The Most Wonderful Time of the Year

Whoever coined that term was not a healthcare professional in the 21st century.

I was on call last week, and I am on call next week starting Christmas Day, and it has been extremely busy. I had more brain frozens last week than I'd had in the last six months, the culmination of which was 9:30 PM stressor on Friday night in between carpooling children to and from where they wanted to go. I had to cut the frozen myself, which is not so easy when you are out of the habit - we are spoiled with our P.A.s I learned after the surgery it was not a resection but a thing new to our institution which I later learned in PMG pathology is a thing some places - a fine needle aspirate of a brain tumor. Which explained why the surgeon wanted me to freeze something that looked like a sneeze on a piece of shiny surgical paper. Not a sick, colored sneeze, just a few clear droplets and some blood. Luckily I had the forethought to do a squash prep first - where I touched the tissue with a slide and smeared it with another - because the frozen yielded nothing but the squash prep was a field of diagnostic information - necrosis, hypercellular pleomorphic cells, giant blood vessels that resembled octopus tentacles - the triad of Glioblastoma Multiforme. I called it suspicious, expected much more tissue, got another sneeze, and a local expert confirmed my diagnosis a few days later. He told me the FNA is much better for the patient, and text updated me throughout his own progression of stains and levels with what I provided him. I alerted the other members of my group of the new procedure - the gross room told me another neurosurgeon did one a couple of weeks ago. If that was the only case I had last week we would be living in an episode of House. But with thirty - sixty cases a day I can't worry over one too much, luckily. Just triage, do my best with what I've got, send the stuff I'm uncomfortable with to the experts, and move on.

One thing good about being on call over the holidays is you don't have any obligations to anyone. I kind of like that. "Nope, sorry, I'm on call." But the way the holiday fell this year Christmas and New Year's Eve are crammed into one week and that doesn't usually happen. I heard from a nurse in bronch lab that Benton schools are out not this week, but the next two weeks, and I think that's a lot smarter than Little Rock, we get an extra week to stress and present shop and make Christmas a little more crazy (or just go to work) then rush back to school after New Year's Day.

Everyone in PMG pathology is lamenting end of the year insurance deductibles. It really does cause a crunch in November and December, but the worst is the last two weeks of the year. I was talking to my friend who is an opthalmologist on Monday and she said she has people coming in on December 15 expecting to get their cataracts done before New Year's Day and when they learn she's booked she has to talk them off of a ledge. Someone in PMG pathology smartly suggested that we switch the cutoff to people's birthday so the work is more spread out. Seems like getting something that monumentally entrenched to change won't come easily.

I can't believe I finally have a lull in my day. Partly because I finished a book I got last week, one that I've been sneaking into whatever gap I can find. I learned new words, elision and benthic. Ha! Look at that spell check doesn't even know benthic. Now I can get back to my other two books I'm juggling, but first I've got to address Christmas cards, a yearly chore but worth it for every one I receive.

I'm starting to think that you get the most out of life by just relaxing into what is, and not worrying too much about what isn't. It certainly yields happiness, I've found.

Doctors Make the Worst Patients

A little vacay blogging, over at MiM

I Really Hate Thanksgiving

This day has been Hell from the moment I woke up. And I think I have talked before about how much I hate this holiday and the food (except rolls and stuffing), and all the freaking gratitude. I'm grateful every other time of the year so on this holiday I'm taking a huge break to sleep in and sit on the couch and watch TV and cook my kids favorite meatballs for dinner then go to work on Friday because the hospital is the only place on the planet where people have to go back to work on Friday. This is probably not true, but I'm feeling really whiny right now as I'm surrounded by too much work - people gotta meet their deductibles!! - and my office is too hot and I've had two workman here to fix it but it's not helping and I can be too cold all day long but blazing hot is not an option I had to go home and change for God's sake to get my work done without getting nauseated that's a first. And propping my door open to let the heat out has somehow invited everyone in the lab to pop in and say hello and ask what I am doing for Thanksgiving and it is so hard to small talk anyway but when you are in a fowl mood (pun intended) it really sucks.

Ok I feel a little better. Now I can concentrate on my bug stains I've got a tray full of them. But first I've got to go prop the door open again it's getting hot. Again.

Tree

Majesty needs no
recognition only qui
et acknowledgement

Shapeshifting

I walk a tight rope
Eight legs searching for stronghold
Eight eyes seeking prey.

The Harvey Effect

I wrote it yesterday afternoon. You can read it over at MiM

Board Meeting

Dr. Music: The Great Pumpkin has arrived.

Me, curtsying as I entered the ancient library: That would be Pumpkiness to you.

Chief: Let's start.

Dr. Music: I'm here now. On the board.

Me: Where is Dr. Woods?

Chief: AWOL. He's rotated off anyway. Let's start. Dr. Music is rotating on. He's the secretary/treasurer. You are the President.

Me: Me? You mean Presidentess? So he's my secretary for how long?

Dr. Music: Can I sit in your lap?

Cheif: Ha! Harvey!

Business leader: For a year. Now let's get started.

High School

Over at MiM

397,000 Points

Me: (answering phone to unknown local number tersely) Dr. Seng

"Um, my boss called you earlier, I work at the bank, I was trying to get him to tell you, he said you were upset,"

"Yeah, tell him I'm sorry I was being cold I just don't like to talk about a deposit box still linked to my name that isn't mine. I was divorced 10 years ago. I don't like being called Mrs. Schneider anymore, especially when I am in the middle of something. Did you get him to close it out?"

"Um no it's not about that. Did you know you have 397,000 points on your credit card?"

"No. I have no idea what that means. I get e-mails about some rewards thing but I've always deleted them."

"It's just that I've never seen anyone with that many points!  I had to tell you!  That's $4,000 in cash!"

"Are you sure you are talking about me, and not some old account?"

"Yes, it's you. If someone told me I had that many points I'd faint!! I mean you can get a vacation or a KitchenAid blender but I'd want the money. Want me to tell you how to get it?"

"Sure I'll get my computer. I only use my phone for bank transactions. I don't know the format."

LOL. I just found out I had 4K I didn't know I had. A few clicks later there is 4K in my checking account.

"Thank you so much for letting me know. I was waiting for a quarterly bonus to donate to Irma and Maria relief now I can do it this weekend. And this will help pay for a couple of upcoming trips."

"Your welcome!! Have a great weekend."

"Thanks again you too."

Gotta check casseroles for doc mom book club tonight. How much better can a day get with book club and 4K. I cannot imagine.

Happy Friday

Mothers in Medicine: THE BOOK

It's finally announced on social media! I'm part of this book I'm so excited. Coming out in the Fall or Spring. I organized one chapter and wrote a third of it (had to delegate the other parts to experienced authors). No money to be made but lots of wisdom on medicine and mothering from fantastic women on the blog - many of whom I have met or at least developed e-mail relationships with over the years. Here's a link for more info:

Mothers in Medicine Book

Man I'm getting rusty I almost forgot how to set up a link lol.

Happy Tuesday - Elizabeth

Checking In

I'm traveling three weekends in a row, starting tomorrow at 8am. And while I'm horribly disillusioned about the conference I am going to tomorrow, I am excited to meet a small cohort of women physicians in Stylish AF for drinks Friday afternoon. Also, Gay Purcell told me about the Omaha Zoo which is supposed to be amazing - so me and my best friend Trishie from residency are going to spend Friday there before the conference starts. I managed to read 5 books on my LA trip (two were short) so I'm being ambitious - packing four. And I'm proud to say I spent not one dime on new PJ's for the pajama party or cocktail dress on Saturday night - I pilloried my own closet.

How many people out there can say they have their own Troubadour? Not many I'll bet. Do you also have the certainty that this lifetime is not unique, I mean, that what you are experiencing now happens in every lifetime? For centuries past and present and future? It's a comforting thought, especially in these chaotic times. Because Houston, LA, Oregon, Puerto Rico, Florida, US and B V.I. - it's so scary it's apocalyptic - Harvey. Irma. Not to mention the White House. Last gasp of the old white privileged mansplaining male I'm praying. My daughter was asking tonight how I get my news and how I am so caught up (Mom, I notice at dinner you know what you are talking about). Loved helping her get apps for Slate, NYtimes, Atlantic, and HuffPo. She's 15 years ahead of me at her age. Navigating public school/high school/ life with aplomb.

Sending love and health and happiness and prayers to the Universe. I'm in a really good mood:). But also lots of money to Houston and plans for Florida and PR. Because tithing. You've got to put out more than you can ever expect to receive.

