23 May 2011

Not everything in pathology is dead

That is, perhaps, what I’ve learned in two weeks. I haven’t been in what’s popularly thought of as pathology – no dead bodies, no tissue specimens. Vials and vials and vials of things, petri dishes grown from people, blood and bone marrow biopsies.

Parts of people, taken out, to see if they are still alive.

(or, parts of people, taken out, to analyze and see exactly what’s in them and what they’re doing) .
It still feels like an inexact science, in some ways. Microbiology is detective work – but this isn’t what they show on House or CSI; it takes days and days to grow. (Then, clinically, what’s the point? In the immediate. . . there isn’t one. Patient is sick, patient looks “toxic”, you treat as if she’s bacteremic.* (Has bacteremia) . Septic. (Has sepsis) .

Rat glioma, nuclei

*Bacteremic means bacteria within the blood stream, meaning they’ve escaped the confines of wherever the initial infection was. Bacteria aren’t supposed to be there, nor fungi. Viruses can be – but this should be more antibodies to than antigens from. Once bacteria escape – and this includes the good, normal kind who are supposed to live in the intestine – they wreak havoc. This becomes sepsis. (Interesting word relationship/derivation to “septic tank.” In medicine, sepsis means shock. It’s a terrifying emergency.)

Then, septic. The body can attack infections where they are. But if the infection is in the blood, it is, by definition, swiftly moving everywhere. What to attack? Itself. The immune response is upregulated and storming through the blood vessels. The blood vessels, in response, are dilating like mad – and things are leaking out – and blood is rushing quickly, quickly, quickly, but there’s not enough pressure and it’s not actually working – and the body is attacking itself because the toxins are spreading, spreading . It’s the one kind of shock where the patient is warm, flushed (with other types, pale and cold) . The blood is moving everywhere but nothing is working.

So the clinical lab scientist in her jeans and sequined head band, mechanically incubating bottles with blood and other bodily fluids (anything that might grow something, whatever might be the initial source of the infection) – is looking for sepsis. A light goes off on the machine if something grows (so much is automated) . But then that gets plated onto various types of agar, separated, separated, then checked by gram stain and color of growth and look of colonies (shiny? mucoid? smell like fruit?) to figure out what the actual organism is and how to treat it.

Meanwhile, the medicine team is throwing every sort of antibacterial, antifungal, antiviral at the patient; anything, anything that might be suspect. When the organism comes back – after days – they can narrow the treatment (and this part is important, too) .

The question becomes, then, how does the patient look.

The pathologists don’t know. I appreciate it when they ask. Pathology rounds – the micro kind, anyway – consisted of petri dishes. Walking around to different stations, looking at them under the microscope – what’s growing, how do we know. Is this actually making the patient sick. And that’s why the ID (Infectious Disease) team is there, to answer. They know the patients.

There are things like the infection control meeting – patient with suspected bacterial meningitis (emergency, fatal w/in 3 days, often. Highly, highly infectious/transmissible. And, like plague, easily treatable with antibiotics. ) . The issue was that the six firefighters who had taken her into the hospital, stuporous, on the ground, hadn’t worn masks. So were they exposed? Then their families? . . . and everyone else in possible contact.

It’s problematic (maybe) that I want to go into ID – to be a “global fund doctor” – HIV, malaria, TB, on to yellow fever, dengue, dysentery all causes, filarial, schisto. . . etc. But I don’t want to be stuck in the lab with the petri dishes at any point.

Rat glioma, nuclei (blue) and mitochondria (red)


Pathology gives the answers. We trust them. Particularly for oncology, they’re the ones who say “cancer” or “not cancer”, and, if cancer, what kind, which dictates what treatment. How bad is the cancer. How far does it spread. Much of this is directly based on what the cells look like – and, yes, there are some biochemical markers and non-subjective measures of this, now.
Take prostate cancer, though – the grade of cancer, related to prognosis given, is 100% based on what the cells from the biopsy look like – that plus how far it’s spread, where else it might be in the body. Radiology, pathology, and surgery will tell you that.
And medicine is left with the patient, and with treating the patient.

