English 200 - 32
Dr. Kathleen Reilly
The Unseen Physician
As I entered the outer room, the scent of blood and other interesting chemicals met me at the door. A gowned individual approached me and asked whether I was a doctor or a student. I responded that I was a student, here to observe the procedure. He showed me where the shoe covers, gowns, hair covers, gloves, masks, and face shields were and asked me to "put them on and come on in." While suiting up, I surveyed what was around me. Inside the inner room were two stainless steel tables. One supported a motionless pale white male over which a female doctor presided. The other table was similar, but empty. To my left was an area in which observers could sit and watch the procedure taking place inside. To my right was a locker room for the doctors.
This was not a surgical suite as one would suspect. As the inscription above the New York City Medical Examiners office says, this was the place where the dead come to teach the living. It was the autopsy suite at McGuire Veteran's Administration Hospital in Richmond, Virginia. I was there to observe the autopsy of the recently deceased man on the table inside. The purpose of this and any autopsy was to learn cause of death of the patient. An autopsy is done with the utmost respect for the deceased. The autopsy team hopes to gain medical knowledge and determine the patient's cause of death. This knowledge can help develop better ways of treating living patients. Studies of the deceased help evaluate and improve medical procedures for future patients. For example, implanted medical devices such as pacemakers and heart valves are evaluated during an autopsy. In the case of foul play an autopsy can reveal information needed to prosecute a murderer. Information gleaned in an autopsy has enhanced the quality of life for many people.
Presiding over this autopsy was Dr. Blount, a soft-spoken female pathologist. A pathologist is "a physician who conducts laboratory studies of tissue and cells to help other physicians reach accurate diagnosis. A pathologist also supervises other laboratory personnel who test and microscopically examine blood and other body fluids." As one may have concluded from our introduction, pathologists also do autopsies (Clayman 775). During an autopsy the pathologist is often called the Prosector. An autopsy assistant, better known as a diener, is also present during the procedure (Uthman, Autopsy).
A history of heart problems had plagued the 60 plus year old deceased male. Gray hair and a light frame were physical features of the corpse. The subject's eyes were rolled upward and they had a dried appearance. His body was ice cold from spending the previous night in the morgue refrigerator.
Our first job was to weigh, then meticulously examine the whole external surface of the corpse. The external examination was done to reveal any unusual bruises, scars, cuts, bullet holes, or injection sites that would have suggested foul play. Since this patient had died in McGuire Hospital under the supervision of nurses, we did not expect foul play. This man had died suddenly and the family wanted to confirm that heart failure was the cause of death.
It was now time for the part I had come to see, the opening of the body. The pathologist made a Y shaped incision starting at the shoulders then meeting at the breast bone and continuing down to the pubic bone. Skin, muscle, and fat was then peeled back to expose the internal organs. The diener removed the breast plate (ribs and breastbone) with a black handled instrument consisting of an U-shaped blade, similar to a farmer's scythe. Its blade was hooked over the top rib and yanked downward cutting each rib as the blade passed down the length of the rib cage. It sounded much like a large zipper unzipping, as the blade hit and cleaved each rib.
With the help of a scalpel to sever the connective tissue, the diener removed the breast plate. The ribs with their overlying muscle looked like a rack of ribs found in the meat department of a grocery store. The pathologist later decided that she did not have enough room to reach the lungs and other organs. Since the part of the rib bone closer to the spinal column is much tougher to cut, she used an electric bone saw to widen the opening.
Odors similar to that of a freshly butchered lamb filled the air. The parts that make human life possible laid there before me. There was the pancreas which supplied the chemicals to break down food so the digestive system can absorb fuel for the rest of the body. I could see the pinkish-grey lungs which had supplied oxygen to the body's cells for combustion of fuel extracted from food. Nestled next to the lungs was the pump of life, the heart, which had supplied this body with life-giving blood for more than sixty years. Under the lungs and heart was the stomach, a large sack, which the corpse had used to hold and mix food to fuel the body. Like coils of large rope, the small intestines which transfer fuel from the food to the blood stream were coiled in the lower abdomen. Like an accordion type hose, the colon was at the bottom of the mass of vital components of life. I could see the spleen, kidneys and many other organs which each had made the life of this patient possible for so long.
