Autumnal histopathology

Autumnal fruit and fallen leaves bring to mind histopathologic specimens glimpsed under the microscope or in the anatomy lab.

Images (left to right, beginning in top row):

(1) Peripheral blood smear depicting red and white corpuscles
(2) Anemia
(3) Leukemia
(4) Cerebral cortex neurons
(5) Right mainstem bronchus, bronchioles and alveoli
(6) Left lateral inferior wall myocardial infarction
(7) Molecules of oxytocin
(8) Seminoma
(9) Deoxygenated blood; methemoglobinemia
(10) Shistocytosis; crenated red blood cells

The Supplicant

I sit at priestly table
Imbibing an early lunch
Of chicken soup and bread,
A heel now bruised, unleavened,
Remnant of last night’s supper.
On tiny tapping pads
The supplicant approaches,
Stands beside my chair,
Eyes turned toward heaven—
The smell of chicken soup.
The supplicant rises to place
Both paws, crossed, on my thigh,
Penitent eyes pleading
Forgiveness and a crumb.
Reluctantly, I break the bread,
Dip a morsel in the broth
Then hold it out before the nose.
This offering of bread and soup
Is measured in one gulp.
The supplicant drops down
On all four paws again;
Pink tongue licks her muzzle.
Renewed, patiently she waits.
“Only one host per communicant,”
I liturgically intone.
Nonplussed, she trots to
The far end of the table
Seeking sustenance from
Another priest.

10/25/12

Digital medicine: Returning to radical medical practice

The era of digital medicine has largely passed us by, leaving us firmly entrenched in the era of digital medicine.

Yes, I composed that sentence properly; I meant what I wrote.

In the first instance, I used the word digital in reference to its radical or root meaning, “of or pertaining to the digits”—in other words, the phalanges or fingers. In the second instance—well, more about that in a moment. more»

Interested readers can examine my thoughts on this issue in my latest Musings blog post newly published in the Journal of the American Academy of Physician Assistants.

It never was about the bike

Thirty years ago, after my knees gave out from pounding the distance running circuit, I took up cycling for exercise.

A neighbor offered me a French racing bike, which he no longer had any use for. It wasn’t a top of the line model, but it handled well. It wasn’t long before I had built up a regimen of short daily rides, culminating with longer treks on weekends, if the weather held out.

Around that time I discovered one of Sam Abt’s early books about the Tour de France on the shelf at the public library and devoured it over the course of a rainy weekend. After that I started to follow the Tour every July, faithfully combing through Abt’s columns in the International Herald Tribune and the New York Times. These cyclists were the inspiration I needed to keep going.

Years passed. My son usurped the bike, and I in turn took up lap swimming for regular exercise.

I learned how to swim largely from my father, who had competed in the pool as an undergraduate. Although my skills were rudimentary, I was able to hone them with the help of the members of a local swim group, most of whom had been competitive swimmers in high school and college.

After weeks of regular training, I was able to keep up with the pack, completing workouts of 3500 to 4000 yards three days a week.

One year one of the fellows in the group put forth my name as the most improved swimmer. Although it was a minor laudatory gesture, I appreciated the sentiment.

Sometime after that, this same fellow developed acute myelogenous leukemia. I made it a point to visit him regularly whenever he was admitted to the cancer ward. One time I bought him a small matchbox car from the hospital gift shop, which he kept on his bedside table. And after I read Lance Armstrong’s book It’s Not About the Bike, I inscribed a copy for my friend as a gift.

Swimming, like running and cycling, demands a rigorous and disciplined training regimen. So does fighting cancer. Through tremendous odds Armstrong fought his own breed of the disease. In part, by slipstreaming along with Armstrong’s inspiring story, so did my friend.

My friend’s battle lasted 19 months before he succumbed to graft versus host disease, a consequence of a second bone marrow transplant. This fall it will be ten years since he’s been gone.

This week, as I read the latest accusations of Armstrong’s doping during most of his cycling career, I reflected on how appreciative I am that my friend never lived to see the day when one of our heroes fell from grace.

