Toads-in-the-Hole

The blood bank nurse stuck her head into my office (which is clearly a space that was formerly a closet) and said, "Joel, could you come here and look at Ed for me?"

The person in question was not dead (nor is Ed his real name), nor was he a small piece of tissue or body part. Rather, he was an elderly man, conscious, and clearly trying not to puke. Why, then, was I, pathologist-in-training, being asked to look at him?

We pathologists generally do not rub up against the patients that we serve. Occasionally we'll field an angry phone call from a patient about an overdue test result, or see an anesthetized patient's surgical opening so that the surgeon can explain what information they want before removing the organ in question. There are some pathologists who regularly see patients in order to sample their tissues, but the majority of pathologists are safely sequestered in dimly-lit offices, surrounded by books, stereo equipment, and espresso makers, calmly and quietly contemplating the Mysteries of Human Disease.

But I am on blood bank this month, and so my life is different. My pager bleeps urgently several times an hour from 7:30 a.m. to 5:00 p.m., triggered by clinicians baying for my blood (not my personal blood, though I'm sure they'd take it in a pinch). I'm summoned by clinical teams to round on patients on the ICU, and I go to patients' bedsides in order to remove their ill humors. In a lot of ways, it's disturbingly similar to my dimly-remembered former life as a medical student. I also am in charge of keeping an eye on people who come into our blood bank to donate, and that's where Ed came in.

Ed is in his late 80s, a retired professor, who comes to our blood bank as often as he is allowed in order to donate platelets. A donor is able to safely donate platelets every four weeks (as compared to eight weeks for red blood cells), and Ed usually appears exactly twenty eight days after his last donation. He donates platelets because he knows that we're always short on platelets (we have to store them at room temperature, so they only last five days [as compared to red blood cells, which are kept refrigerated for 42 days]). He also knows that we're less likely to get platelets from donors because it takes longer to donate. I have a personal stake in keeping our platelet supply healthy, because 90% of the fights I have with clinicians involve them wanting an unreasonable amount of platelets (from my point of view) and my ignoring their patients' clearly defined critical need for platelets (from their point of view).

Someone had told Ed all this, and he made a point of giving us what we most needed. Today, however, things weren't going well. He was pale, clammy, and felt nauseated. The nurse checked his blood pressure: 80/50. I pointed at the table next to his bed. "Hey Ed," I said, using my you-must-not-be-about-to-die-because-otherwise-I-wouldn't-sound-so-cheerful voice, "it looks like you gave us a little extra today." Instead of the usual unit of platelets, there was a unit of platelets and two bags of plasma. Most donors would handle the loss of 700 mililiters of fluid without trouble, but Ed had clearly given too much.

We gave him a liter of saline, and he perked up right away. My pager snarled at me, so I went back to my closet to catch up on the various arguments I was having with clinicians. A little later, the nurse appeared at my door again. "Could you have a little talk with Ed? He's almost 90 years old now, could you maybe let him know that he's done enough for us? We think he's a little too frail to keep this up."

I always do everything my nurses tell me, so I gamely sat down next to Ed's bed and, by way of broaching a painful subject, checked his pulse. "How are you feeling, now?" I asked.

He grinned at me and pointed at the I.V. the nurse was disconnecting from his arm. "Good! That stuff you gave me hit the spot."

"Well that's just salt water. What we took from you is a lot more useful. I'll trade you saline for platelets all day long."

Shaking his fist gleefully, he said, "I've got more to give. You'll see me in four weeks!"

He'd pre-empted me, now. I was hoping he'd still feel a little crappy. His enthusiasm made turning him away harder. Maybe he had a newly diagnosed heart condition or something. If so, I could make this whole thing his doctor's fault. "I was going to ask you about that. Are you regularly seeing a doctor for anything?"

He twinkled at me. "Nope! I'm the picture of health."

"And have you ever had something like this happen to you when you donated in the past?"

"Nope! I'm not sure what happened today."

I gestured at the plasma. "Well, we accidentally took a little more than you're used to."

He laughed, and pointed at the nurse. "Well quit it! I almost puked on Nurse Barb over there!"

Alright, best just to say it. Ugh, I felt terrible about the whole thing. So I weasled a little. "Ed, this is a hard question for me to ask, but do you think that maybe you should stop donating? Maybe what we had today was a warning."