Now that she had exposed all the internal organs, Dr. Blount examined each one carefully for abnormalities. She cut the organs from their attachments, found mostly along the spinal column. During the dissection of the organs from the body the pathologist cut off and tied the arteries and veins supplying the organs. Amazingly, Dr. Blount removed all the organs in one big block leaving behind an empty shell of a body. She then dissected each organ individually.
At this point I was much more interested in what the diener was doing to the man's skull than the preliminary examination of the abdominal organs. When questioned about what he was doing, he responded that he was removing the brain for examination. To do this, he made a cut from one ear to the other on the back of the head. The skin of the scalp was then pulled forward over the man's face and the back flap of skin down to the base of the neck. The diener then brought out an electric bone saw and carefully cut around the middle of the skull being careful not to damage the brain underneath. He removed the tan/pink top plate of bone from the skull with the help of a chisel like instrument and hammer. Once the diener exposed the grayish white brain, Dr. Blount removed it from the remaining part of the skull. She told me that this was very difficult because after death the brain is like soft Jell-O. She had to reach under the brain to sever it from the spinal cord. As the doctor carefully removed the brain, it made a sucking squeaky noise. A hollow bowl-shaped cavity was left behind. The doctor then carefully wrapped the brain in gauze and placed it in a fixative. Dr. Blount was very careful not to deform the brain during this entire process. I thought, how fragile this organ is, yet it is the very essence of life. This organ had directed the many other parts of this body for such a long time. It had also contained the thoughts and experiences of love, the sorrow of heartbreak, the touch of loved ones and the joy of living.
Now that all the organs were out of the body, we examined each organ carefully for abnormal findings and disease to learn the cause of death. Dr. Blount sliced the liver and other large organs into sections like a loaf of bread. The knife used to slice the organs looked like a huge bread knife with a 16-inch blade. Upon examination of the stomach contents we found that the man had eaten just before death. Peas, corn, and a small pink pill were found in the slimy contents of his stomach. Also, he had three bypass grafts on his heart and a dark lymph node in his chest area. We examined the intestines after the diener had washed them to remove bowel material. We observed that the patient had several diverticulum, which are abnormal outpouchings of the large intestines. During examination, the pathologist cut off and placed samples of the organs in a fixative solution. Dr. Blount saved these specimens for future examination under a microscope.
When the process of removing the organs was complete, the hollow corpse looked much like a large empty boat. Organs removed during autopsies at McGuire are kept for a month and then incinerated. The diener sewed up the empty body with coarse cotton twine and a large needle. The stitches he used to sew up the incisions looked like those on a baseball. The hospital delivered the body to a funeral home sewn up with this coarse stitching and without any internal organs. The body was not suitable for viewing by family members after this autopsy. Dr. Blount told me that the mortician would later pack the body with filling so that it may regain its normal shape. At this point the autopsy suite was not a pretty sight. Blood was all over the stainless steel table, sink, floor, and chart. During the autopsy, I did get my gloves bloody by helping in removal of the organ block and by examining the organs with the pathologist. However, I remained fairly clean. The diener stayed to clean up the suite while the pathologist and I washed up.
The procedure had taken more than two hours of intense physical exertion by the autopsy team. Dr. Blount was calm and softly spoken throughout the entire process. It seemed to me that it was just another day on the job for her. The diener contributed a delightful sense of humor and bubbling personality to the morbid task. In all it, was an enjoyable and educational experience.
Some people probably could not eat after such an experience. However, "many prosectors have reported an increased appetite after preforming an autopsy"(Uthman, Autopsy). Dr. Blount, the diener, and I were no different. Luckily a hot dog lunch prepared by the lab technicians was waiting for us. We enjoyed our meal and discussed our morning's work.
Later microscopic examination of the coronary arteries supplying blood to the heart revealed that they were clogged with an ugly yellow fatty substance known as plaque. It appeared that heart was starved of its energy and could no longer pump the blood around the body. It was just like a water pump without electricity. The heart just quit working. Dr. Blount uncovered no other abnormal findings that could have caused death. Since the man had three cardiac arterial bypass grafts, Dr. Blount ruled that heart failure was the most likely cause of death.
