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FUHRMAN & ZIMMERMAN’S
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
Elsevier
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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid ad-
vances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
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contained in the material herein.
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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seemed charged: it simply legitimated them. A romantic adventure
on so classical a basis would assuredly hurt no one.
"I should like a walk very much," said Ludlow; "a walk with a halt
at the end of it."
"Well, if you will consent to a short halt at the beginning of it," said
Adela, "I will be with you in a very few minutes." When she returned
in her little hat and shawl, she found her friend seated on the
veranda steps. He arose and gave her a card.
"I have been requested, in your absence, to hand you this," he
said.
Adela read with some compunction the name of Mr. Madison
Perkins.
"Has he been here?" she asked. "Why didn't he come in?"
"I told him you were not at home. If it wasn't true then, it was
going to be true so soon that the interval was hardly worth taking
account of. He addressed himself to me, as I seemed from my
position to be quite at home here; but I confess he looked at me as if
he doubted my word. He hesitated as to whether he should confide
his name to me, or whether he should confide it in that shape to the
entry table. I think he wished to show me that he suspected my
veracity, for he was making rather grimly for the table when I, fearing
that once inside the house he might encounter the living truth,
informed him in the most good-humored tone possible that I would
take charge of his little tribute.
"I think, Mr. Ludlow, that you are a strangely unscrupulous man.
How did you know that Mr. Perkins's business was not urgent?"
"I didn't know it. But I knew it could be no more urgent than mine.
Depend upon it, Miss Moore, you have no case against me. I only
pretend to be a man; to have admitted that charming young
gentleman would have been heroic."
Adela was familiar with a sequestered spot, in the very heart of
the fields, as it seemed to her, to which she now proposed to
conduct her friend. The point was to select a goal neither too distant
nor too near, and to adopt a pace neither too rapid nor too slow. But
although Adela's happy valley was a good two miles away, and they
had measured the interval with the very minimum of speed, yet most
sudden seemed their arrival at the stile over which Adela was used
to strike into the meadows. Once on the road, she felt a precipitate
conviction that there could be no evil in an adventure so essentially
wholesome as that to which she had lent herself, and that there
could be no guile in a spirit so deeply sensitive to the sacred
influences of Nature, and to the melancholy aspect of incipient
Autumn as that of her companion. A man with an unaffected relish
for small children is a man to inspire young women with a generous
confidence; and so, in a lesser degree, a man with a genuine feeling
for the simple beauties of a common New England landscape may
not unreasonably be accepted by the daughters of the scene as a
person worthy of their esteem. Adela was a great observer of the
clouds, the trees and the streams, the sounds and colors, the
echoes and reflections native to her adopted home; and she
experienced an honest joy at the sight of Ludlow's keen appreciation
of these modest facts. His enjoyment of them, deep as it was,
however, had to struggle against that sensuous depression natural to
a man who has spent the Summer in a close and fetid laboratory in
the heart of a great city, and against a sensation of a less material
color—the feeling that Adela was a delightful girl. Still, naturally a
great talker, he celebrated his impressions in a generous flow of
good-humored eloquence. Adela resolved within herself that he was
decidedly a companion for the open air. He was a man to make use,
even to abuse, of the wide horizon and the high ceiling of Nature.
The freedom of his gestures, the sonority of his voice, the keenness
of his vision, the general vivacity of his manners, seemed to
necessitate and to justify a universal absence of barriers. They
crossed the stile, and waded through the long grass of several
successive meadows, until the ground began to rise, the stony
surfaces to crop through the turf, when, after a short ascent, they
reached a broad plateau, covered with boulders and shrubs, which
lost itself on one side in a short, steep cliff, whence fields and
marshes stretched down to the opposite river; and on the other, in
scattered clumps of pine and maple, which gradually thickened and
multiplied, until the horizon in that quarter was blue with a long line of
woods. Here was both sun and shade—the unobstructed sky, or the
whispering dome of a circle of pines. Adela led the way to a sunny
seat among the rocks, which commanded the course of the river,
and where a cluster of trees would lend an admonitory undertone to
their conversation.
Before long, however, its muffled eloquence became rather
importunate, and Adela remarked upon the essential melancholy of
the phenomenon.
"It has always seemed to me," rejoined Ludlow, "that the wind in
the pines expresses tolerably well man's sense of a coming change,
simply as a change."
"Perhaps it does," said Adela. "The pines are forever rustling, and
men are forever changing."
