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Ebook Fuhrman Zimmermans Pediatric Critical Care PDF Full Chapter PDF
Ebook Fuhrman Zimmermans Pediatric Critical Care PDF Full Chapter PDF
PEDIATRIC
CRITICAL CARE
SIXTH EDITION
PEDIATRIC
CRITICAL CARE
JERRY J. ZIMMERMAN, MD, PhD, FCCM ALEXANDRE T. ROTTA, MD, FCCM
Faculty, Pediatric Critical Care Medicine, Seattle Children’s Division Chief, Pediatric Critical Care Medicine Duke
Hospital, Harborview Medical Center, University of Children’s Hospital; Professor of Pediatrics; Duke University
Washington School of Medicine, Seattle, Washington School of Medicine, Durham, North Carolina
Joseph D. Tobias, MD
Chair, Department of Anesthesiology and Pain Medicine,
Nationwide Children’s Hospital; Professor of Anesthesiology
and Pediatrics, The Ohio State University, Columbus, Ohio
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Previous editions copyrighted 2017, 2011, 2006, 1998, 1992 by Elsevier, Inc.
Printed in Canada
P. David Adelson, MD, FAAP, FACS, FAANS Matthew N. Alder, MD, PhD
Diane and Bruce Halle Chair of Children’s Neurosciences Assistant Professor
Director, Barrow Neurological Institute at Phoenix Children’s Critical Care Medicine
Hospital Cincinnati Children’s Hospital Medical Center
Professor, Department of Child Health Cincinnati, Ohio
University of Arizona College of Medicine;
Professor, Department of Neurosurgery Omar Alibrahim, MD, FAAP
Mayo Clinic Chief, Pediatric Critical Care Division
Phoenix, Arizona John R. Oishei Children’s Hospital
Associate Professor of Pediatrics
Rachel S. Agbeko, FRCPCH, PhD Jacob’s School of Medicine
Consultant University of Buffalo
Paediatric Intensive Care Unit Buffalo, New York
Great North Children’s Hospital
Newcastle upon Tyne Hospitals NHS Trust Veerajalandhar Allareddy, MBBS, MBA
Newcastle upon Tyne, United Kingdom Section Chief, Pediatric Cardiac Intensive Care
Duke University Medical Center
Michael S.D. Agus, MD Professor of Pediatrics
Chief of Medical Critical Care Duke University School of Medicine
Department of Pediatrics Durham, North Carolina
Division of Medical Critical Care
Boston Children’s Hospital Melvin C. Almodovar, MD
Boston, Massachusetts The George E. Batchelor Chair in Pediatric Cardiology
Chief, Pediatric Cardiology
Mubbasheer Ahmed, MD University of Miami Miller School of Medicine;
Cardiac Intensive Care Unit Director, Children’s Heart Center
Texas Medical Center Director, Cardiac Intensive Care
Texas Children’s Hospital Hotz Children’s Hospital, Jackson Health System
Houston, Texas Miami, Florida
v
vi Contributors
From our home working spaces, in the midst of the COVID-19 For pediatric critical care medicine fellows who may read the
pandemic, welcome to the sixth edition of Pediatric Critical Care. textbook cover to cover, and for others who need an updated
The world has finally been provided a realistic glimpse of intensive reference for anything related to pediatric critical care, the new
care units, the work that occurs there, and the dedicated providers edition will not disappoint. Each color-coded section provides
who provide critical care, sometimes at their own peril. This sixth best-evidence clinical approaches to pediatric critical care issues
edition, which now reflects a lifetime work product for many based on contemporary genetic, biochemical, and physiologic
contributors, is dedicated to the multidisciplinary team that infrastructure. Because authors typically want to include all rele-
makes critical care a reality. vant details in their discussion and a hard copy textbook has
What the pandemic has taught all of us is the importance of physical limitations, readers are encouraged to make use of the
being able to adapt to change. As readers page through this new expanded electronic content included with the sixth edition.
edition, many changes will become apparent. Brad Fuhrman, who Board review questions, composed for most chapters, will be
ultimately deserves the credit for creating this publishing adven- valuable for new and repeat readers and are also available in the
ture, decided to move from Co-editor to Section Editor. More electronic content.
than once, likely while sipping single malt scotch together, Brad Finally, all of us must honor the children and families who
noted that Pediatric Critical Care might be our most important provide the meaning for our life work. With the publishing of the
professional contribution. Quality and sustainability over six sixth edition of Pediatric Critical Care, we collectively acknowledge
editions prove his prediction correct. the clinical challenges that critical illness presents. However, these
Meanwhile, Alex Rotta, appropriately one of Brad’s early challenges facilitate curiosity and imagination, growth and experi-
apprentices, has provided outstanding organizational leadership ence, and ultimately personal enrichment. Hopefully the sixth
as Co-editor for the sixth edition. Thanks also to Section Editors edition of Pediatric Critical Care can serve as a valuable tool for
Bob Clark, Sapna Kudchadkar, Monica Relvas, and Joe Tobias. addressing longstanding as well as novel critical care challenges.
Perusing the list of contributors similarly ascertains established
and burgeoning pediatric critical care contributors. Accordingly, Jerry J. Zimmerman, MD, PhD, FCCM
the sixth edition is truly a multigenerational effort. Alexandre T. Rotta, MD, FCCM
xxv
Contents
5 Leading and Managing Change in the Pediatric 15 Ultrasonography in the Pediatric Intensive Care
Intensive Care Unit 29 Unit 114
John C. Lin Erik Su, Akira Nishisaki, and Thomas Conlon
8 Challenges of Pediatric Critical Care in Resource- 17 Pediatric Critical Care Ethics 144
Poor Settings 51 Mithya Lewis-Newby, Emily Berkman, and Douglas S. Diekema
Amélie von Saint André–von Arnim, Jhuma Sankar, Andrew
Argent, and Ericka Fink 18 Ethical Issues Around Death and Dying 154
Meredith G. van der Velden and Jeffrey P. Burns
9 Public Health Emergencies and Emergency Mass
Critical Care 59 19 Palliative Care in the Pediatric Intensive Care
Katherine L. Kenningham and Megan M. Gray Unit 158
Alisa Van Cleave, Eileen Rhee, and Wynne Morrison
10 Lifelong Learning in Pediatric Critical Care 66
Stephanie P. Schwartz, Laura Marie Ibsen, and David A. Turner 20 Organ Donation Process and Management of the
Organ Donor 163
Thomas A. Nakagawa, Mudit Mathur, and Anthony A. Sochet
xxvii
xxviii Contents
33 Disorders of Cardiac Rhythm 329 47 Diseases of the Upper Respiratory Tract 524
Frank A. Fish and Prince J. Kannankeril Todd Otteson, Clare Richardson, and Jay Shah
57 Pediatric Lung Transplantation 679 71 Fluid and Electrolyte Issues in Pediatric Critical
Carol Conrad Illness 866
Idris V.R. Evans and Emily L. Joyce
Section VI: Pediatric Critical Care:
72 Acid-Base Disorders 882
Neurologic 689 Michelle C. Starr and Shina Menon
58 Structure, Function, and Development of the
Nervous System 690 73 Tests of Kidney Function in Children 896
Robert S.B. Clark and Michael Shoykhet Rajit K. Basu
59 Critical Care Considerations for Common 74 Glomerulotubular Dysfunction and Acute Kidney
Neurosurgical Conditions 710 Injury 907
Peter F. Morgenstern, Robert H. Bonow, Isaac Josh Abecassis, Timothy E. Bunchman, Vu Nguyen, and Michelle L. Olson
Samuel R. Browd, and Amy Lee
75 Pediatric Renal Replacement Therapy in the
60 Neurologic Assessment and Monitoring 720 Intensive Care Unit 923
Mark S. Wainwright and Sue J. Hong Raj Munshi and Jordan M. Symons
80 Biology of the Stress Response 971 95 Disorders and Diseases of the Gastrointestinal
Stephen Wade Standage System 1141
Lauren Bodilly and Samuel A. Kocoshis
81 Inborn Errors of Metabolism 976
Cary O. Harding and Amy Yang 96 Acute Liver Failure 1155
Hengqi (Betty) Zheng, Mihaela A. Damian, and Simon Horslen
82 Progress Towards Precision Medicine in Critical
Illness 991 97 Hepatic Transplantation 1162
Mary K. Dahmer and Michael W. Quasney Patrick J. Healey, Britt Julia Sandler, Abigail Apple,
Thomas V. Brogan, and Jorge D. Reyes
83 Molecular Foundations of Cellular Injury 996
Jocelyn R. Grunwell and Craig M. Coopersmith 98 Acute Abdomen 1170
Robert Sawin, Rebecca Stark, and Derya Caglar
84 Endocrine Emergencies 1003
Katherine Ratzan Peeler and Michael S.D. Agus 99 Nutrition of the Critically Ill Child 1177
Ben D. Albert and Nilesh M. Mehta
85 Diabetic Ketoacidosis 1016
Ildiko H. Koves and Nicole Glaser Section XI: Pediatric Critical Care:
Immunity and Infection 1189
Section IX: Pediatric Critical Care:
Hematology and Oncology 1023 100 Innate Immunity 1190
Samiran Ray, Rachel S. Agbeko, and Mark J. Peters
86 Structure and Function of the Hematopoietic
Organs 1024 101 Adaptive Immunity 1199
Seth J. Corey and Julie Blatt Jennifer A. Muszynski, W. Joshua Frazier, and Kristin C. Greathouse
87 The Erythron 1033 102 Critical Illness and the Microbiome 1208
Allan Doctor, Ahmed Said, and Stephen Rogers Rafael G. Ramos-Jimenez, Dennis Simon,
and Michael J. Morowitz
88 Hemoglobinopathies 1040
M.A. Bender and Anne Marsh 103 Congenital Immunodeficiency 1215
Hannah Laure Elfassy, Troy Torgerson, and Christine McCusker
89 Coagulation and Coagulopathy 1052
Robert I. Parker 104 Acquired Immune Dysfunction 1229
Brent J. Pfeiffer
90 Thrombosis in Pediatric Critical Care 1073
Sally Campbell and Paul Monagle 105 Immune Balance in Critical Illness 1242
Mark W. Hall
91 Transfusion Medicine 1082
Jacques Lacroix, Marisa Tucci, Oliver Karam, 106 Pediatric Rheumatologic Disease 1249
and Philip C. Spinella Marla Guzman, Timothy Hahn, Alexandra Aminoff, and Kristen
Hayward
92 Hematology and Oncology Problems 1101
Jesse Wenger, Corinne Summers, and Joan S. Roberts 107 Bacterial and Fungal Infections 1263
Deborah E. Franzon, Emily R. Levy, and Matt S. Zinter
93 Critical Illness in Children Undergoing
Hematopoietic Progenitor Cell 108 Life-Threatening Viral Diseases and Their
Transplantation 1113 Treatment 1273
Prakadeshwari Rajapreyar, Jennifer McArthur, Surabhi B. Vora, Alpana Waghmare, Danielle M. Zerr,
Christine Duncan, Rachel Phelan, Robert T. Tamburro Jr and Ann J. Melvin
Contents xxxi
109 Healthcare-Associated Infections 1284 124 Adverse Drug Reactions and Drug-Drug
Alexis L. Benscoter, Richard J. Brilli, Derek S. Wheeler, Interactions 1464
and Erika L. Stalets Jessie O’Neal, Lauren Dartois, Anny Chan, Wade W. Benton,
and Christa Jefferis Kirk
110 Pediatric Sepsis 1293
Matthew N. Alder, Lauren Bodilly, and Hector R. Wong 125 Principles of Toxin Assessment and
Screening 1486
111 Multiple-Organ Dysfunction Syndrome 1310 April Clawson and Lawrence Quang
Pierre Tissieres and Melania M. Bembea
126 Toxidromes and Their Treatment 1496
Section XII: Pediatric Critical Care: Prashant Joshi
114 Accidental Hypothermia 1332 128 Anesthesia Effects on Organ Systems 1535
Björn Gunnarsson and Christopher M.B. Heard Lindsay M. Stollings, Peter J. Davis, Alison M. Ellis,
and Antonio Cassara
115 Drowning 1337
Jamie L. Bell, Ajit A. Sarnaik, and Ashok P. Sarnaik 129 Anesthesia Principles and Operating Room
Anesthesia Regimens 1544
116 Burn and Inhalation Injury 1347 Joseph D. Tobias
Christian Tapking, Linda E. Sousse, Karel D. Capek,
and David N. Herndon 130 Malignant Hyperthermia 1560
Christopher M. Edwards and Barbara W. Brandom
117 Evaluation, Stabilization, and Initial
Management After Trauma 1363 131 Neuromuscular Blocking Agents 1567
Jessica A. Naiditch, Michael Dingeldein, and David Tuggle Joseph D. Tobias
118 Traumatic Brain Injury 1375 132 Sedation and Analgesia 1583
Patrick M. Kochanek, Michael J. Bell, Dennis W. Simon, Christopher M. B. Heard, Omar Alibrahim,
Hülya Bayır, Jessica S. Wallisch, Michael L. Forbes, and Alexandre T. Rotta
Randall Ruppel, P. David Adelson, Travis C. Jackson,
and Robert S.B. Clark 133 Tolerance, Dependency, and Withdrawal 1611
Joseph D. Tobias
119 Pediatric Thoracic Trauma 1401
Tamara N. Fitzgerald and Christopher R. Reed 134 Pediatric Delirium 1617
Chani Traube and Bruce M. Greenwald
120 Pediatric Abdominal Trauma 1408
Adam M. Vogel and Michael Dingeldein 135 Procedural Sedation for the Pediatric
Intensivist 1624
121 Child Abuse 1417 Nir Atlas, Rahul C. Damania, and Pradip P. Kamat
Tom Kallay and Carol Berkowitz
1
1
History of Pediatric Critical Care
Medicine
DANIEL L. LEVIN AND JOHN J. DOWNES
“In critical care, it strikes one that the issues are three: realism, dignity, and love.”
