Organ Donor Frozens? Seriously??

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LADoc00

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I had something happen that literally I had never heard of over the weekend: the proverbial 1am call from a local hospital that the "Donor Team" had arrived and waiting for me to begin.

My first thought of course was fevered hallucination/dream. I stared blankly into darkness of my bedroom with literally no clue what the guy on the phone was even talking about let alone what he wanted me to do.

I spoke softly to not wake my entire house: "Um what do you want?" Stranger's response "We need you to get suited up and get into OR with the donor team." Tired, fighting back a cold I was trying to recover from, and completely out of it, I responded "Yes, I hear you, but what is my role?" Stranger: "We want you to do wet reads on the organs."

I didn't even know how to respond to that. "Wet reads"? Like cytology preps? On a dead person? Or a dying person? Like a cytology autopsy one organ system at a time?

I was livid at this point and I barked back: "WHO ARE YOU?" Stranger: "Donor Network." Yah, I figured that but I need to get a name to know who I was going to hit with the taser and brass knuckles when I did finally wake up and go in.

I ended up doing frozen sections, awake from 1am to about 6am. I was relatively calm being exhausted out of my mind at that point. I just wanted to crawl in a hole and/or kill someone. On top of this, they swept in like Homeland Security and collected up the specimens, the frozen blocks, slides and hand written note of the reports. All the evidence of me even doing something was all gone, making it even more surreal.

I slipped back home somehow but like a drunk 20-something year old at a Stanford Frat Party literally have no relocation of how I got back into my bed. I went to work today having almost forgot the whole thing before I got call from the "Donor Network" asking me for final diagnoses. I responded that I would have their diagnoses written up along a sweet and savory treat in the back of the parking lot if they met me there...

Now, is this for real? Are we supposed to be at the beckon call of some Team USA World Police Organ Squad and "take one for 'Murica" because some private company which gets a pass to legally sell organs on the transplant ebay needs to ensure the relative quality of their products?

Im still unsure of how to process this...anyone? Bueller?

Is this common and someone I have just never been hit in all the years I have been out?

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Welcome to the team, rook!

I alway have wondered why the damn donor team brings in their own surgeon and anesthesia but can't bring in their own damn dollar a dozen pathologist.
 
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This too happened to me as a resident. But how I got rolled into this process at 2 AM was special. The transplant team was originally to do this at another hospital on the other end of town. However, the pathologist there quite literally said "I don't have a histotech available to cut a frozen at 1 AM and its not in my contract to cut frozens, so you're SOL...I'm not coming in". So then the transplant team packs the show up, hits the road, and travels clear across town to the academic medical center where yours truly is paged at 1:30 AM to do the frozen. The only person more annoyed than me was the faculty that I had to drag into this mess.
 
I remember having to do this for livers and kidneys during residency. They wanted to make sure the organs they were putting in weren't as bad as the ones they were taking out. Glad I don't work in a major medical center that does transplants - that seemed to be the reason for almost every middle of the night trip to the hospital, whether it was assessing transplant organs or trying to do pheresis on someone before they got a mismatched organ. No thanks.
 
This too happened to me as a resident. But how I got rolled into this process at 2 AM was special. The transplant team was originally to do this at another hospital on the other end of town. However, the pathologist there quite literally said "I don't have a histotech available to cut a frozen at 1 AM and its not in my contract to cut frozens, so you're SOL...I'm not coming in". So then the transplant team packs the show up, hits the road, and travels clear across town to the academic medical center where yours truly is paged at 1:30 AM to do the frozen. The only person more annoyed than me was the faculty that I had to drag into this mess.

I like the first pathologists response. I cannot believe someone would put up with this shi* if it was not a specific contractual obligation. I am stunned you did this, LA. I can understand the "resident in an academic med center" scenario getting corralled into this nonsense, but a seasoned PP pathologist!?! please!!
 
