More Swine Flu

This afternoon, I sat down after a much needed trip to the chiropractor, relaxed after traction and electric shock therapy (interferential current, they call it), ready to plow into a pile of neglected work -- patient cases that had taken a back burner to research and interviews about the H1N1.  My phone rang.

"Gizabeth, the news team is coming in a couple of hours -- would you be willing to do an interview dispelling myths about the Swine Flu?"

I had spent the morning briefing with the head of micro and the lab in preparation for an 11:00 interview with Medical News of Arkansas.  The journalist that interviewed me told me she had read my comments in an article in the Dem Gaz this morning, an interview I had given over the phone yesterday afternoon.

"Oh really?  I haven't seen it yet."

I still haven't.  Yesterday afternoon the media representative for the hospital sat in on my interview with the Dem Gaz.  She had done a great job coaching me on the live TV interview the day before.  She told me she wanted to make sure that the journalist didn't need anything more from her, but I knew she was listening to my comments, ready to fact check and clarify in order to protect the hospital.

"You know, I have a pile of work on my desk.  I am pretty overwhelmed.  I have been working late all week, and I want to get home to my family at a decent hour.  Can I say no?"

She was very understanding.  "Don't worry, we'll find someone else."

I knew that if I said yes, I would spend the next couple of hours leading up to the interview researching all possible angles of myth and truth about the Swine Flu.  I just didn't have it in me, at this point.  I probably could have winged it -- it was a taped interview, which is probably easier than a live one, but I am never comfortable unless I am over prepared.  As I stared at the backlog of tough cases left over from my call weekend, I decided what was more important.  

This has been such a big learning experience.  And not just about H1N1, a national now WHO level 5 imminent pandemic.  It is daunting trying to portray a certain face to the public, keeping in mind not just yourself and your own knowledge but also the collective institution that you are speaking for.  There are legal issues involved.  You don't want to be alarmist, but you do want to convey thoughtfulness, intelligence, and preparedness.  

It is difficult to describe the excitement of being involved in the epicenter of a massive hospital's reaction to the pandemic.  I read the statement that the health department put out today, in an e-mail.  As I read it,  all familiar news, I was reminded of the meetings I had been involved in where the information had been generated, in conversation, by experts with experience and wisdom.  Making decisions for our state.  Keeping in mind recommendations by the national experts, but judiciously applying those recommendations on a local level.

I read tonight that the 12 probable cases in Benton County have not been verified, in one blog.  Another blog said that 7 were confirmed NOT SWINE FLU, but that 5 were still pending.  This example illustrates the illusive nature of hard data, both locally and worldwide, that makes it so tough to pin down what, exactly, we are dealing with.

I had a conversation today with a key member of the flu pandemic team.  One of his stories stuck in my head.  I had asked him, "Off the record, of course - I would never say this in the media -- but don't you think this is all being blown out of proportion?"

He replied, "I have been to national conferences on pandemics.  Historically, when you look at response, there are good actors and bad actors.  The major cities that act responsibly - the good actors - the ones that shut down schools and follow the pandemic guidelines - they reduce morbidity and mortality.  The bad actors - the ones that flaunt convention - hold parades and keep schools and workplaces open -- they end up with a lot more confirmed cases."  We don't know yet what our mortality rates will be from the swine flu.  Maybe no worse than the regular seasonal flu.  The numbers from Mexico seem to change daily - it is hard to calculate the exact mortality rates.  But the key is to intervene early.  Because if you wait, you lose your window of opportunity.  Intervention only works if it happens on the front end, before the epidemiology is available to back up the efforts.

That comforted me.  If my school closes, it will be hell for my husband and I - both doctors.  But we will find help.  Grandparents, neighbors, friends - it will work out.  Hopefully we won't have to worry about it.  But if we do, I will try not to complain.  I can see the logic, on a larger scale.

I got home before six today, and reveled in cooking and playing with my kids.  We played a game:  zombie children eat mommy and daddy.  They were hilarious with their Bruce Springsteen underbites - attacking Ike and I alternately.  Sicily's zombie face was especially cute - she recently lost her first tooth.  

I am thankful that in the face of this pandemic, they are a healthy four and six, not just a little premature baby and toddler like they were a few years ago.  They should do fine, even if they contract the flu.  I am confident about that.  

