Three day weekend time!

They've already messed up my reservation!

I'm taking off all day tomorrow. It is my congratulations you got a masters degree day off, just a month later. It worked out having that day that I could schedule at will (or so I reminded myself when I was rotating while everyone else was off enjoying time with their family!). The kids will have their last day of school and I'll be picking up a uhaul to load up everything to go back to SC. It will be a working weekend but I'm still so grateful to have the extra day to get everything done.

It has been a relatively quiet week at the VA, one of the techs mentioned that the surgical residents had their boards so there were fewer procedures scheduled. Our resident is there for her first trip to the VA and it is funny to be the one that knows how to do everything, to be unfazed by frozens, or processors. After almost a year, I feel like I know where most of the supplies are kept even..er, except for the forceps which disappeared again. Where do the good ones always go?

Last week the other student on autopsy and I made eight formalin buckets with blocks full of various tissues. They'll sit in a cabinet in the autopsy suite for a while but sooner than they think they will belong to the first years (soon to be second years). Each one will rotate through histology as part of their first summer block just like we all did last year. So soon, and it will mean that I'll have finished the program! Yikes! Exciting and scary!

12.5 miles down the road

UNC

Duke and UNC are 12.5 miles away from each other. There are a lot of connections between the two schools... academic collaborations, love of NC barbeque, medical residents from one school who go on to fellowships at the other, basketball (okay, so that's a rivalry, but both schools like basketball, that has to count for something right?), etc.

And the staff PAs at UNC are either Duke graduates, worked at Duke, or both. That doesn't mean that being at UNC is like being at Duke. The grossing stations are set up around the periphery of the room in little nooks. I'm in the front of the room and I've felt relatively on my own all week. The person I'm working with this week is available when I have a question or I want him to check out my blocks but otherwise it is just me and my specimens.

I've been on GI large, which has involved a lot of searching for lymph nodes in mesenteric fat and a lot of cleaning out colons. I like the templates they have, which seem fairly comprehensive. And I like that all of their specimens have bar codes. I'm a fan of scanning a bar code and having the blocks print for the case based on that bar code. I know Duke is in the process of upgrading to Cerner Millennium and with moving to the new gross room will be adding new printers and technology. I can only assume that bar codes will be a part of that. It really reduces the incidence of mislabeled blocks to basically nothing.

Tomorrow things change and I will be assigned to some other service. We'll have to wait to see what that is!

In completely unrelated news, house closing was today! Three weeks until the kids are out of school and everyone else moves into our new house! My husband will move there this weekend, but he won't have much furniture for a while. Still, it will be nicer for him there than our old house which is mid-kitchen remodel. I hope the dog adjusts, he's a little neurotic about certain things.

Lab week at Durham Regional

I showed up at Durham Regional on Monday to find out it was lab week and there was breakfast in the conference room. It was a good week to be there, very social! It is a cozier set up than Duke North so the lab services are along the same hall and lab week involves them all. There were lunches, snacks, and treats all week long. It is easy to get spoiled with a week like that!

It is much more of a community hospital set up than Duke North so the specimen load is closer to the VA (except without its overwhelming male patient bias). The staff PAs cover both that hospital and Duke Raleigh and are currently short handed so they are switching off weeks instead of both covering Durham Regional in the morning and one of them joining a part time PA at Raleigh. It is good being there as a student because you get to feel useful since there is enough work to go around.

It was funny being there... at North we get so many complex specimens and we get to be pretty good at complex specimens, but we don't do a lot of the full range of benign things out there that PAs deal with on a regular basis. We get things at the VA but, once again, not that many female specimens. It was useful to experience the pacing and specimen types there.

Slowing down (maybe?)

Last week at the VA was intense... a lot of that was a matter of timing. The techs were short staffed so things weren't getting accessioned until after slide sign out (which ends at 3) which meant the morning was spent grossing larges triaged from the day before and triaging things for the end of the afternoon/next day and the afternoon was spent scrambling to get things grossed. Add in frozens scattered throughout the day and never having more than 20 minutes to get lunch, it made for a very full week.

