urgency in path

[pathnew]

In a pathologist's (or resident's) workday, what type of things stress you out specifically because you are under the gun, ie. a time constraint? Frozens...are you typically given 10-20 min? What other things can make you stressed due to urgency, or high work volume?
For example, ER and Radiology interest me, but they both are constantly trying to un-bury themselves from masses of patients or clinicians wanting an xray report YESTERDAY.

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[Mrbojangles]

In a pathologist's (or resident's) workday, what type of things stress you out specifically because you are under the gun, ie. a time constraint? Frozens...are you typically given 10-20 min? What other things can make you stressed due to urgency, or high work volume?
For example, ER and Radiology interest me, but they both are constantly trying to un-bury themselves from masses of patients or clinicians wanting an xray report YESTERDAY.

Getting frozens on specimens you've never seen before when the attending is not there can be stressful. Otherwise when you get over the initial fear of cutting and possibly "messing things up" it's not that big of a deal. Of course there's the interpretation component of frozens which I geuss could be stressful. It's something my attendings have to worry more about . Otherwise the only other urgency situation in pathology (anatomic pathology) is rush cases and evaluating FNAs (which I geuss is like frozens but not as bad).

I would really hate to be that radiologist who has the neurosurgeons looking over your back.

 

[AngryTesticle]

So far for me, frozen section duty takes the cake. It epitomizes the definition of high throughput stress! I can't count the number of times the F-bomb flew out of my mouth than when I get several to many specimens to deal with all at once. I need to destroy my pager.

And the thing is we strive to reach a diagnosis for the surgeon within 20 minutes of receiving the sample(s). Now, if the OR sent us one specimen at a time that would be fine. But NOOOOOOOOOO! We'll get a call for a frozen and then we'll go down only to find 5 small containers full of random stuff. Yeah, I think I should clone myself x 4 and have each of us take frozen call at once.

What really takes the cake though are INAPPROPRIATE frozens! Frozen sections are to be utilized if they will change the course of surgical management in the real-time OR situation. However, some surgeons here will use our labor for things that are meaningless. Then there are some surgeons who probably think that we will solve the whole case for them in frozen sections. Of course, I hope they realize that permanents do a much better job in answering a lot of the questions that they are seeking to find answers to...and for that, they're gonna just have to wait a few days. Oh, then there are the clowns who send us frozens and when we call in the result, they already closed the patient up. WTF?????

Given all this though, ironically, I do really enjoy cutting the frozens and preparing the slides. There's something to be said about developing manual hands-on skillz.

 

[cytoborg]

In a pathologist's (or resident's) workday, what type of things stress you out specifically because you are under the gun, ie. a time constraint? Frozens...are you typically given 10-20 min? What other things can make you stressed due to urgency, or high work volume?
For example, ER and Radiology interest me, but they both are constantly trying to un-bury themselves from masses of patients or clinicians wanting an xray report YESTERDAY.

1) Several frozens back-to-back
2) Frozens which interrupt one's cutting of a massive pile of specimens (grr)
3) Cutting a massive pile of specimens (see #2) in time to get the tissue into the processor before it goes off

That's all I can think of. Compared to radiology...well, let's just say we aren't doing biopsies on trauma patients in the ER or patients being evaluated for post-op complications in the middle of the night or unstable ICU patients...you get the picture.

 

[Mrbojangles]

1) Several frozens back-to-back
2) Frozens which interrupt one's cutting of a massive pile of specimens (grr)
3) Cutting a massive pile of specimens (see #2) in time to get the tissue into the processor before it goes off.

The A through Q ENT frozens are no fun. And if you're not at a place where you have a frozens rotation (where all you do is cut frozens) it can really cut into your grossing/screening time when you get hammered. But I'd rather have my screening time interrupted than my grossing time.

 

[pathdawg]

What really takes the cake though are INAPPROPRIATE frozens! Frozen sections are to be utilized if they will change the course of surgical management in the real-time OR situation. However, some surgeons here will use our labor for things that are meaningless. Then there are some surgeons who probably think that we will solve the whole case for them in frozen sections. Of course, I hope they realize that permanents do a much better job in answering a lot of the questions that they are seeking to find answers to...and for that, they're gonna just have to wait a few days. Oh, then there are the clowns who send us frozens and when we call in the result, they already closed the patient up. WTF?????

Given all this though, ironically, I do really enjoy cutting the frozens and preparing the slides. There's something to be said about developing manual hands-on skillz.

The same nonsense happens in private practice. If I had a nickle for every time I had to call a surgeon with a frozen section result on his cell phone while he is pulling out of the parking lot, I could retire.

I would estimate that about 50% of the frozens I do are unnecessary and nonsensical.

 

[LADoc00]

Other than frozens, interven rads as well as surgeons will ask for stat aspiration interps, which IMO can be vastly more difficult than even a neurosurgical frozen(gold standard of tough for some). But it depends, many clinicians just want to make sure the FNA is adequate others demand to know if e.g. papillary carcinoma is present. If I had to make a list:
1.) Stat FNA interps of thyroid lesions
2.) Stat FNA interps of liver masses
3.) Lymph node FNAs
4.) Breast FNAs
5.) Neurosurgical frozens
6.) Thyroid frozens (thyroid lesions can just be super tough)
maybe not in that order, some neurosurg frozens can just be crazy whacked out stuff.