Autopsies at McGuire come in spurts, some weeks two or three and some months none. However, it is very seldom that they use both autopsy tables simultaneously (Lippman). The number of autopsies has been on the decline throughout the U.S. due to cuts in health care. Since the 1960's the number of patients receiving autopsies in university hospitals has dropped from 50 to 10 percent. In small rural hospitals today the autopsy rate is as low as 5% (Brown). The pathologists at McGuire, however, do many autopsies since it is a large teaching hospital. Teaching cases for the medical students are truly complete only if an autopsy is performed on the deceased patient. McGuire serves veterans and autopsies must resolve some legal cases involving the servicemen. For example, post mortem information is needed in the hospital's spinal cord injury unit. After death a pathologist must autopsy spinal cord injury patients to determine the extent of spinal cord damage. Information from the autopsy helps decide whether the government should pay benefits to the survivors of the patient (Lippman).
My experience of observing and helping with an autopsy at McGuire Hospital was very interesting. However, I was not there just to observe an autopsy. This was part of an externship that I was doing in pathology. Most people think pathologists do autopsies all day. This is very untrue unless the pathologist happens to be a medical examiner. In fact autopsies are a very small part of the average hospital pathologist's work. I found this out early during my first experience with a pathology at Shore Memorial Hospital, a small rural community hospital on Virginia's Eastern Shore.
As I walked down the main hall of Shore Memorial with Dr. Molera, I had no idea of what I was about to experience. Dr. Molera was an anesthesiologist who had become a friend of my family's in recent years. He had invited me to the hospital a week earlier to observe surgery, but he was unable to get me into the operating room due to hospital regulations. I had returned this week because Dr. Molera knew of my interest in pathology. We were on our way to the lab where Dr. Molera would introduce me to the hospital pathologist.
We walked through the heavy brown wooden door of the hospital lab marked with a large biohazard sign. I could hear the buzzing of the large machines as people in white lab coats puttered around the lab busily manipulating and analyzing tubes of blood. Some machines were magically printing out numbers that would help determine the fate of many patients who filled the beds in the above floors of the hospital. We continued through the lab past the blood bank in which bags of scarlet fluid sat sluggishly on shelves marked O, A, B, and AB. Then we walked past the microbiology where the odors of hot agar and bacterial toxins mixed into a pungent odor that tickled my nose. The place smelled like the odor of an upset defensive skunk.
As I turned the corner with Dr. Molera, we came upon the man that defied all preconceived notions that I had about pathologists. The first thing that struck me was his physical appearance. He didn't fit the stereotype that I had imagined. I had visualized the typical pathologist as an older guy with a white beard, a larger frame, and a Sigmund Freud type of appearance. In contrast, Dr. Kaye was a small built man in his late thirties. A dignified patch of baldness graced the top of his head. The small reading glasses perched upon his nose gave him a timid appearance. I had assumed that pathologists were stern looking people. I thought they did autopsies of the mangled victims of roughened criminals most of the time and supervised the hospital laboratory on the side. Because of their rough work I figured pathologists had to be tough looking people.
Looking around his office, I saw the name plate on his door which read, "James Kaye MD, Director of Laboratories." It did not even state that he was a pathologist. At his desk sat a large double headed microscope. I found this particularly amazing since it was large and had four eyepieces, two on each side so that two people could look at a slide simultaneously with binocular vision. Looking at his bookshelf, I spotted no books on autopsies. His books were from other disciplines of medicine and some titles contained the word histology (histology is the study of tissues) or pathology. I found this perplexing since I had assumed that a pathologist would at least have one reference on autopsies.
Dr. Molera introduced me to Dr. Kaye as a medical student (which I later had to correct since I was a pre-medical student only in my first year of undergraduate studies). Dr. Kaye asked me about myself and my interest in pathology. Then he described his average day which I found very surprising. Unlike forensic pathologists who solve gruesome crimes by preforming autopsies, Dr. Kaye was a clinical and anatomical pathologist. Autopsy pathology played only a small part of his profession. He said his average day consisted of reading the newspaper in the morning and just being there to answer questions that arose in the lab and from other doctors. Viewing slides of tissue under a microscope consumed his afternoons. Evidence viewed on these slides could help diagnose a disease such as cancer. Just before going home he would examine and prepare the tissue that other doctors had removed during surgery or by biopsy that day. He did this so that these samples could be examined under the microscope the next day. I was waiting for him to tell me when he did the autopsies. However, he did not tell me, so I had to ask. Dr. Kaye astounded me when he replied that he had only done one autopsy during the past year.
After introductions were complete, Dr. Molera left the laboratory and Dr. Kaye showed me some slides from previous day's cases. He allowed me to guess at the tissue type I was viewing and then showed me the abnormalities in the tissue, which were mostly cancers. All the slides were of pink colored cells with purple dots in the middle. The purple dots were cell nuclei. Some of the cells were clustered together and had deformed nuclei. I later found out that this is what cancer looks like under the microscope.
