Hello friends 👋
This special episode of The Incubator features guest co-hosts Dr. Amir Ashrafi and Dr. Nim Goldshtrom interviewing Dr. Gil Wernovsky, a pioneer in the field of pediatric cardiac intensive care. The discussion focuses on the evolution of neonatal cardiac care and the upcoming Neoheart 2024 conference.
Dr. Wernovsky reflects on the history of pediatric cardiac intensive care, highlighting key developments like surfactant therapy and prostaglandin treatment that revolutionized care for neonates with heart disease. He emphasizes the importance of cross-disciplinary collaboration between neonatologists, cardiologists, and other specialists to provide comprehensive care for these complex patients.
The conversation explores the challenges of training future specialists in this field, advocating for dual board certification and early exposure for residents. Dr. Wernovsky stresses the need for understanding both anatomy and physiology in managing neonatal cardiac patients.
The hosts and guest discuss the upcoming Neoheart 2024 conference in New York City as an opportunity for professionals to network, share knowledge, and advance the field of neonatal cardiac care. They also highlight available fellowship opportunities for those interested in pursuing specialized training in this area.
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Short Bio: Dr. Wernovsky is a senior consultant in pediatric Cardiology and Cardiac Critical Care at Children National Hospital, having joined the faculty in 2018. He attended Brandeis University, receiving a BS degree in 1978 in anthropology and music. He attended Pennsylvania State University College of Medicine, receiving his M.D. in 1982. He completed a pediatric residency at New York Hospital (now known as Weill Cornell Medical Center) in 1985, and his pediatric cardiology fellowship at Boston Children’s Hospital in 1988, with a focus on cardiac intensive care. He was appointed the Associate Director of the Cardiac ICU through 1995.
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Articles mentioned in this week's episode can be found below 👇
Castaneda AR, Mayer JE Jr, Jonas RA, Lock JE, Wessel DL, Hickey PR.J Thorac Cardiovasc Surg. 1989 Nov;98(5 Pt 2):869-75.PMID: 2811420
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The transcript of today's episode can be found below 👇
Nim Goldshtrom (00:02.868)
Hello everyone, my name is Dr. Nim Goldshtrom. I'm a neonatologist and cardiac intensive care physician at Morgan Stanley Children's Hospital in New York. And I am delighted to be joined here by my cohost, Dr. Amir Ashrafi. Amir, how are you today?
Amir (00:17.246)
Hello, Nam, how are you? It's a pleasure to be here.
Nim Goldshtrom (00:19.848)
Great, it is a pleasure for I think both of us as we're going to soon find out. And I'm sure as the listeners can already notice we are not Ben and Daphna, right? But we really want to thank them and the entire incubator team for giving us this opportunity to talk to someone who's near and dear to our hearts, pun intended. As I mentioned, both Amir and I are neonatologists and we are here representing the Neonatal Heart Society, something Amir helped to found, a collective of professionals from
all backgrounds and disciplines, right? Focusing on cardiovascular physiology and disease of the neonatal. Some of you listening may have heard of our group and if not, please feel free to check out our site at then I'm sure there'll be some postings on the incubator site. And so we again, really want to thank the incubator for giving us this platform and having a few sessions in our lead up to our seventh annual neonatal heart conference. Is it the seventh annual Amir? Did I get that? Did I get that right?
Amir (01:15.286)
We started in 2015. It was originally intended to be an every other year meeting, but it's turned into, I've morphed into an every year meeting. So I'd have to do the math, but seven sounds about right.
Nim Goldshtrom (01:17.525)
Bright.
Nim Goldshtrom (01:26.024)
Sounds about right. COVID confused all of us for really a couple of years. So we're somewhere in the neighborhood of high single digits. But this year it's going to be in my hometown, the Big Apple, New York, in July, end of July 31st to August 2nd. And we're incredibly excited about this conference. They've just been getting bigger and better every year. I'm not sure we can top Disneyland or mechanical bull riding in Texas in a year, but we are certainly going to try in New York. I don't know what we have planned.
Amir (01:28.214)
COVID confused everybody.
Amir (01:53.858)
Can I tell you a funny story about NeoHeart and COVID? I vividly remember, I have a text message and I should have pulled it out and had it ready for this, that I texted Gil just as the pandemic was like in full effect and NeoHeart was like four months away. Oh my God, what are we going to do? What are we going to do? Gil's nodding his head and I was like, Gil, you know what we're going to do? We're going to do the full meeting virtual. And he feels like that's impossible. You can't do it full virtual. And if we do...
Nim Goldshtrom (01:57.249)
Please.
Amir (02:22.326)
I forget exactly what he promised, but I think it was something like this. It was something like, I'll come out and do a podcast or I'll do something for you. It was something like this was the bet. Do you remember this skill? This text thread that we had back and forth? Well, we're collecting on it now. We're collecting on it now.
Gil Warsofsky (02:31.35)
Uh, no. I remember, I remember the panic as the pandemic came through all of our scientific societies, uh, and it was, uh, like, what are we going to do now? Especially with New York, trying to get a room block and everything like that. It was, it was so hard.
Nim Goldshtrom (02:43.109)
Yeah.
Amir (02:44.438)
for sure.
Nim Goldshtrom (02:46.709)
Yep.
Amir (02:50.907)
Yeah, New York was chaos.
Nim Goldshtrom (02:52.653)
It was a tough time, but we are in such.
greener pastures nowadays. And so to give our audience really a sneak preview of what the society is and what our conference is to come, and also to give those from the neonatal community perspectives on how and why, all neonatology professionals, nursing providers, physicians, should be involved. We have really a tremendous honor and privilege today to be talking to a living legend in the field, pediatric cardiology and pediatric cardiac intensive care.
Amir (03:19.606)
The goat.
Nim Goldshtrom (03:21.128)
The immortal, the goat, use the acronym of your choice, Dr. Gil Warsofsky, thank you for joining us and how are you this afternoon?
