Barbara A. Crothers, DO
CAP Cytopathology Committee member Barbara A. Crothers, DO, COL, MC, served in Baghdad from Jan. 17 to July 4 of this year. She wrote the following while there.
The road to Baghdad is paved with good intentions. Like many soldiers, I felt a duty to join my brethren overseas and add what support I might to our efforts. In fact, there were many reasons for my desire to deploy, some of them admirable and some not. For one, if I was going, I wanted to choose a time when my affairs at home were stable and I could afford to be away from my family and job. Volunteering for a future six-month slot was a good way to ensure minimum stress on my family and give myself time to prepare mentally for the journey. Additionally, I could not face myself if I had to send young pathologists overseas but had not taken the plunge myself. How could I advise them on how to get prepared? Discuss what the rotation would be like? Explain what it might mean for their careers? An Army soldier leads by example. As the pathology consultant to the Army’s surgeon general, I am expected to understand our current theater pathology needs and plan strategically for future warfare contingencies. I had a set of objectives for my deployment that I intended to accomplish while there, and that I hoped would improve our preparedness for future deployments in other areas of the world. I had already learned about OCONUS (outside continental United States) pathology from a one-year tour in Korea, an assignment that has some problems in common with an active theater of war. Curiosity was a large part of my incentive to deploy. But deployment was also an opportunity to shed some of the many responsibilities I had assumed over the years and give others in my workplace a chance to take the reins.
None of this means I faced my future deployment without trepidation.
Military pathologists have been deployed in support of Operation Iraqi Freedom since January 2003. Seventeen Army pathologists have been in theater to date, each serving six- to eight-month rotations. Early in the conflict, some of the pathologists served as operations officers because of the low volume of surgical cases. At other times, they have been triage officers, transfusionists, death certifiers, research investigators, and assistants to the command group. Pathologists have also served in operational medicine positions as brigade surgeons, primarily administrating health care in the theater, which often involves local travel and interacting with host nation dignitaries and populations. Autopsy services are not performed in theater. All death-related matters are handled by Mortuary Affairs, the Criminal Investigation Division, or the Office of the Armed Forces Medical Examiner.
One misconception about Army medicine is that hospitals are located in tent-like structures. This is sometimes true, but an army makes use of what it can. Pathologists have the equipment to set up in a tent or other military shelter, or to fall in on an existing facility. In Baghdad, the Combat Support Hospital was based at Ibn Sina, Saddam Hussein’s personal hospital. His regime seized it in 1974, and only his family and the Ba’athist party used it. The hospital is manned primarily by the U.S. Army and its rotating Combat Support Hospital units, each serving a year. Trauma care is the primary mission of this level III facility, but many other services are provided, among them critical care and internal medicine, family practice and pediatrics, radiology, dermatology, psychiatry and mental health, optometry, audiology, general dentistry, and laboratory. Long-term care and chronic care services are generally excluded, as are most elective surgical procedures.
Another civilian misconception about Army pathology, especially during wartime, is that we are exempt from federal regulations governing laboratory practices—specifically, from the Clinical Laboratories Improvement Act of 1967 and CLIA ’88. All military laboratories are held to CLIA standards and, in peacetime, subject to the same inspection and accreditation standards. These laboratories do enjoy slight modifications of the regulation during war under the Clinical Laboratory Improvement Program. CLIP, as it’s known, was written verbatim from the federal regulations in most sections. Most modifications are related to the limitations faced in wartime, but they do not exempt laboratories from following good laboratory practice and standards.
Pathologists are deployed as specialists in a small unit that is augmented to a level III Combat Support Hospital. The 44th pathology team is the augmented unit that falls under the 44th medical brigade and is attached to an existing Combat Support Hospital to provide surgical pathology services for the entire theater of conflict. There is one pathologist and four technicians or technologists, all active duty Army. The clinical laboratory is integral to the deployed hospital and managed by a nonphysician clinical laboratory officer. The pathologist and laboratory officer collaborate to align efforts and share resources. During massive casualty operations, the pathology technicians work in the blood bank while the pathologist monitors blood product usage and serves as a consultant for coagulation disorders and other medical transfusion-related problems. The Armed Services Blood Program officer orchestrates the supply and delivery of the units, most of which are whole blood, and ensures that banking and transfusion operations function smoothly. The pathology team’s primary mission is to provide microscopic diagnoses on surgical specimens and biopsies.
Little cytology is performed because cytology services focus on cancer prevention and tumor diagnosis. Pap tests are performed, and abnormalities cleared, before deployment, even for civilians. Pap tests are performed rarely in theater; when they are, they are shipped for processing to military medical centers. Occasionally, the pathologist is called upon to review sputum or body cavity fluids for organisms. Fine-needle aspirations are also uncommon. Even though a cytotechnologist is always part of the 44th pathology team, she or he does not usually prescreen cytology specimens unless the pathologist requests assistance, but it is comforting to have a colleague experienced in morphology to whom to show cytology cases if the need arises.
