Middle Kids - Edge of Town

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K.Flay - Blood In The Cut

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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."

15

1983 Oldsmobile Toronado convertible and this album - Don't Tell a Soul. It was a rallying cry. Camp Aldersgate, Senior year. How I discovered it I've no idea.

Doctor's Lounge

Admin: Did you happen to talk to new neurosurgeon?

Me: I did. I bumped into him in the hallway end of last week. Saw his name on his jacket, and introduced myself. He thanked me for doing the frozens. I explained to him that we don't do elective brain surgery on Sunday. I think I flustered him a little. I was very polite, but I'm worried I made my first enemy here. He said he would do his cases whenever he wanted and walked away.

Admin (former OB who delivered C): I never did elective surgeries on Sunday.

Me: No one does. It's for emergencies only. And he didn't even give me a heads up. I was yanked out of Sunday School, then a mother and daughter brunch downtown at South on Main. I finished my brunch and carpooled my daughter home, but still.

Admin: The OR is not equipped for those cases on Sunday.

Me: I know! They were more surprised and upset than me. They asked me to talk to someone for them. I promised them I would. Is that guy from around here? I mean, it's tradition, I've been here ten years. No electives on Sunday. I told him that. I think he got the message.

Admin: Well, somewhat. He's military. Moved around a lot. Let me know if that happens again. I'll have head of anesthesia talk to him.

Me: Thanks, I'll let you know.

Sunday

I did a lot today. Baked muffins. Went to Sunday School. Read a not yet released entire book for a friend on MIM and reviewed on email. Hiked the hood. Went to yoga despite the fact that my arms were screaming in pain from doing push ups yesterday. My legs are super strong. My arms are super weak. I worked hard yesterday to hide that from the yoga watchers. Six push ups almost did me in. I feel like my arms today are going to fall off with any slight effort.

And I'm hyperkinetic. I can't relax. I spent an hour prepping a Blue Apron meal for tomorrow night. I've no idea what I'm covering tomorrow, because the schedule wasn't yet made out on Thursday afternoon, but I'm ready for whatever.

Shapeshifting

I've been shapeshifting this month. Metaphorically. On another plane. Have you ever read about the dragonfly? It can see 360 degrees and travel up to 45 miles an hour with minimal wingbeats compared to other insects. It's wildly efficient, and has been revered for centuries by many cultures.

It represents, among other things, resilience and metamorphosis.

I've got lots of dragonfly totems in my office. A bit of an obsession. And to inhabit? Pure bliss.

Mutual Parasites

Did you ever need someone as much as they needed you? And do they even know it?

Sorry? For what?!!??