Pedestals

The internet is a strange and glorious thing. It lures me daily into it's mania and freneticism. Which is why I cannot remember who posted this, on twitter of all things - must have been a link, because I am not active on twitter.

We pathologists look at cells all day long. We diagnose infection, cancer. And it's true, what they say in the New York Times. Colon cancer is becoming ubiquitous among younger and younger people by the day. I have seen this in my 10 years of practice on top of 7 years of training, and it's nice to finally feel validated, but it's awful to have friends fall victim to it.

When we look under the microscope (an observation by anon twitter pathologist) we see cells. We don't see skin color. We see the same cells in everyone. Everyone has the same freaking cells. When I work up a report for cancer - breast, colon, kidney, etc. - I have no idea if they are black or white or Chinese or anything else. I could guess from the name, but I don't do this. I look at age more than name. Cancer befalls us all, at an alarmingly increasingly younger rate.

I read an e-mail newsletter recently, and it has stuck with me so hard. Wanted to talk about it in my Sunday school, but we are booked up this fall. Maybe in Winter. It's about putting people on pedestals. We all do it - mentors, authors, actors, rock stars - hell some of us our own family. They inevitably fall. But that wasn't the lesson. The lesson was that by putting people on pedestals we are eroding our own ego and self worth. We are all the same. Not only under the microscope. I tell my kids - don't ever compromise your own self worth in the light of someone you admire. Don't fall victim to what I did for years. You are not less than anyone around you. You are the same. Cellular level and all. We are all connected.

I read a book recently (hell five in the last week I'm on a roll) called The Soul of an Octopus by Sy Montgomery. It calls into question the idea that animals might have innate intelligence, and souls. I say, is this even a question? Do you have a dog, or a cat? Don't you relate? They are all there. They have talents and abilities that we don't. We can learn from them.

I was doing journey work earlier this week and I saw a hawk. I became inpatient (my status quo) and hurtled my soul into the stratosphere to see where it was leading me. It lost me. It teaches me. Life is unpredictable. Look beyond the skin color, look into the soul, and you will begin to know where it's trying to take you.

What the helminth??!!

I cannot take credit for this amazingly parasite nerd statement. One of my PMG pathology sisters (over 800) posted this a couple of days ago with a pic of a worm, asking "Ascaris?"

I cribbed this off the web bc, strict rules about not taking pics from PMG pathology 

Everyone agreed. Ascaris lumbricoides. A dream specimen - this one was found in the stool of a child and mom brought it to the ED. It was bottled and still alive when she removed it from the plastic container. It measured over a foot. Most of the comments centered around puke emojis and WTF gifs but I was most impressed with "What the helminth?" I think I am going to start saying that every time I see a worm.

I shared the story twice today - kind of fishing for an Ascaris story. The head of microbiology did not disappoint. "We had one case, about 15 years ago. Everyone talked about it for months. I think it was in LRDC, there was a patient with an orthodontist appointment. I guess the anesthesia drove the worm out. It came out of the patient's mouth, when they were under. The nurse fainted. The ortho doc sent the specimen to us. It was still alive too." I was amazed. This is a once in a lifetime case. If you live in a developed country, I guess.

This was a hellaciously busy week. I presented a tumor board for the second time this month - loved it. My quick thinking was probably lost on all the clinicians in the room - but the pathologists were impressed. Normal cerebellum, which is what I called on frozen, can look astonishingly like metastatic small cell from the lung. 

And the week ends a day early - I am headed to LA tomorrow for a 1920's flapper party in Beverly Hills. Going to meet a lot of previously only online mom doc friends. I feel like I am going to the moon - haven't been to LA in thirty years. Simona Bot and her husband grew up in Romania and currently reside in LA. She is hosting a party for 60 people. They outgrew the clinician bubble with biotech skills and patents. My friend Tuhina told me their house was like Lifestyles of the Rich and Famous. One of the other attendees wrote a memoir of her journey from Cambodian refugee to doc in the US. I'm going to read it on the plane. 

Hooray for big time birthday month plans. Hoping things cool down politically with North Korea. Life is too short to worry about crazy male egos.

Souls

An infinite expression of life

Iridescent green and rose

Energy swirls

And lands on a frequency

Energy shifts

Life happens

Sturgill Simpson - Life of Sin (Live from RCA Studio A)

So I'm going to Gun's and Roses on Saturday. I've been listening to the opening act - Sturgill Simpson - all week. I know Guns, I have since I was a teen when Appetite came out. I tried to like Use Your Illusion one and two, but it was a struggle.

I remember going to the concert when I was in my early 20's - musta been - I was still dating Snake so it was '91 or '92. They played at the Pyramid - it was brand new. I'm ashamed to say that my strongest memory of that night was drinking too much beer with a crew in Snake's light blue VW van and waiting anxiously, full of pee, for the doors to open so I could find a bathroom. And afterwards, looking for our car bathed in the blue lights of the Memphis police. I don't remember much of the show.

I only knew Sturgill Simpson for his Nirvana cover of In Bloom that played all over Satellite. He's much more than that. He's intelligent - very alt-country. Looking forward to it.

On call this week and BIG SPLIT among beloved Dr. group Style MD. It was like a divorce. I mourned the drama. A new group formed on Monday, and they adopted my suggestion for a name - Stylish AF Physicians. Less rainbows and sunshine and more reality. Easier to participate in a group of 200 than 6,000. But it will grow. It's gaining momentum. It's much edgier - more my speed.

Shadows

Broad strokes paint negative images
Close your eyes
Cacophony becomes patterns
Brings darkness into light

Believe

A crab skitters
Behind a large rock
Ancient knowledge supersedes
And things go backwards
To heal

The Devil You Know - A Book Review

Over at MiM

K.Flay - High Enough

This girl has caught my ear twice! Need to listen to an album.

Barns Courtney - Golden Dandelions (101.9 KINK)

It's a little Kings of Leon, but better.

You're Beautiful

I normally don't go to work on Saturdays unless I'm on call, but last week was a doozy so I needed to triage for Monday. And I'm glad I did - my barrage of diagnostics with beaucoup immunostains did not read the textbooks (well, two of them did. Out of like 10). So I ordered more stains, then checked in with the on call pathologist who is off next week - he is giving me an additional 8 cases to work up Monday. So Monday will be Hell.

I was walking into work, unshowered in yoga pants and a t-shirt and sandals, but I had on a fresh face. A white suburban was taking the path to the valet in the ED, a scene familiar to my route. I heard a man say, "Ma'am, I was rounding the corner and had to do a double take. Wow, you are beautiful!" I looked around to see who he was talking too, only to realize I was the only one there and it must be me. I turned to his vehicle to see a handsome honest face. I was floored.

"Thank you so much, how is your day?"

"Well, I'm not working, that's a good thing."

"I am going into work, but only for a couple of hours."

"Well at least it's not a full day for you. You are so striking, do you know that?"

"Um no. But you made my day. Thank you again hope you have a good one."

Later I was telling my closet organizer designer the story that had me grinning from ear to ear on the way out of the hospital, recalling the encounter.

"That would have made my year."

"Yeah, you are right. Definitely the week. Maybe the year. I compliment women all the time, but never men. Well, occasionally my partners if they dress up. Maybe I should do it more often. It sure feels good. Especially when there's no creep factor involved."

Monumental Seizure

As of July 1st, we control histology and transcription. A contract years in the making. Histology moved downstairs to a sparkling new lab I toured for the first time today. We now have over a dozen new employees.

It's not without hiccups. We had to call plumbing for the immunostain machines. There are cases from Monday that I still haven't been able to sign out - clinicians are restless and we are too. But our turnaround time is exemplary, and I think they will forgive us this holiday/move week. For the first time in ten years, the possibilities (new stains, less bureaucracy, a semblance of control) seem endless.

There is death, and there is renewal.

This is my homework this week. The Flower of Life. It is fascinating.

Legacy

It's hard to imagine the vastness of evil.

I found out today my good friend, David Kendrick, was a victim of probable homicide.

We last spoke on Saturday. He spoke of new beginnings, I encouraged him in his endeavor and promised dinner with the kids soon. We both signed off with hugs. We have become good friends over the past two years, more than just casual aftercare acquaintances. He was a kind and loving soul. His friendship meant the world to me. I was closer to him than any other teacher at my kid's school. I was his go to for parental and kid volunteering, and I hung the moon to accommodate him over everyone else.

There are so many few good male role models in lower school. David has been a steadfast presence in Jack's life, over the past few years.

