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Teaching and Learning Moments

B-ball and Bread Crumbs

Paul, Trisha K. MD

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doi: 10.1097/ACM.0000000000003060
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“What do you see?” my attending physician asks.

We all lean forward, peering eagerly into the tiny microscope lenses in front of us. Six faces press against a giant teaching microscope, eyes gazing intently into a single smear of blood.

I look out at the cardboard slide covers scattered around the table. One open nearby catches my eye, the name Adam scrawled barely legibly in Sharpie. His face materializes in my mind, a teenage boy with a baseball cap, a patient I volunteered with years ago as a premedical student. He adored his beagle, who always slept at the foot of his bed, and he claimed that his greatest accomplishment was being the best older brother he could be. I blink and look back into the bright microscope window.

We start by noticing the most noticeable: erythrocytes. Red blood cells, like red Fruity Pebbles suspended in cereal milk. But there aren’t as many as we would expect; we can tell from the abundance of white light glaring back at us. “Anemia,” someone offers. “A red blood cell deficiency.” Perhaps that was why Adam would hunch over, his hands resting on his knees, his body heaving as he breathed deeply and gasped for air between basketball quarters.

“What don’t you see?” my attending asks.

Platelets, I think. Those tiny maroon fragments that clump together in the event of vessel breakages, usually broken and scattered like bread crumbs throughout a slide, seem remarkably absent. Adam’s persistent bloody noses come to mind, the ones that wouldn’t cease for hours and hours. As a medical student, I marvel at how pathology offers such an intimate understanding of a body’s workings and failings, allowing me to know Adam in ways I never had before.

Our eyes follow as our attending whisks the microscope’s gaze around the smear. More Fruity Pebbles, sometimes in globular rouleaux formations, where red blood cells cling to one another. Still hardly any bread crumbs.

And then we see. There.

They stand up straight, mighty against the others. Majestic, their prominent dark purple nuclei dominating and defining them, their physiques embodying an incredible capacity to divide without cessation. With hardly any cytoplasm, they look like basketballs, big and round and full.


These are to blame for the lack of erythrocytes and platelets, for Adam’s overwhelming fatigue and easy bleeding. Their excess explains his ultimate demise.

Nauseated, I look away from the microscope. I close my eyes, escaping the objective truth of these ever-present blasts and settling into the memory of butterflies set free into blue August skies at Adam’s funeral. For a moment, I find relief within the comfort of darkness, a brief respite from bright light.

Copyright © 2019 by the Association of American Medical Colleges