Yesterday was spent wrapping up specimens triaged on Friday and doing smalls. I had one really interesting case today that I'm looking forward to see the slides on and a few other bigger specimens, plus an assortment of smalls. It was much better having the smalls throughout the day instead of just all at once right at the end of the day. Soooo much better.

Last week and this week, I've had a first year student come through on Tuesday afternoon for slide sign out and some time in the gross room. I've been trying to let them do things that might be slightly more appealing than straight forward small biopsies. Hopefully they've appreciated it. It would have been good to have a BKA or something to let them work on but I had to take the specimens that were available. Still, they got their hands on a couple larger specimens (even if it was just to triage) and got a chance to practice dictating without a template. Both were super great about pitching in and getting work done, which makes a difference when things are busy!

The downside to the busy week is that I didn't do any of the half dozen autopsy reports from the cases I had the week before this rotation started. I know that I need to do them, and sooner rather than later, but at this point I'm considering it an accomplishment that the kids were fed and laundry got washed last week.

The upside to the busy week is that I had some delightful options for feedback forms, and at the VA you get them back! One of my classmates sent me a text asking how I was doing on feedback forms, so I figured it out. I sent out two to three a day the entire time I was at North, and out of literally dozens of forms I got back about five back. A lot of it is just that the physical forms get misplaced, or received with every intention of being filled out and forgotten. At the VA they basically fill out the forms as they are received, so much more effective!

In other news, I've decided not to close myself off from job opportunities in the Southeast. They'd be weekend commutable to SC (and think of all the frequent flyer miles) and realistically, there isn't a job in Columbia and isn't likely to be one any time soon (years would be the timeline here). So... we'll see what happens.

Meanwhile, it is surprising to be contacted about an interview for a position that I applied to four
months ago and had pretty much forgotten about. But, considering the location in the west it would be a waste of everyone's time to do anything other than politely decline.

Oh well, life will work out like it is supposed to. It always does! I'm excited about buying the house, closing is in a month and I feel really good about it for the family. It feels like the kind of house the kids can grow up in, and I hope it makes up for the instability of the last two years. They will be moving down after they're out of school at the beginning of June to give them enough time to make friends in the neighborhood and get used to the new environment. It will give me time to get the apartment all packed up as well. I like moving with a long lead time and not feeling rushed.

Productive week on autopsy

Last week was bustling, and I was on weekend call having switched ages ago with a classmate. It put me on call not with my normal partner, but rather my PA student BFF who'd I'd actually spent the week already on autopsy rotation with. So much togetherness! I also had a resident that I haven't worked with since July but really like (just one of those people that you meet and think, we should really be friends) and another resident that I'd only been with on one or two cases.

It was great! It is amazing how little it feels like work to be doing things with such happy fun people to be around. Even though it was my busiest week on autopsy ever and sometimes the gross sign out ran later in the day, I really enjoyed it. I also feel like I have a pretty good grasp of prosection now (except I need to practice heart cutting) and if left alone with a cadaver I could do it start to finish. I do struggle with never wanting to eviscerate. After cutting myself at the MEs officer I really don't want that to happen again. I know Duke is different and the way we eviscerate is a lot safer (ie: much less cutting while actually in the body cavity) we have patient history, etc, but... I'm still so reticent to do it. I need to get over that. I do. I think mostly it is a matter of forcing myself to just do it and face the fear. I know how to do it, I just don't want to.

This week I'm at the VA. It is a little different because it is just one PA student and one resident,

Durham VA

instead of two PA students. We do have medical students with us for a couple days so it doesn't feel as quiet. So far it has been pretty good. I had a couple large cases yesterday and lots of small biopsies. Nothing overwhelming and the resident helped out on smalls and mashed fat with me looking for lymph nodes. Slide sign out was good, and having medical students around means you get some interesting questions.

