THE CHILDREN-S HOSPITAL OF PHILADELPHIA

         ONE CHtLDREN'S CENTER

34TH STREET AND CIVIC CENTER BOULEVARD

           PHILADELPHIA. PA 19104
        (2i5) 596.9387

DEPARTMENT OF ANESTHESIA

Senate Committee on Labor and
Human Resources, Senator Orin Hatch, Chairman
U.S. Senate

Washington, D.C.

K. Vi. TERRY LEE M.D
A MICHAEL BROENNLE. M D
EUGENE K BETTS M D
ROBERT G KETTRICW. M 0
JOSEPHlNE J TEMPLETON M 0
RODOLFO I GOD,NEZ M D  PH cl
DAVID 8. SWEDLOW M D
THOMAS P KEON M.D
MARK S HEISER. M D
NORIG ELL!SON M.D
DAVID R. JOBES M 13
ALAN J. ScHwaRTz. M D
GERALD S. LEFEvER M D PH D

Re: C. Everett Koop, M.D.,.
  Nominee for Surgeon General of the United States

   I am John J. Downes, M.D.,  President of the Medical Staff and
Director of the Department of Anesthesia and Critical Care, The Children's
Hospital of Philadelphia.  I am also Professor of Anesthesia and Pediatrics
at the University of Pennsylvania.

   I have known Dr. Koop since 1960, when I was a resident in anesthesiology
at The Children's Hospital and the University of Pennsylvania.  I joined
the staff of the Department of Anesthesia in June, 1963 and worked very
closely with Dr. Koop as a professional colleague over the ensuing 18
years.   In that time we have collaborated in the care of thousands of
infants and children whose problems spanned virtually the entire range
of childhood illness and injury.  We worked together in the operating
room and intensive care unit at all hours of the day and night, as well
as in the classroom and the committee room  In 1967 I became the Director
of the Pediatric Intensive Care Unit and in 1972 Director of the Department
of Anesthesia and Critical Care; in both of these positions I collaborated
closely with Dr. Koop in attempting to solve problems and build programs
at both the local and national level.  We also worked very closely
together as members of the Executive Committee of the Medical Staff and
on various planning committees for the new hospital in the middle 1970's.
Dr. Koop has also served as one of my closest advisors when I assumed
various offices on the medical staff, including the presidency in 1980.
Dr. Koop has also served as friend and advisor to our department in de-
veloping training programs and collaborative research efforts with
members of the Department of Surgery.  Furthermore, Dr. Koop has served
as my personal advisor in my various efforts at the national and inter-
national level to foster interest and develop programs which improve
child health; he was especially helpful in assisting me in numerous
diplomatic problems involved in my role as Chairman of the American


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Delegation t0 the International Standards Organization Technical Com-
mittee (Technical Committee 121) between 1973 and 1977.

   Through these many years of association with Dr. Koop, I have
developed a multifaceted perception of the man.  I consider Dr. Koop a
man of extraordinary intelligence and profound concern for human welfare
who is endowed with consummate skill and remarkable energy in a wide
range of human activity.  Paramount among these virtues, I would rank
his highly developed ability to identify a problem, seek council and
quickly sift out the most valuable advice, and then devise an innovative
plan of action with clear priorities.  Characteristically, Dr. Koop
works with colleagues whose confidence he quickly gains and in these
collaborative undertakings, he stimulates others to a heightened performance
and unusual committment.  His decisions and plans in the management of
patients prove to be right on nearly all occasions. When the desired
results are not being achieved, either in a patient or in an administrative
task, he will regroup the team and with their collegial participation
produce a more effective plan.  This style of leadership has led to many
remarkable achievments in the clinical care of patients, the establishment
of programs at The Children's Hospital of Philadelphia and throughout
the world, as well as in numerous scholarly endeavors.