“It’s a good lifestyle,” they say. Pathology’s not officially part of the ROA(U)D to happiness – radiology, ophthalmology, anesthesia, (urology), dermatology. The specialties that are very, very lucrative, particularly compared to work both in residency and in practice. (For urology, this is generally true in practice, but residency is similar to a general surgery residency) . And there are people who pick a specialty based on those letters. ER counts sometimes as “good lifestyle” because it’s shift work, you don’t have work to do at home or follow-ups on patients, and you can cluster your shifts and then have other weeks to do other things that are important to you. (It doesn’t match the lucrative or less work parts, though) . Pathology – can be very lucrative (one resident remarked to me that his goal was “to make as much money as possible for as little work as possible.” I had nothing to say to that. I only wondered what he’d actually said in his interviews) . Psychiatry is sometimes grouped with these. “Lifestyle,” people tell me, “lifestyle,” as if that has anything to do with anything, for me, in choosing what to do. (Medicine, out-patient medicine, county hospital or international NGO, + public health, is essentially the opposite of all of the “positive” things above. Except that I love what I’m doing. That’s the lifestyle bit) . With other interests (writing, public health work. . .) it would certainly be convenient to like a field with more straightforward hours that allowed more room for that – emergency medicine, for instance.

There was a night I realized that, without a doubt, I’m not a ER doctor* (besides the medicine bits, ER doctors are probably the coolest specialty, and most of them own kayaks and/or go rock climbing a lot) .

* We speak of this in terms of personalities, too. “Finding your people.” “Who are your people.” Mine happen to be internal medicine HIV docs, or medicine working in public health/county settings.

Rhumsiki, Cameroun

Tomorrow, I start on the palliative care service. It’s mostly (as I understand) for patients who have chosen to not pursue further aggressive medical care. There are chaplains (specific and non-religious in bent; whatever the patient wants), medical doctors (pain of all sorts), social workers (perhaps) – we’ll see. It’s not something I could do as a specialty. I have to balance death – and many of them do; not many could do this all day, every day. Pathology has weighed in and no longer matters. Or that’s what mattered in the first place. Or they’re the ones who made the patient (person. person) decide to continue* with treatment – or not.
*I wrote “fighting” and erased it. I try, conscientiously, to avoid words that are negative metaphors in medicine. Medicine as war. Disease as enemy. Is the word “survivor” empowering? Does it necessitate the winning of a war? Is a victim someone who was weaker, or didn’t fight back enough, or let the guys on the street with guns take his wallet because, in the end, it wasn’t worth what the consequences might be otherwise? The chance? That means, also… women who (here and in other countries) get blamed, explicitly or implicitly, in part, for attacks. Can they be compared to smokers, then, who get lung cancer? (and heart disease, etc). IV drug users for hepatitis C, alcoholics for liver failure? (These are ethical issues that come up in transplant committees. We had a discussion about this in class, a few years ago. There were many differing opinions). Former alcoholic who needs a liver versus person with a genetic disease that destroyed their liver. Perpetrator versus victim. Same thing for HIV transmitted from mothers and blood transfusions, versus sex and drugs. Victim. Perpetrator. Same disease. I don’t think the metaphor is fair to either side.

Susan Sontag’s Illness as Metaphor, and the updated AIDS and its Metaphors. Every generation, the culpable disease changes. It was tuberculosis. And then cancer – people were thought to be at fault for that, somehow. It was shameful. And now AIDS is becoming somewhat more normalized – or maybe that’s my socialist working-in-county-hospital-in-liberal-city perspective. What next, then. Meanwhile, for the next two weeks, we are told to – not – think as much about death and how that will be, or about delaying it, but about what the rest of the life should look like. To that end, and to learning it.


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