The Juicy Stuff Grows in the Shade

     Lab week was so much fun! I say was, bc I took tomorrow off to pack for Spain and France, we leave on Saturday. I had a near panic attack on Monday - histology is so unpredictable and even though our plane doesn't leave until 12:43 I did not want a full day of work with possibly leaving a shit ton of cases for my partners to finish off if I couldn't on Sat am. Too much to cram in. You have a lot of three man days left, said Shaver, so I peeled off a day from my vacay in August. Only one case to finish tomorrow, then I'm off for two weeks.

    Lab week started last Friday, when Hope asked if one of the pathologists wanted to go get the proclamation at the Capitol and get our picture taken with the Gov. I had no clue this ever happened. Why do we need a proclamation? I asked as she drove Angel and I downtown. It's just a thing we do every year, in order to make it official. It was terribly unorganized. A hipster with a messy dirty blonde bun didn't know anything about it, and the guy she promised would showed up 20 minutes later with his tight jeans and We The People tattoo was equally flummoxed. It's ok, Hope said, we can get it later.

    There were five groups of people - we were about 10-15, some from Baptist, some from UAMS, and it was nice to meet the medical director of OBI. Oklahoma Blood Institute, it used to be, but bc we work so closely with them it changed recently to Our Blood Institute. More inclusive. She was a charismatic young woman who asked me if I would help her get affiliation with Baptist - she was having trouble with BHPP. I went to Carla (head of blood bank) and Mackenzie (our admin) on Tuesday to advocate for her and hopefully that will get the ball rolling.

    They arranged us in front of a fireplace and arranged another group in front of a fireplace across the room. It was like an assembly line. Sarah came in at the last minute, the photographer shot our pic, and she moved on to the next group. One of the gals from UAMS told me at least Asa sat with us for 20-30 minutes and asked about lab issues. Talked to us. When I was telling a pulmonologist the story in the Dr. Lounge Friday afternoon, he said we are just a stepping stone for her political ambitions. I agreed, she doesn't really care. A true politician would have thanked us for our work during Covid (this was the first time we revived this tradition since Covid). Without the lab, you are only guessing, said one of the coffee mugs I bought for lab week. Carla showed me a statistic this week - 70% of clinician decision making about patient care is based on lab results. We are not the sideline, we are the frontline.

    Had med exec committee Monday night and it was full of acronyms, like alphabet soup. I had to lean over to Julia Goodwin, chair of OB, during the discussion on FPPE. What is that (I'm terrible about reading the topics emailed to us in advance)? Forced physician performance evaluation. We are just starting it, a way to monitor physicians who are deemed faulty, not the immediate revoking of privileges if you are putting patients in danger or are inebriated on the job but to do a six month monitoring of those in the grey area.

    There was a long discussion. Do we in med exec need to get involved? Or can PRC (peer review committee) and credentialing handle it? Ultimately we decided it needs to start in PRC and be handled by a chief or a designee of the chief and the chief can present the findings to credentialing. Revoking or denying privileges is a big deal, so it needs to be handled correctly. The head of credentialing was there, and he appreciated our input as we talked about issues that hadn't been raised yet in their committee. Later, when they were talking about bringing experts to improve ST (I mangled that I think there is another letter I forget) Julia saved me once again. Sterile Procedure in the OR.

    Sarah, who runs the morgue, was in charge of a lot of the doling out of my lab merch. She loved it. This was the best lab week since I've been here in five years! Finally, I told her, we are included again. It used to be so fun, but we've been iced out with changes in personnel. Our AP vendors delivered today. Corky's for lunch and take home dinners - there was food for days (too bad I hate BBQ but Jack and S are reaping the benefits). It's like the Freshman 15, Laurie said this morning, only Lab Week 15. Yes, I laughed, there has been a lot of food. Cupcakes, Potbelly, cookies, Papa John's. Our vendors aren't like drug reps - they don't give us exotic vacations to cause an opioid crisis, they are just molecular and lab machine people. It's all above board.

    I planned lots of things on Sunday - errands and treadmill but my body said Fuck No low energy you are going to be a couch potato. So I binge watched Beef and recommended it to Jack. The last two episodes are some of the finest TV on the planet. Monday Hal had almost finished it (no spoilers! Of course not, I said) and Kimberly's son's in-laws were watching it and Shaver had started it.

    I was walking back to my office on Tuesday after dropping off a consult to Shaver and Hal surprised me by jumping into the hallway with his hands clasped in a gun shape aimed at me. The juicy stuff grows in the shade! He said. (I may have mangled even that one, but you get the GIST - Gastrointestinal stromal tumor LOL). I laughed. You are going to have to help me, I said. I don't remember movie or TV quotes. Hal and Staggs are like encyclopedias, I can barely remember the Succession from the night before and often google it the next day for a recap. I finished Beef! Oh yeah, I said, I remember that now. We recounted the last two episodes for 20 minutes and laughed until we got exhausted. Happy Thursday, much love, Elizabeth.

