Failure is Always an Option

I had some fun this April Fool’s Day and sent some emails out that stated we failed some CAP surveys. I know I’m evil but you have to have some fun sometimes! The reactions were interesting in that everyone deals with failure differently. Show me someone who has never failed and I’ll show you someone who won’t know how to react once they do. It is inevitable. We try to never experience it but we will and it is how you react that sets people apart.

I am proud and speak of my failures regularly because it gives people strength knowing that they are not alone. In my career I have been involved in a total hospital failure and had to work my way back up the ladder. It is through these failures that we learn the most about ourselves and about situations. When I was just out of school I used to think that experience wasn’t that important. I thought, “I’ve learned what I need to know in school, I should be a supervisor NOW!” I am in the second half of the first 10 years of my career and have learned that every situation brings with it experience that becomes knowledge. That knowledge will carry me into the second and third decades of my career. Both the successes and failures will help me as I move forward.

Experience is gained through those situations and it is up to the people involved to either take it with them or forget about it and be vulnerable to repeat them. As leaders we are sometimes under pressure to work or move forward with options that may not be our choices, but we must get our staff to buy in and perform. These directives usually given from a few pay grades above should be followed so that if you do fail you can show that you followed their directives. You do not want to be seen as someone who is resistant to change or someone who will be an obstacle. This will just get you more headaches and possibly affect your advancement in the future. Having said that always state your concerns as well as present ideas that may be a better option. You do not want to be silent when it matters most.

I have always learned more from my failures than I have from my successes. During an interview a CEO once told me, “You want to make your big mistakes early in your career because the higher you get the less forgiving people are of the big ones.” We make our mistakes during a constant search to be the so-called “polished professional.” When we get to the higher pay grades we should be able to see a failure coming a mile away and be able to safely get out of the way. Successes come with great planning and a dump truck full of experiences. Remember, failure is always an option.

 

Herasuta

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.

 

Musings After the RISE

So how did you fare on your recent resident in-service exam, aka the RISE? For most of the residents I know, they did better on the AP portion over the CP portion. I would have to say that not surprisingly, I feel that I did the opposite. Last year, I definitely did much better on the CP portion than the AP portion but my overall percentile was still good.

Even though I usually narrowed down the answers on the AP section to the correct one and a distractor, when I looked up content after I got home, I discovered that I often picked the wrong answer. But even then, I feel that the AP section was fair and not overwhelmingly difficult for someone who is probably better at AP than me.

For me, I thought that the CP section was not that difficult but most other residents that I talked with thought the opposite. They felt that many of the questions were esoteric and possibly not relevant to the practice of pathology once we are out of residency.

What are your thoughts after taking the RISE? Did you feel that it was a fair test? Did you feel that the questions asked are relevant to what we need to learn in residency and for our practice as real-world pathologists?

In other specialties like surgery and anesthesiology, in-service exams have a greater importance and scores are often asked for on fellowship applications. For pathology, this is not the case but it still is important that we test ourselves yearly to pinpoint our strengths and weaknesses in some manner. Do you think that the RISE is the answer or does it need a revamp?

 

Chung

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

Loading Viruses

Occasionally some of our terminology in healthcare has its own set of nuances. We combine words or word-parts to give them more precise and clear meaning, and often they create a unique definition. Take for example, words like symptomology; chemotherapy; biotechnology; or the now-ever-popular term genetic engineering. Then take for example some well-used medical terms that have become mainstream—like the term for a gazillion little strands of RNA, all of which we lump together and call “viral.” Viral loads in laboratory terms indicate diagnostic criteria for the remission or advancement of disease, such as the case in Hepatitis or HIV/AIDS. But it also now means a serious problem with your computer, or the latest cat-video gone rampant on the internet. In my case, it just recently indicated a personalized upper respiratory infection from Central Asia!

Travel has its ups and downs, and at the end of two weeks of wonderful training and interaction with our colleagues in Kyrgyzstan, I succumbed to a “load of virus”—and faced the drudgery of coping with it while cramped into the aisle seat of airplanes, passing time wandering during layovers in foreign terminals, hopping into passport lines and customs checks. With nearly 36 hours of travel ahead of me, I plowed through it all in the fog of decongestants and analgesics and tried desperately not to sneeze or cough—which only made it worse. I’m certainly not the first, nor the last person on the planet to catch a cold, but I was certainly among the most miserable!

Now that the worst is behind me and my diagnosis is just a “horse” and not a “zebra,” I’d be interested in your opinion…is catching a cold considered “a viral load” or just merely “loading a virus?” Just maybe we have a new and even more descriptive term for uploading seasonal cold and flu! Let me know what you think at bsumwalt@pacbell.net and who knows, maybe our new twisted term will actually “go viral.”

 

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

Pseudohyponatremia: Is This Sodium Really Low?

Periodically I get a call from a clinician saying, “What’s wrong with your sodiums?” In general, this call is triggered by a sodium <125 mmol/L. My first response question is always: What are the child’s protein and/or lipid levels?

