Lablogatory

The Poisoner’s Handbook by Deborah Blum–Book Review

I recently read The Poisoner’s Handbook by Deborah Blum, a book about poison and forensic investigation in Jazz-age New York City. Dr. Norris and Dr. Gettler transformed death investigation from a good-old-boy coroner system to one based on science and data analysis. Blum weaves several cases into a narrative that covers several poisons used during the 1920s and ‘30s. Over time, poisoning deaths decreased due to public awareness as well as the realization that murderers were increasingly likely to get caught. Blum discusses Prohibition at length and its contribution to poisoning deaths in New York City. I found this particularly fascinating; not only were people willing to risk their lives to drink alcohol, the government tried to dissuade people from drinking by actively poisoning the supply.

Several of the reviews of this book note Blum’s lack of chemistry knowledge, and I can’t disagree. While my own knowledge base isn’t wide, even I notice a few inaccuracies (HCN isn’t a “potent” acid, for example). One must remember that Blum is a journalist, not a chemist; I tend place blame on the publisher’s fact-checker as well as the author. Because this book is about the evolution of the public perception of forensic toxicology and not just the science behind it, I could overlook the scientific stumbles.

As a laboratory professional, I loved reading about the early days of forensic science and forensic toxicology. While these professions existed in Europe well before 1920, Norris and Gettler forever changed how we treat death, murder, and justice in this country.

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Use of Remembrances, Part Deux

So, I’d like to continue with the thread of thinking on my previous blog post about the use of remembrances–and thank you to those who have either commented on the blog or emailed me. I personally believe that using old questions that I know are questions that will more than likely be recycled on a standardized exam (which is how I define remembrances), is not for me. However, I don’t believe that using other study materials that may give you an idea of topics or styles of questions that may be asked is the same–after all, there is a whole industry devoted to the topic of study materials for specific tests. For me, it’s about the intention more so than the action because I don’t see life in terms of “black and white”. But I understand that it is often difficult to distinguish between these two and that lines may get blurred unintentionally. But writing down the questions after taking a test and using them or passing them down to one’s juniors to use to study for an upcoming version of the test is using a remembrance in my book.

To me, to cheat or not to cheat, that’s a personal choice and I don’t really judge (or honestly, feel it’s worth my effort to do so) and I think we can say we all have different definitions. But for me, the more important question is whether I choose to cheat myself. Multiple times during my medical training, I’ve felt like I’ve had to play catch-up. I think that this is because I didn’t truly take the time and effort when I should’ve to learn the material in a way that I could internalize it enough to stick–and often that may be because I was too stressed to see the “forest through the trees.” But, now I’ve begun to see the outlines of the forest.

Being more of a scientist-trained person and less of a clinical one, I still find myself having to go back and relearn a concept I should’ve learned well during medical school to carry out my resident responsibilities. And while I may internally curse myself for this, I understand that I need to do this–that I may hurt a patient if I just brush under the rug that I’m missing some knowledge, no matter how small a crumb it may be. I might be able to get by without fully understanding it, but I need to participate in their care. First, we need to be self-aware enough to even question ourselves. I believe that starts with at least making the decision to make an effort to ask these questions, which we can all do. And much of that comes from experience. But it also comes from listening to the consistent patterns that percolate throughout the feedback we have been given over time from our mentors and from identifying what characteristics we want to live up to in our role models.

I also believe that this effort should not be one-sided in that all the responsibility is on the trainee. Factors in this equation equally include our residency programs, and specifically, those who serve as our role models and mentors. Even if our attendings may not realize it, they do serve these two roles just as much as they fill the role of being our didactic teachers in their topic area. Also important is the critical thinking or analytical process that we need to learn and make our own. I’ve found that the best teachers, or at least the ones I relate to most, are the ones who lead me through the thinking process–to look first at low power at the architecture and then to move on to high power where I consider the nuclear and cytoplasmic features, chromatin texture, the company that the primary lesional cells keep, and so on, to put together the pieces of the puzzle to come to a reasonable diagnosis and differential. Same process, albeit with different pieces, when it comes to my CP rotations. And I’m slowly but surely attempting to get there.