My ankle is absolutely killing me though. It really hurts after almost a month and a half of being nearly normal. I think it is the result of standing for autopsies for a week straight, not having the weekend to recover, and then being at the VA. Until you go without them for a while, you sometimes forget just how incredibly helpful those anti-fatigue mats are. Duke North has them, otherwise that rotation would have been miserable. I think I'm going to try sitting down and grossing as much as possible while here at the VA. I just feel less productive sitting down (although things still get grossed so it could be a psychological thing!).

Solicitations...

So I finally remembered to ask some of the first years if anyone would be willing to write up a short blog entry about what their classes are like this year compared to ours last year. I know changes have been made, so we'll see if one of them has some spare time to jot their thoughts down.

Also, for people who have been going through interviews, if anyone would like to share their interview experiences at any of the PA programs I'd love to post them!

In other news, so sorry for the silence. I have a list of things I've jotted down that I want to blog so I won't forget them. My laptop has been having issues so as a result I've just avoided being online much lately. I've taken it to the med education IT help desk a couple times, but so far no improvements. It has meant things like missing out on emails reminding us that our autopsy conference is one place instead of the normal place (that was a bad morning!) and such things.

Speaking of autopsy, I'm back on autopsy after a three week stint at Duke North. It was a good rotation, lots of different complex specimens, and I had a practical exam. It is harder grossing with a staff PA over your shoulder watching you with a critical eye, but it went well. I got an A so I'm not complaining in the least and it was great getting that feedback.

Next week is spring break and I'm going to spend mine going back to South Carolina to do home improvements because I love painting, but until then I'd like to have a busy rotation this time around. Brain cutting today was really busy with med students and first year PA students, but we had some very interesting cases so it was good that everyone got to see those. There was a great moment when the neuropathologist was quizzing the students on neuroanatomy and the first year PA students were getting all of the answers right, so she had to tell them that they weren't allowed to answer any more questions. They did an awesome job and all PA students can name the locus coeruleus thanks to one of our staff PAs!

This week in frozens

This is my third week at Duke North on this rotation, which means I'm doing triage/frozens.

Pinned specimen from this site

Triage varies by specimen, but almost everything gets weighed, measured, or both. Margins may be taken, specimens may be inked for orientation, and opened up or bread loafed (sectioned but not cut all the way through) to allow better formalin fixation. Some specimens may be pinned out on cork boards so they fix in the shape they are pinned into (useful for things like an esophagogastrectomy). And everything gets put into adequate formalin. Larger specimens are held until the next day for grossing, which is nice when you're a student picking out the cases you'd like to do for the next day.

Where I worked before didn't do that much with triage. Sometimes we would open the colon specimens, and sometimes we would ink mastectomies for orientation and bread loaf them. Colons and breasts were held until the next day, but everything else was grossed the day we got it. Most of our specimens were received in formalin, but larger things like spleen and liver were usually not. And being in formalin isn't the same thing as being received in enough formalin! Sometimes there was so much specimen crammed into a container that there was just a splash of fixative on it and most of the tissue was still unfixed. So I can appreciate that the PAs or residents doing triage at Duke are the ones ensuring there is enough fixative, and that there is enough flexibility on the the turn around time that things can be held for a day.

Frozen sections are interesting. We go with the staff PA or resident to the operating room and are handed the tissue of interest to take back to the gross room. Then we triage the specimen and whatever section(s) we need are taken and given to the techs. The techs section the tissue and stain the slides. The staff PA works with the tissue bank/research folks to provide needed tissues at that time as well if they can. The pathologist reading frozens that day may see the specimen or ask for additional sections, but once they are done the specimen is put into formalin and accessioned.

It has been nicely steady and I've gotten to work with one of the staff PAs that I haven't worked with before. Plus, I've worked with several residents which isn't something that happens often when we're at Duke North. It is good to get to learn from so many different people.

In other news, today is my dad's birthday! We had a small family celebration at home. 

Feedback...

