Sunday, April 7, 2013

Surgical Pathology Rotations

I recently spent 2 days in the surgical pathology gross room.  I had shadowed at Ruby’s gross room before applying to the program, but I understood and appreciated way more of what was going on this time around. I was able to see a variety of specimens being grossed by the pathology residents and a second year PA student.

For those who don’t know what a gross room entails, I’ll give a scenario so that you can have a better understanding.

Say that you are a patient and you come to the hospital with the following symptoms:
-       Pain near the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen
-       Loss of appetite
-       Fever
-       Nausea and/or vomiting

The doctor decides that you need surgery and the surgeon performs an appendectomy.  The appendix is then taken to the gross room for gross examination (observation with the naked eye).  This is where my job, as the PA, begins.  I start by checking 3 things: the requisition, the container, and the cassettes. We want to make sure that everything matches because we don’t want to end up telling one person that they have cancer, or any pathology, when they in fact do not.

After I'm sure that I have the correct specimen, I will open the container and take out the surgical specimen, in this case the appendix.  First, I will orient and measure the appendix. With appendix specimens it is important to look for any perforations, presence/absence of inflammation, and search for any incidental neoplasms (abnormal mass of tissue).  While I am doing this, I am dictating my findings.  At Ruby each PA has a headset with a microphone, so that a computer records as they speak.  So far this is what I would have on my computer screen: “Part A is received in formalin, labeled “Doe, Jane” and “appendix”. It consists of a 11.0 x 0.7 cm pink-red vermiform appendix with attached mesoappendix.”

After I’ve looked at the outside of the specimen, I serially section the appendix to evaluate the wall, mucosa, and the lumen. Keep in mind that I am still dictating everything that I see.  For this particular case we may see the presence of exudate, evidence of a rupture, and hemorrhage.  I will then finish the gross examination by submitting specific sections for histologic evaluation (check out my post about histology rotation) so that the pathologists can see what is going on at a microscopic level.  Then the pathologist gives the final diagnosis to the surgeon or doctor.
The top specimen is of a normal appendix.  The bottom specimen is an example of what could be seen in the scenario above.
Points to anyone who can tell me the probable diagnosis of this specimen (or give me an example of a pathology that might be seen in an appendectomy specimen)!