I like the first pathologists response. I cannot believe someone would put up with this shi* if it was not a specific contractual obligation. I am stunned you did this, LA. I can understand the "resident in an academic med center" scenario getting corralled into this nonsense, but a seasoned PP pathologist!?! please!!

Yup hence why I posted this. The transplant surgeon I spoke with literally acted like every pathologist in every small town USA does the same thing....yet somehow I had never heard of this, ever. I am stunned trust me.

I am still at loss at exactly how I was conned this hard. In my defense, I did spend literally 12 straight hours in a private firearms training program run by USMC Master Snipers all Sat and then again on Sunday. I was still dirty, smelling like gun powder and CLP when I passed out before they called. Perhaps I was flashing back to boot camp given my day and just did it without actually thinking, dunno. On Sunday night after 2 days of crawling through the dirt and bush of a 100+F blazing hot California sun dragging 50+lbs of sniper gear AND essentially not sleeping at all, I curled up in a Chipotle booth and slept for an hour because I couldnt even drive anymore. Not pretty. Definitely hit a low point here.
 
Yup hence why I posted this. The transplant surgeon I spoke with literally acted like every pathologist in every small town USA does the same thing....yet somehow I had never heard of this, ever. I am stunned trust me.

I am still at loss at exactly how I was conned this hard. In my defense, I did spend literally 12 straight hours in a private firearms training program run by USMC Master Snipers all Sat and then again on Sunday. I was still dirty, smelling like gun powder and CLP when I passed out before they called. Perhaps I was flashing back to boot camp given my day and just did it without actually thinking, dunno. On Sunday night after 2 days of crawling through the dirt and bush of a 100+F blazing hot California sun dragging 50+lbs of sniper gear AND essentially not sleeping at all, I curled up in a Chipotle booth and slept for an hour because I couldnt even drive anymore. Not pretty. Definitely hit a low point here.

i mean the commo seems subpar, but frozens on a liver or kidney transplant happen all the time...,maybe i'm missing something... "donor networks" invariably always facilitate such cases. did you have the fortune of doing the post the next day as well?...

more importantly, why were you dragging a ruck of sniper gear for a private firearms training? not get enough of it in the service or just miss it that much?
 
We do them regularly where I'm at. I'm pretty sure we have a contract with the transplant agency here. Our department chair doesn't loan us out for free.
 
Lifepoint kidneys and livers were one of the few reasons I'd actually get dragged to the hospital in the wee hours during residency. Blood bank would wake me up the most, but then let me pass back out immediately. I wouldn't have minded so much except estimated time and actual time were usually off by a couple hours thus had to hang in the frozen room from 2-4 am until they showed. Our attendings were savvy enough to tell us not to call them until we had tissue in hand. Some attendings would take all comers, but a few others specified to f- off unless it was specifically coming to our hospital. My record was three in a night. One of few times I recall sleeping on the scope during sign out the next morning.
 
Lifepoint kidneys and livers were one of the few reasons I'd actually get dragged to the hospital in the wee hours during residency. Blood bank would wake me up the most, but then let me pass back out immediately. I wouldn't have minded so much except estimated time and actual time were usually off by a couple hours thus had to hang in the frozen room from 2-4 am until they showed. Our attendings were savvy enough to tell us not to call them until we had tissue in hand. Some attendings would take all comers, but a few others specified to f- off unless it was specifically coming to our hospital. My record was three in a night. One of few times I recall sleeping on the scope during sign out the next morning.
We don't go in unless the tissue is already there. You should only make that mistake once.
 
This is fairly common. Usually livers and kidneys. We had a system set up where we used a rapid processor system so it wasn't a frozen, it took 2-3 hours to get the slides ready, then scan them in and then call the pathologist when it's ready to evaluate. But we used to evaluate them for other hospitals so we got more than typical. Typically you don't need immediate read because it isn't going into the patient right away.

The other thing you get is when the transplant team finds something and they want to rule out cancer. In the past 5 years I have gotten a couple of lung wedges with nodules (usually scars), a couple of kidney nodules, a couple of lymph nodes, a pancreatic tail, and a complex cystic ovary.

