Dr. Michael Kleinman in the ER

Holocaust Memorial at
the York JCC

Childhood sweethearts Lili and Josef became separated while they were in the concentration camp, the work camp, during the Shoah, the Holocaust.  When the prisoners at Auschwitz were liberated by the Soviets in early 1945 Josef went to find his love again. He walked throughout Germany for six months anxiously asking anyone if they had seen her.  When some claimed that they heard she was dead Josef refused to believe them. He didn’t give up; he kept searching.  And he eventually ran into an old friend who told him that she was recuperating in a nearby hospital.  He found her and nursed her back to health. 

Ready to start a new life, they got married.  The longed-for State of Israel was created on May 14, 1948, and Josef and Lili moved there to help build the nascent country and to start their family.  

Dr. Kleinman

Lili and Josef are the "two dear parents" of Dr. Michael Kleinman, York Hospital ER physician. Dr. Kleinman said of his parents; “They rarely talked about the horror they saw and were not bitter.  Instead, my parents were protective of me and my sister.  (They were) nurturing, but not stifling.”  This awareness of their actions instilled in him a strong desire to be kind and fair to others.  He did not want to see “the other side of humanity” that his parents had witnessed and lived through.  

They often reminded him to “never forget” the Golden Rule.  The traditional Jewish version of this foundation for all ethical conduct is, “That which is hateful to you, do not do to your fellow.” He said that this deeply-felt belief steered him in the direction of providing service to his community. “And so the path of medicine became clear,” he offered.

“How did you decide to become an emergency room doctor?" I asked

He went to the Des Moines University College of Osteopathic Medicine and graduated in 1979, and after his internship, he went into a general medical practice with Dr. Kieren Knapp.  He enjoyed this, and after seeing patients in the office he spent some time “moonlighting”  in the Emergency Department at the York Hospital. 

How could Dr. Kleinman work in an ER without special training?  

Through the early years of the last century (did I really just say that?) and into the 1970’s the ERs were typically staffed by a general surgeon, a general internist, or a general practitioner

Busy Hectic ER Team

who called in specialists when they required help.  Over time, and seeing the need for improved care, and the benefit of specialization, the American College of Emergency Physicians was born on August 16, 1968, by eight maverick physicians in Lansing, Michigan.  The first dedicated ER Residency program was started in 1970 and the American Medical Association quickly recognized emergency medicine as a distinct specialty in 1972.  

Early in his career, Dr. Kleinman experienced this change in approach firsthand; emergency physicians became specialists.  Falling in love with the experience in the ER and the privilege of taking care of a wide variety of patients, Dr. Kleinman realized that if he was “going to do this” he had better get further training.

Dr. Kleinman did his emergency medicine residency training at Memorial Hospital in York, the first such program in the county.  He completed this in 1982 and received his certification in 1984. With a broad smile, he said, “My certificate is number 11.  I treasure this."  Following this, he and several other physicians including Drs. Ron Benenson, Merrill Cohen, Dave Eitel, and Lynn Jensen developed the program at the York Hospital in 1988.  What did he and the others need to know?

An excellent Wikipedia entry (1) notes: "The emergency physician requires a broad field of knowledge and advanced procedural skills...They must have the skills of many specialists--the ability to resuscitate a patient, manage a difficult airway, suture a complex laceration, reduce a fractured bone or dislocated joint, treat a heart attack, manage strokes, work up a pregnant patient with vaginal bleeding, stop a severe nosebleed, place a chest tube, and to interpret (imaging studies).  They also provide episodic primary care to patients during off hours and for those who do not have primary care providers" (whew, that was a mouthful!).

“After all of your years in practice was there, maybe, a single event that especially moved you?" I asked.

"As an intern, all the patients affected me equally,” he said.  Yes, they were all important to him.  But, he went on,“I clearly remember this one patient, a young woman in her early thirties with metastatic ovarian cancer.  She was married with two small children.  She was admitted to the hospital and never left.  She died quickly.  There was nothing we could do. This was in 1981 and there were no tools to help her back then, and I remember feeling so helpless." 