"Yes, but they can only be said to express it when there is some
one there to hear them; and more especially some one in whose life
a change is, to his own knowledge, going to take place. Then they
are quite prophetic. Don't you know Longfellow says so?"
"Yes, I know Longfellow says so. But you seem to speak from
your own feeling."
"I do."
"Is there a change pending in your life?"
"Yes, rather an important one."
"I believe that's what men say when they are going to be married,"
said Adela.
"I'm going to be divorced, rather. I'm going to Europe."
"Indeed! soon?"
"To-morrow," said Ludlow, after an instant's pause.
"Oh!" said Adela. "How I envy you!"
Ludlow, who sat looking over the cliff and tossing stones down
into the plain, observed a certain inequality in the tone of his
companion's two exclamations. The first was nature, the second art.
He turned his eyes upon her, but she had turned hers away upon the
distance. Then, for a moment, he retreated within himself and
thought. He rapidly surveyed his position. Here was he, Tom Ludlow,
a hard-headed son of toil, without fortune, without credit, without
antecedents, whose lot was cast exclusively with vulgar males, and
who had never had a mother, a sister nor a well-bred sweetheart to
pitch his voice for the feminine tympanum; who had seldom come
nearer an indubitable young lady than, in a favoring crowd, to
receive a mechanical "thank you" (as if he were a policeman), for
some ingeniously provoked service; here he found himself up to his
neck in a sudden pastoral with the most ladyish young woman in the
land. That it was in him to enjoy the society of such a woman
(provided, of course, she were not a fool), he very well knew; but he
had not yet suspected that it was possible for him (in the midst of
more serious cares) to obtain it. Was he now to infer that this final
gift was his—the gift of pleasing women who were worth the
pleasing? The inference was at least logical. He had made a good
impression. Why else should a modest and discerning girl have so
speedily granted him her favor? It was with a little thrill of satisfaction
that Ludlow reflected upon the directness of his course. "It all comes
back," he said to himself, "to my old theory, that a process can't be
too simple. I used no arts. In such an enterprise I shouldn't have
known where to begin. It was my ignorance of the regulation method
that served me. Women like a gentleman, of course; but they like a
man better." It was the little touch of nature he had discerned in
Adela's tone that had set him thinking; but as compared with the
frankness of his own attitude it betrayed after all no undue emotion.
Ludlow had accepted the fact of his adaptability to the idle mood of a
cultivated woman in a thoroughly rational spirit, and he was not now
tempted to exaggerate its bearings. He was not the man to be
intoxicated by success—this or any other. "If Miss Moore," he
pursued, "is so wise—or so foolish—as to like me half an hour for
what I am, she is welcome. Assuredly," he added, as he gazed at her
intelligent profile, "she will not like me for what I am not." It needs a
woman, however, far more intelligent than (thank heaven!) most
women are—more intelligent, certainly, than Adela was—to guard
her happiness against a strong man's consistent assumption of her
intelligence; and doubtless it was from a sense of this general truth,
as Ludlow still gazed, he felt an emotion of manly tenderness. "I
wouldn't offend her for the world," he thought. Just then, Adela,
conscious of his gaze, looked about; and before he knew it, Ludlow
had repeated aloud, "Miss Moore, I wouldn't offend you for the
world."
Adela glanced at him for a moment with a little flush that subsided
into a smile. "To what dreadful injury is that the prelude?" she asked.
"It's the prelude to nothing. It refers to the past—to any possible
displeasure I may have caused you."
"Your scruples are unnecessary, Mr. Ludlow. If you had given me
offence, I should not have left you to apologize for it. I should not
have left the matter to occur to you as you sat dreaming charitably in
the sun."
"What would you have done?"
"Done? nothing. You don't imagine I would have rebuked you—or
snubbed you—or answered you back, I take it. I would have left
undone—what, I can't tell you. Ask yourself what I have done. I'm
sure I hardly know myself," said Adela, with some intensity. "At all
events, here I am sitting with you in the fields, as if you were a friend
of years. Why do you speak of offence?" And Adela (an uncommon
accident with her) lost command of her voice, which trembled ever
so slightly. "What an odd thought! why should you offend me? Do I
invite it?" Her color had deepened again, and her eyes brightened.
