Read Any Good Positrons Lately?

by Hal | December 21st, 2009

Duke Medical is about 55 miles away, a route requiring us to cross a heavy traffic zone that makes drivers from larger cities shake their heads. I once met a CBS News camera crew based in Atlanta that got caught in it; they couldn’t believe a city as “small” as Raleigh (what, a quarter million now?) had such bad traffic. Yes, indeed.

That means we routinely budget ninety minutes to two hours for the trip. Today was good, so we found our way to the lab about fifteen minutes early. The nurse who checked me in was friendly, helpful, and brisk. “Here’s a medical history, this one’s for your choice of music (pick two), and this is an optional customer service survey.”

Music? How unpleasant could this be? I’ve heard of people having claustrophic attacks inside the MRI machine, but this was a new technology to me.

“Just pick one, you won’t be inside long enough for two.” The second nurse had just materialized at my elbow. I was looking at the short list of classical music options and had just decided “Beethoven” probably meant piano sonatas or string quartets – probably relaxing enough. I was about to mark “Mozart” (for short, agressively cheerful selections) when she pre-empted me. Okay, Beethoven it is.

The process is similar to the CT scans I’ve had recently – in fact, the machine turned out to be a General Electric product with the same control panels I’d seen at Johnston Memorial – but instead of tracking intravenous iodine, the PET scan detects a radioactive glucose solution. Fast-growing cells like tumors really suck up the sugar, so the story goes, and if you take a dose of this stuff and lie real still for a couple of hours, the cancers light up on the screen. Melanie, who’s had gestational diabetes, informs me that physical activity makes the muscles more receptive to blood sugar, and obviously muscles aren’t the issue here. Hence, a couple of hours of enforced rest. Dark room, eyes closed, no, you can’t read.

“How much are you giving me?” I asked. Coleen, my nurse, said something like “only 15 millicuries.” She had me lying down on a gurney in a little cubbyhole off the hall, bulky sweater, wingtips and all. Come on, I’m thinking, you’re going to need the arm eventually; I took the sweater off unasked.

“No, I meant how much fluid.”

“Oh, are you on a reduced fluid …”

“No, I’m just curious.” She smiled and said, “Oh, that will depend when I get it.” The radiation is in constant decay so the pharmacist has to calculate the strength of the dosage in terms of time. Coleen returned with a lead-lined tool box and announced “Eleven milliliters.” She had told me it would be an injection; I’d call it more like a 90-second IV. She was good with the needle and I complemented her on her technique.

“I’ve got thirty years’ experience,” she said. I’m thinking that’s no guarantee, though, and she adds, “but sometimes there are problems.”

After infusing the glucose in she added the doctor may want me to do an oral marker as well. I did this at Johnston Memorial last week; they mixed the iodine with orange juice, I told her. “No, we don’t want you to have any sugar,” she said. Duke uses Crystal Lite lemonade, which is pretty mediocre stuff if you follow the directions; add a tablespoon full of organically-bound iodine and you get some pretty bitter stuff.

“You’ll need to drink two of these,” she said, smiling all the while. “Sip them slowly, sometimes they give people diarrhea.” Lovely thought there.

Lights off, no book, no music, though I could watch the passing world through the doorless doorway. It was a good time to pray, meditate, sleep a little. I woke up with stomach growling – did that mean the glucose had hit the system? It was starting to make me irritable, either way. Yep, sugar’s in the blood, and nothing to be done about it. I surreptitiously stretched a few inches.

A few seconds before I buzzed for the nurse, one appeared to announce cheerfully – everyone on staff was cheerful, which was not true in the waiting room – that I could get up, use the rest room, and mosey down the hall to the PET room. Okay, I’m ready for that.

The scanner is a basically a big doughnut; the patient lies on a narrow shelf and slides in and out like a drawer runner. It’s not much different than the CT machine I’m growing familiar with, just thicker. The CT scanner has a rotating ring visible behind a glass aperature. It looks like a chain saw blade when it starts, and I always think of the bad guys tying the hero on the sawmill carriage. Alternately, I think of calculus class, when we did Riemann sums, taking an infinite number of infinitely thin slices of an irregular solid (like myself) to evaluate its volume.

This time we go in head first, and all the way through. Apparently the big machine has both devices inside, because they did another CT scan before the Big Test. (“Hey, did we order that? I’ve already been CT’ed. Gosh, this is going to be expensive.”)

No IV in the arm is a plus. On the other hand, I’ve got both arms over my head, hanging on to handgrips. Can’t take deep breaths. Occurs to me this is how you’d be trussed up for a flogging, but I’m lying down instead. They don’t care about shirts, but pants are bad; I suppose it’s the zipper.

“You can keep on your underpants,” someone had announced. Thanks for small decencies, I think. “You don’t have snaps on them, do you?” No, I’m clean. Thought for another time – maybe if I wore sweatpants …

There’s always this moment of realization in radiology, whether getting a dental x-ray or having your glowing innards sliced a million ways by the Riemann sum machine, there’s always a moment when I realize, “Hmm, everyone else has left the room and taken shelter somewhere. I alone am here to face The Ray.” At least the machine doesn’t crackle, though I admit sometimes the lights dim. (“Well, that’s it, Warden.”)

Ah, there’s the music. What is it … oh, it’s Beethoven all right – the Ninth Symphony. Okay, so I’m waiting to start the 36-minute ride back through the machine, and their idea of relaxing music starts with that slow, building suspension of strings, followed by hammer blows of the whole orchestra. Why not do the whole Stanley Kubrick thing, play “Also Sprach Zarathustra”, the effect is the same. Oh well. The scherzo movement will make up for a lot.

“Is that loud enough?” the technician asks. “A little more,” I request. They’re playing CDs through the single PA speaker on the ceiling. She apologized for the sound quality afterward. “It’s hard to get the volume right on the classical,” she said. Yes, the dynamic range is pretty wide, but I’m not going to ask for show tunes next time either. Walking down the hall, you can hear other patients’ music through the imaging room doors. Mental note: Once rich, donate decent sound equipment to the PET lab at Duke.

I didn’t find the test too confining. Unlike the CT which is done in a continuous pass, the PET scan holds you in place for about six minutes, then advances the table to the next position. You spend about fifteen of those minutes looking up at the inside of the tunnel, about ten inches from your nose, but I’m okay with that; we were into the third movement by that time and I was thinking, the Ninth is a l-o-n-g symphony, how come we’re already this far into it?

So finally I’m turned loose – no results before tomorrow – and walk back to the waiting room. Melanie introduces me to a young father with a cute little girl, about Katie’s age, and wild eyes. Nice guy; he and his wife just discovered, at age 34 and first child, that she has esophageal cancer. She’s getting scanned today too. Very similar story to ours – if she hadn’t had pneumonia, it may have gone undetected. You can tell he’s already been through the wringer and it is about to come across him again. “I’ll pray for you,” he says in a shaky voice when we leave. “I’ll pray for you, too,” I say, thinking in terms of dad to dad, not, as he probably was, as supporter to patient. Obviously, you pray for the patient; but you should never forget the one who brings them to the doctor.

Tomorrow’s the biopsy, starting at 7:15 a.m. for pre-operative check in but not into surgery until 4:00 p.m. I tell Melanie we have to make sure people don’t think this is medical stupidity; this time, we are gunning for available spaces in both departments, and the awkward schedule is simply the cost of securing a biopsy the week before Christmas instead of after. I’ll take it. It will be a long day, though, and no two ways about that.

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