My Professional Journey through Infectious Disease
While some of the policies and collaboration between healthcare professionals may have been better back then than they are today, some seeds of the Covid response were also in evidence.
BY STEVEN KRITZ
View original article at Brownstone.org.
In previous Brownstone Journal posts, I provided a view of American healthcare from the 30,000-foot level, and an experience I had back in 1978, while an internal medicine resident that had a profound impact on my subsequent professional practice. Today, I would like to focus specifically on my experiences in infectious disease (ID) during medical school, internal medicine (IM) residency, and early in my rural primary care practice, as I believe it provides what we once referred to as “clinical pearls” into the unfolding of the Covid response.
I attended SUNY Downstate Medical School from 1973 to 1977. A key ID development during that time frame was the discovery and characterization of T-cells, and their production in the thymus gland. Prior to that time, the only generally recognized function of the thymus gland was its relationship to myasthenia gravis. In fact, prior to the 1970s, versions of the Merck Manual (a diagnostic and treatment compendium published since 1899) recognized radiation to the head and neck as a viable treatment for severe acne. Unfortunately, if the thymus gland was affected severely enough, patients would develop what was and is still known as severe combined immunodeficiency disease (SCID), from which death from sepsis would frequently ensue.
Another ID-related feature of my medical school training was that Kings County Hospital (KCH), which was across the street from Downstate, had a building exclusively devoted to treating patients with tuberculosis (TB). In those days, patients could be compelled to remain in the hospital for months in order to ensure compliance with medication. I do recall, however, that the laws allowing for this type of confinement were being challenged, and were overturned shortly after I started my residency training.
In the fall of 1976, as a fourth-year medical student, I did an elective on the Pulmonary service. At that time, tens of millions of Americans, mostly seniors, were vaccinated for an expected swine flu pandemic that never materialized. In fact, Johnny Carson’s monologue on The Tonight Show occasionally included the quip that we had developed a vaccine in search of a disease. In fact, while there were less than a handful of deaths from swine flu, there were several hundred deaths from the vaccine, predominantly as a complication of vaccine-induced Guillain-Barre Syndrome (GBS). Soon after starting this elective, a woman in her late 70s who had received the swine flu vaccine several weeks earlier was admitted to the pulmonary intensive care unit with inability to swallow, and severe respiratory distress.
It was determined that she had GBS, presumably from the vaccine, that had paralyzed her esophageal and diaphragmatic muscles via immune-mediated damage to the respective nerves of those muscles. She required intubation with mechanical ventilation, and my primary assignment was to place a nasogastric tube twice daily in order to provide nutrition. She remained on the respirator for two weeks, and nasogastric feeding lasted for four weeks. After six weeks, she had recovered well enough to go home. The only residual effect of her GBS was a droop on one side of her face (known as Bell’s palsy).
Several months later, I happened to see her while walking on the KCH grounds (actually, she saw me first), and she practically ran up to me in order to give me a hug. I still remember that incident as if it happened yesterday! I wouldn’t be surprised to find out that Anthony Fauci had a hand in the vaccination effort. At the very least, it’s his modus operandi.
In the spring of 1977, near the end of my fourth year as a medical student, I did a Rheumatology elective. At that time we were seeing a number of cases of Lyme arthritis, usually in the knee joint. It wasn’t until a couple of years later that we determined that those patients were actually in the late stage of their illness, having been infected with the organism that caused the arthritis 3-5 years earlier. It was some years after that when suspicions were raised and generally accepted that this organism was developed and released from a government bioweapons lab on Shelter or Plum Island. Once again, some things never change.
I remained at Downstate for my IM residency training, which began in July 1977. Most of my experience was at KCH, one of the busiest hospitals on the planet, which was and still is part of the New York City Health + Hospitals system. I also spent considerable time at the Brooklyn Veterans Administration (VA) Hospital, which is now part of VA New York Harbor Health Care, with shorter stints at the University Hospital at Downstate.
