Original article 132
The 10th Max Grob Memorial Lecture Zurich, September 5, 1991 ]. Alex Haller, Jr. The Johns Hopkins Ilospital, Di\ision of Pediatric Surgcn. Baltil11ore. \ \an'land 2120:i. 1'S.\
I am deeply honored to presentthe 10tl1 .\/,IX Grob .\Iemorial Lee/lire (Fig. I). Professor Grob is one of m~ gre,ltest surgical heroes l It is \\'ith special pleasure that my \\ ife, I::lllily, and I return to the city and to the institution that has meant so much to our professional careers and our personal li\es together. In Zurich \\'e Ii\'ed in I)ension Bergheim on Berg· strasse just abo\'e the Pflegerinnenschule \\'here Emily \\ as an .\ssistentin under 01'. Reist and 01'. Regll/a El1rat. :\s an Assi· stent in the Pathologisches Institutunder Prof. l'On J/eyenbllrg and Prof. [[allS Zolli11ger, I first met Prof. Grob in the spring of ID53. Only after three months intensi\'e instruction and elose super\'ision in the InstiLut \\'as I finally allm\'ed to perforlll au· topsies in the Kinderspital. The junior Professor of Pathology C. f1edinger \\'arned me that Prof. Grob \\ould regularly allend all autopsies on surgical patienls and \\'ould ask \'ery earching quest ion , but he \\'ould kindly accept my ans\\'ers. On the other hand, I \\'as further \\'arned that Prof. Grob \\ould be accompa· nied by many assistanls incJuding his Oberarzt, 01'. J/arce/ Bettex, who would ask impossible questions for which there \\'ere no answers! AJlthis was true and it was an exciting ad\'enture. Our year, 1952-1953, in Zurich \\'as filled with much medical learning and the formation of \\'onderful friendships \\'hich are embodied in many of you (Fig. 2) \\'ho are kind enough to join u today in this grand celebration of the professional Ii fe of a great pediatric surgeon. After our return Lo the United States and a tour of military service in 1953-1955, [ came back again to The Johns Hopkin Hospital to complete my cardiac and pediatric surgical training under 01'. Alfred Blalock and 01'. •Hark Rat'ilch, both friends of ,\lax Grob. [n 1970, \\'e \\'ere urprised and delighted Lo be \'isited by Prof. Grob and his wife \'reni on the occasion of his honorary membership in the American Academy of Pedialrics. At lhal time he signed my copy of the first edition of his textbook "Lehrbuch der Kinderchirurgie " \\'hich had been gi\'en to me by Emi/y's chief, 01'. Reist, and had been my "Bible" for more than 10 years (Fig. 3).
Anomalie::." (Fig. I) \\ hich focuscd on the common interest lhat 01'. B/a/otk and 01'. Grob shared in a beller underst;lllding of the pathophysiology of many congenital abnormalities. \Yhile the subjecll ha\'e chosen for his \ lemorial Lecturc today, "Emergency \Iedical Sen iees for Children", \\'as not a recognized entit~· dllring Prof. Grob's lifetime, his sCITice to chileIren lIas mueh. l11ueh broader than his teehnicaJ contriblltions to peeliatrie surger.\·. Ilis eOlllmitmcntto the total \\ elfare of the sick child i closcly related to my thesis. These thollghb are. therefore. dedieated \\'ith great respect 10 lhe memor.\ of Prof. .\},IX Grob, \Iaster Pediatric Slirgeon of lhe \\'orlel.
The su rgeon 's roll' in thc dc\'clopment of emergeney medieal seniecs for ehildre_n_ _ Emergency \ led ical Sen'ices for Children (E.\IS·C) is an ielea \\'hose time has come. A comprehensi\'e sy tem of emergency care for chileIren \\'ilh multiple organ injurie 01' life threalening iJlness is long o\'erelue in America anel in Europe, Our children are too precious anelthe future of our society is 100 fragile for us to lea\'e to chance a chileI 's access to the best emergency facilily anel hospital for treatment of a potenliaily lethaI elisea e - for trauma is as much a elisease of moelern societ)' as is o\'en\'helming infeclion 01' malignancy.
MEMORIAL LECTURE FOR PROF. MAX GROB OF ZURICH ASTER PEDIATRIC SURGEON OF THE WORLD
All too soon lhereafter, \\'e \\-ere greally addened by Prof. Grob's untimely death in ID16. 1 feit apart of Zurich again and of the '';:inderspital \\ hen Prof. Pe/er Ritkl1alll so thoughtfully asked me to p;lIiicipate in the Festschrift in Prof. Grob's honor in 1DII. The tille of m~' contribution lIas "Intrauterine Surger~ for the Creation amI Study of r ongenital
1{,'rcl\ cd ,o\clllher
~1I.
1\1\11
Icur I I'cdlatr ~urg ~ 11 \I\I~I I :i~ 1:iß © I Iippokrate, \erlag ~tutlg"rt \\a""11 I-:dltt'ur 1',,",
Zunch, 5 Sept. 1991
Fig. 1
Pr "
1,1ax Grob 01 ZUfi r
Downloaded by: National University of Singapore. Copyrighted material.
