View interactive

Brains behind the lab slides hold patients' lives in balance

By Chloe Johnson

The tables turn on surgeon Martin Rees as three moles are removed from his back and stomach. Photo / Doug Sherring
The tables turn on surgeon Martin Rees as three moles are removed from his back and stomach. Photo / Doug Sherring

The word 'cancer' strikes fear into the hearts of the most battle-scarred users of our health system. Chloe Johnson accompanies patients through the grim biopsy process.

Daniel Reid knows the hospital system pretty well. He is, fair to say, somewhat accident prone.

Just two weeks ago, Reid, 29, suffered a black eye and bruising when he tried to stop a hooded crim breaking into his friend's car outside the local snooker club.

Despite having one hand in a cast after crushing it in a car door a week earlier, Reid confronted the thug - only to be king-hit by an accomplice.

"He knocked me to the ground and I think they put a boot in, too," he says. The Epsom electrician added those injuries to a growing list.

Six years ago he was whacked in the mouth with a golf club; last year he fell 10m down a retaining wall, breaking his back and one leg.

But for all his experience in A&E departments, it was a small, apparently insignificant cyst on his chin that has caused the most uncertainty.

As he was referred to the plastic surgeon to have the cyst removed, his doctor quietly told him that, as a matter of course, the tissue would be tested in a lab to see if it was malignant. It looked benign - but you could never be too careful.

Over the past two months, the Herald on Sunday has told the stories of seven patients who have had their lives turned upside down after errors in New Zealand pathology laboratories.

Five women were wrongly diagnosed with breast cancer or wrongly cleared of the disease. In the worst case, a lab worker dropped two samples on the floor and mixed them up. One woman had her jaw removed unnecessarily and one man was wrongly told he had terminal cancer.

Preliminary investigations revealed five of the errors happened in pathology laboratory mix-ups - one was by a pathologist who read the sample incorrectly and the other was a doctor's decision to override pathology results based on the patient's medical history.

As a result of the revelations, Associate Minister of Health Jo Goodhew has ordered an independent inquiry - but will it go far enough?

Pathologists Ian Beer and Tony Bierre have questioned the processes in medical labs, including the use of batch-testing, tight five-day turnarounds and straitened funding. They fear more mistakes will be made.

WITH THE agreement of Reid, his plastic surgeon Martin Rees and Tony Bierre's Biopsy Solutions laboratory, the Herald on Sunday was allowed to follow the process of taking a tissue sample and testing it for cancer.

It starts with the appearance of a tiny, pimple-like bump on the side of Reid's chin. It gradually turns into a gristly lump the size of an old 5c coin, which Reid pokes and prods with his dirty working-man's hands.

Six years earlier, he had a similar gristly lump removed from his lip after being hit in the mouth with a golf club. Both operations were done at Rees and de Chalain Plastic Surgical Centre in Auckland, so he asks to be referred there again.

Although the cyst doesn't show any signs of malignancy, he is "anxious" and wants it removed, to be on the safe side.

In a sterile operating theatre, Reid is put under a local anaesthetic while experienced surgeon Rees, 64, removes the cyst.

Rees spiels off a string of medical jargon to his assistant nurse, before placing the cyst in a specimen pot.

Once the tissue is securely inside, she labels it with Reid's details and puts the same details on an information sheet - to be delivered to the lab pathologist alongside the sample. "We only ever have one patient's details in the room at a time," the nurse says.

A gauze pad is placed over the stitched wound and, after 25 minutes, Reid is sent home to rest. Meanwhile, his specimen is sent 100m up Remuera Rd to the Biopsy Solutions pathology laboratory, to be tested for malignant cells.

Reid has no clue what is happening to his specimen but trusts the pathologist will get it right.

BIOPSY SOLUTIONS director and pathologist Tony Bierre leaps up the steps into his small house-turned-laboratory with a basket of specimens from the local surgeon.

Medical journals line the top of his desk. A black microscope sits next to two computer screens, with a small pile of specimens on slides, waiting to be examined. His daughter and administrator, Hannah Bierre, sits behind him collating the files.

Despite the success of TV shows such as CSI, Bones and Body of Proof, Bierre says the work of pathologists is not romantic. But, he emphasises, it is critical in determining someone's future. "We often get forgotten about. We are not the glamorous face in surgery but it all comes down to what the pathologist says," Bierre says.

