It’s been more than a week since I started this rotation from Surgical Pathology. A lot of key differences in the area include not smelling formalin anymore, no dead tissues to handle, laboratory machines with reagents nearby, and most importantly, people moving around. In the histopath section, I only have the clerk and a senior to hang with and we often mind our own business in solitude within the same room. Now it’s white coats walking around and conversations have been lively.
I just got back from quarantine and my senior handed me a file containing a 480 page manual on how a machine at the lab works and I’m supposed to understand it as soon as possible. That’s kind of a norm here to be expected of wondrous things but I try to deliver miserably as I can.
The above image is the model we use for our CBC tests and I am still learning how to read the scattergraph to correlate with my manual counts. Somehow our Chief Training Officer wanted to bring back the old school days and incorporate it on our routine, not really a bad idea for academic reasons.
Needless to say this is all alien to me. In theory I can get behind why the tests are done but in practice I couldn’t press the right buttons to run a machine even if my life depended on it. I just thankful it’s not part of the job and I just get to be the quality assurance guy that oversees how things are going well. Let me tell you the value of a capable medical technician, it makes your life as a pathologist easier if they can troubleshoot and take initiative on their own and only calls for you once the resolution arrives.
I know if the machine produces an error I’d have to check the reagents, the hydraulics, pressure, temperature, patient history, processing from start to finish and etc but these are string of thought I can’t readily pull out from the books read. A capable medical technician saves me from that trouble. It’s a humbling experience and there are some co-workers that still tell me I should make the call cause I know more and I know damn well I don’t. Some areas like doing peripheral blood smears and differential counts if it gets too abnormal for the machine to run maybe.
For the most part, a lot of stuff that happens in the lab I have no clue how but it just does and the phone barely rings unless it’s a difficult case I need to be in. I always pray I don’t get to hear a call up but half the time I’m wishing I do just to make my exposure there more of a learning experience. The shift from Surgical Pathology to Clinical Pathology didn’t reduce the workload on the amount of info I need to catch up but the physical routine takes getting used to. I always get tired from cutting up specimens and making documented reports the entire day and night. But on this rotation I can spend the entire 24 hours shift without much worry and that really bothers me as I get to do little and I get relatively paid a lot in terms of the time spent.
So even if I know some call ups can be annoying, I still thank the people that bother to call and not just troubleshoot on their own.
Case 1: A senior medical technician calls me up for a patient that has septic shock from pneumonia. The patient was 4 years old and had a peripheral blood smear full of stabs (immature white blood cells). It’s not a rare occurrence and it’s even an expected reaction for the case but being phoned up over a silly matter to resolve by recount. The guy was capable but unsure and my count didn’t have a significant difference to theirs.
Case 2: Being called for double checking a Coomb’s test on the blood bank, the old medical technician on single duty was aging and her eyes weren’t what they used to be but even so, she was really capable even for her age and can handle the job easily. A positive coombs test just means the likelihood of incompatible blood transfusion (simplified). the slide just showed red blood cells simulating clumping but these were just cells tagging along together moving in a stream of fluid on the slide that looked like a positive test.
Both scenarios have the same energy of being simple to resolve but a simple screw up may mean life and death consequences in our field. The goal here is just trying to build more rapport with the lab personnel and learn from their job as they be great teachers in the area. There are some stuff I know in principle they don’t and vice versa so this mutual coexistence one of the best experiences so far during my tours of duty. I wouldn’t trade my job to any other department.
Just some snapshots I took for my case report to be done on November or December. It's a requirement before proceeding to the next level and the case is a synovial sarcoma masquerading as Ewing Sarcoma. Both are reportable cases due to their rarity and it's hard to distinguish them morphologically so we had to run more tests to rule out some potential contenders at the molecular level. I haven't studied the case fully as there are lots of stuff happening around but I'll get back on this as I don't have much choice when the consultant is grilling me to produce results (this is contest worthy as I was told).
The above sheets of cells have a spindle feature, not a very good formation when you are viewing a kidney because it isn't supposed to look like that. It's highly malignant and little is known about the approach to treatment. The first suspect was an Ewing's sarcoma by morphology but this makes the case even rare as it presented while the patient is already on their 6th decade of life. You would find this common in children. But of course I already spoiled you the answer that its Synovial Sarcoma that mimics Ewings Sarcoma. The term sarcoma makes the malignancy confusing morphologically as a lot of soft tissue tumors have spindle forms. I do encourage you to Google the case for trivia's sake as there is less I can tell on hand about the case right now (still have to research more journals about it and it's rarity).
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