Feedback varies depending on the surgical pathology rotation. At the VA we see the slides made from our sections the day after they are cut in during slide sign out. It is good because we can see how our sections look microscopically while we're there and the pathologist can give real time constructive criticism. At Duke the staff PA we are with for the week looks over our dictations after we edit them and write corrections (if needed!), which is really helpful.

We have case assessment forms that we can submit for the pathologists and residents to fill out on specific cases. Our goal is to get two forms back a week, some weeks are better than others for actually getting the forms back. The VA is pretty fantastic in that regard because the residents and pathologists can fill the forms out at slide sign out, or are really approachable if you're following up on a case (the downside being that to get a copy of your dictations, you have to get someone with VA computer access to print it off for you. They're really nice and accommodating about it though!). It can be a little tougher at Duke to get your forms back since we are more removed from the pathologists. Hard copies are easy to misplace or set aside for later and forget about too! Not to say that we don't get any of them back, but it is generally a good idea to send out a few extras just to be extra sure that you get enough feedback. And, having more than the minimum number of assessments returned is a good thing since it means getting feedback from a wider variety of pathologists.

I've sent out five this week, which feels excessive but I've had some interesting cases.

Rotated through and now back to autopsy

Friday was my last day doing surgical specimens for a while. It was a good five weeks and I feel a lot more comfortable at Duke surg path. I know that I still have a ways to go on getting my dictations where I want them to be but I did get a lot more positive feedback on them on them this go-round.

We have case assessments where the pathologist who reads out the case can comment on our dictations and sections on the cases that we select for assessment. And it can be disheartening some times when the staff PA looks over the blocks being submitted and praises the sections but the assessment comes back with the pathologist not liking them... or having one pathologist wanting larger sections and another wanting smaller ones. That is all part of the learning process. It isn't easy or fun to get feedback (unless it is 100% enthusiastic and positive, because who doesn't love that?) but it is helpful.The good thing about being able to handle constructive criticism and apply it is that it means that there should be improvement. Learning to tailor your sections to the pathologist reading them is a very important professional skill!

Still, I really enjoyed my time on surg path. I felt like things were starting to become more comfortable and familiar at Duke. And I was able to answer the questions the staff PAs put to me about the disease processes going on in the specimens I was grossing and what sections needed to be submitted, etc. It was nice to feel confident about that.

Meanwhile, as of this morning I am back on autopsy for two weeks. Oh autopsy! You never know what the work load is going to be, but I like it a lot - more than I thought I would before I started the program.  The one thing I miss equipment-wise is a scale that you can wheel the gurney on to get the patient weight. But other than that, it is great. Everyone that works there has been working there for years and teaching for ages so they're very focused on us as students. Plus, most of the organs are relatively normal (which is not something you get too often in surg path) and it helps reinforce anatomy information. During this rotation I'd like to get evisceration down, which everyone seems supportive about so hopefully we'll have some cases that are good for teaching (ie: there's not a recent thoracic or abdominal surgery in the patients that would require a more experience hand for evisceration, etc).

In completely unrelated news, the first years had their first gross anatomy practical this morning. Oh goodness, I remember being in their position last year... it hits at the end of a solid month where there was a test in a different subject every Monday. Hopefully they're all recovering from all the studying but having a relaxing night. It is one of those situations where it feels like it has been forever since we were doing that and no time at all.

The coolest thing I saw last week...

So Friday wrapped up my week in imaging, which was mostly getting the opportunity to see how tests I've heard of before were actually performed. It was neat, especially with some of the FISH stuff where they are working on being able to detect extremely low percentages of positive cells. But, by far, the coolest thing I saw was the process that allows them to count circulating tumor cells (CTCs) from patients with tumor metastasis.

It is one of those things I've never heard of before, and I don't think I'm alone in that. The patients come in approximately every six weeks and their levels of CTCs are counted. It allows their doctors to see how the patient is responding to treatment very quickly and to be able to track the extent of metastatic disease in the blood. They can even directly visualize tumor microemboli, as in they can count the number of cells in a microemboli. It was such a cool technology and I was able to see some sample data that really showed how effective it was in practice. I sat with the tech who has been the one to get the process up and running at Duke (it isn't a wide spread technology yet, there is one at Duke and then the next closest one is in Tennessee) with the results of a test up on the screen in front of us and he did his count of cells with me, quizzing me on which cells I thought were positive, negative, or borderline. It was a lot of fun.

