Frozen Section Specimens

At the county hospital they get brought to us.
At the U we have to go fetch them, which is ******ed, especially when they're NOT OUT YET, and when specimen orientation is not an issue, and when multiple frozens are happening at once.

Haven't rotated at the VA or Abbott-Northwestern, so I can't speak to those.

[Update: Just called a colleague who's rotated at the other sites - yup, only at the U do we pick up specimens.]

 

beat ya to it!

 

Well, I was the first one to vote on the poll, so I beat you both.

Only a couple times have I heard of one of us having to go into the OR, and that was for orientation purposes when no one could leave the OR.

 

That might very well be UTSW you are talking about. Here, we pick up the specimen from the OR, take it to the gross room, do the frozen, and then go back to the OR to relay the result personally to the surgeons.

 

what do the staff say as to the educational value of this approach? sounds to me that you're in two departments: surg and path. that you get scutted around by the surg dept and path doesn't have the balls to stand up to the surg dept, care about their residents, etc.

i'm not trying to be mean. i guess i'm frustrated for you.

when i did an away last summer, one surgeon went a little over the top with some of the path residents in his demands. the situation was promptly addressed (within 1-2 days!) when the path dept spoke with the surgeon and the surg dept. I thought that was a class act on the part of the path dept chair/PD. it was evident that the surg dept respected the path dept. (this place was very similar to the brigham in how frozens were handled.)

 

At my program we pick specimens up from the ORs. While picking up the eighth lymph node in a row on busy days gets really annoying, I will say this... Every surgeon who freezes knows my name and I know theirs. There is a level of trust that develops when they personally hand you their tissue. I think it does a lot for the surgeon-pathologist relationship to have the face to face interaction.
So I think you gain something for the time you give up going after the eighth lymph node.

 

We have a vacuum tube system, and then nurses carry down larger specimens.
The OR is not on the same floor as the frozen room.

 

we are not frustrated at all. like what the other poster said, this system fosters a great relationship between path and surgery. at all our hospitals, surgical pathology is located adjacent to the ORs. surgery and path here at UTSW work very closely together. when you pick up specimens, you actually get to talk to the surgeons and ask them specifics about the case - what are they thinking, what their next step is, etc. and vice-versa. as a surgeon, would you not feel more secure if you handed over a precious specimen personally to the people who will be working on it (rather than handing it over to a middle person who really will not be involved in anyway whatsoever with that case)?

 

I get a little ticked when I have to go into the OR. It's rare, and its usually because a surgeon wants a "show & tell"--often to see the adenocarcinoma that they removed dead center in a 50-cm colon resection and no frozen required. With 60 ORs spanning 5 buildings or so, it is easy to get lost.

On another note, how many residents read their own frozens? After hours (i.e. 5:00pm) and on weekends, senior residents diagnose all frozen sections. Talk about needing to get your surgeons to trust you! The surgeons come into the frozen section room and sit down with you and the junior resident, and wait for you to make a diagnosis! Its pretty daunting, but I guess real "graduated responsibility." Anyone else do it this way?

Mindy

 

Same here (BIDMC). Though if we're really busy, we occasionally have it brought to us or call the result back in to the OR. For the cases with multiple sets of lymph nodes, we usually pick up the first one or two, then they know we're working on those and send someone to deliver subsequent ones.

It would be interesting to know how it's done in community hospitals ... I know of one around here where the pathologist goes into the OR to report the diagnosis, so perhaps it's good practice for us to do it as residents in case we end up in an environment like that. I like the opportunity to ask questions, get a pointed history, see the tissue in situ on the video screen if the operation's laparoscopic, etc. Also, I think it's good to get to know the surgeons to at least a limited extent.

 

So if I have 1 of 4 institutions offering pick-up / bend-me-over-and-____ services, how do I vote on this poll?

 

From my limited experience at UCSF...

At Moffitt-Long Hospital: Usually you pick up your own FS specimens (yes, even lymph node frozens), unless you get slammed and then the PAs will help you out. The gross room is up one flight of stairs from the OR so you do run up/down stairs. Usually call down results if there is a lot going on. Not too bad considering your whole day is dedicated to FS (at least it used to be, not sure about this now) and you are in scrubs the entire day.

At SFGH: Pick up your own FS. The path building is completely separate from the hospital, so there is like a 5 or 6 minute walk from path to the ORs, but there is a small grossing room with cryostats over there so its not that painful. Your FS day coincides with your grossing day, so usually in scrubs anyway.