After working with the microscope, Dr. Kaye helped me to sign up as a volunteer for the lab. I went through the orientation process which took a week. After that, I spent many hours in the lab learning about laboratory medicine and procedures. Mornings, I spent my time drawing blood from patients, for lab tests. Afternoons, I was with Dr. Kaye learning about pathology. I got to know Dr. Kaye well while I spent time with him. He had a warped but interesting sense of humor. It is said that most pathologists have a weird sense of humor because of their morbid work. He would often sing, rhyme, and joke around while preparing specimens in the afternoon. He was the unsung poet from the morbid dungeon of a Shore Memorial Hospital. One day we had an unusual assortment of organs and specimens to prepare for examination. Dr. Kaye decided to concoct a "menu of delicacies" from what he had on hand. His main entre would consist of the "roasted fibrotic uterus" (the uterus because of the fibrotic growths had grown to the size of a basketball). The "roast" was to be topped with a whole apple ring that surgeons had removed from obstructing someone's colon. Finally, as a side dish he had tissue paper egg rolls filled with endometrial (lining of the uterus) curettings from a gynecological procedure performed earlier that day. Naturally, he "grossed out" his assistant, but we had a great time "laughing it up." I enjoyed hanging out with Dr. Kaye and he seemed to enjoy teaching me about pathology.
Shore Memorial Hospital on the Eastern Shore of Virginia where Dr. Kaye works is a small hospital. It offered only a glimpse into the true world of pathology. A desire for additional information and experience in pathology gnawed within my soul. My fiery interest in the world of pathology sparked by Dr. Kaye was larger than the lab at Shore Memorial could sustain. I wanted to learn more about pathology so my quest for knowledge and experience continued.
I applied for, and was eventually granted an externship in pathology through the Virginia Commonwealth University Alumni Association. I attended the externship every Wednesday during the spring semester of my freshman year at VCU. This externship was at McGuire Veterans Administration Hospital in Richmond, Virginia. McGuire hospital had a large volume of patients and all the latest equipment including an electron microscope. I was amazed at how modern pathology was done at this large hospital compared to the bare bone techniques used at the rural hospital on the Eastern Shore of Virginia. This externship experience both broadened my knowledge and gave me a greater understanding of what pathologists do.
The doctor I followed was Robert Lippman, MD one of six pathologist at McGuire. He was a small built man with a salt and pepper beard and a brown mustache. Dr. Lippman was a very serious intellectual physician who was a stickler for rank and position. He often reminded me that I was the student and he was the doctor. He amused himself by creating puzzles and challenging me to solve them. Dr. Lippman and I did not have as close a relationship as I did with Dr. Kaye. Lippman's favorite snacks were pretzels, even those that occasionally fell on the laboratory floor.
Upon arriving at McGuire Hospital every Wednesday morning, Dr. Lippman and I would attend Gastro Intestinal (GI) Conference (Gastro Intestinal Medicine is the specialty that deals with the digestive system). All GI physicians and certain medical staff were invited to this conference. The purpose of the conference was to discuss recent cases encountered by the GI doctors. These cases were intended to provide educational examples of proper clinical management of GI patients. The primary reason for the attendance of the pathologist was not to learn about the clinical management of GI cases. The pathologist was there to present the slides of biopsies of the patients being discussed. GI doctors took many of these biopsies from the patients during endoscopy and other examinations. Endoscopy examination is a diagnostic procedure in which a doctor guides a large flexible tube containing a camera and small surgical instruments down the digestive tract. During this procedure the doctor views the digestive system with the camera and collects biopsy samples for pathological analysis.
The role of pathology in this conference emphasizes how pathology interacts with the other medical specialties. Although pathologists may not meet the patient during their stay at the hospital, a biopsy or specimen from most patients comes through the lab. A hospital pathologist plays the role of the laboratory shopkeeper. They provide the services of their expertise and their lab staff to analyze the specimens and help the clinical doctors figure out what is going on with a patient's health. These services often include microscopic examination of tissue and special laboratory testing of body fluids.