Gil Wernovsky (03:28.722)
Nim Amir, thank you. Thanks for such a kind introduction. It's really a pleasure to be here.
Nim Goldshtrom (03:33.704)
The pleasure is all ours. And if you think that was a kind of introduction, I'm going to humor you with just a few minutes of your professional background so people have an understanding of who we're talking to here. Because, you know, as much as the AI revolution is coming to fruition, I just don't see a day where you're able to code in the things such as wisdom and perspective and experience.
and levity and brevity in making the hard choices of what is happening to our kids. And so having a person who has spent his entire professional career and that of many young trainees' lifetimes doing this work, we are truly honored to hear your view on the state of the field and how the neonates can and will continue to get the best care in the coming years and decades ahead. Dr. Wernovsky is a pediatric cardiac intensive care physician now at Children's National in DC.
the Neuro Cardiac Critical Care Program there. He's a professor of pediatrics at George Washington University. He's co-founder of the Congenital Heart Academy, the Pediatric Cardiac Intensive Care Society, the World Society for Pediatric and Congenital Cardiac Surgery, which just had its eighth five-year conference, I think I got that math right, in DC last year, which he helped co-chair and steer an event with 5,000 participants. I can keep reading the CV, but then that'll be the entire interview, so I'm just going to stop there. Thank you again.
and we can't thank you enough for hearing your perspective on the Cardiac Intensive World to come.
Gil Wernovsky (05:03.575)
Thanks, NeoHeart is coming a few months away. I always love going to that meeting because it's, although I've been doing pediatric cardiac intensive care and pediatric cardiology as well, outpatient, my focus has always been on the neonate, the sick neonate. What I enjoy doing is bringing a baby and a family through that. What my research has been has been on trying to make it better for them short term and long term.
So for me, partnering with the Neonatal Heart Society and Amir and Victor and the late John Cleary and with NeoHeart is one of the highlights of my career. So thanks so much.
Nim Goldshtrom (05:41.68)
We are honored and privileged to be able to, yeah, absolutely. Um, you know, it almost feels like the world Congress just ended. I know it's been probably eight months and, and I cannot imagine the work that you had put into this and, and what the feeling's like, and here we go starting another round of conferences.
Amir (05:43.346)
We're thankful to you, Dr. Wernovsky, we're thankful to you.
Gil Wernovsky (05:59.096)
It was 14 years of planning, it was supposed to be 12, but then COVID hit, as Amir was saying before. And after 14 years, now it's in the rear view mirror. And like you said, all right, what's on the dashboard? NeoHeart, here I come.
Nim Goldshtrom (06:06.137)
Yep.
Nim Goldshtrom (06:14.8)
Yeah, no, absolutely.
Amir (06:15.926)
Gil, I will say, having seen you behind the scenes of World Congress, the amount of work is immense. I mean, nobody can put into words how much, Dr. Wernovsky, how much work you put in. But I was almost convinced that was going to be your swan song and we were never going to see you in another conference again. Did that ever cross your mind?
Gil Wernovsky (06:34.358)
That was my wife's wish. Yeah, at that point I was saying, okay, get through this, do the next right thing. And I get to pick and choose a little bit more now, and that's nice. But I'm not done yet, so we'll see what happens.
Amir (06:47.239)
Nice, nice.
Nim Goldshtrom (06:52.7)
we're thankful that you're not. Because we now have an opportunity to hear from you about where the state of things in are for the neonate, right? With severe cardiovascular disease and congenital heart disease. And I think for this audience who may have not heard you before, it's probably great to start at the beginning and to say, how did we get to this place, right? Where congenital heart disease, severe cardiac disease is in the model of care where neonates can be in any one
Amir (06:53.255)
Excellent.
Nim Goldshtrom (07:22.694)
places, right, either around the country or around the world in underserved areas, and to hear your perspective on how we got to this place of neonatal cardiac care.
Gil Wernovsky (07:35.358)
Yeah, thanks, Nim. I can only give my own perspective. It's kind of hard to know from places I haven't been, but I was very fortunate to be in the hub of this in the first couple of decades of my career. So I actually had my residency in New York. Cornell was called New York Hospital then, and that started in 1982. And there were, I would say, four things, four things that started the...
sub-discipline of cardiac intensive care for neonates with its strengths and its unintended consequences. So as I said to you before we actually started, I have never given surfactant. So the field of neonatology completely changed, in my view, when that started. And surfactant and prostaglandin both started around 1981.
So prior to 1981, premature babies basically died, very premature babies, and neonates with duct-dependent heart disease basically died. But right around 1982, 83, 84, which is when I was starting my residency, is when there were things that we could do, and then once we did them, things that we could learn after that. So we talked about surfactant, and we talked about prostaglandin coming out.
bedside echocardiography came out at the same time. So for your younger attendees on the podcast, these are things that we take for granted, but those three things which are not surgery, right? Prostaglandin, surfactant, echocardiography is what opened up the door for our surgeons. Now, when I was, I started my fellowship at Boston Children's in 85. About a year after the cardiac intensive care,
model started. So there was a medical ICU and a surgical ICU, 18 beds. Doctors Norwood and Castaneda brought all the cardiac surgical patients to one end for their convenience. It wasn't that they had a strategic plan of that's how we are going to take care of neonates the best way. That was I don't want my patient, I don't want to put words in...
Gil Wernovsky (09:54.838)
both of their mouths there, may they rest in peace. We clearly wouldn't be doing what we are doing without their brilliance. But basically they recognized for themselves they wanted the patients to be all in one place. What it did was also created an amazing nursing model. Patty Hickey, who's the nurse manager there, they immediately empowered the nurses as in adult cardiac units to titrate drips to determine when patients were ready to be extubated. These are bedside staff.
and were participants in the care in 1985. So that model of subspecialization in pediatric cardiology, intensive care, echocardiography, interventional cath was happening at that time, EP was happening at that time. Subspecialization, putting patients in a single location allowed for tremendous advances. And I would pick two.
operations in particular. And imagine this in your own unit, whoever is listening out there. So when I was in Boston, we were doing somewhere around 90 arterial switch operations per year. So that's two per week. And we got pretty good at it. And as a cardiologist that worked in the ICU, I got to go to the OR and I could...
