7CHAPTER 1 History of Pediatric Critical Care Medicine the number of patients in respiratory failure exceeded the avail able number of iron lung ventilators, Bjorn Ibsen, the chief of anesthesiology a[.]
CHAPTER 1 History of Pediatric Critical Care Medicine the number of patients in respiratory failure exceeded the available number of iron lung ventilators, Bjorn Ibsen, the chief of anesthesiology at the hospital, with the help of his medical staff and nurse anesthetists, performed tracheal intubation and then tracheostomy along with manual positive pressure ventilation with 50% oxygen and tracheal suctioning This treatment was carried out in 200 patients with respiratory failure To provide continuous manual ventilation on a 24-hour basis, Ibsen recruited, trained, and used 200 nursing students and aides along with 200 medical students, each working 8-hour shifts to provide manual ventilation, as well as 27 technicians per day to care for the patients The mortality in patients receiving this treatment decreased from 90% to 40%.31–33 At that time, patients from outlying areas were transported to hospitals in ambulances without sufficient attendants or airway care and arrived moribund Lassen and Ibsen started to send socalled retrieval teams in ambulances out to pick up the patients in the countryside, with marked improvements in status on arrival They also started passing stomach tubes early on for nutrition, and the rubber-cuffed tracheostomy tubes were replaced with a silver cannula that caused less tracheal mucosal damage Even with all of these improvements, Dr Ibsen noted, “Naturally we ran into a lot of complications.”33 Drs Ibsen and Lassen also received help from other people who were focusing their efforts on treating polio The clinical biochemist Dr Poul Astrup developed a micro method to measure capillary arterialized pH and PCO2 in infants, children, and adults C.G Engstrom, a Swedish anesthesiologist, designed and clinically tested the first modern volume-preset positive pressure mechanical ventilator This spectacular and thrilling story culminated in a cohort of patients with respiratory failure being treated in a single geographic area and cared for by full-time physicians, nurses, and technicians: the first modern ICU Although these units tended to disband after the summer-fall polio season, they led to the creation of full-time respiratory care units at the Radcliff Infirmary of Oxford University and elsewhere in Europe and North America in the 1950s Soon after these events, in 1958, Peter Safar led development of the first multidisciplinary ICU in North America at Baltimore City Hospital.34 In 1960, Barrie Fairley and colleagues created the ICU at Toronto General Hospital, followed in 1962 by the ICU at Massachusetts General Hospital under Drs Henning Pontoppidan and Henrik Bendixen Pediatric Intensivist Definitions Although many sources emphasize the role of advanced technology in the creation of adult, neonatal, and pediatric critical care,1,19 skilled nursing care was even more important in this evolving process Porter41 and others remind us of the vital role of 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 with 20 nurses and created a clean environment at the British military hospital at Skutari, Turkey, in 1854 during the Crimean War Although the care consisted mostly of hygiene and nutrition, within months of her arrival the mortality rate dropped from 40% to 2%.42 Nightingale provided the definition of nursing as “helping the patient to live.”42 These efforts were continued in the United States by Dorothea Dix (1802–1887) and Clara Barton (1821–1912), the “angel of the battlefield” during the American Civil War Barton also brought the Red Cross to America in 1882 As the complexity of medical and surgical care evolved in the late 19th and early 20th century, the need to cohort sick patients Some of the difficulty in relating the history of PCCM is defining a PICU and pediatric intensivist The current definitions are as follows Pediatric Intensive Care Unit An ad hoc committee of the American Academy of Pediatrics (AAP), Diseases of the Chest Section established Guidelines for the Organization of Children’s Intensive Care Units in July 1975.35 In 1983, the AAP and Society of Critical Care Medicine (SCCM) published Joint Guidelines for Pediatric Intensive Care Units,36 which were updated