Friday, November 21, 2008

Thyroid

At 1:22 p.m., the veteran cytotech Van showed up at my door as I was looking at a breast aspirate.  "I have a patient in the room.  She is consented and ready.  A thyroid."  He distracted me from the latest chapter in a Laurel and Hardy-like saga between myself, a pulmonologist, an oncologist, a surgeon, and an unlucky patient.  Can't wait to see how it ends.

Thyroids are tough.  The upside-down butterfly shaped organ overlies the trachea between the neck and the collarbone.  The two lobe wings are joined at the base by a bridge - the isthmus.  Normally difficult to palpate, and sometimes even tough to find during an autopsy, we get occasional referrals of an enlarged nodule by an ear nose and throat (ENT) specialist.  Most nodules are non-palpable and get sent to radiologists for ultrasound-guided needle biopsies.  We are called to these to assess for adequacy.  Occasionally they are sent directly to the pathologist.

Van tells me that she is a nervous patient.  She has already half-jokingly requested a Valium.  We don't even use lidocaine, in our fine needle aspiration biopsies.  The liquid numbing medicine tends to cloud up our sample, and muddy the interpretation under the microscope.  So I am already set to calm her down as I walk in the room to introduce myself.  

She is in her mid-forties.  Skinny.  Blondish short hair.  Slightly bluish teeth.  I shake her hand and ask, "Did Van tell you about the procedure?"  She nodded, then stated that she had a breast biopsy a few years ago that was extremely painful and she is worried.  "Did he tell you that we use the smallest needle in the hospital, smaller than the one used to draw blood out of your arm?"  She said "Yes, and that helped."  

I asked her to show me where her mass was.  "It is large enough that you have many places to sample," she nervously declared.  I began to palpate her neck.  It was a rather vague three centimeter enlargement, that became discrete at the base of the thyroid near the isthmus.  I decided to sample that area.  I asked her, "Did he tell you that you are the boss?  That at any time if you feel too much pain you can raise your arm and I will stop?"  She said that he did not tell her that, but that my statement reminded her of a dentist she had when she was younger.  A particularly painful dentist, who always pre-empted his inflictions by giving her the illusion of control.

I quickly readied the stainless steel gun with a syringe and needle and pulled the trigger to create negative pressure.  I pre-treated the area with alcohol and gave her some sterile gauze with instructions to apply pressure to stop bleeding and prevent bruising while we were dealing with the specimen.  Making slides for various stains and coagulating sample for future processing and studies.

When needling a thyroid, I always tell my patients to get their urge to swallow out of the way before I begin.  I used to warn them of the danger of piercing the trachea, or windpipe, which is immediately underneath.  This action causes a violent urge to cough.  But it doesn't happen often, so I quit creating undue anxiety by discussing this possible harmless complication.

After the alcohol, I found the area I wanted to sample and asked her, "Ready?"  Her eyes consented.  "Bee sting now."  After the needle is in, quick back and forth sawing motions for 15-30 seconds draw a drop or two of blood into the syringe hub.  Enough for a sample.  Usually, this action draws intense relief on the part of the patient, because they realize that the procedure is not too painful.  Occasionally, if a nerve is pierced, or a sensitive area such as muscle or salivary gland is sampled, a reflexive jerk or a wince of pain tells me to redirect the needle.  Luckily, my patient appeared relieved.

A thyroid requires at least three needles, for diagnostic material.  After the three passes, I waited for Van to stain the slides in the pink and purple (my daughter's favorite colors) dif-quik stain.  I assessed my sample under the microscope.  Based on the scanty, albeit benign material, I decided to do two more passes.

The next two passes were different from the first three.  I was hitting something.  Tracheal cartilage?  Calcification within a nodule?  Painful nerve?  Not sure.  But she wasn't wincing, so I sawed away, thinking I was home free.  When I pulled out after the last needle, and asked her to apply pressure for the last time, I was surprised to look in her eyes and register emotion.  Tears were forming.  "Oh, I am so sorry!"  I declared.  "Did I hurt you?"  

"No, not at all.  It's not about the needle, I promise.  It didn't hurt.  Much better than that breast biopsy.  It is something from earlier today.  Nothing to do with this.  I will be fine."  Tears began rolling down her cheeks.

Van was staining the new slides, and I wandered over to the scope.  "I understand.  I cry too.  Usually down by the river, is the best place for me.  Sometimes, when you pour a lot of energy into the anticipation of a painful event, the relief is cathartic.  Still, if I did hurt you, I am sorry and don't be ashamed.  Nerves can be really painful."

As I was looking through the scope at my new sample, searching the sea of red blood cells for diagnostic material while my patient was quietly collecting herself, I thought of the times I cried down by the river.   Listening to music.  Placating with visual and auditory aid.  When my brother was in the hospital.  When I was pregnant with my first child, and my husband was struggling with issues yet to be revealed to me.  When I was pregnant with my second child, and worried about job offers.  When I was confused about where my life was headed and what I had gotten myself into so far.  I also worried about my sample, and who was going to be signing it out on Monday.  It had scant cellularity.  Oh well.  I tried.  No need to stick her anymore.  Hopefully the additional material, to be processed overnight, would be enough.

I turned to my patient, who looked like she had just walked in the door.  No sign of recent tears.  Van helped her out of the chair.  I told her we would have the final for her doctor on Monday.  Van told her to take care.  I touched her shoulder.  She smiled and left.


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