Dr. Maller’s Blog

I’ve been waiting two months for an inspiration to resume blogging (nice not to have deadlines) but today is Memorial Day and the fire is lit.

George Will published a great column yesterday called “The Last Doughboy” in which he paid tribute to our last surviving WWI soldier, who is a spry 107 and not only served in France with over 4 million other Americans but spent most of WWII in a Japanese prison camp, having been a civilian contractor in Manila on December 7, 1941.

Our nation is at war but I wonder where we’d be without the thousands of young folks who volunteer to keep us free and safe. Our schools do such a poor job of teaching history, and the Blame-America-First crowd dominates our media and academia so thoroughly that patriotism has been on the defensive since the 60’s. In 2004 presidential candidate Jean-François Kerry famously warned that our kids better do well in school or they’d “wind up in Iraq”, thus insinuating that the military is for dummies. Au contraire the ranks of our military are better-educated than their peers who stay out of the service. General David Petraeus, the counterinsurgency expert now running our liberation efforts in Iraq and Afghanistan, has a masters and PhD from Princeton, for example, and could be making millions as a CEO.

Growing up during WWII, I saw a nation united. People did without; staples were rationed, everyone had a “victory garden” to grow vegetables, there were no new cars. People in coastal cities patrolled for submarines and aircraft (I still have my Aircraft-Spotters Handbook). Gold stars hung in so many windows, denoting lost sons. More Marines died in one day on Iwo Jima and Tarawa than all military deaths in over five years in Iraq.

America is great because America is good. We have conquered fascism and communism but have helped rebuild their breeding grounds into vibrant and free societies instead of seizing their lands. We have conquered slavery at home and built the most successful multicultural society ever known. The rows on rows of crosses and stars in military cemeteries across the world speak to the sacrifices that we honor today. I’ve been to Normandy, to Pointe du Hoc where the shattered guns and barbed wire remain, but it’s the sea of white row on row that I remember.

As I write this I’m wearing a T-shirt that says “Freedom Is Not Free.” Indeed.

“It” was a baseball field, but rather than an Iowa corn field, this one was on the grounds of the venerable Philadelphia General Hospital (built by Ben Franklin) where I took my internship.

Medical graduates must serve at least a year of training before being eligible to practice medicine. The internship no longer exists as such, perhaps because the memo about the Emancipation Proclamation finally got to the powers that be. As was typical of the time, I worked 90-plus-hour weeks for $100 a month. It had been $59 the year before but some interns’ wives marched to City Hall with a contingent of reporters and applied for welfare, embarrassing the mayor and his cronies enough to get us a 70% raise.

There were 90 of us from all over the country. It was an old-fashioned tour called a “rotating” internship, with thirteen 4-week assignments ruled over by faculty from Philadelphia’s five medical schools. Penn, right across the fence, was the best, and I lucked out in getting several of their best teachers.

Our only outlets were the baseball field and poker. Philly had its snowiest winter on record with three 18-inch blizzards, but during the warm months we had a league with several teams. The doctors had two and were usually no match for the orderlies, techs, kitchen crew, security, etc. but our guys were good. I had the honor of hitting the year’s most talked-about home run which broke a window on the fifth floor of the student nurses’ dorm (for the single guys the 500 future RN’s from the hills of Pennsylvania and West Virginia did constitute a third outlet, but I wouldn’t know about that).

Across the street was the Palestra, a popular venue for sports. To our dismay we discovered after a rainy spring night that a number of cars belonging to people attending a boxing match had parked illegally on our baseball field, leaving nasty ruts. Most were big black Cadillacs with New Jersey plates. The administration would not respond to our pleas, so next time our field was misused certain interns went out and flattened one tire on each car. There was a lot of cursing in Italian at about 11 PM, but the field was left alone for a few weeks. Next time they tried, each car got TWO flat tires. Now there is a major difference between having one flat and two. The last car didn’t leave the lot until almost dawn. But the field was ruined and our season ended early.

Our class showed its mettle early. We had been warned by the outgoing group that the administration was going to put a divider along the tray line in the cafeteria so that everyone had to pass through single-file. Our meals were free and time was precious so we’d grab our grub and head straight for a table. Soon after we started an ugly plastic barrier went up, preventing us from breaking out of line. It lasted a day. A furious administrator called an emergency meeting of our 90 rebels and demanded a confession, whereupon all 90 raised a hand and admitted fault.

The next week an even uglier partition was erected, this time anchored by a very sturdy pole through the floor and ceiling. One of the locals in our group had an uncle with a machine shop; this time the removal was challenging but by 2 a.m. the monstrosity was in pieces on the floor. The head honcho called a truce and we promised not to destroy any more city property.

