Edward Tabor
Bethesda, Maryland, United States

I got to know the children’s hospital when I was in my second year of medical school and was assigned to the pediatric rotation. From one perspective, the building had the wrenching sadness of childhood disrupted by illness. But it also had benevolent stories: most of the children who arrived sick eventually went home well. These dramatic “flights” into health occurred so often that I enjoyed my work there. I found myself going back to the hospital to see my patients in the evenings, even when I was not on-call.

The hospital floors were arranged mostly by age: sick newborns on the second floor, toddlers on the third floor, and so forth. The sixth floor was for older children; in addition to a ward, it also had single-patient rooms that were generally reserved for patients of any age who might need to be isolated, either during their current hospitalization or in the future. Many of these children had weakened immune systems that could not protect them from potentially fatal infections. Some were cancer patients being treated with chemotherapy. When necessary, these individual rooms could be quickly converted into makeshift isolation rooms. At that time, this hospital had no dedicated isolation rooms.

Each of the single rooms on this floor had glass doors leading to a balcony. The doors were closed during the summer to keep the rooms air conditioned, but in the cooler days of September, the doors were often opened by nurses or family members to let the fresh air in.

With the doors open, I could see that each empty balcony had a three-foot wall at its outer edge, connected to enormous screens reaching to the top of the balcony. But the screens, without exception, had long rips that allowed pigeons to move freely in and out. The balconies, now unused by humans, had become a resting place for pigeons, and the floors were carpeted with a thick layer of pigeon droppings. On one of the balconies, the pigeon droppings formed a series of gray and white hills about a foot high, apparently from many years of accumulation.

I had already learned enough microbiology to know that pigeons can be infected with psittacosis bacteria, and that these can be transmitted to humans by the respiratory route. I realized this could be a risk to the patients in the rooms with balconies. I decided to discuss my concerns with my preceptor, Dr. M., who happened to be the head of the pediatric pulmonary diseases division.

When I went to see Dr. M. in his office, he was sitting behind a desk piled high with papers and books. I told him what I had observed and pointed out the risk to the patients from the pigeons. Dr. M. sat back in his chair, put the tips of his fingers of both hands together, and said to me, “Doctor” (in the way many of our senior physicians addressed medical students after they arrived on clinical rotations), “those pigeons were there long before you came to this hospital, and they will be there long after you leave.” He looked at me silently for a few moments, while I contemplated the way he had turned the honorific “doctor” into something dismissive. Then he advised me to focus on my work and told me the meeting was over.

Weeks and months passed. During my elective months, I chose additional pediatric rotations and I saw some of the patients whom I had known on earlier rotations.

One day, I got off the elevator on the sixth floor and heard music coming down the corridor. A few nurses and patients were standing around the door of an eleven-year-old lymphoma patient named Timothy whom we all knew from his previous visits. Timothy was not in isolation on this visit, so his door was wide open. Sitting with him was a tall man with a balding head and thin, sandy-colored hair, a beard, and a mustache, playing a guitar and singing folk songs. It was Pete Seeger. Even if I had not recognized Pete Seeger, I would have guessed who he was, because I knew all his songs. The listeners standing outside the door swayed with the music. Someone told me that Seeger was an old friend of Timothy’s parents and he had come to visit Timothy, to sing to him during his hospitalization.

Timothy went home from the hospital that time; everyone on the staff wished him well. But he soon came back, and his condition was bad enough that he was put in isolation in one of the sixth-floor rooms. Now his door to the hallway was closed, and signs were posted warning hospital staff and visitors to put on gowns, gloves, and masks to prevent infections. Equipment and furniture were wiped regularly with antiseptic solutions. Most likely, the glass doors to the balcony were kept closed, but it was not enough.

Timothy went home that time, but a few months later he was readmitted, again to isolation. Two weeks later, he died of psittacosis. Within a week after that, the hospital had repaired all the screens on the balconies and arranged for the balcony floors to be cleaned.

Psittacosis is caused by the gram-negative bacterium Chlamydophila psittaci. More than 130 bird species have been documented as hosts, including pigeons. Pigeons with psittacosis rarely die from it, but they can remain infected after clinical recovery and can infect other birds and humans. Psittacosis can be transmitted to humans by close contact with pigeons or other birds due to inhaling contaminated feather dust or dried feces. A multi-system illness can result, including severe pneumonia.

Was anyone at fault in this sad sequence of events? Even though Dr. M. should have known about psittacosis in pigeons (and he certainly would have been reminded about it by my visit to his office), he might not have ever seen any cases, since it is a rare disease in humans and very rare in children. Perhaps he did not think it was likely to be present. But he failed by not listening and not taking advantage of the most valuable benefit of a teaching hospital. In a teaching hospital, medical students and residents ask questions that lead to discussion about established practices, resulting in deeper thinking about the diagnosis, treatment, and prevention of disease by the entire medical staff.