The Mayo Clinic Department of Anesthesiology:   The Beginning of Intensive Care in Rochester

Prior to 1940, there was no respiratory or inhalation service at Mayo Clinic.  Dr. Walter M. Boothby, an anesthesiologist who spent much of his career in the field of respiratory physiology and basal metabolism, was recruited to Rochester soon after the conclusion of World War I.  He established Mayo’s Metabolic Laboratory and started oxygen therapy for Mayo patients.  In 1940, he recruited Dr. H. Frederic Helmholz, Jr. a physician and physiologist, to join him in the laboratory and assume leadership in oxygen therapy.   This relationship between Drs. Boothby and Helmholz served as the starting point for the development of respiratory and intensive care at Mayo Clinic in Rochester.  It expanded slowly and coincident with the introduction of positive pressure ventilators and other innovations.  In 1966, Mayo Clinic officially approved the development of respiratory intensive care units at both Rochester Methodist and St. Marys Hospitals.   

Today’s story will highlight these 2 key leaders who started what was to become respiratory care at Mayo Clinic.  They were remarkable stars in the fields of medicine and physiology, and their combined efforts established what has become one of the country’s leading institutions in critical care medicine.  Future Update articles will describe the development of intensive care and respiratory care.

Walter M. Boothby, M.D. was born in Boston on July 28, 1880.  After graduating from Harvard Medical School in 1906, he continued his training in Boston.  He served as a physician anesthetist in Boston City Hospital in 1912 under the supervision of Dr. Fred Cotton.  During that year he and Dr. Cotton devised the Cotton & Boothby anesthesia apparatus, a precursor to today’s anesthesia machines (Cotton & Boothby Apparatus - Wood Library-Museum of Anesthesiology (woodlibrarymuseum.org).  Dr. Harvey Cushing, renowned surgeon at Peter Bent Brigham Hospital, learned of Dr. Boothby’s anesthesia interests and in late 1912 invited him to be the supervisor of anesthesia in his hospital.  However, he first arranged for Dr. Boothby to spend a year in Oxford, England with Dr. J.S. Haldane studying basal metabolism, including the measurement and metabolism of gases such as ether.  Upon his return to Boston in late 1913, Dr. Boothby expanded on Dr. Cushing’s concept of an anesthesia record.   Dr. Cushing had previously developed and advocated for the use of an anesthesia record and the concept of minute-by-minute monitoring of patients with blood pressure measurement and auscultation of breath and heart sounds by precordial stethoscope.  Dr. Boothby added the measurement and recording of inhaled anesthetic concentrations, primarily ether at that time, a monitoring addition that is now standard for all anesthetic documentation.

Dr. Boothby was very interested in anesthetic uptake and metabolism as well as other metabolic measurements.  His work with basal metabolism attracted the attention of Mayo Clinic’s Dr. Henry Plummer.  Dr. Plummer recruited Dr. Boothby to move to Rochester and establish a metabolic laboratory.  His arrival was delayed by World War I during which time he was assigned a major role with improving the masks used by front line soldiers to avoid poisoning with chlorine, phosgene, and mustard gases.  After the war and upon his move to Mayo Clinic, Dr. Boothby established Mayo’s Metabolic Lab.  His subsequent work set the worldwide standards for measuring metabolic needs in health and various disease states, including thyroid disorders and diabetes.  He did not work in clinical anesthesia while at Mayo Clinic.  However, he did work with Dr. Plummer on understanding postoperative hypoxia and had a lead role in arranging for oxygen to be provided to hypoxic postoperative patients.  As of this writing, Dr. Boothby does not appear to have worked with Dr. Lundy or other Mayo anesthesiologists before World War II.  However, he did collaborate with anesthesiologists such as Dr. Albert Faulconer after the war.

