Volcanic Explosion

     Well we are finally on the right end of hump day and it feels like a long time coming. I've done two tumor boards in the last week. The first one was CARTI general last Thursday, and it's the first time I've been back since they granted the contract to SVI. On Wednesday Tina handed me a request to present a case. Diane Wilder has retired from running tumor board (I suspect the SVI battle had something to do with it) and Grace Raja is now in charge. She's sweet as can be but the fax request to review and photo a 50 slide case less than 24 hours before TB rubbed me the wrong way. We have boundaries. We ask for 48-72 hours. This shit takes time.

    I was shaking a little, angry about being disrespected and honestly still reeling from the big decision. I crafted a text and smartly showed it to Melody before I sent it to Grace. It was a little snarky and cold, I knew it, and she helped me craft a better one. She doesn't know, Elizabeth. We can teach her. You are right, I said, you catch more flies with honey than vinegar. But you catch the most flies with bullshit, she said, I LOL'd bc I'd never heard that and we both kvetched over someone we know that does just that. We initially wanted to stop doing these bc we were so crushed, but we decided to pull a Michelle Obama - when they go low we go high - bc contracts get dropped and we might have a shot in 2-5 years who knows?

    So I asked Grace to remind the docs that 48 hours is ideal but I am happy to do this last minute for her. She said OMG you don't have to I'll add it next week. No, I told her, its a rhabdomyosarcoma of the uterus and I haven't seen one of those since residency I'm excited to look at it. I told her Quinn was Diane's point person for last minute cases and I'm happy to be hers - Quinn is looking to go part time in the next year or so and I'm far away from that. Just text me, I said. If I'm on vacay I can still figure out who is going. Guess what? Sneed sent his case of hairy cell leukemia for Quinn on Friday of last week. So she is good, Melody was right. She's already communicated it to everyone.

    I showed up early and sat front and center (SVI dude creeped in late and sat in a back corner and didn't present - that's snarky I know but I'm still pissed about it all). My case was first, thank god, there were 31 and I did not want a repeat of med exec committee. I told everyone how rare it was and how I trained with David Parham, the international guru, at ACH. He was also bipolar, I said (no secret the lithium was on his desk and his Jekyll and Hyde personality spoke for itself), and so I looked at all the rhabdo's - alveolar, embryonal, etc. We looked at them together every day for two hours in the afternoon and this is the first one I've seen since (wonder if the guys were subjected to that? It wasn't horribly painful he only made me cry once. He retired during my training. Hope he's still alive. He had a band called The Specimens - they played at an event I cannot recall what it was for. Kind of wedding band-ish). 

    Grace's question, which she worried was silly, was why isn't it a MMMT, - these are much more common in older women. Rhabdo is a peds thing. It was easy for me to answer - there are no carcinoma elements and look at this stunning rhabdomyoblast - but I assured her on text no question is silly you know way more than me in your world. These oncs are incredible. Diane once told a story of fighting with an insurance company (DEVILS INCARNATED) on the phone to get a puking patient a med so she didn't have to be admitting. The patient was puking in her office trash can. She was holding her and comforting her while she was on the phone.

    ENT went well Tuesday but honestly Friday and Monday were so freaking busy - I signed out more cases than ever in one day - that I had chest pain. Luckily the workload has eased so I can breathe. Excited for a long weekend not on call. Paula and I had a great session yesterday - energy is moving and my gut is going nuts but I think it's a good thing. Paula said Pele showed up for her (I have a completely different experience and we share after) and I was delighted. Pele was my divorce goddess when I discovered her and walked on her volcano where she resides. It felt like full circle.