I really learned a lot early on in my career. I'm a third year fellow, first year attending, how the arterial switch is done, what the long-term issues might be. And we were still doing, Dr. Norwood had just left for Philadelphia and when he was in Philadelphia, he was doing 100 stage one Norwoods a year, two per week. So this was at a time when there were not a lot of places doing neonatal heart surgery. And the model became and was transferred to CHOP of you had a dedicated space.
for your babies and you could take care of those babies there. Now the unintended consequences is there were, I don't want to say excluded from that care, but not felt to be needed in that care, were neonatologists, neurologists, nephrologists, and
Gil Wernovsky (12:12.91)
The mantra I was taught was a good operation fixes everything. If you fix the heart, they'll be fine. And we had about a 25% mortality at the time, but that was compared to 100% mortality. So we kind of thought we were doing the right thing and that mantra was good. And a paper was published, and I hope your listeners can have a chance to look this paper up, which is called The Neonate with Congenital Heart Disease, A Surgical Challenge. Dr. Castaneda wrote that paper.
along with Dr. Wessel, who's my colleague here at Children's National. And they made the point that instead of doing palliative operations, you should fix the circulation early or doing Norwood operation early, those sorts of things. Maybe later we'll talk about how that dogma is now being questioned. But that was the model that Philadelphia took.
Children's National took mainly on the East Coast. And again, I can only talk about places I've been. Columbia then took that. Many of us in Boston felt a little bit like Johnny Appleseed. So that I finished my fellowship in 87, 95, I went to CHOP. Steve Roth went out to Stanford. Andy Atts went down to.
South Carolina and Charleston and a number of us went out and then we trained the next generation and we all trained in that same model thinking it was the best model of babies with heart disease are not with the neonatologist, they're with the surgeons and the cardiologists. And as I say that out loud now, it sounds so silly, but that was the dogma that we had at the time. And then the next thing that I'll say that I think happened around the same time is as
babies in the neonatology practice with significant prematurity got to kindergarten. And as the cardiac surgical patients got to kindergarten, their challenges in school, this is not CP and retinopathy of prematurity, but the sort of developmental stuff that we're seeing in half 60% of our cardiac patients was exactly the same thing that was seen in the neonatologist.
Gil Wernovsky (14:23.21)
And then, sorry, exactly the same thing that was seen in the premature graduates. So all of a sudden things were starting to come together that taking care of sick babies is gratifying and has long-term issues that we have to follow up on. So that sort of takes us through the first 20 years in 10 minutes. I hope that answers to how we got here, but.
Amir (14:49.418)
That does. Can I ask one question, Gail? This is actually incredibly fascinating. In your world, when did the definition of success change from survival to discharge to intact survival at discharge? When did that start to change in your brain and in your colleagues?
Gil Wernovsky (15:09.774)
It depends on where you are, right? So just like the wave of neonatal heart surgery spread and there were enough surgeons and perfusionists and anesthesiologists and intensivists to take care of those patients, just as that spread, it took a while for those newer groups to see their survivors not intact. So we started to be concerned about the brain and congenital heart disease, probably in the 90s.
it became a national recognition probably in 2010-ish. The Cardiac Neurodevelopmental Outcome Collaborative started in 2016, just as Neonatal Heart Society started in 2015. And you can see that where we're getting to is parallel convergence here of things where the fields separated, and now I'm glad to say came together. So I think we started to recognize
intact survival, probably the same time you did in neonatology. I would bet it's about the same time because that's when they separate.
Amir (16:14.183)
Interesting.
Nim Goldshtrom (16:16.052)
No, it's a great perspective and one can understand when the options are nothing, right, versus something, you know, you're going to start to move the needle. And, you know, a lot of mantras are, if you want to do something, well, do a lot of it and then get better at doing a lot of it. And it totally makes sense to hear early surgeons and the early development of surgeons and ICUs who are going to focus on cardiac populations, build up their
Nim Goldshtrom (16:46.146)
surgeries and experiences of that surgeon who's just really good and then gets trained by, trained someone else and that person gets to another center. And we've just been replicating that model, which is great. And to hear more from you, thinking about the state of cardiac ICUs now or cardiac care at hospitals now.
Do you see still some of the lingering effect? Do you think we have all as a group actualize enough of swinging that pendulum back, right? Bringing back in the other specialists, the other services, the other organs that you're mentioning, or are there still opportunities for us as a field? And we can use the neonate as a template, right? Are we maximizing what they're getting now in today's time?
Gil Wernovsky (17:30.63)
Yeah, well there's 125 centers in the US alone that do congenital heart surgery. You can imagine the variability of practices, you can imagine the variability of care models, you can imagine the variability to open this to change. And one of the things that's been very interesting to me as I just become crotchety and old and all the other stuff that go with that is to be able to stir the pot now.
as much as possible because what I was told was absolute truth. What I learned was absolute truth. And then what I taught was absolute truth is not. So when you ask the question, where is the state of the field, it's so variable. And there are.
I'm sure you're familiar with the model of early adopters and late adopters and that sort of thing. There are programs that are early adopters and late adopters as well. I certainly can't speak for all of them, but I do think that the same programs that started to separate neonatology and cardiology.
much to, I think, the detriment of neonatology trainees, cardiology trainees, and babies and their parents are the ones that are starting to rethink that model. I love the model you have at Columbia. I think it's absolutely brilliant. And having neonatal cardiac care by a group of practitioners that come to the baby is where I think everybody should go, but.
That's kind of hard to change that model in one generation. But I do want to give you and Ganja and the rest of the groups and Emile some real props because I think that is an amazing thing. I do have to say one thing. I want to tell you the definition of success. So this is a little bit of a brag, but I just had a paper published with one of my former neonatal patients who is now 30 and a physician.
