one section of a Fifth Chance Media book, ISBN 978-1-944861-02-5.
To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous. This chapter begins in January 2020.
It's mid-January and Interview season is over.
I meet my attending at 9:00 am in an office building that is a 10-minute walk from the main hospital. The 68-year-old is a fellowship-trained gastrointestinal and dermatopathologist. He is also the main partner in the pathology associates private practice that serves the hospital. Front and center on his desk is a big microscope that can be used without bending down. With a pedal underneath the desk, he can record statements that go to a dictation service. A mirror system allows a second person on the other side of the desk to view the same slide. I can adjust the microscope to my vision, but an uncomfortable neck bend ends up being required due to the desk panel that prevents putting my legs under the desk.
We begin with his morning cases of skin biopsies, already prepared by pathology assistants and lab techs who have created physical slides. He uses the Epic Media tab to look up any photos that were taken prior to each biopsy. "I train all our dermatology residents to take images. This is from a PA, doubtful they took an image." He puts the first slide of the case onto the microscope. "This must be from acral skin [hand and toes] Thickened stratum corneum layer, prominent reedy ridges." What are reedy ridges? "Oh, they are the invaginations of the basal layer." We look at several mole biopsies. "Look at the papillary lamellar fibroplasia. This is a reaction to melanocytic dysplasia. I really do not want to call this melanoma, but I have to. Look how the melanocytes devour the epidermis. Cells should never destroy something. This is high grade dysplasia," he concludes. "That will progress to melanoma over time. No one knows how long, but it will." He orders S100 (neural crest derived cell label) and elastin stains "on the block" (processed tissue saved in the tissue bank for about a month) for nerve and venous involvement.
It is still prior to the 11:00 am stain-ordering deadline, so we rush to the next case: a polyp biopsy. After five minutes of dictation, he realizes that his statements are going to be tagged to the wrong patient ID. "Oh, boy. Look what I did. I grabbed the wrong slide. The most common medical error is clerical."
I struggled during medical school with several of the vocabulary words used to describe colon polyps. Villous, tubular, serrated, papillary, sessile, pedunculated… During this first morning, I see great examples of each. For example, villous describes fingerlike projections into the lumen by contrast to papillary, which describes smaller indentations and projections. I also learn how to assess glandular dysplasia. For example serrated describes tubular glands, e.g., crypts that instead of forming normal circular glands have ameba-like lumen. I learn several important histologic criteria to evaluate polyps including the crypt:villus ratio.
We diagnose a 24-year-old female with celiac disease after EGD (esophagogastroduodenoscopy; a procedure in which the esophagus, stomach, and proximal small bowel are examined with a scope inserted through the mouth) biopsies show destruction of villi in the duodenum with lymphocytes and neutrophils in the lamina propria (layer under the mucosa). "If the villus is less than three times the diameter of crypts, you have villous destruction." He orders fungal and bacterial gram stains to rule out an infectious process. "This doesn't look like an infection. This is celiac but we have to be thorough."
He explains the two different routes to most cancers. There is a chromosomal damage pathway in which a select number of oncogenes or tumor suppressor genes become mutated (either sporadic or inherited) causing a proliferation phenotype. If this occurs in colonic epithelial cells, this results in the classic tubular adenoma to carcinoma pathway. The other pathway occurs from disruption in the DNA repair pathways, which leads to diffuse damage to chromosomes called microsatellite instability. This results in early dysplasia such as serrations and poor gland formation.
We do a 40-slide case of a colon resection. "Pathologists determine the surgeon's reimbursement. If we can't find at least 13 lymph nodes removed, the surgeon will get penalized." We find 14 or 15 among the 40 slides and then concentrate on the main tumor. "Look at all this fibrosis. The body doesn't have that many ways to respond to abnormal tissue. This is called a desmoplastic reaction when the tissue tries to wall off the cancer with fibrous tissue deposition. The tumor volume is almost entirely desmoplastic reaction and not actually invasive colon cells."
Statistics for the week… Study: 1 hour. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Burgers and Beers with Lanky Luke and Mischievous Mary. Mary is hitting the trail for the next month to interview in cardiothoracic surgery.
