VOI. XVII. No. 1 spring. : 980 fiH ThE WiiDRENS k!OSP;TkL OF FHILADELPHIA Pediatric Surgery: Subspecialties Meet the -Unique Needs of Children . When Dr. C: Everett Koop, surgeon-in-chief, arrrvec at Children's Hospital in 1946 as the Hospital's first full-time pediatric surgeon, the surgical roster included three patients. "One was a true surgical case, and the other two wt'e ipng-tern pa!ients suffering from ortho- oecc bruzlems." Dr. Koop explained. e +e ^Zf -se?, 2; iJ the neim of a service that in -- +rs nas grown tc encompass nine divi- 7 ' SIC-:$ WI;, I `ri "enough depth in each service that ;re-e is no?hing. surgically speaking, that is univa'laole he:e at Children's Hospital." Tocay or,e-r,al: of the Hospiial's 236 beds ^.? *i s^-` c r G:--"c.eu - :o if?& .Su:?iCal sewce. and the n,Tber of surgical admissions in 1979 to the ;-C-I': ,`:cn was 5297, cne-half of ail admis- /: /_. .",I s;czs. The nzn;ber is expanding. The grobt;:p! of the sulgical service at Cy :oren's Hospital parallels-and in many cases is responsible fc*-ihe ad,tiances made Dr. Koop's involvement with pediatric sur- gery came almost by accident, but once his interest was aroused, his commitment was total. "I realized that chiidren didn't get a fair shake in surgery, and I saw this as one of the great ineauities in medicine. Children had as much wrong then as they do now. And yet we were so ill-eouicpecf 10 take care of them," Dr. Koop said. Pediatric surgery was so new at the time of Dr. Koop's arrival at Chiidren's that he was bui lhe sixth surgeon in the country lo change his surgical practice from adults exclusively to children, and he was one of the first to chambion pedia?ric surgery as a specialty based on physiologic principles rather than seeing children as small adults. Once al the Hospital, Dr. KOOD turned his energies to building a staff of gtneral sur- geons as well as surgical subspecialists. The first specialist lo be brought in was a neuro su:geon, in :g47. becacse the large numbers t ol bazies being bc:? v,i;h sp~;a bifida, or cpen t- spine, and +ly d:oce$-.iics. Increased splnai fiuld in the neat, oreseXed a major cha,lerge ;n ped!a;ric care, He czs !Ye na! I -`s firsi !~:ll- next in 3948, SO thar the many children wrth &+f *-. C.L?~LG ceiects O! in2 urinary tracf couid be lrealec. "Because many chilaren's services had grown up a:znC the specialty of orthopedics, 2nd becaus2 II was common practice in those ~2~s fo' every children's hospt?a! to have an ea.. r.ose an= throat man on slaff. we al:eady had those specialties functioning. However, tney were nc! yet associated with an aca- cemic program in the university," Dr. Koop explained. Plastic surge:), had a more rapid deve:cpment a: Children's Hospital in the late 7940s tnan it might have o:herwise because of the presence of Dr. Robert Ivy. a proneer in the field, who was at the Hospital of the University of Pennsylvania, Dr. Koop said. In tcie next few years the other subspecial- ties-cardrovascular surgery. dentrslry and cohthaimoiogy. were brought into the fold as well. "Cardiac surgery at Children's differed in its scope, though. from what is normally thought of for adults. At Children's the cardio- vascular surgeons concentrate their efforts on the heart ana the vascular system, while the general surgeons are responsible for the other surgical problems of the chest. Most heart surgeons who treat adults do both heart and chest procedures," Dr. Koop explained. "Along wi?h the emergence of our depart- men? of highly skilied surgeons came the development of a superb anesthesia depart- ment." said Dr. Koop. "When I first came to Children's I realized that if you can't put the baby to sleep ,and wake him up? the surgical procecure won't work I consider it a great privriege 10 have grown up with this special?y." Ch!Gren's Hospitai is providing the setting for dramatic advances in newborn, or neonatal. stiroery as well. The turnabout in the survivai 07 tiny infants suffering from mejo:, life-threatening surgical deiects came in 1982 with the establishment of the nation's first neonatal intensive care unit at Children's Hospital. The unit was the creation of Dr. Koop, who was frustrated by the high mortality rates of infants undergoing surgery. It was funded through a five-year pilot gran? from the United Stales Children's Bureau. *`I hoped to show that with intensive nursing care of these babies in a carefully controlled environment, ay! v.!i?h clcse: backs3 by the anesthesiolo- g 2:s. rfs>!:i:>`) !