Roger's Textbook of Pediatric Intensive Care - Chapter 1

Chapter 1
The History of Pediatric Intensive Care Around the World
Mark C. Rogers
This chapter provides a history of the development of Pediatric Intensive Care as a specialty. Told in the “first person” by those involved, it represents a unique view of how the many early pioneers and developers of the Pediatric Intensive Care field contributed to its creation.
The contributors of this chapter wrote their own stories, largely unedited and deliberately without references. These are personal stories of the struggle to create such a field, to develop standards for the field, to envision a mechanism by which to pay for patient care, and to evolve a political basis to underpin the documentation and regulation of practitioners in the specialty.
Although many countries are represented, the list of potential contributors is greater than the list of actual contributors. I attempted to contact far more people than could be reached and, as a result, some people who deserve to be included have unfortunately been omitted. Because this “living history” will be updated with each edition of the Textbook of Pediatric Intensive Care, more histories can and will be included in the future. In the meantime, here are the stories of the men and women making important contributions to the field of Pediatric Intensive Care.
The History of Pediatric Intensive Care at Johns Hopkins
Mark C. Rogers MDA1
On August 1, 1969, one month out of medical school and one month into an internship in Pediatrics at Harvard Medical School's Massachusetts General Hospital (MGH) and the Boston Children's Hospital, I arrived for my newborn experience at the Boston Lying-In Hospital. This was the obstetrics and gynecology teaching hospital for Harvard, and I was supposed to attend deliveries in order to resuscitate newborns if needed and to be responsible at night for all newborns, both in the well-baby nurseries (there were several) and in the ICU, which had approximately 30 critically ill newborns.
On arrival, I was met by the junior resident, who happened to have been a fraternity brother of mine several years earlier, when I was an undergraduate at Columbia University. After a brief hello, we toured the facility and made rounds with the attending physician, who was there only during the daytime. I learned where the delivery rooms were and met the nurses in the rather rudimentary ICU. I also learned that, during the day, radiologists were available to read films but that, at night, not only did they go home, they shut down the automatic developer to ensure that the trainees did not break it. I would be responsible for doing old-fashioned “hand-dipping” of x-rays that I then would have to read.
All of this was overwhelming, but not as big a shock as when my fellow resident announced around 4 p.m. that he had been up for 36 hours and would be going home in a few hours. The attending had left to conduct research in the basic science building several hours before, and a neonatal research fellow was supposed to be on call, but I could not count on him arriving for several hours. There were no cell phones, and beepers outside of the hospital were unreliable. An intern for a month, I found myself alone with massive responsibilities for which I felt unprepared.
This frightening circumstance was organized as it was because no effective facilities existed for ventilating newborns or even for getting blood gases. A neonate had to live 36 hours before being put on a small-animal ventilator, and blood gases were limited to only one or two sets per night for the entire nursery because it was necessary to call in the fellow or the technician from home, and they were only required to do one, or perhaps two, per night.
This “primitive” state of intensive care for newborns was somewhat different from how care was being provided to other young infants and children at the Boston Children's Hospital and the MGH. Those institutions had relatively new neonatology support but not yet enough to support the Lying-In Hospital. Older infant and child critical care was developing rapidly out of the need to care for critically ill children in the postoperative period. This was the era of major advances in pediatric surgery, especially pediatric cardiac surgery and the pediatric anesthesia that went along with it. Critical care was largely a continuation of intraoperative and postoperative care. The anesthesiologists, with a new group being dedicated as pediatric anesthesiologists, worked alongside interested pediatricians, largely derived from pediatric pulmonologists and cardiologists. Together, they would care for postoperative patients in the postop recovery room. This system was also being duplicated for critically ill children who had not undergone surgery, sometimes in the postop recovery room and sometimes, but rarely, in a separate area of the general pediatric ward.
Barriers to the Organization of the Pediatric Intensive Care Unit
At this point, small and local attempts to provide this postoperative and medical intensive care of infants and children were

being made in several centers around the US and the rest of the world. They were all running into similar problems that represented barriers to the growth of the field. Among these problems were different perspectives for the pediatrician, for the surgeon, and for the anesthesiologist.
The concern for general pediatricians was that “their” patient was “their responsibility,” even when they were practicing at offices miles from the hospital. There also was the belief that some patients were “too sick to touch”—an actual quote from 25 years ago from an eminent professor of pediatrics in a prestigious British university. This same man was in the audience of the first Grand Rounds that I presented at Johns Hopkins, at which he strenuously objected to my description of how to obtain arterial blood gases from an infant or child. The surgeons had general anxiety about maintaining control of their surgical patients, even when they wanted to spend all their time operating. This anxiety commonly resulted in the assignment of the ICU responsibilities to the most junior (nonoperating) member of the surgical team, often a junior intern, and sometimes even to a senior medical student. The anesthesiologists had a traditional interest in the cardiorespiratory care of patients but needed to grow toward a more broad-based pathophysiologic approach that embraced nutrition, infectious disease, and metabolic issues if they wanted to be fully involved in intensive care.
Reimbursement for time devoted to intensive care was virtually nonexistent and was also a real problem. In fact, my initial primary appointment at Johns Hopkins was in Pediatrics but was changed to Anesthesiology when, on arrival at Hopkins in July 1977, I advertised in the Journal of Pediatrics for fellows for July 1978. The administrator of the Department of Pediatrics objected because he did not want the department to risk the salary of two fellows ($15,000 each in that era) when the department was financially in trouble. However, the Department of Anesthesiology was willing to stand behind the financial commitment and, as a result, my primary and secondary appointments were switched. The Department of Pediatrics was not swayed by the argument that the PICU would end up making more money than any division of Pediatrics, which turned out to be true.
Nursing was the next barrier. Although medical care for critically ill children was making progress, the organization of nursing care would be vital. The skills, both technical and psychological, required to deal with critically ill and dying children comprise such a special set that it would be impossible to rotate nurses from regular wards in and out of the ICU. Nevertheless, for an undeveloped field such as Pediatric Intensive Care, it was difficult for nursing leaders to justify such an organization, staffing pattern, and training program and have it supported by a hospital administration always short of funds. As a result, growth would come from the increasing need for postoperative care for children with congenital defects, congenital heart disease, and trauma. The nurses would often start with a pediatric surgical background and evolve into more generalized PICU nurses. Around the world, many institutions and many individuals were trying to come to grips with these problems, and one of them was Johns Hopkins.
Arrival at Johns Hopkins University School of Medicine
Despite my horrifying lack of preparation for the ICU, not even 10 years later, in 1977, I joined the faculty of the Johns Hopkins University School of Medicine as the director of the PICU, an embryonic but growing separate facility within the Children's Center. My recruitment was led by J. Alex Haller, Jr., MD, Professor of Pediatric Surgery, and my selection probably resulted from the eclectic and unusual background that I had for that era.
During medical school, I had become fascinated with the new cardiac care units that were devoted to the new physiology and pharmacology for cardiac arrhythmias. I volunteered to go to medical school for 5 years, spending 6 months of each year under a National Institutes of Health (NIH) fellowship studying “the theoretical model of the T wave” of the EKG with J. A. Abildskov, a famous arrhythmia expert at the Upstate Medical Center in Syracuse, New York. He encouraged me to study how the central nervous system altered sympathetic tone and, therefore, cardiac innervation and the electrocardiogram. It was a prescient choice, as that was a fascinating way to study problems that would occur repetitively in the ICU. In fact, Dr. Julius Richmond, later to be Surgeon General of the US, was dean of my medical school and a mentor who saw much of my work in the context of his research in sudden infant death syndrome.
As I was fortunate to be able to use the fellowship to study at several institutions, I spent two summers at the University of Minnesota, studying under Dr. Howard Burchell, editor of the leading cardiac journal of the era, Circulation. He asked me write a paper on the T wave, which he published in Circulation just as I was graduating in 1969 and beginning my internship at the MGH and pediatric residency at the Children's Hospital. At those institutions, I saw the beginnings of intensive care, particularly at the MGH. At that institution, I can well remember spending the night of the Apollo 11 moon walk in the “special care area,” a designated area in the Burnham (Children's) Building. During this period, I developed the habit of writing up interesting cases and even had them published in journals such as the New England Journal of Medicine and the Journal of Pediatrics. Several years later, when I returned as a resident in anesthesia to the unit at the MGH, it was organized under Drs. Daniel Shannon and David Todres, and I used the writing skills that I had honed earlier to write multiple papers with them.
For training in pediatric cardiology, I studied at Duke under Dr. Madison Spach and discovered that the natural clinical area of interest for me was not in the cath lab but in caring for patients in the postop period. Many postoperative complications occurred during that era, but the surgery was new and exciting, and few surgeons wanted to spend their time in the ICU. Encouraged by Drs. David Sabiston and Merel Harmel, respectively Chairs of Surgery and Anesthesiology, I decided to look into intensive care. As I saw no training programs applicable in Pediatrics, I chose Anesthesiology—at that time, not an entirely popular choice.
I arrived back at the MGH for my anesthesia residency in the department of Dr. Richard Kitz and realized very quickly that experiences in adult respiratory care with Dr. Henning Pontoppidan and in cardiovascular anesthesia with Dr. Myron Laver would be enormously helpful. In Pediatrics, as previously mentioned, Drs. Shannon and Todres were very helpful in my education, and we had the opportunity to write multiple papers together, making possible my ultimate recruitment to begin my career as Director of Pediatric Intensive Care as my very first academic position.
I arrived at Hopkins to find a small, largely open, six- to eight-bed facility with a few truly dedicated nurses, especially Mary Cronin, RN, and, later, Dottie Lappie, RN. While not

