Issue 2, 2008
Life-saving drug p. 4
Cool-Cap device p. 6
Thoracoscopic surgery p. 8
Helex device p. 10
Specialty Pediatric clinic p. 14
A journal for physicians
Proudly serving children since 1948, Children’s Hospital is the only full-service, pediatric health care center in Nebraska. Located in Omaha, it provides expertise in more than 30 pediatric specialty services to children and families across a five-state region and beyond. The 144-bed, nonprofit hospital houses the only dedicated pediatric emergency department in the region and offers 24-hour, in-house services by pediatric critical care specialists. Children’s Hospital has achieved the Magnet designation for nursing excellence and is an InfoWorld 100 award winner for innovation in information technology. A pediatric affiliation established between Children’s Hospital and the University of Nebraska Medical Center College of Medicine supports enhancements in pediatric education, research and clinical care. Children’s is also the primary teaching site for the family practice and joint pediatric residency programs at Creighton University and UNMC. For more information on Children’s Hospital go to ChildrensOmaha.org.
Contents
Life-Saving Drug p.
4
PICU physicians are working hard to raise awareness of the need to have a life-saving drug on hand.
Cool-cap device p.
Also: 3D Echocardiography p.
6
Children’s Hospital has added a new tool to treat term or near-term infants with hypoxic-ischemic encephalopathy (HIE), a rare but serious condition.
Genetic Arrhythmia Clinic p.
Thoracoscopic surgery p.
8
p. Davey
p.
Regional physician relies on Priority Line
10
p.
Malcolm
Elmwood
Milford
Lincoln
Pleasant Dale
Specialty Pediatric Clinic p.
Denton Rokeby
Martell Kramer Hallam
17
18
A state-of-the-art hybrid catheterization suite and a Greenwood choice of device closures that includes the Gore Helex Septal Murdock Waverly Occluder provides atrial septal defect (ASD) patients the widest possible range of treatment Wabash Alvo options the region. Prairiein Home
Raymond
Garland Seward
16
nine beds added
HelEx device Agnew
15
New Pediatric Specialists p.
Taking a minimally invasive approach to treating congenital lung anomalies results in less pain and scarring for patients and peace of mind for parents.
13
14
Since the March opening of the new Children’s Specialty Pediatric Clinic in Lincoln, Roca physicians and patients’ families have welcomed the facility for making it easier Hickman to access our services in the Panama Holland Lincoln area and beyond.
Firth
Children’s Connection Advisory Council shahaB f. aBdessalam, m.d. thomas m. attard, m.d. david m. christeNseN, m.d. Brady a. kerr, m.d. JohN d. kugler, m.d. Joseph t. (Jay) sNow, m.d. Jayesh c. thakker, m.d. peggy hogaN, r.N., physiciaN liaisoN
Life Saving Drug
PICU physicians spread word of
LIfe-Saving drug Like most people, Edward Truemper, M.D., remembers Sept. 11, 2001. But his memory of that day goes beyond the terrorist attacks in New York and at the Pentagon. Dr. Truemper was practicing at a smalltown hospital in Georgia, filling in for the neonatologist when he took a call about an infant 60 miles away who was being treated for sepsis, but whose condition was rapidly deteriorating. After noting the symptoms, he sensed the baby may have hypoplastic left heart syndrome (HLHS), a serious defect where the major portion of the left side of the infant’s heart is either missing or too small to support normal cardiac function. Once the arterial ductus, the shunt connecting the pulmonary artery to the aorta during gestation, contracts and closes as is normal within a few days of
p.
birth, HLHS can cause hypoxemia, acidosis and shock.
recalls. “I decided right then, ‘We’re not going to have this anymore.’”
“Often with these symptoms, the first thing that comes to mind is sepsis,” he says.
That’s when Dr. Truemper began to personally educate medical providers about the lifesaving benefits of having PGE available beforehand.
In order for the infant to survive long enough to receive necessary cardiac care, the ductus must stay open, or maintain patency, to keep oxygenated blood flowing into the baby’s lungs. Dr. Truemper advised the baby’s attending physician to quickly administer prostaglandin E-1 (PGE) to maintain ductal patency, but she had none available. So Dr. Truemper immediately sent out the medical transport team to deliver the drug to the referring hospital. “By the time the transport team got there, the baby had died of what otherwise would have been an operable cardiac condition,” he
But he faced a major obstacle. The drug was expensive – $2,000 for five vials – with one to two vials needed per child. That cost, when weighed against the average of one in every 1,200 births requiring PGE, was often too much for smaller medical facilities to justify. Today, PGE is available in generic form – and at about one-tenth the cost. Still, many hospital staffs and physicians aren’t aware of PGE’s benefits or its affordability. Since joining the staff at Children’s Hospital in 2003, Dr. Truemper, along with Jayesh C.