She had forgotten herself, and before speaking had not, as was her
wont, sought counsel of that staunch conservative, her taste. She
had spoken from a full heart—a heart which had been filling rapidly
since the outset of their walk with a feeling almost passionate in its
quality, and which that little blast of prose which had brought her
Ludlow's announcement of his departure, had caused to overflow.
The reader may give this feeling such a name as he pleases. We will
content ourselves with saying that Adela had played with fire so
effectually that she had been scorched. The slight vehemence of the
speech just quoted had covered her sensation of pain.
"You pull one up rather short, Miss Moore," said Ludlow. "A man
says the best he can."
Adela made no reply. For a moment she hung her head. Was she
to cry out because she was hurt? Was she to introduce her injured
soul as an impertinent third into the company? No! Here our
reserved and contemplative heroine is herself again. Her part was
still to be the perfect young lady. For our own part, we can imagine
no figure more bewitching than that of the perfect young lady under
these circumstances; and if Adela had been the most accomplished
coquette in the world she could not have assumed a more becoming
expression than the air of languid equanimity which now covered her
features. But having paid this generous homage to propriety, she felt
free to suffer. Raising her eyes from the ground, she abruptly
addressed her companion with this injunction:
"Mr. Ludlow," said she, "tell me something about yourself."
Ludlow burst into a laugh. "What shall I tell you?"
"Everything."
"Everything? Excuse me, I'm not such a fool. But do you know
that's a delicious request you make? I suppose I ought to blush and
hesitate; but I never yet blushed or hesitated in the right place."
"Very good. There is one fact. Continue. Begin at the beginning."
"Well, let me see. My name you know. I'm twenty-eight years old."
"That's the end," said Adela.
"But you don't want the history of my babyhood, I take it. I imagine
that I was a very big, noisy and ugly baby: what's called a 'splendid
infant.' My parents were poor, and, of course, honest. They belonged
to a very different set—or 'sphere', I suppose you call it—from any
you probably know. They were working people. My father was a
chemist in a small way, and I fancy my mother was not above using
her hands to turn a penny. But although I don't remember her, I am
sure she was a good, sound woman; I feel her occasionally in my
own sinews. I myself have been at work all my life, and a very good
worker I am, let me tell you. I'm not patient, as I imagine your brother
to be—although I have more patience than you might suppose—but
I'm plucky. If you think I'm over-egotistical, remember 'twas you
began it. I don't know whether I'm clever, and I don't much care; that
word is used only by unpractical people. But I'm clear-headed, and
inquisitive, and enthusiastic. That's as far as I can describe myself. I
don't know anything about my character. I simply suspect I'm a pretty
good fellow. I don't know whether I'm grave or gay, lively or severe. I
don't know whether I'm high-tempered or low-tempered. I don't
believe I'm 'high-toned.' I fancy I'm good-natured enough, inasmuch
as I'm not nervous. I should not be at all surprised to discover I was
prodigiously conceited; but I'm afraid the discovery wouldn't cut me
down, much. I'm desperately hard to snub, I know. Oh, you would
think me a great brute if you knew me. I should hesitate to say
whether I am of a loving turn. I know I'm desperately tired of a
number of persons who are very fond of me; I'm afraid I'm
ungrateful. Of course as a man speaking to a woman, there's
nothing for it but to say I'm selfish; but I hate to talk about such windy
abstractions. In the way of positive facts: I'm not educated. I know no
Greek and very little Latin. But I can honestly say that first and last I
have read a great many books—and, thank God, I have a memory!
And I have some tastes, too. I'm very fond of music. I have a good
old voice of my own: that I can't help knowing; and I'm not one to be
bullied about pictures. Is that enough? I'm conscious of an utter
inability to say anything to the point. To put myself in a nutshell, I
suppose I'm simply a working man; I have his virtues and I have his
defects. I'm a very common fellow."
"Do you call yourself a very common fellow because you really
believe yourself to be one, or because you are weakly tempted to
disfigure your rather flattering catalogue with a great final blot?"
"I'm sure I don't know. You show more subtlety in that one
question than I have shown in my whole string of affirmations. You
women are strong on asking witty questions. Seriously, I believe I am
a common fellow. I wouldn't make the admission to every one
though. But to you, Miss Moore, who sit there under your parasol as
impartial as the Muse of History, to you I own the truth. I'm no man of
genius. There is something I miss; some final distinction I lack; you
may call it what you please. Perhaps it's humility. Perhaps you can
find it in Ruskin, somewhere. Perhaps it's patience—perhaps it's
imagination. I'm vulgar, Miss Moore. I'm the vulgar son of vulgar
people. I use the word, of course, in its strictest sense. So much I
grant you at the outset, and then I walk ahead."