He sat up a little straighter and looked me in the eye. "No, I don't agree with that. You get to be my age, well, it makes me feel really good to come here and give you people platelets. I know how much you need them, and I like to think about the good they're doing. I'd feel pretty useless if I couldn't come here and give, and when I sit down to eat, I like to think about how I'm going to be coming here to help in a few weeks, and how all the time, whether I'm thinking about it or not, I'm making more platelets for you, here."

I raised my hands, supplicating. "We certainly appreciate your gifts, and you've been so generous, I just want you to think about your own health. Maybe talk it over with your wife."

He barely let me finish, and his tone made me feel that he'd keep on saying the same thing, forever. "It makes me feel really good to come here and give, and you can count on seeing me in the new year, and I really hope for peace in the new year. I was never for this war in Iraq and I said so from the get-go..."

And we talked for a few minutes about the problems in the Middle East, and about history, and about what we hoped would happen in the future. And then he got up and, very carefully, walked out of the blood bank. Whenever he saw someone he knew on the way out he said, "See you next month!" And every person replied, "Merry Christmas, Ed!"

Posted by Joel at 4:07 PM | Permalink | Comments (5)

"A Story in Every Bag" proclaims the logo on the side of a bag of Old Dutch Crunch Original Kettle Chips, and they're absolutely right. Here, for example, is the story of our last bag of Old Dutch Crunch Original Kettle Chips:

One night, at around 9:30, I felt a little hungry. Aimee and Adelaide were already asleep, and I went into the kitchen looking for a snack. I found a half-full bag of Old Dutch Crunch Original Kettle Chips, and wandered back to the couch to have a few chips and read The Dark Valley, Piers Brendon's account of the 1930s. I looked up a little later and saw that it was 10:30, and realized that I'd eaten the whole damn bag of chips. When I woke up the next morning, my mouth really hurt.

Posted by Joel at 2:26 PM | Permalink | Comments (3)

One afternoon when I was working in the emergency room as a third year medical student, a little family checked into our facility. The group consisted of a woman in her early thirties, a guy in his late thirties, and an elementary-school-age girl, who was in tears. This was during the summer, and everyone was dressed for fun at the waterfront.
"Burned by a barbecue?" I wondered to myself. We'd already had a kid with that earlier in the day. "Or maybe a bee sting."

The nurse approached with the girl's chart. I raised my eyebrows enquiringly. She said, with a dismissive toss of her head, "He ran over her with his boat."

The story I was given was something like the following. The guy was not the father. Rather, he was a newish boyfriend to the mother, and, as a way to get to know the daughter, took them out on the lake with his speedboat. Hooray for mom's cool boyfriend!

Unfortunately, the adults had allowed the little girl crawl out on the prow of the boat, and she'd fallen forward off the front of it and been run over. She was a good swimmer and had immediately bobbed, spluttering and crying, to the surface and been easily picked up. Still, they thought it would be best to bring her in to get checked.

I felt bad for everyone involved, but especially for the guy. He just didn't know how to act in the situation. I could clearly see his inner debate. Should he be really apologetic? Or actively comforting the still-sobbing child (who, it seemed to me, was putting a little effort into her sobs)? Or trying to jolly everyone through the situation? The mom just looked stricken.

I checked the girl over, and she seemed okay, just a little battered. The ER attending physician ordered X-rays. As we looked at them together I focused on the bones of her sinuses (And this is how I always am looking at X-rays: "Does that bit look funny? Or maybe that bit? Shoot, the whole thing's just a bunch of gray smudges."). The attending pointed out the silhouette of the little girl's face, "Look at her lower lip sticking out." (My mind raced. Was a protuberant lower lip a sign for something? Henoch-Schonline purpura? Kawasaki disease?) I wisely kept silent, so he continued, "She's totally pouting!" And then he pretended to be her, "Aw man, I got run over by a boat!" I remember this vividly because it was my first day working with him. He is a very good doctor.

When we went back to the room to tell everyone that the patient's X-ray looked fine, there was a cop there. Turns out it's against the law to let a child ride on the prow of a speedboat, and one of the nurses knew this and had called the police. (On the few occasions when the police were called to the ER, it was always the nurses who called them. I'm not saying this to be critical. It just seemed like that was part of their job: taking vitals, delivering medicine and bandages, and basic jurisprudence.)

The cop was very relaxed, smiling at the guy's painfully nervous jokes. The little girl had stopped sobbing and was staring at the cop open-mouthed. The mom still looked stricken. She didn't want to press charges. The cop nodded at her, but didn't seem to see her point (and I realize now that he was probably thinking she was just as exposed legally as the guy). After hearing from us, the cop told the group that they could go, and that he'd follow up with them later. I watched them leave, the mom and daughter clinging to each other, the guy walking well apart, shoulders slumped. Everyone involved was probably already thinking about exit strategies.

