“Primum Non Nocere”

It is my privilege to participate in this festschrift for Dr. Peter A.M. Auld and to reflect on the impact he and others have had on my career. I served as a resident in pediatrics at The New York Hospital-Cornell Medical Center from 1978 to 1981, and took my fellowship in neonatal-perinatal medicine there from 1981 to 1983 before moving to Baltimore with my family.

My exposure to the field of neonatology in medical school was limited to observing a pediatrician perform a newborn exam, being shown how strong a newborn's suck was, and learning firsthand that an infant's first meconium stool had no odor. With that introduction I was to begin my residency on Saturday, July 1st, in the NICU at New York-Cornell. It would also be my first on-call.

Dr. Auld greeted all of the new residents in the week or so prior to the “official” start of residency. I can't recall all these years later what he said, but knew I was in for a terrific experience. And so it was with eager anticipation (and trepidation) that I began my residency.

I decided almost immediately that I wanted to pursue a career in neonatology. What other time in a person's life is as important? What potential impact could a physician make on the rest of a newborn's life? The technology and science were appealing, but so was the art of the practice of medicine. Unlike other subspecialties, the neonatologist had the opportunity to care for the entire baby, if for but a limited time. The field was literally brand-new with a myriad of questions to be answered.

As residents, we learned a great deal about prematurity, what was then called hyaline membrane disease, ventilator management, nutrition, and neonatal sepsis. One of my very first patients was a neonate who died of overwhelming Group B Strep pneumonia. While we had ventilators, bedside sonography and echocardiography were in their infancy. Surfactant was not yet on the horizon. Indomethacin was available only as part of a clinical trial.

Ours was an especially busy NICU. As residents, even as PL-1 residents, we participated in neonatal transport, bringing infants who required the sophisticated care they needed back to New York-Cornell's “N5” unit. We grew up quickly, having been given such an awesome responsibility. It was on transport that I learned many lessons. While there was much talk about regionalization of neonatal care, there was much to be done at the level of the outlying community hospital in the hours prior to neonatal transport, and it would be far better if the mother could be transferred prior to delivery to provide the best possible outcome and avoid mother-baby separation. Dr. Auld would frequently make reference to the need to have a “neonatologist in every pot.” This statement demonstrated vision to me-the need to have effective means of resuscitation available to every newborn regardless of the hospital of their birth, years ahead of the development of the Neonatal Resuscitation Program of the American Academy of Pediatrics.

During my internship I interacted with phenomenal individuals, all of whom have made a tremendous impact in my life. In addition to Dr. Auld, there were Dr. Alfred N. Krauss, Dr. William W. Frayer, Dr. Sylvia Schechner, and Dr. Armando Grassi. I am indebted to each and every one of them who in his or her own way contributed to what was a phenomenal program supportive of education, research, and clinical care. Fellows in neonatology at the time included Dr. Noel Carrasco, Dr. Tom Myers, Dr. Edmund La Gamma, Dr. Jerzy Szatkowski, Dr. Ellen Eisenberg, and Dr. Rob Stavis. Their camaraderie and the enthusiasm they brought to the NICU every day was infectious. Lest I forget all the nurse-clinicians and NICU nurses from whom we all learned so much.

My decision to become a neonatologist came early in my PL-1 year, and I decided to remain at New York-Cornell for my fellowship experience following my PL-3 year. Fellows I worked alongside of included Dr. Marty Katzenstein, Dr. Arnold Mackles, Dr. Frank Ferrentino, Dr. Franz (Joe) Baska, Dr. Johanna Triegel, and Dr. Rebecca Cooper.

During fellowship training we were encouraged by Dr. Auld to find answers to questions we had about a wide range of neonatal conditions. Often we found that the research to answer our questions had not yet been done. How best to treat persistent pulmonary hypertension of the newborn? Paralysis and tolazoline? Hyperventilation? Alkalinization with sodium bicarbonate? Vasopressors? Vasodilators? Transfer for extracorporeal membrane oxygenation? How to make sense out of all of this when the literature was not clear and was largely filled with articles of “'How we do it” or “Why we think you should do it our way”? As sophisticated as the technology appeared at the time, the field was-and still is-very young. There were lots of opportunities for clinical investigation. It was during that time that I developed research interests in neonatal necrotizing enterocolitis and worked under the mentorship of Dr. La Gamma, now an attending neonatologist, and with Ms. Susan Ostertag our nutritionist. We published one of the first clinical trials of early versus late feedings to determine if delaying the introduction of enteral feedings would prevent neonatal necrotizing enterocolitis (La Gamma EF, Ostertag SG, Birenbaum H. Failure of delayed oral feedings to prevent necrotizing enterocolitis. Am J Dis Child 1985;139:385-389). The controversy continues!

Words that have stayed with me from the first time Dr. Auld said them are “primum non nocere.” First, do no harm! How easy it was to do something, anything, even in the absence of clinical data to support certain therapies which have since been shown to be worthless at best, or potentially harmful. Neonatology's history is replete with examples of ignoring the dictum of primum non nocere.

I moved to Baltimore with my family to pursue my career in neonatology at a tertiary-level community hospital with a residency in pediatrics and a clinical neonatology fellowship training program, as well as an active transport program. My training under Dr. Peter Auld was instrumental in improving the care for neonates not only in our nursery but also at those hospitals that referred high-risk infants to us. Our NICU joined the Vermont-Oxford Neonatal Network, providing us the opportunity to compare our experiences over time and within a large universe of patients sharing a common definition set.

My experiences at New York-Cornell and Dr. Auld's instruction served as a strong foundation for me as I chaired the Maryland AAP's Committee on Fetus and Newborn and served on statewide committees. We helped to craft Maryland's Perinatal Guidelines defining various levels of care, and the Maryland AAP Chapter's support was instrumental in legislation being passed which mandated a 48-hour length of stay for mothers and their newborns following uncomplicated vaginal delivery.

After close to 20 years at a tertiary-level community hospital NICU, I took a brief “sabbatical” at the Food and Drug Administration's Center for Drug Evaluation and Research. I worked in the Division of Pulmonary and Allergy Drug Products. There, I learned that the FDA's role in the drug development and approval process was often misunderstood. Drugs needed to be proven both safe and effective prior to approval. My job was to do the right thing without regard to commercial interests, and the dictum of primum non nocere was recalled over and over again as we considered a wide range of drugs under development or being proposed for new indications. My experience at FDA was invaluable as I recently returned to the clinical arena at another community hospital.

In ways that I could not imagine during my residency and fellowship, my years at New York- Cornell, working with many wonderful individuals, had a significant impact upon my career. I thank Dr. Auld for his outstanding leadership, vision, and instruction, and wish him well.