By Leo A. Gordon, MD
Scene: A sparsely furnished church basement. Rain is beating against the windowpanes. Folding chairs are arranged in a semicircle. Participants are drinking from plastic cups. Some are in scrub suits. All appear tired.
Don: Hello. My name is Don and I’m a parathyroid surgeon.
All: Hello, Don.
Don: I will be your facilitator tonight. We have a new member, so let me set the ground rules. All of us in this room are parathyroid surgeons. We maintain our anonymity as we discuss the mental and physical distress that parathyroid surgery engenders. There are no boundaries at our meetings. We speak openly and freely. Use your first name only, and of course, no patient names. Who wants to begin?
Miriam (nervously): Hello. My name is Miriam and I’m a parathyroid surgeon.
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All: Hello, Miriam.
Miriam: I’ve been here a few times, but I’m a little bit nervous.
Don: Don’t be nervous, Miriam. We all share the same problems.
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Miriam: Well, last week … (begins sobbing)
Don: Now, Miriam, just relax. Please continue.
Miriam: I had a 56-year-old woman referred to me with hypercalcemia. She had had elegant localizing studies at our hospital. Both studies—nuclear and sonographic—stated with metaphysical certainty that there was an adenoma of the right lower gland. Yet (sobbing) when we explored the area, there was no adenoma present. All we found was a normal-sized parathyroid gland!
(Al hands Miriam a handkerchief.)
Don: Go on, Miriam.
Miriam: Then the resident asked me why the parathyroid was normal if the studies suggested otherwise (begins crying uncontrollably). The resident started relating the embryology—something about branchial clefts and migration and Zuckerkandl tubercle leading the way. I enjoy teaching, but this resident just chimed in at the wrong time. It was very upsetting. I was going to shout at her, but I didn’t want to get referred to the medical student abuse committee.
Manny: Those damned localizing studies—they’re always wrong. They should be outlawed for what they do to us! Zuckerkandl tubercle, are you kidding me?
Don: Now, Manny, you know the rules—no blaming and no judgments.
Sid (loudly): But it’s the [expletive] truth. We get led down the garden path by these so-called “imaging doctors,” and they’re having coffee, and we’re sweating bullets chasing rainbows entwined with the recurrent laryngeal nerve!
Alice: Tell me about it! So Miriam, what happened next?
Miriam (composing herself): Well, we started to look elsewhere. The right upper gland was also normal.
Manny: That figures! That’s why we call it the “just-a-maybe scan”!
Miriam: So here we are with a definitively located right lower abnormality, and the entire right side was normal with two normal glands.
Phil: No wonder Ivar Sandstrom killed himself!1 He probably foresaw the misery he would bring to parathyroid surgeons for the next 100 years!
Don: Well, Miriam, we have all been there. Did you look in the paratracheal groove?
Miriam (crying, trying to compose herself): The paratracheal groove! We looked there (sobbing), then in the carotid sheath, then in the thymus, then we palpated the right lobe of the thyroid.
Alice: Are you sure you had the right patient? Did you call the radiologist?
Miriam: Yes. I called the chief of radiology and asked him to review the study. He said the study was valid, but had been dictated by the bone radiologist since the head and neck radiologist was on vacation when the study was performed.
Phil: Been there. They’re in their [expletive] darkroom and we’re sweating bullets. You’re lucky the mammographer hadn’t read the study!
Don: Phil, I said no blaming. We are all here for a specific reason. We are all dealing with this. Miriam, what happened next?
Miriam (shaking): We explored the other side and we found … we found four normal glands.
Richard (looking at Miriam with disdain): Did you pull up some thymic tissue?
Don: Richard, we speak at this meeting when we are recognized by the facilitator.
Richard: Well, I’m just saying that’s what the book says to do—you know, Skandalakis’ “Embryology for Surgeons.”2
Al: You and your [expletive] books! Every time I come to a PA meeting, you’re talking about books. Did the book jump onto Miriam’s operating table and find the [expletive] adenoma?
Don: Al, you are a recent member; keep it cordial. Miriam, go on.