The guy's face flashed into my mind today as Adelaide and I hurtled over the snow ramp someone had built on our nearby sledding hill. She was sitting in front of me, well-secured by my legs on our purple plastic toboggan. I hadn't meant to go over the ramp, and had done my best to actively steer away from it. Our toboggan doesn't really steer, however, and as we descended the ramp seemed to pull us in. Going over it quickly began to feel inevitable. We were airborne for almost a second, which was plenty of time for me to wonder if we'd land okay, and, if we didn't land okay, would it be like the time that guy ran over the little girl with his speedboat. He, too, was just trying to show a little girl a good time and maybe went a little... overboard.

We landed with a bone-jarring thump that forced the air out of my lungs with a "Hoo!" As we skidded across the ice at the bottom of the hill I caught my breath and said, "You okay, Lady?" She didn't say anything for a second, and I became even more nervous. Then I realized she didn't reply because she was shaking with silent laughter. "Whoo-hoo, Papa!" she yelled, then laughed and laughed as we slid to a halt. "Let's go again!" she said, so we did, a dozen more times.

I never want to have to take Adelaide to the ER because she was injured while we were playing together. But, on the other hand, life is to be lived. Maybe we'll just stay away from boats. Or anyway, their prows. (photo courtesy of Sephanie Lallet)

Posted by Joel at 1:23 PM | Permalink | Comments (7)

Iowa City was drenched in freezing rain this morning. It didn't seem too bad as we were all driving in to work together. I dropped Aimee off and drove over to Adelaide's school (my work begins a half hour later than Aimee's) and found it dark and locked. "Wait here," I said unnecessarily to a well-buckled-in Adelaide and cautiously ventured up to the front door.

"We're closed today!" a voice came shouting out of the gloom, making me startle and almost slip off the porch. "Oh?" I replied, attempting to make it look like I was just casually inspecting the porch to see if it was really slippery. "Yeah, I just heard on the radio that Iowa City schools are closed, so we're closed, too. Have a good day!"

At first I was a little disgruntled. It was an important day for me at work, one of my last days on the surgical pathology rotation- one that I had been looking forward to as a chance to show my progress. And anyway, I thought as we drove home, it really isn't that bad out. Then, as I slowed to approach a stoplight, the car began to slide. We were fine, I just had to pump the brakes a little, but I admitted defeat. "Let's have a snow day!" I called back to Adelaide. "But mama was supposed to pick me up!" She wailed in reply.

It took a while to get things squared away. I had to call four different people at work to let the various concerned parties know that I couldn't make it in and to arrange for back up. Everyone was very understanding, it's a good program in that respect. And I had to explain what was happening to Adelaide repeatedly and at length. "No school today?" she kept checking. "Where's mama at?" she probed. "Where are all my friends today?" she demanded. Eventually, she relaxed and we started to have a good time.

The icy slush wasn't perfect for a making snow people, but we did our best.

We managed to fashion a kind of lumpy "Snow mama" as Adelaide dubbed her, and a snow baby. Grapes turned out to be a poor choice for eyes. Not only do they look creepy, but they're too squishy to easily poke into the icy skulls.

The snow baby is, if anything, more strange and off-putting than the snow mama. It was while I was trying to make it cuter that my back started to really bother me, and Adelaide started to complain about being cold, and I realized I'd crossed a strange post-modern threshold. The purpose of the activity had ceased to be making a snow mama for the helluvit (the purest and best reason to make a snow mama). I was now struggling to complete my snow mama and baby solely so that I could take a cute picture of Adelaide with them. And then post that picture on my dusty, poorly-used weblog for the delight of others. How often, I suddenly wondered, do Aimee and I do something with Adelaide more for the picture we can show or story we can tell than for the fun of it or the good it would do Adelaide?

Sledding, when it's just you and your two-year-old, is a pure activity. There was no possibility of taking a picture or showing off as we trekked across back yards and parkways with our purple plastic sleigh. It was just for fun. And it was great fun, too. The snow had a good crust of ice that allowed the sled to glide with minimal effort, and I was able to crunch through the snow crust and gain plenty of traction. We found some good hills, too, and crashed a little bit, and had a lot of laughs.

Happy snow day!

Posted by Joel at 3:05 PM | Permalink | Comments (1)