Gil Wernovsky (19:38.654)
So if you want to talk about success, if you're doing well and you can get your patients to the point that they become pediatric cardiologists, that's like the coolest thing in my career right now, I must tell you. And interestingly, it was not on surgical outcomes, it was not on peak inflating pressures on the ventilator or how much milrinone to use, it was on quality of life and how to support families. And.
Nim Goldshtrom (19:40.701)
Wow.
Amir (19:46.465)
That's cool.
Nim Goldshtrom (20:05.268)
Wow.
Amir (20:06.432)
Let's take a dive into that if you don't mind, Gil.
Gil Wernovsky (20:09.414)
Because I avoided Nim's question about sort of how other questions that you're getting in the anatomy. So that...
Nim Goldshtrom (20:14.688)
That's.
Amir (20:15.726)
Avoiding them is a strategy that many of us employ. You're not the only one. So no, I'm totally joking. For people in the audience who don't necessarily follow the literature and the evolution of our understanding of heart disease and long-term developmental outcomes, like that 30-year-old who's now a pediatric cardiologist, for the longest time, we blamed surgery on it. It was the surgeon's fault that outcomes weren't what they should be.
Gil Wernovsky (20:18.318)
I'm going to go ahead and close the video.
Nim Goldshtrom (20:20.352)
Correct, correct.
Amir (20:42.014)
where is the state of the science today? And maybe you could just briefly walk us through how it started and where we are in 2024.
Gil Wernovsky (20:48.311)
I think the reason that in many centers, I'm sure both of yours are included, neurologists are welcome now and neonatologists are welcome now is because they don't say it's the surgeon's fault, because it isn't, right? But for the longest time we thought it was simple. We thought it was, oh, it's because they're blue or, oh, they were on cardiopulmonary bypass. Of course that's not the
The risk factors for abnormal development are multiple, cumulative, and additive. So they occur sequentially. They start with abnormal oxygen delivery to the fetal brain. They continue with, so babies are born with slightly premature brains, 35 weeks or so. You then have a transitional circulation that if you have a ductus, just steals blood from the brain.
and you know this, in diastole, having ductuses is not good. That's why you ask us to close them in these 500 gram babies. Ductuses are not good to have and we give a medicine to keep it open. It's not good for the brain. So that's number two, what we do pre-op in the transitional circulation. And we're getting away from that now. Maybe we'll talk about that. Then the parents hand the baby over to a surgeon or to an anesthesiologist, they go in the OR, and they have PTSD about that moment for the rest of their lives.
And that changes the way that they treat the baby. It changes their mental health. And I just re-read a paper today that 55%, 55% of the variance in developmental scores are due to five things. Cyanosis is one, and four have to do with maternal mental health. So it's an area of incredible stress. I personally can't imagine it. But that handoff to the surgeon
Amir (22:38.443)
Hmm.
Gil Wernovsky (22:41.782)
Then a run on bypass, then return to the ICU with delayed sternal closure. Then lights and noise and pain and narcotics and inotropes and everything, hyperventilation and all these things we do in the ICU to keep them alive. Then they're recovering and many need a G-tube and that's the second most common thing that affects maternal mental health to break that maternal feeding role is how...
terrible a G-tube is, then the second PTSD moment for the parents is handing the baby back and saying, okay, now you go home. And then at every visit, waiting for the shoe to drop. So you can stack that whole line up and think about where should our focus be? It's not bypass. It's the time that the baby's a fetus, pre-op, post-op, and the family mental health. If we can...
If we can get at those factors, we're going to make a big difference.
Nim Goldshtrom (23:41.728)
That's a wonderful summation of the variation in problems and really the challenges. And, you know, I think Amir and I are probably biased because we do this all the time, right? Like this is how we are there to support parents. And, you know, I appreciate greatly, you know, the model that we have at Columbia as, you know, a neonatal cardiac model where we are part of a team, right? And it is not just us. It is us. It is cardiologists and the surgeons. We are really
Amir (23:42.783)
Beautiful.
Nim Goldshtrom (24:11.722)
patient therapist to try to get at exactly those points, right? How can we build up the family, which really seems like the next level of opportunity?
four games, right? Because we let them off, they have this, you know, emotional rollercoaster of a hospital course for however many weeks. And then as you're saying, Gil, we hand it off with some instructions and say, good luck, right? But the stress never leaves them, we know that, right? The stress, the anxiety, too ventricle, complete repair, perfect surgery, or not, or palliation. They are not in a place where they've just come to, acceptance and, you know,
understanding like, yep, I have my baby and everything's great. Um, it, what in your mind then is, is a bridge because I know we all, you know, for at some lack of better words, you know, stop caring for them, right? The intensivist, you know, say goodbye and we have to usher them in. Uh, what do you see as that bridge? Um, how can we be doing better when they're not out of our sight and under our hand? Um,
Gil Wernovsky (25:11.682)
Right, it's a, yeah, it's a great question. Well, first is a philosophical change of your team. So that in many places, the definition of good ICU care is transferred to the floor. In many places, good hospital care is just charge. If the team starts to then focus on good hospital care is a 10th grader who can do the laundry. and can take an SAT and can drive a car without being distracted. If you start to think about that's what we're trying to create here, um, it takes a village, as you say, you know, and, and the important thing, thinking about that long term is what being an outpatient pediatric cardiologist did to change my practice. Because I think you have to see the products of your success, so to speak, to sort of know how to bring that back to your practice. And that's something that doesn't, nor should it happen with neonatology. One of the things also to think about that I've seen in neonatal follow-up programs is somebody graduates. Nobody graduates from congenital heart disease, so they should never graduate from long-term follow-up for themselves and for their parents.
Amir (29:05.43)
Good point.
