Hanging out in the OR for EBUS?

[stickyshift]

Do any of you sit in the OR during an EBUS to provide adequacy assessments? We currently have OR nurses prepare the slides in the OR suite and run them to pathology for staining and evaluation (The OR and lab are right next to each other.). A new pulmonologist is insisting that I be in the room while he does his procedure (Takes him about an hour or so). Does this strike any of you as being unreasonable?

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[WEBB PINKERTON]

It is unreasonable but we have the same problem. It isn't worth what we are paid to be there as many have pointed out. Takes away time from pushing glass. At our institution pulmonologists do 4 or 5 cases back to back at least 3 times a week, expecting pathology to be there for each one. The low cost of cigarettes in kentucky keep the pulmonologists quite busy in our area. If you don't have enough Pap volume to condone having a cytoscreener, guess who ends up wasting their time?

Really sucks when they are sticking a bunch of lymph nodes and you are trying to keep the slides from stations 4R, 11R, 7 etc straight.

 

[stickyshift]

It is unreasonable but we have the same problem. It isn't worth what we are paid to be there as many have pointed out. Takes away time from pushing glass. At our institution pulmonologists do 4 or 5 cases back to back at least 3 times a week, expecting pathology to be there for each one. The low cost of cigarettes in kentucky keep the pulmonologists quite busy in our area. If you don't have enough Pap volume to condone having a cytoscreener, guess who ends up wasting their time?

Really sucks when they are sticking a bunch of lymph nodes and you are trying to keep the slides from stations 4R, 11R, 7 etc straight.

I'm the only pathologist at my hospital, so if my department gets called to perform a frozen section or do adequacies for a radiology FNA, I'd be stuck. That's why I don't think that I can commit to being in the OR when I have docs elsewhere who need my services at a moment's notice.

 

[Ishie]

If you're the only pathologist and could be called on to do frozen sections, that does seem unreasonable. Do you have any cytotechs? They prep for us and run them to the frozen room. I did have to camp out during residency and fellowship. We also have more than one pathologist so one could run and do back up if needed if we had a problem pulmonologist. Otherwise it seems like you could tell the pulmonologist that the only way you could even conceivably make it work if you were willing is s/he'd have to coordinate with the other cases, which I doubt they would.

Does the pulmonologist get the whole one-pathologist thing? If the person's new, they might be used to an academic facility with an endless supply of pathology residents, fellows, and techs to camp in the OR, and might not understand the implication of "No, I actually have thirty other patients and potential frozens during this interval that you only have one".

 

[stickyshift]

If you're the only pathologist and could be called on to do frozen sections, that does seem unreasonable. Do you have any cytotechs? They prep for us and run them to the frozen room. I did have to camp out during residency and fellowship. We also have more than one pathologist so one could run and do back up if needed if we had a problem pulmonologist. Otherwise it seems like you could tell the pulmonologist that the only way you could even conceivably make it work if you were willing is s/he'd have to coordinate with the other cases, which I doubt they would.

Does the pulmonologist get the whole one-pathologist thing? If the person's new, they might be used to an academic facility with an endless supply of pathology residents, fellows, and techs to camp in the OR, and might not understand the implication of "No, I actually have thirty other patients and potential frozens during this interval that you only have one".

Your comments are apt. I have an assistant who handles all of the AP stuff in the lab, but she would, if anything, be even more harried than me.

 

[Torsed]

I go on ROSE for EBUS, but our pulmonologists usually aren't as sexy at 4L R etc. they usually just do carinal mass FNA without ultrasound (hospital is too cheap to buy it). I happens rather sporadically, so I don't mind but it does set you back timewise, even a quick one takes about an hour.

I can see how many would poo poo on it, but it does give me a positive reputation in the hospital of being helpful etc. amongst clinicians. I do bill for the ROSE, if you are going I would bill for each pass accordingly until you hit malignancy. Cibas has a good section on this if you need guidance.

 

[WEBB PINKERTON]

Trying to keep track of billing while you are preparing slides and looking at them is a job in itself. One minute you are making touch preps, then they are bringing you actual FNA specimens. Our pulmonologists go back and forth between forceps and needles and switch sites constantly.