guaranteed, it was possible to have a vision that this would evolve into a large, modern facility with full-time faculty and with dedicated full-time nurses. It was also possible to dream about a training program for fellows, a textbook defining the field, a subspecialty designation with boards, and even the far-out thought of a World Congress in Pediatric Intensive Care in the years ahead. That vision was palpable and real to me because, as a person trained in pediatric cardiology, I had seen these same stages in the growth of that field. I “knew” that a parallel path would eventually occur in Pediatric Intensive Care and that Hopkins could be a platform to accomplish those goals. It was quite a hubristic vision for a 36-year-old but, with the help of Dr. Steven Nugent, whom I recruited from the Children's Hospital in Philadelphia (CHOP), and Dr. James Robotham, who was then in the pediatric pulmonary group and available to us part-time, we began the Hopkins PICU. Many outstanding faculty members, a large number of whom came from our own fellowship program, followed, and all contributed their talents as the unit grew to 14 beds and a full clinical and research program within a few years. Dr. John Downes of CHOP was always helpful to me and available if I wanted to ask for advice.
In the first year, we were able to recruit our first three fellows: Drs. Greg Stidham (now director of the PICU at the University of Tennessee in Memphis), Frank Gioia (then a resident in Pediatrics at the University of Louisville), and Donna Caniano, a surgical resident from Albany who was interested in pediatric intensive care. They began a series of truly outstanding fellows who, among other things, became faculty at Hopkins and ultimately my successors. Hopkins has had over 60 fellows over the years; approximately two dozen former fellows run PICUs in the US, and a similar number run units throughout the world. Perhaps the most important decision that we made in the development of the fellowship was to model it on a 2- to 3-year Pediatric subspecialty program, with 1 year clinical and 1 to 2 years of research rather than the traditional 1-year Anesthesiology clinical-research program. This innovation enabled us to easily approach future issues, such as training for the intensive care boards and related certification, because virtually all our people were certified in Pediatrics and had full research experience, even if a fair number of them were trained in Anesthesiology as well.
With regard to research, Dr. Richard Traystman was Director of Research in the newly created Department of Anesthesiology and Critical Care Medicine to which I was promoted and simultaneously chaired as Professor of Anesthesiology and Pediatric Intensive Care a short 2 years later. His recruitment to the department and dedication to research education of the fellows were singularly responsible for the stream of Hopkins PICU fellows who succeeded with presentations, publications, and NIH grants. Our interest in a research base for the specialty was both a strategic decision and a practical decision to differentiate our program from many others that did not have Dr. Traystman or the resources to support basic research.
One additional advantage that I had in the PICU at Hopkins was created by Dr. Haller, who headed Pediatric Surgery. He had the foresight to get the Johns Hopkins Children's Center designated as the state trauma center for children, including a helicopter system with a helipad. It was not difficult, with that trauma system as a base, to expand the helicopter coverage to include infants and children who had medical and surgical conditions inappropriate for care at local hospitals and who required emergency evacuation to major PICUs. As a result, the concept of having dedicated and even designated PICUs became the norm, and the standards for such units (medical coverage, nursing coverage, facilities, associated operating rooms, emergency transport, etc.) became possible. The establishment of these standards made it difficult for a PICU to develop in any but the most sophisticated medical centers. In Maryland, we were the only PICU for a decade until one of our fellows, Dr. Alice Ackerman, started one at the University of Maryland.
The History of “The Boards” in Pediatric Intensive Care
To paraphrase John F. Kennedy after the unsuccessful “Bay of Pigs” invasion of Cuba, “Success has many fathers, while failure is an orphan.”
At the beginning, no one wanted to be responsible for pediatric intensive care. For most departments of Pediatrics, it was a financial burden that they could ill afford. Nevertheless, a few departments persisted, hired faculty, and built units. For most departments of Surgery and for Pediatric Surgery, all income was derived in the operating room, and it was inappropriate to spend enormous resources on the postoperative care of the children, as residents could do this and care could be supervised at a distance. The situation was largely to stay this way for more than the next decade. For most departments of Anesthesiology, it might be challenging, but it was not possible to get out of doing all of the cases, because the operating room was the primary responsibility. Of all of these specialties, however, Anesthesiology had the most flexibility, as the specialty was in an enormous growth phase, both financially and in manpower. Anesthesiology had the resources to invest and the intellectual need to grow into a major force in the field, and it became very involved in Pediatric Intensive Care in the formative years of the field. That development raised the political questions of how the field would develop and who would control the developing certification criteria and boards.
While the original desire of the American Board of Pediatrics throughout the 1970s and 1980s was to resist new boards, it was becoming difficult to defend that position. The number of physicians concentrating in areas such as Pediatric Intensive Care and Pediatric Emergency Care was growing and, unless Pediatrics developed a home for them, there was a possibility that they would ultimately drift away to Anesthesiology and to the new specialty of Emergency Medicine.
While Anesthesiology was particularly aggressive in developing a field of Critical Care and developing standards for certification in a subspecialty of Critical Care (combining both adult and pediatrics), Pediatrics ultimately decided, through the American Board of Pediatrics, that new specialties should be established in a number of fields, including Pediatric Intensive Care. They were insistent, however, that the entry criteria would require certification in Pediatrics, with sufficient additional training in intensive care to sit for the boards. However, a number of pediatricians had dual-trained in Anesthesiology and some had triple-trained in pediatric cardiology, or pulmonology, or the like. The American Board of Pediatrics finally had to construct an initial sub-board for Pediatric Intensive Care composed of pediatricians with ICU experience, pediatric pulmonologists with ICU experience, pediatric cardiologists with ICU experience, neonatologists with PICU experience, and pediatricians with Anesthesiology and ICU experience. The debate as to what was sufficient ICU experience, how much time was required in other subspecialties, and other

issues took a year to resolve. Individuals representing each group were selected and spent approximately 6 months constructing an examination, so that the first Board exam was administered in 1991. Interestingly, no one who participated in constructing the questions had to take an official exam. As young as we all were, we were “grandfathered” in. I never did take an examination!
The First World Congress of Pediatric Intensive Care and Formation of the International Pediatric Intensive Care Organizations
With Pediatric Intensive Care developing around the world, it was natural that the specialty would work toward developing a World Congress. The problem in doing so was not that representatives of the specialty throughout the world who wanted to hold such a meeting did not exist: Having been the recipient of many, many invitations to visit units around the world (many run by individuals who are contributing to this chapter), I knew that such individuals and such units existed. The problem was financial. Many of the individuals in units around the world who should attend such a Congress could not afford to do so. What would be the point of organizing a Congress that would be attended only by physicians and nurses from the US and other rich, Western countries, but not from sections of the world with real problems to solve and few resources? The solution was simple but revolutionary. Because the PICU at Hopkins was part of a very well supported Department of Anesthesiology and Critical Care, the department would use its resources to support the effort.
With the capable help of Ms. Peggy Riley, who was administrator for the Congress, the department allocated $250,000 from its endowment to underwrite the Congress, which was held in Baltimore in 1992. The money paid for registration fees and accommodations for those who could not afford them and even to pay for the travel for participants from such countries as the Former Soviet Union and parts of South America. Events such as a group visit to a Baltimore Orioles baseball game were free, and some of the new textbooks were donated to units that needed them but could not afford them.
Several hundred attendees came from over 50 countries, including Asia, South America, Europe, Africa, and Australia. One of the more interesting anecdotes from the meeting was a visit to my office from the Federal Bureau of Investigation representatives who were inquiring about how we chose attendees (we didn't) because one of them (never identified) was considered an undesirable by the agency. One of the many beneficial outcomes of this first World Congress was a self-perpetuating committee structure by the time of the second World Congress in Rotterdam, which led to the formation of the World Federation of Pediatric Critical Care Societies (WFPCCS).
Development of Pediatric Critical Care Medicine at the Children's Hospital of Philadelphia
John J. Downes MDA2
The evolution of Pediatric Critical Care Medicine and creation of a PICU at the CHOP proceeded gradually during the early and middle 1960s, with help from several sources. The development in 1962 of a 14-bed medical neonatal intensive care unit (NICU) at the Pennsylvania Hospital by Thomas Boggs, MD, head of neonatology at CHOP and the Pennsylvania Hospital, and of a 12-bed surgical NICU at CHOP by C. Everett Koop, MD, the Chief of Surgery, established the concept and proved the value of a discrete area for providing special care to critically ill patients.
Leonard Bachman, MD, Chief of Anesthesiology at CHOP, collaborated with Dr. Koop in providing tracheal intubation and mechanical ventilation for those “surgical” infants with respiratory failure, created a “stat team” to perform cardiopulmonary resuscitation throughout the hospital, and founded an “Inhalation Therapy Service” (the predecessor of today's respiratory therapy) with technicians whom he trained. On occasion, he and his colleagues assisted in the care of a child in respiratory failure due to a severe asthmatic episode using tracheal intubation and prolonged ether or halothane anesthesia in the operating room. Also, in the early 1960s, Drs. Rachael Ash, Chief of Cardiology at CHOP, and William Rashkind (later the inventor of the balloon atrial septostomy and father of interventional cardiology) established a discrete section of the surgical ward that was staffed by a special team of nurses to provide 24-hour care for postoperative cardiac surgical patients. The anesthesiologists usually supervised their respiratory care and participated in all resuscitations.
My initial experiences were as a rotating pediatric anesthesiology resident at CHOP from the Penn program in June and July 1960, complemented by learning fundamentals about the support of the postoperative neonate from Dr. Koop and his chief resident and the basic care of the child with severe cardiac disease from Dr. Rashkind. Following my completion of a research fellowship in pharmacology at Penn in 1962 and 1963, Dr. Bachman offered and I accepted a staff position in anesthesiology at CHOP. At that time, Dr. Boggs and I applied for an NIH grant to study the efficacy of a protocol of mechanical ventilation and acid-base management in preterm infants with very severe respiratory distress syndrome (RDS). To our surprise, we were awarded the funds to begin the study in January 1964 at Pennsylvania Hospital's new NICU. Through Len Bachman's fundraising, we purchased ultra-micro blood gas equipment, established a blood gas laboratory adjacent that served the entire hospital, and soon had a technician 24 hours per day. We subsequently procured similar equipment using our NIH grant for use at Pennsylvania's NICU. That put the diagnosis of respiratory failure as well as severe acid-base disturbances on a rational basis.
At the time that I began on staff at CHOP, David Anthony (“Tony”) Nightingale joined us as a fellow from the Alder Hey Children's Hospital in Liverpool. Tony already had 2 years of experience as a registrar at Alder Hey with G. Jackson Rees, the founder of the first PICU in the UK. Based on his experience and skill, Tony should have been the attending staff and I the fellow, but that soon proved irrelevant, as we worked together in harmony. He introduced us to the use of chest physiotherapy in infants, and to the Mapelson-D ventilating system, which quickly became the standard device for manual ventilation throughout CHOP.
In 1964, we developed a respiratory care service staffed by Len Bachman, David Wood, an experienced pediatric allergist/pulmonologist, with me to provide respiratory evaluation and assisted ventilation when needed anywhere in the hospital.

