Hawkes Bay to Boston: life of a paediatric intensivist

“When families are going through the toughest, toughest time, that's when we should be able to support them the most”

DR Katie Moynihan was doing her paediatrics training in Hawkes Bay, New Zealand, when a bloke in rugby shorts changed her career trajectory.

“There was a specific resuscitation of a really sick kid, and the intensivist literally rocked up in his rugby shorts and proceeded to resuscitate this kid,” Dr Moynihan tells the MJA.

“That’s when I knew I wanted to do paediatric critical care. I took one look at him and went ‘I want to be you when I grow up’.”

It’s been a peripatetic pathway, but some would say Dr Moynihan has arguably reached one of the great pinnacles in her profession — she is now part of the Cardiac Intensive Care Unit (CICU) Program at Boston Children’s Hospital (BCH), and is an Assistant Professor of Paediatrics at Harvard Medical School.

Australian‐born, Dr Moynihan completed her medical degree at UNSW Sydney before deciding that the best place to start her paediatrics training was in a rural setting like Hawkes Bay.

“I wanted to immerse myself in paediatrics a bit more than what I felt I could do in the city, where it felt a bit like note‐taking, even in the third and fourth year,” she says.

“Honestly, it’s one of the most beautiful places in the world — the beaches are great, the wine is fantastic and New Zealand is a really cool country. I had a fantastic experience there learning about caring for kids.”

Dr Moynihan is the first in her family to pursue medicine as a career, although not the last. “My brother has followed in my footsteps,” she says. “He’ll hate me saying that.”

Her parents brought her up with a strong social justice ethos and that has taken her to far‐flung corners of the globe.

In 2010 she spent a year in Uganda, dividing her time between the obstetric operating theatre of the National Referral Hospital in Kampala, and having responsibility for a paediatric ward in rural Uganda at a not‐for‐profit mission hospital.1

“It was hard,” she says. “I was so naïve. I was 25 years old, going over there with this altruistic but completely naïve analogy of what I was going to be able to achieve.

“I worked myself to the bone 20 hours a day, we dropped the mortality rates significantly but I realised about a month before I was leaving that I wasn't creating anything sustainable there.

“I was trying to apply a Western approach to an African setting. But it helped change my approach in subsequent developing world endeavours.”

Those endeavours have included a 4–5 month overseas visiting fellowship in Fiji after completing her training in Sydney, Brisbane and Auckland. There she worked with legendary intensive care consultant and educator, Dr Elizabeth Bennett2 — “another fantastic experience”.

She has also volunteered in Samoa, teaming up with her brother, and pre‐COVID‐19 was establishing enduring relationships with a group in India, providing mentorship and on‐the‐job training in an intensive care unit.

In July 2017 Dr Moynihan arrived in Boston to take up a one‐year senior fellowship at BCH.

“When I left Australia there was only really one woman working full‐time in paediatric intensive care,” she says. “Things have come a long way since, but there weren’t very many opportunities [at home].

“Luckily the medical training system in Australia makes us clinically excellent, and I passed all the tests.”

At the end of the year’s fellowship, BCH offered her a permanent position in the CICU, an offer she couldn’t refuse.

“It’s a hard place to leave,” Dr Moynihan says, “much to my mother’s distress. It was hard to say no to the opportunity, the resources — just the people. Jane Newburger [Associate Cardiologist‐in‐Chief at BCH, and Commonwealth Professor of Pediatrics at Harvard Medical School],3 cardiologist extraordinaire, walks down the corridor and says ‘hi Katie’.

“It’s like, wow.

“I still pinch myself and there’s definitely an element of imposter syndrome, don’t get me wrong. But it’s pretty remarkable to be here.”

COVID‐19’s impact on Dr Moynihan’s career has been significant, although not in expected ways. It put paid to her plans in India, although she has hopes of re‐establishing ties there soon.

BCH became the only point for paediatric care in Boston at the height of the pandemic there, as other hospitals made room for adults with COVID‐19.

“We did see a drop in elective surgeries but there’s only so long you can wait when it comes to congenital heart disease in kids before it becomes more and more urgent,” she said.

“We did have some paediatric patients with COVID, but from a clinical perspective the biggest impacts were the use of personal protective equipment, being much more cognisant of that, as well as the use of telehealth.”

What Dr Moynihan is passionate about is end‐of‐life care in the paediatric ICU setting. She and colleagues have just published research in JAMA Network Open about how to measure staff perceptions of the quality of dying and death in a paediatric CICU.4

“End‐of‐life care has been a bit of a taboo or no‐go zone in the cardiac intensive care unit, particularly for children, because we're very cure oriented,” Dr Moynihan says.

“That's despite data in adults suggesting that palliative care consultations can prolong life and improve quality.

“We formed an interdisciplinary team who are really interested in improving how we provide care for all kids, whether they live or die. Incorporating palliative care principles, whether it be viewed through a consultative palliative care methodology, or primary palliative care model — it’s one way we can improve the quality of life of children in our unit, and their families.

“Our mortality rates are below 2%. That is what we strive for, obviously — survival is very, very important, that will always remain a quality metric,” she says.

“However, there are other metrics which are equally important, like quality of life in survivors is important. Neurological outcomes in survivors are really important.

“At the same time, focusing only on survival means we forget about the children who die as well. And quality of death is also really important.”5

Moral distress is a phrase that’s come to public attention through the COVID‐19 pandemic, but it’s a concept that is very familiar to Dr Moynihan and her paediatric ICU colleagues.

“Part of our job is alignment with families, and so things that we do are often really, really distressing,” she says.

“We make connections with these families, often they're in hospital for weeks and months. They become part of our CICU family.

“It's hard when things don't go as we planned.

“One way [to deal with the distress], even though no one would want a child to die,6 is to find comfort in the fact that we can actually provide a good death for families in a way that's aligned with their wishes, even though no one would want their child to die.

“The other way is to make sure you've got time and space for yourself.”

Dr Moynihan’s coping mechanisms involve nature and physical activity with friends.

“I just got back from a big hike in the White Mountains. It was stunning. It's a way to switch off and spend time with people you love.

“I'm not saying it's easy. It's hard. I've definitely felt it a few times, really strong connections with families. And there's some solace by providing what I perceive as a good death and receiving their feedback from them in an informal way.”

A social worker from BCH, now a mentor, provided Dr Moynihan with advice that changed how she coped with the deaths of small patients.

“There was one kid in particular who I got extraordinarily attached to, and his family. Prior to him I had never given my mobile phone number out, but I did in this case,” she says.

“The social worker asked me why I’d never done that before this kid. I said that I’d just imagined that they wouldn’t want to hear from me. I’d done this awful thing, given them the worst day of their life.

“And he said, ‘oh, I think you’re underestimating how much they would appreciate you reaching out and just letting them know that you’re thinking of them’.

“That helped me.

“What we can do [in paediatric ICUs] is incredible. But unfortunately 100% survival is never going to be achievable.

“Hopefully, it'll only ever happen once for a family. So, if we can make it the least bad as it can be, we should strive to do that. When families are going through the toughest, toughest time, that's when we should be able to support them the most.”