Remember remember the month of December?

Because I certainly don't.  November... clinical chemistry.  The day after November.  Work.  8 AM on December 31.  No longer work.  Party downtown for NYE and then burn rubber for New Orleans before anyone else can page me.

I'll back up.  As I've mentioned previously, now that I'm a high and mighty second year (though since it's a four year residency, still a junior resident), I can take call.

I probably explained this in a previous post, but I'm too lazy to look back, so quick recap.  Most pathology residencies have people take call a week at a time.  You are on call starting at 5 PM on Monday night until 8 AM the next morning and that's the pattern.  You then take call from Friday at 5 PM straight through until Monday at 8 AM.  If there's a holiday during the week (like Christmas), it's like the weekend, you're on for that entire time.

There are two types of pathology call: AP (anatomic pathology) and CP (clinical pathology).  AP is the headache that frequently requires you to come into the hospital.  Surgery is running late or got scheduled on the weekend and they need tumor margins?  AP.  LifePoint has a potential donor kidney but needs to evaluate whether it's viable for transplant at 2 AM?  AP.  Medical autopsy between Friday afternoon and Sunday afternoon?  AP.  Patient is immunocompromised and may have a necrotizing fungus in their lungs?  AP.

CP is all the lab stuff.  Authorize nonstandard or nonindicated blood transfusion?  CP.  Transfusion reaction?  CP.  Stool cultures?  CP.  Oops, someone forgot to label a specimen may I pretty please oh please I swear I know it's the right patient, PLEASE let me come down and relabel it?  CP.  CP is far more likely to roust you from sleep at 3 in the morning, but typically requires a series of exhausted phone calls rather than rushing out the door with wet hair pulling your sneakers on.

For our first year of call, we are supposed to take AP and CP weeks separately so we don't get overwhelmed.  The thing is... you can have a call week with virtually nothing... maybe three phone calls for the entire week and one frozen section that keeps you at the hospital until 6 PM.  OR you can have your pager go off constantly, fill your weekend with complicated autopsies that you're forced to pause to deal with other calls.

For December, I was on my old friend surgical pathology, which really heats up at the end of the year as everyone attempts to get in their surgeries before they have to pay a new insurance deductible.  People also may also have a week off around Thanksgiving or Christmas or have it easier to arrange so they can put their surgeries then (making a depressing holiday, I'm sure).  So December was beating me to death in general.  Just to get to our own office Christmas party required two other residents tag teaming to get all my specimens handled by 6:30 P.M., which was a job that otherwise would have taken me until 10.  Boyfriend was cooking for me a great deal of the time.

But then Christmas week... that was my call week, as the second years tend to get the holidays.  We lost a resident to family stuff who was my co-call person, which meant either take both calls or cost someone their Christmas.  I figured how hard could it be, and had several reassurances that Christmas is a slow week which turns out to not be entirely true.

Here's the thing... the most junior people are the ones stuck on Christmas, present company included, which means the hospital runs at half staff with the lowest people on the totem pole, who are the most likely ones to be calling me with weird questions, a lack of justification for why they're calling me, and reasons for procedures like "My chief wants the values to be X".

So during the week of Christmas, my pager went off 41 times.  I had autopsies and frozen sections and SO many mislabeled specimens and bizarre requests.  As the week progressed and my grinchitude grew dire, I was pretty much saying no to anything that couldn't be considered irretrievable (like lumbar puncture specimens or brain biopsies).  I did the longest autopsy in the history of autopsies just because the darn pager kept going off.  I took to referring to it as "the wife" because it kept frigging nagging me.

My mom also got to be in town for Christmas, which unfortunately didn't leave me much time with her due to the above.  Unfortunately she got to see the absolutely least exciting/sciencey part of my job "What do you mean you didn't label a random urine catch?  No, you can't relabel it.  Yes, you do have to call the patient back." and not the good stuff.  She also saw me swear at my computer a lot since the apps you need to access really like to bug up when you're on a deadline.

During this time, keep in mind that except for the actual holiday, when you're taking call from home, you're still doing your normal duty hours, and except for Christmas Eve, it was kind of a nasty week.

So when I got off call at 8 AM on New Year's Eve and did the official hand off of my cases, I actually said "If anyone has any difficulty with anything I did last week, I don't want to hear it.  My first week of dual call... I am officially above criticism."  And to everyone's credit, I haven't heard a word about it.

But I handled it.  Gone is all the panicky nonsense from last year, replaced by an aggravation by heavy workloads and unrelenting paging, but I overall like my job and feel like I'm getting better at it, which is awesome.

NYE was pretty fun.  Ended up going to a party at a bowling alley/bar/arcade/silent disco (?), had a hotel downtown, and avoided getting completely ridiculous like I did last year (though in my defense, that was a few days after the house went).  But I knew I needed to be unhungover for the drive to Nola via Jacksonville because hooray.  Replaced my hurricane glasses that got torched last year, got some great cajun food up in Baton Rouge, where it's 15 dollars cheaper, and bummed around Frenchmen street listening to great live music that involved songs that were not hacked up covers of Play that Funky Music.

Came back to cytopathology, which I'm loving far more than I expected.  So in surgical pathology, they deal with larger specimens, at least biopsies, so you are not just getting a cell that may look cancerous, but it is in the context of the surrounding tissue architecture.  For instance, your body frequently gets violently pissed off about getting invaded by cancer, so even when you don't initially see the actual tumor cell, you see the surrounding reaction to it.