Fe110\\ members of the S\\ iss Society of Pedi· atric Surgery, Ladies and Gentlemen,
Eur J Pediatr Surg 2 (1992)
,
J
-I Fig. 2
1 ,
The Zunch Palhology Team 1952-1953
\Yhatthen is the surgeon' role - especially the pediatric surgeon's role - in organizing ystems of emergency care? In the first place, \\'e must continue to learn about the special needs of children from our closest colleagues, the pediatricians. Pediatrics as a specialty differs from Internal .\\edicine and Surgery because it addresses pre7-'ention first and eure seeond. The history of ad\'ances in child health focuses on yaccinalion against di ease: rabies, poliomyelitis, rubella and a host of other infection . Les dramatic but perhaps more fundamental is the fight again t \\"orld\\'ide malnutrition, in \\'hich your o\\"n Professor Fanconi and his Oberarzt, Etori Rossi, played such enormous roles. To these ingredients in child health has more recenUy been added maternal health in the new discipline of perinatology. In most children's hospitals, the first patient transport system and inter hospital referral was for babies with extreme prematurity, a major killer of the early 20th century. Pediatric urgeons have participated in the development of Newborn Intensive Care Units (NICU), and their success attests to the value of the integration of special i ts for newborn care. Hand in glove with the ob tetrician , the perinatal team organized a system for high ri k pregnancie , prenatal diagnosis and treatment to upplement the e newborn inten ive care units. As surgeon , we joined our colleagues and learned about intensi\'e care of these \'ery smaJl neonates. A a result of our collaboratiye experience \\"e are better prepared for the surgical management of the e ne\\'born patients. \Ye incorporated the pediatric concepts of disea e pre\'ention, neonataltransport, and intensi\'e care into our de\'eloping di cipline of Pediatric Surgery. \\'e \\"ere pleased with the e\'olution of our specially \\'hen \\'e suddenly realized in the 19,0' that more children \\'ere d.\-ing from major injuries than from infection. malnutrition and malignancies combined' (Fig.5). As \\"e look back, in the I9..J 5-1950 era, after the Second \\'orld War, our general surgery colleagues in America realized that pre-hospital care on lhe balliefield (mililary
LEHRBUCH DER KINDERCHIRURGIE VON
PRIV.-DOZ. DR. MAX GROB
UNU' MITWIIKUNG VON
OR.MARGRlT STOCKMANN
DR.MARCU IUTEX
MIT 17. ZUM TlIL MIHlfAltllGIN AIIILDUNGI,., IN 1310 11NZELDAasTlLLUNGIN
!f~/fr
GEORG THIEME VERLAG· STUTTGART
Fig.
3
Frontlsplece-Lehrbuch
der
KInderchirurgie
by
Prof
Max
Grob
Originalarbeilen
B8nd 22, Helt J, November 19n
I
Z. KInderchI,.
Intrauterine Surgery for the Creation and Study of Congenital Anomalies: An Example of Clinical Laboratory Research' , [0 memo.)' of Prof MB: Clob.
j. Atex Haller,
Jr.
FrNn ,he Dl .. i"oll of Pcduuic Sur,,,y. Thc Jallns Hopkins U,,;vCrlilr Smool of Mcdicinc, B1JlImo.(, MHY[1nd 2126
Fig.4
Max Grob Festschflft Paper, 1977
133
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The 10th ,\lax Grob l\lemorial Leclure - Zurich, September 5, 1991
Eur j Pedialr Surg 2 (1992)
j. Alex Haller,jr,
CAUSES OF DEATH - AGE 1-14 YRS.
PEDIATRIC TRAUMA A Systems Approach
... ... ... ... ...
I EMT-ABC I Ir-"H-e-Ii-c-o-p-te-r-I
l-A-=--m-=b-u-=I:-'a-n-c-e'
Pediatric
CAT SCANNER
STANDARD+ Resuscitation X-RAY
Center
Fig,5 Causes of Death In Amenean Chlldren Da a from 1975 Wal S a, tlS les, USA
paramedics), rapid transpoli (helicopter) and trauma surgeons at field hospitals had formed a system \\'hich had greatly decreased battle casualty deaths, They could see that such a system \\'as also applicable to high\\'ay and inner city trauma, In the l'nited States, a fe\\' trauma urgeon stepped fOl,\'ard through the Committee on Trauma of the American College of Surgeons to establish graded echelons of trauma care and guidelines for training of emergency medical technicians, and to generate an Ad\'anced Trauma Life Support course (ATLS) as a body of knmdedge \\'ith accompanying skills for treating the injured in America, In Germany and Austria, a simiJar system \\'a e\'oh'ing, Building upon their \\'artime experience and the a\'ailability of incompletely trained physicians \\'ho had been rushed through medical chool a trauma technicians because of the urgency of \\'arfare, German trauma surgeon established hospitals and systems for regional trauma care in the 1960's, Using both transport vehicles and emergency medical skiJls which had been de\'eloped for high alpine rescues, the remarkable S\\'iss adult oriented emergency system reached perfeetion in the 1970's, But what happened to the child? We finally recognized in 1970 that in the Uni ted States, the main cause of death in children between 1-14 years of age was multiple systems trauma (Fig, 5), Who would be the chiJd's advocate in this Emergency Medical Sy tem? A handful of pediatric surgeons stood up and demanded a roll' within the adult trauma system to addres the special needs of children, In 1971, in Baltimore, we originated the concept of a regional pediatric trauma center as a component of a statewide Emergency ledical System, This regional trauma center for children was organized in the Johns Hopklns Children's Center and became a model for the de\'elopment of similar designated regional trauma centers for children within adult emergency systems in the United States and Canada (Fig, 6), From our adult colleagues \\'e had learned the concept of the "Golden Hour" emphasizing the importance of rapid transport to an appropriate re uscitation center for trauma if \\'e \\'ere to ha\'e a succes ful outcome, This idea \\'as quickly modified to emphasize the pecial needs of children and the "Platinum Half Hour" concept came into being, Ain\'ay management in the field, including tracheal intubation of small children by paramedic , quickly e\'ol\'ed because of the critical imporLance of good oxygenation during transport of children \\'ith head in juries, Because all .\\aryland children under I I years of age \\'ere concentrated in one pediatric trauma center, \\ e \\'ere able to document prospecti\'ely the superiority of head and abdomi
I
+ NUCLEAR SCANNER
0··"'1 11 "aam
IPediatric
... ...