    

    

Call Week Number 2

     I remember sitting in the car seat, maybe in the back, curled up around my med school books, studying. It could have been the red Wagoneer, it could have been the Acura Integra. Or the Taurus. Mike went through a lot of cars. Florence, his grandmother, had died in a house fire. Kitchen, in Greensborough South Carolina. We were headed to the funeral.

    A lot of my med school friends skipped their grandparent's funeral, with much regret. We all skipped a lot of things. Baby showers, weddings. The curriculum was brutal. So I was a little bit proud to skip a few days to attend my husband's grandmother's Orthodox Jewish funeral. I don't remember the burial, but I remember everyone going back to the house to stand shoulder to shoulder and wail. Bill and Esta, Florence's kids, were both very secular, which spoke volumes about their upbringing without speaking. Is this called Shiva? I wondered. 

    I had only met Florence once, when Mike and I were dating. We spent the night on the way to meet his Duke educated English major mom who now worked at the Waffle House. Mental health issues can be devastating. Mike warned me. Florence is a bit cantankerous, tough to go to a restaurant with. Everything is wrong. And she thinks Daniel saved me, but I saved Daniel, we really saved each other, so I have a little resentment.

    Sure enough, after a forgotten dinner, she raved about Daniel and Mike was irked. We were tasked to sleep in separate rooms - we weren't married yet - so we took a walk after she and Milton went to bed to vent. It helped. We were on our way to Gaffney in the morning. The next day he took me to his fave restaurant there - Hubcap maybe? Legendary peach iced tea, which I loved, even though I don't love iced tea. Super sweet and refreshing. Giant burgers - I think you got your name on the wall if you ate it all kind of like the plates at The Flying Saucer for your beer consumption.

    Mary was lovely, his Mom. She had made matching pajamas, a soft floral flannel for me and her - Mike took a picture that I continue to adore to this day. Schneider means tailor in German, Suzanne Klimberg told me on an elevator when I was training. Mary lived up to her name. When she passed, Cecelia, then just a tweener, read a poem and held a beautiful doll that Mary had made her. Mary took the kids to the library weekly, and stoked a love for books that I had no time to do. One that my own mother stoked in me. I still have a beautiful stitched potpourri pillow she made me in my office.

    I was up in the night from three to five am on Monday trying to stave off the images of a pathologist in NW AR. One that Melody and Annie had trained with, one that helped with Bill's cancer diagnosis last summer before he passed. Say what you will about Bill, but he moved Milton to Fayetteville and cared so much for his dad it melted my heart. Melody and Annie's friend was killed by her husband, stabbed to death, found in the street in her robe, presumably trying to escape. Melody and Annie had met the husband, a kind but forgettable presence in her background at events. When I was unable to sleep, I fondly remembered Milton and Florence.

    The pathologist's hubs tried to kill himself but failed. So the story will come out in his prosecution. Her story is over, but it will come to life with her friends and family. She didn't seem like an abuse victim, I hear. So what happened. Time will tell. Spinning and spinning on this this call week. How does a relationship get to this? What would this do to our work family, I wondered aloud. The dynamics would be holy hell. 

    Only three days left of call! I've got a 7am meeting - Baptist Health Extended Care quarterly where we discuss infections and falls and metrics and try to meet a fucked up national standard to get the maximum reimbursement. Lab week is next week, and I'm so excited I bought tons of merch on Amazon that I can't wait to disperse. Hope is including us this year. We are having lots of games and a photo booth! Nerdy, I know. Even though admin is still holy hell bottom line I am hoping that we are moving in a better direction. Love the lab. Happy Thursday stay safe in the storm, much love, Elizabeth

    

Call Week Number One

     Is almost under the wraps. Knock on wood tomorrow is a light day. The week, however, has been a doozy. 150 blocks on Monday, plus three big cases to photograph and present at ENT tumor board in the am. Blake Phillips sent me a late brain frozen. Cerebellar mass. WTF. 99.9% of our brain frozens are in the cortex (and easy peasy met vs GBM). The radiologic differential made my heart race and I had to take my white coat of bc I was getting sweaty. Medulloblastoma. Ependymoma. Choroid plexus papilloma. Low grade astrocytoma. Why oh why do you get this crap when there is no one around to consult? These are once in a lifetime if that diagnoses. I nailed it tho - in that hedgy way. Glial proliferation. Reactive gliosis vs. low grade neoplasm. 

    When Jon Wilson called today to follow up, of course I sent it out to Arkana to an expert, he shocked the hell outta me. Ganglioglioma, I think (very rare). I googled it and the history totally fits. Can you get a BRAF and a synaptophysin on C1? He is a nice guy - I used to do yoga with him at the Racquet Club so we caught up. I hadn't sent him a case in a year. Come to sip and stretch tonight! He said. He and his wife are DINKS like Mike and Effie and travel the world. It's been a brutal call, I said, but believe me it is on the radar. My gut health seems to be improving. Guess what? I sent you another case today so we will talk again soon.

