Week Three at Magee Womens Hospital

These past three weeks at Magee’s have really gone by in a flash. I can remember when I was still a fledgling not even knowing how to use the voice software and now… well, I still consider myself to be a fledgling, but I have made much progress.

As this was my first rotation with grossing experience there were many things that I needed to learn, not just about the specimens, but also about how to work as a PA.  Such things included how to handle a scalpel and forceps, how to keep my bench clean while grossing placentas, how to fill and seal bags containing formalin, how to predict when the VoiceOver software will misinterpret your commands, how to order additional cassettes, how to finish the specimens so that you can leave on time, how to read bad handwriting on requisition forms, etc… When it comes to grossing, there is only so much one can learn from just a textbook.

While in the gross room I had the chance to gross a good number of specimens and every day was filled to the brim. The following are just a few of my own personal observations regarding certain types of specimens.

-Placentas are perhaps the most ‘messy’ of all specimens so you need to be especially conscious of keeping your area, hands and tools clean. (Placentas are also messy because they are done in high volume.) I have always been a conservationist (I recycle whenever given the chance, walk instead of drive, turn off lights when they are not needed, never let food go to waste, etc…), so when I was first told to leave the fresh water running so that I could easily keep my hands and tools clean I was skeptical. Eventually, I realized that some things just can’t be helped and let the fresh water run for as long as I had placentas to gross. I also used copious amounts of paper towels to wipe all blood at every opportunity and changed my gloves much more often. Although I surely had created much more waste, it made my life much cleaner and reduced any blood-related hazards.

-It’s easier to stop what you are doing and clean-up blood while it is still wet than to try and clean dried blood.

-I’ve been doing membrane rolls of the amnion with forceps, but sometimes it can be difficult because the forceps taper to a point. The best tool would be one that has a flatter pincer but also leaves an area for a pin to be stuck through. I need to invent a good tool for that one of these days.

-I have found that when doing a placenta the most useful thing to do is to take the placenta out of the bag and hold it under the sink with running water to wash off all of the excess blood. Just make sure that no segments of previously cut umbilical cord fall down the drain. If you are good, you can dictate your clinical history into the computer while you are washing to save time.

-When taking sections of the parenchyma from a placenta, it’s easiest to start cutting from the fetal side. If you cut from the maternal side the cotyledons will often crumple and become deformed.

-When sealing the bags that contain the placentas that you have grossed, every time you must make sure that the inner surface of the bag is clean and dry, otherwise the plastic will not melt when you seal it. Don’t worry about the trees, just use all the paper towels that you need to.

-Almost every other specimen is easier to cut with a scalpel than a placenta.

-Viewing villi under the dissecting microscope is like entering into another world. For some reason, I feel a sense of awe come over me, every time. It is as if I’m being transported into the biological coral reef of a human being.

-Uteruses can be difficult to bivalve with scissors because they are thick and tough, but if you’ve got strong fingers I say go for it.

-It’s important to try and take sections from your specimen without eviscerating the entire thing into a myriad of unattached, un-oriented slices. My worst nightmare would be if a pathologist came back to me asking for more slices from a certain area and then I had to sift through all of my remaining pieces and try to find that one slice. It would be like trying to find a single piece in a jigsaw puzzle that has many pieces already missing. I’ve already got shivers going down my spine.

-Any time you cut into something that you think might squirt, it’s best to keep your head as far away as possible. Better yet, do the cutting in the sink.

-Wearing glasses is not enough to protect your eyes. You absolutely need to wear special visors for eye protection.

-Finding a biopsy clip in a breast is not always an easy feat. I’d like to get more experience in finding clips by just using my fingers, but sometimes, especially in a mastectomy where the lesion is large, you need to be a cheater and go to the faxitron.

From here on out I’ll be heading back to Morgantown to start my rotation at the medical examiner’s office. I’m looking forward to it, but I will miss the kind and patient PAs who helped me at Magee. West Virginia, here we come!

Week One at Magee Womens Hospital

This week was a very exciting week for me as it was the first time I really got to delve into grossing and dictating. My previous rotation location was at the Shadyside Tissue Bank and although I handled patient specimens I didn’t get to ‘dive-in’ so to speak with each specimen. The tissue bank was very involved administratively, but you can’t get much more hands on than grossing and dictating. 

