Carl Jelenko III, MD 1931–1991

EDITO ALS Carl J e l e n k o III, M D 1931-1991 This issue is for Carl Jelenko, and it is deserved. He was m a n y things to m a n y people. Peter, Ron, and John will tell y o u a b o u t h i m . T h e y w i l l speak of his personality, his character, and his a c c o m p l i s h m e n t s . T h e y w i l l t e l l h o w he h e l p e d s h a p e t h e specialty of emergency m e d i c i n e and h o w he n u r t u r e d it in i t s i n f a n c y . T h e y will show y o u h o w he was special. Carl Jelenko was all those things, b u t to m e he was even more. Carl was m y teacher, one of m y role models, and a friend: To this I m u s t write. Carl was a Renaissance m a n capt u r e d ~in t h e t w e n t i e t h c e n t u r y . It never ceased to amaze m e h o w m a n y ideas he could generate in a few moments. He had the ability to look at s o m e t h i n g and see it differently t h a n anyone else in the room, to view a p r o b l e m in such a w a y that the solut i o n b e c a m e n o t o n l y obvious, b u t beautifully simple. Carl had the ability to s t i m u l a t e discussion, to bring h u m o r to the room, to teach his coll e a g u e s , to d i s a g r e e a n d r e m a i n f r i e n d s , a n d to a d m i n i s t r a t e w i t h m i n i m a l discord. For me, of all his m a n y t a l e n t s and gifts, Carl's m o s t i m p o r t a n t ability was to touch every p e r s o n he c h o s e to t o u c h a n d to m a k e each a better person. I first m e t Carl in Dallas in 1974 at the U n i v e r s i t y Association for Emerg e n c y M e d i c a l S e r v i c e s (UAEMS) meeting. A t this time, I was a resident who felt that if a b u n c h of surgeons were going to m a k e decisions about the future of emergency medicine, and therefore i m p a c t m y career, I w o u l d like to have some input. Carl l i s t e n e d to m y opinions. It b e c a m e apparent t h a t although he was willing to listen, he was not easily conv i n c e d b y m e r e words. A c t i o n s to Carl were t h e m e a s u r e of the m a n . W h i l e he felt that I m i g h t have some raw talent, he often said, I was m o r e " r a w " t h a n talent (which opinion he held to the end). Still, Carl was never o n e to g i v e u p o n a p r o j e c t a n d thought that I was one on w h i c h he could test his true grit. So he t o o k it u p o n h i m s e l f to be a mentor. 20:9 September 1991

Carl n e v e r s t o p p e d t e a c h i n g me. He questioned m y actions, but he always encouraged m e to act. He quest i o n e d m y tact, b u t he a l w a y s encouraged m e to speak out. He questioned my thoughts, but he d e m a n d e d that I think. He criticized m y ego, b u t d e m a n d e d t h a t I be a winner. H e c h a l l e n g e d m e to t h i n k and act in a responsible way. Carl always did these things in a constructive, not destructive, way. A l t h o u g h Carl was m y teacher, he t r e a t e d m e as a c o l l e a g u e a n d he shared w i t h m e as a friend. He was n o w m o r e t h a n a source of guidance and a role model. We shared our exp e r i e n c e s . We d e l i g h t e d o v e r e a c h other's accomplishments and we w e r e sad over each o t h e r ' s m i s f o r tunes. But we were never satisfied to let the other sit still. There was alw a y s s o m e t h i n g m o r e to be done. There was always a better way, and there was always tomorrow. Carl was n o t a quitter. He n e v e r quit. His c o m m i t m e n t to his professional life, his personal development, and, m o s t i m p o r t a n t , his c o m m i t m e n t to his friends and family was a n e v e r - e n d i n g source of strength. H e w o r k e d hard, he a c c o m p l i s h e d a lot; he laughed hard and brought h u m o r to m a n y ; he l o v e d h a r d and m a n y shared in this love. T h e last t i m e I Saw Carl was in W a s h i n g t o n at the 1989 Scientific Assembly. I had m y son Jeff w i t h m e and I w a n t e d to i n t r o d u c e h i m to such a special man. As Carl came in to t h e o p e n i n g r e c e p t i o n i n h i s wheelchair, I took Jeff over and introduced him. We spoke for a minute, b u t as is always the case, Carl was surrounded by friends who w a n t e d to visit, so I s t e p p e d aside. Jeff s t a y e d and t h e n c a m e b a c k l a t e r and said: "You know, Dad, he is r e a l l y neat, but y o u have to be real careful and talk very slowly to him. You k n o w he had a stroke, and it takes h i m a while, b u t he is real smart. He really likes you." Carl could not h a v e paid m e a greater h o n o r t h a n to c o m m e n d m e to m y son. T h a t was the last t i m e I spoke to him. That was one of the Annals of Emergency Medicine