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“Just as we do by administering antibiotics for suspected infections, when ductal dependent critical heart disease is identified in newborn infants, PGE should be started until the need to maintain patency can be proved or disproved.” Edward Truemper, M.D. Pediatric Critical Care Children’s Hospital
Thakker, M.D., medical director of critical care outreach at Children’s, have worked to raise awareness in the region regarding the need to have PGE on hand. Drs. Truemper and Thakker are part of the clinical staff at Children’s Hospital Pediatric Intensive Care Unit (PICU) and the unit’s outreach team. Dr. Truemper also serves as clinical director of the PICU at The Nebraska Medical Center. Their effort started with Dr. Truemper sending letters to hospitals and other emergency health care providers. “I sent out 50 to 70 letters in six to eight months,” he says. “Once I explained it, everybody I heard back from agreed that PGE should be readily available.” He and Dr. Thakker then began giving presentations at conferences and at medical facilities throughout eastern Nebraska and western Iowa to educate providers about the value of PGE. Their efforts are making an impact. Dr. Truemper says that in the last 2-1/2 years, at least seven infants have come to Children’s Hospital for treatment of critical cardiac conditions who may not have survived had they not first received doses of PGE. Thanks to PGE and their subsequent cardiac care, their outcomes have been “uniformly
Jayesh Thakker, M.D. Director, PICU Outreach Children’s Hospital
good,” he says. “These infants are getting this life-saving measure at the appropriate time, arriving to us in good condition, getting their operation to repair their heart and going home to be kids again.” Understanding the need for PGE requires understanding how the arterial ductus functions. Prior to birth, the ductus connects the pulmonary artery to the aorta and allows blood to bypass the baby’s shrunken, fluidfilled lungs. After delivery, the lungs inflate and the ductus is no longer necessary. In the vast majority of cases, the ductus closes within two or three days of birth. In babies with hypoplastic left heart syndrome or other cardiac defects, however, this natural closing of the ductus begins to adversely affect their health. The symptoms resulting from these cardiac conditions occur in infants who otherwise appeared healthy and have commonly been sent home. Because the symptoms can rapidly worsen, the affected babies are often taken to emergency rooms rather than the family’s own doctor. “Anywhere from three or four hours later to three or four days later, they can be at death’s door,” Dr. Truemper says. “That’s
why we push for training among emergency room staffs.” Diagnosis of hypoplastic left heart syndrome and other serious cardiac defects often requires an echocardiogram for confirmation, but many small-town hospitals are not able to conduct this test on infants. That is why babies with suspected critical heart conditions requiring the arterial ductus to remain open should immediately be treated with PGE to maintain ductal patency. Hospital pharmacies are developing standardized drug concentrations to ensure accurate drug delivery. Dr. Truemper developed a chart listing four concentrations of the drug provided in easy-to-read tables for infants from 500 grams up to five kilos. “Just as we do by administering antibiotics for suspected infections, when ductal dependent critical heart disease is identified in newborn infants, PGE should be started until the need to maintain patency can be proved or disproved,” he says. “Maintaining an open ductus in this situation gives the infant time to get the right diagnosis and surgical treatment necessary. “PGE can reopen the ductus in a matter of a few minutes and can be life-saving.” A little time that can make a big difference.
p.
Cool Cap Device
cool-cap device Now among HIE treatment options Speed is an integral component in the effort to limit or reduce the severity of neurologic injury when treating term infants with hypoxic-ischemic encephalopathy (HIE), or perinatal asphyxia. The amount of time that the proper therapy can make a significant impact can be as little as a few hours. That is why Children’s Hospital has added a new tool in the treatment of term or near-term (36 weeks and above) newborns with HIE. The tool is the Olympic Cool-Cap System, the only FDA approved device in use today to treat HIE in newborns. Brady Kerr, M.D., neonatologist at Children’s Hospital, says that while the cooling cap is not a “cure-all” for all babies with HIE, it may be able to positively impact outcomes for some babies. HIE, in which the flow of blood and oxygen to the brain of the unborn baby is significantly reduced, is a rare but serious condition. p.
Causes include an abruption, or tearing away, of the placenta from the uterus; or when the umbilical cord becomes tangled, doesn’t insert normally into the placenta, or there is a marginal or weak insertion that places the placenta at risk for tearing; or if the mother is sick, injured or in shock, affecting the blood flow to the fetus. The precise cause of each case of HIE, however, often is not known. “A lot of factors and conditions can lead to HIE,” Dr. Kerr says. “The end result is a compromise in the ability to deliver oxygen to the baby’s brain.” When this occurs, HIE can be one of many results, including damage to vital organs. “While there is commonly evidence of damage to other organs, the condition is often not known well in advance of the birth,” Dr. Kerr says. “And there are emergent situations that can’t be prevented, but can be met with immediate intervention.
“If, for example, there is vaginal bleeding indicating a separation of the placenta from the uterus, as soon as that is recognized the obstetrician will deliver.” If HIE is diagnosed following such an event, a decision must be made quickly as to whether the Cool-Cap System should be used. The Olympic Cool-Cap System is a way of cooling the newborn’s brain, “putting the brain cells at rest,” says Dr. Kerr, while maintaining normal physiology throughout the remainder of the infant’s body. According to the manufacturer, if used within the first six hours of birth, the cooling-cap system “can prevent or significantly reduce the severity of neurologic injury associated with HIE, (as indicated) in a randomized-controlled, multi-center, international clinical trial.” The system consists of a control unit with a touch-screen design and built-in protocols, a cooling unit, which contains a solid-state
Physician’s Priority Hotline 1.888.592.7955
The Olympic Cool-Cap System for HIE therapy is not a cure-all but “it does have the potential for improved, long-term outcomes in some cases.” Brady Kerr, M.D. Neonatologist Children’s Hospital
The Olympic Cool-Cap System is the only FDA approved
The system consists of a control unit with a touch-
Although this therapy will not help every baby, if
device in use today to treat HIE in newborns.
screen design and built-in protocols, a cooling unit,
used within the first six hours of birth, the cool-cap
which contains a solid-state water cooler with precise
can prevent or significantly reduce the severity of
temperature control and a cooling cap.
neurologic injury associated with HIE.
“It’s not to be used with every asphyxiated infant,” he says. “Some babies are so mildly affected that they would not even qualify for this therapy.”
at the same time, it is good to know that another medical facility is nearby that can be of assistance.
water cooler with precise temperature control; and a cooling cap. The cooling cap has three pieces: the water cap, placed against the baby’s skull, has soft, water-circulating channels that provide controlled and uniform cooling without pressure points; the water-cap retainer to hold it in place; and the insulated outer cap, like a foil stocking cap that keeps the proper cooling temperature beneath it while reflecting the external heat emanating from the radiant warmer that maintains the baby’s core temperature.