My first rotation was in the KCH adult emergency department. Given its reputation as a place where you were liable to see anything and everything, I was quite anxious about starting my IM training there. That’s when I learned that, faced with an anxiety-provoking situation, the world can be divided into two groups: (1) those whose esophagus closes to the point where you cannot eat; and (2) those who will eat their way through the refrigerator door in order to get at the food quicker. Most people are in group #2. I’m in group #1, so I lost 10lbs during my first week on that rotation, having started the week at 135 lbs and 5’10”.
I did not regain the weight until the end of my first year of residency. I then got a parking sticker, which allowed me to drive to work, rather than walking. I promptly gained 20 additional pounds and grew a paunch, which I still have more than 45 years later! It was that particular month when the NYC blackout occurred. I was working the 4 PM to midnight shift, which I spent stitching up looters, but that might be a subject for another Brownstone Journal post.
My third-month rotation (September 1977) was in an adult male ward. Almost immediately (over Labor Day weekend), I admitted a strapping 21-year-old with high fever, mild confusion, and small vesicles covering his entire body. The neurologists would have done a lumbar puncture, except that the vesicles were so extensive that they were afraid they’d introduce material from them into the spinal fluid. In those days, we did what was known as a Tzanck test, where the base of a vesicle is scraped, the material obtained is placed on a slide, and stained.
It quickly revealed signs of likely herpes virus infection. In those days, the only antiviral medicine available was intravenous acyclovir, which was still an investigational drug, available from the University of Michigan, Ann Arbor. I still remember the ID fellows having the drug flown into LaGuardia Airport, where they picked it up and brought it to the hospital where I administered it via intravenous drip. The patient recovered completely in about 5 days and was discharged. It was not until 7 years later that I had the first of what I refer to as a “holy sh*t” moment when I realized that this patient had AIDS. It is extremely likely that this young man died within a year of that hospitalization.
An interesting sidebar in this case occurred when an oncologist by the name of Julian Rosenthal asked permission to draw a blood sample in order to do white blood cell research. About five months later, I happened to run into Dr Rosenthal in the middle of the night, while I was on call, and I asked him whether he found anything. He said that while the patient’s white blood cell count was normal, he had no helper-T-cells.
For those of you unfamiliar with the term, helper-T-cells, they are now known as CD4 cells. It turns out that this oncologist had nailed a key marker of HIV disease management as far back as early 1978! At that time, of course, we didn’t know what to do with this finding; it had only been three years since these cells had even been characterized. So, the information and its significance were lost for several more years.
The following month (October 1977), I was at Downstate Hospital where I admitted a retired Brooklyn police officer, who was in his 70s and happened to be Italian. He had an atypical pneumonia. He had had chronic lymphocytic leukemia (CLL) for many years, and had reached the point where, for the previous 2-3 years, he required blood transfusions every 3-4 months. At the same time, I inherited a retired Brooklyn trolley driver, who was also in his 70s and happened to be Irish, who was becoming increasingly depressed because of the number of days in hospital. I don’t recall what his diagnosis was.
While I grew up in Queens, I spent considerable amounts of time in Brooklyn, since almost all of my older relatives had lived there since getting off the ship at Ellis Island during the WWI era. In fact, until I was about 10 years old, I thought that when people living in Queens reached a certain age, they were shipped to Brooklyn! As such, I spent whatever time I had with these two patients asking them about life in Brooklyn before my time (I was born in 1951).
I also recognized that because both patients were getting more and more depressed, it might be a good idea to get both gentlemen in the same semi-private room. I mentioned this to the senior resident who was receptive and made it happen. The two patients got along famously, and their room became the local hangout for everyone working on that ward. Needless to say, the families of these two patients treated me like I was a rock star, and due to improved mental status, their physical status improved more quickly.
Getting back to the patient with CLL and atypical pneumonia, the pulmonologist did a bronchoscopy using a rigid scope (flexible scopes had only recently been developed, and were not widely available). The report came back as pneumocystis pneumonia (PCP), an infectious agent that had barely been mentioned over the course of my medical school training. We now know that PCP pneumonia is a marker for full-blown AIDS, but that wasn’t known until 4 or 5 years later. I don’t recall what medication was used to treat PCP in those days, but I do know that it was not trimethoprim-sulfamethoxazole, which was available, but was only being used to treat urinary tract infections.
