V ol u m e 1 , I s s ue 4
O c t ob e r 20 1 4
L A B O R A TO RY S O L U T I O N S
MANAGER OF ANATOMICAL PATHOLOGY,
MICROBIOLOGY AND REFERENCE AT
RUTLAND REGIONAL MEDICAL CENTER
LABORATORY—JOE WALKER—INTERVIEW BY
INSIDE THIS ISSUE:
Manager of Anatomical
Pathology, Microbiology
and Reference at
Rutland Regional
Medical Center
Laboratory
BRIAN CAMERON
1
Test Announcements
& Updates
2
Pathologist’s Corner
4
Lab Operations
6
Brian: I am joined by Joe Walker today, Manager at Rutland Regional
Medical Center’s Laboratory. Hi Joe, thank you for spending some time with
me. I understand you are from Tennessee, is that correct?
Joe: Hi, Brian. Not exactly. I was born in Memphis, TN but grew up about
2 hours south of Memphis in a small Mississippi town called Water Valley.
Water Valley is about 20 minutes from the University of Mississippi.
Brian: Please tell us about your educational and professional background.
Joe: My educational background is quite varied. I started college seeking a degree in Chemical Engineering with a focus in biology. At that time,
there were no official biomedical engineering degrees, in which I was most
interested. I think it was somewhere around Calculus 3 and a cooperative job with the program that
made me realize, I didn’t really want to be an engineer. I left engineering school and eventually attended the University of Memphis gaining a degree in molecular cell sciences. A friend of my family
introduced me to the field of Cytotechnology and I completed another degree at the University of Tennessee. After Cytotechnology school, I made the move to Vermont, taking a job with Fletcher Allen
Health Care where I worked for 5 years as a bench technologist and as an instructor in their Cytotechnology and Resident program. After the death of my brother from a rare embryonal carcinoma, I decided I wanted to teach more in the hopes that I would be able to help future students identify his and
other diseases more quickly, which would have made the difference in his outcome. So, in 2003, I left
Fletcher Allen for a full time teaching position with Albany College of Pharmacy and Health Sciences,
serving as their educational coordinator. While in academia, I decided to pursue a degree in Instructional Technology, which would help me become a better teacher. I started to miss the clinical setting
and in 2010, I happily joined Rutland Regional as the manager of Anatomical Pathology. I completed
my Masters in Instructional Technology shortly after joining Rutland Regional because I still have a
passion for teaching and can bring that experience to the daily activities of my job. Healthcare is rapidly changing and it requires staying up to date through educational sessions to ensure we provide the
best care that we can for the patients in our community.
Brian: I can definitely see that you have a strong educational background, based on your work
with our technologists. What areas of the Laboratory do you oversee?
Joe: As the Anatomical Pathology manager, I oversee the operations of the surgical pathology and
cytology departments. Our surgical pathology department receives around 8500 surgical and biopsy
cases annually. Our cytology department sees around 10000 cases annually, which includes Pap
tests and non-gynecologic cases. In 2013, Laboratory Services restructured the management team to
better serve our providers and patients. I took over management of our microbiology and reference
departments as well. I don’t think that the microbiology department needs any explanation but perhaps I should explain what our reference department is all about. Essentially, our reference department processes all specimens for laboratory testing that we do not perform at Rutland Regional. We
are part of the North East Community Laboratory Alliance (NECLA) and partner with Fletcher Allen
Health Care and Mayo Medical Laboratories, who perform the specialized testing that we cannot provide locally. Our reference department processes around 35,000 tests annually.
Brian: What is your relationship with the pathologists of Mid Vermont Pathology?
(continued on page 2)
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V ol u m e 1 , I s s ue 4
MANAGER OF ANATOMICAL PATHOLOGY, MICROBIOLOGY
AND REFERENCE AT RUTLAND REGIONAL MEDICAL CENTER
L A B O R A T O R Y — J O E W A L K E R — C O N T I N U E D F R O M PA G E 1 .
Joe: I’d say that we have a very close working relationship. The pathology group provides their services under contract with Rutland
Regional. Two pathologists are on site each week. One covers the surgical pathology services and the other covers Intraoperative consultations (frozen sections) and cytology services. One pathologist member, Dr. Tony Masuck, serves as the Medical Director of Rutland Regional’s Laboratory Services while Dr. William Wiseman serves as the Pathology Section Chief. They each help with the administrative functions of the laboratory along with the daily services they provide to the communities’ patients. The Mid Vermont Pathology
group is an integral part of the daily functions of the laboratory.
