Fetal Autopsy

I was sitting in my home away from home in the rural office, the one with a window, when two heads popped in my door. Both lab techs/administrators - there's more job lumping and less splitting in a small town. "Gizabeth? I think there is going to be a fetal autopsy. A stillborn, delivered last night. Do you remember the rules for the cutoff between surgical specimen and autopsy, in a stillborn?"

Damn it, I didn't. And I wasn't in my own office, the one with amazing organized drawers of folders. I knew exactly where to look, there. But I was here, in my partner's office. I glanced up at her array of books, in desperation. No Lester, that I could see. I was stymied.

"Let me call the on call anatomic pathologist, and check. I'll get back to you in a little bit."

"That would be great. I heard it took her all night to deliver the baby. Hadn't heard a heartbeat in a couple of days. Probably pretty traumatic, for mom. They think she was 27 weeks."

I finished up some cases, and called my partner. Looked at my watch. 2:00. I hoped this would happen quickly - I had dinner plans with my parents and kids at 6:30. Autopsies take a while. But patients are more important than dinner plans.

In the meantime, I got a call from the OB. "What can the parents expect to find, from the autopsy?"

"If the baby has been dead for a couple of days, it's probably pretty macerated. There won't be much to see, histologically. Too much autolysis. I'm not trying to discourage anything. We can get samples for cytogenetics, to see if there are any problems there. We can culture the nares and mouth, to look for bacterial etiologies. There's probably a lot of contamination, but if certain culprits are revealed in cultures, we can point to a possible source."

"The baby looked fine, externally. No obvious malformations to suggest a genetic cause. I'll talk to them. In the meantime, find out whatever you can."

I took the task to heart. Called my dad for suggestions - he deals with babies all the time and might have some good insight. Called my partner and confirmed what I was vaguely remembering - the cutoff was 20 weeks for autopsy vs. surgical specimen. So this was definitely a candidate for autopsy. Alerted the gross tech. Set the lab administrators to the task of looking on the ARUP website for the best source to submit for cytogenetics. Got prepared.

4:00 - Surgical cases done. Autopsy still pending. Heard nothing. I decided to press. Wandered into the administrators office, a little sheepishly.

"Have you heard anything, about the fetal autopsy? I don't mean to press, but it is getting late. I hate to call the on call anatomic pathologist, to deal with this in another town, on a Friday night. I understand about bonding with the baby, but we need to know if this is going to happen or not. I'm willing to stay here for as long as it takes, but I'd like some information. Is there someone you can call?"

I was remembering a case I had in residency, on the weekend. I had a fetal autopsy, and the clinicians were worried about a mitochondrial disorder. We needed skin fibroblasts, for culture, and they needed to be fairly fresh. The mom was so distraught, understandably, and wanted to hold the dead baby in order to process her grief. But every minute was taking away opportunities for diagnosis, and we had to put pressure on her. It sucked.

A few phone calls were made, and the administrator came into my office at around 5:00. "Mom wants to bond for a few more hours."

I looked up at his poker face, and believed him. Planned to call my help and rearrange dinner plans.

"Just kidding. They decided to call off the autopsy. The OB was supposed to call you, but forgot. You can go home. Have a great weekend. Here's my card. Call me if you need anything."

Acute Inflammation

At 2:00 I got a call in my office from the transcriptionists.

"They're ready in CT4."

I headed down the long hallway, toward radiology. I quickly scuttled through the CT room, protecting the ovaries I probably didn't really need anymore, to the scope. The cytotech had some slides ready, fresh from staining. I grabbed a paper towel to clean the slide, so the water on the slide wouldn't hinder the slides movement on the scope. I started looking. Benign lung elements. A little acute inflammation. "I'm not seeing much. Better get cultures."

The radiologist was looking in the computer.

"It's a mystery. They say she has a history of non-small cell lung cancer, but she's never had a biopsy. We can't figure out where the diagnosis came from."

The radiology assistant, a beautiful brunette with sky-blue eyes, echoed the conundrum. All the guys, the radiologist, the radiology P.A., and the cytotech, headed back into the CT room to get more sample. I heard the radiologist questioning the patient, who was on the CT table. I engaged in chit-chat with the assistant.