Although core biopsies are replacing breast FNAs, Im currently at a place that does an FNA and then proceeds directly to surgical management, which is friggin crazy, but oh well.

 

[pathdawg]

Other than frozens, interven rads as well as surgeons will ask for stat aspiration interps, which IMO can be vastly more difficult than even a neurosurgical frozen(gold standard of tough for some). But it depends, many clinicians just want to make sure the FNA is adequate others demand to know if e.g. papillary carcinoma is present. If I had to make a list:
1.) Stat FNA interps of thyroid lesions
2.) Stat FNA interps of liver masses
3.) Lymph node FNAs
4.) Breast FNAs
5.) Neurosurgical frozens
6.) Thyroid frozens (thyroid lesions can just be super tough)
maybe not in that order, some neurosurg frozens can just be crazy whacked out stuff.

Although core biopsies are replacing breast FNAs, Im currently at a place that does an FNA and then proceeds directly to surgical management, which is friggin crazy, but oh well.

IMO (and I did a cytopath fellowship), giving an immdiate dx of an fna is unnecessary and just plain f'ed up. There is no good reason to do this. If a surgeon demanded this of me, I'd explain to him/her that a proper cytologic diagnosis is arrived after thorough and complete examination of all of the material, including monolayer preparation and cell block (in other words, get bent). I think that fna assessments for lesional cells can be performed by your cytotechs (this is the arrangement at my hospital and they do it well, plus it really frees up my time). Having a pathologist be on hand in radiology for an fna assessment is a waste of time.

I am lucky in that I have never had to do a neurosurgical frozen. That would freak me out, since I haven't even seen one since about my 3rd year of residency. If its not a met, I'm screwed.

I would also add that about 98-99% of thyroid frozens are totally unnecessary. Pre-operative fna's should eliminate most of them. The only reasonable reasons to do a fs on a thyroid (in my mind) are a fna suspicious for (but not diagnostic of) papillary ca and maybe the rare thyroid lymhoma (just so I can get fresh tissue for flow before some ***** in surgery throws the damn gland in formulin). I've done frozens for thyroids with follicular lesions, goiters, and Hashimoto's. All utter bullcrap.

 

[cytoborg]

The A through Q ENT frozens are no fun. And if you're not at a place where you have a frozens rotation (where all you do is cut frozens) it can really cut into your grossing/screening time when you get hammered. But I'd rather have my screening time interrupted than my grossing time.

Word. And why is it that A-Q all seem to come out at the same time? I'm trying to leave the OR and the surgeon keeps saying "Wait just a second...here's another one....oh wait, got another." I should ask somebody in ENT about that.

 

[cytoborg]

I would also add that about 98-99% of thyroid frozens are totally unnecessary. Pre-operative fna's should eliminate most of them. The only reasonable reasons to do a fs on a thyroid (in my mind) are a fna suspicious for (but not diagnostic of) papillary ca and maybe the rare thyroid lymhoma (just so I can get fresh tissue for flow before some ***** in surgery throws the damn gland in formulin). I've done frozens for thyroids with follicular lesions, goiters, and Hashimoto's. All utter bullcrap.

I always get the ol' "Is this parathyroid?" frozen on thyroids. Sometimes it takes them a couple of tries.

 

[AngryTesticle]

Word. And why is it that A-Q all seem to come out at the same time? I'm trying to leave the OR and the surgeon keeps saying "Wait just a second...here's another one....oh wait, got another." I should ask somebody in ENT about that.

Here, we have the same thing. Probably because the nurses who bring us the specimens are too damn lazy to walk over to the frozen room 15 times. They would rather come with all 15 at once.

Of course, this means that we take longer 20 minutes to call the OR back with all the results. Some surgeons will then proceed to actually come into the frozen room and look over our shoulders or pace impatiently making snide remarks. Wonderful. They can kiss my angry left nut!

 

[Mrbojangles]

It's so weird. When I was on my cytology rotation, any time the fellow gets called for an FNA the radiologists are so appreciative and thankful that someone is there to make sure they hit the spot. Whereas some surgeons can be total jerks when getting a frozen section.

 

[Mrbojangles]

Here, we have the same thing. Probably because the nurses who bring us the specimens are too damn lazy to walk over to the frozen room 15 times. They would rather come with all 15 at once.

Of course, this means that we take longer 20 minutes to call the OR back with all the results. Some surgeons will then proceed to actually come into the frozen room and look over our shoulders or pace impatiently making snide remarks. Wonderful. They can kiss my angry left nut!

I haven't seen any ENT resection cases as a medical student, but I think they do the resection first and then take the margins when the specimen is outside the patient's body.

