CSA Online First

CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Rita Agarwal, MD, FAAP, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

"Better solutions to difficult problems are usually made when all sides are heard."

Steven Goldfien, MD

 

An Interview with Dr. George Gregory

by
  • Stephanie Ranz Gilbert, MD, and Tuyen Thanh Nguyen, MS-4
| May 04, 2020

The CSA Committee on the History of Anesthesia congratulates the winners of the 2020 CSA History of Anesthesia Essay Contest: Stephanie Ranz Gilbert, MD, and Tuyen Thanh Nguyen, MS-4, co-authors of “An Interview with Dr. George Gregory.” 

Both Dr. Gilbert and Ms. Nguyen are Bay Area natives. Dr. Gilbert, a CA-2 anesthesia resident at UCSF, enjoys surfing on days off. Ms. Nguyen, a medical student at UCSF who also matched there for anesthesia residency, is an avid hiker and camper. We are happy to share their essay with you here.  

It was a close competition this inaugural year, with several remarkable entries from across the state. A blinded judging process was used to determine the winners. As a reward, Dr. Gilbert and Ms. Nguyen received a CSA Foundation for Education prize of $1000. They were also invited to present their piece at the 2020 CSA Annual Meeting, but the conference was unfortunately cancelled due to COVID-19.  Instead, they will give a virtual presentation on Saturday, June 13, during the upcoming CSA Resident Research Day.

The CSA History Committee looks forward to launching the 2021 CSA History of Anesthesia Essay Contest this summer. Please stay tuned for an official call for submissions in August. 

An Interview with Dr. George Gregory

Stephanie Ranz Gilbert, MD, and Tuyen Thanh Nguyen, MS-4

Stephanie Gilbert, MD, CA-2Tuyen Nguyen MS-4A Memorable Night 
Late one night in 1968, the nursery’s intensive care anesthesiologist was called in to hand ventilate another hypoxemic baby. This time, it was the child of a faculty member known to him, and he was dismayed to receive the first blood gas with a partial pressure of oxygen (PaO2) of 30 mmHg. Since the baby was premature, cardiac catheterization had been recommended. The anesthesiologist hand ventilated the infant through the procedure, but he feared intubation was imminent.

He remembered his prior cases of neonatal respiratory distress syndrome (RDS) in premature infants and felt frustrated as he thought: “This one will go just like the others. Intubation only leads to worsening hypoxemia and acidosis, and exposure to high inspired oxygen concentration can lead to an inflammatory response with morbid sequelae after only 5 minutes.”1 In fact, many of the babies treated conventionally for hyaline membrane disease— particularly the ones under 1 kilogram—had only a 15% survival rate. A lack of understanding of neonatal pulmonary physiology often resulted in ineffective mechanical ventilation.2 

As he ran through the management options for the deteriorating newborn, the young anesthesiologist thought of a recent paper, which posited that many babies with hyaline membrane disease grunted as they breathed spontaneously in order to stent alveoli open at end expiration.3 Based on this information, he wondered if the application of positive end-expiratory pressure (PEEP) would help keep his colleague’s child alive. 

In a stroke of genius, he applied 8 cm H2O of PEEP using an Ayres T-piece. The T-piece was connected to fresh gas flow as well as a reservoir bag, and the system could be pressurized either by squeezing the bag or by adjusting the flow rates. Holding his breath, he followed up with blood gas analysis and noted that the PaO2 had risen to 80 mmHg, then to 230 mmHg, over the next hour. He could hardly believe that he was actually able to lower the fraction of inspired oxygen!

