Spring 2023 Newsletter
ASMH Newsletter • Volume 27 Issue 3 • Spring 2023
President's Message
Welcome Spring!
As 2022 came to a close, the Board decided to hold the 2023 Annual Meeting virtually. This was a very hard decision for them to make. The Board is and will be working very hard to hold the 2024 Annual Meeting in person, which will be in Phoenix, Arizona.
The 2023 Annual Meeting Program Committee chair, Zipporah Cassidy and co-chair Brandon Possum, along with the rest of the committee, have been busy planning and developing an exciting Annual Meeting. I would like to say thank you to the Program Committee members Norma Anderson, HT(ASCP), Dan Gong, MS, MBA, C-PM, CWMP, Robert Tagliaferro, HT(ASCP), Jansen Tsakos, HT(ASCP) BS, Jeanie Wade, HT(ASCP), Linda Cesario, HT(ASCP), Stacie Eckhout, Camille Mckay, M.Ed, BSHCA, HTL, CL and Amanda Diaz, MS, HT for their time and commitment to the ASMH. The Program Committee has created a program with many topics that we believe will benefit all skill levels.
The ASMH 2023 virtual meeting will be held May 5-6. Details on the virtual meeting format can be found on the ASMH Annual Meeting website. Please visit the page and register today!
I would like to recognize and give my sincere thanks to Secretary-Treasurer Angel Maden, HT(ASCP) and Director Melinda M. Chow, MS, HT(ASCP) who will be leaving the Board at the conclusion of the 2023 meeting for their continued service and contributions to the ASMH.
We have a number of different committees that are looking for new members. This is a great way to get involved in making our society the best it can be. The committees that are looking for members are the Scholarship Committee, the Membership Committee, Annual Program Committee, and the new Webinar Committee. If you are interested in joining any of these committees or would like more information on them, please contact us at info@mohstech.org.
The Mohs Tech Training Program is looking forward to the next session which will be held in Lakewood Ranch, Florida at Mercedes Scientific on June 22-23, 2023. Visit the website for more information and register today. This is a great way to improve and learn new techniques. If you can’t make it to this training session, we are offering another training in Pine Brook New Jersey on September 28-29, 2023.
A big welcome to all of our new ASMH members and a thank you to all our current members, for all of your continued support in helping the organization grow. Your ongoing support is valued and vital to our wonderful society. Together we can keep it strong and keep improving ourselves as techs.
Lastly, I would like to encourage all of our members to get involved by joining a committee, running for a leadership role, or writing an article for the newsletter . I have learned and grown as a tech by being involved with the ASMH. I have met so many wonderful professionals and made so many friends over the years. I wish everyone a great and healthy 2023!!
Sincerely,
Lindsey E. Riggs, HTL
ASMH, President 2022-24
Register today for the 29th Annual Meeting!
Registration is open! The 29th Annual Meeting will be exceptional, and we’re very excited to bring you this year’s meeting in a virtual format. If you haven’t registered for the meeting, there’s still plenty of time to do so. Meeting content will be available on-demand through the virtual site for three months after the meeting. The General Session has been approved for CEUs through the National Society of Histotechnology (please note that meeting times are listed in the PST). Three optional workshops will be offered prior to the start of the General Session on Friday and Saturday. Workshops may be purchased separately. The members only Business Meeting (Saturday, May 6 8:30 am PST) will be presented live, as will the Troubleshooting Panel scheduled for Saturday, May 6, PST – use the link below to submit your questions and topics to discussion before the April 26 deadline.
Visit the Annual Meeting page for more details and to register. We look forward to seeing you there!Note: In order to register at the member rate, you will be prompted to login using your ASMH member ID and password. Please have them ready before beginning the registration process. Your 2023 member dues must be paid in order to register at the member rate. Pay 2023 dues here.
Submit Questions for the ASMH Annual Meeting Troubleshooting Panel
Have questions or a topic you would like discussed during our troubleshooting panel session? Submit them to be answered during a live panel at 3:30pm PT on Saturday May 6.
The 2023 election results are in!
Earlier this year, the ASMH held an election for Secretary-Treasurer and one Director. The terms for each position will begin at the conclusion of the 2023 Annual Meeting. The Secretary-Treasurer will serve a two-year term, and the Director will serve a three-year term. The results are in: the incoming Secretary-Treasurer is Rodney Barber, HT and the new Board Director is Zipporah Cassidy.
Congratulations to Rodney Barber, and Zipporah Cassidy, on their new positions!