    So I researched her today and it turns out she shows up as a young woman, and old crone (who bums cigs and disappears in the roads around her volcano lol) and a white dog. I learned what she likes to receive, loose tobacco and gin and flowers and coins. She is creative and loves unity but also has a jealous streak and can obv be fiery. Her volcano, Kilauea, is one of the most active ones on Earth and the name means spreading. Like strawberries! If you soak strawberries in brandy and eat them it pays homage to her - the sweet and the fire. So I'm about to do that. Got some good recs from my liquor store guy after work. Happy almost holiday weekend, much love, Elizabeth

Med Exec Committee

     They canceled in June and I had to go home early sick in July. I notice there is a pattern - this GI stuff can be really bad on Mondays. So when I hit a new low yesterday, I won't even go into the embarrassing details, I went into Melody's office at 9am and cried. She made me sit down and hugged me and made me laugh and I picked up and moved on. I told her today you are pretty special. I didn't even cry during my divorce. 

    I had written a statement about autopsies last month that I planned to present last night since I had to skip July. But I was super stressed bc it was a bad GI day and I had to correct a false belief that many doctors and admin had disseminated over the years that would literally be in the room. I was dry heaving up a storm and Melody and Shaver gave me the bright idea to Zoom. So I explained to Sherry, the secretary to a big admin (there are lots of them - bean counters all but I can appreciate some intelligence and care as I get to know them but STILL.) She took Jessica's carefully made autopsy info handouts and supported my decision.

    And let's face it, I can turn very red. Rosacea, hot flashes, you name it, but me dry heaving loudly in front of a room of doctors and admin and having to present in person? After a really bad day? Nope. Jessica met me in my office at 5:00 to Zoom and I made sure not only was there a blue post it over the camera but that it was off. I was dead last, and the meeting went over. We were finally on at 6:30, when I was at the end of my rope, but it went well.

    In a nutshell, admin and docs have this perception that we don't do enough autopsies. But we are right in line with the rest of the private practices across the country. They have been complaining to Shaver and Palmer for years, but there has been no clear communication, so my goal was to remedy that. I explained that we have done autopsies pro bono for years, which may have made sense back in the day, but now it is like a bomb going off in your already busy day.

    And the facilities are so outdated - Blake Phillips was on a bit of a tirade right before me about the slow renovation of the 1971 ORs and I capitalized on this. He's doing surgery late (generating money for the hospital) and we do 5-8 autopsies a year. It's a no brainer not to renovate and send to UAMS, which we did last fall in the contract renewal. Which was a huge relief.

    I told them I knew that it was assumed in our medical community that we turf too many autopsies. We turf everything that is not within the scope of our practice. Anything medicolegal, anything that requires tools we don't have - that's for forensics. Anything family requested gets sent to two local pathologists who do private ones, and it costs money! It's the way I was trained, and a recent Facebook poll of over a grand of pathologists on PMG agree it hasn't changed. We only do physician led autopsies with specific questions. 

    I talked to Susi Jeffus in preparation for July and she told me UAMS only did 57 autopsies last year - a far cry from the 100 I was required to do for my training. She said a new young doc at the crime lab - Ted Brown I think, has taken over the autopsy directorship there and their long term goal is to move them all to the crime lab. They take a few family requested ones, and that's only bc they are a teaching institution and need the numbers. They DO NOT WANT our family ones - inquires there should be directed to Frank Peretti and Jennifer Forsyth - I provided the phone numbers. 

    I was trying to convey that we, in this current climate where getting out patient reports is priority to next step and efficiency, is much more important than playing arts and crafts with a dead body all day in an outdated morgue for no money. I wasn't that crass, but it's really what it is. I have helped get clinicians off the hook over the years (no, you didn't botch that aortic dissection surgery, your sutures are intact), and answered important questions and it's fun! But not practical, and 90 plus percent of the time it's redundant. My one AHA moment in residency was when I discovered a giant esophageal cancer in a woman who had been in the hospital for three months with no CT. Let's not even get into her race, or talk about marginalized women. She'd done snuff her whole life.

