Centralizing advanced care for congenital anomalies

Diagnosing a congenital anomaly and creating a plan for delivery and postnatal care are multidisciplinary endeavors. Too often, however, the institutional separation between pediatric and adult specialists can prevent physicians and patients from achieving the full benefits of multidisciplinary medicine, leading to siloed and inefficient care.

In June 2021, CHOC, in partnership with UCI Health, opened The Fetal Care Center of Southern California on its main campus in Orange. The center meets the need for advanced, centralized care for all types of congenital and chromosomal anomalies and multiple births in Southern California.

“CHOC and UCI have been affiliated for many years at various levels, including a joint pediatrics residency program and a joint neonatal fellowship program,” says Dr. Kushal Bhakta, board-certified neonatologist and medical director of the neonatal intensive care unit at CHOC. “The Fetal Care Center of Southern California is new, but our collaboration is mature.”

A multispecialty team

The Fetal Care Center brings together neonatologists, pediatric surgeons, maternal-fetal medicine physicians and a wide array of additional specialists to meet with expectant mothers during one all-encompassing visit to the center. The entire team meets regularly in a maternal-fetal care conference to review diagnoses and discuss delivery and intervention plans.

“Bringing all the providers to the Fetal Care Center enhances provider-to-provider communication,” says Dr. Peter Yu, board-certified pediatric general and thoracic surgeon at CHOC and co-medical director of The Fetal Care Center of Southern California. “Nobody operates in a silo. The neurologists know what the cardiologists and cardiac surgeons plan to do, for example, and what they anticipate being problematic. Once every clinician has met with and counseled an expectant mother, they send a multidisciplinary document of their assessment to the referring provider.”

Seamless and comprehensive

A key differentiator of the Fetal Care Center is expectant mothers’ ability to undergo advanced diagnostic testing and meet with every relevant specialist and support care provider in one facility during a single visit. The center’s fetal care coordinators field referrals from obstetricians or other clinicians, as well as patients themselves, and facilitate meetings with the appropriate specialists. The coordinators — an obstetric nurse and a neonatal nurse, respectively — also act as points of contact and informational resources for expectant mothers throughout pregnancy.

During a patient’s visit, she may undergo an ultra-fast fetal MRI to diagnose a suspected fetal anomaly. The images are read by a fetal specialist with board certification in pediatric radiology. Obstetric ultrasound is available to confirm the diagnosis, if necessary. Other services include fetal echocardiograms performed by board-certified fetal cardiologists, genetic counseling, case management and social work.

“We offer a wide variety of interventions, from routine procedures, including amniocentesis, to more complex procedures, such as fetal shunt placement,” Dr. Yu says. “We’re building toward offering the full spectrum of fetal interventions, including open fetal surgery.”

The Fetal Care Center is designed to shepherd patients from diagnosis to delivery and beyond. For many infants, that means transitioning to the high-level NICUs at either UCI or CHOC. The quaternary Level 4 CHOC NICU is home to the West Coast’s only Surgical NICU, leading-edge therapies such as extracorporeal membrane oxygenation, and a unique Small Baby Unit.

“Once a woman has met with the appropriate specialists at the Fetal Care Center based on the fetal diagnosis, we create a plan for delivery and postnatal care,” Dr. Bhakta says. “When the baby is delivered and stabilized by the neonatal team, we take him or her to the NICU, or the baby will undergo immediate surgery, if needed, followed by NICU admission.”

Enhancing interconnectedness

The opening of the Fetal Care Center is the latest demonstration of CHOC’s commitment to caring for babies with complex conditions. Additional plans to help mothers and infants are in the works.

Within three years, CHOC plans to debut a unit dedicated to delivering babies with complex conditions who need immediate care. The unit will feature two fetal operating rooms, an adjoining infant resuscitation room and modern amenities for families. The Fetal Care Center will move into the main hospital building, bringing it immediately adjacent to the NICU and new delivery unit. A boon for clinician collaboration, this centralization will also enhance patient care — as will CHOC’s ongoing endeavor to develop its fetal surgery program.