Miriam (sobbing): All of the glands were normal!
Al: I suppose they were all the size of a lentil.
Manny: Wasn’t that a Streisand movie?
Phyllis: No, that was “Yentl.”
Manny: Yentl, lentil—no wonder we need a support group.
Don: Well, Miriam, what happened next?
Miriam: Well, this patient was referred to me by my best referring endocrinologist. I biopsied one of the glands and sent it for a frozen section. But … but … but … (sobbing) the gynecologic pathologist was covering for the endocrine pathologist that day and said the tissue, in his judgment, was too small to analyze! So I just closed, hoping that the dissection would knock enough parathyroid tissue to lower her PTH.
Ray: Did you do a post-procedure PTH before you closed?
Miriam (crying hysterically): Yes! It did not drop.
Manny: Sounds like the patient should have gone to Florida instead of to you!
Don: Now, no finger-pointing here. Let’s give Miriam a break. Who wants to speak next? Leo?
Leo: Hello, my name is Leo and I am a parathyroid surgeon.
All: Hello, Leo.
Leo: I did a case last week with perfect localization to the left upper gland. The patient had a walnut-sized adenoma. I removed it but the [expletive] PTH never dropped.
Al: I’ve been there.
Don: Did you wait long enough?
Leo: I waited a half-hour to repeat the test.
Don: Did you call the lab?
Leo: Call the lab?! I left the OR and took the specimen to the lab. They were calibrating a new machine and couldn’t verify PTH levels for that day. They never told me! So after this long spiel in the office, I could not do what I told the patient I was going to do. I am measuring the PTH next week. Hopefully, it will drop.
David: Hey, where’s Randy?
Don (hesitantly): Randy won’t be with us for a few weeks. He was admitted last month to the Felix Mandl Home.3 He is undergoing some treatment and I am sure that he will be back soon. OK, who’s next? We have a new member tonight. Please introduce yourself.
Yosi: Hello, my name is Yosi and I’m a parathyroid surgeon.
All: Hello, Yosi.
Yosi: What’s the Felix Mandl Home?
Don: Yosi, you are a new member. The Felix Mandl Home, just outside of Boston, is, well, how can I put it? It is a facility for parathyroid surgeons who have suffered mental breakdowns looking for suspected abnormal parathyroid tissue. Many fine medical institutions recommend that some of their parathyroid surgeons spend a few weeks there if those surgeons start acting strangely.
Randy was found in an agitated state in the physicians’ parking lot. He was ranting at his car. He was shouting lascivious comments about “kissing parathyroids.” He was totally convinced there was a rhinoceros in the trunk of his car.4 He had even called the city animal control office and asked them to come to retrieve the rhinoceros! Hospital security calmed him down. His hospital arranged for him to be sent to the Mandl home.
Mandl provides rest and parathyroid reeducation in a warm and nurturing environment. Their parathyroid healing gardens have marvelous restorative power. Mandl counselors give parathyroid surgeons the tools to develop the mental stamina and physical fortitude to find abnormal parathyroid tissue.
I expect that Randy will be back with us in a few weeks.
Yosi: Is it expensive to stay at Mandl?
MANNY: Let’s just say that their motto is “Stones, bones, moans, groans … and loans!”
Don: OK, Yosi, please begin.
Yosi: My situation was a dialysis patient who clearly had four-gland disease. Everything was going smoothly. I use the nerve-stimulating device for safety when I know I am going to be on both sides of the neck.
Manny: Another triumph of surgical salesmanship! Why use a damn machine with all of your experience?
Don: Manny, if you keep this up I am going to have to ask you to leave. I know you had a rough week (three four-gland cases, a missing gland, carpopedal spasm and a non-recurrent nerve), but back off. We are all in the same boat. So, Yosi, what was the problem?
Yosi (haltingly, on the verge of tears): The nurse—a circulating, floating, traveling, visiting, interim nurse with whom I had never worked—had plugged the nerve stimulator into the electrocautery!
(Collective moans and groans)
Manny: So let me get this straight. You burned the recurrent laryngeal nerve with a device you used after you had identified the structure you knew was the proper structure.
