Reader response

Myron Yaster MD

From Ken Goldschneider, MD, Cincinnati Children’s Hospital on vaccine hesitancy

The topic of vaccine hesitancy, especially claims of "experimentation" that were circulated during the pandemic, always raise my eyebrows.  Let me tell you a short summary of fascinating true stories that explain why.

My father, Irving Goldschneider MD (immunologist) and his collaborator, the recently late Emil Gottslich MD (biochemist) developed the original meningococcal vaccine under the leadership of Malcolm Artenstein MD in the late 1960s while stationed at Walter Reed Army Medical Center during the Vietnam War.  The animal studies went well, obviously.  When it came time to do the human experiments, we will fast forward through red tape and just say that they discreetly administered the vaccine to each other before anybody was authorized to received it.  My mother recently told me, "one evening as we went to bed, your father mentioned that if he did not wake up in the morning, that he and Emil had given each other the vaccine that day…I did not sleep at all that night, and have not forgiven him for that, yet [it’s been 55 years, lol].”  After a large number of GIs had successfully received the vaccine, consideration was given to pediatric trials.  First, the authors lined up their own children and administered the vaccine to them (n = 22). I have the minor claim to historical significance of being the first pediatric recipient of the meningococcal vaccine.  It was adminstered in our home kitchen, which is also where we had our blood drawn for subsequent titer measurement.  The 22 of us (plus a second group) became the subjects of the first pediatric meningococcal response paper.  Fast forward a little bit after we did not die, and large scale pediatric trials began (that is a long and fascinating story of public health in and of itself).  The trials took place in the Danbury, Connecticut public school system.  The very first kid who came through was a young man who, upon being stuck with a needle, fell to the ground and had a seizure!  You can imagine the terror, upset and pure chaos that ran through the research group, as they ran to get the boy's mother.  After all, to have such a significant event happen on the very first subject of a mass trial would lead to cancellation of the entire process! Thousands of participants and family members were there, the press was there, TV reporters were doing interviews!  Upon arrival to the scene, the boy's mother said, "oh, he always does that."  When the research group asked her why they signed him up to participate in the trial if they knew that was going to happen, the mother replied, "we just wanted to help."

Historically, vaccine developers have put themselves at personal risk and many have died from exposure to the diseases they were trying to prevent.  Malcolm Artenstein died from a form of hepatitis that he was studying.  Fast forward a few decades, and you have people complaining that they are being treated like guinea pigs despite tens of thousands of people having safely received a vaccine.

Hence, vaccine resistance and the politicization of recipients as victims, raise my eyebrow…

Here is an interesting book written by Andrew Artenstein MD (Malcolm’s son and an ID doc) that covers the history of vaccine development, with a special eye towards the meningococcal vaccine. “In the Blink of an Eye”.  He references a book from 1986 by Dr. LK Altman called "who goes first?" which discusses the tradition of self-experimentation in medicine and sounded interesting, though I have not yet read it. If people only knew the personal stake so many vaccine developers have invested in their work and the risk they were willing to take to bring safe and effective vaccines to the world, they might be willing to listen to the risk: benefit discussion a little differently.

From Dr. Bob Spear (retired), Rady Children’s Hospital,San Diego, Ca

My undergraduate and medical school classmate, Greg Poland MD, is a world-renowned vaccinologist, director of Mayo Clinic’s Vaccine Research Group and editor-in-chief of the medical journal “Vaccine”. His study in 1990 (“Frequency of Adverse Reactions to Influenza Vaccine in the Elderly, a Randomized Placebo-Controlled Trial” JAMA 1990: 264: 1139-1141) demonstrated that the flu vaccine caused no more side effects than saline placebo. I mention this because some surgeons (and parents who are convinced they acquired influenza from the vaccine) may be reluctant to have their patients receive the flu shot during anesthesia fearing side effects that may mimic and perhaps delay the recognition of a surgical complication. These fears are, of course, unfounded.  

I would personally avoid giving the Covid vaccine to children under anesthesia because the side effects, albeit mild and self-limited, often include fever and significant malaise for 12-24h. For example, rare, but potentially life-threatening complications (perforation/bleeding etc) following upper GI endoscopy, colonoscopy and percutaneous liver biopsy would likely present with these very symptoms and would make the early post-operative period difficult as attributing symptoms to the vaccine could delay the diagnosis of a more serious complication from the procedure. (I logged the most hours as a volunteer vaccinator at our local clinic in 2021, so I’m not “anti-vax”). Interestingly, Dr. Poland has a permanent injury from the Covid vaccine, severe tinnitus, and is the de facto leader of a support group of people (16,000 on Facebook, I believe) who also suffer from this entity. He has publicly acknowledged, in a good-natured manner, the irony of his misfortune. 

From Dr. James Thomas Children's Hospital Colorado on cannot intubate cannot ventilate

After reading this I immediately thought about how this conversation is already changing. GPT may VERY soon be able to VERY specifically answer the question of "if there is something, really anything, that could be used to identify patients at risk of being a difficult intubation." In the meantime, I asked ChatGPT the following question:

"Is there anything that could be used to identify pediatric patients at risk for difficult intubation?" and this was the answer in 3 seconds.

Identifying pediatric patients at risk for difficult intubation can be challenging, but there are several factors that can help clinicians assess the likelihood of encountering difficulties. Here are some considerations that can aid in identifying pediatric patients at risk for difficult intubation:

1. Age: Neonates and infants, especially those younger than 1 year, tend to have a higher risk of difficult intubation due to anatomical differences, such as larger heads, anteriorly positioned larynx, and a relatively larger tongue.

2. Physical characteristics: Certain physical features can indicate a potentially difficult intubation. These may include micrognathia (small jaw), retrognathia (receding jaw), macroglossia (enlarged tongue), or craniofacial abnormalities.

3. History of difficult airway management: If a child has a previous history of difficult intubation or airway management, it is crucial to take this into account when assessing the risk for future intubations.

4. Syndromes or medical conditions: Certain syndromes or medical conditions, such as Pierre Robin sequence, Down syndrome, or mucopolysaccharidoses, can be associated with anatomical variations that increase the likelihood of difficult intubation.

5. Limited cervical spine mobility: Children with conditions affecting cervical spine mobility, such as skeletal dysplasias or rheumatoid arthritis, may have difficulties with intubation due to limited neck movement.

6. Airway assessment: A thorough evaluation of the airway anatomy, including the Mallampati score, thyromental distance, interincisor gap, and other relevant measurements, can help identify potential difficulties.

It's important to note that predicting difficult intubation in pediatric patients can be challenging, as each child's airway anatomy is unique. Therefore, a comprehensive evaluation of the patient's individual characteristics and a multidisciplinary approach involving an experienced anesthesia team are essential for optimal airway management.

Happy hunting.