'MAN IN A PAN'

Pathology stories, or in other words, a fictionalized account based on my experiences...

UPDATE: LMF in the comments below has made some suggestions that I think are very good, so I have made changes to, and extended, this story.

The morgue is in the basement. I get off the elevators and turn left, and then turn left again, and go down a short hallway, walls covered in white paint, gently peeling, until I reach the door. It is solid. It has a small keypad located above the door handle - I type in a set of numbers. With a click, a light on the keypad will turn from red to green and I go into a little antechamber with a sink, gray carpet, and a stainless steel table. On the table is a book, filled with pages of lined paper, on which names and numbers are listed. A door is to the right, at the end of the antechamber. The door is open and the smell of formalin greets me. The room beyond the door is large and L-shaped. In it are two tables, adjustable and stainless steel, with water 'jets' and drains. 

There are no bodies lying on the table today. One of the residents waits for me. She is in pale blue scrubs and is wearing a plastic apron, cap, gloves, gown, booties, but no mask. I put on a gown, gloves, booties over my tennis shoes, and a plastic apron. I also put on a mask because the smell of formalin is strong.

"Aren't you going to put a mask on?" I say.

She says, "I can hardly smell anything anymore, and anyway, the mask never helps. I've washed all the organs with water. They've been soaking in a bucket for hours." On one of the stainless steel tables, she has put out a large plastic tray with rows of carefully dissected organs, displayed in groups. The lungs, the heart, the pancreas, kidneys, adrenals and so on. The opened bowel is in a bucket next to the tray.

"What do you have to show me?"

"Well, I think we have a proximate cause of death." And she directs me to a part of the tray, lined with paper, that contains slices of the heart laid out so that I can see cross sections of the right and left ventricles; the upper part of the heart including the great vessels and atria are intact. One of the circles of myocardium has a pale area on the left side, a softening in the tissue, which you can feel if you palpate it, ever so gently, and this area is a yellowish color, surrounded by a rim of erythema. The left ventricle is thickened and there is evidence of old, healed infarcts (firm, white scar tissue is present as well as the more soft, yellow-red area).

"Oh, I see." I say and pick up the section of myocardium. "It looks like an MI. Take a few sections of this area in addition to the routine sections. How are the coronaries?"

"Pretty bad, the LAD is about 90% occluded, but I didn't see any thrombi."

"What about his cancer?"

"The liver is full of it," and she moves on to the liver which is at the end of the tray, enlarged, sliced like a loaf of bread, the slices resting gently, one against the other. Even on the surface, you can see that the liver is studded with white nodules.

"Anything else?" I say.

"No, the rest of the organs look pretty ok." So, we start at the beginning and look through all the organs, one by one, and make a little plan of how we will take a piece of this or that, and submit it in a plastic yellow 'cassette' so that we can examine it under the microscope.

"So, are we gonna present this case at Friday conference? It'll make a nice presentation. How many times have we presented a cancer patient with no clear cause of proximate death? I know they hate it when we say: he died of metastatic disease. 'Yeah, we know that, but why did he die on Tuesday and not Thursday?' Beats me, buddy. That's the 64 million dollar existential question, all right. Why Tuesday and not Thursday"

"Yeah. I know, I know. Anyway, I think the medicine team is coming down to review the case with us."

"Ok, I'll be there. Let me know if you need anything.

"Ok."

I move back from the table, while she takes the sections we have discussed and take off my protective gear. I wash my hands in the sink in the antechamber outside the morgue, check my pager, and poke my head back in through the open door," page me if you need anything, ok?'

"OK."

I leave the morgue, walk back down the hallway and take the elevators upstairs. Once I get to the first floor, the elevator doors open, and I see doctors in white coats, patients, and nurses walking to and fro. The hall is active; just one floor below the halls are empty and quiet, and the resident carefully puts the organs back into plastic containers filled with formalin, where they will sit and wait, surrounded by other plastic containers filled with formalin, and tables and sinks and metal trays containing instruments for dissection, all the while the clock on the wall ticking.

When the resident is done, she comes to my office.

"So, when I get the slides, I'll just look at them and write up the FAD, and give everything to you? Unless you want to double scope."

"No, not unless you want to. I don't think we'll find any surprises, but you never know. Did I tell you about a case I had in residency of sudden death in a young woman who turned out to have disseminated cryptococcus and HIV and no one even knew? Well, at least that's what her family said, and the docs sure as heck didn't know. She was admitted and before anyone could figure out what she had, she died. Weird that the ME's office didn't take the case, but they were always denying cases we thought they should do and telling us we could do them. I guess they were swamped, or something."

"No, you never told me about that case. I'm not really looking forward to the ME's office."

"No, it's not for everyone."

The phone in my office rings. It's John asking if I want to go and get coffee. Sure I say.

To the resident: "Let's go to Starbucks. I'll treat."

"No thanks, I've got to meet Dr. Kennedy to show him some cases."

So, I put on a clean white coat that hangs on a metal hanger at the back of my office door and pick up John. There is a Starbucks in the lobby of the hospital, on the first floor, far from the morgue. On the way, we talk.

"So, what you do this weekend? Did you see that play?"

"Yeah, I saw the play and then after-wards I went to a reception at the Museum school and I also saw that new Iranian movie on Sunday."