in 199337 and 200438 and then retired in 2013.39 The committee defined a PICU as “a hospital unit which provides treatment to children with a wide variety of illnesses of life-threatening nature including children with highly unstable conditions and those requiring sophisticated medical and surgical treatment.” Randolph and coworkers40 defined a pediatric intensivist (in the United States) as “any one of the following: (a) a pediatrician with subspecialty training in PCCM and subspecialty certification from the American Board of Pediatrics (ABP); (b) a pediatric anesthesiologist with special competency in critical care with subspecialty certification from the American Board of Anesthesiology; (c) a pediatric surgeon with special competency in critical care with subspecialty certification from the American Board of Surgery; (d) a physician (as above) eligible for subspecialty certification by the appropriate respective board.” Similar requirements for training exist or are in development elsewhere in the world First Pediatric Intensive Care Units In 1955 Dr Goran Haglund at the Children’s Hospital of Göteborg, Sweden,18 developed the first PICU, which he called a pediatric emergency ward The patient who inspired Dr Haglund to organize the unit was a 4-year-old boy who was operated on in 1951 for a ruptured appendix Postoperatively, he lapsed into a coma; his surgeon declared that he had done all he could and the boy would die of bacteriotoxic coma The anesthesiologist offered to help and the boy was intubated, given manual positive-pressure respiration with generous oxygen, tracheostomized, and given a large blood transfusion After about hours, the boy’s bowels started to function, and hours later he was out of coma After 20 hours, he had spontaneous respiration and had been successfully treated for respiratory insufficiency and shock This new unit had seven acute care beds with full-time nurses and nursing assistants providing 24-hour coverage In the first years, the team treated 1183 infants and children, with a mortality rate of 13.6% Haglund went on to state, “But what we did was something else It was the application of the basic physiology to clinical practice Our main purpose was not to heal any disease; it was to forestall the death of the patient The idea was—and is—to gain time, time so that the special medical or surgical therapy can have desired effects.”18 Haglund was also careful to point out: “There are few jobs more exciting, demanding, and taxing than emergency nursing Our nurses and nurse assistants are tremendous They must be!”18 Central Role of Critical Care Nursing S E C T I O N I Pediatric Critical Care: The Discipline and provide skilled nursing care became apparent, especially for premature newborns and victims of poliomyelitis, as cited earlier Then, as now, the recovery of the critically ill pediatric or adult patient depended on the skilled nurse at the bedside who was trained to use the life support and monitoring equipment at hand but to remain focused on the stability and comfort of the person in the bed.43 In the mid- to late 1970s, as pediatric cardiovascular surgery for more complex lesions in infants was developing, nurses provided postoperative care in designated units Children with Reye syndrome suddenly appeared, requiring complex multisystem care In addition, in the 1980s, emergency medical services systems began transporting severely injured children to hospitals, where they required rapid assessment and intervention by nurses and physicians and initiation of cardiorespiratory and neurologic support.44 Pediatric critical care nurses joined the SCCM from its beginning in 1970 and the American Association of Critical Care Nurses emphasizing the care of children In the mid-1990s, pediatric critical care nurses founded their own society and established a peer-reviewed journal Also in the 1990s, advanced practice nurses and nurse practitioners began to specialize in pediatric critical care They continue to function as important critical care team members to augment both physician and nursing care as well as conduct clinical research.43,44 Role of Pediatric Anesthesiologists and Pediatricians in Founding Pediatric Critical Care Medicine An important early physician-directed multidisciplinary PICU in North America was established at CHOP in 1967 as an outgrowth of a hospital-wide respiratory