At VA: Never rotated there, so I have no idea.

I think going down and picking up the FS is pretty helpful. You can talk one-on-one with surgeon regarding the indications, what they are looking for, clinical hx, etc. Some surgeons (one particular neurosurgeon in mind) didn't like talking with the path residents and refused to disclose much info for whatever reason, but overall they were helpful, particularly the urologists. I am actually quite surprised to see the number of residents actually have some go between bringing you the specimens. On my surgey rotations (at a county hospital staffed by a private path group) the circulating nurse did in fact take the specimen to path and the path attending would call the result in to the OR.

 

Here, almost all of the frozens are brought down by OR staff. Occasionally, the ENT surgeons and one of the thoracic surgeons will call us in to orient a complicated specimen. Honestly, I would be pissed if I had to waste a bunch of time dragging my ass down to the OR's for every frozen. I get plenty of interaction with the surgeons w/o fetching LN's from the OR. If a specimen comes down that isn't completely straightforward, I'll call the OR and talk with the surgeon. If things still aren't clear, I'll ask the surgeon (or resident) to come down and orient the specimen. If a specimen comes down for frozen, when I don't think a frozen is indicated, I'll call the OR and talk to the surgeon about it. I call back the diagnoses to the surgeon (or give the dx directly to the surgeon if they've come down to the scope room). Some surgeons will bring down complicated specimens for orientation. Basically, we have a very good relationship with the surgeons without being little do-boys. Honestly, I don't see how there would be enough time for me to go get all the frozens by myself. I'm busy enough as it is on my frozen days.

 

Here, the fellows and chief residents read after hours and weekend frozens. If they can't make a call, they can beam the image over the internet to the attending on-call.

 

Why didn't the neurosurgeon yesterday hear about this???!!! Essentially: glioma---surgery is done. Metastatic---half of the cerebellum is removed. Tissue---necrosis necrosis necrosis. I had to have him go back (angrily) 3 times before I finally called it a "high grade glioma" risking potential herniation and foregoing resection (crossing my fingers, slides signed out tomorrow...)

I have averaged 3 to 4 frozens per call. One night I had 28! This included 21 from a laryngeal microdissection, a lung wedge, a mediastinal lymph node followed by a lobectomy, a GEJ resection, a chondrosarcoma (femur) resection, a pituitary adenoma, and something else I am forgetting.

Does Brighams have a lot of night frozens? Nights and Sundays at the General are for emergency surgeries mainly. Saturdays are shorter normal OR days, with a typical range of cases. We also read rush cases on weekends.

Believe it or not, we do not make too many mistakes, or else we could never have this arrangement. But they do happen, and generally (as long as it is not a horrible mistake, i.e. your carpenter dad could diagnose it) then life goes on and you feel bad...

It is a good (though scary as &^%$) opportunity.

Cameron! Glad to hear you have a similar set-up. The imaging is a great idea!

Mindy

 

Frozens should be served to the pathologist on a gilded platter by a surg resident (they have nothin' to do anyway), or, in a pinch, by a nurse. At no time should the pathologist leave the immediate scope area. Upon examining the specimen, the pathologist shouldn't really be concerned about the specific dx, subclassification, etc. Because in fact, most of the time the surgeon will actually only want (and sometimes understand) two verdicts: 1) "It's Cancer - and that's a bad thing. Pull it out, now!", or 2) "nah, it's benign. Make sure you've got clean edges, but otherwise, close up the pt."

 

OKay, let's see..I was a resident at a community hospital system( 3 hospitals) each one had a different setup depending on the primary pathologist at that division. One had the pathologist/resident go up and collect the specimens for frozen, one actually had the forzen section suite connected to surgery with a little sliding window and the surgeons or surgical resident would bring the specimen to the window and hang in it while you did the frozen...
the third....nurses or residents brought the specimens to the lab for the frozen and the pathologist called in the report via intercom.
Needless to say each has it's pros and cons...but the second choice worked best for all involved...the surgeon would be at the window providing information...and could remain scrubbed...the 2 headed microscope was situated in the window so we could show him the material we were looking at......we actually had a little projection scope for teaching purposes we added at one point..and that was a major sellling point for students and surgery residents who crowded around during interesting cases.
It all changed a few years ago when a new administration came along and decided it was beyond the dutties of the pathologist to fetch and carry and that little room was too far away from the pathologist office on the lab floor...
I can tell you our relationships with the surgeons are not as good now as they were back then. Some of our surgeons don't even know who the pathologist are and couldn't connect thier name to a face for the life of them

 

Whew... GBM... Thank goodness essentially only 1 more week of call left...