We meet at 5:55 am on Tuesday and walk over to the adjacent building for GI tumor board. Five gastroenterologists, four oncologists, two radiation oncologists, and the chair of radiology arrive at 6:00 am sharp. The surgeons arrived at 6:10 am having been delayed on their morning rounds. A group decision will be made on how to treat every GI tumor that was diagnosed in the preceding week. There are 20 cases to discuss today and, for each one, there are choices regarding radiation, chemotherapy, and surgery. A case coordinator will then schedule the patient for the agreed plan.
We then walk 10 minutes to the hospital to start looking at "frozen sections," prepared via flash freezing. These are slides acquired during ongoing operations that need immediate analysis. Depending on what we say, the patient will be closed up or if the surgeons will keep cutting until they get negative tumor margins..
On the way we discuss why our health system has outsourced its lab, which is still physically in the hospital, to a third party. "Our health system was a large hedge fund with all its investments. During the [2008-2009] financial crisis, we sold the lab to Quest to make up for stock market losses," he explains. "This deal with the devil might have saved the hospital, but we're stuck with a long term exclusive contract. Quest's technicians are slow and don't use the latest equipment. It's the Walmartization of medicine." He is especially animated on the subject of tissue being outsourced to Quest's pathologists. "They're just machines," he says. "Our pathologists are better." One problem with the division of labor is that Quest's pathologists aren't local and therefore can't be present for discussion at the boards. As with outsourced radiology, there is no attempt to use video conferencing to bring the physicians who did the work into a real-time discussion and therefore the boards must rely on often-cryptic notes in Epic.
I ask whether working in a private practice is typical for pathologists. "We're a dying breed. I get 2-3 buyout offers per month. I could make $1.5 million and become an employee with a guaranteed higher salary for three years. But if I did that, how would the young doctors get to where I have been fortunate enough to get to? Employee-pathologists at places like Quest have no control over their work or their pay. They get paid a lot for the first three years of a guaranteed contract and then the company will cut their pay and gut their quality of life. Patient care is better when I'm my own boss and can spend extra time researching an unusual case." (I saw him spend an additional three hours doing research on an unusual lymphoma, work for which he wouldn't have been paid anything extra.)
The first frozen is for a squamous cell cancer located on the hard palate (part of a 60-year-old male smoker's mouth). We look under the microscope and can clearly see HPV-related dysplasia of the epithelial layer at the distal margin. We go over to the pathology assistant who prepared the specimen to clearly articulate which margin is positive to the surgeon. My attending calls the surgeon on his personal cell to give him the bad news. "He probably already closed." Two more frozens are both positive. "You never know if you have good margins. You think you got it all, but you just don't know until you look under the microscope."
Friday at lunch with the five pathology attendings, I give a presentation on pancreatic neoplasms, of which there has been an epidemic coinciding with the rising use of CT and MRI scans. When anomalies are seen, even ones that have only a tiny chance of progressing to malignancy, the health care system springs into action to treat these "incidentalomas". I discuss pancreatic neuroendocrine tumors (e.g., insulinomas in which pancreas tissue secretes uncontrolled insulin) and intraductal pancreatic mucinous neoplasm (IPMN, tumors of the pancreatic duct with malignant potential). I reviewed a pancreatic cancer case that I participated in, showing pictures of the specimen that I helped section and review the negative margins after resection of part of the portal vein. The partner points out that the rise in incidentalomas is not a problem for the healthcare industry: "IPMNs are going to keep pancreatic surgeons in business for the next decade."
Saturday is my attending's "pathology call day". He goes into the office for all of these and catches up on ordinary cases. On roughly half of the days he actually does get a call. Today a 64-year-old presents to the ED with abdominal pain and distention. He has a small bowel obstruction requiring operative exploration. During the operation they find a small bowel tumor as the cause. We go to the gross lab to examine the specimen and assess margins on a frozen section. "The most common reason for call is that surgeons now do elective cases on the weekends. We usually have one or two breast cases where they wait on the pathology read to determine if they need to continue with an axillary lymph node dissection."
Jane has a mundane ED shift until a six-year-old falls off his bike resulting in a 3 cm eye lid laceration. The ED nurse bubble wraps the kid, but he is still squirming. Jane, "I'm terrified. How am I going to suture this kid?" After a few attempts, the mother grabs her phone and plays Frozen. "The kid didn't move an inch with Let It Go blasting."