One patient in particular comes to mind when I recall GI Conference presentations. I had the privilege of meeting this patient a month before his case was presented. I was able to observe his endoscopy and biopsy reading. The morning I met this gentleman, I was in the gastrointestinal department of McGuire Hospital. Dr. Lippman had decided to get me off his back for the day because he felt I needed to learn about other departments of the hospital. On this day I was to follow Dr. Whitfeild and watch the GI doctors torturously shove tubes up people's bottoms and down their throats in the procedures they fondly called colonoscopy and endoscopy. I had seen a few endoscopies that day when the patient came in for examination by Dr. Whitfeild. The patient was in his late 50's and I could tell he took great pride in his appearance by the way he dressed and carried himself. I could tell he was not the type that would complain over minor stomach pains. Dr. Whitfeild and I took him seriously when he said that he had severe discomfort after eating. Often the only way he could relive this discomfort was by making himself regurgitate by stimulating the back of his throat with a toothbrush. The physical examination and initial blood work done a week before by his primary care physician revealed no problems. His doctor decided to recommend him to the GI department for an endoscopic examination. During the endoscopy procedure he was sedated with an IV drug and the GI resident (doctor in training) guided the long black endoscope down the patient's throat much to his obvious discomfort. On the overhead screen we could see the slippery tan walls of the esophagus. As the endoscope entered the stomach, a most perplexing image appeared on the screen. It looked like this man had two different stomachs. After studying the image, Dr. Whitfeild concluded that stomach was lying so that part of it pouched through the diaphragm wall and formed a second sack. It was no wonder that the patient was having such discomfort. It looked as if every time he ate, food would go into the pouch and stay there until he made himself throw up. The endoscopy also revealed abnormal areas of tissue in the esophagus. Miniature instruments passed down the endoscopy tube were used to retrieve a small amount of this tissue or biopsy for examination. The GI doctors sent these biopsies to pathology for evaluation. I later saw the slides of these samples which revealed that the esophageal tissue was ulcerated. This ulceration was probably due to the repeated irritation of the esophagus by acids present in the regurgitated stomach contents. When the case was later presented at GI Board, I was astounded that I had seen the case before. The case background, endoscopy findings, pathologist report, and a X-ray with contrast (confirming the presence of the herniated stomach) were presented at conference. As it turned out, the gentleman had gone through surgery to get the hernia repaired and the ulceration had disappeared. He was doing well without the help of his toothbrush ("Gastro Intestinal Conference").
After GI Conference, Dr. Lippman and I would return to his office to review slides from the previous day. Due to my experience in reading slides with Dr. Kaye I was getting good at determining the presence of abnormalities and cancerous tissue. Dr. Lippman reexamined the slides from the previous day first thing each morning. The doctor was being extra careful not to miss any cancerous tissue or any other disease before he dictated his final reports. He was well aware that inaccurate information could have a devastating effect upon patients, their families and other medical professionals. Possible litigation arising from mistakes in reading and preparing the slides was a natural concern of the doctor. Just imagine, what could happen if a pathologist issued an incorrect report revealing that a woman had breast cancer and surgeons unnecessarily removed her breast. Big trouble would result if they later learned that the abnormality of the breast was benign. After he was sure everything was correct he would describe his findings in very complicated medical terms. The pathology secretary transcribed the pathologist's dictation and the final report was forwarded to the patient's attending physician. The report would aid in the diagnosis of the patient's condition.
Sometimes during the morning the pathologist in charge of frozen sections or fine needle aspirations would receive a page to attend a patient. These are the only times that the hospital calls upon a pathologist for an emergency or immediate evaluation of a patient. Getting a page for a frozen section is like a code blue (cardiac arrest) for a pathologist. In fact the first time that I witnessed a page for a frozen section, the pathologist sprang into action as if the hospital were responding to an influx of patients from a bloody military battle. It is not that the call was a major emergency, but the pathology team at McGuire takes pride in responding in a timely matter. Frozen sections are special examinations of tissues that require immediate evaluation. Usually a pathologist only preforms a frozen section when a patient is in the operating room and the surgeons want to know if a lump they have removed is cancerous. The surgeons often need to know if the lump is malignant so that they can cut away additional normal tissue to insure they have completely removed the cancer. This is to the patient's advantage, since the pathologist can render a diagnosis within minutes. The surgeon can preform additional surgery if necessary while the patient is still under anaesthesia.