    Speaking truth is hard. One of the reasons this got so out of control (Quinn was attacked in trauma committee in early summer which prompted me to get together this talk) is we just listened and agreed and didn't change our correct practice. One of the only guys who had questions, chief of staff Shenker, was incredulous at our numbers and was up in arms that someone was pressing us to do autopsies. He's OB, so probably has never requested one. The irony that most of the people in the room were perpetuating their frustrations over a false belief was not lost on me. They didn't speak up. I replied to Shenker that I wasn't on a witch hunt, I was just trying to clarify our policy and help clinicians get what they needed.

    Death is scary and stressful and I'm not the one dealing with the aftermath. I get it. You lose boundaries, and want to please people (these days for patient satisfaction surveys but that's a whole other rant). So when we draw boundaries docs play with them and we have to play the heavy. Docs get pissed. But hopefully now they understand. There's funny stuff too but I'll save that for later I'm so tired. GREAT session with Paula (who I also called for help after I cried to Melody). She's a godsend. Happy Tuesday, much love, Elizabeth

Friday Eve

     Metaphorically, of course. It's mine, anyway. Thank goodness I need a break. This GI shit ramped up again Friday and Monday and honestly it's so exhausting. I think it's because Paula did a cord cleansing on me last Wednesday - we decided to meet every two weeks on Wednesday. She's a rock star in Reiki, something a lot of people think is silly and on the fringe. Working with her, just twice, has been earth shattering. I've never vibrated before, or dropped into different dimensions, or met teachers (three so far) and NONE of this has any drug enhancement just after work before yoga (I'm trying to go back but it's soooo hard). She recommended a Reiki book I've yet to read - Hands of Light maybe? It was published in 1978 and was recommended by Elisabeth Kubler-Ross who I worshipped in college when I learned about her so that's promising. One book instead of twenty. Cecelia is not the only one who tends to bite off more than she can chew.

    I'm talking to my sister again! Which makes me happy, and seems like her too, so we will see how that goes. Cord cleansing was a big help. - my first. Baby steps with Sara. Mom turns 75 next month so we are planning a low key surprise gift and all the sibs and spouses are involved, and Gkids. Dad's in Atlanta with Mike and Sara getting new cardiology consults. He has had a rough road lately and I pray the tides are turning for a bit of longevity. It's certainly in the Nestrud lineage - I have Great Aunts and Uncles that lived until their late 90's and I think my Polish Mother will probably outlive me.

    Lots of new exciting developments at work lately that are too soon to share. Change is afoot. Not much more to say here - booked dinners and massages for Eureka so planning a lazy fun weekend after getting Cecelia settled. It's getting more and more necessary to do that ahead of time - I guess it's growing. I'm used to procrastinating until the ride up; that doesn't work anymore since the pandemic. Got massages at the Basin for the first time in a long while. Staying in Zelda's room at Cliff Cottages - also a first - it seems a bit more private so I'm excited to check it out and let loose. I assume it's named after F. Scott Fitzgerald's wife - I guess I will find out when I get there can't be too many Zelda's in the world. Maybe she was an author too - haven't read her. Another woman squashed in time by a successful husband. Maybe. I know their lives ended pretty poorly. Who knows. Happy Tuesday, much love, Elizabeth.

Nude Photos

     This call week has been hell, culminating into today, which just created more work for Monday. I have never had a stack so high on a Saturday. Thankfully, it was doable. Now it's pool time and I can finally relax but it was a long time coming.

    This is so funny. I was looking up a heart transplant rejection patient this week, I'm on call, we get those on AP call, it can be exhausting, they do the biopsies to rule out cellular and vascular rejection. Most are none or mild - super easy, but occasionally once a year you get a tanking patient and it's a doozy. Anyway this was not hard, very routine, but I always like to look up the patient to make sure they are ok, ya know, clinical correlation. Ejection fraction, whatnot.

