Thursday, April 22, 2010

A Dispatch From Behind the Microscope

Hi-


I am not hunched over a murder victim at the moment, the glare from the overhead lamp revealing some important clue about the perpetrator. Yes, I am a pathologist; no, that is not how my day goes. I suppose that solving murders all day would be cool, but I also like what I do here at the hospital. I thought that I’d share my day with you so far:

8:00 a.m. Arrive at work. Talk with my associate about what’s been going on in his absence; the interesting cases, and a little hospital gossip.

8:30 a.m. An oncologist (cancer doctor) calls, and is interested in knowing about one of his patients, a person who has a colon cancer that has recurred after treatment. The surgeons just took out a portion of the colon with the new tumor; the oncologist wants to know if the tumor has spread to the lymph nodes and the tissue around the colon. I tell him that I will call him back once the pathology slides are ready for me to read, so that I can look under the microscope at the lymph nodes and the tissue and give him that answer. He’ll have to decide what to do next: whether he’ll give chemotherapy and, if so, what kind and how much.

8:40 a.m. A fax comes through with a report on special studies done on a woman’s breast cancer. The test helps determine what type of treatment the woman is going to receive, and also can help tell how aggressive the tumor will behave. I dictate a report to send to the doctors, and give them this additional information

9:00 a.m. Time to get ready to present cases at Tumor Board. I have taken pictures through the microscope of some interesting cancers; I put these pictures and additional information into a Power Point presentation for the noon conference. I also head to the textbooks to find out some additional information about the cancers that I am going to present at the conference; I like to teach the audience some stuff, occasionally.

9:45 a.m. I get to look at the first microscope slides for the day. The first case is one that we are especially interested: a gentleman with a large mass in the middle of his chest. He’s having a lot of trouble breathing, so it’s very important that we find out what’s wrong with him so that we can treat him appropriately. The surgeon removed one of his lymph nodes for us to look at. He definitely has some kind of cancer, and, from looking at the slides, it looks like he may have a very aggressive lung cancer. We are waiting for a couple more outside studies to be done to be sure, but we are pretty sure that we can tell the doctors what it is for sure today.

10:00 a.m. Making up clues for a scavenger hunt here in the lab. It’s a fun way to take a break.

10:30 a.m. A surgeon sends some tissue samples from the operating room. He needs a frozen section, which is a special procedure where we freeze the tissue, cut it, stain it, and put it on a microscope slide quickly so we can put the slide under the microscope and give him a diagnosis. This sample is a lymph node from under the arm of a woman with breast cancer. He needs to know if the tumor has spread to the lymph node; if it has, he will need to take out all of the lymph nodes in her axilla, both to find out how far the cancer has spread, and to take out as much tumor as possible. If the tumor hasn’t spread to the lymph node, he won’t have to take out all of the nodes (do an axillary dissection); this is a very good thing, because oftentimes women who have an axillary dissection have problems with swelling in the same arm after the surgery, which is very uncomfortable (lymphedema).

11:00 a.m. It’s time to look at more slides (tissue samples) under the microscope. Essentially, the pathologist is supposed to look at every piece of tissue that’s removed from a person when they have surgery. For the most part, that’s true. So I look at skin biopsies, and make sure that skin cancers have been completely removed; I look at gallbladders that were taken out because they had gallstones and caused a lot of pain in the patient; I look at pieces of fallopian tubes from women who had their tubes tied (it’s important to make sure that the doctor cut all the way through the tube, so that the woman can’t get pregnant again, which is exactly what she wants). I look at the slides, then dictate a pathology report that I will sign later.

12:00 p.m. It’s time for Tumor Board. Technically Tumor Board is called a “Multidisciplinary Cancer Conference.” In English, the primary care physicians, surgeons, radiologists, oncologists and pathologists all get together to discuss their patients with cancer. We hear their histories, look at their x-rays, and I show the pictures of their tumors, that I took from the microscope. Then all of the doctors put their heads together and decide what the best treatment for the patient is (this is all confidential, by the way; we don’t use the patient’s names). Things can get a little heated in there, by the way, when all of the doctors don’t agree on the best course of treatment.

1:00 p.m. Tumor Board is over. Whew! I’m a little nervous about public speaking, so I am always happy when I am finished. I take a break and eat pizza with the lab employees. It’s National Medical Laboratory Professional Week, so we’re celebrating and having a party. Since pathologists are lab professionals, too, I get to party too!