"Have you any sisters?"
"Not a sister; and no brothers, nor cousins, nor uncles, nor aunts."
"And you sail for Europe to-morrow?"
"To-morrow, at ten o'clock."
"To be away how long?"
"As long as I possibly can. Five years if possible."
"What do you expect to do in those five years?"
"Study."
"Nothing but study?"
"It will all come back to that, I fancy. I hope to enjoy myself
reasonably, and to look at the world as I go. But I must not waste
time; I'm growing old."
"Where are you going?"
"To Berlin. I wanted to get letters from your brother."
"Have you money? Are you well off?"
"Well off? Not I, no. I'm poor. I travel on a little money that has just
come to me from an unexpected quarter: an old debt owing my
father. It will take me to Germany and keep me for six months. After
that I shall work my way."
"Are you happy? Are you contented?"
"Just now I'm pretty comfortable, thank you."
"But will you be so when you get to Berlin?"
"I don't promise to be contented; but I'm pretty sure to be happy."
"Well!" said Adela, "I sincerely hope you may be."
"Amen!" said Ludlow.
Of what more was said at this moment, no record may be given.
The reader has been put into possession of the key of our friends'
conversation; it is only needful to say that substantially upon this key,
it was prolonged for half an hour more. As the minutes elapsed,
Adela found herself drifting further and further away from her
anchorage. When at last she compelled herself to consult her watch,
and remind her companion that there remained but just time enough
for them to reach home, in anticipation of her brother's arrival, she
knew that she was rapidly floating seaward. As she descended the
hill at her companion's side, she felt herself suddenly thrilled by an
acute temptation. Her first instinct was to close her eyes upon it, in
the trust that when she opened them again it would have vanished;
but she found that it was not to be so uncompromisingly dismissed. It
importuned her so effectually, that before she had walked a mile
homeward, she had succumbed to it, or had at least given it the
pledge of that quickening of the heart which accompanies a bold
resolution. This little sacrifice allowed her no breath for idle words,
and she accordingly advanced with a bent and listening head.
Ludlow marched along, with no apparent diminution of his habitual
buoyancy of mien, talking as fast and as loud as at the outset. He
adventured a prophecy that Mr. Moore would not have returned, and
charged Adela with a humorous message of regrets. Adela had
begun by wondering whether the approach of their separation had
wrought within him any sentimental depression at all commensurate
with her own, with that which sealed her lips and weighed upon her
heart; and now she was debating as to whether his express
declaration that he felt "awfully blue" ought necessarily to remove
her doubts. Ludlow followed up this declaration with a very pretty
review of the morning, and a sober valedictory which, whether
intensely felt or not, struck Adela as at least nobly bare of flimsy
compliments. He might be a common fellow—but he was certainly a
very uncommon one. When they reached the garden gate, it was
with a fluttering heart that Adela scanned the premises for some
accidental sign of her brothers presence. She felt that there would be
an especial fitness in his not having returned. She led the way in.
The hall table was bare of his hat and overcoat. The only object it
displayed was Mr. Perkins's card, which Adela had deposited there
on her exit. All that was represented by that little white ticket seemed
a thousand miles away. Finally, Mr. Moore's absence from his study
was conclusive against his return.
As Adela went back thence into the drawing-room, she simply
shook her head at Ludlow, who was standing before the fire-place;
and as she did so, she caught her reflection in the mantel-glass.
"Verily," she said to herself, "I have travelled far." She had pretty well
unlearned the repose of the Veres of Vere. But she was to break with
it still more completely. It was with a singular hardihood that she
prepared to redeem the little pledge which had been extorted from
her on her way home. She felt that there was no trial to which her
generosity might now be called which she would not hail with
enthusiasm. Unfortunately, her generosity was not likely to be
challenged; although she nevertheless had the satisfaction of
assuring herself at this moment that, like the mercy of the Lord, it
was infinite. Should she satisfy herself of her friend's? or should she
leave it delightfully uncertain? These had been the terms of what has
been called her temptation, at the foot of the hill. But inasmuch as
Adela was by no means strictly engaged in the pursuit of pleasure,
and as the notion of a grain of suffering was by no means repugnant
to her, she had resolved to obtain possession of the one essential
fact of her case, even though she should be at heavy costs to
maintain it.