"I'm sure glad it's Friday. I've been working for two weeks straight."

She replied, "I wish I had been working that long. I just got back from a conference in Vegas. It was amazing."

I said, "I've never been to Vegas. Only the airport. Did you see any shows?"

The crew came back into the control room, with a new sample. The cytotech began to stain the touch preparations, for my review. While I waited, the radiologist solved the mystery from earlier.

"She had a lobectomy. On the other side."

I said, "No wonder. That's where they got the diagnosis. Not a biopsy, but surgery." I noticed the board was conspicuously clean. I remarked on it.

The radiologist said, "Yup! 2:00 on a Friday. No more needles in sight. Normally, I'd be stacking them up, on Friday afternoon. But I'm on call tonight, so I'm keeping it minimal. Part of my new plan. Like transparency in Washington."

I started laughing. The radiology P.A. said, "more like plausible deniability." I laughed harder.

The radiologist said, "Them's big words, Randy! I don't understand what you're talkin' about." He turned to me. "You say you saw poly- mofo (really he said morpho, but I think mofo is funnier) - nucleo- sites? So we should get cultures, right?"

I had stopped laughing, and answered tersely while I was looking in the scope. "If you guys would just stop making me laugh, I might be able to concentrate and help you out." It was the only way to give them a compliment, in hopes that it wouldn't go to their heads. The radiology assistant laughed. "Now you know what it's like to live around here."

They got cultures. I was happy for the patient that I didn't see cancer. I jotted down my preliminary diagnosis on the requisition sheet, and stood up to leave. "So long. Have a great weekend."

The radiologist bowed, with a flourish. "You too, doc-tuh."

Fighting Back Tears

I've been doing a lot of that, this week. First:

- I found out my nanny's granddaughter was in the PICU at the children's hospital. An uncommon, post-viral syndrome (ADEM) giving her uncontrollable seizures for over 24 hours. I'm not much of a praying type, but the kids and I have been praying all week. She's five days younger than Sicily, and they have grown up together. On Tue. after work, I went to Target to get a big gift card - it seemed silly to do - but I can't cook and she is on the vent, so can't yet receive flowers and cards. On the way home, I got a text from my nanny's youngest daughter, through whom I communicate with my Spanish-only speaking nanny.

"You can come see her, if you like. She's on the third floor in the PICU. Bed ---."

I knew this was code for please come help us communicate with the medical team. My nanny probably put her daughter, the child's aunt, up to the text. I felt apprehensive - I hadn't been to the children's hospital in a while and was worried I wouldn't know anyone. I veered away from my neighborhood and headed to the hospital.

As I walked into the PICU, Pamela greeted me. "I tried to communicate with the nurses, but it's hard." She is in nursing school. I followed her back to the enclosed space, and saw little Natalie in bed, asleep, hooked up to the ventilator, with feeding tubes in her nose. Five large medication administrators - they looked like car batteries with digital windows announcing the names of various drugs, sat at her feet. I looked at her, and thought of Sicily. Thought back to my brother, when he was in the PICU almost twenty years ago fighting viral encephalitis in a coma. Started to get choked up, then quickly fought it back - that wasn't why I was here. Not to get sad. I had a job.

I was immensely relieved when I knew the neurologist that walked in the room. Greeted her, and got good information about the diagnosis, treatment, and prognosis. Made small talk, and expressed gratitude and appreciation that she was a part of the team. When she left, my nanny and her daughter thanked me.

- Wednesday afternoon, a cytotech walked into my office with a case. "Do you remember so-and-so? The blood bank tech from the University?" Of course I remember her. I fell in love with her, on my blood bank rotation. We were pregnant with our first kids together. She was tall, bold, incredibly beautiful, sweet, and funny. We joked and commiserated, about our gravid conditions. "She learned she has metastatic pancreatic cancer, on New Year's Day." It was like a blow to the stomach. She has two small kids, about my age. Can't cry in front of the staff, but I almost did.