1:15 p.m. And on we go. We talk to a few more doctors about their patient’s pathology reports; I call a doctor for more information on his patient, which will help me make a diagnosis on his biopsy; we talk to a surgeon, whose patient is in the examination room, waiting to hear if her breast tumor is benign or malignant (it’s most likely malignant, but we have to do some additional studies to confirm that; it’s not always a matter of looking at a slide and diagnosing a cancer— oftentimes, there are a lot of grey areas between benign and malignant, and even after all of the tests, you may not be able to tell—but, of course, try to tell that to a malpractice lawyer).

2:15 p.m. And our report is back on the very sick guy with the respiratory problems: it is indeed a very aggressive lung tumor. Fortunately, chemotherapy and radiation can shrink the tumor quickly, so he may be feeling better soon. Unfortunately, the long term prognosis is not so good.

2:30 p.m. My fourth Diet Coke of the day.

2:35 p.m. Looking at a particularly hideous tumor under the microscope: a malignant blood vessel tumor. The surgeon couldn’t get the whole thing out. He took a large piece of skin and fat, but there is still tumor at the edge. It looks like he may have to go back and get more; luckily, he was very careful to mark the skin, so I can tell him exactly where he has to go back and take more tissue. Surgeons rock.

2:55 p.m. I am signing reports now, on the computer. We used to have to manually sign the typed reports, not so long ago, but now that we have electronic medical records it’s a lot better. These reports will all go onto the patients’ medical charts, and copies will be sent to their doctors.

3:00 p.m. A little down time. It’s not my turn to gross today: that’s when you look at all of the tissue that comes out of the operating room, with your eyeballs, not your microscope. You can tell a lot just by looking with your eyes, and feeling the tissue. Breast cancer will look like a crab and feels very hard when you touch it, for example. After we look, and touch, and measure, and describe the tissue in a report, we take little pieces of it that our techs will make into slides that we will look at the next day. I will take a little piece of the hard area that feels like a breast cancer; I will take a little piece of tissue from the edge of the specimen to make sure that the tumor has all been taken out. Not everything that we examine is cancer; we look at tonsils from little kids, and appendixes; we look at tissue when a woman has a miscarriage, and try to find out why her pregnancy failed.

3:30 p.m. The slides from the colon cancer are here, the one the oncologist and I discussed this morning. Her tumor has gone through the whole colon; the cancer has spread to most of the lymph nodes around the tumor. The oncologist has to figure out what to do now.

4:00 p.m. Things start winding down for the day, in my office, anyways. I finish signing my reports, check my email, check my snail mail, check my inbox, and check my list of pending cases, to see what I’m going to need to do tomorrow.

5:00 p.m. Outta here. I wear a pager, and carry the phone at all times in case a doctor has a question, or a surgeon needs us in the OR, or there is an autopsy that may need to be done. So it’s never really done here- I am still pretty much tethered to the hospital. We take turns taking call, though, so each of us can have a break, or go out of town- as per our contract, we have to be within 20 minutes of the hospital if we are needed.

I will post, eventually, on the thing that makes us pathologists notorious: The Autopsy. I think it’s not quite what most people envision, and maybe I can dispel some myths.

Tuesday, April 20, 2010

Feeding the Critters: A Poem (of sorts)

Feeding the critters


One of the dogs is eating the cat food that I threw out for the chickens.

The chickens are eating the dog food that I set out for the dog.

The cat got chased under the house, so he cannot eat anyone's food.

The other dog is eating everyone’s food- except the chicken food.

No one is eating the chicken food.

Monday, April 12, 2010

From Nowhere to Somewhere to Here

Growing up in Florida, I felt like I was from Nowhere.


I envy my husband’s family- we live in the house that his grandfather built. We can drive down the road to the little cemetery next to the little church and see great-grandparents and great aunts and great uncles.

In Florida, you were usually transplanted from New York. Or New Jersey. Or Cuba. Or, in my case, Connecticut. So I’ve always glommed onto any evidence that I was “from” somewhere, where generations of my family once lived in the same place, that there was some place in the world where I originally “came from.”

When I was a kid, I would tell people that I was “Three quarters German and one-quarter English.” I believe that this was the simplified view that was explained to me, because the truth is somewhat more complex. Like this:

“Well, on your Dad’s side, his dad’s family traces back to one little tiny part of pre-Revolutionary Maine— a big huge branch of the family tree. His mom’s family emigrated from Germany and Austria a few generations ago.