During the fall of 2011, our class spent a week at Ruby Hospital to practice grossing and dictating simple specimens, such as biopsies, as a kind of preparation for these rotations now. I’m very grateful for that experience because I struggled enough as it was through this first week.

As might be suggested by the name, UPMC (University of Pittsburgh Medical Center) Magee Womens Hospital especially deals with gynecological specimens and pathologies that commonly involve women. I may have mentioned this earlier, but the hospitals in Pittsburgh under UPMC each specialize in their own field and are known as “Centers of Excellence”. The pathologists and pathologist’s assistants who work here are highly trained and knowledgeable about women’s health and it’s a great opportunity to learn from the best here. 

That being said, starting out was a bit daunting. The surgical pathology laboratory at Magee commonly receives such specimens as placentas, endocervical/endometrial curettages, uteruses, ovaries, breast core biopsies and breasts. Perhaps their most routine specimen is the placenta and that is where I had the opportunity to spend the majority of my time practicing grossing and dictating.

The placenta was quite different from most of the other specimens that I had encountered up until that time. It may be difficult to explain for people who are unfamiliar with how a dictation works, so I’ll try my best to explain.

The role of the pathologist’s assistant is to create a gross description of a specimen, that is, to describe a specimen’s appearance, measure the specimen’s dimensions and submit appropriate sections (cuts of the specimen) to histology so that the pathologist can look at the specimen under the microscope. This is much easier said than done. The gross description is a medico-legal document and just by reading it you should be able to recreate how the specimen looks in your head. There is a specific ‘language’ that pathologist’s assistants use that make the whole description sound foreign, so I’ll try and give an example using something that happened to me after I had microwaved my potato last night.

“The specimen is received cooked, labeled “Mr. Potato” and 3122 (ok, it really wasn’t labeled). It consists of a 9.1 x 5.5 x 5.2 cm firm kidney-shaped potato weighing 184.2 grams. The external skin appears brown-yellow, rough and intact with multiple focal areas of pitting ranging from 0.2 cm in greatest dimension to 1.1 x 0.6 x 0.2 cm. Sectioning through the potato reveals a yellow-white, glistening, smooth and friable cut surface with a 1.1 x 0.2 cm in diameter tan worm which is filled with a  tan, watery fluid. The worm is located 2.1 cm from the nearest anatomical margin. The specimen is submitted entirely into the trash for disposal.

Time in trash: 7:34 p.m. 2-4-2012

fgm”

Hopefully you were able to get a picture of what this potato looked like just by reading the description. Describing a potato is leagues easier however than trying to describe something such as a uterus with bilateral adnexa attached.

Thus, my first week was more than just practicing on placentas. It was also getting used to the whole system of dictation, trying to come up with good descriptive words, learning how to cut with a scalpel and handle different utensils quickly, learning all of the different commands in ‘VoiceOver’ (the dictation system), remembering what sections need to be submitted for each specimen and learning how to approach a specimen.

The first time I I took on a placenta, it seemed almost overwhelming. Where do I even start? What do I say? What words do I use? How do I orient this thing? Fortunately, the kind PAs at Magee were there to answer every question I had, and I had plenty of them. By the time I had finally gotten through my first placenta, I looked at the time and realized that more than an hour had passed. Nonetheless, it was a triumph and I felt great. The next placenta I took on took me about an hour. The more that I did, the more that I became used to the flow. 

The reason that the placenta was so much more intimidating than just a biopsy was because it was difficult to tell where to even start. But, as I worked on each successive specimen, I realized that despite its complexity, it could be broken down into smaller fragments that you can accomplish one at a time. Basically, a placenta needs four things to be identified and described, 1) the umbilical cord, 2) the membranes, 3) the fetal surface and 4) the maternal surface. Once you take this large and daunting specimen and break it down into its component parts, it becomes much more workable. It’s as if you have a plan laid out in front of you and you are going to do each part in step rather than jump around wondering which part to do next. 