- Thursday, after a fun but intense hour-plus of science fair judging after work, I showed up late to book club at The House. Enjoyed a great burger and fries. After two of the members left early to relieve their sitters, me and a friend opened up to each other about our lives and struggles. Listening to her helped me process my own situation. I invited her back to my house and we stayed up late talking, drinking wine, and listening to music.

- Friday morning when I got to work, my friend Laurie from the gross room - the amazing mix-maker - showed up in my office. I had shut the door the day before, and let her in on some personal stuff. She made me a mix, and gave me a gift certificate to Starbucks. I was moved to tears. "This is not sad music. It's angry music. Listen to it, on your way to see your brother and sister in Atlanta next week. I think it will help." I am driving to Memphis on Friday - much better plane fares. I smiled. "Thanks. I need some angry music."

- Today I was crossing the Arkansas River to Maumelle, car full of smoked salmon, meats and cheeses from Boulevard, on the way to a baby shower for my friends that adopted on Christmas Day. I was co-hosting with a large group. Staring at the river (and my iphone for directions - I only made one wrong turn), I started thinking about my own life situation. Feeling sorry for myself, and lonely. Listening to Jeff Beck (more Laurie). Then I pulled out of my two minute self-pity party. Backed up to Loretta Lynn, and sang at the top of my lungs. I'm going somewhere. I don't know where yet, but it's got to be better than where I've been.

Medical Terminology

Sometimes, you think you've heard it all. Then you follow your medical blogs, during a lunch break or waiting for immunos, and you delight in adding new terms to your current repertoire.

This week I learned two new ones:

Uniboob: I have heard of the unibrow. But uniboob? Dr. Bates, over at Suture For a Living (remember, I can't figure out how to link on this computer, so click to the right if you are curious about more details) reviewed the symptoms that lead to symmastia. Apparently, if you have a certain kind of breast enhancement, one that either sits under the pectorals or is just too ambitious for your chest size, you are in danger of the uniboob. The bilateral, surgically implanted "falsies" migrate together at the center of your chest and create an otherworldly effect. A more caudal version of the cyclops.

Vaso-Bagel: Swallowing syncope. The Happy Hospitalist had his first case of this, this week. It occurs when the simple act of swallowing liquids, or large boluses of food (bagel!) elicits a vasovagal response that induces fainting. I've passed out to the sight of my own blood, the crunch of a bone marrow biopsy, and to the pain of having my teeth pulled. But never, thus far, thank goodness, during the act of swallowing.

Consider yourself educated, this Saturday night. Rest peacefully. Swallow carefully. And don't overestimate your body's capability for large breast implants.

Tracking Patients

Read it over at MiM. Use the link on the blogroll at the right because I am using an inferior PC (can't get on wireless with my laptop for an annoying two weeks now at home) and can't figure out how to link. I will fix the link at work tomorrow, if/when I have time.

Incredible Cartoon Talent

Someone on the MiM blog, her name is Fizzy, recently linked to some cartoons she has been posting, on her own new cartoon blog.

They are fabulous. She posted one to the MiM blog called Resident/Mother:

This was me for three years straight. except there were a lot more milk stains - all over my pump case, pants, and shirt. I remember once I was in the sign-out room - I was a fellow and nursing John - and my attending Dr. Styles said, "Gizabeth, you cannot come back to work without shopping. Your pants are falling off." Indeed, I was crazy skinny. No time to eat, only time to pump/nurse. It was ridiculous. A far cry from my waistline a few months previous, which earned me the nickname "Big Belly Betty."

I would add 8 inch roots from only having time to get your hair cut/colored once a year, and lack of make-up from absolutely no time to think about it much less apply it. I'm not really into too much make-up - don't know what to do beyond lipstick and eyeliner (eyeshadow and foundation are a mystery) but even my mom was buying gloss and stashing it in my car and coat pockets as a gift/hint - however personally I decided to take it, at the time. And I don't know how Fizzy could button up that shirt, if she is nursing. I had to wear tank tops under my open button downs for two years.