And on your Mom’s side, a big chunk of her dad’s family is from New York State, from way back, along with a few representatives from Germany (as well as an alleged member of the Seneca tribe). On her mom’s side, there’s a contingent from the town of Czervenka, which used to be part of the empire of Austria-Hungary and subsequently was absorbed into Yugoslavia and then Serbia (I think) and appears now to be located somewhere in the Czech Republic. But the Arvays and the Roths- that side of the family- identify themselves as Hungarian, not Austro-Hungarian or Yugoslavian or Serbian or Czechoslovakian.”

I can see why they just told me that I was three-quarters German and one-quarter English.

This week, containing two of the alleged birthdays of my late Grandma (the birth certificate says one day; the baptismal record lists another), I thought that I’d remember her experience.

Like I have done many times before, I went back to Ellis Island’s website and searched for my grandmother and her family: Elizabeth Aranka Roth. And, like the other times before, I found her name in the database and pulled it up. There she is, her name typed on the S.S. Rochambeau’s manifest: Roth, Elizabeth. Age 6. Last residence: Cervenke, Yougo-Slavia. Traveling with her parents, August and Aranka, sister Mary and brothers August and Willy, whose name was somehow entered as “Nigly”. A big rubber stamp over the family, with the words “admitted.” It was a close call, I have been told: sister Mary apparently was about to be quarantined in the infirmary with some unknown ailment; my grandma rubbed off the “X” chalked on Mary’s coat, the one that would keep her from being admitted to the country, and off they all went. That’s how the story goes, anyways.

It’s gratifying to know that I’m not from Nowhere- I’m from lots of Somewheres. And to see the evidence there, in black and white, on a ship’s manifest, in July 1920, of that part of my family coming to America from Somewhere—it makes me happy.

My kids love their Hungarian heritage- it makes them feel exotic. They have done their research, and probably know more about Hungarian culture than I do. For Lib’s school cookbook- you know, the ones where every child contributes a recipe that reflects their family’s heritage- she wrote a recipe for Ischl cookies, a Hungarian sandwich cookie filled with apricot jam and covered with chocolate. I laughed when I saw it. In between the recipes for peas and rice, and lasagna, was her contribution. It was three pages long.

I plan on visiting all of the Somewheres. Our first stop will be this summer, to that teeny tiny part of Maine which produced my father’s family. We’ll visit New York, and see the family that still lives there. Someday, to Germany, to Köln. And, hopefully, to Czervenka, in whatever country it will be in the future. And, Ellis Island, of course. All Somewheres became Here at Ellis Island. Because that’s probably the most important thing: you may think that you’re from Nowhere, or you may have come from Somewhere, but we all end up from Here.

I wish people would remember that: with bigotry and prejudice and anti-choose-your-own-group-to-hate, we still all from Here, all of us. And I know that Grandma, who I'm thinking about today, was damned proud to be Here.

Thursday, April 8, 2010

The Great Miami Tornado of 1997

I was a fourth year medical student at the University of Miami. We lived on the hospital campus, on the top floor of a large pink high rise which housed numerous hospital staff and medical students. It was convenient: it only took me five minutes to walk to the hospital for my clinical rotations. There was a grocery store and a restaurant. The building also housed my one year old daughter’s day care center. It had a swimming pool on the roof, and stunning views of the Miami skyline and Biscayne Bay behind it.


I had finished my internal medicine rotation for the day: my patients were all signed out to the resident on call. I came back to the apartment for a few minutes, and kicked back in the easy chair while I waited for Libby to finish her nap, and I could pick her up. I flipped the television over to the afternoon soap operas.

All My Children was unexpectedly pre-empted by a special report. The station was broadcasting the view from the TowerCam at the top of the SunTrust Tower, downtown on Brickell Avenue. High-rise office buildings were in the picture- as well as a large black funnel cloud. The funnel stretched down to the street below, and was as tall as the high-rises which it stood next to.

It had to be some kind of joke. It looked like those stupid emails that get forwarded around the internet: giant tornadoes threatening to engulf some weird place or another. You know the ones I’m talking about: the ones with the heading “Unbelievable!!! You have to see this!!!”

