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.
Wednesday, November 26, 2008
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.
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.
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.
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.
Monday, September 29, 2008
Done with Step 3!
I will write about my week on call shortly. But for now, Step 3.
First of all, the basics: This is a two-day test, with seven hours of material each day. Most of it is multiple-choice, but there are some clinical cases toward the end where you are given a patient and you decide how to proceed (what tests to order, what treatment to give, etc.). You get feedback on what's happening after you make a decision (test results, change in patient's condition). It's pretty neat, though the cases had a nasty habit of cutting off right before I felt I finally had a good grip on what to do.
Now, like Step 2 and (kinda sorta) Step 1, this is a test of clinical medicine. Unlike those tests, I did not have a month off to study. I did manage to read First Aid once and do about 400 practice questions. Studying more would have helped a good bit, I'm pretty sure, but regardless, I can say this: The test stunk.
I really had no idea what was going on maybe 20% of the time. Now, I haven't completely forgotten clinical medicine -- I graduated back in May -- but even if I'd taken this test at the end of my third year, I would have balked at some of the questions. No, I don't know what symptoms result from mistletoe ingestion. No, I don't know which of these weirdo tests to order when the patient clearly needs an abdominal CT. No, I don't know which of my four slightly different options for a translator is best. (The psychosocial questions in particular were completely off the wall.)
A lot of the time, I was able to get the choices down to two possible answers, both of which sounded really good. And a few dozen times during the test, I stared at the answers, fully aware that I once knew the correct choice but now just have a hazy recollection of half the details.
I am glad the test is over. From what I've heard, the grading is pretty lenient. Some of the upper-level residents in my program told me they took it years out of medical school and passed just fine. I just want to put the two days and $670 behind me. Past this point, all my standardized tests will be pathology-specific. All I have to do now is learn pathology ...
First of all, the basics: This is a two-day test, with seven hours of material each day. Most of it is multiple-choice, but there are some clinical cases toward the end where you are given a patient and you decide how to proceed (what tests to order, what treatment to give, etc.). You get feedback on what's happening after you make a decision (test results, change in patient's condition). It's pretty neat, though the cases had a nasty habit of cutting off right before I felt I finally had a good grip on what to do.
Now, like Step 2 and (kinda sorta) Step 1, this is a test of clinical medicine. Unlike those tests, I did not have a month off to study. I did manage to read First Aid once and do about 400 practice questions. Studying more would have helped a good bit, I'm pretty sure, but regardless, I can say this: The test stunk.
I really had no idea what was going on maybe 20% of the time. Now, I haven't completely forgotten clinical medicine -- I graduated back in May -- but even if I'd taken this test at the end of my third year, I would have balked at some of the questions. No, I don't know what symptoms result from mistletoe ingestion. No, I don't know which of these weirdo tests to order when the patient clearly needs an abdominal CT. No, I don't know which of my four slightly different options for a translator is best. (The psychosocial questions in particular were completely off the wall.)
A lot of the time, I was able to get the choices down to two possible answers, both of which sounded really good. And a few dozen times during the test, I stared at the answers, fully aware that I once knew the correct choice but now just have a hazy recollection of half the details.
I am glad the test is over. From what I've heard, the grading is pretty lenient. Some of the upper-level residents in my program told me they took it years out of medical school and passed just fine. I just want to put the two days and $670 behind me. Past this point, all my standardized tests will be pathology-specific. All I have to do now is learn pathology ...
Sunday, September 21, 2008
boards
I am really not looking forward to taking Step 3 tomorrow and Tuesday. It's amazing how much clinical medicine you can forget after just half a year of not using it. I've been studying, but I took a month off for Step 1 and Step 2. Getting an hour or two of reading in after work each night for a few weeks just isn't the same.
I did see a cool thing in the micro lab earlier this week: the "hockey puck sign." Colonies of Moraxella, when pushed, slide across agar like a hockey puck. Very neat.
I did see a cool thing in the micro lab earlier this week: the "hockey puck sign." Colonies of Moraxella, when pushed, slide across agar like a hockey puck. Very neat.
Monday, September 15, 2008
quick update
CP call hasn't been too bad, aside from a few rough hours last night. I'll post more about it once it and Step 3 are over.
Someone came into the student health clinic here last week not feeling so good. He grew out Salmonella typhi. Yep, typhoid fever. They had to quarantine him, vaccinate his roommate, and interview all the other students who live on his hall. Good times ...
Someone came into the student health clinic here last week not feeling so good. He grew out Salmonella typhi. Yep, typhoid fever. They had to quarantine him, vaccinate his roommate, and interview all the other students who live on his hall. Good times ...
Thursday, September 11, 2008
haven't killed anyone yet
I'm on CP call this week. We take CP call for seven days at a time, and then at the end we present all the cases. My call began yesterday, and I only got called once. I just wish it hadn't been at 3 a.m.; I have been dragging all day.
The call concerned a child brought into the hospital who needed a blood transfusion. He had gotten a few units of blood at an outside hospital before being brought here. When they typed him here ... his blood type was not the same as the units he'd received. This is, of course, bad. The blood bank wanted to know whether to give the same blood type as the other hospital, or switch to the patient's actual blood type. He'd received so many units already that he was about half and half.
Not having rotated through the blood bank yet, I got as much information as I could, then called the attending. I think that's how most of the calls this week will go. The case actually ended up being pretty interesting (at least, the parts of it I could understand were), and I may do a presentation about it.
The call concerned a child brought into the hospital who needed a blood transfusion. He had gotten a few units of blood at an outside hospital before being brought here. When they typed him here ... his blood type was not the same as the units he'd received. This is, of course, bad. The blood bank wanted to know whether to give the same blood type as the other hospital, or switch to the patient's actual blood type. He'd received so many units already that he was about half and half.
Not having rotated through the blood bank yet, I got as much information as I could, then called the attending. I think that's how most of the calls this week will go. The case actually ended up being pretty interesting (at least, the parts of it I could understand were), and I may do a presentation about it.
Sunday, September 7, 2008
Working with ID teams
I wrote most of this post a few weeks ago (i.e., in August), but never got around to finishing it. I'm back at the "main" hospital for this month, but I wanted to share this anyway.
Aside from the occasional call for a mislabeled specimen or to discuss inappropriate use of lab resources (see below), the only real clinician interaction we have on our microbiology rotation is with the ID (infectious disease) team. As I mentioned in a previous last post, I am at a different hospital this month than I was in July, and man, what a difference a ten-minute shuttle ride makes.
At our "main" hospital, rounds start every day after lunch. The ID attending and fellow are always there to join us. As a result, we discuss cases in depth, with the clinicians knowing everything about the patient's hospital stay and the pathologists discussing the lab findings and their implications. It makes rounds longer but more interesting, as the case becomes more than "this plate grew out some weird bug." The patient becomes a person with a story, not just some lab results. It's easy to get into this mode of thinking when you're tucked away in the hospital lab, and talking with the ID folks about cases really reminds you why you're doing what you're doing.
In contrast, I have yet to see a non-pathologist in the micro lab I'm at this month. The ID team is apparently too busy to make rounds in the lab (I don't mean that sarcastically; with the patient population we have here, they certainly have their work cut out for them). This means that, for the most part, the patients exist as names on specimens, or data in a computer chart. I will occasionally research the clinical presentation of an interesting patient (like last week's Rhodococcus patient) and even go to the floor and look at the chart, but it's not the same as having a knowledgeable clinician discuss the case with you. Fortunately, while I'm on the floor, I can usually find a nurse or resident involved in the patient's care, but I had to go to them, not vice versa.
I've only even heard the term "ID consult" once this month. We wanted to suggest one to a doctor who has been swamping the lab with specimens. He has seemingly cultured his patient's one wound in three separate locations, twice a week, for the past two months. The computer can't even pull up all the lab results without crashing. And the results always show the exact same bacteria with the exact same susceptibility profiles (i.e., they never change in terms of what antibiotics will kill them). This patient has been put on a few different antibiotics, but nothing seems to change. This doctor is apparently upset at the lab, and we're not too happy with him. I feel like I am missing something, but I have gotten as involved in the case as I can, and I'm still confused. Hence recommending an ID consult to sort things out. I just hope that actually happens, and since we never see the ID doctors face to face, it's harder to get everyone working as a team, since we're all just names on a pager to each other.
Aside from the occasional call for a mislabeled specimen or to discuss inappropriate use of lab resources (see below), the only real clinician interaction we have on our microbiology rotation is with the ID (infectious disease) team. As I mentioned in a previous last post, I am at a different hospital this month than I was in July, and man, what a difference a ten-minute shuttle ride makes.
At our "main" hospital, rounds start every day after lunch. The ID attending and fellow are always there to join us. As a result, we discuss cases in depth, with the clinicians knowing everything about the patient's hospital stay and the pathologists discussing the lab findings and their implications. It makes rounds longer but more interesting, as the case becomes more than "this plate grew out some weird bug." The patient becomes a person with a story, not just some lab results. It's easy to get into this mode of thinking when you're tucked away in the hospital lab, and talking with the ID folks about cases really reminds you why you're doing what you're doing.
In contrast, I have yet to see a non-pathologist in the micro lab I'm at this month. The ID team is apparently too busy to make rounds in the lab (I don't mean that sarcastically; with the patient population we have here, they certainly have their work cut out for them). This means that, for the most part, the patients exist as names on specimens, or data in a computer chart. I will occasionally research the clinical presentation of an interesting patient (like last week's Rhodococcus patient) and even go to the floor and look at the chart, but it's not the same as having a knowledgeable clinician discuss the case with you. Fortunately, while I'm on the floor, I can usually find a nurse or resident involved in the patient's care, but I had to go to them, not vice versa.
I've only even heard the term "ID consult" once this month. We wanted to suggest one to a doctor who has been swamping the lab with specimens. He has seemingly cultured his patient's one wound in three separate locations, twice a week, for the past two months. The computer can't even pull up all the lab results without crashing. And the results always show the exact same bacteria with the exact same susceptibility profiles (i.e., they never change in terms of what antibiotics will kill them). This patient has been put on a few different antibiotics, but nothing seems to change. This doctor is apparently upset at the lab, and we're not too happy with him. I feel like I am missing something, but I have gotten as involved in the case as I can, and I'm still confused. Hence recommending an ID consult to sort things out. I just hope that actually happens, and since we never see the ID doctors face to face, it's harder to get everyone working as a team, since we're all just names on a pager to each other.
Wednesday, September 3, 2008
ah, doctor humor
We had a printout today on a patient that read "Current Diagnosis: CTD" and the culture report listed five assorted organisms. We decided that CTD stood for "Contaminated Tube Disease."
not dead, just busy
The past few weeks have been bumpy, yet uneventful. Micro does not lend itself well to interesting stories and anecdotes, unfortunately. I start surg path next month, so I will definitely have good posts come out of that.
I do have one post I half-wrote a few weeks ago and then never got around to finishing. That will be up in a day or two.
I'm taking Step 3 at the end of the month. This is part of the boards and consists of questions pertaining to clinical medicine. I haven't dealt with clinical medicine for half a year now! Neither have the other pathology interns, which is why I'm glad I am taking this thing so early. Imagine if I waited until fourth year. The test is basically pass/fail, but since some of the pathology fellowships I'm considering are rather competitive, I'd like my score to be as high as possible. Wish me luck ...
I do have one post I half-wrote a few weeks ago and then never got around to finishing. That will be up in a day or two.
I'm taking Step 3 at the end of the month. This is part of the boards and consists of questions pertaining to clinical medicine. I haven't dealt with clinical medicine for half a year now! Neither have the other pathology interns, which is why I'm glad I am taking this thing so early. Imagine if I waited until fourth year. The test is basically pass/fail, but since some of the pathology fellowships I'm considering are rather competitive, I'd like my score to be as high as possible. Wish me luck ...
Saturday, August 16, 2008
different hospitals, different patients
One cool thing about microbiology is getting a sideways glance at the epidemiology of a lot of diseases, both in seeing what specimens get handled and in observing trends over time.
One example comes from my being at the "downtown" hospital this month. With a much more indigent population, the AFB bench is a lot busier because of all the tuberculosis patients. However, the hospital only runs fungal cultures once a week, whereas my program's "main" hospital does it every day. Why? If I remember the explanation correctly, the main hospital does a lot of fungal cultures on immunosuppresed patients, mostly transplant recipients. The downtown hospital doesn't do transplants, though. They have a whole lot of HIV patients, but the regular blood culture bench is sufficient to look for most fungal infections that they might have.
Even more interesting is a story the main hospital's lab director has told us once or twice. A few years ago, Klebsiella Pneumoniae Carbapenemase started popping up. These are Klebsiella pneumoniae bacteria that are resistant to one of the most powerful categories of antibiotics. One particular strain, KPC 2, first showed up in New York. The very first KPC strain our lab saw was KPC 2, in a patient visiting from New York. After he arrived, a bunch more examples showed up. The patient returned to NY, and the incidence of KPC 2 died down. Of course, KPC 3 started showing up and got a stronger foothold in the area. A few weeks ago, another KPC 2 specimen registered in the lab, and yep, the patient was from New York. The clinical approach would be the same in all these cases, but it's fun to keep tabs on this sort of stuff.
One example comes from my being at the "downtown" hospital this month. With a much more indigent population, the AFB bench is a lot busier because of all the tuberculosis patients. However, the hospital only runs fungal cultures once a week, whereas my program's "main" hospital does it every day. Why? If I remember the explanation correctly, the main hospital does a lot of fungal cultures on immunosuppresed patients, mostly transplant recipients. The downtown hospital doesn't do transplants, though. They have a whole lot of HIV patients, but the regular blood culture bench is sufficient to look for most fungal infections that they might have.
