Saturday, January 16, 2021

Heterogeneity

     The physical sxs are out of control. I don't know if it's pandemic anxiety or what but I've hit new lows. Thursday when Jack and I went to Walgreen's around five to buy some presents for a belated Christmas get together for him and his friends - Izzy just got back from two months in France - I puked all over the sidewalk near the entryway while Jack stood on as a concerned sentinel. All day at work Friday thoughts of throwing up in broad daylight at Walgreen's made me laugh at myself. I was fine to shop afterwards and take him to get his haircut - he had an out of control tumbleweed growing out the side of his head. But there was a clean up process the puke got all over my mask and my glasses it was gross. I thought about alerting the staff of the incident for clean up purposes but decided hell no. I didn't want to call attention to myself.

    When I upchucked again at the same time of day last night (Cecelia worriedly got me some ice water and stood by) I assured them both I had no nausea I felt fine after it was related to the state of being of my mouth. On Wednesday I was certain I had a fever blister erupting in the corner of my mouth but the mucosa took on a more cobblestone feel that was truly disconcerting. Yesterday after the shower I reached in and was able to scrape out fingernails full of dead mucosa - it was sloughing off like never before. So now I'm not only brushing my teeth but my entire mouth.

    I have an acquaintance who had mucosal ischemia of the bowel while running marathons - she would bleed out her ass (which reassured me that marathons are not meant to be run by me) in the middle like she had colon cancer but it was just sloughing of the mucosa due to extreme activity and I googled it and it is a thing. Mine isn't bloody ischemic sloughing it's just white build up I'm not sure what the hell is going on but it causes no end of dry heaving during the day I'm sure the secretaries are sick of it I'm reassured that they are listening to transcription most of the day and hopefully miss it.

    Okay enough of that. At tumor board on Thursday morning one of the thoracic surgeons Jason Muesse (pronounced Missy according to the gross room Jessica said he told them) presented a case of a youngish guy, thirty something, who had a 19 cm mass in his lung. IR (interventional radiology) had done two biopsies that yielded nothing. I asked where he said Baptist I told him I'd pull the cases to review and see if it was worth sending off. He was worried about solitary fibrous tumor which is a rare diagnosis and tough to make. He said I cannot subject him to a third biopsy please help.

    I pulled the cases and damn. I took pics of the slides and sent them to him lamenting about the state of radiology today. I have told Ken Robbins more than once the new guys are not getting us enough tissue. Back in the day I did FNA's if soft tissue was in the differential I'd bring my 18 gauge core needle you need a lot of tissue to even conjecture a diagnosis and still you might be wrong. Years ago Derlis Martino - super sweet thoracic surgeon who moved on - did a core on a 20 something year old with a mediastinal mass and I made the mistake of calling it benign cartilage (like maybe a chordoma?) but soft tissue tumors are heterogeneous and when the resection occurred it was sent out and proved to be a low grade chondrosarcoma. Taught me to say bland instead of B9 because the part you see might look B9 but the other parts might contain malignancy.

    So I tried to do immunostains on the paltry sample (name that tumor on 30 cells) and came up with not much more than my chief had signed out but we did an addendum and hedged and suggested it could be and SFT but the CD34 didn't bear out and 90% of SFT's have CD34 but the BCL2 was beautifully positive need resection to give definitive dx. Jason was super thankful - I got a second phone call I assumed was a question he forgot to ask but it was just profuse appreciation for the extra work we did I was a little embarrassed. He asked about synovial sarcoma and I was like we didn't stain for that and there isn't much tissue left but that is a rare dx and if I ever entertained it I would send off to Cleveland Clinic for the characteristic translocation we learn for our boards (X;18) because that is the gold standard for that tumor and I've seen it like once in my years of practice so I'd have to research the current immunos.

    Jason was ok with that. He told me that he was going to probably take the guy to UAMS because the tumor was so big and pressing on the liver he wanted  a certain GI guy to be in the OR with him to help. He told me he would take lots of pics and share and update me. He said y'all are much quicker than UAMS I might not have a diagnosis for a few days (he is not the first thoracic surgeon that has told me this Matt Steliga sang our praises in quick turnaround) and I told him with a soft tissue differential they would struggle too so don't expect a rapid dx. Plus the heterogeneity is confounding in these tumors like a squame is a squame and adeno is easy and small cell is straightforward but a higher grade lesion in a soft tissue tumor can be elusive. Sampling is the key.

