Jun 24, 2014

My Path to Pathology. Becoming a Pathologists’ Assistant (PA)

I have been receiving a million emails and messages through www.iheartautopsy.com and my Instagram account @mrs_angemi regarding my education and career. I can not answer all of these individually so I hope this post provides helpful information to those who are interested.

I have a long, extensive, well rounded experience in a medical laboratory setting for a person my age. When I was 19  I was a single mom with a 4 year old, and I knew I had to do something with my life. I enrolled in college with no idea what I wanted to do. I  was fascinated by all things medical, so naturally being a 19 year old female in the United States, I joined college as pre-nursing.

In my first semester I had pre-biology as one of my courses. Let me preface this by saying I dropped out of high school at 16, so I never took a science class more advanced than earth or food science. On my very first day of biology class, my teacher had us looking at some cells under the microscope. I instantly fell in love. I asked my teacher if there was a job out there that I could just sit there and look at cells under the microscope everyday. Luckily my teacher was a Medical Technologist working in microbiology in a local hospital part time. She was very excited to tell me all the jobs available being a microscopist! That was when I got introduced to the medical laboratory.

The next semester I ditched the pre-nursing major and was now a science major with a plan. I fell in love with the microscope and that was going to be my career. Over the next year I was introduced to many different parts of the medical laboratory. The medical laboratory is split into 2 divisions: clinical pathology and anatomic pathology. Clinical pathology consists of of multiple parts such as microbiology, hematology, blood bank, chemistry, etc. Anatomic pathology also consists of multiple parts including cytology, histology, surgical pathology and autopsy- all subjects I love. Right from the start I knew I wanted to go into anatomic pathology, more specifically cytology. Cytology is the study of cells and a job where I could look under the microscope all day. I found out that Thomas Jefferson University in Philadelphia offered a bachelors degree program in cytotechnology. I applied and was accepted. (To read more about what cytology is check out my post “My Old Love: Cytopathology”)

As I was working on my prerequisites, about a year before entering Jefferson, I started working as a microbiology assistant in a hospital which I continued to do throughout my entire time at Jefferson. That job was super cool and I learned so many things about microbiology and the other parts of the lab. I was working at Hahnemann Hospital at the time and the pathology residents would always bring over chunks of organs from autopsy for microbiology studies. I was so curious about autopsies and one day I viewed my first one. Before I went in the morgue I was very scared of the unknown. Even though I was 20 years old, I had never seen a dead body, not even at a funeral. I didn’t know what to expect of how to feel. I walked into the morgue and there was a dead body, 38 year old male, HIV +, who died due to complications of AIDS. The first thought I had when they wheeled the body out of the fridge was OMG this guy is really dead, but I kept my cool because it did not seem to be bothering anyone else there! After I got over the initial shock of being in the same room with a dead person, the rest came easy. Now I will sit down next to a dead body, eat a snack, talk to my friends and its like second nature. I have come a long way!

I graduated Jefferson as a certified cytotechnologist and immediately was hired at Thomas Jefferson University Hospital. By this time I was in love with college and wanted to go for my masters degree. I also really wanted to do autopsies and I found out about this career called a Pathologists’ Assistant. I looked into this degree program but the closest one was in Connecticut or Maryland. Moving was not an option for me because I was a single mom. So I stayed a cytotechnologist for about 2 years.

I was very happy being a cytotechnologist at Jefferson but I wanted more. At that time I was becoming closer to the pathology residents and they were showing me the different parts of anatomical pathology like surgical pathology and autopsy. I was so fascinated by all of it immediately. Just around that time one of the employees of the surgical pathology lab quit, so I asked the director if I could move over there for the same pay and start dissecting specimens and he agreed! Soon after I started in surg path, the Drexel PA program was up and running and within 2 years I had applied and been accepted to the program.

My plan was to work full time as a “PA” while going to PA school full time, which I was able to do because my supervisor at the time was awesome and willing to work with me. As I was working as a PA, before I was certified, I was doing smaller dissections like gallbladders, biopsies, and appendixes and helping with frozen sections. I had a totally different experience than anyone in my PA school class because I had already been working in the lab for years. People always ask me if school was worth it. Absolutely. Trust me I hate making that student loan payment every month, but it definitely formed me into what I am today. Drexel was an excellent program in my opinion and it really brought everything together for me. I will never forget the day a light bulb went off and I said “I get it!” It was just like that, one day I felt like I just understood everything in pathology and what my role was.