>e:iO!SiS 2nd la3ora:oiy Gaff, we co;,d overcome many of the prob- lems which caused so many infants to die." Dr. Koop's nznch proved valid. Today the s;`:vivs! rate ;n these infants has been turned around "If we icst 90 percent of the babies v;.:r. i pa!:!c",a r wfecl 25 years Ego. tocay we save 93 percent," Dr. Koop explained. He c :ed esopha~ eal atresia as the "index case" for iilL.Ci:Gil?C iile success of the neonatal i::ensjve care unit. "This probiem, where the bioy's esoo^agus ends blind!y. instead of 5: -2 co:?ne:`ec ic ;he s:o71acb Crecen!s as *e: c "$l'f a .:r+;ense as you car; fin5 in the ,g ;---:.< v..= we-, i-f;:-es,a s~;~c::. z,`-,c:ary care a-; i=:Ja' --r;e:y. I can ~eirf -rick 17ail c **.= ,-. *;-,:.a. :* -',I -^. .m -0u4. 5 =.:d'i!r'C '-'Q'CE se:- '.' :c :. 5:. -; 2: :pe C:Css s:i.::s: cs 07 &'-.'-2;.zi' a"e$,; _-WY, D! y30> St 2 At Chtidren's Hospital !hose statistics are impressive. "In the 1950s. when we did our first assessment of survival for esophageal alresia, we were saving 50 percent, which was considered phenomenal jn those days. Today we never expect 10 lose a full-term baby with esophagea! atresia, anc we haven't lost one for the past nine years. We've done about 475 of these procedures, and even with premature infants who have additional life- threatening problems the survival rate is 87 percent." Dr. Koop said. Another innovation has been creation of a day surgical center, where youngsters may undergo certain procedures in the operating room without being admitted overnight to the Hospital. The children come in the morning. undergo surgery and usually are home by dinner. The service has been in such demand that the Hospital is currently seeking approval from the Health Systems Agency to construct a larger Center on the fourth floor of the building, with funds contributed by the Widener Estate. Dr. Koop explained, "With the huge expan- sion of our orthopedics and otorhinolaryn- gology services and the demand for more patient bed days by our plastic surgeons, it seemed we'd never be able lo satisfy our sur- gical needs because of a freeze on beds by the Health Systems Agency. "By expanding our outpalknt surgery we can open up beds in the Hospital aulomali- tally and provide more operating time for those services that require development. "It isn't sufficient just lo have an outpatient surgical service, though. One must have a self-contained unit lo do best by the patient and lo prevent infections that these children can catch from others if they are not in a separate area." Despite its pioneering role in neonatal surgery and some of the other subspecialties, Dr. Koop feels proud that "we never have rid- den one hobby horse, so to speak. This is not a hospital where patients come just for one kind of problem. Its attractiveness as a train- ing program is that there is a constant variety of all types of surgiczl problems, ranging from the common to the esoteric. "And although a lot of surgery in children is routine. we pay just 2s much atteniion to that chiid as to tne one undergoing a comoiex pro- ceuure. We hive i0 remember tha! cnlidren have remarkable bounce, but limited reserve, and that they offer the same challenges in inrraoperative and posiopera?ive care no mat- ter how straight-forward or how intricate the surgery." Dr. Koop said. "I ihrnk one of the ether unusual aspects of our surgica! department is ihe operating room staff, especiatiy the dedtca?ion and longevity of many of the OR nurses. They help make our deoarlmenl a `team effort' that creates a pieasant environment for all who are invcived.