Poke It With A Pin

Poke It With a Pin

ADLs, that’s what we call them in the business – Activities of Daily Living.  You can let your imagination go and probably figure out what many of these are: eating, sleeping, eliminating … and the list goes on and on.  I mention the three I did because they frequently are in short supply in medicine.  Early on in one’s medical career a person has to become quite adept at finding a quiet place, drifting off for a power nap of 20 minutes and awakening just as quickly and feeling rejuvenated for another 4 hours or so of intense work.  Often family members can’t understand how we can go to sleep in an instant and be what appears to be quite clear headed a mere 20 minutes later.  One also becomes quite good at not going into a cardiac arrest as you are startled awake by you pager in the dead of night.  Equally important is trying to remember the following morning the conversations that took place during those brief midnight moments of when you directed a patient’s care over the phone.  Not infrequently one would ask a nurse, “I told you to do that” having very little recall but being somewhat amazed at the clarity and wisdom you may have brought to the problem.  I won’t spend any time on elimination but suffice it to stay one becomes very efficient at that as well.

Now eating is another thing.  Eating was never guaranteed.  You can tell who are the residents at hospitals.  They are the ones eating on cardboard disposable cafeteria trays rather than the re-useable trays that most hospital patients, guests and family members use.  Invariably, nearly without fail, if one was distracted enough to put your food on a reusable cafeteria tray, the instant you sat the tray down at a cafeteria table and began to eat and regale you colleagues with stories of your diagnostic and healing prowess, you would be paged away from your lunch or dinner. Many a good, or in some instances not so good, dinner went wasting sitting on a cafeteria table.  Experienced residents would never make such a fatal error. A disposable tray allowed you to take your dinner with you if you were paged and continue eating your food, be it cold and somewhat tasteless by then, at a later time in some hideaway spot known only to other residents.

The food at the hospital cafeteria was for the most part palatable – with a few notable exceptions.  Someone somewhere along the line decided that it would be cool to have ‘meatless Mondays’.  What a notoriously bad concept.  God in her or his infinite wisdom provided us with enzymes to digest meat!  And I firmly held that those enzymes should be used at nearly each and every meal.

I remember my first in depth introduction to the process of digestion was well before starting medical school.  As circumstances had it – yet another story for another time – I could never gracefully extract myself from college, or stated more accurately, I had a terrible time getting into medical school so I just kept going to graduate school.  Early in 1970’s I found myself in a PhD program at the University of North Dakota.  I fondly remember those years as the most miserable years of my life, not because of school but because of the miserable miserable winters they had there.  I also remember on several occasions climbing up the river embankment that skirted the edge of campus upon which the Amtrak train tracks ran – not sure it was called Amtrak back then – and looking due west back toward home and thinking the only reason I couldn’t see Pinehurst was simply because of the curvature of the earth.  Flat hardly described that landscape around Grand Forks.

Back to digestion.  It was during my qualifying exams, the first set of comprehensive exams that I was required to take and pass in order to continue in the graduate program, that I came face to face with the intricacies of digestion. I will not bore you with the complete treatise I was forced to write as one of the questions of my qualifiers. However, as part of this first exam I was asked to follow and describe in excruciating detail very enzyme, every physical change that a hamburger with lettuce, tomato, onion, mustard, catsup packed in a plain white bread bun underwent from the moment a person sees it sitting in front of them, to their first masticatory munch, to the moment of elimination (there is that word again from the beginning of this story).

To appreciate the full impact of the story I a writing, unfortunately, it will be necessary to review the beginning moments of digestion.  It may come as a surprise to many but digestion starts well before one puts food in one’s mouth.  The first phase of digestion is called the cephalic or psychic phase.  The sight or smell, or for that matter, even the thought of food starts enzymes being release both in the mouth and stomach.  The phrase ‘mouth watering’ is quite accurate.  You actually do start secreting both saliva in the mouth, that contains enzymes for the digestion of carbohydrates, as well as gastric (stomach) enzymes that begin preparing the stomach for the much more arduous task of digesting meats and proteins.  This process is kicked into warp speed when food actually enters the mouth and the masticatory (chewing) phase begins.

Now where do those wonderful ‘mouth watering’ enzymes actually come from.  Well your mouth is well endowed with salivary glands.  There are two very large glands on both sides of your mouth, the parotid glands, which secrete their digestive enzymes out small openings very near your first molars into your mouth.  And to compliment these there are two smaller, but equally potent glands in the floor of your mouth, the sublingual glands, that secrete their juices out small ducts, or tubes, just under your tongue.  Juices from these glands have nearly all carbohydrates one ingests completely digested before you have a chance to swallow each and every mouthful of food you choose to eat.