Even more interesting is a story the main hospital's lab director has told us once or twice. A few years ago, Klebsiella Pneumoniae Carbapenemase started popping up. These are Klebsiella pneumoniae bacteria that are resistant to one of the most powerful categories of antibiotics. One particular strain, KPC 2, first showed up in New York. The very first KPC strain our lab saw was KPC 2, in a patient visiting from New York. After he arrived, a bunch more examples showed up. The patient returned to NY, and the incidence of KPC 2 died down. Of course, KPC 3 started showing up and got a stronger foothold in the area. A few weeks ago, another KPC 2 specimen registered in the lab, and yep, the patient was from New York. The clinical approach would be the same in all these cases, but it's fun to keep tabs on this sort of stuff.
Sunday, August 10, 2008
learning pathology
One challenge facing pathology interns is, well, we have no idea what we're doing. Medical school prepares you to be a clinician -- a general practitioner or a surgeon. Sure, I took a pathology class my second year, but that was more than two years ago, and compared to what a pathologist actually needs to know, that would be like saying an arithmetic class prepared me for upper-level calculus.
(Note: My fellow interns feel the same way; i.e., they possess very little actual pathology knowledge and have a ton to learn. There are certainly some well-prepared interns out there, but they are the exception more than the rule.)
Fortunately, our residency program is cognizant of our neophyte status and has many things in place to get us up to speed:
* We all observed an autopsy our first week here. While that doesn't mean I'm ready to do one myself, it was good to have a general idea of how to approach them.
* Once a week for the first month, we have a "grossing conference" where one of the upper-level residents shows us how to prepare a surgical specimen for microscopic examination. For example, we were shown how to take a kidney, examine it outside the body, cut it into pieces, take appropriate specimens (cancer, margins, etc.), and submit them to be placed on slides.
* Also once a week, there are "normal histology" sessions where we relearn what normal tissue looks like. We learned that first year, which is even more toward the back of my brain, and you can't diagnose the abnormal without recognizing the normal.
* We have occasional lectures on how to survive CP call. This is especially important for those of us who haven't had blood bank/transfusion, since the majority of calls the CP resident receives deals with those issues.
* Every week, there are unknowns that the attendings go over with the residents. As first years, our goal is to describe what the lesions look like. We aren't expected to offer a differential diagnosis until second year, which is good, because I still can't even describe the things properly.
* There are study sets of surgical pathology slides for us to look over. This is mostly interesting cases, but I think some bread-and-butter diagnoses are mixed in as well. In the microbiology lab, there are plenty of study sets, which is about the only way to actually observe the more rare bugs. Other CP rotations probably do something similar to this as well.
* Once a month, we get a test over a particular topic (mediastinal masses, for example), where we have an hour to offer diagnoses on slides and answer fill-in-the-blank questions. All the residents participate in this. It's both comforting and unsettling to see that, while the PGY-1s averaged about a 30 on the one we just took, the PGY-4s averaged about a 70 on the exact same test.
If that sounds like a lot, it is! I feel overwhelmed, not just with how much I need to know to be a great pathologist, but with how much I need to know just not to feel like an idiot at the microscope. It's gonna be a long four years ...
(Note: My fellow interns feel the same way; i.e., they possess very little actual pathology knowledge and have a ton to learn. There are certainly some well-prepared interns out there, but they are the exception more than the rule.)
Fortunately, our residency program is cognizant of our neophyte status and has many things in place to get us up to speed:
* We all observed an autopsy our first week here. While that doesn't mean I'm ready to do one myself, it was good to have a general idea of how to approach them.
* Once a week for the first month, we have a "grossing conference" where one of the upper-level residents shows us how to prepare a surgical specimen for microscopic examination. For example, we were shown how to take a kidney, examine it outside the body, cut it into pieces, take appropriate specimens (cancer, margins, etc.), and submit them to be placed on slides.
* Also once a week, there are "normal histology" sessions where we relearn what normal tissue looks like. We learned that first year, which is even more toward the back of my brain, and you can't diagnose the abnormal without recognizing the normal.
* We have occasional lectures on how to survive CP call. This is especially important for those of us who haven't had blood bank/transfusion, since the majority of calls the CP resident receives deals with those issues.
* Every week, there are unknowns that the attendings go over with the residents. As first years, our goal is to describe what the lesions look like. We aren't expected to offer a differential diagnosis until second year, which is good, because I still can't even describe the things properly.
* There are study sets of surgical pathology slides for us to look over. This is mostly interesting cases, but I think some bread-and-butter diagnoses are mixed in as well. In the microbiology lab, there are plenty of study sets, which is about the only way to actually observe the more rare bugs. Other CP rotations probably do something similar to this as well.
* Once a month, we get a test over a particular topic (mediastinal masses, for example), where we have an hour to offer diagnoses on slides and answer fill-in-the-blank questions. All the residents participate in this. It's both comforting and unsettling to see that, while the PGY-1s averaged about a 30 on the one we just took, the PGY-4s averaged about a 70 on the exact same test.
If that sounds like a lot, it is! I feel overwhelmed, not just with how much I need to know to be a great pathologist, but with how much I need to know just not to feel like an idiot at the microscope. It's gonna be a long four years ...
Friday, August 1, 2008
so ... what do pathologists do, anyway?
One of the reasons I started this blog is that most people don't really know what pathologists do. When I was a medical student, patients would ask me what field I wanted to enter, and my answer usually gave them a puzzled look. A few people replied, "So you're just going to work with dead people?"
A lot of physicians also don't seem to understand what pathologists do, or at least aren't aware of their full range of skills and limitations. So, here is a quick rundown. If this is too long to read, just know that anytime something gets sent to "the lab," a pathologist is responsible for the results that are returned.
ANATOMIC PATHOLOGY
There are actually two halves to pathology: anatomic and clinical. AP is the branch that most people are more familiar with, and that medical students study during second year. The three main "sub-categories" are surgical pathology, cytopathology, and autopsy.
Surgical pathology is the preparation and evaluation of patient tissue. This includes both surgical specimens (a gallbladder removed during surgery, for example, or a breast cancer mass) and biopsies (a mole removed at the dermatologist's, or a polyp plucked out during a colonoscopy). These tissues are sent to pathology, where they are "grossed," or cut into and prepared. They are then stained with colorful dyes, and a pathologist looks at them under the microscope and determines what exactly is going on.
This is a topic for another post, but I do want to mention that this is rarely cut and dry. Medical students may learn that basal cell carcinoma of the skin looks one way, but a pathologist knows that it can have many different appearances. Furthermore, many diseases exist along a spectrum, and determining where exactly something sits on the spectrum can be as difficult as looking at one spot on a spectrum of 1,000 colors and identifying the corresponding crayon. Fortunately, there are ways of getting answers, usually through staining the tissue with dyes that only stick to certain entities.
Autopsy is what everyone associates with pathologists. There's not much to say here, except that there is a lot more to the field than just this. Some pathologists gain additional training in forensics and do these all the time, but some just cover them occasionally for their hospital or practice, and others probably manage to avoid them altogether. Autopsies are also performed less frequently than in the past, for a few reasons.
Cytology is similar to surgical pathology, except that the specimen being looked at under the microscope is a cluster of cells instead of a firm piece of tissue. Pap smears are a good example of this. Cytology also offers pathologists patient contact, as they perform fine needle aspirations (FNAs) to suck out the cells that are going to be examined.
CLINICAL PATHOLOGY
This covers such a wide variety of fields that I'm pretty sure I don't know everything that's involved. Pathologists oversee or consult on labs running tests on bodily fluids. This includes microbiology labs, clinical chemistry labs (where routine blood tests get sent), and many more. Disciplines such as transfusion medicine and hematopathology also fall within CP.
Some of this is just oversight and troubleshooting. Techs do the day-to-day work in the lab, but when a weird test result pops up, a machine is clearly producing bad results, or a clinician has a question to ask, the pathologist steps up to the plate.
Pathologists also oversee the blood bank and approve giving out blood products. As a good example, my institution is really, really short on a particular blood type right now, so we have to be stingy with it. A surgeon may call and ask for twenty units, and the pathologist on call will approve five (sounds bad if you are that patient, but not if you're the car-crash victim coming in ten minutes from now).
This aspect of pathology is poorly communicated to most medical students (we had one guy come in for an hour and mumble about a bunch of tests the lab ran; if you'd asked me then, I wouldn't have been able to identify him as a pathologist). Most nonmedical people probably aren't aware that doctors oversee all the labs, either, since on the surface it doesn't seem like you'd need a doctor down there.
That's everything in a nutshell. I'm only one month into my four-year residency. Maybe 47 months from now, I will write this essay again in light of what I've learned and what I think is important to emphasize.
A lot of physicians also don't seem to understand what pathologists do, or at least aren't aware of their full range of skills and limitations. So, here is a quick rundown. If this is too long to read, just know that anytime something gets sent to "the lab," a pathologist is responsible for the results that are returned.
ANATOMIC PATHOLOGY
There are actually two halves to pathology: anatomic and clinical. AP is the branch that most people are more familiar with, and that medical students study during second year. The three main "sub-categories" are surgical pathology, cytopathology, and autopsy.
Surgical pathology is the preparation and evaluation of patient tissue. This includes both surgical specimens (a gallbladder removed during surgery, for example, or a breast cancer mass) and biopsies (a mole removed at the dermatologist's, or a polyp plucked out during a colonoscopy). These tissues are sent to pathology, where they are "grossed," or cut into and prepared. They are then stained with colorful dyes, and a pathologist looks at them under the microscope and determines what exactly is going on.
This is a topic for another post, but I do want to mention that this is rarely cut and dry. Medical students may learn that basal cell carcinoma of the skin looks one way, but a pathologist knows that it can have many different appearances. Furthermore, many diseases exist along a spectrum, and determining where exactly something sits on the spectrum can be as difficult as looking at one spot on a spectrum of 1,000 colors and identifying the corresponding crayon. Fortunately, there are ways of getting answers, usually through staining the tissue with dyes that only stick to certain entities.
Autopsy is what everyone associates with pathologists. There's not much to say here, except that there is a lot more to the field than just this. Some pathologists gain additional training in forensics and do these all the time, but some just cover them occasionally for their hospital or practice, and others probably manage to avoid them altogether. Autopsies are also performed less frequently than in the past, for a few reasons.
Cytology is similar to surgical pathology, except that the specimen being looked at under the microscope is a cluster of cells instead of a firm piece of tissue. Pap smears are a good example of this. Cytology also offers pathologists patient contact, as they perform fine needle aspirations (FNAs) to suck out the cells that are going to be examined.
CLINICAL PATHOLOGY
This covers such a wide variety of fields that I'm pretty sure I don't know everything that's involved. Pathologists oversee or consult on labs running tests on bodily fluids. This includes microbiology labs, clinical chemistry labs (where routine blood tests get sent), and many more. Disciplines such as transfusion medicine and hematopathology also fall within CP.
Some of this is just oversight and troubleshooting. Techs do the day-to-day work in the lab, but when a weird test result pops up, a machine is clearly producing bad results, or a clinician has a question to ask, the pathologist steps up to the plate.
Pathologists also oversee the blood bank and approve giving out blood products. As a good example, my institution is really, really short on a particular blood type right now, so we have to be stingy with it. A surgeon may call and ask for twenty units, and the pathologist on call will approve five (sounds bad if you are that patient, but not if you're the car-crash victim coming in ten minutes from now).
This aspect of pathology is poorly communicated to most medical students (we had one guy come in for an hour and mumble about a bunch of tests the lab ran; if you'd asked me then, I wouldn't have been able to identify him as a pathologist). Most nonmedical people probably aren't aware that doctors oversee all the labs, either, since on the surface it doesn't seem like you'd need a doctor down there.
That's everything in a nutshell. I'm only one month into my four-year residency. Maybe 47 months from now, I will write this essay again in light of what I've learned and what I think is important to emphasize.
Tuesday, July 29, 2008
one month in ...
The first month of my residency is coming to an end, and here are the take-home messages I've, well, taken home.
-Pathology is all about self-motivated study. I've spent a month in the microbiology lab, and I've seen more Staph and Strep than I have bricks on a wall. A couple of other "known" bugs have shown up (Nocardia, Klebsiella), but there are plenty of bread-and-butter pathogens I haven't seen. And, of course, there are tons of rare guys I haven't spotted and never will. How to learn about them? Hit a book.
-It's the same story for surgical pathology. Even if you look at slides all day every day (which some of the residents feel like they're doing), you might not see half of the entities you have to be able to diagnose. So, study. Grab a book. Grab the study slides. Grab a colleague. And study. (After you've worked until 9 p.m., of course.)
-Books. So many books. I have bought three so far with my book fund, and I know roughly which other books I want to get this year. This leaves me with about six "must-have" books I need to get, and, oh, thirty or forty "should-get" books to pencil in somewhere on my list. In Internal Medicine, you can get by with Harrison's, Pocket Medicine, and a good PDA. In Pathology, you can get by after you've purchased a nice, sturdy bookshelf.
-Thank goodness I have four years to learn all of this. Or at least, enough to feel like something more than a total moron. I'll never know it all. It's not even remotely possible.
-The other residents are really cool. We've gone out to dinner and out for drinks, there was a 4th of July barbeque, another gathering is scheduled for this weekend, and then there's the big "beginning of the year" party next month. Pathology gives you time to be social, and while we feel for our colleagues in ob-gyn and surgery residencies, that doesn't stop us from enjoying our free time.