Brian: How would you like to help the Laboratory move forward?
Joe: Well, I think there are short term and long term goals for the laboratory. Over the next year we are looking at several opportunities in various departments. In our microbiology department will be looking to update our blood culture device and to look at a new
technology that would help identify septic patients earlier. We will also update our sensitivity and resistance to antibiotics for a variety
of infectious organisms that do shift over time in our community. This will help ensure that providers will prescribe the most effective
treatment plan for their patients. For the reference department, we are looking to obtain a new analyzer so that we can perform several tests locally instead of sending them to a reference lab. This should reduce the turnaround time for results. We are also looking
to improve our EMR interface with the community providers, making it easier to order and receive results for many of our reference
tests that are not currently available as distinct orders. Our cytology department is looking into how we can help assist providers who
need to perform a fine needle biopsy on their patient; reducing the need for more invasive procedures and helping to provide immediate results to the patient. Our surgical pathology department will be investigating new immunohistochemistry (IHC) stains that will aid
our pathologists in their diagnostic decisions. Long term goals for these departments will be to evaluate test utilization. In the changing landscape of managing our patients’ health, making sure that providers have the best tests and the results quickly will have an
impact on how they will manage their patients’ care. Sometimes a new, expensive genetic test is not needed if the less-costly serological results do not support the need to order it and this can save the patient and the healthcare system money that could be spent on
patients that require the more specialized testing.
Brian: It has been great talking with you today!
T E S T A N N O U N C E M E N T S & U P DA T E S
Opiates Urine-Mayo
Specimen Requirements
Specimen Type: Random Urine
Container/Tube: Sterile Plastic Urine cup
Specimen Volume: 20 mL
Specimen Minimum Volume: 2.5 mL urine
Collection Instructions: No preservative
Transport Temperature
Refrigerated 7 days.
Reference Values
Negative
Cutoff concentrations
Codeine by LC-MS/MS: <100 ng/mL
Hydrocodone by LC-MS/MS: <100 ng/mL
Hydromorphone by LC-MS/MS: <100 ng/mL
Oxycodone by LC-MS/MS: <100 ng/mL
Oxymorphone by LC-MS/MS: <100 ng/mL
Morphine by LC-MS/MS: <100 ng/mL
Methodology
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Additional Information
This procedure reports the total urine concentration; this is the sum of the unconjugated and conjugated forms of the parent drug.
This test detects drugs structurally similar to morphine. Other drugs in the opioid class, such as fentanyl, meperidine, methadone, and
opiate antagonists such as naloxone, are not detected. (continued on page 3)
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V ol u m e 1 , I s s ue 4
TEST ANNOUNCEMENTS & UPDATES CONTINUED FROM
PA G E 2
PTT (activated Partial Thromboplastin Time)
Specimen Requirements
Specimen Type: Whole blood
Container/Tube: Light-blue top (citrate)
Specimen Volume: Full tube
Specimen Minimum Volume: 2.7 mL
Collection Instructions: TUBE MUST BE FILLED TO TOP OF LABEL. (Do not underfill or overfill tube.) Send specimen in original tube.
Transport Temperature
Stable for 4 hours when refrigerated.
Reference Values
Normal reference range: 23.0 – 37.0 seconds
Heparin therapeutic range: 65.0 – 97.0 seconds
Critical Values
>130 seconds (automatic call-back)
Methodology
Photo-Optical
Kidney Stone Analysis-Mayo
Specimen Requirements
Specimen Type: Stone
Container/Tube: Stone Analysis Collection Kit (see below) or Sterile Urine Container
Specimen Volume: Entire dried calculi specimen
Collection Instructions:
1. Use the filter provided to filter your urine.
2. Check the filter for any particles that may be a stone. The stone may be very small so check
carefully. The stone could look like a grain of sand or a small piece of gravel.
3. If a stone is found, place it in the clean, dry container provided.
• Do not tape stone to container as tape will affect testing.
• Do not put any liquid in the container.
• Do not send the filter.
