oxide rolling out ECPR Dr. Del Nido was here with his arrival in 1984 the program evolved in a new way and remarkably over the course of Dave's time as being director from 87 to 2002 lowered the mortality rate and saw a decrease in the mortality rate in that unit from 10% down to about 2%. Equally important you can go to nearly any hospital in the United States and find the leadership of their pediatric cardiac intensive care who at some point trained here. In the MSICU the multidisciplinary ICU at that time probably dealing with a different set of problems in terms of the structure there was the introduction of Brenda Dodson the first pharmacist dedicated to the ICU now standard. Later on there was the introduction of portable CT scanning. The research continued to focus on congenital to that diaphragmatic churnia and ECMO but as you'll hear there was also the introduction of high frequency ventilation and studies on cerebral edema. There was a decline in the illnesses that just 10 to 15 years earlier Dr. Cron or Rorke, Pascoci and Rock Off were dealing with. Kevin and I did not see rise and as we discussed H flu as a vaccine made H flu go away but there was an increase in technology dependent children and the questions about the limits of care and there was an expansion of the fellowship. You see here the change in the usage of ECMO and the growth of ECMO in the cardiac program up till the arrival of Dr. Del Nido in 94 95 the cardiac ECMO patients came to the multidisciplinary ICU they were mostly exclusively patients who could not get off of bypass and therefore often had bleeding complications afterwards and the outcomes were not so promising. Dr. Del Nido had brought with him a different concept and that is to use ECMO preemptively on patients with low cardiac output syndrome to rescue them before the decline and the amazing growth of that program that followed and here too is the decline in mortality in the CIC over that time. It is not an exaggeration to say that the work that came out of the CICU defined and further defined the field listed here are some of the more prominent citations all of several hundred or more. What the ones that deserve special mention are the work that Dave did to bring inhaled nitric oxide to pediatrics and as approval for the FDA. Nitric oxide was not initially found by Warren Zapel at MGH but Zapel had done a lot of the original work but in 1990 nitric oxide was not commercially available and had not been used in children. Dave through a series of research studies worked with John Thompson to create and cobble together analyzers and their seminal work here reported the use and beneficial use of nitric oxide in pulmonary hypertension. It is also difficult to exaggerate the influence of the so-called primacore study which demonstrated that there was a predictable decline in cardiac output. This image is probably the most cited and recognized image in all of pediatric critical care today. The predictable decline in cardiac output roughly 12 hours after repair of an arterial switch procedure and the beneficial effects of using a phosphodispecine inhibitor and milrinone in this context. In the ICU they were asking similar questions. They were continued to be multi-discipline collaboration. These eight studies, nine studies all concerned congenital to diaphragmatic hernia and the use of ECMO and the problem that it remains today. But there were other issues reflecting the care of the population that they were taking care of. John Arnold in this study brought high frequency to the field of pediatrics. It was based on the observation from colleagues of the School of Public Health, why do dogs pant? What's the physiologic advantage for a dog after sprinting for hundreds of yards to take fast short breaths? That was the basis for high frequency auditory ventilation, a therapy that we use today that gives 600 breaths per minute to these children but in very small tidal volumes. John studied demonstrated that there was a beneficial outcome with the use of this. Martha Curly did an elegant study looking at prune which was very difficult. Dr. Sturgewell and Nick Manis reported in the Wing and Journal their work on cell volume regulation with Kevin Strange. In a particular Bob started to take on and ask and answer some of the more difficult questions that we faced in an age of how much is too much? How do we know what the limits of therapy would tend and should be? These studies have, as you see, been widely studied not just in the pediatric literature but in the adult literature. He's the principal author of the guidelines for the Society of Critical Care Medicine. This was its first publication and later to be followed in one in 2008. But there was also the introduction in 1998 of our transport team. This will be a surprise to the House staff in the audience. But prior to 1998, we cobbled together a transport team. It was a swing resident that went out with a pack over your shoulder and one of the available nurses and you and your nursing colleague who had worked together in the ICU but never on transport went out someplace across New England. In a least ambivalence with two EMTs that can't really couldn't help you in a truck whose equipment is unknown to us. If it doesn't sound like a great idea, it really wasn't. But I must say, I have to say this, about several years ago, I got an email from a young man saying, Dr. Burns, my mother tells me that you resuscitated me as an infant on transport and I'd like to come in and talk to you because I'm interested in career medicine and I thought my goodness, I've never had a patient come back. And especially under such circumstances, and I met him and I thought, well, he's in good shape. And I said, what are you doing? And he said, actually, I'm a medical student at University of Pennsylvania. And I said, good for