Statistics for the week… Study: 1 hour. Sleep: 9 hours/night; Fun: 1 night. Example fun: Jane and I go to the local pound for a puppy search and come home with an 8-week-old black lab mix. We are added to the selective Dog chat on GroupMe for meet ups. Several classmates graciously gift us their old crates and puppy accessories.
I am excited to start a surgical elective with my favorite retired trauma surgeon who led our first-year anatomy lab. Jane, Buff Bri, Southern Steve, Lanky Luke,, and myself each choose various surgical techniques to work on for the next two weeks. We have three untouched cadavers to work on.
We meet at a local coffee shop that is walking distance from the anatomy lab. Jane and I bring our new puppy for socialization! The trauma surgeon spends the initial 30 minutes giving us puppy advice from her experience training service animals. We each identify various surgical techniques to focus on. Jane, Luke, Steve and myself will use our time with the cadavers to focus on abdominal exposures and neck dissection. Bri, applying to neurosurgery, will perform an external ventricular drain (EVD) and various craniectomies for aneurysm exposures.
The next day, we meet at 9:00 am in the anatomy lab. We focus on placement of thoracostomy tubes ("chest tubes"). Our professor describes the triangle of safety bordered by the latissimus dorsi, pectoralis major, and the imaginary horizontal nipple line. We pair up. I extend the cadaver's arm to open up the rib spaces. It's no small feat due to the rigidity of the joints. Jane makes a small incision and then uses Metzenbaum ("Metz") scissors to dissect down through the subcutaneous fat and through the intercostal muscles. "The surest way to get kicked out of the OR is to use Metz to cut suture. Metz are incredibly expensive and ruined by cutting suture." Jane then takes a Kelly clamp and tries to push through the last centimeter of muscle and pleural lining. "Heave!" exclaims the trauma surgeon. "Push harder!" With an audible pop, Jane shoves the instrument into the pleural cavity. "Good! It's a lot more force than you realize." She then does a finger sweep. "I feel the lung!" She then smoothly places the chest tube. "Some people will say to orient the chest tube towards the apex for a pneumothorax and towards the base for an effusion. The apex always works."
My turn. Jane holds the arm up while I make an incision. "You're really digging deep!" the trauma surgeon comments. "You have just made the most common mistake of interns and ED docs. Don't tunnel up along the chest wall to the axilla; go straight to the ribs." Once I pop into the pleural cavity, I struggle to advance the chest tube, unable to push through the resistance. The trauma surgeon takes a feel sweeping her finger in the cavity. "Wow, feel all the adhesions. This patient must have had a bad pneumonia causing all this scarring of the lung to the pleura." She adds, "This is how you really hurt a patient. If you just blindly shove the tube in, you can tear the lung causing bleeding or a bronchopleural fistula [connection between lung airway and outside]. Always, always feel for adhesions with the finger thoracostomy before you insert the tube."
Thursday morning we meet at a local coffee shop to discuss rectal bleeding and peptic ulcer disease. The nearby coffee drinkers must have loved our discussion on the significance of the "sweet smelling black loose melena" versus "red-streaked formed stool". Trauma surgeon: "Blood is a spectacular cathartic." Bri: "If a patient is bleeding out, they are shitting out." The trauma surgeon chuckles, "Exactly."
Statistics for the week… Study: 2 hours. Jane and I watch a section of Acland's Video Atlas of Human Anatomy over wine to prepare for next week. Sleep: 7 hours/night; Fun: 2 nights. Example fun: weekend AirBNB with Jane's family, including a 6-month-old nephew. There would be less depression and anxiety in this country if everyone held an infant once a year.
[Editor: It might be best to hold someone else's infant. "Parenthood and Happiness: a Review of Folk Theories Versus Empirical Evidence" (Hansen 2012; Social Indicators Research) says "people tend to believe that parenthood is central to a meaningful and fulfilling life, and that the lives of childless people are emptier, less rewarding, and lonelier, than the lives of parents. Most cross-sectional and longitudinal evidence suggest, however, that people are better off without having children. It is mainly children living at home that interfere with well-being…"]
Still with the cadavers… this week we focus on neck procedures. Budding neurosurgeon Bri will focus on the anterior approach to a cervical fusion (called an ACDF, anterior cervical discectomy and fusion), while the rest of us focus on the technique for a tracheostomy ("trach") and thyroidectomy. Bri passes out expired tracheostomy kits including a percutaneous ("perc") trach kit.