Frozen sections were done right outside the operating rooms at McGuire. Usually a surgical technician would bring the specimen out of the operating room and the pathologist would cut off a sample of the specimen for evaluation. The pathologist would then put the tissue in a special fluid that stops ice crystals from deforming the cells. The specimen would then be placed into a freezer like machine called a cryostat. (Leong, 23-25) The cryostat would almost instantly freeze the specimen to sub-zero temperatures. Once the specimen had frozen, a microtome within the cryostat cut the tissue into breath thin sections (around .005 mm thick). These slices were placed on a slide and stained (Uthman, Biopsy). The pathologist would then examine the specimen for disease and cancer. If the specimen was normal, the immediate response from the pathologist saved the patient from having to undergo additional surgery. Also the pathologist could reduce the time that the patient had to stay under anaesthesia. Usually a pathologist could have results for the surgeon within 10 minutes of being paged.
A fine needle aspiration (FNA) is another immediate procedure that pathologists preform. This is one of the very few procedures that require the pathologist to have direct contact with the patient. In this procedure the pathologist sticks a needle into a lump on the patient that is suspected to be cancerous. Then the doctor applies as much suction as possible to the turkey baster size syringe in an attempt to remove some tissue from the lump. (In many hospitals clinical doctors or radiologists do FNA's instead of the pathologist.) (Uthman, Biopsy). The tissue or fluid obtained from the lump is placed on a slide, stained and viewed under the microscope to determine if cancer is present. Pathologists at McGuire pride themselves that they can have a test result back to the patient's doctor within fifteen minutes of being paged.
Pathologists seldom get to meet their patients and someone may never thank them for doing a job well. However, I had the special privilege of being around when a pathologist made a patient feel a whole lot better. The Chief of Oncology had called us to preform an FNA on a man who had a melanoma tumor removed from his back a few years ago. The scar on his back from the surgery was a foot in diameter. Lumps had appeared under his arm recently and he was worried the cancer had recurred in his lymph nodes. Dr. Lippman initiated the FNA. He inserted the needle and applied suction. Straw colored fluid rushed into the syringe. Dr. Lippman recognized the fluid and told the patient that the lumps under his arm were not cancerous. Instead the entrapment of lymph fluid had caused enlargement of the nodes. Previous surgery had caused blockages of the lymph vessels. The patient was so full of joy that one would think that Dr. Lippman had cured him of cancer on the spot. This is the only time that I have seen a pathologist praised and thanked for their work. It made me feel good to know that this patient so deeply appreciated my future profession.
Throughout the day pathologists answer many questions for the hospital laboratory staff. Interesting and difficult cases often arise in a clinical laboratory. The departments of the laboratory include clinical chemistry (study of chemicals in body fluids) and hematology (the study of blood cells and the parts of the body that produce them). Other departments are microbiology (concerned with the study of microscopic infectious organisms) and coagulation (the study of the clotting mechanism of the blood). Also included is clinical microscopy (which deals with the viewing body fluids such as urine and spinal fluid under the microscope) and the Blood Bank. The pathologist is ultimately in charge of the lab and all difficult cases from the lab come to a pathologist for final determination of results. At large hospitals the pathology team divides the different clinical laboratory departments among themselves. For example Dr. Lippman was in charge of clinical chemistry and sometimes helped out with difficult hematology cases. Because he was supervisor of the chemistry department, Dr. Lippman spent a few minutes every afternoon reviewing the protein electrophoresis results. This test detects levels of proteins in the blood serum which can often help diagnose liver disease. It requires some degree of expertise to interpret the electrophoresis results. As a result a pathologist is often required to sign off on the electrophoresis. Laboratory technologists also called upon Dr. Lippman if a chemistry analyzer broke down or abnormal findings arose in a routine tests.
The afternoon is when most of the work is done in the pathology departments of both McGuire and Shore Memorial hospitals. This is when all the new slides are ready for viewing. It is also when at McGuire the pathologists do an amazing task. They control a robotic microscope at a hospital in Berkley, West Virginia over the Internet with a desktop computer. The system transmits audio and video of medical personnel between Richmond and Berkley. Real time images from the microscope in Berkley are transmitted to pathologists in Richmond. This system allows a pathologist at McGuire to examine slides prepared by a histologist (a lab technician specialized in the preparation of tissue) at Berkley. The pathologist can render a diagnosis instantaneously. If the need arises pathologist at McGuire can also view whole organs under a grossing camera. This amazing technology is called Telepathology.