For livers they usually want to know how much fibrosis and how much steatosis. I think about 30% becomes a risk factor for graft failure, and once you get bridging fibrosis it's also marginal. But you might be amazed at just how much interobserver disagreement there is with liver steatosis. I have seen papers that talk about it, and they will show a picture that is at best 10% steatosis and they call it 30. Then another paper looks like 50% and they call it 20.

Kidneys they usually want to know % sclerotic glomeruli and how bad the vascular disease is.

I am not sure what organs or clinical situations warrant evaluation of the donor organ.
 
They were unpredictable on the times. Sometimes 10 minutes was 10 minutes; sometimes it was two hours and it wasn't good to wake up again once they were there because it would be followed by cranky calls from transplant surgeons. I just brought a book or snoozed at the accessioning desk.

My favorite was a rule/out lymphoma nodule in a transplant liver that turned out to be wall to wall granulomas. That was an exciting next day with a broken down cryostat along with the constant "what on earth were you freezing in the middle of the night?????" questions.
 
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This is fairly common. Usually livers and kidneys. We had a system set up where we used a rapid processor system so it wasn't a frozen, it took 2-3 hours to get the slides ready, then scan them in and then call the pathologist when it's ready to evaluate. But we used to evaluate them for other hospitals so we got more than typical. Typically you don't need immediate read because it isn't going into the patient right away.

The other thing you get is when the transplant team finds something and they want to rule out cancer. In the past 5 years I have gotten a couple of lung wedges with nodules (usually scars), a couple of kidney nodules, a couple of lymph nodes, a pancreatic tail, and a complex cystic ovary.

For livers they usually want to know how much fibrosis and how much steatosis. I think about 30% becomes a risk factor for graft failure, and once you get bridging fibrosis it's also marginal. But you might be amazed at just how much interobserver disagreement there is with liver steatosis. I have seen papers that talk about it, and they will show a picture that is at best 10% steatosis and they call it 30. Then another paper looks like 50% and they call it 20.

Kidneys they usually want to know % sclerotic glomeruli and how bad the vascular disease is.

I am not sure what organs or clinical situations warrant evaluation of the donor organ.

What is your incentive? Do you have a group agreement with a Donor Network company or you are merely doing this as part of your medical directorship agreement of the lab or you are burning time to be a good citizen and perhaps earn a ticket to heaven or ?

THE biggest question for me is why isnt the end organ taken to the facility where the transplant is occurring, which I assume is a massive academic medical center and THEIR pathologists get woken up and do this? I asked them directly this and they stumbled around with BS answers.

My problem is:
1.) This is not helping my patients whatsoever, my "patient" is dead. I dont have the energy to burn to Team USA World Police up all the patients everywhere. Those are on someone else's care plate.

2.) This is not helping any of my colleagues. The Donor Team is a completely non-credentialed non-local group of contractors from: who knows where but not here. I could burn night after night on this and early the next day when Im still dragging my butt, my local docs will wonder why the reports are taking so long to get out. This is the literal definition of thankless.

3.) As far as I can tell, there is NO WAY to bill for this. I even asked and the Donor folks claimed they know nothing about any payments to pathologists.

4.) I went to the hospital admin board on Monday after this and they literally shrugged their shoulders. They couldnt give a damn.

And to the first person who posts we need to all just "Take One for the Team" on this, I will reach through the internetz and choke you out. Fair warning.

This is a big thing with me probably because I have long experience working in government: everyone wants YOU to help them but I can guarantee if the shoe was on the other foot, they get in your face to tell you to take care of your own sh-t by yourself.

Ive pondered this and frankly there is literally no side I can determine of telling them you cant help. Probably best not to tell them you are going to render them so damaged they will be the ones in need of transplant, but politely say "cant help, wish I could. Its outside my comfort zone."