By the end of the week I had become proficient enough to gross and dictate a placenta within 30 minutes. It’s still a long ways off from the average 7 minutes or so that the PAs around me are able to complete these in, but I’m still very pleased with my progress. Now if I could only get the software to recognize my words more accurately I’ll be the go-to-guy for placentas. The voice-recognition software has been frustrating at times, but I’ll leave that rant for another time.

I also had the opportunity to work on my very first uteruses. I expect to do many more this upcoming week, so I’ll save that for another time, too.

It was an exhausting but very educational experience this first week. Completing my first week of grossing and dictating has been similar to the euphoria one gets when having hiked all day and come home. It’s going to be tough, but I can’t wait to get some more experience.

Week Three at Shadyside Tissue Bank

[Written in the third week of January]

Well, there are only a few more days until our first test of the year, so I have been mostly focusing on studying for that. There are still many things that I’d like to talk about in regards to the tissue bank however.

I haven’t touched on any of the hands-on work at the tissue bank yet. I think that it would be easiest to divide the specimens that we work on between ‘patient non-consented’, ‘patient consented’ and 'special protocols'.


Non-consented Specimens
As mentioned in an earlier post, even if a patient has not given their consent to use their excess tissue for research, if the tissue has become de-identified/anonymized, then it can still be used. For these specimens, first, the PA grosses the specimen in the pathology laboratory. While they are grossing, if they can see obvious tumor and don’t need to submit all of the tissue to the pathologist for diagnosis, then they can give some of the excess tissue to the tissue bank technicians fresh from the bench. As soon as the tissue is put into the hands of the tissue bank, the tissue is assigned an anonymous number and all of the original patient information is put into a database that only the tissue bank workers can access. (Only ‘honest brokers’ can view this information and that is why all people working in the tissue bank are certified honest brokers.) So now, the tissue can only be identified by a number. The tissue is placed into a large freezer in pieces that are no heavier than 0.50 grams (or as close to 0.50 grams as possible). This means that if a large piece of tissue is given to the tissue bank techs, then they will need to cut the tissue.

There are a few other things about banking that I left out, but the above describes the basic process for most tissues.


Consented Specimens
When a patient consents to let their excess tissue be used for research, in addition to the normal excess tissue being donated, a blood sample is also taken. Researchers use this blood to mainly look at RNA or DNA. The blood is put into a centrifuge and separated into its component parts. Blood that is collected into normal tubes is separated into an upper layer of serum and a lower layer of red blood cells. Blood that is collected in tubes containing an anti-coagulant are separated into an upper layer of plasma, a middle layer of white blood cells and a lower layer of red blood cells. The middle layer of white blood cells contain the RNA and DNA that is of most interest to researchers.

Each of the blood components is put into a number of different small plastic vials and placed into a freezer.

Special Protocols
Another task of the tissue bank is keeping track of all of the various researchers and their research projects. There may be more than a dozen different projects going on at any one time and some of these projects require that fresh tissue be handled in a special way. Each researcher creates a protocol to follow for tissue that is for their particular study, which means that the tissue bank technicians need to keep track of and remember how to handle each different specimen. For example, (the following is just a protocol I thought up) some special study may require bladder tissue and the bladder needs to be prepared in a special way by the pathologist assistant or the tissue needs to be put in a special medium rather than frozen. In addition to blood, the tissue bank technician may also receive urine to be frozen. Not all tissue may be usable either. Some researchers are only looking for tissue with a certain kind of tumor or the tumor has to be a certain size or it has to show invasion through the serosa or any number of other conditions must be met. It’s a daunting task keeping everything straight and can get hairy when things get busy in the lab. And on top of all of that the tissue needs to be processed as fast as possible to prevent degradation, especially of RNA.

Because of the time-sensitive nature of many of these protocols, often the surgeon in the OR will call the tissue bank directly and request that they come and pick up the specimen by hand. The tissue bank has been my first experience in going to an OR and I found it to be interesting. We are only in-and-out of the operating room but there is a slight rush of adrenaline because you are racing against the clock to get the tissue/blood back to the laboratory as soon as possible.

Week Two at Shadyside Hospital Tissue Bank

[Written in the second week of January]

The end of another busy week has come to its conclusion. I think I'm getting the hang of my daily schedule as well as integrating into some of the daily activities at the tissue bank.