"Well, I have very little time," said Ludlow; "I must get my dinner
and pay my bill and drive to the train." And he put out his hand.
Adela gave him her own, and looked him full in the eyes. "You are
in a great hurry," said she.
"It's not I who am in a hurry. It's my confounded destiny. It's the
train and the steamer."
"If you really wished to stay you wouldn't be bullied by the train
and the steamer."
"Very true—very true. But do I really wish to stay?"
"That's the question. That's what I want to know."
"You ask difficult questions, Miss Moore."
"I mean they shall be difficult."
"Then, of course, you are prepared to answer difficult ones."
"I don't know that that's of course, but I am."
"Well, then, do you wish me to stay? All I have to do is to throw
down my hat, sit down and fold my arms for twenty minutes. I lose
my train and my ship. I stay in America, instead of going to Europe."
"I have thought of all that."
"I don't mean to say it's a great deal. There are pleasures and
pleasures."
"Yes, and especially the former. It is a great deal."
"And you invite me to accept it?"
"No; I ought not to say that. What I ask of you is whether, if I
should so invite you, you would say 'yes.'"
"That makes the matter very easy for you, Miss Moore. What
attractions do you hold out?"
"I hold out nothing whatever, sir."
"I suppose that means a great deal."
"It means what it seems to mean."
"Well, you are certainly a most interesting woman, Miss Moore—a
charming woman."
"Why don't you call me 'fascinating' at once, and bid me good
morning?"
"I don't know but that I shall have to come to that. But I will give
you no answer that leaves you at an advantage. Ask me to stay—
command me to stay, if that suits you better—and I will see how it
sounds. Come, you must not trifle with a man." He still held Adela's
hand, and they had been looking frankly into each other's eyes. He
paused, waiting for an answer.
"Good-by, Mr. Ludlow," said Adela. "God bless you!" And she was
about to withdraw her hand; but he held it.
"Are we friends?" said he.
Adela gave a little shrug of her shoulders. "Friends of three
hours."
Ludlow looked at her with some sternness. "Our parting could at
best hardly have been sweet," said he; "but why should you make it
bitter, Miss Moore?"
"If it's bitter, why should you try to change it?"
"Because I don't like bitter things."
Ludlow had caught a glimpse of the truth—that truth of which the
reader has had a glimpse—and he stood there at once thrilled and
annoyed. He had both a heart and a conscience. "It's not my fault,"
he cried to the latter; but he was unable to add, in all consistency,
that it was his misfortune. It would be very heroic, very poetic, very
chivalric, to lose his steamer, and he felt that he could do so for
sufficient cause—at the suggestion of a fact. But the motive here
was less than a fact—an idea; less than an idea—a fancy. "It's a very
pretty little romance as it is," he said to himself. "Why spoil it? She is
an admirable girl: to have learned that is enough for me." He raised
her hand to his lips, pressed them to it, dropped it, reached the door
and bounded out of the garden gate.
The day was ended.
IV
Late in the spring of the year 1865, just as the war had come to a
close, a young invalid officer lay in bed in one of the uppermost
chambers of one of the great New York hotels. His meditations were
interrupted by the entrance of a waiter, who handed him a card
superscribed Mrs. Samuel Mason, and bearing on its reverse the
following words in pencil: "Dear Colonel Mason, I have only just
heard of your being here, ill and alone. It's too dreadful. Do you
remember me? Will you see me? If you do, I think you will remember
me. I insist on coming up. M. M."
Mason was undressed, unshaven, weak, and feverish. His ugly
little hotel chamber was in a state of confusion which had not even
the merit of being picturesque. Mrs. Mason's card was at once a
puzzle and a heavenly intimation of comfort. But all that it
represented was so dim to the young man's enfeebled perception
that it took him some moments to collect his thoughts.
"It's a lady, sir," said the waiter, by way of assisting him.
"Is she young or old?" asked Mason.
"Well, sir, she's a little of both."
"I can't ask a lady to come up here," groaned the invalid.
"Upon my word, sir, you look beautiful," said the waiter. "They like
a sick man. And I see she's of your own name," continued Michael,
in whom constant service had bred great frankness of speech; "the
more shame to her for not coming before."
Colonel Mason concluded that, as the visit had been of Mrs.