you. And I said, what do you want to do? He said, I want to do pediatric critical care. At that moment, I thought, this resuscitation worked really well. That young man became a doctor. He's in the audience today. He is a intern in our program. But for that success story, there was reasons that we had to do something different. We recruited Monica Climent in 1998. And as has been the case, it was driven by a particular instance that forced us to look back and say, is this the right thing to do? Monica was starting a nurse nurse transport team in Brown. And we shamelessly recruited her away from Brown. She started with colleagues who are here today, a remarkable team, a nurse led transport team that by far and away provides much better care. Think about what they do. At any given moment, they are extending children's hospital all the best that we are, all the best that we have for critical care at any place across the Northeastern United States on a moment's notice. They walk into environments where typically what they hear is children's is here and everyone leaves. And they work by themselves to bring the child back. And now with mobile ECMO, Boston's Roblo's Hospital in the care of the critically old child is clearly scaling beyond the walls. Now we're moving towards the new building and it's 2005 the South Building. And one of the most remarkable things is that it allowed parents to have a place to stay with their child. As we currently experience on seven North, when the design doesn't allow the parent to stay by the bed, there's a cost. And as we now know from the three ICUs on 11 South, 8 South, and 7 South, that's not the case. What is long ago is the early 1970s, there were articles in the Grove saying that surely this shouldn't be the case. And the picture in this corner of the lower left here may look this young girl may look familiar to you. This is Dr. Betsy Bloom. And in the article, her mother was saying, you know, there really should be a place for the mother to stay with their child. What was the structure? I started my current job into a four-peter had been there for several years and Tom then became interim chief Robbie today and Patty has been in her role since 2004. And with the introduction of this new ICU, there was a change of care. And it also was driven by a patient incident. And regardless of the details of the incident, what it did was it produced for us an awakening that we had to change our process of care. We were caring for more children. And at the time, we had gone so called into a closed unit and into a unit where there was attending coverage at night. In short, there were more handovers. And Peter and I were discussing this over the weekend. That prompted the need to provide more cohesive care to make sure that we were all in the same page. Some of the older faculty in the room said we're going towards cookbook medicine. But as it is today, these are guidelines. And guidelines can be deviated from. But that we have to have a common frame of reference as to how we're handling these problems. And these are now uniformed through the three ICUs. So in the MSICU was the closed unit concept moving at 30 beds. There was the remarkable development of a collaboration between surgery and critical care which exists to this day. In some respects, it was the resurrection of the closed collaboration that existed in 1980 and the early 1980s where surgical faculty are providing care in the MSICU and the fellowship is merged. And today with Natalie Roy, the same thing is happening on eight south. Rob Graham started the K program in 2007. Low technology follow up going into the home. Imagine that extending critical care on follow up into the home. There was increase in stem cell patients. Leslie Layman is here today. And I'm almost I'm sure grand to have to report to you. But throughout the 90s, stem cell patients who came to the ICUs rarely survived, rarely survived. And since that time in the collaboration that she was formed with Adrian Randolph, we have turned that completely on its head. And in the CICU, there were challenges related to the introduction of the Berlin heart and the advent of mechanical support, the use of ECPR as I've described, and Peter's personal interest in what he calls adaptive visualization or the development of T3. As now, the issue of repair of the single ventricle remained a huge challenge as well as pulmonary veins stenosis. I told Peter he had to get it down to what he saw as the six key publications. And surely he would cite more. What was notable in what Peter and his faculty did during their stage was they first saw the importance of healthcare associated infections. David Russell and I were talking and we both agreed that Peter saw this before either one of us. He understood the importance of this. And the CICU led the way in that regard as well as reporting their work with rapid response ECMO. In the MSICU, again, reflecting the nature of the population, there was the development of studies related to the use of mechanical ventilation by Adrian Randolph, ongoing work in collaboration with the surgeons on diaphragmatic hernia, and recommendations on end of life care and monococlimin's emerging work with the American Heart Association. But these three studies deserve special mention. Adrian's work here reported in JAMA was landmark for two reasons. It was a negative study. It didn't demonstrate that any particular weaning style worked better than another. But what it did demonstrate was that the so-called extubation readiness test was a tool that could be used around the country. Mark Puders early work with Pratema on suggesting that, excuse me, this is the Omega-Vence study was clearly landmark and Bob Trubes work here. But Adrian's work in 2002 in JAMA was notable for something else because that was the first paper from the P.