Tuesday, December 23, 2008

Christmas Presents

Wrapping Christmas presents reminds me, quite frankly, of running the bowel during an autopsy. Catch a good pair of scissors at the right angle, and you can fly. If you did a good liver block, your duodenum is mostly gone, but you still have miles and miles of jejunum, ileum, ascending, transverse, and descending colon. Lastly, the rectum.

Running the bowel is a much stinkier endeavor than wrapping Christmas presents. The entire structure is a tube. The small intestines consist of many feet of coiled grey-brown double thumb-thickness pipes, like a bag of worms. The outside, called the serosa, is smooth. Running along one edge of the bowel is the mesentery, which is like a linear mass of fatty scrambled eggs, housing lymph nodes and blood vessels in a protective cushion. We run the bowel on the anti-mesenteric side. When you get to the larger colon, there is a guide. The tenia coli is the muscle that stripes the anti-mesenteric side. It puckers the colon with its narrow, 0.5 cm existence.

Opening the bowel creates foul smells that permeate the autopsy room, your scrubs, and your nostrils for days. If you are lucky, a good autopsy assistant, also known as a diener, will run the bowel for you, in the large toilet-like structure that exists along the wall of a well-equipped autopsy suite. If you are a resident at the VA, or out of favor with the diener, you are generally on your own.

It is extremely bad form to nick the bowel during the autopsy, before you are ready to dissect that area of the body. Intestinal contents, which are better saved for quick evacuation down the toilet, will spill out into the body cavity amidst the blood and organs, making it both tough to see and breathe while you continue your work. An autopsy party foul. Sometimes unavoidable, in a body with numerous past surgeries. This creates multiple adhesions that bind and tear at the bowel during dissection, like dense sticky spider webs obscuring vision and masking landmarks. Don't ever say adhesed (i.e. "The intestines were adhesed to the liver.") Dr. Styles will have your head at autopsy conference. Instead say "The intestines were adherent to the liver." Adhesed is not a word, and she is a red-pen wielding, very grammatically correct disciplinarian princess. I mean that in the best possible way, as she is a good friend of mine.

My daughter saved me tonight. She is only five, but when I was stressing about wrapping presents over dinner, and worried about being up until the wee hours of the morning, knowing that I not only have to work tomorrow but am also hosting an extended family Christmas Eve of approximately thirty, she said: "Mom. Get the presents up here already. I learned how to wrap with Babcia (Polish for grandmother, my mom) today. I would LOVE to help. Please hurry."

So we had a very Montessori wrapping experience. Jack was pulling too-large pieces of tape, creating multiple wrapping paper adhesions, but learning how to tear and shorten the tape to prevent waste with my gentle correction. Cecelia was happily wrapping various candles and kitchen soaps with the confidence of a much older child. I was curbing my natural tendency to perfect her attempts in order to build character (both hers and mine).
So now I have time to write in my blog. And to make a CD for a friend in the gross room. And to think about the meaning of Christmas. Which is more about what we did together, tonight, than all of the presents they will receive from relatives in the next couple of days.

A couple of Friday nights ago, I took Cecelia to the store to pick out some tins for an ultimately failed candy-making experiment for her teachers for Christmas. I plan to try again when I am off next week. And I will not to use peanut butter this time (this ingredient was not the only problem with the candy), which I forgot was banned from the school, due to allergies. We stopped at the hospital to get the recipe I had left in my office. We wandered around the halls, and bumped into a thoracic surgeon that I work with. He winked at me then bent down and asked Cecelia,

"So who are you most looking forward to coming to see you on Christmas day?"

She paused, looked mildly confused, then looked up at him with a big smile and answered with shy confidence.

"All of my family."

He glanced up at me, surprised, then back down at her, answering her smile.

"That's really great kid."

From the mouths of babes. Merry Christmas.

