Encountering Random Art . . .

. . . is one of the things I love about being the mother of a five year old.  This was in my shower Monday morning.

I must've left her to her own devices longer than I thought while I was making a goodwill sweep.

I never would have encountered this B.C. (before Cecilia).

This was on the kitchen window, looking out into the backyard.  The medium in the middle is play-doh.  

"The Land of the Living Dead"

That is what Ruby, in Bob Dylan's "Brownsville Girl"  dubbed Amarillo, Texas.  I still remember my dad playing Dylan on the way to school when I was little.  Clearly Ruby was not as excited to be in Amarillo as I am to visit next week. 

I have never been to Amarillo, Texas.  I am dying to see a tumbleweed.  I hope it looks as incredible as this one.  My husband Ike assures me I will have plenty of opportunity - he and Sicily visited my brother-in-law and his wife there a couple of years ago.  I couldn't get off - I was still in residency and all of my vacation was eaten up by maternity leave for three years in a row.  To all of you who call maternity leave vacation:  I stick out my tongue and make a noise I cannot spell.  Not that I didn't enjoy the six weeks home with baby Sicily and John, but it was a lotta work - no vacation.

I plan not to repeat the grave error we made last year on our road trip to Eureka Springs.  We decided to let Sicily and John pick out anything they wanted to eat in the convenient store - they chose cheese puffs.  So we uncharacteristically assented and abandoned control of the large bag of neon puffed petroleum products to the 5 and 2 year old in the back seat.  They were happily munching away, tossing them back with swigs of milk from their sippy cups, and we congratulated ourselves on the hedonistic behavior that allowed us to zone out to our choice of tunes without any whining from the back seat.

Ike said, "Let's take the Pig Trail!"  I agreed, forgetting that my past experience with Ike driving up the Pig Trail often ended in vague nausea that persisted for a couple of hours.  I was not thinking straight when John complained of a tummy-ache about 3/4 of the way up the windy, steep, mountainous Ozark scenic road.  I replied, "You'll be ok!  Just sit back and look out the window."

So I should have not been as surprised as I was when John projectile vomited cheese puffs and sour milk all over the back seat of my new Forerunner.  The enormous quantity defied rational stomach capacity of a two year old boy.  We were in the middle of nowhere, but the stench required us to stop the car immediately.  Easy gag reflex Sicily was threatening contagious spew, so we had to be quick about it.  Luckily, I had the foresight to buy a pack of wipes at the gas station; my OCD brain was not thinking of puke but of cheese puff fingers in my car.  I stripped John down and removed the car seat cover, stuffing them into a plastic bag.  Ike grabbed the rubber car mat (which had taken the brunt of the calamity) and ran off into the forest.  As I took care of the kids and cleaned off my leather seats, I became mildly frustrated at his absence.  Then he came back with a clean, dripping wet car mat, seemingly magical.

"Where did you find water?"

"In the stream." 

"What stream?"

"In the forest."

He turned around.  I asked, "Why do you have a gaping hole in the back of your t-shirt?"

"I do?"

"Yes."

"It must have gotten caught on the barbed wire."

"What barbed wire?"

"When I jumped the fence."

"Why did you jump a fence?"

"To get to the stream."

Despite the fact that I felt like I was stuck in the song "There's a Hole in the Bucket,"  myself being Eliza and Ike being Henry, I was impressed.  We managed to extinguish the smell quickly, and make our way to Eureka.  I hand washed all the emesis-filled items in the footed tub as soon as we got there.

Many of my friends are vacationing in tropical locales this late winter/early spring.  Hawaii, Rio (for Carnivale), and Costa Rica.  You might think I am jealous, but you would be wrong.  Amarillo has something those places haven't got.  My brand new niece and nephew twins, now five months old, ready to meet.  My pathologist brother-in-law - I am excited to see his hospital/practice for the first time.  My amazingly beautiful (Raphaelite - according to my former chair), intelligent (she is defending a thesis in Dallas this week), and artsy sister-in-law.  I can't wait to pick her brains about how she got stabbed at Vino's in the back, which I learned on her facebook 25 random things.  Her ultra-calm personality is antithesis to inviting knife wounds.  