Swine Flu

For someone who hates the spotlight, I sure have garnered a lot of glow lately.

Yesterday, at 3:58, two minutes until my call was over, I got a call from hospital administration.

"Will you do a live interview on Fox 16 tomorrow about the swine flu?"

It was a challenge.  One I had to think about, especially since I had been on call all weekend and work had deprived me of knowledge about the new pandemic.  I first learned about it from Gasper on his blog.  Now I had 24 hours to bone up on the swine flu so I could be perceived as an expert on TV.

It was a rough 24 hours, fraught with stomach knots and, again, GI distress.  I read all the info on nytimes reader questions and cdc.gov.  I memorized it.  Then I discussed the matter with the head of microbiology, and attended some meetings today to learn about what we, at our hospital, were doing to prepare for what the World Health Organization had deemed a Level 4 pandemic.  I felt like I was reading Stephen King's The Stand all over again.

I was cursing myself for agreeing to go on live television all the way up to the 5:00 news.  I reached the Channel 16 metroplex at 4:45 and called my dad.

"I don't want to do this.  I don't know why I agreed.  I'm gonna make a fool out of myself and all the people that trusted me to represent the hospital."

"Don't worry, Elizabeth.  You'll be fine.  Pretend you are discussing it with your kids."

Good advice.  I am so uninhibited with them.  As I entered the building, and was escorted to the breakroom, I became strangely upbeat about the whole situation.  I was prepared, damn it.  Despite the fact that I had attempted to hide my tv appearance from everyone I knew, so I wouldn't have to worry about being watched by friends, I felt like I might actually do ok.

Ike was impressed.  My dad was encouraging.  Both expected, because after all, if your husband and dad aren't on your side, who is?

The Fox 16 news team told me they wanted me back, for future interviews.  Maybe they say that to everyone, to make them feel better about their interviews.  I was just happy I kept a running conversation and didn't freeze up, or god forbid, projectile vomit on Donna Terrell (sp?).  I was surprised to find that I didn't really have enough time to discuss all that I wanted to about the swine flu.  I wanted to say more.

I know everything, currently, that there is to know about the swine flu.  Including the hilarious battle of the name - no one can really isolate the original pig.  Israel is trying to call it the Mexican flu, and Mexico is in a tizzy.  They don't want to be forever saddled with the nomenclature baggage, like the 1918 Spanish flu, which really originated in Kansas.  Hard to blame them.

Any questions?  Feel free to ask.  I can probably answer them.

Too Much Information

I am finally getting over a sore throat/cold enough to taste, run, and feel good enough to clean up my call weekend, which unfortunately is lingering and promises to keep me working late.  Ike finally called me in some antibiotics last Thursday and other than an uncomfortable alteration in my gastrointestinal flora, everything is A OK.  I could go into more GI details, but then you would have to call me Helen after the main character in Charlotte Roche's Wetlands.  

I picked up this book as a part of my binge - it sat near Everything Ravaged, Everything Burned and beckoned with it's petite size and cute cover.  It also bragged a read that would make The Vagina Monologues seem tame, so I bit.  Someone on the back described it as a compulsive read.  I agree - compulsive in the same way rubbernecking on the highway is compulsive.  You hate yourself for doing it, but you just can't help it.  

Helen is a complete mess.  She reminded me of someone I used to take care of on the adolescent ward of a lockdown psychiatric unit - a fifteen year old who was so borderline she made your skin crawl.  I was assigned to her one-on-one during the 3-11 shift because she had a habit of burying metal objects under her skin.  This meant I had to watch her shower (she could do wonders dismantling shower parts).  She often pulled a masturbation power play to try to make me uncomfortable and turn away - apparently this had worked previously on other counselors so she could discreetly further her self-mutilation agenda.  I watched her, cold and aloof, in attempt to meet and discourage her challenge.  It worked.

Using sex as power at such a young age must come out of something much more than a divorce.  Further disturbing childhood experiences were hinted at, but not really well developed.  Now THAT would have been an interesting story.  

Poor Helen tried to imply that anyone not enjoying and savoring their dried bodily secretions (among other things) was an uptight, warped, sexually frustrated female.  Like the nurses she described.  I like to think that most of us women fall somewhere in between.

Anyway, I had a reaction to the book, obviously.  But it has not been seared indelibly into my brain like the image of the blood eagle in Wells Tower's short story that shares the title of his collection.  I think I will join the cult following of this classically wonderful Viking tale.