Those assessment criteria include the baby’s gestation period, the evidence of neurologic injury, and the result of a baseline brain recording obtained from a cerebral function monitor (CFM), a device that rapidly provides a generalized map of brain activity but not to the extent of a full electroencephalogram (EEG).
The Cool-Cap is used for 72 hours, followed by a four-hour, gradual rewarming period.
“The more quickly we can conduct an assessment,” Dr. Kerr says, “the higher the probability that we can slow the damage and make a difference.”
The extent of HIE can range from very mild to severe (stage 3), which is estimated to occur in two to four cases per 1,000 births. According to the World Health Organization, somewhere between 50 percent and 75 percent of infants with stage 3 HIE will die, with 55 percent of these deaths occurring in the first month.
The Olympic Cool-Cap is among the medical devices used in the Children’s Hospital Newborn Intensive Care Unit, where critically ill infants from around the region are taken for immediate and thorough care. Dr. Kerr estimated that the Cool-Cap System will be used from five to 10 times each year.
Dr. Kerr says the neonatologists and neurologists at Children’s Hospital have criteria that they use to assess the extent of neurological damage and determine the potential benefit of the Cool-Cap System.
The Cool-Cap is also in use at the Nebraska Medical Center, the teaching hospital for the University of Nebraska Medical Center.
Traditional treatment for HIE includes attempting to normalize body and organ function by maintaining blood pressure, treating seizures and adjusting fluids through intravenous feeding. “But none of these things really addresses the stoppage of brain injury,” he says. “You’re treating the symptoms but not getting at the source of the neurological injury or addressing the long-term effects.” That’s where the therapy provided by the Olympic Cool-Cap System could have an impact. “Physicians and parents need to be aware that this therapy will not help every HIE baby,” Dr. Kerr says. “In the long-term, the severely asphyxiated or those with so much neurological injury will not find this to be a cure-all, fix-all. But it does have the potential for improved, long-term outcomes in some cases.” And that potential is reason enough to add the Cool-Cap System to the therapy options available at Children’s Hospital.
Dr. Kerr says that in the rare event more than one baby would need the Cool-Cap therapy p.
Thoracoscopic surgery
Thoracoscopic Surgery Treating Congenital Lung Abnormalities
p.
Physician’s Priority Hotline 1.888.592.7955
“If we can perform the operation as effectively with a minimal incision, the level of discomfort, the recovery and the scarring are all vastly improved.” Shahab Abdessalam, M.D. Pediatric Surgeon Children’s hospital
A minimally invasive surgical technique for treating congenital lung anomalies is now available to the region’s patients at Children’s Hospital. The technique is being employed by Pediatric Surgeon Shahab Abdessalam, M.D., who joined the surgical team at Children’s about two years ago. In addition to his five years of general surgery and two years of pediatric surgery training, he has additional fellowship training in surgical oncology and pediatric critical care – making him one of about five people in the nation trained in pediatric surgery and surgical oncology. Dr. Abdessalam has been performing minimally invasive, thoracoscopic lung lobectomies to treat congenital cystic adenomatoid malformations (CCAMs) and pulmonary sequestrations. CCAMs are non-cancerous masses of abnormal lung tissue that form in one or more lobes of the lungs and are abnormally connected to the trachea. The abnormal tissue can form fluid-filled cysts, and limit or prevent normal development of the lung. “There are also reports of cancer arising in these CCAMs,” Dr. Abdessalam says. If diagnosed during routine prenatal ultrasounds, “we like to fix these CCAMs within the first 3 to 6 months of age.” He says that with better quality prenatal ultrasounds, and almost universal performance of prenatal ultrasounds in today’s American society, more congenital lung abnormalities are being diagnosed prior
to birth. Subsequently, the number of such operations has increased. He has performed six in the past year. Some, however, are not diagnosed until later in life – if at all. “You can go your whole lifetime without knowing you have one, but once they become infected or cancerous, they are much more difficult to deal with.” Treating CCAMs involves surgical resection, removing the abnormal lobe of the lung. This is performed either through a small incision, as in a thoracoscopic lung lobectomy, or a large incision called a thoracotomy, which involves spreading the ribs in order to reach and remove the abnormal tissue, even when the patient is an infant. “If we can perform the operation as effectively with a minimal incision,” Dr. Abdessalam says, “the level of discomfort, the recovery and the scarring are all vastly improved.” He says the same is true with pulmonary sequestrations, where there is an abnormal blood supply connected to the lung as well as an abnormal connection to the trachea and in treating diaphragmatic hernias. “We’ve repaired five or six diaphragmatic hernias through a thoracoscopic approach, all with tremendous results,” he says.
In treating CCAMs via a thoracoscopic lung lobectomy, Dr. Abdessalam utilizes three or four 5mm incisions to access the abnormal tissue. Because the abnormal masses are generally flexible and soft, they can be removed by simply enlarging one of the incisions to about a centimeter – the width of his finger. The operation takes about two hours. “It’s hugely advantageous to take a minimally invasive approach to these surgeries,” he says. “Besides all the advantages regarding less pain and scarring, afterward mom and dad see little Band-Aids on their baby instead of a huge incision.” That’s a comfort to the parents – and the patient.
1.888.592.7955 Physicians’ Priority Line Your 24-hour link to pediatric specialists for physician-to-physician consults, referrals, admissions and neonatal transport service.
With CCAMs, early diagnosis is important. “These babies have a chance of being very sick when they are born,” he says. “If they live far away and have a CCAM diagnosed in an ultrasound, they should be in a specialized center like Children’s to care for them upon delivery.” p.
