Taking On Butler

The 7th rotation of my clinical year has been off to a strong start in surgical pathology at Butler Memorial Hospital in Butler, PA. Butler is about 40 miles north of Pittsburgh, so it makes for a rough commute, but I can manage it for six weeks.  As for dynamics of the facility, the gross room is directly connected to histology, so there is a lot of interaction between the employees of both areas.  I am the only "PA" in the facility and work with a gross tech to take on steady load that comes through from not only the hospital, but facilities around Butler County as well. There are five pathologists that work in the department, with one specializing in dermatopathology (so we get a LOT of skin specimens). It has been an interesting two weeks adjusting to a new facility and their way of doing things, but other than the commute, it has been quite enjoyable.

The rotation has been consistently busy with only a day or two that have been on the slower side.  As I stated before,  a bulk of the work is composed of skin specimens (skin shaves, ellipses, etc.). In addition to the these, I have had the opportunity to gross breast specimens, hysterectomies, colon resections, extremity amputations, and lung lobectomies. I usually get one to two complex specimens a day, so it's mostly the simple specimens and biopsies that comprise a majority of the work.  I am also responsible for all of the intraoperative consultations.  Intraoperative consultations are when a surgeon sends a specimen down to surgical pathology in order to obtain a quick, tentative diagnosis while the patient is still in surgery.  This helps to guide the surgeon in deciding the next step of surgical procedure.  For example, if the surgery is for a tumor resection, margins will be sent to ensure the they are clear of tumor cells before finishing surgery.  When we receive the tissue, we use a cryostat and flash freeze the tissue in OCT (Optimal Cutting Temperature) embedding medium and then cut sections with a microtome blade. The sections were put on slides and a quick H&E stain is performed in order for the pathologist to evaluate the tissue. The whole process from the time the specimen is received until the pathologist reads the slide and calls the OR is 20 minutes or less. 

Overall, being the only PA at a facility means a lot of responsibility, even as a student, so it has been a great experience so far and I enjoy the challenge!  As for school, we have only had one test since my last post, which was the last Friday in July. The test covered the last 4 or 5 chapters of Robbins, a.k.a. the disease mechanisms textbook. From here on out, our tests will be "random," so there won't be any direct objectives or set chapters that the tests will cover. With that said, it will be very good preparation for our boards since they are supposed to mimic what they will be like. 

Other than school, the job search continues! I have had interviews, but am just waiting for the right offer to come along...fingers crossed it will be a good one :)

Five Weeks Down, One to Go

Where has the time gone? I literally feel like I just began my Ruby Memorial surgical pathology rotation yesterday and now I'm about to start my last week. It has been a very busy fives weeks, but I have welcomed it with open arms because I have had the opportunity to gross so many complex and interesting specimens that I had never had the chance to do before. For example, I finally was able to gross a laryngectomy, which other than a Whipple (which is still on my "to do" list), is one of the most daunting and complex specimens that will probably come across my bench. It's not that the overall process is complicated, you just need to have a thorough understanding of the anatomy before tackling the specimen because it is important for tumor description, sectioning, and staging. I made sure to review the anatomy before I started and had Lester close by just in case I needed a reference or confirmation on anything along the way. Overall, I thought it went well for my first laryngectomy, so I am confident in my knowledge and abilities to take on another one in the future.

Another specimen I had the opportunity to do was a 21 week old fetus with Trisomy 18, also known as Edwards Syndrome. This condition can be characterized externally by a small head (microcephaly), small jaw (micrognathia), low set ears, and clubbed feet to name a few. Internally, you can see things such as kidney abnormalities, congenital heart defects such as a VSD, and esophageal atresia. Since I received the fetus at 21 weeks, I was able to appreciate some of these characteristics. These particular cases are a little more difficult to do than other's, but I do find genetic cases like these very interesting. It's fascinating to see how one additional chromosome can create so much "chaos" within the body.  When you receive a case like this, you essentially do a very thorough external examine, taking all measurements of the body and describing any features that could be abnormal, such as webbed fingers, clubbed feet, fused nares, etc. This was the most demanding aspect of the process.  Then, a "mini" autopsy is performed to make sure all the organs are there and in their respective positions as well as to make sure they have been developing normally.  As for sections, we submitted the gonads to definitively determine the gender, and put through representatives of the lung, kidney, liver, heart, and brain.

Other than these particular cases, I also had the opportunity to do a gastrectomy, multiple lumpectomies and mastectomies, colon specimens, and melanoma skin excisions to name a few.  Even though this has been a busy rotation, I think it has been my favorite so far just because of the vast majority of specimens I've had the opportunity to do.  Other than the routine biopsies and small cases, every day brings something different and that is one thing I've really enjoyed about it.

I can't believe I'm already over halfway and in the home stretch of my graduate career at WVU, but I'm ready to see what the future holds with my up and coming career as a Pathologists' Assistant. I have applied to a couple of jobs and am just waiting to see what those opportunities may have in store for me!

