Barry F. Saunders is Associate Professor of Social Medicine, Adjunct Associate Professor of Anthropology and of Religious Studies, and Clinical Associate Professor of Medicine and of Family Medicine at the University of North Carolina, Chapel Hill. He is also an emergency room doctor at Chatham Hospital in Siler City, North Carolina.

CT Suite

The Work of Diagnosis in the Age of Noninvasive CuttingBy BARRY F. SAUNDERS

DUKE UNIVERSITY PRESS

Copyright © 2008 Duke University Press
All right reserved.
ISBN: 978-0-8223-4104-8

Contents

Acknowledgments………………………….viiIntroduction…………………………….11 Reading and Writing…………………….132 Cutting……………………………….933 Diagnosing…………………………….1304 Curating………………………………1595 Testifying and Teaching…………………1996 Exposition…………………………….275Impression………………………………300Notes…………………………………..307Clinical Terms and Jargon…………………345Bibliography…………………………….349Illustrations……………………………375Index…………………………………..379

Chapter One

READING AND WRITING

“If it is any point requiring reflection,” observed Dupin, as he forebore to enkindle the wick, “we shall examine it to better purpose in the dark.” EDGAR A. POE, “The Purloined Letter”

In the Body CT Reading Room, overhead lights are off. There is a museal glow from the viewbox, dappled blue by rows of images. The room has six empty chairs: no body is here-save the ethnographer’s. Two double-tiered viewboxes and several computer monitors stretch along the wall opposite the door. On the viewboxes, rows of backlit ovals look like … what? Modernist photomontages? Cinema filmstrips? Eyes in the mantle portrait? The door, opened inward, displays names and pager numbers of the attending, fellow, and resident on duty. In these first morning hours, it still shows yesterday’s names.

I am here to observe a tomographic workday. Oddly, this unpopulated room feels less empty than expectant: the viewbox is replete already with quiet filmic presences. I set up my tape recorder and sit.

The attending radiologist du jour arrives, having hung her coat in her office on another hall. She knows about my study, acknowledges my greeting. She has already met with the night-duty resident (elsewhere) to review the evening’s emergency CT cases. It is 8:15.

En route to her seat, the attending taps a wall phone just inside the doorframe. “The DND button-it’s my favorite one.” She elaborates: “In here, we are doing physical examination. You don’t walk in on a rectal exam. It’s sacred.”

Eventually I understand: DND is “do not disturb.” I am surprised there exists such a button-that a mere device enforces this room’s decorum. I had assumed the subdued ambience of this privileged space was conventional, tacit-not a technical production. The CT reading room is like a library chamber: rapt readers gathered around small pools of light, silent or in hushed conversation-chastened by the exigencies and nobility of reading. True, the CT reading room is, in University Hospital, also a kind of commons: door usually open, no warning light, no access code: strangers enter unbidden, without knocking. However, most visitors wait quietly, in deference to radiological concentration. Groups in discussion tone down. The quiet ambience of radiologic attention seems to need no extra enforcement, no librarian’s shushing.

Though the DND button surprises me, I feel privileged to be within its cone of silence-to be counted as welcome within this space that is so mannered and protected. I am also reminded that my presence is welcome so long as I do not disturb. While this attending’s touch of a button may be part of a morning routine, her explanation serves as a gentle warning shot across my bow, my ship from foreign waters.

I consider the attending’s assertion that reading is sacred. Was the religious idiom chosen for me as ethnographer? Possibly-though her claim could be conventional, an echo of ancient Hippocratic pieties. I am glad to consider CT reading as priestcraft, but I wonder: how is CT reading like physical examination? Materials inspected at the viewbox are silver-salted films, inked paper, phosphor screens. CT and other x-ray images substitute for bodies. Like ordinary photographs, they are fixed; but they do not trade on resemblance. One may observe similarities in silhouette between body and film-yet a patient would probably not recognize himself in his ct scan (or even, for that matter, in his x-ray). Relation between film and flesh derives from an event, a registration. CT images relate to bodies as do fingerprints to fingers, dossiers to subjects: they are traces, signs of passage. The substitutability of an x-ray image for a particular body relates to a historical moment of alignment-body, beam, film-during which shadows, morphological residues, were captured. If there is sacrality in CT reading deriving from bodiliness as such, it is transmitted to filmic image in that brief, regulated pose.

Perhaps associations between filmic exam and physical exam would be better staked not on similarities between objects (films and rectums), or on the modesty of human subjects (who are elsewhere), but on similarities among gestures and practices.