Jacob Javitz, 1986 (Posthumous Inspirational
Award Honoree, Society Of Critical Care Medicine)
PEARLS
• The evolution of pediatric critical care medicine reflects long starting in the 1970s. This retrieval medicine holds great promise
progress in anatomy, physiology, resuscitation and ventilation, for future improvements in care.
anesthesiology, neonatology, pediatric general surgery, • In pediatric critical care medicine, there have been remark-
pediatric cardiac surgery, and pediatric cardiology. able achievements in the ability to understand and treat criti-
• The role of nursing is absolutely central to the evolution of cal illness in children as well as progress in the organization
critical care units. of pediatric critical care medicine, education, and research in
• Until the 1950s and 1960s, intensive care units were organized the field.
by grouping patients with similar diseases. However, in the • Increasing use of improved technology has advanced the care
1960s, neonatal intensive care units grouped children accord- of critically ill children but has not eliminated errors, complica-
ing to age and severity of illness, and pediatric intensive care tions, or potentially long-term sequelae, and it is associated
units followed this example. with a need for greater focus on establishing a humane, caring
• Sophisticated interhospital transfer services proved significant environment for the patients and their families.
in reducing morbidity and mortality of critically ill children
Evolution of Modern Medicine the development of cardiorespiratory support, and eventually led
to the establishment of intensive care.
The evolution of pediatric critical care medicine (PCCM) reflects Andreas Vesalius (1514–1564), the Flemish anatomist, cor-
a long series of contributions from anatomy, physiology, resuscita- rected many previous mistakes in the understanding of anatomy
tion and ventilation, anesthesiology, neonatology, pediatric gen- and provided positive pressure ventilation via a tracheotomy tube
eral surgery, pediatric cardiac surgery, pediatric cardiology, and to asphyxiated fetal lambs. Michael Servetus of Spain (1511–1553)
the many individuals responsible for the discoveries and innova- correctly described the pumping action of the heart’s ventricles and
tions.1,2 Intensive care units were originally organized by grouping the circulation of blood from the right heart through the lungs to
together patients with the same or similar diseases. However, the left heart. Matteo Realdo Columbo (1515–1559) described
when neonatologists grouped children according to age and sever- pulmonary circulation and the concept that the lungs added a
ity of illness, pediatric intensive care units (PICUs) followed their spirituous element to the blood by the admixture of air. William
example. Transport, or retrieval medicine, developed and nurses Harvey (1578–1657) confirmed the function of the heart and arte-
took on a major role in providing care to critically ill and injured rial and venous circulations through both animal experiments and
children. observations in humans. He published De Motu Cordis3 (On the
Motion of the Heart) in 1628. Because he did not yet have the
Anatomy and Physiology microscope, he could not see the capillaries and thus could not
include the mechanism for transfer of blood from the arterial to
What seems simple and obvious today took a great deal of time, the venous systems of the pulmonary circulation. Capillaries were
effort, and insight to understand. This section discusses some of first described by Marcello Malpighi (1628–1694, Italian) in De
the contributions that advanced the practice of medicine, enabled Pulmonibus (On the Lungs) in 1661. Thomas Willis (1611–1675)
2
CHAPTER 1 History of Pediatric Critical Care Medicine 3
and, eventually, William Cullen (1710–1790) led the way to the provided artificial ventilation to both animals and dead humans
understanding of the role of the nervous system as the site of con- using a bellows.6 Andreas Vesalius, the aforementioned Flemish
sciousness and the regulation of vital phenomena. Richard Lower professor of anatomy, in De Humani Corporis Fabrica, reported
(1631–1691) proved that it was the passage of blood through the ventilating open-chest dogs, fetal lambs, and pigs using a trache-
lungs, ventilation of the lungs, and gas exchange with blood that ostomy and fireplace bellows in 1543.7–9
vivified the blood and turned it red. Stephen Hales (1677–1761) The French obstetrician Desault, in 1801, described how to
measured blood pressure with a brass tube connected to a 9-foot successfully resuscitate apneic or limp newborns by digital oral
glass tube in a horse. Joseph Black (1728–1799) identified carbon tracheal intubation with a lacquered fabric tube and then blow-
dioxide as a gas expired from human lungs. ing into the tube.1 In 1832, Dr. John Dalziel in Scotland devel-
Karl Wilhelm Scheele (1742–1786) isolated oxygen, as did oped a bellows-operated intermittent negative pressure device
Joseph Priestley (1733–1804), who named it “dephlogisticated to assist ventilation.8 In 1864, Alfred F. Jones, of Lexington,
air” and determined its vital role in supporting combustion. Kentucky, built a body-enclosing tank ventilator; in the 1880s,
Antoine-Laurent Lavoisier (1743–1794) identified oxygen as the Alexander Graham Bell developed a so-called vacuum jacket
vital element taken up by the lungs that maintains life and gave it driven by hand-operated bellows.8 In 1876 in Paris, Woillez built
its name (literally “acid generator”). Oxygen’s essential role in what was probably the first workable cuirass ventilator, which
physiology and biochemistry was not clarified until the late 19th was strikingly similar to the “iron lung” respirator introduced by
century when Felix Hoppe-Seyler (1825–1895) described the McKhann and Drinker in 1929 and manufactured for wide-
transportation of oxygen in blood by hemoglobin. spread use by Emerson in 1931.10 Braun developed an infant
Giovanni Morgagni (1682–1771) initiated the field of ana- resuscitator, as described by Doe in 1889, which was used suc-
tomic pathology in his classic book De sedibus et causis morborum cessfully in 50 consecutive patients. A respirator developed by
per anatomen indagatis, published in 1761. He described in detail Steuart in 1918 in Cape Town, South Africa, apparently success-
his observations of the diseased organs in more than 700 autopsies fully treated a series of polio patients, but he did not report it.8
of persons with a wide variety of disorders and made correlations In 1888, Joseph O’Dwyer, a physician working at the
with the patient’s appearance and symptoms, the initial clinical- New York Foundling Hospital who was concerned about the high
pathologic basis of medicine. death rate in croup and laryngeal diphtheria, instituted the man-
In 1842, Crawford Long in Georgia and in 1846, William ual method of blind oral laryngeal intubation using short, tapered
Morton in Boston demonstrated the efficacy and safety of ether brass tubes that entered the subglottic lumen. Despite severe
anesthesia, thereby opening the era of modern surgery. Joseph criticism, he persisted in developing a series of various-diameter
Lister (1827–1912), one of the founders of modern surgery, tubes for the palliation of severe adult and pediatric laryngeal
reasoned that bacteria were the source of pus in rotten organic edema due to infections, including diphtheria. They were
material and in 1865 used carbolic acid in surgical fields and in used until the 1930s. George Fell, another New York physician,
wound dressings to eliminate bacteria. This technique dramati- devised a method of ventilation with a foot-operated bellows
cally improved patient outcomes after surgery. Robert Koch and exhalation valve connected by rubber tubing to the
(1843–1910) developed his postulates in 1882 in order to at- O’Dwyer tube.8
tribute the etiology of a disease to a particular microorganism in In 1898, Rudolph Matas of New Orleans adapted the Fell-
a logical, scientific manner. He also identified the tubercle bacil- O’Dwyer technique to ventilate patients’ lungs during chest wall
lus as the cause of tuberculosis and was awarded the Nobel Prize surgery. In the early 1900s, George Morris Dorrance of Philadelphia
in 1905. Wilhelm Conrad von Röntgen (1845–1923) discov- used the technique to perform resuscitations.8 In 1910, at the
ered x-rays in 1895. Scipione Riva-Rocci (1863–1937), in 1896, Trendelenburg Clinic in Leipzig, two thoracic surgeons. A. Lawen
measured blood pressure using the sphygmomanometer, and and R. Sievers, developed a volume-preset, positive-pressure, elec-
Nikolai Korotkoff (1874–1920) introduced his auscultation trically powered piston-cylinder ventilator with a draw-over hu-
method of determining systolic and diastolic pressure in 1905.1 midifier. It was used successfully with a tracheotomy tube during
and after thoracic surgery and for a variety of disorders causing
respiratory failure.1
Resuscitation and Ventilatory Support Chevalier Jackson (1858–1955), a surgeon at Temple Univer-
sity in Philadelphia, developed a highly specific series of tech-
The key to understanding the present practice of intensive care for niques for laryngoscopy, bronchoscopy, and tracheotomy.1 He
children lies in knowing the history of scientific study of cardio- revolutionized the procedure of tracheotomy and developed a
respiratory anatomy and physiology and the discovery of detailed protocol of airway care. His design of tubes, made of
techniques to support ill patients. Although one could think that silver, for patients of all ages set the standard for tracheotomy
current practice suddenly emerged with the late 20th century, tubes for more than the first half of the 20th century.
