Thursday, January 3, 2019

When the Human Body Works Like a 3D Printer

Here is a case of human reproduction that does not involve a gamete, egg, or mitosis. I would have mentioned "ploidy" too, but I'll be darned if I can remember what that involves. A 35 y/o man who was critically ill had a vigorous  coughing fit which was so  productive that he hacked up this blood clot which formed in his right main stem bronchus; a near perfect anatomic reproduction of the airway cast in blood.

Hemoptysis in the extreme, which formed a perfect casting demonstrating 5 branches of the bronchial tree. The clotting cascade was a real challenge to memorize and about the only thing I can remember  is the cross linking of fibrin forming the framework for the clot. It certainly out performed it's intended purpose in this case.

 The right main stem bronchus is like a grease trap in a fast food restaurant because almost anything that goes down the trachea winds up here. It's the first bronchial segment to branch off and has a larger lumen than the left main stem bronchus. It's also more perpendicular making it the perfect exit ramp for just about anything coming down the trachea. Anesthetists always checked for bilateral breath sounds because it was so easy to selectively intubate the right main stem bronchus. An absence of left sided breath sounds?  Time to pull the endotrach tube out a bit to clear the right bronchus.

It's difficult for me to understand how a clot of this size could form because the most likely scenario would be a clot occluding the upper segment and blocking the filling of  the middle and lower branches.  This perfect cast of the bronchus jolted my memory and brought to mind another memorable anatomic replica produced by the human body.

Fecal impactions were a miserable experience for all parties involved and were common in old school hospitals as a side effect of prolonged bed rest combined with opiate analgesia. With the passage of time, pressure from the upstream accumulation of stool in the sigmoid colon  numbed the nerve endings of the internal sphincter. The end result was a massive hardened bowel movement firmly lodged in the sigmoid colon.

Removing these forbidding fecal accumulations was no easy task because the stool hardened to a consistency of Sakrete concrete. The first step in the unpleasant (to say the least) removal process was the rectal installation of warm mineral oil  in an often times futile attempt to soften the painful putrid plug. The final step was similar to a Roto Rooter operation whereby the mass was manually extracted.

One of my colleagues, Ann, was especially proficient at removing fecal impactions. Her fingers were lithe and she had the unique ability to curl the distal metacarpal at a right angle to the rest of her finger resulting in a hook. Her fecal impaction removal technique involved twisting her index finger much like a boring brace to gain entrance to  the tenacious turd. Having bored inside the monstrous mass much like an African dung beetle  she hooked her finger and gently increased traction until the massive mess slid out.

After the patient's  screams of agony subsided, the oows and ahhs began as attending staff members marveled at a perfect sculpture in brownish stool  of the sigmoid colon. The distal part of the colon is lined with haustral markings which delineate colonic saculation.  As the stool hardened a perfect colonic cast was formed.

Most nurses chipped away at fecal impactions which resulted in a hodge podge collection of fecal shreds. Ann's technique of rmoval in toto resulted in an anatomic model not  unlike the cast of the bronchus. Simply amazing!


  1. Brings back memories... the LOL in NAD who came into our ER about once a month with a serious impaction... fortunately for me, my fingers were much too large.

  2. Yuk thanks for bringing back some of the less pleasant memories of nursing days. I remember being taught the manual evacuation of faeces in my first couple of weeks as a nurse in the Preliminary Training School, and all of us going out afterwards praying we'd get through three years' training without having to do this awful job. Once a Sister (RN) you could delegate a lesser mortal to do such tasks). I got through with only having to do it a couple of times thank Heavens.

    That blood clot is impressive. I do remember a massive haemoptysis where the entire room - walls, ceiling, floors - were covered with blood. I heard a feeble voice call out "Nurse" as I walked by and went into one of those side rooms I hate because I think they're dangerous and found a woman who had covered the room with blood and been unable to hit the call bell. I've never forgotten the sight and the poor woman's terror. Don't get me started again on how much safer those old Nightingale wards were with every patient in clear view! Thanks for an interesting post OFRN. Sue.

  3. As a resident, I once removed a cerumen impaction that molded to a near perfect facsimile of the external auditory canal. Tonsiliths are also capable of reproducing models of the fissures found with infected tonsils.

  4. We would occasionally see the fecal impactions on our general surgical service. My fellow first year surgery resident thought he was quite the hot shot and went in and tried to remove the current candidate with his usual full steam ahead non-thought. He was so rough and caused so much bleeding that the 76 y/o man went into septic shock and died. At the children's hospital I had to repeatedly dig out impactions from a 17 y/o teen which resulted from profound hypokalemia from being on amphotericin for over six months for a disseminated fungemia.

  5. Sue, your mention of Nightingale wards brought back memories. When the transition to semi-private rooms began, older nurses thought the call bells were one of the worst abominations they had ever witnessed. For them, call bells were a blatant admission that the patient would be left alone without a nurse in the room which was against their training. How times have changed.

    An ENT surgeon told an interesting tonsillectomy post op tale involving tonsiliths. A patient bitterly complained to him that he was no longer able to produce those little white wrinkly spheroid things when he coughed. He had the habit of pill rolling them between his fingers and inhaling the unusual odor. Since tonsiliths were composed of bacteria and dried up mucous I suspect the smell was quite distinctive, to say the least. Patients have the most unusual habits.

    1. I got caught in one of those ubiquitous side rooms as a patient once OFRN - suspected of a post-op bleed after major abdominal surgery I was re-admitted post discharge via Emergency to a large private (ie. expensive) hospital here. Having no beds available I was left on a trolley (very uncomfortable when you are in agony) and left in a side room with the call bell having fallen out of reach and the nurse CLOSED THE DOOR behind her as she left me. I couldn't even call out for help from anyone passing by! I was left like that for a couple of hours before a young Resident (junior doctor) came in and I told her to KEEP THE DOOR OPEN and give me the damn call bell! It just confirmed what I always thought about these rooms! Fine if you are ambulant and just recuperating, but few patients like that remain now, as you are booted out pretty much as soon as you wake up from the anaesthetic. Grrr. That's my peeve for the day...

      That patient does sound gross. I didn't come across anyone quite that weird thankfully... must have been lucky! Sue.