Most annoying task as a pathologist?

[Strength&Speed]

Well? I've always wondered whats the most laborious, mindnumbing, and unfruitful thing you do. Prostate biopsies? Cancer Grading? Pap smears?

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[macrocyte]

I'd say searching for those 12 lymph nodes in a colon CA specimen.

 

[b&ierstiefel]

Well? I've always wondered whats the most laborious, mindnumbing, and unfruitful thing you do. Prostate biopsies? Cancer Grading? Pap smears?

Mashing for lymph nodes in colectomy and gastrectomy specimens.

 

[b&ierstiefel]

I'd say searching for those 12 lymph nodes in a colon CA specimen.

damn you beat me to it

the worst is when you get a total colectomy specimen from a patient with familial polyposis. the few that i've gotten, there was no cancer and i found two very small lymph nodes in the 100+ cm segment of ass!

 

[deschutes]

Can of worms, dude

1) Writing apheresis orders.
2) Platelet parameter re-evaluations.
3) Transfusion reactions, to a lesser degree.

Which together make up the bulk of my role as a glorified telephone operator.

What can I say, bloodbank and I don't get along

It reminds me of Internal Med - the science is fascinating, but the practice is stupefyingly dull

 

[Pingu]

Frozen sections on some of the big head and neck cases suck.

Although colon lymph nodes pretty much take the cake for absolutely annoyingness. And it's always the colon i don't gross (the one that the PA gets) that has the nice firm lymph nodes. Mine has zero

 

[b&ierstiefel]

Frozen sections on some of the big head and neck cases suck.

Although colon lymph nodes pretty much take the cake for absolutely annoyingness. And it's always the colon i don't gross (the one that the PA gets) that has the nice firm lymph nodes. Mine has zero

I love it when you thought you found 15 nodes and then you show up to signout with 3. Then you gotta go back and try again. Then it's time to submit the fat baby! Then when the surgeons give you ****, you're like, "sorry, it's all in slides now...there's nothing to go back to...how you like them apples?"

 

[Pingu]

I had a gyn onc case where i found about 10 large lymph nodes in the 'inguinal fat' that they gave me. That's ten on each side, or twenty total. The surgeon still wanted me to go back and look for more. "oh we felt there were more there in the fat. They might be fatty replaced" Yeah, i bet you 'feel' alright. Let's leave the brainwork to those with the brains, mmkay. Go back to making women infertile and free of leiomyomas.

 

[b&ierstiefel]

I had a gyn onc case where i found about 10 large lymph nodes in the 'inguinal fat' that they gave me. That's ten on each side, or twenty total. The surgeon still wanted me to go back and look for more. "oh we felt there were more there in the fat. They might be fatty replaced" Yeah, i bet you 'feel' alright. Let's leave the brainwork to those with the brains, mmkay. Go back to making women infertile and free of leiomyomas.

My intense hatred towards clinicians who page me during the day while I'm working continues to grow and fester.

 

[Strength&Speed]

if they give you a huge specimen....and its not always easy to see lymph nodes...how do you look at it all?

 

[sohsie]

if they give you a huge specimen....and its not always easy to see lymph nodes...how do you look at it all?

Strip off the fat, then 3 easy steps:
Slice, inspect, smoosh (lymph nodes dont smoosh)
Repeat until you swear off of shmaltz

 

[yaah]

Well? I've always wondered whats the most laborious, mindnumbing, and unfruitful thing you do. Prostate biopsies? Cancer Grading? Pap smears?

Platelet approvals. Especially dealing with *******es who have a parameter for transfusion (like, keep platelets above 50,000) but have no rationale for doing this. ****ing platelets.

 

[Mrbojangles]

I love it when you thought you found 15 nodes and then you show up to signout with 3. Then you gotta go back and try again. Then it's time to submit the fat baby! Then when the surgeons give you ****, you're like, "sorry, it's all in slides now...there's nothing to go back to...how you like them apples?"