But this was indeed a live picture from downtown Miami, and that was indeed a tornado. It was not a little wispy funnel like we sometimes see associated with our summer thunderstorms, nor was it a waterspout, spinning harmlessly offshore. This was a tornado which most definitely did not belong in downtown Miami, on a fairly sunny day, no less. If it were in Oklahoma, I could believe what I was seeing. But this was almost beyond comprehension.

Anticipating our disbelief, the weatherman came on the air. “Ladies and gentlemen, this is for real. This is an extremely dangerous situation. You must take cover immediately!”

I went cold. Being fascinated by tornadoes in books and television shows was one thing; having a real tornado actually bearing down on you was quite another. I was terrified.

Even though, from my study of tornadoes, the last thing you want to do is to run outside and check it out, I headed down the hall to the fire escape balcony, and looked over to the east. There it was, just like on the TowerCam. It was quiet outside, but I thought that I heard a roar in the distance. I was frozen in place for a moment.

But then I thought of Libby and all of her little baby friends, downstairs, napping next to a wall of plate glass windows.

I completely panicked. I was eighteen floors above her, and I needed to get there. In my state of panic, I decided that the elevator would be too risky- what if the power suddenly went out and I couldn’t get down there?

I flew eighteen floors down the fire escape stairs.

I am sure the teachers thought I was a little whacked when I burst into the school and told them that there was a tornado heading toward us, but still agreed to come with me and to take all of the babies into the ground floor hallway of the apartment building, away from the plate glass windows of the day care.

We stayed there for a few minutes, waiting. Someone finally told us that the threat had passed, that the tornado had crossed the bay and was now moving over the hotels on Collins Avenue. In reality, the tornado was actually moving away from us rather than towards us, but I was too scared to stop and decide which way it was moving at the time. I felt like an idiot when I heard that, but I still think that I would have done the same thing over again. We brought the babies back to the school, and my daughter and I took the elevator home.

Later, we learned that the tornado appeared out of a fairly unassuming thunderstorm west of Little Havana. It pulled a few roofs off some old apartment buildings near Calle Ocho, and proceeded downtown, where it basically scared the pants off the corporate executives in their 23rd floor offices. It caused surprisingly little damage to the skyscrapers, and only caused minor damage, flipping a single car, I believe, once it crossed the bay.

Needless to say, the story made the national news. The picture was on the cover of The Miami Herald the next morning.


The 1997 Miami tornado- from the Miami Herald (our apartment was off to the left of this picture, more toward the northwest)

The information for this post, by the way, was a little hard to find. If this had happened in 2010, there would have been innumerable pictures, videos and eyewitness reports submitted instantly to The Weather Channel, by tornado junkies like me. But in honor of Tornado Week, I thought I’d share this story.

Tuesday, April 6, 2010

Confessions of a Tornado Junkie

It is finally Tornado Week on The Weather Channel. I went home last night and spent a couple of hours in front of the TV, watching Storm Stories: episodes about storm chasers, about tour groups which specialize in following severe weather, and about people with way too close encounters with tornadoes.

Confession: I am a secret tornado junkie.

I watch The Weather Channel especially for the severe weather updates.

I secretly long to be a NOAA spotter.

I know the Storm Prediction Center’s web address by heart (http://spc.noaa.gov/ ). I actually read the Mesoscale Discussions on the website.

I can tell you the Latin name of the strange clouds that sometimes precede a tornado (cumulonimbus mammatus).

I can tell you that the southeast corner of a thunderstorm is most likely to produce tornadoes.

I am familiar with both the Fugita and Enhanced Fugita Scale.

I can spot a hook echo on Doppler radar.

I actually own a weather radio.

I realize that this obsession is a little weird. I didn’t grow up in a tornado-plagued part of the country. Connecticut isn’t exactly in Tornado Alley. I am both terrified and fascinated by tornadoes.

I blame it on The Wizard of Oz, which was broadcast on network television at least once a year when I was a kid. Forget the flying monkeys; it was that tornado in the black and white portion of the movie, at the beginning, that would send me scurrying to hide behind the couch in the living room. I would have nightmares in which, like Dorothy, I struggled to get somewhere safe, away from the twister, but couldn’t (I still occasionally have that nightmare. I’ve researched the hidden implications of that dream scenario- more on that in a later post).