We applied for an NIH research grant to study the pathogenesis of respiratory failure in infants and children with asthma, bronchiolitis, and pneumonia; this was funded in early 1965 and enabled us to hire a fellow to work on our “service” to obtain data and help care for patients. Our first fellow was Theodore “Ted” Striker, who had just finished an anesthesiology residency at Penn and who later became Chair of Anesthesiology at Cincinnati Children's Hospital (1976–2000). He had ideas, enthusiasm, and boundless energy for our projects. Also joining us in 1964 was Sylvan Stool, a pediatric otolaryngologist from Denver, later to become internationally renowned for his work with hearing disorders in children and children with upper airway anomalies.
In January 1964, I visited the new NICU at Toronto's Hospital for Sick Children, spending several days with Paul Swyer, the Director of Neonatology, and his fellows, Maria Delivoria (who later came to Penn) and Henry Levison. They were the first group to achieve success in treating a series of severely asphyxiated preterm infants with RDS using mechanical ventilation. Also during 1964 and 1965, I visited MGH, learning from Henning Pontoppidan and Mike Laver in their respiratory ICU. In 1965, I visited Paris and the 16-bed PICU and the NICU at St. Vincent de Paul Children's Hospital. There, two pioneers in Neonatal and Pediatric Intensive Care in Europe, G. Huault and J.B. Joly, received me warmly, and I spent time with them in their PICU, which had opened in 1963.
In 1966, John Waldhausen, a Hopkins- and Penn-trained cardiovascular surgeon, joined CHOP as the first full-time Chief of Cardiothoracic Surgery. From John and Bill Rashkind, we all learned about the modern care of the infant with congenital heart disease. That same year, Honorato Nicodemus, a Penn-trained anesthesiologist originally from the Philippines, became our fellow for a very productive 2-year period. He later became the ranking anesthesiologist in the US Navy and personal anesthesiologist for President Ronald Reagan when he had colon surgery.
Also in 1966, Len Bachman and I, with the support of our colleagues, began pushing hard with the leadership of the medical staff and the hospital administration for creation of a discrete PICU. Once the Chair of Pediatrics, Alfred Bongiovanni, a pre-eminent endocrinologist, and Erna Goulding, the Director of Nursing, understood and embraced the concept of a PICU, and with advocacy from Drs. Koop, Rashkind, and Waldhausen, the Medical Staff Executive Committee and the hospital administrator agreed to proceed with establishing a PICU under the leadership of the Division of Anesthesiology. However, the location remained problematic in our old, crowded hospital building that dated back to 1916. Harry Bishop, a senior surgeon and president of the medical staff at the time, devised a plan of bed exchanges, and we were able to get adequate space.
In January 1967, the PICU opened and was immediately full. We cared for over 600 infants and children that first year, approximately 150 of whom were cardiac surgical patients. I served as medical director, and one of our four pediatric anesthesiology fellows was assigned to the unit for a week at a time. Our three anesthesiology staff members rotated on-call duties for the operating room and the PICU. We had three to four fellows, all anesthesiology trained, spending 1 or occasionally 2 years in pediatric anesthesia and Pediatric Critical Care Medicine (PCCM). Most pursued academic careers, usually in pediatric anesthesiology, with PCCM as an alternative interest.
In May 1967, because our PICU accepted nonsurgical neonates, I admitted a 34-week-old, 2,500-g, newborn boy with acute respiratory failure due to RDS. After 2 weeks of mechanical ventilation, one cardiac arrest, and several pneumothoraces, he developed a chest x-ray with fibrosis and small cysts, much worse than the Wilson-Mikity syndrome pictures we had previously seen in a few RDS survivors. He required a tracheostomy and long-term mechanical ventilation, because no end was in sight and the parents were fully committed to an all-out effort. A few weeks later, an article by Northway and Rosan appeared in the New England Journal of Medicine that described a new disorder, bronchopulmonary dysplasia. Our baby's condition now had a name. Finally in July, after nearly 2 months, we were able to liberate him from mechanical ventilation and discharge him home with the tracheostomy that was finally removed at age 18 months. Thus began our experience in caring for children with chronic respiratory failure and with home care. This boy thrived, graduated from college, and has a lovely family living in upstate Pennsylvania.
In 1968, Russ Raphaely returned from serving with the US Navy in Vietnam; after completing a fellowship year at CHOP, he joined our staff with a focus on cardiac anesthesia and pediatric intensive care. Also in 1969, Stephan Kampschulte, a native of Munich who had trained in anesthesia and critical care medicine (CCM) with Peter Safar in Pittsburgh, spent 4 months with us in the PICU. He then returned to Pittsburgh Children's Hospital to be director of their new PICU. He was our first PCCM leader export.
In January 1972, Len Bachman left CHOP to become Pennsylvania's Secretary of Health, and I became his successor. I negotiated for 6 months with the CHOP Board for department status and for their commitment to more appropriate staff compensation and adequate clinical, administrative, and training budgets.
In 1974, CHOP moved, and we opened a brand new PICU with 14 open-ward beds and six isolation rooms, but we outgrew our space within a year, in part due to children with long-term critical care needs, especially mechanical ventilation. Critical care had taken on a new dimension—chronic care. We opened an “intermediate” unit of 10 beds, called the “PICI,” adjacent to the acute unit. The focus shifted from acute care to maintaining ventilation, achieving growth and development, and preparing families to take a partially disabled infant or child home. We discharged our first ventilator-dependent infant home with her parents in late 1975. Over the next 4 years, several other families went home with infants on mechanical ventilation but with limited nursing care or other support. In July 1979, we obtained a contract from the State Department of Health for a statewide home-care program that included both medical and nursing oversight. It was run by Bob Kettrick of our department until he left in 1987 and, since then, by me.
Our training program in PCCM began admitting pediatricians without Anesthesiology training in 1975 with Steve Nugent, who performed extraordinarily well and was one of the first staff in the new PICU at Johns Hopkins Hospital. However, we encouraged interested students and pediatric residents to also train in anesthesiology prior to their PCCM fellowship, as many did during the 1970s and early 1980s. Most of our new staff had such training. When, in the late 1980s, the American Board of Pediatrics required 3 years of training for program approval and sub-board certification, and the Health Care Financing Administration rules made dual residencies difficult to

finance, the numbers of physicians pursuing that course plummeted. However, PCCM has thrived and remains allied to its pediatric anesthesiology roots in most leading programs.
Pediatric Intensive Care at the Massachusetts General Hospital
I. David Todres MDA3
Daniel C. Shannon MDA4
The development of the NICU and PICU at the MGH came about as a result of the insight and efforts of the Chief of Pediatrics, Dr. Nathan Talbot. Dr. Talbot was deeply sensitive to the need for personalized, dedicated facilities for high-risk children as a result of the death of two infants from chemotherapy overdose. Dr. Talbot then worked with Dr. Henning Pontoppidan, Chief of the Respiratory ICU (RICU), to have critically ill children in need of mechanical ventilation cared for in the RICU while preparations were being made for the development of a separate NICU and PICU. Dr. Daniel Shannon assumed the primary role of caring for the pediatric patients admitted to the RICU. Dr. Talbot converted one of the general pediatric floors to a 7-bed PICU, a 12-bed NICU, and an 8-bed step-down unit. The step-down unit was one of the earliest to be developed in the country and cared for children who were recovering from critical illness but required a level of care that could not be provided on the general pediatric floor. These new units were established in 1971, with Dr. Shannon appointed as director of the three units. Dr. John Herrin, a pediatric nephrologist, joined Dr. Shannon as associate director, and Dr. David Todres was recruited as associate director through the Department of Anesthesia, then under the direction of Dr. Richard Kitz. Dr. Todres' experience in postoperative care of cardiac patients was gained from training in Britain. When Dr. Shannon later became Director of the Pediatric Pulmonary Unit, Dr. Todres assumed leadership of the three units.
In addition to the pediatric residents at MGH, residents from Children's Hospital and the MGH Department of Anesthesia rotated through the PICU and NICU to gain experience in managing critically ill infants and children. Fellows began training in 1972, and formed the first generation of ICU staff at the MGH and directors of other major units across the US.
Crucial to the care of these critically ill children was the development of an ICU laboratory to provide data on blood gases, electrolytes, and drug levels. The blood gas laboratory for the RICU, under the directorship of Dr. Myron Laver, was helpful in guiding the development of the PICU micro-sample laboratory, located adjacent to the ICU units. He also taught us about vasopressors and muscle relaxants in newborns and, in general, had a brilliant, far-sighted vision.
The units soon established a national and international reputation through a number of studies and publications. Dr. Shannon's work on congenital central hypoventilation (Ondine curse) was among the earliest in this rare and life-threatening condition. Other contributions included the appreciation that critical illness in the child affects not only the child, but also the immediate family, a report of the first use of methylxanthine (theophylline) to treat and prevent apnea/bradycardia of prematurity, a demonstration that chemical regulation of breathing was defective in “near-SIDS” babies, cardiorespiratory monitors to digitize the signal and identify abnormal cardiac and respiratory waveforms that could be compared to events witnessed by nurses in the ICU and parents at home, and the use of 133Xe to measure regional lung function in critically ill children and infants in the ICU. We also produced some of the pioneering work on newborn intraventricular hemorrhage and its sequelae. Finally, Dr. Jay Roberts, working in the Department of Anesthesia and the NICU, successfully treated the first infant in the world with inhaled nitric oxide.
The ICUs produced outstanding graduates from its fellowship program. Among them was Dr. Robert Crone, who is now Director of the International Health Program at Harvard Medical School. Dr. Mark Rockoff became nationally known for his expertise in neurologic intensive care and anesthesia and is currently Director of Operating Room Services at Children's Hospital in Boston.
Origins of A Pediatric Intensive Care Unit in Canada
A. W. Conn MD, FRCPCA5
During the 50 years following World War II, the Hospital for Sick Children in Toronto, underwent almost continuous expansion. During that period, the bed capacity was enlarged from approximately 250 to 815 beds, with all of the ancillary services increasing proportionately. My association with all of the changes was first as an anaesthetic resident, then as Chief of Anaesthesia (1960–1971), and finally as Director of Paediatric Intensive Care (1971–1981).
The expansion was created by the increasing numbers of “sicker” patients in both paediatrics and surgery, but especially in the anaesthetic world, by the major advances in the cardiovascular and neurosurgical fields. In the 1950s, major postoperative patients were sent to isolated beds scattered throughout the hospital and cared for by nurses who had no special training (in the time-honoured tradition). Change began with the creation of a recovery room that operated on an 8-hour daytime shift. Soon it was obvious that some cases were not ready to disappear into the wards, so they had to remain in the recovery room overnight. Later, some cases had to remain several days, curtailing space for the next day's postop patients. By 1960, an eight-bed separate unit was established for long-term use under the aegis of Anaesthesia for administration and respiratory care (respirators were coming into general use). Pressures for more space continued, and planning began for larger quarters, including a small laboratory, isolation beds, specialized equipment, and most importantly, full-time medical coverage and specialized intensive care nurses. In 1969, a whirlwind tour was conducted of 26 different ICUs in six major centres by a SickKids team that included nurses, surgeon, anaesthetist, architect, and administrator, to get the latest “gen” before finalizing our own plans.
In 1971, the R.S. McLaughlin PICU was formally opened, funded by a $2 million bequest from the McLaughlin Foundation. This 22-bed unit was complete with laboratory, isolation rooms, sophisticated equipment, and full-time medical and nursing staff. Its purpose was to provide a multidisciplinary service to a wide variety of life-threatening conditions

