Objectionable specimens

[yaah]

---

Members don't see this ad.

OK, humor me, I am curious and on call awaiting an objectionable specimen.

Of the following anatomic pathology things that you would have to do, which do you find the most objectionable? Alternatively, which one would you try like heck to avoid doing?

I realize many people may have other ideas about what objectionable is - I tried to be inclusive. So pick one, but if you have another idea, please post 🙂

I should note: These are all things I have had to do 😉

 

[beary]

I was just starting to feel better about residency. 🙁

The only one of these I have done is the APR s/p radiation. Mighty objectionable. That gets my vote, for the time being. Though now I have the others to dread.

 

[LADoc00]

OK, humor me, I am curious and on call awaiting an objectionable specimen.

Of the following anatomic pathology things that you would have to do, which do you find the most objectionable? Alternatively, which one would you try like heck to avoid doing?

I realize many people may have other ideas about what objectionable is - I tried to be inclusive. So pick one, but if you have another idea, please post 🙂

I should note: These are all things I have had to do 😉

Some of those things you will see in residency and never again. Truly objectionable specimens are those which require a greatdeal of effort, yet reimburse at such low rates that time it takes to read them is a total waste, compounded with the potential liability, are true millstones of pathology. The number one example of this without a doubt for me are: Paps.
The ratio of PAPs/pathologist directly parallels the shiattiness of a group.

 

[yaah]

Yeah, I am on cytology now and damn do I hate these things. I think if I was in practice I would call everything ASCUS and be done with it. Then I could test for HPV too and make $$$. 😉

I was trying to construct the amount of time each of the above took me to do.

Screening 25 Paps: I don't know. A LONG time. Hours? I couldn't do it consecutively.
Grossing in and then previewing a total Larynx (calcified!) with bilateral neck dissections I think this is an underrated specimen for this poll. Probably will get no votes, but it took a total of about 3 hours when you factor in taking all the margins, decalcifying and checking, hunting for the nodes, and then previewing every single ****ing slide (probably 50 slides or so, including the approximately 100 nodes) and then, to top it all off, filling out the ****ing templates.
Grossing an APR for rectal cancer, s/p radiation with the largest lymph node 0.1 cm: This gets my vote for shear tedium and frustration. Probably a total of 2 hours work but pure hell.
Hemipelvectomy I dunno - 2 hours? A pain in the ass (literally) with sawing, decal, and trying to move the damn thing around - too big for the saw, too big for a bucket, etc. Have to slice it up into pieces.
Autopsy on a morbidly obese patient with multiple prior abdominal surgeries: This one takes a while but whatever, at least there is variety. The one I had in mind died of ischemic bowel though. Attending: Find a clot! Me: **** you! (not really) Total time: 4 hours.
radical vulvectomy for paget's disease: This can suck because you have to submit a ton and check all the margins, and sometimes it can be subtle on the slides. Curse it! Took maybe 3 hours total.
Double mastectomy in an obese patient with no residual tumor: Took 2 hours or so, including going back because I didn't find the right scar.
Counting a bone marrow on a patient with a monocytic leukemia: Not a ton of time (maybe 30-40 minutes if you are thorough) but frustrating as hell - what do you count as a blast?
Previewing a set of 32 prostate core biopsies (3 levels on each core) I personally don't mind this (30 minutes) but other people hate it so I felt obligated to include it. My case there was cancer on two of the cores, 5% each.
Getting 22 simultaneous frozen sections (margins): I lost track of time. Half of the frozens were suspicious though because of the damn radiation.

 

[b&ierstiefel]

I sense rage in you. Keep it up...rage is healthy and therapeutic 🙂

Good choices in there, I'd have to say. I've been through all of your choices...many of them are a pain in the arse. I'm gonna have to channel the rage, stew on this a little, before I make my vote.