-I sold my oto-ophthalmoscope for cash. Sweet! I'm keeping my stethoscope, though.
-I need to carry around a little pamphlet that explains what pathologists are and do. It would cut down on the confused looks I get. Or, even better: I'll post about it on my blog! Stay tuned; it should be up later this week. No, really.
-Pathology is all about self-motivated study. I've spent a month in the microbiology lab, and I've seen more Staph and Strep than I have bricks on a wall. A couple of other "known" bugs have shown up (Nocardia, Klebsiella), but there are plenty of bread-and-butter pathogens I haven't seen. And, of course, there are tons of rare guys I haven't spotted and never will. How to learn about them? Hit a book.
-It's the same story for surgical pathology. Even if you look at slides all day every day (which some of the residents feel like they're doing), you might not see half of the entities you have to be able to diagnose. So, study. Grab a book. Grab the study slides. Grab a colleague. And study. (After you've worked until 9 p.m., of course.)
-Books. So many books. I have bought three so far with my book fund, and I know roughly which other books I want to get this year. This leaves me with about six "must-have" books I need to get, and, oh, thirty or forty "should-get" books to pencil in somewhere on my list. In Internal Medicine, you can get by with Harrison's, Pocket Medicine, and a good PDA. In Pathology, you can get by after you've purchased a nice, sturdy bookshelf.
-Thank goodness I have four years to learn all of this. Or at least, enough to feel like something more than a total moron. I'll never know it all. It's not even remotely possible.
-The other residents are really cool. We've gone out to dinner and out for drinks, there was a 4th of July barbeque, another gathering is scheduled for this weekend, and then there's the big "beginning of the year" party next month. Pathology gives you time to be social, and while we feel for our colleagues in ob-gyn and surgery residencies, that doesn't stop us from enjoying our free time.
-I sold my oto-ophthalmoscope for cash. Sweet! I'm keeping my stethoscope, though.
-I need to carry around a little pamphlet that explains what pathologists are and do. It would cut down on the confused looks I get. Or, even better: I'll post about it on my blog! Stay tuned; it should be up later this week. No, really.
Saturday, July 19, 2008
answering some questions
Thanks to everyone who has been reading so far! A few people have posted comments with questions; I thought I'd just answer them here.
"I'm not a fan of digging through dead bodies"
LOL Really? So why Path then? I mean, you would expect that a Pathologist-to-be would at least be semi-excited about dead bodies. Unless you're aiming for clinical path.
I would call autopsy the part of my job I least look forward to. I don't hate it, but it doesn't fascinate me. I prefer investigating the body on a microscopic level, not a gross level. But then, I haven't performed an autopsy yet (I start in November), so perhaps I'll change my tune. Clinical path is neat, but I think surgical pathology is my calling.
just curious about the pronunciation of the Tsukamurella spp.
is it SOO-ka-myoo-rell-a? or some other such business?
I only heard it once, during a review session. I think it was SOO-ka-moo-rell-a.
And now a question for you folks out there -- any ideas how to promote this blog?
"I'm not a fan of digging through dead bodies"
LOL Really? So why Path then? I mean, you would expect that a Pathologist-to-be would at least be semi-excited about dead bodies. Unless you're aiming for clinical path.
I would call autopsy the part of my job I least look forward to. I don't hate it, but it doesn't fascinate me. I prefer investigating the body on a microscopic level, not a gross level. But then, I haven't performed an autopsy yet (I start in November), so perhaps I'll change my tune. Clinical path is neat, but I think surgical pathology is my calling.
just curious about the pronunciation of the Tsukamurella spp.
is it SOO-ka-myoo-rell-a? or some other such business?
I only heard it once, during a review session. I think it was SOO-ka-moo-rell-a.
And now a question for you folks out there -- any ideas how to promote this blog?
Wednesday, July 16, 2008
haven't quit yet
Sorry for going a week without posting. I've been pretty busy! Residency is hard enough on its own, but most of us are still settling into our new homes and trying to learn the city. Oh, and sleeping, sometimes.
I got my first "real" page today (not counting conference reminders and such). A swab made its way to the lab unlabeled. It was in a bag that contained the proper paperwork, but since the swab tube itself was unmarked, it was unacceptable (thanks, trial lawyers!). I had to contact the attending, who told me to tell the nurse to send another swab. So I called the nurse, and he said he'd try to do it if he could. Mission accomplished, I guess.
Speaking of swabs, we once again got an unnecessarily tiny specimen. We heard about a patient with a large abscess in his leg. The lab attending specifically requested a vial of the pus. We got -- yep -- a swab.
Lesson of the day: Do not smell plates that are growing Shigella. It's so infectious that you can get sick from even ten of the little guys. Most bacteria take a few hundred or thousand to inoculate you.
And now, this week's list of bacteria I had never heard of before:
Staphylococcus schleiferi
Moraxella osloensis
Enterobacter cancerogenus
Tsukamurella spp.
I know this is disjointed, but this rotation (and, I think, pathology in general) lends itself toward smaller stories rather than larger, detailed ones. In the next week or two, I hope to do some real posts, explaining what exactly pathologists do, and how the department is getting the new PGY-1s up to speed (they realize we know nothing).
I got my first "real" page today (not counting conference reminders and such). A swab made its way to the lab unlabeled. It was in a bag that contained the proper paperwork, but since the swab tube itself was unmarked, it was unacceptable (thanks, trial lawyers!). I had to contact the attending, who told me to tell the nurse to send another swab. So I called the nurse, and he said he'd try to do it if he could. Mission accomplished, I guess.
Speaking of swabs, we once again got an unnecessarily tiny specimen. We heard about a patient with a large abscess in his leg. The lab attending specifically requested a vial of the pus. We got -- yep -- a swab.
Lesson of the day: Do not smell plates that are growing Shigella. It's so infectious that you can get sick from even ten of the little guys. Most bacteria take a few hundred or thousand to inoculate you.
And now, this week's list of bacteria I had never heard of before:
Staphylococcus schleiferi
Moraxella osloensis
Enterobacter cancerogenus
Tsukamurella spp.
I know this is disjointed, but this rotation (and, I think, pathology in general) lends itself toward smaller stories rather than larger, detailed ones. In the next week or two, I hope to do some real posts, explaining what exactly pathologists do, and how the department is getting the new PGY-1s up to speed (they realize we know nothing).
Wednesday, July 9, 2008
D'oh
So, to celebrate the fact that I made it on time yesterday ... I promptly slept through my alarm this morning. Oops. I missed a presentation on two autopsy cases and a half-hour primer for the interns on how to gross a colon. I really need to get back on a proper sleep schedule, after staying up late and waking up past noon for most of summer vacation. Hopefully this will kick me in the butt a bit.