Helex Device
Helex Device Now Among Options For Treating Atrial Septal Defects
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Physician’s Priority Hotline 1.888.592.7955
The state-of-the-art hybrid catheterization suite at Children’s Hospital, coupled with a choice of device closures that includes the Gore Helex Septal Occluder, provides atrial septal defect (ASD) patients the widest possible range of treatment options in the region. An ASD is an abnormal hole between the top two chambers of the heart. Most ASDs are amenable to device closure, says Children’s Hospital Interventional Cardiologist Jeffrey Delaney, M.D. With an ASD, the hole may be as small as the tip of a pencil or as large as the entire septum. The precise cause of these defects is not known, and roughly one-fifth close on their own in the first year of life. Those that do not close spontaneously are targeted for repair because, over time, an untreated ASD could result in pulmonary hypertension, heart failure or stroke. Diagnostic tests for an ASD are noninvasive and include an electrocardiogram and ultrasound imaging. The current standard treatment for ASDs is open-heart surgery, which requires an incision to the chest and a hospitalization of several days. This highly invasive form of treatment can now be avoided in many cases by using one of the minimally invasive device closures, fed to the heart using a catheter and an image-guidance system. Prior to Dr. Delaney joining the staff at Children’s in July, the Amplatzer device from AGA Medical Corp. was the primary device used for pediatric ASD closures at the hospital. The Amplatzer is wire mesh made of nickel and titanium covered in polyester fabric. The Gore Helex device, which is a more recent addition to the market, resembles a set of round sails that are delivered within a catheter. Once in place inside the heart, a wire disk covered with a Gore-fabric membrane is unfurled on one side of the hole, then the
second disk is unfurled on the other side. The catheter is removed and the Helex seals the hole from both sides. “In time,” Dr. Delaney says, “the device will seal with the child’s own tissue and never have to be replaced.” As the heart grows, the device eventually occupies less and less space. Dr. Delaney is a certified implanting physician for both the AGA and Gore devices. The procedure typically takes less than two hours, he says. There is no surgical incision because the access point for the catheter is a vein in the patient’s leg. “The average hospital stay is less than 24 hours,” he says. “The patients have to be cautious regarding physical activity for five to seven days, and we recommend no contact sports for two or three months. Otherwise, they can resume normal activity.” A native of South Dakota, Dr. Delaney is a graduate of Creighton University School of Medicine. He completed his internship and residency at Madigan Army Medical Center in Fort Lewis, Wash. He completed a pediatric cardiology fellowship at Yale University, where he was the recipient of the Yale Pediatric Residency Fellow Teaching Award.
Jeffrey Delaney, M.D. Interventional Cardiologist Joint Division of Pediatric Cardiology at Children’s Hospital/UNMC/CUMC
“We can offer our ASD patients the widest range of options based on their anatomy.”
He came to Children’s Hospital after serving as interventional cardiologist in the Division of Pediatric Cardiology at Duke University Medical Center in Durham, N.C., where he also served as director of the Pediatric Cardiology Outreach Program. Dr. Delaney has high praise for the hybrid catheterization suite at Children’s Hospital. “Catheterization procedures are evolving to accommodate both surgical and interventional procedures at the same time,” he says. “But you need a room where the cardiothoracic p. 11
“Children’s has a room that is state-of-the-art, capable of full cardiothoracic surgery with cardiopulmonary bypass, and at the same time top-quality, biplane fluoroscopy.” Jeffrey Delaney, M.D. Interventional Cardiologist Joint Division of Pediatric Cardiology at Children’s Hospital/UNMC/CUMC
surgeon and the interventionalist can work together.” “Children’s has a room that is state-of-the-art, capable of full cardiothoracic surgery with cardiopulmonary bypass, and at the same time top-quality, biplane fluoroscopy.” The 1,000-square-foot catheterization suite features a Toshiba America Medical Systems flat panel diagnostic imaging X-ray system, capable of rotating 180-degrees in multiple planes around the patient while still capturing high-resolution images and affording patient access to several medical specialists at the same time. “The facility is outstanding,” Dr. Delaney says. “It’s one of the best and certainly one of the largest in the United States.”
p. 12
Catheterization Suite Manager Stacey Froemming, RCPT, says the lab is linked digitally to an adjacent operating room (OR), allowing an interventional cardiologist in the lab to collaborate with a surgeon in the OR when necessary, as well as feed images from the lab to the OR. “We also have pediatric anesthesia support on every procedure we do, 24-7, 365 days a year,” Froemming says. “We have headsets for the medical personnel to wear so they can speak to each other in a normal voice and eliminate miscommunication.” Dr. Delaney says the combination of the hybrid catheterization suite, experienced imaging specialists, cardiac interventionalists and surgeons, anesthesiologists and other
medical specialists and support staff make Children’s Hospital unique in the region. “We can offer our ASD patients the widest range of options based on their anatomy,” he says. “We can use the best devices on the market to achieve maximum outcomes with the lowest risk.” Froemming says the investment Children’s Hospital has made in the catheterization suite “illustrates the level of commitment we’ve made to pediatric cardiac care. The goal is building the best program in the Midwest, and we’re well on the way to doing that.”
Physician’s Priority Hotline 1.888.592.7955
Cardiac MR and 3D Echocardiography Expand Role at Children’s The addition of technologically advanced equipment and software in cardiac magnetic resonance (CMR) imaging and threedimensional echocardiography will enable Children’s Hospital to take noninvasive imaging beyond its current diagnostic applications. Applying 3D echo imaging to the realm of the operating room will provide the most accurate visual information attainable directly to the surgeon, says Shelby Kutty, M.D. “We are getting equipped with state-of-the-art echo imaging platforms and workstations that will enhance our capabilities and the quality of the images we produce,” Dr. Kutty says. “Adding the third dimension to the images certainly helps understanding heart pathology better, and using it in the operating room setting improves the situation for both the patient and the surgeon.” Dr. Kutty, of the Joint Division of Pediatric Cardiology at Children’s Hospital/UNMC/CUMC, says complex anatomy and spatial relationships are inherent to congenital heart defects. Until recently, the clinician’s ability to image the heart by echocardiography has been limited to two-dimensional images. Despite advances, limitations to two-dimensional echocardiography include the need for the echocardiographer to mentally reconstruct multiple images in order to successfully portray the three-dimensional anatomy. In addition, two-dimensional techniques have limitations to accurately quantify heart function. “We have started to use both two-dimensional and three-dimensional imaging before and after surgery to look at the heart anatomy and valves,” Dr. Kutty says. “3DE is superior in the assessment of atrial and ventricular septal defects and valve abnormalities, and can be used as a real-time guide to perform catheterbased as well as surgical interventions.”
