Wednesday, February 10, 2010

Still around ...

I really wish I could have gotten this blog really going, but it clearly didn't happen, and it's too late to start now. Between regular work hours (we hit 70-80 hours per week on surg path), doing two research projects, making presentations, studying (I am reading Sternberg cover-to-cover), and having some semblance of a life outside residency, this blog was just always too far down the "to-do" list. For that, I apologize.

Here's what I can do. If you have any questions about pathology residency, about the life of a pathology resident, or etc., feel free to ask, and I will post a response as soon as I am able.

Thank you to the handful of people who are here.

Sunday, May 31, 2009

dead ... tired

I really am not happy that I haven't had time to update this blog. I had big plans for it, which have clearly fallen through. I have plenty of topics to write about and stories to share, but I just haven't had time. I just did two months in a row of surg path, which involved being at work for 70+ hours per week and studying at home for an additional 15+. Still good hours compared to other residents, but man, I am beat. I am on autopsy for June, which should be a little more calm. I will definitely try to actually post some during the month. Thank you to the folks who keep popping their heads in.

Sunday, January 11, 2009

not dead!

Just busy. I have ideas for some posts I want to write, but I can never seen to find the time. I will definitely keep posting to this blog, though.

Wednesday, November 26, 2008

note to clinicians

If your patient dies on Monday and you want an autopsy on them, please do not:
* Bring the body into the morgue at 2 p.m. Wednesday (we get there at 8 a.m. every morning, and the daily "cutoff" for autopsies is 3 p.m.)
* Not mention anything to any of the pathologists or the pathology assistants
* Leave the chart on the gurney with the body, instead of on the computer desk where it's supposed to be (so we can spot it and go, "Oh! We have an autopsy.")
* Call the funeral home and tell them to go pick up the body, seeing as how you haven't told the people performing the autopsy they even have an autopsy to do

I found out about this case because I went into the morgue to use the restroom and spotted an extra sheet of paper tacked to the door of the refrigerator where they store the bodies. Finding my attending and PA at 2 p.m. the day before Thanksgiving was hard enough, but the clinical attending and resident were both off-service (again, the patient died 2 days ago). I managed to hunt the attending down. The funeral home folks showed up, to our surprise, before we even started cutting the body; if they had shown up before nature had called me, they might well have just wheeled off the body before we became aware of the autopsy.

Usually, the system works pretty well, but every now and then ... sheesh. The body was kept mechanically alive for two days in order to harvest organs, but if they knew on Monday they wanted an autopsy done Wednesday, a phone call would have been nice. On top of it all, they already knew how the patient died; they were just curious about one of the patient's organs and decided to have us plunge in. We can't say no. And we don't get paid for it.

Monday, November 17, 2008

surg path basics

OK, I've been off surg path (and on autopsy) for a few weeks now, but I am finally getting around to posting about the service. Sorry for the delay. Yesterday, one of my friends in a surgery residency across the country called, asking me exactly what pathologists do regarding surgical specimens. I figure that's as good a topic as any to start this off with.

There are four main "duties" that pathology residents have during surg path. At my institution, we cycle through these every few days, then start over.

1. Frozen sections. Let's say a surgeon is dealing with a nasty invasive cancer. He cuts it out, but he wants to make sure he got all of it. He takes a margin (ie, a piece of tissue just past the edge of the tumor) and sends it to the frozen section room. There, the pathologist cuts the tissue up, freezes it with a special compound, uses a cryostat (a machine that holds the frozen tissue in place and cuts super-thin slices of it) to place a piece of the tissue on a slide, stains the slide with hematoxylin and eosin, then looks at it under the microscope to say whether there's cancer there. The slides this technique produces aren't quite as good as "permanent" slides (see below), but they'll do in a pinch. If there's cancer in the margin, the surgon has to go back and take out more tissue. Frozens are done for various other reasons, including transplant viability (they want to put a fresh liver in a patient -- how healthy is it?). Making a frozen section isn't terribly difficult, but some tissues are hard to orient or cut properly, and when five surgeons send you specimens all at at once and wonder what's taking the lazy pathologist so long (hint: you're fourth in line!), it can get quite hectic.

2. Grossing. Anything that gets taken out during surgery -- a gallbladder, a cancerous kidney, a diabetic leg, a jaw full of tumor -- gets sent to us for grossing. Basically, we inspect the tissue, describe it, cut it open, and take representative sections. For the gallbladder, that means one section of mucosa (to see if it's inflamed) and one section of the cystic duct margin (to see if it's blocked). For the cancerous kidney, we take sections of the cancer (to see what kind of cancer it is) and sections around the cancer (to see if the cancer invaded the capsule / fat around the kidney / draining system of the kidney / renal vein / etc.). And so forth. This is a lot harder than it sounds, especially with weird specimens (the aforementioned jaw), complicated specimens (a Whipple -- ie, parts of stomach, pancreas, duodenum, and sometimes more), and annoying specimens (any colon cancer requires that we find ten lymph nodes in the fat -- which means mashing through the fat and hunting for tiny lymph nodes, usually for 90-120 minutes per colon). These days can run long; the last processor cuts off at 9 p.m., and that deadline is sometimes missed. The pieces of tissue removed from these specimens get placed in a processor and fixed in formalin overnight. The next day, they are turned into "permanent" slides in a more controlled and clean version of the "frozen section" procedure described above. The histology technicians handle that part.

3. Previewing cases. Once the slides are out, the resident looks at them before signing out with the attending. A fourth-year resident can make most diagnoses and get all the paperwork in order without breaking a sweat. Me, as a first year? I'm usually happy if I can tell it's a cancer, any cancer. Forget identifying, staging, etc. We also have to look up clinical history on the patients, and sometimes we order special immunostains. These stains come in handy for diagnosis (is this skin lesion melanoma? order a S100 stain and see if it's positive) and/or prognosis (breast cancer, eh? is it ER and PR receptor positive?). Especially as a first year, these are actually your longest days. Just getting the paperwork in order takes forever, and if you're giving the slides a good honest look, be sure you brought some cash so you can get dinner and coffee from the hospital cafeteria.

4. Signing out cases. This involves sitting with the attending, giving them whatever information they may need about the clinical history or the gross findings, and listening to them teach you why something is what it is. Usually somewhat painless, though each attending has his own style of doing things, and you're always preoccupied handling the small tasks you forgot to take care of while you were previewing the day before.

There are other little things we have to do, including preparing surgery schedules for the next day so we always know what frozen sections to expect, but this covers the bare bones. In future posts, I'll dive into more detail on each of these points, as well as discuss the other crazy things that always pop up on the surg path service.

Wednesday, October 22, 2008

lessons learned from micro

My first three months of residency were spent in the microbiology department. Aside from learning a whole lot (though, of course, never enough) about various organisms, diseases, and lab tests, I walked away having picked up a few other helpful tips -- ones I think would be important to all physicians, not just pathologists.

So, here are my "lessons learned" from microbiology:

Some labs take a while
As a medical student, I remember checking culture reports every day, wondering why it was taking so long for information to come back. Now I know. Aside from a Gram stain, which is relatively quick and easy but doesn't tell you a whole lot, these tests take a while to get done right. The blood samples have to incubate for a day or two. If positive, then the Gram stain is performed and a culture plate is prepared. That's another few days for the organism to grow right there. Then it goes through the machine that tells us exactly what kind of organism it is and what antibiotics it's susceptible to. Some of the specimens -- fungal and AFB specimens -- have to sit for weeks and weeks before a lack of growth can comfortably be called negative. It stinks that this all takes so long, but that's the name of the game. The lab is not slacking.

The techs know their stuff
I learned some things out of books or lectures, but most of the microbiology knowledge I gained came from the techs I watched at work. They aren't doctors, but neither was I a few months ago. They're well-trained and definitely know what they're talking about within their field. I've heard them converse with doctors and get treated like idiots, which just isn't fair. They keep things working smoothly 99% of the time, and that 1% of the time that something goes wrong, it's a genuine issue that usually is not their fault.

There are way too many microorganisms out there
Seriously. I had enough trouble keeping track of all the ones I learned in my second year of medical school. Turns out that was just scratching the surface. There are all sorts of "obscure" bacteria and parasites I've never even heard of. We had tutorial CDs that presented information on all of them. After about the 20th somewhat similar organism, your eyes start to glaze over. The microbiology fellow on the rotation with us definitely knew his stuff, but I can see why a fellowship (or even a PhD) in microbiology is essential to understanding everything that comes through the door.

A doctor runs the lab
This is possibly a "duh" statement, but I never really thought about it. At the head of the lab are MDs and PhDs making sure everything runs smoothly. You really need a medically trained person in there who can grasp the issues fully and appropriately. And this brings me to my last point ...

Lots of crazy little issues pop up
When not working with the techs and learning the basics of micro, I spent 1/3 of my time checking out interesting cases and the other 2/3 listening to troubleshooting. The micro directors have to swoop in whenever a test is acting funny, a specimen is mishandled, an outbreak appears to arise, and etc. The lab can run on autopilot for a little while, but something always comes up that pulls things off course. One skill a CP pathologist absolutely has to possess is office management.

I have a ton of ideas for posts about surg path. Hopefully I will have time to write them in November, when I'm on autopsy.

Wednesday, October 8, 2008

CP Call

Surg Path is keeping me really busy. I've got plenty to post about, just no time to type it up! And now that I do have a spare moment, I want to write about my first week on call (from a month ago).

CP (Clinical Pathology) call is taken one week at a time by one resident in the program. Any call that has to do with a lab -- blood bank, clinical chemistry, microbiology, etc. -- goes to us. Most of these calls are about blood products. We have been triaging blood some at our hospital, as supplies are low for one type in particular. Transfusion reactions also get reported to us, and complicated blood bank cases are run by us for answers on what to do.

My first page (as I mentioned here) came at four in the morning and involved a child whose blood type test was sort of showing two different blood types, because he'd received many units of a blood type not his own at an outside hospital (with no obvious adverse effects, luckily). It also showed antibodies to his original blood type, presumably from the transfusion. The question was, what type of blood should we give from this point forward?

Now, the case wasn't super-complicated, but it wasn't simple. And I haven't rotated through blood bank yet. So I did what I ended up doing pretty much every time -- I called my attending. He was really nice and understanding, even though I wasn't able to answer most of his questions (since they were questions I didn't even know to ask the blood bank tech).

We decided to keep giving the same type of blood the patient had been getting. I *think* I understand all the details at this point.

Other complicated calls included a sickle-cell anemia patient with low hemoglobin whose blood sample was reacting to stored blood that it hadn't previously reacted to, making it difficult to find a match; a patient whose sample in the blood bank was reacting to blood similar to blood she had been sent for transfusion (this was harrowing); and an ER patient needing lots of blood with a very specific antigen set.

If those summaries don't make sense, it's both because I don't want to bore you with the details and because that's the best way I can describe the cases without starting to get confused myself. Needless to say, I will find call much much less stressful once I've actually done my blood bank rotation!

We got a few calls for transfusion reactions -- patient developed a fever, or a rash, or etc. after receiving blood products. These were typically straightforward.

At my program, pathology resident approval is required to give out a certain super-specific anti-bleeding drug. I got a request for it once, pretty early in the morning, from a surgeon. After spending half an hour getting all my facts straight and having the attending tell me to approve it, I called back and the surgeon had already left the OR, apparently not needing it.

Some blood tests also require resident approval. I had to authorize the ordering of a urine myoglobin test (the clinician wanted it stat, but it's a test that an outside lab has to perform for us -- sorry!) and a HIT antibody test.

Two other calls are worth a mention. Phlebotomy called us asking if we were OK with them drawing blood on a patient from above a tiny IV in their hand (which is tricky), since the patient's other arm was unusable. I contact the attending, and his response? Just draw it from a leg. Nice and elegant solution. Wish I had thought of that.

Finally, we had a call about a clinic patient with a critically low lab value. The problem? The doctor's information was nowhere in the paperwork the lab received. They had the patient's home phone number and asked me if I should call the patient directly. I decided it was easier to go into our EMR and get the doctor's name that way. Contacting him once I knew who he was wasn't too hard.

So, a lot of complicated calls, a lot of straightforward calls, and a couple minor calls. It started out slow (maybe one a night) but really avalanched toward the end. One night, I was busy fielding calls from midnight to 4 a.m. straight, including two at once at one point, and I didn't quite make it to 7:30 a.m. lecture that day.

Sure, I know any surgeons or OB-GYN residents are shaking their head in disbelief about how easy my call is compared to theirs. All I have to say is, that's one of the many reasons I signed up for pathology.

Stay tuned for one last post about my microbiology rotation, and then as many posts about surgical pathology as I can steal time to write.