Tuesday, June 21, 2011

Gross Room Survival Guide Part 3. Practical issues of the gross room

I am not going to go into details of grossing each type of specimen. Those you will either read about or pick up on the job. These are just a few general tips to make your life as a first year resident somewhat more tolerable.

Be organized. Arrive early on your gross room days. Get the surgery schedule and go over it. Cross off the cases that you are unlikely to get a specimen on. Highlight those that are likely to require a frozen section or a gross consult. Look up the patients’ histories and any previous pathology reports. Print out relevant information and highlight the most important findings.

Check your station. Have your tools clean and available. Check the supplies (formalin, ink, frozen section embedding compound, frozen section fixative, the staining panel etc). Make sure you have slides, coverslips and mounting medium for the frozen section. Nothing worse than cutting a perfect frozen section, reaching out for a slide and not finding any. Change the blades on the cryostats every morning even if they look visibly new. All these things will save you time during the day.

Triage the specimens as they arrive. This will depend on your institution policy on grossing fresh or fixed tissue. In my program most specimens are grossed fresh. Things that get fixed overnight are bladders, stomachs, and any late specimens. Certain kinds of specimens only need to be in formalin for a few of hours and can be grossed the same day (prostates, Whipple resections, partial mastectomies). Sections of any breast specimen, whether you gross it fresh or fix it first, need to go in formalin as soon as possible, preferably within an hour of surgery, in order to preserve estrogen and progesterone receptor immunoreactivity. If you cannot gross a breast when it arrives – ink it, measure it, cut into the tumor and put it in formalin. It only takes 10 minutes, you can gross it at any time at your convenience, and you haven’t compromised patient care. Same applies to prostate. Ink the capsule and throw it in formalin. You don’t even have to measure it – all that can be done later. If you cannot get to the specimen now, put it in the refrigerator. If you are swamped with specimens – ask for help from your fellow residents and/or PA’s. See what has to be grossed today and what can be held until tomorrow without compromising patient care and turnaround time, when possible.

When taking representative sections of an organ, be consistent in the order you do it. I usually go proximal to distal, right to left and top to bottom. You can do it any way you like, but make it the same way for each specimen, unless you encounter something unusual that would warrant a different approach. This way you eliminate the time you would spend on keeping a track of your sections.

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