American Medicine: I survived the death knell thanks to the devil.

Elena Reyes started feeling something was wrong with her right shoulder five months ago.

At that time, she had just gotten a full-time job at Aldridge Law Firm.

The top 15 commercial litigation firms in New York offer an annual package of $195,000 in the first year. With performance bonuses and year-end bonuses, it can be even higher.

For a Dominican girl who grew up in the Bronx and completed Fordham Law School with federal student loans, this number means she is cutting ties with her past.

At first, she thought her shoulder pain was due to her office posture.

New law firm employees sit for fourteen hours a day; whose shoulders don't ache?

As she reached for the top shelf of the file rack, her right arm felt like it was being bitten from the inside.

After waiting in line for a long time, the general practitioner prescribed her ibuprofen and muscle relaxants.

Useless.

After taking an X-ray, the general practitioner told her to see an orthopedic specialist.

After finally getting an appointment with the orthopedics department, undergoing a CT scan and biopsy, she was transferred to the Metropolitan Hospital.

They say they "recommend a referral," but in reality, they just don't dare to take the case.

They were previously passed around like a hot potato, but here they've become the focus of contention.

When Elena was wheeled into a private room on the twelfth floor, the nurse hadn't even finished recording her admission information when the first doctor arrived.

Ryan Prescott.

He was wearing a well-tailored white coat with his full name and the words "Bone Tumor Specialist Trainee" embroidered on his chest.

Upon entering, they shake hands with a professional smile.

"Ms. Reyes, this is Dr. Prescott, specializing in musculoskeletal tumors."

He sat down on the edge of the bed and opened her video files.

"I've reviewed your CT scan and biopsy results from the other hospital. To be honest, the invasion pattern of this lesion is very unusual."

Elena leaned against the headboard, her right arm secured with a triangular bandage.

"What does 'unusual' mean?"

"Your shoulder blade is being eaten away by something, but we're not sure what that thing is yet."

Prescott turned the CT scan toward her, pointing to the edge of the osteolytic area:

"The biopsy performed at another hospital yielded a very small piece of tissue, and no malignant cells were found."

"But that doesn't mean it's not there. A puncture is like using a straw to scoop water from a swimming pool. The sip you take is clean, but that doesn't mean the whole pool is clean."

"What's your suggestion?" Elena asked in return.

"Open biopsy".

Prescott put it bluntly:

"A large enough piece of tissue is surgically removed for pathological examination. If it is confirmed to be malignant, especially osteosarcoma or Ewing sarcoma, early and extensive resection is the only chance of a cure. Every day it is delayed, it eats away at more bone."

"What if the open biopsy is still negative?"

Prescott paused for a fraction of a second.

"Then we've at least ruled out the worst-case scenario."

Elena took a course called "Evidence Law" at law school.

She still remembers what the professor said in the first class: When someone answers your question by avoiding the key words, it's not that they forgot, it's that they don't want to touch on them.

Prescott did not say "what to do after a negative result".

He just wanted to cut himself open and see what was inside.

"What are the risks of this surgery?"

"It's just a routine surgical risk: bleeding, infection, nerve damage. But our team is very experienced, so you don't need to worry too much."

How high is the risk of bleeding?

Prescott thought for a moment:

"We will be prepared to stop the bleeding during the operation."

He stood up, took a business card out of his white coat pocket, and placed it on the bedside table.

"Please contact me anytime if you have any questions. These kinds of cases are rare worldwide, and I will do my best."

Elena noticed a subtle excitement in the doctor's tone when he said "rare".

It wasn't concern about her condition, but interest in the case itself.

She had seen that expression far too many times at the law firm.

When a partner sees a complex lawsuit with a claim of over 100 million, he might say he will protect the client's interests, but what he's really thinking is: if we win this case, I can be promoted to equity partner this year.

Less than forty minutes after Prescott left, the second person arrived.

Taylor Garrett.

His white coat was a bit worn, with a ring of pale yellow stains around the collar that couldn't be washed off.

The name tag reads "[Osteomyelitis Tumor - Clinical Instructor]".

He sat down and flipped through the medical records for a long time.

So long that Elena thought he might have forgotten she was still around.

"Um."

Garrett finally looked up, adjusted his glasses, and said, "I've seen your imaging and the biopsy from the other hospital."

"Dr. Prescott just came by and recommended an open biopsy."

"I know."

Garrett's lips twitched slightly. "Dr. Prescott is always...decisive."

He closed the medical record.

"Ms. Reyes, you've already had a biopsy, and the result was negative."

"Although the pathology department at the other hospital isn't the most advanced, they've done the staining and immunohistochemistry. Making another incision would be quite traumatic, and given the dense blood vessels in your lesion area, the risk of bleeding during surgery isn't low."

"So what's your suggestion?"

"A follow-up CT scan will be performed in six to eight weeks to compare with the current images. At the same time, a complete set of tumor markers, calcium and phosphorus metabolism, and immune indicators will be checked."

"If the lesion progresses, we will consider the next step. If it is stable, it may be a self-limiting process."

"You think it will self-limit? What do you mean by self-limitation? Does it mean it will get better on its own?"

"It's possible, I'm just saying it's possible. In medicine, many times the wisest decision is not to rush into making a decision."

Elena looked at the man.

He looked to be around thirty-eight or thirty-nine years old, and his hair was already thinning a bit.

There's probably a reason why he hasn't been promoted after working as a clinical lecturer in a place like the Metropolitan Area for several years.

"Dr. Garrett, a third of my bones have already been eaten. You want me to wait another two months?"

"I want to help you avoid having a potentially unnecessary surgery without a clear diagnosis."

He stood up after he finished speaking, walked to the door, and looked back once.

"If anything goes wrong with Prescott's surgery, you can come to me."

Elena understood; he was gambling, betting that Prescott would fail.

The third person arrived in the afternoon.

He looked younger and leaner than the previous two, and walked with a brisk pace.

The white coat had two pens, a small flashlight, and a notepad covered in writing clipped to it.

The man was in a hurry. He knocked on the door twice, and before anyone could answer, he pushed it open, his voice ringing out as he did so.

"Hello, Ms. Reyes. I am Park Jung-woo, a spinal surgeon."

His English is so fluent that he has no accent.

"Spinal surgery?"

Elena glanced at her right arm, which was slinged in place by a triangular bandage. "My problem is in my shoulder."

"Your imaging shows a lesion in the fourth posterior rib, and the posterior border of the osteolytic area is close to the paravertebral region."

Park Jung-woo pulled over a chair, and as he sat down, he casually adjusted the chair to face her.

"Many people can treat scapular diseases, but once the chest wall-spine junction is involved, that's my area of ​​expertise."

He opened his tablet, which already displayed her CT 3D reconstruction.

"Let me first talk about the plans of the two colleagues before me. Prescott wants to have an open biopsy, but the problem is that your lesion is highly vascularized, and it may not be able to stop the bleeding after cutting it open."

"Garrett will have to wait six to eight weeks, but the problem is that at the current rate of progress, there might be very little of your shoulder blade left after six weeks."

His criticisms of the proposals from the first two colleagues were accurate and to the point.

"And what's your proposal?"