Mason's own seeking, he would receive her without more ado. "If
she doesn't mind it, I'm sure I needn't," said the poor fellow, who
hadn't the strength to be over-punctilious. So in a very few moments
his visitor was ushered up to his bedside. He saw before him a
handsome, middle-aged blonde woman, stout of figure, and dressed
in the height of the fashion, who displayed no other embarrassment
than such as was easily explained by the loss of breath consequent
on the ascent of six flights of stairs.
"Do you remember me?" she asked, taking the young man's
hand.
He lay back on his pillow, and looked at her. "You used to be my
aunt,—my aunt Maria," he said.
"I'm your aunt Maria still," she answered. "It's very good of you not
to have forgotten me."
"It's very good of you not to have forgotten me," said Mason, in a
tone which betrayed a deeper feeling than the wish to return a civil
speech.
"Dear me, you've had the war and a hundred dreadful things. I've
been living in Europe, you know. Since my return I've been living in
the country, in your uncle's old house on the river, of which the lease
had just expired when I came home. I came to town yesterday on
business, and accidentally heard of your condition and your
whereabouts. I knew you'd gone into the army, and I had been
wondering a dozen times what had become of you, and whether you
wouldn't turn up now that the war's at last over. Of course I didn't
lose a moment in coming to you. I'm so sorry for you." Mrs. Mason
looked about her for a seat. The chairs were encumbered with odds
and ends belonging to her nephew's wardrobe and to his equipment,
and with the remnants of his last repast. The good lady surveyed the
scene with the beautiful mute irony of compassion.
The young man lay watching her comely face in delicious
submission to whatever form of utterance this feeling might take.
"You're the first woman—to call a woman—I've seen in I don't know
how many months," he said, contrasting her appearance with that of
his room, and reading her thoughts.
"I should suppose so. I mean to be as good as a dozen." She
disembarrassed one of the chairs, and brought it to the bed. Then,
seating herself, she ungloved one of her hands, and laid it softly on
the young man's wrist. "What a great full-grown young fellow you've
become!" she pursued. "Now, tell me, are you very ill?"
"You must ask the doctor," said Mason. "I actually don't know. I'm
extremely uncomfortable, but I suppose it's partly my
circumstances."
"I've no doubt it's more than half your circumstances. I've seen the
doctor. Mrs. Van Zandt is an old friend of mine; and when I come to
town, I always go to see her. It was from her I learned this morning
that you were here in this state. We had begun by rejoicing over the
new prospects of peace; and from that, of course, we had got to
lamenting the numbers of young men who are to enter upon it with
lost limbs and shattered health. It happened that Mrs. Van Zandt
mentioned several of her husband's patients as examples, and
yourself among the number. You were an excellent young man,
miserably sick, without family or friends, and with no asylum but a
suffocating little closet in a noisy hotel. You may imagine that I
pricked up my ears, and asked your baptismal name. Dr. Van Zandt
came in, and told me. Your name is luckily an uncommon one; it's
absurd to suppose that there could be two Ferdinand Masons. In
short, I felt that you were my husband's brother's child, and that at
last I too might have my little turn at hero-nursing. The little that the
Doctor knew of your history agreed with the little that I knew, though I
confess I was sorry to hear that you had never spoken of our
relationship. But why should you? At all events you've got to
acknowledge it now. I regret your not having said something about it
before, only because the Doctor might have brought us together a
month ago, and you would now have been well."
"It will take me more than a month to get well," said Mason,
feeling that, if Mrs. Mason was meaning to exert herself on his
behalf, she should know the real state of the case. "I never spoke of
you, because I had quite lost sight of you. I fancied you were still in
Europe; and indeed," he added, after a moment's hesitation, "I heard
that you had married again."
"Of course you did," said Mrs. Mason, placidly. "I used to hear it
once a month myself. But I had a much better right to fancy you
married. Thank Heaven, however, there's nothing of that sort
between us. We can each do as we please. I promise to cure you in
a month, in spite of yourself."
"What's your remedy?" asked the young man, with a smile very
courteous, considering how sceptical it was.
"My first remedy is to take you out of this horrible hole. I talked it
all over with Dr. Van Zandt. He says you must get into the country.