 

[DarksideAllstar]

As someone who has completed 5 posts on patients greater than 350lbs, I chose autopsy, if for no other reason other than the main purpose of said autopsies is because the patient was too big for the CT scanner (and patients too unstable to transfer to SF Zoo for open scanner). Compounding matters is that I did three of them with a diener weighing in at 110lbs soaking wet and standing 5' 4" (she still kicks ass though). Anyway, anything bony automatically should get a vote for pain in the ass. I think I escaped a hemipelvectomy my last surg path month. There was a patient (homeless, IVDA) with chronic osteomyelitis (and pevic abscesses) of the pelvis who was going to get one, but for someone reason they kept pushing the date back for surgery. The end of the month arrived and I switched off service without said specimen making it to path. 👍

 

[djmd]

Have to go with FS.
Too many FS can break the best system, and when that happens **** gets messed up, and occasitionally SERIOUSLY messed up.

The Autop, the Hemi pelvis are up there, and be a huge time suck, but you just do it and move on.

The Prostate and the Paps? You have to know your pace... don't get lazy/bored and not pay attention.

Today had three FS cases cooking at once with a total of 12 separate FS all in a 25 minute period...
And the OR managed to mislabel a paper...
Thankfully our techs are better than their OR nurses and we caught it..

 

[yaah]

As I have become familiar with the bandsaw, the bony lesions are not as objectionable to me. But yet, the hemipelvectomy is too big for the bandsaw!

I would have added in the worst specimen I have had yet, but it is rare and unlikely to be a shared occurrence.

3/4 of a mandible was resected for (if I remember right) a fibromatosis replacing most of the marrow. It was still bony on the outside though, and mandibles are extremely thick. And the woman had all of her teeth. So the specimen I got was a solid mandible where the lesion was in the center, and I had to submit one section every 1-2 cm or so to rule out a nastier lesion.

Problems:
1) Decal doesn't really work at the start, because the mandible is too thick and you have to cut it into slices before decal can do anything.
2) She had all of her teeth, so using a stryker saw was prohibitive because teeth do not cut well. Since the teeth were involved by the lesion at the roots, I couldn't really pull them out either unless I wanted to destroy the specimen.
3) Bear in mind that overdecalcification will destroy histology, and the histology was important in this case.
4) The mandible is not really an appropriate specimen for the bandsaw we have.

What I ended up doing was throwing the whole think in formalin for the rest of the day, then RDO overnight. At that point I rinsed it off and was able to use the stryker saw to cut it between each tooth. Then back in formalin, then back to RDO until it was soft enough to cut. It took about 4 days. What would other people have done?

 

[DarksideAllstar]

What would other people have done?

Go to the bar and have a few drinks. Conveniently come back to work and "cut myself by accident". Go to ER for like 5 hours. Have other poor schmuck cut it in.

Seriously though, I think that your approach sounds reasonable. I probably just would have pissed myself, consulted our gross manual, then asked a fellow for advice.

This site is friggin dope.
http://www.thesurrealist.co.uk/slogan.cgi?word=hemipelvectomy

 

[Cabbage Head]

specimen for the bandsaw we have.

What I ended up doing was throwing the whole think in formalin for the rest of the day, then RDO overnight. At that point I rinsed it off and was able to use the stryker saw to cut it between each tooth. Then back in formalin, then back to RDO until it was soft enough to cut. It took about 4 days. What would other people have done?

Mandibles are such a pain to decal. The bone is so damn dense. Why did you use a stryker? We have a few bandsaws, and ranging in size from tiny to massive, so I would have tried to section it with the large bandsaw. I've had to do that to a mandible before, but that one had no teeth. It took forever to decal, though. The worst thing about those oral specimens with teeth is how bad they always smell.

 

[yaah]

We only have one real bandsaw - it is a large blade and only really works for things you can brace with blocks of wood - like femoral heads, long bones, etc. Crooked things like mandibles will just get torn up. Plus, I have tried before and the bandsaw does not do well with teeth.

 

[deschutes]

Haven't done some of the specimens listed, but I personally hate the autopsies on 21-week fetuses found to have no cardiac activity by ultrasound x1 week, for sheer low-yieldness. Behold, liquid liver!

 

[EUA]

I dunno man, any autopsy on someone s/p multiple abdominal surgeries gets my vote, after one lovely afternoon spent trying to figure out this one twisted mass of bowel from some lady who'd had an old-school gastric bypass way back in the day and then had multiple revisions and, later, radiation for cervical CA. I really wanted to hang myself. Blind loops here, jacked up anastomoses there, like the world's most smelly and challenging puzzle.