The Return to Mountaineer Country

Another rotation has ended and I've jumped right into the next. I am a week into my sixth rotation at Ruby Memorial Hospital at WVU and needless to say, it was quite an eventful week.  I've been through autopsy and surgical pathology rotations for six months now and this rotation has by far been the busiest. I expected a higher workload and I've come to like the change of pace because it keeps me on my toes and makes the time go by much faster. For the first week, I was able to gross a few breast specimens that ranged from benign fibroadenomas to invasive ductal carcinomas, thyroids, partial colon resections for tumor, and a lot of skin specimens. This rotation has had a large variety of specimens, which I have welcomed with open arms because I would like to see as much as I can before I dive into the workforce after graduation. Up to this point, I haven't had the opportunity to do a large amount of specimens that originate from the head and neck and thoracic regions, so I'm hopeful that I will get some of that experience while on this rotation.

Aside from grossing, we also had our sixth test of the year this week that covered the urinary system, male genital tract, female genital tract, breast, and endocrine system. It was the same format as all of the other tests, with 100 multiple choice questions. As usual, it required a lot of preparation time and studying, which was difficult with the transition between rotations.  However, I made it happen with early mornings and late nights to get everything accomplished. It will be such a relief once I don't have to worry about studying and tests anymore, but that day will come soon enough.

With the year flying by, I have also started applying to a few PA positions that have caught eye and was honored to have my first phone interview last week (yes, it was quite a busy week all around). It was the first phone interview that I've ever been a part of it and I was quite nervous going in.  I wasn't sure how to prepare so I just made a list of general questions that I felt could possibly be asked during the interview and made notes in response to that. I also made a list of questions that I wanted to ask them about the position and the facilities, so I could learn more about what would be expected of me if I was to get offered the job. Overall, I thought the interview went well and I hope to hear something soon on whether or not I will have the opportunity to go in for an in-person interview.

Round 5: Children's Hospital

My short time in the ME's office came and went and it's hard to believe that I've already completed one week at my new rotation at Children's Hospital of Pittsburgh of UPMC. This is a three week rotation just like my previous one, however, this is in surgical pathology rather than autopsy.  It has been an interesting week so far, but I will note that it is slightly difficult going from an autopsy rotation back to surgical pathology in relation to getting back in the groove of creating dictations. My first day was a little rough and for a split second I was concerned I forgot everything, but after the first couple of cases, I was good to go!

The Children's Hospital has been interesting in that you could have the opportunity to see rare childhood disease cases that you may not be able to see elsewhere. On my first day, I was able to observe one of the PAs do a Wilms' tumor, which is a rare childhood kidney tumor.  I had never seen one before in person and it was interesting to see one and how it was processed at their facility.  As for regular, day-to-day cases, I have been doing a lot of gallbladder, appendices, testicles, and small masses from various parts of the body.  The only complex case I've done is a metastatic cancer case in a 1 year old.  Cancer had spread all over the body and they were sending in all the masses to be grossed, so it ended up being quite a large case.  Other than grossing, I have had the opportunity to attend a lot of conferences that range from pediatric autopsy to pediatric tumors and new cancer screening techniques.  They have all been very informative and I get to experience a how a group of pathologists come together to see histological slides for a case and discuss the potential diagnoses and the reasons why they came to that conclusion.  It has been eye opening and I have really enjoyed getting to be a part of it.

Other than school, I have just been enjoying the nice summer weather that has finally come our way! My only wish is that I lived closer to the ocean so that I could enjoy even more :). Maybe one day soon, I only have 6 more months of this journey before it's time to see what else is in store for me! 

Three Weeks in the Life of a Medical Examiner

Yesterday marked the first day of rotation number 4 in the Medical Examiner's Office in Morgantown.  I expect these next few weeks to be filled with exciting autopsy cases that I didn't get to experience while on my hospital autopsy rotation in Pittsburgh.  On this rotation, I will get to see and assist on cases that are "suspicious" in nature and do not fall under death due to natural causes.  These cases are typically classified as accidents, suicides, or homicides. The office does do hospital autopsies as well for Ruby Memorial, but a majority of the cases performed are medical examiner (ME) cases. The ME cases are performed on Monday and Tuesday's and the rest of the week is set aside for hospital cases.

So far this week, I have been able to observe and take part in four cases, which included a drug overdose, a work-related accident, drowning, and a stabbing. In comparison to hospital autopsies, ME cases have a larger emphasis on the external and internal gross examinations and toxicology results rather than the microscopic examination. However, the latter can be important in some cases. As for toxicology, femoral blood, heart blood, bile, vitreous, and gastric contents are taken to be sent off to be tested for drugs, alcohol, electrolyte levels, etc. to help in determining a cause of death or contributing factors to the death.  The external examination is extremely important in all the cases and can be correlated to the internal gross examination, especially in cases of trauma, gunshot wounds, or stabbings. Extensive photography is also utilized in these cases to document all findings to be used as evidence in court hearings.  For identification purposes,  a headshot, fingerprints, and occasionally a DNA sample are taken for all cases.  After all of the external steps have been performed, the body is opened and the organs are removed one by one, which is known as the Virchow method. These organs are then prosected and examined for any additional abnormalities, with focus on the lungs, heart, and kidneys since this is where most systemic diseases lie. Sections are submitted for each of these organs for histologic examination. As for the remaining organs, including the brain and tongue, sections are kept in a stock jar in case it is needed in the future.