The first topic I'd like to mention is when we are supposed to study. That's because I haven't found the time to hardly study yet! I expect the pace of things to settle down a bit because now we have completed a lot of the administrative things that needed to be done such as applying for UPMC accounts, receiving UPMC IDs and attending orientations on the various software that we use such as CoPath. The lack of time after arriving at home at the end of the day actually makes me want to stay at work longer. During the weekdays, I actually like it better at work than at home. Home has become a place where I basically sleep, shower, cook and eat. My daily itinerary is something like this:
6:00 AM - Wake up
7:00 AM - Leave for work
7:45 AM - Arrive at work
12:00 PM - Break for lunch
1:00 PM - Return to work
4:30 PM - Head home
6:45 PM - Arrive at home, shower, cook dinner, eat, wash dishes
8:15 PM - Where did my day go???
10:00 PM - Sleep
I'm not saying this to scare anyone or complain. I'm just pointing out that when you do this rotation (and perhaps others), you're going to have to make time to study. One strategy that I've been doing is studying while I eat lunch and while I ride the bus. I'm grateful for the three-day weekend that we have ahead of us because I need to play some catch up.

It's great that I've been busy in the tissue bank because there have been so many different things that I've been exposed to. I actually think that I'll learn more (in volume) here at the tissue bank than at the gross room.

There are so many experiences I want to write about that it's difficult to choose where to start.

You can think of the tissue bank as a special kind of salad bar. Just as a salad bar has all sorts of different vegetables, a tissue bank has all sorts of different tissues and blood specimens. The purpose of the tissue bank is to serve as a repository full of different biological specimens that researchers/scientists can use for their research. Think of the patrons of the salad bar as the researchers. They are hungry for a certain salad and they're really picky. They want 15 lettuce leaves, 5 baby tomatoes, 7 croutons and 3 tablespoons of Italian dressing. Before the patron can get their salad, they have to write their order down and hand it to the salad chef. Once the salad chef approves of the order, the salad chef hands off the salad items to the patron.

Ok, it's actually a lot more complicated than that, but that's the best I can do.

Why do we need tissue banks?
In order to test the effectiveness of certain therapies, discover new pathways for drugs, etc... often, the only thing that is suitable for research is real human tissue. Experimenting on mice is better than nothing, but experimenting using human tissue gives researchers more accuracy in predicting the behavior of a drug or therapy. Without tissue banks, researches would have to get their own tissue themselves, store it, prepare their own tissue, etc... Doing all of this on one's own would cost an immense amount of time and money.

Why is there so much fuss about protecting patient tissue? It's just tissue, right?
In the past there have been horrific instances where researchers disregarded human dignity and caused much harm, such as with the Tuskegee syphilis experiments, Unit 731 and Nazi scientists, so you can't just request human tissue willy-nilly. (99.999% of researchers are not the 'crazy mad scientist gone amuck' as may have been suggested in the previous sentence. They are working their butts off to advance health care and save lives all in a day's work.) A researcher who requires human tissue must get approval from a special group called an Institutional Review Board (IRB). The researcher needs to explain what their study is and exactly what tissue is required. Once the IRB approves, the tissue bank can send the requested tissue or blood to the researcher. The IRB is not meant to be a road block to acquiring tissue, but rather a facilitator and a guide to help the researcher get the tissue that they need.

So what does a person who works at the tissue bank do?
The people who work at the tissue bank serve as what are known as 'honest brokers'. An honest broker acts as a mediator between the researcher and the data/tissue/patient. The honest broker protects the private information of the patient by de-identifying the patient's data/tissue. (One de-identifying system that is used is called 'caTIES' or Cancer Text Information Extraction System) The researcher never has a name or face to associate with any of the data or tissue that they receive.The honest broker is the lynchpin who connects the researcher to the data/tissue.