intensive care service.1,45 The unit consisted of an open ward of six beds equipped with bedside electronic monitoring and respiratory support capabilities and an adjacent intensive care chemistry laboratory staffed 24 hours per day The nurses were assigned full-time to the unit; most had previously served in the recovery room, infant ICU, or cardiac surgery postoperative ward Dr John Downes was the medical director and worked closely with two other anesthesiologists, Dr Leonard Bachman, chief of anesthesiology, and Dr Charles Richards, and a pediatric allergist/pulmonologist, Dr David Wood Four pediatric anesthesiology/critical care fellows provided 24-hour in-unit service Dr C Everett Koop (chief of surgery), Dr William Rashkind (the father of interventional pediatric cardiology), Dr John Waldhausen (one of the nation’s few full-time pediatric cardiac surgeons), Dr Sylvan Stool (a pioneer in pediatric otolaryngology), and other staff and residents provided close collaborative patient care, education, and clinical research By 1975, with the establishment of the new CHOP building, the acute PICU was expanded to 20 beds with an adjacent 10-bed intermediate step-down unit In 1969, Dr Peter Safar and his trainee, Stephen Kampschulte, developed a 10-bed PICU at the Children’s Hospital of Pittsburgh That same year, James Gilman, a pediatric anesthesiologist, and Norman Talner, a pediatric cardiologist, established a six-bed PICU at the Yale–New Haven Medical Center In 1970, at the Hospital for Sick Children in Toronto, Dr Alan Conn resigned as director of the Department of Anesthesiology to become director of a new multidisciplinary 20-bed PICU, by far the largest and most sophisticated unit in North America During the prior decade, Dr Conn and his colleagues had treated critically ill infants and children in a sequestered area of the postanesthesia care facility where they had developed considerable expertise in critical care The new state-of-the-art PICU was the forerunner of units developed in major pediatric centers throughout North America spanning the 1970s and beyond Dr Geoffrey Barker, who went on to develop one of the largest multinational fellowship training programs in the world, followed Dr Conn as director of the PICU Also in 1971, Dr David Todres, an anesthesiologist and pediatrician, and Dr Daniel Shannon, a pediatric pulmonologist, founded a 16-bed multidisciplinary unit for pediatric patients of all ages at the Massachusetts General Hospital.1,4 The units in Philadelphia, Toronto, and Boston established vibrant training programs in critical care medicine and conducted clinical research Among their numerous accomplishments, Dr Conn became a noted authority on the management of near-drowning victims, and Dr Todres and Dr Downes pioneered long-term mechanical ventilation for children at home with chronic respiratory failure These early PICUs and their training programs had a favorable impact on mortality and morbidity rates, particularly those associated with acute respiratory failure, leading to the development of similar units and programs in most major pediatric centers in North America, Western Europe, and Japan during the 1970s and early 1980s The development of the PICU at Children’s Memorial Hospital (CMH), Northwestern University Medical School, Chicago, illustrates how many of the early PICUs evolved The unit was first started as a four-bed area set in one of the postoperative care wards by pediatric anesthesiologists David Allen and Frank Seleny Anesthesiologist Dr John Cox arrived in August of 1964 and was named director He has stated that the unit never formally opened It began in the four-bed unit in the postoperative ward in 1964 and became a 14-bed separate designed unit in late 1967 Dr Cox was the director until 1975, when he was succeeded by Dr Richard Levin During this time, Dr Hisashi Nikaidoh, who was a surgery resident from 1966 to 1967, remembers taking care of a renal transplant patient; the care was provided by nephrology, general surgery, and immunology without a centralized PICU service Dr Zehava Noah, who was educated in Israel and trained in the United Kingdom, did a critical care fellowship in anesthesia at CMH, developed a closed medical-surgical PICU in 1979, and was named the director in 1981 There was also an associate surgical director.46–49 Some of the early PICUs were