This memorable night changed the course of Dr. George Gregory’s career, and with it,

George Gregory MD
George Gregory, MD

the history of pediatric anesthesia internationally. He began to study neonatal pulmonary compliance and resistance and measured functional residual capacity with and without PEEP. He performed an initial study on neonates with respiratory distress syndrome and found that none of the first babies treated with nasal continuous positive airway pressure (CPAP) had developed chronic lung disease. The survival rate went from 15% in 1960 to 85% by 2000.2

In Dr. Gregory’s landmark New England Journal of Medicine publication in 1971, he presented two methods to apply CPAP: 1) via an endotracheal tube as described above, and 2) using a plastic pressure chamber without an endotracheal tube. The latter method made him the first to apply CPAP without intubation.5 Originally called the “Gregory box,” this plastic chamber surrounded the infant’s head and had openings for fresh gas inflow and outflow. The chamber itself could be squeezed manually to apply positive pressure.

Dr. George Gregory’s Life and Contributions      
Dr. Gregory was born in Denver, Colorado. At 8 years of age, an abscess formed on his leg, and the immediate alleviation of pain when it was lanced sparked an interest in medicine, and eventually led him to a career in anesthesia.4 He attended UCLA for undergraduate studies and went on to receive his medical degree from the UCSF School of Medicine.

He remained at UCSF to complete his residency in anesthesiology (1965-1967) and fellowship at the Cardiovascular Research Institute (1967-1968). After fellowship, he was introduced to Dr. William Hamilton, who was then Chair of Anesthesiology at UCSF. Based on Dr. Gregory’s interest in neonatology and respiratory distress syndrome, Dr. Hamilton recommended him for the role of intensive care nursery anesthesiologist—one of the first in the nation at the time.

When Dr. Gregory first began work at UCSF in the 1960s, anesthesia and critical care, particularly in pediatrics, were only beginning to modernize. Dr. Gregory recalled being taught to intubate an infant by sticking his finger into the mouth and passing the endotracheal tube along the palpated epiglottis, looking for an improvement in pulse rate and cyanosis. This was before the widespread use of pulse oximetry. Ventilators for pediatric patients were rudimentary, leading to pulmonary trauma and diffuse systemic complications.  Mortality rates were alarming for infants with RDS.2

In addition to his life-saving discovery of the use of CPAP in neonatal RDS, Dr. Gregory made numerous subsequent contributions to the field of pediatric anesthesia, such as defining differing anesthetic requirements for children. His landmark textbook, Gregory’s Pediatric Anesthesia, remains a cornerstone reference for trainees in anesthesia and critical care. Today, he tirelessly continues to train pediatric anesthesia residents, fellows, and attendings as Professor Emeritus in Anesthesia and Pediatrics at UCSF. 

References

1. George Gregory, M.D, phone interview, February 3, 2020.

2. Philip, A. The evolution of neonatology. Pediatr Res. 2005; 58: 799-815. 

3. Harrison VC, Heese Hde V, Kline M. The significance of grunting in hyaline membrane disease. Pediatrics. 1968; 41: 549-559.

4. Mai CL, Yaster M, Firth P. The development of continuous positive airway pressure: an interview with Dr. George Gregory. Pediatric Anesthesia. 2012;23(1):3-8. doi:10.1111/pan.12075

5. Gregory GA, Kitterman JA, Phibbs RH et al. Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. N Engl J Med. 1971; 284: 1333-1320.

 

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  1. tschares@mac.com | May 07, 2020
    I had the opportunity to meet and have discussions with Dr. Gregory as part of the informal group BAYPAC.  BAYPAC was formed  by Pediatric Anesthesia providers in the Bay Area to discuss Pediatric Anesthesia and Perioperative issues.  One of the issues we discussed was in regards to the proper comptentices, training etc for a pediatric anestheisologist. One comment Dr. Gregory made made a lasting impression on me and displayed his vision, humility and view of the "bigger" picture.   He (paraphrased) stated that if he were to exchange places with a Community Practice Anesthesiologist,  i.e. he would go to the small Community Hospita and the anesthesiologist there to UCSF,  the person coming to UCSF would be able to provide better care.  His point was the importance of the overall perioperative team and enviornment.  His view helped bring clarity and a patient focus to how best to deliver care to our Pediatric Perioperative patients.

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