What is the most number of slides you've submitted for mesentary? I only submitted ten blocks after I only positively found three nodes in a LAR. I didn't follow up on the case because someone inherited it from me when we switched rotations.

 

[SLUsagar]

if they give you a huge specimen....and its not always easy to see lymph nodes...how do you look at it all?

another great way...
strip (off the fat that is)...

and place it in Carnoy's soln...
wait a few hours (go take a long dump, chill out, godforbid preview slides), then come back, and LN's light up lighter among fat. You still gotta slice and palpate, but hell, you can see them at least.
I won't do a colon without Carnoy's.

 

[b&ierstiefel]

What is the most number of slides you've submitted for mesentary? I only submitted ten blocks after I only positively found three nodes in a LAR. I didn't follow up on the case because someone inherited it from me when we switched rotations.

34 is my record. And that's after finding one lymph node in a gastrectomy specimen. Surgeon said, "you only found one?" I'm like, ok this case is going to end one way or another. I entirely submitted the previously compressed, searched through adipose tissue. How you like 'dem apples biotch! And this was after people told me, "that's omentum, you're not gonna find hardly anything there."

 

[deschutes]

Platelet approvals. Especially dealing with *******es who have a parameter for transfusion (like, keep platelets above 50,000) but have no rationale for doing this. ****ing platelets.

Today's lesson: The key to surviving bloodbank and still keep your mind is to have a sidekick.

 

[beary]

Today's lesson: The key to surviving bloodbank and still keep your mind is to have a sidekick.

Is your sidekick cute?

 

[deschutes]

Is your sidekick cute?

My sidekick is married.

My original response was going to be "My sidekick is Midwestern", but on second thought I figured it would be an invitation to get clobbered - even if they mean the same

Since you are coming to interview, I will tempt you with promises of wine, women and song... oh wait, wrong gender.

He is cute though. He swears almost as loud as I do when going through the EMR - and it's only his first day.

 

[beary]

Since you are coming to interview, I will tempt you with promises of wine, women and song... oh wait, wrong gender.

How about wine, song, and cute sidekicks?

 

[Mrbojangles]

another great way...
strip (off the fat that is)...

and place it in Carnoy's soln...
wait a few hours (go take a long dump, chill out, godforbid preview slides), then come back, and LN's light up lighter among fat. You still gotta slice and palpate, but hell, you can see them at least.
I won't do a colon without Carnoy's.

They say you can find enough lymph nodes without using the solution, but so far that hasn't been the case for me.

34 is my record. And that's after finding one lymph node in a gastrectomy specimen. Surgeon said, "you only found one?" I'm like, ok this case is going to end one way or another. I entirely submitted the previously compressed, searched through adipose tissue. How you like 'dem apples biotch! And this was after people told me, "that's omentum, you're not gonna find hardly anything there."

Surgeons have access to your pager number when they have questions on how a specimen is grossed .

 

[b&ierstiefel]

Surgeons have access to your pager number when they have questions on how a specimen is grossed .

Well, when a case is signed out, the diagnosis report has both your name and the attending's name. Clinicians will usually call the main path office and ask for the resident who looked at the case. That's when the "operator" pages you and tells you that the clinician is on the line and would like to speak to you. I think this is absolutely ******ed. Yeah, and I'm supposed to remember the name of the patient and the details of the case days to weeks after the case has been signed out. Yeah, like I round on this f*cking patient every morning and say "good morning, how are you, did you fart, did you **** yet?" so that I know these patients well. Yeah, and I'm supposed to put down everything that I'm doing and go hunt **** down for them at a moment's notice. Yeah, f*cking right...so not gonna happen.

This is important because the thing about pathology is that clinicians are trigger happy and once you tell them a certain phrase or diagnosis, they're gonna jump the gun and progress further with their management plan. I got burned on this once because I really wanted to give the clinicians an answer because I sensed their impatience and wanted to appease them out of the goodness of my heart. But see, what can happen is that your memory is faulty and you end up saying something you didn't mean to say. Yeah, that's when you're f*cked in the ass. So, I usually ask the clinicians to leave a message. Then I get back to them via email when I see fit.