Since then I have dissected more than 50,000 surgical pathology specimens as well as performed up to 1000 autopsies. I also teach Drexel students throughout the year as their student mentor and I teach them a course yearly as a review for their board examination through the ASCP (American Society of Clinical Pathology). I have also served time on the board as the Vice Chair and Chair of education for the AAPA (American Association for Pathologists’ Assistants) which I stepped down from because of my crazy life with work and a baby. I also have been volunteering for years for science events around Philadelphia for the Mutter Museum, Franklin Institute and Philadelphia Science Fest.

To learn more about a career as a pathologists’ assistant or PA check out http://www.pathassist.org/ or https://www.drexelmed.edu/Home/AcademicPrograms/ProfessionalStudiesintheHealthSciences/AlliedHealthProfessionPrograms/PathologistsAssistantPathAProgram.aspx

pa

Jun 17, 2014

Did You Know Your Organs Can Fall Out!? Organ prolapse.

Hi all! I’m sorry it has been such a long time in between writing! Work, a baby, moving and pure laziness has kept me from it. I have been posting lots of awesome photos with short descriptions which is a sort of “lite” version of this blog. These photos can be seen on the Figure 1 app (username iheartautopsy) or Instagram app (username @mrs_angemi). Also, I am working on a post describing in detail my work history in the laboratory and becoming a Pathologists’ Assistant. I am receiving so many emails and messages regarding my education and I can’t keep up! Hopefully this post will be helpful! Thank you for your continued interest and support. I have some very cool posts coming up!

All of the organs in the human body are held in place by muscles, ligaments and surrounding organs. They are designed to function properly when they are in place. They are also designed to function when the body undergoes certain conditions such as pregnancy. Unfortunately pregnancy and a vaginal childbirth can be responsible for organ prolapse. Organ prolapse can also occur in any age in both men and woman. Other causes of organ prolapse include previous pelvic surgeries, constipation, infections, straining during bowel movements and weakness of the bowel muscles  due to age. The most common organs to prolapse are the uterus, bladder and rectum.

The pelvic organs are held tightly in place by the muscles of the pelvic floor and perineum. When these muscles get damaged, the organs begin to slip out of place and eventually fall out.

Uterine Prolapse

Here is an illustration of a prolapsed uterus compared to the normal female anatomy. As you can see, as the uterus begins to slip out of place it begins to protrude into the vagina.

prolapse uteus

Woman of perimenopausal age are at most risk for uterine prolapse, but it can happen at any age. The decrease of estrogen can be a contributor. When the pelvic muscles are weakened, the uterus can begin to slip into the vagina. The severity varies from person to person. If the prolapse is mild, it may cause no symptoms. A more severe case would present with symptoms such as pressure, heaviness or pulling of the vagina, low back pain, sexual problems including loss of vaginal tone, and tissue protruding into the vagina.

This is a clinical example of 2 severe forms of uterine prolapse showing the uterus protruding through the vagina. This severity would be difficult to repair with any other method but surgery.

uter pro clin uterine prolapse clinical

With less severe cases of prolapse, treatment options include a vaginal pessary.  This device fits inside the vagina and holds the uterus in place. This can be used as a temporary or permanent treatment. They come in many shapes and sizes, so the doctor will measure and fit each patient for the proper device. Vaginal pessaries can irritate vaginal tissues causing sores ulcerations. They may also interfere with sexual intercourse.

obgyn-pessaryPessaries

 

Sometimes when the uterus begins to prolapse and fall out of place, other organs surrounding the uterus and vagina come along for the ride. This most commonly occurs with the bladder and rectum.

Cystocele 

Cystocele refers to the bladder prolapsing into the vaginal canal. This commonly occurs with uterine prolapse because the pelvic muscles are so weak when the uterus begins to fall out it pulls the bladder along with it. It can also happen without uterine prolapse. This has the same symptoms of uterine prolapse. The patient may also having a feeling that the bladder is not emptied completely or recurrent bladder infections. Mild prolapse will cause no symptoms. A vaginal pessary can also be used to repair mild cases of this, if surgery is needed, the bladder will be pushed back into place and the extra stretched tissue will be removed.

cytocele

Here is a clinical photo showing the bladder protruding into the vagina.

cysto

Rectocele

Rectocele refers to the rectum prolapsing into the vaginal canal. This also commonly occurs with uterine prolapse because the pelvic muscles are so weak when the uterus begins to fall out it pulls the rectum along with it. It can also happen without uterine prolapse. Constipation, straining during bowel movements and heavy lifting contribute to this. This has the same symptoms of uterine prolapse. The patient may also having a feeling that the rectum is full or difficulty making a bowel movement.  Mild prolapse will cause no symptoms. A vaginal pessary can also be used to repair mild cases of this, if surgery is needed, the bowel will be pushed back into place, but unfortunately the bowel function may not improve.