Yosi: Yes.
Manny: I think you got what you deserved!
Don: OK, Manny, I am going to ask you to leave. (Manny exits the room.) Yosi, continue.
Yosi: So after this beautiful case with a dropping PTH, I have a burned laryngeal nerve.
Don: Did you call the nursing supervisor to counsel the nurse who set up the machine?
Yosi: The nurse who set up the machine left for Chicago during the case! So I called the chief of head and neck surgery and she repaired the nerve. Now I’m dying every time the patient calls me. Of course, I have to turn the volume up on the office phone because I can hardly hear her. They’re calling me the “parathyroid whisperer” in the surgeons’ lounge! It’s a career disaster!
Don: Ouch! What does the patient do for a living?
Yosi (sobbing): She does voice-overs for television commercials!
Don: Who wants to share next? Alex.
Alex: Hello, my name is Alex and I am a parathyroid surgeon.
All: Hello, Alex.
Don: Please share with the group.
Alex: Well, I’ve done hundreds of parathyroid resections, but last week I was referred a patient with bone loss and recurrent kidney stones. The kicker is that I had resected a parathyroid adenoma two years ago in the same patient. Now the studies said he had an adenoma in the thymus.
Manny (off-stage): Here we go again! No wonder Parathyroids Anonymous is the fastest-growing surgical group in the world. The old double adenoma gambit!
ALEX: Everything fit: the nuclear scan, the ultrasound, the rapid CT. I figure, deliver the thymus, pluck out the adenoma and then have coffee. I never even notified the chest guys on call. But there was nothing in the thymus.
Yosi: At least your cautery was hooked up properly!
ALEX: We skeletonized everything. The damn innominate was pounding away.
MIRIAM: Was the patient localized at your hospital?
Alex: No, he came from another hospital.
Miriam: Did you repeat the studies?
Alex: Why repeat them?
Miriam: Because the “imaging” physicians are like art critics. They hang the picture on the wall, then they think they are writing art criticism for Slate. Always repeat outside studies!
Alex: But what about the cost?
Miriam: Cost? The hospital cost controller is in a beach chair in Barbados sipping Mai Tais, and you’re there dissecting near a pounding vessel looking for a needle in a haystack! It’s a [expletive] endocrinologic afikomen!5
Don: Miriam, calm down. Alex, what happened next?
Alex: Well, after two hours of sweating, the rotating third-year medical student asks me what that funny-looking thing is on the lower pole of the thyroid. It was the [expletive] adenoma! So we removed it. Sometimes I think the imaging physicians consult psychics before dictating their reports.
Don: Well, I think that’s enough for this week. Thank you all for coming. Remember, this organization was founded because so many of our colleagues have been driven to distraction searching for abnormal parathyroid glands. Parathyroids Anonymous has recently set up a hotline if you have a problem and want to discuss it with our parathyroid counselors: 1-800-LOST-GLAND.
See you all in two weeks. And please remember that our membership prides itself on anonymity. If you think you ever meet someone who may be a member, just ask the surgeon if he is “a friend of Captain Martell.”6
~FINIS~
Footnotes
Ivar Sandstrom discovered the parathyroid glands in humans. He did this during an anatomy rotation as a medical student. He published his findings but was stymied by his professors in disseminating this discovery. Depressed over his lack of academic recognition for his discovery, he went home on a summer day and put a bullet through his head. He had commented to his family the previous evening: “It would have been nice to become a professor and get a name.” He was 37 years old.
Gray SW, Skandalakis JE. Embryology for Surgeons. Philadelphia, PA: W.B. Saunders Company; 1972.
Felix Mandl, MD, performed the first successful parathyroidectomy. He proved the physiologic basis of hyperparathyroidism.
The parathyroid glands were first described during an autopsy on a rhinoceros that had died at the London Zoo. The rhinoceros is the worldwide mascot of parathyroid surgery.
An item, usually a piece of unleavened bread, hidden as part of a Passover meal. The person who finds it gets a reward.
Capt. Charles Martell is the most famous patient in the history of parathyroid surgery.