    So that was one case of over 30 yesterday but definitely the most challenging looking forward to the follow up. I'm so happy it's Friday looking forward to a relaxing weekend maybe tackle the 30 or so boxes we have left in the living room. I'm on call next week and Jessica assured me when I went to gross room for frozens yesterday afternoon (name that brain cancer on 30 cells it was a doozy I called for consult the uterine cancer frozen was much easier) that we will have an epic block count on Monday her people came in at three and four am to gross. She posited that people are rushing electives (and surprisingly cancer is elective) because Covid is hitting so hard we might get shut down again. I honestly would welcome that to get caught up on QA and admin but we will see whatever happens happens. Happy weekend much love, Elizabeth

Wednesday, January 13, 2021

Meeting Jesus

     Well I'm going to meet Jesus today and Michelle and I have had no end of fun on text with that. He's our fourth interviewee and our only clinical path candidate - we are losing Rex in June he's CP and BDQ is also CP so Brent, Maria, and Melody are towing the clin path line right now (Rex gave up CP on the condition of staying until June he was ready to bail in the fall but we appreciate his willingness to help us out). We don't hire often so this has been a stressful time and we will meet on Thursday to make our preliminary decisions. Honestly I wish we could hire them all but our hospital contract is pending and we can't afford to be flush with pathologists.

    Jesus has been in the states for about six years or so originally from Mexico City. Maria is from Mexico City too so she is excited and Melody had the rec from a friend she trained with (we tried mass advertising once before I came on and got a bunch of yoo hoos so that's not an option) and his training looks excellent. He was going to come on Friday but is getting a lot of job offers that are giving deadlines (so silly people take advantage of those just out of fellowship and pressure them) so today it is. Somehow hemepath is a lot harder to find these days than anatomic. Melody said he sounds lovely on the phone so I'm excited to meet him and he seems to have picked Little Rock as he and his wife's first choice if everything works out. 

    Brian seems to have turned a corner. Cautiously optimistic. He was able to withstand MRI yesterday without intubation and all the scary shit was ruled out. He has lost 24 pounds since December 1st (muscle atrophy can lead to gait issues and he did NOT have much to lose he was too skinny already) and they are thinking his hallucinations are from lack of sleep from coughing and Covid pneumonia not encephalitis or myelitis (which was our big concern). I saw Yousef yesterday and he is a neuropsychologist he rounds at St. Vincent's. He told me about a girl he knows who contracted it in August at Fville and she has vision loss and is having to learn to walk again after severe transverse myelitis. It's so unpredictable how this thing is going to affect people. 

    My doc mom book club texted some interesting stats from med exec committee yesterday (Kewen). Currently 20% of total admisssions are due to Covid. 45-50% of ICU pts are Covid. Total in house Covid at Baptist LR only are 111. If Covid + requiring ICU but not vent, about 40% mortality. If ICU requiring vent, 75% mortality. If vent + CRRT (continuous renal replacement therapy aka dialysis my dad had this for a short stint and it was scary as hell) 85-90% mortality - only 4 at BMC have survived this. There has been misinformation disseminated that if you had the infection you have to wait 90 days for the vaccine. 3 weeks out and symptom free you can get it. 

    Also importantly Wellington Pharmacy has a website where you can sign up for vaccines through phase 1C. My rad doc mom friend who shared has a husband with history of hypertension so he qualifies for phase 1C she signed him up yesterday. Wellington is one of the pharmacies that does the antigen test - we researched before going to see my dad. Phase 1C is currently not predicted to play out until April but still. Get on the list.