Intensive Care
Iintermediate Care Pediatric Rehabilitation
I
I
+ Lang
Term Care
...
1
IHome 1+-- 1 Fig, 6
Components of a Pedla rle Trauma System
nal CAT scans in the e\'aluation and management of children \\'ith multiple sy tems injury, At about the same time, reports were coming from the Hospital for Siek Children in Toronto of their important obsen'ations on techniques of splenic sal\'age in children with ruptured spleens, Soon thereafter came their remarkable, e\'en heretical, recommendation that children \\ith documented ruptured pleens could be treated non-operati\'ely with cerUin impoliant precautions and with careful monitoring in a pediatric intensive earl' unit (Fig, 7), Other designated pediatric trauma centers developed quickly in Boston, in San Diego, and most recently in the state systems of Pennsylvania and Washington,
ABDOMINAL TRAUMA
/
I 1
Unstable
"
Stable Suspected Serious Injury
I C.T.
SCAN
Obse~ation
Dete~ion
.---_.;....._C_Ii..,;ni........ :;cal
Stable
1
l~t~;i1~~~.Observation
1
"'stabl~r-:--_-'-_-:-, Non-operative Management
Fig, 7 Algonthm 0 non-opera Ive management of blun abdominal rauma (Modlfled by Dr Donald R. Cooney- Buffalo Chtldren·s Hospital),
Downloaded by: National University of Singapore. Copyrighted material.
134
Eur J Pediatr Surg 2 (1992)
The 10th ,\lax Grob ,\lemorial Leclure - Zurich. September 5, 1991
135
Advanced
June 15 - 17, 1992 PEDIATRIC - -_ _. .UFEJMrt°RT.._ November 4 - 6, 1991
Day 1
Day 2
15·
30 a m
Reglstrallon and Contlnental Breakfast
8'15· 830am
Introduction
830· 9;15 a m
Paul D Sponseller M D
David G Nlchols M 0 8'30 . 900am
Initial Asscssmenl of the Pcdiatric Patient james R Buck M D
900· 945 a m
Pediatric Airway Management Myron Vaster M 0
9.45· 1015 a m
Shock and Fluid Resu.scitation Randall C. WeIzei M D
10 15· 1030 a m
Panel Oiscussion
1030· 1040 a m
Refreshment Break
1040· 11:30 a m
New Concepts in Advanced
915· 10:00 a m
Pediatric Head Trauma BenJamm S Carson MD
1000· 1O-15am
Panel Di.scussion
1015· 10-30 a m
Refreshment Break Crilical IssutS in Meningitis aod Sepsis
1030· 1100 a m
Allee D. 11'00 . 1130 a m 1130· 1200 noon
Ack~rman
M0
Approach to Altered Sensorium Ivor 0 Berkowltz. M 0
Status Epilepticus joseph R. Tob,". M D
Cardiac Support Donald H Sharener, M D
1200 . 12:15 p m
11.30· 1200 noon
Thoraco-Abdominal Trauma Boome L Staver M 0
12'15·
1;00 P m
Lunch with Facully
100·
130pm
1200· 1215 P m
Panel Discussion
Respiratory Failure David G Nichols MD
1215·
Lunch wllh Faculty
130· 200pm
Acute Management of Ihe Pediatric Burn Victim Chades N Paldas M 0
Epiglollitis and Croup Myron Yaster MD
200 . 215 pm
Panel Discussion
2 15· 230 P m
Refreshment Break
230· 500pm
Animal Laboralory/Skill Stations ISa me as Day 11
115 P m
I 15· 200pm
200· 215 P m
Animal Laboralory kill Station Orientalion james R Buck M D
2 15· 230 P m
Refreshment Break
2:30· 500pm
AI Emergency Procedures
Animal laboratory Faculty Endotracheal Intubation Venous Cutdown
Thoracostomy Tube Placement Ccolral Venous Catheterization
Cricothyroid Puncture Intraosseous Infusion BISkill Stations X·rar Evaluation in Pediatnc
Emergencies Airway Management Mock Pediatric Arrest Management
Because we pediatric surgeons had learned to work together with our pediatric colleagues in neonatal trans, port and in newborn intensive care, critical care pediatricians in turn easily began working with pediatric urgeons in the 1980's in the management of chiJdren with multiple systems injuries. These emergency ped iatricians learned the skills of airway man, agement, breathing and circulation re u citation from the Ad, vanced Trauma Life Support cour e which had been originated by the American College of Surgeon . This mix of pediatric sur' geon and emergency pediatrician uggested an exten ion of the concept of ATLS to Advanced Pediatric Life Support course which were first gi\'en at]ohns Hopkins in 1982. The curricu, lum for the 1991 Ad\'anced Pediatric Life SUPPOlt Course (APLS) is shown in Figure 8. The continuing critical care input of lhe pedia, lrician into the management of lrauma sef\'es to remind us sur' geon of their time honored pedialric credo: prevenlion first' A pedialrician in Tennessee inlroduced in 197/ lhe importanl Concept of child restraints in aulomobiles and O\'er lhe next 10 year a 50 percent decrease in mortality for children \\'as documented from the stale of Tenne see. \\'ilh accumulaling experience and data, legislali\'e aclion resulted in lhe requirement thai all 50 stales musl ha\'e child reslraints up lhrough age l years: and thereafter seal belts are mandatory. Injury conlrol became
Panel Oiscussion
Day 3 800· 8:15am
Contmenlal Breakfast
8:15· 8:45 a m
Approach to Suspected Child Abuse Lawrence S WISSQW, M 0
845· 9:30 a m
Course Evaluation
9'30· 12:00 noon
Pediatric Emergency Case Studies David G. Nichols. M 0 aod Medical Faculty
James R. Buck, M 0 aod Surglcal
Fig. 8 CUrriculum for 3,Day,Advanced-Pedlanc,Llfe'Support Course - The Johns Hopklns Chlldrens Center, 1991
Contlnental Breakfast Pediatric Orlhopaedic Injuries
Pediatric Critical Care Preceptorship One weck program al The Johns Hopkms Hospllal For mformation. call Program Coordinator 13011 955-3839