  I have found Dr. Koop'to be a man of unusual innovative talent in
seeking solutions to problems, but also a person of remarkable consistency
of interest and action spanning more than 40 years of professional
life.  He is a scholar who seeks to determine the underlying causes of
disorders in patients and in social problems that relate to health, to
develop solutions, and to disseminate important information to the
widest possible audience who will find it of use.  He is a pioneer in
the education of surgeons in the care of children, and in the development
of the specialty of Pediatric Surgery in the United States and abroad.
I continue to be amazed at his personal efficiency and organizational
skills, and his endurance and tenacity carrying out his professional
life goals.

   I wish to cite some specifics in support of my statements. In
clinical medicine Dr. Koop was a pioneer in developing the collaborative
"team" approach in patient management in which the anesthesiologist,
pediatrician, surgical subspecialist, and nurse play a unique and
crucial role.  In 1949, Dr. Koop brought Marjory van Deming to the
Children's Hospital as its first full time Pediatric Anesthesiologist.
He collaborated with her in developing techniques which overcame many of
the difficulties associated with anesthesia, especially in the infant,
that enabled the pediatric surgeon to undertake more extensive and
effective procedures.  Dr. Deming left in 1955 for reasons of health and
Dr. Koop brought Dr. Leonard Bachman to Children's Hospital from Johns
Hopkins Hospital to continue the development of pediatric anesthesia and
to establish a research and training program.  Today, this program has
become the largest center for the training of specialists in Pediatric
Anesthesia and Critical Care in the world, and over the past five years
has educated numerous leaders in pediatric anesthesia in Europe, Japan,
India, Australia, Mexico, Canada, and the United States.  Thus, Dr.
Koop can be looked upon as one of the major forces in the development


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of the allied field of pediatric anesthesiology and critical care which
has benefited millions of children around the world.

  Dr. Koop's early interest in cancer, shock, and nutrition are
evidenced in publications that date from 1942.  These interests have
persisted for nearly 40 years, and he has publications in 1980-1981 as
well as in press relating to these clinical areas.  Dr. Koop established
one of the first pediatric tumor registries in the United States and
participated in numerous clinical research protocols for the therapy of
various forms of cancer from the early 1950's up to the present. The
development of total parenteral nutrition (provision of all nutrition
through a vein for long periods of time) was first applied to infants
and children, and subsequently developed to a safe and practical technique
of wide applicability in Dr. Koop's department with his assistance, en-
couragement throughout the 1960's and 1970's; this type of supportive
care ranks with antibiotic therapy and pediatric anesthesia as one of
the most significant contributions to the care of critically ill children
in this century.  As reflected in Dr. Koop's bibliography, he has been a
pioneer in the diagnosis and successful repair of numerous congenital
defects of the newborn, with publications dating from 1946 up to the
present.

    I view Dr. Koop's most important contribution, however, to.be the
establishment of the first newborn surgical intensive care unit in the
world in 1962.  He sought and obtained funds from the Commonwealth of
Pennsylvania at a time when welfare programs and health insurance pro-
viders (including Blue Cross) did not provide for extensive coverage of
infants with congenital anomalies.  In this unit, a team approach involving
pediatricians, anesthesiologists (for intensive respiratory care),
nurses, and allied health personnel was developed and served as a model
for the professional staffing,  as well as the surveillance and life-
support equipment needed for the care of critically ill newborns. This
model was quickly copied and emulated throughout the llnited States and
abroad.  In 1967, Dr. Koop provided the essential support and encourage-
ment which led to the establishment of the first pediatric intensive
care unit (for the care of critically ill children over one month of
age) in the United States,  and the second in the world.  This multidisci-
plinary unit cared for both medical and surgical patients. At the time
the majority of these patients were surgical, and Dr. Koop recognized
the special interests and skills of the anesthesiologists in this newly
developing field and strongly supported the concept that the direction
of this unit be under the Department of Anesthesia; at the time this was
a unique step for a surgeon to take, and this precedent was a major
factor in the future development of pediatric intensive care throughout
the nation and the world.