Gil Wernovsky (29:11.029)
And I think it's all well and good that we have a lot of stuff within our intensive care units We similarly at Children's National OTPT pharmacy nutrition couldn't do our work without them And of course the people who touch the babies, which is the excellent bedside nursing staff But if we send them home Without the same sort of support maybe not as intensely but without the same sort of opportunities we've missed the boat, you know, we've just not done what they can. So I think, as I said, a philosophical change, find out how they're doing in the outpatient department, and be sure you're using all the resources of your institution. It doesn't have to be a follow-up program like Columbia's or CHOC's or Children's National. It needs to be a follow-up program that fits within the resources that you already have, but you have to have it.
Amir (30:05.174)
Awesome. I'm going to get controversial for a second here. We talk a little bit about, actually, you know what? Before we get, yes, exactly. Before we get controversial, I'm going to ask a lead up question first. You were instrumental in getting CICU to where it is. You were boots on the ground right from the get go. If you had to redesign it, you could go back in time. What would you do differently?
And my next follow-up question, I'm going to sort of maybe weave it in there as well, which is more controversial. A lot of neonatologists want to be involved in care of these babies with congenital heart disease, but I'll be honest with you. I can pretty comfortably say that they're not qualified to do so. And NICU fellowship does not give you the qualifications, the understanding to really be an integral member of the team. So there's always this delicate battle between, I want to do it, but those guys don't know how to do it. So how do we, number one, redesign?
And how do we get everybody up to par so that we can provide best possible care for these complex patients? Sort of a two-parter.
Gil Wernovsky (31:11.741)
Yeah, yeah, let me do the second part first. And we've started doing this at Children's National and it's probably just as important as anything is. If this is a goal of your cardiac program and your neonatology program, there's no substitute for non-Zoom meetings at the bedside of neonates with heart disease once or twice a week. It may only be the fellows.
but if you can bring babies by, and I'll give you just a good example. The notion of removing UV lines from the right atrium. We'll use that as a controversial point. We know that UV lines, I think I know this, that UV lines based on premature babies can perforate the right atrium and they shouldn't be kept there. We also know that our surgeons have been placing trans-thoracic right atrial lines
since 1984 without, it's never zero complication, but basically without a question that we could leave it there. So I'm not saying one is right and one is wrong, but bring that dialogue to the bedside and say, why are these practices so differently? Why is the, have we extrapolated too much from term babies with surgical intervention? Have you extrapolated so much from preemies?
that may not be relative to a term infant, I don't know. Those conversations have to happen to find the more common ground, rather than by fiat saying, oh, we want to be involved and we'll do the TPN and we'll do this kind of billing, whatever it might be. Get the stakeholders together at the bedside with babies and just listen to each other. It sounds easy. I wonder if somebody could do that.
Amir (32:41.43)
Totally.
Amir (32:52.574)
Mm-hmm.
Amir (33:00.102)
If only there was a meeting for that, Gil, if only there was a meeting for that. Where neonatologists and CVSU could get together.
Nim Goldshtrom (33:08.104)
Yeah, Meir, get on that. We got to get something together.
Gil Wernovsky (33:10.858)
Neo-heart society? Anyway, the first one though, I think, is a tougher question. What would I do differently? I don't know. It's easy for me to say. You know I've said this at the neo-heart meetings in the past. I wouldn't have involved. I wouldn't have made neonatal ICUs this way and blah, blah.
I read a great, I love memes, you know I love these little aphorisms. And you know, they said that the butterfly doesn't look back at the caterpillar with shame. It was just a necessary process to get to where we are now. So would I have done something differently? Well, we wouldn't be here right now. Would we have had a better outcome? It's all speculation. I don't know. I don't know what I would have done differently. I certainly could think of
The theoretical or the real advantage is if we had term cardiac babies, near term cardiac babies, near term babies with emphysema and CDH, near term babies with infection, near term babies with neurosurgery, near term babies with HIE, in one place, there would be a lot of cross-pollination of how the blood goes around in a CDH.
And do we need, as I think you've said before, a CDH adduct-dependent lesion, interesting ways to think about taking care of neonates that don't have congenital heart disease but are parallel to congenital heart disease, et cetera. Would that have been a better model? I've thought so, but I know for a fact with everything we've ever done, there would have been unintended consequences also. And I don't know what those consequences would have been. So the only thing I would say to that,
Amir (34:52.374)
Good night.
Gil Wernovsky (34:54.165)
To close that thought is we have to embrace, at least think about changing the model periodically. So, yeah, please go ahead.
Amir (35:02.762)
Can I jump in again, Nim? Sorry, sorry, Nim, to jump in multiple times in a row. Actually, I want to give big credit to Gil on what you just said right here about being together in the same room, cross-pollination. Gil, you, and I've told you this, and I'm just going to say it online now, you are responsible for changing my thought process about how we manage congenital diaphragmatic hernia. You've completely changed how our institution at Chalk manages congenital diaphragmatic hernia. This is a great story I love telling people. I'm sure some people have heard.
It was the first meeting we had, it was 2015, and of course, oh my God, Dr. Gil Wernovsky, again, he's the goat, he's here at this meeting. I mean, we were, I mean, I was like, more so than, you know, I was starstruck, I'm not going to lie to you. And so I went to him and I was like, hey, you know, Gil, you know, what do you think, how's things going? And I was hoping for some attaboys and some accolades, and he gives me, you know, yeah, it's good, it's good, but you know, it needs to be better. Okay, tell me how it needs to be better. He's like, you know, you have a room of Neos, talking to a room of CVSU people, but we're not really...
talking to each other. What kind of Neos are talking to Neos and CVs are talking to CVs? We need to get people talking to one another. I'm like, okay, so what do you have in mind, Gil? He says, you know, diaphragmatic hernia is a lot like a Schoen's complex. I don't remember exactly what Li Jianyu said. Interrupted arch, yeah, Schoen's complex is a small left-sided structure. It is basically the same, right? And then you started talking, and I didn't hear a word Gil said after that, because I was sitting there nodding my head, trying to be smart, going, what is he talking about? Diaphragmatic hernia is like interrupted aortic heart,
Gil Wernovsky (36:16.791)
Interrupted arts. It was like interrupted arts.