From what I have gathered in my first two days, ME cases have a much more systematic approach in comparison to hospital autopsies, which is understandable with the nature of them.  If the pathologist is to go to court to present their case, it is helpful to have performed every autopsy the same way so it is easier to explain and present all imperative findings. I'm excited to see what the next 2.5 weeks have in store for me!

Midway on Round 3

Today marks the beginning of my fourth week here at UPMC Shadyside and it has been an eventful rotation so far.  Since this is a "Center of Excellence" as I noted in my last post, my last couple of weeks have been filled with bladders, kidneys, prostates, and lower extremity amputations. In addition to these daily specimens, I also had the opportunity to gross a sarcoma, which was very interesting since I hadn't had the chance to do one before.  It wasn't as difficult to gross as I had expected it to be after seeing the size of it, but it ended up being an interesting case.  I started out the case by differentially inking the specimen like a "box," so I inked the medial, lateral, superior, inferior and deep margins.  The anterior surface would normally be inked as well, but in this case, the anterior aspect was covered entirely by skin. Then, I described the lesion on the epidermis and it's relationship to all the margins. Finally, I serially sectioned the specimen and submitted my sections, which included submitting the medial and lateral margins completely, the lesion to all margins, and sections of just the lesion. 

Another case I received was a lymph node search for a melanoma case. I have a love/hate relationship when it comes to doing lymph node searches, just because sometimes you find them and sometimes you don't.  I could have a giant container full of fibroadipose tissue (fat) to search through and may only find one lymph node.  Luckily, in this case, I found over 20 and it made if feel more worthwhile and successful (in my eyes that is), than only finding one or two.

Other than rotations, I've just been keeping up on my readings and preparing for a presentation I have to give at the UPMC Regional Conference.  I will be presenting with my classmate, Sierra Sheppard, on rectal cancer specimens and different grossing techniques. We are a little nervous, but I think it will be very worthwhile to do it!

Round 3 is Underway

My time in the morgue has ended, but the new adventure of UPMC Shadyside has begun. I just completed my first week at my new rotation and I'm pleasantly surprised at how much I am enjoying it.  UPMC Shadyside is a "Center of Excellence," which means they specialize in a certain area of pathology and in this case, it's bone, soft tissue, and genitourinary specimens.  Even though it was only my first week, I had the opportunity to work on several complex cases and gross specimens that I've never had before.  Some of the things I have received, such as hip and knee replacement hardware, were gross only specimens.  In this case, I just have to do a dictation to describe what I have in front of me.  These types of cases aren't difficult to do at all.  Some of the more complex cases include the following:

• Below the knee amputation (BKA): I had the opportunity to do two amputation cases this week.  One was for an non-healing ulcer on the foot and the other was a traumatic amputation due to a crushing injury.  The process of grossing these specimens isn't too bad, but it requires knowing the vessels of the leg and where they are located.  To gross a BKA, you begin by taking overall measurements, measurements of any lesions and/or scars and taking photographs.  Then, a bone saw is used to take the bone margin of the tibia.  A vascular margin and skin/soft tissue margin sections are also taken.  Then, for the fun part, you have to dissect the leg to find the anterior and posterior tibial arteries, the peroneal artery, and the dorsalis pedis.  These have to be evaluated for occlusion and atherosclerosis to determine if they contributed to the injury that lead to the leg having to be amputated.  Sections of these are submitted and sections of the lesion are also submitted.
• Cystohysterectomy: These are bladder resections that also come with the uterus, ovaries, and fallopian tubes.  Most of the time, these types of surgical procedures are performed because of cancer.  I received two of these this week for bladder cancer and it was one of those specimens that I never thought I would have the opportunity to see and I was able to do two in one week.
• Prostate: I had the pleasure of doing one prostate this week and that was an interesting process.  UPMC Shadyside has a special procedure with their prostates that isn't done in a lot of places.  They "strip" their prostates of the capsule so it can be evaluated separately.  I had never seen it before and it actually is quite easy to do.  You first differentially ink the prostate (right and left), take your proximal and distal urethral margins, and then score the prostate to separate the anterior and posterior halves of the capsule.  Then you just carefully remove the capsule so it can be submitted entirely.  I know that may not be the best way to describe, but it makes a lot more sense to see it in person than to describe it in words.  
• Nephrectomy: I received one kidney resection this week for renal cell carcinoma and it was a very interesting tumor to see in person, especially after learning about it throughout last year.   

Needless to say, it was fulfilling to finally be able to see and do specimens that previously, I had only heard about and seen in textbooks.  I learn something new everyday and I can tell I am getting better day by day as well.  I look forward to what the next 5 weeks have in store for me.

On a more fun note, I hope everyone has been enjoying the craziness of March Madness this year.  Even though my bracket was busted after the first round, I have still enjoyed all the games and upsets that have occurred and am excited to see who wins it all on Monday night.  Oh, even more exciting news, baseball season starts this weekend and I'm quite excited to see how my Cubbies do this year! Maybe 108 years without a World Series title will finally come to an end ;)