a discipline of pediatric preventive medicine and the strong programs in the American Academy of Pediatrics for bicycJe heImets and smoke alarms followed. An important area of recent pediatric activity is focused on the major problem of hand gun injuries to children in the United tates, especially in our inner cities. This will become a higher priority over the next fe\\' year. Pediatric surgeon mu t now pr0\1de the lead, ership and the catalytic influence 10 expand these trauma syslern into a truly comprehensive emergency medical syslem for children which \\iJl incJude all types of life threatening illness and trauma in children, for example, Q\'ef\\'helming infection, prematurily, thermal injuries, drowning, multiple syslems lrau' ma, epiglollilis, Reye's syndrome, elc. Our clinical research group has recenUy shown lhal it is possible to identify in the doclor's office or in lhe gener, al ho pital emergency room, children \\'ilh early on et of illness \\'hich may proceed 10 Iife lhrealening complications. These early \\'arning crileria are referred 10 as the Pediatric Se\'erity Asse sment Tool (PSAT) score and are similar 10 the Pediatric Trauma Scores \\'hich ha\'e been so useful in idenlif~'ing se\'erity of injury. These trauma scores ha\'e lead to appropriale lriage of children in our trauma systems. \\'e musl further define se-
Downloaded by: National University of Singapore. Copyrighted material.
7.45· 815 a m
EurJ Pediatr Surg 2 (1992)
j. Alex Haller,Jr.
EMS·C: An Integrated System. Pediatric Surgeon (General Surgeon)
+
Emergency-Medicine Pediatrician (AAP, ACEp·)
Pediatric Inlensivist (Aclive or Liaison)
Nurse-Specialisl
+
Nurse-Speclalist
+
Nurse-Specialisl
Primary-Care Pedialrician/ Family Physlcian
Lile-Threalening Trauma and Illness
Lile-Threatening /
Lile-Threatening Illness
/Trauma/
~
~ Basic Lile Support-Illness and Trauma
t
Parents
t
First Responders in Field
medical y tem for children i our challenge oflhe 1990' ! Thi truly means that surgeons must harpen their critical care skill and continue to work with their pediatric inten ivi t colleagues. Emergency pediatricians must continue to learn from pediatric surgeons the ABCs of trauma management and the skills which are necessary for resuscitation of children ,,'ith life threatening injurie, To this end we have just published a new handbook of Advanced Pediatric Life SUPPOIt called "The Golden Hour", Such a system must naturally include injury control and illne s pre"ention. Parenls and parenls-to-be a teenagers must be taught Basic Life Support skills because they are usually the first responders. This BLS instruction should be repeated during pregnancy ,\'hen there is a capti,'e mother and father-to-be. Pediatricians mu t eontinue their time honored role in illness and injury pre,-ention by allticipatar)' gl/idance of parenls and eonstant refresher courses in safety for their growing patienls. Finally, pediatrie surgeons must eontinue their imporLant Jeadership role in aggressi"e expansion of the trauma systems and the eareful eolleetion of clata ,,'hieh make it possible to organize cost effeeti,'e facilities ancl personnel. The E IS-C managers must pro,-ide eonstant sl/r;:eillallce afthe system to deteet any ,,'eaknesses ,,'hieh ean be eorreeted and to provide inno,'ation on line for bettel' care of ehildren ,,'ith life-threatening eondition , Finally, as parenls, pediatrieians, and surgeons, we must eonslanlly remind ourseh'es that ehildren ean't ,'ote! We are their ad,-ocates in all aspecls of the democralie proeess, politieal and medical. Their li,'es are truly in our hands.
~
References •AAP = Amenun Academy 01 Pediatncs, ACEP = Amencan College 01 Emergency Physldans
Fig,9 From Repnnt 01 the 97th Ross Conference on Pedlatnc Research, 1989 (used wlth permissIon)
verity of illness at ils earliest source wheLher in the horne, office, or the emergency room and then provide rapid triage to the best resuscitation centers for our children, truly comprehensi,'e and integrated emergency medical sy tem for children will include education of parents in prevention of illness and injury, easy access of patients and family to emergency care, designation of pediatric criticaJ care centers and incontinuity programs in rehabilitation (Fig, 9). Surgeons have led in the development of comprehensive trauma system, now pediatric urgeons must speak up for children, For parenls, pediatricians, and surgeon , emergency
Haller JA]r: Problems in children's trauma. J Trauma 101 (1970) 269271 2 HallerJA]r, Shorter S: Hegional pediatric trauma center: Does a ystem 01 management impro\Oe outcome? Z Kinderchir 35 (1982) 44-45 3 Haller JA ]r: Pediatric trauma: The :--Jo. 1 killer 01 children. JA,\IA 249 (1983) I Jlaller JA ]r: Emergency medical sen'ice for children, Heport of the 97th Hos Conference on Pediatric Hesearch. Columbus, OH 1989 5 Haller JA ]r, Beaver BL: A Model: Systems management of lifethreatening injuries in children for the state of Maryland, USA. Int Care ,\Iedicine 15 (1989) S53-S56 1
j. Alex Haller.]r., JI.D.