It is a quick entry, I just wanted to get that down while I was thinking about it (I still have three things from autopsy I haven't written!). Some days technology just amazes me, I'm so lucky to be able to see things like this.

First years and bowels

I'm so happy for the first years since today was their histology exam, which signals the end of Molecules and Cells (I can't believe it has only been a year since I was in that position!). They will have a day off before jumping into the Normal Body unit on Thursday (first day of gross anatomy is Friday! I helped outfit folks with scrubs and pointed at the bucket o' dissection tools with the admonition to only touch it with gloves). Hopefully some of them will come out for the massive PA dinner tomorrow night that one of the autopsy PAs organized at a local pizza place and socialize a bit (I do feel a bit guilty about not having had a dinner party since they started classes but the whole kids in cubscouts and soccer has eaten up a lot of my down time.).

FISH, I figured it was more appropriate than pictures of bowel

So (and I fully admit that this is a horrible segue), I was running the bowel during an autopsy which involves taking the small bowel and colon that the autopsy techs have helpfully removed and opening it up so that the entire length can be examined (for polyps, ulcerations, diverticulosis, tumors, strictures, etc any disease process that might be present there). And I realized that it was one of those activities that most people just wouldn't want to do, yet there I was not only doing it but having cheerfully volunteered for the task (after double checking to make sure the scissors in that autopsy suite were sharp, because that really makes that job easier). Not to say that it is a fun task necessarily but one of those that I had done once or twice and wanted more practice with and it isn't something that anyone is really going to fight you to do. "No, no, I want the bowel, you had it last time!" isn't a phrase you hear often, or possibly ever.

I'm glad that I had weekend call coming off of an autopsy rotation, I felt pretty confident in what I was doing. Hopefully it'll all still seem as familiar next time I'm on call since I'll be in the middle of a surg path rotation. I feel like it will. It helps so much that while we're rotating, we are doing it mostly through the same locations. It means that we're not wasting the start of every rotation figuring out where this gross room keeps its supplies, how they like to have their prostates sections, being trained on whatever form of dictation software they use, or learning what they want in their dictations (although I'm still learning that for Duke surg path! It might be a long process, but hopefully it doesn't tax the patience of the staff PAs too much.). After the summer semester we've been at all of main rotation sites so the rest of the year is less disorienting.

Well, except for me this week since I'm on imaging! I've been with the molecular pathology department this week, which means flow, immunopathology, FISH, etc. It was always something that we sent off to another lab when I was working (except for immuno stains) so I've never actually seen what happens when they run the various tests until now. There is a big difference between knowing what a test is and seeing it, very useful and I might even understand some of the slides during grand rounds a little better now.

Different mindset

I started my first surg path rotation today (it went well!) but... I got in early this morning and looked over what was there before my classmate arrived. I figured I'd knock out the small stuff really quickly so we could concentrate on the bigger stuff. Which is what I would have done at work... but this is not work and getting the smalls out of the way would mean stealing educational experience from my classmate...

And then later when we were going over the larger specimens there was one type I'd done before at my old job so I said I would take it since I was comfortable with it. Except... that would have been less helpful when it comes to learning new things so my classmate took that specimen and I took something I'd never done before.

The goal of these rotations is not the same as working. We still need everything grossed and on the processors but so that everyone's had a chance to do their share and that we've all gotten to do specimens that we haven't done before. I need to remember that. I'm just used to where I used to work where we also wanted to get everything done as fast as possible since we had sort of a set schedule for when processors needed to be loaded (and also because we couldn't leave at the end of the night until everything was done). To that end, everyone grabbed what they were good with and did them.