Some of the other ones are a lot more fun like this:

It's true. This takes work. It doesn't come naturally. And this one:

The one above reminds me of the antics people went through for our yearly Skit Dance, where classes would compete for lewdest medical humor-based skits. It was finally kicked off of campus and disassociated from the University, it became so bad. I think that was after the year a girl in my class shaved the letters "Skit Dance" into her pubic hair as the opening shot for our class' skit. It was a close-up. At the time, I was awed by her shameless exhibitionism. That's just not in my genetic make-up. I think she wanted to be a neurosurgeon.

Keep cartooning, Fizzy! Amazing talent. She does qualify her artistic talent, on her blog (better than I could manage), but her humor certainly overcompensates. You can find it at the link above, if you are interested.

Happy Valentine's Day

This afternoon I went to Katie's house, one of my oldest and dearest friends. It was a pre-party for her daughter Sophia, turning five. It was a small pre-party, with just her, myself and another friend Lisa. My two kids were there, her 12 year old son Noah and two of his friends (one was Lisa's older son), and another three and four year old - her friend Lisa's son Sam and Noah's little brother Isaac, who had been dropped off by his Mom and Dad to join in the festivities. We were going to make snow cones and do a pinata on the front porch, before heading over to Jump Zone.

Katie said, "When I planned the snow cones this morning, it was warm and sunny." We looked at the snowflakes starting to fall in the front yard.

I replied, "The kids don't care. Any time is good for snow cones. I'll bet they've never had snow cones in the snow."

Indeed they hadn't, and all the kids were in awe, older and younger alike. Alternately eating their snow cones and catching large goose feather snowflakes on their tongues in the front yard, while Katie and I were frantically attempting to hang up the pinata by an electrical extension cord from a hook in the ceiling. It fell when she ran in the house to get the baseball bat, and we were a little relieved that there was a giant hole in the pinata, now necessitating relatively few slugs by the bat on the cold front porch in order for it to regurgitate toys and candy for the kids.

We headed over to Jump Zone, and I offered two extra spots in my car to her son Noah and his friend Craig. I remembered Craig while I was in the bathroom at her house - he came with Noah a year and a half ago over to my house and I dissected cow eyeballs with them. Noah was a little squeamish about the whole thing - he was only ten and preferred to watch - but Craig dove in with both hands and had a ball.

I'm not really comfortable with twelve year old boys - my brothers didn't hit puberty until after I was in college. I was thinking I either scored points with them when my son John requested his favorite Kanye West song or horrified them when I played said Kanye West song for my four year old son and six year old daughter. I said apologetically, "I don't think they really understand the couple of bad words, yet. Maybe I shouldn't play this for him, but I worry he gets too much girlie stuff from his sister's repertoire. I hope your parents won't get mad that I am playing this song for you." Craig said, "This is one of my favorite songs." We listened - John and Sicily sang at the top of their lungs. We watched the giant snowflakes fall on the windshield, on the way to Maumelle. I asked Noah about basketball and his Dad - I remember hanging out with Katie and his Dad before he was even born. I told him that.

After a raucous hour and a half of jumping and sugar, we headed back. I told Katie I would drop the boys off at her house before going home. John was fired up on sugar and adrenaline, and was being crazy and loud in the back seat - even Noah was laughing. I switched CD's to a science one I made for Sicily's birthday last year, and turned it down. Got all the kids going on a round of "No laughing" game - Noah was the referee and tickling John in the backseat, who was happily losing over and over. I was a little surprised when the stoic Craig, now in my front seat, couldn't suppress giggles. It was cracking me up. I thought it was a little overboard for what was going on in the backseat, so I finally asked him, "What is so funny?"

"This song. It is absolutely ridiculous. Who sings it?"

It was Pancreas, by Weird Al Yankovic. I was so used to it, I forgot how funny it was when I first heard it. I replied, "Isn't it great? I'll bet you could find it on YouTube, pretty easily." I told him the name. After it was over, a They Might Be Giants song came on. I forget the name.

"The sun is a mass of incandescent gas, a gigantic nuclear furnace!"

Craig was laughing out loud, now. "Is this Weird Al, too?" I told him no, and gave him the name of the band. In the backseat, Noah had turned the No Laughing game into the No Talking game, in attempt to gain a little peace and quiet. Every minute or so he announced, "Sicily won again!" I turned around and smiled at her, "Go girl power!"

