Being on call stories

[yaah]

I think we should post a bit about on call experiences for the benefit of those considering path as a career.

My last night on call was tuesday - it was an ok night, but made more unpleasant in that I was woken up at 1am by a page to call the childrens hospital OR.

Night started off ok, I had an early neuropath frozen section to do, and a few calls about passed products of conception that we had to call the clinician on to determine if they wanted a cytogenetic analysis on it or not. Also had to deal with the children's hospital being unable to find any media for cytogenetic testing, and I had to find it and send it over. Also had a transfusion reaction - a leukemia patient's temperature had gone from 100.7 to 103.9 during a RBC transfusion. Unlikely significant, as he had been spiking fevers that high for the past 7 days, but we ordered a test to rule out hemolysis anyway.

The neurosurgeon had taken a 16 month old to the OR urgently (she had been scheduled for 9am the following day) because her 7cm brain mass was now causing severe symptoms. I text paged the neuropath on call that there would be a frozen in about a half hour and headed in, and the specimen was waiting. I paged the neuropath again and started freezing it. It was a nasty specimen to cut. Full of blood and mucoid material, and it shredded a lot when I tried to cut it. The neuro frozen I had earlier in the night was much easier - no shredding, smooth cut, looked almost like a regular H&E on a tissue block, so I wasn't quite sure whether it was me not being able to handle the tissue or it was the tissue. The neuropath eventually arrived after I had to call her home since she had apparently left her pager in another room. But she lives very close so it was fine. When she came in she saw that the frozen section was a bit shredded and said she had a good thought about what the diagnosis was going to be because certain tumors are notorious for doing that.

We looked at it - small round blue cell tumor with some necrosis and possible rosettes - could be PNET, Medulloblastoma, rhabdo. Called the OR and sent the neuropath home while I cleaned up. Got a page from the blood bank, a resident was trying to bump up an asymptomatic leukemia patient's platelet count because he was getting an IV line removed in radiology that morning and they would not accept the patient without a documented platelet count of 50,000. This, as I have posted about before, is not really evidence based, but it is malpractice avoidance based. What generally happens is that the first 5 pack of platelets is approved without my say so, because the patient's count is low. The second goes through me, and I tell them no, because giving them platelets now will just result in them being consumed by the time the procedure comes along. I say they can have them later in the morning, before the procedure, when they will be most effective. Then I got about 3 hours of sleep before I had to start the next day.

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[drPLUM]

This is a great idea for a thread. I hope all you residents will post some experiences when you get some time. As a student you don't really see what goes on during path call. I look forward to reading some good stories.

 

[Mrbojangles]

So you cover both AP and CP on call? So out of curiosity what did you end up calling the brain lesion?

 

[sapience8x]

this is a great thread. i honestly did not know that's what call was like for path. do you alwasy get called in on your call nights? just curious...

 

[deschutes]

Haven't done any night call yet (am on for December for the county hospital), but I did have the service pager Monday and Tuesday while the attending was offsite because the fellow and half the city's bloodbankers were away at the AABB meeting.

It actually was not that bad - at least I was answering pages and looking stuff up on the computer instead of watching someone else answer pages and look stuff up on the computer. Ah the joys of transfusion medicine.

I am very thankful though, that the rationing in the setting of both the U and the local Red Cross being short of O negs and B negs while two B neg patients were in OR (one OR in progress for brain tumour resection, another going for CABG) happened on the day that the fellow returned.

It seems like the key is to keep up the harassment (anesthesiologist #1, anesthesiologist #2, bloodbank inventory, bloodbanks around the Cities...) until one party or another is willing to budge.

 

[b&ierstiefel]

Weekend call a month and a half ago...head and neck surgeon trying to resect some extension of recurrent skin cancer to the eyesocket. Got called in on frozens.

Specimen #1 - fibrovascular tissue negative for tumor cells.
Specimen #2 - fibrous tissue and skeletal muscle negative for tumor.
Specimen #3 - skeletal muscle and nerve, no tumor present (AKA STOP! YOU AIN'T GETTIN' IT!)

 

[yaah]

Weekend call a month and a half ago...head and neck surgeon trying to resect some extension of recurrent skin cancer to the eyesocket. Got called in on frozens.