“We plan to offer the full spectrum of fetal interventions, from less invasive procedures, such as aspiration of fluid, to more complex procedures, such as open fetal surgery for giant tumors and babies who are facing demise,” Dr. Yu says. “We also plan to offer therapy for complicated multiples, such as twin-twin transfusion syndrome.”

Learn more about The Fetal Care Center of Southern California.

Surgeon, NICU nurse say their lifesaving professions have made them better fathers

The patient was 6, a boy – the same age as a pediatric general and thoracic surgeon Dr. Peter Yu’s son, “P.K.”

The patient’s kidney cancer had spread to his lungs.

When Dr. Yu recently performed surgery on the boy, he caught himself thinking of P.K., whose full name is Peter Kai Yu – a ball-sport-loving kid with grown-up tastes in food such as sushi.

“When I looked at him,” Dr. Yu recalls of the patient, “I saw P.K. I thought, ‘What would I do for my son?’ And I would do anything for him.”

With Father’s Day this Sunday, Dr. Yu and Gene Paredes, a neonatal intensive care unit (NICU) nurse at CHOC at Mission Hospital, reflected on the challenge of balancing their demanding and often emotionally exhausting work with fatherhood.

Both Gene and Dr. Yu are married with three children.

Both say their professions make them better fathers, and both say having kids makes them better at what they do.

Ample time with children

Gene has been a father almost as long as he’s been a nurse.

His son, Gabriel, is 20. Gene has been a nurse at CHOC for 21 years (23 years overall).

Gabriel is in college, as is his 18-year-old sister, Gillian. Gene’s other daughter, Eliotte, 14, just started high school.

Even though his parents both were nurses, Gene never grew up thinking he wanted to be one, too.

Gene Paredes, a nurse in the NICU at CHOC Mission, and his family

But the Mission Viejo native did just that, joining CHOC in 1999 after completing training for two years in a neonatal intensive care program in Berkeley.

Like his father, who worked three 12-hour shifts per week, Gene has been able to be involved in his kids’ lives because of his work schedule.

“Working three days a week,” Gene says, “I was one of the few dads who were able to be involved in mid-week classroom activities at my kids’ schools. That was kind of rare. You didn’t see a lot of dads there.”

Gene and his wife, Chantelle, who used to teach, decided that the benefits of her being a full-time mom outweighed the challenges of being a single-income family.  

And that decision has paid off.

Over the years, Gene and Chantelle have enjoyed travelling with their children.

They did an RV road trip up the coast to the Pacific Northwest and have been to various national parks and states throughout the U.S. Two years ago, they vacationed in Paris and London.

Gene and his family taking in the sites of England

At CHOC Mission, where for years he was the only male nurse, Gene works throughout the hospital because he has special training in placing PICC (peripherally inserted central catheter) lines, which are used to dispense medications and liquid nutrition. At CHOC Mission, he also performs ultrasound-guided IV placements.

For 2 ½ years, Gene also picked up shifts at CHOC’s campus in Orange in the main NICU and Small Baby Unit.

But he spends most of his time caring for sick babies in the NICU at CHOC Mission.

“I think being in healthcare, you realize there are a lot of things that can go wrong in childhood, such as illnesses and accidents,” Gene says. “I definitely had an appreciation for having healthy children. Knock on wood, I’ve never had to bring any of my kids to the hospital.”

Being a nurse has huge benefits when raising kids, Gene says.

“I approached fatherhood with a lot of confidence,” he says. “I taught my wife how to give our babies a bath. And she never worried about the kids getting sick. She was like, ‘Gene’s got this. He knows babies.’” 

Being a male and a father, Gene brings a unique presence to the NICU.

“A lot of the focus tends to be around the moms and the connection they have with their babies,” he says. “I think me being a male allows fathers to have someone to connect with. I change diapers, I feed the babies – I do all the hands-on things. I like to empower fathers to get in there and get very involved — to make them feel they can be as involved as much as the moms.”

Gene is known throughout the hospital for his calm demeanor in stressful situations.

“As a nurse and father, I hope that my calm energy and presence would bring comfort to parents experiencing the stress and unknowns of their child’s hospitalization,” he says.