I had to tell Jack tonight, before someone else got to him. It was one of the hardest conversations I have had in my lifetime.

R.I.P. David Kendrick. We love and grieve and mourn and miss you. I vow to continue your legacy - championing LGBTQ rights. May your soul live on to continue your good works. 

Steady

The rise and fall of breath
The push and pull of the ocean's tide
The upstroke and downstroke of wings in flight
The rise of dawn
The constriction and relaxation of the beat of the heart
Unconditional love

That last one is hard. The hardest person to bestow unconditional love upon is the self. I've been working on that a lot over the past year - forgiving myself my curves, my habits that society deems bad, my getting flustered at being the center of attention, my crooked nose. It is important, because you cannot give your loved ones unconditional love, no matter how much you fool yourself that you can, until you give it to yourself. It leaks out unconsciously - the conditions.

Happy holiday. I've been working. Time to start playing. In a few. I've got some homework to do.

Breath

I was on a long bike ride today. In pounding summer heat. Thinking about what I would teach tomorrow.

I'm teaching Sunday School this month - me, a heathen! It's the last of my series of four - interrupted by Alaska. I'm thinking it's going to be a small group, after all - it's a holiday weekend. My first week was my faith journey - I talked the whole hour. My second week focused on a book I bought for my entire class. Light is the new Black, by Rebecca Campbell. It's astonishingly positive, I skimmed and forgot it already, but it speaks to my new worldview. The third week was an open discussion about angels. It was sublime.

Breath is the center of everything. The center of yoga, meditation, and connecting with your soul. I had a panic attack about three years ago. Full of hyperventilation, carbon dioxide, constricting brain vessels, and ultimate tingling of the hands and unconsciousness. In a freaking parking lot of an apartment complex on Rodney Parham. A man saw my hazards, pulled over to make sure I was ok, and I locked the doors and screamed for him to go away. Saw him as a threat.

When I came around, the world seemed different. Kind of scary. I needed beta blockers more than ever before - more than lecturing a group of over 100 med students, more than being interviewed about the Swine Flu on TV. Slowly I came around to driving again, without a threat of a panic attack. It took time. Where, I wondered, was the foolhardy teenager that drove all over the South with a book on the wheel? Eyes darting from book to road. Pulling over when emotions overcame me. That girl was bottled up.

We breathe to live. When I do journey work, breathing is the main focus of Reiki. I imagine Mother Earth's energy - a soulful white light - entering through my bare feet and exiting my head to connect with the Divine. When I was in high school, I learned a breathing method that I taught to my kids at a young age. Breathe in, really belly breathe, and pretend it's a color. I use white for the in - to heal. When you breathe out, breathe an angry color - I use red. It works for physical ailments, which are really only a manifestation of an injured soul.

We just need our breath. It can sustain us. Slow us down. Our breath is enough.

Armageddon

I walked into work, unceremoniously, after over a week off.

Palmer: We've been hit by a Ukranian virus! No dictation. I've had to live dictate for three days. The entire hospital is incapacitated. Surgeons are telling me it is ruining them. They hit Nuance, which is the superior of our system InSync.

Me: Doubled over in laughter.

Palmer: What's so funny?

Me: I've been angry about this system all year. Why did we change? Who's in bed with who? I have worked here 10 years, and over the last year, I've complained a ton. Got a Butterfinger and latte from the lab director, but no follow up. Dropped cases, system freeze in the middle of the day requiring redictation. It sucks. I don't know why they changed a good thing. When is it supposed to go back online?

Palmer: They don't know. Maybe a few days, maybe weeks.

I showed a challenging GI case to Dr. Woods early this morning.

Dr. Woods: I'm going Melody. Typing all of my own cases. Much quicker than live dictate.

Me: Please teach me that system- I'm a fast typer - would love to bypass it.

So I did. Much to the chagrin of the transcriptionists. This was a day of unprecedented chaos. I hear it was supposed to target banks. Whatever the target - it maimed hospitals in a new way that I've never experienced.

Alaska Wildlife Conservation Center

Tlingit Indians

"In the beginning, they say, was water and sky. Here on high you could find Nesaru the sky spirit, and Wolf and Lucky-man. Below lay a watery vastness, empty, it seemed, with only two small ducks swimming about, making eternal, small ripples. Envisioning another kind of earth, with space and variety for myriad creatures, Wolf and Lucky-man asked the ducks to dive down for mud. Using his endless energy, Wolf took half of the mud to build a great prairie for hunting beasts like himself. Lucky-man, his partner in creation, built hills and valleys where the Indians could hunt and live. Last they pushed up the remaining mud into banks of a river, which you can still see, to divide their territories. 

 

Earth was ready. Wolf and Lucky-man understood that large creatures must emerge from the reproduction of smaller, humble ones. They enter deep into the earth to find two Spiders who are meant to begin propagating the world. Imagine their disgust when they find the Spiders to be not only ignorant of the business of reproduction, but so dirty and ugly that they aren't interested in each other. Wolf and Lucky-man scrub down their charges and explain the pleasures and responsibilities of fertilization. Clean and enlightened, the Spiders give birth to earth's many creatures - the eight-legged like themselves, the six, the four, and finally the two-legged ones." 

 

      - Cottie Burland

ALASKA

I'm here. And it's a little anticlimactic. Very middle America. But I've been researching this for years, and we are traveling to four different hotels around the Kenai Peninsula, so I'm hopeful.

This is a bucket list trip. Back when I first got divorced I was trying to figure out how this could work, how I might do it, when the kids might like it.

Now. We had hotel dinner of fish chowder and crab cakes and fish and chips. Not good for my diet, but oh well.

This moment is just Embassy Suites but day after tomorrow - summer solstice - we will head out on the adventure of a lifetime. Glacier hiking, kayaking, biking, and dogsledding.

So it's 10:30 at night here, 3 hours behind Arkansas time, and it's still light. Does it ever get dark around here? I asked the drunk in the parking lot. He said no, it never does, and offered me some rum.

I'm a whiskey girl.

Is that whiskey in your cup?

No, it's wine. Chardonnay.

Ok can I add rum.

No, I'm fine with wine.

Ship's Hull

Standing at the forefront
Hand touches weathered wood
Scent of ocean salt washes
Over me

Tumor Board

Newest onc, I remember her pregnant. She just had her third baby. Long dark hair, eyes you can trust: So I want to present a case. I sent a pic to rad.

Rad: Yes, I remember - you sent it last night while I was at dinner! How do we get it to project on the big screen? Should I just pass my phone around?

Assist: If you can send it to a CARTI email I can get it on the big screen.

Hushed anticipation by twenty docs.

Onc: I'll tell the story while we are waiting. So this guy comes in the ED with a sternal wound. Seems he was biopsy proven squamous cell carcinoma of the skin four years ago. He didn't tell his wife, and it grew. Now it smells. I debrided it, and am wondering what to do from here.

Ancient crusty surgeon with a pronounced Southern drawl: Call wound care. Let them get it real clean. We can see where it goes from there.

Rad: Here's the pic.

Collective gasp. Wow. This is like half an orange depressed wound right in the center of the sternum, in the middle of both nipples. Red and raw, but no pus.

Surgeon: Pretty impressive Grace. I imagine that was taken after you cleaned it out. Let me give you a bit of advice, if you are going to be doing this on night call. Get some cinnamon extract - local store should carry it. Put it under your nose if you encounter this again. All the best surgeons carry it around.

Everyone laughed, but it got me thinking. We pathologists use menthol for the autopsy suite, but I've only really needed it for the decomp room at the Crime Lab. Cinnamon might be a nice change.

Surgeon: Seeing it, It might be amenable to surgery. Gotta get the bad cells out, but we could fill that in. Get some tissue from another site, do some grafting. But I'd get wound care first. That might not be necessary.

Onc: Thanks a bunch. I'll start there. His wife was so mad.

I was thinking, how could you hide that from a spouse for four years?!!?

Other onc: Seeing that pic, makes me feel brave enough to want to show you all my Stage III squamous cell carcinoma of the anus.

Me: Only if you send it to rad while he is eating dinner.

Rad laughing: Yes send it to me at dinner!

Everyone else: No thank you.

The Nightingale: Next case?

Interventional Radiology

Rad: So what are you seeing? Lung mass. Spiculated. Suspicious.

Me: I'm looking. There's no frank cancer here.

Rad: So what are you telling me? It's unfrank cancer?