Now I am onto Memoirs of My Melancholy Whores, as part of the Marquez-fest that Ms. White has dragged us into (me quite happily).  It is the bonus optional read - it's been a while since we have had book club so there are two books.  It's a short read, so luckily I will be finished early for a change - I usually find myself pulling all-nighters the night before.  

Enough escaping the inevitable piles of marrows, lymph nodes, livers, SPE's, IFE's,  and consult on my desk.  Books are such a great escape.  At least I feel good enough tackle my work!  And my insides are as clean as a whistle.  Oops.  Too much information.

Book Binge

Unfortunately, my mother-in-law broke her leg.  I imagine it affects her in many ways, most of which are negative, but I'm not going there today.  Luckily, it is not a bad break, and she should recover in a month.  Here's how it affects (effect, affect, I'm suddenly doubting my language here, but whatever) me:

We've run out of books.

She picks up my kids once a week - each has their own day - and takes them to the library.  Then she brings them back to her house, which is a block from ours, and feeds them ice cream and chocolate milk.  Thus each kid comes home once a week with a bag of books appropriate for their age level.  I am in currently in charge of Sicily, and we have been doing chapter books since last fall.  We stick to the 3rd-6th grade level - I shy away from the Young Adult section at her age (6) since I quickly skimmed the Twilight series last fall - a little too much teenage angst, in my opinion, for a 6 year old.  

Coincidentally, I've run out of books.  The few I have leftover from my Christmas haul I am having trouble getting into, for some reason.  And Sicily and I have been re-reading old childhood favorites for two weeks and have both been getting bored.  So when I read an interview with Wells Tower in the paper on Sunday, and he made me laugh when he said the theme of his debut short story collection in his new book Everything Ravaged, Everything Burned (how do you underline on a mac?  Why did I buy a mac?  I can do molecular research, I promise) was "stories that I had written that did not make me feel like projectile vomiting", or something like that, I decided I had to run out and get it.  So over lunch on Monday I spent fifteen minutes in the adult section and fifteen minutes in Sicily's section at Barnes and Noble and walked out approximately $300 poorer, but about 13 or 14 books richer.

We are both much happier, now that I have taken control of the situation.  Sicily and I are reading Mrs. Frisby and the Rats of NIMH by Robert C. O'Brien and she reported a dream about Dragon the cat on the way to school this morning - a sure sign of a good book that leaves you on the cliffhanger nightly.  I am happy to have some good literature for her again - I also picked up lots of new stuff I haven't read in the Newberry section and otherwise.  I don't know if you've ever tried to read Magic Treehouse or Magic Schoolbus but somehow they were landing in our house and Sicily and I were both suffering from misery and boredom (or maybe I was projecting).  

And Wells Tower is a helluva short story writer.  Read the reviews for yourself.  The hype is well-deserved, so far, in my opinion.  I've gotta run to the lab luncheon - I'm late.  It's National Laboratory Week, and there's a big three hour shindig.  Food disappears fast.

Gynecomastia

I walked into the family practice clinic at the Veteran's hospital.  At least I thought it was the family practice area - the VA is a complex geometrical maze of colored arrows on the floor and confusing signs on the wall.  Family practice was a less familiar haunt, during my cytology fellowship, than radiology or ENT, so I often got confused when called down to perform a needle biopsy on a patient in this area.  The cheerful desk attendant recognized me and guided me to the nurse practitioner's office, who re-iterated what she had already told me over the phone, as if I was someone new.  

"It's a breast mass.  Under his nipple.  You'll feel it.  I'm worried about it.  He says it's been there for a while, but better safe than sorry."

I hated getting called for male breast masses.  I have never known any cytologist under which I have trained that has yielded more interesting results than benign adipose tissue or the proliferation of benign glandular ducts that defines the condition of gynecomastia.  Male breast hypertrophy has many etiologies including drugs, prostate cancer therapy, low testosterone, or high estrogen states due to adrenal tumors, liver disease, or obesity, to name a few.  When the breasts hypertrophy they often develop vague, irregular nodules.  Sometimes, the patient becomes worried about a nodule, and a quick needle biopsy can reassure them that it is not cancer.  In other cases, the clinician palpates the mass and opts for a good night's sleep by calling a cytologist, to confirm benignity.  Men can get breast cancer, I don't want to downplay that possibility, but it is exceedingly rare.