We're the f*cking doctor's doctor. The "patient" is just gonna have to wait a while and be patient. Take a number and wait in the line just like everyone else.

 

[Pingu]

I have to add another dislike, namely that of the opening of the colon and the washing out of the poo. I'm all for the last meal when you are going to lose part of your colon, but I don't want to be the one washing it out!

 

[Mrbojangles]

I have to add another dislike, namely that of the opening of the colon and the washing out of the poo. I'm all for the last meal when you are going to lose part of your colon, but I don't want to be the one washing it out!

What's with the bowel prep? Why are we cleaning out colons if patients have been prepped? Isn't that what it's intended to do? Maybe the enemas need to be stronger. I also believe if you want an autopsy the patient must be prepped before hand.

 

[beary]

I also believe if you want an autopsy the patient must be prepped before hand.

"Seems like this guy's gonna die!! Break out the GoLytely!"

 

[LADoc00]

Most annoying tasks are never seen as a resident or a fellow, they involve money. Mainly the game of people keeping it away from you and your group, and you hustling to get it. Like tag when I was 6 years old. Sometimes its the group keeping the bling bling from you, so the game can be pathologist vs. pathologist as well. If you read CAP, pathology is getting battered by pods labs, especially outside of California (where it is illegal On the plus side I passed the MIME test, so I guess I can bill for paps. Woohoo, cha ching the whole 5 bucks a pop on those bad boys.

 

[deschutes]

"I have a platelet count of 163! Gimme platelets!!"

Sigh.

 

[Strength&Speed]

I have trouble believing people would be this dumb. But maybe I'd be surprised. Did these people go to medical school?

"I have a platelet count of 163! Gimme platelets!!"

Sigh.

 

[deschutes]

This wasn't the fault of the clinicians.

The parameter on this patient was to transfuse for platelets <100k. It popped up on my review list, yesterday. My job was to figure out why it was set at 100k, since as you can imagine very few situations require a platelet count of 100k.

Fine. Looked though the EMR, the paper chart, the labs, the orders. Patient hasn't been transfused since the beginning of October. Platelet count creeping up. As far as we can tell no active bleeding. I marked it down to "OK for 10k".

Today, BAM! it's back. Still at 100k. WTF??! Did someone not update the parameters in the computer system?

Apparently not.

Reviewed patient. Nothing changed, except for the ever-increasing platelet count.

It is no less annoying than the first review, because I'm supposed to be thorough and when the EMR and chart don't mention the words "actively bleeding" or pending invasive procedure in any way shape or form it means that I have to go up to the unit to talk to the nurse to rule out active bleeding, or go up to the board and figure out which clinician I should page to get an answer to the question "Do you know of any reason why this patient should OK'ed for transfusion to >100k??"

And worst of all, at no point through any of this am I allowed to be snarky.

Gotta love patient care. I'm a scutmonkey and I love my job!

 

[sandyworks]

Gots to be the colon fat mashing.

Although, clinicians are a close second. My favorite is the clinician calling about a teeny tracheal biopsy with nothing but chronic inflam in it and wondering if that's really all we saw, since this was a really fascinating case of a woman with xyz labs and xyz family history and s/p xyz treatment blah blah blah.
< I mean, that's really fascinating and all, but there's still only inflam in it. Of course, if the history actually were relevant, nobody would give you the time of day >

 

[yaah]

This wasn't the fault of the clinicians.

The parameter on this patient was to transfuse for platelets <100k. It popped up on my review list, yesterday. My job was to figure out why it was set at 100k, since as you can imagine very few situations require a platelet count of 100k.

Here, 100k is apparently for neurosurgery and optho procedures. And one time, on a pediatric patient who was getting an EGD with biopsy - they said they needed a platelet count of 100,000 to prevent duodenal hematomas.

Most of the whining comes from radiology who refuses to do procedures without a documented platelet count of 50,000, and that includes pulling a central line that they inserted. Clinicians whine and whine about how radiology won't do the procedure unless the count is 50. Because apparently, having a count of 50,000 at 2am when the procedure is at 9am is MUCH better than having a count of 35, and giving platelets immediately before the procedure. Because there is no documented count of over 50 and if anything goes wrong apparently a lawyer will **** on them. Damn lawyers. I hate these damn radiology procedures. Every night on call you get at least 2 calls from people who have a patient with a count of 25 or so, who orders two five picks of platelets, and the blood bank makes them get approval on the second. Unfortunately, they always get the first one, even though the only reason they are giving them is for a procedure that is 10 hours away. we waste so many platelets and turn so many patients platelet refractory just so we can treat numbers.

 

[Strength&Speed]

Here, 100k is apparently for neurosurgery and optho procedures.
.

It is the brain, but I'm not sure there is good evidence for that

Because apparently, having a count of 50,000 at 2am when the procedure is at 9am is MUCH better than having a count of 35, and giving platelets immediately before the procedure. Because there is no documented count of over 50 and if anything goes wrong apparently a lawyer will **** on them.

we waste so many platelets and turn so many patients platelet refractory just so we can treat numbers.

I unfortunately have to treat numbers too. Its ridiculous. I order 4 U of FFP the other day and have labs checked one hour after they are given, just to get a good number. No matter the surgeon won't come around to do the procedure (a simple pulling of a tube) until 6 hours later, when most of the FFP has worn off. Just so I get a good number on the chart though.

 

[b&ierstiefel]

Goddamn...I just got another segment of ass today. I gotta go elbow deep in fat again to search for those non-existent lymph nodes

 

[yaah]

I have managed to go the whole week without an armpit to dissect.

 

[EvilNewbie]

The worst is when you get 23 containers for a head and neck dissection (albeit most are frozens) and have to gross in a total laryngectomy. I have done several and it still takes a couple of hours. Cystaprostatectomy is the second worse. Finding LN in bowel is not so bad, but opening an ischemic bowel is much worse.

 

[b&ierstiefel]

The worst is when you get 23 containers for a head and neck dissection (albeit most are frozens) and have to gross in a total laryngectomy. I have done several and it still takes a couple of hours. Cystaprostatectomy is the second worse. Finding LN in bowel is not so bad, but opening an ischemic bowel is much worse.

Yeah, it's like you have to spend quite a bit of time orienting the damn specimen and then you have to sort out what the false and true margins are in relationship to the other 22 containers. Had a tongue and floor of mouth resection case yesterday that pretty much was the same deal...however tongue resections are not as bad as laryngectomies, I can imagine (haven't had to do any laryngectomies yet...knock on wood...I'm on call this weekend and receive all the big specimens).

Cystaprostatectomies are pain in the ass specimens as well. Bladder cancer cases have been the bane of my existence lately. Typically the cancer has been slurped out during a previous cystoscopy and then a later biopsy shows a few cancers cells in the lamina propria and muscularis (if the biopsy went deep enough). So then they take out the bladder and when you open it, what do you see? A crater full of granulation tissue...and sometimes, you search long and hard on the slide to even see some cancer! This once case, I entirely submitted all the suspicious areas and saw NO cancer...the clinicians were a bit anxious. I mean damn, the patient got no bladder left and he's gonna be pissed when he hears that there was no cancer in the resected bladder!

 

[yaah]

Some of the boob specimens are a pain in the ass too - one today I had an oriented, but fragmented, 8 cm piece of fat without a lesion, and then separately submitted margins on 5 different margins. I hate inking things in multiple colors.

 

[DrBloodmoney]

It is the brain, but I'm not sure there is good evidence for that




I unfortunately have to treat numbers too. Its ridiculous. I order 4 U of FFP the other day and have labs checked one hour after they are given, just to get a good number. No matter the surgeon won't come around to do the procedure (a simple pulling of a tube) until 6 hours later, when most of the FFP has worn off. Just so I get a good number on the chart though.