For example, in repairing an atrial septal defect (ASD), which is an abnormal hole between the top two chambers of the heart, the interventionalist can benefit greatly from a three-dimensionally reconstructed image of the hole. “With 3DE, the location and size of the hole can be shown accurately,” Dr. Kutty says. In patients with abnormalities of heart valves, 3DE technology can precisely define the leaflets of the valve, how the valve moves and how it leaks. A typical scenario is an atrioventricular septal defect (AVSD), where instead of two valves separating the heart’s upper and lower chambers there is an abnormal single large valve. The valve structure can be shown better with 3DE imaging, and this information obtained prior to surgery helps the surgeon repairing the defect.
Shelby Kutty, M.D. Pediatric Cardiologist Joint Division of Pediatric Cardiology at Children’s Hospital/UNMC/CUMC
A
Dr. Kutty obtained graduate and postgraduate degrees from Calicut Medical College and Kasturba Medical College in India. He is experienced both in CMR and 3DE, having trained in cardiology and cardiac imaging at Children’s Hospital Boston, Children’s Hospital of Wisconsin and the Cleveland Clinic. His research interest is in the application of newer tools to quantify heart function. He says that in addition to enhancing the echocardiographic imaging capabilities, Children’s Hospital is upgrading its current cardiac MR scanner and software to stateof-the-art. He estimates that fewer than 20 medical centers in the nation currently perform diagnostic CMR for pediatric and congenital heart disease, and fewer than 10 perform 3DE. Those figures place Children’s Hospital among the pediatric cardiac imaging elite. “We are making significant upgrades in technology and software, both in CMR and echocardiography,” he says, “which certainly will enhance our capabilities in noninvasive cardiac imaging.”
B
C
A
Coronary anatomy derived from navigator-gated, 3-D isotropic cine MR
B
3-D volume rendering following MR angiography in a patient with Scimitar syndrome
C
Quantification of ventricular volume and function by 3-D echocardiography
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specialty pediatric clinic
New Specialty Pediatric Clinic Welcomed in Lincoln
Agnew Davey
Seward
Milford
Greenwood
Raymond
Garland
Prairie Home
They say the clinic at 86th Street and Pioneers Boulevard, a free-standing, single-story building with ample free parking, makes it easier for them to access Children’s Hospital specialists. For 10 years prior to the opening of the new clinic, patients and their families would meet with Children’s specialists at the St. Elizabeth Regional Medical Center campus. “The patients really like our new building,” says Clinical Coordinator Connie Honke. “It’s a child-friendly place with lots of bright colors and toys and games. They also like being able to park at the door and come right in, rather than park in a multi-level garage and take an elevator to get to their appointments.”
Lincoln
Pleasant Dale
Honke and Clinic Coordinator Kerry Fisher, R.N., worked together at St. Elizabeth Hospital for 30 years, and were among the staff at the Children’s clinic when it was situated at that facility. When the clinic moved to its new location, patients were happy to see that Fisher and Honke had come along with it. “I think it was a relief for them to see our familiar faces,” Fisher says. Some patients with chronic conditions must visit the clinic so often, “we get to be like family to them,” Honke says. The clinic, which has expanded from 11 to 18 pediatric specialists and increased days of operation, fits well into Children’s goals of expanding its outreach to Lincoln and communities farther west, says Vanessa Walls, vice president for Ambulatory Services.
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Rokeby
“Our pediatric specialists currently serve more than 1,000 children through outpatient visits in Lincoln,” Walls says. “Offering greater access to our services in the Lincoln area and beyond helps establish Children’s Hospital as the regional provider of choice for specialty pediatric care.”
Roca Martell
Hickman Holland
Kramer Hallam
Panama
Firth
Convenience has always been a goal of the Children’s clinic in Lincoln, Fisher says. “With us right here in the community, people don’t have to take the day off to drive to Omaha for their appointments,” she says. “Quite frankly, some of our patients’ families don’t have the means to drive to Omaha.”
The Children’s Specialty Pediatric Clinic in Lincoln is at 86th Street and Pioneers Boulevard.
When patients must meet with several specialists, Honke says, they can coordinate their appointments at the Lincoln clinic to coincide whenever possible.
Diagnostic services including radiology, echocardiography, electrocardiography (EKG) and lab draws are available, and the numbers and types of specialists available have increased.
In addition to the clinic, the new building has a satellite office for Children’s Home Healthcare, supplying medical items such as nebulizers, apnea monitors and oxygen to patients in Lincoln and surrounding areas. Children’s previously offered limited home services in the capital city.
Specialties include: ➜
Cardiology
➜
Neurosurgery
➜
Endocrinology
➜
Gastroenterology
➜
Surgery
“I use specialists according to the individual patient,” he says. “Having the pediatric specialties from Children’s together under one roof improves the quality of care all around.”
➜
Respiratory
➜
Hematology/Oncology
➜
Rheumatology
Dr. Swisher says he has many patients who are able to utilize the variety of different specialists Children’s provides.
➜
Orthopedics
Lincoln Pediatrician William Swisher, M.D., says he refers patients to the Children’s Specialty Pediatric Clinic several times a week.