    Yousef said his wife is a pharmacist at St Vincent rehab they are currently overflow for Covid and she has witnessed six deaths in the last week. She is not trained to run crash carts and not prepared to witness deaths but nevertheless that's our new alternate reality. We got an alarming text last week from some admin assistant asking us to be prepared to chip in but that hasn't really born out I'm still hunkered down in the lab. Lunch reads yesterday were Caligula and new modes of snake transportation (lasso!). Nice to know there are still academic niches out there debating history and snake transportation. Happy Wednesday. Much love, Elizabeth

Monday, January 11, 2021

Shit Show

     When I was walking to get my second coffee of the day this afternoon, I bumped into Jeff - the head of security at Med Towers. I've seen him all around in the ED too he covers. He asked what's up Doc and since I hadn't talked with him since before the New Year I wandered over to his desk. I told him I was kind of sad my partner who has Covid isn't doing so well. He told me this is nothing to sneeze at I got my first shot last week. I told him I got my second and we discussed shot side effects. He said, Doc, I just don't get it, half the country wants the shot but doesn't have access half the country has access but doesn't want the shot. It's like our whole country is raining upside down. I was like absolutely and laughed and said it's crazy this week but last week topped the charts. He raised his hand up for a high five and laughed back.

    I wish everyone would get their shot because we have got to get rid of this disease. Over the weekend Kewen, who is in my doc mom book club, alarmingly texted that Tanner was in the hospital on the floor with Covid. The three other girls in the text don't know him but he's the kind of guy you wouldn't think would get kicked by a virus - no pre-existing conditions that I know of and super in shape head of a dojo Jack used to train at. Luckily his wife Melanie texted Kewen worried when he got out of the shower winded because she urged him to get admitted sooner rather than later there are windows for treatment the convalescent plasma doesn't work after a period of time. My partner BDQ missed that window. Jauss bumped into Mandee Novack and alerted her that her friend was in with Covid pneumonia and made sure Mandee checked in with him and was on the case. He turned the corner.

    Last Fall I signed up for all the Boulevard Cocktail classes scheduled once a month. Saturday waa Gin-uary lol Ben Singleton is my mentor Gene's grandson (doc Ken OB's son) and I introduced myself in November we sang the praises of his grandad. He told me that Gene and wife Sandy both were having a rough go after testing positive for Covid. UGH COVID. This morning my chief texted that BDQ was readmitted over the weekend with symptoms of imbalance (two falls) and hallucinations it's been well over two weeks since he's tested positive this shit should be over but it's not and when my partner Michelle called in and Rex called me around six to explain the plan for covering I almost had a panic attack. Luckily hers was just a GI bug we were texting today she will probably be back tomorrow. I also texted Gene his diagnosis was in November they are doing better but it was a rough course. He lives right down the road from my new house I told him we need to do coffee when this shit show is over (kidding I could NEVER cuss in front of Gene but that was the sentiment).

    My OB Cindy Hubach called me at the end of the day to help expedite some slides on one of her patient's - we had sent them for expert consult to Cleveland Clinic and her patient, my age, is being treated at MD Anderson for nasty cancer of unknown origin. They need to review the slides before they treat her. I was getting help from head transcriptionist and thinking what in the hell am I gonna do without Cindy? I found out a couple of months ago she was transferring to New Mexico where her youngest daughter got into college she's been my OB for almost 18 years I am so sad. I saw Amy Wiedower on the way out the other day and asked if she would take me on and we commiserated at the loss. Laura and Scott and Cindy and Ash and S and I are going to have a couple's dinner before she starts her new job on February 19th.  I know, we aren't gathering, but maybe it will be warm (outside gathering?) and all except Ash and S will be 95% protected so it should be safe.

    So take home don't play cowboy with your life if any of you out there happen to get Covid get to the hospital right away and get all the good treatments we have available Arkansas is a hotspot right now and I can't afford to borderline lose or lose or worry about anyone else my emotional bucket is almost empty. Happy Monday is finally over blech what a nasty day stay safe much love, Elizabeth

Thursday, January 7, 2021

Second Shot

     Everyone is talking about the side effects of their vaccination. My first one had none. I had a deep tissue massage two days later and did not experience any pain in the area. The second one, the one I had Monday, made me really sore, not resting sore, but raise your arm up sore and roll over on that arm in the middle of the night it will wake you up sore. Doc mom book club intelligently took ibuprofen and naproxen to counteract the soreness but I just dealt with it. Others had it worse, with the second dose. My ex had flu like symptoms - stuffy nose and fatigue - someone in micro had a massive headache. So I felt kinda lucky.