technical discoveries and accomplishments in the development of In 1958, Peter Safar, then at the Baltimore City Hospital,
resuscitation and ventilation taken for granted today date back to published studies proving that the long-standing pulmonary re-
the Bible, and numerous events and contributions led to current suscitation technique of chest pressure and arm lift was virtually
practice. In a biblical story,1,4,5 Elisha resurrected a young boy worthless. In effect, he went back to Elisha and proved jaw thrust
who was dead when “he climbed onto the bed and stretched and mouth-to-mouth resuscitation superior.11 Soon after, W.B.
himself on top of the child, putting his mouth to his mouth, his Kouwenhoven and James Jude at Johns Hopkins published work
eyes to his eyes, and his hands to his hands, and as he lowered on the effectiveness of closed-chest cardiac massage.12 In 1946
himself onto him the child’s flesh grew warm....Then the child Beck and his team demonstrated open-chest electrical defibrilla-
sneezed and opened his eyes.” In 117 CE, Antyllus performed tion. In 1952, Zoll and coworkers proved the efficacy of external
tracheotomies for patients with upper airway obstruction.6 Para- defibrillation and, in 1956, the effectiveness of external cardiac
celsus, a 16th-century Swiss alchemist and physician, first pacing.13
4 SECTION I Pediatric Critical Care: The Discipline
TABLE
1.1 Some Early Pediatric Intensive Care Units and Programsa
TABLE
1.1 Some Early Pediatric Intensive Care Units and Programsa—cont’d
Ped., Pediatrics; Ped Anesth., pediatric anesthesiology; Ped Pulm., pediatric pulmonology.
a
This is not intended to be a complete list. It is primarily composed of units well documented in the literature and personally known to the authors.
b
Primary specialties (not all-inclusive).
c
Although conceptual development of unit started in 1965, Dr. Berlin states that the first year of operation of the present ICU was in 1969 (opened December 1968).
d
Columbia Hospital District of Columbia was a precursor of Children’s National Hospital Medical Center.
e
This 20-bed state-of-the-art unit followed an experience with four designated beds in the PACU beginning in 1964.
Data from references 1, 4, 14–23.
development of many techniques to operate on noncardiac con- was established in the 1880s in Paris by obstetrician Etienne
genital malformations. His protégé, Dr. Robert Gross, first suc- Tarnier and his young associate Pierre Budin at the Hôpital la
cessfully operated on patent ductus arteriosus in 1937 and later Charitre with a unit that had a full-time dedicated nursing staff,
on other congenital cardiac lesions. an antiseptic environment, incubators, and gavage feeding of
Dr. C. Crawfoord in Sweden and Dr. Gross in Boston both breast milk. The practices reduced hospital preterm infant mortal-
successfully repaired a coarctation of the aorta in 1945. In the ity in less than a decade from 197 per 1000 live births to 46 per
same year, at Johns Hopkins, Dr. Alfred Blalock (surgeon) and 1000 live births. Their work presaged the development of modern
Dr. Helen Taussig (cardiologist) with Mr. Vivien Thomas (labora- neonatal intensive care in the 20th century. In 1914, the first
tory assistant) created the subclavian-to-pulmonary artery shunt premature infant center in the United States was opened at Mi-
for tetralogy of Fallot. Dr. John Gibbon at Jefferson Medical chael Reese Hospital in Chicago by Dr. Julius Hess (1876–1955).
College Hospital in Philadelphia performed the first successful Canadian pediatrician Dr. Alfred Hart performed exchange trans-
open-heart surgery using cardiopulmonary bypass for closure of fusions involving peripheral artery cannulation in 1928. In 1932,
an atrial septal defect in an adolescent girl in 1953.1 These Drs. Louis Diamond, Kenneth Blackfan, and James Batey at
advances in pediatric surgery created the need for excellent and BCH determined the pathophysiology of hemolytic anemia
often complex postoperative care. and jaundice of erythroblastosis fetalis. In 1948, they described
Dr. C. Everett Koop, who had completed surgical residency at exchange transfusions using a feeding tube inserted into the
the University of Pennsylvania in 1945, then trained in Boston umbilical vein.
with Dr. Gross for 6 months. He returned to the University of In the 1950s and 1960s, Dr. Geoffrey Dawes at the Nuffield
Pennsylvania and the Children’s Hospital of Philadelphia (CHOP) Institute for Medical Research at Oxford University described for
in 1946. With the help of Dr. Leonard Bachman, director of an- the first time the fetal and transitional circulation of mammalian
esthesiology, and the nursing staff, Dr. Koop developed the first newborns using fetal and newborn lambs. In the late 1950s,
neonatal surgical ICU in 1962. Dr. Bachman and his young as- Columbia University’s obstetrical anesthesiologist, Virginia Apgar,
sociate, John J. Downes, subsequently set up North America’s first who had devised the Apgar score for assessing birth asphyxia,
PICU service with a full-time medical and nursing staff in 1967 recruited Dr. L. Stanley James to develop animal and human in-
at CHOP. vestigation of transitional pulmonary-cardiovascular adaptation
during labor, delivery, and the postnatal period. Dr. James and his
Neonatology team at Columbia and Dr. Abraham Rudolph, a South African
pediatric cardiologist, and his team at Albert Einstein Medical
Pediatric critical care owes a great debt to neonatologists and their Center in New York City and subsequently at the Cardiovascular
special care nurseries.1,4,24 The first and most prominent of these Research Institute in San Francisco, performed extensive studies
6 SECTION I Pediatric Critical Care: The Discipline
in fetal lambs, rhesus monkeys, and term and preterm human Neither specifically designed pediatric ventilators nor small-volume
newborns that defined the human cardiopulmonary adaptation to blood gas analysis was available. Dr. Smythe had to overcome
delivery and postnatal life. They also determined the biochemical these obstacles by innovation. Due to local cultural practices,
factors and time course of birth asphyxia and recovery. In 1959, a Bantu children from tribal areas were particularly prone to de-
research fellow at Harvard, Dr. Mary Ellen Avery (with mentor velop tetanus. On July 13, 1957, at Groote Schuur Hospital, he
Dr. Jere Mead), discovered deficiency of alveolar surfactant in performed a tracheostomy and began intermittent positive pres-
lungs of newborns dying from respiratory distress syndrome sure ventilation for these infants with the assistance of anesthesi-
(RDS). This discovery led to a better understanding of neonatal ologist Dr. Bull. This was truly a landmark event in the evolution
pulmonary disorders and eventually led to the intratracheal instil- of PCCM. Although considered a success story in that it was the
lation of surfactant in newborn preterm infants to prevent or first time that infants survived up to weeks of positive-pressure
mitigate the severity of RDS. In the 1960s, state-of-the-art neo- mechanical ventilation, the first seven of nine patients died. Even-
natal ICUs were established at Columbia-Presbyterian Hospital tually, their survival rate reached 80% to 90%. Drs. Smythe and
(Dr. William Silverman), University of Pennsylvania (Dr. Thomas Bull commented, “No praise can be too high for the nursing staff,
Boggs), Vanderbilt University (Dr. Mildred T. Stahlman), who were all student nurses and without any special training.”
Toronto Hospital for Sick Children (Dr. Paul Swyer), and the David Todres, a medical student at that time, was giving curare to
University of California at San Francisco (Dr. William H. Tooley). and observing these infants, sparking his interest in critical care.
In 1963 to 1964 in Toronto, Drs. Paul Swyer, Maria Delivoria-
Pediatric Cardiology Papadopoulos, and Henry Levison were the first to successfully
treat a series of moribund premature infants with RDS and respi-
As previously indicated, the vision of Dr. Taussig in devising a ratory failure. They used positive-pressure mechanical ventilation
method to treat “blue babies” and successful cardiac operations and supportive care27 and emphasized the importance of a full-
led to infants and children who survived surgery and needed time team, including dedicated nurses and therapists as well as
postoperative intensive care. Advances in technology, especially in physicians. In 1968 Dr. George Gregory and colleagues at the
imaging, have allowed clinicians to “see” into living patients with University of California at San Francisco demonstrated improved
astounding accuracy. Increased understanding of anatomy and survival with early use of continuous positive airway pressure
physiology has led to improved surgical and nonsurgical care for without assisted ventilation or with positive end-expiratory pres-
children with complex cardiopulmonary problems. Develop- sure added to the mechanical ventilation regimen.28
ments in cardiac catheterization and interventional radiology have An important contribution to the development of intensive
enabled clinicians to treat many lesions without open-heart sur- care and long-term mechanical ventilation was the use of plastic
gery and potentially difficult postoperative intensive care. This endotracheal tubes for prolonged intubation and ventilation.
concept was introduced in 1968 by Dr. William Rashkind at the Dr. Bernard Brandstater, an Australian working at the American
Children’s Hospital of Philadelphia (CHOP) with the introduc- Hospital in Beirut, Lebanon, reported prolonged nasotracheal
tion of the balloon atrial septostomy for infants with transposi- intubation as an alternative to the tracheostomy at the First
tion of the great arteries. Growth of techniques that allow effective European Congress of Anesthesia in Vienna in 1962.29
intervention in many complex cardiac conditions, both nonsurgi-
cal and surgical, has resulted in many pediatric centers creating
specific cardiac ICUs, often run by pediatric cardiac intensivists. Poliomyelitis and Creation
Cognitive impairment in some infants with complex lesions or of the First Intensive Care Units
chromosomal abnormalities and the occasional development of
chronic respiratory failure with dependence on mechanical venti- Poliomyelitis epidemics occurred worldwide in the early 20th century
lation for months or years are two of the occasional major se- but seemed especially severe in Western Europe and North America.
quelae of these highly successful endeavors. The value of PCCM There was no treatment and, until the late 1920s, no effective life
for these cardiac patients and other critically ill children has been support for those victims with respiratory failure. Fortunately, the
well documented by Dr. Jacqueline Noonan, who noted, “Much confluence of great scientific and clinical minds and the organiza-
success of the surgery can be attributed to a group of pediatric tional efforts of physicians, nurses, and therapists addressing the
intensivists, pediatric intensive care units, improved ventilator needs of polio patients led to the creation of dedicated polio respira-
support, and trained respiratory therapists.”25 tory care units for patients of all ages. In 1929, Philip Drinker, an
engineer—with pediatricians Louis Shaw and Charles F. McKhann at
BCH—published their experience with an electrically powered
Early Use of Mechanical Ventilation negative pressure, body-enclosing mechanical ventilator, later termed
in Neonates and Children the iron lung.10,30
Polio outbreaks occurred in the summer months worldwide in
The first series of carefully observed infants and children treated the 1930s and 1940s. The polio epidemics of the early 1950s were
for respiratory failure was published in 1959. In that year, Drs. very severe in Los Angeles and Copenhagen. In 1952, Dr. H.C.
