Grossing stinks!

Grossing stinks

Not figuratively, but literally.

Specimens come in preserved in formalin, which has its own smell... sort of a dusky chemical smell, not sharp like alcohol, but pervasive. What is worse though is that it fills your sinuses and it burns. Your eyes weep from the fumes. Old histotechs and lab assistants seem to take pride in how tolerant they are and how after decades of marinating in it they can stand calmly while the rest of us writhe on the floor gasping for fresher air. The CAP standards for ventilation are pretty high though so formalin stink isn't that big a deal anymore. Just don't open a large formalin filled specimen container that has been in the back of a hot courier car because the vaporized fumes hurt!

It should also be noted that formalin fixed feces still smell like feces. And anything that is putrefied still smells just as bad as it did before formalin was dumped on it. You would think that because formalin is killing the bacteria that is causing the rot, some of the stench would go away but you would be wrong. Oh, so very wrong.

There's a smell that you get when you cut bones on a band saw...It is hard to explain and I've only ever smelled it when doing that so it is rather hard to compare it to anything. All in all it isn't a bad smell, just one that is unique to grossing. My best comparison would be dry dog food...but hot dry dog food.

Skin and fat removed with a cautery pen sitting in a specimen container with no formalin on it? That smells like burnt rubber, but more like a pencil eraser rubber than burnt tire rubber. Expect this with breast reductions, pannectomies, etc. It isn't horrible, dissipates quickly, and seems to be lessened by the addition of formalin.

Autopsies tend towards B/O, methane, blood and urine. Although, not necessarily in that order. The morgue has a faint slaughter house funk, a definite hint of offal. Not overwhelming in the places I have been but noticeable and persistent.

And of course a blog entry on grossing and stench would not be complete without mentioning cyst cheese*. Cyst cheese... after you cut into a big nasty cyst you have no choice but to stop 

This is cyst cheese, avoid it at all costs

what you're doing and disinfect your station. Your gloves stink, your forceps, your scalpel blade reeks. Even after putting it all back into a formalin container with a screw on lid they can still be overpoweringly rank. We once had a case so bad that even with the ventilation in our gross room (which was built in 2009 with amazing ventilation) there was a 10 foot radius of stink. We put it in several layers of gloves and tied it off, then double bag it in ziplocked specimen bags before it was down to a tolerable level. The worst part is that even after going through processing with formalin, alcohol and xylene, cyst cheese still stinks and will contaminate the embedder's forceps and the histotech's microtome.

So yeah, just a heads up.
I'm not saying everything stinks or that it is something that makes my job miserable. More that it is something that comes with the territory and if you're getting into grossing as a tech or a pathologists' assistant that you should be aware of it.

*Not the technical term.

Applying to the Duke Pathologists' Assistant Program

Duke University Medical Center

I thought I would write this because there is a severe lack of information about the application/interview process for the various PA programs. The only "resource" I've found is this thread which is long and doesn't have a ton of information about interviews but is a good read if you're interested in becoming a pathologists' assistant.

Duke is the only one I have experience with, but I will share what I know. First off, their website lists Pamela Vollmer's contact information and she really is the point person for admissions. She was very helpful when I was applying and was very prompt about replying to emails. She is also the one who notifies applicants about their status, which is mostly handled via email so use an address you check often.

The application isn't that long, there are two essays (one 250 words or less and the other is 500 words or less) and the application fee is a bargain ($55 currently). The academic requirements--if you don't want to read their page-- are GRE (they will accept MCAT scores but prefer GRE) and the college course prerequisites the NAACLS requires (biology, english, mathematics, organic or biochem, and microbiology). Competitive GRE scores are above the 50th percentile. Shadowing or work experience in pathology is strongly recommended (ie: you should really have this. The AAPA can help you find someone to shadow, info@pathassist.org,  but it may take them a while to get back to you). Applications are due January 31st of the year for which you are applying, but earlier is better since to get to Pam's office your application, transcripts and other mailed information has to make it through the Duke University mail system which make take a while. You do get an email when they have received all of your application materials, or if you mail your application in before January you get an email during the first week to let you know what you still need to send in.

The official time line to let people know when they are invited for an interview or not is by Feb. 15th  but both years I applied I knew earlier. I think I got my interview invitation on Feb. 8th. They offer you multiple interview dates (there are basically three weeks of interviews) and you rank them in order of preference. Replying quickly helps ensure you get the dates that work for you.

You are own your own for transportation costs but they put you up for the night and buy you lunch the day of your interview. Since you will be arriving the day before your interview, it is nice to allow yourself extra time the day before to tour the campus a bit and visit the Sarah P. Duke Botanical Gardens. You might be stressed out about your upcoming interview and taking a nice walk might help.

