Parents & Caregivers

 

 

An Evolution in Pediatric Neurology

When Richard Nordgren was a medical student at the University of Rochester, undecided about his future specialty, he went on rounds one day with his pediatric neurology professor.

Pediatric Neurology

They visited a child who was having difficulty with balance and coordination. Nordgren's professor examined the child and diagnosed him with Freidreich's Ataxia, a rare, progressive, genetic disorder, named after the German physician Nikolaus Friedreich, who first described the condition in the 1860s. This spontaneous and rather obscure diagnosis so impressed Nordgren that he decided "on the spot" to go into pediatric neurology. "It's the most intellectually challenging field," he says, "because we deal with hundreds of different disorders, most quite rare. You might see only one or two cases of a certain condition in your whole career."

Nordgren, who retired at the end of March, arrived at Mary Hitchcock Memorial Hospital in 1972, as the hospital's first, and only, pediatric neurologist. In fact, according to Dr. James Filiano, a pediatric neurologist and section chief of Pediatric Critical Care, whom Nordgren helped recruit in 1993, Nordgren was the only board-certified pediatric neurologist in the entire state of New Hampshire. When hired, Nordgren was supposed to split his time: 50% treating adult neurology patients, and 50% treating pediatric patients. In fact, Nordgren states with a laugh, "I spent 50% of my time treating adults and 100% treating children."

Both the section and the field have come a long way in forty years. Diagnosis was, and remains, the key to successful treatment of pediatric neurologic conditions. But the way diagnoses are made has evolved dramatically. In the early days, physicians assessed patients solely on examination and assessment by history. CT scans, which came along in the mid-1970s, helped, but, Nordgren recalls, "the results took a long time to process and the pictures were small and of poor quality." The MRI revolutionized pediatric neurologists' ability to view the brain. Dr. Richard Morse, now Section Head in Pediatric Neurology, whom Nordgren recruited in 2001, calls the inception of neuroimaging, "transformative.

It allows us to test more, discover more, and understand better what ails the patients." Notes Nordgren, "We could now see that certain conditions, far from being a single condition named for the person who first identified them, exist on a wide spectrum."

Under Dr. Nordgren's careful stewardship, the pediatric neurology section grew "by leaps and bounds," says Morse. "He maintained an incredible presence at the medical school and at the hospital, educationally, as well as seeing patients." Morse also notes the wonderful work he did with Dr. David Roberts, Section Chief of Neurosurgery, in the area of corpus callosotomy, an epilepsy surgery in which the brain is split, disconnecting one hemisphere from another, and for which DHMC is a recognized leader.

Morse, a DMS graduate, was drawn back to DHMC primarily because of the epilepsy center. He's seen tremendous neuroimaging advances there as well, listing PET scans, SPECT scans, brain-mapping capability, and video EEGs. "We have all the state-of-the-art tools here to evaluate people with intractable epilepsy," he says, adding that this heightened ability to diagnose, allows physicians to prescribe more targeted medications, perform even more effective surgeries, or, for non-surgical epilepsy patients, prescribe a ketogenic diet or implant a vagal nerve stimulator.

In 2010 Nordgren helped recruit Dr. Linda Specht, former Head of pediatric neurology at Tufts, and a long-time colleague. Nordgren cites this team of world-class pediatric neurologists as the reason DHMC is now, "although relatively small, better equipped than a vast majority of medical centers around the country to take care of pediatric neurologic patients." He also regards their hiring as his greatest accomplishments.

While Nordgren is proud of the team he established, and loves taking care of patients, the most rewarding aspect of his career, he says, has been working with patients' families. He feels they deserve special mention. "They take care of the most complicated kids, many of whom have other medical problems and cannot communicate. The parents are dedicated and do a superb job. They are wonderful, fantastic, caring people, and I admire them so much."

Apparently the feeling is often mutual. The grateful parents of one of Nordgren's epilepsy patients asked Nordgren what his department needed. He replied, "Video EEG monitoring." They donated the equipment.

All agree that molecular biology is the wave of the future. Says Morse, "We're finding, more and more, a genetic basis for many neurological conditions. Understanding the mechanisms mediated by these genetic disorders leads to better and more effective interventions." There are blood tests for many conditions⎯including Freidreich's Ataxia, now known to be caused by a defect in a gene called Frataxin (FXN), which is located on chromosome 9.

What began as a department of one, half time, pediatric neurologist is now a department of four with a dazzling array of sub-specialty and multidisciplinary clinics. Filiano runs the neurometabolic program, Morse focuses on epilepsy and epilepsy surgery, Specht the neuromuscular program, and Dr. Stephen Mott, who joined the team in 2009, specializes in child development, with an emphasis on autism and developmental evaluation. And they are actively recruiting additional pediatric neurologists.

What drew Dr. Nordgren to the Upper Valley in the first place? "Funny story..." he says, with characteristic humility and subtle humor. "I'd not really been to New England. I saw a movie with Shirley McClain, The Trouble with Harry, which was shot in Chester, Vermont. I said, 'Gosh I'd like to live there.' DMS was just starting as a full medical school, and to be accredited, they needed a pediatric neurologist. So I raised my hand." The rest is history.

The man, the neurologist, the legacy: Dr. Dick Nordgren Retires

Richard Nordgren, MD

Richard (Dick) Nordgren, MD, doesn't like to spend much time talking about himself. Fortunately, his colleagues are not so reticent. A few share their thoughts with us on his pending retirement, his impact over the years, and the legacy he leaves behind.

Dr . James Filiano:
Dick Nordgren started the Muscular Dystrophy clinics for kids in New Hampshire; was the first in America to publish about corpus callosotomy, a split brain surgical procedure for intractable epilepsy; and the first in New Hampshire to bring in video EEG to evaluate seizure patients. He had an early interest in recognizing fetal alcohol syndrome and helped many people with that problem, and, way back in the 1970s, lobbied (unsuccessfully) for a smoke-free hospital. He was able to look at a patient and very quickly, get to the core of their problem. He was a central part of my decision to return to Dartmouth. No doubt about it.

Dr. Richard Morse:
He was a personal mentor to me, back when I was a med student at DMS and got the notion of doing pediatric neurology. He supported me and even got me a spot in a premier program for training. He kept in touch, and, when he got a new position, got me up here to interview, and sold me on the place. He's been a major influence on my career, a great mentor and colleague, and probably the main reason I came back to DHMC.

Dr. Nordgren's retirement leaves a gigantic hole that will be impossible to fill. He has worked part-time for the past several years, but has still seen a tremendous number of patients, and they are very loyal to him. It's a testimony to how much he's loved.

Dr. John Modlin, Chair of Pediatrics:
I consider him to be an excellent clinician and special individual, who served admirably and devotedly. I remember a three-month old patient we cared for together, who had acute poliomyelitis. Dick continued to follow that patient, who now must be close to 20-years old. I developed a great admiration for Dick in the way he communicated with the family and managed to care for the patient over a long period of time. That's Dick's legacy: he was a remarkable resource for children in our region. The collective experience and wisdom of someone like Dick is irreplaceable.

Dr. Gregory Holmes, Chair of Neurology:
Dick is a legend here at Dartmouth in New England in the field of Pediatric Neurology. He is a compassionate caring MD who combined outstanding knowledge base in neurology with humility and candor. We are very grateful for all of his contributions and are confident he will remain connected to Dartmouth.