P.M. Smythe (pediatrician) and Arthur Bull (anesthesiologist) re- Lassen, the chief epidemiologist at Blegdam Hospital in Copen-
ported the first real success in mechanical ventilation of a series of hagen, described treating 2772 patients with polio. Of these, 316
neonates with respiratory failure caused by neonatal tetanus. were in respiratory failure and initially received assisted ventila-
These infants were paralyzed with curare to relax the tetanic tion with iron lungs in a large respiratory care unit. During that
muscle spasms and ventilated for 4 to 14 days using tracheotomy summer, they had as many as 70 patients in respiratory failure in
and a modified Radcliff adult ventilator.26 Until that time, infants that unit. Unfortunately, the mortality of patients supported by
or children were rarely given ventilator support for more than a an iron lung ventilator was nearly 90%, with the cause of death
few hours, with either adult ventilators or manual ventilation. frequently being unrecognized upper airway obstruction. When
CHAPTER 1 History of Pediatric Critical Care Medicine 7
the number of patients in respiratory failure exceeded the avail- Pediatric Intensivist
able number of iron lung ventilators, Bjorn Ibsen, the chief of
anesthesiology at the hospital, with the help of his medical staff Randolph and coworkers40 defined a pediatric intensivist (in the
and nurse anesthetists, performed tracheal intubation and then United States) as “any one of the following: (a) a pediatrician with
tracheostomy along with manual positive pressure ventilation subspecialty training in PCCM and subspecialty certification
with 50% oxygen and tracheal suctioning. This treatment was from the American Board of Pediatrics (ABP); (b) a pediatric
carried out in 200 patients with respiratory failure. To provide anesthesiologist with special competency in critical care with
continuous manual ventilation on a 24-hour basis, Ibsen re- subspecialty certification from the American Board of Anesthesi-
cruited, trained, and used 200 nursing students and aides along ology; (c) a pediatric surgeon with special competency in critical
with 200 medical students, each working 8-hour shifts to provide care with subspecialty certification from the American Board of
manual ventilation, as well as 27 technicians per day to care for Surgery; (d) a physician (as above) eligible for subspecialty certifi-
the patients. The mortality in patients receiving this treatment cation by the appropriate respective board.” Similar requirements
decreased from 90% to 40%.31–33 for training exist or are in development elsewhere in the world.
At that time, patients from outlying areas were transported to
hospitals in ambulances without sufficient attendants or airway First Pediatric Intensive Care Units
care and arrived moribund. Lassen and Ibsen started to send so-
called retrieval teams in ambulances out to pick up the patients in In 1955 Dr. Goran Haglund at the Children’s Hospital of Göteborg,
the countryside, with marked improvements in status on arrival. Sweden,18 developed the first PICU, which he called a pediatric
They also started passing stomach tubes early on for nutrition, emergency ward. The patient who inspired Dr. Haglund to organize
and the rubber-cuffed tracheostomy tubes were replaced with a the unit was a 4-year-old boy who was operated on in 1951 for a
silver cannula that caused less tracheal mucosal damage. Even ruptured appendix. Postoperatively, he lapsed into a coma; his sur-
with all of these improvements, Dr. Ibsen noted, “Naturally we geon declared that he had done all he could and the boy would die
ran into a lot of complications.”33 of bacteriotoxic coma. The anesthesiologist offered to help and the
Drs. Ibsen and Lassen also received help from other people boy was intubated, given manual positive-pressure respiration with
who were focusing their efforts on treating polio. The clinical generous oxygen, tracheostomized, and given a large blood transfu-
biochemist Dr. Poul Astrup developed a micro method to mea- sion. After about 8 hours, the boy’s bowels started to function, and
sure capillary arterialized pH and PCO2 in infants, children, and 4 hours later he was out of coma. After 20 hours, he had spontane-
adults. C.G. Engstrom, a Swedish anesthesiologist, designed and ous respiration and had been successfully treated for respiratory in-
clinically tested the first modern volume-preset positive pressure sufficiency and shock.
mechanical ventilator. This spectacular and thrilling story culmi- This new unit had seven acute care beds with full-time nurses
nated in a cohort of patients with respiratory failure being treated and nursing assistants providing 24-hour coverage. In the first
in a single geographic area and cared for by full-time physicians, 5 years, the team treated 1183 infants and children, with a mor-
nurses, and technicians: the first modern ICU. Although these tality rate of 13.6%. Haglund went on to state, “But what we did
units tended to disband after the summer-fall polio season, they was something else. It was the application of the basic physiology
led to the creation of full-time respiratory care units at the to clinical practice. Our main purpose was not to heal any disease;
Radcliff Infirmary of Oxford University and elsewhere in Europe it was to forestall the death of the patient. The idea was—and
and North America in the 1950s. is—to gain time, time so that the special medical or surgical
Soon after these events, in 1958, Peter Safar led development therapy can have desired effects.”18 Haglund was also careful to
of the first multidisciplinary ICU in North America at Baltimore point out: “There are few jobs more exciting, demanding, and
City Hospital.34 In 1960, Barrie Fairley and colleagues created the taxing than emergency nursing. Our nurses and nurse assistants
ICU at Toronto General Hospital, followed in 1962 by the ICU are tremendous. They must be!”18
at Massachusetts General Hospital under Drs. Henning Pontop-
pidan and Henrik Bendixen. Central Role of Critical Care Nursing
Definitions Although many sources emphasize the role of advanced technol-
ogy in the creation of adult, neonatal, and pediatric critical
Some of the difficulty in relating the history of PCCM is defining care,1,19 skilled nursing care was even more important in this
a PICU and pediatric intensivist. The current definitions are as evolving process. Porter41 and others remind us of the vital role of
follows. nursing in triage and organization of care for patients by degree of
illness. Long before the organizational efforts of the 20th century,
Florence Nightingale (1820–1910) organized a volunteer service
Pediatric Intensive Care Unit with 20 nurses and created a clean environment at the British
An ad hoc committee of the American Academy of Pediatrics (AAP), military hospital at Skutari, Turkey, in 1854 during the Crimean
Diseases of the Chest Section established Guidelines for the Organi- War. Although the care consisted mostly of hygiene and nutrition,
zation of Children’s Intensive Care Units in July 1975.35 In 1983, within 6 months of her arrival the mortality rate dropped from
the AAP and Society of Critical Care Medicine (SCCM) published 40% to 2%.42 Nightingale provided the definition of nursing as
Joint Guidelines for Pediatric Intensive Care Units,36 which were “helping the patient to live.”42 These efforts were continued in the
updated in 199337 and 200438 and then retired in 2013.39 The com- United States by Dorothea Dix (1802–1887) and Clara Barton
mittee defined a PICU as “a hospital unit which provides treatment (1821–1912), the “angel of the battlefield” during the American
to children with a wide variety of illnesses of life-threatening nature Civil War. Barton also brought the Red Cross to America in 1882.
including children with highly unstable conditions and those requir- As the complexity of medical and surgical care evolved in the
ing sophisticated medical and surgical treatment.” late 19th and early 20th century, the need to cohort sick patients
8 SECTION I Pediatric Critical Care: The Discipline
and provide skilled nursing care became apparent, especially for America. During the prior decade, Dr. Conn and his colleagues
premature newborns and victims of poliomyelitis, as cited earlier. had treated critically ill infants and children in a sequestered area
Then, as now, the recovery of the critically ill pediatric or adult of the postanesthesia care facility where they had developed con-
patient depended on the skilled nurse at the bedside who was siderable expertise in critical care. The new state-of-the-art PICU
trained to use the life support and monitoring equipment at hand was the forerunner of units developed in major pediatric centers
but to remain focused on the stability and comfort of the person throughout North America spanning the 1970s and beyond.
in the bed.43 Dr. Geoffrey Barker, who went on to develop one of the largest
In the mid- to late 1970s, as pediatric cardiovascular surgery multinational fellowship training programs in the world, followed
for more complex lesions in infants was developing, nurses pro- Dr. Conn as director of the PICU.
vided postoperative care in designated units. Children with Reye Also in 1971, Dr. David Todres, an anesthesiologist and pedia-
syndrome suddenly appeared, requiring complex multisystem trician, and Dr. Daniel Shannon, a pediatric pulmonologist,
care. In addition, in the 1980s, emergency medical services sys- founded a 16-bed multidisciplinary unit for pediatric patients of
tems began transporting severely injured children to hospitals, all ages at the Massachusetts General Hospital.1,4 The units in
where they required rapid assessment and intervention by nurses Philadelphia, Toronto, and Boston established vibrant training
and physicians and initiation of cardiorespiratory and neurologic programs in critical care medicine and conducted clinical re-
support.44 search. Among their numerous accomplishments, Dr. Conn be-
Pediatric critical care nurses joined the SCCM from its begin- came a noted authority on the management of near-drowning
ning in 1970 and the American Association of Critical Care victims, and Dr. Todres and Dr. Downes pioneered long-term
Nurses emphasizing the care of children. In the mid-1990s, pedi- mechanical ventilation for children at home with chronic respira-
atric critical care nurses founded their own society and established tory failure. These early PICUs and their training programs had a
a peer-reviewed journal. Also in the 1990s, advanced practice favorable impact on mortality and morbidity rates, particularly
nurses and nurse practitioners began to specialize in pediatric those associated with acute respiratory failure, leading to the de-
critical care. They continue to function as important critical care velopment of similar units and programs in most major pediatric
team members to augment both physician and nursing care as centers in North America, Western Europe, and Japan during the
well as conduct clinical research.43,44 1970s and early 1980s.