Intraoperative frozen sections are not performed but intraoperative touch preparations are useful substitutes. When surgeons aren’t certain of the disease process, the patient is usually redeployed for definitive care. However, radiology services are excellent, and most of the time providers have a good idea of the disease differential diagnosis from radiographic studies before committing to surgery.
Clinicians may seek out the pathologist for information and guidance on whether they should operate in theater. Will the patient benefit more by being sent back home for definitive surgery and care? Can we get a sufficiently firm diagnosis in theater to know how to triage the care for this patient? What is the likely differential diagnosis? What type of biopsy will be most suitable, and how should it be sent? What is the possibility that the process is benign and the patient can remain in theater? When can we have the result? With many of the remote health care providers physician assistants and nurse practitioners, a pathologist’s services as a consultant are especially valuable, particularly regarding laboratory results and laboratory capabilities in theater.
As in most clinical laboratories, the work is performed at night through shift work. For soldiers, shifts can be 16 to 18 hours long. We would vary our days off and even working hours, but it was always based on the workload. All of my soldiers were cross-trained in the clinical laboratory to enable them to cross-cover their colleagues, if necessary. The clinical laboratory was often short-staffed because of rotations, illnesses, and missions whereby technicians were transported to provide clinical laboratory services to forward operating bases during periods of high-intensity workload, as occurred during mass trauma. (FOBs are secured forward positions used to support tactical operations and supported by main operating bases.) It was helpful to have a reserve in place, my technicians, to pinch-hit when needed. The reverse, however, was not possible, because of the amount of training required to teach a technician the artistic skill of cutting and embedding.
Imagine starting a new histology laboratory with people who had never been exposed to or performed histology. That was my task. Initially, I was constantly supervising the embedding, cutting, and staining process; taking cases back for re-embedding, re-cutting, or re-staining; and reviewing outcomes with my technicians. Each step is rate-limiting when the work is primarily manual. During the weeks that I had my slowest technologist embed, cut, or gross, I would adjust the workday hours so that we started earlier. The pathologist’s day was the longest of the team. I would monitor the “incoming” (specimens) daily and triage some of it to the next day if the volume looked too onerous for one day. By reviewing the requisitions and clinical history, I could determine which patients would require a faster turnaround time. Lipomas could wait; a lymph node for a potential infectious disease could not. Whenever possible, I tried to give the technicians one day off each week. It was necessary for me to be there to troubleshoot and answer questions, especially early on in the assignment when the technicians were still in training. My own requests for consultation were highest early in my assignment, when sleep deprivation was almost a daily companion. Adjusting to a new time zone, lumpy mattresses with central depressions, an unfamiliar environment, nocturnal helicopter noises, and long hours wreaked havoc on my melatonin neurotransmitters.
The technicians worked extremely hard to perfect their techniques, and it showed, but the process was slow. An experienced histotechnologist might take four hours to cut 50 to 60 blocks; my technicians could take four hours to cut 15 to 20 blocks. Initially, some tissue would be exhausted in the attempt, and I quickly learned to have my experienced noncommissioned officer in charge cut tiny tissues. It helped to devise printed guidelines for the number of levels, serials, and slides per case type, but this required a cutting sheet listing the case type for each block. In time, they came to recognize the type of tissue visually and no longer required the sheet.
Most technicians come into the theater without much, if any, histology training. There is no military occupational skill identifier for a histotechnologist in the Army. Interestingly, and appropriately, cytotechnologists are typically deployed as histotechnologists, and every team has at least one cytotechnologist. There are several advantages to having cytotechnologists on the team. They have an innate understanding of anatomic pathology operations, specimen accessioning, and workflow. They are familiar with the requirement for a high degree of attention to detail and precision while performing manual tasks. They understand the critical issue of irretrievability of specimens. Unlike a tube of blood, a skin excision of a melanoma cannot be repeated if rejected or consumed by processing. Specimens were usually shipped to the laboratory from remote areas and subject to extremes in temperature. Specimen containers leaked formalin in transit. Specimens were sometimes submitted fresh or in saline. The technicians worked with the forward operating bases and hub laboratories (explained later) to ensure proper specimen shipping and submission and were seldom shy about browbeating them into adhering to standards.
Cytotechnologists are used to working directly with pathologists and comfortable approaching them with questions or suggestions. I benefited greatly from this relationship and was equally blessed with a non-cytotechnologist noncommissioned officer in charge who kept me informed of hospital activities, kept her soldiers healthy and in line, and worked toward the mission goals I had established. She had been trained to embed, cut, and stain specimens before her deployment and subsequently served to train and monitor all of the other technicians. Early in the assignment we spent time looking at stained slides with problems and discussing how to correct those problems. Common problems were aligning and orienting embedded tissues in the block and not facing deeply enough into the block to get all epidermal surfaces on skin, as well as numbers of levels or serials per tissue type, orientation of cervical biopsies, and unequal staining. Within four weeks, she had trained all of the technicians to continental U.S. standards and my re-cut requests dropped to zero. The quality of the slides was superb.