Hobert Garrelt Professor of Pediatric Surgery The Johns Hopkins L'ni\'ersity School of \Iedicine 601:--J. BroadwayC,\\SC 7-113 Baltimore, ,\\a,,'land 21205 l'SA
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136
The 10th Max Grob Memorial Lecture Zurich, September 5, 1991 ]. Alex Haller, Jr. The Johns Hopkins Ilospital, Di\ision of Pediatric Surgcn. Baltil11ore. \ \an'land 2120:i. 1'S.\
I am deeply honored to presentthe 10tl1 .\/,IX Grob .\Iemorial Lee/lire (Fig. I). Professor Grob is one of m~ gre,ltest surgical heroes l It is \\'ith special pleasure that my \\ ife, I::lllily, and I return to the city and to the institution that has meant so much to our professional careers and our personal li\es together. In Zurich \\'e Ii\'ed in I)ension Bergheim on Berg· strasse just abo\'e the Pflegerinnenschule \\'here Emily \\ as an .\ssistentin under 01'. Reist and 01'. Regll/a El1rat. :\s an Assi· stent in the Pathologisches Institutunder Prof. l'On J/eyenbllrg and Prof. [[allS Zolli11ger, I first met Prof. Grob in the spring of ID53. Only after three months intensi\'e instruction and elose super\'ision in the InstiLut \\'as I finally allm\'ed to perforlll au· topsies in the Kinderspital. The junior Professor of Pathology C. f1edinger \\'arned me that Prof. Grob \\ould regularly allend all autopsies on surgical patienls and \\'ould ask \'ery earching quest ion , but he \\'ould kindly accept my ans\\'ers. On the other hand, I \\'as further \\'arned that Prof. Grob \\ould be accompa· nied by many assistanls incJuding his Oberarzt, 01'. J/arce/ Bettex, who would ask impossible questions for which there \\'ere no answers! AJlthis was true and it was an exciting ad\'enture. Our year, 1952-1953, in Zurich \\'as filled with much medical learning and the formation of \\'onderful friendships \\'hich are embodied in many of you (Fig. 2) \\'ho are kind enough to join u today in this grand celebration of the professional Ii fe of a great pediatric surgeon. After our return Lo the United States and a tour of military service in 1953-1955, [ came back again to The Johns Hopkin Hospital to complete my cardiac and pediatric surgical training under 01'. Alfred Blalock and 01'. •Hark Rat'ilch, both friends of ,\lax Grob. [n 1970, \\'e \\'ere urprised and delighted Lo be \'isited by Prof. Grob and his wife \'reni on the occasion of his honorary membership in the American Academy of Pedialrics. At lhal time he signed my copy of the first edition of his textbook "Lehrbuch der Kinderchirurgie " \\'hich had been gi\'en to me by Emi/y's chief, 01'. Reist, and had been my "Bible" for more than 10 years (Fig. 3).
Anomalie::." (Fig. I) \\ hich focuscd on the common interest lhat 01'. B/a/otk and 01'. Grob shared in a beller underst;lllding of the pathophysiology of many congenital abnormalities. \Yhile the subjecll ha\'e chosen for his \ lemorial Lecturc today, "Emergency \Iedical Sen iees for Children", \\'as not a recognized entit~· dllring Prof. Grob's lifetime, his sCITice to chileIren lIas mueh. l11ueh broader than his teehnicaJ contriblltions to peeliatrie surger.\·. Ilis eOlllmitmcntto the total \\ elfare of the sick child i closcly related to my thesis. These thollghb are. therefore. dedieated \\'ith great respect 10 lhe memor.\ of Prof. .\},IX Grob, \Iaster Pediatric Slirgeon of lhe \\'orlel.
The su rgeon 's roll' in thc dc\'clopment of emergeney medieal seniecs for ehildre_n_ _ Emergency \ led ical Sen'ices for Children (E.\IS·C) is an ielea \\'hose time has come. A comprehensi\'e sy tem of emergency care for chileIren \\'ilh multiple organ injurie 01' life threalening iJlness is long o\'erelue in America anel in Europe, Our children are too precious anelthe future of our society is 100 fragile for us to lea\'e to chance a chileI 's access to the best emergency facilily anel hospital for treatment of a potenliaily lethaI elisea e - for trauma is as much a elisease of moelern societ)' as is o\'en\'helming infeclion 01' malignancy.
MEMORIAL LECTURE FOR PROF. MAX GROB OF ZURICH ASTER PEDIATRIC SURGEON OF THE WORLD
All too soon lhereafter, \\'e \\-ere greally addened by Prof. Grob's untimely death in ID16. 1 feit apart of Zurich again and of the '';:inderspital \\ hen Prof. Pe/er Ritkl1alll so thoughtfully asked me to p;lIiicipate in the Festschrift in Prof. Grob's honor in 1DII. The tille of m~' contribution lIas "Intrauterine Surger~ for the Creation amI Study of r ongenital
1{,'rcl\ cd ,o\clllher
~1I.
1\1\11
Icur I I'cdlatr ~urg ~ 11 \I\I~I I :i~ 1:iß © I Iippokrate, \erlag ~tutlg"rt \\a""11 I-:dltt'ur 1',,",
Zunch, 5 Sept. 1991
Fig. 1
Pr "
1,1ax Grob 01 ZUfi r
Downloaded by: National University of Singapore. Copyrighted material.