On Father’s Day, Gene and his family will host a large afternoon feast with relatives at a favorite park in Dana Point.

“Then we’ll take a sunset walk on the beach,” he says.

Off cooking duty this Sunday

Dr. Yu usually relieves his wife, Jean, of cooking duties on weekends, when he’s off his hectic weekly work schedule that often totals 80 hours.

This Sunday will be different.

“I told him I would cook for him,” Jean says, adding: “He’s a very good cook.”

Being a former clinical nurse, Jean totally gets the demands of her husband’s profession.

“I get what the daily grind is like and things that may come up,” Jean says. “As a family, we try to cherish every moment, even just little things like watching a show together at the end of the day. He can’t make every event, but the kids are very understanding and very aware he’s probably helping out a sick baby or a sick kid, and they don’t hold that against them.” 

Dr. Peter Yu, a CHOC pediatric general surgeon and co-medical director of the Fetal Care of Southern California, and his family

The two met in the surgical ICU at the medical center at UC San Diego School of Medicine, where Dr. Yu completed his internship, residency, and research fellowship in general surgery. Jean was a surgical ICU and trauma nurse there, and they met while taking care of a very sick patient.

Married for 11 years, the Yus have three children: Max, 10; Sasha, 8; and P.K. They dated for two years before marrying. Dr. Yu proposed to Jean in Nigeria while both were on a surgical mission. 

Almost every day, Dr. Yu awakes at 4:30 a.m. to hit the pools. He’s an avid swimmer who will compete in the U.S. Masters Swimming National Championships in Greensboro, N.C., on July 26.

Max also loves to swim, and is a voracious reader.

“He’ll read a Harry Potter book in one day,” Dr. Yu says.

Sasha loves to dance and is a huge avocado fan.

Dr. Yu hits the sack around his kids’ bedtime.

“Usually 8:30 – 9 p.m. is really pushing it,” Jean says.

Dr. Yu says once he’s at home, he strives to be present with his children. Things have been even more hectic than usual at work recently, with the just-opened Fetal Care Center of Southern California, of which Dr. Yu is co-medical director.

“Our family works very well,” Dr. Yu says. “The credit really goes to Jean. She’s the chief operating officer of our family. I am so blessed to have her. She really allows me to work. Being a nurse, she knows how important it is for me to take care of these kids (at CHOC). She never gives me grief when I have to work, and that’s huge.”

Dr. Yu has been at CHOC for six years. Jean worked at CHOC for two years in the post anesthesia care unit (PACU).

“Jean was an amazing nurse,” Dr. Yu says. “I think she could have been a high-level nursing leader, but she sacrificed her career to follow me.”

Hospital work lends perspective to mishaps at home, such as a scraped knees, Jean says.

“Things that happen at hospitals can be completely life-changing for families,” she says. “So, when things happen at home, we don’t get too alarmed.” 

Dr. Yu and his son take it to the hoop with authority

Dr. Yu, whose parents emigrated to the United States in the 1960s, was born in America, and spent most of his early years in St. Louis, Mo. He has an older brother, David, also a physician, who adopted a boy from China who now is 10.

Dr. Yu says he became sold on California after attending Stanford University as an undergraduate, majoring in psychology.

It’s a good thing Dr. Yu has a ton of energy. He will need it to continue his balancing act of caring for sick and injured kids at CHOC and tending to his three young kids at home.

Says Dr. Yu: “You have to be present in the operating room, and you have to be present for your family.”

CHOC surgeons thriving as productive researchers outside the operating room

CHOC surgeons are known for performing the latest procedures, no matter how complex, in areas including heart, trauma, gastrointestinal, urology and neurosurgery.

Outside the operating room, the seven physicians who make up CHOC’s pediatric general and thoracic surgery team also are excelling in another realm that is critical to CHOC’s mission of developing into one of the nation’s leading pediatric healthcare systems —

Research.

In the last five years, the surgery team has published some 35 papers, bolstered by recent new hires and a renewed commitment to dramatically transform CHOC from its roots as a community children’s hospital to an academic institution.