"That was me in 1981, but I lived, I left the hospital," I said, frozen in fear.

I asked Dr. Kleinman to repeat the story, and he did.  Though he was taken off guard by what I had just told him. Yet, I still couldn’t take in what he was saying. When I listened to the recording of the interview later I was jarred by my deafness.  Why did I not hear what he said? I don’t know. (I guess that’s why doctors learn to repeat themselves, repeat themselves, repeat themselves.)

Calvin and Hobbes

Yes, denial.  "Something horrible happens, and our mind plays tricks on us, tells us that it never happened, that it occurred differently than it really did, that it isn't quite what it seems.”  This often works for what has happened in the past. According to Dr. George E. Vaillant, “such trickery can reveal the mind at its most creative and mature, soothing and protecting us in the face of unbearable reality, managing the unmanageable, ordering disorder...putting out in the world what was not there before."  But in the ER the truth must be faced directly; denial is a poor option.

Dr. Kleinman knows this.  In his decades of work, how many thousands of times has he had to give unwelcome news to his patients?  How many times has he imparted unbearably sad information to loved ones?   How many times has he been forced to give up and admit failure?  That Josef will not find Lili.  But how many more thousands of times have things turned out well, much better than expected?   

Maybe, like the Swedish diplomat Raoul Wallenberg or Oskar Schindler, he is just trying to

One of many such plaques

save as many souls as possible.

References:

1.   "Emergency Medicine." https://en.wikipedia.org/wiki/Emergency_medicine

2.  George E. Vaillant. The Wisdom Of The Ego. Harvard University Press, Boston, 1993.

by Anita Cherry 2/17/18

Pediatrician Dr. Nussbaum Says: "Yes, Listen to Your Mother"

Allen Nussbaum, M.D.

"I love kids, and I love watching them grow," said Dr. Allen Nussbaum, recently-retired York pediatrician.  During his 35-plus years of practice he watched carefully as mother and baby formed their unique and critical attachment.  He also observed the mother's overwhelming anxiety about being able to protect her baby, the baby she loves with a new version of loving she had not previously experienced.  He responded by allaying mothers' fears by calm reassurance, frequently saying to them, "You're a good mother, a good mom."  That was nice for us to hear.  

He told me that as a new mother, "It seems that everyone has advice for you."  Because this can be disorienting he said, "So pick one person for advice.  Read one thing on the Internet.  And pick one book on child-rearing.  Because if you don't, you will get confused."

Only one book?  Only one Internet site?  When he said this I was taken aback at first, but as I thought about it later I realized why.  

As I awaited the arrival of our adopted baby I started reading "What to Expect When You Are Expecting" (though I wasn't technically "expecting") and quickly put it down.  My husband was absolutely sure that Burton White's book on the first three years was the best, and we read the first chapter together and gave up (too much).  We knew that Dr. Spock was popular once but sorely out of fashion now.  

Lioness and Cub by Billy Dodson

But later, as I held our daughter in my arms and looked down at her and she looked up at me I realized that if I followed my mammalian biologic evolutionary heritage, and was fully present, and in the moment, and went by instinct everything would go the way it was meant to be.  Dr. Nussbaum was right.  

What is involved in the specialty of pediatric medicine, a specialty that, according to Dr. Nussbaum, must be a true calling?  James Hughes (in his "Synopsis of Pediatrics," 1979, p.1) states that:

"Pediatrics is the knowledge of genetics, for this governs the seed.  It is the knowledge of the events of prenatal life, for this is the soil in which the seed grows.  It is the knowledge of the newborn, the infant and the young child, for this is the early growth period.  And it is the continued scientific supervision of the child until he [or she] achieves maturity."