(multiple trauma, near-drownings, epiglottitis, maxillofacial injuries, as well as the major cardiac, neural, and general surgical cases, pulmonary and cerebral oedema, poisonings, burns, etc.). Between 1,300 and 1,400 cases were admitted per year, providing a great training centre for paediatric trainees of all disciplines. Costs for monitoring equipment approached $100,000 per bed, while daily rates were triple those of general ward care. Administratively, the unit was under the director, who had direct access to the CEO of the hospital and appointments to most clinical services. Each patient remained under the overall control of the referring paediatrician or surgeon, although in practice, responsibility was shared. Initially, such sharing was quite a novelty to some, but the good results overcame such qualms! The nursing service remained under the head of nursing, and very few problems were encountered—in fact the PICU was a “happy ship.”
In 1971, on my retirement, Dr. Geoff Barker was appointed director and, shortly thereafter, in keeping with tradition, began planning a much larger and more spacious unit (doubled in size), with ever-more expensive equipment requirements. This superb unit, which was incorporated into a brand new wing of the hospital, opened in February 1993 and was named the Critical Care Medicine ward. It continues to make remarkable advances in paediatric treatment and research.
History of Paediatric Intensive Care—Personal Experiences
Duncan Matthew MB CHB, FRCP, FRCPCH, DCHA6
Having trained in Scotland, I began my paediatric intensive care journey in 1969, when I was a houseman/intern at the Royal Hospital for Sick Children in Edinburgh. A desperately ill 8-year-old with severe diabetic ketoacidosis was admitted to our general paediatric ward. An attempt was made to resuscitate her in the ward's treatment room, where, despite our best efforts, she died. We had rather basic resuscitation skills and no intensive care team or unit. Critically ill children, including those who required ventilation, were managed on the ordinary wards. I was aware that we should have done better and that ICUs had recently become available in the UK for adults, so the question immediately arose, “why not for children?” Next came my involvement in the management of the first premature baby to be ventilated for RDS in Edinburgh. Unfortunately, the Bird 7 ventilator decided that it would only provide inspiration if its manual breath button was pressed, and this became my job—60 times per minute for the next 15 hours until intraventricular haemorrhage intervened—a truly Scandinavian apprenticeship!
At that time, some paediatric centres had developed special facilities for the postoperative management of children following cardiac surgery, but, in the UK, only Alder Hey Children's Hospital had a general PICU. It had been opened in 1964, and was led by Drs. G. Jackson Rees and Dick Jones. Although there was no recognition of the subspecialty, no training program, and no such unit in Scotland, I was determined to make paediatric intensive care my future.
Three years later, after a self-constructed training programme of paediatric neurology, pulmonology, nephrology, cardiology, general paediatrics, and adult intensive care, I was on hand when Dr. Hamish Simpson returned from a Neonatal Research Fellowship at the Cardiovascular Research Institute in San Francisco, determined to open a PICU at Sick Kids, Edinburgh. This he succeeded in doing, with the help of two paediatric anaesthetists, Drs. Donald Grubb and Dick Burtles. He took me in tow, and the unit opened in 1972 with all of two beds. Hamish had the novel conviction that children on ventilators should have their arterial blood gases monitored. We responded to this, but it was to be some years before intra-arterial cannulae could be inserted percutaneously into small children; so, we became masters of the arterial stab, and our patients became pin cushions.
My first winter of intensive care involved continuous 24/7 on-call and certainly provided a steep learning curve. Two years later, I was about to broaden my experience with a year's training in paediatric anaesthesia, when Dr. Edmund Hey, the eminent neonatologist at Great Ormond Street (GOS) Children's Hospital, recruited me to help in setting up a general PICU. I recruited a fellow Scot, Dr. Bob Dinwiddie, recently back from the CHOP, to help run the unit and the annual St Andrew's night party!
At GOS, a post-cardiac surgery unit had been set up by Mr. David Waterston and Dr. Dick Bonham Carter, but other critically ill children were cared for and ventilated on their own wards, using the enormous industrial washing machine-like Engstrom ventilators, otherwise known as medical students. The new unit was to be run by paediatricians, with some assistance from the anaesthetists. This was an important decision, as it moved paediatricians into the front line of delivery of care to critically ill children, which had previously been mostly the preserve of paediatric and adult anaesthetists. The new 10-bed PICU opened in 1975 and, along with its sister unit at Guy's Hospital, provided most of the general paediatric intensive care for the children of the South East of England for the next 10 years.
I soon made a pilgrimage to Alder Hey Children's Hospital to meet one of the true pioneers of paediatric intensive care in the UK, Dr. Dick Jones. He had already established an efficient regional service and had written, with Dr. J.B. Owen Thomas, the seminal book The Care of the Critically Ill Child. Dick's lucid challenge was forthright: “The management of cardiorespiratory failure is in the main easy—sort out brain failure!” Responding to this, the main area of research of the PICU at GOS over the next decade was in neurointensive care with pioneering work by Dr. Robert Tasker. Respiratory failure was not entirely ignored; Drs. Peter Helms and Rob Ross Russell produced important work on regional ventilation (good lung up) and on diaphragmatic failure.
By 1993, Paediatric Intensive Care in the UK had become recognised. The Paediatric Intensive Care Society for nurses, anaesthetists, paediatricians, surgeons, and others involved in providing intensive care for children had been formed. At GOS, a purpose-built, 30-bed PICU had been opened and, with the Institute of Child Health, an academic department under Professor David Hatch had been created. The British Paediatric Association developed a report in 1993, “The Care of Critically Ill Children,” which highlighted the deficiencies and specified the changes needed, urging the government to act. It found that only 51% of children who

required paediatric intensive care received it in PICUs. Unfortunately, the government shelved the issue. Fortunately, there was a happy ending, albeit delayed. In 1997, the new working party, The National Coordinating Group on Paediatric Intensive Care, produced “A Framework for the Future,” which, at long last, produced action and funding.
History of Paediatric Intensive Care—Spain
Francisco Ruza MD, PhDA7
I started my career in Paediatric Intensive Care in the late 1960s, having newly finished my paediatric residency at the Children's Hospital La Paz (HILP). I was given the task of managing the paediatric part of a new surgical NICU, which was part of the paediatric surgical department, dedicated to the attention of the newborn children and infants who required surgical treatment. This unit constituted the germ of what, years later, would become the PICU.
It soon became clear that there was a need to treat in an organized way all critically ill children, regardless of the kind of pathology they had. At that time, the HILP had an enormous clinical load, as it was the first of a series of big paediatric hospitals that were being built in Spain. The need was growing because of the medical pathology seen with alterations of metabolism frequently associated with severe dehydration and acute renal failure. Dr. Francisco Rodrigo and I organized a young team of paediatricians for the continuous and well-standardized treatment of severe dehydration. We established the original therapeutic patterns needed for aggressive and individualized treatment of intravenous electrolytic alteration. Importantly, we were able to develop reliable, early diagnosis of acute renal failure and particularly of renal venous thrombosis. The evidence of improved outcome that we achieved accelerated the creation of a multidisciplinary PICU for all children, regardless of their age and illness.
To plan and organise the unit, I visited many of the existing PICUs in the US and in some European countries, compiling as many documents as possible. This information, allied with a lot of will and a certain amount of imagination, made possible the development of a PICU that was truly functional. The creation of diagnostic and therapeutic protocols constituted a hard and exciting job that reminded me of the words of the Spanish poet: “Walker, there's no path; the path is made by walking.”
I remember that period as the most creative and exciting that I have ever lived. We were starting a specialty that constituted an authentic revolution in clinical care in the paediatric hospitals. The opening of the PICU drastically changed the organization of our hospital, as all of the critical patients were concentrated in a specific physical area of the hospital, moving them away from the general hospitalization halls.
Another important challenge associated with these organizational and physical changes in the paediatric hospitals was the education and training of the doctors and nurses in the techniques and protocols of intensive care. Publication of our courses was the origin of our series of books. Right from the beginning, we had a great number of applications from paediatricians who wanted to train in Paediatric Intensive Care and wanted to work in our PICU. A great number of paediatric intensivists achieved their training in full or in part in our PICU, and they now work in numerous PICUs in Spain, Central and Latin America, several European countries, and Russia.
A special problem that we had in the early days was how the PICUs would be structured within the organizations inside the hospital. Adult intensive care, Anaesthesia, and Paediatrics worried about them. Times of turbulence finally resolved in the most rational way when the PICUs were organized with Paediatrics. Very dynamic protocols were established with general paediatrics and with the medical and paediatric surgical subspecialties. The organization of the PICUs as multidisciplinary medical-surgical units provided the best solution to appropriate organizational demands.
Nowadays, the outlook of the specialty has radically changed. In Spain, an authentic network of PICUs covers almost the entire country. The number of paediatric intensivists is large, and the demand for education in the field is very great. The fellowship programs now provide physicians in training with a well-planned and organized training program, with wide and varied sources of information, structure, and resources to make advances in the field. To a great extent, this is the best legacy that the veterans leave to the new generations of paediatric intensivists.
The specialty has now become a full member of the university educational program, integrating teaching programs in Paediatrics with the doctorate and master's programs. This guarantees a serious and well-established teaching program. We have created the Spanish Society of Paediatric Intensive Care (SECIP), with great scientific activity, congresses, and reunions. We are now positioned to properly train new generations of doctors and nurses who can contribute to research to sustain the progress that has been made.
When I contemplate the evolution that the specialty has had and the huge work accomplished by many people since the beginning, I feel an earnest satisfaction, knowing that the progress made has positively influenced the quality of care of critically ill children.
The Pediatric Intensive Care Unit in Australia
In 1970, not long after I graduated from medical school, I was working as a junior doctor in the Emergency Department of the Royal Children's Hospital (RCH) in Melbourne. A child was brought in with severe hypovolemia, and the senior medical staff was unable to insert an intravenous cannula. They pressed the emergency button, which summoned the intensive care consultant. Geoff Mullins strode into the resuscitation room, picked up a large-bore catheter (not one of those wimpy, fine-bore ones) and popped it in at the first attempt. I was watching breathlessly from the back row and, when The Great Man walked past me on the way out, I murmured, “That was fantastic!”—to which he replied, in an off-handed fashion, “I remember almost missing one of those once.” Clearly, I had to work in intensive care. But I didn't get there straight away. I finished training as an internist in adult medicine, spent a year