“It’s unprecedented in the history of pediatric surgery at CHOC – there’s no question about that,” pediatric surgeon Dr. Peter Yu says of the volume of research going on with his team.

“We are proud to be one of the most academically productive divisions at the hospital, and we have some impressive partners in other specialties here,” Dr. Yu says. He calls fellow pediatric surgeon Dr. Yigit S. Guner  the leader behind the recent flurry of research.

“The number of papers that we’ve published in the last several years would be something to be proud of at any children’s health system, even the ones that have a longstanding academic tradition,” Dr. Yu says.

Dr. Yu also cites two more recent hires as critical players: John Schomberg, PhD, a biostatistician in nursing administration and trauma, and Elizabeth Wallace, MPH, a clinical research coordinator in the trauma department in Research Administration.

Schomberg has been instrumental in the team’s research efforts, providing statistical expertise to help investigators, both experienced and new to research, formulate and refine their research questions, Wallace says.

“The research team’s accomplishments are due in large part to the progressive leadership of CHOC executives and the CHOC Research Institute for prioritizing research and providing support needed to make these research endeavors possible,” she adds.

“Though we rarely think of it when we’re waiting for our child to be seen by their physician, ultimately research is the foundation for providing our pediatric patients with leading, innovative and excellent care,” Wallace says. “This group’s research has potential to inform best practices, policy and advocacy that addresses the needs of our community and to advance pediatric care on a more global level. I’m excited to see what the future brings.”

Dr. Guner says conducting research is a central part of his effort to care for children. “We always strive to provide great care, but research raises the bar on what can be done to help our patients,” he says.

Three general areas

The research being conducted by doctors in CHOC’s pediatric general and thoracic surgery division falls into three general categories: general pediatric surgery, trauma and extracorporeal membrane oxygenation (ECMO), a critical care technology that can be used to bypass a failing heart or lungs.

One trauma study, expected to be submitted for publication in February 2021, looked at legal intervention — any injury sustained from an encounter with a law enforcement officer. While studies have been conducted in adults, none have focused on the pediatric population. Legal intervention as cause of traumatic injury in the pediatric trauma population is infrequent yet reported.

Schomberg, Wallace, Dr. Guner and Dr. Yu were among the researchers who examined the National Trauma Data Bank (NTDB) for health disparities related to legal intervention in the pediatric population.

The team’s key finding: Legal intervention in children disproportionately affects the African American population.

Of the 1,069,609 pediatric trauma patients identified in the NTDB, according to an abstract of their paper, 622 sustained injuries involving legal intervention. When these patients were compared to the general pediatric NTDB, they were more likely to be older, male and test positive for illegal drugs or alcohol.

They were more likely to be African American (44.37% vs 17%), Latino (22.82% vs 15.10%), or Native American (0.96% vs 0.94%).

Mortality was higher in trauma involving legal intervention than in the general pediatric trauma population (4.82% vs 1.11%,), particularly in African Americans (63.33% vs 36.66%). Understanding the issue can hopefully point to more effective strategies to minimize harm while protecting public safety.

Variety of research papers

Several of the pediatric general and thoracic surgery division’s research papers concern congenital diaphragmatic hernias (CDH), a rare birth defect in which a hole in the diaphragm allows the intestines, stomach, liver and other abdominal organs to enter the chest, impairing typical lung development.

In another research project in collaboration with St. Louis Children’s Hospital-Washington University and The Children’s Hospital of Philadelphia, Dr. Yu looked at the incidence and length of stay for pediatric appendicitis during the initial days of the COVID-19 pandemic.

Dr. Yu is also currently working on a model to predict a rare traumatic injury referred to as blunt cerebrovascular injury (BCVI) and an interactive web app that would allow a trauma team to better understand their patient’s risk for BCVI.

Dr. Mustafa Kabeer, a CHOC pediatric surgeon, has published work in trauma and neonatology as well as basic science research on the stress response following splenectomy in mice. Dr. Kabeer’s most notable work includes research on the pioneering use of newborn umbilical cords to repair congenital birth defects such as gastroschisis.

