James had been a pathology resident for six weeks. His first month was spent on the surgical pathology service but for the past two weeks, he was now in cytology. The Pap smear's success story resonated daily with James. He now contributed to that success and he was proud of it. Every morning, James received about 40 Pap smears, pre-screened by a cytotechnologist. The slides, decorated with numerous inked dots, were silent testimony to the hours spent scanning each Pap smear. Pathologists reviewed these slides, examining the cells selected by the cytotechs, to either confirm their interpretation or modify it to reflect their opinion. This process ensured that every abnormal cell was viewed by at least two sets of eyes. It was a tedious task but James kept his attention focused by imagining that each abnormal cell he found could save a woman's life. It was an obscure map of cells that led to the elusive diagnosis of cancer. James was determined to decipher the trail, no matter how long or arduous the route.
During cytology, pathologists were called to perform a fine needle aspiration (FNA). Today, the call came from the ENT clinic for a FNA of a neck mass. It was his first time flying solo, no senior resident overseeing his performance. The ENT resident emerged from behind the drawn curtain of the examination room as James arrived with a small cart carrying a microscope, slides, and bottles of stains.
"James! Thanks for coming." The resident motioned to the bearded man in the examination chair. "This gentleman comes to us with a one month history of a rapidly growing mass in his left neck. Possible night sweats and low grade fevers, no recent travel history."
James nodded as he prepared his aspiration setup. "I will take a sample for cultures, including tuberculosis."
The patient reclined in the examination chair which resembled a dentist's chair. His dark brown beard was streaked with gray. His face, long and furrowed, was driven with deeply ingrained wrinkles encircling his eyes, nose, and mouth. His receeding hairline accentuated the length of his face.
"Hello Mr. Krause..." James simultaneously looked at the patient and his chart which he held. "I am Dr. Deetan from pathology. Did Dr. Samuelson explain to you what we are going to do today?" The patient stared at James and carefully followed his every move. No response. "Well then, today, we will be doing a fine needle aspiration biopsy. I will be placing a small needle into the lump that you have in your neck, remove some cells, and smear them on these slides. I will stain the slides and look under the microscope to make sure we have enough material to make a diagnosis. I will also be taking a small amount for cultures to see if you have an infection. I understand you have been sweating at night and have some fevers?"
The constant stare answered. "Ok...I need to tell you about some of the risks. There is a small chance of bleeding but we use a needle that is smaller than the one we use to draw your blood. Also, there is a small chance of infection but we perform the aspiration with sterile technique, minimizing the risk. Do you have any questions?" Another stare. "Ok...I will take that as a no." James grabbed the consent form and placed it on the clipboard, positioning it in front of the patient. "Mr. Krause, I need you to sign and date this consent form authorizing me to perform this procedure and that all the risks and benefits have been explained to you." James was losing patience. "Mr Krause..."
"What kind of name is that? Japanese?"
Startled by the voice, James blurted, "It's Chinese."
"You don't look Chinese."
"Well, I am. Could you please sign this consent?"
Signing the consent, he momentarily removed his stare from James. "I was at Pearl Harbor when the Japs attacked. I could see the pilots in their cockpits. You don't look Chinese."
"I assure you sir, I am Chinese. My family is from the Philippines and we fought alongside the Filipinos against the Japanese."
"I was in Saipan and had to fight them bastards face to face, " the patient continued, ignoring James, who did his best to ignore the patient's diatribe.
"I need to examine you. Please lean your head back...it's on the left side, correct?"
"You don't look Chinese..."
"Yes, we've established that fact. I'm going to be gently pressing your neck, tell me if any of this hurts." James palpated the firm nodule below the skin just below the angle of the left jaw. "Feels like a lymph node. Let me clean the area up with some alcohol and we will be ready to go." A few wipes of the alcohol pad, a drape of a surgical cloth on the patient's shoulders, and James was ready to enter the nodule with his needle.
The needle and syringe were held in a device that allowed the plunger of the syringe to be withdrawn while holding the needle in place. As James inserted the needle into the soft tissue of the neck, the syringe was pulled back creating a negative pressure, sucking the tumor cells into the needle hub. After a few movements of re-positioning the needle within the tumor, the negative pressure was released, and the needle was retracted.
James quickly removed the syringe and needle and carefully positioned the needle over a clean slide. With a gentle motion, he forced air into the needle which produced a small drop of blood onto the slide. Picking up another slide and placing it on the blood drop, he smeared the two slides together, placing one in an alcohol fixative and the other left to air dry, to be stained by a rapid Diff-Quik stain.