Amir (36:32.554)
What could he possibly talk about? And it wasn't until two to three days later that I actually understood what he was saying. It wasn't until two to three days later that we really started to take this. One of my fellows, I'm sorry, one of my residents did a research project, turned out he was exactly right. And so that crosstalk, cross-pollination was hugely helpful for me, changed how we do diaphragmatic hernia in our institution. And there've been multiple publications since then. So I wanted to make sure that you get full credit for that, Gil. That was entirely a side conversation in the hall.
Again, mind expanding.
Gil Wernovsky (37:03.047)
I remember that. Yeah, thanks. Thanks, Amir.
Nim Goldshtrom (37:05.62)
But these speak to, I mean, it really cannot be overstated what you just said, Gil and Amir, that you reiterated cross-pollination, right? Like think about the trainees and the people who have been coming up in the last 20 years, right? How much extra fellowship and extra training they're getting, right? How much the three years of critical care and then two years in cardiology or CICU, right? How much at least, let's say on physician provider levels,
attempts and the efforts of individuals to go get cross-discipline training, understand your colleagues, right? Who you may not be a full-time echocardiographer, but you do some cardiology training and get the perspective of what they're looking for, learn how to read an echo. And I, and I, you know, to keep in the controversial scheme theme, let's talk about training and education. From what you guys are saying, it seems like not just communication at the bedside, right? Like,
bring the teams together in person, have dialogues, listen to what your other specialists are saying. But it is just as important potentially that individuals who want to work in these more highly specialized fields, and here we are talking about heart disease and the neonate, one could also be talking about the premature baby with severe chronic lung disease, right? And we're maybe having the perspective of a neurodevelopmental follow-up person as a neonatologist getting extra training
and learning what's going to happen long term can be a bridge, right, where you work in a team. Should that be the standard? Should we be moving to places? And I worry, not worry, but I wonder from it more even from our nursing colleagues. We are getting so good, right? David Wessel talks about the 3% where we're stuck at this 3% globally of mortality. So we're good at keeping kids alive. The preemies are going to be growing and surviving and getting longer.
should we be asking or putting in places ways for our trainees, our nurses, our future physicians and leaders to get more cross education? And the counter to that is, I'm going to speculate here again from my own experience, but I wonder if sometimes people are too eager to get to work, that they're waiting to get out of their training, or wanting to quote unquote start their career.
Gil Wernovsky (39:10.23)
Mm.
Nim Goldshtrom (39:26.)
rather than think about this investment of time, right? And where it does take time to get to a mastery of something. And that people want to kind of like get out of school and start to work. Are we going to maybe have a challenge getting people to buy in where spend some time learning how to take care of this population, then come over here and learn how to care of this population and then come and bring it together. And now you've truly mastered a combined skillset. Are we entering an age where that's going to be harder? Should that be the standard?
in how we educate and train the future at all. Nursing, I think, is even more important than the physician for a preemie with a truncus arteriosus who's 30 weeks and needs to grow for two months because you don't want to band them and screw up the truncal valve. That nurse is the lifeblood of that child for the next two, four, six weeks until you can do a full repair.
Gil Wernovsky (40:14.185)
This is where I become the grumpy old boomer and say, this is what happens with a generation.
Nim Goldshtrom (40:18.836)
You're, you know, be as joyous or not as you want to be. It's definitely not meant to be a conversation on the changes of societies and of individuals, but if we ask more of individuals, right, what do they get back other than this mastery? And how do you...
how do you put on the concept of mastering for the sake of mastery to be even better for your patient can be a reward of itself, even though it takes more time, it takes more investment, doesn't get you quote unquote to start your career.
Gil Wernovsky (40:48.361)
Yeah, I'm sure the three of us can not relate to the visceral response of, I've got a gazillion dollars of loan to pay. All of my friends are traveling with their families. And I just want to start to work again. And that's not an inferior choice to an extra certain amount of time with training. It is what it is. So the challenge is.
Nim Goldshtrom (41:05.564)
Absolutely. Yeah
Nim Goldshtrom (41:12.316)
No, absolutely, absolutely.
Gil Wernovsky (41:17.237)
for our field to move forward is to find those people early on so everybody has the right expectation. Expectations are the seeds of resentment. So the notion that the expectation for a cardiac ICU, for me, is I personally am not a fan of doing a full fellowship and an extra year in the ICU. That if you've done a cardiology fellowship,
that doesn't make you an intensivist. If you've done a cardiac intensivist, a cardiac, I'm sorry, if you've done a PICU fellowship, it doesn't make you a cardiologist. That just gives you more pattern recognition to what you already knew. If you're going to be a cardiac intensivist, you have to understand anatomy and physiology. That's bottom line. That's all you have to understand is anatomy and physiology. You need to know a little bit of EP, you need to know a little bit of...
other parts of the cardiology fellowship, but as you were saying before, you're not going to learn how to do an echo as a neonatologist for complex congenital heart disease. That's not the point. But you need to learn how the blood goes around. You need to know why the blood goes in this direction, how the surgeon intervened, and why this tent is going to look different post-op than this tent is going to look different post-op.
Nim Goldshtrom (42:27.72)
course. Yes.
Nim Goldshtrom (42:34.161)
Yes.
Nim Goldshtrom (42:39.284)
Yeah.
Gil Wernovsky (42:39.717)
So I think our generation is going to be very institution dependent, but I think we want to find people and show them why we love our jobs so that yes, you have to do five years to do this, right? And then you have to do another three years as a junior faculty member knowing that you haven't mastered it yet.
Nim Goldshtrom (43:00.585)
Yeah.
Gil Wernovsky (43:01.805)
So, and in terms of turning, in terms of growing the field of neonatal cardiology, I think I would feel exactly the same way. I don't know enough about 2024 neonatology, but I know there's everything I don't know. Like I said, I never gave surfactants. So, you know, what is being done now needs a full neonatology fellowship, and then you need to understand anatomy and physiology, period. That's
Nim Goldshtrom (43:17.789)
Yeah.
