Month: July 2015

Categories
Clinical

Journey to the Center of the Lab

What is a stat laboratory? As far as most doctors are concerned, the stat lab is a mysterious place, located somewhere in the dungeon of the hospital, wherein a slew of unkempt “lab people” feverishly work to turn tubes of blood into useful numbers in the electronic medical system. While this view is not a complete misconception, I do think it would be constructive to provide a quick overview of how exactly these labs work, and how they fit into the overall healthcare picture.

There are two kinds of laboratories in the healthcare world: reference laboratories and stat laboratories. Reference laboratories perform high-volume, routine (non-time sensitive), specialized testing on samples sent from outpatient clinics and hospitals. These labs are generally located away from hospitals, in their own buildings, so they may have the extra space required to house highly specialized testing equipment and personnel. The downside to these labs is that the “turnaround time” for tests is slow (many hours to days), both because they are located offsite and because the specialized tests may take much longer to run. On the other hand, stat laboratories are smaller labs located on site in order to perform time sensitive (“stat”) tests. Although not very many highly specialized tests are available from these smaller labs, they provide all the basic testing necessary to support the emergency room and inpatient floors in a hospital, with turnaround times usually under an hour. Considering my work experience has been entirely at stat laboratories, I will focus on them in this article.

Stat labs have understandably become a staple in ERs and hospitals around the world because they quickly provide vital information about patients, allowing doctors to plan proper treatments in the short term. I mean, sure, you might be fairly certain that your patient has DIC, but wouldn’t it be nice to have a positive D-dimer to be sure?

First off, what is actually considered a laboratory, and how can you be sure the lab at your hospital isn’t churning out garbage? Well, according to the Centers for Medicare and Medicaid Services (the governing body for laboratories in the U.S.), the law requires:

“all facilities that perform even one test. . . on ‘materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings’ to meet certain Federal requirements.”

I find it comforting that people (who are not me) dedicate their careers to quality control. Incorrect results lead to inappropriate treatment, which can have disastrous consequences on patient care. As such, each lab has its own quality control (QC) program in place, which includes running instrument calibrations/QC daily and monitoring the results over the short and long term. Much of the labor in the lab is dedicated to QC; in fact, depending on the test, the daily calibration and running of QC samples for one test can take the better part of an hour, and that’s if all the samples come into range as they are supposed to.

QC is the only way to be sure test results coming off the analyzer are accurate and precise. It is an unforgivable sin to release patient results when QC has failed, even when the other members of the healthcare team are adamant about getting the test results now. If QC has failed, all the results from that instrument are garbage until QC comes back in. Period.

Most stat laboratories are divided into roughly the following departments: hematology, urinalysis, chemistry, microbiology, blood bank, coagulation (PT/PTT), immunology, and specimen processing. In smaller labs, there are “float” lab techs who work in all of these departments. In larger labs, the techs are usually more specialized and stay in one department.

When, in this computerized day and age, an ER doctor puts an order for a blood test into the electronic medical system, the phlebotomist receives the draw order (if the nurse isn’t going to draw it). The draw order is usually a printed label, with the patient information, orders, and tube types listed on it. The tube type is very important; each colored tube contains specific additives tailored to certain tests (a CBC is run on a “purple top” tube with EDTA as the anticoagulant, etc.). Additionally, some tests require special handling (e.g. “on ice”) or can’t be opened until just before the test is run, as is the case for ionized Calcium.

The phlebotomist then goes to the ER, draws the blood, and transports it back to the lab. The specimen processor will then double-check to make sure all has been collected correctly, and mark in the system that the tubes have been received. At this point, the tubes diverge. The “red top” or “yellow top” tubes, which have no anticoagulant in them, must be set aside to be allowed to clot before being put into the centrifuge. The anticoagulated chemistry and coagulation tubes are thrown into the centrifuge and spun immediately to separate the RBCs, WBCs, and platelets from the plasma. The hematology tubes, which are also anticoagulated, are not spun, but put directly on the analyzer as whole blood.

After the proper tubes have been placed on the proper analyzers, most tests are automatically run and resulted. Exceptions to this include: a) chemistry results that are above the linear range of the instrument need to be diluted and re-run, b) blood slides that the hematology analyzer flags for tech review need to be looked at under the microscope, and c) the results that are critical values need to be called in. A critical value is the cutoff value at which the tech must call up to the patient’s nurse or doctor and report it. For example, the cutoff for a low potassium level may be <2.6 mEq/L at a particular lab, so if a potassium level of 2.4 comes off the machine, it cannot be resulted in the computer until the tech has verbally passed the information along to the direct caregiver. This is done because critical values are deemed dangerous enough that the doctor must know about it as soon as possible so as to treat it immediately.

