Tuesday, May 12, 2009

Brain Frozens

I powered through my morning work in order to blog, as promised, this afternoon - but I got bogged down in brain frozens.  My pager went off at around 2:30 p.m. (911 - main OR) and it wasn't over until almost 4:00.  Then I had to get finished with my work, get gas (the light had been orange for two days), and get home to a mini-Schneider family dinner in honor of a one-night visit by Ike's little brother Jake, who is flying to New York at the end of the week to train for his summer job in Hong Kong.  I asked him what he was getting trained to do.  "Lawyer etiquette."  He is a pretty smart guy who has lived in China and can both speak and write the language fluently.  In this tight economy, he is one of the only ones in his law class at Washington University who was snatched up by one of the "Magic Circle" law firms - I think that is a title reserved for the top six or ten firms in the world.  Sounds kind of hokey, but very prestigious, I am assured.

Anyway, I headed to the OR with a mild adrenaline rush, despite having skipped my afternoon coffee.  Brain frozens are not easy for even the most experienced pathologist.  My neurosurgeon neighbor met me at the door of the gross room.  He is tall and distinguished - I usually see him walking his golden retriever Max, and he sometimes stops to chat in front of the house.  Once I came home from work and Max was walking around our house, owner-less, with a pair of Sicily's panties in his mouth.  My nanny was cowering in the backyard with our kids - she doesn't much like dogs.  I laughed and shooed Max out - never mind about the panties.

My neighbor's rugby and khaki's were traded in for full OR gear - sterile gloves, surgical mask, and OR hat.  The only part of his face I could see were his eyes, behind his loupes, which replaced his glasses.  We greeted each other, and he began to tell me the history and anatomy of the tumor, which I had already read on the computer chart.  I knew his impression, the radiologist's impression (both different), and the patient's presenting symptoms before my pager went off.  

The gross room tech was having trouble freezing the specimen, so I chipped in with the touch and squash preparations.  The neurosurgeon needs a diagnosis, and they are some of the most chintzy surgeons when doling out tissue.  Hard to blame them - they are in the brain, after all.  We usually get a 1 mm piece of brown-grey gelatinous tissue.  I touched the tissue with one slide, and handed it to a tech to stain.  Then I used a fresh surgical blade to separate a tiny fraction of the tissue and put it on second slide.  A third glass slide is used as a vehicle to "squash" the tissue and smear it down the slide - another preparation for cytologic evaluation.  We don't do touches and squashes on every tissue, but it helps, in the brain.  The remainder of the tissue is placed in a small square metal chuck, embedded in gooey clear liquid, and then placed in a cooler and sprayed with a gaseous freezing agent for quick freezing.  Now the tissue is buried in an opaque white frozen square that fits in the cooler microtome, ready for cutting with a fresh blade in 3 um slices. When it looks like we have a good slice, we use a paintbrush to catch it with a final slide, and we get a nice two dimensional image of the tissue.  It's quite an art.  If you are slow and clumsy, your fingers get so cold it feels like they are going to fall off.  All slides are stained in hematoxylin and eosin, and we take them to the microscope in the gross room for diagnosis. 

As I said, the freezing tech was having trouble with the tissue - it was jumping out of the chuck, and she called a senior gross tech for help.  In the meantime, the neurosurgeon and I had exhausted the topic of the patient and started talking about canoeing, the weather, and how lucky we were to live on a hill.  He followed me into the scope room while I was looking, and started asking me questions.

"What if I were to want to freeze some tissue?  Could I take pictures, and send them somewhere for a diagnosis?  What would I need?"

As I stared at the tissue, moving the slide up and down the stage with my left hand, I answered, "Well, you would need a cryostat.  And a microscope.  A camera, for the scope.  And a computer, to e-mail the pictures.  You would need a stain line, too.  And an experienced technologist to prepare the frozen."

"How do you embed it in paraffin?  For the final diagnosis?"

"You need a lot more equipment.  A closed machine that passes the tissue, in plastic blocks, through various chemicals on a timer overnight, before they are embedded in paraffin for permanent sectioning.  Our techs come in at 3a.m. to start cutting, so that we have slides ready when we walk in the door."

I was wondering why he was asking all these questions, and I was wondering what in the heck I was looking at at the same time.  I figured the tumor was primary to the brain, not metastatic, because there were slightly pleomorphic neurons in a glial matrix, but there wasn't enough there for a diagnosis.  I had all of the differential diagnoses whirring around in my head, but couldn't narrow them down into specifics.  

"We need more tissue.  I can't be certain."

"Do you mean I need to get more tissue for permanents, or do we freeze it again?  I need to be sure I've got a diagnosis."

"Then we'd better freeze it again."

I walked back to my office, after getting a quick QA consult from a senior partner.  I showed him the frozen to see what he said - make sure I was on the right track.  He agreed.

I looked at two breast slides and was paged back to the gross room again.

We repeated the process, and I looked at the touch and squash.  The cells were obscured by blood.  "Your patient is bleeding."

He answered gruffly, "I was afraid of that."

As we waited for the frozen, he started in with the questions again.  "Is there a smaller cryostat?  One that would fit on a desktop?"  Our cryostats are huge, about the size of a waist-high filing cabinet.

"I don't know.  I've only seen the big ones.  But I couldn't be sure - I've never looked.  I guess you could try to google it."

"That's a good idea."

I decided to ask him.  "What do you need this information for?  Are you operating in one of those surgical centers across town?"

"No, I only operate in this hospital.  In the United States.  I go to Kenya, and operate.  We don't have pathology there.  We do the operation, but we rarely know the diagnosis.  The treatment is a guessing game."

I turned around to look at him.  "That's really incredible."

The frozen came, and I was frustrated.  More of the same.  I cringed internally as I told him we needed more.  Most of the tissue was dead.  We need viable tissue for a diagnosis.

"I guess I will convert to open biopsy and call you again."  I could feel his frustration, as he was sitting behind me, and even though he was calm, I was mildly flustered.  Sometimes the surgeon takes it out on the pathologist, when they are not getting a diagnosis, and even though that wasn't his style, my past experiences were projecting onto the current situation.  

Like the time when I was brand new to the hospital and the radiologist was angry that I told him we didn't have enough tissue for a diagnosis, and he got hostile and defensive.  "Well, that's all there is.  If we don't have enough, I don't see how I can get any more information."  I turned around and looked him square in the eye.  "Look, I am happy to be descriptive.  If that is all you think you can get, I'll just tell them what is there and they can follow it radiologically and clinically."  He looked surprised and immediately loosened up and smiled.  "All right, all right.  I'll get a couple more passes with the needle."

The neurosurgeon converted to open biopsy and we finally got diagnostic material.  He had stayed in the OR this time and I called to tell him over speakerphone.  "We've got enough."  I told him the diagnosis, and he sounded happy, if somewhat muffled.  They all sound muffled over the speakerphone, and my bad ears necessitate embarrassingly frequent repetition, at times.  But I could hear him plainly.  "I knew if I converted to open we would get it."  

I can't believe people are being treated in Kenya without a diagnosis.  I want to go there and help.

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