Thursday, December 18, 2008

Paradoxical Undressing

The pathology library that existed during the first four years of my residency is completely obliterated. In its place are shiny new offices for business staff, adjacent to the chairman's quarters. I spent at least five hours a week in that space from noon to one every day for four years, receiving lectures. It was a magical cave, now only a memory.



Walking into the library, one had a sense that the ceiling shrank a foot or two from the rest of the the 4th floor of the Shorey Building. The ceiling was indeed uneven, and many of the square tiles were blotched with brown stains from old water leaks. The floor was a color somewhere between royal and navy blue, covered with old food stains. The dimensions of the room defied geometric categorization; it is best described as a rectangle with odd protuberances. It is possible that the many bookshelves created this impression. The wall immediately opposite the hallway entrance, as well as the one adjacent to it, (both long walls), were lined by floor to ceiling bookshelves overburdened with bound journals and textbooks dating back to the early 1900's. Looking to the right from the entrance was another doorway that led to the antechamber of the chairman's office, and more bookshelves contained stacks of boxes of kodachromes from old lectures. To the left was a dry erase board and a pull down screen for the slide projector. There were two brown tables parallel to the bookshelf walls, one surrounded by old executive chairs covered in industrial yellow-brown cloth. In addition, twenty to thirty small plastic chairs with barely cushioned seats were arranged haphazardly in different configurations daily, pulled out for lectures only and then stacked along the walls for the rest of the day to allow for walking room. A built-in corner triangular brown cabinet contained a mismatched jumble of every type of non-perishable food accoutrement one could ever hope to require: paper plates, napkins, utensils, ketchup, mustard, salt, pepper, and sweet n' low, to name a few. Maybe the old path library is better described as a magical pit.



I entered the lecture room one day toward the end of my first year, during inservice review. We took inservices at the end of every year, to measure our performance. For weeks prior to the test, attendings would review various topics from blood banking to microbiology to surgical pathology, in preparation for the two day proctored testing session. They claimed our results were anonymous, known only to our program director, but we suspected differently. We knew that the higher-ups peeked at our results and adjusted their individual attentions for the new year accordingly, if unintentionally. So those of us who cared, tried.



Our chairman at the time, Dr. Strong, provided lunch daily. The program director's assistant would set up lunches along on one of the brown tables daily at about 11:30. The early birds got their pick; choices included Arby's, Daddy's Deli, and Two Sister's Catering. The highlight of the resident's day was free lunch, and we competed yearly for the favored pick of the program director's assistant, rewarded with the power to choose the lunch menu for an entire week.


On this day, I got there early, got my pick of lunch choices (Daddy's Deli Veggie -- one of my favorites - it had guacamole, sprouts, and an interesting spicy olive tampenade, along with Lay's potato chips and a chocolate chip cookie), and one of the five or six choice executive chairs to curl up in and lean back for the hour lecture. Dr. Strong was lecturing. He entered the room disheveled as usual; shirt partially un-tucked, uneven cowlicks grazing the back of his balding head, glasses askance, tie askew. I remember passing him in the hall one day and noticing his shirt was on inside out. This quality is endearing, as he was an extremely popular and generous leader, despite being sometimes long-winded, but usually interesting, in conversation.



It was important to try to finish your food before the lights went down in the old path library, because once they did you could barely see your hand in front of your face if you were more than two feet from the projector screen. This was a nice opportunity for residents and attendings alike to take a midday snooze, if so desired, in relative peace (unless you were called upon, then your nice nap turned into an embarrassing hell). There is nothing like easing the pain of getting pimped at the scope all morning by watching your tormentor nod off and start to drool during noon conference. He needed a rest, after all of that berating.



Dr. Strong has two speeds: manic and melancholy. The manic is often exacerbated with an audience, especially of residents. The melancholy is laced with hypochondria-sis, and he tends to retreat to his office during these moods, occasionally coming out to seek the attention and sympathy of an often female staff member, resident or attending. Women are, after all, more maternal and sympathetic by nature. Dr. Strong was manic that day. His topic was forensic review for inservice. He loaded the slide projector with one of two trays full of kodachromes, and started showing pictures.



With each click of the slide projector button, Dr. Strong presented a different picture and afforded us a brief opportunity to show off our knowledge of the subject, prior to his explanation. We didn't get many forensic lectures during residency - it was a rare gift when one of the state pathologists came to talk to us about the crime lab. Dr. Strong packed a lot of forensics into that hour. Fascinating stuff. Everyone was awake, learning about patterns of gunshot, knife, and ligature wounds by looking at dead bodies. Learning how to estimate the distance of the perpetrator by the appearance of the gunshot wound. Determining the exact placement of the motor vehicle accident (MVA) victim by studying patterns of glass shatter on the side of the face, and analyzing seat belt and steering wheel bruises. Looking for tell-tale signs of child abuse in unsuspected places, like the hemorrhages in the back of the retina (shaken-baby syndrome). And then there was the naked man in the snow.



Dr. Strong gave a long dramatic pause when he got to this picture. We all studied it intensely. It was of a dead man lying near a park bench in the snow, clothes and shoes shed in the foreground. I looked for injuries on the body - there were none. What had happened to this man? Eventually, he clued us in. Apparently, when you are about to freeze to death from hypothermia, your mind and body play tricks on you. You begin to think that you are extremely hot, and start shedding clothing, immediately prior to your demise. This was a bum in a public park. Not a crime victim, but a victim of paradoxical undressing, the fabulous term used to describe this phenomenon. It is also referred to as being "cold stupid."



I have always found this term fascinating. I think of it when my daughter gets tired -- she starts flopping around frantically, claiming to be hot, and commences stripping off her clothing. Early last spring, I took her to see Annie on a school night. Right after the excitement of visiting the bathroom at intermission, she started wiggling around uncomfortably in her seat. Then she began to remove her tights. A couple of minutes later, her dress shoulders were around her tummy. I looked at my mother. "I don't need to stay and watch the end, I have seen it before. I think C needs a bed." She agreed. My dad picked up the half-naked Cecelia, covered her with a coat, threw her over his shoulder, and carried her to the car. Almost five is a little young for late Broadway musicals on a school night, but she enjoyed the first half, and it was plenty for us.



So as the holiday season approaches, I think of old haunts. The pathology library. I am old enough now, to have haunts, and enjoy reminiscing by the fire, after the kids are in bed. And as the icy weather sweeps through the state, I think of all the requisite things: snowmen, sleigh bells and hot chocolate. I also think of the naked bum in the snow. A victim of hypothermia and paradoxical undressing.





So don't get stuck in the cold. You might get caught with your pants down.



If you would like to learn more about the physiology behind paradoxical undressing, visit this site. Wikipedia also has a nice summary.



http://www.survivaltopics.com/survival/paradoxical-undressing/

No comments: