“Who’s on call?” Dr. Elliot, chief of ENT surgery, bellowed into the resident sign-out room. Residents scattered like mice. Dan pointed toward James. It was five o’clock on a Thursday afternoon — time for Elliot’s weekly commando procedure.

But tonight’s case was different. Not an old alcoholic with a fungating face tumor. A boy.

The CT showed a mass filling the right orbit of a ten-year-old child. “I’ll need frozens,” Elliot said. “Lymphoma, rhabdo, PNET, maybe neuroblastoma. Haas knows the case.”

James’ stomach dropped. He thought Nomura was on call. But Haas had switched.

In Haas’ office, she looked up sharply. “Differential?”

“Small round blue cell tumor: lymphoma, rhabdomyosarcoma, Ewing’s, PNET, neuroblastoma.”

“And how do you differentiate?”

“Immunohistochemistry…electron microscopy.”

“Which immunohistochemical stains?”

James froze. “I’ll look it up.”

“Do that before the frozen.”

Her voice cut like a scalpel. James scurried out, textbook in hand, and wolfed down a tray dinner in his office. As he ate, Carter’s voice whispered in memory: There is a patient at the other end of the slide. Never forget that.

He scribbled the stains — cytokeratin, desmin, CD99, LCA, WT1, S100. His heart pounded, not from the food but from the weight of Carter’s admonition. He thought briefly of Deanna — her gentle encouragement after last week’s conference — and steadied his breath.

The first frozen came. James cut, stained, and carried the slides to Haas.

“Crush artifact,” James said carefully. “Small round blue cell tumor. Adequate for diagnosis, but I think we should ask for more tissue for cytogenetics.”

Haas nodded. A rare smile. She dialed the OR. “Stan? Irene. Yes — small round blue cell. Adequate. Send more tissue for cytogenetics.”

James rushed to the OR. Elliot handed him the tissue. “You escaped my midnight madness. When can I have an answer?”

“Tomorrow, once we have the immunostains.”

Elliot pressed. “Could be lymphoma or rhabdo. What do you think?”

James swallowed, then offered a pearl he’d read by chance. “It might also be an extraskeletal mesenchymal chondrosarcoma.”

Elliot raised an eyebrow. “Interesting…you may be right. Keep me posted.”

The next morning, Haas reviewed the immunostains. “CD99, S100 positive. Likely PNET. Call Elliot.”

Elliot appeared at the door before James could move. “So — PNET? What about that chondrosarcoma you mentioned?”

James froze. Haas bristled. “That was his speculation. When you hear hoofbeats, think horses, not zebras.”

“But Pittman at Children’s had an identical case last year,” Elliot countered. “Run it by him.”

Haas’ cheeks flushed. “Fine.”

By evening, Pittman had reviewed the case. It was a mesenchymal chondrosarcoma. Cytogenetics later ruled out PNET. James had been right.

Word spread like wildfire. Elliot praised James publicly, telling anyone who would listen that his resident had nailed the diagnosis. Everyone in pathology congratulated him — except Haas. She rearranged the sign-out schedule to exclude him for a month.

That night, James sat alone in his office, case folders stacked like sandbags. He stared at the phone, tempted to call his mother, or Carter, or even Deanna. Her laugh, her faith in him, replayed in memory like a lifeline.

Then Wilma appeared at his door with a tray of slides. “Working late again, Dr. Deetan?” Her eyes glinted as she brushed a strand of auburn hair from her face. “Careful — the hospital eats people alive who don’t watch their backs.”

Her words echoed Franklin’s warning. Someone is always sacrificed in this department.

James pressed his hands flat on the desk. Haas had made her move. But he was still standing.

Next Chapter: Chapter 12-A Surefire Plan