~They cant complain to the medical staff because they arent on the staff and have to formal mechanism to do so.
~Cant complain to the hospital admin because I can guarantee no pathology group has contract language that actually covers this (or at least I have NEVER ever seen it).
~Cant complain to the state medical board because they have no basis, you told them it is outside your normal scope of practice and that is pretty much is guaranteed legal shielding for all community based pathologists
~There is no EMTALA violation because the patient is DEAD. The receipt patient is not only not under your care but likely not even known at the time of the tissue acquisition.
 
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And to the first person who posts we need to all just "Take One for the Team" on this, I will reach through the internetz and choke you out. Fair warning.

Why don't you just suck it up and take one for the team? You guys really whine too much. Choke me now HAHA.
 
What is your incentive? Do you have a group agreement with a Donor Network company or you are merely doing this as part of your medical directorship agreement of the lab or you are burning time to be a good citizen and perhaps earn a ticket to heaven or ?

3.) As far as I can tell, there is NO WAY to bill for this. I even asked and the Donor folks claimed they know nothing about any payments to pathologists.
We have a direct contract with hospital and organ sharing alliance. We bill and get paid very well. It is part of the contract to provide services for the hospital. The physician taking the organs is usually a general surgeon who is granted "emergency privileges", hence a service performed to the medical staff. You do not bill the deceased individual. Use the UNOS number and have a bill sent directly to donor network company. This is at least how it works for us.
 
What is your incentive? Do you have a group agreement with a Donor Network company or you are merely doing this as part of your medical directorship agreement of the lab or you are burning time to be a good citizen and perhaps earn a ticket to heaven or ?

THE biggest question for me is why isnt the end organ taken to the facility where the transplant is occurring, which I assume is a massive academic medical center and THEIR pathologists get woken up and do this? I asked them directly this and they stumbled around with BS answers.

My problem is:
1.) This is not helping my patients whatsoever, my "patient" is dead. I dont have the energy to burn to Team USA World Police up all the patients everywhere. Those are on someone else's care plate.

2.) This is not helping any of my colleagues. The Donor Team is a completely non-credentialed non-local group of contractors from: who knows where but not here. I could burn night after night on this and early the next day when Im still dragging my butt, my local docs will wonder why the reports are taking so long to get out. This is the literal definition of thankless.

3.) As far as I can tell, there is NO WAY to bill for this. I even asked and the Donor folks claimed they know nothing about any payments to pathologists.

4.) I went to the hospital admin board on Monday after this and they literally shrugged their shoulders. They couldnt give a damn.
....
To be honest, all the transplants i've done in practice (liver and kidney) have been weird hours and I've always just assumed the transplant was occurring at my medical center...

If you have a chunk of liver or kidney to eval for transplant, chances are they already have the organ out (assuming cadaveric transplant)...does it make more sense to have it eval'd in house before Life Flight'ing an organ somewhere?
Probably--safer and cheaper [like, free] to trouble the pathologist then to fly organs around with no knowledge if they're any good or not.

But yea that should be in your contract.
 
What is your incentive? Do you have a group agreement with a Donor Network company or you are merely doing this as part of your medical directorship agreement of the lab or you are burning time to be a good citizen and perhaps earn a ticket to heaven or ?

Bingo. Our hospital system gets paid by the organ procurement organization, and the pathologists are obliged to serve gratis as part of our medical lab directorship agreement. Not exactly gratis, but not worth losing sleep over. Well, correction--SOME of the pathologists are obliged. You might as well add this duty to your list of Uneven Task Allocation Red Flags To Watch Out For.

If you are to be stuck with them as we are, you might benefit by curbing some of the Donor Dream Team excesses, like their farting around until godawful hours to finally cough up the biopsy or calling you in long before the specimen finally hits your table. In fact, I would recommend strongly against being perceived in any way as accommodating. We found out that they were calling us in nights to read organs procured from corpses who died in other hospitals, whose pathologists weren't as "nice" as we were.
 