best m o m e n t s to r e m e m b e r Carl. He was starting to teach another generation the lessons that are so valuable in life. Carl did touch me, he built up the good, he p u t d o w n the bad, always forcing others to be better. He taught m e that this is the responsibility of e a c h of us t o w a r d our f e l l o w m a n and t h a t it m u s t be done carefully and w i t h love. Carl was m o r e t h a n a dedicated physician, an accomplished scientist, a published scholar, a skilled editor, a recognized a u t h o r i t y , and i n s p i r a t i o n a l leader. He d e m o n s t r a t e d the r e s p o n s i b i l i t y we have to each other.

Joseph F Waeckerle, MD, FACEP Editor

I first m e t Carl Jelenko at an early m e e t i n g of the Society for A c a d e m i c Emergency Medicine, then named the U n i v e r s i t y Association for Emergency Medical Services. While I have never thought that names mean much, it is no accident that UAEMS w a s a n o r g a n i z a t i o n for s e r v i c e s rather than one concerned w i t h the p r a c t i c e of a specialty. T h e society was d o m i n a t e d by a series of junior f a c u l t y surgeons w h o had been assigned the emergency d e p a r t m e n t as the low m a n on the t o t e m pole. T h e y were n e i t h e r happy w i t h the assignm e n t nor w i t h the prospect of being labeled an emergency physician. I thought Carl was yet another example of this and was preparing to do b a t t l e w i t h h i m w h e n I discovered just h o w unique he was. He had chosen to be in emergency m e d i c i n e because he saw it as a natural part of burn care, for w h i c h he had m a j o r responsibility in his institution. O n c e over the b r i s t l i n g p o s t u r i n g that all surgeons seem to find inevitable before they can c o m m u n i c a t e , we discovered that we shared a comm o n i n t e r e s t in m a n y things, t h e m o s t i m p o r t a n t of w h i c h was a delight in off-color jokes. A n y t i m e I need cheering up, I reflect on a joke t o l d in a f e r o c i o u s Y i d d i s h d i a l e c t 1041/161

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that Carl told m e at this meeting. It is one of m y favorite stories, and I often a t t e m p t to tell it in his honor, but nowhere near as well. If it fails, I of course ascribe it to him, but if it succeeds, I n a t u r a l l y claim it as original. We s p e n t a b e g u i l i n g h o u r o n c e w r i t i n g a p r o s p e c t u s for a r e s e a r c h p r o j e c t t h a t w o u l d t a k e us to t h a t dark r o o m in central Africa where all jokes originate. The project failed not only for lack of funding, but because we felt that the search should start in Paris rather than in Africa. Carl and I served on m a n y comm i t t e e s together, i n c l u d i n g t h e Annals Editorial Board, the test developm e n t c o m m i t t e e for the e m e r g e n c y m e d i c i n e board examination, and, ultimately, on the A m e r i c a n Board of Emergency Medicine. Carl always was a livener of any meeting, and I will remember with affection his willingness to educate his colleagues. He taught a series of lectures on statistics so that we could be m o r e effective in our e d i t i n g roles. O n the m a n y c o m m i t t e e s , I often disagreed w i t h Carl. We had s o m e w o n d e r f u l shouting m a t c h e s that disturbed our colleagues m o r e than t h e y did us because we were n o t afraid to disagree and k n e w it w o u l d pass d u r i n g the next

recess.

In reflecting on Carl's career, I realize that he embodied everything that I strive to be: h u m a n i s t , raconteur, husband, father, friend, scientist, adm i n i s t r a t o r , and last b u t n o t least, teacher. Carl loved people: he n o t only genuinely cared about patients, residents, and colleagues, but he was a loyal and p r i n c i p l e d friend. He was not a good politician because he always said w h a t he thought and never made any effort to appease those to w h o m he was opposed. He t h o u g h t that decent people could negotiate their differences, and as we agreed to do more than once, if need be retain their differences w i t h o u t r e a c h i n g a consensus. Being stubborn, he often m a d e others r e t h i n k their position. Would that there were m o r e people in the world w i t h his honesty, clarity of thought, and creativity. He as a man, not just as a physi162/1042

