By ANISH KOKA
The year was 1965, the place was Boston Children’s and a surgery resident named Robert Bartlett took his turn at the bedside of a just born baby unable to breathe. This particular baby couldn’t breathe because of a hole in the diaphragm that had allowed the intestines to travel up into the thoracic cage, and prevent normal development of the lungs. In 1965, Robert Bartlett was engaged in the cutting edge treatment of the time – squeeze a bag that forced oxygenated air into tiny lungs and hope there was enough functioning lung tissue to participate in gas exchange to allow the body to get the oxygen it needed. Bartlett persisted in ‘bagging’ the child for 2 days. As was frequently the case, the treatments proved futile and the baby died.
The strange part of the syndrome that had come to be known as congenital diaphragmatic hernia was that repairing the defect and putting the intestines back where they belonged was not necessarily curative. The clues to what was happening lay in autopsy studies that demonstrated arrested maturation of lung tissue in both compressed and uncompressed lung. Some systemic process beyond simple compression of one lung must be operative. It turns out that these little babies were blue because their bodies were shunting blood away from the immature lungs through vascular connections that normally close off after birth. Add abnormally high pressures in the lungs and you have a perfect physiologic storm that was not compatible with life.
Pondering the problem, Bartlett wondered if there was a way to artificially do what the lungs were supposed to do – oxygenate. Twelve years later in 1977, while most pediatric intensive care units were still figuring out how to ventilate babies, a team lead by Bartlett was using jerry rigged chest tube catheters to bypass the lungs of babies failing the standard treatments of the day. In a series of reports that followed, Bartlett described the technique his team used in babies that heretofore had a mortality rate of 90%. A home made catheter was placed in the internal jugular vein and pumped across an artificial membrane that oxygenated blood before it was returned via a catheter to the carotid artery. The usual hiccups ensued. The animal models didn’t adequately model the challenges of placing babies on what has come to be known as ECMO (Extra Corporeal Membrane Oxygenation).
Patient 1 developed a severely low platelet count, hemorrhaged into the brain and died. Patient 2 survived but was on a ventilator for 7 weeks. Patient 3 developed progressive pulmonary hypertension and died. Patient 4 died because of misplacement of one of the ECMO catheters.
The team improved, and mortality in this moribund population improved to 20%. The pediatric journals of the day refused to publish the data because they felt ECMO for neonates was irresponsible. Once published, the neonatology community came out in force against ECMO, and some penned editorials implying the children only became supremely ill because Bartlett’s team was incompetent. The team persisted, as is anyone that is driven by the desperate need of patients. None of this should be surprising. The constant battle between skeptics and proponents is a recurring theme known to anyone with even a limited understanding of medical history. But this is where the story goes off the rails.Continue reading…