Specimen #1 - fibrovascular tissue negative for tumor cells.
Specimen #2 - fibrous tissue and skeletal muscle negative for tumor.
Specimen #3 - skeletal muscle and nerve, no tumor present (AKA STOP! YOU AIN'T GETTIN' IT!)

They had a case like that the other night - 8 specimens on a laryngectomy or something for frozen, all 8 were called either fibrovascular tissue or benign mucosa all negative for tumor. They called in, the surgeon said, "But #8 was lesional tissue! It came from the center of the tumor!" Resident said he told them there was no tumor on the slide, and then the surgeon asked if he wanted to come into the OR and see the tumor. Resident said, "There is no tumor on the slide and we cut multiple levels." They also called in with another frozen on a parotid mass which they said had a lymphoepithelial lesion and they left the intercom on to see what the surgeon would say, and 15 seconds later he says out loud, "What the hell is a lymphoepithelial lesion?"

What we called the brain tumor was a round blue cell primary brain tumor. You can't usually tell on frozen precisely what it is, nor do you have to.

It bothers me too that so much of blood bank is based on persistence and harrassment. In fact it outright pisses me off that there aren't more algorithms, and more understanding on the part of interventional radiology as to how to give platelets when doing an interventional procedure. The other irritating part is that interventional radiology makes the medicine or surgery house staff do their platelet ordering and begging for them.

 

[deschutes]

But what IS a lymphoepithelial lesion?

 

[Brian Pavlovitz]

But what IS a lymphoepithelial lesion?

I just think it's funny how those little platelets can cause our dear Yaah so much misery!

 

[b&ierstiefel]

What we called the brain tumor was a round blue cell primary brain tumor. You can't usually tell on frozen precisely what it is, nor do you have to.

Yeah, here frozen section based diagnosis is pretty conservative. You'd hate to be burned by calling something one thing and then the diagnosis on permanents being something else...especially when impox is used to aid in the diagnosis.

Frozen section seems to hinge on identifying a few things...is it malignant or benign?...is it consistent with a metastasis from a known primary?...are the margins positive or negative?

 

[b&ierstiefel]

Ended up getting shreds of scrotum and testicle today on call. Apparently, this dude got shot in the balls. Reminds me of pulp fiction.

"Who's Zed?"
"Zed's dead."

 

[b&ierstiefel]

One thing that sucks about call is that you have to deal with extreme idiocy on the parts of people who shall not be mentioned. Specimens coming up with the wrong forms. Specimens not being put in the fridge and being misplaced after the surgery so that I have to run around the goddamn hospital trying to track where that thing is while wondering, "How long has this specimen been NOT sitting at 4 degrees?" Getting calls from teams about a specimen that was received one day ago..."Do you have the results yet?" "No! It's not even finished fixing in formalin yet!"

OK here's a question for you residents: In your hospital, what type/team of physician(s) is the worst offender when it comes to pestering your ass with calls? I swear I think sometimes people pester you with calls because they think doing so will move the process forward faster.

Man, I can only imagine that the situation in CP call is much much worse. Many more requisition forms involved. Many more calls not only about "When will the result be ready?" but about "Can we get this? Can we get that? Can I get a cookie?"

 

[yaah]

OK here's a question for you residents: In your hospital, what type/team of physician(s) is the worst offender when it comes to pestering your ass with calls? I swear I think sometimes people pester you with calls because they think doing so will move the process forward faster.

In terms of who asks the most questions that they don't know the answer to: Surgeons

In terms of who asks the most questions and makes the most demands and insists their abnormal requests are justified even when they are not: Pediatrics.

The latter is much worse. Every patient is special, every patient is hurting, and every patient has needs. Just because the patient has a whiny parent does not mean we can break the rules for them.

 

[yaah]

Ended up getting shreds of scrotum and testicle today on call. Apparently, this dude got shot in the balls. Reminds me of pulp fiction.

"Who's Zed?"
"Zed's dead."

I got a resection of a mastectomy scar for "recurrent breast cancer." Entire specimen was benign fat and skin with a scar. No tumor. Hate when that happens.

 

[deschutes]

In terms of who asks the most questions and makes the most demands and insists their abnormal requests are justified even when they are not: Pediatrics.

And all this comes to a head on Friday afternoon.

