I just learned of the very recent death of Dr Robert Hawkes Bartlett, May 8, 1939 – October 20, 2025. He was a surgeon who had been developing extracorporeal oxygenation systems for cardiothoracic surgery who realised that extracorporeal circulation could be used for prolonged support, and was willing to try it out for a baby who was dying.

He told the story in his Presidential address to the American Society of Artificial Internal Organs in 1985 Bartlett RH. Esperanza. Presidential address. Trans Am Soc Artif Intern Organs. 1985;31:723–6, of the first baby who received ECMO treatment.

“That child, treated in 1975 was.. a little girl. Her mother was just a girl herself. A Mexican peasant girl living in Baja who could neither read nor write and who realized, when she became pregnant in 1974, that her baby, if it lived at all, would fare no better. We all have hopes and dreams, and when we become parents our most fervent hope is that our children will live well, grow up bright and beautiful, and exceed the station of their parents, whatever that is. Poor Mexican mothers know that they can give the gift of opportunity to their new offspring in the form of United States citizenship by having the child born in this country. So it was that this young mother, consumed with the wish for a better life for her unborn child, crossed the border and set out for Los Angeles when her labor pains began. But as fate.. would have it, her water broke on the freeway and she took the next off-ramp to Orange County Medical Center. The baby was born – a perfect little girl- but something was wrong. The delivery had been difficult. The neonatologist tried to explain, “Mal respire. Mal grande. Intubation. Ventilator, Oxygen. Pressure. Hypoxia, Seizures.”

“The neonatologist knew that we were working with ECMO (rather unsuccessfully) with adult patients. Would we give it a try? The babe was dying. The arterial PO2 was 12. In the middle of the night, with the aid of a flashlight so as not to disturb the other patients, we tried to explain to the mother through an interpreter the ultimate in high tech procedures which had never been used successfully for an infant. She signed the consent form with an X, scared to death for her little girl and more scared that the official-looking form would bring recognition, deportation, perhaps imprisonment. She went in to see her baby girl, cyanotic, on a ventilator, with tense nurses and residents standing about. And the next day she disappeared, leaving her baby 2 gifts : a US citizenship and a name – Esperanza- Hope.

…we ligated the patent ductus arterosus and placed a catheter to monitor pressure in the pulmonary artery. This established the diagnosis of persistent pulmonary hypertension of the newborn. When the spasm finally relaxed and the blood flowed through the lung, our patient could be weaned off bypass, and off the ventilator. Soon she had a foster family.

The baby survived, and Ann Arbor started a program of offering ECMO for full term infants who were expected to die because of cardiorespiratory failure, usually hypoxic secondary to PPHN. They developed predictive criteria which were reasonably good at predicting which hypoxic babies under full intensive care would die, with over an 80% accuracy. But with ECMO they had over 80% survival.

Bob was criticized for not doing a randomized controlled trial, when introducing this new life-saving technology. Which could be likened to doing an RCT of parachute use when falling out of a plane (Yeh RW, et al. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial. BMJ. 2018;363:k5094); but nevertheless there were many sceptics in many parts of the world who thought they could have saved these babies without ECMO. He listened to them, and designed a study which minimized the number of potential deaths (Bartlett RH, et al. Extracorporeal circulation in neonatal respiratory failure: a prospective randomized study. Pediatrics. 1985;76(4):479–87). The “randomized play the winner” trial was a unique approach to a trial design, where potential adverse outcomes (death) were extremely likely. In essence, the first baby was randomized, and depending on whether they survived or died, the successive randomizations were weighted to increase the chance that a baby would be in the group with survivors, or decrease the chance of being in a group where the previous infant had died.

This design was likened to randomizing by pulling a ball from a sack, within the sack one starts with a black ball (ECMO) and a white ball (standard care). If a baby was randomized, to ECMO for example, and then survived, then an extra black ball was added to the sack prior to the next randomization. Likewise if the baby was randomized to ECMO and died, then an extra white ball would be added, or if they were randomized to standard care and survived. That way the previous “winner” group would have more chance of being the group assignment for the next baby. As it happened, the first baby was randomized to ECMO and survived (so a 2nd black ball was added) the second baby was randomized to routine care and died (so a 3rd black ball was added). This progressively increased the chances of a subsequent baby being in the ECMO group, and another 10 babies were randomized to ECMO who all survived. This reached the pre-specified success criterion, and the trial was terminated.

If this had been a standard RCT then 0/1 compared to 11/11 would not be “statistically significant”; by Fisher exact test the p value is 0.08. But it wasn’t designed as such a trial, and the results did exceed the pre-specified criterion for advantage of ECMO, without consigning large numbers of babies to the inferior treatment, or, to put it less politely, to die.

The observational data reported prior to this trial were already convincing enough for Neil Finer in our centre, and he went off for a few months to train in ECMO, then returned to Edmonton to start the first Canadian ECMO program, a process I was delighted to have a small part in.

A couple of years later we held an ECMO conference in Lake Louise, at which I got to meet Bob Bartlett, a delightful, thoughtful, humble man, you can detect those characteristics in the kindness of his description above of the dilemma of the mother of Esperanza.

The conference we held was in the winter, and the schedule was designed so that we could go skiing in the afternoons. Bob was a much better skier than I was, and I remember him skiing down the slopes, of the most beautiful scenery on earth, with his Sony walkman playing his favourite tunes as he skied.

Dr Bartlett was a thoracic surgeon whose dedication to improving patient care saved tens of thousands of newborn babies. A page on the ELSO website is dedicated to his memory, and includes a link to a fairly recent video about the development of ECMO.