Why, my dear boy, this is enough to kill you outright,—one Broadway
outside of your window and another outside of your door! Listen to
me. My house is directly on the river, and only two hours' journey by
rail. You know I've no children. My only companion is my niece,
Caroline Hofmann. You shall come and stay with us until you are as
strong as you need be,—if it takes a dozen years. You shall have
sweet, cool air, and proper food, and decent attendance, and the
devotion of a sensible woman. I shall not listen to a word of
objection. You shall do as you please, get up when you please, dine
when you please, go to bed when you please, and say what you
please. I shall ask nothing of you but to let yourself be very dearly
cared for. Do you remember how, when you were a boy at school,
after your father's death, you were taken with measles, and your
uncle had you brought to our own house? I helped to nurse you
myself, and I remember what nice manners you had in the very
midst of your measles. Your uncle was very fond of you; and if he
had had any considerable property of his own, I know he would have
remembered you in his will. But, of course, he couldn't leave away
his wife's money. What I wish to do for you is a very small part of
what he would have done, if he had only lived, and heard of your
gallantry and your sufferings. So it's settled. I shall go home this
afternoon. To-morrow morning I shall despatch my man-servant to
you with instructions. He's an Englishman. He thoroughly knows his
business, and he will put up your things, and save you every particle
of trouble. You've only to let yourself be dressed, and driven to the
train. I shall, of course, meet you at your journey's end. Now don't tell
me you're not strong enough."
"I feel stronger at this moment than I've felt in a dozen weeks,"
said Mason. "It's useless for me to attempt to thank you."
"Quite useless. I shouldn't listen to you. And I suppose," added
Mrs. Mason, looking over the bare walls and scanty furniture of the
room, "you pay a fabulous price for this bower of bliss. Do you need
money?"
The young man shook his head.
"Very well then," resumed Mrs. Mason, conclusively, "from this
moment you're in my hands."
The young man lay speechless from the very fulness of his heart;
but he strove by the pressure of his fingers to give her some
assurance of his gratitude. His companion rose, and lingered beside
him, drawing on her glove, and smiling quietly with the look of a long-
baffled philanthropist who has at last discovered a subject of infinite
capacity. Poor Ferdinand's weary visage reflected her smile. Finally,
after the lapse of years, he too was being cared for. He let his head
sink into the pillow, and silently inhaled the perfume of her sober
elegance and her cordial good-nature. He felt like taking her dress in
his hand, and asking her not to leave him,—now that solitude would
be bitter. His eyes, I suppose, betrayed this touching apprehension,
—doubly touching in a war-wasted young officer. As she prepared to
bid him farewell, Mrs. Mason stooped, and kissed his forehead. He
listened to the rustle of her dress across the carpet, to the gentle
closing of the door, and to her retreating footsteps. And then, giving
way to his weakness, he put his hands to his face, and cried like a
homesick schoolboy. He had been reminded of the exquisite side of
life.
Matters went forward as Mrs. Mason had arranged them. At six
o'clock on the following evening Ferdinand found himself deposited
at one of the way stations of the Hudson River Railroad, exhausted
by his journey, and yet excited at the prospect of its drawing to a
close. Mrs. Mason was in waiting in a low basket-phaeton, with a
magazine of cushions and wrappings. Ferdinand transferred himself
to her side, and they drove rapidly homeward. Mrs. Mason's house
was a cottage of liberal make, with a circular lawn, a sinuous
avenue, and a well-grown plantation of shrubbery. As the phaeton
drew up before the porch, a young lady appeared in the doorway.
Mason will be forgiven if he considered himself presented ex officio,
as I may say, to this young lady. Before he really knew it, and in the
absence of the servant, who, under Mrs. Mason's directions, was
busy in the background with his trunk, he had availed himself of her
proffered arm, and had allowed her to assist him through the porch,
across the hall, and into the parlor, where she graciously consigned
him to a sofa which, for his especial use, she had caused to be
wheeled up before a fire kindled for his especial comfort. He was
unable, however, to take advantage of her good offices. Prudence
dictated that without further delay he should betake himself to his
room.
On the morning after his arrival he got up early, and made an
attempt to be present at breakfast; but his strength failed him, and he
was obliged to dress at his leisure, and content himself with a simple
transition from his bed to his arm-chair. The chamber assigned him
was designedly on the ground-floor, so that he was spared the
trouble of measuring his strength with the staircase,—a charming
room, brightly carpeted and upholstered, and marked by a certain
fastidious freshness which betrayed the uncontested dominion of
women. It had a broad high window, draped in chintz and crisp
muslin and opening upon the greensward of the lawn. At this
window, wrapped in his dressing-gown, and lost in the embrace of
the most unresisting of arm-chairs, he slowly discussed his simple
repast. Before long his hostess made her appearance on the lawn
outside the window. As this quarter of the house was covered with
warm sunshine, Mason ventured to open the window and talk to her,
while she stood out on the grass beneath her parasol.
