Friday, April 10, 2020

Tumor Board

The Thursday before Spring Break I had my last in person attendance of tumor board. It was also my first temperature screen to enter a hospital. It was still dark before 7 a.m., so it felt especially apocalyptic. I was surprised that my temperature was only 96 degrees. I lathered up with hand sanitizer and answered the requisite questions to enter CARTI, a routine that has now become familiar at my own hospital. No I have not coughed, ran a fever, etc. I signed into tumor board. Dr Hays was already fiddling with the laptop in attempt to load the radiographic images onto the large screen. He joked, "My temperature was 93.1. I'm pretty sure that is incompatible with life."

Yesterday at 10: 20 a.m I got a text from my microbiology supervisor. This was my first text from her - I gave her my cell when the whole pandemic thing began. Her predecessor had my cell, as well has the previous infection control nurse, but I just hadn't thought to relay it to her when she took over around a year ago. "We got the GeneXpert test for COVID in, we may be able to go live as early as this afternoon." I'd already had six frozens. It was a crazy morning, so I hadn't checked in with her like I have over the rest of the week. I jumped up from my scope and ran into the micro lab. We celebrated with smiles and incredulous looks. My body felt like it was vibrating. I ran to my chief's office to relay the news. He asked, "How many test kits did we get?"

"I don't know. I didn't ask her. I'm just so excited!!! Finally we've been waiting forever. Let's go back together and ask her." We walked back in to the lab to query Amy. We learned that we are getting 120 test kits, to start, with more promised. This is the PCR test that will turn around results in house in under an hour. We will only use the in house test on inpatients - ED patients and outpatients will still go to outside labs. It will take 32 kits to validate the test, which shouldn't be a problem because we've had the validation lined up for weeks. Sixty tests kits were allocated to North Little Rock, and 60 to Fort Smith. That doesn't sound like a lot, but to us it's gold. Shaver asked, "How good is the test? All the clinicians have been asking me for weeks. I keep telling them it's good, but I need the details."

I replied, "It has a false negative rate of around 30%, from my research. But it's good!! It's freaking PCR. If the virus is there, it will detect it. All the clinicians are worried about the test because of the cited false negative rate. But it's not the test problem, it's the acquisition of the sample. The OP and NP swabs don't always get a good limit of detection to allow the PCR test to work. It's a wonky virus - it doesn't like to be seen easily for some reason. Another kink in the testing process." We went over our plans again for the serologic test, in case we should acquire it. Amy showed us some hard data about the test, and I took pictures of the charts in case I got any questions.

The other night at dinner - Cecelia was over at one of the three friends we are allowing her to hang out with during this thing - Jack was asking me to explain PCR. We had a sort of DYI dinner of leftovers - I was eating my favorite palak paneer and garlic naan from Trader Joe's and they were having more beef tamales. I kind of laughed because my DNA research days are so remote, and nowadays you just stick the sample in the machine and it does all the work. In my explanation I slowly remembered being in my friend Katie's dad's research lab prior to medical school, building primers and going through painstaking work to replicate our target at the time - markers  that would hopefully be early detectors of ovarian cancer. Hard to believe I was only 20 back then - freshly graduated from Hendrix College. When I got into the part about matching adenosine to thiamine and guanine to cytosine, Jack said, "Never mind, it sounds really complicated. I'm in chemistry. We are studying atoms right now. Nothing like this." I said, "You will soon. and it's not complicated, it's fascinating. You will love it. I can't wait for you to learn about it."

Yesterday morning I went to work at 6 a.m. I beat Dr. Bell into work for the first time in 12 years, and I lorded it over to him on text. I was nervous, because I had to chime into tumor board remotely, and I hadn't figured out the technology yet. I started by loading the URL into Google Chrome - Melody had told me the day before that you couldn't download the app in Explorer. It was Global Meet - something I was completely unfamiliar with. I fiddled around for a bit, and ended up being the first one at the meeting at 6:15 a.m. I laughed at myself and read a couple of chapters in my book club book. I'm reading American Dirt, a book we selected at our last meeting after discussing the controversy and battering the author got after her launch a couple of months ago. I felt sorry for her, but I also understood the point of view those that criticized her. Still, it went too far. Death threats causing someone to cancel a book tour? We decided to read and discuss. It's a fascinating book - a thrilling tale of a mother and son escaping a Mexican cartel.  Once again this week, I have a theme. We are watching the third season of Ozark. The other day when I was getting out of the shower, I worried over the pandemic, but gained relief in the thought that I wasn't being targeted by a Mexican cartel. Friday night I have my first ever Zoom meeting for book club. I'd better finish the book by then so I don't have any spoilers. I'm usually the first one done but the last few weeks have found me distracted.

Hearing the familiar voices of Dr. Hays and Dr. Wilder, the only docs at the actual tumor board at CARTI, was reassuring. I enjoyed hearing him cuss in his Southern twang (THIS IS BULLSHIT) when the radiology took 20 minutes to share on the webcam. I figured out I could sync with my dictation machine and talk to them - I didn't need my laptop or my phone like my other partners suggested I might. I got to watch as other oncologists and radiologists chimed in remotely - I was able to see who was there on my computer screen. I worried about no one realizing I was leaving when I had to pee during a discussion of treatment of Waldenstrom's macroglobulinemia, but realized that no one would really care, or probably notice,  if I muted myself to briefly to run across the hall. I chimed in when they were talking about the convalescent plasmid COVID treatment, to pass along information in case they needed it for their cancer patients. There was a funny moment when someone who had connected by phone, a doc who was muted and probably attending to other matters, picked up the hold pattern at CARTI and briefly sabotaged the entire meeting with a loud soothing voice. "Welcome to CARTI. Our mission is too . . . etc. etc." We found out who's phone was responsible, and someone texted him so he could fix it and we could resume the meeting.

I liked the format. I was a little frustrated with tumor board a couple of years ago because they don't routinely use or ask for path like they do radiology, and we often sit there like bumps on a log, answering the occasional path question or looking into something confusing. I rotate going to the meeting now, once a month, with three of my other partners. But I like this remote format - it will allow me to attend more often while covering needles or frozens, and I can work while attending, so I e-mailed the contact person and asked her if we could continue to go to the meeting this way after COVID. I was happy when she replied yes.

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