B
b&ierstiefel
OK...at your institution, when you get paged for a frozen section, are the specimens brought to you or do you have to go into the OR's and fetch them?
grow upbeat 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.
In the distant past, there were a few times where I did go into the OR. The surgeons were very thankful that I was able to come by and they understood why I couldn't get there right away (considering that I had to change into scrubs and all). Once I got to see the CT scans that were hanging up and they were explaining why the given resection was difficult and the margins in question made more sense. Another time, I saw the operative field and the surgeon actually oriented the specimen in relation to the patient's open incision. In either of those two cases, there was no disrespect, there was a good reason for things, and productive dialogue took place.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)?
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.
So if I have 1 of 4 institutions offering pick-up / bend-me-over-and-____ services, how do I vote on this poll?
I've met a few MGH'ers these last few months and I am aware of this practice at MGH. One of the residents did tell me though that after-hours frozens are not as common there as at BWH because of this. Imagining from a surgeon's point of view, a surgeon would not be inclined to schedule complex surgeries requiring difficult frozens for late at night because he/she would know that the frozens would be read by a resident rather than an attending. That was his point. Nevertheless, honestly, I was blown away by this (in a good way)...the residents over at MGH must grow up real fast ey?Mindy said: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?
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
Sounds exactly like my frozen section days.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.
I've met a few MGH'ers these last few months and I am aware of this practice at MGH. One of the residents did tell me though that after-hours frozens are not as common there as at BWH because of this. Imagining from a surgeon's point of view, a surgeon would not be inclined to schedule complex surgeries requiring difficult frozens for late at night because he/she would know that the frozens would be read by a resident rather than an attending.
I think for the most part, late night cases are mainly emergency surgeries here. Everyday, cases get added on or already scheduled cases get delayed and start after hours. This happens more often than not so we do get quite a bit of frozens after 5 pm. But it's like rush hour traffic...the majority of the frozens happen between 5-6 pm, or maybe until 7 pm. The number of frozens on a given night really does vary...it can be like 3-4 like you said, but I've had nights when things were hoppin' nonstop for 2 hours (lost count of the # of frozens I cut). Weekends here are pretty light when it comes down to frozens...I've usually averaged 1-2 on a Saturday and 0-1 on a Sunday. Weekend cases are usually emergency cases...you can tell cuz whenever you get a colon specimen on a weekend, the poo is thick, smelly paste (i.e., no bowel prep before the ex lap). Neurosurg cases do get scheduled on Saturdays and maybe Sundays...those undoubtedly end up requiring a frozen.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.
Well, I'd expect nothing less!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.
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."
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.
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...)
Whew... GBM... Thank goodness essentially only 1 more week of call left...
Mindy
Whew... GBM... Thank goodness essentially only 1 more week of call left...
Mindy
Yeah, I rotated at the OCME...was there for 2 weeks. Most of us in our class have rotated through there by now, I think.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).
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).
I'd take frozens over cheese jumpers.
So I experienced several instances this week where I was simply paged to pick up a specimen. It's not like the surgeon wanted to tell me compelling clinical information or even orient the specimen. It was just to simply pick up the specimen. Isn't that what circulating nurses are for? In one case, it was around 8:30 pm where I was called back into the hospital. The nurse says I was need for a frozen section...which was a guise. No frozens were actually needed. Absolutely insulting and unacceptable.
I miss the Brigham. Shenanigans such as the above does not happen there.
You hit it on the nail...it was a pediatric OR and the situation was almost identical to yours.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!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.
I just discovered that the U now has that setup. It's super sweet!
A good question to ask programs on the interview trail potentially. An indirect indicator as to how the surgeons view the pathologists.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?