What type of things might a researcher want from the tissue bank?
Many researchers just want data. For example, (the following is entirely fictional) they just might want a list of all white men between ages 40-50 who had a nephrectomy for renal cell carcinoma without metastasis who underwent a certain chemotherapy and then showed relapse after 3 years, etc... In such a case, the researcher still needs to go to the IRB, explain about his study, be explicit in what information he needs and get it approved. The data that the researcher wants is called a an 'LDS' or 'limited data set'. The honest broker then needs to give the LDS to the researcher so that no superfluous information has been revealed. This is easier said than done. Often times, the researcher will discover something else and request more data, in which case they need to get another approval from the IRB.
In the case of tissue being requested by a researcher, it must be handled under similar strict guidelines. Of course, all patient identifiers must be removed. As with data, the tissue must be used strictly for the purposes of the study submitted to the IRB. (You can't decide to do a different experiment with the tissue or give it to your research colleague who also wants it.)

So what tissue exactly does the tissue bank collect?
It can really be almost anything. UPMC Shadyside focuses on genitourinary specimens, so a lot of prostates, bladders and kidneys are stored. You'll also find other tissue that is stored such as lung, liver, soft tissue, thyroid, etc...
Researchers typically need three things all from the same patient in order to do their studies.
1. Tissue containing tumor
2. Tissue free of tumor
3. Blood (particularly white blood cells)
You might be wondering why the researcher wants blood even though they already have the tumor and some normal tissue to serve as a control. A lot of research is done on gene expression or sequencing and either DNA or RNA is needed. White blood cells are needed because they contain the DNA/RNA. (Remember that red blood cells don't have a nucleus.)

You mean I could be unconscious on the operating table and the researcher can sneak in, draw my blood and snip out my organs while I'm knocked out without me knowing?  No way Jose.
The above was an exaggeration, but this is where consent comes in. If a researcher needs your blood or tissue for research, they'll notify you and explain to you why yours is needed. Life saving treatments wouldn't exist without tissue donations and although you might not benefit directly, in the future, any person who shares your same malady might not have to suffer through what you did.
Tissue that is needed for research always comes secondary to the clinical diagnosis and treatment. Your care is primary and supersedes everything else. Only excess tissue that is leftover can be used for banking. In the end, people almost always consent when asked for using their excess tissues for research.
In cases where you do consent, during the surgery, the only thing that will be different is that a little bit of your blood will be drawn as well. (Your tumor infected tissue was going to be taken out regardless of whether you consented or not.) This blood is so that researchers can do DNA/RNA research.

What if a person is never asked for their tissue? Can their tissue still be put into the tissue bank?
Yes. As always, diagnosis and patient care come first. Even without a patient's explicit consent, if there is any leftover tissue it can be banked. Of course, all identifiable information is removed by the honest broker, so there's no way anyone else will know who the tissue came from. Because the patient wasn't asked to donate leftover tissue to the bank, blood will not be drawn from them during the surgery. (Drawing blood would only occur for research purposes, not for the sake of the operation, so drawing blood is prohibited.) It would be a waste to let precious leftover cancerous tissue be thrown in the trash, so some of it is frozen and stored for future researchers who might need it. In addition, according to law, once tissue has been de-identified it is no longer considered to be human tissue, but rather non-human tissue.
Without patient consent, research becomes much more difficult, since the valuable DNA/RNA component is not there from the blood.
It's a little strange, but I agree in that you shouldn't let things go to waste, especially if there is no harm in doing so and the thing being thrown away is very precious. Think of it like a person who sifts through a garbage heap to take out the plastic recyclables. It's not like the person who threw out the plastic specifically wanted their plastic trash to be put into a landfill rather than be recycled. Except with tissue it is magnitudes of greater importance.


Man, I haven't even gotten to the general routine duties that we do in the tissue bank. So far what I've typed has just been an outline of the tissue bank. Next time I'll get around to what honest brokers do to prepare and store tissue. That's the fun part!

Oh, and welcome to my humble abode. These pictures are from when I just had moved in with Prashant, my classmate, on the 31st of December. I've got a mattress now, so sleeping has become good once again.

Dazed and weary from the moving. My roommate must have had three times as many items as I did.

Traveling light is the way to go.

First Day at Shadyside Hospital Tissue Bank

[Written in the first week of January]

Finally, I have found the chance to sit down and contemplate for the first time today.  Prashant and I left our home at 6:30AM and we finally got back at 7:20PM.