We have a direct contract with hospital and organ sharing alliance. We bill and get paid very well. It is part of the contract to provide services for the hospital. The physician taking the organs is usually a general surgeon who is granted "emergency privileges", hence a service performed to the medical staff. You do not bill the deceased individual. Use the UNOS number and have a bill sent directly to donor network company. This is at least how it works for us.
i like that idea--just send the DN a bill!
 
I had something happen that literally I had never heard of over the weekend: the proverbial 1am call from a local hospital that the "Donor Team" had arrived and waiting for me to begin.

My first thought of course was fevered hallucination/dream. I stared blankly into darkness of my bedroom with literally no clue what the guy on the phone was even talking about let alone what he wanted me to do.

I spoke softly to not wake my entire house: "Um what do you want?" Stranger's response "We need you to get suited up and get into OR with the donor team." Tired, fighting back a cold I was trying to recover from, and completely out of it, I responded "Yes, I hear you, but what is my role?" Stranger: "We want you to do wet reads on the organs."

I didn't even know how to respond to that. "Wet reads"? Like cytology preps? On a dead person? Or a dying person? Like a cytology autopsy one organ system at a time?

I was livid at this point and I barked back: "WHO ARE YOU?" Stranger: "Donor Network." Yah, I figured that but I need to get a name to know who I was going to hit with the taser and brass knuckles when I did finally wake up and go in.

I ended up doing frozen sections, awake from 1am to about 6am. I was relatively calm being exhausted out of my mind at that point. I just wanted to crawl in a hole and/or kill someone. On top of this, they swept in like Homeland Security and collected up the specimens, the frozen blocks, slides and hand written note of the reports. All the evidence of me even doing something was all gone, making it even more surreal.

I slipped back home somehow but like a drunk 20-something year old at a Stanford Frat Party literally have no relocation of how I got back into my bed. I went to work today having almost forgot the whole thing before I got call from the "Donor Network" asking me for final diagnoses. I responded that I would have their diagnoses written up along a sweet and savory treat in the back of the parking lot if they met me there...

Now, is this for real? Are we supposed to be at the beckon call of some Team USA World Police Organ Squad and "take one for 'Murica" because some private company which gets a pass to legally sell organs on the transplant ebay needs to ensure the relative quality of their products?

Im still unsure of how to process this...anyone? Bueller?

Is this common and someone I have just never been hit in all the years I have been out?

I get called out every other year or so to do this, and as far as I know, I have to do it. So far, I've only done livers, and they want to know the extent of steatosis and fibrosis. The histologic assessment (which I perform on frozen section) is just one part of the final decision.
Our group has figured out a reimbursement scheme, which is fair for the service provided. It is not fair, however, if you're in the lab for 5 hours! I tell the coordinator to call me about an hour and a half before they need me (It takes me a little more than an hour to get to the hospital.), and I usually get the specimen when I hit the door.
It is key to insist that you be called in only when the need for the service is imminent: I have had coordinators blithely tell me that they will need me in three hours and not get the actual frozen until two days later.

(Oh, by the way, don't mention being a drunk at a Stanford frat party--too soon!)
 
We have a direct contract with hospital and organ sharing alliance. We bill and get paid very well. It is part of the contract to provide services for the hospital. The physician taking the organs is usually a general surgeon who is granted "emergency privileges", hence a service performed to the medical staff. You do not bill the deceased individual. Use the UNOS number and have a bill sent directly to donor network company. This is at least how it works for us.

This makes a lot of sense. Knowing that the donor network can be billed, a contract should be set out before any further organ procurement so that you are adequately billed for your services. Otherwise the donor network should find someone else. Providing free consultations to an outside network is not proper business. The surgeons are not providing free surgery.
 
Obviously you should be paid. However the reason not to wait until the organ gets where it's going is cold ischemic time. You can read while the liver is moving.
 
Donor services is all about the money.