4. Write the source, if known, on sticker of container (i.e., left kidney, bladder, right ureter.)
Place container in bag provided.
5. Keep the stone at room temperature
6. Return the stone to your doctor’s office, collection site, or wherever you were instructed to
return the specimen.
Transport Temperature
Room temperature
Reference Values
Quantitative report
Methodology
Infrared Spectrum Analysis
Additional Information
Kidney stone weights will no longer be measured or reported.
The kit contains:
A Packing Instruction Sheet
An Ambient Specimen Bag
A 13 mL specimen container for Stone Analysis
A Patient Collection Instruction Sheet
A Filter
L a b o ra t o ry S o lu t i on s
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P A T H O L O G I S T ’ S C O R N E R — A C O L O N P O LY P B Y
ANY OTHER NAME. BY WILLIAM TARRANT, MD
A polyp of the colon refers to a protuberance into the lumen from the normally flat colonic mucosa. Colon
polyps are typically asymptomatic but may bleed, ulcerate, or when very large result in intestinal obstruction.
Colon polyps are typically categorized according to their histologic features as non-neoplastic, hamartomatous,
neoplastic (adenomas and carcinomas), serrated (either neoplastic or non-neoplastic), and submucosal (either
neoplastic or non-neoplastic). The vast majority of colon polyps are small and non-neoplastic, the most common of which are hyperplastic polyps, and typically found on routine colonoscopy screening. The malignant
potential and subsequent screening intervals are determined by polyp type.
Hamartomatous polyps are those made up of normal tissue elements that result in a mass due to a disorganized growth pattern. Examples of hamartomatous polyps include Juvenile polyps, Peutz-Jeghers polyps, and
Cronkhite-Canada syndrome. There is an associated increased risk of cancer with Peutz-Jeghers syndrome
(PJS) and Juvenile polyposis coli (JPC ). Individuals with PJS are at increased risk of both gastrointestinal and
nongastrointestinal cancers, including breast cancer and testicular cancer, with a cumulative overall cancer risk of about 50 percent
by age 60, while patients with JPC have an increased cumulative lifetime risk of colorectal carcinoma of approximately 39 percent. 1,2
Adenomatous polyps are neoplastic and account for approximately two-thirds of the neoplastic colonic polyps. By definition, adenomas are dysplastic and have malignant potential. Adenomatous polyps can be categorized by endoscopic morphology
(pedunculated, flat, sessile, or depressed) and histologic features (tubular, villous, and tubulovillous along with the degree of dysplasia
high vs low). Risk factors for cancer development within an individual adenoma include villous histology, increasing polyp size, and
high-grade dysplasia. Polyps with high grade dysplasia are considered to represent an evolutionary progression from a low-grade adenomatous polyp to invasive cancer. 3
Serrated polyps are a heterogeneous group of polyps with variable malignant potential that share a common serrated distortion of the colonic crypts. Serrated polyps include hyperplastic polyps, sessile serrated polyps or sessile serrated adenoma, and traditional serrated adenomas.
Hyperplastic polyps (HPs) are composed of normal cellular components with a characteristic non-dysplastic crypt serration
exhibited mainly in the superficial and surface portions of the crypts. 4 HPs are typically located in the rectosigmoid colon, less than 5
mm in size, and do not appear to increase the risk of colorectal cancer. 5
Sessile serrated polyps (SSP), also known as sessile serrated adenomas (SSA) are more commonly located in the proximal
colon and typically lack classic epithelial dysplasia. As a result of evolving classification schemes and differing histologic interpretation
among pathologists, there has been considerable variation in terminology within the literature regarding sessile serrated polyps. (6-8)
Unlike hyperplastic polyps, the crypt serration extends to the basilar crypt region with crypt dilation, inverted crypts, and horizontal extension of the crypt base along the muscularis mucosa. 9 In contrast to HPs, foci of epithelial dysplasia do sometimes occur in SSP/
SSA and should be noted by the pathologist, as this is considered a step toward cancer progression. For this reason the pathologists
at Mid-Vermont Pathology prefer to use the term Sessile Serrated Polyp and specify with or without dysplasia. This designation avoids
the term “sessile serrated adenoma” as the word “adenoma” implies true epithelial dysplasia and may lead to a miscommunication as
to the severity of the lesion. Below is a table of the classification scheme used by Mid-Vermont Pathology.
