Medicine - BM Bx

Yesterday I got to watch a BM Bx - the heme/onc fellow's abbreviation for bone marrow biopsy. Our pt had been in the hospital about a week before our service took over - 1st of the month phenomenon - and in the 3 days we had her, we could still not figure out why she had had multiple embolic strokes without a single risk factor, and eosinophilia up to 45% of WBCs. But in those 3 days the heme/onc fellow managed to convince her to let him take a little piece of her bone to try to figure out why she's got all those damn orange/pink-staining cells in her blood.

I happened to be on the floor when the heme/onc fellow arrived, 6pm on a Friday evening, which seemed an odd time to biopsy a woman's hip. I walked into her room while he was prepping her lower back with iodine, looking up as I stuttered the question "Can I watch?" I quickly added, "I'm the medical student who's been following her this week," mostly so that the pt, lying face-down-in-a-pillow and getting an IV ativan push, might recognize me.

She gave her muffled consent to me being present, and I realized that I was the least of her concerns. I know she had been nervous about the procedure and I tried to think of a way to help console her, coming up short. Instead I tried to imagine what she was going through: multiple strokes that put her in the hospital for 10 days, a slew of tests including a lumbar puncture that took 3 tries, and now going through the painful-sounding procedure that might diagnose her with cancer. And only 50. No, I couldn't even imagine it.

I couldn't help her right now, but I could help him: I rolled her pajama bottoms down from the biopsy site with my gloveless hands, to keep the fellow's gloves sterile. Her pj's kept rolling back up, so I had to expose most of her butt, apologizing silently to the back of her head. The fellow set up his slides and made small talk to the nurse assisting, who shamelessly flirted back to him. The fellow was young enough that I found myself glancing at his ring finger (as I've only started doing since starting in the hospital) though of course his hands were covered with gloves. The patient liked him too, a day ago she was dead set against the biopsy but, as she put it, "he seemed nice."

And he was. While he numbed the area and injected more anesthesia, he continued to talk to her with his soothing voice, explaining what he was doing but also frequently asking if she was doing ok. Observing his bedside manner, I decided that he could have a piece of my hip bone marrow too, if he smiled at me like that.

It wasn't until it was time for the biopsy that there was a problem. The fellow's procedure was perfect. He progressed a long needle into the sit, continually asking the pt if she could feel anything and giving more anesthesia accordingly. My eyes were glued to the skin, the indentation of the needle, and the slow rotating motion of the fellow's hands screwing the needle further and further into bone. I started to feel funny. The pt gasped a few times, but did not speak, tensed the upper half of her body but did not pick up her head. And the fellow continued digging into bone. I had to sit down.

I silently ducked into the next bedside and sat down, leaning back and trying to recover from my vasovagal reaction. All the associated symptoms were there: dizziness, palpitations, diaphoresis, blurry vision, and nausea, and I damned my weak stomach. How embarrassing. I hoped that the fellow didn't think I was bored and just left.

Once I felt well enough to stand I returned to the bedside, in time to watch the fellow make it to the marrow and draw a vial of it. He told me, "It looks like blood, but it's called 'marrow,' it's where blood cells are first made before they go into the blood." I wondered if there was a polite way to tell him that even though I look 16, I did in fact pass step 1 and he didn't have to simply so much.

For the end of the procedure he progressed a hollow needle into bone once again this time to take a biopsy of tissue. I had to leave to sit two more times. Man. I don't know how he could do it. He wasn't one of those surgeons we hear about who can depersonalize the patient and just cut, he was interacting with her personally, checking in with her and explaining each step of the way. He could watch her struggle through the anxiety and pain and continue drilling into bone, all the while consoling her and explaining to me how blood cells start in the marrow.

I wonder if this is what humanism in medicine is. I had thought that by trying to put myself in the patient's place, that I was being humanistic, but by doing so I couldn't even stand through the procedure. If it were me, as much as the patient would have liked me holding her hand, she would have had to console me to get through the biopsy.

After the procedure, I followed the fellow and fetched the chart and a progress note for him, getting rewarded by one of those smiles. "How was it?" he asked me. "I was getting a little vasovagal, sorry I had to keep leaving to sit down." "Really?" he answered, looking confused. Pause. Then his brow furrowed, and he solemnly continued, "Yeah, I remember the first one I did, it was hard." Apparently after 500 procedures he was able to perform a biopsy while attending to the patient humanistically, but I can only imagine how "hard" that first biopsy was.