    I really miss teaching, and I have a shot at giving a cytopath lecture at UAMS - Susie Jeffus and I are texting, but we keep missing the mark and now Covid. So a few months ago I offered a two hour tour/lunch to anyone in micro wishing to see path (my retired partner Diane Johnson started off as a lab tech and she was a badass pathologist) and I have given it a chunk of times to them and a sis of an ED doc who helped me navigate to the ice machine one weekend on call. He asked Are you Rhonda Gentry's sis I said no that's Melody I'm Elizabeth but I'd love to show her around. She hung out with me for two days and despite her teetotaling ways she gifted me a bottle of wine and a sweet thank you note. I encourage everyone I tour to keep in touch and let me know of their progress. I'd love to help anyway I can.

    Yesterday I toured one of Cecelia's BFF's older bro John Peyton. He's on full scholarship at OBU. His sister Charley came with us to Florida last year - she is lovely (an introvert like me) so I was excited to meet him and show him around. He's on this path that requires rigorous study and guarantees 90% med school acceptance. He told me all he does is study - he doesn't socialize at all. But he has no window into medicine - his family is non-medical - so I told him I would be his gateway. I know lots of docs that would be happy to let him be a shadow and he was grateful. I introduced him to my path bro Staggs who graduated from OBU and they shared contacts too. I told Brent as I got a second on a lung cancer Wasn't he lovely? He said yes I gave him my contact too. 

   A lot of people were asking me if I was swaying him toward Path. I said hell no I was just showing him the ropes. You don't choose your specialty your specialty chooses you. Staggs laughed and said that sounds super Star Wars but I believe it's true. I was at the top of the wailing wall in path. It's not a sexy subspecialty. I had a place in optho but path called me. From the bottom of the lab. And I'm lucky it's been a good life for me and my kids. I told John we have a saying in path when the clock strikes four don't block the door. 

    Even though I get frustrated at admin they adhere to religious tenets that make our lives better. No Sunday surgeries - I told John when I go home on call I'm pretty sure that the OR has wound down for the day. Melody is Baptist and so is Staggs but Quinn and Rex are Catholic I started off Catholic but now I'm a Methodist Heathen if you put me in a box I don't belong in.

    Quinn needs prayers. Yay Georgia. Weird Capitol. Happy Thursday. Much love, Elizabeth

Tuesday, January 5, 2021

UK Strain

     So I wasn't planning to write two days in a row but so much happened today I don't want to forget. Very interesting news in huddle. Turns out we are the only ones in the state that can detect the UK strain, as you know the one that is more transmissible, and so we are going to start tracking it for the Health Department. Here's how it works. There are three targets in the Covid PCR machine, the open reading frame and the N gene and the S gene. The S gene is the one responsible for the cute spiky things on the surface of the virus. The UK version has S gene dropout. It also has a lower threshold of detection, only 27 cycles, we do up to 36 cycles and native Covid 19 is higher. So we can look for the positives that are picked up at 27 cycles and don't have the S gene target light up only open reading frame or N gene or both and tell ADH. They can track our data on the UK strain and do - whatever they need to do with it. I'm not sure what it would mean clinically - higher precautions? More isolation? 

    I'm sure Mandy Novack would know I met her new PA yesterday we were singing the praises of Amy director of micro out loud. She was off last week like me and Monday morning one of the really good new techs Valerie I toured my department a couple of months ago (she aspires to be an M.D.) pointed out that all she did all week was put out fires Amy was not allowed to be off again. Mandy and new PA and I marveled over the fact that we are running out of pipettes (pipettes!!!) and since the company won't have them until June the new QC coordinator found them on LabDirect (which we laughed about sounds like Office Depot). Amy assured us she's a whiz at finding lab supplies in crazy places Mandy said did you try Amazon. Yup no dice. Amy told us she'd been working on the pipette issue since she walked in the door. It was 2:30 pm. 

    I had an hour after lunch in limbo so I decided to cut in the autopsy heart it had fixed for over a week. We looked for local invasion of cancer, which we did not grossly see but took tons of sections of the epicardium in a scarred looking place to make sure there was not microscopic infiltration. Then we opened the atria and ventricles and I marveled to Jessica about how the heart looked like a cave. The other thing we are looking for is myocarditis that can't be seen grossly only microscopically so she's going to take tons of sections of the ventricles. Jessica remarked that it did look like a cave and that made sense because caves are like the arteries of the Earth they transport life goods.