Part of the botanical gardens

The interview day starts at 8:30 and ends around 3:00 pm. There are two candidates per day but you are split up and on slightly different schedules. You meet with the program director, the assistant director, the surgical PAs, the autopsy PA's, the head of pathology at the VA where some of the clinical rotations are, the PA who is in charge of the off site clinical rotations, the financial aid office and finally you have lunch with the current batch of second year students. The financial aid presentation and the lunch are the only times you are with the other applicant. You get a good walking tour of the University Medical Center and nearby VA facilities when visiting various locations for your interviews, which is nice as well. You may also see the construction that will house the pathology department when it is completed in 2013.

Let me say this, the people who are interviewing you (other than the students--who do have input on who is invited to the next class) have all of your application materials and have read it all in depth. I was very impressed with their familiarity with the applicants' transcripts, essays, work experience, and even the people who wrote letters of recommendation. Be prepared to discuss any of it - good or bad. Unfortunately, this means that the interview questions are very tailored to the individual and I can't tell you what questions to expect to answer. No one asked me why I want to be a PA, but at the same time I am a grossing tech so PA is the next logical professional step. I was asked by a couple different people to give a brief biography, but that is good to have in any interview situation.

All in all, the interviewers are very nice, informative and easy to talk to. Read all of the instructions in the interview information Pam sends you, most importantly the part about having questions you can ask the people interviewing you. In addition to getting more information about the program itself, it shows them you have researched both the school and the profession enough to ask educated questions.

The second year student's lunch is also a great place to find out first hand experience about the program and also learn about the area- what to do, where to live, etc. The only information they have about applicants (I think anyway) is their current profession, where they are from and their name so be prepared to give another autobiographical summary.

After all the interviews are finished the admissions committee meets and invitations to the next class are issued. I interviewed during the second week of interviews, then there was a week with no interviews because a lot of faculty and PAs were at the annual AAPA meeting, then there was the final week of interviews. In hindsight I wish I had interviewed the last week possible because the waiting killed me! But in Duke's defense, from the time applications were due to the time they offered appointments to the next class was less than 6 weeks. It was an extremely short time frame from start to finish.

If you get an invitation to join the class you get a phone call from Pamela Vollmer with the good news and information about what happens from there (they mail you an official acceptance letter and a the technical standards which you sign and mail back along with a deposit check to secure your spot in the class. After everyone in the class has mailed in their stuff then a big packet of information gets mailed out, but I'm still waiting for that!). If you're waitlisted you get an email, and after everyone's deposit is received I assume you get an email telling you that the class is full. I know I read that you receive an email April 1st letting you know your standing and an official status as of April 30th, but I think Pam calls people as soon as she has an opening for them.

So that was my experience... One quick piece of advice when it comes to shadowing: Try to shadow a PA as opposed to a pathologist. Also, the PAs I have worked with have all mentioned that the various programs like to see letters of recommendation from PAs.

Eyes - Thoughts on loss of autonomy

I grossed an eye last night. It was a veterinary specimen as are most of the eyes we receive where I work (While we do occasionally get human eyes for things like melanoma, it is much more likely that we get eye parts like corneal buttons, schlera and conjunctiva), so I grossed it. The important thing to remember is to use a brand new blade (so it is very sharp) and to--in the abscence of a large mass--make sure to submit the optic nerve. We get a bizarre number of specimens with absolutely no clinical history, I'm not sure if it is a case of "make the pathologist guess why we cut this off!" or what. The paperwork for this case just read "L. eye" which was not particularly helpful.

My days of relative independence are sharply numbered. Our veterinary pathologist trained me and for the past couple years I've had a fair amount of freedom in grossing her cases. Occasionally I do have to consult with her to find out what to do with a particular specimen but months can go by without that happening. With our human specimens, as long as it is something I am signed off to gross I will do it or one of the other two grossing techs I work with will.  Anything larger either gets the on-call pathologist called in or it is held for one of the hospital PAs to gross the next morning. Very rarely anymore do we ever have to grab a pathologist and ask them how to do something.

But I'm going to be a student.  I need to put aside pride and what I think I know how to do. I will have months of school before I ever start grossing anything, it is time enough to forget the rhythm and cadence of my dictations. I am not so old as to be set in my ways or think myself so perfect that I feel like I don't have anything else to learn. I'm pretty sure the first few months of didactic learning will be humbling enough to make me realize there is lots that I don't know.

I am going to be graded, I am going to be challenged, I am going to be tightly supervised. I will not be a relatively experienced grossing tech that can be trusted to do her job without direct supervision--I will be a student awaiting instruction because getting as much out of the program as they are willing to teach me is so much more important than my ego.

This is my new perception of self

Points of information and my attempted self portrait in MS paint.