Well, what does all of this have to do with where this story is going?

Cream-puffs, cream-puffs, cream-puffs, now those are delights the hospital cafeteria really knew how to put together.  During my residency, when time was limited and eating ‘hit and miss’, cream puffs became a favorite mid-afternoon snack of mine.  What, you may ask, are cream puffs made up of? Well a fluffy, hollow buttery pastry, filled with luscious whip cream – a carbohydrate bomb waiting to go off in your mouth.  You can just imagine the psychic phase of digestion that is being excited at merely the very thought of one never mind the amplification of this process once one is spotted.

For most of my career I was the anesthesiologist covering the labor and delivery ward – yes, there are a number of stories yet to be penned about that location, fasten your seat belts when those are finished.

Mornings were typically very busy with scheduled cesarean sections or ‘external cephalic versions’ – turning a baby who was trying to enter the world butt first rather than head first by applying turning pressure to the outside of the mother’s belly.  This particular morning was no exception and the cases went in to early afternoon, but by mid-afternoon things were slowing a bit.  It became clear that a formal lunch was not in the offing. Consequently, I could think of no better substitute than quickly downing a fresh gooey, silky smooth cream puff to quench my hunger.

Off to the cafeteria I would go, dreaming of the pure bliss I was about to experience with the first bite of my ‘surrogate lunch’.  As I turned the corner and entered the cafeteria a server was just delivering some freshly made pastries to the counter.  I couldn’t wait. I snatched one up off the delivery tray and as quickly as possible made my way to the cashier.  It was considered poor form to devoir your food before paying for it.

As I recall, I think I can almost remember an achy sensation building up under my tongue as I made my way to the cafeteria. Of course, I paid little attention to that as I could think of nothing else than to sit down for my savory repass.

Out past the cashier I went, her final comment being “I see you are having lunch again Dr. Ross”.  It’s amazing how cashiers can remember everything you like and buy.  I never had to order my drink at the espresso stands either, as I got to the front of the line, there was my single shot, tall, non-fat mocha, no whip, cap on and heat protecting ring on the outside (there is a story there as well) waiting for me.

I quickly found a secluded spot in the cafeteria to enjoy my few moments of relaxation.  It had to be secluded or one would have to endure no end of ridicule for having such a decadent treat.

As I took my first bite, it happened, under my tongue, an excruciating pain and the instantaneous development of what felt like a very large golf ball.  That was just not how this quiet respite was supposed to go.  I needed help and I needed it immediately.  Off to the Urology clinic I went.

I had the good fortune to have my wife, Susan, working at the same hospital where I did most of my training and eventual staff physician work.  It was always nice when we could sit down together and take a few minutes to eat and chat and maybe most importantly, commiserate.  Sue was a nurse who worked in the Urology clinic as well as manage a number of NIH grants focused on Urological science.  I would frequently pop over to the clinic just to say hi and see how things were going with her.  Little did I know, that as I aged, I, as is true of most men, would be inevitably drawn by the curses of nature more and more to the Urology clinic, not as a physician, but as a patient– ugh.  Yes, I know that this was not a urological problem, but that was where there was someone I could confide in, Sue.

I came in the back door of the clinic and luckily the first person I saw was Sue.  I think she could tell something was wrong so she came over and asked what was going on.  “My tunn, my tunn, somffthhinng haffened under my tunn”.

“Open your mouth and let’s see what’s going on in there”, she said.  As she started her examination a colleague of Sues, Kay Noe, an incredibly nice and competent Korean nurse, saddled up behind her to assist in the examination.  I heard a lot of hmmm’s and ummm’s and ahhh’s. Then Sue made her diagnosis, “it looks like a cyst or something”.  A cyst, a or something, I am dying, what is it!  Then I heard it, “I’d poke it with a pin, just poke it with a pin”.  I open my eyes and there is Kay looking over Sue’s shoulder pointing with her finger and all I can hear is “a pin, a pin”.  Oh my God, what!  A pin, A PIN!!!  What are they thinking.  I am dying and they are looking for a pin.  I need a doctor, a real doctor!  A surgeon, that’s what I need, a surgeon, a specialist.  I am surrounded by them every day.  I need someone who really knows what they are doing!!! 

