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A Patient is at the Other End  

“Who’s on call?” Dr. Elliot, chief of ENT surgery, bellows the question into the resident sign out room. Residents, who are not on call, slink away while others feign interest in an old acute appendicitis case that is sitting on the multi-head scope. Dr. Rosenthal, the chief resident, points to James who fixes his gaze upon the clock.

Five o’clock on a Thursday afternoon. It is time for Dr. Elliot’s weekly commando procedure. During the next several hours, Dr. Elliot will take some poor resident and attending through a plethora of frozen sections with countless orientations of his resected specimens. The patients are usually eldery men with a long history of alcohol and tobacco use, now rewarded with a fungating and necrotic tumor eating away at half of their faces. A radical procedure with later reconstructive surgery may provide a passing chance for survival and certainly improve the quality of life for these unfortunate souls. Commando is a slang term for a composite resection that removes the tumor as well as half the face of the poor patient. However, amongst the residents, it is affectionately referred to as a face-ectomy.

James had seen the schedule two weeks ago when it was first posted and knew he had a date with Dr. Elliot that evening. His only solace was knowing his attending physician was Dr. Nomura. It is a solace soon replaced with despair.

“You the resident on call? These are the head CTs of our man, or should I say boy.”

Boy? This is not a typical Elliot case. The CT scans are mounted on the portable radiograph viewing box, tucked away in the corner of the surgical sign out room. An opaque mass is situated within the right orbit, compressing the optic nerve and eroding into the bone.

“This is a 10 year old boy presenting with a month long history of a slowly growing mass in his right orbit. No other medical problems. Family history negative. I’m going to need frozens for diagnosis and then decide where to proceed from there. I’m thinking lymphoma or some small round blue cell tumor. I spoke to Haas when I was coming down the hall, she knows about it.”

“Dr. Haas? Dr. Nomura is on call with me.”

“You’d better check with Haas, she told me she was on call.”

James felt the blood drain from his head. A quick check with the department secretary confirmed Dr. Elliot’s impression; the two made a last minute switch.

"We'll be starting in a few minutes. I will scope him first and send you a few pieces for diagnosis then depending upon what you tell me, I'll decide upon the surgery."

James heads to Dr. Haas' office. She looks up from her microscope as he enters. "Did you speak with Dr. Elliot about the case?"

"Yes maam."

"What is your differential?"

"A large soft tissue tumor in the head and neck area of a ten year old boy...a small round blue cell tumor is the highest in the differential."

"And that means what?"

"Uh...it means a lymphoma...a rhabdomyosarcoma....Ewing's sarcoma...a PNET...and um....oh yes, a neuroblastoma."

"And how will we differentiate between these tumors?"

Dr. Haas loves to pimp residents, firing off a battery of more specific questions until they cannot answer. She has a nasty habit of doing this to other attending pathologists, earning their ire.

"We can do immunoperoxidase stains, maybe electron microscopy."

"Which immunoperoxidase stains?"

James reached the point of no return. Haas has won this round.

"Look it up and tell me before we do the frozen."

James heads back to his office, glancing at the wall clock. Better get some dinner before that frozen comes, James thinks. On the way to the cafeteria, he passes by some of the internal medicine residents, finishing their dinner.

"I thought pathologists had bankers' hours?"

James smiles. "Someone has to keep you guys honest."

"Oh yeah, you guys got it so easy. We're up all night admitting patients and you can put your patients in the refrigerator."

"Well, I'll be here pretty late tonight with Dr. Elliot's case."

"It's about time you guys earned your keep!"

It is a different kind of pressure, James whispers to himself, turning to enter the cafeteria. He is proud of his work and cannot understand why other physicians equate long and irregular hours with credibility. Is there any less pressure in diagnosing a malignancy that will forever change a patient's life?

"There is a patient at the other end of this slide. NEVER forget that!"

Those words pierced James' soul. Before he left the Philippines, his father counseled him.

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