    I was alarmed reading about one guy who was complaining about peeing all night long (dude needs a TURP) and asking the interventional cardiologist for a refill of his Cialis (card said ask your PCP for that please) and then the next paragraph? LOLOL Wife told doc that someone in the community had alerted her to the fact that he was sending nude pics to women and after two therapy sessions that seemed to have abated. For now. No more vast sums of money or social security numbers given to random women. 

    I took a screen shot without identifiers and sent to partners and gross room. WTAF? Is IV card getting into psych? This man got a new heart did he get a new lease on life with this? I have never gotten this much information researching a heart bx for rejection. This goes down in your permanent record. Don't get so distressed. Did I happen to tell you I'm a mess. Sorry. Sidebar.

My birthday is coming up! Christy is throwing a huge brunch party on the 28th since we will be in Eureka on the 20th. I shared 15 contacts with her - mostly women but Jack and S are invited too. It's gonna be at Yaya's, I've heard their brunch is amazing and I've never done it so I'm super excited. C scheduled Sullivan's next Wednesday at 6:30 since she can't be there for the brunch. Their cocktail menu looks incredible I'm dying to try some of the drinks. Happy Saturday, Much love, Elizabeth

Queen Bee

     It's already a Friday on a Tuesday good lord. Two twelve hour days in a row - I'm not used to that on call. I realize that I've been getting lucky - I've pounded out the Jan-June Q/A and started working on July today - and I see all the late frozens that mostly Shaver and Nelson are getting stuck with and thinking in the back of my head that I must have a call angel on my shoulder but no. Karma came around last night with a late brain frozen, probably metastatic breast cancer but we won't find out until tomorrow bc it was too late to process.

    Today I walked into the gross room assessing the afternoon - I had dinner plans with Noah's caretaker Ms. Candy - we have been planning this for two years and she had to postpone last week bc they all got Covid. When I told her that Notorious Freezer Sims was supposed to start at one but he didn't until four and he wanted frozens on both cases could we postpone again until next Tuesday? She said sure the case I just walked in to probably needs more attention so it works out good for me too. Maybe I told you, she's a social worker for the government she does sexual assault intake (holy hell of a job) and is a single mom of two and takes care of Noah. I'm dying to get to know her.

    Between five and seven Sims sent six frozens and it was doable. You always think and reflect and overthink - like last night on the way home from the brain - could that have been an epitheliod meningioma in disguise? Sims' last case today was a 3 cm neck mass in an older lady - number one two and three dx is squamous cell carcinoma of the head and neck of occult etiology but I was underwhelmed. I favored a branchial cleft cyst, but I don't see them very often so I was consulting Melody's frozen section book as he was googling lymphoepithelial cysts on his phone. I showed him the gross, it also did not fit for metastatic cancer at all - a cystic mass with motor oil colored goo all over the cutting board. See? I said? If this was met SCC it would be hard, defined, scirrhous. Stellate. You know what I mean? He agreed. Think I'm going to stop now and close, he said. That's safest for now, I replied.

    Luckily my children are still cooking away - they plan homemade sushi for tomorrow (that was a helluva long stressful grocery trip on Sunday morning) but I've frozen a few perishables bc they got invited to see Pine Grove in NO with C's friend Ainsley - they play tonight. They also saw them at the Rev Room last Saturday. They should be back tomorrow but I don't want to hold them to it. Last night C had made homemade tomato soup. Jack was underwhelmed and wanted me to add chicken bouillon on the sly. I said absolutely not she wants me to taste it as she made it. As I was eating it she described roasting the tomatoes and pureeing them. Very garlic forward, I told her. Yes! I used garlic and onions. Jack said he could not taste them. I lowered my voice. Maybe Jack is frying his taste buds with all these spicy foods. If any vampires come around tonight, I'm well protected. She smiled, pleased.

    Jack was kvetching over the four almost rotten bananas he just bought a couple of days ago. What are you going to do with rotten bananas? Well you know what I used to do, I said, make banana bread. Chocolate chip. Of course he remembered, especially when I accidentally burned it on South Lookout and they covered it with bandaids. C had eaten all the chocolate chips but he decided to make banana muffins for the New Orleans trip and he added some nutmeg and they were fabulous.

