Saturday, August 14, 2010

Reflection on a Saturday: TB or Not TB? That is the Question.

acid fast bacilli of Mycobacterium Tuberculosis


I got stuck in a Grady stairwell last week. I entered one of the locked stair entrances behind someone else who'd just gained access using their magnetic badge. I thought nothing of it. I mean, it's not like I needed the person to be all super-nice and let me into the door like some kind of visiting medical student. I mean, I'm on staff here. My badge works. But if someone wants to offer me an act of chivalry by holding a door for me to enter the stairwell, I'm cool with it. Completely cool with it.

But the chivalrous house officer who let me in bid me adieu at the 9th floor. I gave him a wave and kept trudging up a few more flights to the 12th. Huffing and puffing, I touch my badge to the plate waiting for the red light to turn green signaling an unlocked door.


That was the sound of me trying to pull open the heavy metal door. That's weird. I carefully separated the badges on my hook to make sure I was using the right access card. Let's try this again.

::clunk, clunk, clunk::

Damn. I was locked in the stairwell. Like a visiting medical student. No, worse than that since, now that I think of it, even visiting medical students have working badges.

I looked at my badge and. . . . awww shoot! "7/2010" was the expiration stamped boldly across the bottom it. I smacked my hand against my head. Aaaarrrggggghhh! The dreaded expiration lockout.

::clunk, clunk, clunk:::

(Visiting medical student) "Uhhh, Dr. Manning? Is that you?"

::clunk:: "Errr. . .yes, can you let me in please?"

Access granted. By a visiting medical student, no less.



You see, at all hospitals, but especially public hospitals caring for folks from literally everywhere, badge renewal comes with one special little rite of passage: the PPD or TB skin test. For those who aren't in the medical field, a PPD test is something that looks to see if you have been infected with tuberculosis. And seeing as folks in hospitals randomly cough and hock all sorts of things near you, on you, and around you--every year, it is the hospital's responsibility to the public to make certain that one of those folks didn't bless you with some acid fast bacilli (such as tuberculosis.)

I was supposed to have my badge renewed by the 31 of July, which means I needed to get a PPD test first. Okay, I'll admit it, I dropped the ball. I kept "forgetting" to take care of it. . . .that is until last week when I had to be rescued from a stairwell by a visiting medical student. Great.

So. . . . I hang my head and shuffle up to the 15th floor to get my TB skin test. Here's how it works:

You enter the Employee Health Clinic.

They ask you, "Is this for badge renewal?"

You say, "Yes, ma'am."

They say, "Let me see your badge, baby."

You say, "Yes, ma'am."

They take your badge and look at it. If you are a good egg with an unexpired badge, they smile and hand it back to you. If you're a hard-boiled (aka hard-headed) egg (like me), they see that your badge expired in July when it is now August. Then they ever-so-subtly turn the corners of their mouth downward and ever-so-audibly say, "Ummm hmmm." This is followed by a much deserved hairy eyeball as they hand your badge back to you, searing you with a scarlet letter for being a menace to the society (and public health.)

They inject you just below the skin of your forearm with this TB detection potion. If you're unlucky, it causes your arm to explode into a big red mound at the injection site if indeed you have been infected with TB. Oh, and it takes a minute to resolve. Um, yeah. That's pretty much how it works.

the positively positive puff-daddy PPD (with control)

When I say "infected with TB" I don't mean sick with consumption and coughing, per say. Millions of folks are "infected with TB" but it lies dormant in their systems. A positive PPD just means you've been exposed and infected at some point--but it doesn't mean you will get sick. Taking medication for 9 months after finding out you have the dormant or latent type of TB usually keeps it knocked out like Sleeping Beauty. So what's the big deal?

Okay, so here is my confession:

Sigh. I know I need my TB skin test every July and . . . .admittedly, I don't actually forget completely. At risk of sounding horribly horrible, I'll admit that:

  • 1) I am annoyed that my badge is up for renewal during the hottest, most humid, most short sleeve bearing time of the year since
  • 2) I have this secret fear of having an exploding mound on my forearm for the entire summer if I have indeed converted, and
  • 3) It would really suck to have on a lovely sundress in July accessorized with a positive PPD. . . oh yeah and,
  • 4) for the 48 hours after I get the test, I can't help but to chronicle every patient I've met all year who coughed, belched, sneezed or showed me a basin, cup or kleenex filled with giant, blood streaked lougies for my inspection. (I mean just maybe they could have been teeming with tubercles. I'm just saying.)

What happens to me every year:

  • 24 hours after getting my skin test, the site is itchy, red and a little bit puffy. Oh no. Was it the man in the elevator who coughed from the ground floor all the way to the 12th last winter?
  • 36 hours after the injection, the puffiness is mostly gone, now it's just red.
  • 48 hours later, it's just red. Whew.

(For the record, a certain number of millimeters worth of puffiness, not redness, is what counts as a "positive" PPD test.)

Looks like my PPD is red, yes. But puffy? No, ma'am.

48 hours on-the-dot later, I skip into Employee Health all happy that I am no longer a menace to public health and society. I pull up my lab coat sleeve and show her my left forearm. Ting. (That's me smiling at my clean bill of health.) When I notice the nurse looking at my red (but not puffy) forearm, I decide I don't like the silence. Rut roh. I feel myself having a Grady flashback from four years ago with my PPD skin test reading.

Oh no. Not again.