Breast masses caused by gynecomastia are tough to hit and require aggressiveness to yield cellular material.  If you only get fatty tissue, without the benign glandular elements, it is "non-diagnostic" - which pleases no one.  A mass in the female breast is often easier to manipulate and stabilize within the fatty tissue, but I had only performed that once - the takeover of ultrasound guided core biopsies, a procedure performed by radiologists, had predated my fellowship.  A more likely call for a cytologist is a chest wall mass in a woman post-mastectomy to rule out (or in) recurrence of the breast cancer.  In this case, the cancer usually recurs in or on the muscle directly below the skin and scar.  Intuitively, a male breast mass would be easier to hit without all of the excess fat, but the irregular, dense nature of the lesion - think bumblebee trying to artfully gouge an large eraser - prevents easy access.

Cancer is not only easier to stick than benign entities - it is a hard, fixed lesion - it is also, generally speaking, much less painful.  Gynecomastia is by far one of the most subjectively painful procedures I had to perform.  Guys don't like it, and are often surprised at how much it hurts.  I have seen many men squeeze back tears and yelp in pain.  One flat out refused the second and third pass with the needle that are often required for any hope of diagnostic material.  I could hardly blame him.  

The nurse practitioner led me into the peach-colored clinic room.  A leather motorcycle jacket was slung over a low chair, and a tall, hulking man in a white t-shirt, jeans, and black work boots was perched on a flat examining table.  I had performed enough of these procedures during the year to learn that I liked the patient to lie down, but I briefly considered leaving him sitting - I couldn't possibly imagine him fitting comfortably in a supine state.  Then I pictured the multiple possible angles from which I could perform the procedure while he was sitting up -- all being terribly awkward -- so I walked over to the end of the examining table and pulled out the extended portion as far as it would go.  I asked him to take off his t-shirt and lie down.

I usually like to feel out a patient's propensity for chattiness -- many times engaging someone in conversation will distract and alleviate from the anxiety of the impending procedure.  But I am often relieved when my honest efforts aren't encouraged - I can just explain the procedure, get the consent, and concentrate on what I am doing.  This patient didn't require small talk, so I started working.  Examining a male breast is different than a female.  I remember the first time I did it I automatically pulled the modest, political correct female beast exam way of covering one while examining and/or performing a procedure on the other.  As I did it I felt silly - after all, men bare their chests all the time and probably don't care.  

I could feel the fibrotic nodule under the nipple.  I had never stuck a lesion directly under the nipple, and contemplated my approach.  I decided to go in directly outside of the areola and angle down and inward, so I could saw back and forth in a wide, sweeping arc.  I worried - from my own experience, the nipple is a pretty sensitive area, and I already knew that these lesions were painful.  I plunged in and started working, checking his face out of the corner of my eye for signs of distress.  There were none.  I performed the second and third pass quickly.  Before I pulled my needle out for the last time, I looked at his hands.  His fists were clenched, knuckles white.  I wondered about nail marks on his palms.

I thought of this yesterday when I was reading a dictation on a reduction mammoplasty - we get these all the time - I think reducing your breast size may be more popular than enhancing it - and the name was male.  Unusual, but not unheard of.  But it would be unusual, thank goodness, these days, for me to do a procedure for male gynecomastia - I haven't since my fellowship.  Maybe someone else is capturing that business, or maybe that was just the diagnostic trend at my training hospital.  Who knows.  But I am really glad they are in my past.  It's no fun to hurt people.

Happy Birthday Ike

We're partied out (three this weekend!).  My mom, the kids and I made a red velvet cake with homemade cream cheese icing today.  You should have seen the sugar coma we induced in the kids.  Now that would have been a great picture.

Luckily, future uncle Dave counteracted the initial hyperactivity with a post-prandial trampoline super jump.

Annie's favorite part:  When John announced a kissing game after Vino's pizza.  "Now!  Ereybawdy wisten.  You have to tiss.  On da cheek.  Dave tiss Annie.  Grampa tiss Bapsha.  Daddy tiss his mommy.  I tiss Sicily.  Sicily tisses mommy.  O-tay.  Tiss."

Hard to deny a three year old's wishes.  After all, he did blow out the candles.