    Remember the bathroom series from a year or so ago? Well, I've been using the one they remodeled and left open bc it was fit for public consumption in contrast to the lab one. I correctly surmised that they added an overflow ED across from the lab and so we have traffic. The one of two stalls I've been using is OUT OF ORDER so this morning I used the other one, forgetting why I abandoned it in the first place.

    The flushing. My goodness. I did a courtesy one, even though I was the only one in the room (courtesy to me) and it went on and on and on. Way longer than before. And the water was hot and viciously flushing - it wasn't really a bidet? But felt like a steam bidet. After lunch I decided to time it it was so ridiculous. One minute, thirty six and .07 seconds. Isn't that crazy? I told Kimberly. I mean, what all is that contributing to our climate issues? She LOL'd. You are adorable Dr. Seng. Not sure about that, but we shared the story with Tina and I showed her my phone timer and she laughed too.

    Many years ago I became addicted to NYT Spelling Bee. Before the crossword, which I used to do religiously but I just am not finding the time or inclination these days. I introduced my dad and husband to it, and they play too. It changed a few years ago - and got a lot harder with weird words. Before that I used to think the highest honor was genius, and reveled in getting it pretty easily every day. Then my dad taught me about Queen Bee, and looks at the hints every day, and gets it. Even S got it once a few months ago. Frustrating me to no end, bc I have never gotten Queen Bee.

Last night waiting on brain frozens I FINALLY GOT QUEEN BEE!!!! I was so excited it eclipsed my exhaustion - I had a nice weekend but maybe slept too much? Very low energy yesterday. Luckily it was better today. I'm four words short of Queen Bee today but I'm ok with that. I tried to cheat last night with Scrabble scramble stuff online but that didn't work I had to intuit the last word. So it was a true all me queen bee. I told the kids last night they had to call me Chief Queen Bee. LOL. Happy Tuesday, much love, Elizabeth

Purging

     Last week Cecelia decided in characteristic OCD Type A oldest child fashion that she had to start packing for college right away bc she's seeing it happen on social media. I got a couple of days off - August 18 and 19 - to move her in. That's almost a month away. Jack and I were laughing as we were helping her wrap all the goodies I gifted her in her mountains of clothes into suitcases. Both Jack and I would be doing this the night before. Or a week or two into school when we realized how little we had pre-planned. But, she's a pre-planner. So we indulged her.

    It was super satisfying. I got rid of miscellaneous glasses and coffee cups and baking items and wine glasses. A pumpkin cake mold I've never used and didn't even know I had. Are you sure momma? She asked incredulously and I assured her that I was not a baker but if I happened to get a wild hair I'd order something online or just go to the baking isle at Kroger. She squealed when I gifted her a never used juicer I won at an auction to benefit the Shakespeare program at UCA a decade ago. To support a college friend. I could see the wheels turning in her head - imagining future juicing sessions after class. Mia is going to love this mom, thanks a bunch.

    I saw on social media a couple of weeks ago that an acquaintance does Reiki sessions and her space looked so inviting I called her up and talked to her. Had an in person session last week. It's hard, Lisa and I have worked sporadically since the beginning of the pandemic, to gain anything from a phone conversation and I've been so stuck lately. This was such an incredible session - I had a major breakthrough. I'm looking forward to working with Paula more, and offered to take her to dinner Wednesday night to talk about her journey. Lisa clearly inherited all her talents, but Paula has had to work for them. And she seems like one of the most disciplined people on the planet. 