Traditional serrated adenomas are more common in the rectosigmoid colon, have diffuse, often low grade epithelial dysplasia, papillary or villiform growth pattern, and epithelium with confluent pink eosinophilic cytoplasm. 10 These are characteristic difference
from HPs and SSPs. Traditional serrated adenomas are relatively less common than SSPs. Traditional serrated adenomas and SSPs
are managed similarly to adenomatous polyps, as they are considered neoplastic and associated with molecular alterations linked to
sporadic colon cancers. (11-15)
Rarely serrated polyps will have overlapping features or processing artifact that hinders the distinction between hyperplastic polyps
and other serrated polyps. For this reason, the term “unclassifiable serrated polyp” is used, and the pathologist will specify if epithelial
dysplasia is present or not.
Below is a classification scheme summary for serrated polyps used by Mid-Vermont Pathology Associates:
NON-DYSPLASTIC SERRATED POLYPS
HYPERPLASTIC POLYP
SESSILE SERRATED POLYP WITHOUT DYSPLASIA
DYSPLASTIC SERRATED POLYPS
SESSILE SERRATED POLYP WITH DYSPLASIA
TRADITIONAL SERRATED ADENOMA
UNCLASSIFIABLE SERRATED POLYPS
UNCLASSIFIABLE SERRATED POLYP WITHOUT DYSPLASIA
UNCLASSIFIABLE SERRATED POLYP WITH DYSPLASIA
(continued on page 5)
L a b o ra t o ry S o lu t i on s
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P A TH O LO G I ST ’ S C O RN E R — A C O LO N P O LY P B Y A N Y
OTHER NAME. BY WILLIAM TARRANT, MD CONTINUED
F R O M PA G E 4
Bibliography:
1. van Lier MG, Wagner A, Mathus-Vliegen EM, Kuipers EJ, Steyerberg EW, van Leerdam ME. High cancer risk in Peutz-Jeghers syndrome: a systematic review and surveillance recommendations. Am J Gastroenterol. 2010;105(6):1258.
2. Lodewijk A A Brosens, Arnout van Hattem, Linda M Hylind, Christine Iacobuzio-Donahue, Katharine, E Romans, Jennifer Axilbund,
Marcia Cruz-Correa, Anne C Tersmette, G Johan A Offerhaus, Francis M Giardiello. Risk of colorectal cancer in juvenile polyposis. Gut
2007;56:965-967
3. Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med. 1992;326
(10):658.
4. Higuchi T, Sugihara K, Jass JR. Demographic and pathological characteristics of serrated polyps of colorectum. Histopathology.
2005;47(1):32.
5. Laiyemo AO, Murphy G, Sansbury LB, Wang Z, Albert PS, Marcus PM, Schoen RE, Cross AJ, Schatzkin A, Lanza E. Hyperplastic polyps
and the risk of adenoma recurrence in the polyp prevention trial. Clin Gastroenterol Hepatol. 2009 Feb;7(2):192-7.
6. Snover DC, Jass JR, Fenoglio-Preiser C, Batts KP. Serrated polyps of the large intestine: a morphologic and molecular review of an
evolving concept. Am J Clin Pathol. 2005;124(3):380.
7. Glatz K, Pritt B, Glatz D, Hartmann A, O'Brien MJ, Blaszyk H. A multinational, internet-based assessment of observer variability in the
diagnosis of serrated colorectal polyps. Am J Clin Pathol. 2007;127(6):938.
8. Khalid O, Radaideh S, Cummings OW, O'Brien MJ, Goldblum JR, Rex DK. Reinterpretation of histology of proximal colon polyps called
hyperplastic in 2001. World J Gastroenterol. 2009;15(30):3767.
9. Sandmeier D1, Seelentag W, Bouzourene H. Serrated polyps of the colorectum: is sessile serrated adenoma distinguishable from
hyperplastic polyp in a daily practice? Virchows Arch. 2007 Jun;450(6):613-8.
10. Torlakovic EE, Gomez JD, Driman DK, Parfitt JR, Wang C, Benerjee T, Snover DC. Sessile serrated adenoma (SSA) vs. traditional serrated adenoma (TSA). Am J Surg Pathol. 2008 Jan;32(1):21-9.