See? It's always drama when it comes to me and the PPD. As mentioned before, every year, there's some preservative in the TB test potion makes my arm turn red, puffy and slightly itchy for the first 24 to 36 hours. During that time I get to worry and wonder if I've converted this year, (and nearly burst into flames in the 100+ degree Atlanta heat while wearing long sleeves to keep folks from asking me, "Ooohh! You PPD positive?") So far, that reaction has always subsided--leaving behind a small, flat red spot. For the most part, once they see that it's red but not raised, it's all good. For the most part with the exception of four years ago. . . . .

Employee Health circa 2006:


"It's red but not indurated," I protested. (indurated = hard, puffy)

"I don't know about this, baby. . . .I don't know."

"Nuuhh uuuuhh!" I started feverishly rubbing my hand over my forearm and before I knew it, was defending myself like a 5 year old. "It's flat, see? It's not puffed up."

The nurse looked at me and shook her head. "I don't know, baby. . . ." she repeated.

She ran her hand over my arm a few more times and then said, "Come with me."

::smush smush ::click click:: smush smush::click click::

(that was the sounds of my heels following behind her nursing clogs.)

::smush smush ::click click:: smush smush::click click::

I walked behind her to what I thought was going to be the next room to get a second opinion from the other nurse. Nope. She passed that room and two more nurses. We kept walking. Down the hall, through a door and into another hall. Around a corner and yet another hall to a door, deep in the bowels of Grady. The nurse rapped on the door softly and waited for a response.

"Enter," a raspy voice commanded. My pulse quickened.

We opened to door and -- maybe it's exaggeration but is my recollection that the door creaked open slowly and a gust of smoke flew from beneath it. The first thing I see is an intimidating-looking woman with reading glasses hanging on a chain around her neck. (I am convinced that this is akin to meeting Yoda or The Wizard of Oz or the Oracle from the Matrix.) As soon as we crossed the threshold, she rose from her desk and slid the readers onto her nose. She slowly approaches me offering not even the slightest expression that could be mistaken for a greeting or welcome of any sort.

Instinctively, I thrust my arm out in front of her. Gulp.

Without uttering a word, she studied it with her readers, and then glided her hand over the red patch on my forearm. I held my breath and waited for the verdict.

::rub, rub, rub :: smack! ::

Pulling the glasses off her nose, she turned her back to us and muttered, "Negative."
And that was that. The master had spoken. No questions. No "but don't you think this part is questionable?" No back talk. Best of all? No TB for me (at least that year.)

Ever since then, I break out into a cold sweat when the time comes for me to get a PPD test. . . .one part vanity from not wanting the possibility of wearing a red mound on my forearm all summer (I'm just saying. . .) and one part PTSD from walking the green mile with that nurse to go see the Dumbledore of PPD readings.

Fortunately, I passed my test this year, too. And without having to get a second opinion. Whew.


Today on my hospital rounds at Grady:

:: clunk, clunk ::

Turns out that once you let your badge expire, you have to go to the secret badge dungeon even deeper in the bowels of Grady to get it reactivated again. . . .but that's another post for another time. . . . .

my so-called renewed badge (I look so happy 'cause I'm PPD negative this year.)


  1. In all seriousness Dr. Manning, I think your life needs to be filmed and made into a reality TV Show

  2. ugh I hate TB testing. We are lucky though... at the VA we've switched over to blood tests instead of skin checks.

  3. PPD tests are forever and always a pain in the.....arm.

  4. You have just simultaneously entertained me and informed me about what I can expect for my TB test. Thank you.

  5. I'm just starting work at a public hospital (procurement) and got my first TB test since childhood the other day. I was looking for what a positive test should look like, and I stumbled upon your page. Even though I'm going to be late for my appointment now (thanks!) I'm really glad I stumbled upon this. You really have a talent!! Keep writing! Thank you!

  6. I just got my TB test and I am in the 24-36hr window. Its now red, a little raised and itchy so I was getting worried I would end up with a positive test. I have been searching through Google results trying to find something to tell me how the test usually progresses. Your posting here is the first to give me some idea about what happens between the time the test is administered and read. Now I have some hope that it will still turn out to be negative.


    1. Me too! So nervous that mine is so itchy n puffy. Now the second day it's flat n all pinky. Slightly hard. This is my fourth test n I felt like the nurse put it in too deep unless the others before her didn't go deep enough but there wasn't a bubble left behind his time and I hurt! And I'm preggo n all hormonal n worried. This made me feel better though! Crossing my fingers!

  7. OMG TY TY, that was so hysterical! I loved every second of it! I recently had to have a TB test, and it has currently been 14 hours, it is red but not really raised, yet I still find myself trying to look at it from every angle to see if it's considered to be raised from this view or that, which is how I ended up here.

    I was trying to be nice by giving this guy a ride, then he gets his checked just before me and it is positive. So now I'm in a complete panic thinking he has infected me, and I'm watching this ugly blotch like a HAWK! *crossing fingers*

    Glad you tested negative on yours though:)

  8. I am a medical lab scientist and I am in the same boat. I hate being allergic to the stuff the tb-gunk is in. Every year, hoping you find someone who really knows how to read them, the obsessive "it's still just red, right?"

  9. Great post, made me feel a lot better I too get this same type of reaction every year.

  10. I could have written this post! I feel exactly the same way every year and was similarly challenged in 2005. "There is no induration, it's just red!! You only count the induration!" In my case they called in another MD to say, "No, it is indeed NOT positive, it is negative." It traumatized me so much that now I never trust the "reader" of the PPD result, always worried they're going to look at my red arm again and say it's postive. I dread the annual PPD. Glad I'm not alone.


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