So the downside to starting this blog a good four months before I start classes (as of today four months and one day!) is that nothing too exciting is happening yet.. it is just me getting ready and making plans. Of course, at the same time I'm not forcing anyone to read this blog (except my husband, ha!) so feel free just to hang tight and wait for August for classes to start.
A few points I wanted to discuss:

1. My deposit check has been received so I am officially official. It doesn't seem real yet. I remember when I was accepted into the residential high school I went to (SC Governor's School for Science and Math) and even after I'd been there for a couple weeks it still just felt like I was at a science oriented summer camp (Why yes, there are biotechnology oriented summer camps and cloning plants will always be cooler than whatever crafts people do at normal summer camps--yeah, I fail at thinking up examples of normal kids crafts, do people actually make macaroni pictures?). I think maybe having the full information packet with dates, fees, recommended texts, etc will go a long way towards making it seem more concrete.

2. I am a mom, this is a blog, but this is not a mommy blog. My kids will come up from time to time because wanting to give 

Mock up of acceptable children's artwork

 them a better life is one of my motivators in education/life and because I will essentially be a single parent while I am going to school so some issues might arise. But I promise, to you, the reader, never to blog in this blog about my children's pooping* habits, the cute pictures they draw (unless the pictures involve their mommy decked out in a lab coat cutting up specimens, but only the first time that happens), or the many adorable things they say.

3. I need to study anatomy this summer. I don't think I'm going to take an official class but there are a lot of useful online resources that teach anatomy that I am going to take advantage of. As much as I enjoyed learning microbiology in college it didn't give me much of a background in human biology (other than cell biology, biochem, some immunology... okay, maybe it gave me a semi-decent background but was severely lacking in anatomy, how is that? I've picked up some both by teaching the Kaplan MCAT biology course and by working in grossing, seeing organs etc. but I feel like in terms of biological foundations it is the place I am most lacking).

4. I read through the unofficial guide they sent us and found this blurb about a class I am scheduled to take next January: For the practical you will be given a brain that has been cut in the same way that it is done during brain cutting. Your job will be to put it back together and identify structures. How cool is it that I will know (or at least should know!) how to do that in less than a year?! I haven't figured out yet if I'm terrified by the amount of information I will be receiving and need to be able to pass a test on (Duke's PA students' classes are the Duke Medical students' classes and I've heard at least three people describe trying to master the first six week's worth of material as trying to drink out of a fire hose) or excited by the prospect. I think excited is okay for now, but terror might rear its head as the summer progresses. I want to do well in this program and I sure as heck want to graduate from it so as cliche as it is to say this, failure is not an option.

*In the spirit of full disclosure, I have blogged about my kids' poop in the past in my personal blog. Mostly because it was hilariously awful and I had to share it with my friends. But you guys aren't here for poop stories (or at least hope not... I mean you do get a fair number of colons in pathology but I shouldn't think it should be anyone's focus. I bet there are blogs dedicated to people's bowel habits though...I wouldn't put it past humanity), so I'll keep that stuff quiet.

Skin and liver and spleens, oh my!

My dog, who is healthy**

Spleens. Seriously, spleens. Who knew, right? Prior to working for a veterinary pathologist I never knew splenectomies were so common. We've gotten one to two spleens a night for the past two weeks solid, which is a lot even for us. I would have to double check but I think after skin with attached subcutaneous tissue they are our most common specimen type.

Hm, maybe liver though because usually if they take the spleen for hemangiosarcoma they send liver since that's where mets would show up and then we also get liver as a specimen on its own. Okay, so I've revised it: skin > liver > spleens > everything else. On the upside spleens aren't hard to gross, they are just big and bloody.

Even formalin fixed splenic masses are messy

Plus the vet specimens are interesting/challenging*. With human specimens we usually get things that are taken as part of an outpatient procedure with occasional mastectomies, legs, or buckets full of bowel for the on-call doctor to cut in, but with vet specimens it could be a jaw, testicles, an eye, a reproductive tract full of puppies, a snake necropsy, bowel intussusceptions, limbs, toes, and pretty much every internal organ you can think of. And those I actually get to gross right now instead of having to call someone in. Of course, after I'm finished with PA school, I'll be signed off and trained on all of the human equivalents (um, not that here is a human equivalent to a snake necropsy) and I'll have a much broader understanding of why I am submitting the sections I am submitting and what diseases are likely for the tissues I'm grossing.

I'm good at my job, but I'm ignorant. I know how to gross things because I've learned that on this particular specimen type I submit this, on another type I submit that. Ink here, section there, etc. Brute memorization with some ability to apply previous knowledge to new situations. 

This is one of the reasons I wanted to become a pathologists' assistant. I want to know why I do the things I do, not just the how to gross part I have on some things now.



*Like fitting all the necessary sections in three 3 x 2 x .5 cm blocks from a mass the size of a grapefruit. 

**I am aware that because of the massive amount of hair on my dog he could actually be covered in mast cell tumors and I wouldn't know until we shaved him for the summer.