The poker games were great fun and intense. About eight or nine of us were regulars, and what made the risk manageable was the presence of two Irani doctors on fellowship who seemed to have a limitless supply of the Shah’s money and no idea how to play good poker. Every time they’d fill an inside straight we’d tell them how brilliantly they played, assuring enough money at the end of the night for the rest of us paupers. Our best player was a 6′7″ rube from Louisiana named Travis Jeter Harrison. He’d win forty dollars or more every game. It was odd that in our last game he was nowhere to be found - that is until he strolled in wearing an outrageous green plaid suit and said, “Ah wanna thank you boys fo’ bahin’ me this-heah suit!”

One night the game was disrupted by a yell from the first floor - “Chicky the cops!!” By the time the fuzz had run up three flights, seven of us were sitting in chairs in the lounge reading sections of last Sunday’s NY Times. Cards and dollars were nowhere to be seen.

Twelve months of tension came to a head the last night. Someone started a bonfire on our baseball diamond and soon hundreds of medical text books were ablaze. The fire was at least three stories high and attracted the Philly PD and FD. As the fire was extinguished by hoses, turning the former ball field into a smoking swamp, a police officer mounted the bleachers with a bullhorn to give us a lecture on civics. At that moment the wildest intern in our group, a full-blooded Cherokee from Oklahoma, came storming out of the kitchen on a hand-pumped cart, whooping as if on horseback, beer bottle in his free hand, picked up speed down the ramp and crashed into the bleachers, sending the sergeant face-first into the mud. We felt lucky to finish the year without criminal records.

A year later while serving my stint in the Public Health Service, I picked up a local California paper and read that a “crazed mob” of young doctors had run amok in the streets of Philadelphia, turning over a trolley car. Now why didn’t we think of that?

The old hospital is no more, a victim of progress. For two hundred years the Blockley Medical Society, as the training staff was called, turned out future physicians who went out into the world knowing how it felt to deliver a baby in an unheated, rat-infested tenement, how to tend to dying patients with no family to care, how to save premature babies in a low-tech world (my son Danny among them). I believe medicine is not well-served by having young doctors go straight from school to specialty training, but I’m glad I had the opportunity. Last time I visited in 1976 the old place had lost its accreditation and was eerie in its silence, like an empty cathedral. And fittingly, the former baseball field was now a parking structure.

My wife loves to regale new patients with my resumé, including announcing that I am an epidemiologist (or was, actually). Folks sound impressed but I suspect they’d be hard-pressed to define what that means. I’m glad you asked.

CDC in Atlanta, originally created to combat malaria, had by the early 50’s become the world’s top communicable disease command post. In order to put trained investigators at the scene of outbreaks and research facilities they came up with an elite group called the Epidemic Intelligence Service (EIS) which took about two dozen physicians, veterinarians and statisticians yearly, trained them and assigned them either to Atlanta or around the nation. EIS officers spearheaded the conquest of smallpox and polio, and its alums make up a major share of heads of health departments and professorships in the spheres of infectious and chronic diseases around and beyond our nation.

Doctors were subject to the draft when I graduated and finished the required internship in 1961. Were my number to come up then with no specialty training, I’d likely be assigned to a dispensary in Greenland. With a wife and two kids, that sounded grim. When one of my favorite teachers recruited me for the EIS, enabling me to satisfy my military obligation, I jumped at the chance.

The science of epidemiology (the study of epidemics) began about 1840 with Dr. John Snow of London and the Broad Street pump. A cholera epidemic was ravaging the city. Dr. Snow spotted cases on a street map and showed that the closer one lived to the infamous water pump, the more likely one was to get cholera. It must have been like a police station tracking a serial murderer.

Learning this exciting discipline from Dr. Alexander Langmuir and his staff was like learning astronomy from Galileo. “Alex” had come from Johns Hopkins to set up the program and treated us like princes. After training for a summer in pre-airconditioned Atlanta, we were encouraged to choose our assignments in a surprisingly open way. The requests for EIS officers far outnumbered us, so Alex took the five of us who were left unmatched because we lacked the years of residency and field experience that others had, and made sure we were all happy with our destinations. I had always wanted to live in California and could barely contain my glee when he suggested I take Berkeley and the California State Health Department (since moved to Sacramento).

My primary responsibilities were tracking influenza, hepatitis and other major diseases and reporting back to CDC. I had a lot of latitude to pursue whatever medical problems popped up around the state, and managed to get into all but three of its 58 counties. When I needed some R&R with the family I’d often find some potential calamity threatening the good people of San Diego or Santa Barbara. I also saw trachoma in the Coachella Valley and took part in the annual health fair for Alpine County, America’s least populated (800), in its county seat of Markleeville (pop. 300). Getting snowed in just added to the adventure of it all.