Nim Goldshtrom (43:24.992)
Well, I liken it to the hemodynamics arm that is growing at a places like Toronto, Montreal, and Iowa with Patrick McNamara's program. That is extra training. You are gaining a skillset to take back to the premature baby and really open up a brand new window of diagnostic opportunities and therapeutic targets that you did not have before. And again, I personally agree with you because I think to have a conversation
a multidisciplinary team or in complex physiology requires us to stretch ourselves, right? And as you just noted, critical care in cardiology has been doing this cross-pollination for years. And again, I never want to mention it as kind of like, this is why neonatologists aren't there, but I think we just haven't realized as a group, right? Because of also some of the systematic stuff that you had mentioned, right? Like the system is, the world of cardiac ICU as it's placed babies in certain parts of hospitals
has, again, not for exclusionary reasons on purpose or not to try to limit the access of neonatology as a craft to that patient, but just as a way the system has evolved, has just not given the neonatologist much opportunity to realize, oh, if I did these things, right? If I did neonatology and then spent two years in cardiology and then got a CICU job, either as like the consultant or the CICU person, I could do the exact same things, but they've just made me not being exposed to it. And what I'm hoping that the Neonate Heart Site
continues to do is say that you are no different. You are a critical care person who has mastered babies and premature infants. They are a large population. But just like we ask our PICU colleagues and our cardiology colleagues, just like you said, to do more, it's needed. This is a much higher stakes, much more complex patient care management system, all rooted in anatomy and physiology, as you're saying, but of a mastery of it.
cannot be sitting around there thinking about this complex heterotaxia with left atrial isomerism, who's got transposed gray vessels in a double outroute and this outflow transconstruction and figuring out where the blood flows to manage a patient, you have to know these things innately and you don't do that without additional treatment exposure.
Gil Wernovsky (45:41.405)
This will, you know, this took 40 years, right, to get to where we are now. It's not going to change in four, right? But looking back over the past 10 to 15, I think that the larger programs, both training programs and surgical volume programs, have brought back in expertise of neonatology and neurology in particular. If I had to pick...
Amir (46:06.124)
Agreed.
Agreed.
Gil Wernovsky (46:09.737)
the two most important consultants that we have from there looking at the baby through a different lens. It's those two subspecialists.
Nim Goldshtrom (46:20.232)
No, we want to be involved. I know so many people who want to be a part of this. And so to ask maybe slightly less controversial question, putting on your leadership hat, right? You are thinking about a program and a hospital system. What would you think would be either a minimum standard or a degree of extra training, right? You have an neonatologist who's interested in it.
how would you guide them to the level of extra training? It is easy and again, I'm just going to give you my personal recommendation. I counsel people who are interested in this to think about it just like a critical care person. You are going to have to do extra training, they do it as well. Someone who really loves this craft and if you really love it, this extra training is going to seem like seconds of your life once it's done and you're doing it every day of your life.
Gil Wernovsky (47:11.505)
Oh, it's so easy to hear, but don't tell, don't tell somebody. Oh, it's just going to.
Nim Goldshtrom (47:14.624)
Correct. No, I look my year at Boston was it was intense. The travel and the commitment when you're in it, it is tough, right? You can't, you know, it doesn't look as fondly when you're in it. But if you love it, it doesn't feel like a struggle. And that's the thing. That's how you know you're doing the right thing. For neonatologists to be more involved. What's the minimum that you think or where should they all be looking at? CICU years, do the second, you know, do the two year cardiology fellowship as well to get involved.
I don't want to put people on the spot in terms of like, how do we get more involved? But to me, it just seems like the simple answer is, do what our other colleagues do, right? Learn about your other field, right? So you can be more of, understand their language, know how to communicate. And then it's easier also for hospitals to help you be a part of that team because you have the clinical training expertise and partly also the quote unquote certification that you get from these endeavors.
Gil Wernovsky (48:07.457)
Yeah, let me address that certification question because I think it's very important. If you are a neonatologist and you're in a neonatal cardiac program and you don't like the way you're getting your echo reports read, something about it, the timeliness or whatever, it's really hard to walk into the head of the echo lab and say that, harder. Whereas if you're a board certified pediatric cardiologist, you've done a fellowship and you can say exactly why.
These are realities of what we deal with in academic institutions. So that's to become a leader in this field. If you want to be a leader in this field, the reality is you have to have, at least as of today, you have to have double board certification. It's just the only way it's going to work out. But in terms of answering the question the way you asked them, I chose the profession that I'm in right now
older than me love what they do. It wasn't so much that I had a strategic plan that in 2024 I was going to sit on a podcast with you dudes. And it wasn't that I was going to necessarily do the research that I've done or the patient care pathway that I've done. I looked at people and I said, I want to be like that. I want to be like her. I want to be like Jane Neuberger. I want to be like Peter Lang. And...
I think the best, when we talk to people and say it'll go by fast, I don't address that. Frankly, I tell people that this sucks, that you got to do an extra amount of time and you have to delay your loan payment and you're going to get paid like a, not like what you thought for another year. At the same time, I love what I do. What else are you going to be, where else are you going to be able to say? And I say this all the time. I'm 67 years old.
I come into work now and every week, every single week, I see something I've never seen before. I don't know how many neonatologists can say that in a usual population. I don't know any adult cardiologists that can say that. Right? Valve, hypertension, valve, hypertension, valve, hypertension, arrhythmia, valve, hyper... I mean, that's what an adult cardiologist does. So we have kids out there right now in the ICU that I've never seen before.
Gil Wernovsky (50:33.541)
You know, so for me, if I can generate the interest in this is a great field, this is what it takes to get to this point. And it's worth it. That's the way I've approached it. And it you know, we have three of our PICU fellows have decided to do cardiology fellowships this year. I'm really proud of that. Not, you know, not do an extra year, but they want to double board. And that.