It is a nice service to provide but I really do wonder if it is worth it. Other than triage for possible lymphoma, why exactly do we need to be there?

 

[Euchromatin]

We provide ROSE of EBUS cases at the large hospital where our main office is located and at one other smaller hospital in the same city, where at least one pathologist is stationed on site every day. We go to either the OR or endoscopy suite/procedure room with a cytoprep tech for the cases because, at both hospitals, the pathology department is far enough away that it would be impractical to have someone run the slides back and forth during the case. Neither ROSEs nor frozen sections are particularly frequent at the smaller hospital, so it has not been huge problem to cover with only one pathologist, and we occasionally have two on site there. I'm not entirely sure about volumes at our larger/main hospital, as whichever pathologist is covering the cytology service for the day does them. Only a subset of our group (those boarded in cytopath) are assigned to that service, which does not include myself. I don't think they get more than 2-3 cases a day, at most, and, given how much our pap volumes have been dropping, I don't think it has been a huge problem.

 

[Amylacea]

I also provide ROSE for EBUS in the OR, mostly as a courtesy as a new pulmonologist gets their handle on the procedure. I would caution that my courtesy has been somewhat taken advantage of, as some cases have gone 2-3 hours. I am about to set a time limit of one hour. I still have all my regular work to do, so I have to start setting some limits. Being in the room during EBUS does allow direct conversation with the EBUS operators, viewing of the ultrasound, which all helps. I am also picky about slide prep, I don't want to get thick slides that are unreadable if they are made by someone else. Also, being in the room I can allocate the specimen properly. It's also nice to see and talk to the person actually doing the passes, which in my case is actually a nurse. The pulmonologist just hold the scope steady and gets into position. Emphasizing proper FNA technique to the nurse has been helpful.

 

[stickyshift]

I also provide ROSE for EBUS in the OR, mostly as a courtesy as a new pulmonologist gets their handle on the procedure. I would caution that my courtesy has been somewhat taken advantage of, as some cases have gone 2-3 hours. I am about to set a time limit of one hour. I still have all my regular work to do, so I have to start setting some limits. Being in the room during EBUS does allow direct conversation with the EBUS operators, viewing of the ultrasound, which all helps. I am also picky about slide prep, I don't want to get thick slides that are unreadable if they are made by someone else. Also, being in the room I can allocate the specimen properly. It's also nice to see and talk to the person actually doing the passes, which in my case is actually a nurse. The pulmonologist just hold the scope steady and gets into position. Emphasizing proper FNA technique to the nurse has been helpful.

2-3 hours?!
The last two times my pulmonologist has had EBUS procedures, I've been called to deal with other procedures (frozen sections, FNA adequacies for radiology) at the same time. Don't you run into the same difficulties?

 

[pathstudent]

Availability is the most important ability. If you are unavailable for ebus, touch preps or frozen, they will complain to administration and you will eventually lose your job. Saying you are unavailable because you are helping someone else is not acceptable.

Fortunately for us we are in 500 bed tertiary care center with 25 ORs so it takes us three of us and a PA to cover the service, so we never are short handed.

Yes stickyshaft you should learn how to cover the service or you will lose the contract.

 

[Ishie]

Re: FNA technique: Also true. I've had a few come through that look like they went through a blender.

 

[Amylacea]

2-3 hours?!
The last two times my pulmonologist has had EBUS procedures, I've been called to deal with other procedures (frozen sections, FNA adequacies for radiology) at the same time. Don't you run into the same difficulties?

I arrange coverage for the other services. The three hour case was a problem, that only happened once. I was trying to accommodate a new pulmonologist. Just found out that pulmonologist is leaving the hospital, so much for that. Now I get to start over with a new one. Great.

 

[yaah]

We have cytotechs go and prepare the slides and do a quick screen. If it's just blood or benign junk they don't call us. If it's abnormal they call us. So we don't have to spend as much time. Occasionally I have had to sit there and wait for close to an hour because they keep doing passes and I'm already there, or multiple cases at once. But typically am in and out under 10 minutes. But you have to have good cytotechs.