My biggest project in my two years was a hepatitis epidemic in the little town of Los Banos which occupied the better part of six weeks in my first summer. They speak of “shoe-leather epidemiology” and indeed my associate and I met most of the 7800 people living there. I eventually published a description of the peculiar outbreak in our state medical journal.

A 12-year-old nephew of a local rancher deplaned at SFO from Italy with a sickly yellow complexion. The town had no hospital but one of the four local doctors had a “clinic” with a few beds. The youngster was treated there but for some reason his sickness was not considered contagious. Infectious hepatitis (The A/B/C system was yet to be defined) has a long incubation period but eventually 19 of 21 clinic employees caught it. By strange coincidence some snake-oil salesman passed through town hawking a miracle cure for liver ailments. Since the four doctors were overwhelmed (and undertrained) the word went forth: leave a urine specimen by the back door and if it shows hepatitis we’ll call you in and give you shots for it. Blood tests weren’t done and of course there is no treatment, but we were able to determine through interviews that about 500 cases occurred.

A side issue is worth mentioning. During the six weeks of tooling about in the motor pool Studebaker Lark without air conditioning (choice 1: close windows and suffocate in the 105-degree heat or 2: open windows and inhale the pungent dust of the San Joaquin Valley) I expressed concern about catching Valley Fever (coccidioidomycosis), a fungal disease of the lungs, but I was reassured by my colleagues. That summer the state hired Dr. Bill Reynolds to come down from Seattle and organize medical surveillance of the migrant worker program. Bill contracted Valley Fever and spent almost a year in the hospital!

While assigned as I was to the state, I was a federal officer and CDC made sure its young pups got a taste of real-world epidemiology. My Mission Improbable was to fly to Ketchikan, Alaska (by Constellation and Grumman Goose) to investigate a diphtheria outbreak. The locals greeted me with a banner headline (”Top Epidemiologist Arrives From Alabama”) - not quite geographically accurate - and I got to give a speech at the Lincoln’s Birthday Toastmasters meeting. I spent five days touring the village’s 35 bars doing nasal swabs. The patrons knew of the outbreak and were more than helpful; no one objected to a poke in the nose but first I had to hear their life story!

I found one diphtheria carrier, and left in triumph. On my EIS diploma is a cartoon of a well-dressed fellow who looks a lot like Dr. Langmuir sliding downhill on the right side of a graph, the message being to arrive after the peak of the outbreak so as to add to one’s air of wisdom. I revisited Ketchikan to refuel in later years, and by then there was a real airport and a more prosperous town. That first arrival in the Goose in 1962 was memorable. No one announced that it was an amphibian because it seemed obvious, except to the poor older lady opposite me who screamed and about fainted when the plane splashed down in the bay.

The scene was grim but familiar. A gurney arrived on the floor carrying a motionless young man. The attendant casually remarked, “Just another drug overdose; he’s DOA” (dead on arrival). I was in my infectious disease fellowship at Los Angeles County/USC Medical Center.

The patient was a 14-year-old black boy. He had been brought to the Emergency Department by police ambulance. He was admitted because the ED doesn’t like to handle deaths. We had no history. His mother came along soon afterward, and when the cause of death was suggested to her she became outraged. “My boy didn’t do drugs; he was a good boy!” He had stayed home from school with mild symptoms of a viral infection.

The intern on the floor then did something I can never forget. He examined the boy thoroughly. Although no rash could be seen on his mahogany skin, the young doctor retracted an eyelid and on the inside fleshy part he saw what he was looking for - a petechia, a broken capillary, purple and star-shaped. He ordered the stunned nurse to bring him a large syringe and needle, which he plunged into the still heart, drawing a post-mortem blood culture which did indeed yield the dreaded Neisseria meningiditis.

The intern’s diligence did two things. It removed doubt that his death was the result of drugs, giving the family some peace. It also alerted all the personnel who were in contact with the victim to obtain preventive antibiotics, thereby averting further tragedy.

Meningococcal disease is the stuff of medical drama. It is one of the three major causes of spinal meningitis, all of which are now preventable with vaccines. In my one year at County I saw about 350 cases. When the first vaccine arrived in 1985 (against “H. flu”) I had treated about ten cases in my own practice. Thousands of American children died yearly; now a case is so rare that most young doctors have never seen one.