In the afternoon I would go to Tumor Board with Dr. Mohanty (another pathologist). At Tumor Board they discuss interesting cancer cases. Upon walking in the door of Tumor Board a crowd of people in white lab coats bedazzled my eyes. It appeared from the size of the gathering that all the hospital residents and medical students were in the room along with the attending physicians. I always wondered why so many residents and medical students attended. I was unsure if they came because it was a requirement. If so, why didn't they go to GI Conference in the morning? Perhaps they were doing other duties during GI Conference or maybe they just came to Tumor Board for the food. The free food there was delicious. It was provided as a lobbying gimmick by of the chemotherapy drug companies to encouraged the hospital to use their products.
Usually a resident would present the case background and the clinical findings of a patient. Then radiology would show their films of abnormal lumps and present reports from MRI's and CAT scans. Next, slides and photographs of organs removed in surgery were shown by the pathologist. The pathologist would comment on the abnormalities and give a diagnosis of the condition. I was very distraught, however, that the crowd did not give the pathologist the same respect during their presentation as the presenting resident or radiologist. Those present would talk and get up for seconds of food while the pathologist spoke. They acted as if they did not care about what the pathologist had to say. Usually the pathologist did not receive many questions. I don't know if this were because the doctors did not know what questions to ask because pathology is so different from other medical specialities. Perhaps the attendees did not understand the importance pathology or they just didn't respect the pathologist. I had also observed this general attitude toward pathology in the morning GI conferences.
Later I found out that this same disrespect of pathologists extended to the medical laboratory technologists. Upon asking Dr. Kaye and several technologists about the lack of respect for their profession, I found that this disrespect was because most people do not understand the duties of lab technicians and pathologist. Sometimes even doctors don't understand and appreciate the wealth of information possessed by pathologists and laboratory professionals. They have traditionally viewed the pathologist as a service provider and not an equal among other physicians.
Probably the most interesting case I have ever encountered was presented at Tumor Board. The 70-year-old patient had arrived at the McGuire emergency room with an altered state of consciousness and an excruciating headache. The ER doctor ordered a CAT scan of the patient's head. A large mass was found in the covering half of the left hemisphere of the patient's brain. They called in a neurologic surgeon and a cancer specialist for a consultation and the patient was admitted to ICU until the doctors could diagnose the case. However, this extraordinary case would be solved before long. The patient developed seizures during the night and the brain swelled until it was crucial for the intercranial pressure to be relieved. The neurosurgery team was called in at 2:00 A.M. because they had to open the patient's skull to relieve pressure. They also needed to decide if they could remove the mass. Upon opening the skull and inserting a probe into the mass rancid yellow puss came pouring out. The surgeons had discovered the mass on the CAT scan was actually a huge baseball sized cyst filled with pus! The surgical team sent the pus to the laboratory to determine what had caused this cyst. The laboratory quickly provided the answer to the surgeon's question. It was determined that the bacterium causing the cyst was only found in dental infections like abscesses of teeth. The emergency room doctors had noted earlier that this patient had badly decayed teeth, his family said he often had to pick food out of his huge cavities with a pencil after eating. Apparently the bacteria from his decayed teeth had gotten into his blood stream and spread to his brain causing this life threatening condition. The gentleman survived, had his teeth pulled, was issued dentures and entered an assisted living facility. The old fellow had to be "tough as nails" to put up with all that pain from his bad teeth and the cyst before he decided to come to the hospital. This case was presented in Tumor Board as an example for residents which showed that every mass is not necessarily cancerous ("Tumor Board").
Arriving back to the third floor pathology lab after tumor board, I would usually catch the end of specimen grossing. (Grossing gets its name since it is the gross, as opposed to microscopic, examination of organs.) This was the most interesting part of the day. This is a time when the pathologist examines tissue removed during surgery or biopsy and prepares it for microscopic examination. Usually the tissues were small fragments removed from the skin or small core biopsies of organs such as the prostate gland. However, sometimes we would receive a complete organ such as the stomach or maybe an amputated leg. The smaller specimens usually arrived immersed in formaldehyde which helped to pickle the tissue. Larger body parts were refrigerated until they were examined. The pathologist would conduct a visual examination of the specimen and dictate their observations into a dictation recorder. They would then use ink to mark the surgical margins of the specimen. Afterwards, the pathologist would cut out slices of the most cancerous or diseased part of the specimen. The slices were then placed into small plastic cartilages and put into a special machine. Overnight, the machine stabilizes the tissue, removes all the water, and replaces the water with paraffin wax. The next morning a histology technician would embed the processed specimen in molten wax and cut thin slices of the specimen on a microtome. The histology tech would then float these thin sections out on a water bath and pick them up on a slide. Next special chemicals were used remove the wax from the sections of tissue allowing water to rehydrate the tissue. The histologist then stained and sealed the slices under a cover slip (Uthman, Biopsy). The slides were then ready for the pathologist to examine by that afternoon. The entire process of tissue preparation and slide making took about 20 hours to complete.