    I marveled internally at this astute observation and wasted about 20 minutes in my office googling and google imaging underwater caves. They were lifelines for prehistoric populations they provided fresh water and attracted flora and fauna that sustained the populations. The pictures mesmerized me.

    My bone spur surgery is February 12 I decided not to watch the scary movies until after I go under his knife. He was so humble when I mentioned his accomplishments I read about. He said Tribeca was cool. I will be in a surgery shoe for 3-4 weeks (this is better than a boot) but can walk and use an exercise bike if I want. And I'll have a pin in my bone! I've never had a pinned bone. 

    The highlight of my week so far was getting the first surgical case of the year S21-1. I've had the first cytology case but never the first surgical it was such a thrill I'd tell you the diagnosis but that's two identifiers I worry it's a HIPAA violation. I did have a really cool case today probably adenosquamous carcinoma of the pancreas diagnosed it on cell block it's so rare only like 3% of pancreatic cancers unfortunately super aggressive. When I was called to gross room this morning early for pancreas FNA Sven Hida marveled (GI interventionalist) I've only ever seen two of those. It requires surgical resection for definitive diagnosis bc you have to have 30% squame component to call it and you can't really do that on a handful of cells from FNA but it will still point them in the right direction.

    Happy Tuesday. I'm going to think about nachos and watch some TV and wind down. I've got a big time crazy thing happening this weekend that's a huge surprise I can't wait to blog about it when it's all over. Let's just say my friend Christie plans some amazing birthday parties. Much love, Elizabeth

Monday, January 4, 2021

Happy New Year

     Well Florida was honestly SCARY. There is no mask mandate there - DeSantis hopes to be the next President after Biden so he is catering to the no-maskers. We went to Piggly Wiggly twice (Dad calls it The Pig and I looked for that for 10 minutes on maps before I realized it was an abbreviation) and the first time it was at about 30% capacity and only 15% no maskers but the second time on NYEve it was super crowded and scary and about 50% no masks so I was glad we only had about ten items to get. Ran to the liquor store for champagne and this guy without a mask tried to hold the door open for me and smiled - I turned my head and waited until he left to enter. He probably thought I was rude but he was the rude one and he probably had no concept of it because half of the country lives in an alternate reality. 

    Cooking and shopping and cleaning up for the kids twice a day was fun but exhausting by the end. Their night starts at 9 when I'm ready to wind down. It was funny when they were plotting their Risk and poker games and Harry Potter marathons after dinner but not so funny when they were running around in the middle of the night making tons of noise. Luckily the bathroom vent in the master was super loud and created lots of white noise so after the first night sleep wasn't interrupted. 

    Beach walks were amazing so much so I was inspired to walk the neighborhood when I returned. It was the same stretch I walked in my twenties when I was home from college - about four miles - and it's funny wondering about what 20 year old me was thinking about when I was walking this same path I cannot remember. Walks can really help you wind down mentally and might help me get back into my scrubs by the Spring. Hopefully. Not that I'm self-deprecating - I'm finally getting over that - but I could stand to lose a few of these pandemic pounds, if only because I'm getting sick and tired of picking out an outfit every day. Matt texted me today he is doing a virtual yoga class - I missed his last one due to GI issues - so I hope to feel healthy enough to join at 6:00 tomorrow he is going to send me the link.

    I'm so sick of this bone spur callus on my pinky toe requiring me to get to the podiatrist every 6 weeks now to excavate so I can fit in my shoes that I am going to try to get on his surgery schedule tomorrow. I'm seeing a new guy this past year - Jesse Burks - the old clinic on Aldersgate Road shut down so I have to drive all of the way to St. Vincent's. At 9:30 am his assistant will take a scalpel to my callus - it doesn't hurt - and I am going to ask him if I can do the surgery the second week in February when I am off. If the boot will be off by the planned Spring Break to Crested Butte I'm going to go for it. I was googling him today to get the phone number and learned that he is a celebrated director of short horror films I was fascinated. The article in Arkansas Times was in October of 19 it was too long to read on this busy day but I got enough for good conversation. A silent film he published on YouTube - I can't remember the name - has 11 million views. He's been to fancy indie film festivals around the country. I didn't watch it yet but plan to - I read it's so creepy it cannot be unseen and my day was too busy to handle that tonight.

