Dr. Ahmadi Sees a Melanoma

Dr. Layla Ahmadi has spent years imagining that day, although in her motivational visions she had not accounted for the effect of the July humidity in Tampa on her curly dark hair. No matter though, her frizz would be covered up by a light blue bouffant scrub cap in a minute, then further smashed down by the MelVis headlamp. The MelVis looked like the light-weight LED headlamps she had worn for complex abdominal cases as a surgical oncology fellow, but it emitted more than bright light. So much more. And today was its day to shine in the operating room.

As an undergraduate physics major at Stanford, she couldn’t decide between a career in clinical medicine or scientific research and was thrilled to discover the option to pursue an MD-PhD degree and do both. Her PhD thesis had described the light refractory characteristics of melanin, and she knew she was on the cusp of something incredible. Her mentors in the pathology department expected her to join them, spending her life analyzing specimens, slides, and stains, but she had been completely entranced by general surgery on her third-year rotation, and shocked everyone by matching in surgery at UCLA.

During her five years of general surgery residency, she was mostly focused on surviving the long hours of work and the intense and exhausting call shifts. She had been accepted to a prestigious research fellowship at the National Institutes of Health and considered taking two years off from residency to do that, but the urge to start her career before turning 40 had been too strong after the extra years she spend on her PhD. Following residency she matched to a two-year surgical oncology fellowship at Moffitt Medical Center in Tampa Bay, which is how a girl with Somali parents who grew up in Minnesota and loved the quintessential American-ness of California had ended up in Florida, a different flavor of America.

Although she had started working on the concepts that would lead to the MelVis during her PhD years, it all finally came together for her when she rotated with the melanoma surgeons as a fellow. There had been incredible strides in the medical treatment of melanoma with immunotherapies, a truly lifesaving regimen for patients with advanced disease, but these new medications were not without side effects. Dr. Ahmadi saw that the holy grail would still be a cheap, fast, comprehensive screening tool to allow for diagnosis of in-situ lesions that could be treated with minor procedures instead of systemic therapies – like a mammogram for the skin. She spent years bridging the gaps between academic research, public grant and scientific industry funding, and skeptical doctors to develop the MelVis.

Now she was 43, single and childless much to her mother’s disappointment, but about to confirm what she had felt to be true deep in her bones for at least the last eighteen months: when shined on tissue at a direct angle, the MelVis could detect and illuminate (in green, a color chosen because of the paucity of overlap between spring-grass-green and human tissues) melanoma cells otherwise invisible to the human eye. The preliminary trials her graduate students had performed on in dermatology offices and her own preoperative clinics had been extremely promising, with the MelVis having a higher correlation with a biopsy demonstrating melanoma that the clinical assessment of the most experienced dermatologists, but she knew the intraoperative identification of the extent of these cells was the missing piece of proof she needed before introducing the MelVis to the world. 

Dr. Ahmadi stood with a reassuring hand on her patient's shoulder as he drifted off to his anesthesia-induced dreamless nap, and then stepped back outside to scrub her hands in preparation for the operation. Before peeling the outer packaging from the chlorohexidine soap sponge, she clicked the MelVis on, unable to suppress a grin underneath her mask. Performing the scrub ritual on auto-pilot as she had done thousands of times, she was humming with excitement and almost tiny flashes of green on her left forearm as she rotated her arms to scrub and rinse. A surgeon-scientist to the core though, her career built on differentiating tiny variances, she did notice. Incredulous, she actually looked around at the area around the sink to try to find an occult green light. Her eyes scanned the automatic faucets, the white ties of the masks hanging from the boxes on top of the sink where they threatened to contaminate her just-washed hands, the stack of disposable plastic goggles, the framed reminder about the surgeon’s role in keeping the room running on time (impossible not to roll her eyes at this piece of clueless upper management intrusion – the surgeons were the rushers, not the delayers), and the shiny chrome of the sink itself before settling back on her forearm. The truth felt like a slap across her face, first just startlingly but painless with the sting following quickly. She must have a melanoma on her arm. She believed in her own technology and had always been covered up by a lab coat when she had worn the MelVis in other situations so it made sense that she hadn’t seen it before. 