Our trauma surgeon professor describes the scene: "It is an eerie night on call. At 2:00 am, an airway alert is sent out. It's only you there. You arrive in a crowded room with a blue patient and the anesthesiologist puts the laryngoscope in for the third time. He isn't able to intubate. The patient's heart rate is dropping." She pauses. "The patient is about to code. He needs an airway. What do you do?" With blank stares, she gives us the answer: "Well first, you need God on your side so pray the patient is not obese. After that, all you need is an endotracheal tube and a scalpel."
"Everyone palpate landmarks on each other. Feel the cricoid cartilage." (The horizontal prominence below the Adam's apple.) Our professor explains that there are multiple paths forward. "You have to choose one. Know what you are most comfortable with performing." There are three main options: a cricothyroidotomy (tube inserted into the larynx through the cricothyroid membrane); an open tracheostomy (cut down on the trachea to insert a tube); a percutaneous tracheostomy (tube inserted into the trachea through a needle stick with serial dilations). "A cricothyroidotomy is a temporary procedure. It will need to be revised to a tracheostomy to prevent damage to the larynx over weeks, but in this scenario nothing matters if the patient can't oxygenate." She continues, "Old surgeons trained in an age of open trachs. Most trainees are more comfortable performing perc trachs."
We head to the anatomy lab to practice performing a tracheostomy with the expired kits. "My advice when you arrive at your new hospital is grab a kit for each procedure and open it up. An experienced surgeon will struggle performing a procedure if there is a new kit."
For the next three days, we focus on the technical aspects of a thyroidectomy. The general surgery residents join us for this. The fourth and fifth year residents help walk the interns and medical students through removing one lobe of the thyroid. "Stay as close as you can to the thyroid when you divide blood vessels." A third year chimes in, "Thyroids scare me. One small misstep and you'll hit the recurrent laryngeal nerve."
We finish the rotation at a coffee shop that is a five-minute walk from the anatomy lab. The trauma surgeon recounts her experience on a civilian medical response team, which was deployed after Hurricane Katrina in New Orleans and following the 2010 earthquake in Haiti. "Contrary to popular belief, a vast majority of the patients we treat are not injured from the disaster. Instead, we care for typical medical emergencies, for example, heart attacks, wound infections, appendicitis, and preterm labor, in a suddenly austere environment," she explains. "In Haiti, a single generator powered the makeshift intensive care unit and operating room. Of course this went down for about 24 hours. Our team bagged a preterm intubated baby when the ventilator backup power stopped. She survived!"
Bri comments that his sister is in the Army Reserves as a nurse. She was recently mobilized, but the entire unit is staying in a hotel waiting for orders. This does not surprise the trauma surgeon. "Yeah, my team was sent to Iowa for two weeks waiting for orders only to be sent home eventually without having done anything."
Statistics for the week… Study: 0 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Burgers and beers with Lanky Luke and Sarcastic Samantha. Samantha deliberates on the pros and cons of switching jobs. She is exhausted from stringing along patients who need consults with specialists who hide in hopes that someone on the next shift will take the patient instead. "I looked at the academic hospital, but they pay $30,000 less." Luke: "I strongly recommend against a pay cut."
I ask to focus on abdominal CT during this final week of radiology, which turns me into an expert on finding steatosis (fatty liver, caused by alcohol, viral hepatitis, or obesity). It's easy to identify because it's on every abdominal and pelvic CT! Prasanna's partner explains how to differentiate steatosis from fibrosis/cirrhosis by the liver morphology. CT can differentiate interfaces between air (-1000 Holmzfeld units), fat (-100), water (0), soft tissue (30), and bone (1000). The liver and spleen should be similar densities. As fat infiltrates the hepatocytes, however, the liver density begins to drop below 60. NASH (non-alcoholic steatohepatitis) is expected to surpass alcohol-associated liver failure to become the number one cause of liver transplantation. The radiologist explains, "The liver edge should be smooth. Once fibrosis occurs, it becomes nodular. Cirrhosis is also associated with enlargement of the caudate and left lobe. You can do a ratio, but just eye-ball it."