We say no here. We are not trained in transplant pathology, don't do continuing ed in it, doing it once in a blue moon doesn't make a person trained, not covered in our granted hospital privileges(?) and really important ....our malpractice doesn't cover it. They provide their own surgeon, then they can provide their own pathologist. Yes, they will contact admin and make issues. Best to get out ahead of this issue.

Yep, they totally lie to you about when they need you. If you do it, tissue in the lab and call from your own tech. These people suck. Unfortunate considering the importance of the situation.
 
Donor services is all about the money.

We say no here. We are not trained in transplant pathology, don't do continuing ed in it, doing it once in a blue moon doesn't make a person trained, not covered in our granted hospital privileges(?) and really important ....our malpractice doesn't cover it. They provide their own surgeon, then they can provide their own pathologist. Yes, they will contact admin and make issues. Best to get out ahead of this issue.
.

This isn't transplant pathology. Transplant pathology is evaluation of transplanted organs after they are transplanted. But that being said there is an experience part of the evaluation, not the greatest to have people evaluating them who don't do it routinely.

We had a contract with the state gift of life for a time. Got several a week, most from other hospitals.
 
I need to dig further. This has to be a rare occurrence where I am because I have been at Q2 for 11+ straight years here now and Sat. was the literally the first time it had hit me...

Im loath to do all the work for contracting only to have it be another 10 years before they come again.
 
Hopefully they will be growing organs in a lab sometime in the near future and render these people obsolete.
 
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We do this in our group. We bill the donor agency on a per occurrence basis for both the frozen section and then processing and interpretation of the permanent tissue. I notify the resident that it is happening, but I don't require them to come in (I make it voluntary) - I don't think it's very educational to count viable glomeruli or estimate the percentage of fatty change in a liver.
 
This could be very critical to the graft. Sounds easy but if you don't have experience you could really shorten someone's life.
They can tote the organs down to the University. I am not messing with this.
 
This could be very critical to the graft. Sounds easy but if you don't have experience you could really shorten someone's life.
They can tote the organs down to the University. I am not messing with this.


They call us in to look at biopsies of the livers they are taking out occasionally. Invariably it is in the middle of the night since that is when they can get the OR time, though sometimes they do it during the day. I'm sure they redo the biopsies and when they arrive at whatever institution they are going to transplant the liver at. I usually just cut an extra level and send an extra H&E along with the organ team.

It seems they usually keep the donor on life support for a day or so while getting everything set up, so we usually get a heads up at least a half day or sometimes more in advance. I'm very clear with them that I only live 10 minutes from the hospital and they should only call me once they have the tissue in their hands. I can usually make it to the lab from my house before they can find their way to the basement of the hospital with the specimen.

Usually they have a little sheet with check boxes for the amount of steatosis, necrosis, and fibrosis. Make sure to keep a copy of it with the UNOS number so you can send a bill to organ network for the frozen and final interpretation. Sometimes I put a disclaimer on the form that the slides and organ should be reviewed at a center with expertese in transplant pathology.

I trained a place that did a lot of transplants, so I was used to this a resident, but it was not until maybe the last 3 or 4 years that the organ teams have started asking for frozens at my private practice hospital. Maybe we didn't have that many organ donors before. I'd say we probably do this once a month so, but it's divided among all the the pathologists in our practice so it's infrequent.
 
I had to do this as staff a couple months ago for the first time in 12 years. My mistake was doing the liver at 7 pm going home and getting called to do the kidneys at 3 am. I should have known....
 
I wonder how important these frozen really are. Those of us who have done a ton of posts get very good at gross organ examination. I don't think that a liver or kidney that appeared "normal" would harbor SIGNIFICANT steatosis and/or fibrosis or sig glomerular sclerosis to the extent that it would be unsuitable for transplant. This all sounds like something that the surgeons and hepatologists decided was a "good idea" because they have no idea of what we can do without (or with, for that matter) a microscope. Just more abuse. Nice to be retired.
 
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