Hannah records the patient's specimen details in the computer before Bierre takes the tissue to the "cut-up" station. Wearing rubber gloves, he lays his instruments on the board. Ruler, check. Tweezers, check. Tissue cassette, check. One specimen pot and the matching information sheet, check. "This is a job that only the pathologist will do," he says.

He uses an HB pencil to transfer the patient's identification details and surname on to the cassette where the tissue will end up. Bierre takes the specimen pot - "one patient at a time" - and places the tiny piece of tissue into the cassette. "It's the number one rule.

"If I saw someone have two pots open at a time, I'd kill them." He triple-checks that the patient's details on the cassette are the same as the initial information sheet from the surgeon.

The cassette is then put into a processing machine where the tissue goes through alcohol and wax washes for up to eight hours.

The wash removes moisture from the tissue, allowing the wax to set for the next stage.

Technician Anton Schollum takes over. He sets the samples in hot wax and leaves them to cool into a block mould. Then, in the "bacon-slicer", he cuts shavings of wax and specimen and places them on a transparent slide in a water bath. The slides are run through a robotic ink-stainer, which helps the pathologist identify cells and activity in the tissue to make a correct diagnosis.

Bierre says he has only one technician dealing with each patient's specimen, from the alcohol machine to the robotic ink, to avoid errors. It's a slower, old-fashioned process but it's a safer and more accurate one, he says,

"The big labs print thousands of slides and labels for blocks at a time, and that is where mistakes can happen," he says.

AT DIAGNOSTIC Medlab, where one of the largest laboratories in New Zealand is tucked away in a plain blue office-building in an Ellerslie cul-de-sac, general manager Ross Anderson rejects Bierre's implied criticism. He, too, takes the Herald on Sunday on a tour through the company's histology laboratory, which processes 230 patients a day.

A technical assistant is sitting at a table with several specimen pots around him, some as big as paint buckets with tumours the size of croissants floating around the bluey-purple embalming fluid. Next to him is a reel of individual identification stickers, which he peels off and places on each specimen pot.

Scientist Theresa Arroyo is waiting at the second station with a tray of identified specimen pots, where she records the patient information in a computer database, which automatically prints labels on to a tissue cassette.

At least 15 cassettes can be processed at one time and each specimen is colour-coded. For example, brown cassettes are for skin and mauve are for breast tissue.

The sample is then cut up in a similar manner to Bierre's laboratory, though at Diagnostic Medlab it is done by technicians and scientists. They also dictate each step through a voice-recorder, which is transcribed and filed with the patient's records.

Anderson agrees errors can occur when more than one specimen is dealt with at the same time - which is why that is forbidden in his lab.

PLASTIC SURGEON Rees should be in a position to judge the processes, considering he sends samples to both labs everyday. But it's horses for courses, he says. Sometimes he'll send a sample to the small Biopsy Solutions for its 24-hour turnaround; other times he'll send a sample to the bigger Diagnostic Medlab because it's cheaper.

This month, Rees found himself on the other end of the scalpel when he had tissue samples taken from moles on his back and stomach.

Dressed in a medical gown and hair-net, Rees lies bare on the operating table while co-director Tristan de Chalain removes three suspicious-looking moles.

Rees is a father of three and is awaiting the arrival of his first grandchild in October. He should be nervous, but shows no signs of it. "I know what a fish must feel like on the hook," Rees says. "It's funny - you can just feel the pulling but no pain."

He has faith in the pathologists, yet he is surprised errors don't happen more often, given the mass of samples processed each day. His own samples are sent to Biopsy Solutions, because they are close at hand and can process the sample quickly.

The main point, he says, is that the processes have to be clearly outlined, understood and implemented. "You have to have a pathologist who really knows what he is doing.

"We tend to accept a pathologist's verdict whether normal or tumorous. They are almost like God, really, making the decision whether we are going through the pearly gates or not."

Rees is in a good position to talk to Daniel Reid about the implications of his cyst as both of them wait for their biopsy results. Rees' come back first: he is in the clear. The news is also good for Reid. "Nothing nasty was found in the cyst," Rees' nurse tells him as she removes his stitches.

- Herald on Sunday

© Copyright 2014, APN New Zealand Limited

Assembled by: (static) on red akl_a3 at 20 Sep 2014 21:10:45 Processing Time: 851ms