It was during my first year of IM residency that, in addition to the relaxing of the quarantine laws regarding TB patients, the number of TB cases had declined precipitously, such that the TB building was converted to other uses, and the few remaining TB inpatients were transferred to the regular medical wards. The only change that was made to accommodate these patients, once they no longer required isolation, was the addition of UV lighting behind the window shades.
It was my recollection of this early in the Covid pandemic that I began pushing for the use of UV in HVAC systems at all indoor public venues, rather than the use of worthless personal protective equipment. In fact, masks were not required on the wards where TB patients were being treated, and I don’t recall masks being required in the TB building once patients were transferred from the isolation section to an open ward. I’ll note that during my seven years of medical school and IM residency, less than a handful of students, nurses or house staff tested positive for TB.
Actually, the much bigger risk for house staff was needle sticks and the contracting of HIV (which wasn’t characterized until 1984) or, much more likely, hepatitis C (which was known at that time as non-A/non-B hepatitis, since the virus had not yet been characterized definitively). Needle sticks happened to all of us, on average, about 2-3 times per year. In those days, nobody wore gloves when drawing blood or while engaging in other patient care activities where there was exposure to body fluids, given that standard/universal precautions were not formulated and implemented until several years later. In addition, our ability to protect the blood supply from HIV and hepatitis C didn’t occur until 1994!
The reduction in TB cases turned out to be short-lived. The beginning of the HIV/AIDS epidemic in the 1980s, which caused an immunocompromised state, resulted in a surge in TB, with many of the cases being multi-drug resistant. It took more than a decade, and the development of highly active antiretroviral therapy (HAART) to get TB prevalence back to what it had been in the late 1970s. Of note, there was a significant delay in HAART development due to the quest to develop a vaccine, an effort spearheaded by one Anthony Fauci. Some things never change!
Let’s fast-forward to June 1978. It was the last month of my first year of residency, and I was on a female ward at KCH. I received a call around 11 PM that a 12-year-old was being admitted to me. Usually, someone that age is admitted to a pediatric ward; however, due to the medical complexities, the decision was made to admit her to the medical service. This young girl had had a flu-like illness for several days that progressed to the point where she couldn’t get out of bed. Her blood pressure could not be obtained, and she was extremely pale. As I was examining her, she suddenly raised her head to within an inch of my face, said, “Please help me,” and immediately collapsed and died.
We did CPR until dawn, a period of at least six hours, and never obtained a single heartbeat. Permission for an autopsy was obtained, and three months later, it revealed the cause of death as viral myocarditis. Over the course of the Covid debacle, whenever myocarditis, especially in children, was mentioned in dismissive terms, my blood would boil. It still does.
Let’s move on to the period around Labor Day 1978, when I was a second-year resident and senior resident of the pulmonary ward at KCH. We admitted two brothers with pneumonia, who turned out to be the index cases of the Legionnaires’ outbreak in the Garment Center outside Macy’s Department store. They were treated with erythromycin and did well. The CDC, the NYC Dept of Health (prior to being combined with the NYC Dept of Mental Hygiene), and the NYS Dept of Health collaborated to confirm the diagnosis and provided treatment advice that was relayed to us via the ID fellows. All went quite smoothly. Given what we’ve seen during the Covid response, whooda thunk that that could happen!?
Today, we have hand-held spirometers that quickly and easily provide lung function information that helps to determine when patients are ready for discharge. Back then, we would have had to use the pulmonary lab (by appointment only), where a five-foot-tall metal bellows in a water bath was used to obtain the same information. I don’t recall ever seeing a patient in that lab. It just so happened that my first-year residents and I were making a midnight go-round when we found the two patients in the stairwell smoking joints and making out with their girlfriends. I turned to the first-year residents, and stated that the two patients didn’t look short of breath to me…what do you think? When they agreed, we decided to send them home the following morning. How’s that for clinical medicine in its purest form?