in Africa, and then trained for 2 years in general paediatrics at the RCH. Only then did I work in the ICU as a senior resident, in 1976.
The ICU at the RCH began in 1963, so it was one of the first paediatric ICUs in the world. It started in part of the postoperative recovery room, and all of the doctors were from the anaesthetic department. The first paediatricians to work in the unit were Peter Loughnan, in 1973, and me, in 1976. The first paper describing prolonged endotracheal intubation in children was published from Melbourne (Brit J Anaesth. 1965; 37:161–73). Tracheostomy had a very high complication rate in small children. Dr. Bernard Brandstater, an Australian working at the American University Hospital in Beirut, demonstrated (1959–1962) that polyvinyl chloride nasotracheal tubes could be used instead of tracheostomy tubes. Because polyvinyl chloride tubes soften at body temperature, they do not cause subglottic stenosis if tubes of the correct size are used—unlike rubber or metal tubes. This seemingly trivial observation enabled the development of modern neonatal and paediatric intensive care, because it allowed prolonged mechanical ventilation in children. Dr. Brandstater's original report, at a meeting in Vienna in 1962, was an extraordinary document. It spelled out all of the important principles of endotracheal intubation in children: The tube must fit easily through the cricoid ring, it must be firmly fixed in place with the tip in the mid-trachea, meticulous humidification and suction are essential, and the tube should be changed only if there are signs of obstruction.
Do you remember your first anxious night alone in charge of an ICU? In 1976, in Melbourne, there was only one doctor in the unit at night (expertly supervised by a superb team of experienced nurses). At approximately 3 a.m. on my first night, I had to ring the consultant on call. The phone was answered by his wife. “It's Frank Shann here, from Intensive Care at the Royal Children's. Is Dr. Mullins there?” “Just a minute; I'll see if he's the man in bed next to me.” A short pause. “That is my wife's idea of a joke.”
After spending 1976 in the ICU at the RCH, I worked as the only paediatrician in the highlands region of Papua New Guinea, serving a population of approximately 1.5 million people. In 1982, I returned to Melbourne as a senior resident in intensive care at the RCH. I was appointed as a consultant in 1983, as director of the unit in 1986, and as Professor of Critical Care at the University of Melbourne in 1995.
The ICU at the RCH is the only specialist paediatric ICU for the whole of Victoria, Tasmania, and southern New South Wales—an area approximately the size of California, but with a total population of only approximately 6 million people. Because we are the only specialist ICU for the region, we never refuse an admission, and we take a close interest in public health issues that affect children in our area. For example, three ICU consultants are members of a statutory committee that investigates the cause of every child death in Victoria. In 1979, the unit established a transport service for critically ill children. For many years, all of the transports were done by the ICU consultant on duty, but now almost all of the approximate 300 transports per year are done by a senior resident and a nurse from the unit, many of them by fixed-wing aircraft or helicopter.
Regionalizing paediatric critical care has many advantages. Large units have more experience with difficult or uncommon problems, they can be staffed by full-time specialists in paediatric critical care, and they can provide a high-quality emergency transport service at little extra cost. An important benefit from regionalization is that the unit feels responsible for all children in the region—for the provision of critical care, for teaching, and for public health issues.
I conclude with the two Golden Rules of paediatric critical care. Rule 1. The most important thing is to get the basics exactly right all of the time: airway (the right size tube in the right place, properly secured, with good humidification and suction), breathing (the right PO2 and PCo2), and circulation (a euvolemic patient with good myocardial contractility). Rule 2. Organizational issues are crucially important: We need large PICUs responsible for all of the children in a region (with a population of approximately 1 million children), staffed by doctors and nurses who are full-time specialists in paediatric critical care, with a properly funded transport service for critically ill children.
Origins of the Picu at Yale
George Lister MDA9
My interest in critical care medicine arose somewhat precipitously when I found myself working as a resident in an area referred to as the “croup room,” which I thought resembled Loch Ness; the fog was so dense that one could not see the patients but could only locate them by sound. Some of my other patients with serious cardiac or respiratory disorders were clustered close by but, fortunately, were not subjected to the thick air of anonymity bestowed by the mist. Our program had a neonatal special care unit, originally designed by one of the fathers of neonatology, Lou Gluck, but older children with critical illness were more scattered and had no single individual or group to champion their needs. Needless to say, this left us residents to rely on a mixture of nervousness and inventiveness to find assistance when our responsibility exceeded our skills and knowledge. I awoke one morning, just prior to a visit to Yale by Abe Rudolph, who was scheduled to be the Grover Powers Lecturer, with the idea that I wished to gain the background to take care of critically ill children and develop a curriculum to get an education to prepare me—although I had no clue whether this was possible. I must admit that, when I expressed this interest, one of my attendings quipped that I would soon enter a field of tertiary or quaternary pediatrics in which I would only be taking care of sick machines. Others advised that this was not a field for a pediatrician. Others simply gave me bewildered looks. But, I also received plenty of support and assistance for taking a novel path.
By the time of my residency, I had already developed a deep interest in cardiorespiratory physiology by virtue of some serendipitous events. As part of my education as a medical student, I was required to complete a thesis. During my pediatric clerkship, I participated in the transport of a neonate with total anomalous pulmonary venous return (i.e., I went along for the ride while trying to write a history and physical without getting nauseated in a cramped, hot ambulance). When we arrived, I asked if I could observe the emergency cardiac catheterization. Although the infant had a tragic outcome, I took interest in the data and the physiologic interpretation and asked the attending cardiologist, Michael Berman, if he would check my calculations of blood flows, which were riddled with erroneous