The abdominal work list is exploding. The attending yells, "Six scans come off one scanner in one hour. Six abdominal scans. Why couldn't they have interweaved some lumbar and head CT? Come on! I can do maybe 5 CTs per hour. Six from one scanner, and this seat covers five other scanners. We are just getting slammed." As soon as he is done venting and has refocused on another case, his phone rings. "Come on!"
We overhear Prasanna yell, "God Dammit." We walk over to investigate. Prasanna waves me in. "This is the MRI from the hip arthrogram we did earlier today. What do you see?" Based on irregular T2 signals with T1 replacement (bone marrow destruction) and articular cartilage flattening, I answer, "O-N." Osteonecrosis is bone death, typically due to reduced blood flow. He tries to pull up the X-ray. "They didn't get a f***ing X-ray. This is why you always get an X-ray first. This could have been diagnosed weeks ago instead of waiting for an MRI. He's going to lose both hips." I ask what caused this? "O-N can be caused by lots of things. Osteomyelitis (or infection of the bone) is one, but I don't think both his joints are infected. It could be from long-term steroid use, inflammatory conditions, congenital abnormalities, and trauma. There's a whole differential. Sometimes it's just idiopathic [unknown cause]."
We do a leg bone length study on a 13-year-old. Children who suffer a broken leg can end up with one leg growing dramatically longer than the other. We measured from the top of the femoral head to the top of the talus. "The truth is orthopedists do their own measurements, so I don't get too technical. Each has his or her own favorite method. Some old school private practice orthopaedists keep their radiographs in-house. I do all this for our health system billing and CYA. They need our help for MRIs and CTs." Prasanna asks, "What do you think the most common lawsuit is for orthopaedists that keep radiographs in house? … Missing lung cancer on a shoulder X-ray."
On Friday, I work with a guy who finished radiology training only three years ago. "This seat [MSK] is so boring that it erodes my soul." He drones "Normal" into PowerScribe after every X-ray, which allows ample time to discuss the coronavirus: "I don't think people realize what is coming. The virus is reported to have almost a 20 percent infection rate. On the cruise ship, one asymptomatic person infected 600 people. Our health system covers about 1 million people. We have 54 ICU beds. The numbers just don't work."
[Editor: This is late February 2020, about two months after the media began intensive coverage of COVID-19. As it happens, the hospital never did run out of ICU beds. The hospital filled up completely in January 2021, but mostly because patients couldn't be discharged to their nursing homes so long as they tested positive for COVID-19. See "Our hero’s hospital is full (but not with patients who should be there)" in which I noted "Essentially, the hospital is packed because, even with nearly a year to prepare, state and local health departments that regulate hospitals and track hospital capacity couldn’t get organized to turn empty hotels into Covid-19 halfway houses."]
The junior radiologist continues: "On top of this will be a supply crisis. Our health system reverts back to the medieval age when we don't have common medications. Penicillin is not made in the US anymore. There is going to be a huge shortage of needles. China supplies everything, and they are shut down." Is he stockpiling? "Oh yeah." He grabs another coffee, his fifth today. "Let me get caught up." He speeds through 10 radiographs in a few minutes, dictating with prefilled phrases. He turns to me. "The three fastest radiologists I have ever seen are all here. The fastest offered to do 1.5 lists and get paid at 1.5 FTE. I can see his point because he could handle it, but it would set a dangerous precedent if all you care about is speed. His offer was rejected, so he started the medical student clerkship. We're not all as fast as him, so we fall behind when students are here."
We review a pelvic CT. He laments, "Look at this! Hip pain. It doesn't specify if the pain is in the hip joint, greater trochanter, or SI joint. No clinical history. I'm so used to it, but this lack of communication hurts the patient. Help me help you! The worst is when we get an abdominal/pelvic CT for 'abdominal pain, unspecified'." He continues, "Epic has made this communication crisis worse. The ED doc or PCP just clicks a worthless button and moves on. I can use Epic to read the doctor's notes, but I shouldn't need to do that. The MSK seat is not as bad as the abdominal seat as there are far fewer potential diagnoses."
Statistics for the week… Study: 0 hours. Sleep: 9 hours/night; Fun: 2 nights. Example fun: Dog playdate at a local park followed by a dog-friendly brewery.