Lance Armstrong photographed by Mike Hutchings/Reuters

Humane Medicine — Ebb and flow

Weatherbeaten by Winslow Homer

It’s always difficult to hand a new patient a disturbing diagnosis, or even to suggest that there might be something amiss. more»

Interested readers can now access my latest Humane Medicine column — Ebb and flow: Murmurings that are more than sweet nothings — recently published in the Journal of the American Academy of Physician Assistants.

Elective surgery isn’t what it used to be

Elective surgery isn’t what it used to be. Before the advent of modern anesthesia and antibiotics, amputation was the only way to effectively treat a gangrenous limb. The successful surgeon had to be quick to slice through the skin and muscles just proximal to devitalized tissue before sawing through the bone and ligating the bleeding vessels. The best surgeons could perform this procedure in less than a minute, some in under 30 seconds. Pity the poor patient, who many times, despite the alcohol imbibed beforehand, would have fled the operating theatre in dread, postponing the inevitable for another day.

Such thoughts run through my head as I sit in the small cubicle, clothed in a Johnny top and scrub bottoms. Already an aide has taken my vital signs and given me instructions on what clothing to remove and where to put it. I notice that my systolic blood pressure is up a tad, probably due to my anxiety about facing the anesthesia and the surgeon’s knife.

This would not have been the case four years ago when I lay acutely injured on a gurney, waiting to be wheeled into the operating suite. Then, I had little choice; the bad fracture of my right ankle had to be fixed with screws and a steel plate. Today’s procedure — removing the plate and the set of screws — is purely elective in the sense that I have chosen to have it done. For good reason, mind you — the screws had begun backing out of the bone and became more painful in the process. I could no longer tolerate the footwear that was once the staple for my wilderness excursions. If all goes well, after the hardware is removed I should be able to wear my high-topped hiking boots once again.

A nurse enters the cubicle with a clipboard bearing partially completed forms in triplicate for my review and signature. I have already stowed my eyeglasses with my clothing, so she reads me the questions instead and I answer in kind. I sign at the bottom of the form by wrote; to my hyperopic eyes the pen strokes are little more than blurred scribble.

I walk to the bathroom across the hall while the nurse procures a basket bearing IV intracaths, gauze squares, alcohol wipes and surgical tape. When I return she fastens a rubber tourniquet around my upper arm. The vein pops up; she inserts the catheter and secures it with tape.

Next the OR charge nurse stops by to introduce herself; shortly afterwards, the anesthesiologist makes an appearance to brief me on the procedure of putting me to sleep.

The phrase strikes me a bit odd: we put dogs to sleep, not people. I should say that we put dogs down, not asleep; although that is how my father referred to it when he told me that he had taken our dog to the vet during the week I was away at camp that boyhood summer.

My surgeon arrives, bearing a small bag, looking rather sleepy. He smiles when I remark that I recognize him without my eyeglasses in place. “I need to sign your right leg, even though we both know that that’s the ankle we are operating on — standard hospital procedure, you know.” I know. I would rather have it done that way, to play by the rules instead of waking up to face an undesirable glitch.

The charge nurse returns and escorts me down to the operating suite. She helps me onto the table. I lay my head back onto the purple foam donut and stretch out my arms. Someone clips a pulse oximeter clothespin on my left index finger and wraps a blood pressure cuff around my arm. One or two other people introduce themselves. I nod and smile, then stare up at the cluster of tiny dots on the ceiling. Suddenly, my thoughts vanish; all trace of consciousness is wiped out.

I wake up in a different place. The people who attended me in the operating suite have disappeared. New people have taken their place. One woman approaches me and speaks my name. She asks how I’m doing, if I’m in any pain. Apart from a small twinge of discomfort on the outside of my right ankle, everything seems fine. Only the dull early morning headache remains.

Soon I’m back in my clothing again, hobbling toward the bathroom to empty my bladder. The nurse walks by my side. She escorts me back to my cubicle and goes over the final discharge instructions. “Your ride should be here shortly,” she says. “Do you have any questions?”

“Is there coffee?”

My daughter is waiting for me just outside the doorway in the parking garage. It is an uneventful drive home in the rain. She has brought the crutches, the same set that I used while recuperating from the original injury four years ago.

Using crutches is just like riding a bicycle, I muse as I hobble up the driveway through the wet fallen leaves. Once you learn, you never forget.

“Ankle Hardware” 2012 © Brian T. Maurer