Dr. David Gibbs, director of trauma services at CHOC, has been a staunch advocate for research, pushing CHOC to become the leading institution for pediatric trauma research in Orange County while pursuing a Pediatric Level 1 Trauma Center designation.

Dr. Gibbs’ published work includes developing prediction models in the trauma population to better understand prolonged hospital stays and return visits to the emergency department, revisiting the practice of X-rays post chest tube removal, and trauma case reports.

A true team effort

Dr. Yu  says the surgeons in his division work as a team on many research projects.

“Just like you can be a great surgeon,” he explains, “if you go in to operate and you don’t have any anesthesiologists or a nurse or a scrub tech to hand you instruments, there’s only so much that you can do by yourself.”

Dr. Guner says he enjoys understanding as much as possible about the diseases that he treats, and that research is an ideal vehicle to deepen that understanding.

“I really respect people who come here to work and take care of patients – it’s a vital service that people need,” he says. “In addition, I’ve always felt that I really wanted to know about the diseases themselves. Conducting research allows me to contribute to my field and to society at large.”

Another important aspect of research, Dr. Guner adds, is that it helps residents.

“Part of their training is more than taking care of patients,” Dr. Guner explains. “Learning and research go hand in hand. Research makes residents more motivated to work with their mentors and gives them something to do in the early stages of their career by increasing the energy they devote to academia.”

Baby with Rare Condition Undergoes Expert, Life-Saving Surgery at CHOC

Lizette Lough, experiencing a seemingly normal pregnancy, was making final preparations to welcome her first baby, when her water unexpectedly broke at 33 weeks. She was rushed to San Antonio Regional Hospital in Upland, close to home, where her son Landon was born early on May 3, 2016.

After a few days in the hospital, Lizette and her husband Sean noticed the baby had not made a bowel movement. Tests revealed that Landon had an obstruction in his intestine. His physician recommended Landon be transferred immediately to CHOC for an emergency surgery with Dr. Peter Yu, a pediatric general and thoracic surgeon.

“My husband and I lost it,” Lizette says. “Our baby was only three days old and weighed about 4 pounds. The thought of surgery was beyond frightening.”

Upon arrival at CHOC, the Loughs were immediately made to feel at home by the staff, who helped them find a nearby hotel. Dr. Yu explained every scenario of the complex surgery in a compassionate and confident manner, the Loughs recall.

Dr. Peter Yu, pediatric general and thoracic surgeon at CHOC.

“Landon was in stable condition when he arrived at CHOC, and I’m very pleased that our expert transport team was able to get him here quickly and safely. If there had been a delay in transfer, Landon could have become very sick and it’s very possible that more of his intestine could have died.  If that would’ve happened, he may not have had enough bowel to adequately digest food, which can be incompatible with life,” Dr. Yu says.

Landon was diagnosed with jejunal atresia, a rare condition – approximately 1 in 5,000 births – in which the small intestine is incompletely developed, leading to one or more gaps, or blockages, in the intestinal tract.

Lizette had gone through the required genetic tests prior to Landon’s birth, and jejunal atresia – often diagnosed prenatally – was not detected.

Additionally, Landon had malrotation of his intestines, which failed to coil in the proper position in the abdomen. This led to twisting of his bowel. If surgery had been delayed for longer, Landon could have died.

Landon’s surgery involved making an incision on his abdomen, examining the entire length of his intestine and untwisting it, removing the dead bowel, stitching together his small intestine, and performing a Ladd’s procedure. A Ladd’s procedure places the intestines back into the abdomen in a safe configuration to prevent future twisting of the bowel.

Landon, recovering in CHOC’s surgical NICU.

Sean, who works as a law enforcement officer, recalls how traumatic this was for his family. “I’m used to working in stressful situations, but this was a different kind of stress,” he says. “We were so happy that our baby had a successful surgery and that he was better. However, we were still waiting for him to have his first bowel movement. We were trying to stay positive.”

After his first bowel movement indicated that his intestines were recovering well, and spending about a month in CHOC’s surgical NICU, Landon was finally able to go home with his family.