assumptions. I am deeply grateful to him because he took the time and interest to teach me and then suggested that I take an elective in pediatric cardiology. I followed his advice and, in so doing, met one of my lifelong mentors and friends, Norman Talner, Chief of Pediatric Cardiology.
Although I began a research project in cardiology that could serve as my thesis, Norman suggested that I apply for a Bay Area Heart Association Fellowship because he thought that one of the preceptors, Julien Hoffman, would be a terrific teacher and that the environment in San Francisco would be ideal for a student with my interests. I was awarded the fellowship during my fourth year of medical school and, in the process, met the most remarkable group of physician-scientists imaginable at the Cardiovascular Research Institute (CVRI) of the University of California at San Francisco (UCSF). Having Julien as a preceptor was the most fortunate event in my professional career. I arrived in San Francisco, he handed me a huge stack of papers, presented a problem related to the error in estimating oxygen consumption when calculating blood flow in infants, and suggested that I figure out how to solve it. I will not recount the details, but in the course of this all-too-brief fellowship, I was able to complete the project; develop a system for measuring oxygen consumption; submit my first manuscript, which was published with an editorial; initiate an enduring friendship with two great teachers, Julien Hoffman and Abe Rudolph; and launch a sustaining career interest in oxygen transport.
Thus, when Abe Rudolph visited New Haven during my residency, I was given the opportunity to meet with him and discuss my career options. Brash as I was and somewhat oblivious to barriers, I asked if I might take a trip to UCSF and meet with him, the head of neonatology (Rod Phibbs), and the head of pulmonology (Bill Tooley) to see if a program could be fashioned to prepare me to take care of critically ill children. Remarkably, I visited and was given a schedule to meet with each of these individuals and an offer to try to fulfill my wild and overly ambitious plans. With such an invitation and 2 years as a pediatric intern and resident under my belt, I loaded my car and headed for California. I started my odyssey as a fellow in cardiology for 6 months, then spent 6 months in neonatology, and returned to cardiology the following summer.
After I learned a bit more about the opportunities at UCSF, I arranged a meeting with Hillary Don, the director of the adult ICU, and asked if I might spend a month working there so that I could begin to learn about the management of critically ill adults. For many years, the pediatric cardiac surgical patients had been cared for in the NICU because of the commitment and talents of such individuals as George Gregory, who attended there and had extensive experience in managing such patients. When Paul Ebert (Chairman of Surgery and renowned pediatric cardiac surgeon) arrived at UCSF a few years earlier, the volume of cardiac surgery increased so much that it created a need to have some of the children cared for in the adult unit. Hence, my inquiry was well received, because of the supposition that I might even be useful in the care of those “babies” with heart disease. The experience proved to be invaluable to me. And, shortly after I finished and much to my surprise, Bill Hamilton, Chairman of Anesthesiology, asked if I would take a faculty position to work in the adult (and pediatric) ICU, which was under the aegis of Anesthesiology. A subsequent meeting was arranged with Bill Hamilton, Mel Grumbach (Chairman of Pediatrics), and Abe Rudolph to work out the details. We agreed that I would finish the planned rotations I had arranged during my second year as a fellow, continue with my research, and start on the faculty at UCSF in July—as a Pediatric Intensive Care physician. Perhaps one more element helped to accelerate my education. After I was on the faculty only a few months, the director of the ICU had a serious medical condition (from which he fortunately fully recovered); in very short order, I found myself as a codirector of an adult-pediatric ICU—an experience that might be viewed as a baptism by fire, but one that served as another opportunity to learn.
After remaining on the faculty at UCSF for approximately 18 months, I decided that I should leave because it was time for me to see if I could develop my own research directions and perhaps create a program for others who were interested in Pediatric Intensive Care. Following this, a few other accidents helped to launch my career. Before leaving UCSF, I was speaking at a seminar on cardiovascular care when I met a cardiac anesthesiologist from Johns Hopkins who heard my presentation on postoperative care of the child. He subsequently invited me to speak at Hopkins, where I met Mark Rogers, which initiated a long-time friendship and professional interaction. Soon after taking a faculty position at Yale, as I was struggling to get my laboratory off the ground, I received a phone call on a Saturday afternoon from two friends and collaborators whom I had met at research meetings: Doug Jones and Mike Simmons, the codirectors of the neonatal nursery at Johns Hopkins. They announced to me that they had a fellow for me; I stated that I did not have a training program, to which they responded, “Now you do.” Thus began a fellowship program at Yale and the start of recruitment of additional faculty to develop that program.
The Beginnings of Paediatric Intensive Care in France
Gilbert Huault MDA10
The beginning of paediatric intensive care in France owes much to accidental circumstances.
As I was trained both in adult intensive care and paediatrics during my residency, I initiated paediatric intensive care in the stream of other pioneers in adult intensive care medicine. Besides my paediatric duties, I spent many nights on call in the first unit of medical transports that was created by Dr. Maurice Cara at Necked Hospital in Paris. I also spent 1 year of my residency in the first unit of adult intensive care medicine created in the early 1950s by Professor Pierre Collaret, the inventor of the concept of “coma depose” (later “brain death”), at Claude Bernard Hospital in Paris. There, the young resident that I was dared once to transfer an adult patient with very severe pulmonary tuberculosis (who was being cared for by the Assistant Professor) into another department that I judged much more appropriate for the patient. This was, of course, not at all appreciated by the Assistant Professor, and all of my hopes of a career in adult intensive care medicine suddenly vanished, as it was the only adult intensive care department at that time in France. Dr. Jean-Jacques Pocatello, one of the pioneers in adult intensive care medicine in France (not a physician, but a pharmacist who developed the technique of blood gases in the department), had the final word in the dispute when he said to

the young resident, “It's never wise to tell a husband that he is cuckold…! Why won't you practice intensive care medicine in children?”
As I had practiced paediatrics before, I decided to spend 6 months in the paediatric neurology department, which was created by Professor Stephanie Thieffry at l'Hôpital des Enfants Malades (The Hospital for Sick Children) in Paris. This department was taking care of all children with poliomyelitis or tetanus using iron lungs, swivel beds, and, sometimes, the Engstrom adult respirator. Because I was very shocked to have to refuse all of the demands to take care of distressed newborns, I decided as a resident to accept a newborn from a French province who was suffering tetanus, on July 14 (the French independence day), 1963. A bit anxious, I phoned Jean-Jacques Pocidalo, who spent most of his professional life in the Claude Bernard Hospital adult ICU. He pointed me toward a recent paper from South Africa that described how to treat neonatal tetanus using muscle paralysis and mechanical ventilation. The newborn was cured after 3 weeks of mechanical ventilation using a very original respirator, called “R.P.R.,” which was actually developed by a submarine engineer in 1940. This case report was the subject of my medical thesis. Then, the respirator was developed by an industrial man and commercialised in France, where it was the only ventilator in use for newborns and children for almost 20 years.
At the end of my semester in neuropaediatrics, I severely criticized the organisation of the department openly with the chief of the department. Once again, my total lack of diplomacy was about to make me definitely renounce my career as an intensivist, when several months later, I was suddenly called on by Professor Thieffry. He explained to me that he was leaving for another institution and would be transferring the poliomyelitis unit. “You severely criticized my unit,” he said, “I now want you to run it. We will see how well you manage it!”
It was, indeed, a real challenge, as the new hospital, Saint Vincent de Paul in Paris, had minimal access to modern techniques. I prepared by living in the hospital and learning as much as I could and, finally, with the help of colleagues of the Cara's team, 18 children, supported either by iron lungs or by positive ventilation, were transferred within a single day. The unit was opening, although to much skepticism.
The equipment was at first very archaic. Then, the unit started to use a new device for measuring blood gases and stepwise acquired the first cardio monitors in use in France. In the unit, we performed the first peritoneal dialyses, conceived the first kits adapted to chest drainage, put in practice the first total parenteral nutrition techniques, and performed the first defibrillations ever made in children in France.
On May 8, 1965 (Victory Day in France), Professor Jean-Paul Binet, a famous French cardiac surgeon, operated on an infant who was suffering from an abnormal vascular ring. The occurrence of two cardiac arrests in the operating theatre convinced him that the infant was going to die. He was very surprised to learn 3 days later that the child was doing fine and was ultimately discharged from the unit. He suddenly realised the great importance of paediatric intensive care to congenital cardiopathies, in which the postsurgical mortality was very high. Thus, within the 10 subsequent years or so, approximately 1,500 cardiac children were operated on.
Of course, I could not do everything on my own. Over time, a team was structured around me (including an energetic and powerful head nurse), which constituted a group of high-quality nurses and highly enthusiastic fellows who were seduced by this new type of medicine. At the end of the 1960s, the unit was covered by the so-called “Four Musketeers”: Jean-Bernard Joly, Jean Kachaner, Jacques Saint-Martin, and Gilbert Huault. Within a few years, the unit served as a teaching and training centre for new physicians and nurses interested in this new type of practice in paediatrics. Quite quickly, the “hive” spread: Michel Cloup opened up a new unit in Les Enfants Malades Hospital in Paris, as did Jean Laugier in Tours, in 1968. François Beaufils created another unit at Bretonneau Hospital in Paris, in 1971. Michel Dehan started a NICU in the brand new hospital built in Clamart (in the environs of Paris). Nowadays, approximately 50 NICUs and 35 PICUs can be found in France, including overseas territories. This is a nice outcome for what began as an accidental circumstance.
The Development of Pediatric Intensive Care in Israel
Zohar Barzilay MDA11
I went to London (Imperial College) in 1974, during the First World Congress on Intensive Care, to meet with Peter Safar, then program director at Presbyterian Hospital in Pittsburgh and Chairman of the Department of Anesthesiology and Critical Care at the University of Pittsburgh. Peter interviewed me in London and accepted me for his fellowship program in Pittsburgh, a leading center for intensive care.
In December 1974, I began a rotation at the Montefiore Hospital Surgical ICU (SICU) with Dr. Arnold S. Sladen for 3 months, working with Dennis Greenbaum. Subsequently, I rotated through various units with the well-known faculty in adult critical care, including Drs. Ake Grenvik and Jim Snyder, for 3 months (adult MICU, SICU). It was only after completing that training that I spent 12 months with Bob Binda and David Ryan at Children's Hospital in Pittsburgh (including rotations in pediatric cardiology and in neonatology at The Magee Woman's Hospital).
Upon returning to Israel in late 1976, I first joined the adult ICU team but gradually took on more and more pediatric patient responsibilities at Sheba Medical Center. In November 1977, we finally organized and opened the first PICU in the country. The head nurse at the time, Ms. De-boer, had also completed 6 months of training at the Children's Hospital in Pittsburgh. Apart from organizing the physical facility (the actual unit), we had to train nurses and residents in pediatric critical care medicine. The first PICU was a five-bed unit, attended by eight nurses and two physicians. Word of our capabilities spread through the medical community, and we began teaching and training medical students, physicians, nurses, and paramedics. In addition to more traditional training, we provided training in cardiopulmonary resuscitation and in advanced cardiac life support.
In 1982, I went on a sabbatical in Anesthesiology and Critical Care Medicine with Dr. Mark Rogers at the Johns Hopkins Medical Center in Baltimore, Maryland. This was my first organized exposure to a well-manned, well-equipped, and functioning multidisciplinary PICU that was part of a distinguished department. The research that I conducted with