We have thresholds of 100 k for neurosurg, optho, and neonates... seems pretty reasonable

 

[yaah]

We have thresholds of 100 k for neurosurg, optho, and neonates... seems pretty reasonable

Do you have evidence for this? I keep continuously looking for good research studies that provide evidence of appropriate threshold for platelet transfusion, and the best I have found are a few which study leukemia patients and suggest that a count of 10,000 should be adequate as prophylaxis for anyone who is not actively bleeding, and 10-20000 should be ok for anyone undergoing a procedure such as BM biopsy, central line placement, etc, even lumbar puncture. I also saw one study which said a count of 50,000 was adequate for even CABG procedures.

I understand the theoretical rationale for 100k for neurosurg and ophtho, as they are tight enclosed spaces where any bleeding can have disastrous consequences. But does a count of 100,000 really prevent more bleeding episodes than 50k or 75k? I do not really understand the need for 100,000 in a neonate with otherwise functional platelets, just with a low count.

Somehow, interventional radiology has corrupted these studies to allow for them to demand a count of 50,000 for anyone undergoing a procedure, whether it is thoracentesis or simply a PICC line removal.

Part of the problem is that doing such a study would be considered unethical, so I doubt it is going to change.

 

[deschutes]

It's all about the "art" of medicine, isn't it...
Platelet approvals haven't struck me as being particularly cerebral.

 

[DrBloodmoney]

Do you have evidence for this? I keep continuously looking for good research studies that provide evidence of appropriate threshold for platelet transfusion, and the best I have found are a few which study leukemia patients and suggest that a count of 10,000 should be adequate as prophylaxis for anyone who is not actively bleeding, and 10-20000 should be ok for anyone undergoing a procedure such as BM biopsy, central line placement, etc, even lumbar puncture. I also saw one study which said a count of 50,000 was adequate for even CABG procedures.

I understand the theoretical rationale for 100k for neurosurg and ophtho, as they are tight enclosed spaces where any bleeding can have disastrous consequences. But does a count of 100,000 really prevent more bleeding episodes than 50k or 75k? I do not really understand the need for 100,000 in a neonate with otherwise functional platelets, just with a low count.

Somehow, interventional radiology has corrupted these studies to allow for them to demand a count of 50,000 for anyone undergoing a procedure, whether it is thoracentesis or simply a PICC line removal.

Part of the problem is that doing such a study would be considered unethical, so I doubt it is going to change.

No good studies other than those early leukemic studies. I think that it's just that those seem like instances in which it's a good idea to play it very conservatively.

 

[b&ierstiefel]

Some of the boob specimens are a pain in the ass too - one today I had an oriented, but fragmented, 8 cm piece of fat without a lesion, and then separately submitted margins on 5 different margins. I hate inking things in multiple colors.

Green ink sucks ass. It runs all over the place. Red ink sucks ass too...sometimes you end up barely seeing it on the slide. I have to section and cut in a boob specimen today. Tons of motherf*cking fun. Oh boy! I can't wait. Boobs are the best!

 

[yaah]

Green ink sucks ass. It runs all over the place. Red ink sucks ass too...sometimes you end up barely seeing it on the slide. I have to section and cut in a boob specimen today. Tons of motherf*cking fun. Oh boy! I can't wait. Boobs are the best!

Yellow ink is the worst here. One dab and it creeps over the entire specimen and mixes with the other inks so you can't tell which site you inked which color. And then to top it all off, the yellow ink shows up like crap on the histo sections. At least green and blue show up. Orange is another ****ty color. It looks like yellow under glass and can be confused with both red and black as well.

 

[LoaLoa]

Goddamn...I just got another segment of ass today. I gotta go elbow deep in fat again to search for those non-existent lymph nodes

Segment of ass. har.

 

[deschutes]

I was going to take a step back and say for the benefit of all the med students and applicants - just because you get into the residency you want doesn't mean you have to stop whinging...

This thread will always be longer than the "Favourite things" thread!