Making The Leap from HT to PA-CP
Ryan Reusch, HT (ASCP)
Director, 2021-24
If you would have told me 14 years ago that I would have the opportunity to become a Physician Associate, I would have laughed out loud. After finishing part of a dual enrollment program back in 2009, getting my HT certification, and continuing my education, all while working full time cutting for a Mohs surgeon, that was about all I could handle. Over the next several years, I continued to hone my skills as a tech, running the lab and venturing into the clinical side of dermatology. I stepped in where ever I was needed and this exposure eventually led me to my newfound love of medicine. Another eight years would pass before I decided I wanted to attempt to continue my education, and become a Physician Associate. I continued to manage my team of medical assistants, scribes and PAs, while working towards my application.
I decided to apply to the only school I was interested in attending, Yale’s Online Physician Assistant Program. James Van Rhee, the creator and former lab fanatic (Med Tech/PA-C), designed this program with the flexibility to learn from where ever you are, while still maintaining the same rigor as the in-person program. I am proud to say I was afforded the opportunity to become a Yalie.
After the initial excitement of being accepted, I began to feel the stress of starting this new venture, while leaving one of my passions behind. I was the only tech in our lab, the only back-office supervisor and the only one who had the knowledge to do both for three practice locations. For the next year, I created countless documents, shared pearls I picked up over the years at the annual Mohs meetings and gave everything I had as a tech and leader back to the profession. I shared all my tips and tricks, shaping and forming the new tech while passing down the art of histology to the next generation. I decided I wanted to continue giving back what I learned and now sit on the Board of Directors for ASMH.
Although I have finished my first year of PA school, learning new skills to treat my patients, I am and will always be, a HT at heart. It is something that is a part of me and I plan on continuing to give back to our small, tight-knit community as a Physician Associate. A special thanks to Dr. Mann and Catalina Dermatology for allowing me the opportunity to grow, Tara Dumas for making me the leader I am today, and Jessica Lester, PA-C for your pearls of wisdom getting through the first year of PA school.
In Vivo Grossing:A way to reduce Mohs Technician Grossing Time and Improve Surgical Accuracy
Zipporah Cassidy, BS & Andrew Herbst, M.D., FACMS
Chair, Annual Meeting Program Committee
Mohs micrographic surgery is considered one of the most effective techniques for treating basal cell carcinomas and squamous cell carcinomas, two of the most common types of skin cancer. Mohs micrographic surgery is performed in stages with lab work while the patient waits. This allows the surgeon to check for clear margin, removing all the cancerous cells, while sparing healthy tissue and leaving the smallest possible scar.
The Mohs technician receives the specimen from the surgeon during surgery and processes it in about 10-20 minutes from start to finish for an average size specimen. Grossing the specimen is the first step of this process. An experienced Mohs technician can gross a specimen in under 4 minutes. This time can be substantially reduced by in vivo grossing done by the Mohs surgeon during the procedure prior to specimen removal from the body. In vivo grossing can reduce Mohs technician grossing time to under 30 seconds and reduces the chances of errors or false positives because the specimen arrives almost completely flat and ready to embed.
For a round specimen, the Mohs surgeon should start the in vivo grossing by debulking the center of the affected area with a scalpel, if needed. After debulking, the surgeon holds the scalpel at an approximately 45-to-60-degree angle to cut a beveled edge in towards the middle of the affected area, approximately 3-5 mm in from the desired outer margin but only half as deep as the total depth of the specimen. The surgeon can decide if the cut should be straight or beveled depending on the depth of the specimen. After the inner edge is cut, a shallow bisecting line can be cut length wise if the specimen is an elliptical. This will cause the sides of the specimen to fall flat once removed from the patient. Once the in vivo grossing is complete, the specimen can be fully removed from the patient with a margin around the inner edge no more than 3-5mm. The specimen is then given to the Mohs technician.
Picture #1 shows a specimen ready for removal after in vivo grossing. Notice the inner edge bevel cut line. See below photo.
This technique allows the Mohs technician to finish grossing the specimen very quickly, reducing total processing time to 5-15 minutes on average. The accuracy of the procedure increases with this method because in vivo grossing makes the specimen almost entirely flat when received by the Mohs technician, leaving little room for error on the Mohs technician's part. There is less of a chance of getting a false positive because the full margin can be reached at a shallower depth than when the specimen is not embedded completely flat.
Picture #2 shows specimen received in the Mohs lab. See below photo.
Pictures #3 and #4 depict specimen after the Mohs technician finished grossing and inking. See below photo.
Picture #5 shows specimen grossed, inked, and ready to embed with the reverse slide embedding method. See below photo.
Specimen is embedded in the cryostat as shown in Picture #6. See below photo.