rectocele

Here is a clinical photo showing the rectum protruding into the vagina.

recta

Rectal Prolapse

There are 2 types of external rectal prolapse, partial prolapse (also called mucosal prolapse) is when the lining of the rectum slides out of place and usually sticks out of the anus. This can happen straining during a bowel movement and is most common in children younger than 2 years. Complete prolapse is when the entire wall of the rectum slides out of place and usually sticks out of the anus. At first, this may occur only during bowel movements. Eventually, it it can occur when standing and walking and in severe cases it sticks out all the time.

Here is an illustration showing the normal place of the rectum and a rectum with prolapse.

rectal pro image

 

Many things increase the chance of developing rectal prolapse in children including cystic fibrosis, anus surgery as an infant, malnutrition, deformities of the bowel, straining during bowel movements and infections.

Here is a clinical photo of a child with rectal prolapse.

rectal-prolapse-grade-ii

An infection common in children that causes rectal prolapse is a whipworm infection. This is not common in the western world. Trichuriasis also known as whipworm infection is an infection by the parasitic worm Trichuris trichiura. Whipworms live in the large intestine and whipworm eggs are passed in the feces of infected persons. If the infected person defecates outside  or if human feces as used as fertilizer, eggs are deposited on soil. They can then mature into a form that is infective. Whipworm infection is caused by ingesting eggs. This can happen when hands or fingers that have contaminated dirt on them are put in the mouth or by consuming vegetables or fruits that have not been carefully cooked, washed or peeled. People with heavy symptoms can experience frequent, painful passage of stool that contains a mixture of mucus, water, and blood. Rectal prolapse can also occur. Children with heavy infections can become severely anemic and growth-retarded. Whipworm infections are treatable with medication.

Here is a clinical photo showing a whipworm infection in rectal prolapse.

worm

Here is a clinical photo of complete rectal prolapse in an adult.

rectal pro clinicalrectal prolapd clinical

If the choice is made to do surgery, like in a severe case of prolapse seen above, a segment of the rectum or rectosigmoid colon will be removed and sent to us in pathology. This is what the specimen looks like. Here you can see the end of the colon which is the rectum that was sticking out of the patient. These specimens are not complex, we basically just look at it to confirm prolapse. One section I always tell residents and PA students to exam is perpendicular sections of the prolapse. Sometimes with long standing prolapse, metaplasia of the rectum lining can occur changing the cells from glandular to squamous because it is exposed and gets irritated. This metaplasia can be seen microscopically.

rectal prolapse gross

TRAUMA!!!!!!!!! The Forensic External Exam in Hospital Specimens

Traumatic amputations are one of the more disturbing specimens we receive to the pathology lab. Seeing things that are so recognizably human can be crazy for the mind. Some of these specimens seem rather complicated and trip out many pathology residents and PA students, but they are actually quite simple to handle if you know the proper terminology.

Some gross terms used to describe wounds are just fancy variations of words we learned as children- for example a “scrape” is called an abrasion. These fancy terms are used very frequently during the forensic autopsy to describe trauma associated with accidental, suicide and homicide deaths. We use these same terms in the surgical pathology laboratory when we receive traumatic  amputation specimens. Usually these specimens are from accidents, but they can also be from attempted suicides or homicides. Regardless of the traumatic event, most of the specimens are considered medico-legal cases because of either law suits or prosecution.

Abrasion. Abrasion is a fancy word for a “scrape”. This occurs when the skin contacts an opposing surface and the movement of either the skin or the surface results in friction that pulls away the superficial layers of skin. These are commonly seen in amputations involving pedestrians because of the scraping of skin against the road.

Contusion. A contusion is a fancy word for a bruise and occurs when capillaries and large blood vessels tear, resulting in the escape of blood into the extravascular space.

There are 4 terms to describe the gross appearance of  contusions. Petechiae, purpura, ecchymoses and hematoma.

Petechiae are small punctate hemorrhages (approximately less than 3mm in diameter). Petechiae are not common in traumatic amputations because of the mechanism in which they occur. They are not caused by blunt trauma. They can be seen in cases of strangulation or other cases of asphyxial death, sepsis and other disease processes. Purpura are hemorrhages that are a little lager than petechiae (3-10mm). These type of hemorrhages are also not present in blunt trauma specimens. They can also occur in cases of sepsis along with other disease processes. If either of these are seen in a trauma specimen, it can be mostly be attributed to the patients underlying health rather than the trauma itself. The photos below show petechiae and purpura.

