Friday, March 17, 2017

Gross Room

8:15 a.m. - a phone rings in my office from the gross room PA.

"OB surgeon wants to do a frozen on a cervical cone. It's a tiny specimen, I could probably get it all on one slide. But freezing a cervical cone? What do you want me to do?"

"You are right, that's weird. I'll call the OB. What OR is she in?"

"OR 6."

"OB? Can you please tell me why we are freezing a cone?"

"I'm so sorry, I should have called you. I know this is unusual. I'm giving her a hysterectomy. I just need to know if there is cancer or not. It will change what I do."

She detailed the history, the previous procedures, and the decision making process that carried her to this point. She's an amazing surgeon.

"No problem, we are happy to do it."

I wander slowly to the gross room. It will take 15 minutes or so to freeze an entire cervical cone. I lament on the way there to a phlebotomist about the current construction that necessitates double the amount of walking. The worst of which is part of the way involves the main entrance hallway, where it is easy to get stuck behind patients or generally slow general visitor population. He empathizes with me, and tells me he hears it will be about three more weeks before the back way opens up again. At least I don't have to push a cart like he does, I think.

I finally enter the gross room full of five P.A.'s and look up at Jessica. "Oh! You look fantastic. I love your glittery hat and your shirt. I knew it was St. Patrick's Day all week, but I forgot this morning. Thank goodness Baptist Hospital color is green. It's on my name tag, my only green in my outfit. Your hat is amazing - love how it contrasts with your strawberry blond hair."

"Thank you! See - it says I'm a wee bit Irish. And it's a wee little hat. I found it at Kroger last week. No forgetting in my family - it's a National Holiday. In fact, I really should be carrying around a pint of Guinness all day long."

"Can I give you permission to do that? If so, I'll grant it." I move in closer to Jess and Laurie.  

"Look at this ring I got in Chinatown! Five bucks. I love the vintage look. I've been wearing it all week, and it hasn't turned my finger green yet - I take that as a good sign. I've never worn more than one ring on my ten fingers, I'm kind of liking it."

Jessica replied, "When I met Houston I wore a ring on every finger. I was crazy flashy. Now I only wear my wedding one."

"It's beautiful. Y'all did good. And I almost forgot to show you my new Swatch watch! Brand new series."

Laurie asked, "Do they still make Swatch?"

"There was a whole store!! The kids weren't very interested, so other mom took them to the next stop. I was there over a half hour, trying on every watch that fancied me. This glittery band series, it's super lightweight, had three colors - gold, silver, and rose gold. I was drawn to the rose gold, but when I put it on it disappeared. Seems my skin is rose gold."

"But that would have been kind of cool!" cried Jessica. "It would have looked like the watch was growing out of your skin."

"Yes and no. I chose the silver. Nice contrast."

Laurie looked up from the uterus she was grossing. "I had the Swatch with the white band and the red, blue, and yellow face. I loved that Swatch."

I looked at her incredulously. "That was my Swatch. I had the same one. I loved how when I got tan in the summer the white band contrasted with my skin like a beacon. You could have seen it from miles away."

Laurie and Jessica both laughed. Laurie is a dark haired alabaster skinned beauty, and Jessica is a pale fiery Irish redhead. Jessica said, "The one time I tried to tan I ended up in the ER with severe burns." Laurie concurred, "Tanning is not something I'm good at."

Steve H. interrupted our reminiscing. "Frozen is ready."

"Oh thanks. Man, wow. This is amazing. It looks like an H&E. You got great mucosa on every slice. It's clean as a whistle. No cancer. I'll call the OB."

The sigh of relief was palpable over the OR phone. "Thank you so much. I'll proceed now."


Incipient Murderess

I got a call from an endocrinologist early this week about an adrenal case I had signed out with Dr. Music in December. "The symptoms are coming back. Are you sure it's medullary hyperplasia? Are you positive it isn't an incipient pheochromocytoma?"