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/

Friday, December 12, 2008

Stomach Contents

Monday morning, I was fighting the tendency to drift into daydreams more than usual. I had been up most of the night with my son Jack, who was suffering from a cold. Cecelia's colds stay in her head, but Jack's tend to quickly claim his lungs and leave him fighting for air. He inevitably spends the first or second night tossing and turning fitfully, requiring scheduled puffs off of his inhaler to keep him from working too hard to breathe. When I finally got him settled for the fourth time, at 4:30 a.m., I realized that sleep for me was now a futile effort. So I got up and ran.



Thank goodness I ran. At about 10:00 a.m., the supervisor of microbiology popped his head in my door.



"The big Christmas party is today. Would you rather judge the chili competition or the dessert competition?"



I had forgotten it was the day of the lab-wide Christmas party. The hospital I work for is large, licensed to house 739 beds. Currently the numbers of patients run in the 500s. This hospital is also a large employer (around 8,000). It takes a pretty big clinical laboratory staff to support the hospital. Each year there is a three hour festival in a large auditorium with poems, singing, door prizes, and a potluck. The pathologists generally judge the food competitions. Last year, I was not asked, and I remember feeling both relieved and miffed. So I was kind of excited to be asked. The decision was a no-brainer. I choose savory and spicy over sweets, any day.



"The chili competition."



"Are you sure you are up for that? You know that some of the chili has deer meat."



"We cook deer chili in my house. No problem. How many are there?"



"Ten crock pots of chili and six soups. Dr. Hayes is judging as well. There will be a winner in each category. You both had better start around eleven, so the food doesn't disappear before you start to judge it."



Now I had incentive to get moving on my cases. At 11:00, I walked into the auditorium. One long wall was lined with tables filled with crock pots of chili and soup, each with large orange numbered signs in front. Jim and I were given scorecards and plates. I got a bowl of fritos, and he got a plate of saltines, to clean our palate after each sampling. Then we began to taste.



There were good ones and bad ones. I was trying to shield my scorecard from Jim's, so I wouldn't be tempted to cheat or be biased. When we both got to number four, we looked up.



I said, "Well, it loses a point for claiming to be hot. Otherwise, this is one of the best I've ever tasted."



Jim agreed. "We are definitely on the same page."



After that, it became frustrating. There were many more mediocre ones, and I really wanted to stop tasting and wasting space in my stomach. I wanted to get a big bowl of number four and enjoy it. But I had agreed to the job, so I kept going. When I got to number ten, I was once again interested. It claimed to be heart-healthy and meat-free, which is automatically a big warning sign, but revealed itself as a delightfully hearty cumin-laced black bean and sweet potato concoction with green chilis. I don't even like sweet potatoes, but it was amazing. Dr. Hayes did not share my enthusiasm over number ten. So number four was the winner.



It was tough going from chili to soup. We needed a lot of saltines to clear the spices, in order to give the mostly veggie and meat stews a fair shake. I was starting to get really full. But we persevered, and declared a winner in that category, as well. After all that spice, I needed something sweet. The dessert table was twice as long as the chili/soup table, and by the time I was done judging the chili, there were some clear dessert favorites, all of which I felt driven to sample. The winner was a pumpkin cheesecake. My favorite was a homemade candy with a mixture of peanut butter, powdered sugar, butter, and rice krispies in the center, drenched in chocolate. I got the recipe.



As I walked out of the auditorium back to my office (no need to stick around for the winning announcement - didn't want to get booed) I couldn't help thinking. I sure hope that I don't choke, or become the victim of a sudden random crime. I would hate for someone to have to open this stomach during my autopsy.



Stomach contents were one of the funniest parts of an autopsy, when I first started performing them. The stomach is shaped like an old-fashioned leather water bottle, with an oblong angled neck, a large body, and a tapered end like a spout that empties into the duodenum. We cut into it along the greater curvature (larger part of the body) and lay it flat, to examine the folds, or rugae, which resemble the ridges of a desert. We look for lesions, ulcers, and other abnormalities, after we empty the stomach. Many times, there isn't much in the stomach, since average gastric emptying time is about two hours. But there is nothing like opening a stomach and seeing carrots, meat, peas, and corn, to remind you that you are wading around in blood and muck that was recently a person, eating a meal. Sort of a nice distraction for an anxious beginner who is worried more about cutting something that will generate mass ridicule at Autopsy Conference than finding out the reason that the body ended up on the table in the first place.



