Critical Results: Use Them Wisely

All laboratory professionals know what a critical value is. The original definition was coined by Lundberg in MLO in 1972 as: “A laboratory test result that represents a pathophysiologic state at such variance with normal as to be life-threatening unless something is done promptly and for which some corrective action could be taken”. There are two pieces to this. First of all, it’s a life-threatening value. Secondly, it’s a value that needs to be acted upon immediately and for which some action can be taken.

All laboratories and healthcare systems define their own tests that have critical values, what those critical values are and which tests that are themselves “critical.” A “critical test” must have the results reported every time, no matter the result. “Critical values” are life-threatening values on tests that are routinely not life-threatening. When creating and defining this list, the people involved should keep the definition of a critical value firmly in mind and make an effort not to include analyte concentrations which are not life-threatening. Most hospital lists include sodium, potassium and glucose as a minimum on their list of tests with critical values; many hospitals contain a large number of other tests. For example, creatinine is a test that is oftenoften included, and yet, at what level of creatinine is the patient’s life emergently threatened? It’s sometimes difficult to please all your medical staff with which values should be considered critical and which should not, and  which tests will need to be called back to a care-giver immediately.

One solution has been to create carve-outs – areas of the hospital that don’t require notification about certain “critical” results. For example, dialysis may not need notification every time one of their patients has a “critical” creatinine. Or the ICU may not need to be notified for each separate critical potassium on a patient they are following closely and monitoring often during a single shift. The problem with “carve-outs” is that if you have many of them, you’re setting the technologist up to fail. How can they keep track of what needs to be called and what doesn’t?

It’s important that laboratory professionals define their list of critical values to make this system as streamlined as possible. If your institution has defined too many “critical values,” it may be taking too much time out ofthe laboratory professional’s and the caregiver’s day for making and /or receiving too many unnecessary calls with values.  You may wish to look at that definition again and see if all the tests on your critical list truly meet the definition of “critical.”

 

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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.

 

Trainee Worries, Level III Anecdotal Evidence, and Thoughts to Keep in Mind During Training

As you know, I serve as a junior member on one of CAP’s councils. Besides enjoying the opportunity to participate and represent the resident voice on issues that will shape the future of our profession, I always value the thought provoking conversations I am fortunate to have during our meeting dinner. And this past weekend’s meeting did not disappoint.

So, we’ve all heard the opposing arguments. There’s the one side that anticipates an impending “retirement cliff” and not enough pathologists to serve the needs of future patients. Then there’s the “doom and gloom” side that states that we have too many pathologists and no jobs for those of us who will graduate in the near future. So which side is correct?

As someone who was trained in critical analysis and statistics during my public health training, I can see a scenario where both of these situations can co-exist. Like the Indian story of six blind men who feel different parts of an elephant, our perception of reality is based on our experience (or if you think of grossing-speak, sampling informs our eventual conclusion). For trainees, of course, we fear  not being able to obtain this “competency.” Everyone seems to be stressing as of late and more so of not being able to find a job when we graduate. Couple that with the frequent nay-saying we hear about the paucity of job opportunities available (which amounts to level III anecdotal evidence), the landscape is set for us to believe that our profession is in a crisis.

We discussed these issues and more during our dinner last week and practicing pathologists pointed out to me that they had heard the same when they were training and yet, they were indeed employed, and in jobs that they love…so there is hope. I was told that if we focus on becoming “good” pathologists and working to obtain “true competency,” the rest should follow. A “good” pathologist is always employable and sought after.

But what about those of us who don’t make that cut of being the “cream of the crop” and who are your average trainee? After all, average means the majority. What I seem to hear repeatedly (even from the nay-sayers) is that there are jobs out there…just maybe not in the location or at the salary/benefits we initially want. But maybe we need to look at this as a “glass half full” opportunity. Most of our future “dream” positions may still be within our grasp but we need to be humble and realistic and may need to work our way up to it.

The most desirable characteristics in a successful job applicant, from what I heard over and over during this conversation and multiple others, are competency (especially since no one wants lawsuits), ability to fit in (of course, people have to like you and not think you will cause drama), and experience. This often translates to a fellowship or junior attending experience during residency training where we can build up our confidence and ability to sign out on our own (or almost with little supervision). So, the suggestion was to obtain employment (and it may not be your “dream” job) to nurture that capacity and then if you possess the other two characteristics, you should be able to find employment at a situation closer to what your “dream” job looks like in time. But patience is the main virtue here.

I found this outlook a little more practical than either of the two aforementioned, more extreme arguments. And either way, it is not worth wasting time and energy worrying about what may never come to pass (and attendings really get tired of the whining)…but rather to set the goal to become the best pathologist we can be in the present. Obviously, this is easier said than done or we’d all be acing our boards and RISE.

Making the transition from student to almost practicing pathologist is difficult. We may not be as used to the demands of a job (versus studying mentality) that we are expected to already possess during training and the volume of knowledge we need may seem prodigious at times. But set yourself some small sequential goals and push yourself to have the humility and dedication to meet them…and put entitled behaviors aside. If your residency isn’t giving you what you need, proactively (and nicely) ask for it…or find other outlets to obtain it – there are a lot of online free resources and your fellow residents, at your program and others, are a valuable, understated resource. Don’t expect others to do for you what you must now learn to do for, and demand, for yourself.

I feel inspired after the meeting last weekend and the conversations we had and I am re-dedicating myself to continue to address my weaknesses. Leave us a comment if you have an opinion on how we should approach residency training or how we should view the future of pathology in this ever changing health care environment.

 

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.

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.