Friday morning. It was 9 a.m. when I left the office. The morning meeting had been a long one, the previous night’s on-call shift summary was presented then other issues discussed. Afterwards, I spent a few minutes discussing a case with my colleague; we had a pediatric patient booked for a bone marrow aspiration in the operating theatre, suspected leukemia. Bone marrow examination would give us more information about the diagnosis. All our pediatric patients for bone marrow aspirations go to the operating theatre (OT) because they require anesthesia for the procedure. This is not the case for adults whom we can do in the ward or at the procedure room in the pathology lab.
Although pathologists do not have patients in the sense of a ward full of them the way doctors in other specialties do, the patients whose samples and procedures we manage are still considered ours. Pediatric leukemia patients are co-managed with the pediatric team, so our assistance is often required in theatre for bone marrow aspirations.
I opened the door to the laboratory and walked in, passing the microbiology lab on my left before turning right toward the biochemistry and hematology benches, which sit adjacent to each other. The place was buzzing with activity. Laboratory scientists were running the show, residents were assigned to benches within the different sections, and since it was Friday, laboratory science students from the University of PNG medical school were also present as part of their training schedule for Thursdays and Fridays. Porters moved back and forth from the lab window, attending to clients and delivering results. Machines whirred, phones rang, conversations overlapped. It was like a factory pushing out results around the clock.
I nodded greetings to anyone who made eye contact, though most people were too busy to be interrupted. At the far end of the room I located the bone marrow box. A quick check told me I had everything except some 10 mL syringes which we would need for the aspirates. We could get that in theatre but I preferred to have it before we left the lab. I asked which hematology resident was assigned to the staining bench and available for theatre. He appeared shortly after, and I briefed him on the case. While he prepared, I went into the cytology section to collect specimen bottles for a trephine bone biopsy. This is essentially a small core of bone that is usually gotten during the bone marrow aspiration, which goes to histology rather than hematology.
When I returned to heamtology, the resident was ready. He grabbed the bone marrow box and we made our way out, stopping at phelbotomy to get some syringes before continuing upstairs to the theatre. At the entrance, we went straight to the cupboard for scrubs, then into the change room. In the operating theatre there is a point beyond which outside clothes are not worn, in order to maintain cleanliness and infection control. In addition to scrubs, we put on head caps and shoe covers, then carried our box inside to the operating rooms.
We passed the holding bay which had some patients in beds. Staff went about their business. Apart from nursing officers and anesthetic teams, the majority of doctors you encounter in OT are surgeons, which include ENT (Ear, Nose and Throat), Dental and OMF (Oral and Maxillofacial) surgeons. Pathologists come to OT less frequently.
There are four operating rooms (OR) with cases running at the same time. We headed to OR 4, where pediatric case are done. We met the pediatric registrar and her consultant and greeted them. The anesthetists was setting up, there were three of them, all guys. One was drawing drugs while the others were handling the anesthetic machine.
The first patient brought in was not ours. We were early. This child was there for intrathecal chemotherapy, where medicine is given through the spinal space into the cerebrospinal fluid. The pediatric team handled that. We double checked our equipment while waiting.
Since our case was not yet ready, we went to the holding bay to see our patient before he was brought into the OR. He had just arrived from the ward with his father and the nursing staff was helping him change into his gown. Afterwards he was placed on a bed where we could examine him. The examination focused on the hematopoietic system, checking for signs of abnormal bleeding, enlarged lymph nodes, and any enlargement of the spleen or liver.
Once done, we returned to theatre. The previous case was being completed and the patient was prepared for transfer out. We set up our equipment while the nurses cleared the room and the anesthetists prepared their machines. I glanced over to the adjacent OR and I could tell from their various attachments and equipment that it was an orthopedic case.
When the child was brought in, we performed the time-out procedure to confirm identity and planned intervention. This involves all parties participating in the procedure which is the patient’s guardian, the anesthetists, the nurses, the pediatricians and us the pathology team. After time out we could start, the anesthetists leading the way. The patient’s parent stayed with him until the anesthesia took effect, then he was escorted out.
We had our procedure table ready. The resident positioned it to my left, and the nurse stood to my right. The child was laid on his side so we could access the back of the hip, the site for bone marrow aspiration. Once the anesthetists gave the go-ahead, we began. The nurse passed me the sterile equipment, I washed the area, then proceeded with the aspiration. Once collected, the samples were handed to the resident, who placed them into bottles containing anticoagulant to prevent clotting, as bone marrow clots quickly.
The aspiration itself took about 15 minutes. Preparation before and after the procedure was what consumed most of the time. Once we finished, we applied a dressing over the site of the aspiration, the child would also need analgesia for the pain that would await him when he returned to full consciousness.
With the procedure done, we organized our samples, some slides we prepared in the OR while the rest we would make from the samples in the bottles. We repacked our box. The OT clock showed it was approaching 11 a.m., so we would be in time for CME. One last job remained in OT before we left; I documented the procedure in the patient’s chart before we headed back to the change room, then downstairs to the laboratory. Since the resident that went to OT is the same one responsible for staining the slides, he would continue the work on the bench. The end product will be a bone marrow smeared on a glass slide and stained, ready for a pathologist to read and report to the pediatricians.
I briefed the scientist on the bench, thanked the resident, and returned to the office for CME. There were two presentations that day, the topic being intracellular cell signaling presented by a registrar and part two of pathologies of the cervix presented by a consultant. My colleague was setting up the projector as I entered. I found a chair and sat down.
After CME and a short lunch break, I walked outside before heading to the mortuary. The mortuary is situated a few hundred metres from the main hospital and the laboratory. I had a post-mortem scheduled for the afternoon. It was windy and quite dusty. There was a crowd at the mortuary but I didn’t see anyone I knew, which was a good thing since it wasn’t the best time to be making conversation.
As soon as I entered the mortuary perimeter, I checked that all parties were present: relatives of the deceased, police officers, mortuary staff. After which I went into the office to wear a gown, then I called my boss to update him. Exiting the office I saw a group of medical students identifiable by their white lab coats. I guessed they were here to observe the procedure, a requirement in your fifth year of medical school. They soon approached me to ask if we were doing one. I briefed them on what to expect during the procedure plus the requirements for their report. Then we entered the post-mortem room.
The deceased was already on the table, the attendants standing at the ready. The role of the pathologist is to determine the cause of death and contributing factors by reporting what he observes in the examination. We began with the external examination, describing injuries while the mortuary attendant assisted by taking measurements and helping position the body. Once done, we moved to the internal examination, inspecting the skull, chest, and abdominal cavities. I asked and answered questions from the medical students throughout. My boss arrived, asked a few questions to me then to the students, did some teaching and then we wrapped up. The students would later write their reports, which we would review and grade.
I thanked the police and mortuary staff, then returned to the mortuary office to complete some documentation before returning to the main hospital to start my post-mortem report. This would later be reviewed with my boss before being finalized and dispatched.
The time was 2:45 p.m when I returned to the office. I would get started on my report then do some light reading around the case before heading home.
Note: Events depicted here are patched together from separate occasions to protect the identity of patients and the deceased, but otherwise represent a typical Friday workflow for a registrar in training in hematology and forensic pathology. Minor interactions throughout the day that do not lend context to the story have otherwise been omitted.
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