“With the access I have to them through the Lincoln clinic,” he says, “together we’re able to practice a higher level of medicine.”
Alvo
Wabash
Elmwood
Denton
Since the grand opening in March of the new Children’s Specialty Pediatric Clinic in Lincoln, physicians and patients’ families have welcomed the facility for its added convenience.
Murdock
Waverly
Malcolm
One phone number reaches all these specialties. Just call 402.486.1500 if you have questions or wish to make an appointment. The clinic’s hours are Monday through Friday from 8 a.m. to 4:30 p.m.
Physician’s Priority Hotline 1.888.592.7955
Genetic Arrhythmia Clinic Can Test, Treat Whole Family When an autopsy indicates Grandpa Jack’s death may have been caused by a form of inherited cardiac arrhythmia, his sons and daughters often turn their concerns to their own children, thinking the young ones should be tested to see if they share the same genetic cardiac disorder. A good idea, but not enough. Instead, says Christopher C. Erickson, M.D., those most closely related to the one with an inherited arrhythmia or concerning symptoms should be tested. Dr. Erickson is the director of the Genetic Arrhythmia Clinic, a collaborative service of Children’s Hospital and the University of Nebraska Medical Center Adult Cardiology division. “We get calls saying ‘My mother died of Long QT Syndrome, and I’d like to know if my kids might have the condition,’” Dr. Erickson says. “Unfortunately, they’re omitting themselves from the equation. We’ll back up and tell them, ‘Before we evaluate your children, you and your siblings need to come in.’” Inherited arrhythmias are passed on silently from generation to generation. If left untreated, an apparently healthy person may be at risk for severe dizziness, syncope or even sudden cardiac arrest. “Arrhythmias are common and can occur in an otherwise healthy heart,” says Dr. Erickson. “Most of the time, arrhythmias are not serious or life-threatening. But on occasion they may indicate a serious problem that could mean a risk for heart disease, stroke or sudden cardiac arrest. That’s why early detection, proper diagnosis and complete treatment are important.” Symptoms common to inherited cardiac arrhythmia include loss of consciousness and syncope, palpitations with dizziness, unexplained non-epileptic “seizures,” aborted sudden death with or without athletic participation, or an incidence of sudden, unexplained death, drowning or one or more incidences of Sudden Infant Death Syndrome (SIDS) in a family’s history. In addition, there are several forms of inherited arrhythmias that can affect multiple family
Christopher Erickson, M.D. Director, Genetic Arrhythmia Clinic Joint Division of Pediatric Cardiology at Children’s Hospital/ UNMC/CUMC
members, many of whom have not exhibited symptoms. Through the Genetic Arrhythmia Clinic, the entire family has the option of being tested together in a single visit, or individually. Dr. Erickson says assembling a detailed family history, or pedigree, is a first step toward diagnosing many of these life-threatening conditions. “Once there is a sudden death due to an inherited arrhythmia, or an unexplained cardiac arrest not due to coronary disease or heart attack, we will review autopsy reports and interview family members to build a pedigree,” Dr. Erickson says. “With a pedigree, we can start to see the holes fill in and identify any inheritance pattern that might emerge.” Dr. Erickson is a native Omahan who earned his medical degree from the University of Nebraska College of Medicine, where he also completed his internship and residency and was chief resident in pediatrics. He completed a fellowship in pediatric cardiology at Baylor College of Medicine/Texas Children’s Hospital in Houston; and a fellowship in electrophysiology at Harvard Medical School/ The Children’s Hospital in Boston. Prior to joining the staff at Children’s Hospital in 2001, he spent 11 years at the Arkansas Children’s Hospital in Little Rock, Ark. In addition to clinic director, he is associate professor of internal medicine and pediatrics, director of electrophysiology and pacing, Joint Division of Pediatric Cardiology at Children’s Hospital/UNMC/CUMC. The clinic’s electrophysiology support staff includes Drs. John D. Kugler, John R. Windle, Arthur Easley and Daniel Anderson. Shelly Smith, Ph.D., is the clinic’s molecular geneticist and genetic counselor. The clinic’s nurse coordinator, LuAnn Mill, R.N., B.S.N., has developed close working relationships with a number of labs across the country for genetic mutation analysis. She also developed a protocol that a large insurance company is using nationally to determine who should be screened for genetic testing. “Ours is a new type of clinic that is unique in the region,” Dr. Erickson says. “We handle everything from initial evaluation through
testing and complete treatment. We can provide a one-time opinion or long-term followup and consultations.” The Genetic Arrhythmia Clinic is a single source of complete care for the whole family regarding inherited cardiac arrhythmias. Because Grandpa Jack may have passed down more than his prized coin collection.
The Genetic Arrhythmia Clinic is available for one-time referrals, consultations or long-term evaluation and care. Patients and families under care elsewhere who are moving to Omaha are also invited to take advantage of the clinic’s services, which include: ➜
Individual patient or whole family consultation
➜
Inpatient consultation
➜
Pedigree formation
➜
Genetic mutation mapping
➜
Regular patient follow-up
➜
Device (Pacemaker/Implantable defibrillator (ICD)/Implantable loop recorder (ILR) follow up
➜
Patient education
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Cardiac MRI/CT with cardiac imaging specialists
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Signal averaged ECG (SAECG)
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Metabolic stress testing
To refer a family to the clinic, contact LuAnn Mill, R.N., B.S.N.; at 402.955.4350, or toll free at 1.866.467.9399, or via email at lmill@chsomaha.org.
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New Pediatric Specialists
Intensivists
Brian Olsen, M.D.
Dr. Olsen received his medical degree from the University of Kansas School of Medicine in Kansas City, Kan., in 2002. He completed his internal medicine/ pediatrics residency in 2004 and his pediatrics residency in 2005 at the University of North Carolina in Chapel Hill. He completed his fellowship in pediatric critical care in 2008 at the University of North Carolina School of Medicine. Dr. Olsen serves as an intensivist at Children’s Hospital.