Saturday was great too.  Mrs. Jacobs announced that Ike's smoked chicken tasted "like butter."  I believe that Helen tried on every dress that Sicily owned -- I caught her trying to squeeze into the Queen Elizabear dress right before dinner.  I warned her that it might not work.  I remember trying the same thing when I was her age and got the bear for my birthday.  Lily looked superfab in the orange velvet mod pumpkin girl dress.  And Annika was so cute in the Easter dress with Sicily's pink panda.  John played dragon and wizard.

Friday was date night.  Warning:  Do not order the chef's special with wine pairings at Ashley's unless you have eaten massive amounts of carbs to soak up the copious quantity of wine they pour with each tiny entree.  We gave them the credit card and the twenty-something waitress (I loved her - she mistook me for an old friend she used to listen to New Kids on the Block with  -- "This is gonna sound really weird but is your name Mary?" and looked genuinely shocked when I told her I was way too old for New Kids on the Block -- she made my entire weekend) told us we couldn't pay because we had two more courses left.  We told her we didn't care.  We needed to drive home while we were still capable.  Next time (in a year maybe - when we can afford it again), I think we might need a cab for that dinner.  We laughed Saturday with Ian and Carrie, who had the exact same experience the weekend before, for Carrie's birthday dinner.  Carrie is friends with the chef and his wife, and felt bad when she couldn't remember the dessert she had to describe to Martha.  "Not that it wasn't memorable, there was just so much wine on board!"  I do remember the frog legs.  They were yummy.  Ike was mortified that I ordered them.

I could tell Ike had a great weekend.  Although he said at one point, "I was kind of hoping it would go by unnoticed."

A birthday?  In this household?  Impossible.

New I Shuffle

Don't buy it.  I just took it back after two weeks.  I was so excited when I accidentally left my ishuffle in Nebraska - and excuse to buy a new one.  So I did.  I excitedly loaded up my new shuffle with all the tunes in my library.  Then I woke up early and went down to run.

I couldn't find the control button.  So I had to listen to schoolhouse rock.  Where the hell were the controls?

I had to read (god forbid) the manual.  I learned that the controls were on the godforsaken ear buds.  The ones that come with the product -- those that need to be thrown out, because if you try to run over 2 miles/hour (I like six or seven best), they fall out.  

I tried to use them.  I was excited about the new features -- the ones that announced the battery and the next song.  But the ear buds kept falling out.  Of my ears.  Definitely not worth the almost 100 dollars I spent.  Furthermore, I couldn't keep the damn thing charged.  Even when I tried on my supercomputer at work (they finally replaced our ten year old models last week at work).

I exchanged it for a nano.  Can't wait to load it up again.  

DON'T BUY THE NEW ISHUFFLE.

Numberz

Annie and I walked up the wooden steps into Cajun's Wharf.  A gust of wind carried the smell of stale beer and cigarettes, overpowering the odor of food from the restaurant.  I asked her rhetorically, "Did you ever notice how Cajun's just can't seem to get rid of the night before?"

She was taking me to meet a group of her girl friends, two of whom were also bridesmaids in the upcoming wedding.  

"They said they would be here at 5:30."

I looked at my pager.  It has become my substitute watch ever since I lost my 13 year old Movado two years ago in Florida.  I try to hide it when I'm not at work so I won't look cheesy, but I would be lost without it.  It was ten 'til six.  I was late picking her up cause I had to stop at a store and buy John an Easter shirt and do some last minute Easter basket shopping, then run home and get out of my scrubs.

We walked in and got stamped to go in the bar.  I love going places with Annie.  She is so pretty and petite.  Her long unruly mane of dark brown hair and shocking blue eyes highlight her natural beauty.  Without a stitch of makeup, she turns the head of every guy in the room.  We wandered around the bottom floor of the cavern-like atmosphere, and as she looked for her friends I watched the band setting up.  

"I don't see them."

"Why don't we go upstairs?"

We walked up and looked in the seating areas, then out on the patio.  The patio seemed smaller than I remembered; I probably hadn't been up there in over 12 years.  Still no luck.

I said, "Maybe they are in the restaurant?" 

After a careful double sweep of the entire premises, Annie reached into her purse to get her phone.  We were wondering if they had gone to another bar - changing plans last minute.  

"Oh no!  I left my phone at the house.  I can't call Carissa."

"I have my phone - you can use it."