Radical necks are OK as long as you stay organized and keep your levels in order. Paps I actually kind of like (shhhh). Colons I like. I actually really enjoy vulvectomies. I'm weird.

 

[djmd]

I dunno man, any autopsy on someone s/p multiple abdominal surgeries gets my vote, after one lovely afternoon spent trying to figure out this one twisted mass of bowel from some lady who'd had an old-school gastric bypass way back in the day and then had multiple revisions and, later, radiation for cervical CA. I really wanted to hang myself. Blind loops here, jacked up anastomoses there, like the world's most smelly and challenging puzzle.

 

[Mrbojangles]

What I ended up doing was throwing the whole think in formalin for the rest of the day, then RDO overnight. At that point I rinsed it off and was able to use the stryker saw to cut it between each tooth. Then back in formalin, then back to RDO until it was soft enough to cut. It took about 4 days. What would other people have done?

I end up breaking alot of scalpels, which is kind of dumb and dangerous.

I find grossing radical neck dissections to almost be therapeutic.

 

[yaah]

I don't really find grossing anything to be therapeutic. My back starts to hurt and my fingers get sore from mashing stuff like fat.

 

[deschutes]

I don't really find grossing anything to be therapeutic. My back starts to hurt and my fingers get sore from mashing stuff like fat.

I hate the juxtaposition of keeping stuff close up to your eyes and yet away from your mouth.

 

[Mrbojangles]

I don't really find grossing anything to be therapeutic. My back starts to hurt and my fingers get sore from mashing stuff like fat.

I feel satisfied when I find alot of lymph nodes, must be feeding into my OCD hence the therapeutic feeling. I don't like looking for lymph nodes in colon specimens. I've wondered why colon mesentary is more fibrous than small bowel mesentary.

You probably need one of those adjustable height grossing stations.

 

[Mrbojangles]

I hate the juxtaposition of keeping stuff close up to your eyes and yet away from your mouth.

Not everything you look at goes in your mouth and please always wear a face shield.

 

[beary]

I don't really find grossing anything to be therapeutic. My back starts to hurt and my fingers get sore from mashing stuff like fat.

Same here. I mashed so much fat the other day that my fingers went all the way past sore to numbness.

 

[deschutes]

Trying out the multi-quote function...

Not everything you look at goes in your mouth

😱 I hope nothing YOU look at goes in your mouth. Cannibal.

Same here. I mashed so much fat the other day that my fingers went all the way past sore to numbness.

Missing CP yet? 😉

How have you been otherwise, beary?

 

[Mrbojangles]

Trying out the multi-quote function...

😱 I hope nothing YOU look at goes in your mouth. Cannibal.

Missing CP yet? 😉

How have you been otherwise, beary?

I've never been tempted to eat a specimen even when really hungry. But don't you wonder what it'd be like to eat cow fibroids? or pig multinodular goiter?

 

[beary]

Missing CP yet? 😉

How have you been otherwise, beary?

Yes, I most definitely am! 🙂 I have chemistry in sept. and oct. so will be good with that. 🙂

I'm doing all right. Had a rough month of surg path at the VA. But only four days left, woohoo!!!!

 

[yaah]

Someone finally picked the Larynx! I should post part of the template we have to fill out and show you how objectionable it can be.

 

[deschutes]

I've never been tempted to eat a specimen even when really hungry. But don't you wonder what it'd be like to eat cow fibroids? or pig multinodular goiter?

In a word, no. 😛

I've heard of tongue being eaten. Stomach, intestine, kidney, liver, testicles, eyeballs. But never never uterus or thyroid. Bleargh. And I would be even less drawn to eat them if they were obviously diseased

 

[torero]

In a word, no. 😛

I've heard of tongue being eaten. Stomach, intestine, kidney, liver, testicles, eyeballs. But never never uterus or thyroid. Bleargh. And I would be even less drawn to eat them if they were obviously diseased

You left out the tastiest: sweetbread!