Seminar and the reality of change

The last thing we do as students is present a case study or disease process at a seminar with all of our classmates, some family, and various staff (attendings, course director, some staff PAs, etc). I spent my memorial day immersed in patient history and looking up things in pubmed. The Duke library system is really good about emailing electronic copies of articles not otherwise available, which means I have more reading to do tonight. Ha! I thought I could buy myself a day off with that.

I have a general outline and a meeting with the attending that is advising me so we can go over the outline to see if I'm on track. This week will be spent fleshing out the outline and doing my slides. The class has a preliminary meeting next Monday to go over everyone's rough draft, which will be good. I don't want to go too far with the work if I'm going in the wrong direction all together.

Meanwhile, I looked over past year's presentations over the past few weeks and I've decided autopsy cases are so handy because you have so many more things you can take gross photos of. Unfortunately, there weren't any cases I had that stood out to me as seminar-worthy. There was a very interesting case a few weeks back but I wasn't on it and only heard about it after the fact, which was disappointing. Surgical pathology offers up a lot of good cases and fairly rare conditions to choose from but you only get the specimen for photos. I do have a lot of slides though...so I have a lot of different things I can use for microscopic photos (and I do like the microscopic photo set up). I just have to meet with the attending and figure out what exactly I'm looking for in all of those slides and special stains.

My husband came up this weekend and drove off with my dining room table and boxes of assorted non-essentials. We have about ten days before the kids are done with school and we do the big shuffle. Most of the things in the apartment will go to our new house, but a few things will go a hundred miles west to my parents' house and we'll pick some things up from my parents' for the new house (since they're selling it, they are kindly handing down some furniture. Great timing!). Not having a dining room table and having the boxes around the apartment make the move seem more concrete. It is almost scary how quickly time has been passing! Still so much to do and learn! No time to slack off now.

My autopsy rotation has been productive. We're faster than we were at the beginning of rotations by a lot. No where close to the staff PAs, but not doing too badly I think.

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!

Injury, interviews, and surveys.

It happens when you work with scalpels all the time that you might cut yourself, and I did while I was at the medical examiner's office. It was the first time I was doing a full evisceration by myself and resulted in two stitches and a visit with the exposure folks at Duke who talked to me about infection rates, blood draws, and side effects of anti-retroviral drugs. If I was going to cut myself during my clinical rotations I would have preferred doing it on formalin fixed tissue or on a case where I had the full clinical history. Of course if I could have chosen, I probably would have opted not to cut myself at all but these things happen.

Anyway, the time at the medical examiner's office was busy and instructional. It was so much evisceration, and really good exposure. It did make me realize that I missed being involved in the prosection part of the autopsy! Two weeks of doing no organ dissection at all felt like a long time, so I'll be glad to be heading back to surg path at Duke this coming week.

And being back means that I'll get to meet some of the interviewees for the class of 2015! I missed the first week or so of them, but I trust my classmate's opinions on the folks that I wasn't able to meet. Good luck to everyone and I hope that people are having a good experience throughout this application season.

In other news, I'm still job hunting. It is getting more into the time period where most people tend of find jobs. I've been applying here and there as there have been openings that interest me, but nothing too seriously. I had an interview on Friday that went really well, but I withdrew myself from the running because of salary. As an AAPA member I have access to its member surveys which are broken down by state and include things like salary, so going into an interview I have an idea of what typical salaries are for a given area (in addition to using cost of living calculators online for specific cities since some places are cheaper to live than others). It was unfortunate, but it would have been a waste of their time and mine to continue on given how large the disparity was between their salary range and the range typical for the state. Still, it was good interview practice!

Calling and calling...

This is my on-call weekend. I called last night and there wasn't a case. I went to bed at 10 pm and set my alarm for 6 am. I called at 6 am, no answer from the decedent care office... So I kept calling and calling. At 6:30 I got in the car and headed to the hospital because I have to be there at 7 if there is a case, regardless of if someone is there to tell me that we have one or not. I get a text from my fellow oncall student ten minutes later to say that he's giving up and heading in too. I keep calling. I left my number to be paged and a voicemail on their line. As I'm pulling into the parking garage one of the autopsy techs gives me a call saying he heard my message and that we're clear. It saved me the walk in from the parking garage, which considering how little I'm enjoying walking right now, was pretty nice.

I don't mind going in if there is a case since around a third of all of the autopsies happen on the weekend, and I go to bed early so I'm okay waking up and being there on time. But this morning was frustrating, doing what we are supposed to do and getting no answer.

Hopefully tomorrow is better!

Meanwhile, I'm in a walking boot. It is a huge improvement over the crutches! It still hurts to walk but I can walk.

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.

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.

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!

Autopsy, special cuttings, and histology

Paraffin tissue blocks (not mine though!)

In deference to the Duke social media policy I will continue with my (maddening to some, apparently) tendency towards vagueness.

Duke's autopsy service is pretty busy, some cases come from outside hospitals and some from Duke itself. Autopsies happen and I will be present for some of them (some as the person eviscerating, some assisting a resident or staff PA, and some as the lead prosector). We have three diener's (known collectively as "The guys") who do most of the eviscerations, prep work, lung inflation, and clean up. It is very helpful to have such experienced techs, especially considering how much time the autopsy services spends training residents, med students, and PA students.

I like autopsy, in general (although the smell can be very noticeable at times)...the schedule can be irregular though. In addition to the actual autopsies, which can start any time between 8 am and 1:30 pm, there are the slide sign outs (going over the slides with the attendings). Some sign outs have more of a set schedule, but other times it is when the residents have had a chance to look over their slides and can grab an attending. There are also the special cuttings (brain, eyes, and sometimes heart if there is a reason for it) which may or may not have a regular schedule (brain definitely does) and may or may not be mandatory (eyes aren't). It just makes me worry that I'm going to miss something. But the autopsy PAs are fantastic and the residents I was with last week were so great to work with, so it was a really amazing first rotation.

This week is histology! They set aside sample tissue during preceptor week and I took my blocks down for processing on Friday. I embedded them this morning (with a break to go to a special cutting) and spent the afternoon cutting slides. I've embedded before, but this was my first time making slides. Oh my goodness, I would be the worst histotech ever! Or at least the slowest. And paraffin shavings get everywhere! The rest of the week will be spent doing special stains and studying the histology textbook.