Picture #7 shows specimen embedded and faced in the cryostat. See below photo.
Got Drift? Sources and solutions for protocol changes
Angel R Maden, MS HT(ASCP)CM
Secretary/Treasurer, ASMH
Do you have protocol drift? What is protocol drift? How does it happen? Why does it matter? Does it impact your inspection process? Protocol drift is when there is a buildup of small incremental changes in how work is done in the lab until what is actually done is different than what is in the procedure manual. It can happen when there are personnel changes, normalization of shortcuts, and/or the results of troubleshooting improvements. Protocol drifts can result in processes that suddenly stop working as the changes compound and people no longer remember how things should be done. Changes in personnel can really effect this type of drift. Hopefully, drift is the result of incremental improvements as troubleshooting occurs. This is the type of drift that is desired. Process improvement driven drift is the goal.
During the inspection process, checking that what is done in the lab matches the manual is a big part of compliance. Ignoring the buildup of changes can result in a citation even if the end result is improvement. The person charged with maintaining the manual needs to keep tabs on the process and decide when changes in the lab warrant either an update in the manual or a retraining reminder for lab personnel. CAP requires a manual review every two years and recommends that it be done in subsets over the whole two years to avoid having to do it all at once, although most Mohs manuals are not that big. Reading and signing the manual without checking what is actually being done in the lab gets the job done but fails the intent of the standard and may result in an inspection ding. The CAP checklist verbiage is “significant” changes need to be signed off on by the director when this duty is done by a designee. But there is not a hard definition of what significant means so an agreement between the director and designee of where the boundary lies and evidence for the inspector that it has been used may be helpful. An example of this would be correction of a typo vs a change in process. Either way tracking for document control should be followed. It may take some effort to discover what the barriers to following a good protocol are for the lab. Some of these barriers may be that not enough time is scheduled to set up the lab before tissue arrives, and/or not enough time is taken to clean up and complete closing the lab at the end of the day. Other important sources of issues are the lack of time to do regular equipment cleaning and lab organization and a lack of understanding that compliance is important. Adherence to the manual should not stifle innovation or troubleshooting, but big changes should be validated before processing patient tissue.
Monitoring the lab process for protocol drift is an essential component of our regulatory landscape. Change is not a bad thing and process improvement is an important desired process. Stay ahead of issues by making the necessary changes in a timely manner while reminding people to not take shortcuts. This will help ensure that inspections are smooth because the manual matches what is done in the lab.
Hematoxylin and Eosin Stain without the use of Xylene or Xylene Substitutes
Norma Anderson, HT (ASCP)
Eosin bleeding continues to be an issue, even with fresh alcohols, compatible clearing agents and mounting mediums. Automatic Stainer, slide carriers and clips, can be a problem; the slide carriers or clips can retain water or clearing solution that will interfere with your stain results. Water retained in carriers will dilute your alcohol and clearing agents retained in the carrier can cause streaks on your slides that result in uneven staining.
Just when I thought I had my Hematoxlin and Eosin staining protocol finalized I’m introduced a new mounting medium. (Thank you Marilyn McCulloch) I was hesitant to change my protocol at first but I gave it try. LiquiMount is mounting medium that can be used to coverslip your stained slides from 100% alcohol. LiquiMount is not viscous and flows easily; the slides can be dry when cover-slipped. I do love not having to use clearing agents.
I use a Leica ST4020 stainer; my staining protocol is now as follows: Alcoholic Formalin fix, Rinse, Gill 2 Hematoxylin, Rinse, Scott’s Bluing, Rinse, 100% Reagent Alcohol, Alcoholic Eosin, Reagent Alcohol x4 , Isopropyl Alcohol x2, empty staining container.
You might be thinking, why Gill 2 hematoxylin and Isopropyl Alcohol. The Gill 2 Hematoxylin does not leave the slides with a blue background; therefore, I do not need to use an acid wash. The Isopropyl Alcohol doesn’t seem to wash out Eosin so I use it as the end of my stain line. Since the Isopropyl is more expensive than the Reagent Alcohol, I only us at the end. Once the slides are in the empty container I can cover- slip them with LiquiMount. It is also possible to dip the slide into in a fresh Isopropyl Alcohol, in a coplin jar, then cover slip.
Disclaimer: I am not endorsing Liquimount medium. I tried this product since it was recommended by my friend Marilyn, who I have high admiration . It works for our Mohs Lab and I hope that it will work for yours.
