Wednesday, May 19, 2010

Sitting On Top of the World

Good ole Lenny. He says it.

This week, I've been a squeaky wheel. In a good way. I'm back on my home turf in LR, and work is tough, but I'm rising to the challenge. Here's an example.

Monday, I got paged to the OR around noon. One of the cardiothoracic surgeons is doing a new procedure once a week. EBUS, stands for endoscopic bronchial ultrasound-guided biopsies, or some such. Basically, the surgeon is doing bronchoscopies in the OR. Guiding lights down the trachea, and doing not-so-blindly guided biopsies through the tracheal mucosa into the bronchial hilar nodes. The ultrasound (not a perfect picture - I'm sure you all remember those embryo pics) helps to tell him where to stick the enlarged nodes, in hopes of getting a diagnosis.

I wandered into the gross room and chatted with the techs while my slides were being prepared. Happened to glance over at the first two smears, that had just been stained.

"What stain is this? I don't recognize it."

"It is the modified dif-quik."

My mind screamed in alarm and I reacted poorly out loud.

"What? The modified? I've never read that stain before!"

Three of my partners who read cytology prefer the modified, on immediate evaluation. Me and my estrogen lifeboat - she is currently on a cruise - like the dif-quik. A much quicker, easier stain to perform on dirty evaluation.

I yelled, "What makes anyone think I want to read this stain! I never read this stain. This is patient specimen, you are compromising. This is bullshit."

I called the supervisor of cytology, who was out to lunch. Quickly instructed the tech to go to the OR and instruct the nurses to air dry the subsequent smears, to perform my stain. Shook my head in disgust.

"Who planned this protocol? And why weren't Michelle or I informed?"

"Um, don't know. They thought it might be easier, to train his nurses on one protocol."

"As if M and I haven't been reading the same stain for, oh, three years for me and five for her, now? What made anyone think an immediate eval in the OR might be, oh, different? And does anyone think that any nursing team that the surgeon has is not intelligent enough to handle two protocols, like everyone in radiology?"

I sat down at the scope and stewed. Called a partner that prefers the modified and told him to be available for the next few minutes, in case I needed him. Luckily the specimen was no good, modified or not. Predominantly blood and benign bronchial cells.

Another tech, the one who made the protocol, wandered in. I apologized for my earlier rant.

"This is an immediate eval, on a patient. I'm scared of screwing it up, and that is where my anger came from (isn't that where all anger comes from - fear?). But what kind of harebrained person decided that M and I might suddenly switch our stain preference in a critical situation?"

"It was me, Dr. I wasn't thinking. Not hare-brained, just no-brained. I promise I will revise the protocol right away."

Jesus. OK. Everything went well, and the patient didn't suffer.

Also having a glut of FNA's this week - each patient experience deserves a blog post of its own. I'll refrain, and hit the highlights of a particularly moving one.

A woman, status post laryngectomy, was sent to me by her specialist to evaluate a new lump near the stoma site. He was worried about recurrent cancer. It was extremely painful to her, so I wasn't surprised to see inflammatory cells under the scope, and performed appropriate cultures in order to attempt to discover the offending culprits. After I made my final pass, her partner said, "She's been through a lot, this girl."

He listed numerous hardcore surgeries she had been through in the past few years, then moved on. "She lost both of her sons. Previously healthy. Freak accidents, in their young adult years. No woman should have to go through that."

I got all teary, and looked at her. She was teary too, but I had already made her that way by sticking a needle into her neck three times. So I wasn't sure where it was coming from, but grabbed her hand anyway, and looked into her eyes.

"I have two kids. God, what you must suffer. Just bringing kids into this world is facing a potential loss that is unimaginable to me."

I looked away. Couldn't go on, in front of the tech and the student. The tech helped her out of her chair, and I was thankful that I hadn't diagnosed a recurrent malignancy, which is what the clinician was fearing. I collected myself, and started in on the paperwork. As she walked out the door, I looked over at her.

"Nice to meet you. Good luck."

She walked over and grabbed my hand. "Thank you doctor. Very much." More wet eyes. Stuff emotion. Damn it.

I've got to prepare for early breast conference with the surgeons and oncologists. Need to bone up on metaplastic (chondroid) carcinoma, so I might sound intelligent. Work goes on.


Ginger said...

Regardless of the field, all Drs like their set-ups and preps done just so. I don't know how nurses keep it all straight, lol!

When I would work in the Urgent Care and did my own UA, I always had to read my micro stained. That was the way I had learned. I completely flipped out the time I was told there was no sedi stain available and I made an MA run across the street to the hospital to get some from the lab. I really didn't mean to be crazy.

Ginger said...

I sooo can't believe you didn't make fun of me for that... ;o)~

Gizabeth Shyder said...

I think I published this in my sleep, or I certainly would have made fun.

I've never read a U/A, and don't know what the hell a sedi stain is. We pathologists consider ourselves above the U/A. Pap smears and semen analysis, baby. Sorry, I can't top your emoticon.