Besides not learning anything, I was counted absent for the presentations. We have to attend a certain amount of presentations over the year, or there are consequences, such as increased call or decreased book fund.
Wait, pathologists take call?
First-year residents have three weeks of CP call, taken a week at a time. It's usually home call, since we just field questions. In theory, we might have to come in and write orders. Most of it is blood bank/transfusion questions, and since we haven't had those rotations yet, we'll mostly be taking down information and contacting the transfusion fellow. Seconds years have two weeks, third years have half a week, and fourth years have no CP call.
AP call is different. If you're on surgical pathology, you have call every couple days, which is basically coming in and doing a frozen section if one comes up. If you're on autopsy, you have call every other weekend; if there's an autopsy, you come in and do it. Not paradise, but not surgery call either.
Holidays are also divvied up; each intern has to take call for one major and one minor holiday. I'm on call over Christmas and Memorial Day this year. Every remaining holiday, I don't even have to come in.
As for book fund -- we get a couple hundred dollars to spend a year on books. If you've ever seen a typical pathology program's library, you realize that this is almost chump change. There are dozens of books out there that people might recommend. Most residents will get one of the main surgical pathology references (either Rosai/Ackerman or Sternberg) and probably a CP book. Other options include Differential Diagnosis in Surgical Pathology (since we don't know what the diseases look like), Histology for Pathologists (since we don't remember what the normal tissue looks like), a grossing manual, and more organ-specific textbooks that you can shake a stick at.
Another "clinical faux paus" got discussed today during micro rounds. A patient had four out of four blood cultures come back positive for Bacillus, despite having a clinical presentation that wouldn't fit that diagnosis at all. Bacillus can be a contaminant, and if it shows up in one of four cultures, it's usually dismissed as such. Apparently, sometimes, the ER here will perform one blood draw (from one site), then inject the sample into four different culture vials. On top of that, they sometimes won't disinfect the top of each culture vial before injecting it. Voila -- one contaminated sample spread over four vials.
Later, we went over a few questions with the micro attending. He discussed proper sampling, and gave a talk about what is and isn't good to receive. Lots of people send swabs, which are really only good for a few things (nasal, throat, and urethral cultures, and perhaps a few others). A swab holds about 150 microliters of fluid, and only 3% of bacteria on the swab come off when culturing a plate. Tissue and fluid are much preferred. The attending said some doctors will draw a few cc's of fluid, then swab the fluid and send that. The lab would be much happier to receive the vial of fluid instead. He said he is trying to get the message out about stuff like this, with only moderate improvement.
The worst word I overheard today: "scrotectomy."
Besides not learning anything, I was counted absent for the presentations. We have to attend a certain amount of presentations over the year, or there are consequences, such as increased call or decreased book fund.
Wait, pathologists take call?
First-year residents have three weeks of CP call, taken a week at a time. It's usually home call, since we just field questions. In theory, we might have to come in and write orders. Most of it is blood bank/transfusion questions, and since we haven't had those rotations yet, we'll mostly be taking down information and contacting the transfusion fellow. Seconds years have two weeks, third years have half a week, and fourth years have no CP call.
AP call is different. If you're on surgical pathology, you have call every couple days, which is basically coming in and doing a frozen section if one comes up. If you're on autopsy, you have call every other weekend; if there's an autopsy, you come in and do it. Not paradise, but not surgery call either.
Holidays are also divvied up; each intern has to take call for one major and one minor holiday. I'm on call over Christmas and Memorial Day this year. Every remaining holiday, I don't even have to come in.
As for book fund -- we get a couple hundred dollars to spend a year on books. If you've ever seen a typical pathology program's library, you realize that this is almost chump change. There are dozens of books out there that people might recommend. Most residents will get one of the main surgical pathology references (either Rosai/Ackerman or Sternberg) and probably a CP book. Other options include Differential Diagnosis in Surgical Pathology (since we don't know what the diseases look like), Histology for Pathologists (since we don't remember what the normal tissue looks like), a grossing manual, and more organ-specific textbooks that you can shake a stick at.
Another "clinical faux paus" got discussed today during micro rounds. A patient had four out of four blood cultures come back positive for Bacillus, despite having a clinical presentation that wouldn't fit that diagnosis at all. Bacillus can be a contaminant, and if it shows up in one of four cultures, it's usually dismissed as such. Apparently, sometimes, the ER here will perform one blood draw (from one site), then inject the sample into four different culture vials. On top of that, they sometimes won't disinfect the top of each culture vial before injecting it. Voila -- one contaminated sample spread over four vials.
Later, we went over a few questions with the micro attending. He discussed proper sampling, and gave a talk about what is and isn't good to receive. Lots of people send swabs, which are really only good for a few things (nasal, throat, and urethral cultures, and perhaps a few others). A swab holds about 150 microliters of fluid, and only 3% of bacteria on the swab come off when culturing a plate. Tissue and fluid are much preferred. The attending said some doctors will draw a few cc's of fluid, then swab the fluid and send that. The lab would be much happier to receive the vial of fluid instead. He said he is trying to get the message out about stuff like this, with only moderate improvement.
The worst word I overheard today: "scrotectomy."
I'm official
My program director has officially OKed this blog. Hooray! I am, of course, keeping names out of it and changing minor details here and there (for example, I think everyone will be a "he" unless it's a breast/gyn patient), but that's just the standard CYA stuff.
Today was the first day I had to be there at 7:30 a.m. for morning conference (usually, we'll have to be there at 7:30 Mon.-Wed. and 8:00 Thurs. and Fri.). We had "unknown" conference, where the attendings give residents a quick case history and then slides to identify. Based on the differential, the resident also suggests what other tests to run. The main thing I learned this morning is that touch preps look like crap. Also, I will sound more intelligent at the scope once words like "monomorphic" enter my effortless vocabulary.
The lab was slow today. The ID docs told us about a patient with pyomyositis -- basically, abscesses in his calf muscles and who knows where else. In molecular diagnostics, we got to hear the attending vent a little about how two of his machines aren't exactly compatible. One prepares a certain type of specimen in batches of 32 (an 8x4 grid), and the other analyzes them in batches of 24 (a 5x5 grid with the center hole blocked).
Female ID attending: "Well, that was clearly designed by a man."
Male lab attending: "Yes! In fact, it was a German man."
There was also a little issue with the HCV (Hepatitis C) PCR machine. Someone stuck himself on accident a few weeks ago, and the viral load came back in the low hundreds (which is very low for an acute onset). Turns out his specimen got ran after a specimen with a high load (millions), messing the test up; it actually should have been negative. Good news all around.
I managed to get a picture of that velvety yeast plate I mentioned yesterday. It was identified as Cladosporidium:
As a bonus, here's a "peanut butter" plate. This is Epicoccum nigrum:
And here's Epicoccum on a slide (who knew my camera could get such a good picture through the microscope lens?):
No, I'd never heard of Epicoccum either. Cladosporidium, mmmmaybe.