The mid-1930s were a remarkable time in aviation history as planes were designed that could reach more than 10,000 feet in altitude.  Flight into the upper heights presented problems with oxygen supply and metabolic needs.  With trouble brewing in Europe and the potential need for high altitude military aircraft and with the support of Drs. Will and Charlie Mayo in their final years, Dr. Boothby established the Mayo Aero-Medical Unit in conjunction with colleagues Drs. Earl Wood, Randolph Lovelace, Art Bulbulian, and others.  Dr. Bruce Fye, famed Mayo cardiologist and historian, describes this unit and its contributions to the military in an excellent summary found on our institution’s heritage website (Top Secret: Mayo Aeromedicine and Operation Paperclip - W. Bruce Fye Center For the History of Medicine - Guides at Mayo Clinic).  The team studied the physiology of high G-forces and oxygen delivery to aviators in freezing, low oxygen altitudes, resulting in the development of G-suits (compression devices), the use of the Valsalva maneuver to maintain cerebral blood flow in high G-force turns, and the Boothby-Lovelace-Bulbulian (BLB) oxygen mask.  All of these are still used by today’s fighter pilots.  They received the 1939 Collier Award, the highest recognition in aviation, for their efforts.    An excellent 36-minute Mayo Clinic movie about the Aero-Medical Unit and its impact on the Allies winning WWII may be viewed at Rising to the Challenge: The Mayo Aero Medical Unit in World War II (mayoclinic.org).

In 1940, Dr. Boothby recruited Dr. H. Frederic Helmholz, Jr. to join him in providing respiratory therapy and support for Mayo Clinic patients.  An extensive account of Dr. Boothby’s career may be found here.

Henry Frederic (Fred) Helmholz, Jr., M.D. was born in Evanston, Illinois on December 27, 1911.  In 1921, his father, Dr. Henry F. Helmholz, Sr., was recruited by Dr. Charlie Mayo to move to Rochester to establish the new clinic’s first Section on Pediatrics.  The younger Dr. Helmolz was 10 years old when he rode the Northwestern Railway from Chicago to Rochester with his family.  He initially attended the Rochester Public High School but spent his final two years (1927 through 1929) in Faribault, Minnesota attending its military academy, Shattuck School.  Upon his graduation from Shattuck School, he attended Dartmouth College, earning his degree in 1933.   This was followed by four years at Johns Hopkins Medical School and a year as a intern at the Massachusetts General Hospital. 

Parenthetically, while in medical school in 1935, Dr. Helmholz married his Rochester girlfriend, Mary Balfour.  Mary was a granddaughter of Dr. Will and Hattie Mayo and the daughter of Dr. Don and Carrie (Mayo) Balfour.  Their bridal dinner was held on the top floor of the home of Dr. Will and Hattie Mayo.  That room is now known as Balfour Hall in the Foundation House.  Dr. Helmholz noted in a 2007 interview with Dr. David Plevak  (see link below) that the original upper floor room was beautiful but not as ornate as the current Balfour Hall.

In 1939, he applied for a physiology fellowship at Mayo Clinic.  Ironically, his MGH mentor did not know that Dr. Helmholz was the son-in-law of Dr. Balfour, the fellowship director, when he wrote his letter of recommendation.  Dr. Helmholz was assigned to work with Dr. Fred Mann (yes, Mann Hall in Rochester’s Medical Science Building is named after this Mayo physiologist) at the new Institute Hills laboratory facility southwest of the city.   He made and published several of the world’s first measurements of fetal circulation in animals during his initial fellowship year at Institute Hills.  His work impressed Dr. Boothby, and Dr. Helmholz was invited in 1940 to join the nascent Mayo Aero-Medical Unit.  In 1942, Dr. Lovelace and the U.S. Air Surgeon were so impressed with Dr. Helmholz’s knowledge of respiratory mechanics and oxygenation in flight that they asked him to move to San Diego to work with the pilots and engineers at Consolidated Aircraft Corporation.  This company was producing the B-24 bombers used in World War II, and Dr. Helmholz served as a consultant as they worked to help airmen handle the challenges of high-altitude flight.

In 1947, Dr. Helmholz returned to Rochester as a consultant in the Section of Physiology.  Dr. Boothby asked him to serve as the Director of Inhalation Therapy.  He thought he was up to the challenge but did not know what it entailed when he started.  He was blessed to find that Bernie Gilles, a nurse anesthetist working with Dr. John Lundy and a former Marine, was not only interested in inhalation therapy but someone who wished to improve and grow the field of respiratory therapy.  Mr. Gilles wished for it to move beyond the delivery of oxygen to patients (inhalation therapy).  Working together, they established a strong respiratory therapy program and played key roles in having inhalation therapists deliver chest physiotherapy and starting Mayo Clinic’s Pulmonary Function Lab.  The lab proved the potential of analyses of exhaled gases to detect pulmonary diseases as well as metabolic disorders involving the thyroid, liver, and pancreas. 