You may have seen the TV ads for Menactra, the newest of the three vaccines and one targeted especially at adolescents. Young people in dormitories or military barracks are at somewhat greater risk, although actual numbers are quite small (about 3 per 100,000) and the victims are often smokers and party-animal types. Whereas the other two types of meningitis are essentially always fatal without treatment, some 40% of meningococcal patients recovered in the pre-antibiotic era, many with severe disfigurement from loss of extremities. At the other extreme are patients like the youngster described above who die so quickly that meningitis has no time to develop.
The only other infections I can think of that kill so quickly are plague in its pneumonic form and Ebola virus. Yet the bacterium is commonly found in healthy people. It is analogous to being struck by lightning.

I’ve seen exactly one case in my practice. My first Labor Day on call in 1967 an alarmed grandmother phoned me. Her daughter had taken her 8-month-old baby girl to an urgent care but was sent home with reassurance. Grandma wasn’t buying it. She called one of the pediatricians she knew (she was an LVN) and I was on call and in the office (our hospital did not have an Emergency Room yet). The baby was there in 20 minutes and had the classic petechial rash of meningococcal disease. Many children develop these little spots after vomiting or coughing, and they also appear on the soft palate in strep throat, but these were not benign little red spots. They were purple and star-shaped, caused by plugs of bacteria and dead cells clogging up small blood vessels. I gave Baby Paula a shot of penicillin and followed her with Grandma to an ED 5 miles away where she was admitted. My spinal tap was diagnostic of bacterial meningitis (she needed no anesthetic, so lethargic was she by that time) and she recovered fully.

Choosing pediatrics raised many an eyebrow among colleagues and friends, and still does on occasion. Most have trouble imagining how I stand the screaming kids all day (”What screaming?” I reply). Others can’t imagine putting up with all those (fill in your own adjective) mothers.

Truthfully, I’ve never regretted my choice. Kids do grow up; by 3 most are great patients, and many have stayed with me and are bringing me their children. Mothers continually inspire me, and this entry is about one of those mothers who taught me that a wounded baby can turn a mother into a lioness.

Celeste was delivered on a January morning in 1976. Her mom had been seeing me with her son since the year before. He has the distinction of being the only baby ever to urinate all over me (I’ve had many close calls). The reason was simple; I was too distracted by the dazzling mom and let down my guard. Baby Celeste was critically ill; she had hydrocephalus and spina bifida, far too severe to correct surgically. The diagnosis had not been made before birth as it would be now, but Mom worried all through the pregnancy and refused offers of a baby shower. Her intuition was right. I was returning from a ski trip to Idaho with my kids and missed the delivery.

By the time I entered the picture Celeste had been transferred to Childrens and Mom, who had not been permitted to see her baby, had signed herself out of Valley Presbyterian (after a cesarean!) and driven her Flower Power VW van to Hollywood to be with her. At the time I was quite active teaching there and held a clinical professorship at USC (I do to this day) so I was able to intervene on her behalf. The nursing staff tried to take over the baby’s care and keep Mom at bay. Mom knew the prognosis but demanded her rights, including nursing the baby with a pump and taking her home. I put myself on the line for her and got the staff to back off and let her do just that. Regional Center had demanded that she relinquish guardianship, and when she refused a psychiatrist was dispatched to “reason” with her. Perhaps in 2008 this doesn’t seem remarkable, but in 1976 parents didn’t challenge the system like that.

Mom was alone in her battle. Dad (20 years older and from a macho culture) warned her, “Don’t bring that thing into my house.” Also “That can’t be my baby or she’d be perfect.” Grandma’s contribution was to tell her G-d was punishing her for being such an evil child (I later learned that on the contrary she had been severely abused by her family for years as a child.)

Celeste clung to life for three months, getting enough nourishment to survive. Mom barely slept. I dropped by often to support her as I could. On one visit I was holding her hand when her husband walked in. His reaction was to accuse her of having an affair with me. Mom and I agreed that she needed to place the baby in institutional care. The best facility was Pacific State Hospital in Pomona. Their waiting list was a year; Celeste didn’t have a year. I contacted the Medical Director, a former colleague from Childrens, and got her in right away. I drove Celeste and Mom out there because no parent should ever have to make that trip alone. I was curious as well. The children’s ward was cheerful and immaculate. I asked my colleague how he and his staff did it, how they kept up their spirits amid dying and insensate children. His answer has stayed with me. “They elevate us, make us feel privileged because their lives are so innocent and they need us so much.”

No one ever questioned whose baby Celeste was, or whether her death was to be as comfortable and dignified as possible. There would be no “Code Blue”. Mom never stopped thanking me for my support. The experience strengthened my belief in the sanctity of all human life and in the proper role of a physician. A year and a half later a perfect daughter arrived, a gift Mom earned for her courage.

They say no good deed goes unpunished. Au contraire! That Mom is now my wife Cynthia, still dazzling and still inspiring.