Reeling with this discovery, Dr. Ahmadi did what she had been trained to do for years – ignored her own feelings and got on with the case. Everything went smoothly, and the MelVis identified a halo of green surrounding the site of the initial biopsy even though the dark mole had been removed. After marking the boundaries of her planned wide local excision on the patient’s back and removing the tissue, the MelVis demonstrated a faint green lucency at the inferior border. She took a small sliver of additional tissue from this area to send as a separate final margin specimen. Her research coordinator then carefully slid the MelVis off her head, put it on her own head, and used it to photograph the illuminated specimens before they were plopped into formalin. Dr. Ahmadi closed the surgical site in multiple layers, talked to the patient’s wife, responded to a few messages from her office, checked on the patient in the recovery room, repeated the cycle with three more surgeries, and then finally texted one of her dermatology colleagues that she had melanoma on her arm and needed a biopsy.

***

Two days later in the dermatology clinic, Dr. O’Neill was skeptical.

“Layla, I really don’t see anything there besides your pen mark. Are you sure you want me to biopsy this?”

“Absolutely. MelVis lit up, and we needed it in my clinic today so I couldn’t bring it to show you, but I am totally sure. I trust it!” Dr. Ahmadi replied without hesitation. “Come on, just humor me. If it’s negative then we both win – you got to catch up with a friend and bill for a procedure and I won’t have melanoma after all.”

Dr. O’Neill smiled. “We could just grab a drink after work, you don’t have to talk me into maiming you.”

Dr. Ahmadi was steadfast. “If you don’t do a punch biopsy, I will, I just figured insurance would be more likely to cover it coming from you.”

With a sigh, Dr. O’Neill relented. She cleaned the area, gently injected the lidocaine, and removed a small piece of skin from the area marked with a blue ballpoint pen “X”, a piece of skin that looked completely normal.

***

Dr. Ahmadi hadn’t wanted to have melanoma, but not as much as she hadn’t wanted the MelVis to be wrong. It wasn’t though. The biopsy showed she had an early-stage melanoma, and she was soon scheduled for her own wide local excision of the area. Her partner performing the surgery wasn’t listed on the MelVis research protocol – an oversight that the research coordinator responsible for protocol personnel maintenance had already been reprimanded for – but Dr. Ahmadi insisted on having a research coordinator with the device in the operating room to take specimen photographs. Her partner was more than willing to humor her since she had been an excellent colleague and had once spent an entire weekend helping him write his first major grant.

He was nervous about operating on someone he knew so well but understood why she would refuse to go to any hospital besides where they worked, and the surgery went smoothly. Dr. Ahmadi woke up in the recovery room feeling as if no time at all had passed, and in fact had to look at the two-inch scar on her left forearm before she believed the surgery was finished. As she eagerly awaiting the final results from the surgery, her mind reeled with the implications of the power of the MelVis and, by association, her own power and responsibility.

***

Dr. Ahmadi woke up on a hard bed, with what felt like firm teddy bears cinched around her wrists. Just as she was about to open her eyes, she heard her name, and decided to pretend to still be asleep.

“Who do we have here?” asked a clipped, authoritative female voice.

“This patient is Layla Ahmadi, uh, I mean Dr. Layla Ahmadi. 43 year old woman admitted for acute psychotic episode with, uh, symptoms suggestive of underlying schizophrenia and I think even possible histrionic personality disorder,” replied man, his voice wavering uncertainly.

“Tell me the story,” the female voice said.

“It’s actually really sad,” another, more confident male voice, said, dropping to a whisper. “She’s a surgeon and had spent years researching this headlamp thing that could diagnosis melanoma, which is obviously super cool, but then she found a melanoma on her own arm.”

He paused, glancing into her room to make sure she was still asleep Dr. Ahmadi assumed, before continuing, “When the path from her surgery confirmed it, she started wearing the device all the time. Like not just at work, but all the time. She went to crowded public places, like restaurants and 5K races and Rock the Yacht, and she would just walk around shining it on people then telling them they had melanoma and imploring them to get tested. She took a leave from her actual job because she insisted she could help more people by bringing it ‘out in the wild’ but obviously it was a bit much. I mean the data hasn’t even been published, this thing is years away from FDA approval. They even looked back and apparently it seems like she faked a lot of the animal trials and rushed into human trials, so now research administration is looking back at all of her stuff…anyway, that’s why she’s here. She had to get Haldol about an hour ago because she was combative when the nurse told her she couldn’t go to do her surgeries today. She might not be up to talking to us yet, but we’ll see.”