At issue here is the type of ion-selective electrode (ISE) used to measure the electrolytes. There are two basic types, indirect and direct, and knowing which one your chemistry analyzer uses is important. Direct ISEs are exactly that. They measure the ion activity in the sample directly, in whatever fluid volume is present in the sample, and are basically not affected by other constituents in the sample. The activity is then converted to concentration and a result is produced. Indirect ISE’s do not do a direct measurement. They dilute the sample first and measure the concentration of electrolytes in the diluted sample. This usually works well, but becomes problematic when the sample happens to have a high concentration of proteins or lipids. The reason for that is this: systems using indirect ISE measurement assume that the sample is all water. In reality, normal plasma/serum is roughly 93% water with 7% solids present (proteins and lipids). If the sample being analyzed has less than 93% water, for example when either protein or lipid makes up more than 7% of the volume, the resulting measurement will be falsely low, as you can see from this table. A normal, 7% solids sample that an indirect ISE measurement would give you a value of 135 mmol/L; if the solids are 20%, that sample will give you a value of 116 mmol/L.

True concentration % water Direct ISE measurement Indirect ISE measurement
145 mmol/L 93 145 mmol/L 135 mmol/L (145/0.93L)
145 mmol/L 80 145 mmol/L 116 mmol/L (145/0.8 L)

This is called pseudohyponatremia. The sodium is not really low; it’s perfectly normal. The instrument is giving you a falsely low value. The vast majority of wet chemistry analyzers measure electrolytes by indirect ISE. Only a few big chemistry analyzers measure electrolytes using direct ISEs, and those usually have a correction factor so that the directly measured results are more in line with the big majority of indirect ISE measurements.

What can you do about falsely low sodiums caused by hyperproteinemia or hyperlipidemia? If it’s related to lipids, you may be able to clarify the sample by centrifugation or chemicals and get a real result. Alternatively, blood gas analyzers and some POC analyzers, like the i-STAT, measure electrolytes by direct ISE. If you have or can get a whole blood sample, you can use these analyzers to give you a real result. Otherwise you may be explaining pseudohyponatremia to a concerned physician.

 

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-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.

Haemophilus influenzae Infections in Pregnant Women

The Journal of the American Medical Association recently published a paper about the association of invasive Haemophilus influenzae infections in pregnant women and fetal outcomes. The researchers studied British women who had an invasive H. influenzae infection (defined as recovery of said organism from a normally sterile site). The researchers concluded that pregnant women had a greater risk of invasive infection than non-pregnant women, and these infections resulted in poor pregnancy outcomes.
H. influenzae is a fastidious organism that grows on chocolate agar. Normally associated with respiratory infections, if the organism is an encapsulated strain, it can spread to other parts of the body and cause meningitis, septicemia, pericarditis, and even urinary tract infections.
In terms of identification, H. influenzae are small, gram-negative coccobacilli on microscopic examination. The opaque colonies appear grayish on chocolate agar. Because it requires X and V factors to grow, the organism will appear on blood agar only in the presence of an organism that hemolyzes the blood (like Staphylococcus aureus). In addition to the X and V requirements, H. influenzae ferments glucose and is catalase positive.

Want to learn more? The CDC has great information on this organism.

 

Swails

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

For Whom the Match Tolls

Last week, hundreds of M4 students across this country hoping to match at pathology residencies learned their fates. On the flip side, training programs also learned whom they would welcome as trainees come end of June/July 1st. We also learned that there were 51 unmatched positions, even at some of the so-called “highly prestigious” programs that one expects to always fill. That’s the most I’ve seen in recent memory and more than double the number that were unfilled when I matched 2 years ago.

Several questions went through my mind when I learned of the increased number of unfilled spots this year. Is this a harbinger of things to come for our profession? Did programs make their rank lists too short? Was there a significant decrease in the number and/or quality of the applicants this year? And if less people applied, what is the reason? Are the significant anticipated reimbursement cuts, for pathology services in the most recently released federal physician fee schedule part of the problem? Besides the decrease in compensation, did the uncertainty of the pathology job market also contribute?
I was talking with another resident who thought that it was a good thing that we had more unmatched spots. He felt that we have too many trainees and not enough jobs for when we graduate. Although I did point out that after the SOAP week, the majority, if not all of those 51 positions would most certainly fill. This year’s match results may indicate the start of a possible trend for our profession or it may just be a fluke…we’ll have to wait until next year to have a better idea.

Robboyet al in an article entitled the “Pathologist Workforce in the United States” in the Archives of Pathology and Laboratory Medicine predicted that a retirement cliff would begin in 2015, resulting in a steady decline in the number of working pathologists in this country. I served as the resident representative on ASCP’s Future of the Pathologist Workforce Round Table that discussed some of the preliminary data that was included in the aforementioned article. I’ve also participated on other ASCP and CAP committees/councils since then. Despite the predictions, what I’ve heard personally from the physicians that I’ve worked with on those committees/councils is that at their current locations of employment, the overwhelming majority are not looking to hire any new pathologists in the near future.

So for those of us hoping for employment as new physicians in the next few years, will we have even more difficulty finding jobs than those who are currently struggling now to get enough interviews to ensure employment? Do you have suggestions as to a solution to this issue? It’s hard to predict what our profession will look like in a couple of years, especially with all the changes occurring post-ACA. But instead of being passive bystanders to this process, we need to actively interact with other specialties and engrain our worth into the clinical process in a very visible and palpable manner that we are missed when we’re absent, or be left behind.

The results of the match highlighted to me that our profession is going through some growing pains right now. While the etiology is unclear, we can start attempting to treat our differential to shape the outcome we would like to see. So how did the match go for your program? Do you feel that the match results were a good measure of the pulse of our profession right now? And what do you see as our profession’s biggest issues and what are some possible solutions?

 

Chung

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