"Well, I trained with a chair who wrote the first adrenal fascicle, he's a world expert, but admittedly these cases are rare. I haven't seen a pheochromoctyma since I trained. Would you like me to send it off?"

"Yes please, where will you send it to? How long does it take?"

"I know a guy at Cleveland Clinic, Dr. Genius. I trained with him when I was a resident. I've never sent an adrenal out, but I'm sure he can handle it or show it to someone who can. He's the quickest turnaround I know."

"Thank you so much."

I told Dr. Music the plan, since his name is on the report. "Sounds good, yes send it to Dr. Genius."

I got an e-mail from Dr. Genius last night. "Family's great, thanks for asking, I'm traveling way too much for work. Your case just showed up on my desk. As expected, no tumor."

I bragged to Dr. Music in the hall this morning that as usual when we have a finalized case that gets sent out at the request of the clinician we were right.

"What the heck is an incipient pheochromocytoma anyway? Have you ever heard of that? By the way, incipient is my favorite word this week, thanks to that endocrinologist. I've decided this morning I'm an incipient murderess. The drilling has become so loud and incessant that I had to dig out my earplugs and wear them again, but they only dull the constant din. I'm not sure of my target yet, but when it happens it will be very spontaneous and chaotic. Watch out."

"I have never heard of an incipient pheochromocytoma either. Is that a thing? I haven't googled it yet. By the way, isn't this (he points to his arm) an incipient tumor? Aren't we all incipient tumors headed for the Grim Reaper?"

Turns out there is such a thing as incipient pheochromocytoma. This is the full blown malignant pheo.

Zellballen sheets of polygonal cells in a complex vascular network

The gross image is super disgusting so I'll leave it out of this very clean prim and proper blog.

Thursday, March 16, 2017

Musings

It was fun tonight, to see Phantom of the Opera. It was, if I understand correctly, the first time the Broadway production has come to Little Rock. I saw it over 20 years ago on Broadway. I still love some of the songs, but I had lost the context. I remember fidgeting and squirming through the second act when I was a teenager, but as an adult I got the psychological nuances parlayed through song that aided in character development. She wasn't just a victim of circumstance - Christine - she was a complex character that was searching for a father figure after the premature loss of her own. And the Phantom wasn't a monster but his circumstance created one - his disfigurement and confinement cut short a promising early bright start, warping his personality. I didn't get all that back then.

It's tough listening to a soundtrack without context. I struggled through Hamilton last summer, but after seeing it, and becoming surprised and enraptured in my daughter's enjoyment of it last week in San Francisco (tonight, it was my son - he loved Phantom), the music finally presented itself to be appreciated.

Warning: whining about to happen.

I lost my pager when I was on call Christmas week. I don't lose things, so I imagined it would turn up sooner or later, but it hasn't. I slowly started doling out my cell number to all the cytotechs and secretaries and gross assistants. I found it much easier to keep up with one thing instead of two, and much more efficient for everyone to just text when I had a frozen or needed to go to read a needle. So I told my business manager to cancel my pager service. I feel no longer stuck back in the 1980's. It's freeing.

10 years ago, when I joined my group, one of my partners approached me and asked if I would consider giving him some of my call for money. I was worried about what my other soon to be partners might think about my work ethic, so I told him I would be happy to pending approval by the board. They approved. I have given up half of my call - paring 10 or 12 weeks a year down to five or six, ever since. Refused to give up more, because I didn't want to lose my call skills. Our fiscal year starts in October. By January, I still had no takers. Seems my two partners who have been willing to take my AP call for the last few years are now in a position to value time over money. "I love going to the gym with my teenage son after work." "I don't really want to drive over from NLR more than I have to - it adds so much more work." Good for them, sucks for me. This is the first year I've had to take full call - I believe twelve or thirteen weeks. And this is the first time I've done a two week stretch in a row. Spring is the most concentrated time. Our chief graciously took my call tonight so I could go to Phantom. But I'm missing Spring Break with my kids, for the first time since I joined the group. Luckily with AP call the OR usually dies down at a certain hour, so I can enjoy some wine. I was a call teetotaler for many years of CP call. It's more common on that rotation to be bugged unexpectedly at 2am.

