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.

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/

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

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

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.

Post-Call Exhilaration

"I can see clearly now the rain has gone.
I can see all obstacles in my way.
Gone are the dark clouds that had me blind.
It's gonna be a bright (bright), bright (bright) sun-shiny day."


I love post-call Mondays. After a week of being slave to the pager, up nights answering the phone at all hours (and sometimes, on an unlucky night, having to go in for a few hours) and working through the weekend. Here I am on Sunday night, writing in anticipatory pleasure and bliss, cheesy songs rolling around in my head. I am worried I will get busy tomorrow, and miss the opportunity. So here is my tribute, to a lovely tomorrow.


I have a random piano, right outside my doorway. Bait for the occasional wandering, lost hospital employee adept at playing chopsticks or toddler of a mother waiting up front for a blood draw. Luckily, it usually only attracts 5-10 minutes of attention. Rarely, a gifted individual will pick an opportune moment (for me, of course, 'cause it's all about me -- when I am not busy) and I will enjoy the distraction. More often, I become highly annoyed. Take last week, for instance.


A dishwater-blond, pony tailed, scruffy-faced young man had been commissioned by an unknown person to tune the piano -- a first in my year-and-a-half residence adjacent to the instrument. I was not the only one frustrated -- even those with offices far away were complaining. It lasted well over an hour. I was trying to dictate a bone marrow (my partner once compared the dictation of this difficult specimen to giving birth -- much to my delight and utter agreement), but could not think. PLINK-PLINK-PLINK. A futile effort, the tuning of this piano, according to my next door neighbor who is the head of histology and is musical. He claimed the piano's constant exposure to wind will surely reverse this young man's effort within less than a week. This realization only further frazzled my already jangled nerves. I slammed my door twice in passive-aggressive anger, shot him two or three dirty looks as I was going across the hall, and finally gave up working and headed to the doctor's lounge for an afternoon coffee.


Tonight, on the eve of post-call Monday, I would invite the piano tuner back. To tune the piano all day long. I would smile at him frequently, encouraging the tuneless, pointless endeavor, and leave my door open. Nothing could disturb my good mood.


Once, someone told me a hilarious story about a woman who came into the ER while they were a resident. She seemed perfectly normal, but would suddenly shriek hysterically and convulse at random intervals. This was her chief complaint -- it had been happening for a couple of hours. She was interviewed by multiple trainees and attendings at length, to no avail, with continued interval shrieking and convulsing. Just when a psychiatric consult was being ordered, they finally saw something on her chest x-ray. She had an internal cardiac defibrillator, which had been implanted years ago and was not uncovered during the interview because she in no way linked her symptoms to this device. An internal cardiac defibrillator is surgically placed inside the body to shock the heart, just like the external paddles do on the television shows when a patient is in cardiac arrest. Internal defibrillators are put in when a patient has an uncontrollable heart arrythmia (unregulated beating that can trigger a heart attack) that is unpredictable and can be life-threatening. The device is supposed to only be activated during an irregular heartbeat. This woman's device had taken on a life of its own. Shock-shriek-convulse. Anti-psychotic drugs wouldn't touch that. She was immediately taken to the OR to have it removed.


There is this sound that is emitted from the histology lab about once a week or so. My partner down the hall swears it will be the death of her. It is best described as something akin to having a wayward internal cardiac defibrillator. The last time it went off, I was walking down the hall in a post-prandial somnolent state, in a futile attempt to revive my mind to make it through the afternoon. Suddenly, a long loud bullhorn did more toward that effort than if I had drank an entire pot of coffee in under five minutes. The sound reminds me of war drills in movies (I am embarrassingly thinking of that awful song in Grease 2 "Let's Do It For Our Country").


On post-call Monday, I could happily listen to this sound all day long, and sing along with it. Maybe add a little of Michelle Pfeiffer's rendition of "Cool Rider." Nothing could disturb my mood, on this glorious day. I told you I had cheesy songs rolling around in my head.


I have a now-part-time partner hitting me up for call. He is trying to support his music studio and large piano collection. I am awaiting a board decision in December, to determine if everyone is OK with the idea. I would gladly offload two or three weeks, in order to spend more time free from work. But I would definitely want to hang onto the other five or six. I have known few feelings in my life that compare to post-call Mondays. The best natural high on the planet. On a Monday, of all days.


Can't wait to have a glass of wine tomorrow night. Or two.

An Ode to Semen Analysis

I was walking through the transcription area one afternoon about two weeks ago, and I noticed a sheet of paper in my box. I grabbed it, quickly scanned the contents, and twirled involuntarily with glee. The lone secretary in the room, covering all the others for lunch, looked up curiously. I thrust the memo from my lab director into her hands. It read something like this:

Attention all clinical pathologists:

From now on, it is no longer cost effective to perform semen analysis reviews in house. Therefore, we will be sending them out to (so and so) reference lab. If you have any questions or concerns, please contact me.