The development of the PICU at Children’s Memorial Hospi-
Role of Pediatric Anesthesiologists tal (CMH), Northwestern University Medical School, Chicago,
illustrates how many of the early PICUs evolved. The unit was
and Pediatricians in Founding Pediatric first started as a four-bed area set in one of the postoperative care
Critical Care Medicine wards by pediatric anesthesiologists David Allen and Frank
Seleny. Anesthesiologist Dr. John Cox arrived in August of 1964
An important early physician-directed multidisciplinary PICU in and was named director. He has stated that the unit never for-
North America was established at CHOP in 1967 as an out- mally opened. It began in the four-bed unit in the postoperative
growth of a hospital-wide respiratory intensive care service.1,45 ward in 1964 and became a 14-bed separate designed unit in
The unit consisted of an open ward of six beds equipped with late 1967. Dr. Cox was the director until 1975, when he was
bedside electronic monitoring and respiratory support capabilities succeeded by Dr. Richard Levin. During this time, Dr. Hisashi
and an adjacent intensive care chemistry laboratory staffed Nikaidoh, who was a surgery resident from 1966 to 1967, re-
24 hours per day. The nurses were assigned full-time to the unit; members taking care of a renal transplant patient; the care was
most had previously served in the recovery room, infant ICU, or provided by nephrology, general surgery, and immunology
cardiac surgery postoperative ward. Dr. John Downes was the without a centralized PICU service. Dr. Zehava Noah, who was
medical director and worked closely with two other anesthesiolo- educated in Israel and trained in the United Kingdom, did a
gists, Dr. Leonard Bachman, chief of anesthesiology, and critical care fellowship in anesthesia at CMH, developed a closed
Dr. Charles Richards, and a pediatric allergist/pulmonologist, medical-surgical PICU in 1979, and was named the director in
Dr. David Wood. Four pediatric anesthesiology/critical care fel- 1981. There was also an associate surgical director.46–49
lows provided 24-hour in-unit service. Dr. C. Everett Koop (chief Some of the early PICUs were directed by pediatricians. In
of surgery), Dr. William Rashkind (the father of interventional 1966, Dr. Max Klein joined Drs. H. de V. Heese and Vincent
pediatric cardiology), Dr. John Waldhausen (one of the nation’s Harrison in a two-bed neonatal research unit at the Groote Shuur
few full-time pediatric cardiac surgeons), Dr. Sylvan Stool (a pio- Hospital in Cape Town. Their research resulted in many signifi-
neer in pediatric otolaryngology), and other staff and residents cant papers, not the least of which was “The Significance of
provided close collaborative patient care, education, and clinical Grunting in Hyaline Membrane Disease,”50 demonstrating that
research. By 1975, with the establishment of the new CHOP oxygen tensions fell when infants had tracheal intubation, elimi-
building, the acute PICU was expanded to 20 beds with an adja- nating the ability to grunt on exhalation. By 1969, at Red Cross
cent 10-bed intermediate step-down unit. War Memorial Children’s Hospital in Cape Town, South Africa,
In 1969, Dr. Peter Safar and his trainee, Stephen Kampschulte, pediatric patients with respiratory failure (e.g., Guillain-Barré
developed a 10-bed PICU at the Children’s Hospital of Pitts- syndrome) were ventilated on the general wards. Although out-
burgh. That same year, James Gilman, a pediatric anesthesiologist, comes improved, deaths were still common. Dr. Max Klein en-
and Norman Talner, a pediatric cardiologist, established a six-bed couraged Dr. Malcolm Bowie (consultant) to start a six-bed ICU,
PICU at the Yale–New Haven Medical Center. or “high-care ward.” After further training in South Africa and at
In 1970, at the Hospital for Sick Children in Toronto, the University of California San Francisco (UCSF), Dr. Klein re-
Dr. Alan Conn resigned as director of the Department of Anes- turned to Cape Town in 1974, where he combined the neonatal
thesiology to become director of a new multidisciplinary 20-bed tetanus ward of Dr. Smythe and the six-bed ICU of Dr. Bowie
PICU, by far the largest and most sophisticated unit in North into the first full-time PICU in South Africa.51
CHAPTER 1 History of Pediatric Critical Care Medicine 9
The path for pediatricians providing care for the sickest pa- training with Dr. Peter Safar in Pittsburgh, who welcomed him as
tients on a full-time basis remained unclear for an extended pe- a fellow in critical care medicine. In 1975, Dr. Holbrook and
riod. Subsequent early leaders in the field each carved out their pediatrician Dr. Alan Fields, who also trained in Pittsburgh, were
own path. Dr. Daniel Levin completed pediatric cardiology and recruited to the new, modern Children’s Hospital National Medi-
neonatology fellowships to learn the care of sick children. How- cal Center (Washington, DC) as pediatricians in the Department
ever, he found few Chairs of Pediatrics interested in hiring an of Anesthesia to direct the PICU.
“intensivist.” Then, in 1975, Drs. Levin and Frances Morriss Dr. Bradley Peterson,52 after pediatric and neonatology train-
(trained in pediatrics and pediatric anesthesia) were recruited to ing and an anesthesiology residency at Stanford University,
start a PICU at Children’s Medical Center of Dallas. became director of the new PICU at Children’s Hospital of
There were so few of this new breed of intensivists that many San Diego in 1977. Dr. Bradley Fuhrman, following pediatric
became directors upon completion of residency and fellowship. At cardiology and neonatology fellowships, started the first PICU at
the beginning, few other physicians wanted to be responsible for University of Minnesota Hospital in 1979.53
pediatric intensive care.23 Eventually, more pediatricians decided Dr. George Lister,54 after a pediatric residency at Yale and a
to devote their careers to being members of a multidisciplinary fellowship in cardiopulmonary physiology at UCSF, joined the
team taking care of the sickest children in hospitals on a full-time staff at the UCSF Moffitt Hospital San Francisco in 1977 as an
basis. In 1975, the CHOP program started to accept PCCM attending in its combined adult-pediatric ICU. Due to the direc-
trainees who were pediatricians without anesthesia training. tor’s illness, he quickly found himself the co-director of the unit.54
In 1967, Dr. Peter Holbrook as a medical student at the Uni- He eventually returned to Yale as an attending in the PICU.
versity of Pennsylvania began a part-time job in the PICU at Dr. Mark Rogers, after completion of a pediatric residency at
CHOP and developed a strong interest in PCCM. Informed at BCH, an anesthesiology residency at Massachusetts General
the time that one needed anesthesia training to successfully work Hospital, and a pediatric cardiology fellowship at Duke, became
in the PICU, Holbrook shelved the idea and entered pediatric director of the first PICU at Johns Hopkins Hospital in 1977.55
residency training at Johns Hopkins. When the PCCM idea Subsequently, in 1980, Dr. Rogers became chair of the Depart-
resurfaced, he found that many still felt a physician needed anes- ment of Anesthesiology and Critical Care Medicine at Johns
thesia training to function in the PICU. Disagreeing with the Hopkins and chief editor of a major textbook of pediatric inten-
reasoning behind such a requirement, he pursued critical care sive care (Table 1.2).
TABLE
1.2 Textbooks in Pediatric Critical Care Medicine
Continued
10 SECTION I Pediatric Critical Care: The Discipline
TABLE
1.2 Textbooks in Pediatric Critical Care Medicine—cont’d
Growth of Pediatric Critical Care Medicine American College of Graduate Medical Education (ACGME)
and for the subspecialty of PCCM by the American Board of
The field of PCCM grew rapidly in the late 1970s and 1980s. Pediatrics (ABP). Legitimization of the subspecialty was achieved
However, there was a struggle for authority in both adult and with establishment of a new subboard of Pediatric Critical Care
pediatric units. The culture of intensive care was changing from Medicine of the ABP in 1985 and the first certifying examination
one in which each specialty service cared for its part of the patient in 1987, at which time 182 subspecialists were certified.95 Certi-
to one in which a full-time critical care service cared for the whole fication provided a clear basis for hospital credentialing of
patient, with help of consulting specialties.2,94 PCCM physicians.96 In addition to certification by the ABP, the
For PCCM to achieve its full potential, it required several ele- American Board of Anesthesiology and the American Board of
ments: a national organization to provide a venue in which to Surgery confer subspecialty certification with special competency
meet and communicate, acceptance and validation of pediatric in critical care. In 1989, special requirements for training in
critical care as a subspecialty, nationally approved training require- PCCM were developed by the ACGME, with formally accred-
ments, and academic credibility with meaningful research. ited programs first recognized in 1990.97
A small group of interested physicians met at the SCCM Na-
tional Meeting in 1979 and decided to petition the SCCM to Growth in Numbers of Pediatric Intensive
form a section on pediatrics. The society had no subsections, but
the petition was successful. The pediatric section with Dr. Russell
Care Units
Raphaely as chair was formed in 1980.1 In 1983, a committee of In 1979, there were 150 PICUs of four or more beds identified,
the SCCM developed guidelines for organization of PICUs36 that and another 42 thought to exist.98 Most were just special care
were regularly updated37,38 until January 2013, after which time nursing units, and only 40% had a pediatric intensivist available
they were retired.39 at all times. Forty percent of the units had fewer than seven beds
In 1984, after petitions by pediatric intensivists, a Section and only one half had affiliated transport systems. Pediatric
of Critical Care Medicine was established in the AAP with ward beds decreased by 22.4% between 1980 and 1989—by
Dr. Russell Raphaely as chair.95 These organizations then 10.8% between 1990 and 1994 and by 15.7% between 1995
petitioned for recognition of PCCM fellowships from the and 2000. During the same three time periods, PICU beds
CHAPTER 1 History of Pediatric Critical Care Medicine 11
increased by 26.2%, 19.0%, and 12.9%, respectively.40 Between In April 2004, the Eunice Kennedy Shriver National Institute
2001 and 2016, the US pediatric population grew 1.9% to of Child Health and Human Development (NICHD) established
greater than 73.6 million children, and PICU hospitals de- funding for the first federally supported network for pediatric
creased 0.9% from 347 to 344 (58 closed and 55 opened). In critical care research, the Collaborative Pediatric Critical Care
contrast, PICU bed numbers increased 43% (4135 to 5908 Research Network. The network is a multicentered program de-
beds). Sixty-three PICU hospitals (18%) accounted for 47% signed to investigate the safety and efficacy of treatment and
of PICU beds.40a According to the FY2017 American Hospital management strategies to care for critically ill children as well
Association (AHA) survey database, there are 399 hospitals as the pathophysiologic basis of critical illness and injury in
in the United States and territories that have a PICU in their childhood.114–117
hospital.100 Although not all children’s hospitals are members The NICHD has also supported research in PCCM by devel-
of the Children’s Hospital Association, of the 155 children’s oping and supporting young investigators in the field through
hospitals that contribute data to the fiscal year 2017 Children’s the Pediatric Critical Care and Trauma Scientist Development
Hospital Association Annual Benchmark Report Survey, 128 Program (PCCTSDP), a K-12 research training program. The
(82%) stated they had staffed PICU beds.101 PCCTSDP has been funded since 2004 and is directed by
Dr. Heather Keenan at the University of Utah. Eligible applicants
are board-eligible or board-certified PCCM faculty, or pediatric
Growth in Training Programs and Education trauma surgery faculty.114
In 1983 to 1984, there were 32 PCCM training programs; the Perhaps most notably, in 2013 the NICHD created an inde-
ACGME accredited 28 of them in 1990. By 2018 to 2019, the pendent branch, the Pediatric Trauma and Critical Illness Branch,
number had increased to 68 accredited training programs with to further support research in pediatric critical illness and injury.