    All of this because I'm still trying to figure out my journey. I heavily researched Andrew Weil's Integrative Medicine Fellowship a couple of years ago and Yousef urged me to wait - he said it was the beginning of the pandemic and I'm just too busy. Despite the fact that I'm a procrastinator I can easily bite off more than I can chew, much like Cecelia. He was right. It's so intensive and we are so understaffed and overworked and as a pathologist what the hell am I going to do with all that patient related stuff. I could apply it to myself, but I can just read a book and do that without having to take classes and follow a schedule, none of which I have time to do.

    I was telling Paula all about my GI issues and lack of energy and how I was hoping to eclipse all this. As I was describing my awful dry heaves she said maybe a spiritual purging? I smiled. Intuitively, I think I know this is what is going on. But still I seek modern medicine out because I'm at my wit's end. It's been three years. It's getting better, but still. My physical health throws my mental health sideways and it's just not good. 

    Tonight I came home and decided it might help to clean out my closet. Get rid of all those size 6's and 8's and anything with a waist size under 30. Those aspirations are toxic, and in my past I think. I'd like to get back into yoga and get back on the treadmill slowly and strengthen my core but never again with the goal of being as small as I can possibly be. Kimberly lives near a halfway house for women and children recovering from addiction (and I'm sure abuse and neglect and all the other things women are subjected to in this world as third class citizens). I've got five large bags of half of the clothes in my life to donate. Another satisfying purge.

    Well it's been a halfway decent Monday for a change. Had time to start working on April Q/A and do the annoying monthly time sheet that came into vogue a few years ago. I swear, if every overworked person had to write down everything they did all day long to benefit the hospital and not our company - with numbered codes and time increments - we would all explode. But we do it, because they task us to. And luckily I'm still intact.

    Oh funny story I told micro huddle and Mike Perkins, the new Greg Crain in the game of hospital admin bingo and Mackenzie last week - with her I was searching for help. I told Eddie Phillips in line for lunch on Friday (he's the OB who delivered Cecelia and turned admin - how do I turn admin? Looks like a path of least resistance) and he chastised me for almost ruining is lunch. Former OB, I laughed, acting squeamish. LOL, I teased him.

    We had our gross room fridge replaced last October. Brand spanking new, transparent glass doors. It's been circling the drain for about two months and finally went kaput two weeks ago. We put in a work order to Darrell, the refrigerator guy for all of Baptist, and despite his earnest efforts there have been manufacturing supply issues. Weekends are not too busy - we put in a mini fridge in the gross room for the gallbladders and appendixes, which go on formalin, until we can get to them on Monday. Sunday is the only day we don't have anyone staffed.

    Legs are the only things too big for buckets of formalin - we gross them straight from the fridge where they have been placed in their red biohazard bags. And they also won't fit in the mini-fridge. So for the past two weekends all the legs amputated on Saturday afternoon, evening, and Sunday are going into a dead fridge. And who knew how many legs are amputated on the weekend? A LOT. So nurses have been paging and calling and complaining and making our lives a literal hell for the past two weeks. Jessica has been getting the brunt of it, but I got paged last Sunday after Shaver was paged the Sunday before and what do you expect us to do? Wave a magic wand and make a large fridge? This is a Baptist issue.

    The nurses, who have been a little hysterical about the legs in the past (NOW we can see them with this new fridge! We hate to see them it's so offensive). Um, they are wrapped in bags, and you are OR nurses surely you see a lot worse. I actually hear all the stink was started by a male DR. LOL. Hysteria is contagious. Our Sunday calls have been because the stink of rotting flesh coming from the unrefridgerated legs is soooo bad that they don't even want to wheel patients back to the OR to get their mostly emergent surgery. I get it, but what are you going to do?

    Mackenzie found no short term solution but just being able to tell the nurses we had admin involved took loads of pressure off of PLA gross room and weekend on call path. I got a text today that Darrell made a new connection and someone would be here Wednesday, with the proper part this time (they screwed it up last week). I was kvetching with Mackenzie about new appliances and their problems and she agreed. Nothing is made to last like it used to be. Happy Monday, much love, Elizabeth