Today was the first day I had to be there at 7:30 a.m. for morning conference (usually, we'll have to be there at 7:30 Mon.-Wed. and 8:00 Thurs. and Fri.). We had "unknown" conference, where the attendings give residents a quick case history and then slides to identify. Based on the differential, the resident also suggests what other tests to run. The main thing I learned this morning is that touch preps look like crap. Also, I will sound more intelligent at the scope once words like "monomorphic" enter my effortless vocabulary.
The lab was slow today. The ID docs told us about a patient with pyomyositis -- basically, abscesses in his calf muscles and who knows where else. In molecular diagnostics, we got to hear the attending vent a little about how two of his machines aren't exactly compatible. One prepares a certain type of specimen in batches of 32 (an 8x4 grid), and the other analyzes them in batches of 24 (a 5x5 grid with the center hole blocked).
Female ID attending: "Well, that was clearly designed by a man."
Male lab attending: "Yes! In fact, it was a German man."
There was also a little issue with the HCV (Hepatitis C) PCR machine. Someone stuck himself on accident a few weeks ago, and the viral load came back in the low hundreds (which is very low for an acute onset). Turns out his specimen got ran after a specimen with a high load (millions), messing the test up; it actually should have been negative. Good news all around.
I managed to get a picture of that velvety yeast plate I mentioned yesterday. It was identified as Cladosporidium:
As a bonus, here's a "peanut butter" plate. This is Epicoccum nigrum:
And here's Epicoccum on a slide (who knew my camera could get such a good picture through the microscope lens?):
No, I'd never heard of Epicoccum either. Cladosporidium, mmmmaybe.
Monday, July 7, 2008
Still truckin'
I finally got some time at one of the plate benches today. It was really cool. I got to look at a bunch of culture plates and see what was or wasn't growing. I saw some alpha and beta hemolysis, some gold Staph colonies, and some nasty-looking mucoid Klebsiella growth. I also watched a latex agglutination test for Staph and an oxidation test for Pseudomonas. Later that day, I saw a yeast plate with an amazing growth pattern -- it looked like bunched-up black velvet. I really wish I'd had my camera with me.
We also learned a simple but valuable lesson during rounds. We had a sample from one patient with a liver abscess that showed Gram-positive organisms on the stain but no culture growth. From another patient, there was a plate with no growth in area 1 (the most dense), but as the sample was diluted, growth appeared. Lesson: take the sample BEFORE starting the patient on antibiotics.
I also discovered that people will send just about anything down to the lab for sampling. There was a patient with suspected infection of the spinal cord. He had an apparatus implanted in him that delivered pain medication to his spine. The doctors took the entire device out and sent it to the lab in a huge bucket. This is, of course, massive overkill (you can usually just send the tip that's most inside the patient), but the lab director remarked that he'd rather get the whole device than not get anything at all.
I still feel like an imposter, walking around the hospital in my long white coat (which doesn't even have my name embroidered on it). I think it'll be a long time before I feel confident and competent enough to walk around in it and not feel like I'm being deceptive.
We also learned a simple but valuable lesson during rounds. We had a sample from one patient with a liver abscess that showed Gram-positive organisms on the stain but no culture growth. From another patient, there was a plate with no growth in area 1 (the most dense), but as the sample was diluted, growth appeared. Lesson: take the sample BEFORE starting the patient on antibiotics.
I also discovered that people will send just about anything down to the lab for sampling. There was a patient with suspected infection of the spinal cord. He had an apparatus implanted in him that delivered pain medication to his spine. The doctors took the entire device out and sent it to the lab in a huge bucket. This is, of course, massive overkill (you can usually just send the tip that's most inside the patient), but the lab director remarked that he'd rather get the whole device than not get anything at all.
I still feel like an imposter, walking around the hospital in my long white coat (which doesn't even have my name embroidered on it). I think it'll be a long time before I feel confident and competent enough to walk around in it and not feel like I'm being deceptive.
Saturday, July 5, 2008
One week down, 207 to go
This week has been nice and slow. In theory, I'll usually be showing up at 7:30 in the morning for conferences, but since things are just starting out, some of them have been canceled. Micro is a slow rotation by nature, so I'm usually done with "work" by 3 p.m., though I have to stay until 5 just in case. I had the 4th off, and I'm free this weekend too. Oh, and I have no call until September. The interns on surgical pathology are getting slammed -- one girl didn't go home until 9 p.m. the other night -- but they don't have to work weekends either. This is in stark contrast to my friends in other fields, who are all already pulling their hair out.
The micro lab has had a few technical issues this week, preventing me from observing what I've been scheduled to observe. I have three months to get it done, though, so the lab directors aren't fretting in the least. We have rounds at 1, which consists of the pathologists and the ID docs going over interesting cases. A lot of it is still over my head, but I'm not completely lost. The molecular lab also had some interesting dilemmas facing them, such as calibrating new tests. It quickly became clear why they need doctors overseeing the labs.
Thursday's "highlight" was sniffing some bacteria. Pseudomonas did indeed smell to me like grape -- fake, cough-syrup grape. The other intern (who is of Mexican descent) said it smelled like a corn tortilla; this is apparently a known and acceptable alternative. Streptococcus milleri smells like butterscotch.
The program in general is working hard to get us gradually acclimated. There are always upper-level residents helping you out; the micro fellow has been especially kind to us. The first few weeks' worth of morning lectures will be on how to gross, how to survive CP call, and other similar topics. There was an autopsy Thursday morning that all the interns were asked to watch. It was straightforward but very helpful. I'm not a fan of digging through dead bodies (grin and bear it ...), but seeing a massive pulmonary embolus wriggled out of a pulmonary artery is pretty darn cool.
I went out for drinks with the other interns and some PGY-2s Thursday, and there was a cookout Friday. For the most part, everyone's really friendly and laid-back, which makes the program even better.
So basically, no complaints so far! We'll see how I feel when I start surg path in October.
The micro lab has had a few technical issues this week, preventing me from observing what I've been scheduled to observe. I have three months to get it done, though, so the lab directors aren't fretting in the least. We have rounds at 1, which consists of the pathologists and the ID docs going over interesting cases. A lot of it is still over my head, but I'm not completely lost. The molecular lab also had some interesting dilemmas facing them, such as calibrating new tests. It quickly became clear why they need doctors overseeing the labs.
Thursday's "highlight" was sniffing some bacteria. Pseudomonas did indeed smell to me like grape -- fake, cough-syrup grape. The other intern (who is of Mexican descent) said it smelled like a corn tortilla; this is apparently a known and acceptable alternative. Streptococcus milleri smells like butterscotch.