Robert Chaplin, M.D.
Dr. Chaplin received his medical degree from the University of Kansas School of Medicine in Kansas City, Kan., in 2002. He completed his pediatrics residency at Children’s Mercy Hospital in Kansas City, Mo., in 2005. His fellowship in pediatric critical care was completed at Children’s Hospital of Wisconsin in Milwaukee in 2008. Dr. Chaplin serves as an intensivist at Children’s Hospital.
Heidi N. Killefer, M.D.
Hospitalists
Dr. Killefer received her medical degree from Mayo Medical School in Rochester, Minn., in 2005. She completed her pediatrics residency at Baylor College of Medicine in Houston in 2008. Dr. Killefer is a hospitalist at Children’s Hospital.
Cassandra Susman, M.D.
Dr. Susman received her medical degree from Eastern Virginia Medical School in Norfolk, Va., in 2005. She completed pediatrics residencies at the University of North Carolina School of Medicine in Chapel Hill in 2007 and with the Creighton-Nebraska Universities Health Foundation in 2008. Dr. Susman serves as a hospitalist at Children’s Hospital.
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Physician’s Priority Hotline 1.888.592.7955
Cardiology
Shelby Kutty, M.D.
Dr. Kutty received his medical degree from Calicut Medical College in Calicut, Kerala, India in 1994. He completed pediatric residencies at Kasturba Medical College in Manipal/Mangalore, India in 1998 and at Miami Children’s Hospital in 2003. Dr. Kutty completed pediatric cardiology fellowships at Amrita Institute of Medical Science in Kochi, India in 1999; Hospital for Sick Children in Toronto, Ontario, Canada in 2001; Cleveland Clinic Foundation in 2006 and Children’s Hospital of Wisconsin in Milwaukee in 2008.
Jeffrey W. Delaney, M.D.
Dr. Delaney serves as the joint division director of cardiac catheterization services at Children’s Hospital. Prior to joining Children’s, Dr. Delaney was an interventionalist at Duke University Medical Center in Durham, N.C. Dr. Delaney received his medical degree from Creighton University School of Medicine in Omaha in 1994 and completed his pediatric residency at Madigan Army Medical Center in Tacoma, Wash., in 1997. Dr. Delaney completed fellowships in pediatric cardiology at Yale University School of Medicine in New Haven, Conn., in 2004 and in interventional cardiology at Duke University in 2005.
Surgery
Kenneth S. Azarow, M.D.
Dr. Azarow received his medical degree from the F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences in 1987. He completed his surgical internship and his surgical residency at Walter Reed Army Medical Center in Washington, D.C. He completed his fellowship in pediatric surgery at the Toronto Hospital for Sick Children. He is the former chief, Department of Surgery, Madigan Army Medical Center. He is currently serving as a staff pediatric surgeon at Children’s Hospital and professor of surgery at the University of Nebraska Medical Center.
Rheumatology
Adam L. Reinhardt, M.D.
Dr. Reinhardt received his medical degree from the University of Nebraska College of Medicine in 2002. He completed his pediatrics residency at the Children’s Hospital of Denver in 2005 and his pediatric rheumatology fellowship at Children’s Hospital of Pittsburgh. Dr. Reinhardt is an assistant professor, Section of Rheumatology in the Department of Pediatrics at the University of Nebraska Medical Center. He is currently a staff pediatric rheumatologist at Children’s Hospital.
Children’s Behavioral Health Offers ADHD Clinic Children’s Behavioral Health offers an ADHD Clinic for children ages 5 to 12, who are having difficulty with behavior at home or at school. These behavioral struggles may include inattention, distractibility, hyperactivity and impulsivity. The ADHD Clinic provides specialized diagnostic services, best practice method of assessing ADHD symptoms, using parent and teacher rating scales, diagnostic interviews and direct observation. Patients receive follow-up for individual therapy focusing on behavior management and referral to a child psychiatrist, if needed. Children’s Behavioral Health is an outpatient mental health facility that provides individual, family and group therapy in a variety of areas requiring special expertise. To schedule appointments, please call Children’s Behavioral Health at 402.955.3900.
Nine Med/Surg Beds Added Children’s Hospital has added nine more beds for medical/surgical patients. The beds are located on 4 Med/Surg Skywalk, in the Methodist North Tower. The space serves our infant population (newborn to 6 months). The unit opened a week earlier than scheduled,
Hematology/Oncology
to take care of our NICU patients. The space is designed to match current Med/Surg rooms
Don W. Coulter, M.D.
Dr. Coulter received his medical degree from the University of Arizona College of Medicine in Tucson in 2002. He completed his pediatrics residency at the University of North Carolina School of Medicine in Chapel Hill in 2005 and completed his fellowship in pediatric hematology/oncology also at the University of North Carolina School of Medicine in 2008.
on floors 4, 5 and 6. New features include parent sleep beds, new flooring and nurse call. Every room includes a bouncy chair and age-appropriate toys and activities. Plans are under way to increase the flexibility of our existing beds by renovating six rooms on Med/Surg – 4th Floor into true intensive care rooms for use as PICU overflow. In addition, two PICU beds will be added to the existing unit by relocating office space.
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quick reference directory
One Phone Number, One Call Accesses Children’s Specialists Dawn Larson, M.D., has the ability to consult with the specialists at Children’s Hospital whenever she needs to – even though her practice is 160 miles away from Omaha. Dr. Larson is a pediatrician at the Yankton Medical Clinic in South Dakota. She sees a wide variety of cases, and when she has
a question or wants to collaborate on a diagnosis, she calls the Children’s Hospital Physicians’ Priority Line at 1-888-592-7955.
or hematologists or any other specialists. When I call the line, they know how to find everyone I need.