directed by pediatricians In 1966, Dr Max Klein joined Drs H de V Heese and Vincent Harrison in a two-bed neonatal research unit at the Groote Shuur Hospital in Cape Town Their research resulted in many significant papers, not the least of which was “The Significance of Grunting in Hyaline Membrane Disease,”50 demonstrating that oxygen tensions fell when infants had tracheal intubation, eliminating the ability to grunt on exhalation By 1969, at Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, pediatric patients with respiratory failure (e.g., Guillain-Barré syndrome) were ventilated on the general wards Although outcomes improved, deaths were still common Dr Max Klein encouraged Dr Malcolm Bowie (consultant) to start a six-bed ICU, or “high-care ward.” After further training in South Africa and at the University of California San Francisco (UCSF), Dr Klein returned to Cape Town in 1974, where he combined the neonatal tetanus ward of Dr Smythe and the six-bed ICU of Dr Bowie into the first full-time PICU in South Africa.51 CHAPTER 1 History of Pediatric Critical Care Medicine The path for pediatricians providing care for the sickest patients on a full-time basis remained unclear for an extended period Subsequent early leaders in the field each carved out their own path Dr Daniel Levin completed pediatric cardiology and neonatology fellowships to learn the care of sick children However, he found few Chairs of Pediatrics interested in hiring an “intensivist.” Then, in 1975, Drs Levin and Frances Morriss (trained in pediatrics and pediatric anesthesia) were recruited to start a PICU at Children’s Medical Center of Dallas There were so few of this new breed of intensivists that many became directors upon completion of residency and fellowship At the beginning, few other physicians wanted to be responsible for pediatric intensive care.23 Eventually, more pediatricians decided to devote their careers to being members of a multidisciplinary team taking care of the sickest children in hospitals on a full-time basis In 1975, the CHOP program started to accept PCCM trainees who were pediatricians without anesthesia training In 1967, Dr Peter Holbrook as a medical student at the University of Pennsylvania began a part-time job in the PICU at CHOP and developed a strong interest in PCCM Informed at the time that one needed anesthesia training to successfully work in the PICU, Holbrook shelved the idea and entered pediatric residency training at Johns Hopkins When the PCCM idea resurfaced, he found that many still felt a physician needed anesthesia training to function in the PICU Disagreeing with the reasoning behind such a requirement, he pursued critical care training with Dr Peter Safar in Pittsburgh, who welcomed him as a fellow in critical care medicine In 1975, Dr Holbrook and pediatrician Dr Alan Fields, who also trained in Pittsburgh, were recruited to the new, modern Children’s Hospital National Medical Center (Washington, DC) as pediatricians in the Department of Anesthesia to direct the PICU Dr Bradley Peterson,52 after pediatric and neonatology training and an anesthesiology residency at Stanford University, became director of the new PICU at Children’s Hospital of San Diego in 1977 Dr Bradley Fuhrman, following pediatric cardiology and neonatology fellowships, started the first PICU at University of Minnesota Hospital in 1979.53 Dr George Lister,54 after a pediatric residency at Yale and a fellowship in cardiopulmonary physiology at UCSF, joined the staff at the UCSF Moffitt Hospital San Francisco in 1977 as an attending in its combined adult-pediatric ICU Due to the director’s illness, he quickly found himself the co-director of the unit.54 He eventually returned to Yale as an attending in the PICU Dr Mark Rogers, after completion of a pediatric residency at BCH, an anesthesiology residency at Massachusetts General Hospital, and a pediatric cardiology fellowship at Duke, became director of the first PICU at Johns Hopkins Hospital in 1977.55 Subsequently, in 1980, Dr Rogers became chair of the Department of Anesthesiology and Critical Care Medicine at Johns Hopkins and chief editor of a major textbook of pediatric intensive care (Table 1.2) TABLE Textbooks in Pediatric Critical Care Medicine 1.2 First Edition Title Editors Reference 1971 Care of the Critically Ill Child R Jones, J.B Owen-Thomas 56 1971 Pediatric