Go away! I haven't got around to it yet because of your OTHER clinical teammates who have been bugging me about OTHER patients! If you leave me alone I might actually be able to LOOK at the thing.

And if you please, if you bring your entire team in here and dawdle over the only multi-headed signout scope in the department, don't whine about why the prelim isn't out yet.

And No we DON'T all leave at 4:30pm.

 

[DarksideAllstar]

OK here's a question for you residents: In your hospital, what type/team of physician(s) is the worst offender when it comes to pestering your ass with calls? I swear I think sometimes people pester you with calls because they think doing so will move the process forward faster.

While not having dealt with this personally, I have watched several surg path fellows on the transplant service perpetually bombarded by clinicians, usually in the form of a horde of them coming up to "look" at a case because they think there is GVH, and oh, are those CMV inclusions?. It seemed like a pretty ****ty month, if only because of the grating quality of the clinicians that would practically beg to look at slides.

Is it common at a programs to take AP and CP call simultaneously, or does it depend on how your program is structured?

 

[deschutes]

Can't say for the others, but where I am, call is based on whatever rotation you happen to be on at the time.

 

[yaah]

Can't say for the others, but where I am, call is based on whatever rotation you happen to be on at the time.

We do call for the whole department from 5pm-8am. During the day it's based on what service you are on. We do both AP/CP together unless it is one of the days where an AP only or CP only person is on. I hate those days.

 

[deschutes]

We do call for the whole department from 5pm-8am. During the day it's based on what service you are on. We do both AP/CP together unless it is one of the days where an AP only or CP only person is on. I hate those days.

Why? I thought having a AP or CP-specific person would spread the grief a little better.

 

[yaah]

Why? I thought having a AP or CP-specific person would spread the grief a little better.

Yeah, but it kind of feels like an "extra" call day, as though we are getting more call days in the long run because it is technically only 1/2 of a call. AP call is IMHO much less objectionable though, despite my recent call and having to come in at 1am - generally it is CP stuff that wakes you up.

 

[b&ierstiefel]

So I pick up a specimen today and realize that the requisition form is wrong for one of the parts. So of course I page the surgeon. She's mad cuz I paged her which makes me feel even better! Anyways, she tells me to page the scrub nurse...I do that.

"Umm...yeah, my name is Andy Milonakis...yeah...so I gots this specimen here and part 2 needs a cytology requisition form...we don't process brushings here in surgical pathology."
"Are you the doctor or somebody who just picks up the specimens?"
"I AM THE DOCTOR AND I AM PICKING UP SPECIMENS BECAUSE I AM THE RESIDENT ON-CALL FOR THE WEEKEND!"
"Oh...I'm so sorry. What was the patient's name? I'll get that filled out right away and where should I go to give you the form?"

Several minutes later, she runs into me while I'm on my way to get lunch. Since I don't like wearing just scrubs to public areas, I put on my long daddy-sized white coat (which is rare). I like wearing my daddy-sized white coat...it makes me feel important and special and like a mac-daddy!

"Are you Dr. Milonakis? Here is the form. I'm so sorry. I feel so bad about this."
"OK...it's all good. I'm glad we got this **** taken care of. Now go to church and ask your lord and savior for forgiveness."


Morals/Lessons for the day:
#1 - Nurses like to piss all over people. From now on, I shall establish dominance in the phone conversation right from the get-go by introducing myself as Dr. Milonakis.
#2 - I need to wear my daddy-sized white coat* more often! It does make me look fatter but hey, when I wear that white coat, it says, "I'm a f*cking doctor damnit!"

*Here at the Brigham, the medicine and surgery residents wear the short white coats. I think even the senior residents have to wear the short coats. But if you're in the pathology department, you get a choice as to wearing a short or long white coat. Nice friendly suggestion...I suggest you pick the long one.

 

[deschutes]

This whole white coat/dominance thing is however, flung right out the window when you're a small Asian woman (okay, girl) who apparently looks like a lab tech.

Me: (to rude woman sitting at nursing station) Hi, I'm trying to find the nurse who is taking care of this -
Rude woman: (not looking at me) It's on the board.
Me: Yes, I realize that, but I don't know what she looks like.
Rude woman: (still not looking at me, yelling over to next desk) Hey Lisa, this person wants to talk to you.