The Physicians’ Priority Line is a 24-hour telephone line designed specifically for physicians, putting them in direct contact with Children’s pediatric specialists.
“I used it so much for a time that I got on a first-name basis with one of the nurses who answers it.”
Calls to the Priority Line are answered by a nurse, or other specially trained staff, who then promptly locates one of the hospital’s physicians. The line can be used to secure admissions to Children’s or to consult on a case and gain the advice of the hospital’s many specialists. Dr. Larson says she’s used the line for several years and averages one call a week. “I trained in Omaha, so I still have a very close relationship with many of Children’s physicians,” she says. “Years ago, one gave me the number for the Priority Line and said, ‘This will get you to me faster.’” It works. “You can get in touch with anyone calling the Priority Line,” Dr. Larson says. “I can arrange for an admission or speak with the GI doctors
Educational Presentations Available for Primary Care Providers, Hospitals
Children’s Hospital provides a broad range of educational and consultative outreach services for primary care physicians and hospitals throughout the region. Many speakers are nationally recognized as experts in their field and all are physicians associated with Children’s Hospital. Pediatric education is offered as a professional service at no charge. There are a number of topics available based on your interests. The presentations are evidence-based and can be applied in daily practice. Continuing Medical Education (CME) credit is available. The hours are designated and approved during planning. To schedule a program for your hospital or clinic, contact Peggy Hogan, R.N., Children’s Hospital Physician Liaison, at phogan@chsomaha.org, or 1.888.791.0707.
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The nurses are always pleasant, efficient and accommodating, she says. “If they can’t reach someone right that second, they offer to call me back so I don’t have to wait on hold.” She says the Physicians’ Priority Line is a way for her to maintain her working relationships with Children’s specialists as well as seek out the advice of new physicians at the hospital. “In primary care I don’t see some of these cases as often as do the specialists at Children’s,” she says. “The Priority Line gives me another outlet to manage my patients.”
1.888.592.7955 Physicians’ Priority Line
Did you know that you could receive continuing medical education (CME) credits right from your home or office computer? Log on to www.childrensomaha.org and click on the Health Professionals tab to view Pediatric Grand Rounds. You can view live and archived Grand Rounds by nationally recognized experts. Then simply complete the survey for CME credit.
Physicians’ Priority Line (physician-to-physician consult and referral line) 1.888.592.7955
Transport (Physicians’ Priority Line) 1.888.592.7955
Hospitalist Service 955.5400 or 1.888.592.7955
PICU 402.955.4200
NICU 402.955.6230
CHILDREN’S HOSPITAL OUTREACH CLINICS
Clinic
Location
Rotation Frequency Phone
Carl Gumbiner, M.D.
Norfolk
Monthly
North Platte
Quarterly
402.955.4350
Kearney
Quarterly
402.955.4350
Neurology
Lincoln
Weekly
402.486.1500
Young Oliver, M.D.
David Danford, M.D.
Hastings
Monthly
402.955.4350
Grand Island
Quarterly
402.955.4350
Neurosurgery
Lincoln
Weekly
402.486.1500
Mark Puccioni, M.D.
Cardiology
Clinic
Location
Rotation Frequency Phone
Lincoln
Weekly
Hematology/Oncology 402.955.4350
David Gnarra, M.D.
402.486.1500
Sioux City, Iowa
Monthly
402.955.5372
Lincoln
Weekly
402.486.1500
Scott Fletcher, M.D.
Columbus
Quarterly
402.955.4350
Sioux City, Iowa
Semi-annually
402.955.4350
Orthopedics
Holdrege
Semi-annually
402.955.4350
Paul Esposito, M.D.
Lincoln
Weekly
402.486.1500
Lincoln
Weekly
402.486.1500
Brian Hasley, M.D.
Lincoln
Weekly
402.486.1500
Christopher Erickson, M.D.
Lincoln
Weekly
402.486.1500
John Kugler, M.D.
Lincoln
Weekly
402.486.1500
Respiratory Medicine
Jeffrey Delaney, M.D.
Lincoln
Variable
402.486.1500
Mark Wilson, M.D.
Sioux City, Iowa
Monthly
402.955.5570
Shelby Kutty, M.D.
Lincoln
Varible
402.486.1500
Lincoln
Weekly
402.486.1500
John Colombo, M.D.
Lincoln
Weekly
402.486.1500
Paul Sammut, M.D.
Lincoln
Weekly
402.486.1500
Endocrinology Monina Cabrera, M.D.
Lincoln
Semi-monthly
402.486.1500
Sioux City, Iowa
Semi-monthly
402.955.3871
Rheumatology
Kevin Corley, M.D.
Lincoln
Weekly
402.486.1500
Adam Reinhardt, M.D.
Sioux City, Iowa
Monthly
402.955.4070
Jean-Claude DesMangles, M.D. Lincoln
Semi-monthly
402.486.1500
Lincoln
Monthly
402.486.1500
Semi-monthly
402.955.3871
Sioux City, Iowa
Surgery Gastroenterology
Shahab Abdessalam, M.D.
Lincoln
Monthly
402.486.1500
Thomas Attard, M.D.
Lincoln
Semi-monthly
402.486.1500
Kenneth Azarow, M.D.
Lincoln
Monthly
402.486.1500
Fernando Zapata, M.D.
Sioux City, Iowa
Monthly
402.955.5700
Robert Cusick, M.D.
Lincoln
Monthly
402.486.1500
Stephen Raynor, M.D.
Lincoln
Monthly
402.486.1500
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1.888.592.7955 Physicians’ Priority Line Your 24-hour link to pediatric specialists for physician-to-physician consults, referrals, admissions and neonatal transport service.
ChildrensOmaha.org