Sunday, November 30, 2008

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.

Thursday, November 27, 2008

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.

Saturday, November 22, 2008

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

Friday, November 21, 2008


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.

Saturday, November 15, 2008

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.

Tuesday, November 4, 2008

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.