I also believe that the American Board of Pathology (ABP) who writes our board exams, and even the American Society for Clinical Pathology (ASCP) who writes our resident in-service exam (RISE), have an equal responsibility to help us transform our culture. Pathology and diagnostics are changing at a rapid pace and both organizations need to be up-to-date and reflect this in how they construct our exams. We are (or are training to be) the diagnostics experts and we need to know not only certain facts but also understand the relevant concepts—and truly understand the importance of training ourselves to be life-long learners. If both organizations want to absolve themselves from culpability in maintaining a culture that silently endorses the use of remembrances, must not recycle old questions. Of course, this does not mean writing exams from scratch each and every year. And of course, I am not trying to belittle the efforts that these organizations do make every year on our behalf when they write these exams. I am only entreating them to make honest, focused, and deliberate efforts each year to re-examine the content of these exams and to retire those that may fall under the definition of a remembrance. We need to have these exams truly reflect the knowledge and critical thinking we need as a practicing pathologist—more case based multiple-step questions rather multiple-choice (which I’ve always called “multiple-guess”) might help.

So, fellow residents, figure out how you learn best–and in a nice and respectful way, convey your expectations to your teachers–ask questions, read more books and journal articles, step up and take more responsibility in your rotations for patient care and safety issues and don’t just do the minimum amount of work required.If you are so inclined, get more involved. Next week, I’ll talk about resident engagement in pathology organizations and my recent experience serving as the resident representative on ASCP’s Annual Meeting Steering Committee Education Working Group. I encourage all residents to at least take advantage of the FREE resident memberships from both ASCP and CAP (you get discounts on books, apply to serve on committees, etc).

And also, turn in abstracts to present at their annual meetings, both have their submission period open NOW!

CAP in Chicago, IL Sept 7-10, 2014

ASCP in Tampa. FL during Oct 8-11, 2014

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Blood Management: The Power of “Why”

There are five established questions that should always be embedded in our quest for knowledge and review within the ever-changing evidence base in medicine: what, who, when, how and why. Of these very important and inclusive queries, the final question wields the most power. For it is the why we do, or should do something that truly empowers us. “Why,” by definition, represents the cause, reason, or purpose for action.

Considering the rapid evolution of the evidence base in transfusion medicine and patient blood management, once again, these critical questions should be included in our appraisal. The why remains, however, the most important. Once we grasp that quality, safe, responsible transfusion practice is the purpose, then the what, who, when and how should more easily move forward.

The Joint Commission has begun evaluating patient blood management elements as part of a possible certification for hospitals. The AABB recently published a draft document of patient blood management standards for potential use by its participating facilities. The Society for the Advancement of Blood Management just announced a hospital affiliation program to align principles of blood management with the Society’s mission. All of these organizations are pushing the mission of evidence-based transfusion practice in order to promote patient safety and improve outcomes.

It is our duty as healthcare providers to constantly and consistently evaluate practices, whether they represent procedures, devices, pharmaceuticals; whether they are new or time-honored. Hemovigilance i.e. blood management, must also be included in this ongoing assessment.

Time and time again, the literature is pointing us in the direction of restrictive transfusion practices; avoiding unnecessary transfusion and utilizing blood products as part of our armamentarium when truly life-saving. This concept, thus exudes the ideals of appropriate patient care, best practices and stewardship of community resources. Our cause, our reason, our purpose is clearly to improve patient outcomes and well -being.

Embrace it! Get on board! It is the WHY!

-Carolyn D. Burns, MD, is the Medical Director of Transfusion Services at Strategic Healthcare Group and Assistant Clinical Professor in the Department of Pathology at the University of Louisville in Louisville, Kentucky. She also blogs for TheBloodyTruth.com.

Glucose Meters

There’s been a serious buzz in the laboratory community recently (especially among the Point of Care [POC] community) about glucose meters. Most laboratory professionals know that glucose measurements on the average glucometer are not as reproducible as those performed on the average main lab analyzer. Some of the reason for that is simply related to issues around proper sampling and use of the glucometers. However, glucometers are only required by the FDA to have precisions of ±20%. For that reason, glucometers are not recommended to be used for diagnosing disorders, for monitoring critically ill patients, or for maintaining tight glycemic control. And yet, glucometers are routinely used nearly everywhere for all three of these purposes.