I don't know if she was a nurse, or unit clerk, or what she was. But damn, if I hadn't forgotten it is a dog-eat-dog world out there on the floors. My baseline Dr. Nice is going to have become a big baddie.

 

[Patrick O]

just in respone to the frozen section of the brain tumour in a previous post.... why not try a squash prep and avoid the whole frozen section to get the diagnosis?

 

[b&ierstiefel]

just in respone to the frozen section of the brain tumour in a previous post.... why not try a squash prep and avoid the whole frozen section to get the diagnosis?

That's a legitimate point. When we get called for neuro frozens, we usually get a really small sample...especially brain biopsies. Typically we will do a touch prep and see what that shows first.

 

[Pingu]

#1 - Nurses like to piss all over people. From now on, I shall establish dominance in the phone conversation right from the get-go by introducing myself as Dr. Milonakis.

On the phone, I always introduce myself as Dr. Pingu...it truly is the only way to get ANYTHING done. Any department you call, if you say this is Pingu, they'll brush you off. But if you say this is Dr. Pingu needing to speak with Dr. so and so, it's just a minute please and so sorry for the wait. Truly sad how two little letters can make someone be nice and helpful to you.

 

[b&ierstiefel]

On the phone, I always introduce myself as Dr. Pingu...it truly is the only way to get ANYTHING done. Any department you call, if you say this is Pingu, they'll brush you off. But if you say this is Dr. Pingu needing to speak with Dr. so and so, it's just a minute please and so sorry for the wait. Truly sad how two little letters can make someone be nice and helpful to you.

I do too now. A few times this past week, I've had to call a few clinicians because the PA's received an unlabeled specimen container. The first time I called, I introduced myself as Andy Milonakis. Yeah, not good... "Can I take a message?" ... "Yeah I guess."

An hour later, I decided, "F*ck this! This is getting settled right now." I called again introducing myself as Dr. Milonakis. "The doctor is seeing a patient now...Can I take a message?" I would then respond, "Actually, this is an urgent matter which needs to get cleared up now." One minute later, the clinician is on the phone. Now that's how **** gets done!

Seriously, everytime I'm in the grossing room, clinicians will page me because they want a diagnosis on a case that came in the day before. And every time my pager goes off, I have to take off my gloves, degown, and answer the call which is really disruptive to my workflow. So if they're gonna make me do this...I'm gonna do the same to them! Being someone's bitch isn't a one-way street. When I'm dealing with your specimen and I'm involved in processing of said specimen, you're my bitch now.

 

[Pingu]

I've had to call a few clinicians because the PA's received an unlabeled specimen container.

Our techs are great about making sure people know what paperwork needs to be done and what labels need to be on the containers. After the first screwup, the nurse or whoever brought the wrong thing has a pretty darn clear idea about what needs to be done next time or otherwise face the wrath of our techs....

I would rather fight for bits of wildebeest with a pack of hyenas than incur the wrath of our techs.

 

[yaah]

just in respone to the frozen section of the brain tumour in a previous post.... why not try a squash prep and avoid the whole frozen section to get the diagnosis?

We have 3 neuropathologists here. One of them, the one who was on that night, will slaughter you and your yet unborn children if you do a squash or touch prep. I think she believes it can ruin the tissue. She has a point when the tissue is scant, I guess, although I am certainly no expert. The neuropath director is a strong advocate of squash preps though.


Last night was on call - got a lymphoma workup on a large axillary node right at 5pm. Interestingly, we had seen a pleural fluid on the patient that day and reported it as highly suspicious for lymphoma (since we didn't have flow or tissue, just the fluid). Lymphoma workups take some time because you have to triage tissue for flow and cytogenetics and molecular studies, then sit some in B5 for awhile. While I was sitting there waiting I had a platelet request which I approved, and looked at a couple of slides for the dermpath conference on monday. Rest of the night was fairly mild. No frozens. Got paged for an unnecessary request for irradiated RBCs at 10:30.