There are times that at the mention of a pin I will break out in a cold sweat.   Pins were a main stay of the Ross homestead first-aid kit.  It seems that with a collection sewing needles, a box of wooden farmers matches, and a bottle of Bactine my mom could provide much of the basic first aid the Ross family ever needed.  To this day I hate the site of a sewing needle with its tip heated crimson red as the result of part of the ‘formal’ sterilization process the sewing needle underwent prior to being used as a homemade surgical instrument. 

 The 5 bedroom 1 bathroom 2-story house that the Ross’s lived in was heated by a single, small, wood fired stove located in the living room. Needless to say, I endured many freezing winter days in Northern Idaho trying to get dressed under the covers of my bed or sitting huddled in front of a small gray space heater that was frequently turned on in the kitchen to allow that room to be somewhat inhabitable during breakfast.  I will admit, however, thinking back on those moments when my twin brother and I would be sitting on our knees, looking in to the glowing red coils of that heater and being basked by its warmth still brings back fond memories.  And, yes, we often had frost and ice on the insides not the outsides of our houses windows during the winter months.  Chopping wood and bringing it in to the house (there are a number of stories around this task) was a nightly ritual that the Ross boys endured every day of their lives until, gloriously, the summer of my junior year in high school when my mom and dad replaced our wood burning heating stove with the magic and wonder of gas.  This ‘bringing in the wood’ ritual was frequently associated with life threatening fights between the brothers, but more likely than not, the task would end with one of us having a good sized sliver of wood stuck firmly and deeply into one of our fingers.  A cry would go out across the land, “a pin, a pin” and out would come a match and a sewing needle and with a no nonsense ‘stop your whining’ approach, my mom would begin the surgery.

  Our home was surrounded by a rather dense woods that was the site of many frontier adventures -TV came a bit later into the Ross house.  The cost of these woodland adventures, particularly in the spring, was the risk of becoming a host to one of Northern Idaho’s most abundant pests, the wood tick. As part of our return home from ‘opening the frontier’ my mom would subject us all to Helen’s ‘wood tick decontamination routine’.  Our hair, as well as any other exposed skin, was carefully checked to make sure we were not harboring one of those pesky bugs.  If by chance one was missed, then, invariably 3-4 days later we would find a lump in our scalp or feel a tickling in our ear and low and behold there would be a wood tick firmly attached, plump with blood, slowly draining us dry of our vital humors.  If irrational behavior overtook us we would just quickly pluck the pest from our skin or dig it out of our ear canal (they loved our ears for some reason).  The risk of that, however, was leaving the head of the tick, unseen, but still firmly attached to our skin and as a consequence a serious infection would ensue.  The correct extraction process involved my mom, one of those sewing needles, and a wood match.  The bright red tip a sewing needle would be delicately applied to the ticks body.  In short order  the tick would let go, back out of its ‘dining room’ and the tick extraction would have been completed without incident.  Occasionally, if the needle were left too long on the ticks body, the tick would pop like a popcorn kernel and it would look like my mom had punctured a major artery.

 Of all the dangers that could have awaited the Ross boys in their rural setting, however,  it seemed the treacherous car door was their greatest nemesis.  One of my earliest memories was a dark green 2 door 1953 Buick that our family owned and drove for many years.  There are several stories in that memory, as well, of piling in that tank for a car and heading to Minnesota on our bi-annual vacations there.  Twenty four hours straight, packed tightly in the car, 5 kids and 2 adults, seeing the visitor sites as they whizzed by, stopping only for gas – one had better have their bathroom breaks timed with the gasoline stops.  My dad always loved Buicks.  They were a sturdy built car – body by Fischer – with very large heavy doors.  The car served a vital role in our daily existence, though, and that was our weekly escape to the thriving metropolis of Kellogg for grocery shopping and an occasional foray uptown for cloths shopping at the tiny Pennys or Huttons store, maybe a chocolate milk shake at a soda fountain bar combination called Fergies, or the oft chance of talking a bit of spare change out of our dads pocket to buy a cheap toy at the Ben Franklin variety store.  These were exciting times for us a little kids.  As a youngster Kellogg seemed so busy and full of surprises and adventures. But the excitement came with a price. When we would arrive back home we could hardly wait to pile out of the car and play with our new toy.  Several times a year the second to last kid out of the car would start the heavy door of the car shutting and the last one out would not quite get their fingers out of the way in time.  A blood curdling scream would ensue, the finger would be extracted from the closed door, the finger examined, and virtually every time my dad would proclaim “no broken bones” but there would be the beginnings of a very large ‘blood blister’ under the finger nail.  Blood blisters were also a common finding on the heal of the Ross boys feet early in the school year when they were finally allowed to wear their ‘new school shoes’ for the first time.  Blood blisters were no competition for my mom.  Out would come a sewing needle, a wooden match would be struck for sterilization, and the tip of the needle would burn its way through the finger nail to relieve the pressure of the blood accumulation under the nail. The finger would always feel much better after the pressure was relieved, but try telling that to a 5 year old who sees only a brightly glowing tip of a very sharp pin.  Yes, the nail would fall off about a week later only to grow back over several months and the whole process would amazingly repeat itself.