One of the strangest specimens I ever encountered in the gross room was from the stomach. I didn't know that at the time, I just opened a plastic bucket and dumped out an irregular grey-black softball-sized mass on my cutting board that was firm and surprisingly focally hairy. It did not look native to a human body interior. I looked at the surgical requisition sheet to see what the surgeon's assistant had written under the specimen name. Bezoar.



I had no idea what a bezoar was. I had to look it up. A bezoar is a mass of food or other materials that collect in the stomach. There are many different types of bezoars. They can be made from food, pills, or hair. A hairball is called a trichobezoar. Bezoars can amass in many different mammals, but in humans they are rarely significant enough to reqire surgical removal. If I remember correctly, the patient was a client at a home for mentally challenged adults.



I got a call from my pathologist friend in Iowa yesterday morning when she was on her way to work. She is covering a small town about an hour away from her house this week, so she gets the dialies. I asked her what came to mind when I said strange stomach contents. She replied, "I got a toothbrush recently. As a surgical specimen. It was boring a hole through her stomach. She was a psychiatric patient, I think."



Two hours after the chili competition, I was not only fighting daydreaming, but also sleep. If I thought a night of staying up with my son was making for a tough Monday, I just exacerbated that feeling a thousandfold by volunteering to judge a large chili competition. But that two hours allowed my stomach to empty. Now I could be the victim of a random crime spree, and not disgust the forensic pathologist, too much. At least by my stomach. I pity the poor autopsy assistant that would have to run my bowels.



Things that speed gastric emptying: moderate exercise, Valium, well-masticated food



Things that slow gastric emptying: narcotics, >80 proof alcohol, large food particles, extreme hot or cold weather, emotional stress, old age, obesity



April 27 - National Hairball Awareness Day



http://nmhm.washingtondc.museum/exhibits/virtual/hairball.html

http://www.merck.com/mmhe/sec09/ch123/ch123c.html

Spitz and Fisher's Medicolegal Investigation of Death

Tuesday, December 9, 2008

She Breathes

She is heavy like your skin, when you've been all day in the sun.  And she moves me from within.  With her sketches she's inside me.

She breathes, through water.

She is quiet like the bottom of a swimming pool, when all you hear are clicks, and taps.

She breathes, through water.

David Rice

Thursday, December 4, 2008

Brush Your Teeth/Don't Do Meth

Last Saturday night, I went to Movie Gallery to return some movies. They were long overdue. When I returned, my husband was sitting at the PC, flanked by my three and five year old, who were obviously mesmerized. They were supposed to be in bed. I asked, "What are you doing?"

"Looking at teeth, mom."

Apparently, my three year old Jack was refusing to brush his teeth. So my husband decided to show them what happened when you ignore your teeth. To the ultimate extreme. He was on a meth website, showing them the aftereffects of how methamphetamines could wreak havoc on the mouth.
A couple of weeks before, I was on the way to the pumpkin patch with my kids, a friend, and her two children. My five year old, Cecelia, was sitting with my friend's five year old, Helen. I overheard Helen asking Cecelia, "Do you even brush your teeth in the morning? Your breath stinks. You really need to brush."

I felt guilty and responsible. My mom has been telling me for over a year to get Cecelia to brush her teeth twice daily, instead of just at night. I have been procrastinating on the morning brushing. First of all, I had enough to do in the morning before school: get them dressed, cook eggs, find mittens, be Pollyanna. It was enough of an effort, already. And besides, Cecelia was going to lose all those teeth, in a couple of years. Why should I worry about one more step at this point?