The program in general is working hard to get us gradually acclimated. There are always upper-level residents helping you out; the micro fellow has been especially kind to us. The first few weeks' worth of morning lectures will be on how to gross, how to survive CP call, and other similar topics. There was an autopsy Thursday morning that all the interns were asked to watch. It was straightforward but very helpful. I'm not a fan of digging through dead bodies (grin and bear it ...), but seeing a massive pulmonary embolus wriggled out of a pulmonary artery is pretty darn cool.
I went out for drinks with the other interns and some PGY-2s Thursday, and there was a cookout Friday. For the most part, everyone's really friendly and laid-back, which makes the program even better.
So basically, no complaints so far! We'll see how I feel when I start surg path in October.
Monday, June 30, 2008
More orientation
This morning, I attended the general orientation that all the new interns (and fellow) go to. I liked that I had to wake up at 5:30, so I could sign in at 6:30 and watch the 7 a.m. lecture on preventing sleep deprivation. It wasn't easy, especially since I've been waking up at noon (or later) nearly every day for the past two months.
Most of the lectures actually had little to do with me. There was, of course, another HIPAA lecture, as well as the usual unintentionally hilarious sexual harassment video. There was a talk on how to handle emergency pages. Since I'm not even ACLS certified, I think my reaction to a code would be to stand back and let the other doctors handle things. I mean, if the effort fails, I'd be happy to take the body to the morgue ...
Infection control is something I need to keep in mind, but since I won't be seeing too many patients hacking up their TB-ridden lung, I don't feel bad about nodding off during the lecture. Same with risk management and quality control.
Don't get me wrong; pathologists have to think about all these things. We just have to approach it differently than most other physicians. I won't be performing wrong-site surgery any time soon, but I might mis-label a piece of tissue or do a poor job cutting through a tumor and miss a margin.
It's also comforting to know that even big-name institutions can't always get their acts together. We had to get parking passes for two separate hospitals. They ran out of passes early for one of the hospitals, so the people manning that table just up and left for the day. They knew how many people were going to be there today! I fortunately don't have to work at that hospital until August, but the folks who start there tomorrow aren't so lucky.
And tomorrow is July 1, the fabled "go to a hospital and die instantly" day. I have a pathology-specific orientation in the morning, and then I start work after lunch. Well, unless they let me slip out and take care of the aforementioned parking stuff. I think they will. It's not like I'm going to save anyone's life in the micro lab tomorrow. Heck, it will be a good day if I simply don't contaminate or break anything.
Most of the lectures actually had little to do with me. There was, of course, another HIPAA lecture, as well as the usual unintentionally hilarious sexual harassment video. There was a talk on how to handle emergency pages. Since I'm not even ACLS certified, I think my reaction to a code would be to stand back and let the other doctors handle things. I mean, if the effort fails, I'd be happy to take the body to the morgue ...
Infection control is something I need to keep in mind, but since I won't be seeing too many patients hacking up their TB-ridden lung, I don't feel bad about nodding off during the lecture. Same with risk management and quality control.
Don't get me wrong; pathologists have to think about all these things. We just have to approach it differently than most other physicians. I won't be performing wrong-site surgery any time soon, but I might mis-label a piece of tissue or do a poor job cutting through a tumor and miss a margin.
It's also comforting to know that even big-name institutions can't always get their acts together. We had to get parking passes for two separate hospitals. They ran out of passes early for one of the hospitals, so the people manning that table just up and left for the day. They knew how many people were going to be there today! I fortunately don't have to work at that hospital until August, but the folks who start there tomorrow aren't so lucky.
And tomorrow is July 1, the fabled "go to a hospital and die instantly" day. I have a pathology-specific orientation in the morning, and then I start work after lunch. Well, unless they let me slip out and take care of the aforementioned parking stuff. I think they will. It's not like I'm going to save anyone's life in the micro lab tomorrow. Heck, it will be a good day if I simply don't contaminate or break anything.
Thursday, June 26, 2008
First post
Might as well get things started. This blog is going to be about pathology residency and everything it entails. Most other path blogs I've seen focus on issues facing pathology and interesting cases. I want this one to be more of a window into what a pathology resident's life is like. Most laypeople, and even many physicians, are not entirely sure what all pathologists do, what they are capable of, and what they cannot do. I hope this blog gives a little insight into that.
I'm about to start my internship year as a pathology resident at a "name" program. At least for now, I'll use "PathRes" as my nickname, though hopefully I'll come up with a better one the next time I've had a few drinks.
Most of the other incoming interns (for surgery, medicine, etc.) at my institution have been doing orientation all week -- learning how things work at the program's multiple sites, getting ACLS/BLS certified, and all that good stuff. Me? I slept in all week, and I had a four-hour "mini-orientation" today, learning a bit about the microbiology lab (which is where I will spend my first three months). I met some of the other incoming interns, heard from all the chief residents, and, more importantly, learned that the cafeteria food is OK at best. I have a longer orientation day on Monday, and then I begin work Tuesday.
Micro is supposedly an easy rotation, compared to many of the others, so I'm hoping to start things out slow. This will also give me time to brush up on my histology and anatomy before I start surgical pathology (cutting up specimens and looking at tissue slides) in October. I am like most of my fellow path interns in that I'd planned to do a lot of reading before starting residency, but ended up just enjoying my final summer vacation instead. I also want to take Step 3 during this three-month block, since I have to take the same clinically oriented test as all other residents, and I assure you that the information isn't getting any clearer.
I'll post again Monday after orientation. Thanks for stopping by! I will be reading comments and only editing for content in cases of excessive language or personal attacks. Feel free to ask me questions, and I'll respond as able.
-PathRes
I'm about to start my internship year as a pathology resident at a "name" program. At least for now, I'll use "PathRes" as my nickname, though hopefully I'll come up with a better one the next time I've had a few drinks.
Most of the other incoming interns (for surgery, medicine, etc.) at my institution have been doing orientation all week -- learning how things work at the program's multiple sites, getting ACLS/BLS certified, and all that good stuff. Me? I slept in all week, and I had a four-hour "mini-orientation" today, learning a bit about the microbiology lab (which is where I will spend my first three months). I met some of the other incoming interns, heard from all the chief residents, and, more importantly, learned that the cafeteria food is OK at best. I have a longer orientation day on Monday, and then I begin work Tuesday.
Micro is supposedly an easy rotation, compared to many of the others, so I'm hoping to start things out slow. This will also give me time to brush up on my histology and anatomy before I start surgical pathology (cutting up specimens and looking at tissue slides) in October. I am like most of my fellow path interns in that I'd planned to do a lot of reading before starting residency, but ended up just enjoying my final summer vacation instead. I also want to take Step 3 during this three-month block, since I have to take the same clinically oriented test as all other residents, and I assure you that the information isn't getting any clearer.
I'll post again Monday after orientation. Thanks for stopping by! I will be reading comments and only editing for content in cases of excessive language or personal attacks. Feel free to ask me questions, and I'll respond as able.
-PathRes
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