Fe110\\ members of the S\\ iss Society of Pedi· atric Surgery, Ladies and Gentlemen,
Eur J Pediatr Surg 2 (1992)
,
J
-I Fig. 2
1 ,
The Zunch Palhology Team 1952-1953
\Yhatthen is the surgeon' role - especially the pediatric surgeon's role - in organizing ystems of emergency care? In the first place, \\'e must continue to learn about the special needs of children from our closest colleagues, the pediatricians. Pediatrics as a specialty differs from Internal .\\edicine and Surgery because it addresses pre7-'ention first and eure seeond. The history of ad\'ances in child health focuses on yaccinalion against di ease: rabies, poliomyelitis, rubella and a host of other infection . Les dramatic but perhaps more fundamental is the fight again t \\"orld\\'ide malnutrition, in \\'hich your o\\"n Professor Fanconi and his Oberarzt, Etori Rossi, played such enormous roles. To these ingredients in child health has more recenUy been added maternal health in the new discipline of perinatology. In most children's hospitals, the first patient transport system and inter hospital referral was for babies with extreme prematurity, a major killer of the early 20th century. Pediatric urgeons have participated in the development of Newborn Intensive Care Units (NICU), and their success attests to the value of the integration of special i ts for newborn care. Hand in glove with the ob tetrician , the perinatal team organized a system for high ri k pregnancie , prenatal diagnosis and treatment to upplement the e newborn inten ive care units. As surgeon , we joined our colleagues and learned about intensi\'e care of these \'ery smaJl neonates. A a result of our collaboratiye experience \\"e are better prepared for the surgical management of the e ne\\'born patients. \Ye incorporated the pediatric concepts of disea e pre\'ention, neonataltransport, and intensi\'e care into our de\'eloping di cipline of Pediatric Surgery. \\'e \\"ere pleased with the e\'olution of our specially \\'hen \\'e suddenly realized in the 19,0' that more children \\'ere d.\-ing from major injuries than from infection. malnutrition and malignancies combined' (Fig.5). As \\"e look back, in the I9..J 5-1950 era, after the Second \\'orld War, our general surgery colleagues in America realized that pre-hospital care on lhe balliefield (mililary
LEHRBUCH DER KINDERCHIRURGIE VON
PRIV.-DOZ. DR. MAX GROB
UNU' MITWIIKUNG VON
OR.MARGRlT STOCKMANN
DR.MARCU IUTEX
MIT 17. ZUM TlIL MIHlfAltllGIN AIIILDUNGI,., IN 1310 11NZELDAasTlLLUNGIN
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GEORG THIEME VERLAG· STUTTGART
Fig.
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Frontlsplece-Lehrbuch
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KInderchirurgie
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Prof
Max
Grob
Originalarbeilen
B8nd 22, Helt J, November 19n
I
Z. KInderchI,.
Intrauterine Surgery for the Creation and Study of Congenital Anomalies: An Example of Clinical Laboratory Research' , [0 memo.)' of Prof MB: Clob.
j. Atex Haller,
Jr.
FrNn ,he Dl .. i"oll of Pcduuic Sur,,,y. Thc Jallns Hopkins U,,;vCrlilr Smool of Mcdicinc, B1JlImo.(, MHY[1nd 2126
Fig.4
Max Grob Festschflft Paper, 1977
133
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The 10th ,\lax Grob l\lemorial Leclure - Zurich, September 5, 1991
Eur j Pedialr Surg 2 (1992)
j. Alex Haller,jr,
CAUSES OF DEATH - AGE 1-14 YRS.
PEDIATRIC TRAUMA A Systems Approach
... ... ... ... ...
I EMT-ABC I Ir-"H-e-Ii-c-o-p-te-r-I
l-A-=--m-=b-u-=I:-'a-n-c-e'
Pediatric
CAT SCANNER
STANDARD+ Resuscitation X-RAY
Center
Fig,5 Causes of Death In Amenean Chlldren Da a from 1975 Wal S a, tlS les, USA
paramedics), rapid transpoli (helicopter) and trauma surgeons at field hospitals had formed a system \\'hich had greatly decreased battle casualty deaths, They could see that such a system \\'as also applicable to high\\'ay and inner city trauma, In the l'nited States, a fe\\' trauma urgeon stepped fOl,\'ard through the Committee on Trauma of the American College of Surgeons to establish graded echelons of trauma care and guidelines for training of emergency medical technicians, and to generate an Ad\'anced Trauma Life Support course (ATLS) as a body of knmdedge \\'ith accompanying skills for treating the injured in America, In Germany and Austria, a simiJar system \\'a e\'oh'ing, Building upon their \\'artime experience and the a\'ailability of incompletely trained physicians \\'ho had been rushed through medical chool a trauma technicians because of the urgency of \\'arfare, German trauma surgeon established hospitals and systems for regional trauma care in the 1960's, Using both transport vehicles and emergency medical skiJls which had been de\'eloped for high alpine rescues, the remarkable S\\'iss adult oriented emergency system reached perfeetion in the 1970's, But what happened to the child? We finally recognized in 1970 that in the Uni ted States, the main cause of death in children between 1-14 years of age was multiple systems trauma (Fig, 5), Who would be the chiJd's advocate in this Emergency Medical Sy tem? A handful of pediatric surgeons stood up and demanded a roll' within the adult trauma system to addres the special needs of children, In 1971, in Baltimore, we originated the concept of a regional pediatric trauma center as a component of a statewide Emergency ledical System, This regional trauma center for children was organized in the Johns Hopklns Children's Center and became a model for the de\'elopment of similar designated regional trauma centers for children within adult emergency systems in the United States and Canada (Fig, 6), From our adult colleagues \\'e had learned the concept of the "Golden Hour" emphasizing the importance of rapid transport to an appropriate re uscitation center for trauma if \\'e \\'ere to ha\'e a succes ful outcome, This idea \\'as quickly modified to emphasize the pecial needs of children and the "Platinum Half Hour" concept came into being, Ain\'ay management in the field, including tracheal intubation of small children by paramedic , quickly e\'ol\'ed because of the critical imporLance of good oxygenation during transport of children \\'ith head in juries, Because all .\\aryland children under I I years of age \\'ere concentrated in one pediatric trauma center, \\ e \\'ere able to document prospecti\'ely the superiority of head and abdomi
I
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IPediatric
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Intensive Care
Iintermediate Care Pediatric Rehabilitation
I
I
+ Lang
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...