Amarillo also has signs like these, which are scattered around Route 66 (a Nat King Cole song).  An eccentric billionaire named Stanley Marsh III sponsors these random artistic road signs.  There are over 200.  There were so many cool ones on a website I found I couldn't decide which ones to post.  The one below is Igor.  

"Art is a legalized form of insanity, and I do it very well."

Stanley Marsh III

Science Genius Girl

By Freezepop.  My new anthem.  She totes a microscope.

Definitely going on Sicily's science birthday CD.

Better on itunes than youtube.  Check it out.

Breasts

Let's just get it all out in the title.  That's what I am talking about tonight.  Breasts.  Some days I feel like they exist as a nidus for cancer.  We see so many breasts, in pathology.  Yesterday, my partner ordered nine special hormone studies.  That means he had nine breast cancers, in one day.  And that's just one guy -  Surgicals are split among many pathologists.  Come to think of it, we see a lot of uteri as well.  Most are benign, but there's a lot of cancer there, too.  Penises, testicles, not so much - both are rare specimens.  Sure, there's a lot of prostate cancer, but the prostate is internal, and doesn't carry quite as much weight, when you are naming male and female private parts.  There seems to be an imbalance, in the cancer category.  We females are always getting shafted.

Most breast cancer patients are in their 50's and 60's, but I swear they are getting younger and younger.  40 is not rare at all.  30 is becoming more and more common.  The first time I saw an ugly breast cancer in a 20-something, I was shocked, but now I know - it happens.  Some days it's enough to make you slam your door in complete paranoia and perform a self-breast exam.

The other day I was reading the gross dictation on one of my breast cancer specimens.  It was mid-morning, about 2 hours after my first of two coffees for the day.  I was skimming along, searching for the important information needed for staging - size of lesion, distance from margins, etc.  I read about the size of the breast, the size of the areola, and all of the sudden I got to the nipple.  "The nipple appears erect."  

I felt like someone had slipped pornography into my gross dictation.  Erect?  I read it again, thinking I must have made some egregious mental error.  Nope, it was still there.  I immediately thought, "What disgusting boy gross tech described the nipple as erect?"  I scanned down to the initials at the end of the dictation to find out.  There were two sets of initials, not uncommon in a double mastectomy specimen - if there are two breasts, they are often tag-teamed.  Both sets of initials were female.  I mentally decided which female was more likely to have described the nipple of a detached, still-warm slab of breast on a cutting board as erect.  Which probably means it was the other one.  Or maybe it was a typo on the transcriptionist's part (also all female).  Possibly, it was an intentional gaffe; a mischievous trick meant to catch my attention, or lack thereof.  I decided it wasn't really important to chase down the culprit, I would just strike it from the dictation before I released the report.

As I continued to work on the case, I grew paranoid.  What if erect nipples had been peppering my gross dictations for months, and I was just now noticing it for the first time?  How many of my breast reports were out there, with my medical signature on them, describing erect nipples?  I decided to take an informal poll of a select group of partners.

First I showed one of my female partners.  "Read this."  She pulled out her glasses.  I had to point to the right spot, she wasn't getting to it fast enough.  When she read the sentence she looked up in alarm.  "Oh my god!  It sounds like the breast is stimulated!  That is awful!  Who grossed that breast?"  She assured me that she had never seen a nipple described as erect, and since she is one of the most amazingly OCD in a good way pathologists I have ever met, I trusted her, and was relieved.

I went to another female partner.  She was equally shocked.  Good.  I decided then that I needed one male opinion, so I went to my colleague that I have known for almost 12 years.  We went to med school together, but I didn't really know him well because he spent most of his time on the golf course.  We got to be friends during residency, but our relationship was always laced with competition, since we were in the same class, and gunning for the same jobs.  It has been nice to experience that edginess melt away into easy camaraderie over the last couple of years, although I am still jealous of his supreme confidence.  I learned a lot from watching him, during residency, shake off the criticisms and berating stemming from attending stress and bad moods like water off a duck's back.  Rather than sulk and get defensive, he would have them laughing in short order.  He is the one male in my group I feel comfortable enough with, based on our long history, to broach the subject of erect nipples without turning an irreversible shade of crimson that would necessitate an excuse for a quick exit.

