Not so foreign object

I like almonds.


Thankfully I've never had one get stuck in my mainstem bronchus.  An unfortunate patient this week wasn't so lucky.  


A 67 yo mentally challenged male was admitted to the ICU this week for respiratory failure.  He couldn't provide much history, and the caregivers only reported a fever and that he wasn't feeling well.  Chest xray showed a dense left lung consolidation consistent with pneumonia.  He was intubated, started on antibiotics, and transferred to the ICU.


Bronchscopy (small scope to look into the lungs) was done and revealed an unexpected surprise - a almond wedged in the left mainstem bronchus!


Here's a look at what normal vocal cords look like.  In order to get to the mainstem bronchus, the almond had be swallowed whole and then push right through the vocal cords.  Not an easy task!   The opening is about the size of an almond - imagine what that would feel like!

Fortunately the almond was able to be easily removed with the bronchoscope and the patient is doing much better.

Now here's where it gets good.  The physician sent the almond down to pathology for review.  This is standard procedure any time you suck gunk out of the lung, but I've never seen a foreign object sent down when it's identity was already known.

Nonetheless it made the trip down to the basement in its very own little sterile cup.

I have to explain a bit about pathologists before I go on.  They are an interesting breed of people.  Imagine the type of personality that finds joy in handling dead bodies and microscopic tissue samples.  Yum.  They are represented by both males and females alike.  Then men tend to have beards and thick bifocals at a higher rate than the general population and are generally soft spoken, serious, and deliberate with their words.  The women, on the contrary, don't stick out as much and tend to fit in with the general population quite well.  

One of my good friends in medical school trained to be a pathologist.  While all of us in anatomy lab were generally disgusted by the smell of formaldehyde and dissecting through dead tissue, he couldn't get enough.  I remember vividly the time that he got a little too aggressive with the forceps during dissection of the lower back and unintentionally flung a piece of subcutaneous fat across the table into the hair of a future psychiatrist.  He kindly apologized, reached up and grabbed the fat out of her hair, and then continued right along with the dissection as if nothing had happened!  

Even though I can't understand how they find joy in their work, I am incredibly grateful that they do what they do.  They are doctors' doctors.  Without them, a majority of diagnoses would never be made.  They are essential to good healthcare.  And they are incredibly intelligent folks - they have a robust knowledge base and understand pathophysiology of the human body perhaps as good as - if not better - than any physician.

So imagine the scenario this week when the pathologist, sitting at his workbench in the basement of the hospital (why are they always relegated to the basement?), receives the specimen container with the almond in it.  

If I were in his shoes, I might think it was a practical joke.  I may even think that someone was kind enough to share their trail mix and just pop that crunchy little thing in my mouth and move on to the next specimen.  But not the pathologist - to him this is a curiosity that deserves the utmost respect and attention.  This is not simply an almond, but perhaps something sinister that only superficially mimics an almond and thus must be examined with all the same scrutiny as a liver biopsy.  Here's the official report he rendered:

          Gross Description:

The specimen consists of a foreign body (almond). It tapered at one end and rounded at the opposite end. The almond measures 1.8 cm length and is up to 1.2 cm in diameter. The almond is light brown but some of the surface is peeled-off and the surface underneath is cream-colored. The specimen is retained in pathology. No sections are submitted.

You would think that a one word description would have sufficed, right?  Who doesn't know what an almond is or looks like?  I laughed out loud when I read this - it truly made my day.


And why was the specimen retained in pathology?  Perhaps we can send it for a DNA PCR test of some sort just to make sure that it's not some macrovirus particle that cleverly morphed itself into the exact shape of an almond in order to evade routine detection by the body's immune system!  Or perhaps it will come out later that a serial almond murderer is on the loose, stalking and killing victims one at a time by inconspicuously forcing an almond into his helpless victim's windpipe!  This could be the evidence that finally cracks the case (lol my sides are hurting)!  I don't even need to watch TV, because we have our own little CSI - Hospital going on each and every day!  


It's little things like this that happen every day that keep me entertained.  You have to have a sense of humor in medicine to keep you from getting down - especially in internal medicine.  We deal with chronic illness - which by definition means that our patients never really get better.  How's that for being a doctor and wanting to help people?  We manage symptoms and try to prevent further deterioration of your chronic illness, but rarely do we cure anything.  So you have to find things to laugh at - whether it be flying back fat or a pathologist's description of an almond - but you have to laugh.  And I'll even bet that pathologists giggle once in a while, although I'm pretty sure I don't want to know why because I just ate dinner.


Stay tuned.