As the senior ward resident, I got to do the case presentations at the Grand Rounds, which had high-ranking representatives from the aforementioned agencies and numerous ID attendees from all over the NYC metropolitan area. The entire Grand Rounds was published. In recent years, there has been a resurgence of Legionnaires’ cases, despite the fact that we had developed definitive protocols to prevent this infection that are as valid today as they were then.
Once the organism causing Legionnaires’ was isolated, the CDC tested blood samples from outbreaks going back to the 1920s, when the cause had not been determined. It was discovered that this organism likely mutated during the late 1920s when water-cooled air conditioning systems came into use. Those of you who were around prior to this Legionnaires’ outbreak might recall that when you walked in the streets of Manhattan during the summer, there was a mist that could be felt. It was the effluent from the water-cooled air conditioning systems that floated down from the roofs of the skyscrapers. This mist carried the Legionnaires’ organism. By capturing the effluent, the risk of infection was eliminated. Recent Legionnaires’ outbreaks have been caused, in most instances, by neglecting this long-known public health measure.
One of the CDC samples tested, and confirmed to be from the Legionnaires’ organism was from an infectious outbreak in 1968 in a government office building in Pontiac, MI that came to be known as Pontiac Fever. There is an apocryphal story regarding the Pontiac Fever outbreak, in that it coincidently happened on a day when the employees were going to engage in a sick-out, with the government threatening to fire anyone who didn’t come to work. Given that the nature of the illness was not determined definitively until the CDC checked blood samples a decade later, employees were fired.
I had first heard this story back in the early 1980s. However, in 2012, I was able to get in touch with public health physicians who were active during both the 1978 Legionnaires’ and the 1969 Pontiac Fever outbreaks, and they had no recollection of this event. Given the types of cover-ups we’ve seen from public health agencies during the Covid response, I’m sticking with my memory of events until proven otherwise!
Around Labor Day weekend of 1979, I was a third-year resident covering a KCH general medical ward. A couple of first-year residents, who had been on call the night before presented the case of a young woman who had high fever and diarrhea. She had a history of hyperthyroidism, so the immediate thought was that this was a thyroid storm, which can be life-threatening. I was suspicious, since the woman was quite obese, which is not a feature of hyperthyroidism, and certain other typical signs of hyperthyroidism were not present.
I asked if they had done a stool culture. When the response was, no, I had it done immediately. It returned a day later positive for Salmonella. It turned out that she was a food handler at the KCH cafeteria. Over the next 24-48 hours, over 400 house staff came down with Salmonella. Some of the services were completely decimated. The worst hit was Psychiatry. So much for psychiatrists being viewed as tightasses! The good news is that everyone recovered. I was one of the few residents who did not get sick, mainly because I wouldn’t be caught dead eating at the KCH cafeteria (or any other cafeteria at the hospital where I trained). I would always find a nearby pizza place (I was in Brooklyn folks. Enuff said!).
I completed my IM residency at the end of June 1980 and immediately moved to a rural county in upstate NY to begin my medical practice. Once again, around Labor Day weekend, I admitted an elderly man with severe diarrhea, who grew Shigella on stool culture. Shigellosis is an extremely virulent infection in that it only takes as little as 100 organisms to cause full-blown illness. Most bacterial infections causing diarrhea require thousands of organisms per milliliter to cause illness. Several nurses and lab techs got sick, even though they were well aware of the precautions necessary. I did not get sick nor did I transmit it to anyone else, indicating that my hand washing practices must have been reasonably good.
The original patient died from his illness, but not before it was transmitted to the other patient in his semi-private room. This patient was also very elderly but survived. My main memory of that patient was that prior to this illness he had suffered from chronic constipation that went back to the Roosevelt administration (Teddy, not Franklin)! Let me assure you that Shigellosis has never been a treatment for chronic constipation.
My experiences in ID appear to indicate that while some of the policies/practices and collaboration between healthcare professionals may have been better back then than they are today, some of the seeds of the wrongheaded Covid response were also in evidence. One thing for sure is that given the fact that so many of the events I’ve presented occurred around Labor Day, I’ve come to believe that it’s perfectly safe to be me on Labor Day, but it may not be such a great idea to be around me on Labor Day.
Thank you. "Please help me" is unforgettable.