11. Higuchi T, Sugihara K, Jass JR. Demographic and pathological characteristics of serrated polyps of colorectum. Histopathology.
2005;47(1):32.
12. Wong JJ, Hawkins NJ, Ward RL. Colorectal cancer: a model for epigenetic tumorigenesis. Gut. 2007;56(1):140
13. Jass JR. Classification of colorectal cancer based on correlation of clinical, morphological and molecular features. Histopathology.
2007;50(1):113.
14. Spring KJ, Zhao ZZ, Karamatic R, Walsh MD, Whitehall VL, Pike T, Simms LA, Young J, James M, Montgomery GW, Appleyard M,
Hewett D, Togashi K, Jass JR, Leggett BA. High prevalence of sessile serrated adenomas with BRAF mutations: a prospective study of
patients undergoing colonoscopy. Gastroenterology. 2006;131(5):1400.
15. Deng G, Bell I, Crawley S, Gum J, Terdiman JP, Allen BA, Truta B, Sleisenger MH, Kim YS. BRAF mutation is frequently present in
sporadic colorectal cancer with methylated hMLH1, but not in hereditary nonpolyposis colorectal cancer. Clin Cancer Res. 2004;10(1 Pt
1):191.
L a b o ra t o ry S o lu t i on s
Page 6
RUTLAND REGIONAL MEDICAL CENTER’S
- Anatomic Pathology Department
Cytology Department and the Prep Lab:
The Cytology Department at Rutland Regional is open from 7:30am to 4:30pm, Monday through Friday. Cytology is staffed by three
Cytotechnologists who share a combined 44 years of experience and one Preparation Technical Aide who is an expert at receiving and
processing specimens for examination. We process around 8000 specimens annually, which includes Pap testing and non-gynecologic
specimens. Our turnaround time for verifying cytology results is 24 hours for non-gynecologic specimens and 5 days for Pap testing.
We are here to answer any of your questions regarding ordering, sample submission or results.
Rutland Regional’s Cytology Department is under the umbrella of Anatomic Pathology, which is why you’ll find our orders in Cerner
listed under “Pathology Request.” Cytology is the portion of Pathology that deals with specimens that are too small, or in a fluid state,
and cannot be cut into pieces for microscopic examination. Cytology, in its most simple definition, means the study of cells. Here in the
cytology laboratory we look at cells under a light microscope magnified 100 to 600 times their normal size, in order to diagnose disease,
infection and conditions based on the characteristics of their nuclei, cytoplasm, chromatin, and structure (singly and within groups).
Cytotechnologists and Pathologists work together to interpret and diagnose a wide variety of specimens.
Our specimens include:
Fine needle aspiration material from palpable masses or areas sampled utilizing diagnostic imaging.
Samples obtained by scraping, brushing or washing/irrigating.
Fluids from the body such as urine, sputum, CSF, cystic fluid, and other body cavity fluids.
These specimens may be spread onto glass slides that are fixed with either alcohol submersion, spray fixative, or preserved by airdrying the slide. Non gynecological specimens are also submitted to us in Cytolyt© fixative. Rutland Regional utilizes the ThinPrep®
Pap test, which is currently the only FDA approved collection fluid for performing reflexive HPV testing and is significantly better than the
conventional Pap test at detecting high grade intraepithelial lesions. Each of these preparation methods may reveal slightly different
information and are subject to different artefactual limitations.
Surgical Pathology Department and the Histology Lab:
Here at Rutland Regional we strive to provide the best health care possible. In our journey towards excellence, we recently completed construction of our new space in the Surgical Pathology Lab with state of the art equipment. The department is fully staffed with
two certified Histotechnologists and four board certified Pathologists. Two administrative assistants also help coordinate operations and
completed pathology reports for the department. We are open Monday through Friday from 6:30 am to 5:00 pm. There is a Pathologist
on call at all times and specimens are received into the lab 24 hours a day, 7 days a week. Depending on the required testing, specimens may be submitted in three different ways: Fresh, Fresh for Intraoperative Consultation (Frozen Sections), and in a Neutral Buffered Formalin.