Resident initially requested leukopoor irradiated RBCs because the patient was a renal transplant recipient. Although, I should say, a person years status post renal transplant who is off all of his immunosuppressants because his transplant failed probably doesn't even need leukopoor, but I don't know for sure. Regardless, all our products currently are leukopoor, so that wasn't an issue. I declined the request for irradiation because we generally only do that for severely immunosuppressed patients like bone marrow transplant recipients or premature babies. Of course, because such a thing is nearly guaranteed to happen, this patient received his tylenol premedication before the RBC transfusions, and when he was halfway through the second unit (about 6 hours after the tylenol) his temperature went up 2 degrees. Irradiation has nothing to do with febrile transfusion reactions but no doubt the resident who ordered this is now convinced I should have permitted the irradiated blood. This call was at 3:30am and I couldn't go back to sleep right away so I watched the Godfather.

 

[Homunculus]

In terms of who asks the most questions and makes the most demands and insists their abnormal requests are justified even when they are not: Pediatrics.

The latter is much worse. Every patient is special, every patient is hurting, and every patient has needs. Just because the patient has a whiny parent does not mean we can break the rules for them.

that's just becasue y'all are heartless SOB's!!!

actually you may be right, but i think *most* of our requests are justified. most of our abnormal requests come from the heme-onc folks who, for some reason or another, have this strange disdain for pathologists. it's like surgeons and internists, only not nearly as severe or as outwardly shown. it's strange. . .

--your friendly neighborhood gimme my damn cross matched leukoreduced irradiated CMV negative washed prayed over slighty shaken not stirred MSG-free low sodium low fat organic PRBC's right now caveman

 

[yaah]

Yeah but see, the thing is, even if most of your requests are justified, then every night there is a shortage. That is why we have to be so heartless. We also have a patient on our service every week who acquired the disease that is killing him/her from transfused products.

Part of the problem: Lots of calls are from covering interns/residents who say "We need platelets to keep the count above 50,000." And I ask why, and they either say that it was because that was what they were told by the attending or what the consultant tells them. There are a lot of patients who you cannot get to above 50 unless you have a constant platelet drip, and yet these patients will hover at 20-25k without any complications of bleeding.

Hmm, I guess we are kind of lucky here. The heme-onc people are not really obnoxious at all. They generally have good justification for setting guidelines, and only have the "keep above 50k" for patients with active subdural bleeds or something. The annoying requests come from or as a result of INTERVENTIONAL RADIOLOGY, who has yet to provide any modicum of proof that their demands for a certain count have any basis in fact or evidence.

 

[Homunculus]

Yeah but see, the thing is, even if most of your requests are justified, then every night there is a shortage. That is why we have to be so heartless. We also have a patient on our service every week who acquired the disease that is killing him/her from transfused products.

Part of the problem: Lots of calls are from covering interns/residents who say "We need platelets to keep the count above 50,000." And I ask why, and they either say that it was because that was what they were told by the attending or what the consultant tells them. There are a lot of patients who you cannot get to above 50 unless you have a constant platelet drip, and yet these patients will hover at 20-25k without any complications of bleeding.

Hmm, I guess we are kind of lucky here. The heme-onc people are not really obnoxious at all. They generally have good justification for setting guidelines, and only have the "keep above 50k" for patients with active subdural bleeds or something. The annoying requests come from or as a result of INTERVENTIONAL RADIOLOGY, who has yet to provide any modicum of proof that their demands for a certain count have any basis in fact or evidence.

i agree. especially with the platelets-- unless they are symptomatic we'll leave them alone in the 20's. Even if they havea procedure coming that we'll need to bump the counts up we'll wait until immediately before the procedure to transfuse-- reason being they'll waste all the ones we give them if we do it too far in advance.

--your friendly neighborhood blood bank holdup planning caveman

 

[yaah]

Wow, you need to come to talk to the interns here! It seems like every call night we have someone trying to order platelets 12 hours before the procedure. Again, though, it's because interventional radiology continues to insist on seeing a count.

 

[deschutes]

--your friendly neighborhood gimme my damn cross matched leukoreduced irradiated CMV negative washed prayed over slighty shaken not stirred MSG-free low sodium low fat organic PRBC's right now...

Y'sure there's any of them left whole still?

My personal winning item on the menu has got to be the volume-reduced platelets.

"Yep we'll take off the 50cc or so of plasma, but platelets don't like that spinning down and don't work as well. On one hand you infuse 50cc less fluid, on the other hand you're looking at giving another unit to get the count up..."

I really feel sorry sometimes for the poor clinicians we harass. Especially the BMT folks.

