Duane Graveline MD MPH
USAF Flight Surgeon
NASA Astronaut

My Introduction to Autovaccination

I shall never forget my arrival at Walter Reed Army Medical Center.
“I am to report to Major General Leonard Heaton, Commander, Walter Reed Army Hospital”.

I didn't realize how little I knew about military protocol until the airman at the gate told me that the general would probably be too busy to see me right now, regardless of what my orders said and suggested I just check into the intern's quarters and personnel.

The back of my neck hurt with a sore unlike anything I had ever had before. As I was leaving home half a day before, my wife said the sore had a greenish center with a fiery red halo. This I recalled was much like that on a patient I had treated at a doctor’s office two weeks earlier while wrapping up my senior year of medical school and I was thinking the worst.

Just a few months prior, I had sat in on the autopsy of a young woman who had died of overwhelming sepsis resistant to every antibiotic available at that time. The pathologist who nicked his hand on the rib cage — despite wearing double gloves — almost lost his hand. Like most medical students, I had gone through a phase of relating to every illness, which could be called hypochondriacal, and I was just barely out of that phase.

The airman gave me directions and tossed me a snappy salute, knowing that although I was a civilian today, I would be a first lieutenant tomorrow. The Air Force recruiting officer had told me that ordinarily I would be getting a three-week military indoctrination, but he wanted to get me in the next group of interns, so I was going to have to wing my military indoctrination.  Sure, I replied innocently, never suspecting what I was letting myself in for.

I had just moved my bags into the intern  quarters when my roommate arrived, Doctor James Hefner, former tank commander in France and Germany during World War II. "Mah gawd," he said in the heaviest southern drawl I had ever heard, "is they-at a byle on yo neck?"

I was fortunate to be put in with Hefner. Not only was he the funniest guy I had ever met but he had the best war stories and, most importantly for me, knew his way around the military. We hit it off immediately and remained great friends throughout my early military career.

"Yo-all gotta see the post surgeon," he drawled. A military term for the emergency room, I soon found out. I was placed on penicillin.

Uniforms were issued the next day. Thanks to Hefner, I soon learned how to put the silver bars on my collar and cap and the proper placement of my nameplate. Standing before the closet mirror, I looked good in the uniform and felt proud.

The infection on my neck worsened, showing no response to penicillin. I could not let anything touch my neck and carried my head with a pronounced tilt. For several weeks I was unofficially and begrudgingly granted authorization to keep my shirt collar loose with my tie hanging casually around my neck. Salutes were awkward, but fortunately I was in the hospital most of the time.

Meanwhile, new lesions developed elsewhere on my body. As one sore would clear, new ones would start. The addition of sulfur and substitution of tetracycline and finally Chloromycetin, the only other available antibiotic in those early days, was no more effective than penicillin. Finally, the infectious disease department returned to a technique which was gradually falling into disuse with the advent of antibiotics, that of autovaccination.

A vaccine was prepared from the purulent discharge of the sores and administered under the skin in gradually increasing doses. By the fourth injection, I was cured. I had already developed a great respect for the medical treatment techniques we were rapidly leaving behind.

My First Penicillin Sensitivity Reaction

I thoroughly enjoyed the ever-changing challenges of a rotating internship. The companionship of this close-knit group was new for me. I found my associates more outgoing and adventurous than my medical school colleagues and realized this represented continuation of the selection process, which had been at work throughout my education.

The more traditionally oriented medical students tended to arrive at civilian institutions for internships and the more venturesome trended towards the military. I liked this group and was well liked by them. I knew I was in the right environment.

My most glaring example of this involved a hospital orderly with a large boil resistant to all available antibiotics. My personal siege with multiple boils was over and I had acquired a reputation as a boil specialist.

For resistant infections so few antibiotics were available that alternate therapies frequently had to be considered, especially for hospital-acquired infections. I had read an article in a medical journal about the use of local penicillin infiltration in the case of resistant boils. The principle was that by raising the tissue concentration of penicillin you could overcome resistance.

"I'm not going to inject this into the boil, I'm going to infiltrate the tissues around it," I said, after first inquiring about the patient’s history of any previous penicillin sensitivity. I also had added Xylocaine to minimize the pain of infiltration.

"It is unlikely that anything will happen but if you have any unusual symptoms go directly to the emergency room. They will contact me," I added and went back to my regular duties. About six hours later I received a call from the emergency room. My patient was there with wheezing, shortness of breath and whole body itching.

My response was automatic.
"Adrenaline 0.5 cc subcutaneous, stat; 50 mg Benadryl, intramuscular, stat and 1 cc of Hydrocortisone, intramuscular, stat."
I then headed for the emergency room — almost ten minutes away by fast walk in this huge cantonment style hospital.

By the time I arrived, the patient was already improving but there was little doubt without prompt treatment he could have died. He required one more adrenaline injection before he stabilized.

I was never comfortable with injectable penicillin thereafter. It would take days before my shattered self-confidence would recover. I concluded that throughout my medical career drug sensitivity reactions were going to occur. I had to live with this reality and do my best.

Duane Graveline MD MPH
Former USAF Flight Surgeon
Former NASA Astronaut
Retired Family Doctor

July 2016

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