Intensive Care: Manual K Roberts, J Edwards 57 1972 Smith’s The Critically Ill Child: Diagnosis and Medical Management J Dickerman, J Lucey 58 1977 Pediatrie d’urgence G Huault, H Labrune 59 1979 through 1997 A Practical Guide to Pediatric Intensive Care, first and second editions (and accompanying Essentials volumes) D Levin, F Morriss, G Moore 60–63 1980 Tratado de Cuidados Intensivos Pediatrucos (Textbook of Pediatric Intensive Care) F.J Ruza 64 1980 Core Curriculum for Pediatric Critical Care Nursing M.C Slota 65 1983 Pediatric Critical Care J Bloedel Smith 66 1984 Nursing Care of the Critically Ill Child M.F Hazinski 67 1984 Textbook of Critical Care W.K Shoemaker, W.L Thompson, P.R Holbrook 68 1984 Pediatric Intensive Care E Nussbaum 69 1985 Temas em Terapia Intensiva (Critical Care Issues in Pediatrics) J Piva, P Carvalho, P Celiny Garcia 70 1985 Critical Care Pediatrics S Zimmerman, J.H Gildea 71 1987 Pediatric Intensive Care J.P Morray 72 1988 Textbook of Pediatric Intensive Care M.C Rogers 73 1992 Pediatric Critical Care B.P Fuhrman, J.J Zimmerman 74 1993 Textbook of Pediatric Critical Care P.R Holbrook 75 1994 Urgences & Soins Intensif Pediatriques (Pediatric Emergency and Critical Care) J Lacroix, M Gauthier, P Hubert, et al 76 Continued 10 S E C T I O N I Pediatric Critical Care: The Discipline TABLE Textbooks in Pediatric Critical Care Medicine—cont’d 1.2 First Edition Title Editors Reference 1995 Critical Heart Disease in Infants and Children D.G Nichols, D.E Cameron, W.J Greeley, et al 77 1996 Critical Care of Infants and Children I.D Todres, J.H Fugate 78 1996 Critical Care Nursing of Infants and Children M.A Curley, J Bloedel-Smith, P.A Moloney Harmon 79 1997 Illustrated Textbook of Pediatric Emergency and Critical Care Procedures R.A Dieckmann, D.H Fiser, S.M Selbst 80 1997 Pediatric Intensive Care N.S Morton 81 2003 Essentials of Pediatric Intensive Care C.G Stack, P Dobbs 83 2005 Medicinia Intensiva em Pediatria J Piva, P Celiny Garcia 84 2005 Cuidudo Intensivo Pediatrico y Neonatal J Forero, J Alarcon, G Cassalett 85 2006 Pediatric Critical Care Medicine A.D Slonim, M.M Pollack 86 2006 Manual de Cuidado Intensivo Cardiovascular Pediatrico G Casselett, M.C Patarroyo 87 2007 Pediatric Critical Care Medicine: Basic Science and Clinical Evidence D.S Wheeler, H.R Wong, T.P Shanley 88 2010 Critical Care of Children with Heart Disease R Munoz, V Monell, E da Cruz, C.G Vetterly 89 2012 Comprehensive Critical Care: Pediatric Medicine Society of Critical Care Medicine 90 2012 Pediatric Critical Care Study Guide S.E Lucking, F.A Maffei, R.F Tamburro, N.J Thomas 91 2015 Pediatric Critical Care Nutrition P.S Goday, N.M Mehta 92 2017 Pediatric Intensive Care S Watson, A Thompson 93 Growth of Pediatric Critical Care Medicine The field of PCCM grew rapidly in the late 1970s and 1980s However, there was a struggle for authority in both adult and pediatric units The culture of intensive care was changing from one in which each specialty service cared for its part of the patient to one in which a full-time critical care service cared for the whole patient, with help of consulting specialties.2,94 For PCCM to achieve its full potential, it required several elements: a national organization to provide a venue in which to meet and communicate, acceptance and validation of pediatric critical care as a subspecialty, nationally approved training requirements, and academic credibility with meaningful research A small group of interested physicians met at the SCCM National Meeting in 1979 and decided to petition the SCCM to form a section on pediatrics The society had no subsections, but the petition was successful The pediatric section with Dr Russell Raphaely as chair was formed in 1980.1 In 1983, a committee of the SCCM developed guidelines for organization of PICUs36 that were regularly updated37,38 until January 2013, after which time they were retired.39 In 1984, after petitions by pediatric intensivists, a Section of Critical Care Medicine was established in the AAP with Dr Russell Raphaely as chair.95 These organizations then petitioned for recognition of PCCM fellowships from the American College of Graduate Medical Education (ACGME) and for the subspecialty of PCCM by the American Board of Pediatrics (ABP) Legitimization of the subspecialty was achieved with establishment of a new subboard of Pediatric Critical