It was Bernie Gilles who proposed to Dr. Helmholz that Mayo Clinic should seek respiratory therapy certification of its locally trained inhalation therapists.   With Dr. Helmholz’s coaching, Bernie became Mayo’s first certified respiratory therapist.  This educational activity started Dr. Helmholz’s introduction to the newly formed American Association of Respiratory Care (AARC) and its certification process.  During the 1950s and 1960s, Dr. Helmholz began to play a significant role in the development of respiratory care locally and nationally. 

• Locally:  He was an advocate for establishing a training program for respiratory care in conjunction with Rochester Junior College (today, the Rochester Community and Technical College).  He became one of the primary instructors for the school and has been recognized with the Distinguished Emeritus Award from the Mayo Clinic School of Health Sciences for his efforts.
• Nationally:  He joined the AARC’s Board of Schools and, after a major squabble between the American Society of Anesthesiologists and the AARC led to the dissolution of the Board, rekindled oversight of respiratory therapy schools across the nation by serving as the first chair of a new Joint Review Committee on Inhalation Therapy Education.  Over time, he served as President of the National Board of Respiratory Care.  The AARC has recognized Dr. Helmholz’s contributions with honorary membership and its Jimmy Young Medal, the highest award given by the association.  The National Board of Respiratory Care has honored him with an H. Frederic Helmholz, Jr., M.D. Education Research Fund and a named scholarship.
•  

Much more on the fascinating life and career of Dr. Helmholz can be found in a 2007 video interview organized by our own Dr. David Plevak and Mr. Jeff Ward (A Conversation with H.F. Helmholz Jr., M.D. (mayoclinic.org).  Dr. Helmholz died in Rochester on January 7, 2012, at age 100. 

Mystery Photos 

Last week’s Mystery Photos were Lloyd H. Mousel, M.D. and David M. Rosenfeld, M.D.

Lloyd H. Mousel, M.D. was born in Cambridge, Nebraska on December 24, 1903.  After receiving his M.D. degree from the University of Nebraska in 1930, he did his internship year in Tacoma, Washington and established ties there that would eventually draw him back to the Seattle area later in life.  He practiced general medicine in McCook, Nebraska and in his nearby hometown of Cambridge until 1936.  He moved to Rochester as a resident in anesthesiology, completing his training and earning a Master’s degree from the University of Minnesota in 1939.  His Master’s degree was on the effectiveness of respiratory stimulants during anesthesia and provided him with insights that directed much of his academic career to the study of anesthesia for the nascent use of thoracic surgery. 

In 1939, Dr. Mousel was appointed as a consultant in our department, joining a department of 3 other anesthesiologists, Drs. John Lundy, Ed Tuohy, and Charles Adams.  Dr. T. Harry Seldon subsequently joined the department in 1940.  Although a member of the department until 1946, Dr. Mousel was called to military duty in 1942 and served most of his remaining four years as a Mayo consultant in U.S. Army assignments.  Much of his duty was focused in Washington, D.C. running Gallinger Municipal Hospital, a primary hospital in the nation’s capital used for the care of injured soldiers, Marines, airmen, and sailors.  He also was assigned as the Army’s leader of anesthesia for thoracic surgery during his service.  In this role, he standardized data collection about the care of thoracic surgery patients who received their care in the Army’s 7 designated “thoracic surgery” hospitals.  Based on the findings of the accumulated work, he wrote extensively about anesthesia for thoracic surgery, with his insights guiding clinical practices across the country for the article next several decades.  His 1947 provides a fascinating look at the development of anesthesia for thoracic surgery and its status, clinical practices, and morbidities during World War II.

In 1946 and upon his military discharge, Dr. Mousel resigned from Mayo Clinic and accepted the position as chief of anesthesia services at the George Washington University, a role he held from 1946 through 1951.  He subsequently moved to Seattle and became the chief of anesthesia services at the rapidly growing Swedish Hospital.  He worked closely with the University of Washington and his hospital’s anesthesia services became an integral part of the anesthesia training program at the university. 

Dr. Mousel died on June 13, 1970.