The two Hisotechnologists that work within the lab are responsible for the preparation and staining of tissues for microscopic examination. We have four American Board of Pathology certified pathologists that review the prepared slides and diagnose disease. The tissue submitted to our lab may be obtained from our operating room, our clinics, community provider's offices, or our emergency room.
Histotechnologists may also assist the pathologist in the preparation of Intraoperative consultations, which are used to provide a rapid
diagnosis while the patient is still undergoing surgery.
Histology is a specialized part of the laboratory. Histology is the study of tissue and the cellular components utilizing a light microscope. We provide a variety of tests that allow our pathologists to more accurately diagnose disease, which will ultimately lead to a better treatment plan for your patients. We recently implemented a state of the art device for use with immunohistochemistry (IHC) stains.
This new IHC stainer uses various selected antibodies to form bonds with specific antigens in cells, which help aid in the diagnosis of
various diseases in submitted tissue. Our new IHC stainer is highly specific and sensitive and utilizes one- third less reagents in the
process. We offer nearly 40 different IHC stains and are currently in a validation phase of additional antibodies that will aid the pathologist and provide a faster turnaround time for diagnoses. In addition to our portfolio of IHC stains, we also perform what we call "special
stains." Some of these help aid in the diagnosis of bacterial and fungal infections, as well as a variety of disease processes.
We also have a working relationship with several other laboratories such as Dartmouth Hitchcock, Fletcher Allen, the Mayo Clinic,
Johns Hopkins, etc. Having this working partnership with outside laboratories gives us the ability to perform more necessary testing that
can better drive treatment options.
As technology changes, so do we. We are constantly improving our testing to provide our patients with the best care available.
L a b o ra t o ry S o lu t i on s
Page 7
R u t la n d R egi o na l Med i ca l
Cen t er L a b o r a t o r y
RUTLAND REGIONAL MEDICAL CENTER’S BLOOD DRAW LOCATIONS:
3rd Floor
160 Allen Street
Rutalnd, VT 05701
Rutland Regional Medical Center Blood Draw Station. 802.747.1771
1st floor, 160 Allen Street, Rutland VT 05701 Monday-Friday 7am -6pm & Saturday 8am-12 noon.
Phone 802.775.7111
Website: www.rrmc.org
Commons Street Blood Draw Center. 802.776.2721
4 Commons St, Rutland, VT 05701. Monday-Thursday 6:00am-11am & 11:30am-4pm, Friday
6:00am - 11am & 11:30am –1:30pm. New Hours Effective October 13th, 2014.
WE ARE ON THE WEB!
rrmclab.testcatalog.org
Our Vision:
To be the Best Community
Healthcare System in New
England.
Allen Street Blood Draw Station . 802.775.3657
98 Allen Street (Located in Dr Dier’s office), Rutland, VT 05701 Monday– Thursday 6:30am - 12noon,
Friday 6:30am-12:30pm. New Hours Effective October 13th, 2014.
Brandon Medical Center. 802.247.6305.
420 Grove Street, Brandon, VT 05733 Monday-Friday 7:15 am-12 noon.
Castleton Family Health Center. 802.671.2114.
275 Route 30 North, Bomoseen, VT 05732 Monday-Friday 7:30am-12noon & 12:30-4pm.
Mettowee Valley Family Health Center. 802.645.0584
278 Route 149, West Pawlet, VT 05775 Monday-Friday 7-11am.
Rutland Community Health Center. 802.747.1837
214 Stratton Road, Rutland, VT 05701 Monday-Friday 8am-12:15pm & 12:45pm-4:30pm.
2014
LABORATORY HOLIDAY
SCHEDULE CLOSING
January 1, 2014
May 26, 2014
July 4, 2014
September 1, 2014
November 27, 2014
December 25, 2014
Laboratory Editors
Lab Director: Sana Bruno
AP/Microbiology Mgr: Joe Walker
Outreach Coord: Brian Cameron
Admin Coord: Wendy Bixby
Laboratory Spartan Race Team
Dr William Tarrant, MD. Pathologist; Sarah E Baker, Medical Technologist;
Shealyn Siliski, Laboratory Supervisor; Sana Bruno, Laboratory Director and
Dr William Wiseman, DO. Pathologist participated in the Spartan Race on
Sunday, September 21st, 2014.
Rutland Regional Medical Center Laboratory
160 Allen Street
Rutland, VT 05701