"Of course, I have seen that before.  Erect nipple.  Isn't that the opposite of inverted?"

Go figure.  He has seen everything before.  It is important, when examining the nipple, to note if it is inverted.  Breast cancers are hard, stellate, arachnoid masses, that sometimes traverse ducts and fix and grab as they go.  If their tentacles crawl around in the nipple ducts, the traction can pull a nipple inward, retracting or inverting it.  So it is necessary to note if the nipple is inverted.  Importantly, before I alarm the reader, inverted nipples are common, and most are not the result of cancerous fixation.  Breast cancer can also infiltrate the dermal lymphatics - the lymph channels of the skin -- and create a similar pull on the skin that has a catchy descriptive term - peau d'orange.  

I told Dr. Woods that I had never seen a nipple described as erect.  In my world, erect is not the opposite of inverted.  And I had never really mentioned the nipple, during my grossing days, unless it was inverted or retracted.  He said, "Oh sure, haven't you ever described the penis as erect?  You know, those guys with penile implants?"  

"What?  You had a penis removed for a penile implant?"  I had only had two penises as specimens, that I could remember, and both were partials for squamous cell carcinoma.  "No!  Autopsies.  Those old guys at the VA."  Oh.  Duh.  Well, if I had ever seen one of those, I don't remember noticing.

I decided to quit there.  I had enough information.  I have been reading my gross dictations much more closely since then, and have not noticed any more pornography.  I have another funny breast story, but I am tired.  It was a rough week.  I had way too many interstitial lungs - fascinating but very mentally challenging cases.  Happy Friday!!!  

Boy Things and Girl Things

I went into a birthday invitation place after calling twice the other day - apparently they were having a hard time finding a science-themed birthday invitation.  Sicily turns six in a couple of weeks and I have waited way too long to order online.  I grabbed the box containing hundreds of kid birthday invitations but my search was futile.  

Had I been searching for a princess birthday invitation, I would have been in luck.  There were probably over a hundred.  I would have loved to have found a princess scientist.  When I went on line and googled women in science cartoon images there was an appalling paucity of material.  Take the one above, for instance.  Not that I am knocking her individuality, by any means, but as a 5-year-old would you have wanted this to appear on your birthday invitation?

I eventually enrolled each store assistant in various ways to help me.  One was looking online at a site where I had found one cute science invitation earlier in the day - we were trying to cheat and figure out the manufacturer, but they were too smart.  Another was going through large notebooks full of invitations.  No one at the shop could ever remember having a request for a science-themed party.  

"Aha,"  cried a clerk.  "I've found one."

It had a mini-Albert Einstein with glasses and a bunch of equations on the chalkboard.  It also had two things wrong with it.  1) no girl, which I would have been willing to overlook, and 2) it was the same invitation that was for a boy's science party that I was pretty sure Sicily was remembering as she created her ideal party upon my query last Sunday afternoon  ("At the house"  "CD's for party favors" "A science show" "vanilla cake").  So I rejected it.

Frantically I searched my memory for the "Add-ons" that the Mad Science representative I had booked earlier in the day had touted for an extra $25.  Cotton Candy making, Static Hair, and Laser Light/Indoor Fireworks show.  Hmm.  Fireworks.  Fourth of July.  There's an angle!!

I grabbed the Fourth of July Box and found a nice watercolor of sparklers.  I also found a lone multicolored firework display (apparently, on Fourth of July invitations, red, white, and blue fireworks command the great majority -- all others are heavily prejudiced).  The multicolored firework display was discontinued - go figure.  Probably not prejudice - just lack of sales.

Last night I overheard Ike explaining to Sicily the meaning of "tomboy" in a positive light.  It made me wonder if someone at school had used the term negatively, so I went in the kitchen to investigate.  Apparently, she had wished she was a boy aloud, so she could openly enjoy boy things, such as camping, fishing, and hunting.  I told her, "There are no boy things or girl things.  Just things.  You can do whatever you want.  Except stand up while you are going to the bathroom.  And you can do that if you want, but it might be messy."  Sicily giggled.  Ike agreed.  Apparently clip art creators and kid birthday party invitation manufacturers need to take some lessons.