Me: No. It's not Frank cancer. It's Joe cancer. No, kidding. It's not cancer. There is inflammation. Get cultures.

Next morning at the scope, looking at the core. It's cancer. Well differentiated. Bronchioloalveolar type. Lepidic. But definitely invasive. Stains support pulmonary origin. Frank cancer.

This Just Happened

I'm so excited I have to share! Started watching House of Cards and obsessed over Robin Wright's hair. Props to Deidre - love it! Now who's overusing exclamation points.

Deeds sold me a product made of volcanic clay to help style it. I hope I can figure it out in time for tumor board. If not, oh well.

Interventional Radiology

Me: She's way up in there. What are you sticking?

Rad: Hello! It's you! Where's Shaver??!!

Everything this guy says ends in an exclamation point. He's jovial.

Me: He went on vacation. I switched from frozens to needles. We have started splitting cytology weeks because they are incredibly busy.

Like today. I'll be back. I need to go do an EUS in the OR. Already had two bronchs and radiology. At least I'm getting exercise.

Damn pancreas is hard. Fried egg looking cells could be a number of things. Back to IR.

Rad: We are in the apex of the lung! Hey, who are you?

Cytotech: That's our new cytotech student.

Rad: What's your name? Where are you from?!

Cytotech student: I'm Crystal. I was born in California.

Rad: I knew it!! You look way too fancy for Arkansas.

Me: I'm going to LA in a few weeks.

Rad: I've been there.(You can imagine the exclamations now I'm sick of typing them). That's a crazy place. We were at that Kardashian store, well, my wife and daughter went in, I sat outside, everything is so expensive there.

Me: Your daughter in med school? The one I met?

Rad: No, the youngest one. She's obsessed. We've been to Dash in New York City too. She loves the Kardashians. We are Kardashian stalkers! Never seen one though. We will keep trying.

Cytotech: Who are the Kardashians?

Rad: You don't know who the Kardashians are? Where are you living, under a rock?

Me: I've heard of them, but I don't know them very well. I'm not sure what Dash is.

Crystal: That's me too, just heard of them. Isn't there a show or something?

Me: One of them is married to a famous artist, or musician . . . wait? Kanye West?

Crystal: Yes! That's Kim I think? And there's a Chloe maybe?

Cytotech: How are they famous?

Me: Not sure, aren't they related to that famous guy, who just turned into a girl? The Olympic athlete? Can't think of the name.

Cytotech: Bruce Jenner! Finally a name I recognize. Man, I remember when he was on the Wheaties box. Maybe they should do another Wheaties box with him, I mean her on it.

Me: Yes! 2017 LGBTQ version. This is just, macrophages. Inflammation. Get cultures.

Crystal: I know there is a Kylie Jenner, but I'm not sure if they are related to the Kardashians.

Rad: Man, you guys need to pick up a People magazine every now and again. But I guess I wouldn't know anything about them either if it wasn't for my daughter.

Off to bronch lab.

Eir

The path from fear to love
Is letting go of control (ego, self)
And connecting to the Universe
We are but vessels for our souls
Seeking purpose on this Earth, at this time
I am you and you are me

Eir, Norse Goddess of Healing

Stay at home Starchitect

New post, over at MiM


Man I slept 30 hours this weekend. Never saw darkness. I think that's a first since childhood.
Re-reading old faves, just because.

Mirror

Backlit leaves
Shadows in the fading sunlight
Hold promise of a New Day

Tumor Board

Plastic surgeon: I haven't been to a tumor board - It's been 15 years.

Breast surgeon: Tell the story.

Plastic surgeon: Look at her left breast. It's about to explode.

The Nightingale: This is fascinating. Where is the fluid accumulation? Near the pectoralis?

Plastics: No, in between the implant and the capsule.

Me: What exactly is the capsule? Is it that part we receive during implant removal that is a rind of fibrosis and calcification?

Plastics: Yes, that's it. It's the reaction to the implant. The scar tissue. It varies - different with textured implants.

Rad: Why do you want a textured implant?

Plastics: It prevents contracture.

We see pics. Of the breast. Of the mammogram. Of the surgery. Of the path, some of which I present.

Syd texts me: Longest case ever.

Me (text): My good friend used him. He's the best in the South. Girls fly in from Vegas to get implants from him.

Syd (text): Wow. Great niche.

Plastics: We were worried about Anaplastic Large Cell Lymphoma (ALCL). It happens. It bled like hell. It was a Friday afternoon. I had to rush it to Breast Surgeon for help.

Breast Surgeon: We had two different path specimens. Conclusion up to path.

Me and other path: Carcinosarcoma. Here's pics.

Breast Surgeon: She's so young. It's in your court now onc. What do we do?

Weightless

A translucent wing
Soars upward into space
Bright white soul, detached
Winking at gravity

Cajun Sno

So Jack and I have this game. I bought these sayings, painted onto wood, and we try to surprise each other with them. Kind of like Elf on the Shelf but all year long. Most of the time we really aren't that creative. But occasionally he catches me off guard. This time in my closet. I was surprised and overjoyed.

Making online friends become IRL friends is a bit of an effort. But it pays off. We took Mr. Are You Living the Spicy Life (a walking meme, according to his lawyer mom, and yes I agree) and the infamous maybe a like interest Izzy to dinner tonight after they played all day in the pool - a rendezvous initiated by my almost twelve year old and his encouraging older sister. Their conversation was indelible.

Russ: "So you've never done the cinnamon challenge? It hurts."

J: "What's up with all these people taking those new Cheetos to school? Flaming Cheetos are ok. But that new lime twist? So fake. Some guy took a family size version the other day and ate the whole thing. Disgusting."

Russ: "Is that a mushroom on your salad? Can I have one?"

Me: "Sure, take two."

Russ: Proceeds to torture Jack with the mushrooms . . .

Me: "Am I missing something?"

Russ: "Jack hates mushrooms. This is so fun."

Izzy: "Did you know that we just played three rounds of Mortal Kombat in the back room? Two with Russ and one with Jack. I won all three."

She said this with ultimate humility and pleasure.

Me: "Congrats. You rock."

Russ: "She had a superior character to us."

Izzy: "No I didn't."

Me: "Accept your failure with grace. Grace makes the world go round. That, and Flaming Cheetos."

Russ, Izzy and Jack, in that order 

Tiger's blood (not in my car!), lemonade, and wedding cake mixed with homeade ice cream (Jack learned well from me at a young age - we all agreed his was the best).

Gout!!!

Here's a good one. Great things happen in threes. Which means I have one more gout in my near future. 

Chief: So you've never heard of the Shidem's stain?

Me: 5 years ago. "No. We stained the alcohol fixed gout with H&E."

Chief: Be careful with the transcription. I've had to edit Shit 'em's.

Me: Ok. Stunning, right?

Uterus Unicornis

Dr. Music: Rebecca? I think this is a hard case. Soft tissue mass in the ascending aorta. Is it luminal or adventitial?

Mary Pickford

He's been calling me Rebecca of Sunnybrook Farms today, on account of my dress. One I found last week on Amazon for 28 bucks. I told him I thought of it as more poodle skirt with a modern print. I've fielded more compliments, catcalls from phlebotomy, and requests for where I bought it than any other dress I've worn in history. I think the petticoat I bought online leads to a more vintage appealing look. I took a terrible selfie for Style MD that doesn't do it justice. I stopped a handsome yard guy at the wine store in his tracks. "I can't help but admire your dress, it's amazing." I replied, "Thank you, I've been hearing that all day! It's so comfy too. I ordered four different patterns - solid too - in the same dress this morning."

Terrible selfies

Me: That's a good question, I'll call cardiothoracic surgeon. I didn't think to ask. I thought the site was wrong, I felt for sure it was an atrial myxoma, but op note says it's in the ascending aorta. You know this week has been a treasure trove of unusual cases. Did you know I have a freaking uterus unicornus? I had to google that I've never heard of it.

Dr. Music: Me neither. I've heard it's a myth.

Me: No! Google it it's a true rare thing! I can't wait to call gross room and tell them about it. They thought the surgeon missed the uterus and got the cornu. But it's a true horn. Apparently an extremely rare congenital uterus anomaly is to have a banana shaped uterus and a horn. There are different variations. Mine has endometrium and myometrium.

Dr. Music: That was supposed to be a joke. Based on the uni . . .

Me: Oh duh. Ok I get it. But seriously, you can't top that can you?

Dr. Music: No. But back to the aortic mass.

Me: I know. I only found one case report from 1974 about a myxoma in the ascending aorta. She died. Not too encouraging. But this patient is fine.