527 enrolled fellows, of whom 336 (63.8%) are women.99 Since The mission of the new branch is to prevent and reduce all aspects
its inception, the subboard has certified 2693 subspecialists.99 of childhood trauma and critical illness and to enhance health
Educational programs in PCCM have progressed consider- outcomes for all children across the continuum of care.114,116,117
ably at the annual SCCM, AAP, Pediatric Academic Societies, The growth of education and research in PCCM has coincided
American Thoracic Society, and American College of Chest with, and presumably resulted in, better care for children as re-
Physicians meetings, as well as at independent meetings such as flected in the decrease in mortality from septic shock. Between
the Pediatric Critical Care Colloquium and the World Federa- 1958 and 1966, in patients younger than 16 years of age at the
tion of Pediatric Intensive Critical Care Societies (WFPICCS). University of Minnesota, mortality in septic shock was 95%; now,
Dr. Barker envisioned the need to bring together pediatric inten- with PICU care, it is less than 10%.118 Drs. Murray Pollack and
sive care from many parts of the world. This led to his founding Timothy Yeh established the basis for studying severity-adjusted
directorship of the WFPICCS, which has done much to foster mortality in pediatrics and demonstrated that patients do better
development of pediatric critical care around the world, bringing when cared for by pediatric intensivists.119 Although many would
vital critical care skills and experience to benefit multiple coun- attribute these improvements to technology and scientific ad-
tries. Numerous textbooks on PCCM have appeared in many vances, Dr. Yeh and others remind us that the presence of a full-
languages (see Table 1.2), and the journal Pediatric Critical Care time nursing and medical team and attention to basic principles
Medicine was launched in 2000.102 rather than exotic high technology improve outcomes.120 This is
Academic credibility that results from meaningful scientific echoed by Dr. Shann’s two rules of PCCM: (1) “the most impor-
research has come slowly. In the early days, intensivists were tant thing is to get the basics exactly right all of the time,” and
mostly consumed by clinical care and research and administrative (2) “organizational issues are crucially important.”23 In addition,
responsibilities. High-quality basic science, epidemiology, and Yeh as well as Ibsen33 and Orr have emphasized the important
translational studies addressing a broad range of problems have contributions of regionalization and the quality of PCCM trans-
gradually emerged. Multiinstitutional organizations have allowed port teams in improving outcomes.121,122
studies that require more patients than can be drawn from a single Modern medical simulation originated in pediatrics and has
institution to be designed, funded, and completed. In the early made significant contributions to education. In 1960, shortly af-
1990s, the Pediatric Critical Care Study Group was formed.103 It ter resuscitating his 2-year-old son following a drowning, Asmun
was followed by the Pediatric Acute Lung Injury and Sepsis Inves- Laerdal, the owner of a Norwegian doll factory, partnered with
tigators (PALISI) network,104–106 which employed the successful the Red Cross to create the first medical simulation mannequin.
programming model of research developed by the Canadian In 1988, Laerdal partnered with the American Heart Association
Critical Care Trials Group.107–109 PALISI has grown and pros- and the AAP to create Pediatric Acute Life Support simulation-
pered through the voluntary collaboration of currently 94 mem- based training. Since that time, evolving pediatric residency and
ber PICUs110 and has supported more than 200 articles address- fellowship requirements, duty hour restrictions, and an increased
ing the spectrum of PCCM.111 focus on medical safety have catalyzed exponential growth in simu-
The virtual PICU was started in 1997 to bring data manage- lation training.123–125 The International Network for Simulation-
ment technologies to critical care. In 2004, Virtual PICU Based Pediatric Innovation Research and Education has docu-
Systems (VPS) was formed by Drs. Thomas Rice and Ramesh mented an increase in pediatric simulation centers from
Sachdeva (Children’s Hospital and Health System of Milwaukee) 50 to 268 in the past 7 years. A recent meta-analysis documented
and Dr. Randall Wetzell (Children’s Hospital Los Angeles) in 57 studies and over 3500 learners engaged in pediatric simula-
conjunction with the National Association of Children’s Hospi- tion education. Studies compared simulation education with no
tals and Related Institutions to develop a PICU registry to facili- intervention and found large effects for outcomes of knowledge,
tate quality improvement and research. VPS currently has more behavior with patients, and time to task completion.126
than 125 members and a massive database describing more than Dr. Elizabeth Hunt along with pioneers in simulation at Johns
1 million critical care admissions.112,113 Hopkins have been able to document progressive acquisition of
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The Project Gutenberg eBook of Gem of neatness
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no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the
terms of the Project Gutenberg License included with this ebook or online at www.gutenberg.org. If you
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located before using this eBook.
Language: English
SPARKLING GEMS
BY MRS. MADELINE LESLIE.
Gem of Neatness:
OR,
THE COUSINS.
BY
BOSTON:
ANDREW F. GRAVES.
20 CORNHILL.
LIST
OF
SPARKLING GEMS
FOR YOUTH.
OF
SPARKLING GEMS
FOR YOUTH.
DEDICATION.
THE AUTHOR.
PREFACE.
THE author of these volumes recently attended the commencement of a seminary, in which
sparkling crowns were placed on the heads of such of the graduates as had been
distinguished for diligence, faithfulness, neatness and other virtues. Being very much
pleased with the design, I have appropriated the idea in these small volumes.
On the illuminated title page, the teacher and pupils appear. He holds up to their view a
sparkling gem, just taken from his cabinet. We may imagine him explaining to them, that
these precious stones are used in the Bible as emblems of the different graces which adorn
the character of Christians, even as God says: these graces "shall be as the stones of a
crown," put upon their heads.
CONTENTS.
GEM OF NEATNESS.
CHAPTER I.
EMILY'S BUREAU.
MRS. MORGAN stood at the door of her little daughter's chamber, a bright smile of
satisfaction illumining her countenance. Presently she stepped back into the hall, and,
leaning over the balustrade, called out:
"Cousin Mary, come up here a moment."
A light step on the stairs, and cousin Mary stood by her side.
"This is Emily's room," said her mamma—"just as she left it for school. Everything has a
place, and is in its place."
Mrs. Roby, who was cousin Mary, entered the neat chamber, her eyes beaming with
pleasure.
"See! That book-rack,—How very even the row of volumes, and not one speck of dust on
them;—and this tiny vase, with one carnation-pink! Priscilla, your daughter is a jewel of a
girl as our old Pat used to say. Her habit of neatness and order will be worth a fortune to
her."
"She is naturally neat and orderly," added Mrs. Morgan. "When she was not more than
three years old, she used to want to help when I dusted the parlors. I always take that
duty on myself, you know. So Emily must have an old veil tied over her golden curls,
because mamma wore a veil to keep off the dust; and she must have a piece of silk for a
duster. It was too funny to see her fly from one chair to another, just as soon as I had
dusted it, and rub, rub, with all her strength."
"Yes, now she does," answered mamma. "Hannah used to open the bed, and turn the
mattress; but she was so anxious to do it all; and sometimes she had to wait for Hannah
to get through with other work, so her father had the mattress carried to the upholsterer's,
and cut in two parts. She can lift it now without any difficulty."
While Mrs. Morgan was speaking, her cousin had gone toward the bureau, and with her
hands on the knobs of the upper drawer asked:
"May I look?"
"Certainly."
It was, indeed, a beautiful sight. A box in one of the front corners contained a pile of
pocket handkerchiefs. Another at the left was filled with ribbons of various colors used for
her hair and her neck. Each piece was rolled up nicely and laid by itself. Then there was a
tiny box, holding a pretty brooch,—her last birthday gift from papa. A black silk apron and
two or three white ones neatly folded lay at the back part of the drawer.
The next two contained different kinds of under clothes, each variety in a pile by itself.
"She puts everything away herself," explained her mamma. "Hannah lays her clean clothes
on the bed, as they come up from the wash; and when she comes home she takes care of
them without being reminded to do so. But look here?"
The lady opened the underdrawer, and displayed a beautiful wax doll covered with a small
quilt pieced from tiny scraps of bright-colored silk. Miss Rose Standish lay with a sweet
smile on her round face; and well she might smile, for there within her reach at the back
part of the drawer was every thing in the shape of a wardrobe which the most extravagant
dolly could desire. There was a set of white furs, muff and tippet to match; and another
set of gray with the cunningest little wristers you ever saw. There were hats with plumes,
and hats with velvet trimmings, and sacks, and skirts, and shoes and parasol to shade the
little Miss from the sun. Oh, it would be easier to tell what there was not!
"It's a perfect show," exclaimed Mrs. Roby. "It's as good as Barnum's baby show. I wonder
what aunt Lydia will say to it."
"The best of it is," added mamma, "that she has made the most of the clothes herself. I
used to cut and baste for her; but of late, she has had a pattern and cut them herself. Her
father says he hopes she will play with dolls till she is married. He is enthusiastic on the
subject. Why, you'd laugh to hear him talk. He believes that, the dressing and undressing
of dolls, and disciplining them, as Emily does hers, is the very best preparation for the
duties of a mother that a child can possibly have. He would give Emily any amount of
money she would ask to buy materials to make up for Miss Rose. By and by, I must tell
you a story about that gray set of furs."
"Tell me now, please. I'm sure," added Mrs. Roby laughing, "if I had ever disbelieved in
hereditary traits, I would give up my doubts after this."
"Why from the stories I've heard Aunt Lydia tell about you, I think Emily is just her
mamma over again."
"Yes, I used to be ridiculously fond of dolls, there is no denying it; but in those days, a wax
doll was a thing unknown. My best doll was a beauty though. She had eyes that shone like
diamonds, and painted curls. I used to call her Esther, after Queen Esther, I suppose; and I
was very proud of her."
CHAPTER II.
OLD FRIENDS.
MRS. MORGAN shut the bureau as she spoke, saying with a smile: "Emily will know in a
minute, that somebody has been to her drawers."
"I had better confess beforehand then. Are you going to sew now?"
Ina few moments, Mrs. Morgan joined her cousin in the pleasant sitting-room. But before I
tell you what they talked about, I wish to explain who these two ladies were.
Mrs. Morgan was the wife of a gentleman of good fortune connected with the great Express
lines from north to south. They were both members of the Episcopal Church; and it was
their earnest prayer that they might be not professors only, but possessors of vital
godliness. During the first years of their married life, they went much into company,
attended balls and concerts night after night. By this means, they lost much of the fervor
of their religion.