Syncope

I started fainting at a young age - I think I was only six when I had my first of fourteen teeth pulled.  According to my dentist, I had too many teeth and not enough space in my mouth - an unfortunate Mendelian roll of the dice that dealt me much pain in my formative years.  I still remember the first time - the procedure was already over and I was standing in the waiting area next to the child-sized table and chairs with a big bear painted on it, my mouth full of gauze, reaching into the treasure chest to pick out a small plastic prize for having tolerated the procedure.  When I woke up, I was lying on the couch, surrounded by concerned adults.

This pattern repeated itself throughout my childhood and teenage years, mostly in the dental chair.  Once, at about 16, I had to have an irregular-shaped, oddly colored macular lesion removed from my right arm.  When I woke up after having passed out, I was mortified and embarrassed, but my family doctor reassured me with a story I was sure he had told to many people before myself, one that I like to use today when my patients succumb to the vasovagal response.  He said that my response to pain was a survival instinct left over from the battlefield long ago.  Soldiers who "played dead" at the first sight of pain woke up intact long after the battle was over and got to return home to their families.  So I was the genetic legacy of the wimp that survived, somewhat, but not entirely, reassuring.

I kept fainting from pain:  getting my braces in high school, getting a belly ring in college, donating blood.  When I decided to go to med school, sort of by default, parents and friends worried.  "But you always pass out at the sight of blood!"  Well, that was my own blood.  I was pretty sure I could learn to tolerate blood and guts, as long as it was somebody else's.

When we had our blood draw lab at the end of the second year of medical school, I was alarmed to learn that we had to practice on each other.  I teamed up with a guy in my class, and volunteered to go first; he was clearly uncomfortable.  I got him easy on the first stick, and I passed off the variously colored tubes of blood I collected to the clinical laboratory volunteers; they used the second year med students yearly as a large normal lab value cohort.  When it was his turn to do me, I took a deep breath and gritted my teeth.  He missed the first time, and then he began to sweat.  I watched the shaky needle approaching my antecubital vein uncertainly.  I don't remember the rest, except for being the subject of my classmate's gentle ridicule for the next few weeks.

After that, I began to take precautions.  I had heard stories of med students fainting in the OR.  It is one thing to go unconscious when there are lots of sympathetic people around to deal with it, and quite another to risk a sterile environment and require the attention of the already understaffed operating suite when there was a much more critical patient on the table.  The kiss of death, as far as reputation goes.  I learned that if you tank up on sugar in the early morning, you are less likely to get woozy at the sight of blood.  Based on my past history, it was a safe bet that I was at considerable risk in the OR.

So I started stocking juice boxes, m&m's, and candy bars in my backpack.  Once I found myself sugarless at 5:30 a.m. before a big ortho case at the Children's Hospital - I knew there would probably be a lot of big hardware involved with screws and pliers, and this particular attending really enjoyed testing me to see whether or not I had the strength to cut various metal rods with massive pliers after they had already been inserted into the child's body.  I began to frantically search for a sugar source in an area of the hospital that I was not familiar with at all, and still remember the enormous relief I felt when I saw that I could afford some Lifesavers (I just realized the irony here) in an old, ill-used vending machine tucked into a corner outside the dressing rooms.

When I got into pathology, I got over it.  Autopsies became routine, and I eventually stopped loading up on sugar.  I had to get my blood drawn a lot during my two pregnancies in residency, and tolerated that well, except for one unfortunate incident when the phlebotomy novice nervously crushed the blood tube in her hands, spilling my blood and broken glass all over my arm and the floor.  But that was the exception.