It is March 30, 2020. Our rotations are now "socially-distanced": medical education (Zoom meetings with M1s and M2s), pathology (share a screen with a pathologist), and anatomy (handful of masked people in a large lab). The most popular choice is an additional two-week block of "study time" (i.e., vacation) for the Step 3 exam, a two-day multiple choice exam that costs $895 and duplicates material from Step 2. It is impossible to register for the exam until after we graduate, so nobody is actually studying. Jane and I have decided to learn anatomy from our favorite retired trauma surgeon for two weeks.
There are just two other students on our elective, including Buff Bri who matched into neurosurgery and a Canadian who matched into Internal Medicine. School administrators have decreed that everyone wear masks in the anatomy lab and that no more than two students at a time can be present in the thoroughly ventilated cavernous anatomy lab. Jane: "I'm surprised that our professor is teaching. She's the ideal patient to actually be harmed by COVID-19." We will meet five times over two weeks, starting at 10:00 am and working until the early afternoon.
The first week we focus on trauma exposures. Jane and I start Monday on a cadaver with an untouched abdomen! Our attending first goes over how to make a midline incision. "A lot of residents do not extend the incision all the way to the xiphoid process. That few extra centimeters gives you a much better exposure." We both take turns cutting, then suturing each fascial layer back together, and then cutting the sutures. Next we play the "Exposure Game": she tells us an organ or structure, and we have to describe how to get to it once inside the peritoneal cavity. We perform the Kocher maneuver, medialization of the duodenum through incision of the inferior lateral border of duodenum, and the Cattell-Braasch, medializing the lateral edge of the ascending colon. A typical abdominal organ can be mobilized (or "medialized") from its natural resting place by incising a thin layer of connective tissue ("peritoneum") thereby releasing its long blood supply attachment (mesentery) to its full length. From this principle, you can bring the right colon or spleen out of the abdominal cavity while still attached to its blood supply.
We quickly realize that the cadaver's anatomy is way out of whack, which makes winning the game a lot more challenging. There is a seven-inch predominantly solid mass in her midline, which encircles the aorta and pushes her vena cava to the right. We cannot identify the abdominal aorta at all, but slowly dissect it out moving backwards from the bifurcated right and left iliac arteries. We also perform the Mattox maneuver in which the left colon and kidney are medialized to reveal the aorta.
We go in Wednesday and Thursday to continue to dissect the abdomen and remove the mass. During our dissection, we find that she had a ureteral stent placed in her left ureter due to obstruction from the mass. Our professor hands us a bucket to save the specimen for future classes. "Next year's class wont have cadavers because authorities are requiring all cadavers be Covid-negative. There just won't be any supply."
We then perform a resuscitative thoracotomy (creating a hole in the chest). I make an oblique incision from below the nipple to the sternum, dissect down to the ribs, and place a rib expander ("Finochietto") device in between the two ribs. Jane starts turning the crank to expand the ribs apart. We switch and Jane takes over to dissect out the heart and lungs. "Bedside thoracotomy is a procedure that is a last ditch effort to bring a trauma patient back from death," our attending explains. "Imagine a 30 year old with multiple stab wounds is dropped off at the ED entrance. He is in extremis – he doesn't open his eyes and is groaning only. His heart rate is 160, and the automatic BP cuff cannot get a reading. He has a pulse when he is transferred over to the trauma bay bed, but shortly thereafter, an astute medical student says that she cannot feel a pulse. What do you do?" A resuscitative thoracotomy is performed to try to bring this dead patient back to life. A large incision is made, the ribs are spread. The heart is delivered out of the chest. The aorta is clamped to decrease the circulating blood volume and divert blood flow to the brain. Frankly, attendings sometimes let residents do it to practice even though it doesn't significantly improve patients' outcomes." She concludes, "The best evidence suggests performing resuscitative thoracotomy after traumatic arrest from penetrating injuries to the chest – maybe you can stitch a hole in the heart – or penetrating injuries to the abdomen where you can halt massive hemorrhage by clamping the aorta."