1.5 weeks to go. Doesn't seem nearly as daunting as it did a few years ago. I can do this. And the extra money in my paycheck will help pay for all the fun.

Monday, March 6, 2017

Giant Colon

"You've got to go see the colon. It's on tour, and it's hitting Conway this week. I'm busy - you go with Dr. Woods and Dr. NWA."

Conway is my place - I went to college there. I planned a trip with Stoby's cheese dip on the agenda. After all, I was super pregnant with C, I deserved it.

Me and Dr. Woods to my right (he looks so young!) and Dr. NWA to my left. The colon is behind us.

Dr. Woods, kind of sideways, inside the colon next to the internal hemorrhoids. Despite my preggo state, I crawled through the colon too.

I asked this tubular adenoma of the colon - mildly dysplastic polyp, to take a pic with me in the bathroom. Made me feel good. I'm pregnant, but she's way bigger than me.

Me and Dr. NWA with a Fleet's enema. My daughter turns 14 on Friday, so this is 15 years ago. As the old adage goes, time flies.

Friday, March 3, 2017

Rise

Sasha from SMD posted today about a struggle with a critic. An excerpt:

"It can wear you down to listen to your critics, can't it? But the fire is where iron is hardened and where we are molded and where strength arises. Where fortitude and character are built, and where your weaknesses are burned away. The fire is also where it is evident who has your back, and who will pick you up when you fall down.

You can't please everyone, and you can't listen to people who aren't in the same arena fighting with you. You can't take everyone to the top of the Ferris Wheel, and the biggest thing I learned, it's not YOUR JOB to figure out WHY you are too much for some people. That's their choice, not yours.

Pursuing your dream, living your life - this will be too much for others. The way you talk, dress, work, laugh, even smile, will offend someone, somewhere.

Be kind. Be respectful. But don't cave in the corner and stay silent or inactive bc you're "too much" for some person. Go forward humbly and live your dream."

Hundreds of comments. Someone reminded her of a Maya Angelou poem:

Still I Rise

You may write me down in history
With your bitter, twisted lies,
You may trod me in the very dirt
But still, like dust, I'll rise.

Does my sassiness upset you?
Why are you beset with gloom?
'Cause I walk like I've got oil wells
Pumping in my living room.

Just like moons and like suns,
With the certainty of tides,
Just like hopes springing high, 
Still I'll rise.

Did you want to see me broken?
Bowed head and lowered eyes?
Shoulders falling down like teardrops, 
Weakened by my soulful cries.

Does my haughtiness offend you?
Don't you take it awful hard
'Cause I laugh like I've got gold mines
Diggin' in my own back yard.

You may shoot me with your words,
You may cut me with your eyes,
You may kill me with your hatefulness,
But still, like air, I'll rise.

Does my sexiness upset you?
Does it come as a surprise
That I dance like I've got diamonds
At the meeting of my thighs?

Out of the huts of history's shame
I rise
Up from a past that's rooted in pain
I rise
I'm a black ocean, leaping and wide,
Welling and swelling I bear in the tide.
Leaving behind nights of terror and fear
I rise
Into a daybreak that's wondrously clear
I rise
Bringing the gifts that my ancestors gave,
I am the dream and the hope of a slave.
I rise
I rise
I rise.

Her post and this poem really hit home. Taking on other's negative opinions is like absorbing their problems into your own psyche. Many women have enough of a harsh inner critic that they don't need others to reinforce it. And many critical people are only projecting their own insecurities and misery onto those around them to try to make themselves feel better, which ultimately doesn't bear out. Seems my lesson this year is to learn to let go of other's negativity - it's hard, but I'm getting there. Time heals. 