So intent on performing his task, James failed to notice the growing anger of the patient. "Don't you stick that in me again. You didn't tell me you were going to stab me!"
"Sir, I explained the procedure to you. I didn't stab you; I used a very small needle to take a sample of the tumor for my tests."
"HE'S STABBING ME!"
The cry echoed throughout the clinic. The ENT resident bolted over from the next room. "Mr. Krause, everything is okay." He quickly grabbed the patient's hand and motioned to several orderlies.
"HE'S NOT CHINESE!"
"James, are you finished?"
James shook his head. "It looks like a reactive lymph node, probably infectious. I need to stick him one more time to get cultures."
"All right, let me help you. Mr. Krause, we need to do this one more time. We are not stabbing you, it is just a simple blood test. No one is going to hurt you, understand?"
"I don't trust you. I don't trust JAPS!"
"Mr. Krause, please hold still, this will only take a few seconds."
In his haste to prepare the needle and syringe, James forgot to remove the safety cap on the needle. Positioning himself close to the patient, Mr. Krause lunged forward causing James to push the syringe forward. The positive pressure in the syringe forced the needle to shoot off the syringe, propelling the needle past Mr. Krause's face, implanting into the cork bulletin board next to him. The orderlies and the ENT resident stared at the imbedded needle then at James.
"WHAT THE HELL ARE YOU DOING?"
"Mr. Krause...settle down. Let me take a quick blood test to make sure you don't have an infection."
"WHAT THE HELL ARE YOU DOING?"
The ENT resident motioned to James to confer behind the curtain. "Bad needle day, huh?"
James attempted to muster a smile.
"Look, let's let things cool down a few minutes then I'll stick him for the cultures. You obviously remind him of some nasty war experience."
James nodded his head. Anything to get out of there, he thought.
After a few minutes, a muffled laugh emerged from behind the curtains and within a few minutes, the resident produced a syringe. "Got it, you can use this for the cultures."
"You know, funny thing, the guy's wife is Chinese. So I guess he really did know what a Chinese person looked like."
James rolled his eyes, shaking his head. Gathering up the microscope and slides, he drew the curtain aside, and peered in.
"GET OUT OF HERE!"
Just another day in St. Louis, James muttered to himself. James wheeled the cart to the cytology department. Three flats of slides on his desk awaited his return. The FNA took longer than he thought and he would not be able to eat lunch and have time to review the Pap smears before his 1PM signout. No lunch again, James sighed. Fishing around his bag for an energy bar, he headed to the end of the hall to the overheated pot of tarred coffee. Coffee in hand, James sat at his microscope to review the dots placed by the cytotechs who first reviewed the smears.
After a half hour, James had reviewed about a third of his cases. As he proceeded to the next case, he found a memo attached to the paperwork. "Call Dr. Treacher STAT about this case". Peering at the slide, James was greeted with the characteristic cytologic changes of an infection with the human papilloma virus. "Condyloma." he mumbled. He checked off the corresponding diagnosis box on his worksheet and placed the case aside. Another half hour quickly passed when the overhead intercom blared, "Dr. Deetan...line one!"
"This is Dr. Deetan."
"Are you the pathology resident looking at my case?"
"I'm sorry, who are you?"
"This is Louise Treacher. I told the cytotechs I wanted the pap on Madison looked at STAT. She's sitting in my office and I need the result."
"Yes..yes, Dr. Treacher." James quickly shuffled his paperwork. "I have the case right here. Donna Madison, 34 year old...right?"
"That's her! Does she have the wart?"
"I'm afraid so. I still have to show this case to my attending but it looks pretty classic for condyloma."
"I knew it! I can't believe how many of my patients have condyloma, it's an epidemic! I'm the condyloma queen!"
"Uh...yes, maam. I'll call you if there are any changes after I sign the case out with my attending."
"Well, aren't you nice? What is your name again?"
"Is that Chinese?"
"My nurse is Chinese...Shirley Kwok. Maybe you know her?"
"I'm afraid not, maam."
"Very nice talking with you, Dr. Deetan."
I don't know Shirley, but I know the other billion Chinese, James chuckled to himself. A quick glance at the clock reminded James of his impending signout. He placed the stat case of Dr. Treacher's on the top of the pile.
"Nice talking with you, Condyloma Queen!"
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