I would hope that neonatologists will see, hey, not only can I learn about complex congenital heart disease and all the things that I can do to the mother, do to help the mother of a hypoplast, I can do to help the mother of a 900 grammer. And I can still go back and take my skillset in both places. So to answer your question is to cross-pollinate, is to hybrid the training to do, to...
Talk to the board in advance if you can to say I want to do five years. This is the program director here, this is the program director here. This is how I'm going to divide it up. My one year of research, I'm going to do X. Thinking about it early on is crucial.
Nim Goldshtrom (51:45.92)
No, it's a great point. I mean, I echo your sentiments and it's great to hear that in such a seasoned place of your life and your career, you're still passionate, and gain the kind of personal reward from your work.
Gil Wernovsky (52:00.316)
I'm on a podcast with you Schmigegs. I mean, come on.
Nim Goldshtrom (52:03.484)
This is true. This is, I can't believe it's even close to a highlight of your career, but I mean, I have pinnacles here, but I, I mean, I agree. I think I, again, looking at my situation, I would say, as you pointed out in the air, like we're kind of the lucky ones. We got exposed, right? I candid to a program with a lot of heart disease and you as well.
Amir (52:08.082)
I was going to say, pinnacle, pinnacle of his career, pinnacle. Bigger than World Congress.
Gil Wernovsky (52:10.697)
That's right.
Nim Goldshtrom (52:27.368)
And we took those opportunities and I'm wondering systematically as a society, meal hard, the pediatric cardiac intensive care study.
Are there things we could be doing more to give these ancillary team members, right, people who could be doing this, just more exposure to see what brings us so much joy, why we enjoy, why we spend those extra years? I would do Boston again in a heartbeat. Two times over, I would double board because I enjoy my job so much. But I got that exposure, I got to see what the opportunity could be like. I'm wondering if we're missing, right? Getting other highly dedicated and potentially wonderful individuals.
Gil Wernovsky (52:54.593)
Thank you.
Nim Goldshtrom (53:03.264)
because they, again, as you had pointed out, right, the system is the way it is. There's cardiac ICUs, there's PICUs, we are cohorting where we are historically, and that's changing, right, that's changed over the last 20 years. But are we, can we be doing more to get NEOs, to get nurses, neonatal nurses, more exposure?
Gil Wernovsky (53:19.539)
I'll tell you about the physicians. I think where we might be able to leverage this better, I don't know what it's like at your places, but our pediatric residents are just not getting exposed to this and they make their decision by their second year, what they're going to match in, or what they're going to, I'm sorry, what they're going to do a fellowship in, long before they get exposed to this podcast, right?
Nim Goldshtrom (53:40.42)
Oh yeah, absolutely.
Gil Wernovsky (53:41.949)
So if I had to pick something where we could maybe influence it is to go to the training programs in our hospitals and find second year residents or even interns and say, hey, this is, if you have some time, come spend a couple of weeks with me. That's where we're going to find those enthusiastic people who by the time they hit their second year say, you know, I'm going to call the American Board of Pediatrics and I'm going to see how I could do a dual fellowship in neonatology and cardiology. I would love to see that happen.
But if they don't get exposed, by the time they get to be a fellow, that ship may have sailed already. I mean, we see some, but, and I, like I said, I'm really proud of the, the three fellows who are there. They're phenomenal. So I'm really happy for them. And I hope that there's some neonatal fellows at your program are going to see the same sort of thing, but.
Nim Goldshtrom (54:32.924)
No, certainly the fellowships are opportunities, but as you said, residents can be a great opportunity. I don't see them nearly at all in a cardiac ICU, as much as they get to rotate in a...
Amir (54:42.47)
And we don't see it at all. We actually do have a, we do have a third year fellow right now who's actually going into a cardiology fellowship. We have another third year fellow who's going to do a fourth year fellowship in Iowa for hemodynamics. And let me just put in a cheap plug, if there's anybody listening on this call, we do have a fourth year fellowship at CHOC in neonatal cardiac intensive care and hemodynamics. So if anybody's interested in applying for that, please reach out to me. But I do think that this is how we're going to get people in the field. I think this is how we're going to move the field forward.
to Dr. Raffi's point, it took us 40 years to get here.
Gil Wernovsky (55:11.797)
Well, not to take it away from your plug-a-mirror, but as I understand, there'll be a great opportunity to meet all sorts of training program directors at a meeting called NeoHeart 2024, New York City, July 31st. Obviously. We can see that.
Amir (55:22.122)
Ha ha.
Amir (55:25.58)
Tell us about that, Nim. What's going on in New York City?
Nim Goldshtrom (55:28.488)
Yeah, well, if you guys enjoyed this broadcast, then you're certainly going to enjoy even more of this in the summer, in the next couple of months. But no, you bring up a great point right there. There are some gateways, right? The largest programs, DC Children's, the Bostons, the Seattles, Texas, you know, if your spot gets filled up, Amir, for advanced training, we have a fourth year spot in neonatal cardiac ICU at Columbia. So yeah, we have an available spot. Oh, thank you. And so you're right, there are opportunities
Amir (55:50.774)
Do you guys have a fourth year spot now? Do you guys have a spot now? Congrats.
Nim Goldshtrom (55:58.402)
They're small, but it's still not nothing. And we have observerships. People can come in to kind of just see the unit and understand it. And this can really be the next gateway to getting people interested. And so if you guys have liked what you heard here, and again, Gail, we cannot thank you enough for your time. And if you think the podcast version of Gail is great, the in-person one is even better. We hope to continue these conversations and get to what the next generation of neonatal trainees
Amir (56:16.318)
Thank you so much.
Gil Wernovsky (56:20.992)
No.
Nim Goldshtrom (56:28.462)
babies with cardiovascular disease are going to be looking for in the future at the Neon Heart Conference again this summer. Guys, thank you so much. This has been great. Thank you to the incubator for giving us this opportunity and we look forward to other special guest podcasts in the future coming up. Thank you guys and we'll be in touch.
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