This grossing or viewing of the specimens usually concludes an average pathologist's day. However, sometimes pathologists must take their turn in confronting death even in the hospital environment. Dr. Lippman is a medical examiner for the state of Virginia. However, he tries to avoid criminal cases because he says they are "a lot of headaches." The paper work complicated and court testimonies are nerve-wracking in forensic cases. He says that he would rather let the state medical examiner's office take care of criminal cases. However, Dr. Lippman does certify cremation certificates. It is necessary that this certification be completed by a medical examiner because once the body is cremated criminal evidence is destroyed. Most corpses that Lippman examines usually die in McGuire Hospital and he seldom encounters any problems. I observed Dr. Lippman conduct several pre-cremation examinations. When I think of him now, I visualize him standing in the morgue inspecting a corpse for foul play while munching on pretzels.
One personal experience that I will share is that my grandfather lost an extended fight with congestive heart failure and was autopsied at McGuire Hospital. My grandfather's autopsy was about two years before my externship at McGuire. But seeing a deceased grey-headed man around the same age of my grandfather when he died was very symbolic. My grandfather's body had laid on the very same autopsy table. The scene brought back many memories of my grandfather. Graciously Dr. Lippman allowed me to view the slides of tissue obtained from my grandfather during his autopsy. That was an enlightening experience and it gave me a good feeling. I knew my grandfather in heaven was proud of me. I was on my way to becoming a doctor and he was helping me learn. He had always said he wanted to be my first patient and in a way he was. When I helped with the autopsy, I imagined it was my grandfather there on the table and I was his final attending physician.
Though pathologists usually do not see patients directly, they in some way meet every patient that
enters the hospital. They can may meet the patient through a tissue specimen sent to them for
microscopic examination or through a tube of blood which is brought into the lab for analysis. No
matter how the pathologist and patient encounter each other the pathologist is there to help that
patient get better faster. The pathologists are here to help us understand what is going on in the
human body and gain new knowledge as they explore a body during an autopsy or look at a pink
and purple stained slide under their microscope during a histologic examination. Pathologists are
the unseen physicians but they help us all live a better quality life. For their hard work they
deserve the respect of all health care consumers and other physicians.
Blount, M. MD. Autopsy Experience. 6 Mar. 1998.
Brown, Edwin W., MD. "Autopsies - Are They Really Important in This Era of High-Tech Medicine?" Medical Update. Jan. 1999: 3.
Clayman, Charles B., MD. ed. The American Medical Association Encyclopedia of Medicine.
New York: Random House, 1989.
"Gastro Intestinal Conference." McGuire Veterans Administration Hospital. Richmond, 22 Apr. 1998.
Inscription on Lintel. New York City Medical Examiners Office. Trans. from Latin to English by William R. Maples in Dead Men Do Tell Tales. Doubleday: New York 1994 : 280
Kaye, James P., MD. Volunteer Experience. Shore Memorial Hospital.
Nassawodox, VA. 16 Dec. 1997 - 16 May 1998.
Leong, Anthony S-Y., MD. Principles and Practice of Medical Laboratory Science: Basic Histotechnology. Vol. 1. Edinburgh: Churchill Livingstone, 1996.
Lippman, Robert, MD. Volunteer Externship Experience. McGuire Veterans Administration Hospital. Richmond, Va. 18 Feb. 1998 - 29 Apr. 1998.
"Tumor Board." McGuire Veterans Administration Hospital. Richmond, 8 Apr. 1998
Uthman, Edward O. MD. "Biopsy Report Guide (monthly posting, 30K, v. 1.004)." Online Posting to Newsgroup sci.med.pathology. 2 Sep. 1996. Accessed: 4 Feb. 1999.
Uthman, Edward O. MD. "Autopsy-A Screenwriter's Guide (monthly posting, 27K, v. 1.003)."
Online Posting to Newsgroup sci.med.pathology. 7 Aug. 1996. Accessed: 4 Feb. 1999.