cian, had w h a t Lewis T h o m a s called " t h e gift of affection." This is clear in his feelings for his wife and children, for his friends, and for the residents he nurtured. As a scientist, Carl m a d e m a n y important contributions to the care of the badly burned. He reintroduced the concept of hypertonic saline solutions for burn resuscitation, and I predict that his solution will one day be p a r t of c o m m o n r e s u s c i t a t i o n techniques for the t r a u m a t i z e d shock patient. His production of m o r e than 100 original papers is a true sign of his great creativity and productivity. Carl's a d m i n i s t r a t i v e a b i l i t i e s are e x e m p l i f i e d w e l l in t h e b u r n u n i t that he supervised, but w h a t is m o r e i m p o r t a n t , in the e m e r g e n c y m e d i c i n e r e s i d e n c y t h a t he c r e a t e d in Dayton, Ohio. It is no small task to start a residency, especially in a n e w specialty. W h e n I consider that Carl had a c o m f o r t a b l e n i c h e in general surgery and did n o t need to b r a n c h out into an unaccepted and n e w field, I a m e s p e c i a l l y i m p r e s s e d by h i s achievement. But w h e r e Carl s h o n e a b o v e all was as a teacher. He b e l i e v e d t h a t t e a c h i n g is t h e a c t of s h a r i n g of knowledge and that the teacher m u s t i m p a r t a w a y of life, n o t just factual knowledge. As a role m o d e l and as a m e n t o r , C a r l h a d no equal. I h a v e m e t m a n y of his students and was always i m p r e s s e d by their unqualified a d m i r a t i o n for h i m . M o r e o v e r , he had a once-in-a-lifetime gift of imparting his e n t h u s i a s m and curiosity to all of his students. He was never selfish in his talents and o n l y w a n t e d e v e r y o n e to share his ideas and creations. W h e n he sustained the first wave of his d e v a s t a t i n g illnesses, he did not give up and w a l l o w in a wave of self-pity as probably any of the rest of us w o u l d have done. The t r e m e n d o u s s u p p o r t t h a t he r e c e i v e d f r o m his wife, Judith, was wonderful to watch. Between them, he c o n t i n u e d to strive to c o m p l e t e his scientific projects. I cannot help being saddened by the loss of this very great teacher and m a n , b u t I c a n n o t help rejoicing in having had the o p p o r t u n i t y to k n o w him. I treasure m y m e m o r i e s of h i m Annals of Emergency Medicine

and will continue to draw on his exa m p l e as i n s p i r a t i o n for m y o w n striving.

Peter Rosen, MD, FACEP, FACS Departments of Medicine and Surgery University of California San Diego School of Medicine

I first m e t Carl Jelenko w h e n I was a medical student at the U n i v e r s i t y of Maryland, where he was a surgical resident. He was truly a unique individual. T h o u g h we had broken bread and enjoyed the fruit of the vine m a n y t i m e s t o g e t h e r , it w a s n ' t u n t i l w e both became involved with emergency m e d i c i n e that I found he was an i n s u l i n - d e p e n d e n t d i a b e t i c . Of course, in t h o s e days e v e r y o n e was pleased if a diabetic didn't spill sugar all (or part) of his day. Consequently, Carl .would eat and d r i n k w h a t he liked, u s u a l l y w i t h a cigarette - an unfiltered Kool - and adjust his insulin accordingly. He had a v i b r a n t sense of h u m o r and an intense high level of expectation of his colleagues. Carl expected research to be sound, innovative, and creative. His frequent comments c o n c e r n i n g the v a l u e of a presentat i o n b y y o u n g i n v e s t i g a t o r s at t h e UAEMS meetings were, however, polite and courteous. I often m a r v e l e d at his a b i l i t y to handle large n u m b e r s of participants at his conferences, allowing and enc o u r a g i n g i n p u t , a n d r e p l y i n g to c o m m e n t s and q u e s t i o n s in a nonj u d g m e n t a l fashion. He was the cons u m m a t e teacher - at the U n i v e r s i t y of M a r y l a n d , w h e r e he w a s a resident; at U A E M S m e e t i n g s ; at t h e Medical College of Georgia, where he rose to the level of professor of surgery; at W r i g h t S t a t e U n i v e r s i t y , where he began the emergency medicine program; at his seminars; at the editorial board meetings of this journal, w h i c h he served as associate editor; and at the c o u n c i l m e e t i n g s of UAEMS, w h i c h he served as president. Carl m a y have been one of the few truly eclectic physicians (not doctor, 20:9 September 1991