Gesell and Ilg 1943

Gesell and Ilg write that "in a biological sense the span of human infancy extends from the zero-hour of birth to the middle twenties.  It takes time to grow."   And that, "physical growth is a modeling process which produces changes of form, and at the same time preserves a basic constancy of form.  That is the paradox of all growth--the baby remains himself despite the fact that he is constantly changing.  It might even be said that he is never so much like himself as when he is changing!" ("Infant and Child in the Culture of Today," 1943, p. 15).

So our pediatrician has a unique window on how we become who we are, and who we will be.  

I asked Dr. Nussbaum if he could tell me what led him to want to be a physician?  Without hesitation he said, matter-of-factly, "My mother decided I would become a doctor."   In his nerve-wracking medical school interview he was asked this same question (of course) and he replied the same way, and, as he told me with no irony, "And they took me!"  He then went to Temple and did his Pediatric training at Children's in Cincinnati.

I wondered if he could recall for me some especially high or low moments in his nearly four decades of practice.

"Getting an 18-month-old through an exam without tears was job satisfaction."  Though this sounds like a particularly low bar it is more likely the mark of a caring physician constantly honing his craft.  Dr. Nussbaum paid close attention to seemingly simple things.

Where other physicians might be satisfied by responding to parents' questions in the middle of hectic office hours by texting he needed to hear their voices to gauge their needs, and he always called them on the phone.  If there was a problem at ten o'clock in the evening he told parents to meet him at the office.

"One of the saddest memories was of a baby with acute meningitis.  This was due to Haemophilus influenzae type b (a bacterial illness, not the flu)," he said.  She was diagnosed and treated fairly quickly but the disease progressed rapidly and she died.  Her tragic death and the terrible pain it caused stayed with him.  

The vaccine against Hib was introduced in 1985 and it is 99% effective in preventing disease.  Before it was available there were about 20,000 cases of invasive Hib disease yearly in the U.S. and 1,000 deaths.  In 2006 there were 29 cases.  In 2008 there were seven cases in Pennsylvania.  One child had only a single dose of the vaccine (three or four are needed); the others were not vaccinated at all.  Three of these children died.

Hib cases in England before and after vaccine

In light of his experience Dr. Nussbaum said, "This (vaccine) has been a blessing and I always give that shot first."   The Hib is, of course, one of an ever-lengthening list of recommended childhood immunizations that have saved millions of lives worldwide over the past 50 years including two to three million deaths yearly due to diphtheria, whooping cough, tetanus, and measles, according to the World Health Organization.  Vaccination is one of the great success stories in medicine; prevention is way better than cure.  

But what about people now who fear or mistrust vaccines, saying that such treatments are dangerous and not necessary and refuse to allow vaccination of their children?  He said, "There has always been a group of people that is against vaccinations of any kind."  He and his group wrestled with this dilemma.  He said that while parents have an "absolute right to decide what to do for their child" his practice, as a group, also has the right to follow their conscience and to refuse to treat such patients.  They were, therefore, nicely referred elsewhere. 

Though no longer in practice he remains part of the York community and he is still surprised when parents greet him around town and happily remind him of the pearls of child-rearing wisdom he gave them.  He thought that he was just imparting, in his words, "common sense."  Maybe we all need more of that.  

by Nguyen Thanh Bin

After thirty years the mystery of the long journey of reciprocal love that is parenting has become clearer to me.  A woman is rarely fortunate enough to be at the right time and the right place emotionally, fully prepared, when her baby is placed in her arms.  Parents, like children, are incomplete works and are always becoming who they will be.  The stage may be set, a home, a special room for the baby, a crib, and a box or two of diapers.  But the woman is new to her task and learns on the job.  As children develop they teach their parents that while parenting itself is a fully-natural job it is still maddeningly confounding!

I wonder what would have happened if, when I was developing as a child, I had listened to my mother, like Dr. Nussbaum listened to his?  What if we all listened to our mothers?

References:

1. Hughes, James G. Synopsis of Pediatrics, Fourth Edition. C.V. Mosby, 1975 
2. Gesell, Arnold and Ilg, Frances Infant and Child in the Culture of Today. Harper and Brothers, 1943