"It's time to think of your physician," she said. "You shall choose
for yourself. The great physician here is Dr. Gregory, a gentleman of
the old school. We have had him but once, for my niece and I have
the health of a couple of dairy-maids. On that one occasion he—well,
he made a fool of himself. His practice is among the 'old families,'
and he only knows how to treat certain old-fashioned, obsolete
complaints. Anything brought about by the war would be quite out of
his range. And then he vacillates, and talks about his own maladies
à lui. And, to tell the truth, we had a little repartee which makes our
relations somewhat ambiguous."
"I see he would never do," said Mason, laughing. "But he's not
your only physician?"
"No: there is a young man, a newcomer, a Dr. Knight, whom I
don't know, but of whom I've heard very good things. I confess that I
have a prejudice in favor of the young men. Dr. Knight has a position
to establish, and I suppose he's likely to be especially attentive and
careful. I believe, moreover, that he's been an army surgeon."
"I knew a man of his name," said Mason. "I wonder if this is he.
His name was Horace Knight,—a light-haired, near-sighted man."
"I don't know," said Mrs. Mason; "perhaps Caroline knows." She
retreated a few steps, and called to an upper window: "Caroline,
what's Dr. Knight's first name?"
Mason listened to Miss Hofmann's answer,—"I haven't the least
idea."
"Is it Horace?"
"I don't know."
"Is he light or dark?"
"I've never seen him."
"Is he near-sighted?"
"How in the world should I know?"
"I fancy he's as good as any one," said Ferdinand. "With you, my
dear aunt, what does the doctor matter?"
Mrs. Mason accordingly sent for Dr. Knight, who, on arrival, turned
out to be her nephew's old acquaintance. Although the young men
had been united by no greater intimacy than the superficial
comradeship resulting from a winter in neighboring quarters, they
were very well pleased to come together again. Horace Knight was a
young man of good birth, good looks, good faculties, and good
intentions, who, after a three years' practice of surgery in the army,
had undertaken to push his fortune in Mrs. Mason's neighborhood.
His mother, a widow with a small income, had recently removed to
the country for economy, and her son had been unwilling to leave
her to live alone. The adjacent country, moreover, offered a
promising field for a man of energy,—a field well stocked with large
families of easy income and of those conservative habits which lead
people to make much of the cares of a physician. The local
practitioner had survived the glory of his prime, and was not,
perhaps, entirely guiltless of Mrs. Mason's charge, that he had not
kept up with the progress of the "new diseases." The world, in fact,
was getting too new for him, as well as for his old patients. He had
had money invested in the South,—precious sources of revenue,
which the war had swallowed up at a gulp; he had grown frightened
and nervous and querulous; he had lost his presence of mind and
his spectacles in several important conjunctures; he had been
repeatedly and distinctly fallible; a vague dissatisfaction pervaded
the breasts of his patrons; he was without competitors: in short,
fortune was propitious to Dr. Knight. Mason remembered the young
physician only as a good-humored, intelligent companion; but he
soon had reason to believe that his medical skill would leave nothing
to be desired. He arrived rapidly at a clear understanding of
Ferdinand's case; he asked intelligent questions, and gave simple
and definite instructions. The disorder was deeply seated and
virulent, but there was no apparent reason why unflinching care and
prudence should not subdue it.
"Your strength is very much reduced," he said, as he took his hat
and gloves to go; "but I should say you had an excellent constitution.
It seems to me, however,—if you will pardon me for saying so,—to
be partly your own fault that you have fallen so low. You have
opposed no resistance; you haven't cared to get well."
"I confess that I haven't,—particularly. But I don't see how you
should know it."
"Why it's obvious."
"Well, it was natural enough. Until Mrs. Mason discovered me, I
hadn't a friend in the world. I had become demoralized by solitude. I
had almost forgotten the difference between sickness and health. I
had nothing before my eyes to remind me in tangible form of that
great mass of common human interests for the sake of which—
under whatever name he may disguise the impulse—a man
continues in health and recovers from disease. I had forgotten that I
ever cared for books or ideas, or anything but the preservation of my
miserable carcass. My carcass had become quite too miserable to