    The craziest thing I read today was about a guy in an ER in a Kaizer hospital in California who dressed up as an inflated Christmas tree to cheer up the ER on Christmas Day. It had a mechanical blower built in to keep him inflated. Turns out he unknowingly had Covid and the blower acted like a superspreader 44 people have tested positive, mostly staff, and one has died. The consequences are devastating - not funny - but the incident itself is so full of stupidity and predictability it had me chuckling all day. Who on Earth would have thought that was a good idea. The hospital put out a statement that they banned inflatable costumes (ya think?) and that the intentions were good and not malicious. Apparently their ER is still up and running I'm sure that is taking an act of God. 

    Lately, for a month or so, the Foo Fighters are chasing me around on Satellite Radio I'm so frustrated I've never gained an appreciation for them they are too screamy. Some songs are good but most drive me crazy. And The Killers are like watered down old Bruce Springsteen I don't know how they are so popular. The top song of the year by 21 Pilots on Alternative Radio makes me cringe as much as the DJ Madison (every song by them makes me cringe). But there's good stuff out there too you just gotta sift.

    Well I'm gonna wind down and maybe watch that YouTube video of Jesse's and listen to music and head to bed by ten or so. Hope you all are doing well. Happy New Year - much love, Elizabeth

Saturday, December 26, 2020

Heart Only

     Christmas Eve was quite a day it started off at CARTI tumor board at 7 Diane had so many cases to present cancer doesn't rest on the holiday. On the way over to Baptist autopsy doc texted me a consent and I replied this is not my job contact Jessica. Well he was probably feeling bad so he had his resident contact her that guy was really nice and she texted me a little after 8 that the consent was legit and we would proceed with the procedure in an hour.

    Got my cases triaged and went downstairs to the morgue. We all get in a tizzy and bitch and moan about autopsies but there is something so sacred and serene about the performance. Jessica and Evans were recording the external exam as I walked in - noting the scars and the details about her nails and I would describe it to you in better detail but it seems like sacrilege. We do a U shaped incision on women instead of Y for obvious reasons. As Jessica was getting into the chest someone from Central Processing accidentally wandered in, and jumped and shrieked and apologized as if she walked in on someone going to the bathroom.

    She opened the door back up a minute or two later and asked if she could watch. I said I had no problem with that and asked Evans and Jessica if they objected they did not. As we opened the rib cage and started to dissect the heart from the surrounding vessels - Jessica and I had to use a lot of suction to clear the area of blood for better visibility - she swooned. "I was having such a bad day, week really, and to see this - I feel like I am the luckiest girl in the world. This is so amazing. Thank you so much." I told her a little about the history and what we were going to look for and her awe was infectious. 

    It was a short autopsy since it was heart only. Evans weighed it and cut into the ventricles a little so it would get adequate fixation when we gross it in week after next. It will be easy to answer docs question and I told him that the autopsy went well it should be signed out in a couple of weeks. So I got my easy autopsy after all.

    Got home a little after 3 and prepared the catered meal from Boulevard. When you have a little one - Rennie - things start and end early and I was grateful for that I was exhausted. Rachel watches It's a Wonderful Life with the kids every year S and I have never seen it so we started it on Christmas Eve and ended it on Christmas morning it's so long I'm surprised the kids sat through it Jack only remembered a few key parts when we discussed it Christmas afternoon. It came out in 1946 years before any one of us was born. 

    S and J and C and Woody all got tested for Covid when I went to work today and I was proven right - they were all negative. You pray for negativity sometimes - cancer margins and Covid tests. It's nice when your prayers are answered and you can travel and visit loved ones in relative security that you aren't a threat to them. Since I had the vaccine I didn't get tested. Thinking despite not yet receiving the second dose I'm ok too. Christmas on the couch in yoga pants and comfy t-shirt was lovely. Hope yours was too. Much love, Elizabeth.