"But I don't have her number."  I thought this was a little weird, not knowing your bridesmaid's phone number, but I didn't mention it.  I said, "Well, we can call your phone.  Maybe Dave will pick it up and he can look it up for us."

"Dave won't answer my phone.  I know him."

I continued to problem solve.  "Let's call Dave.  Maybe he can help us."

She looked up at me apologetically.  "I don't know Dave's number."

This time I couldn't keep my mouth shut.  "You are about to marry a guy and you don't even know his phone number!!???"

"I know, I really should learn his phone number.  I'll do that, I promise."

That didn't help us now.  "I'll call Ike.  I'll bet he knows Dave's phone number."  She smiled.  "Yes!  Ike will know it, I am sure."

Ike didn't answer his phone.

We continued to wander around and eventually discovered that the Cajun's patio was indeed much larger than it's perceived dimension from the patio doors.  A group of five girls was parked around a bowl of cheese dip, and lit up when Annie walked out.  We sat down to a chorus of "ANNIE!!  Let's hear it.  Tell the story."

That was the prime purpose of our get-together, so that Annie could relay THE STORY.  Of HOW SHE GOT ENGAGED.  After a quick round of introductions, she jumped in, and they all listened with rapt attention.  Meanwhile, Ike had noticed I called and was returning it.  I stepped away from the table and listened to him rattle off the number that I no longer needed.  It was loud in the background.  I asked, "Where are you?"  He had been stood up by his mom for a bridge game and was planning to go out to eat by himself.  

"I found Gasper, Brett and some other guys at The Fountain."

As I walked back to the table Annie was finishing up her story.  I had to interrupt.  "Does anyone else here find it odd that Annie is about to get married and doesn't even know her fiancee's phone number?"

They all looked at me with blank faces.  A couple shook their heads and one girl voiced aloud what it quickly became apparent to me that all the others were thinking.  "No."  Now I was the weird one.  Their expressions reminded me of the one I got when I was exchanging my palm pilot (yes they still make those) because the screen was messed up.  No one at the Alltell store knew how to fix a palm so they just gave me a new one.  My cheerful helper became suddenly upset as she relayed a glitch.  "I'm so sorry!  You will have to come back on Monday so we can move your contacts to your new phone.  Our computers are down right now."  I was momentarily confused, then realized what she was talking about.  "Oh, it's ok, " I reassured her, "I don't have any contacts."

I have always remembered phone numbers.  Sometimes, to my detriment.  I still accidentally dial my high school friends old numbers, when I am calling them, forgetting that they have long since moved out of their parent's houses.  Last week, when Ike and I were in the Nebraska ER with John, his first trip to the ER, Ike became upset that a urologist would not see John until the next day (luckily, we didn't end up needing one).  I told him I would call Mel, my friend from residency.  Her husband is a urologist.  Problem was, I hadn't dialed her number in months, and was at a momentary loss, partially due to the stress of the situation.  Ike was frantic, "Can't you remember it?"  

"Please be calm and patient.  It will come to me.  I just have to get the area code and the rest will fall into place.  Give me a minute."

Sure enough, her cell materialized after a quick mental sorting.  I'll spare you the details of the ER story.  My friend Trish urged me to blog about it -- It is highly entertaining but a little personal, and I am reluctant to commit it to words.  It makes for good dinner party conversation.  To be fair, I did end up calling my friend Dr. Styles for Mel's home phone.  She wasn't answering her cell.  Luckily Walt was still up - it was close to 10 Knoxville time.

Back at Cajun's, we continued the girlie conversation as the wind picked up and Mr. Happy warbled popular bar tunes.  I looked out over the river and pondered the fate of that sunken bar I had been reading about on Arkansas Blog (The Salty Parrot?).  Two others at the table were engaged, and wedding plans were the dominating theme.  If I didn't know better, I would have thought engagement was some sort of contagious disease among this lot.  I felt like an old maid, despite being only 5 or 6 years older than most of them.  But I loved them all, and am looking forward to hanging out with them over the next few months planning showers and the all important bachelorette party.  We sketched it out.  An overnight - shopping, pedicures.  We pledged to keep an eye out for a great band to go see for the evening portion.

I love that Annie surrounds herself with non-medical friends, much as I enjoy doing.  They were lawyers, make-a-wishers, working at Box Turtlers.  NO DOCTORS.  It was wonderful.  I'll have to get their numbers.