Dr. Music: You did better than me. I found nothing. I'd send that to Jesse.

Me: I was thinking the same thing. Rare things have different rules. Ones best left to the experts. I'll send it to Cleveland Clinic tomorrow. After I find out exactly where it was growing.

It was growing in the pericardial space on the adventitia of the ascending aorta. I can't wait to see what Jesse thinks.

Blues Traveler - 100 Years

The best Blues Traveler song ever. Chris Cornell died, and that sucks, but I can't help thinking about John Popper. 

Ovary Frozen

"Ugh. An ovary frozen? On top of breast cases and interstitial lung disease and a full caseload on a Saturday? When does it end? Can you please look up the history?"

"I've got it pulled up right here."

"It's so confusing. She was diagnosed with cancer almost 15 years ago. So did she already get a hysterectomy? Why do we have the ovary?"

"Capsule looks intact. But it's huge. Gotta be cancer."

"The sections you took are necrotic. Let's take it over to the grossing station and breadloaf it - there must be viable tumor somewhere."

"Well, he (gyn/onc surgeon) would know if there is still a uterus."

"I'll ask him." Dial batphone. "Is there a history of endometrial cancer?"

OR help answers. "I'll ask him. No, there is no history of endometriosis."

"???!!!"

"Evans, she just told me there was no history of endometriosis. That's not what I asked her to ask him. I'm frustrated."

"Hello? Is there someone who knows medicine in there?"

"Right, calling all medicine help. Hello? Screw it. Just take this section and freeze it, it looks viable."

"OR. I've got malignant tumor. Not sure what kind. Do you still have the uterus? We will need to do stains."

"He's taking the uterus next."

"That's a big help. Thanks."

Living the Spicy Life

So my kids are making all kinds of new friends so quickly it's making my head spin. Cecelia hangs with mostly public school kids now (she's dying to go all of a sudden, maybe 10th grade I tell her - convince your father - I've already put down a deposit for next year), and I've met a couple of new moms and girls in the last month. Jack has an online friend from his video games that he apparently knows from 2nd grade maybe? He's been begging to get together with him for weeks. They reunited at a friend's house Friday night for a sleepover. Today he desperately wanted an afternoon playdate and despite my exhaustion from work I knew I'd be missing the hell out of him all next weekend so I acquiesced.

Jack finally found Russ online at 1:30 p.m. to set it up, and interrupted my walk texting me the number to call his mom. She didn't answer. Back at the house, Jack said no she's in bed sick. Call his uncle. Uncle answered the phone, "You have 30 seconds I'm on a bike ride." I said, "I want to pick up your nephew and take him for a treat with my son, his online friend, but I don't know where he lives" all the while thinking how bizarre this was. He gave me more than 30 seconds and found Stepdad's number.

Stepdad answered, "Yes, his Uncle told me you would be calling. I'll bet he would love that. Is this the Jack on Woodlawn?"

"No, we are in Foxcroft, they are online friends. I haven't met y'all yet, but I spoke with your wife on the phone to get her e-mail for Jack's birthday party. I'm just going to take them to get some ice cream and back to my house to play. I'll be there at three and I'll drop him back by six or so. Jack told me your address, thank goodness you are only 5 minutes away. Does that work?"

"Sounds great. I'm the contact now. Not mom or uncle. So funny how these boys get these ideas and everything gets messed up. I was right upstairs."

"Yes I've contacted three of Russ' family members to set this up. I hope they have fun."

I drove to the house with Jack and Russ ran out of the garage. I got out of the car and shook his hand, introducing myself. "So do I need to meet an adult? Or are they ok for us to go?"

"Oh, we can just go. I haven't had lunch, can we do that before treat?"

"Do you like Subway? My stomach is growling I need something too before yoga. Then we can go to Baskin Robbins." I brought my book so I could give them privacy and found a great table outdoors between the two restaurants.

"I love Subway!"

Jack had eaten lunch, so I told Russ to order what he wanted. After he ordered a foot long sandwich, politely asking if it was ok, I ordered a cup of jalapenos to go with the Sun Chips I picked out. He turned to me, looked up, and said with a straight face, "So, you are living the spicy life?"

You could have knocked me over with a feather. My kids friends don't address me quite so candidly, especially new ones. I was excited, and decided to hide my surprise and engage. "Yes, I live the spicy life. Do you live the spicy life?"

"Well, I used to live the spicy life. Then I ate this pepper, it was so hot, it hurt me. I had to give up the spicy life."

"Entirely? You gave it up for good?"

"Yes. I haven't had anything spicy in a while."

"You know, when I was your age, I ate some really spicy hot sauce at a Mexican restaurant at the Epcot Center in Disney and I spent about 30 minutes at a water fountain before I felt like I wasn't going to die. It scared me away from the spicy life. But eventually I got back to it, and I have no regrets. So I would encourage you to keep it open - you might enjoy the spicy life again someday. Now I'm going to go outside it's freezing in here. Enjoy your sandwich and come find me at Baskin Robbins when you are ready for ice cream."

I tucked Jack into bed tonight. I told him I really liked his new friend. "He gave me a new identity. I've irrevocably changed. Up until now, I was just Gizabeth. Now I'm living the spicy life. I can't wait to have him over again. Now I'll sign all my Instagram posts hashtag living the spicy life."

"No mom, please don't."

"Just kidding - I've never hashtagged. I'm above that. Or below it. Or off to the side maybe. Not a hashtagger. So did y'all have fun?"

"Yes, he was really scared when that song he played for you on Spotify had a cuss word in it."

"I noticed him whispering to you frantically in the back seat. I didn't mind."

"Yeah, I told him it was ok. No worries."

"There are worse things in life than cuss words. Just don't cuss at your teachers and you will be ok."

"Yeah mom, I know."

"I know you know. Good night, love you."

"Love you more."

Gout

Dr. Music barged into my office at 2pm.

"What is all this stuff you have written down. Pseudogout? Tumoral calcinosis? This is just gout."

I'm staring down the scope at the slide I am working up, but turn to look at him.

"Those were just ideas. Because, how can this be gout? It's so damn ugly."

"It's just gout."

"Are you sure? When I polarize it, it looks like crap. Like no gout I've ever seen. Like gout's red-headed stepchild."

"What do you mean?"

"I love gout. It's gorgeous. This is not like any gout I've ever seen."

"But it does polarize. There are crystals."

"Yes, few and far between. I'm a big fan of gout. I always take pictures."

"Show me."

"I'm not sure if I could find it on my phone. I only see it once every year or so. This gout is not picture worthy, if it is indeed gout. I'm not taking a picture of this. Gout usually takes my breath away. Not this one."

"Gout takes your breath away? That's crazy. Gout has never taken my breath away. Marie Osmond, in those weight commercials, she takes my breath away."

"Marie Osmond? And you watch TV that has commercials? Where does that still exist?"

"What, you only watch Netflix? And Marie Osmond has never looked better."

"Well, that and other TV with no commercials. I'll google her. She came to Baptist a few years ago, for Bolo Bash. Did you know that? Radiologist was bragging that she was at his house for a dinner. I didn't realize she was a thing. Wow, yes she's pretty hot, I'll give you that. But she can't hold a candle to a good gout."

"Just sign it out descriptively. Crystalline soft tissue deposits with giant cell reaction, favor gout; clinical correlation recommended."

"Sounds perfect. Thanks a bunch."

This is good gout. I cribbed it from the web. 

Conquer Me

I love this song so much. Watched the video over and over. Bought a striped shirt at Banana Republic in solidarity. Only it didn't bare my midriff. I wasn't that brave.

Fireflies

Pinpoints of bright light
Draw children streaming through dew
Longing for magic

Nature's Image

Thoughts today while signing out a ridiculous number of complex cases on call.

Feathers = fern leaves = muscular striations

Heart = caverns

Lung = trees and root systems

Pulmonary parenchyma = honeycomb of bees

Cracked dry Earth = pulmonary and liver fibrosis

Arteries = Rivers and tributaries

Thyroid micro = creeks with cobblestones

Brain and electrical synapses = stars, Universe, higher conciousness, a spider's web

Our bodies parallel nature. There is no ego. There is no one. There is only collective.

And when it goes haywire, I'm there to diagnose disease. As a placeholder. I'm not unique - others have done it before me, and others will do it after me. I'm just here for the duration, doing the best I can in my brief moment on Earth.

IT: 8:30 am

IT: You are having problems with your keyboard?

