Anesthesiology and Critical Care Medicine at CHOP: A Legacy of Hope

Children's Hospital cares for some of the sickest children in the nation in its operating rooms and intensive care units. Founded in 1964, the Department of Anesthesiology and Critical Care Medicine has played a pioneering role in improving outcomes for children in intensive care. Watch the video to learn more about the decades of hard work and innovation that have brought us to where we are today, and meet one of our early patients, whose care was a milestone in our team's history.


Anesthesiology and Critical Care Medicine at CHOP: A Legacy of Hope

Aruna Nathan, MBBS: I think when people choose to become physicians they are driven, really they are driven by the need to make a difference, but you truly, truly, truly leave a legacy behind of people who continue the service to humanity. But the deepest personal satisfaction comes from the patient interaction. That's what keeps you going back there every day. That's what makes you feel. That's what makes you, you know, in the middle of the night when you are doing a transplant and you think everything's falling apart, it keeps you to together to deal with kid, to take that child back and hand it back to its parents.

It's the ultimate act of trust when somebody gives you their child.  It is not about the doctors, the nurses or anybody else or even CHOP. It’s about the child. 

Russell C. Raphaely, MD: What attracted me to the Children’s Hospital was actually Dr. Downes and Dr. Bachman and in particular what I found appealing was the extension of the anesthesiologist's care beyond the Operating Room and Critical Care and the opportunity to interact with all the disciplines in medicine was very appealing to me.  We were breaking new ground in various ways of supporting and treating illnesses. 

Leonard Bachman, MD: When I first became the head of the department, I was young, 30 years old but this was the standard conventional wisdom of the time in an academic department. And that is that research was a very important part of being an academic physician, that you should look at the work that you were doing and try to find new knowledge about what you were doing. 

As our skills got better as we did research and we learned how to breathe for patients and we learned how to support their circulation.  In the Operating Room, people began to get the idea and a lot of that originated right here that we can take those same skills and take them into all parts of the hospital for all kinds of critically ill patients.

John J. Downes, MD: Critical care was an outgrowth of the knowledge and skills that an anesthesiologist should possess to take care of patients in an Operating Room and we eventually were able to prevail on administration and move a number of wards around to create a six-bed pediatric ICU right outside the operating room in the old hospital.  So that’s the evolution of critical care.

William J. Greeley, MD: I think it is a fair assessment to say the timing in getting Anesthesiology and Critical Care medicine together as a collective discipline was very important, particularly in the early years. So, if you are looking at any ICU in the country at least half the patients in there are post-operative patients and the best person that has the best perspective on the recovery is an anesthesiologist who is in the OR, knows what is going, sees the elements, and then can foster the post-operative care.

Marilyn Ritter, Mother:  Michael came to Children’s Hospital, Philadelphia on April 24th in 1967. 

John J. Downes, MD: Michael was obviously struggling and we had a chest x-ray from Reading that showed that he had a classic picture of respiratory distress syndrome. We knew he wouldn’t survive unless we intervened and intubated his trachea and assisted him with mechanical ventilation which we proceeded to do. And a picture was evolving and he could not be liberated from the mechanical ventilator and we told the parents we were out here in new territory.

Marilyn Ritter, Mother: In the beginning it was a very, very stressful time, it was like up and down, and up and down and we would be encouraged and then discouraged.  He was hooked up to all kinds of tubes. That first trip home was very difficult and I think I cried most of the way home. 

John J. Downes, MD: I was receiving some criticism from - indirectly from some of the pediatricians that by doing what we did instead of letting this baby’s natural process evolve which would have been death.  We were creating a situation where we would have a baby who would probably be brain damaged and have permanent lung damage and probably have a miserable life, if he did survive. 

Susan C. Nicolson, MD: I think a large program like the Children’s Hospital of  Philadelphia with sub specialties in Pediatric Anesthesia and Critical Care medicine, not only has the opportunity to identify the unanswered questions in the field but really has an obligation to come up with the answers.

I think there is a huge number of firsts that have been done here at CHOP in all the sub specialties within the department, not only in clinical investigation but translational Investigation and even extended into basic science research.

Leonard Bachman, MD: Anesthesia was very attractive to me because you saw your results right away, you injected something and you saw something happen and the intellectual stimulation of how these things work even today why anesthetics work is still a great mystery.

Russell C. Raphaely, MD: It was a matter of having everybody develop a confidence that these things that we were doing wouldn’t be harmful and leave a person handicapped or disabled – that in fact, they would allow them to return to a productive and normal lives.

Myron Yaster, MD: I think one of the key things to think about is terms of Anesthesia and Critical Care, Pain Management and Quality Improvement is that we have become, to a large degree the mortar that holds the bricks together in the hospital and that much of what we think of as was important in making the experience of patients better, improving quality, is being driven from the operating room and from people who do Anesthesia, Critical Care, Pain Management.