There are many tasks we are trained to perform that are never utilized. There are also those we encounter in our new jobs that are completely foreign. I remember the first time I got a semen analysis slide for review on my desk. I thought it was a peripheral blood smear - it came in a single cardboard slide tray with a sheet of paper. I threw it on the stage and peered through the microscope, expecting red blood cells. I thought, "What the hell is this?" and looked at the sheet of paper that came with it. Semen Analysis for Review. I jumped back from the scope, as if stung.

I walked across the hall into my partner's office to find out what to do. "Yes, we get these occasionally. Our job is to count the sperm, and to report if they are normal or abnormal." There is a saying in pathology: We Know Abnormal When We See It. At that time, I could not include sperm in that declaration. I asked her, "What does an abnormal sperm look like?" She gave me a book. An Atlas of Sperm Morphology by Adelman and Cahill. I decided to flip through the book that night, and get back to the slide the next day.

I remember e-mailing my friend that evening with incredulous horror. I had no idea there were so many ways that sperm could be abnormal. There are four parts to a sperm - head, neck, midpiece, and tail. Each part contains potential for grave error. Pointy heads. Flattened heads. Rounded heads. Enlarged and malformed heads. The neck can assume many undesirable conformations that render sperm nicknames; bullet, mushroom, acorn and dumbbell, to name a few. The midpiece might be kinked. The tail can be too short, too long, coiled or curled. Multiplicity is not normal in the head or tail; double and triple heads and tailpieces are the kiss of death. My all-time favorite description of an abnormal sperm is pear-shaped. Apparently pear-shaped sperm, like their gynecoid male counterparts, are highly undesirable.

The number of normal sperm required for fertility is 13%. A rather unlucky number in many circles, but not in the sperm world. A 9-12% sperm count denotes indeterminate fertility. [I love the word indeterminate. It is fabulously hedge-y. Indeterminate for dysplasia (pre-cancerous cells). Indeterminate for fertility. I try not to use it too much, but it certainly comes in handy sometimes.] If there are under 9% sperm, the specimen (who are we kidding? The MAN) is declared subfertile.

I have a good friend who has experience with subfertility. She and her husband decided about ten years ago to start a family. They tried for a few months unsuccessfully but their obstetrician was not alarmed because they were both young. Finally after almost a year with no results, the obstetrician began the infertility work-up by taking a detailed history and physical. Turns out her husband was having his breakfast and reading the paper each morning in their hot tub on the deck. The poor sperm didn't have a chance; they were being denatured each morning in boiling hot water. He quit the hot tub. They got pregnant immediately.

When I set myself to my new task the next day, armed with the information I needed, I actually contemplated putting on gloves. To put the slide on the scope. Hell, maybe I even did it the first time. Silly in retrospect. There are all kinds of body fluids smeared onto slides. Blood. Sputum. Cervical and vaginal smears. Why should semen be any different? Yet another mind over matter hurdle required in medicine. Akin to holding the heart for the cardiovascular surgeon during bypass surgery, so he or she can sew the new vessels together. Or walking into the decomposition room in the crime lab and blocking out the sights and smells of the long dead body in order to get to the task at hand.

When I actually looked at the slide, I got a little angry. Not only did I have to figure out which sperm were normal vs. abnormal, I had to do it on a crappy slide. They call these slides double frosted along the entire length. They were in vogue long ago, prior to the advent of positively charged slides. The point of both is to catch the cells and hold them to the slide for better yield. The positively charged slides use physics. The double frosted slides are sandblasted; they try to catch the cells with their rough texture. To the gross eye, the slides look like a morning windowpane in the dead of winter. Under the scope, it's like flying over the Ozark Mountains. The sperm are traversing mountains and craters. It is hard enough looking for abnormalities on a clear sunny day. Many of these sperm were hiding in shadows.

After a while semen analysis, like any other job one performs frequently, became banal. Semen analyses were the scourge of my clinical pathology rotation. Like placentas in surgical pathology, they tended to pile up on my desk over the course of the week, finally grasping my begrudging attention on Friday afternoon while cleaning up loose ends prior to the weekend. Before a new rotation began on Monday.

One Friday, I amassed quite a pile of semen analyses. It had been a couple of months since I had performed one so I grabbed the atlas, my sperm bible, again for review. I became curious. I performed counts and determined normalcy, but what about the all important motility test? How was that done? The book clued me in. There are all sorts of tests done for motility. But first, you must review the safety precautions for handling semen specimens. My favorite: Nothing should be pipetted by mouth.

Before the semen can be analyzed it must be liquefied in 5% alpha amylase. The first test is the simplest. One drop of liquefied semen is placed on a slide, and is covered by a coverslip rimmed in, of all things, petroleum jelly. The slide is incubated at room temperature and the percent of motile sperm is examined under the microscope at high power. From here, the tests get more complex. The swim-up test measures speed and endurance by averaging the time of the fastest sperm to travel up a conical tube. The estrous bovine cervical mucus test (that's cow in heat cervical mucus) measures how far they can travel through the cow goo.