Evisceration and adventures in histology

This morning we had a conference with some of the autopsy staff where we had a presentation on evisceration. One of the PAs made us cinnamon rolls. As we all sat around munching on breakfast and watching slides on how to properly remove the chest plate (and hearing about how to deal with a heart that is adhesed to it if the patient has had bypass surgery), I realized that the level of squeamishness of the people in the room was ridiculously low. This is probably a good thing given the profession we are training for.

The autopsy staff PAs are also pretty accommodating about student guided learning. If we want to practice a given skill, then we can (I want to see if I can get the brain out by myself, for instance. I feel like I can do that so I'd like to try it and see how it goes). If we want to focus on a particular organ block then we can or if we need someone to walk us through removing the bowel one more time, then they're there. Not that I've removed a bowel yet. That was more of a resident thing since they were getting ready to be on their own for weekend call. But the next time I'm there I should be able to do the evisceration with assistance (for the summer rotations I started out in the middle of the two weeks of autopsy, so I'll have my second week after I go through the VA and Duke surg path).

Random internet picture of a cryostat

Moving on to today's rotation, I practiced frozen sections which I haven't done in ages and didn't feel very secure about. However, using the microtome on Monday made it easier to use the cryostat. The tissue was also well frozen and not very fatty, which I'm sure helped immensely. The histology lab manager mounted one block for me and showed me how to use the machine. Then he left and I practiced a bit before mounting a second specimen on my own and making my slides. They turned out much better than I thought they would, so that is a relief!

Also I went through my now stained and cover-slipped slides from Monday to pick out the ones for grading and see which ones needed recuts. I had a couple that I redid and will stain in the morning after conference. The histology manager looked over my special stains and said they were all just fine so that's good! I just have to finish up the written portion of the rotation (which is not going as quickly as I would like) and I should be all set to turn everything in on Friday.

So far, so good with regards to rotation. Next week is the VA though, which is more surg path and a grab bag of specimens so we will see how that goes!

Orientation today!

This week is preceptor week, but before that starts in earnest we have orientation! More chapters will be added to our PA student manual and we will find out more specifically what we will be doing day to day.

We're transitioning from the predominantly classroom first year to the predominantly clinical second year, but not really feeling like we're really almost second years yet. Of course our second years are still here but they are all thinking about taking the certification exam, moving and starting their new jobs. I can't believe that will be us in a year! I can't believe they were us this time last year... they seemed like old pros by the time we arrived in August!

It is an exciting period. We'll bid farewell to our second year's, welcome our incoming first years, some of us will start work study positions (I won't have one, in large part due to not knowing what the children's schedule will be with sports and how much I will see them just with rotations, etc), and we'll try to make our way through our first experience in each of our rotations.

I still really need to practice frozen sections... I'm sure that'll happen this week sometime.

Also, my laptop has another virus... I've lost count. I really wish I could have had a Mac, but at least the incoming students seem to have been given the choice. Hopefully it means fewer visits to the IT department for them. 

From now until next July!

Our course director sent out our rotation schedules for next year. It is good to know what I will be doing starting in July. After the preceptor week I start off on a week of autopsy, then a week of histology, and then a stretch of surg path split between the VA and Duke North.

It is funny looking at the schedule because the attitude is, "Yes! I'm working with _____, I love working with them!" but then it is also a lot of looking at it and going, "Awwwww, I don't get to work with _____, I really like them." But there are much, much worse problems to have in the world! We will all still see each other in the PA room, in other classes, and socially so it isn't like being scattered across a dozen different rotation sites in different states or anything like that.

In a way I'm really excited to see the schedule, in another it makes me impatient to be on rotations! I did have a stint at the VA this past week. The derm path folks didn't come in so I got to stay for the entire slide sign out. It was really interesting! For example, I've grossed in so many prostate biopsies (literally thousands! The guy I worked with didn't like them so I would always grab them when they they came in.) but it was the first time I've ever really seen them microscopically. The difference between healthy tissue and neoplastic tissue is pretty drastic. I am sure it will all be old hat by the time I graduate, but for now I like being able to see the whole process through diagnosis.