Recently, the FDA began to try to get a handle on the utilization of glucometers by coming out with two draft guidance documents (links below). By releasing these documents they have essentially reclassified glucometers into two categories: those suitable for over-the-counter (ie home) use, and those suitable for by prescription or health-care-setting(ie professional) use. The differences include:

OTC meters – 95% of values within ±15% of reference measurement, 99% within ±20%; Professional – 99% within ±10% or ±7 mg/dL below 70 mg/dL
OTC meters – AMR 50 – 400 mg/dL; Professional – AMR 10 – 500 mg/dL
Professional – should also include neonatal studies
OTC meters – labeling – for use by persons with diabetes for at home monitoring; Professional – labeling – with intended use, but not for use in critically ill or tight glycemic control

Thus the FDA has reiterated that glucometers should not be used for critically ill patients.If they are used for any purpose not specified in the package insert, their use must be classified as a moderate complexity off-label use of the glucometer, requiring the extensive validations specified by CLIA for non-FDA approved tests. These draft guidance documents have already caused the New York State Department of Health to react and send a letter to all laboratory directors stating that “…the use of glucose meters in health fairs, other community screening events, and/or critical care settings must be discontinued” until such time as CLIA validations have been performed. Thus a huge burden has been placed on the POC community in NY to either pull their POC glucometers from their facilities or validate their uses. And the rest of the country is waiting to see how it will all fall out. Glucometers are ubiquitous in the majority of health care settings and it will not be easy to meet the new FDA draft guidelines.

http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM380325.pdf

http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM380327.pdf.

-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

To Test or Not to Test

Recently the editors of Lab Medicine received a request for information regarding referral of sensitivities from one site to another or to the same site within three days. Here are a few examples of what I mean so we’re all on the same page:

A pan-sensitive Staphylococcus aureus is recovered from a left ankle wound on 1/28; the same organism is recovered from the same site on 1/31.
An E. coli with a typical susceptibility pattern is recovered from a right knee incision on 2/3; the same organism is recovered from the right ankle on the same date.

Referring sensitivities can streamline processes; thereby saving time and money (for the lab as well as the patient). According to the CLSI guideline M100-S23 (January 2013), Enterobacter, Citrobacter, and Serratia may develop resistance within three to four days of treatment with third-generation cephalosporin; Staphylococcus spp. may develop resistance to during prolonged therapy with quinolones. Since resistance can develop over the course of the same disease occurrence, it’s advisable to retest the susceptibility after three days so therapy can be adjusted if needed.

As for referring one site to another—such a left ankle to a left knee—I couldn’t find any source that advocated this practice. However, I am aware of facilities that have implemented such policies. What policies does your microbiology department follow when referring one sensitivity result to another?

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Are We Cheating Ourselves Out of Our Competency?

Last October, I attended the CAP Residents Forum where I heard the President of the American Board of Pathology speak about the use of remembrances for boards studying and how it was considered cheating and a breach of the honor code. I was a bit surprised when we took a live vote via text that the majority of residents felt that the use of remembrances was not cheating. But this all goes back to the medical school culture (and maybe even before that) in which we were trained.

During my 1^st year of medical school, I remember feeling that it was inequitable that some students got old exams from their assigned 2^nd year “big siblings” and that others got nothing. So I did something to neutralize the playing field – before every test, I scanned the old exams I had and emailed them to the class listserv. For the few exams that I didn’t have an old exam, other classmates stepped up and scanned and emailed them out. And so we built a culture of sharing. I was very proud that my classmates did not put having a personal advantage over the concept of equity.

But unexpected and unintentional shenanigans ensued. Once a classmate emailed out what was thought to be an old exam but was later found to be a “stolen” exam as that professor purposely did not give back his exams. This required our waiting while he re-wrote parts of the exam as this was discovered only on the morning of our actual exam. And during my 1^st year of PhD (I was initially DO/PhD), when my original classmates were in the midst of their 3^rd year rotations, a classmate emailed some study materials they had obtained from a friend at another DO school that unbeknownst to them were remembrances from previous NBOME shelf exams.

Eventually as the year went on, my classmates began to realize that what they had were remembrances and one classmate actually stepped up and turned them into one of our deans. Since I was no longer in this class, I only heard after the fact, but our dean had called the NBOME to warn them to retire the questions in these remembrances and had also called the school from which they originated to let them know what their students had done. At that time, I was not very invested in what was unfolding as I was in the graduate school portion of my dual degree program. But I do understand the fear of others having advantages that you may not and having that thought cloud one’s thinking.