The practices of “physical examination” vary across specialties, institutions, and periods: inspecting; palpating; percussing; auscultating; sniffing-even tasting. These practices share an existential authority derived from proximity-the copresence (arm’s length or so) of examiner and examinee. They implicate bodies of examiners. These practices are focused, deliberate, and often absorbing (for the examiner); they constitute forms of intensely “personal knowledge.” They are also styled, emulated, scripted practices, constituting forms of social, institutional knowledge. They are among forms of attention on which the role of “attending” is staked. What sacrality they claim pertains to venerability of traditions-crafts of knowing, honed over years, taught in apprenticeship, by worthy teachers-as much as to vulnerability and trust of patients.

In exam practices at the viewbox, seeing prevails. Experts look closely, search for legible signs of disease, say what they find. Like physical exam, reading CTS engenders absorption. Perhaps close viewing-deliberate, intense, arm’s length-accounts for part of CT reading’s sacrality. Yet other professionals and craftpersons look closely at objects, from arm’s length and closer, without claiming that their work is, ipso facto, sacred. What distinguishes attentiveness of the diagnostician from that of the welder?

Again, there are venerable traditions of seeing and knowing that inform work at the viewbox. Sacrality here, as in physical examination, trades on more than intimacy of inspection, or priestly deliberation, or traces of malign agencies of disease. The quiet, dark reading room is a social space with a complex history. Exercises of CT reading are ritualized, informed by doctrines and canonical texts, organized around anxieties that are social as well as personal.

This chapter is about viewbox practices of reading. It is about scenes and contexts of reading, about conventions and structures and habits of reading, about conversations informed by reading. And it is also about writing. Tomographic writing is not just Nature’s writing, tracings of bodily norm and anomaly. Writing in CT is, like reading, a suite of practices.

Proximity and Autopsis

At the Body CT viewbox:

Investigator: Dr. Bynum, have you always been able to read a study from six feet away?

CT attending: Ah, yah.

CT fellow: He usually does it from the back of the room.

Attending: Yah.

Fellow: He prides himself on that.

[brief pause]

Attending: You know what, I don’t know whether this is right. Is the patient bleeding? I don’t feel like this is-is this an artifact or is this real?

Investigator: What are you looking at?

Attending: This patient’s got anasarca with subcutaneous edema.

Investigator: Mm-hmm.

Attending: This is a sickie. This is a sick patient.

This virtuoso radiologist positions himself as close as he needs in order to see-no closer. Even as he redirects conversation to images before us, he leans back. He habitually sits farther from the viewbox than do most of his colleagues (two to four feet is average), and this distance is emphasized by occasional use of a pointer. The acuity of his vision (and, by extension, his diagnoses) is emphasized by such remove.

On this occasion, the attending preempts further remarks about his “sharp eyes” by addressing the images. Look here, look with me. See what is salient: see comprehensively, urgently: “this is a sick patient.”

Seeing for oneself is more central to the sacred task of each CT radiologist than, indeed, feeling sick is to being a CT patient. Likewise this is a goal of most visitors to the reading room: to view things on the viewbox for themselves. The dramaturgical center of the reading room is the lookout’s role, the observer’s role-not Parsons’s famous sick role. The visual empiricism which unfolds in the reading room is a drama of proximity to the image and, above all, autopsis.

“Autopsy” is wrested here from common usage-opening a corpse, as in the coroner’s inquest-and restored to broader connotations. Autopsis is a term from ancient rhetoric which pertains to testimony of the eyewitness. It is about seeing for oneself and saying what one has seen.

Neuroimaging fellow: [on phone with attending:] Are you coming down soon? [pause] Oh, OK. ‘Cause Terrance [a neurosurgeon] called again. He wanted you to look at this. OK, well, I’ll tell you what it looks like [laughing]. Tell me your diagnosis. There’s a nonenhancing, no mass effect, high signal T2, low signal T1 lesion in the white-periventricular white matter kind of going up in the centrum semiovale. Looks like PML, but he’s fifty-nine years old and it’s the wrong location, so it’s something demyelinating. And it was read outside as a tumor but there’s nothing there. [laughing] OK. [pause] OK, I’ll tell Terrance. Thanks. [laughing]

Investigator: What’s the word?

Fellow: I guess he didn’t trust my, uh, description.

Investigator: So he’s gonna come down.

Fellow: In half an hour … [laughing]

Autopsis comprises the fragility of seeing, the perils of poor seeing. As mode of personal knowledge, autopsis connotes existential weight-a sense of immediacy for the subject whose faculties are enrolled in an act of attention. Yet ocular witnessing in a teaching hospital is often a social event as well-embracing both object of viewing and context for bearing witness-audience, dramatic conventions, scripts. The term conjures a larger representational and rhetorical economy within which some modes of viewing and modes of testifying are superior, convincing. If autopsis connotes self-possessed direct observation, it also connotes a problematic of persuasion and reception, a performative milieu in which the veracity of the viewer is not so much presumed as it is at stake.

