My first three months of residency were spent in the microbiology department. Aside from learning a whole lot (though, of course, never enough) about various organisms, diseases, and lab tests, I walked away having picked up a few other helpful tips -- ones I think would be important to all physicians, not just pathologists.
So, here are my "lessons learned" from microbiology:
Some labs take a while
As a medical student, I remember checking culture reports every day, wondering why it was taking so long for information to come back. Now I know. Aside from a Gram stain, which is relatively quick and easy but doesn't tell you a whole lot, these tests take a while to get done right. The blood samples have to incubate for a day or two. If positive, then the Gram stain is performed and a culture plate is prepared. That's another few days for the organism to grow right there. Then it goes through the machine that tells us exactly what kind of organism it is and what antibiotics it's susceptible to. Some of the specimens -- fungal and AFB specimens -- have to sit for weeks and weeks before a lack of growth can comfortably be called negative. It stinks that this all takes so long, but that's the name of the game. The lab is not slacking.
The techs know their stuff
I learned some things out of books or lectures, but most of the microbiology knowledge I gained came from the techs I watched at work. They aren't doctors, but neither was I a few months ago. They're well-trained and definitely know what they're talking about within their field. I've heard them converse with doctors and get treated like idiots, which just isn't fair. They keep things working smoothly 99% of the time, and that 1% of the time that something goes wrong, it's a genuine issue that usually is not their fault.
There are way too many microorganisms out there
Seriously. I had enough trouble keeping track of all the ones I learned in my second year of medical school. Turns out that was just scratching the surface. There are all sorts of "obscure" bacteria and parasites I've never even heard of. We had tutorial CDs that presented information on all of them. After about the 20th somewhat similar organism, your eyes start to glaze over. The microbiology fellow on the rotation with us definitely knew his stuff, but I can see why a fellowship (or even a PhD) in microbiology is essential to understanding everything that comes through the door.
A doctor runs the lab
This is possibly a "duh" statement, but I never really thought about it. At the head of the lab are MDs and PhDs making sure everything runs smoothly. You really need a medically trained person in there who can grasp the issues fully and appropriately. And this brings me to my last point ...
Lots of crazy little issues pop up
When not working with the techs and learning the basics of micro, I spent 1/3 of my time checking out interesting cases and the other 2/3 listening to troubleshooting. The micro directors have to swoop in whenever a test is acting funny, a specimen is mishandled, an outbreak appears to arise, and etc. The lab can run on autopilot for a little while, but something always comes up that pulls things off course. One skill a CP pathologist absolutely has to possess is office management.
I have a ton of ideas for posts about surg path. Hopefully I will have time to write them in November, when I'm on autopsy.
Wednesday, October 22, 2008
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.
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