These memories flooded back into my mind as I listened to this talk at the Residents Forum and voted. I didn’t realize it then when I watched from the sidelines but do now, that the use of remembrances—whether it is considered cheating or not—is in fact cheating oneself. A Machiavellian “ends justify the means” mentality is often used to justify such actions. But in the end, what have we truly accomplished? Yes, maybe passing our boards. But what happens when we become practicing pathologists if we didn’t understand what it was that we so diligently memorized off of remembrances?

It may be slower and more difficult, but I’ve pledged to myself that I won’t take the easy road, no matter how tempting it may be (I admit I’m just as vulnerable to temptation as everyone else). I tell my M2 students when I TA their pathology small group discussion lab that if they don’t know even one word when they are reading to learn a concept…to stop immediately and look it up, even if it just means to Google. And I’ve tried to practice this as well. I still may not pick up on surgical pathology concepts (especially grossing) as quickly as I do clinical pathology concepts, but I have noticed a difference. Concepts seem to stick better in my aging brain because I have shifted how I focus my efforts. I try not to waste as much time on worrying (but I still sometimes do) that others may have an advantage over me because that is wasted effort.

Gaining competency means to take ownership and responsibility for one’s learning. Figure out how you learn best and make a plan to do it. And if you fail, keep trying until you make it. Really try to understand the mechanisms and not just memorize minutiae or facts. I find that I can figure out the answers this way if I had a solid foundation. And don’t take too many shortcuts, which invariably, remembrances may turn out to be. But I’d like to hear your take on the topic…is the use of remembrances cheating or not? And do you think that using remembrances cheats you out of obtaining competency as fast and as well as you might have gotten there without them?

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Thinking Outside (or Rather, Inside) the Box

“The weather outside is frightful…” The west is facing unprecedented drought, the east is having debilitating storms, and the Midwest a “polar challenge” that keeps everyone on frost-bite watch. In times like these when we can’t reconcile with Mother Nature, I tend to reflect on the challenges of specimen and supply chain transport. Consider the challenges that we face with those issues when weather isn’t cooperative? Plane flights cancelled = delayed specimens to referral labs = delayed results and diagnoses. Interstate shut-downs = trucks sitting still = reagents too hot or too cold for too long. Blizzard or sand-storm conditions = couriers unable to travel = delayed pick-up/delivery = compromised specimen integrity.

Now translate that to our international colleagues, and you can see the difficulties they face on a daily basis. Long distances in the heat of the deserts, or snows of the tundras. Difficulties with transport, with trucks breaking down or planes unable to fly. Concerns with reliable transport via public buses, taxis, independent drivers/pilots who are not specifically trained in laboratory supply and specimen transport. The quality of the reagent and the integrity of the specimen = the precision of the result. It’s that simple…but it isn’t simple at all, is it?

So while we are dealing with the present weather conditions and issues, be reminded that our global laboratory colleagues deal with these issues in all kinds of weather and climate challenges every day, and have the same concerns. It’s a challenge Mother Nature provides for us, and one we must have contingency plans for in order to provide the best service to our patients.

If you are having weather challenges at the moment, I will hold good thoughts. Stay warm, or hydrated, or whatever the conditions require—and when our weather has passed, try to hold good thoughts for your colleagues around the globe who face it year around! If you want to know how they cope, let me know at bsumwalt@pacbell.net and I’ll share some recommendations I have learned from many of them over the past few years!

–Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

Bird Watching

Every inspection cycle we receive our checklists from the regulatory organizations and that is usually when the latent lawyer in me breaks out like the Hulk and I start interpreting the meaning of every word contained within the document. CAP has said on multiple occasions that some of the checklist items are open to interpretation and that there can be several ways to satisfy them. CLIA has their 6 elements of competency and when I first read them my eyes started to turn green and my clothes started to get a little snug. The element that I think is open to the most discussion is the first: “Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling, processing, and testing.” Some of my colleagues have interpreted this as once a year directly observing a technologist/technician perform each test and then signing them off. When I read this element I can’t help but think that once a year is not enough to verify that an employee is correctly performing each test. The question I always ask is how do we know that an employee does it correctly when we are watching but then does it a different way when we aren’t?