 

[LADoc00]

IMO (and I did a cytopath fellowship), giving an immdiate dx of an fna is unnecessary and just plain f'ed up. There is no good reason to do this. If a surgeon demanded this of me, I'd explain to him/her that a proper cytologic diagnosis is arrived after thorough and complete examination of all of the material, including monolayer preparation and cell block (in other words, get bent). I think that fna assessments for lesional cells can be performed by your cytotechs (this is the arrangement at my hospital and they do it well, plus it really frees up my time). Having a pathologist be on hand in radiology for an fna assessment is a waste of time.

I am lucky in that I have never had to do a neurosurgical frozen. That would freak me out, since I haven't even seen one since about my 3rd year of residency. If its not a met, I'm screwed.

I would also add that about 98-99% of thyroid frozens are totally unnecessary. Pre-operative fna's should eliminate most of them. The only reasonable reasons to do a fs on a thyroid (in my mind) are a fna suspicious for (but not diagnostic of) papillary ca and maybe the rare thyroid lymhoma (just so I can get fresh tissue for flow before some ***** in surgery throws the damn gland in formulin). I've done frozens for thyroids with follicular lesions, goiters, and Hashimoto's. All utter bullcrap.

I completely agree. When I first arrived here, I was expected to render stat FNA interps on breast lesions who were then immediately scheduled for surgical management. Imagine the stress as I hadnt done cyto literally in 3 years and had never done more than 6 total FNAs in my AP training. When I raised an objection I was told I could do FNAs or do pure pap smears (10-14 trays/day) or leave the job (this was around 6 weeks into the gig). I dont know how many Ive now done, maybe 150+, but Im done with that crap. I called an attorney last night and am gonna find a way to get of this situation asap. Of course this was on top of being disallowed from sending any surgical cases out in consultation due to "budgetary concerns." Total crapola, luckily my options are very nice after this.

 

[AngryTesticle]

I haven't seen any ENT resection cases as a medical student, but I think they do the resection first and then take the margins when the specimen is outside the patient's body.

This varies from surgeon to surgeon. My limited experience has been that surgeons will take out the main specimen. After that, they don't f*ck with it. Instead, after the initial excision, they may be worried about certain margins. Then they will go back to the patient and excise chunks of tissue here and there and ask if those fragments of soft tissue have tumor present or not.

 

[Mrbojangles]

This varies from surgeon to surgeon. My limited experience has been that surgeons will take out the main specimen. After that, they don't f*ck with it. Instead, after the initial excision, they may be worried about certain margins. Then they will go back to the patient and excise chunks of tissue here and there and ask if those fragments of soft tissue have tumor present or not.

I geuss that's probable too. I got a nose the other day. I wonder how the hell they tried reconstructing a new nose. I assume they used a flap from a different part of the body? How would they maintain vascularity? What if the only skin they had was hairy? I wonder why I care .

 

[AngryTesticle]

I geuss that's probable too. I got a nose the other day. I wonder how the hell they tried reconstructing a new nose. I assume they used a flap from a different part of the body? How would they maintain vascularity? What if the only skin they had was hairy? I wonder why I care .

You've watched way too much college football and stared way too long at Frank Beamer's right neck.

 

[deschutes]

I wonder how the hell they tried reconstructing a new nose.

Prosthesis?

The husband of the very last patient I wrote discharge orders for had a very strange head.

 

[Mrbojangles]

I had to google that. Perhaps s/p mandiblectomy?

 

[CameronFrye]

I had to google that. Perhaps s/p mandiblectomy?

He got burnt pretty bad in a fire when he was a kid. For many years, he would always turn that side of his face away from the cameras during an interview. Now that tech has gotten more exposure over the past few years, he doesn't appear to try to hide it as much.

 

[pathdawg]

I completely agree. When I first arrived here, I was expected to render stat FNA interps on breast lesions who were then immediately scheduled for surgical management. Imagine the stress as I hadnt done cyto literally in 3 years and had never done more than 6 total FNAs in my AP training. When I raised an objection I was told I could do FNAs or do pure pap smears (10-14 trays/day) or leave the job (this was around 6 weeks into the gig). I dont know how many Ive now done, maybe 150+, but Im done with that crap. I called an attorney last night and am gonna find a way to get of this situation asap. Of course this was on top of being disallowed from sending any surgical cases out in consultation due to "budgetary concerns." Total crapola, luckily my options are very nice after this.

Thats horrible, dude. Who was the medical genius savant that came up with the idea of stat breast fna interpretations? Thats the stupidest thing I 've ever heard. And they have "budgetary concerns"? Did they make room in the damn budget for law suit settlements when invariably some woman gets a mastectomy for a cellular fibroadenoma?

Get a good lawyer and I mean good, like Dershowitz good, just to screw with them. They are crazy. You need to get out of there and work with reasonable centered people.

 

[yaah]

Of course this was on top of being disallowed from sending any surgical cases out in consultation due to "budgetary concerns." Total crapola, luckily my options are very nice after this.

To tell you the truth, if I encountered this situation I would seriously be tempted to sign out the case as:

Probably synovial sarcoma, see COMMENT:

COMMENT: This case should be sent in consult to a national expert who sees many of these cases, but due to budgetary concerns this is not an option. I wish I could help you more. Please correlate with clinical suspicion and say a prayer.