The best are the hallway fly-bys.

deschutes: "Bleeding?"
Peds resident: "Bleeding."
deschutes: "Okie doke!"

Sounds cold-blooded really, when you think about it...

 

[cytoborg]

I do too now. A few times this past week, I've had to call a few clinicians because the PA's received an unlabeled specimen container. The first time I called, I introduced myself as Andy Milonakis. Yeah, not good... "Can I take a message?" ... "Yeah I guess."

An hour later, I decided, "F*ck this! This is getting settled right now." I called again introducing myself as Dr. Milonakis. "The doctor is seeing a patient now...Can I take a message?" I would then respond, "Actually, this is an urgent matter which needs to get cleared up now." One minute later, the clinician is on the phone. Now that's how **** gets done!

Seriously, everytime I'm in the grossing room, clinicians will page me because they want a diagnosis on a case that came in the day before. And every time my pager goes off, I have to take off my gloves, degown, and answer the call which is really disruptive to my workflow. So if they're gonna make me do this...I'm gonna do the same to them! Being someone's bitch isn't a one-way street. When I'm dealing with your specimen and I'm involved in processing of said specimen, you're my bitch now.

Just tell them, "If you want a timely diagnosis, STOP F*CKING PAGING ME! Thank you. Have a nice day."

I've started introducing myself as Dr. too. I hate doing that, but sometimes it seems like the only way to get somebody to pay attention.

 

[deschutes]

There is an art of telephone-manship that I'm only just beginning to clue into.

"This is Dr. So-and-So from _____ I was paged."

The experienced practitioners of this artform just say "Dr. So-and-So". And the way they say it manages to convey boredom, mild annoyance, I've-seen-it-all why-the-hell-are-you-paging-me - in just those two words.

Not chirpy. Not helpful. Chirpy and helpful is bad and will immediately relegate you to the realms of the underling.

 

[yaah]

The phrase I always like to hear is, "Thank you for calling me back." Well, no ****, you paged me, that's what it's for. When people don't call me back after I page them I get pissed off.

 

[drPLUM]

Being someone's bitch isn't a one-way street.

Once again Andy chimes in with a quotable quote. I like that attitude, man. You've got to demand respect brotha!

When a clinician bothers me, I simply get up from the scope, give him a cold stare, and then -never taking my eye off of his- do 23 one-armed push ups. Yes right there in front of everyone, in the bone marrow lab. Because, how can you not respect one-armed push ups? Then, without speaking, I slowly get up, go back to the scope- again, never taking my off of him- and resume sign out. At that point the clinician finds he has no option but to give due respect and wait patiently for my path report to be delivered. From then on I usually have no further problems with said clinician.

I recommend you give this method a try, my friend. Pathologists must stand together... oh wait..I'm just a student and no clinician ever pages me... hmmm... but IF THEY DID... I would undoubtedly use this method.

 

[deschutes]

Once again Andy chimes in with a quotable quote. I like that attitude, man. You've got to demand respect brotha!

Wow that was deep.

 

[b&ierstiefel]

 

[yaah]

When my pager goes off, my initial response is either "mother****er" or "Bull****" or "now what, douchebag?"

I hate the "now what, douchebag" pages more than everything else, because it's usually from someone whiny who thinks their issues are more important than anyone else's. I treat every issue with importance when I get paged, ok douchebag? I don't delay results or do a half assed job just because I am not being harrassed by someone who wants results.

I take that back - my most common response to hearing my pager go off is "****ing platelets," because it is usually a page about platelets on someone who doesn't need them. How do I know that? Because if they did need them, the blood bank would give them to them without having to go through me.

 

[deschutes]

Thank you Captain Obvious

Hey, it's not always so Obvious.

Besides, I wasn't even responding to your post!

 

[b&ierstiefel]

ha

 

[yaah]

Call night on thursday kind of sucked. It was CP only call but it was a real pain because I kept getting weird calls. At 2:30 AM I got a nice call from blood bank where the girl said, "The transfusion reaction workup tube is hemolyzed." This is the last thing you want to hear, of course. The initial reaction is the get another sample to make sure it wasn't a traumatic draw. In this case that happened and it was negative, so all is well. But it took a long time to get it and I had to make sure the patient was still stable by calling the floor and having quite a long discussion with the nurse.