I am a very hands off leader. The reason I can do this is because when I train a new employee it is rigorous and I make sure that they can handle pretty much anything that comes their way. When I read that first CLIA element I feel as if they want us to babysit our employees. I understand the importance of direct observation but where is the line drawn that says so much observation is enough? If you ask me once a year is not enough; however, the more we observe the less time we have to do our countless other tasks as supervisors/managers.

When I thought about it, I came up with a couple methods or ways to “directly observe” my employees. The first obviously is to stand behind them and watch them perform a test. Then the question of how do we observe the off shifts without actually being there? We all have smart phones with cameras so could employees could set up their phones to record a procedure and then we could watch it back later. In blood bank I can have each employee save their gel cards so that I can read them at a later time and make sure the volumes in each well look ok. That would qualify as direct observation of their results and process since if the volumes are incorrect I would be able to tell. As supervisors we are also called to consult with other technologist/technicians frequently. Troubleshooting with your employees usually involves something test related and that to me would count as direct observation as well. Finally, we have students almost year round and our employees usually take on the role of teacher when they are in that spot for the day. When I observe them teaching the students how to perform tests this is a great way to confirm that the employee is competent.

My favorite way to observe is when my employees don’t know I’m watching. I have an office that is not directly in the blood bank so I have to wander in and out fairly often. Sometimes I will sit down or file papers all the while observing my employees and their technique and processes. There are many ways to “directly observe” and using all of them ensures that you are meeting the guidelines enforced by CMS. When inspection time comes you can show the signature that says you directly observed but also have a list of answers when they ask how you did it. When I need some practice I grab my binoculars and do a little bird watching.

–Matthew Herasuta, MBA, MLS(ASCP)CM is a medical laboratory scientist who works as a generalist and serves as the Blood Bank and General Supervisor for the regional Euclid Hospital in Cleveland, OH.

Estimated Average Glucose

Most people in the clinical lab and among the Diabetes population are aware that there is not a good correlation between a blood glucose level and a hemoglobin A1C (HbA1c) level. This only makes sense. A blood glucose is essentially a snapshot of what the glucose concentration is in your body at that particular point in time when the blood sample is collected. HbA1c is a measure of the percent of your hemoglobin that has glucose attached to it. The longer your glucose is high and the higher it is, the more glucose will be attached to hemoglobin and the higher your percent HbA1c. The hemoglobin with glucose attached stays around for the life of the red blood cell that holds it, 120 days. Therefore, a HbA1c level is an indication of what your blood glucose has been averaging for the last 4 months.

That’s where an estimated average glucose (eAG) comes in. eAG is a value that’s calculated from the HbA1c, so it is also an indicator of what your blood glucose has averaged over the last 120 days rather than being a snapshot of your current blood glucose. Like HbA1c, its utility lies in that a person may not have been in control of their glucose for the last 4 months, but they are careful the day they come in to have their glucose checked. Their snapshot blood glucose may be 130 mg/dL or close to the normal range, but their eAG would still be 200 mg/dL or more, indicating what they’ve been averaging the last 4 months.

The formula for calculating eAG was developed by Nathan et al (1). Their study in which they derived it is impressive. They collected roughly 2700 separate glucose measurements on each of 507 study subjects. The study cohort contained 268 persons with type 1 diabetes, 159 persons with type 2 diabetes and 80 normal controls. All participants in their study had their glucose under control for the 3 month run of the study. With so many individual measurements on each study subject, the authors were able to determine an average glucose for each subject and correlate it with the subject’s HbA1c. The formula they derived is:

eAG = 28.7 X HgbA1C – 46.7 (for US units of mg/dL)

Interestingly, HbA1c gives you essentially the same information as eAG: an indication of what a person’s average glucose has run over the last 120 days. The difference is this: most people monitoring blood glucose know what a glucose value means and when their glucose value is too high. Thus an eAG of 250 mg/dL may make more sense to them than an HbA1c of 10.3 %. They now know that they have been averaging a glucose of 250 mg/dL, even if today’s glucose was 126 mg/dL. Whether it’s true or not that eAG is easier to understand than HbA1c, HbA1c has become widely used and eAG has not. Despite that, it does have the potential to be a useful calculation.

1. Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine JR. Translating the A1C assay into estimated average glucose values. Diabetes Care, 31(8):1473-1478. 2008.

Under Pressure

Wired features an interesting article on their website about how bacteria behave in stressful environments. Does stress direct bacterial mutation? It’s a fascinating article about evolution and environment. Check it out.