1
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Components of a Pedla rle Trauma System
nal CAT scans in the e\'aluation and management of children \\'ith multiple sy tems injury, At about the same time, reports were coming from the Hospital for Siek Children in Toronto of their important obsen'ations on techniques of splenic sal\'age in children with ruptured spleens, Soon thereafter came their remarkable, e\'en heretical, recommendation that children \\ith documented ruptured pleens could be treated non-operati\'ely with cerUin impoliant precautions and with careful monitoring in a pediatric intensive earl' unit (Fig, 7), Other designated pediatric trauma centers developed quickly in Boston, in San Diego, and most recently in the state systems of Pennsylvania and Washington,
ABDOMINAL TRAUMA
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I 1
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"
Stable Suspected Serious Injury
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Fig, 7 Algonthm 0 non-opera Ive management of blun abdominal rauma (Modlfled by Dr Donald R. Cooney- Buffalo Chtldren·s Hospital),
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134
Eur J Pediatr Surg 2 (1992)
The 10th ,\lax Grob ,\lemorial Leclure - Zurich. September 5, 1991
135
Advanced
June 15 - 17, 1992 PEDIATRIC - -_ _. .UFEJMrt°RT.._ November 4 - 6, 1991
Day 1
Day 2
15·
30 a m
Reglstrallon and Contlnental Breakfast
8'15· 830am
Introduction
830· 9;15 a m
Paul D Sponseller M D
David G Nlchols M 0 8'30 . 900am
Initial Asscssmenl of the Pcdiatric Patient james R Buck M D
900· 945 a m
Pediatric Airway Management Myron Vaster M 0
9.45· 1015 a m
Shock and Fluid Resu.scitation Randall C. WeIzei M D
10 15· 1030 a m
Panel Oiscussion
1030· 1040 a m
Refreshment Break
1040· 11:30 a m
New Concepts in Advanced
915· 10:00 a m
Pediatric Head Trauma BenJamm S Carson MD
1000· 1O-15am
Panel Di.scussion
1015· 10-30 a m
Refreshment Break Crilical IssutS in Meningitis aod Sepsis
1030· 1100 a m
Allee D. 11'00 . 1130 a m 1130· 1200 noon
Ack~rman
M0
Approach to Altered Sensorium Ivor 0 Berkowltz. M 0
Status Epilepticus joseph R. Tob,". M D
Cardiac Support Donald H Sharener, M D
1200 . 12:15 p m
11.30· 1200 noon
Thoraco-Abdominal Trauma Boome L Staver M 0
12'15·
1;00 P m
Lunch with Facully
100·
130pm
1200· 1215 P m
Panel Discussion
Respiratory Failure David G Nichols MD
1215·
Lunch wllh Faculty
130· 200pm
Acute Management of Ihe Pediatric Burn Victim Chades N Paldas M 0
Epiglollitis and Croup Myron Yaster MD
200 . 215 pm
Panel Discussion
2 15· 230 P m
Refreshment Break
230· 500pm
Animal Laboralory/Skill Stations ISa me as Day 11
115 P m
I 15· 200pm
200· 215 P m
Animal Laboralory kill Station Orientalion james R Buck M D
2 15· 230 P m
Refreshment Break
2:30· 500pm
AI Emergency Procedures
Animal laboratory Faculty Endotracheal Intubation Venous Cutdown
Thoracostomy Tube Placement Ccolral Venous Catheterization
Cricothyroid Puncture Intraosseous Infusion BISkill Stations X·rar Evaluation in Pediatnc
Emergencies Airway Management Mock Pediatric Arrest Management
Because we pediatric surgeons had learned to work together with our pediatric colleagues in neonatal trans, port and in newborn intensive care, critical care pediatricians in turn easily began working with pediatric urgeons in the 1980's in the management of chiJdren with multiple systems injuries. These emergency ped iatricians learned the skills of airway man, agement, breathing and circulation re u citation from the Ad, vanced Trauma Life Support cour e which had been originated by the American College of Surgeon . This mix of pediatric sur' geon and emergency pediatrician uggested an exten ion of the concept of ATLS to Advanced Pediatric Life Support course which were first gi\'en at]ohns Hopkins in 1982. The curricu, lum for the 1991 Ad\'anced Pediatric Life SUPPOlt Course (APLS) is shown in Figure 8. The continuing critical care input of lhe pedia, lrician into the management of lrauma sef\'es to remind us sur' geon of their time honored pedialric credo: prevenlion first' A pedialrician in Tennessee inlroduced in 197/ lhe importanl Concept of child restraints in aulomobiles and O\'er lhe next 10 year a 50 percent decrease in mortality for children \\'as documented from the stale of Tenne see. \\'ilh accumulaling experience and data, legislali\'e aclion resulted in lhe requirement thai all 50 stales musl ha\'e child reslraints up lhrough age l years: and thereafter seal belts are mandatory. Injury conlrol became
Panel Oiscussion
Day 3 800· 8:15am
Contmenlal Breakfast
8:15· 8:45 a m
Approach to Suspected Child Abuse Lawrence S WISSQW, M 0
845· 9:30 a m
Course Evaluation
9'30· 12:00 noon
Pediatric Emergency Case Studies David G. Nichols. M 0 aod Medical Faculty
James R. Buck, M 0 aod Surglcal
Fig. 8 CUrriculum for 3,Day,Advanced-Pedlanc,Llfe'Support Course - The Johns Hopklns Chlldrens Center, 1991
Contlnental Breakfast Pediatric Orlhopaedic Injuries
Pediatric Critical Care Preceptorship One weck program al The Johns Hopkms Hospllal For mformation. call Program Coordinator 13011 955-3839