Dr. Richard Traystman, Director of Research in the Department, also became an unforgettable experience and a milestone in my future career. Upon returning to Sheba in 1983, many procedures and therapeutic modalities were adjusted according to my experiences at Hopkins. By now, Israel had four PICUs, and four more were in the planning stage.
In contrast to adult critical care medicine in Israel, which is organized in Anesthesiology, PICU physicians are mostly pediatricians who become interested in critical care medicine. This is probably true because Pediatric Anesthesiology was nonexistent in Israel in the era in which Pediatric Intensive Care developed as a specialty. Today, we have approximately 120 PICU beds and in 12 PICUs in the country, and fellowship training, including board certification, is available in Pediatric Critical Care Medicine.
In 1984, the PICU at Sheba was renovated and expanded to include patients coming from all disciplines of medicine. We began caring for children in Israel and those from neighboring countries. Most major PICU physicians and nurses in Israel completed their critical-care rotations at Sheba. Among them were G. Hauser of Georgetown in Washington, D.C.; M. Sagy-Schneider, now in New York; and N. Noviski, who went to the MGH in Boston. In the mid-1980s, we trained four Palestinian physicians (two pediatricians) for 2 years. They later established the ICU and PICU in the Gaza Strip. Our PICU continues to be home for most transferees from Gaza, mostly patients in need of cardiac surgery, treatment for cancer, or rehabilitation.
The PICU had become a department, the Department of Pediatric Critical Care. It is the largest PICU in the country and has approximately 1,000 patients per year; they are admitted for trauma, sepsis, congenital anomalies, cardiac surgery, neurosurgery, and respiratory failure. Care is administered in an 18-bed facility, with 10 ICU beds and 9 step-down beds uniquely designed as 10 and 8 separate patient rooms located in 2 circles around central halls. In addition, the department has a small operating room, an extracorporeal membrane oxygenation room, and 2 sleep-study rooms with electroencephalogram capability (located in the Safra Children's Hospital at the Chaim Sheba Medical Center, a tertiary care center that serves a population of approximately 1 million). Ours is one of the few PICU facilities that also does sleep studies. The 3 full-time faculty, 37 nurses, and the fellowship program are all certified in Pediatric Critical Care Medicine.
How I Became Interested in Intensive Care in Austria
George Simbruner MDA12
Interest in a field arises from being confronted with needs and from meeting people. Pediatric care, in its wider meaning, includes newborns and children. Freshly graduated from Vienna University, I started to work at the University of Stellenbosch, Tygerberg Hospital, in Cape Province, South Africa. Professor Victor Harrison and his team at Groote Schuur Hospital were the first to intubate and ventilate newborn infants with RDS. In Tygerberg Hospital, we used the negative-pressure ventilator (air-shields) to ventilate premature infants. After my return to Vienna in 1972, I got fully involved in neonatal intensive care. My first statistics about survival of ventilated newborns were shocking. Only 1 out of 100 ventilated newborns had survived in 1973. The ventilator in use was a bulky respirator constructed for adult patients and badly adapted for prematures. I decided to construct a new, modern ventilator, bought fluidic elements from Corning, New York, and assembled a fluidic-controlled, jet-stream respirator that allowed ventilation with frequencies up to 5 Hz. Testing this apparatus and studying lung mechanics with a Beckman Amplifier got me more and more involved in respiratory intensive care.
During early 1980s, I was asked to set up a PICU at Vienna's Children's Hospital. I probably had never met Professor Mark Rogers in person before but knew about him from reading his standard book on Pediatric Intensive Care (the “Red Book,” but 10 times larger than Mao's). I decided to invite this famous professor as guest professor to visit and lecture at our new PICU. I knew that he was engaged in improving the PICU in Ljubljana, Slovenia, and that he would fly there in the near future. Encouraged by a vision, I wrote a letter (e-mail had not yet been invented) to invite him to stop over in Vienna on his way to Ljubljana. Professor Rogers, open to all interested in PICU, agreed. I took him to the most distinguished old pubs and to a small-orchestra performance in a small room of the famous concert hall, “Musikvereinssaal.” When I realized his enthusiasm for the site, I proposed to him to come for a month to Vienna. During that time, we could also attend a concert in the large, beautiful hall of the “Musikvereinssaal,” where the famous New Year's Concert was performed. Thus, in 1986, Professor Rogers spent a month in Vienna, lectured on intensive care, and helped to set up the PICU. He stimulated and helped us to fully develop intensive care techniques. Due to this personal encounter with Dr. Rogers as teacher and, later, friend, I participated as an invited lecturer in the first World Congress on Pediatric Intensive Care held in Baltimore. As a young doctor, I was very proud to be among the founding members of the WFPCCS.
This experience also fostered my personal view that teaching intensive care medicine was an important and very rewarding task. I remained in the field of intensive care but focused on neonatal intensive care, became editor of the section on “Neonatal and Pediatric Intensive Care” in the journal Intensive Care Medicine, and developed a worldwide postgraduate teaching enterprise named IPOKRaTES. Those early days of Pediatric Intensive Care were dominated by one person, Dr. Mark Rogers. In this historical review, it is appropriate to acknowledge his enormous contributions to the development of Pediatric Intensive Care, particularly in Europe.
The History of Pediatric Intensive Care in Thailand
Subharee Suwanjutha MD, FCCPA13
Pediatric Intensive Care has received special recognition as a new specialty over the past 25 years. Thailand also recognized its need for an organized area to deliver specialized care and to train individuals devoted to the care of critically ill children. This need led to the development of PICUs in several hospitals in both urban and rural areas.
The NIH in the US regards the PICU as an area where assigned, full-time personnel—qualified physicians and nurses—are available 24 hours per day. In Thailand, before the year

1980, only a few teaching hospitals were qualified with these criteria, because resources were limited.
The first PICUs were established at Chulalongkorn Medical School in 1968, at Siriraj Medical School in 1970, and at Ramathibodi Medical School in 1973. At present, Thailand has a total of 12 medical schools: eight in Bangkok and the vicinity and four in rural areas. Each of these medical schools has its own PICU. In hospitals under the control of the Ministry of Public Health, 21 medical centers and hospitals are under the responsibility of the “Office of Rural Doctor Production.” All of these medical centers are affiliated with five medical schools, and most of them have their own PICU.
Personnel Development in Pediatric Intensive Care
An inadequate pediatric intensive care background among ICU personnel prompted the establishment of an organized pediatric intensive care training program. The Department of Pediatrics of Ramathibodi Hospital was one of the earliest groups to develop such a program. The group is comprised of a pediatric pulmonologist, cardiologist, neurologist, infectious disease specialist, nephrologist, and other subspecialists in critical care. These individuals are knowledgeable in the application of new technology and practical management of patients with multisystem involvements. The four leading problems in our PICU during that period of time were respiratory, neurologic, cardiac, and gastrointestinal diseases. During the pediatric intensive care training program's inception, a group of pediatric pulmonologists and pediatric anesthesiologists made a strong effort to incorporate both fields into the care of critically ill children. In 1980, this group started the first organized critical care team and, subsequently, the first national training program in Pediatric Intensive Care for physicians and nurses at the national level. This course included 2 weeks of clinical training and, for nurses, an additional 2 weeks of ward practice. Since 1980, physicians have sent ICU and respiratory care nurses into the program for 2 weeks of practical training.
In 1982, a nationwide training course in Pediatric Intensive Care at the international level was organized by the respiratory care committee members of Ramathibodi Hospital. I was assigned by the committee to be the coordinator of the program and to submit a proposal to the World Health Organization requesting the sponsorship of an overseas adviser for the course. The adviser approved by the World Health Organization was Professor Mark Rogers, who was then the Chairman of the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University Hospital in Baltimore. All participants in the course were physicians and nurses actively involved in the care of critically ill children in provincial and large general hospitals throughout Thailand. The program was very successful, and the event was the beginning of a new era in Pediatric Intensive Care in Thailand. Since then, more pediatricians and pediatric nurses have gone abroad for further training in pediatric pulmonology and critical care. After 1982, three of the staff members from the faculty of medicine at Ramathibodi Hospital, including two physicians (Drs. Teerachai Chantarojanasiri and Aroonwan Preutthipan) and one intensive care nurse (Mrs. Suparat Vaicheeta) went to the US for further training in pediatric critical care and pulmonology at the Johns Hopkins University Hospital through the kind support and collaboration of Professor Rogers.
In 1988, a fellowship training program for the subspecialty of pediatric pulmonology and critical care for board-certified pediatricians was approved by the Medical Council of Thailand, and I was appointed chairperson of this subspecialty board. Ramathibodi and Chulalongkorn University Hospitals were the first two medical centers approved by the medical council of Thailand to be institutes for training in pediatric pulmonology and critical care. The first two fellows received their sub-board certification in June 1992. At this writing, 23 clinical fellows have received sub-board certification in pediatric pulmonology and critical care.
Progress and Development of PICU in Thailand over the Past 25 Years
Since the introduction of the specialty of pediatric pulmonology and critical care medicine, the mortality rate of the nation's critically ill children has been reduced. However, the morbidity rate of chronic illness or disability due to the intensive management of chronic pulmonary problems and impaired neurologic function has increased. Many patients cannot be discharged due to the need for chronic respiratory therapy that requires more sophisticated equipment. One way to lessen the problem of prolonged hospitalization, especially ICU care, and to speed up the turnover rate, was to establish a respiratory home-care program, which has been successfully developed. This program was introduced at Ramathibodi Hospital in 1995. Other initiated programs include the creation of extended ward-care facilities and a training course for respiratory care nurse specialists in 2004. In 2006, the first national seminar for pediatric critical care nurses was organized by the faculty of medicine at Ramathibodi Hospital. More than 250 nurses participated in the course. A program for the training of pediatric critical care nurse specialists is being planned for the near future.
Organization of the Thai Critical Care Society
It is evident at present that Thailand and other developing countries are facing the problem of financing a good healthcare program. PICU specialists must be aware that the goal of this specialty is not only to save lives or to improve the care of critically ill children, but also to maintain a good quality of life. The fact that many colleagues in other PICUs around the country were involved in the care of children generated great enthusiasm and led to the successful founding of the Thai Society of Critical Care Medicine in 1984. This society became a member of the Western Pacific Association for Critical Care Medicine and successfully organized the Sixth Congress of the Western Pacific Association for Critical Care Medicine in Bangkok in December 1991. More than 800 participants joined the Congress, including experts from all over the world, who not only contributed current knowledge in this field but also created a better understanding among critical care specialists. The success of this meeting and its repercussions was greater than expected.
The Thai Society for Pediatric Respiratory and Critical Care Medicine was founded in 1998. As a president of the society, I was honored to be one of the founding members of the World Federation of Pediatric Intensive and Critical Care Societies, which was successfully organized under the leadership of Professor Geoffrey A. Barker in 1998.
Since 1982, considerable progress has been made in pediatric critical care in Thailand. The Thai Society for Pediatric Respiratory and Critical Care Medicine, with approximately 400 members comprised of physicians and nurses from hospitals throughout the country, has successfully organized the national