So I was surprised, on my first day at the crime lab, when I got woozy.  When I walked in the basement morgue for the first time it was a Monday.  Monday is the busiest day at the crime lab; many crimes happen over the weekend, when people are bored and indulging in drugs and alcohol.  At our crime lab, the pathologists don't work weekends, so there are often twenty to thirty bodies laid out on metal tables on Monday morning.  We all round together, and I listened to the story of each death.  By the time we got to the third or fourth one, I started zoning out to buzz of blowflies and fluorescent lights in attempt to dissociate from my surroundings and save my reputation. I suddenly realized I wasn't going to make it unless I got some sugar.  I pulled one of the dieners aside and asked if anyone had an m&m or candy bar stash somewhere.  He said he didn't know of any candy, but thought he had seen some peanut butter and crackers somewhere.  I must have looked ghostly and desperate, because he quickly ran back to some cabinets and returned with an open package.  I sat down and ate them all, fortunately saving myself from embarrassment, and tried to return to rounds as unobtrusively as possible.

So I am living testament to the fact that you can experience chronic syncope, and go into medicine successfully.  It takes an enormous amount of exposure, precaution, and discipline.  The mind will eventually adapt, and gain control over the psychosomatically-induced vasovagal response consisting of dilated arteries, plummeting heart rate, and the rapid draining of blood from the central nervous system that renders one unconscious.

What to do if you see someone faint or become woozy:  Place a cool cloth on their forehead, and quickly place them in a supine position, feet elevated.  Feed them some candy or Sprite, if they are or when they become conscious.  

Faith

Faith is a fine invention 

When Gentlemen can see

But Microscopes are prudent

In an Emergency

Emily Dickinson

Pardon Me

Tonight I was trying to wind the kids down early - they had been camping overnight with their dad Saturday night and a rogue boy scout troop so I could spend some much needed one-on-one time with my best friend from medical school (we saw a fabulous movie - I know everyone has already seen it, but for those that haven't - GO SEE SLUMDOG MILLIONAIRE).  Sicily was the only "kid girl there," as she put it - and I think that even her bold personality was intimidated by all the eight year old boys.  John, on the other hand, fancied himself an eight year old boy and jumped right in.  

"Mom, I hode a tadpoe!  We got two fishes! I ate batin for breatfist!"

When they got back Sunday at around eleven I had a mad schedule prepared that blatantly ignored the fact that they were up too late telling ghost stories around a campfire and completely worn out from all the johnboat/four wheeler riding.  I dumped them into my large swimming pool-like bathtub, hauled them out West to Ridgefield to visit my friend's 20 month old daughter (who had stayed with her grandparents overnight) and her parents, and then downtown to the Children's museum for a birthday party.  I figured that they would be so worn out that they would veg and watch movies all late afternoon/early evening, but John followed me out to the backyard where I was reading my book and puttered around, and Sicily demanded my participation in the party gift art project.

I decided to start bedtime at 6:30, and tucked them into bed with books - finding hidden animals in the wild for John, and James and the Giant Peach for Sicily.  When we started brushing teeth before song, Sicily had shed her earlier angst and frustration that had built up while they were taking turns doing interpretive dance to Beethoven's Fur Elise - I was continually winding the small wooden music box that was a present to John from my mom from Germany.  John kept talking during her performance - each small utter from him precipitated a large scale melt-down from Sicily.  Anyway, they were back in good spirits, and Sicily was singing again.  She created a twist on an Incubus song that had me in stitches.  She turned to me seriously, flayed her arms out in all directions, mouth covered in toothpaste and belted out "Pardon me while I burp!"  I started laughing, and John joined in singing her new version.  They danced around the toilet, singing it over and over.  Sicily knows the right words, because she made me explain them to her.  But she said, "Isn't this way better mom?"

Yes, much.

Pardon me, while I burst.

The Art of Being Invisible

I walked down the long bright white bridge linking the main hospital to the cancer center.  I stopped midway at an elevator - a small sign next to it said "MRI."  Although I had passed this elevator many times, I had never been to MRI.  I walked in, pressing the down button that initiated the journey to a subterranean level.  It was my first day on my radiology rotation, a subspecialty that was on my short list.  It appealed to me much in the same way that pathology did:  It was visual.

I had called the previous Friday to ask what time to show up.  Someone told me to be there at 7:30 a.m.  I arrived at 7:25, and the frosted glass door was locked.  I waited five, ten, fifteen minutes, and then slumped to the floor, opening a book.  Finally, at 8:10, a tech showed up.  She glanced at me wordlessly and proceeded to unlock the door and walk in.  I jumped up and introduced myself, following her.