 

Thyroid/Neck

Randy pulled up to the double head on the microscope.

"What do you see?"

"Blood, blood, blood.  A little colloid.  No cells."

In order to have an adequate thyroid biopsy, six groups of ten thyroid follicular cells are required.  That is what we search for, under the microscope.

Randy asked, "Aren't those cells?"

He had performed the needles.  Four passes under ultrasound guidance.  Quick in and out gestures with a 27 guage - usually enough for adequacy, if lucky.

"No.  Just platelets caught up in clot.  A few naked nuclei.  Doesn't count."

"Damn it."

I kept looking.  To no avail.  I decided to rib the tech.

"I think it's Jeff's fault.  He must have done something."

Jeff is the newest tech, so I have to be careful in my teasing.  He's still pretty literal.

Randy took my lead. 

"Jeff was there when I arrived.  They called him too early, to make the smears.  He was probably pissed, so he may have sabotaged the needle."

I continued, "That's just like Jeff.  He likes to smear the diagnostic cells right on the floor, and step on them for good measure."  Jeff smirked.

"Whoa.  Wait a minute.  There are some groups.  Beautiful, honeycombs.  Not stuck in clot.  I think we may have adequacy.  Do we have any paps?  Is there a cell block?"

Jeff replied.  "Paps, yes.  No cell block, not enough blood."

"I think we're gonna be ok.  You're done.  What's next?"

"We have a neck coming after lunch.  Large lesion, under the muscle.  Outpatient from ENT."

Later on, after lunch   . . .

"I see lymphoid cells.  That's it.  Heterogeneous.  What's the story?"

"48 year old.  Long time smoker.  Just lymphoid cells?  Shall I get flow?"

"Doesn't make sense.  This shouldn't be lymphoma.  Wasn't he referred by an ENT?  Large neck mass?  We are definitely in a node, but based on the history, we should be seeing squamous cell carcinoma.  I'm not satisfied.  Go back."

Second pass . . .

"Blood, fibrous tissue, and fat.  You aren't even in the lesion.  Go back again."

Third pass . . .

"Bingo.  Positive.  Squamous cell carcinoma.  Metastasis to a neck node"

Sometimes you've gotta hold out for the obvious diagnosis.  Because you know it is there, somewhere.

Physician Spotlight

I'm famous!

I knew there was a reason I joined facebook.  Contacts, contacts.  Thanks Christie!

Thanks, Jennifer, you did a wonderful job making my ramblings sound as well as they possibly could.

I've gotten lots of feedback over the past couple of weeks.  I don't think a pathologist (read social isolate) has ever been in the physician spotlight (well, one other, according to Jennifer's memory).  We pathologists tend to like to stay far away from the spotlight.

My partner's wife surprised me by laminating the newspaper version as a gift and passing it along through her husband (Thanks, Ginger!).  

http://www.medicalnewsofarkansas.com/news.php?viewStory=740

Melena

I wonder if, when Gregory Maguire wrote Wicked, he realized that he was naming Elphaba's mother after the medical term for black, tarry, foul-smelling stools that are usually the result of a gastrointestinal hemorrhage?  If so, great, but it sure made for a distracting first third of the novel.  Especially since she is supposed to be so ravishingly beautiful.  Maybe the name is a comment on her mothering abilities.  Excellent book so far, by the way = been meaning to read it for a long time.

Thank goodness I just got a pile of immunostains so I can quit pondering this.

By the way, we learned, on the heels of a Nebraska spring snowstorm that kicked up right after Mike and Effie tied the knot, that Annie and Dave got engaged in Panama!  I just got asked to be in the wedding and am SOOO excited - I never thought I'd be a bridesmaid (I prefer maid to matron) again.  Tentative date:  October 24.  More weddings, weddings . . .

Congratulations Dave and Annie!!!!!  Sorry the title of this blog where I mention your engagement is black, tarry, foul-smelling stool.  May you have none of that (personally, of course, you are doctors) in your future together.

The Prisoner

I have been completely obsessed, in my head.  I was listening to a lecture in chest conference yesterday, about tuberculosis.  The speaker was a beautiful pulmonology fellow (or possibly new attending) from India.  I love listening to lecturers from India -- sometimes their lilting voice lulls me into a parallel universe.  They sing our language, in a beautiful way that is probably only a tiny fraction of how wonderful they sound in their native tongue.  