I guess Helen taught me the reason. Forget hygiene. It is all about peer pressure and ultimate acceptance. So I began to remind her to brush in the morning, but it was difficult. Some mornings it worked, some mornings it didn't.

The meth pictures worked like magic. I have never seen such bubbly toothpaste froth around either kid's mouth, as I did the night of the meth teeth exposure. The next morning, Mike left around 4:30 a.m. to duck hunt. I got up with the kids and started to cook breakfast. I asked Cecelia one of my usual questions, "What did you dream about last night?" She replied, "I dreamed I had a black tooth."

"How did you realize you had a black tooth? Did you see it in the mirror, or did someone point it out to you?"

"I just knew mom. Then I saw it in the mirror. I wasn't brushing enough. My tooth turned black."

As I was putting the biscuits in the oven, Jack looked up at me. He asked me a question, his voice filled with both anxiety and awe. "Mom, can we see the teeth again? On the computer?"

I remember when I was at the crime lab, there was an amazing book. I tried to order it, but it was government issued -- you had to have a special code only befitting a government paid pathologist. It categorized all the drugs on the planet, specializing in those that were abused. It had pictures of all forms of every drug with associated paraphernalia, and also graphic images of the ways they were smuggled and hidden in body orifices. For example, there was an unfortunate individual trying to smuggle cocaine in a plastic bags in his stomach. The bags ruptured, killing him instantly in the massive overdose. His organs were visually immortalized, in his embarrassing attempt to covertly plunder the goods. The meth pictures in the book were the most grotesque. There were pages and pages of before and after photographs of users, like in the plastic surgery ads, only backwards.

One day on morning rounds at the crime lab, I spent all my efforts smothering giggles. On morning rounds, we walk around to each body dumped from the night before and discuss "The Story." Of their death. Immediately prior to our scientific evisceration, full of measurements, x-rays, and professional opinions. There were two bodies, out of approximately twenty, that looked like they had been invited to the party but were not privy to the manners and rules. Most bodies lay flat on the cold stainless steel table, waiting for our evaluation. But these two had been burned in a meth explosion.

Meth is rampant in Arkansas. Secret scientific meth labs are stashed all over the state. Just like in professional research, the meth cooks don't always know what they are doing. Explosions abound. When bodies are burned up in a fire, they often adopt a position of escape. This can be dramatic and exciting, in an end-of-the-world zombie novel, when the bodies are burned into the asphalt, reaching for salvation. But in the florescent lights of the crime lab basement, it is a literal black parody. Crispy-crittered humans in strange and various poses, grimacing in attempt to escape the grim reaper, often with their meth teeth blaring.

I wanted to go over and whisper to them. "Lie down! You are drawing unwanted attention. Everyone else is peaceful and proper. Gunshot wounds. Suicides. Murders. THEY know the rules. Follow." But the burn victims never got it.

The other night, I was singing my son Jack to sleep. He still had remnants of toothpaste on the rim of his mouth. He interrupted me in genuine concern. I had cooked a dinner of tacos, with admixed jalapenos, onions, and garlic; the ultimate breath freshener. Jack whispered urgently, "Mommy, teeth!" They have both been obsessed, since the meth pictures. I didn't get it at first. I assured him that he had brushed, and his teeth would be OK. "No mommy, your teeth! Please brush!" I guess the strong scents emanating from my mouth elicited the darkest images he had seen on the computer. I apologized, and popped a cinnamon Altoid. That wasn't good enough for Jack. "No, mom, you need to brush!" I promised him I would, after I finished my cleaning.
All week long, we have been dreaming of, discussing, and avidly brushing teeth. Thanks to the meth pictures. I have always had a healthy fear of illegal drugs. I try not to show my fears to my kids, because fear, like the common cold, is highly contagious. Let them develop their own, not inherit mine. But this fear is worthy of passing along. I'll save the meth advice for next year. This week's lesson: Brush your teeth.