Things Aren't Always As They Seem

I saw a thoracic surgeon in the doctor’s lounge today.  I have read his cases and frozens for a year or so, but never introduced myself.  I still get intimidated in that man’s world of the doctor’s lounge.  It's not just me, my female partner was urged by her male recruiter to eat with him every morning in the lounge when she started seven years ago, and chit chat with the men.  She said although she realized he was trying to be nice, it was excruciating and she bowed out politely after a few weeks.  Walking in there is like walking into an all male club room.  The thoracic surgeon was sitting around the table with a cardiologist, an OB/GYN, a surgeon, and a hospital administrator.  All men I knew individually, but I’m a silent parasite in the lounge, at least during the morning rush.  I breeze in, grab my coffee, smile and wave occasionally, and breeze out.  I wanted to talk to the surgeon about a case, so I waited until he finished regaling an entertaining story about his son’s report on a holiday for school, took a deep breath after grabbing a couple of hard boiled eggs for my lunch in a few hours, and walked over to the table. 

“Hi, I’m Gizabeth Shyder.  I don’t think I’ve met you before.”

A couple of hours earlier I had read a frozen for him.  I called him on the OR bat phone.  Gave him my diagnosis.  “Abnormal lung.”

He countered me sarcastically from the OR.  “Um, abnormal lung?  Is it benign or malignant?  Do you see signs of DAD (Diffuse Alveolar Damage)?”

I took a deep breath.  We use the words Abnormal Lung as a catch all for interstitial lung diseases, which are notoriously difficult to diagnose on frozen section.  Of course I had combed the patient history and knew that cancer wasn't high on his differential.  He wanted more, however.  I gave it to him.

“Well I don’t see any hyaline membranes on frozen section, but they are much easier to see on permanents.  There isn’t much well developed fibrosis in this section.  Or inflammation.  There are a lot of macrophages, I’m wondering about DIP (Desquamative Interstitial Pneumonia).  But that’s not something I would ever diagnose on frozen.  We need to see a lot of tissue to get a good reading on interstitial lung diseases.  I’ll be able to tell you more tomorrow.  I can tell you it is not malignant.  There is no cancer here.”

I think I gained his confidence.  At least his ear.   He replied, “OK, thanks.”  I hung up the phone.

In the lounge, he shook my hand and I struggled briefly to maintain my composure now that I was the center of attention.  I was happy to find that my excitement about the case relaxed my nerves.  “Remember that case we had the other day?  Mediastinal lymph nodes?  The one that was granulomatous inflammation?  All the frozens showed just that, and I reviewed them ad nauseum because you questioned me, thinking there was more, from the OR.  When I got the permanents I found more.  Not on anything you froze, but on your fourth specimen.  D2 to be exact – there were swarms of classic Reed-Sternberg cells.  Not the Owl’s Eye type that's always on the boards, but the mononuclear version.  There were also mummified cells – ones that looked like the nuclei had been squashed by the palm of my hand.  It’s Hodgkin’s.  Hodgkin’s can have granulomas, but I’ve personally never seen them so diffuse and confluent.  They masked the disease entirely in your frozens.  I turfed the case to a lymphoma specialist, and the stains were still pending yesterday, but I’m confident that’s what it is.”

The thoracic surgeon was listening and became energized.  He stood up and walked me to the door – opened it and held it for me.  “I knew there was something more!  Thank goodness it’s lymphoma.  I always tell my patients that’s a much better diagnosis, with a much better prognosis overall, than carcinoma.  Is the report out yet?”

Suddenly I became nervous.  I hadn’t seen the stains, what if my hypothesis hadn’t borne out?  What if it was some sort of rare T-cell lymphoma, with a worse prognosis, that mimics the Hodge (as we affectionately call it)?  I covered up my doubts with confidence.  “I’ll check on it for you.”

Turns out my partner had released the report as Hodgkin’s, just as I suspected, a half hour previous.  Whew.  The surgeon had followed me to the lab and I reported this to him.  We chatted about some other difficult cases he had that week that I had signed out, marveling at the combination of clinical and pathology; patient details he revealed to me matching findings under the scope that I divulged in detail to him.

No matter how far along we get in our careers, it isn’t always easy to handle cases. I’m learning that good communication helps.  Experience and confidence can make a dicey situation more smooth and clear.  But just when you let your confidence allow you to stand up a little too straight, a challenging case will take it down a notch.  This is probably a good thing.  No matter how good we get at diagnosing and treating diseases we will always be reminded that each human is unique and patterns, while helpful, aren't always predictable.  There is a larger design, one that is not in our control, as much as we would like it to be.

The hospital I work at is large.  We no longer have town meetings, we don’t get to know our colleagues easily.  But the extra effort can make a difference.  Now I've got one more person I can speak to informally on the bat phone.  "Hey, this is Giz.  Here's what I see.  Does that fit with what you see?  With the clinical picture?  With what you are thinking?"  The more informal and comfortable we are with our colleagues, the easier and quicker we can diagnose our patients.  There is no room for fear or intimidation in patient care.  Things work best when smart, well-trained people put our heads together to solve the puzzle.  Puzzles aren't single cases necessitating week long work-up, like on TV.  They come hard and fast and in massive daily numbers.  We are all trained intensively over many years to handle it, and we step up to the plate every day.

I got the permanents on the interstitial lung, and was glad I was hedgy on frozen.  With more to look at, without all that nasty frozen artifact, there were loose balls of fibrous tissue filling the alveoli and mild chronic inflammation.  An organizing pneumonia pattern, classically patchy - somewhat nonspecific histology findings that nonetheless direct patient care.  In this case there was a clinical scenario that fit like a glove.  One of the things I love about my specialty is that there is quick satisfaction of closure - 95% of cases are turned around in 24 hours.  99 plus% in 48.  But a first glance, without the clinical and radiographic picture to fill in the gaps, can send you down the tubes if you don't keep an open mind.  Things aren't always as they seem.  A wise clinician holds that thought in the back of his or her mind.