Here is some of what I learned:  mycobacterium tuberculosis inhabits one of three humans worldwide (WHO 2007).  It is an international epidemic, mostly in underdeveloped countries.  So widespread that massive efforts have been instituted in attempt to eradicate this bug.  We don't see it so much in the U.S., but it is pervasive enough that we perform acid-fast stains on many lung biopsies, stains specially designed to penetrate their lipid shell and highlight their miniscule rod-shaped bodies a bright cherry red in a background of cerulean blue counterstain.  We hunt and peck through the microscope for the sometimes dearth of organisms that requires careful screening on high power, all the while adjusting the focus in and out.

Once I became extremely paranoid that I was missing an organism, a needle in a haystack, since I had searched the lung tissue twice and couldn't find anything.  This person had a history of infection, so I was extra worried I was missing something, and passed it onto a senior partner for his inspection.  He said, "Why don't you perform a fluorescent?"  

I asked, "What is that?"  

A fluorescent stain is much easier to read -- looking for a bright white organism against a black background.  We had never done those in our training.  Mine came back positive, just two or three organisms, but enough to make me self-flagellate and re-screen the acid fast (the gold standard stain) for twenty minutes.  I found one organism -- one that was easy to lose even while focusing up and down between my carefully placed dots with a marker.  I was mortified.  I showed it to my consultant, full of chagrin.  "It was there.  I missed it."

He smiled at me compassionately.  "Gizabeth, I never would have seen that in a million years."

In order to facilitate eradication, a policy called directly observed therapy (DOT) has been instituted worldwide.  The Indian doctor was discussing this, and mentioned in passing a case where DOT had failed her.  A prisoner, diagnosed with TB and treated, had his symptoms return in a few months.  The guards were watching him take the meds - he should have been staying in remission.  Everyone was stymied.  Turns out, he was pocketing the pills in his cheek.

I have been obsessed with this guy - for the past 24 plus hours.  One thing I have learned about obsessions - write about them, talk about them, they will go away.  Leave them secret, and they will grow and fester like an open wound.  I've been thinking about him - going to sleep, in my car, on the treadmill.  Not so much what he looks like, or why he was in prison, or even how old he is.  I much prefer him as a blank slate.  Better to climb inside and try to deduce his motivations.  That is my real obsession.

Why would someone in a prison cell pocket his medication for TB?  Surely he was told of his diagnosis and knew the meds would make him better - make his lung symptoms disappear.  The cough, the night sweats, the shortness of breath, the bloody expectorants.  From what I understood, he had been treated enough to go into remission, then started pocketing furtively for three months until he once again had full-blown TB, the kind that rendered men in the early 20th century to be banished to sanatoriums to die, before the advent of medications, within six months to a year.  He allowed the necrotizing granulomas that we see under the scope, the hallmark of the disease, to take over his lungs.

Was he psychotic?  That would certainly explain it.  Many psychiatric patients pocket their meds - he may have thought that he was being poisoned.  Maybe he was exerting the only semblance of control that he could create in his imprisoned state, even if the ultimate outcome was self-abuse.  Did he enjoy slowly experiencing the advent of his symptoms, day by day, charting their progression internally?  Was it attention-seeking?  Did he think that if he got sick enough he might be transferred to a health facility where he would experience a much needed change of environment and personnel?

Or maybe his motivation was artistic.  Many pills are coated with dyed material that could be used for art.  Crush, add water, and voila.  A medium.  Probably hard to come by, in a prison cell.  Alternately, he could be a mathematician, interested in higher theory, which requires a visual aid in order to advance thought.  Pills, beans, what's the difference?

As the Indian tied down her lecture, advancing a couple of new techniques that may render the painful subcutaneous TB skin test we receive yearly as hospital employees obsolete, I was thankful that I was in a developed country, where we have few cases of TB.  The highly drug resistant strains, ones so prominently displayed on exhibitionist news networks, had not even hit Arkansas, according to the maps.  The few reported cases skirted the outside of the US - countries receiving the most immigrants.  Hopefully, when she learned the prisoner was pocketing his pills, she was able to convince him the folly of his ways.  Unless he had given up.  The last motivation -- the lack thereof.  Perhaps he had his ticket out, and he was taking it slowly but surely.