Me: This always happens, when I'm gone for a week. Something crazy with my computer. Not to mention the dust bunnies in my office. It's not working. The blue tooth light is on, which makes me think it isn't the batteries, but I can't log in to try to reconnect it. Because it won't work to put in my password.

IT (Incredulous): Do you know about Trojan? Did you know what happened over the weekend? Did you even read the news? Do you realize we have more important problems?

Me: Um, no I didn't. I was at a music festival with my brother in Atlanta.

IT: So you were partying?

Me: Yes, I was. But apparently I missed the IT Armageddon. What happened?

IT: We were getting messages all weekend. Texts. They are all in meetings all day. I'm on my way to one now. This ransomware, Trojan, infiltrated hospital systems through e-mail. Two of our units are shut down. It incapacitated the NLR hospital. Apparently entire hospitals were affected in Europe. And there are more dangerous ones on the horizon.

Me: Dangerous what? Is that a virus?

I was thinking, isn't that a condom? Or a wooden horse?

IT: It's a type of virus yes. Don't open your e-mail unless you trust it.

Me: So what should I not trust?

IT: Anyone who normally contacts you by another medium, suddenly does thorough e-mail. Don't open it. They are using your contacts.

Me: So chief normally texts me. If I get an e-mail from him, suspicious?

IT: Yes. Very. Delete. And go and get me some batteries from transcription.

Twenty minutes later.

IT: We got it working! We had to do something, something, something.

Me: Well I'm glad my keyboard is working. Thanks so much. Good luck with um, Trojan. So what happens, if you are affected? Just so I know.

IT: You get a blank slate. Try to get in the EMR, and nothing.

Me: That sounds pretty bad. Hope it doesn't happen to path.

Airport: 1:30 pm

Me: I'm running really late because I accidentally called Uberpool? Who knew there was such a thing. I paid the Uber girl $20 to kick two girls out of the car and get me to the airport as quick as possible. So anyway, my plane is boarding and I'm too late to check my bag and I want to see my kids for Mother's Day and I've got a bunch of liquids - where can I get rid of them?

Security: Over there. Get rid of whatever you need to.

Me: In the interest of time, I'll toss it all. ($350 dollars worth of beauty and bath products. Ugh.)

Security: No worries, happens all the time.

Made it.

So do you think they troll those trash cans looking for stuff? Because if they did today - Big time score.

Wheelchairs

Airport 10am

Hematology head tech: I'm so excited about the new wheelchairs!!

Lab director: I know me too. We get our first shipment soon. It will be so good for the hospital to get those wheelchairs.

Me: What new wheelchairs? 

Lab director: They are going to be so great. They are stackable, kind of like grocery store carts. And they will be color coded. For example, OB has pink, so if you see a pink wheelchair that isn't on OB, it will stick out like a sore thumb. 

Me: How is this good for the hospital?

Lab director: They have no way to drive, only push. So the person in them can't maneuver it. They can't steal the wheelchair.

Me: I didn't know that stealing wheelchairs was a problem.

Lab director (with other techs chiming in): Yes. Huge problem. Patients check out, and they steal anything that isn't nailed to the floor. You name it: wheelchairs, oxygen tanks, bed sheets, etc. Look! It's kind of like that airport one. That's stackable, and the person in it cannot drive.

Me: So the airports beat the hospital.

Lab director: Yes, they did. Wish I'd have thought of it. That's a billion dollar idea.

Hate?

Stirs slowly, in an effervescent stew.

The opposite of feeling is indifference.

Of which I'm an expert.

Words

Your words are a scorn
Ones I attempt to eschew
From the depths of my soul

Cryptococcus neoformans

Me: Cancer,  active esophagitis, all can be turfed until Monday. I'm passing the cases out like candy. I'm flying out early Monday morning for a lab inspection. I won't be available for the fallout. But this, this is a medical emergency. I've got to do some carpooling around noon - get my daughter and her friends from volunteering to lunch to Heights, so please do the special stain and I will be back in an hour and a half.

Mycology tech (after inconclusive India Inks and mucicarmines): I'd go suspicious. I found a single colony on the plate. Too young for stains. I will follow up on Monday. It's a fast grower. 24-48 hours.

Me: This is a rare bug. I need to call ID, and make sure it is covered.

ID: Thanks so much for calling me. We aren't currently covered for that fungus. I'll add an extra anti-fungal, and make sure she is covered until Monday.

Me: I'm flying out early Monday morning. But the tech will call you with the results. Thanks for adding coverage; this is highly suspicious  - I think you are being prudent.

Isn't that halo breathtaking? India ink and mucicarmine positive, in a perfect world. But we have to wait.

Bishop Briggs - Dark Side (Audio)

One week from tomorrow.

Musings

So I've decided not to lose the last few pounds. I'm enjoying the cleavage. It turns me on in yoga, during down dog. My own cleavage. And I can eat more. Finally indulge in what I've been denying my whole life.

I was at LuLu Lemon with my daughter last month. She was trying on a cute bralette, and I asked the clerk if I could try one on too.

"Um, no. Those are only for A and B cups. You are at least a C cup. You need to be looking in the C and D section. Over here."

I've never been guided to the C and D section. Seems like a milestone. One that I'll gladly take.

Gross Room

2:30 p.m.

Me: What? Who the heck is freezing testicle? I've never heard of such a thing.

Lin: I know. It's hard to freeze and gross, it's super fresh, I found a small lesion. Come look.

We normally fix testicles in formalin for a long time before we gross them. They are very squishy.

Me: That's so small. At least it seems clear of the margins. But a frozen? These tumors are so hard - we need stains to figure them out. Frozens ruins the tissue. At least we have the other half for permanents.

I looked through the microscope. Testicular tumors are so rare - we always need to pull out a book. I called Dr. Music for backup, and did just that - found the 1963 issue of male GU fascicle on the shelf and started to peruse. My best guess on first look was Leydig Cell tumor with extensive hyalinized stroma. But to call that on frozen? Pretty ballsy.

Dr. Music: I agree, this one is hard. But I think you love throwing the word testicle around.

Me: Isn't it fun? We get all the parts. Can you imagine a urologist throwing around the word breast, or vagina? They would be ostracized. But we can chant cervix, breast, penis, all day long.

Dr. Music: We can build a whole person. We can talk about every part. We look at it all. I agree. Suspicious for neoplasm, but we need stains.

Me: Thanks for your help. That's exactly where I was. I'll call the doc.

Of course the gross tech brings me his cell, because he has already left the OR. I'm a little incensed about the waste of the tissue for frozen. I explain to him nicely over the phone that we don't like to freeze these, because we need the tissue for immunostains. I think the message was lost.

Urologist: So it wasn't normal testes?

Me: Um, no. Not normal. I'm really worried about it. We need to do studies on the permanent sections to determine what it is.

I walked out of the reading room into the gross room. Told the techs if anyone ever decides to freeze a testicular mass they need to call me first, so I can try to talk them out of it.

Beetles and Wine

I stomp furiously to redirect the encroaching beetles. They persist.

The wine glass in my hand is jarred. Sweet wine drips down my calf.

People gather. Energy is garnered. Roots. Nets. Webs. Light. Earth. Divine.

It is time.

Diarrhea of the Mouth - Law and Order Version

It's close to midnight, and I'm up too late as usual, even though I've been up since 4am, and I'm talking too much (I do that sometimes, don't I?).

I had a unique experience today. I was a witness, not an expert witness, but a friend witness in a post divorce trial. Not sure of the outcome yet, but it was intense. What was supposed to be a half hour turned into 4 hours of an already busy call Monday. It was so toxic I was ready to pitch a tent for my friend. I've never been to the Pulaski County Courthouse, except to obtain marriage degrees.

Despite a dose of beta blockers I was nervous as hell. Sitting outside waiting, talking to other witnesses. At one point I learned my testimony might be blocked by the opposing counsel. They tried for over an hour, to no avail. I think they thought they could stall long enough that I would exasperatedly return to work. They thought wrong. I was strengthened by their determination to silence me.

The lunch in the basement of the courtroom was primitive. Ham or turkey sandwich, or choose from a variety of junk food. I found a Nature Valley oats and honey granola bar, and a large bottle of cold water. The plainclothes detective with handcuffs emerging from his back pocket moved aside so I could pay. I approached the counter. "Do you take a card? Check?"

"No, only cash. But I'll take your purse."

"Ha, I get lots of compliments. I'm keeping the purse. But I've got to go get some cash from my friends."