“It takes a team to successfully care for sick babies and complex patients,” Dr. Yu explains. “Landon would not have had the excellent outcome that he had without our wonderful neonatologists, experienced and skilled pediatric anesthesiologists, Melissa Powell, our dedicated surgical neonatal nurse practitioner, and the outstanding NICU nurses who have dedicated their lives to taking care of newborn babies such as Landon and countless others.  Together, we have the only dedicated surgical NICU in the area, with a special focus on taking care of newborns with surgical problems.”

Landon today at 11 months.

Thanks to the expert multidisciplinary care provided at CHOC, today Landon is a happy baby, meeting all his milestones. The Loughs are enjoying their brave little boy, and look forward to his first birthday next month.

“Dr. Yu, as well as the nurses in the NICU, were so empathetic and amazing. They saw us through so much throughout our stay and we will forever be thankful,” Lizette says.

Learn more about surgical services at CHOC.

In the Spotlight: Peter Yu, M.D.

Peter Yu, M.D. A new pediatric surgeon with unique expertise in fetal surgery has joined CHOC Specialists Pediatric Surgery. Dr. Peter Yu specializes in the full spectrum of pediatric surgery, including neonatal, thoracic, and hernia surgery, and has quickly become an integral part of the surgery team.

“I’m extremely happy to be at CHOC,” Dr. Yu says. “There is so much talent and potential here, as well as a pioneering spirit and willingness to undertake big things.”

He is working closely with Dr. David Gibbs, division chief, pediatric surgery, CHOC Specialists, and Dr. Mustafa Kabeer, pediatric surgeon, CHOC Specialists, to launch a multi-disciplinary fetal surgery program at CHOC in the near future.

This highly complex surgery was uncharted territory about 30 years ago, Dr. Yu says. Many advances have been made in the field since, including new techniques that have allowed for the in utero surgical intervention of previously unsurvivable conditions. With special training from The Children’s Hospital of Philadelphia, one of the pioneering institutions in fetal surgery, Dr. Yu is determined to bring that level of expert care to CHOC and add to his team’s scope of services.

Among his goals, he hopes to help his team enhance the trauma program, advance CHOC’s minimally invasive surgery program, and increase CHOC’s national reputation through quality patient care and innovative research.

A passion for pediatric surgery

Dr. Yu followed in his older brother’s footsteps to become a doctor and attended Stanford University for his undergraduate studies. He graduated from the medical school at University of Missouri School of Medicine, where he fell in love with the culture and technical aspects of surgery, as well as the potential to make sick patients better quickly.

“I realized that the best surgeons were kind, dedicated, hard-working and team players – traits that I really value. When I discovered pediatric surgery, I felt it was a perfect fit for me, as it allows me to take care of children with an incredibly broad spectrum of pathology through surgical excellence,” he says.

Dr. Yu completed his general surgery residency at University of California, San Diego, followed by a surgical critical care fellowship at Boston Children’s Hospital and a pediatric surgery fellowship at The Children’s Hospital of Philadelphia. Additionally, he is board certified in general surgery, pediatric surgery and surgical critical care, and is currently working on a master of public health degree from Johns Hopkins Bloomberg School of Public Health.

This dedicated physician is interested in outcomes research to better understand the end results of specific health care practices and interventions.

“We presently live in an era where massive amounts of data are available at the click of a few buttons. The roadblock for many physicians is that we often don’t know how to access this data or organize it,” Dr. Yu explains. “My goal, along with my partner, Dr. Yigit Guner, as well as the division of pediatric general and thoracic surgery at CHOC, is to build an outcomes research center. This center will help all CHOC physicians access healthcare data and turn it into something meaningful so that we can provide the highest quality of clinical care to our patients, and do so in a financially sustainable manner.”

Dr. Yu has given numerous national presentations at meetings such as the American College of Surgeons Clinical Congress and the Association for Academic Surgery and Society of University Surgeons Academic Surgical Congress. He is a member of several organizations, including the American Pediatric Surgical Association and Society of Critical Care Medicine.

In his spare time, he enjoys spending time with his wife and three children. He also enjoys surfing, basketball and competitive swimming on a local U.S. Masters swim team.

To get in contact with Dr. Yu or to refer a patient, please call 714-364-4050.