On Friday, we perform a mastectomy, much to Jane's disappointment after her two-week breast service rotation. "After a few mastectomies, it is boring. You're just cutting into fat." I make an oblique incision along the cadaver's breast and find the pectoral fascia (connective tissue plane overlying the pectoral major muscle). I then dissect, mostly with my hands, to remove the breast tissue (all fat in this 86-year-old). We then perform the much more exciting axillary lymph node dissection! Jane begins it by reflecting the pectoral major to identify the clavipectoral ("clavipec") fascia which runs up to the coracoid process (bony protuberance on the front of your shoulder). "The coracoid is the key to the axilla," exclaims our attending. Jane and I have not studied this anatomy for awhile, having not been in the hospital since almost January, let alone on a surgery rotation. We pull out Netter's Atlas of Human Anatomy, multiple copies of which are strewn around the lab, and turn to the axilla plates. We receive a ten-minute tangent about the most important books for surgeons to have: Netter's Atlas of Human Anatomy, Maingot's Abdominal Operations, Skandalakis' Surgical Anatomy, Netter's Surgical Anatomy and Approaches.
We review the shoulder anatomy, and head back to our dissection. "In an axillary node dissection, you typically should not see the neurovascular bundle. You mostly have to watch out for what two nerves?" Jane responds, "The thoracodorsal (latissimus dorsi) and the long thoracic (serratus anterior)." Women are already self-conscious enough about losing a breast. It's best not to also give her a winged scapula [injury to long thoracic nerve leading to impaired function of the serratus anterior]."
Buff Bri comes in every day for several hours, defying social-distancing orders from the administration, but our elderly trauma surgeon doesn't care ("the cadavers are far enough apart"). From the first two cadavers he removes the brain by removing the skull and cutting the brain stem from the spinal cord. On the third cadaver, however, he spends hours meticulously dissecting out each vertebral arch/lamina to have an undisturbed nervous system from the brain to the end of the spinal cord. When it was time for final removal, our attending hands him the scalpel. "You know what to do." He shrieks, "No, no, I can't! You do it!" After a few more shrieks, he begins cutting each of the spinal nerves to finally remove the entire central nervous system – the brain connected to the spinal cord. I am amazed how small it looks. "We're saving this one," as she grabs a bucket. "Not a bad haul for two weeks. Two interesting specimen buckets!"
Type-A Anita is actively sharing "Sassy Socialist Memes" on Facebook. She adds her own gloss: "People, if we're afraid that giving people $600 per week in unemployment benefits will stop them from working, that's an argument for raising wages, not for refusing to bail out the people!" If any of her friends are turning to her posts in hopes of reassurance regarding coronavirus, they will be disappointed: "viruses can mutate into different strains. Look at how hard it is to guess which flu strain to account for in annual vaccines. We just don’t know enough about this virus to assume anyone is immune."
During small group sessions, Anita frequently expressed her hatred of immunology (e.g., "Who cares about CAR-T cells and HLA types?"). A classmate who has specialized in immunology responds to Anita's fear of lethal mutations: "The mutation rate of this virus is orders of magnitude less than either the flu or HIV, two viruses that have much more genetic diversity than SARS-CoV-2 due to extremely error-prone replication machinery. This bodes well for development of effective vaccines and possibly antibodies in comparison to circulating influenza viruses. Doesn't change the fact that the duration of post-infection immunity is unknown, though!"
[Editor: Maybe they were both wrong, like most people who made predictions about COVID-19. SARS-CoV-2 never mutated into a virus capable of killing people with different characteristics than the early victims (i.e., the death rate kept falling because the virus killed those susceptible to death in the first year or two). But the immunology nerd was also wrong. We never developed a vaccine that reduced infection or transmission and maybe the vaccine had no effect on the death rate either. See "Where is the population-wide evidence that COVID vaccines reduce COVID-tagged death rates?" and "Did vaccines or any other intervention slow down COVID?". Anita's prediction that Americans would go back to work after long-term unemployment was at least partly wrong. Bureau of Labor Statistics data showed that the U.S. labor force participation rate remained lower in 2023 than it had been in 2019, though the most dramatic fall was from 2009 through 2015, after the 99 weeks of unemployment authorized by Congress during the first weeks of the Obama administration ("99 weeks of Xbox").]
Statistics for the week… Study: 0 hours. Sleep: 9 hours/night; Fun: 2 nights. Jane and I continue packing up our house and training our two puppies. We go to the dog park every other day.. Pinterest Penelope ordered graduation-themed tee-shirt pullovers for each dog and arranged a class dog photoshoot. Wine night every night.