IT’S LIKELY NOTHING | Ariel Bugosh Boswell
I lie on a table in a bikini as the technician adjusts the sheet around my waist. Five attending and resident doctors use their new point-of-care ultrasound devices to view my intestines. A year into COVID, we all wear masks and can’t see each other’s mouths. However, they can see my jejunum; my husband hasn’t even seen that. I want to make some remark like “you should buy me a drink first,” but I swallow my salty wisecracks because this is a medical education seminar, and as a nurse I don’t want to compromise my professionalism anymore than I already am.
I reassure myself that I’m just an anatomical model on a table to look inside, not someone they know with pearlescent stretch marks. To them, I’m a garden-variety liver, a stoneless gallbladder, a healthy spleen.
Two weeks ago, my friend had asked a big favor; would I show people my guts? He organized an ultrasound course for physician colleagues to learn and practice new point-of-care ultrasound skills but was still short a model. Could I please drive over and be a standardized patient for a few hours? The department would pay me. I accepted immediately. I liked the compensation, and doing my friend a favor, but my main driver was curiosity. I’m a nurse! How could I pass up a chance to glimpse the unseen parts that keep me alive? Like Pandora, I just wanted a look inside.
Channeling my inner artist’s model, I raise and lower my legs, put my arm above my head, and turn my neck side to side. They use a warming gel that tracks across my body like a snail.
The ultrasound technicians traveled here from Florida. Bea, the tech at my table, has gray hair and glasses; she moves her probe like an extension of her own hand. She has worked with ultrasound for 20 years. If I were in a bad accident, they could use the probe to see blood in my belly. “It would be black like the background,” explains Bea patiently over and over again. “She has nice anatomy,” she tells a group and I giggle inside as they examine my gorgeous gallbladder, my alluring appendix.
As a registered nurse, I’m not accustomed to looking inside people. In nursing school, we learned how to insert IV catheters, urinary catheters and enemas. My current role in outpatient family medicine requires more talking: assessing patients, delivering test results and coordinating care. I can listen to patients’ hearts, lungs and bowels; I don’t look in there. When I give vaccines — the only invasive procedure I do in my current role — I use a chilling spray to ease pain and always bring a bandage. Insides stay in.
I hadn’t realized how many of the doctors around the ultrasound table I would know just from working in primary care for many years. Many avoid eye contact; they may not recognize me outside of scrubs, my abdomen bare, my face obscured by a mask. They are here to learn, not socialize or reflect. This strangely intimate interaction feels like work to them. Only one resident greets me warmly, asks permission before pressing, and warns me about the cold gel. “You have a great bedside manner,” I tell her.
Bea shows the onlookers my eyeball, my heart, my veins. No blood clots. She presses on my neck to show the thyroid. I have a few nodules, she notes as she deftly investigates my neck.
“That’s interesting,” she says, pointing to a blot on the screen. “That thyroid nodule is clinically significant!” Seeing my wide eyes, she reassures me. “Many people have these and don’t even know it. Still, you should get it checked out.”
After I finish for the day, Bea writes the dimensions of the nodule on a print-out, ominously titled “Suspected Pathological Findings.” She jots a note: “complex with some vascularity.” In other words, the nodule contains a mixture of fluid and solid parts, and evidence of some blood flow, all factors that increase the concern for cancer.
On my thirty minute drive home, I keep palpating my neck, imagining I feel something. I wonder if anyone will remember my thrilling thyroid.
***
Three years after volunteering for the course, I lie in a dark ultrasound suite for another thyroid follow-up. I have had two so far with rechecks recommended every one to two years.
“Lie back,” says the tech. I arch my neck backwards. “Farther,” he says. I force my chin higher. Intellectually, I know there’s no threat, but my body tries to guard my trachea.
On the screen, I see the nodules. With Doppler, a setting that detects movement and blood flow, some shimmer like living rainbows. One looks like a night full of tiny white stars. The images on the screen are abstract, no more than Rorschach ink blots to me, but the technician measures and describes everything for interpretation.
The next day, I get the results; the concerning nodule may have grown, or the technician may have measured it differently. Either way, the radiologists consider it borderline, eligible for a needle biopsy.
My provider notes that it’s likely nothing. On the other hand, it could be something. She leaves it up to me. What do I think? What would I like to do?
I’ve never smoked, never had a tattoo, never drive without a seatbelt. The thought of not checking seems absurd. “Let’s do it,” I write back.
A few months later, an ultrasound tech, two nurses and a doctor assemble in another twilit room to perform the biopsy. “Will it cause a thyroid storm?” I ask as they swab my neck with iodine. “Will it stir things up, release hormones, make me sick?”
“Very unlikely,” the doctor soothes. They try to keep the needles out of my field of vision but I can tell they are longer than anything I use.
Even after the nerve block, the biopsy feels like a bee sting I can’t slap away.
***
Back at work, I call a patient about her test results. “The doctor says your chest CT scan didn’t show any worrisome cause for your cough, but it did show some small nodules.”
“What? What does that mean? Do I have cancer? I don’t even smoke.” Panic pours over the phone.
“Lots of people have these nodules,” I reassure her, pulling from the doctor’s note and the dozens of similar conversations I’ve had about these over the years. “They are very small.” I review the algorithm based on the number and size of nodules. “They recommend rechecking in one year, just to see if they’ve grown.”
“Shouldn’t I have them checked right away? Shouldn’t they do a biopsy or something?”
She wants certainty. Don’t we all want certainty? Don’t we all want black-and-white answers in a shifting gray world studded with stars and streaks of rainbow?
I talk about all the things that can cause lung nodules - old, obscure fungal infections, inflammation, scarring. “We’ll see how it looks in one year. If they grow, they’ll take a closer look.”
“I’ll write it down in my calendar,” she says.
***
“The thyroid biopsy pathology is normal. No malignancy,” my doctor tells me via portal several weeks later. “I think it’s still reasonable to continue watching.” I start the countdown to my next ultrasound.
Running my finger along my neck, I imagine I can feel the divot where the needle went in. When I signed up to be a model, I couldn’t wait to catch a glimpse beneath the surface at the smooth, abstract shapes of my organs. I forgot that once you look inside Pandora’s box, scary, uncertain and difficult truths escape as well.
But simmering in constant anxiety is no way to live, especially for a nurse exposed to illness, pain and bad news everyday. I reframe and reassure myself the way I would a patient.
Most people never know they have these. This nodule won’t grow. If it does, we’ll catch it in time. Thyroid cancer is extremely treatable and survivable.
When Pandora opened the box, filling the world with illness and sorrow, one gift stayed inside. The same finding never shows up on medical imaging: hope.
Ariel Bugosh Boswell writes poetry and fiction. Her work has appeared in Vox Poetica and the Barefoot Review. She works as a nurse in family medicine and writer-at-the-bedside providing creative writing activities with patients and staff at Mayo Clinic. In addition to her patients, she takes care of her husband, two kids, two dogs and a silk orchid.