She was in her mid-forties, and her green scrubs fit loosely on her thin frame.  Her hair was dyed black and hung limp on her shoulders.  She looked tired and bored.  

"So how long have you been here?" 

I answered, "They told me to be here at 7:30."

She laughed, the largest display of emotion I would see from her all morning.  "No one gets here until 8:30 at least.  You can wait over there."  She pointed to a large wall of fluorescent light boxes, empty of films.   Then she walked over to a large circular desk with enough lights, screens, and gadgets to evoke the control center for the Starship Enterprise.  She began fumbling around with schedules and paperwork, and I studied her actions while I waited.

Eventually, a resident walked in the room.  He was of average height and build with brown short hair.  He was strikingly pale, with small pointed facial features, except for his eyes.  They stuck out disproportionately wide, as if he was used to being in a dark room.  The juxtaposition reminded me simultaneously of a rat and a mole.

I walked over and introduced myself.  He stared at me warily, not returning the introduction.  Ignoring his rudeness, I proceeded to ask a couple of questions, subtly declaring my interest in his chosen field.  He discouraged my questions with short answers and lack of eye contact, as if he had already pegged me as a pesky medical student that didn't know how to take a hint.

Frustratedly, I resolved not to be the med student he had decided I was without even engaging with me.  I was already a pro on the wards and clinical rotations - I could read people relatively easily and had navigated my third year quite well.  I was a little put out, but as the med student, it was not my place to let that show.  I had also encountered this behavior many times, most prominently in surgery, where masks and goggles make it easy for residents and support staff to treat med students as a non-entity.  I was a little surprised it was happening on radiology, where my face was in full view, and there was not so much formality and ritual, like in surgery, to foster such easy contempt.

Eventually, an attending walked into the room.  He was casually dressed in a sweater, jeans, and hiking boots.  He was overweight and had a long ponytail.  He looked like someone who might be interesting to talk to, but I wouldn't know.  I was never introduced.  He walked over to rat/mole and started small talk about sports and office politics.  I tuned out until they began to put some films on the light boxes.  I walked over and sat near them; to someone standing across the room, I might have appeared to be a part of the conversation.  But certainly not from my vantage point.

Rat/mole asked the attending, "Do you think there is a tear in her lateral meniscus?" 

"I'm not sure.  If it's there, it's pretty subtle.  But you may be right."

They continued on, and eventually a third radiologist walked in the room.  From her age, I guessed that she was a resident.  Early thirties, pleasant features.  I hoped her personality matched her face; I wasn't getting anywhere with these other two.

Suddenly, rat/mole turned to me.  I was surprised that he was making eye contact, and allowed myself to imagine that I might actually become recognized as a person, in the room.  I wondered what he might say.  Would he pimp me?  Maybe a little nerve wracking, but negative attention was better than no attention at all.  I remembered from studying psychology in college that even kids raised in families with physical and/or verbal abuse turned out better than the ones that were totally neglected.  I allowed myself a glimmer of hope.  I'm such an idiot.

Rat/mole sneered down and asked me, "How many chairs do you see in this room?" 

I looked around.  There were three.  I was in one of them.

He continued meanly without waiting for an answer, "And how many radiologists do you see in this room?"

Well, there were now three with our new addition.  I wasn't dense.  I excused myself, stood up, and offered her the chair.  She snickered at rat/mole, sat down, and they proceeded to discuss the films, continuing to ignore my existence.

When I left for lunch, I never returned.  

The next day, I requested to be moved upstairs to CT, where I met a lovely resident who I work with today.  Sometimes we bump into each other at the park, and talk shop while our kids play.  I also work intimately with radiology at work, and they are some of my favorite people.  I just happened to start off on the wrong foot.  Crossed it off of my short list.

I bumped into my sister-in-law at Kroger last Saturday, and she stopped to vent about her miserable rotation while her boyfriend ran around and shopped for their dinner guests.  Talking with her reminded me of how demeaning being a third year med student could be.  Also of how the people you work with can make or break your rotation.  It is a difficult task, to separate the personalities from the specialty - after all, the personalities will disappear but you will be working in your chosen field for the rest of your life.