Indeed, so conformed were they to the world and its pleasures, that they could scarcely be
distinguished from the world's people. But their Father in heaven was watching over them.
He saw into their hearts, and he knew that even while involved in this round of gayety,
they were not satisfied. He knew there were times when they turned with loathing from all
this hollow friendship, and longed for the quiet happiness they once enjoyed. God in his
abounding kindness had a purpose of mercy toward these his wandering children; and he
took means to bring them back to himself.
He removed first a beautiful babe who had scarcely opened its eyes in this world, to his
paradise above. Then, when this did not wean the mother from circles of fashion, from the
theatre and opera, he took another child, a darling boy, the pride of both parents, to swell
the song of infant worshippers before his throne. A few months later, and while their
hearts were still bleeding with sorrow, Emily their first-born and best-beloved was seized
with scarlet-fever, and lay for days hovering between life and death.
Now, when the waves and the billows of trouble were rolling over them, they began to call
upon God for help. But to their aching hearts, he did not seem a refuge near at hand. He
appeared to be afar off, so far that their cry could not reach him. But if not to their
heavenly Father, to whom could they go in their deep distress? Then they began to feel
that they had sinned.
In their days of prosperity, they had forgotten to give thanks. They mourned together over
the sinfulness which had led them far away from real happiness; and then in infinite
compassion, their elder brother, their Saviour appeared to comfort them. The gracious
spirit suggested words of cheer: "Return unto me, and I will return unto you."
By the bedside of their sick and apparently dying child, they renewedly consecrated
themselves and all that they had, to the service of their Saviour. They bowed in sweet
submission to the will of God. They cried indeed "Spare her, Lord," but from the heart they
added, "if such be thy holy will."
And a merciful God did spare the child. She was gradually restored to perfect health. From
this time her parents commenced a new life. They were constant at church. They took
classes in the Sunday school. They visited the poor and afflicted. They did all in their
power to stay up the hands of their faithful pastor.
All the energy and activity they had before displayed in the invention of new pleasures
were now employed for the good of those about them. They were indeed a blessing in
society; and in blessing others, they received a rich reward in their own hearts. One glance
into the serene countenance of Mrs. Morgan showed that her soul was at peace.
Sickness and sorrow might come as it comes to every one; but she felt that all events for
her were ordered by a Father's hand. Emily was their one treasure, spared to them from
the grave. Is it strange that she was taught from her earliest recollection that her chief aim
in life should be to love and serve her Maker and Preserver?
Mrs. Roby, own cousin to Mrs. Morgan, had married young, and gone with her husband to
the West. He had been successful in business, and had now come East for a few months,
his wife improving the occasion long desired, to revive her acquaintance with those so dear
to her. She had only arrived the day before; and every moment that her cousin was at
liberty was improved in asking questions about herself and other friends.
Aunt Lydia was Mrs. Morgan's mother who usually passed a part of every year with her,
greatly to the delight of Emily.
CHAPTER III.
MILLY'S ARRIVAL.
THERE is another member of Mr. Morgan's family not yet introduced. Her real name is
Amelia Lewis; but everybody seems to have forgotten it; and she now answers to the
names Milly, or Mill. She is an orphan niece of Mr. Morgan, the child of his favorite sister,
who went to India with her husband, and died there shortly after Amelia's birth.
For seven years, her father kept the child with him in Calcutta; and then she was sent
home to his mother, where she remained until the old lady's increasing infirmities made
the care a burden.
Mr. Morgan, hearing at last of Milly's destitute situation, consulted with his wife as to what
was best to be done with the little girl. He proposed a boarding-school, and offered to be
answerable for all expenses; but Mrs. Morgan, with great feeling, exclaimed:
"No, George, never to a boarding-school with my consent. What she needs is a home,
where she can be loved and taught her duty."
"But we know nothing about her habits, and I cannot have our sweet Emily exposed to
influences which may corrupt her pure mind."
"Listen a moment, George. Somebody certainly owes a duty to the poor orphan. If it is
ours, we will undertake it, trusting in God to preserve our child from harm. We have
endeavored to teach her to love her Saviour, and to pray to him to shield her from
temptation. Now we must have faith to believe he will answer prayer."
"But, Priscilla, think how Milly has been brought up. You know what life in India is, from
poor Ida's letters. And without a mother, the child has been tossed about from one native
servant to another. I really can't see the way clear; and then think what a care for you!"
"Give me twenty-four hours to reflect," said the lady, cheerfully. "I will tell you then
whether I will undertake it."
The next evening, a letter was written inviting Milly to make her uncle a visit; he
volunteering a promise to pay her expenses for a year, either at his own house or at a
suitable school. A week later, Milly arrived, in company with a neighbor of her
grandmother, and quite a sensation did her debut create.
Milly was now in her tenth year, eight months younger than Emily. She had eyes that
shone like stars; and a complexion dark as an Indian. Her form was slender, and her
movements graceful. Her limbs were so supple that she could throw herself into any
attitude and did so to the alarm of her aunt, who feared every moment that she would
dislocate some bone.
It would be difficult to conceive a greater contrast than existed between the cousins. Emily
was of fair complexion, with deep blue eyes and auburn hair. In her person and dress, she
was the picture of neatness, while from her birth her parents had carefully guarded her
from every breath of harm.
Milly, on her arrival from a day's journey in the cars, looked like a wild girl. Her face was
covered with dust; her hair which floated loosely over her shoulders, looked as though
unacquainted with a brush; her hands were grimy with dirt; her nails even had a deep
border of black; her dress was buttoned awry; her boots were only half laced; and the
strings hung dangling around her ancles, threatening every moment to trip her up.
When the child had carelessly bid the neighbor who accompanied her to the door good-by,
without a word of thanks, and then, no ways abashed, stood in the centre of the room
gazing curiously at her new found relatives, Mrs. Morgan cast a despairing glance from her
husband to Emily.
The little girl, in the meantime, was trying hard to convince herself that this poor,
neglected creature was the dear cousin, for whose arrival she had been so impatient. She
blushed crimson as she noticed the slovenly hair and soiled dress; all desire to have Milly
share her room and bed vanishing on the instant. She could not endure the thought of a
kiss from a mouth with teeth so entirely a stranger to the brush.
But Milly did not notice the neglect. Alter one long, searching gaze into the faces of her
relatives, she threw her hat into a chair, tossed back with a quick jerk of her head the
locks fallen over her face; then with a loud yawn, exclaimed:
This appeal changed Emily's aversion to sympathy. She stepped forward eagerly, and
seizing her cousin's hand, said:
"Come with me to your room and wash. Supper will be ready in a few minutes."
She led the way to a small chamber on the opposite side of the hall from her own, saying
as she did so, "I'll help you to dress for tea."
"Oh dear!" exclaimed Mrs. Morgan, throwing up her hands when the children were out of
hearing, "Isn't she a real Hindoo? Can she ever be civilized?"
Mr. Morgan sighed repeatedly. "Oh, Ida!" he murmured, "How your child reminds me of
you! So like, yet so different; impulsive and careless, but with a warm heart!"
They were interrupted by a loud, prolonged laugh from the chamber; and in a few minutes
the cousins came down stairs hand in hand, just as the bell in the hall called them to
supper.
CHAPTER IV.
MILLY AT PRAYERS.
IT was evident that Emily had attempted to improve her cousin's appearance. Her face and
hands were clean; and one lock of hair next her face had been brushed smoothly, and tied
back with a cherry ribbon, from Emily's drawer. An apron and collar had been added from
the same place.
At the door of the dining-room, Milly snatched her hand from her cousin, and dashed up to
her aunt, asking, in a loud voice, "Say, doesn't I look smart? May I keep this red ribbon for
my own?"
At the table, while her uncle said grace, Milly folded her hands to be sure; but her eyes
wandered from one dish to another. She did not wait till the plate of biscuit was passed,
but snatched one, and commenced eating it, biting a huge piece off the side as a dog
would have done.
"Did you have no dinner, Milly?" inquired her uncle, greatly annoyed.
"I had a paper bag full of doughnuts and cheese," answered the child, talking with her
mouth full, and showing all the process of masticating her food, occasionally using her
tongue to disengage the bread from her teeth. "Martha made them on purpose. You know
old Martha, don't you?"
Mr. Morgan gravely bowed assent. Every moment he was becoming more convinced that
Milly must be sent away to school.
When Mrs. Morgan passed the visitor a glass dish of currant jelly, she smacked her lips,
and glancing in her aunt's face with a smile, she burst out:
"I'm glad you like it, my dear," was the kind reply.
Mr. Morgan pushed back his plate, saying in rather a petulant tone, "My appetite has
gone."
When the tea had been removed, Emily carried the Bible and hymn books to her father,
taking the opportunity, as she leaned over his shoulder, to whisper to him:
He glanced in her anxious face, nodded pleasantly, and then named the hymn they would
sing.
The exercises which followed appeared to interest Milly intensely. She listened to the
reading with open mouth, her keen gaze being fastened on her uncle till he closed the
Bible.
During the singing, her expression softened, till the tears stood in her eyes. But after the
first verse, she hummed an accompaniment, entirely ignoring the words, her voice, as
they all acknowledged afterward, being as sweet and clear as a nightingale in his native
woods.
When they rose from their seats to kneel, Milly squatted awkwardly down in front of her
chair, her chin resting on her hands. Her eyes were at first fixed on a beautiful painting of
fruit which hung above her; but presently her attention was arrested by the petitions:
"Help us, Lord, to be kind to the poor orphan who has this day come to us. May she be
docile and affectionate; and may we be patient and faithful. May we always bear in mind
that she has not been so highly favored by Providence as we have been, and may we, both
by precept and example, teach her that the ways of wisdom are ways of pleasantness, and
all her paths are peace."
When the prayer was finished, Milly stood still for a moment, while Emily, as usual,
gathered the books and restored them to a shelf in the bookcase. Then, with a sudden
impulse, the poor little stranger dashed to the side of her uncle, exclaiming:
"I like you. I thought at first I shouldn't; and I like to hear you talk to God as you did just
now."
"Stop a minute, Milly," cried her uncle, as she was darting away. "I want to speak to you.
Do you know," he added affectionately, taking her hand, "that your mother was my sister
Ida, whom I dearly loved? For her sake, and for your own, too, I hope we shall do
everything in our power to make you a useful and happy woman. But tell me, Milly, do you
ever talk to God? Do you ask him to take care of you, and make you his child?"
"I did once, on board ship," returned Milly. "A man told me God made everything on sea
and land; but I don't believe he made Juggernaut. It's such a horrid creature, and kills so
many people under its great wheels."
Before Mr. Morgan could say any more, the child darted away.
CHAPTER V.