In elementary school, I checked out the same book over and over: Hurricanes and Tornadoes. I skipped past the hurricane descriptions and pictures- those were boring. I had already been through a hurricane: my neighborhood was struck by what my parents said was the tail end of Hurricane Belle. I imagined it as some kind of big dragon with a big tail that whipped around and smacked North Haven. It uprooted a tiny sapling on the side of the house, but that was about it (Sixteen years later, my encounter with Hurricane Andrew was not so benign).

My real interest, in Hurricanes and Tornadoes, were the black and white plates in the center of the book. I pored over the pictures of the monster funnels and of their aftermath: two by fours driven through trees, upside down houses and cars. I imagined my own house, flattened to bits.

Florida, where we relocated in the late 1970s, is more of a hotbed for tornado activity. Actually, it’s pretty much right up there with the Midwest in the number and intensity of tornadoes. As the years went by, I became a little less frightened of bad weather. Tornado watches and warnings were common, but I only witnessed a rare, harmless funnel cloud or two, F0 storms, and a few benign waterspouts.

I saw my first real tornado at the age of 27, in a very unlikely place: downtown Miami, FL. The infamous Miami Tornado of 1997.

Friday, April 2, 2010

You Never Forget Your First...

…Mile.


I got to hand out medals at the 1 mile Fun Run that we held in conjunction with the Swamp Run last Saturday. Although only the kids were supposed get medals, the run is for both kids and adults. And, honestly, I did hand adults out medals, too.

The race starts out with dozens of kids and a handful of adults, paper numbers pinned on their shirts. When the horn blares, the kids take off like a bunch of Kenyan marathoners, except that they’re hollering and wearing shoes. The cacophony of running shoes and basketball shoes and the occasional pair of flip flops striking the ground is deafening. And then they’re gone, out of sight, and it’s quiet. We stand under the finish line clock as it ticks away, and we wait.

About six minutes later, the first boy and girl fly across the finish line- invariably some cross-country stars from the local middle school. They run off to the side of the road and hurl, and then we wait some more.

Then more runners start to trickle in. The kids seem to have employed various race strategies-- although most strategies seem to consist of running as fast as you can until you are unable to breathe, walking, catching your breath, and then taking off running as fast as you can again. This strategy seems to work remarkably well for the younger set- they have no concerns about pacing or finishing kicks. They just haul ass down the road.

Here comes a girl in a skirt and a pair of green flip-flops. And a little guy in a huge white t-shirt who hasn’t stopped smiling yet—I call dibs on him. I want to give him his medal, because he’s so freaking adorable.

Then here come the kids walking across the finish line, exhausted, unable to breathe, and still trying to smile when they take their medal. Then one or two with skinned knees from when they tangled arms and legs with the other kids at the start line.

Then here come the youngest “runners” in the back of the pack: holding Mommy’s hand, getting carried on Daddy’s shoulders, and riding in strollers. Everyone gets medals. We all love medals.

In the midst of all of this action are the adults running the Fun Run alongside the kids. Some of them are out there, encouraging and having fun with their kids. But, admixed among the competitors are some grownups for which the Fun Run is an epic event. They are running their first mile, ever. They may have done the distance at the track, or on the treadmill, but this is really their first “official” mile. They are going to run one mile, in public, without stopping.

They wake up in the morning, nervous. They’re afraid they’re not going to be able to make it. They’re afraid they’re going to have to stop and walk. They’re afraid that people are going to make fun of them for running in a “kiddie” race and they’re afraid, God forbid, of being the last person to cross the finish line.

So, when they do cross that line, I make sure that they get a medal. Handing out those medals makes me the happiest. These folks just became runners.

“What turns a jogger into a runner? A race number.” You’re no longer just “working out”, or “exercising”. You’re not just trying to get into shape or to lose weight. You are a runner.

Over a decade later, and after four Ironman Triathlon finishes, Allen still treasures his One Mile Fun Run ribbon- he keeps it near the running trophies and marathon medals and Ironman paraphernalia.

I never entered a Fun Run, or got a medal. But I can still tell you the exact date: January 20, 2002. I was wearing a blue and grey pair of New Balance trail shoes that fit horribly, but were my first real pair of running shoes. I ran up and down the streets in my neighborhood until my pedometer read one mile. And then I stopped and marveled. I had run an entire mile without stopping. No finish line, no medal- but I couldn’t have been happier. So I turned the corner and ran another mile. And I never stopped running.

Congrats to all of the Fun Run finishers. We’ll see you at the start line soon.