Care Medicine of the ABP in 1985 and the first certifying examination in 1987, at which time 182 subspecialists were certified.95 Certification provided a clear basis for hospital credentialing of PCCM physicians.96 In addition to certification by the ABP, the American Board of Anesthesiology and the American Board of Surgery confer subspecialty certification with special competency in critical care In 1989, special requirements for training in PCCM were developed by the ACGME, with formally accredited programs first recognized in 1990.97 Growth in Numbers of Pediatric Intensive Care Units In 1979, there were 150 PICUs of four or more beds identified, and another 42 thought to exist.98 Most were just special care nursing units, and only 40% had a pediatric intensivist available at all times Forty percent of the units had fewer than seven beds and only one half had affiliated transport systems Pediatric ward beds decreased by 22.4% between 1980 and 1989—by 10.8% between 1990 and 1994 and by 15.7% between 1995 and 2000 During the same three time periods, PICU beds CHAPTER 1 History of Pediatric Critical Care Medicine increased by 26.2%, 19.0%, and 12.9%, respectively.40 Between 2001 and 2016, the US pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed and 55 opened) In contrast, PICU bed numbers increased 43% (4135 to 5908 beds) Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds.40a According to the FY2017 American Hospital Association (AHA) survey database, there are 399 hospitals in the United States and territories that have a PICU in their hospital.100 Although not all children’s hospitals are members of the Children’s Hospital Association, of the 155 children’s hospitals that contribute data to the fiscal year 2017 Children’s Hospital Association Annual Benchmark Report Survey, 128 (82%) stated they had staffed PICU beds.101 Growth in Training Programs and Education In 1983 to 1984, there were 32 PCCM training programs; the ACGME accredited 28 of them in 1990 By 2018 to 2019, the number had increased to 68 accredited training programs with 527 enrolled fellows, of whom 336 (63.8%) are women.99 Since its inception, the subboard has certified 2693 subspecialists.99 Educational programs in PCCM have progressed considerably at the annual SCCM, AAP, Pediatric Academic Societies, American Thoracic Society, and American College of Chest Physicians meetings, as well as at independent meetings such as the Pediatric Critical Care Colloquium and the World Federation of Pediatric Intensive Critical Care Societies (WFPICCS) Dr Barker envisioned the need to bring together pediatric intensive care from many parts of the world This led to his founding directorship of the WFPICCS, which has done much to foster development of pediatric critical care around the world, bringing vital critical care skills and experience to benefit multiple countries Numerous textbooks on PCCM have appeared in many languages (see Table 1.2), and the journal Pediatric Critical Care Medicine was launched in 2000.102 Academic credibility that results from meaningful scientific research has come slowly In the early days, intensivists were mostly consumed by clinical care and research and administrative responsibilities High-quality basic science, epidemiology, and translational studies addressing a broad range of problems have gradually emerged Multiinstitutional organizations have allowed studies that require more patients than can be drawn from a single institution to be designed, funded, and completed In the early 1990s, the Pediatric Critical Care Study Group was formed.103 It was followed by the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) network,104–106 which employed the successful programming model of research developed by the Canadian Critical Care Trials Group.107–109 PALISI has grown and prospered through the voluntary collaboration of currently 94 member PICUs110 and has supported more than 200 articles addressing the spectrum of PCCM.111 The virtual PICU was started in 1997 to bring data management technologies to critical care In 2004, Virtual PICU Systems (VPS) was formed by Drs Thomas Rice and Ramesh Sachdeva (Children’s Hospital and Health System of Milwaukee) and Dr Randall Wetzell (Children’s Hospital Los Angeles) in conjunction with the National Association of Children’s Hospitals and Related Institutions to develop