  

Ecchymoses. An ecchymosis is larger than a purpura (>1 cm). These are small contusions and in elderly patients (senile ecchymoses) can be caused by minimal trauma or can occur spontaneously. Although these ecchymoses can get quite large they are not to be confused with a hematoma. These collections of blood generally appear to be confined to right below the skin.

Hematoma. A hematoma is what we classically think of as a bruise and occurs when a blunt object tears the vessels causing a blood accumulation in the soft tissue underlying the site of impaction. These are the most likely contusions to be seen on a traumatic amputation specimen. If a true hematoma is incised as seen in the second photo a blood accumulation will be seen in the underlying soft tissue. This is how you can confirm an area of blunt impact compared to the above contusions or livor mortis (post mortem blood pooling).

      

Incision. An incision is a clean cut on the skin that is made with a sharp object, such as a knife or blade. This hand was traumatically amputated by an electric saw, one clean slice. In the second photo, look closely at the edges of these wounds, the borders are very smooth and clean. This is something you would see if a person is working in an industry with equipment with sharp blades or as defense wounds by a victim getting stabbed with a knife.

  

Laceration. A laceration differs from an incision. A laceration is not caused by a sharp object, but is caused by the skin and tissue either being twisted, stretched or ripped to the point of it splitting. This first patient had extensive laceration after getting hit by a motor vehicle off of a bicycle. The next 2 photos show a closer exam of lacerations. The borders are irregular, compared to the above incisions. Tissue bridging is a key feature of a laceration. Tissue bridging are the areas seen where there is not a complete tear and strands of of skin are still attached to the edges of the wounds. Lacerations can also be seen in blunt force trauma cases, for example hitting the skin with a baseball bat to the point of it tearing or multiple fractures breaking through the skin in the case of a motor vehicle accident.

    

Degloving. Degloving is a nasty injury in which the skin (which is referred to as the glove) is literally ripped off the bone leaving the skin completely detached from the underlying bone. Like taking a glove off of your hand. The quality of this first photo is not that good but shows a degloving injury in which the patient had their hand stuck in an elevator shaft. The remnants left are phalangeal finger bones with attached muscle and tendons that extend the length of the forearm. These injuries are usually caused by getting an extremity stuck and pulled off of the body. The second photo shows a partial degloving of the arm. The entire arm skin is removed like a sleeve. This patient was ran over by a train.

      

One of the most common degloving injuries is caused by patients wearing rings.

Bone trauma. Most of these wounds will coincide with underlying bone fractures. There are many types of fractures, but the main categories are displaced, non-displaced, open, and closed.

In a displaced fracture, the bone snaps into two or more parts and moves so that the two ends are not lined up straight. In a non-displaced fracture, the bone cracks either part or all of the way through, but does move and maintains its proper alignment.

A closed fracture is when the bone breaks but there is no puncture or open wound in the skin. An open fracture is one in which the bone breaks through the skin.

Here is a simple drawing of multiple types of fractures. Multiple types of fractures can be seen depending on the mechanism in which the amputation occurred.

Here is an example of an open fracture. It is common for multiple types of fractures to be seen in one specimen.

Multiple wounds. Some traumatic amputations can have a mixture of wounds going on. This first patient stuck their hand in an industrial size lawn mower to fix a jammed blade. The blades caused multiple incisions while pulling in the hand causing partial degloving, lacerations from tugging and tearing and bone fractures. Also note the blades of grass present. These fingers to the right are from a snow blower accident. Again lacerations, incisions and fractures.

  

Failed reattachment. I like this lady, even in the worst of times she still maintained her manicures. Sometimes an extremity lost can be reattached. These surgeries are tedious and intense but usually have a high success rate. Reasons for the attachment failing can vary, but most specimens received all have the same appearance- necrotic or dead.

Sometimes it is acceptable for these specimens to be for gross examination only (no microscopic slides). Other times the pathologist would like to see the margins of the specimen under the microscope to prove the tissue still attached to the patient is viable. The margins become more important in cases where an amputation has an attempted reattachment that fails. The most crucial part of the examination of these specimens is documentation of the anatomy present, what wounds and bone fractures can be identified and photographs with multiple views.

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Disclaimer. All materials posted on my website are intended to showcase my love of pathology and art and the correlation between the two. In no way am I trying to exploit any patients or their specimens. All images and information should be used to educated people in the pathology field and enlighten others into my profession. Enjoy.