It is no wonder from the trauma of my childhood, that, there I stood, in the throws of PTSD, having flash backs to times gone by, facing the possibility, yet again, of being jabbed with a sharp pin as the treatment for some ailment that should really be approached by a highly skilled surgeon.

I immediately turn, leaving the clinic and head for the main operating room to find my specialist, saving myself from the clutches of two urology nurses hoping to ‘poke it with a pin’ – what else in God’s name do they ‘just poke with a pin’ in their clinic I begin to wonder.

The main operating room was just a short distance from the Urology clinic and in no time I am standing in front of the operating room control board where patients, procedures, and most importantly, the surgeons who are currently operating are listed.  Wonders of wonders and thanks be to forces controlling the universe, there before my very eyes is the name of the man who will save me, Charlie Cummings. I do a double take, and yes, it is Charlie Cummings, I can hardly believe my good luck.  Room 8, that’s where I am heading.

Now, Charlie Cummings was a very funny, somewhat unpredictable but incredibly competent surgeon.  He was a tall, thin, very distinguished looking University professor and physician.  Jet black hair with just the hint of frost at the edges.  Thin face punctuated by black perfectly place eyebrows and a thin, finely manicured mustache.  He was the chairman of the Ears, Nose, and Throat and Head and Neck surgery department. Any place else but the University of Washington he would have been considered the chairman of the Otolaryngology Department, but the UW has never been a place that spared long titles. Charlie also had served as the president of the national Otolaryngology Society, a surgeon I had worked with for years and one who could bail any of us out of very difficult oral and airway disasters.  Little did he know that he was about to be forced into a ‘roadside’ consult.  Roadside consults are informal consults that docs get from one another about patients or problems that are felt to be too urgent to wait for the painstakingly long clinic appointment process.  My case was just such an urgent case.

As luck would have it, as I turn to head to operating room 8, I spot Charlie  making his way to the recovery room.  Quicker than you can say, “anyone have a pin”, I am standing right next to Charlie as he is tucking in his most recent surgical success story.

“Hey Charlie”, I say casually and as best I can with that golf ball in my mouth, “have a quick consult for you”.  Never one to miss an opportunity to feel good about himself, he immediately says, “what’s on your mind”.  I drag him behind a support pillar in the recovery room as I didn’t want to make a public scene about my urgent case.  I tell him quickly what happened and he says, “well let’s take a look”.  “Right here?” I say incredulously.  “Why not,” he replies.  I open my mouth and hear very similar ‘hmmm’s and ummm’s and ahhh’s, that I heard in the urology clinic.  I look up and he is peering into my mouth through those half-lensed reading glasses pulled nearly down off the end of his nose that many intellectuals use.  He feels around a bit – those were the days before you even thought about putting on a pair of gloves – and said, “hmmm, think you have a stone plugging up your sublingual salivary duct”.  God, at last, I am finally in the hands of a real professional.  “What are we going to do?”, I ask, a bit nervous about what may come next. “Hmmmm, well you know”, taking a very thoughtful moment, “I think I would just poke it with a pin”!!!!!!

Oh my God, am I surrounded by buffoons, incompetents, or what !!!  “No one is going to just poke it with a pin”, I said. “Suit yourself, it will probably take care of itself in time but it’s going to hurt until the pressure is relieved behind that stone, come back if the pain gets too much, I have a pin right here”, he said almost too gleefully as I recall.

I left the recovery room dejected in my search for a cure and with Charlie standing there smiling at my dilemma.  No more than 15 minutes later I felt a gush of salivary fluid into my mouth and the pain instantly subsided.  Who needs a pin when you have the healing tincture of time.