My experience attending my first ASMH meeting
Nicole Ryan, RMA. HT (ASCP)
My name is Nicole Ryan and it was my honor and privilege to be the first recipient of the 2020 ASMH annual meeting scholarship. I have been a Mohs Technician for 10 years. Attending my first ASMH annual meeting allowed me the opportunity to enhance my knowledge in embedding, staining, cryotomy, and troubleshooting. Allowing me to attend workshops improved my skillset as well as provided me an exciting opportunity to network with other technicians and physicians across the nation, whom are all striving to provide the best patient care.
From the start of the meeting, I was welcomed with smiles and friendly faces. I learned new staining techniques and was able to see what different artifacts look like under the microscope Gel-form, tattoos, cautery, and aluminum chloride which are definitely not seen in a regular day. I was also able to see different ways that other technicians stain and troubleshoot. I improved my efficiency in keeping logs, laboratory safety, improving new technician training, and I gained knowledge to help pass CAP and CLIA inspections.
I listened to physicians present on how intricate operating on someone with a DSFP can be and the importance of our role as technicians in such a challenging case. I saw different techniques to treat nail malignancies. They can be challenging due to the fact that there is less than a millimeter of space between the matrix and bone. I learned some physicians choose against removing the nail prior to surgery and instead they have the patient soak their nail in chlorhexidine. The processing of that tissue with the nail attached to the tumor is no different than cutting any other tissue. I learned the importance and growth of Immunohistochemistry regarding Mohs sections and where the future stains are headed in the next two-three years. In the future, multiple antibodies will be able to be used on the same sections improving the patient’s diagnosis. It was amazing to learn how different offices operate, where some physicians bring their technicians in the room with them while others do not.
I had the opportunity to attend the two optional workshops (advanced cryostat training and immunohistochemistry workshop) which were very beneficial to me. The advanced cryostat workshops allowed me to work with other technicians to improve cryotomy, troubleshooting, and staining. Working with pig skin to mimic human skin in order to practice grossing, embedding, and cryotomy. I was able to process wedge sections to improve my knowledge on the process which is not commonly used. Attending the immunohistochemistry workshop allowed me to perfect my technique in the MART-1 stain, which in turn allowed me to network with other technicians who may not be as familiar with special stains.
Some other workshops which I enjoyed and gained vast knowledge from were the rubber cement technique workshop and the #Mohshacks workshop. Within the last 6 months I have started to process whole mounts which can be very challenging. Getting the epidermis to lay flat can be an extremely difficult task. Learning different ways to relax the tissue by using the rubber cement technique allows the epidermis to lay flat on to the slide. You are able to see the epidermis is flat by looking at the underneath of the slide which ensures that you are providing the physician with a full face for each section. The #Mohshacks workshop was great as well. It provided us with fabulous tricks of the trade. I would have never known spraying an inked specimen with distilled white vinegar would enhance the adherence of the dye to the tissue causing it not to run. You can also use the grossing ink to make the embedding medium into unique colors to keep track of the patient's sections.
Overall, this experience was very memorable. The knowledge I took away in these two days was incredible. I met many amazing people who share the same passion as I do. It is such a rewarding experience to know that the quality of my work is giving skin cancer patients the highest degree of care. It was an honor and privilege to attend my first annual ASMH meeting via winning the scholarship. I look forward to attending future ASMH meetings to enhance my knowledge in this fulfilling career.
June 2023 Mohs Technician Training
The next opportunity to register for trainings is for our June program which will be held at Mercedes Scientific in Lakewood Ranch, FL. For more information and to register, please visit the training webpage!
Member Resources
ASMH Online Bibliography
The ASMH bibliography is your resource and we strongly encourage you to explore it. Efforts will be made to keep the articles up to date and relevant to current best practices while keeping the scope wide enough to interest the broadest of minds. It is our intention to cover subjects ranging from basic lab techniques, Mohs embedding, cryotomy, routine and immunohistochemical staining, lab safety, ethics and work flow. This is a continually evolving project that will be guided by your feedback, suggestions and more importantly, your contributions, so please share interesting articles and send topic suggestions to info@mohstech.org.
Go to the bibliography to find new COVID-19 resources: Laboratory Biosafety & Coronavirus Disinfection in Histopathology.
Showcase your ASMH membership in your online profile
Members are encouraged to download and use this graphic in your email signature, on your social media profile or added to your professional online presence. Please remember that you may not, in any way, alter, manipulate or change this graphic. Contact info@mohstech.org should you have any questions about proper use.
Note to ASMH newsletter readers: Reference to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise throughout this e-newsletter, does not constitute or imply its endorsement, recommendation, or favoring by the American Society for Mohs Histotechnology. The views and opinions of authors expressed do not state or reflect those of the American Society for Mohs Histotechnology.