a PICU registry to facilitate quality improvement and research VPS currently has more than 125 members and a massive database describing more than million critical care admissions.112,113 11 In April 2004, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) established funding for the first federally supported network for pediatric critical care research, the Collaborative Pediatric Critical Care Research Network The network is a multicentered program designed to investigate the safety and efficacy of treatment and management strategies to care for critically ill children as well as the pathophysiologic basis of critical illness and injury in childhood.114–117 The NICHD has also supported research in PCCM by developing and supporting young investigators in the field through the Pediatric Critical Care and Trauma Scientist Development Program (PCCTSDP), a K-12 research training program The 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 trauma surgery faculty.114 Perhaps most notably, in 2013 the NICHD created an independent branch, the Pediatric Trauma and Critical Illness Branch, to further support research in pediatric critical illness and injury The mission of the new branch is to prevent and reduce all aspects of childhood trauma and critical illness and to enhance health outcomes for all children across the continuum of care.114,116,117 The growth of education and research in PCCM has coincided with, and presumably resulted in, better care for children as reflected in the decrease in mortality from septic shock Between 1958 and 1966, in patients younger than 16 years of age at the University of Minnesota, mortality in septic shock was 95%; now, with PICU care, it is less than 10%.118 Drs Murray Pollack and Timothy Yeh established the basis for studying severity-adjusted mortality in pediatrics and demonstrated that patients better when cared for by pediatric intensivists.119 Although many would attribute these improvements to technology and scientific advances, Dr Yeh and others remind us that the presence of a fulltime nursing and medical team and attention to basic principles rather than exotic high technology improve outcomes.120 This is echoed by Dr Shann’s two rules of PCCM: (1) “the most important thing is to get the basics exactly right all of the time,” and (2) “organizational issues are crucially important.”23 In addition, Yeh as well as Ibsen33 and Orr have emphasized the important contributions of regionalization and the quality of PCCM transport teams in improving outcomes.121,122 Modern medical simulation originated in pediatrics and has made significant contributions to education In 1960, shortly after resuscitating his 2-year-old son following a drowning, Asmun Laerdal, the owner of a Norwegian doll factory, partnered with the Red Cross to create the first medical simulation mannequin In 1988, Laerdal partnered with the American Heart Association and the AAP to create Pediatric Acute Life Support simulationbased training Since that time, evolving pediatric residency and fellowship requirements, duty hour restrictions, and an increased focus on medical safety have catalyzed exponential growth in simulation training.123–125 The International Network for SimulationBased Pediatric Innovation Research and Education has documented an increase in pediatric simulation centers from 50 to 268 in the past years A recent meta-analysis documented 57 studies and over 3500 learners engaged in pediatric simulation education Studies compared simulation education with no intervention and found large effects for outcomes of knowledge, behavior with patients, and time to task completion.126 Dr Elizabeth Hunt along with pioneers in simulation at Johns Hopkins have been able to document progressive acquisition of ... principles rather than exotic high technology improve outcomes.120 This is echoed by Dr Shann’s two rules of PCCM: (1) “the most important thing is to get the basics exactly right all of the time,” and... anesthesia) were recruited to start a PICU at Children’s Medical Center of Dallas There were so few of this new breed of intensivists that many became directors upon completion of residency and fellowship... Urgences & Soins Intensif Pediatriques (Pediatric Emergency and Critical Care) J Lacroix, M Gauthier, P Hubert, et al 76 Continued 10 S E C T I O N I Pediatric Critical Care: The Discipline