  Dr. Koop also supported the development of the pediatric intensive
care training program with input from anesthesiology, pediatrics, and
surgery.  This program has flourished and is today the largest such
training program in the world; over 75 physicians have been trained in
the subspecialty of Pediatric Critical Care Medicine during the past 14
years and provide much of the leadership in the United States and Canada


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as well as Europe, Japan, and Australia. Thus, through his pioneering
efforts and continuing support, the care of critically ill infants and
children in the United States and throughout the world have benefited.
Survival rates for virtually all of the newborn congenital anomalies
amenable to surgery have increased dramatically, and this in turn has
contributed to the overall survival of newborns throughout the United
States and other developed countries.

  Dr. Koop's administrative skills can be attested to by his election
to the Presidency of the Staff at The Children's Hospital of Philadelphia
from 1957 to 1963, and again from 1973-1974 (a crucial time 'in the
Hospital's history when we moved to a much larger hospital and pediatric
medical center).  In the planning for the new hospital, Dr. Koop was a
key person in the collaboration between physicians, architects, and
hospital administrators.  His ideas and his support for the creative
ideas of his colleagues led to the development of one of the best equipped
and designed pediatric health facilities in the world.  Furthermore, Dr.
Koop built the first truly multispecialty integrated pediatric surgical
department which provides, on a full time basis, surgeons who cover the
entire range of pediatric subspecialty surgical disciplines.  Again, Dr.
Koop realized very early in his career the need for collaborative efforts
in modern medical care.  Dr. Koop's participation in national and inter-
national societies has led to the recognition of pediatric surgery'as a
major component in the health care of children.  He was a.founding
member of the Surgical Section of the American Academy of Pediatrics,
the major professional organization of child health specialists in the
nation.  He was a founder and subsequently President (1971-1972) of the
American Society for Pediatric Surgery.  He led the struggle against
opposition from many quarters for the formation of the American Board of
Pediatric Surgery to standardize the education, evaluation, and certification
of surgeons specializing in the care of children.  He currently serves
on the Commission for Cancer of the American College of Surgeons, a
major voice in the development of national policies regarding cancer.

  Dr. Koop's role as a scholar is attested to by the more than 170
articles and chapters that cover the entire range of pediatric interests.
He was the founder and the first editor of the Journal of Pediatric
Surgery, the original journal in this subspecialty.  He served on the
Editorial Board of a number of journals and has been a frequent reviewer
of articles for journals in other fields.

  One of Dr. Koop's most unusual and outstanding roles has been that
of a medical diplomat.  His interest in world health, especially that of
children, is documented in his curriculum vitae and extends around the
world, including Mexico, the Carribean, Africa, Asia, and Europe. He
was the principle founder of the American Children's Hospital in Krakow,
Poland, and has been a frequent visitor and consultant to that organization
which regards The Children's Hospital of Philadelphia as a sister insti-
tution.  An extensive collaboration has been developed, through the
efforts of Project Hope and the Agency for International Development,
between the Children's Hospital of Krakow and The Children's Hospital of
Philadelphia for the development of safe and effective pediatric surgery


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and intensive care in Poland.  Dr. Koop has been a long time supporter and
one of the leaders in the Medical Assistance Program (MAP) which provides
medical supplies and equipment to needy institutions throughout the
world.

  I would be remiss not to mention my admiration for another facet of
Dr. Koop's personal and professional life, i.e., his compassion for
parents as well as children, and his understanding of the psychological,
emotional, and philosophical aspects of death and dying as they relate
to children and their families.  He has been my model and ideal of the
physician who can and does form a warm and supportive relationship based
on mutual trust with parents and children.  In that function, I believe
he has few peers.

   In summary, I believe that Dr. C. Everett Koop has the necessary
intelligence, skills, and ability as a leader and diplomat, combined
with deep concern for the welfare of his fellow man, to be an outstanding
Surgeon General of the United States.

John J. Downes, M.D.
.' President of the Medical Staff
Anesthesiologist-in-Chief
  Director, Department of Anesthesia
   and Critical Care
The Children's Hospital of Philadelphia
          and

  Professor of Anesthesia and Pediatrics
University of Pennsylvania School of Medicine

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