Susan C. Nicolson, MD: I think there is a huge legacy here at CHOP of pioneers such as Jack Downes, Len Bachman, Russ Raphaely who really move the field forward and I think that that’s what is the driver to come to work every day because you want to continuously learn and you want to continuously be able do something that you weren’t able to do five years ago and I think that every decade we get better at what we can do.

Robert A. Berg, MD: In almost any important, serious endeavor people always have to be improving because if you stay still you are going backwards. It's stunning that in many places the mortality rates used to be in 20 plus percent and now we're less than – 1 ½ - 2% of children that come into our Intensive Care unit do not survive; that is 98 to 99% survive their illness and move on and we keep wanting to get better and better at that. 

William J. Greeley, MD: In life everything is about luck, this was the right place at the right time, things were changing, people were beginning to see anesthesia as a good career to go into, this was one of very few places that had training program so if you had that vision of going into anesthesia and critical care really the only places you could train was at CHOP. 

John J. Downes, MD: The dual trained individuals that we trained in the 70s and early 80s went out and many of them became heads of pediatric anesthesia and critical care departments in other children’s hospitals.  So we trained I think as that well over 300 fellows. In fact, I think that is probably our major contribution to healthcare in this country.  As far as our department was concerned was the number of people that we trained who came through our program.

Aruna Nathan, MBBS: When you are a woman in medicine, there are two things you want, one is of course you want the resources, you want to you know learn all the stuff you want to be on the cutting edge of medicine, you want to do all those things that make a difference, you want the knowledge base, the research base and everything else but you also want to see women doing that work; you want to aspire to be like that and that CHOP had. So whilst I was in training in Britain, I got a sense that this is what would fascinate me and keep me engaged with doing what I did. So, I spoke to one of the surgeons there and asked where I would go to train and he said only one place and that would be CHOP under Susan Nicholson.

Susan C. Nicolson, MD: I think that it’s very important to recognize at the end of whatever time that one trains that you're not fully an expert in what area you seek to be and that you have to continue that process with ongoing mentorship into whatever practice you join.

Maryam Y. Naim, MD: I can tell you that the first six months of my fellowship here at CHOP was more difficult than medical school. It was tough and it is the kind of training where – it's almost like boot camp. When you are in it, it is really, really difficult. When you're done with it, it's a huge accomplishment but it was tough.

Russell C. Raphaely, MD: When someone commits to you as a faculty member three years of their lives to be prepared for a career you have an obligation to train them properly.

John J. Downes, MD: That has been one of the most exciting aspects is to see these bright young, very dedicated people come through our program and learn from them. It has been an exciting part of my career that’s for sure.

I got a lot of encouragement from one of our fellows and he said, "Don’t give up, don’t give up."  He said, "We don’t know where we are going but don’t give up."  So we persisted but then things began to improve a little bit. By eight weeks of age he was off the ventilator completely.  So long story short, he has grown up fine.

But Michael was the sentinel case. He was the one that got us started and if he had died or the outcome it would have been horrible maybe our attitudes would have been quite different.

Maryam Y. Naim, MD: It really is a privilege to be with families; it's a very unique experience not many people get to be with a parent on the worst day of their life and what we do on a day to day basis is try to take care of kids as if they were our own.

Robert A. Berg, MD: When parents bestow on you the responsibility of taking care of their critically ill child at the most tender moment in their lives and the most important moments in their lives; that's both an honor and an onerous responsibility.  It is in the moment you don’t think about it, but there are moments you are aware of it.

Marilyn Ritter, Mother: What CHOP has done for Michael in saving his life, is certainly worth doing because he's grown up to be a good man and he's giving to society. He's a good husband and father. He's a good family man. It takes a lot of energy and toil and work and I know that the doctors sacrifice and anyone in this field, it's not a field that you go into if you are selfish. It's a giving field and I hope that they are rewarded with really having a sense of satisfaction when they see their little ones grow up into good adult people.

William J. Greeley, MD: I got the best job in the world. Are you kidding? I got the best – working in a wonderful institution with wonderful colleagues, incredible faculty, incredible nursing, and trainees.  I mean it’s just – there are times when I just pinch myself and say,"This is unbelievable. This can’t be real."

John J. Downes, MD: The dedication is there, a deep and abiding concern. Are we doing the best we can for this child? That’s the essence of what makes this hospital a great place.

Michael Ritter: Well today’s and tomorrow’s doctors, I would just like to say in advance thank you and even though we can’t ask you to help us because we are too small, I would like to say,"Please help us and continue to help us the way your predecessors like Dr. Downes has helped myself and keep fighting for those that don’t have a voice."


Related Centers and Programs: Department of Anesthesiology and Critical Care Medicine