After the first few weeks, I began to train my technicians to gross small specimens, and after they had all been trained, their quality of work and their speed improved dramatically. I attributed this to their being able to understand the specimens three-dimensionally and what the pathologist needs to see and why. At the gross bench, I would draw diagrams of what I would see under the microscope, explain general principles of dissection, and discuss disease processes and why they presented with different gross appearances. It was enjoyable for all of us, and the technicians were keenly aware of the additional responsibility and gravity of this task. They had a formal training program, and I kept totals of their specimen types and quality until I was confident in their ability.
On my first day in theater without overlapping my predecessor, our tissue processor broke down, and none of the technicians were familiar with the instrument. I walked in that morning to find all of the techs gathered in the room, anxiously awaiting me, staring aghast at the processor. I discovered that the processor had stopped with the tissue in xylene and set about to rig up a manual paraffin bath. The xylene bath was empty; it had leaked out onto the floor. I was fairly certain the culprit was a faulty gasket, even though the processor had just been through maintenance the week before when a power surge erased the program from its screen. Amazingly, the mishap affected very few specimens that day, but one case was a basal cell carcinoma that was never able to be cut adequately. Fortunately, one section showed a minute area of basal cell carcinoma consistent with the clinician’s impression.
Problems with the tissue processor and the automatic staining instrument were constant throughout the six months and required creative engineering. We managed to semiautomate some processes until the problem could be fixed permanently. Other processes became manual and the timer was an essential piece of equipment. The lifespan of instruments in theater is halved because of the sandstorms. We implemented a bimonthly cleaning program to remove dust from all surfaces and equipment, because the dust acts like fine sandpaper between working parts, slowly grinding them down and impeding operations.
We implemented a rigorous specimen acceptance policy and monitored each site and health care provider’s submission, sending e-mails or placing comments in the report when submission deficiencies were noted. Because of the high turnover of health care providers in theater, it was a challenge to keep up with points of contact. We implemented a policy of laboratory “hub and spoke” accountability, so that each forward operating base sent specimens first to the nearest medical treatment facility laboratory, or MTF, and that laboratory checked demographics, submission requirements, and shipping requirements before sending it to Ibn Sina Hospital. Each oversight laboratory (which advises and monitors the point-of-care labs in some MTFs) had an officer in charge or noncommissioned officer in charge who enforced procedures and policies and monitored specimen receipt. These people were also the critical link to the final report and tenacious in following up on specimens sent. Because communication systems were not always operational between sites, and because the Air Force or Navy operated some of the sites, interoperability was always an issue, requiring most reports to be e-mailed to the providers. The hub laboratories served as the conduit through which all reports moved and ensured that reports got to the health care provider or his or her replacement.
Special stains were limited to PAS, tissue gram, and Giemsa, to cover most of the more common conditions. Complicated tumors requiring immunohistochemical stains were initially evaluated and sent for consultation to a continental U.S. military medical center. Telepathology was available through the Trestle MedMicroscopy and SL50 Slide Loader equipment in my office, providing a direct link to the Armed Forces Institute of Pathology and its pathology experts. The turnaround time on telepathology consultations was less than 24 hours, and results were posted on a secure Web site. Most of the specimens I submitted for a second opinion were dermatologic and evaluated easily by H&E alone. Some required further sections or stains. Quality control review of my cases could be performed remotely using the system. Initially, we had problems with dust collection on the optical and slide surfaces diffracting the light and resulting in blurred images. The lesson learned was that the slides and system must be kept meticulously clean. Bandwidth was an issue for live viewing and resulted in slow transmission of images. It was easier and more practical to create digital slides that could be reviewed remotely, given the seven- to eight-hour time difference between sites.
I try not to think too much of my last day in the after and I don’t count the days. I’ll exhale when I land in Georgia. It is still a war zone, and anything can happen. The journey back will be as grueling as the journey in, only this time hotter, encased in a shell of battle armor, lugging more than 100 pounds of gear. Travel is dangerous, flights are dangerous, and incidences of aggression have become more frequent as the troops begin to draw down. My team members and I will watch out for one another on the return trip. And I know what my first act on my return will be: to burn the letter that I left for my husband “in case of my demise.” I want him never to have to read it.
Dr. Crothers is now back at Walter Reed Army Medical Center as director of cytopathology. The views expressed in this article reflect the observations and interpretations of the author and do not necessarily represent the official policies or positions of the Department of the Army, the Department of Defense, or the U.S. Government.