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OK, four people have asked for it, so I guess I'll try to describe my week in 
Mohs hell. By my long gray beard and glittering eye, now wherefore stopp'st 
thou me?

A small private pathology practice in a high risk area of the country for 
skin cancer. The solo pathologist (none of the other pathologists in town 
will touch it) drives a short distance to the dermatologist's clinic. 
Appointments with the pathologist are made in advance, usually in the early 
afternoon. I filled in for him while he was on vacation.

The dermatologist is young, personable, and honest. He actually does 
something you could call Mohs surgery. He cuts out the tumor in a 
saucer-shaped piece, roughly circular as a rule. He may have two patients 
going at once. He operates looking through a 2-power loupe (rather than an 
operating microscope such as an otolaryngologist or ophthalmologist) and the 
pathologist has a lighted magnifier also.

The frozen section attempts to display the entire raw surface of the tumor, 
and the epidermal margins, all in one piece. To do this, the specimen is 
squashed flat against a plastic plate, and frozen using nothing more 
sophisticated than compressed gas (what once was Freon). I won't try to 
describe the inking.

The cryostat is an ancient Ames Tissue-Tek, but it works. Blades are 
non-disposable and dull. The stain is H & E, done without Coplin jars, just 
pour it on the hand-held slide and wash it off, finally mounting in an 
aqueous medium. The room had no running water.

Results? Catastrophic. Usually I couldn't even see the section because of the 
low refractive index of the mounting medium. I had no idea whether the 
sections were flat or not. Sometimes the dermatologist looked at the sections 
- he thought they were fine, and I wasn't going to tell him otherwise.

Frankly, I had to falsify results to escape with a whole hide. Am I going 
back there? No way. Perhaps this procedure can be done honestly, but not by 
me in the conditions I worked in. 

As I've said before, it's the dirtiest four letter word in surgical pathology.

Bob Richmond
Samurai Pathologist
Knoxville TN

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