a discipline of pediatric preventive medicine and the strong programs in the American Academy of Pediatrics for bicycJe heImets and smoke alarms followed. An important area of recent pediatric activity is focused on the major problem of hand gun injuries to children in the United tates, especially in our inner cities. This will become a higher priority over the next fe\\' year. Pediatric surgeon mu t now pr0\1de the lead, ership and the catalytic influence 10 expand these trauma syslern into a truly comprehensive emergency medical syslem for children which \\iJl incJude all types of life threatening illness and trauma in children, for example, Q\'ef\\'helming infection, prematurily, thermal injuries, drowning, multiple syslems lrau' ma, epiglollilis, Reye's syndrome, elc. Our clinical research group has recenUy shown lhal it is possible to identify in the doclor's office or in lhe gener, al ho pital emergency room, children \\'ilh early on et of illness \\'hich may proceed 10 Iife lhrealening complications. These early \\'arning crileria are referred 10 as the Pediatric Se\'erity Asse sment Tool (PSAT) score and are similar 10 the Pediatric Trauma Scores \\'hich ha\'e been so useful in idenlif~'ing se\'erity of injury. These trauma scores ha\'e lead to appropriale lriage of children in our trauma systems. \\'e musl further define se-
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7.45· 815 a m
EurJ Pediatr Surg 2 (1992)
j. Alex Haller,Jr.
EMS·C: An Integrated System. Pediatric Surgeon (General Surgeon)
+
Emergency-Medicine Pediatrician (AAP, ACEp·)
Pediatric Inlensivist (Aclive or Liaison)
Nurse-Specialisl
+
Nurse-Speclalist
+
Nurse-Specialisl
Primary-Care Pedialrician/ Family Physlcian
Lile-Threalening Trauma and Illness
Lile-Threatening /
Lile-Threatening Illness
/Trauma/
~
~ Basic Lile Support-Illness and Trauma
t
Parents
t
First Responders in Field
medical y tem for children i our challenge oflhe 1990' ! Thi truly means that surgeons must harpen their critical care skill and continue to work with their pediatric inten ivi t colleagues. Emergency pediatricians must continue to learn from pediatric surgeons the ABCs of trauma management and the skills which are necessary for resuscitation of children ,,'ith life threatening injurie, To this end we have just published a new handbook of Advanced Pediatric Life SUPPOIt called "The Golden Hour", Such a system must naturally include injury control and illne s pre"ention. Parenls and parenls-to-be a teenagers must be taught Basic Life Support skills because they are usually the first responders. This BLS instruction should be repeated during pregnancy ,\'hen there is a capti,'e mother and father-to-be. Pediatricians mu t eontinue their time honored role in illness and injury pre,-ention by allticipatar)' gl/idance of parenls and eonstant refresher courses in safety for their growing patienls. Finally, pediatrie surgeons must eontinue their imporLant Jeadership role in aggressi"e expansion of the trauma systems and the eareful eolleetion of clata ,,'hieh make it possible to organize cost effeeti,'e facilities ancl personnel. The E IS-C managers must pro,-ide eonstant sl/r;:eillallce afthe system to deteet any ,,'eaknesses ,,'hieh ean be eorreeted and to provide inno,'ation on line for bettel' care of ehildren ,,'ith life-threatening eondition , Finally, as parenls, pediatrieians, and surgeons, we must eonslanlly remind ourseh'es that ehildren ean't ,'ote! We are their ad,-ocates in all aspecls of the democralie proeess, politieal and medical. Their li,'es are truly in our hands.
~
References •AAP = Amenun Academy 01 Pediatncs, ACEP = Amencan College 01 Emergency Physldans
Fig,9 From Repnnt 01 the 97th Ross Conference on Pedlatnc Research, 1989 (used wlth permissIon)
verity of illness at ils earliest source wheLher in the horne, office, or the emergency room and then provide rapid triage to the best resuscitation centers for our children, truly comprehensi,'e and integrated emergency medical sy tem for children will include education of parents in prevention of illness and injury, easy access of patients and family to emergency care, designation of pediatric criticaJ care centers and incontinuity programs in rehabilitation (Fig, 9). Surgeons have led in the development of comprehensive trauma system, now pediatric urgeons must speak up for children, For parenls, pediatricians, and surgeon , emergency
Haller JA]r: Problems in children's trauma. J Trauma 101 (1970) 269271 2 HallerJA]r, Shorter S: Hegional pediatric trauma center: Does a ystem 01 management impro\Oe outcome? Z Kinderchir 35 (1982) 44-45 3 Haller JA ]r: Pediatric trauma: The :--Jo. 1 killer 01 children. JA,\IA 249 (1983) I Jlaller JA ]r: Emergency medical sen'ice for children, Heport of the 97th Hos Conference on Pediatric Hesearch. Columbus, OH 1989 5 Haller JA ]r, Beaver BL: A Model: Systems management of lifethreatening injuries in children for the state of Maryland, USA. Int Care ,\Iedicine 15 (1989) S53-S56 1
j. Alex Haller.]r., JI.D.
Hobert Garrelt Professor of Pediatric Surgery The Johns Hopkins L'ni\'ersity School of \Iedicine 601:--J. BroadwayC,\\SC 7-113 Baltimore, ,\\a,,'land 21205 l'SA
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