MILLY AT TABLE.
IT was not an easy task for Mrs. Morgan to tame this wild creature; but when her husband
said, hopelessly:
"It will take years, Priscilla; and in the meantime Emily will be ruined."
"God has given us the work, George, I would not dare to refuse it."
There were many times every day that she was ready to despair. Milly had not one idea of
neatness and order, and could not be made to comprehend that it was of any consequence
to put her clothes, books and toys in place. Her hat as often was tossed on a chair in the
hall, her sack on the doorstep as on the hook and shelves allotted to them. In her room
were a bureau and closet. Her aunt showed her Emily's clothes, hung or folded so neatly;
but when she asked kindly:
"Won't you try, Milly, to keep yours in place?" the only answer was the laughing one:
"My poor child," said the lady tenderly, "it would be much easier for me to send Hannah to
dress your bed, and make your room tidy, than to teach you to do it. But can't you
understand that I do it for your good?"
"If you do not learn to be neat now, while you are young, you never will be likely to learn
at all. If you have a house of your own, you will not be able to find anything. You
remember what an inconvenience it is every day not to find your hat, your gloves, your
jumping-rope, your hoop-stick; and how much time it takes to hunt for them, when, if you
had a place for every thing, and kept every thing in its place if not in use, you would—"
"Oh!" interrupted Milly, "I say, what's the use of learning so many things, when, as soon as
I'm grown, I'm going back to India to live with father. There are plenty of servants in the
bungalows, and if I did the work, they would have nothing to do, but chew betel nuts,
which makes them lazy."
"But, Milly, you know the Bible is God's word. God, our heavenly Father, who loves us and
preserves us from harm, tells us—"
"Yes, I know about him. The man on board ship told me that he is not cruel and hateful
like the gods the Hindoos worship. I like him first-rate."
"Well, my dear, our God tells us what we must do in order to get into heaven when we die.
I'm sure you want to please him and go there."
"One of his rules is this: 'Let every thing be done decently and is order;' and a writer has
told us—'Order is heaven's first law.'"
"But he won't tell anybody to throw us to the crocodiles. The man told me that, or else I
shouldn't like him. The man says he forgives everybody."
"He does, every man, woman and child, who pray for forgiveness; but not those who go on
breaking his laws. That would be only mocking him."
And before Mrs. Morgan could put out her hand to detain the child, she had darted away.
Two weeks passed. To Mrs. Morgan, it did seem as though there was a slight improvement
in the habits of the motherless girl. Her looks and dress were decidedly better. Her hair
had been shortened, and showed a disposition to curl. She was required to brush it
carefully several times in a day. Her face, hands and neck, were examined thoroughly by
her aunt before she was allowed to leave her room in the morning, and her cousin's
influence had made her more thoughtful concerning her dress.
Since the first evening of her arrival, she had never eaten at the table with her uncle,
though. Unless they had company, she took her dinners with her aunt and cousins, Mr.
Morgan being absent in the city. She had taken daily lessons, and not without some effect,
in the handling of her knife and fork, keeping her elbows off the table, keeping her lips
closed while eating, waiting until the food was passed her by a servant, asking when she
wished anything, instead of making a dive at it. When she had cured herself of these
uncouth habits, and learned to eat like a lady, instead of like a dog, she had been
promised the reward of going to the table with her uncle.
At first, Milly said she'd rather not eat with him; it would be a great deal jollier to sit down
with Hannah and Phebe in the kitchen. She wished she could go there; but when day after
day she was sent from the room, and heard outside the pleasant talk, and the merry peals
of laughter from Emily, she changed her mind, and really tried to do as her aunt wished.
CHAPTER VI.
MILLY'S REQUEST.
WE have left Mrs. Morgan and her cousin a long time, and must now return to them.
When they were seated at their sewing, Mrs. Roby said: "I have been wishing to ask you
about Milly. What a very strange child she is! It is a perfect fascination to watch her."
"Yes, one never knows what she will do next. She has always been governed by her own
impulses, good or bad. I am glad to say many of them are good. She is capable of the
warmest attachments. I never knew until lately, how much she loves Emily. The poor child
fell a short distance from home, as they were going together of an errand, and sprained
her ancle. Milly actually tried to lift her cousin and bring her home; but finding she had not
strength, she rushed back in her furious way, crying as though her heart was broken, to
tell me Emily was hurt. Then, when Emily fainted, I thought Milly would faint too, she was
so terrified for fear her cousin would die. I had to take her up stairs, and leave her with
Hannah for a time. When I had bathed and bandaged Emily's ancle, I went to Milly, who
was sobbing bitterly."
"'Oh, Aunt Priscilla, I wish it had been my ancle! Emily's so good and kind. Oh, dear! I'm
so sorry I've vexed her so many times, I never, never will again. I'll let her things alone.
Will she get well, aunty? Will she? Oh, I'd rather go back to India! Things are always
happening here to make me ache,' putting both hands to her heart."
"I improved the opportunity while her feelings were tender, to talk with her about herself. I
told her we were all growing to love her very dearly; and that, when she tried to be good
and polite and tidy, it made Emily and all of us very happy."
"'Truly, truly, Aunt Priscilla, are you beginning not to be tired of me and thinking me a
bother, with my things thrown all about?'"
"Truly, truly, I am beginning to like to have you here, and to be able to say, Milly is
improving every week."
She covered her face with her hands, and laughed till she shook all over, when suddenly
she spoke again.
"'But I never can be like Emily; never in this world.'"
"'Because she is a real Christian. When I struck her once, she did not get angry. She
said:'"
"'Oh, Cousin Milly!' And then she went in her own room, and locked the door. I listened at
the keyhole, for I heard her talking; and I thought she was telling you of my badness. But,
oh dear!—beginning to sob again, 'she was telling God that I was a poor, motherless girl,
and that the Hindoo ayah's hadn't taught me any better; and then she asked God to
forgive me. Isn't that being real, truly good?'"
"It is indeed, my dear child; and then I kissed her. But here they come."
Mrs. Morgan smiled as she glanced through the window. The cousins walked side by side,
engaged in animated conversation, Emily at the time being the chief speaker. Milly's hat
was, as usual, hanging by the elastic on the back of her neck; and her hair was in wild
confusion.
"You will see," said mamma softly, "that Emily will coax her cousin to the chamber, and
make her presentable, before she comes to the parlor."
And so it was, but they had business in hand, and Milly never was patient under delay.
They came down stairs together, talking in subdued tones, when the ladies heard Milly say:
"Uncle George has come home; and I'm going to ask him now."
"Yes, I am," in Milly's decided voice, "I hate waiting for things."
So into the library Milly went, while Emily sat on the stairs in the hall, waiting and blushing
with eagerness.
Mr. Morgan had just entered the library. Seeing his niece with nicely brushed hair, and
clean muslin apron, he smiled so pleasantly, that she plunged into her subject at once.
"I'm quite at your service, Miss Milly," he answered, throwing himself upon the lounge, as
was his habit after his walk, "but where is Emily?"
"She's somewhere; but Uncle George, would it cost a great deal of money to go to the
shore? Emily and I want to go awfully. It's a secret and you must be sure not to tell Aunt
Priscilla."
She put her mouth close to his ear, "Emily says Aunty's birthday is coming pretty soon,
and she says I'm not so bad as I was, and I'm trying hard to be good. See how smooth my
hair is and my clean apron on. I like her ever so much now; and I put my things in the
drawers. I mean, I do when I don't forget; and then Emily reminds me. So I want to make
Aunt Priscilla a present; and I know how to do mosses, the woman on board ship showed
me; and that's the reason we want to go to the shore."
Milly stopped to recover breath, and then went on, eager to explain:
"Aunt Priscilla can go with us, of course; because Emily and I can pick the moss while she
isn't seeing us, and then I can do them at home for her birthday."
"There, I knew you would. I'll go and call Emily. She said I might ask you, 'cause it's going
to be my present."
The child laughed merrily; and then in her impulsive way began to kiss him, eyes, nose
and mouth. "When your eye twinkles, I love you dearly, Uncle George."
"There, Milly, you looked just like your mother when you said that; and so for her sake,
and because of your smooth hair, and your clean apron, and your attempts to be neat, I
will take you to-morrow afternoon, if it is pleasant."
Milly jumped a foot from the floor, laughing and clapping her hands, in great glee. Then,
she ran out to communicate the good news to her Cousin Emily.
CHAPTER VII.
GRANDMA'S ARRIVAL.
UNFORTUNATELY, the next day was rainy. And the following, Mrs. Morgan's mother arrived,
and they could not leave her.
Milly's patience was nearly exhausted when the second disappointment came. She knew
nothing about this grandma, and could not sympathize with Emily's joy at seeing her once
more. Grandmother Morgan was very feeble and often irritable. Milly had never become
attached to one who was always lamenting that Ida's child should be exactly like a Hindoo
girl, and finding fault with her for not doing things that the poor, neglected Milly had never
heard of.
Grandma Harris was fatigued with her journey, and lay down for an hour keeping hold of
Emily's soft hand all the time, even when she fell into a short doze. But she came from her
chamber quite refreshed, and gave a willing consent that Milly should come and hear the
story she had promised to tell.
Everybody said, Grandma Harris was a great story-teller. It was certain that when she was
at her daughter's, she had a great many stories to tell. She had heard all about the
motherless child, and heartily approved of Priscilla's intention to befriend her. Now, when
Emily urged that her cousin should be invited to join them and listen to the story, the old
lady smilingly consented.
Milly never in all her after life forgot that interview. Grandma was sitting in her favorite
chair, a deep seated maroon-covered one without arms; a narrow fold of delicate gauze
framing her beautiful silvery hair. Her dress was black silk, the rich, heavy folds lying on
the carpet by her side, the waist open and turned back at the neck to show the snowy
muslin kerchief folded across her bosom.
At first, Milly saw nothing of all this, except as a part of the beautiful picture. She only saw
the kind eyes, and the welcoming smile.
"You must be my granddaughter too, my dear, and give me a kiss," she said, taking the
child's hand and patting it softly. "Say, will you be my little girl as Emily is?"
Milly's face expressed great emotion. It was a very tell-tale face. Now it looked pleased
and penitent, and astonished by turns. At last, trying to wink back a tear which the loving
words brought to her eyes, she answered softly:
"I'm not good enough. Emily can tell you what a bad girl I am; and when everybody is so
kind, too."
"Indeed, Emily has told me nothing of the kind. She says you're her own darling cousin,—
that she loves you dearly,—and that you are trying so hard to be good."
"Yes, I do try sometimes. I mean, when I think of it. But I'm not nice and clean like Emily.
Aunty has a great deal of trouble with me, though my bed looks real smooth to-day, and
all my clothes are hung up."
"That is very cheering. Emily tells me you wish to go back to India. It will be very pleasant
to your father to have a neat, thorough housekeeper."