"I'll buy your lunch." This, from the detective. I thanked him profusely. Small courtesies in a long hard day seem overly gratuitous, and my appreciation swelled to astronomical heights.

When I was finally called I was so exhausted from lack of decent lunch and afternoon coffee I was ready for anything. I swore in, settled on the stand, and fielded questions through the microphone from both counsel. It was like a TV show - but I've never much preferred lawyer/court TV shows so I felt at a disadvantage. Maybe that played well for my friend. I hope so. She deserves it.

Despite objections and overrulings I think I got my point across. I could go into way more detail but I value confidence. Last question:

"So you don't think it was too much for her to ask where her son was."

"I'm a mother. I like to know where my kids are."

Middle Kids - Edge of Town

More new music.

K.Flay - Blood In The Cut

New music!!

Rainy Weekend

I holed up in a cottage in Eureka Springs. Re-reading an old trilogy. Just finished book one. And I must say, someone needs a medical editor. Human beings cannot pass gallstones, only kidney stones. Other than that it was as good as I remember.

Time for a glass of wine.

Hope everyone is having as blissful a weekend as I am.

Gross Room

3:30 pm.

Me: I told him that I was 80% sure it was parathyroid. He's sending more. Guess I'll wait. He gives me less than the brain surgeons! What does he expect - Sorcery? Witchcraft?

Jessica: I'll freeze it. Hey, did you ever hear anything back from that neurosurgeon that did the Sunday elective? Is he still doing that?

Me: No! We've got admin backup. But I don't think I need it. Strange, I've never met him, he's been here 1.5 years, but I've seen him four times in the last few weeks. First time, in the front hallway, he studiously ignored my attempt at eye contact. Second time was in the parking garage stairwell. I said, "Good morning!" and he replied kindly. A couple of days later I saw him in the doctor's lounge, and he said hello to me. He must have checked my creds and run the situation by with other doc's and realized I wasn't just messing with him. We really, not just us, also OR, are not prepared for Sunday electives.

Jessica: Great! I know right? It's not like this is UAMS.

Me: Right! We are civilized here. We don't respond to crazy egos wanting frozens in the middle of the night. Cardiothoracic surgeons cannot have sex in the stairwell with their nurses. Chairmans cannot screw their business admins in the wee morning hours and get caught by janitors, only to be the butt of every joke on campus except from those in power protecting their bad behavior. We don't bring that stuff to work. We don't do elective surgeries on Sunday. That's family day. (Well, there was the incident with the sink being ripped from the wall, but we all talked and laughed about that, we didn't just brush it under the rug as normalcy.)

Evans (ponytailed motorcycle head of gross room - well, not head anymore, I took over last week as the lead pathologist over the gross room and my first move was to make it a triumvirate with Jessica and Laurie. Everyone is happier. I told them not to fight about who gets to be Julius Caesar, or Pompey, or that other one Crassus that no one remembers, just divvy up the duties to their satisfaction): It didn't used to be that way.

Me: Really? Nefarious things in the past? Do tell.

Evans: Certain people forgot to lock the doors when they were doing things they shouldn't at work. That didn't last long. They got exposed.

Me: Good. That shouldn't happen here. In my experience, when crazy stuff flares, it gets quieted by the reasonable members of our hospital. I hope they keep it that way.

Jessica: Weren't you wearing something different when I saw you this morning?

Me: Yes, I went home and changed. Forgot it was our head cytotech's family member's funeral today and I really wanted to attend, and not look like I was going to a dance party. It was at St. Mark's on 12th street.

It was amazing. He was incredible. Largest and possibly best funeral service I ever attended. Glowing tributes from best friend and brother. Beautiful sermon. Live music so good I got goose bumps. I sat next to the youngest daughter's best friend. I watched her eyes well up, and told her she was so strong and supportive to be here for her friend, who will be needing her. She smiled. I was glad, as I headed back to work, that I didn't know what an amazing good person he was when I did the post last week. I would have been incredibly intimidated, and probably screwed something up. The service made me want to book a flight to Mayo to make sure everything we needed was done right.

Jessica: Here's the other frozen.

Me: It's smaller than the other one. It's just fat, adipose tissue. I'll call and tell him.

Jessica: Is he sending another?

Me: He didn't say, so I'm going to bet no and head back to my work. Thanks a bunch.

Dinner Conversation

It was just me and J. C was coming home late from a track meet and I was trying to nourish him before the annual Spring Chorale concert at the school - he loves the choir. I cooked last night, but tonight was just mac and cheese and hot dogs and watermelon. Comfort food.

"There's this girl, she's definitely the nerd of the grade. She works really hard, always does the extra worksheets."

"She's super cute. I know her parents, they are both docs like yours. She will probably go far. Who's the boy nerd?"

"Definitely me. There are other ones, but I'm a nerd. I mean, I'm the only one who always has my nose in a book. All the time. But I'm smart, I don't do the extra work she does. I don't have to study. But I think all her extra studying might come from her parents? I'm not sure. She's really smart."

His nose in book constancy is the subject of parent-teacher conferences. He even has his nose in a book over recess. "The not having to study part will probably change. But I was a nerd too. The apple doesn't fall far from the tree. You remember, we tried you out in all the sports. You always had your head in the clouds. That was me. I'm glad you and C have finally found some individual sports that you like. And you have a best friend! He's awesome. Popularity isn't everything."

"So if you could choose between flying and telepathy, what would it be?"

"Definitely flying. Telepathy is for the birds."

Tumor Board

The Nightingale: So I've got a proposal. Pharm wants to come to our tumor board, and bring food. I'm reluctant. What do you all think?

Rad, Path (me), Rad/Onc: No.

The Nightingale: I agree. It's a safe space, for us docs and our patients. As soon as they come along, it will become about them. Let's keep it this way.

Me: Did you meet Dr. Kahn?

He's the Cyd Vicious of pancreatic pathology. He does EUS, and he's really good, and I'm so excited he's here. I'm pulling my pancreas book out and dusting off the muck (I was GI path so I knew it well way back when), and he's unearthing pancreas pathology that we haven't seen here in the past ten years. He's also ordering studies I've seen at conferences but haven't yet made it to Little Rock. Until now.

The Nightingale: Yes.

Me: Good. Oh hi!!

Big hug to St. Vincent pathologist friend.

B: Wow this is beautiful. I haven't been here before.

Me: Welcome. Glad you all are here. Can I introduce you to oncologists?

B: Yes, I've only met them over the phone. Please do.

Cyd: I think the pathologists are dominating today. They will soon take over.

Me: Lol yes. Ratio is 2:1 pathologist vs. other docs. There have never been so many here. That's how it should be.

The Nightingale: 7:00 a.m. Let's go. Can I take the first case? I've got someone who can really use our help.

Work Family

Read it, over at MiM

Rate Limiting Factor

the slowest, therefore rate-limiting, step in a process or reaction involving several steps.

Today my rate limiting factor was my shoes. They reminded me of a hang up in an organic chemistry experiment. I bought them last Saturday, and after wearing them to Sunday School I knew they weren't practical. But they looked so good (confirmed by random stranger in the hall today) and matched my dress so I went for it. "What could go wrong?" my mind rationalized against my senses. "You'll maybe have two frozens. It will be ok, you sit at your scope most of the day."

I was sitting at a stoplight this morning at 8:02. I'm on call, I should be at work at 7:30 a.m. to cover the OR, but I've learned to push the envelope, and 99% of the time it works out. My phone rang. "We've got a frozen."

"Ok, I'll be there in five minutes."

The interminable stoplight finally changed to green. When I got on the interstate I gunned the accelerator to 90. Stepped out of my car in the parking lot and realized my dilemma. I could not run in these shoes. My normal walk is faster than the average female jog - I'm not a superhero, I've just got long legs. But these shoes rub and elevate me to an awkward stance - I've got to slow down to the average human speed. I finally reached the gross room three minutes past my estimate. I internally cringed when I realized the head of the gross room had not even started the frozen. But he had a good reason.

"Seasoned OB wants to freeze the cervical cone."

"What? What OR is he in? I need to call him. We never do that." My purse was dangling on my arm.

"I knew you would want me to wait. Here's the number."

Call seasoned OB, get him on the phone. "Can you tell me what you want? I haven't done this but once in ten years. She wanted to know if it was invasive cancer to do a surgery."

"That's what I want to know."

"Freezing tissue compromises the specimen. We cannot evaluate for dysplasia. Your specimen is huge. It will take us 45 minutes to an hour to freeze this tissue. Can I freeze a representative section? We cannot identify microinvasion grossly, so there are no guarantees."