In the morning, we awoke to snow covering the cars and icy streets in a layer of powdery white. Just yesterday, we had passed an SUV in our neighborhood that ran right up into a telephone pole and we were hesitant to drive under these conditions. We even considered taking the bus line, but we decided to try our luck with driving. Driving turned out to be a mixed bag of rocks.

Prashant’s GPS (who we jokingly refer to as his girlfriend because of the monotone female voice) led us astray off of our normal path and we took longer than expected to arrive at Shadyside. Fortunately, we had the foresight to leave extra early just in case something like this happened. What should have been a 25 minute drive turned into a 50 minute drive. Let this be a lesson that in some cases foresight/preparation can overcome bad luck.

At Shadyside I met the staff at the tissue bank and the gross room and was given a short tour of the facilities. Soon after, I spoke with the manager of the tissue bank. She explained to me the great breadth of work that goes on regarding the tissue bank and its administration. Although it is her goal to facilitate and encourage surgeons/researchers to make use of the tissue bank, there is a lot of paperwork that needs reviewing, guidelines that must be followed and all sorts of communication is needed between many of the various organizations that are involved. She was very kind and patient with answering my questions, but there was so much information to be absorbed that I fear my brain half turned into porridge.

There were many concepts that we covered, but some of the main ones included the role of the Tissue Bank Institutional Review Board (IRB), the role of the Committee for Oversight of Research and Clinical Training Involving Decedents (CORID), the role of honest brokers and the role of Tissue Utilization Committees (TUC). She also discussed patient consent , which tissues require which protocols and the process that surgeons must undertake in order to use tissues for research. I could probably spend a year or two just here at the tissue bank and still not know half that there is to know.

After lunch I had the opportunity to get some hands on experience with retrieving, filing and storing tissue. As a general rule, tissue needs to be collected as fresh as possible and frozen as quickly as possible. Tissue to be stored for research can come from either
1) Directly from the operating room
2) From the frozen section room

 At the beginning of the day, there is a printout that details all of the surgeries with harvestable tissue for the day. This way they can expect when to go and pick up the tissue directly from the operating room. Of course, the diagnosis and grossing of each tissue takes priority over the research, so often a tissue will be sent to the frozen section room first, or a gross needs to be done before a piece of tissue can be stored for research. In many cases though, the surgeon will just provide a piece of tissue that we can pick up directly from them and store for research immediately.

Tissue stored for research usually has three components.
1) The tumor itself
2) Uninvolved ‘normal’ tissue
3) Blood

The main thing that researchers ask for is the tumor, but oftentimes uninvolved tissue and blood is requested as well for their research. For this reason, uninvolved tissue and blood are also taken and stored with each piece of tumor when possible.

With the guidance of a very kind tissue bank worker, I tried my hand at filling out the necessary forms and storing the tissue. It took a couple of tries to remember all of the components needed on each form, but I’m sure that as the week progresses it will become second hand.

The end of the work day came at 4:30PM and Prashant picked me up at 5:00PM. This is when our day really turned to a screeching halt. Today was the first big day of real snow in Pittsburgh and traffic was grinding to a halt all across town. Joggers were passing us by at every block (I could hardly believe they were jogging in this weather) and the roads were so crammed that each green light cycle only allowed one car to cross the street. One measly car! Escaping from Pittsburgh was a nightmare. I have not experienced any worse congested traffic in my life. We tried to take the freeway and when we finally got on it was bumper to bumper for 5 miles. The freeway system is a mess, similar to a spider web except that a spider can spin its web faster than you can get to your destination. If it weren’t for the weather being so cold, I would have gotten out of the car, ran home and had more than an hour to spare. If there is anything that I gained from being stuck in traffic for nearly 2:30 hours, it is that I can understand how people can succumb to road rage.

There are three modules (Conflict of Interest, HIPAA and Research Integrity) that I will need to complete online as soon as possible. After getting home at 7:20PM, eating dinner and taking a shower, I have had no energy to go to the local library to use their internet and complete each module. However, I am thankful that they are giving me some leeway time to complete them.

I could definitely use some more of their foresight.

Temporary Hiatus

There are a few issues that need to be resolved before blogging can resume. In the meantime, to all of my readers, keep up your hard work!