Native Vision

Body CT attending: Today I haven’t been doing any work other than just using my eyes and my few neurons.

Body CT fellow: That’s quite all right.

Attending: I haven’t done any physical work.

Fellow: You don’t get paid to do physical work.

Attending: That’s right.

Fellow: You get paid for the mental / visual.

Attending: Actually, I did do some physical work yesterday. I did a couple of GI studies. I even did a couple of walkie-talkie upper GIs yesterday.

Notwithstanding this attending’s distinctions between seeing and doing, it would be a mistake to apprehend the viewbox “gaze” as a simple, coherent, or merely visual experience. Looking comprises a multiplicity of gestures, especially pointing. Even without a patient’s body at hand, the visual/visible is intertwined with the speakable/audible and the tactile/touchable.

“Did you see that chest wall process, Don? There’s both a intraparenchymal component as well as a component out in the chest wall. Um-Barry, can you see? Need to pull up a chair …” Summons to closer engagement, and specific postures. Radiographic reading is usually done sitting. It is not that images cannot be reviewed standing: they often are, especially by visitors. Viewing images involves various postures-sliding back to see more wholly, leaning forward for minute details. But for radiologists, sitting is a posture of method-and of being at home at the viewbox. Legs tucked under the writing surface, feet on the floor. (In some reading rooms, feet work film transport controls; in some they work dictation controls; in some they work an auxiliary “hot light.” At University Hospital’s CT viewboxes they are often more solidly planted.)

A senior attending recounts his visit to a distinguished New England hospital with a large radiology department, during which he was struck by the battered chairs in a reading room-mismatched, “all taped up and everything.” In contrast, chairs in his CT reading rooms match and are in good shape-adjustable heights, smooth casters, hinged backs-and comfortable.

Once seated, radiological vision uses few prostheses. Occasionally one sees a reader of mammograms holding a magnifying glass. And on computer monitors, magnification and contrast can be adjusted. But diagnostic film viewing, including CT reading, is mostly macroscopic: it employs a “native” vision, a repertoire of squinting and scanning and gazing, a few feet from the image surface. This is especially true of ct as compared to “plain” radiography (e.g., chest x-ray): CT scans are relatively coarse-grained.

Unlike “life-size” plain radiographs, CT images are typically displayed an order of magnitude or so smaller than the specimen they reference, with many images on one sheet of film. Film size is standard, but the “matrix” of slices on each sheet-“3 by 4” (columns by rows)-is variable, subject to differing conventions, even to ad hoc specification by readers. The smallest CT findings represent millimeters of tissue. One ct fellow quotes an attending-“My eyes are calibrated to two millimeters”-and then quips that, for his part, he is accurate to “plus or minus five millimeters.” Conventions of ct display calibrate an arm’s-length gaze, with respect to film, to the scale of arms-length handwork, with respect to the body. CT findings represent objects that might be held between the fingers.

One indication of how scale and size relate to ct reading is a recurring phrase: “too small to characterize”-as in, “little low density area in the kidney, too small to characterize.” This has a concrete meaning: “[If] we put cursors on that we will not get a valid [Hounsfield] number.” CT readers often note darker or lighter flecks too small to be registered to density scales (whereby liquid is distinguished from gas or solid, fat from muscle). Findings too small to characterize are not below the threshold of the significant-but are unquantifiably ambiguous.

“Cursor on the lesion” highlights practices of pointing. The cursor is a prosthetic extension from hand to screen, a gesture. Radiologists do a lot of pointing.

As a fellow at the board moves images with right hand on the toggle, she points with her left hand at specific locations. A clinical attending beside her points and asks: “Is this compatible to a met?” Pointing is collegial: it orients the gaze of another to what one is inspecting. It is a feature of conjoint autoptic practice: seeing for oneself, together. Pointing is more common in CT than in some other kinds of collegial radiologic viewing. This is in part due to the multiplicity of viewable locations-many slices, much detail, at small scale. Verbal denotation becomes clumsy: “look at slice 33” or “below the level of the renal arteries.” A corollary function of pointing is more impersonal: indexing, targeting. The index connects a regime of search to a locus of suspicion. Index>Target is a staple of the radiological imagination: arrow in the bullseye, crosshairs on the enemy: accuracy in service of conquest.

Body CT resident: [deleting patients from MagicView archive] Hey, Amy, what am I doing here? … OK, see if I click anywhere in here nothing happens, but if I click on one of these little dots right here, that happens. If I click over here on this dot, that happens-

Fellow: It must have something to do with this-this is like a magnifying thing. I don’t know what that one does.

(Continues…)

Excerpted from CT Suiteby BARRY F. SAUNDERS Copyright © 2008 by Duke University Press. Excerpted by permission.
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