    So it's been a brain zebra theme week. Blake Phillips sent me a frozen one morning and I was like I think it's a pituitary adenoma? Sellar mass. But I've never seen bone in one of those? He yelled back over the OR speaker phone, you and me both! Sure enough they can rarely have osseous metaplasia. Melody and I handled that one on our own. Then yesterday Tim Burson sent a submillimeter frozen from the spinal meninges. I called Melody from the gross room. I'm so sick of these weird neuro cases. Can I bring it to you for consult?

    Of course, she said, and we puzzled together over the tiny tissue. It's a multifocal spinal meningeal lesion. Lots of spots, I told her, in an immunosuppressed patient. They think it might be infectious. What are those clear cells, I asked. I can't tell, she said. I'd just say degenerative tissue no definitive lesional cells seen. Sounds good. Today, something that frozen lost (like I said wax is way better than ice) you could see little capsules in the cleared cells. I jumped up to show Melody. Holy shit cryptococcus. I ordered a crypto mucin and a GMS. Lindley called in the am, ID doc, so I called to give prelim and told him I'd text in the morning when I got the stains. Wow. He said. There is a history. His serum Ag is pos but his CSF Ag is neg so this is a true shocker.

    Tuesday morning I presented the three cases at ENT. Me, David Hays excellent IV Rad I've known forever, Stern, Sims, new ENT Travis, and newish Rad Onc Howard. A few support staff who didn't speak. I presented a nasty sialadenitis (It was like trying to FNA a street, Hays said, and we all laughed). I'm a little lazier that I used to be - when Hays brought up the pics of this from my jump drive Stern said I need my 3D glasses! I laughed. I forgot to put it in portrait mode for these. I didn't go back and retake them. The rest are in portrait mode, I assure you.

    Renal cell carcinoma to the thyroid - that is a board question, I said, what is the most common met but this is the first I've seen it 7 cm oh my. Look at the clear cells and the blood lakes - Hays can tell you why these are dangerous to FNA in the kidney they bleed like stink. It's the second one I've had this month, Sims said, and they do bleed like hell. The other was a once in a lifetime plasmablastic lymphome vs. low grade B cell lymphoma. They sent it to the NIH to see if they can be more decisive, I said. 

    Stern said a lot of time when y'all send it off they are just as hedgy. My heart swelled with pride. I notice that too, I said, but it's good to get an expert's name on it. You know that rare parotid tumor, I had one with Sims a couple of years ago, pleomorphic adenoma ex carcinoma? Bruce Wenig's comments read like a book and seem like they leave a lot of wiggle room. Stern said, oh my god his comments are so long. I imagine him drinking two bourbons when he's writing them. We all laughed, and Sims said I have blacked out trying to read his comments.

    Speaking of Sims, he kept me late on Wednesday doing frozens, about five or six. when I looked up the history I cringed. Adenoid cystic carcinoma? Recurrent? Talking to Savanna, who was covering for Laurie bc she had to go to a funeral. He was using a CO2 laser, and all of the tissue was burnt to high heaven and hard as hell to cut, according to Savanna. John came in to see what I thought of his margins. I sweated and took my white coat off for the second time in a week.

    Adenoid cystic is a really basaloid neoplasm that when crushed and burnt can look like lymphocytes or tumor, honestly. I said John, you are going to hate what I have to say. Atypical, cannot exclude neoplasm, on one and two. Savanna is still cutting the others. So, he said, tell me about atypical. Well you know cytology, I said, there is negative, atypical, suspicious, and positive. I want to break it down further, he said. OK. This one is atypical, favor negative. The other one is atypical, I'm really suspicious. Sometimes I feel like he misses the forest for the trees. But I"m not in the OR digging around in the complex head and neck, so it's hard to judge. I'd certainly pick him as my surgeon if I needed to.

    I made the gross room order permanents today, in order to try to find more viable tissue like I said ice leaves holes and wax is better. Was able to be more definitive on some of the margins. But adenoid cystic? It's like chasing the devil. It is extremely painful bc it wraps around nerves - that's it's predilection - and once you get a hold of a nerve, like a firepole, you can go anywhere.

    In good news I'm planning a 50th bday party with my cuz Eleanor (we had a big 40 too) and she and Anna came for lunch. Sooo excited we discussed possible cool venues and music and interactive guest art (for Eleanor she's the amazing artist) and signature cocktails. Eleanor and I are gonna split it. They loved seeing my office and I told them in a month or so we should do it again and I'd show them the gross room. Anna was thrilled. I want to see breast frozens! She kind of mangled what I promised her (we don't freeze breast) but I can't wait to deliver. Happy Friday, much love, Elizabeth