Another commenter posted a famous quote by Theodore Roosevelt:

"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasm, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while DARING GREATLY . . ."

In between a boatload of needles and cases and running a meeting today I got to visit a mock up of a new bronch endoscopy suite. I felt like I had just walked into a space station. They had it set up in Shuffield Auditorium all week. We may even be able to project what we see under the scope into the procedure room in real time. Seems bronch lab might finally climb out of the basement.


When I was at my wit's end this morning because I hadn't had time to look at any of my cases due to procedure after procedure, I came into my office to find this. My eyes welled up. 



I found out later my cytotech, who is aware of my love of dark chocolate and almonds, left this by my scope. I thanked him. The day got easier. We are all in this together. When people like Tony and all the anonymous SMD sisters notice you are struggling and support you, rather than try to tear you down, it makes every effort and struggle and hard day worth it.


Tuesday, February 28, 2017

Interventional Radiology

9 a.m. I sit down at the scope, flanked by the radiologist, and my wingman cytotech.

Me: So what am I looking at.

Rad: Indiscrete mass in the lung. Maybe pneumonia. Why are you so dressed up.

Me: I've got a meeting at the school today, C's advisor. And tonight I'm going to a breast molecular update. Breast surgeon hosts these one or two times a year, usually at good restaurants. We get free food, and learn about the latest prognostic information. It's path, rad/onc, and onc.

Cytotech: I've never been invited.

Rad: Me neither. But I'm not a breast man.

Me: Really? You aren't a breast man?

Cytotech: He must be an Ass Man.

Rad: That's actually what is on my license plate. Ass Man.

Me: I was asking cause I was wondering. What man isn't a breast man.

Rad: It's not that I don't like breasts. It's just that it's a hobby, it's not my day job.

Me: I see macrophages. No big inflammation, no malignancy. Good news for the patient. It always feels good to hand out good news. No news is good news, right?

Rad: Sounds good to me. I'll get cultures. We've got a couple more cases for you after lunch.

Me: Good - bronch lab has two cases, but they should be done before lunch. See you later.

Friday, February 24, 2017

INFJ

I was lurking in a PMG Pathology thread the other day - they were talking about how they scored on the Myers Briggs personality scale. Many pathologists are INTJ's. I was a psych major, I took that test over 20 years ago, I'll never forget my type. INFJ. But I forgot what it meant, so I googled it today over lunch.

I found out I am a rare and complex personality type, shared by Eleanor Roosevelt. Gandhi. Umm, Nicole Kidman. Piers Morgan? Them's fighting words. Reading about who you are, based on a personality test, is indulgent. The ego is a necessary evil of human existence. Watering it seems trite, but is nevertheless satisfying. There are entire books, I learned, on Myers Briggs personality types, but a quick scour of the internet was enough for me. My ego is fine. Overly indulged last summer - like someone took my ego's mouth to a fire hose.

There are days when you are tasked to challenge your nature. Today was one of those. I had to show humility to a clinician I had unintentionally misled on a frozen. Separately, I had to (gulp, cough, spit) ask for help, something that is akin to torture for me. The volumes of challenging cases I had on call this week, some of which I hope to resolve tomorrow, set records in my ten years of practice.

I reminded my daughter today while I was carpooling her to her church retreat weekend that when we are faced with obstacles that seem insurmountable, ones that we hope to but cannot control, it's happening for a reason. Kind of like destiny. The challenges we face are tests to our ego, lessons that need to be learned. If you are impatient, there will be a test to challenge your patience. If you are overly confident, a missed call will humble you. If you think your diagnoses can help a clinician, there will be a difficult case that will stymie you and the patient will go downhill no matter what the morphology shows you. A blow to the ego necessitates a surrender to the divine. You duck and shield, you stand up, and you move forward. Experience, including mistakes, begets fresh revelation.

"It is better to light a candle than to curse the darkness." - Eleanor Roosevelt