Sometimes, You Can See Whales

February 24, 2020

Making a diagnostic discovery can feel like catching an elusive glimpse while whale-watching.

I recently took a vacation trip that I’d uncharacteristically planned almost a full year in advance. Usually, my style is “Gosh! That vacation week is coming up fast-where the heck are we gonna go?” But, this particular destination had been in my sights for years, and I’d finally decided to make it happen: A relatively-undeveloped area in the Baja peninsula, much more for fans of unspoiled nature than it is for the party-hearty Spring Break crowd.

Its primary appeal for me was that a lot of whales winter there. Grays, blues, humpbacks, orcas, the list goes on. They’re sufficiently abundant that it’s as close as it gets to a sure thing that you’ll see them if you go looking at the right time of year. Hence, last spring I began planning this winter’s trip.

My track-record with whale-watching has been far from great. My first outing, in med school, not only turned up zero cetaceans, but also ended with me pretty darned seasick because I’d clambered up to the highest spot on the boat to get a good view. When the craft stopped moving forward, I was effectively at the tip of an upside-down pendulum as the craft swayed back and forth. Oops.

On this trip, we headed out twice: One excursion to the Pacific coast, where gray whales and their calves would reliably be seen, and another in the Sea of Cortez, where blue whales were the main focus. As promised, the first excursion broke my bad luck streak. Short of closing one’s eyes, there was no not seeing the critters. Look in any direction, there they were.
Not so fortunate for the second outing. While other folks on my boat got to briefly see a solitary blue in the distance, by the time I had turned to share the view it had re-submerged. We had a decent consolation prize, in my opinion - later we encountered a pod of bottlenose dolphins who were very eager to play with us. They probably would have hung around our boat as long as we lingered, but eventually we had to move on.

Although I would, of course, have loved to see the blue myself, not to mention some other types, I had been prepared for missing it. Spending time and money on previous unsuccessful whale-watching trips had steeled me. The thought also occurred that other walks of life, diagnostic radiology included, have their parallels. (Were you wondering how, or even if, I’d be tying this to the loose theme of my column? Ye of little faith.)

Being out on the open water and hoping to catch a glimpse of a whale’s spout, if not part of the creature itself, isn’t all that different from opening up an imaging case in search of a diagnosis or evidence of the absence of one. You might have a method that increases your chances-a search pattern for body CTs, for instance. Our guide for whale-watching tried to get each of us to look in different directions so we’d have all points covered, everyone ready to announce a sighting in terms of “clock position” so others could swiftly know which way to look.

Even with the best, most efficient search pattern, as a mere mortal one is not going to be 100-percent attentive to and appreciative of every little detail as one’s eyes pass over it. Missing or misinterpreting an abnormality, or failing to recognize a pertinent negative that would rule out a particular diagnosis, is to be expected.

It’s happened more than once to me that I briefly mistook a prominent wave - or a rock just breaking the water’s surface - as my very own sighting. Then, even when I recognize my error, I, not uncommonly, continue to scan the area because some part of my brain isn’t quite ready to let go of it. I’ve done the same with imaging “lesions.” I thought I saw something in the liver, realized there wasn’t anything there…but I go back and look in the area a few more times before I sign off and close the case.

The observer (rad, whale-watcher, or whatever else) is also not the only factor. Just as a whale-watching boat might not happen to be in the right place at the right time, maybe the imaging study that was ordered by the referrer wasn’t the best modality to use, or it focused on the wrong body part as result of referred symptoms. Maybe the study was ordered when the patient was having symptoms two weeks ago, but he’s since recovered, and now there’s nothing to see. And, of course, technical limitations on studies have been known to impair our diagnostic work.

But, when we do make a diagnostic difference-just like happening to see a whale poke its head above water to “spyhop”-that can more than make up for the boredom, even frustration of having searched fruitlessly on other cases for half of the day thus far. It’s why many of us got into this biz in the first place, and hitting a little paydirt goes a long, satisfying way.