On the Lab Medicine Website

We’ve posted some great features over the last few weeks. A sampling:

-How do NASA scientists test analyzers to see if they’re capable of accurate analysis aboard the International Space Station? This article discusses the process, as does this podcast by the lead author.

-If you’re curious about the effects of brown recluse spider bites, this paper and this video will tell you everything you need to know, including laboratory considerations.

-Middle East Respiratory Syndrome hasn’t reared its ugly head in the States yet, but with international travel it’s just a matter of time before it does. Check out our resource page so you can be prepared.

 

What Are Better Ways to Learn and Retain New Pathology Concepts?

So, I’m curious…how are pathology concepts taught in your program and are these methods effective? We use multiple modalities in my program. We have mandatory core curriculum didactics three mornings each week, 2 days of AP and 1 day of CP. Additionally, we also have either cytology (lecture or multi-headed session) or hematopathology interdisciplinary conference on alternating Fridays. On some Tuesdays, we have invited guest lecturers for grand rounds. During PGY-1 while on our “intro to SP” rotations, we had additional histology, gross organ, and subspecialty didactics.

And even though, we have 4 sites, those who cannot be at the main site for lecture, teleconference in to the core lectures. So, our mornings are pretty full and it almost feels like we’re still in medical school during our clinical years with needing to balance service work with didactics. This year, they’ve tried to make the curriculum more interactive with more pre-assigned virtual slides or reading, occasional pre- and post-didactic quizzes, and a case-based rather than lecture-based structure.

And this is before all the tumor boards, morbidity and mortality, interdisciplinary specialty conferences, journal club, conferences, and CP call conferences that we make presentations that require prior research. So, sometimes, I’m amazed that in the midst of all this, that we can fit in all our service duties. We also make consistent use of our slide scanner – to create virtual re-cut sets for study, prepare presentations, and put together educational modules (at least our attendings do for this last one). And I didn’t realize until I met other residents at conferences, that heavy use of virtual slides isn’t the norm everywhere so I feel fortunate. And of course, there is sign-out (and sometimes, grossing) with the attending and learning from our fellows.

So in terms of the aforementioned, I expect that many programs teach utilizing a similar mix of modalities. But how do you learn on your own personal time? I’ve never been a student who would win an award for lecture attendance but since our “core” is mandatory, I attend most despite the fact that I don’t learn best in this way. I’m not a big textbook reader either – I have a decent number of books but can’t say I’ve finished any entirely. Having been graduate school trained initially, I’m much more of a journal article reader, which for me, as a CP-inclined resident, works well when I’m on CP rotations where I tend to excel more than I do on AP.

But what is the best way to learn on AP rotations? As an artist, I like pictures and there are some good websites (and even textbooks out there). But most days, I come home too tired to retain anything even if I could read more than for the pre-assignment for our “core”. I have to admit…I have not figured out that secret yet and would love to hear your thoughts. How best do we learn and retain pathology concepts?

-Betty Chung

 

Never a Dull Moment

As an international laboratory consultant, there is never a dull moment.  One minute you are working with energized people from another country engaged in spirited dialogue, learning and sharing experiences—and the next you are up very late with your team colleagues in a smoke-filled hotel lounge with multiple computers plugged into walls trying to capture information into an assessment template not designed for the technically challenged.  It’s better than Sudoku for mental exercise!

I recall one trip where the biggest challenge was keeping our notes and information straight.  We were scheduled to visit two laboratories on the same day; small but relatively full service labs, so there was much to review, discuss and digest in order to understand their capability and progress.  Some people can type notes into a laptop, but I find that a pencil and paper are the most useful tools. Working with people, making eye contact and facilitating interactive discussion provides a backdrop for what you are able to observe.  After a walk-through and overview, questions and comments, log reviews and notations it is imperative to elaborate on your notes and add comments immediately after an assessment visit.  Believe me, after 6 laboratories in 4 days covering >1000 miles, they can very easily “all run together” if you are not careful and diligent.  Laboratorians  tend to be overly organized and a bit obsessive about documenting things—it’s the nature of the beast, since we live our career lives in data production and information dissemination—and it has to be correct, all the time, for every patient. I smile as I remember many nights on that trip with my ASCP colleague Wendy, plugged into the wall in a deserted hotel lobby and barely able to see the computer screens as we compared and contrasted assessment scores late into the night before getting up before dawn to take off and do it all over again.  Well, it was all in a day’s work!  She and I will both admit to wishing we’d had a little more sleep, and we would also tell you we wouldn’t have missed it!

So if you find yourself up late at night studying, preparing for a presentation, catching up on journals or even waiting for a teenager to get home at the appointed hour, I recommend keeping a hot cup of tea and some local chocolate near at hand.  I can highly recommend chocolate from Kazakhstan, and also from Namibia— contact me at bsumwalt@pacbell.net and I’ll send you the name of my favorite brands.  But even if you can’t read the label, the pictures are all you really need!

Blog 9 Working Late

 

Cheers,
Beverly Sumwalt

Pain Management Drug Testing

Traditionally, urine drug testing has looked for the presence of drugs that should not be there. You are hoping for a completely negative drug test. Because tests for measuring drugs in urine haven’t always been incredibly accurate at the low end of the measurement range, and interferences from other compounds can cause false positives and negatives, back in the early 1990s the Department of Health and Human Services provided cut-off concentrations for abused drugs that gave the best discrimination between samples that actually contain those compounds and those that don’t. What that means today is that if the concentration of the drug in the sample is higher than the cut-off, that sample is positive for the tested drug. If the concentration is less than the cut-off, the test is negative, whether there is actually any drug present or not.