David M. Rosenfeld, MD was born May 9, 1969, at Michael Reese Hospital in Chicago, IL.  He grew up in Glencoe, IL, a small town twenty miles north of Chicago.  His undergraduate education was at the University of Colorado, Boulder, where he earned a degree in Political Science in 1991, considering a career in law and the foreign service.   In 1992 he acted on his long-repressed desire to be a physician and enrolled in a one-year post baccalaureate pre-medical program at Loyola University in Chicago.  He graduated from Northwestern University Medical School in 1998, where he participated in research focusing on the immunology and cellular rejection pathways of Islet of Langerhans transplantation.  Dr Rosenfeld served his internship in general surgery at University of Wisconsin Hospital in Madison, followed by his anesthesiology residency at UCLA Medical Center.  He completed his residency training in 2002.  While a medical student at Northwestern he met his future wife Missi, at the time a visiting medical student from University of Arizona, and the couple was fortunate to train in anesthesiology together at UCLA.  His residency was followed by a Pain Medicine fellowship at Brigham and Women’s Hospital in Boston.  

Dave joined the department at Mayo Clinic Arizona in 2003.  In his first years of practice, he combined clinical work between general, regional, and cardiac anesthesia, while devoting twenty-five percent time to clinic and in-patient pain medicine. The first decade of the 21^st century saw tremendous advances in pain medicine, but also an explosion in the use of prescription opioids prescribed to treat mostly benign pain conditions leading to what is now referred to as the opioid epidemic.  Well intentioned improvements in pain management for hospitalized patients led to an increase in adverse events mainly due to opioid-induced respiratory depression.  In 2007 Dr. Rosenfeld and partner Julia Griffin, RN, CNS, established the first MCA Pain Management Committee, with a focus on quality improvement and safety. Many initiatives were advanced across MCA to improve education, standardization of opioid use protocols, and improved monitoring for patients.  At the enterprise level he worked with one of our Rochester colleagues, Dr. Terre Horlocker, on the “Surgery + Opioid = Narcan” project in 2007.  The project helped define these issues and spearheaded collaborative improvements.  Dave served as division chair in Pain Medicine from 2008 through 2014, overseeing steady growth, the relocation of the clinic to the Phoenix 3 Building, and comprehensive reorganization of operations.  In 2014 he partnered with administrator Roshy Didehban to recruit Cynthia Townsend, PhD and establish the Pain Rehabilitation Center, the first of its kind in the region.  

In 2005, Dave’s clinical anesthesia responsibilities migrated from cardiac to liver transplantation.  During the past nineteen years, he has been involved in more than 400 transplants.  He is a national leader in abdominal transplant anesthesia and serves on committees in the ASA and the Society for the Advancement of Transplant Anesthesia.  He has devoted his career to advancing the specialty of anesthesiology in education, research, mentoring, and patient safety.  In 2022 Dr Rosenfeld was appointed as chair of our Department of Anesthesiology and Perioperative Medicine in Arizona.  He has also served as the department Vice Chair, medical director of Surgical Services and section chair of Abdominal Transplant Anesthesiology before becoming department chair.  

Dave has been married to Dr. Missi Rosenfeld for 26 years.  Missi works for Valley Anesthesiology Consultants/Envision Healthcare and recently joined Mayo Clinic as a supplemental consultant.  They have two children, Ethan and Eliana.   In his spare time, Dave plays ice hockey, skis, and is an avid hiker who loves the outdoors. He is an accomplished musician/guitarist and has played in a number of different rock bands since high school.

Mystery Photo Contest Winner

Last week’s contest winner was Alyssa Janousek.

Here are this week’s Mystery Photos.  Reminder:  We are now featuring two individuals each week for the Updates.  To be placed into the Mystery Photo Starbucks contest, you will need to correctly guess at least one of the featured individuals.  If you identify both of them, you will double your chances of having your name drawn.

Please email your response at warner.mark@mayo.edu within 3 days of this update.  I will also need your name and contact information.  All correct responses will be placed into a Monday morning drawing for a $10 Starbucks card.  Only one winner per individual over the 80 weeks of Mystery Photos.  If you win a weekly drawing, however, please keep submitting your responses.  An overall winner (with the most correct responses in the series of 80 Updates) will receive a $100 Starbucks card.