"Ok, yeah, sure, one section is fine."

Fifteen minutes later. "No cancer."

"Thank you."

I was called to the gross room an hour later. "What? Breast surgeon is freezing the breast? Why are we freezing cervical cones and breasts today? Has the world flipped upside down?"

Fifteen minutes later. "You've got everything on this slide. DCIS, invasive cancer."

"Thanks so much."

Luckily no more frozens, but busy day. Double surgical load (with double reimbursement to boot) and call duties. Plus I was reminded scrolling through FB on a short break at 2 it was National PA (physician assistant - that is, all the people in the gross room) Day. Crap. The walk to Tipton and Hurst to buy gifts to bring to the gross room normally seems short, but with these shoes it was like 10 miles. But I did it. I took over the gross room from our chief last week, and am already orchestrating many changes behind the scenes. I'm so excited - micro and the gross room. My two fave departments. I feel like I'm on top of the world. But the cost of staring Dr. Music right in the eyes (I told you I would find the shoes that I could look down on you someday soon) is steep. No pun intended.

Preview shows unintended highlights. I've got to get up early and I'm in no mood to problem solve this issue, so enjoy.

Edited to add pic of shoes per Maren's request. They do look pretty badass, right? From now on, only for limited walking like out to dinner. 

Doctor's Lounge

To be fair, I was an eavesdropper, not an interlocutor. I was just getting some afternoon coffee.

ED doc: I was a senior in college. She was a freshman. She agreed to a date; I was on top of the world. We were in my car, I was playing Beach Boys and singing along. She asked me, "Who is this singing?" I was so proud to know the answer, and to explain it to her. "It's the Beach Boys." I kept singing. She said, "Can we just leave it to them?" Man I was crushed. My whole world exploded.

Me: LOL! Mean, but you've got to give it to her. I never think of clever things to say in the moment until a couple of hours later.

ED doc: Yeah, I've got to hand it to her. Here I am 30 years later, still thinking of that. She took me down a notch, that's for sure. I can't forget it.

In Case You Were in Doubt

I've got my hands in my pocket, and I'm waiting for the day to come.

Tumor Board

The Tigress: I've got this patient. Two separate lung cancers. Small cell and adeno. Not sure what to do with her. She'll accept resection, but she's opposed to neoadjuvant therapy. Only the natural stuff. And, by the way, that includes cocaine.

The Nightingale: Oh, well, since chemo's out of the picture, let's do resection. And I'm not sure there are a lot of studies out there about cocaine and cancer? Maybe it will help? We can hope.

Ancient thoracic surgeon: Anyone who considers a surgeon's hands natural should maybe think twice.

Senior year pic I found in an office drawer today. Ack that sweater vest and those 90's earrings. And chunky chipmunk cheeks. This was obviously before my late 20's when I discovered how to use the three items of make-up I use today. But that hair! I'd kill to have it back. 

Fan Crush

Have you ever identified with a celebrity in a little overly familiar way?

For me it was Louis C.K.

Granted I learned about him from a rebound after my divorce. I was mostly reading books only, but after a few episodes of his show I became addicted. He's a single parent like me. His show cracks me up, and I need a little laugh in my misery. Um, can I just go out for pizza with him after he does comedy on a night without kids? I fantasized about commiserating with him. I sort of stalked him.

So I was super excited when it was announced that he would drop a Netfilx comedy show in April. But I was so damn busy yesterday that I didn't check my calendar and forgot. More damn busy today. No worries. Season ending of Walking Dead was suffice.

So I jumped on it tonight. Laughed so hard I worried my kids. I needed that. Shitty day. Laughter is the best medicine.

Alternative Facts

You know your day is going to be long when it starts the day before. I got a call from my chief carpooling my son home from after school activities.

"It's 6:30, I'm still here, this call already sucks. (Don't know if you remember, but the pathologist's motto is When the Clock Strikes Four - We Hit the Door). I need to tell you there's an autopsy tomorrow. It was ordered Saturday, but there was a problem with the EMR. We just found out about it at 4:30, you were already gone. I'm up, but since you are covering me tomorrow you will have to do it."

OK, I'm thinking, his call sucks and I have an autopsy tomorrow that was already ordered and supposed to be his? While I'm covering call duties and OR? "Have you called the physician? Maybe I can get rid of it."

"No I haven't. I think she died two hours after she got discharged. It's been chaos."

"An autopsy isn't an order, it's a consult. I'll call the physician in the morning, don't worry about it. Take care of your wife." She was having a minor medical procedure, and I was covering him so he could support her.

I called the cardiologist first thing in a.m. Explained our policy. "We do this pro bono for physician inquiries. We refer families to private autopsies. Do you have a question?"

"She's pretty young, I just want to know if there's a PE (pulmonary embolus)."

"OK, I can do that for you. No problem. This is just a big bomb into my already full day. Can we limit it to lungs and heart only?" I'd heard she was pretty big. I didn't feel like mucking around in guts all afternoon.

"Absolutely. Chest only."

I entered the gross room about 9 am to set it up with the deaner. He's the head of the gross room. Got a new motorcycle recently to match his long silver ponytail. An ex criminal defense lawyer. He's got two speeds - gruff and silent vs. entertaining and loquacious. This morning it was the latter. I perused the death note. "It says here she died in the hospital. I was told she died at home. Where the heck are we, Washington D.C.?"

"Propaganda. Smokescreen. Rumors. Alternative Facts."

"Yes! Alternative autopsy facts. We don't need that around here. Let's set it up for 12:45. That will give me time to eat lunch after covering morning frozens."

Thirty minutes later I get a call from a secretary. "They are ready for you in bronch lab."

"Um, I'm not covering EV this week. Where the heck is Palmer."

"He's at jury duty. If he doesn't get picked, he will be here around noon."

After covering bronch lab I send a text to chief. "WTF??"

"My fault, he told me but I didn't tell you. Autopsy chaos." My angst leaked over to my head transcriptionist. "Did you just cuss?" "Yes, I'm sorry, I'll try not too."  "No, I thought it was really cute. I've never heard you cuss." "Ok, I'll do it more often."

So I'm covering OR, bronch, and scheduling an autopsy. Unprecedented, in ten years. It was a helluva busy morning. I went to PMG pathology for support. Got lots. Someone made me a meme. God I love PMG pathology.

I called the morgue at 1:00. "Can you please call me when you are ready to open? I'm trying to get through my surgicals."

Head down the morgue about 1:30. Get lost (it's been almost a year and it's confusing down there). Get guided. I enter the morgue and there are 10 people, mostly young women, gloved and gowned and masked around the dead body and my deaner, who is clearly enjoying the audience. "I'm sorry, we used up all the gowns. There aren't any left."

"No worries, I'll just steer clear of the juicy parts. I will glove up though. I plan to stick around for the eval of the PE, then I'm headed back upstairs to work."

"These are all nursing students. Happened to bump into them and they helped me load the body on the table. It was hard."

"I know a tech at the VA who is still drawing a check from disability after dislocating her shoulder moving a 600 lb. man onto the table. This one's only half that size. Glad you could get help. I get the gowns, but why are they all masked? This scene looks crazy."

Nursing sup spoke up. "I'm their supervisor. I mandated it."

"No argument there. Students need the most protection."

The deaner started the Y-shaped incision, fueled by the nursing students surrounding him and asking questions in awe. I laughed internally at two of them earnestly holding the massive breasts that were now covering her face. As if it was helping. As if they were needed. Well, damn, we all need to feel needed. I told a few crime lab stories to add to the entertainment.

One girl couldn't handle it. "I see deer all the time, but this is too much. I'm going to go sit in the other room."

Others were manic. "Never seen deer here, but this is so cool!"

The deaner preened. "No no, she's the MD. I'm just a JD. Now look at how I can find the right junction between the cartilage and the ribs to use the scalpel. Oops, no, this is too hard."

I asked him, looking at my watch, "Can you just get the bone saw?"

"Oh, sorry, I know you have a 3:00 appointment."

"I'm just going to stick around for the evaluation for the PE. Then I'll leave you to your teaching exercise."

Finally the sternum and the ribs were excised. The heart, when pulled from the chest, seemed abnormally large. Unusual - large people have normal sized organs. There was no PE, deaner confirmed, after first accidentally searching for one in the aorta. I met his eye. "I was thinking that wall looked too thick to be a pulmonary artery. Let's fix the organs and finish at the end of the week. Thanks for your help."