How is pain management drug testing different? When testing urine samples for drugs for pain management, you are looking for the presence of drugs that SHOULD be there. In essence, you’re hoping for a positive drug test. Controlling pain with medication is a massive industry, but to keep prescribing those drugs, the physician needs proof that the patient is actually taking the medication and not diverting it for sale or use by someone else. Thus pain management drug testing looks for the presence of the specific drug and may actually require a quantitative result rather than a simple positive/negative.

In addition, although the assays used for both types of drug testing may be the same (mass spectrometry or immunoassay), traditional urine drug testing often only includes drugs in the major classes of drugs of abuse. Pain management drug testing must also include specific drugs prescribed therapeutically for pain, like methadone and oxycodone. Thus point-of-care (POC) devices for drugs of abuse drug testing may not be adequate for pain management drug testing.

Here is a list of drugs usually included in POC testing panels:

Drugs of Abuse
Amphetamines
Opiates
Cocaine
Benzodiazepines
Tetrahydrocannabinoids
Barbiturates
Phencyclidine

Pain Management Testing

Amphetamines
Opiates
Cocaine
Benzodiazepines
Tetrahydrocannabinoids
Barbiturates
Phencyclidine
Oxycodone
Methadone
Propoxyphene

-Patti Jones

Acquisitions and Takeovers

Early in my MBA classes I had one professor with over 35 years in Healthcare consulting say to the class, “There are very few examples of actual mergers; usually someone is acquired or someone is taken over.” This resonated with me when my previous hospital was informed that in 90 days we would be closing the doors. Now, it resonates with hospitals at an increasingly rapid rate. If you’re a person who loves keywords, “integration” will be your new favorite on the list. I currently sit on two integration committees (Blood Bank, Education) where we discuss the different ways we do things and how we can standardize our procedures to make sure that a patient receives the same testing at any Cleveland Clinic location. As big healthcare systems acquire more and more independent entities, integration will be the axiomatic factor to their future success.

If you’re a small community hospital laboratory manager/supervisor that has just received word you are going to join in a partnership with a large system, what next? The really big issues that laboratories deal with are instrumentation and supply chain. Once your service contracts are up, you’ll need to switch to the systems the big laboratory uses. You will be thrust into a much larger network of people and more importantly, talent. If you have open spots you will have a larger talent pool to pull from much easier than going to the job sites.

The biggest challenge you will have is watching your services be consolidated. If you were a full service hospital you will more than likely lose some services and this can have an effect on your test menu in the lab. Low volume but high profit tests will almost always be consolidated into a single location to get the most profit out of it. The send out department of your lab may become much busier because of this increased workload. The system will try its absolute hardest to lower their cost structure and this will include changes in your laboratory.

On a personal level the first thing to do as a manager/supervisor when you find out your hospital is being acquired is don’t panic. Very rarely do they come in immediately and “clean house”. They usually have a period of time when talent is evaluated and then decisions are made. The real question becomes do you want to work for the new system? The integration period can be difficult and time consuming. If you feel your hospital may be acquired, stay prepared. Keep your resume updated and just scan the job sites every once and a while and see what is out there. My biggest piece of advice is don’t get caught in a situation you have no control over. You are the manager/supervisor of the laboratory so you are the reason that it succeeds or fails. These are the same reasons the managerial staff is kept or let go once an acquisition has been completed.

This consolidation is only going to increase as the new healthcare legislation takes effect. Decreasing reimbursement from the government will force entities to combine forces and form systems of healthcare. Put yourself at the forefront and know what in your test menu that you could do without and what you could use from a larger system to be more profitable. When the time comes you are the talent they are looking to acquire, not take over.

-Matthew Herasuta

A Possible Method to Diagnose Invasive Meningococcal Infection

Saying the word “meningitis” is a sure-fire way to scare parents of young children or college students. Invasive infections caused by Neisseria meningitidis are rare but serious. Mortality rates can run around 15%; complications include amputations due to tissue necrosis and hearing loss. In short, N. meningitidis infections are nothing to mess around with.

In order to avoid death and extremity loss, the infection needs to be diagnosed early. Trouble is, the early symptoms can be similar to those of a run-of-the-mill viral infection. Some patients do not exhibit the elevated white blood cell count so common in bacterial infections. Without clear signposts to guide the way, how can clinicians catch this fast-moving infection early in its course? A handful of esoteric hematology parameters might hold the key.

Demissie et al recently published this paper in The Pediatric Infectious Disease Journal about using neutrophil counts to diagnose meningococcal infection in children. It’s behind a paywall, but here’s the gist:

-Your automated hematology analyzer needs to report immature white blood cells.

-Using total white blood cell (WBC) counts or total neutrophil counts alone is insufficient.

-The parameters to check are absolute neutrophil count (ANC), immature neutrophil count (INC), and immature-to-total neutrophil ratio (ITR).

-Patients with invasive meningococcal infection (or, the authors also say, a serious bacterial infection) display abnormalities in at least one of the three parameters.

What do you think about these guidelines? Do you think they’d be effective in diagnosing invasive meningococcal infections?

-Kelly Swails