After the boys spilled out of the car, I watched them find the key and get in the front door safely. I thought of how the wall of pre-teen cool melted over the few hours I spent with them. Their laughter on the way home, filling my car, was the best Valentine's present ever. I worry about when John is a teenager. How I might become uncool, and lose my ability to relate to him. Today made me look forward to it, very much.

Party at the Hilton

I feel like I'm in Groundhog Day. I remember the last time I felt this way - I had gone to the airport to pick up my daughter and her dad and I was with my then two year old son. We arrived early, and John was restless. I entertained him by riding up and down the escalator. Over and over. Ad nauseum.

I upgraded to the Hilton, not because I was disappointed with the Hampton Inn rooms a couple of weeks ago, but because the fitness room sucked. It was a small room with one ancient treadmill and an Exercycle. The room temperature wall unit was cranked up to 80 degrees - not really conducive to a brisk morning run. The treadmill was one step up from a unit that has no power - the one that is kind of like a hamster wheel, you just hop on and run. I had forgotten to pack my inano, so I just turned on my phone ipod as loud as it would go. The good news was that there was no one in the room to compete with for the machines, or to become annoyed with my music, but the treadmill motor was so loud I couldn't hear the music. When I first turned on the treadmill, the display was like a primitive Atari game that had lost half of it's juice, so you couldn't really see what was going on.

There was an automatic program on the treadmill that was stubbornly resistant to manual override. I cranked up the speed to 6.5, but every minute it dropped me down to 2, necessitating a brisk re-negotiation of the speed with the up arrow. Not only was I on a treadmill that moved across the floor with me while I ran, it also resisted all logical button manipulation (there were only four, it couldn't be that hard) to gain control. I tried random, illogical pressing, to no avail. I even noticed that the manual was connected to the treadmill by a silver ring (I wasn't the only one who was frustrated), and I sat down to read it, but it offered no new insights into getting rid of the ridiculous stair-step program, so I had to admit defeat and work the buttons with my fingers during each workout in attempt to simulate my normal run.

So when I learned today at work, in between doing CME (continuing medical education), finishing tough cases, getting new passwords for remote connection to the main Baptist system for sign out and plugging my CME into a national website, reading paps, doing frozens, etc. - that it might (gasp) snow, again, I surfed around for a different hotel. Even though the chances are slighter, and it is so ironic that my second planned day in Conway in three months is on the eve of possible bad weather, I decided it would be easier to get overnight child care and be in Conway than face a sleepless night worrying about a crazy, slippery interstate commute to work. I mocked my remembered thoughts from two weeks ago that I would not have to stay in a hotel for work again for at least a few years. Here I am again.

A couple of the guys made fun of me. One - a partner, two - a gross room supervisor. So what? I'll admit it. I am an OCD, white-knuckled bad weather driver who would rather face a twenty minute commute than a possible many hour one. Give me a break. Both of these guys won't even go on an airplane due to their own fears - both taking long, cross-country drives to Disney World with small children to avoid flying. We've all got fears. They are just different.

I wondered, when I ate dinner at the hotel restaurant tonight while I was reading my book (there is a restaurant here!), whether there is some sort of universal signaling for hooking up in hotels. Kind of like the ones that were published in the New York Times when that legislator, I forget his name, was caught soliciting sex from a male in an airport. Not that I would want to - random hotel tail is kind of gross to think about - but I remembered being naturally friendly to this guy in the Hampton Inn lobby a couple of weeks ago, a guy that could have easily passed as my father, and he invited me to smoke pot with him in his room. I politely declined, and steered the conversation back toward the twenty-something year-old daughter he had told me about, then quickly exited. How did I get there, in our chat? I wondered, as I walked back to my room. What did I do or say to make him think it was OK to proposition me? I resolved never to be friendly to any random strange guy, ever again, knowing it wouldn't hold very long. I can't help it. Never in hotels, I decided.