I learned so much over the past year and a half about semen analysis. Now I will no longer need the information. But if I am ever required to recognize abnormal sperm again in my life, I have the tools. Medical technologists and clinical pathologists - we are all rejoicing that the semen is now sent out. I decided the semen analysis deserved a eulogy. Darn it. I'm gonna miss those little guys.

Method in madness

"He may be mad, but there's method in his madness.  There nearly always is method in madness.  It's what drives men mad, being methodical."

G.K. Chesterson

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.

Lucky Toe Revisited

This week, I have been a deer widow doctor mom.  A superhero.  Diagnosing cancer and making carpool cutoff time.  All in a single breath.

I was cooking dinner -- the kid's fave.  Breakfast for dinner, on Thursday night.  I hadn't cooked pancakes in years, and screwed it up a couple of times before I got it right.  But when I got it right, boy did I.  Cecelia said, "Mom, these pancakes are the best ever.  Better than daddy's, even.  Will you make them again and again?"  Funny how our kids learn to appeal to our egos, at such a young age.  

I sent her to the tub after dinner.  While I was cleaning, I heard a high-pitched scream from her bathroom.  Not a wimpy little attention-seeking scream, but a true oh my god there is a giant cockroach in my bathtub type scream.  She was in agony, and I quickly responded.

When I went into the bathroom, she had her lucky toenail on display at the edge of the tub.  It had been stationary and stabile for months.  Now, it was about 99.9% removed.  She was crying hysterically.  I quickly assessed the situation.  "Cecelia, are you crying because you hurt, or are you crying because you are scared?"  "I am scared, mom.  My toenail is about to fall off."  I told her not to worry, that a new one would grow, and everything would be ok.  I asked her if she wanted me to get some scissors and cut it off.  "NO."  Then I went back to Jack and cleaning.

A few minutes later, I heard hysterics again.  Lordy, lord.  But this time, it was hysterical laughter.  She came pattering into the kitchen, buck naked and dripping, holding her blue lucky toenail in her hands.  "Mom, can you get me a baggie?  So I can take my lucky toenail to show and tell?  Guess what?  There is a NEW toenail underneath!  And there is this red line (between the new and the old) that is so pretty.  So I still have a lucky toenail!"

Thank GOD for lucky toenails.  I promise to quit writing about lucky toenails.

Lucky Toe

About five months ago, my family and I were heading up to Eureka Springs, AR for a short vacation.  My five year old daughter, Cecelia, had kicked off her shoes in the back seat.  As I turned to respond to her hundredth request, I noticed that half of her big toenail was missing, and the remainder was a deep indigo.  I asked her what in the world had happened to her toe.  She quickly and exasperatedly replied, Mom.  I was born with it.  That's my lucky toe.

Immediate head spin.  I cut those toenails weekly from infancy until age four, when she became old enough to grow into her father's habit of picking and biting both finger and toenails to the quick.  She was not born with that toe.  I explained to her that most toes that look like hers have been traumatized.  Can you remember hurting your toe really bad, Cecelia?  Well, mom, there was that time with the trash can.

I flashed back to a month previous.  A typical Sunday morning when my husband was working.  The kids were cranky (I also have a three year old, Jack) from staying up too late the night before, yet unable to fight the chronologic clock that vaulted them out of bed at 6:30 a.m.  The television was blaring annoying, high-pitched toddler TV, which was failing miserably in distracting my children from seeking my attention while I was trying to clean up from a breakfast of biscuits, eggs, and sausage.  Jack was whining in tune with the TV, and Cecelia wanted me to start an art project.  I told her she could help me clean up, if she wanted a project.  So she dutifully, if somewhat reluctantly, grabbed a plate of leftovers to scrape into the trash.

Within a few seconds, I heard a high-pitched scream and turned to see her writhing on the floor holding her toe.  Apparently, when she had stepped onto the lever to open the top of the trash can, she accidently let it go abruptly and painfully onto her big toe.  Bad for her, but one more crisis for me to attend to in what seemed like an endless morning of crying wolf.  I dutifully went over to examine the toe, and when I saw that it wasn't bleeding, I muttered half-hearted empathic statements, gave it a kiss, and turned back to my cleaning.  Now I sat and stared at one of the ugliest toe injuries I have ever seen, and my heart twisted in agony and guilt.

Maternal guilt.  A black hole.  A large block of real estate, occupying free rent in all of our heads.  Luckily, a few days later, Cecelia sneezed.  I repeated the sneezing mantra I learned from my mother.  One's a wish, two's a kiss, three's a letter, four's something better.  Cecelia, you get a wish.  Mom, what do I need with a wish?  I've got a lucky toe.

I wish I had a lucky toe.