conference, seminars, workshops, and short-course training for physicians and nurses who care for critically ill children. We hope that the continued cooperation and collaboration among the intensive care specialists and societies at the national and international levels will make available a high standard of pediatric intensive and critical care to all children of the world.
The Development of Neonatal and Pediatric Intensive Care in Guayaquil, Ecuador
Jose Fernando Gomez-Rosales MD, FAAPA14
Our hospital was inaugurated as the Hospital Gineco-Obstetrico Enrique C. Sotomayor in September 1948, and in 1950, we started a premature babies department to try to help those very tiny babies to live. We confronted the usual problems of that time: Rh incompatibility, hyaline membrane disease, kernicterus, sepsis, immaturity, and the like using four incubators in a small room. Dr. Manuel Ignacio Gomez-Lince was the first director of the department and was in charge of the newborns of the hospital. He created a group of physicians who wanted to work with neonates and begin this new specialty. Support for this effort came in an unusual manner.
The H. Junta de Beneficencia de Guayaquil is a central charitable institution that was created to help the very poor people of the country. It supports the four biggest hospitals in each field in Ecuador, including the Children's Hospital “Roberto Gilbert,” with 342 beds, and the Maternity Hospital “Enrique C. Sotomayor,” with 320 beds. Currently, we have between 32,000 and 40,000 births every year at the Maternity Hospital. We deliver approximately 80% of the babies born in our province. Our history, like many others, was to begin in Neonatal Intensive Care and to grow into Pediatric Intensive Care.
As the maternity hospital grew, it was necessary to increase the area for premature babies, and in 1981, the H. Junta de Beneficencia de Guayaquil decided to create our NICU, because the small prematures needed respiratory assistance and we did not have ventilators or experience in this field. So, in 1982, I went to the Ochsner Clinic in New Orleans to spend some time in their NICU with Dr. Jay P. Goldsmith to learn mainly the management of respiratory problems of premature infants.
We started in 1983 as a small unit with three open incubators, ventilators, and monitors; this area grew to 10 places in 1988 to service the need. In that year, we also started the postgraduate course in Pediatrics in the Children's and the Maternity Hospitals. At that time, mortality was very high, but we cut it by nearly 50% by 1993.
After the first international congress that our department held in 1989, Dr. Mark Rogers, one of our guests—who was subsequently nominated as the international coordinator for all our Congresses—awarded a fellowship for one of our doctors. We sent Dr. Guillermo Munoz, who spent 6 months in the NICU and PICU at Hopkins.
One of the events that brought us national attention occurred in 1993, when sextuplets were born in our hospital at 26 weeks of gestation. Unfortunately, we lost one after 29 days of fighting with many complications. We ultimately ended up with four healthy children, all of whom are now normal adolescents and good students with normal neuromuscular and brain function.
After we increased our beds, Discovery Laboratories of Pennsylvania approached us and proposed testing Surfaxin, an artificial surfactant, in our patients in a U.S. Federal Drug Administration-approved trial. In turn, they provided us with a new set of eight beds for the unit; when we finished the work, we consolidated both areas and now are working with a total of 18 beds. By 1980, the interest in improving the care of critically ill children had grown from its neonatal beginnings into interest in Pediatric Intensive Care. The H. Junta de Beneficencia started a seven-bed PICU with Dr. Ines Zavala in charge at the Children's Hospital Roberto Gilbert. Dr. Cecilia Masache started a separate NICU in 2000. The unit now has 19 beds in the PICU and 22–26 beds in the NICU. Dr. Ines Zavala is in charge of the PICU, and Dr. Marisol Kittyle is in charge of the NICU. The NICU receives babies who are born in small clinics in the city and mainly babies who are born out of the city in small towns or in the country. The children in the PICU can be postoperative or brought to the Children's Hospital with all of the conditions that are seen in similar PICU environments throughout the world.
The Development of Pediatric Intensive Care in Brazil
Jefferson Pedro Piva MD, PhDA15
Pedro Celiny R Garcia MD, PhDA16
In the early 1970s, several epidemic disease outbreaks occurred in Brazil. Some of them (measles, poliomyelitis, diphtheria, diarrhea, and meningococcal disease) had remarkable mortality rates and represented a big challenge to Brazilian general pediatricians. Most of the referral hospitals (general and pediatrics) created small units for better isolating these infected patients and providing better care. The skilled staff members (medical staff and nurses) and the limited available technical resources were concentrated in these units. At the same time, the neonatal mortality rate in Brazil was very high because of infections, and the model of caring for premature and sick newborns in closed units was immediately adopted and extended to those pediatric units for infected patients. This was the birth of Pediatric Intensive Care in our country.
Rapidly, the concept of PICU was consolidated and adopted in large hospital centers of Brazil. The leaders of this movement were: (a) in São Paulo, Anthony Wong, Mario Telles, Jr., Werther Carvalho, and Mario Hircheimer; (b) in Curitiba, Izrail Cat and Ismar Strachman; (c) in Porto Alegre, Pedro Celina Garcia, Paulo Carvel, and Jefferson Piva; (d) in Belo Horizonte, Julio Sena and Waldemar Fernal. During the early 1980s, looking forward to the growth of Pediatric Intensive Care in Brazil, this group identified that it would be imperative to organize the new specialty, disseminate the knowledge throughout our country, interact with outside centers of pediatric intensive care, and promote research development in this area.
In this era, Jefferson Piva and Pedro Celiny Garcia, who were two pediatric intensivists working in Porto Alegre

(southern Brazil), assumed their leadership in this process. Dr. Piva was the director of the PICU at Hospital Santo Antonio, a large university-affiliated children's hospital, and Dr. Celiny Garcia was the director of the PICU at Hospital São Lucas, a university-affiliated general hospital located in the same city.
Although working in two different PICUs, Piva and Celiny Garcia joined efforts in the development and organization of the specialty. In particular, they worked inside the Brazilian Pediatric Society and the Brazilian Critical Care Association and held relevant positions on the executive board of both organizations, which contributed to creating more opportunities for this new specialty. As a result of these and other actions, the Brazilian Pediatric Society and the Brazilian Critical Care Association, in 1990, formalized joint board certification in Pediatric Intensive Care. Since then (nearly 16 years ago), more than 1,200 pediatric intensivists have been board certified in Brazil.
Drs. Piva and Celiny Garcia published the first edition of their book in 1985, which is now in its fourth edition. With each new edition, they incorporate a broad spectrum of authors from diverse regions of Brazil and different parts of the world. Their book, Medicinal Intensive me Pediatric (Critical Care in Pediatrics) is considered one of most important and relevant books in the Brazilian intensive care field, with over 10,000 copies in circulation in Brazil and South America. The last edition (5th) of this book was published in 2005.
In 1986, Piva and Celiny Garcia promoted the first meeting, enrolling all of the South American Pediatric intensivists. It was at this meeting that the Latin American Committee of Pediatric Intensive Care was created; it later became the Latin American Society of Pediatric Intensive Care (SLACIP). During the first World Congress on Pediatric Intensive Care in Baltimore (1992), the first SLACIP meeting was organized as a pre-congress meeting, a practice that has continued at all subsequent World Congresses.
In 1996, Dr. Piva moved to the Hospital São Lucas (PUCRS University) to work in the same PICU with Dr. Celiny Garcia. A new, modern PICU was created, and the pediatric emergency department was incorporated under their leadership.
The History of Pediatric Intensive Care in the Philippines
Mae Ouano MDA17
Herminia L. Cifra, MD, known as the mother of Pediatric Critical Care Medicine in the Philippines, graduated from the University of the Philippines Medical School in 1972. After graduation, she trained in Pediatrics at the University of the Philippines-Philippine General Hospital (UP-PGH). Subsequently, she started formal training in pediatric critical care and spent time at the Royal Alexandra Hospital in Australia. For many years, her work focused on training nurses and doctors in pediatric critical care.
At her PICU at the Philippine Children's Medical Center, she eventually had 10 PICU beds and six intermediate beds. An additional nine beds were located at the UP-PGH. In 1990, Dr. Cifra founded the Philippine Society of Critical Care Medicine, an integrated society for both adult and pediatric critical care specialists. By 1997, a total of 11 Pediatric Intensive Care fellows had graduated from the pediatric critical care training program that she pioneered. This significant milestone prompted the need to form a separate pediatric intensive care society. In the same year, Dr. Cifra formed the Society of Pediatric Critical Care Medicine Philippines and held the position of founding president, with other founding officers from around the country.
Dr. Cifra remained the driving force and inspiration behind Philippine Critical Care Medicine, especially in Pediatrics, until her untimely death in 2005.
  • Founder, Pediatric Intensive Care Unit, Johns Hopkins Hospital.
  • Founder, Pediatric Intensive Care Unit, Children's Hospital of Philadelphia.
  • Associate Director of Pediatric Intensive Care, Massachusetts General Hospital.
  • Founder of Pediatric Intensive Care, Massachusetts General Hospital.
  • Founder, Pediatric Intensive Care Unit, Hospital for Sick Children, Toronto.
  • Formerly, Director of Intensive Care, Great Ormond Street Children's Hospital, London. Founding Chairman of the Paediatric Intensive Care Society.
  • Founding Director, PICU and Emergency Service Hospital Infantil La Paz, Professor in Pediatrics, Universidad Autónoma Madrid.
  • Founding Director and Professor, Intensive Care, Royal Children's Hospital, Melbourne.
  • Founding Director, Pediatric Intensive Care Unit, Yale University.
  • Founding Director, Pediatric Intensive Care Unit, Saint Vincent de Paul Hospital, Paris.
  • Founding Director of Pediatric Critical Care Medicine, Sheba Medical Center, Israel.
  • Professor of Pediatrics and Neonatology, Med University Innsbruck, Austria.
  • Founder, Pediatric Intensive Care, Ramathibodi Hospital. Honorary advisor of PICU Committee, Ramathibodi Hospital. President of the Thai Society for Pediatric Respiratory and Critical Care Medicine, Thailand.
  • Hospital Gineco-Obstetrico Enrique C. Sotomayor.
  • Associate Professor of Pediatrics at the School of Medicine at PUCRS University and the School of Medicine at UFRGS University. Associate Director of PICU, Hospital São Lucas da PUCRS. Member of the Executive Board of the World Federation of Pediatric Intensive and Critical Care Societies (WFPICC). Associate Editor of Pediatric Critical Care Medicine.
  • Associate Professor of Pediatrics, School of Medicine PUCRS University. Director of PICU, Hospital São Lucas da PUCRS, Associate Editor, Jornal de Pediatria (Brazil).
  • Former fellow of Dr. Herminia L. Cifra.
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