Tonight I listened in on a conversation at the bar, between two fifty plus year old strangers. Him trying to impress her with his history of travel and business savvy. Her obviously annoyed by her inability to get a word in edgewise, ultimately begging off to her room for sleep. His frustration, declining a third whiskey to head to his room. No matter how we try to disguise it, we are all just animals.

Groundhogs. I checked out the workout facilities, for the morning. I haven't run all week - all the crazy weather, valentine projects, work, and kids kept me too busy. Not to mention my treadmill at home is in the basement, where the weather is not much warmer than the below-freezing temperatures outside, at 5 a.m. The treadmills here look nice. I remembered my inano, this time. Looking forward to a nice long run before work.

Trying to Diagnose Disease - Med Student Style

Read it, over at MiM.

Simplification

Anger is self-righteous. Clean. Unadorned. It takes you where you feel you need to go, and has no apologies for the past. It strikes like a snake, without consideration for it's prey. It's just looking for it's next meal. It wears blinders, and isn't always objective. It tries to justify poor-decision making - about yourself, and regarding others around you.

Work is tough. But it is what we all need, to work on anger, and become clear-headed and focused in our decision-making. I don't care how you do it: Gurus, counseling, the church, etc. There's lots of ways to get there. Growth is inevitable. Anger doesn't go away, but it becomes more manageable.

Doubt creeps in slowly like a thick fog, masking reality. It clambers after the gauzy edges of your mind, trying to take hold and destroy you, and all of your work. It carries false promises of savior and renewal through old, worn-out paths.

Hope springs forth. It comes from faith. Faith in whatever: God, Allah, Buddha, Kali (one of my favorites from college - she is so bad ass - here's the photo credit), the human spirit, Darth Vadar, The Wizard of Oz. In the words of George Michael, "You Gotta Have Faith." Without it, you will be lost.

I just Wikipedia'd Kali, to remind myself why I was so fascinated with her in college that my Mom brought me a statue from India. I remember sitting in the Hendrix library reading obsessively about her, going beyond the required text for my world religion class. I have dragged that statue around to the many houses I have lived in. Somehow she always ends up in a prominent place in the house. Right now, she is sitting on a large console in my living room I am blogging in. Holding her human head and wearing her necklace of skulls. Mother of all the Universe. An amalgam of woman as warrior and benevolent nursing devotional mother. I smiled as I read and re-identified with her, in a whole new way, 20 years down the road. Might be fun to read some more.

John Learns to Swim

He had just turned three, this summer. I love this video. My Dad shared it with me a little over a week ago, when we were working on Sicily's Star Student poster. I love that my Dad was encouraging them to slide, not just ham it up for the camera. And me, nervous Mom, hanging out in the background in case John got in trouble. But he didn't. He finally went horizontal, and made it. He's got some good swimming genes. His grandfather, my Dad, swam alongside Mark Spitz (albeit fleetingly) on a swim scholarship to Iowa. Dad held state records in the Butterfly in Tennessee. He realized in college, on a burst of war drafts, that he needed to do something besides swimming to avoid the war - at that age, like many others around him, he was a conscientious objector. So he went to medical school, and got accepted right before he got drafted. Med school was his golden ticket out of Vietnam. Thank goodness, or I might not be alive today. Not to mention the thousands of neonates he has saved during his career.

I think what I love most about this video is Sicily at 5 being so incredibly sweet to her little brother. Making room for him on the slide, and teaching him how to mug for the video camera. She was an old veteran at the swimming, and steered clear so he could have room to get there. Brother and sister interaction isn't always kind and nurturing, which is OK, because that is how we learn to get along in the world. But it is nice to have proof that sometimes (actually a lot of the time) - they are looking out for each other.

My New Hero

I'm not really sure if it's MoNique, or the prisoner that sang at the end of this hour-long video I just watched. The song made me cry. The show made me laugh. I first saw this actress/comedian perform in Push, and I think her performance won her an Oscar. I became addicted. The raw stuff, in this video, is way better than the movie.

It's long, but it is fucking amazing. Take the time to watch, when you have it. Laugh, and cry. If you have ever been a woman, on the wrong side of a man, you will really appreciate it. And I know there are a lot of us out there.