Mindy

 

Jeez... I STILL HAVE A WEEK LEFT!!! Don't jinx me!


Yup, forensics in Boston. No more frozens. I cannot wait!

Did you go through the OCME yet?

 

So, neuro frozens get lumped in with all the other frozens? Here, neuropath handles all of their own "frozens". Some of the gods of neurosurgery practice at UVA, so they probably don't won't some middling surgical pathologist looking at their frozens. (Technically, our neuropath service does almost all brain smears and not true frozens. I don't know how it is at other places).

 

At UCSF (the main hospital, not SFGH), there is a neuropath attending on call usually 6 out of 7 nights per week (not sure why they get a day off from call-- I think Neurosurg is not supposed to be running on that day) who handles all neuro frozens. UC has one of the largest neuroonc services on the west coast, so of course neurosurg only gets neuropath people calling the frozens. There is neuro coverage during the day as well (duh). That one night a week where there is no neuro cover, the surg path fellow or attending on call handles all frozens, including neuro if it comes up. Most attendings wanted us to make a crush prep, then do a standard frozen. I did a neuropath elective month and thought it was pretty interesting, but very difficult.

 

At GW we also go into the OR to retrieve the specimen. I feel this sets up a very bad dynamic between surgery and pathology. The resident is forced to enter into the lion's den where the resident is subject to being abused by the surgery attending who is comfortable because he's in his "home", the OR. It's like always giving the surgeon home field advantage. And when you are a junior resident and you're not entirley sure the purpose of the frozen and your attending is nowhere to be found, the surgeons can smell the fear and take this as an opportunity to treat you poorly. I feel this contributes to a negative view of the pathology department as a whole. And of course there's the issue of having the time to fetch all the things when you have a few rooms running at once. It's a pain.

 

I'd take frozens over cheese jumpers.

 

Hi: Neuro does there own frozens--- except nights& weekends when the senior residents do neuro frozens. The neuro staff is excellent about making sure the seniors are comfortable and available to come in as needed though.

Mindy

 

Jeez, I've never even heard the term "cheese jumpers". Didn't know that could kill ya!

 

Frozens today were par for the course.

When the path resident gets paged in to collect a specimen, it's lame things like, "Can we get a frozen on this breast reduction" or "This is a 6cm ovarian mass that looks benign, please confirm".

When the gross room calls because the surgeon brought the specimen down and would like to orient it for us, it's a post-auricular SCC.

 

Is there someone you can report this to? I'm sure they'll say it was a "misunderstanding" if they get confronted.

I know that here people don't really know what "frozen section" even means. The nurses have the terms "Frozen," "fresh," and "permanent." And anything that doesn't fit these three categories just doesn't make sense. Why things get into these three categories also doesn't seem to be of concern, they will just drop them off and say one of those three words. The worst are the pediatric ORs, because there is a "pediatric tumor protocol" which basically means deliver something, don't put formalin on it, and tell someone so the path resident can take samples for cytogenetics, flow if necessary, etc. But to some people that just turns into anything that comes out of the pediatric ORs, one time we actually got a re-resection of an atypical nevus (i.e., nothing left except skin and scar) and they said pediatric tumor protocol.

So often we get into these discussions with nurses.

Me: What is this specimen for?
Nurse: It's fresh.
Me: What do they want? What are they looking for?
Nurse: It's a fresh specimen.
Me: Do they want a frozen?
Nurse: They want it fresh.
Me: A lymphoma workup? Certain other tests?
Nurse: They just said fresh.

That was an actual conversation. God help us all when the surgeon uses the combination "Fresh frozen."

 

I should mention though, it's far from just the nurses, she was just relaying the surgeon's poorly communicated message. On the re-excision of atypical nevus that I mentioned above, I got the specimen and it said PEDIATRIC TUMOR PROTOCOL on it, so I called the OR and asked them what they wanted since it was just an ellipse of skin with a scar. They said it was for pediatric tumor protocol. I asked if they wanted any additional tests, and they responded that it was for pediatric tumor protocol and this was per the pediatric pathologist. So I called him, and he sighed and told me to just put it in formalin.

I guess pathology is just too complicated sometimes.

 

I just discovered that the U now has that setup. It's super sweet!

 

Except when it doesn't work or the attending has no internet access!

 

Anyone know about UCLA and specimen retrieval? Do you have to go to the OR there or does the nurse/tech bring the specimen to you?