EDITORIALS

but physician) that I have ever met. He knew history, literature, and the fine arts. At an ACEP annual meeting held in Atlanta, when a hostage situation occurred (I can still see the SWAT team invading the lobby of the hotel), he offered to help the police and entered into discussions with the hostage taker. Above all else, Carl loved living and loved medicine. Most especially he was devoted to what was then the new specialty of emergency medicine. He wanted great things for us, and he participated in the building of those great things - at UAEMS, at Wright State, at Annals, and at the American Board of Emergency Medicine (where he was an original board member). I visited Carl in Baltimore, where he and his family went to live after his stroke. I had breakfast with him. When we parted, I cried. I knew I would never see him again. I cried not because I felt sorry for Carl, but because I felt sorry for myself, and for all of you who would never know the person Carl had been. What a shame! When I got the call telling me he had died, I called his wife, Judy. Both of us knew that, in fact, Carl had died years before when he had his stroke. It may sound heartless and cold, but the call was actually anticlimactic, especially for all those who had been close to him. There are now three who served

this journal and emergency medicine so well who have died - Carl, Jim Mills, and Hal Jayne. All died before we were ready. Although they were all honored by the specialty they loved so well, I don't think any of us really told them how much we appreciated their efforts. I know I regret never saying thank you and that, in a way, I loved and respected them. But somehow, I can still hear Carl l a u g h i n g as he once did as Hal searches for a new topic for debate, while Jim tries to teach them both some class. God, what fun the three of them must be having! Without us.

Ronald L Krome, MD William Beaumont Hospital Royal Oak, Michigan

Emergency medicine residents need coaching and guidance. As they learn, they need a role model and mentor. Carl Jelenko was a mentor. He will be missed. Only a handful of emergency physicians had the opportunity to serve as residents under the leadership of Carl Jelenko. As one, I will be forever influenced by this pioneer in emergency medicine. Carl possessed all of the qualities important to the training of a new generation of emergency physicians. He was a gentleman, yet a strong diplomat. He was kind and compassion-

ate, yet strong willed. He was serious, yet good natured. He was committed to the specialty of emergency medicine and instilled his love of the specialty in those around him. Carl was a true academician in emergency medicine. He passed on the importance of scholarly investigation, a questioning mind, an ability to coerce and convince, and the importance of service to the specialty, all built on a base of excellent clinical care. Carl instilled in his residents the importance of being a complete person and an excellent physician. The specialty of emergency medicine and the A m e r i c a n Board of Emergency Medicine are lasting tributes to Carl Jelenko. Annals of Emergency Medicine and the Wright State U n i v e r s i t y Residency Program in Emergency Medicine will forever be a part of Carl's legacy. However, the greatest tribute to Carl is in the minds and souls of those who trained with him and in our ability to carry on his ideals and traditions. As Carl might have said, dress properly, do what you want, ruffle a few feathers a l o n g the way, and enjoy t h o s e around you. I will forever miss Carl and yet will always enjoy his presence.

John B McCabe, MD, FACEP State University of New York Health Science Center Syracuse

Preventable Sudden Death in Children With Sickle H e m o g l o b i n o p a t h i e s and Fever: T h e N e e d for a Protocolized Approach Children with sickle cell anemia and. its variants are at much higher than normal risk for sudden death due to overwhelming sepsis from encapsulated organisms. This problem has been recognized for at least 20 years and is caused by physiological asplenia, which develops in early infancy. 1-3 The incidence of bacterial sepsis in the affected population has been estimated to be as high as 30%, 20:9 September 1991

with a case-fatality rate of 25% to 35%.4 7 Pediatric hematologists have developed elaborate protocols for the evaluation and treatment of febrile children with sickle hemoglobinopathies to avoid undertreating this potentially fatal syndrome.8, 9 Despite the i m p o r t a n c e of this p r o b l e m and the g e n e r a l l y h i g h awareness of the significance of fever in children with sickle cell disease Annals of Emergency Medicine

among pediatricians, ~°,~2 the general emergency medicine literature has been almost completely silent concerning this phenomenon; a review of three major emergency medicine journals for the past 15 years could identify no article that specifically dealt with this issue. One relatively l e n g t h y review by G a l l o w a y and Harwood-Nuss of sickle cell disease that discussed the increased inci1043/163