A Trip to the Pathology Laboratory / Gross Room

These past couple of weeks have gotten really busy with the end of the semester coming. Tests have been coming at two per week for the past month, but the good news is that there's only two weeks and four more tests left. Everyone is getting wore out, but the end is near (in a good sense).

Yesterday, Friday, was a much needed holiday and I spent the most satisfying day of my life doing almost nothing. That holiday was Good Friday, and like any good PA student I decided to drop by the pathology lab / gross room. (No, it's not called the gross room because there's blood and guts everywhere. It's because it's where the pathologists' assistants observe specimens 'by eye', or grossly, as opposed to using a microscope. Although, I will say that some of the specimens that come in are quite up there on the gross scale.)

All of us students at WVU have a two day rotation in the gross room during the first semester and the truth is that I had already been there a month before back in March. I just hadn't gotten around to making a post about it. So, I am happy to say that instead of studying extra hard for my final tests I'm going to take a break and write about what you've all been waiting for. The gross room. The gross room (or surgical pathology laboratory, whatever you want to call it) is the environment where PAs will spend the majority of their time working.

You might remember in my post on my trip to the histology laboratory that I outlined the progress of a specimen and the different places that it moves through. After a piece of tissue or organ is cut out by the surgeon, the first place it is sent to is the gross room. There are histotechs (I believe they are histotechs and not laboratory assistants but correct me if I'm wrong) in the gross room who will accept the container and log that it was received into the computer system. It would be a disaster if someone had their kidney removed and then we couldn't find out where it went, so specimens are tracked wherever they go.

You might also remember these cassettes from before.

Each of these cassettes will hold a piece of tissue that the PAs cut off of a specimen and submit to histology. A single specimen may require many cassettes to hold all of the different pieces of tissue that the PA cuts off and each of these cassettes needs to have some kind of identifier. Wouldn't want to get the cassettes of one patient mixed up with another. So, the histotechs kindly label each cassette with a case number by using this machine.

I don't know the name of this machine, but it does remind me of a jenga tower. 

After the specimen has been inputted into the system and the proper cassettes have been made the pathologists' assistant comes onto the scene. The next picture is what a typical PA's lab bench looks like.

Pretty neat. The gross room at Ruby Hospital here at WVU has four benches like this one.

You'll see that this bench is all tidy and ready to get to work. The PA receives the container with the specimen in it, the empty cassettes from the histotechs and of course a requisition form for the specimen. Once again, everything is compared to what's in the computer. It's good to be obsessive compulsive here.

The PA's job is to basically look at the specimen, describe what it looks like in words, look for evidence of tumors or other suspicious areas and properly cut the right pieces from the specimen so that the pathologist can make a diagnosis. (The cut pieces will be put into those cassettes and sent to the histology lab before it gets to the pathologist.) It's important not just to cut pieces of tissue that show the tumor itself, but also slices of tissue at the borders of the specimen that can show whether some of the tumor might still be in the patient! The surgeon will have to go back and cut out more from the patient if tumor is along the edges, so for the PA to determine what to cut and where to cut is especially important.

Each specimen has its own procedure on how to prepare it, how to cut it, what sections to submit to histology, how to describe it and so forth, so unfortunately, I can't tell you all on this blog what to do when you get something like a heart or a brain. You'll have to join me for two years of PA school heaven to find out. It's really great. We even get to do things like go back to elementary school and do painting! Don't believe me?

All those pretty colors there are inks that PAs use to paint their specimens. Not only is painting fun, it helps the pathologist. The pathologist wants to see whether the tumor in a specimen extends out and reaches the edge, but it's kind of difficult to tell which border is the outside surface when looking in a microscope. If a PA covers the outside surface of a specimen in, let's say, green ink and cuts out a piece of tissue that includes the green ink, then when the pathologist looks under the microscope he'll automatically know that the border with a line of green ink is the outside surface of the specimen. Any tumor that reaches the green line may still be in the patient.

Now, the PA also needs to describe in words what the specimen looks like. But it isn't as simple as just saying, "The tumor looks like a marshmallow". PAs have to learn a completely new language. Well, it's not completely new, but if you've ever heard a PA dictate a specimen into the computer, you would be in awe of their foreign language skills. Although I haven't learned to speak PAnese yet, I can speak a good amount of Japanese so I should be alright in the end.

The PA speaks through a headset with a voice recorder connected to the computer that looks something like this.

Whatever the PA says is put into the computer as text. The special program in the computer called "Dragon" takes care of the conversion, but it's not always perfect. I would not recommend trying to sing the "Pheasant Plucker" song through here. Even if you don't screw up the program will make sure that you do.

Whenever the computer makes a mistake, you'll be able to correct the mistakes the old fashion way, with a keyboard and mouse.

You'll notice that the keyboard that PAs use is a bit different from your normal keyboard. The keys are completely covered by rubber and it isn't because the fingers of PAs are messy from eating donuts. I'll let you figure it out.

So after the PA has described the specimen and cut out some pieces of tissue to send to histology the PA needs to put those pieces into the cassettes. Not all tissues are the same, so they'll be put into different cassettes and each one will be handled and prepared differently. Here's just a box of cassette holders that some cassettes can be put into before being fixed further.

In some cases, the patient will still be on the operating table while all this is going on. In such cases, evidence of tumor near the borders of a specimen need to be identified with great haste. Everything described up until now has been for specimens that have no urgency. If your patient is on an operating table with their abdomen open and the surgeon is waiting for the word on whether or not more needs to be cut out, it is not the time for you to be doing dictations. In these STAT specimens, you'll have to become both a PA and a histotech.

Fortunately, there is a device that will make sure your head doesn't roll down the hallway. Below is the awe-inspiring cryostat.

Does it look familiar? It's very similar to the microtome that histotechs use, complete with hand crank on the right. Unlike histotechs though, the tissue that PAs cut on this machine hasn't been fixed in formalin. That makes things a bit tricky. Tissue that hasn't been fixed in formalin or some other medium is more fragile and can tear when it's cut into thin slices. The solution is to freeze it.

It's actually pretty cold inside the cryostat. A special cooling gel called "Optimal Cooling Temperature" (confusing, I know) and a huge block of metal called a heatsink are put on the specimen to freeze it. Once the specimen has been frozen, it can be mounted and then cut like in the microtome. It's still a bit trickier cutting with the cryostat than with the microtome, though.

After you've got your slice of tissue on your microscope slide it needs to be stained.
 

You can dip the slides into these containers to get the right stain that you want. After that, all that's left is for a pathologist on call to take a look.

Normally, tissues submitted to histology will be completed the next day after they've been fixed overnight, but with this you can get a slide for the pathologist and they can make a diagnosis all within 10 minutes. Now, the poor patient doesn't have to stay on the operating table overnight with their abdomen open.

There are a lot of neat things in the laboratory that I haven't been able to cover. Here's one that might pique the interest of you photographers. They say that a picture is worth a thousand words and here in the gross room, they aren't kidding. You can take a picture of any specimen that you receive with this camera setup, though it's not going to save you from having to say a thousand word dictation.

Here's a somewhat grim last picture for you all. It's another tool that you would think you would find in a carpenter's workshop, but this saw wasn't made for cutting wood.

Hopefully, this quick run down of the pathology laboratory has given you a little more insight into the workings of a hospital and the lives of PAs. If you enjoy being able to concentrate on your work, use your head and share a love for the biological sciences, then becoming a pathologists' assistant may be a career you should consider. Don't forget, you get to paint like a grade schooler and use a bunch of cool power tools, too.