Thursday, January 5, 2017

Station 7

Ok this one requires a little education. Endobronchial ultrasound guided biopsy (EBUS) is a procedure where the pulmonologist places a scope down the esophagus or the trachea to sample one of many lymph nodes - see above. They all have names: Station 10, Station 7, 4L, 2R. A needle is inserted through the trachea or the esophagus to sample the lymph node. Blood and tissue are aspirated through the needle, which is at the end of a long thin clear catheter, and retracted from the endoscope in the trachea or esophagus. A nurse pumps the sample onto a slide. The cytotech smears the blood, dries it, and stains it for the pathologist to read on a slide.

I got a text from the cytotech at 12:30 today. Interrupting my soup. Come on down to bronch lab.

It's in the basement of the hospital. If you are thinking white walls and shiny equipment, you are thinking wrong. The linoleum is yellowed, and there are large ancient metal shelves and cabinets floor to ceiling against the wall, holding old and new medical supplies. There are holes in the walls, some of which have gaped for years yearning for outdated equipment. The main area holds maybe one patient being prepped for the next procedure, lying on a gurney. My scope is set up in the main area, on a cart next the metal shelving. I often have to scrounge for a chair so I don't have to hunch over the microscope.

Right next door is the procedure room with the pulmonologist, the patient, the endoscope, a male nurse, a male respiratory therapist, all assisting. Imaging equipment hangs from the ceiling for constant reference. It's dark in there, it's light out here.

I'm glad to have one of my best techs working this week. He's already got a slide on the scope. I scan it, seeing only blood and lymphocytes. I walk into the procedure room. Thank God. It's Cyd Vicious. I relay my diagnosis, while he's getting more tissue.

"So what's the story?"

"I'm going to hit 4R, 11R, and Station 7."

That might take him 20 minutes or so. Any other pulmonologist would take over an hour. Thank goodness for the iphone. I picked the right field. He's working hard to get tissue, I can Facebook and Insta while I wait for the slides. It's a busy day, but I knocked out most of my work before lunch. "Ok, no rush."

In the meantime, I talk to the nurse standing in the main room. I've seen her, but didn't realize she worked with him. She's adorable, in a bookish way. Startlingly young for her wit. I finish 4R, still more of the same, and while he moves to 11R we start to talk. She regales me with stories of him - her sarcastic low voice so lulling that she can pop out a zinger and it takes my brain a few seconds to grasp it. She had me laughing so hard I wasn't paying attention. Cyd calls from the procedure room. "Haven't you read 11R?"

I turn around and realize there are two slides on the scope. Scan them quickly. More blood and lymphs. I tell him this, and he moves onto his final node, Station 7. More of the same. He walks out and I apologize for being late with 11R. "She is so entertaining. She's telling me stories of you." He looks at me and rolls his eyes. "I wouldn't call her that."

I ask him, "So what are we doing?"

He becomes animated. "This is why EBUS is so important. This 74 year old guy has a large lung mass with contralateral lymph node enlargement. A few years ago, he would have been treated with chemo and radiation. Not a surgical candidate. Presumptive metastasis. Now, we can prove it's not there - it's just reactive. Now he can have surgery."

That is a huge difference in prognosis and survival. Presumptive chemo can kill. Surgery can cure for much longer term.

He goes to talk to the family. I tell the nurse, "I didn't believe in this procedure, before he came here. We would sit here for an hour reading blood after blood after blood. They were hunting in the dark. Blind pigs looking for an acorn. But I know when I'm working with him, he's in the tissue. It's not just a fruitless patient waterboarding, it's making a difference."

She walked over to me. "We could use you. We are having a big party. A fun one - we are renting out a bar, maybe during the Kentucky Derby. We want docs and health care workers who know what he can do, to explain it to the one's who don't. We are inviting a lot of primary health care docs. You can talk to them about what he does."

"I'm Gizabeth. What's your name?"

"I'm Molly."

"Here's my phone number. If I'm in town, I'll be there."

The next day I get a phone call from the patient's primary doc. "Cyd told me it was negative, and that makes a big different in treatment. I need to hear it from you."

"Yes, it is. Great sample. He's the best. Call anytime."

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