I am laughing. "John, why do you feel you have to fill up every single minute with an activity. Can't you just be still?" But even as I say that I know why he does it, and why I feel I need to do it, too. Why you fill up each minute so there is no time to think, and no time to reflect.

When we get to Starbucks, there is a line out the door as usual. The line is filled with people in scrubs, white coats, business suits, track suits, jeans, and t-shirts, leaning on crutches, carrying briefcases - a microcosm of the hospital. The line moves quickly and the kids working know the names of a lot of the customers: they get the drinks ready before you even order. They are a flirty lot, the kids who work at our little Starbucks, or is it just idle charm and a way to battle the boredom of doing the same thing over and over? Different than the banter I hear around the department, which has it's own undertones, that's for sure. If you are perceptive, you could walk into the department and on the first try figure out who is being promoted and who has tenure and who has been denied tenure, just by the banter. Or, at least, I imagine you could.

One of the baristas is an amateur photographer, a budding artist, and puts up black and white images of his travels on the wall in back, next to the signs for coffee. Each image has a little square white label underneath, describing where the picture was taken, and has a number, the price, scrawled underneath. Each day, another photo is gone and leaves a blank spot. The doctors are a buying bunch, I guess. On weekends, if my office feels too close and hemmed in, and I am tired of looking at the same four walls, I will walk across the lobby to this place and buy a coffee and just look at the pictures, or maybe I'll just stand for a few minutes, looking out the big glass plate windows. I don't have any windows in my office and I can't stand not knowing what the weather is like. So, in between looking at slides and e-mailing clinicians, and walking back to the gross room to look at a specimen, I come here.

One of the kids behind the counter has the brightest blue eyes. He looks about twelve. He knows my name (why wouldn't he? We are both often stuck here on Sundays) and will immediately start making my coffee when I walk in the door. We will chat while he does that, and I think: man. It is quiet here on Sundays. And gray and dreary, so often. I wish I lived somewhere with palm trees. So, I say this to him. He says,

"I dunno. I kind of like it here. Wouldn't mind going to New York for a while, though." And then I don't say anything, and I'll just look at the pictures some more, and then walk back to my office and finish looking at slides. I'll call John when I am done, so that we can go to a movie or a play or an art exhibit and look at other things, images beyond the colors under the microscope and the organs on the grossing benches. Paintings and actors and musicians on the stage. Instead of looking through the microscope, we will look at different images - images that tell us of life, as it is lived.

Comments

[jcwinnie]

Well, if we are supposed to guess the access code, then spelling out WENDYSCHILI probably is too many numbers, eh?

[Gratisgab]

What was your first time in there like? Your account shows that you don't really bat an eyelid in there now....it's so routine for you - the transition from the so-alive upstairs to the basement.

The organs are wrapped in paper and then put in formalin? Wonder why..? Isn't formalin a solution (a mix of formaldehyde gas and water and methyl alcohol) if I recollect correctly from my 12th standard Chemistry..?

[Ingrid]

Heh. Great story Madhu. Thanks. I've blogged it :)

P.S. I am still trying to visualise that L shaped door.

[Ingrid]

Sorry Madhu, I misread the line. The room is L-shaped, not the door. I should have read your post again before commenting. You wrote the story so well, it was like walking into the room with you. You don't miss anything. Love your observation skills and attention to detail. The contrast between floors reminds me a little of attending daytime cinema in London's West End. After a few hours of concentration in a hushed darkened environment, you step out into daylight and the bustle of daily life. Sort of like stepping from one world into another.

[LMF]

I attended a couple of autopsies recently after a long time. It always amazes me that pathologists and morgue attendants are so matter-of-fact about what they do.
A couple of suggestions for your story. One is to remove the parentheses where you explain about the family choosing to have the organs removed. Or else, make the explanation come out during the conversation with the resident ("I'm glad the family gave permission for us to keep the organs, we always get a better look that way"). The second is to add an element of reflection - if the MI had not gotten him, the cancer would have, wonder what he looked like, what his life was like, in the end this is what his life was reduced to - a few organs in a formalin bucket. I realize that some of these are cliched but may still work for the story. Or else, introduce a contrast with something mundane - for example, the pathologist goes from the morgue to eating lunch, or picking up her kid from school. For the lay person and for many doctors, it will be interesting to get a glimpse of the ease with which pathologists transition from the activity in the morgue to routine daily activities.

[MD]

jcwinnie: you are a riot. I am laughing as I type this...

gratisgab: you smartie, knowing what formalin is and all. I'd have to look it up again if a resident asked me. Sometimes I think there is only so much room in my brain and when I learn new things, the old ones fall out...

ingrid: you sweetie. I just wondered if the sentence made sense. Thanks for the bloggy blog. I love your descriptions - coming out of a silent West End theater into the crowded street. I read so many British authors that I feel I know this place that I've never actually been....

LMF: excellent suggestions. Have made changes to the story as you indicated. I think it is much better this way.

[Gratisgab]

Love the changes. I really think this is your best one to date.

[susan]

Hi, I just wanted to let you know that I couldn't stop reading this. I linked to your site and then wondered
(when the page went private yesterday) if you'd rather I didn't. Regardless, it's a great story.

[MD]

susan! Thanks so much. No, I was just playing around with the site yesterday and changing things, and when I do that I sometimes take the site 'off-line' as it were!

I am always tickled pink when anyone wants to link to this thing: somehow I can never really believe anyone is reading it....