Cytopathology deals with single cells, either from aspirates from suspicious tissue so that if it's nothing, the patient is only subjected to a deep needle stick and not a full surgery, or fluids that aren't blood (hematopathology's territory).  For instance, urine is supposed to be relatively cell-free.  People with bladder cancer; however, may shed those cells into the urine where we see them and go "AHH  Bad Nucleus!".  Any fluid that's accumulating around the lungs or in the abdomen, we check for cancer or bacteria.

It's teaching me about problems at a cellular level so I'm getting to know the features to look for, which will help me for surgical pathology particularly for sneaky cancers like melanomas, which the surrounding tissue may ignore.

We also see patients when we go on aspirates.  Granted, we barely speak to them and we *definitely* don't tell them what we see other than "this specimen is adequate" since the last thing a patient wants to hear is a positive cancer diagnosis by way of a complete stranger looking into a microscope near your feet and going "Holy crap".  Rapport fail.  The process is important though.  We literally influence the number of times a clinical has to stick a needle into someone's neck.  And they get frustrated with us for it.

What else.. we had a sudden warm snap, which was awesome.  It coincided with a visiting Jersey friend, which led to a beach day, a failed surfing attempt (on my part; not on her part; that crap is harder than it looks), so she finished off the surfing day while I drank beach juice (tm) with Boyfriend and Friends.

So that's what I've been up to.  Another call week is heading up on me, so I'm throwing myself into restaurant week to go out with a bang.  Unfortunately, holiday baking + stressful month + no exercise due to workload + New Orleans + Restaurant Week = the next three months of broccoli and treadmills.

More than you wanted to know about autopsies

Hola amigos. Autopsy's been pretty crazy this last week. There's an interesting split in pathology because there's more than one type of autopsy. There are baby autopsies, forensic autopsies, and medical autopsies. The babies tend to involve perinatal circumstances so more to find out why something went down either before birth but after 20 weeks gestation, or right after birth, and hopefully find something to give the parents some idea of how likely it is to happen again.

Forensic autopsies are what everyone things pathologists exclusively do, and also, people think they encompass way less than they do. Essentially, if you don't die in the hospital, you get a forensic autopsy. Homicides, the famous one, but suicides, car accidents, bike accidents, pedestrian accidents, old people found at home, boaters found in rivers, etc. Full spectrum. When you're not the lead on these cases, they're actually less of a pain in the butt then people would expect since mail off labs are the ones that have to do the extremely slow version of all that CSI stuff.

Medical autopsies are the ones that are most important to the residents, and constitute the most paperwork. They give you a benefit over forensic autopsies because you have all the hospital paperwork at your disposal. Unlike most forensic autopsies though, this complicates the course because people in hospitals don't tend to die of really straightforward things. So... what killed this person? Cardiac arrhythmias are a particular headache. If it's not caught on a monitor, we can't demonstrate it happened. An MI will leave evidence (sometimes) but the arrhythmia it triggers? Not so much. We were given a handout describing death not as a loss of structure, but of function, and since we get them after the cease of function, it can be something of a mystery.

An added aspect to medicals is unlike with forensics, unless the forensic has a really medical-ly component to it, is we have to explain it to their clinicians AND families in a write up. This is difficult. Laymen understand why getting crushed by a truck causes death. They do not generally know what an amniotic fluid embolism is, why their mortality rate is so high, why doctors couldn't really do anything about it, and what the mechanism of death is, all without using words like "disseminated intravascular coagulopathy", and I have to explain it without being callous. And cite references.

But it's all good, and ultimately, way less stressful than surgical pathology. My attendings are super cool, and one of them caused me to discover an autopsy scully doll that I didn't know existed, and sparked my long dormant desire (coupled with Slappy mailing me a Scully action figure to replace the one burned by a fire, and yes I am a complete dork) to collect X-Files things. I'm trying to temper it with a more normal grown up habit like buying nice shoes or purses, but damn that stuff is expensive. I feel like a yuppie tool every time I pay 80 bucks for running shoes (worth it) but I saw a pair of Gucci boots that I liked decently online and they were 1100 dollars. Noooooo.

What else... Oh! People have been sending me pictures! See???

My nudibranch from Monterey!

Grenada hash!

The Alps!!!

Soooo awesome. Great to have memories back.

You want me to tell what to whom?

"I bivalved the uterus. The endometrium looks normal."

"All right, let me come see. Okay, you're calling the OR."

"... what?"

"Call them and tell them."

(Deep breath) "Okay." (picks up phone)

"Wait! What are you going to say?"

"Uhhh... I... this is pathology."

"Do you have a name?"

"Yes."

"Do you have a degree?"

"Yes."

"So use it! Women, we always do this. You're DOCTOR Sancho and you have his results. Now what are you going to say?"

"Um... this is Dr. Sancho from pathology. The... uterus..."

"I examined the corpus and..."

"The endometrium appears benign. There are no polyps or lesions visible."

"Okay."

(Picks up phone) "Hello! This is Dr. Sancho from pathology. I examined the uterine corpus and the endometrium appears benign."

"Oh! This is his nurse. I'll put you on with Dr. ScarySurgeon."

"Hello? This is Dr. ScarySurgeon. You're on speakerphone."

"Meep."

Meanwhile:

Accessioner: "Ooh, that's Dr. ScarySurgeon? Tell him to call ahead on his frozens. I can't, but you can."
Ishie: "I'm a first year. He'll beat me up and take my lunch money."
Accessioner: "You have lunch money?"
Ishie: Dammit.