 

[deschutes]

The Infectious Disease team...enuff said

I don't understand. They can't be bugging you about culture results - is it things like gastric biopsies?

 

[pathstudent]

Rush cases that come in on a Saturday don't get rush signed out until Monday. Cuz the slides aren't cut on that same day or on a Sunday. They don't get this and again, we have to tell them that. And no, just because you page me, the specimens are not going to get any sort of special treatment. They will get signed out on schedule since I can't do much to change that.

.

Wow, so BWH doesn't have any cases where a diagnosis within 24 hours makes a difference to the patient? That's suprising. Most large tertiary centers provide rush services (even on Sundays) for certain scenarios.

 

[AngryTesticle]

Wow, so BWH doesn't have any cases where a diagnosis within 24 hours makes a difference to the patient? That's suprising. Most large tertiary centers provide rush services (even on Sundays) for certain scenarios.

Well, if people need a really quick answer, we can resort to do a frozen section. For instance, let's say the clinicians want to rule out an ectopic pregnancy and they give us a products of conception sample. We would, of course, look for villi grossly under the dissecting scope. If we don't see villi, then we'll freeze some of the tissue.

The problem is this...the rate limiting step of any diagnosis is when a sample gets put in the processor. Here, the processor runs from 6 pm to 6 am M-F and on Sunday. The histotechs come in bright and early to start preparing the slides from the cassettes/specimens that were in the processor the night before. However, the processor does not run on Saturday. How do I know this? Well, I was on call this weekend and it is ultimately my responsibility to load the processors by 6 pm on Sunday. I don't load anything on Saturday.

Any other day, when a rush comes in, it does get evaluated within 24 hours. The case gets dictated on a separate Rush tape and the histotechs cut these slides first. Then they get brought directly to the resident who immediately hunts the attending on that service down to read the slide and subsequently, we call in the diagnosis to the clinician. Saturday is one of those oddball days.

Now, that is the usual rule. I'm sure there are exceptions...but the circumstances have to be pretty dire. Of course, pathology is everyone's bitch but these negotiations occur above the resident level--the discussion happens between attending and attending.

 

[yaah]

The bane of my call existence lately has been the mislabeled specimens. We have a policy here which is JUST flexible enough to be a pain in the ass. All specimens that are not labeled with two unique IDs (like name and MR#) both on the specimen and the requisition are rejected. However, because there are some specimens that cannot be recollected (like CSF or a hemicolectomy) we allow them to relabel some specimens. This is interpreted by some as "We should be able to relabel" anything from a blood culture bottle (because the patient has started antibiotics) to a vanco trough to a 24 hour urine to ANY blood sample on a child. So we get called a few times every call from someone who doesn't want to recollect and wants approval to go and relabel the specimen. Some residents are a little more lenient than others, which is the main problem for others who want to actually follow the policy. I spent about 10 minutes on the phone once with an upset NICU nurse who had sent down a blood bank specimen with the wrong patient's name on it, saying they needed to relabel it because it took 45 minutes to draw it. It's unfortunate, but these are patients' lives at stake here. Running the test on a potentially wrong sample doesn't do anyone any good at all.

So today am on call and got called about a 24 hour urine collection that they put the wrong patient label on. NO. That sucks for the nurses though. I bet next time the right label will be on that gallon of urine.

 

[deschutes]

Do any of these re-labelled specimens eventually get reported out into the lab results/EMR computer system with a tag attached saying "this specimen was re-labelled, advise redraw" or something of the sort?

 

[yaah]

I don't think so. If it gets rejected sometimes a note pops up that says "Specimen cancelled due to improper labeling" or something like that.

No, see, clinicians would LOVE a policy that allows them to run the sample with that caveat on it. Attendings and experienced people would hate it probably because they don't think they can trust the results, and have been perhaps burned before. But for young residents and nurses who just don't want to get in trouble for not getting the specimen to the lab, that would be enough because often by the time this all comes to pass it is someone else's problem. It is sometimes the job of the hospital lab to provide the necessary common sense to protect patient safety.

The worst one I ever got called about was an unlabelled type and screen sample. I asked the resident if he really wanted to take the chance that the specimen actually was incorrect, and get a hemolytic transfusion reaction. Or just redraw it.

 

[deschutes]

I completely agree - I guess I was just thinking if there was a way to CYA for those that DO get okayed.