After all the tests have been reported out, the tubes are taken off the analyzers and saved for a week in the refrigerator. This is necessary in case additional orders are added on later, or the patient dies and the medical examiner needs the blood, or to troubleshoot in the case of mislabeled specimens, etc.

And that’s the lab, at least the basics. Is it less mysterious now? I hope so.

 

Featured image:
The Chemistry Of Inversion by Raymond Bryson

Categories
Clinical Opinion

Does this make you uncomfortable?

“Homo sapiens is one of the few species on earth that care if they’re seen having sex. The impala is unconcerned. The dingo roundly flaunts it. A masturbating chimpanzee will stare straight at you. To any creature other than you and I and 6 billion other privacy-needing H. sapiens, sex is like peeling a mango or scratching your ear. It’s just something you do sometimes.”
– Mary Roach, Bonk: The Curious Coupling of Science and Sex

Mary Roach is one of my all-time favorite writers because she delves into topics that make the average person squeamish. I’ll admit, as I read Bonk: The Curious Coupling of Science and Sex, I found myself peering over the top of the pages at the pool, carefully checking that no one realized I was reading about sex. After finishing this text I wondered, why was I trying to hide? Why is our society so confined (in comparison to, for example, Europe) when it comes to our sexual well-being?

Even though many medical students will boast that very little makes them uncomfortable (they get excited to dissect cadavers or watch an open heart surgery), it is clear from the literature reviews that a large number of medical students are not comfortable, nor prepared to take accurate sexual histories from their patients. A study published in the Journal of Sexual Medicine reported that, “The majority of medical students (75.2%) feels that taking a sexual history will be an important part of their future careers, yet only 57.6% feel adequately trained to do so. Furthermore, 68.8% feel that addressing and treating sexual concerns will be an important part of their future careers, and only 37.6% feel adequately trained to do so.”1

This data is pretty alarming seeing that many Americans, young and old, struggle with sexual disorders and diseases. In my opinion, there is one main reason that underlies these statistics – lack of education (don’t scold me for saying this, I know our training is already quite lengthy, but, hey, we are lifelong learners).

In the 2008 article “Medical school sexual health curriculum and training in the United States,” researchers reported that a whopping 44% of US medical schools lacked formal sexual health curricula.2 Although a few years have gone by, it is clear that this percentage is way too high. Similar results were reflected in a study done in Malaysia by Arrifin et al.; researchers reported that only half of research participants (final-year medical students) reported feeling comfortable taking a sexual history and only 46% felt that they had received adequate training to take the sexual history.3 This level of inadequate training reflects in the demeanor of medical students when they are asked to take a sexual history.

Although I can’t speak for medical students at other institutions, many of my classmates, including myself, have expressed a certain level of unease when asked to question patients about their sexual history. What is the proper way to ask a person about his or her sexual identity and orientation? How can I make patients comfortable enough to tell me about the rash they are panicking about, but too embarrassed to bring up casually in conversation? What if the patient identifies as a transgender individual, how am I supposed to know what his or her needs are from me as a health care provider?

All medical students should know it’s okay to struggle through these questions and mess up, possibly offending a patient (future patients please be kind to the students who are still learning!). These are all questions that I don’t have the answer to, but I want to learn more so I can give my patients what they need from me. These are essential questions for medical students to ask and explore, but more importantly these discussions really require an individual with years of experience and education to be present. Although many US medical schools may be working towards providing a more solid education on sexual health, it is urgent that this be done swiftly and accurately, because our patients are the ones who are suffering as a result of our inadequate training on this aspect of health.

To the medical school officials, please answer our desire to learn more about these topics. To medical students and other health care providers, don’t be afraid to bring up sexual health with your patients. Our minds and the overthinking we do are the only things that hold us back.

  1. Wittenberg A, Gerber J. Recommendations for improving sexual health curricula in medical schools: results from a two-arm study collecting data from patients and medical students. J Sex Med. 2009 Feb;6(2):362-8.
  2. Malhotra S, Khurshid A, Hendricks KA, Mann JR. Medical school sexual health curriculum and training in the United States. J Natl Med Assoc. 2008 Sep;100(9): 1097-106.
  3. Ariffin et al. BMC Res Notes (2015) 8:248

Featured image:
sex and love (because when love meets sex, bodies and souls become one and time, colours and place are on ecstasy…) by dim.gkatz

Categories
Reflection

A Touch of Musicianship in Osteopathy

While the “power of touch” is a key aspect of osteopathic medicine, its practicality transcends that of its function as a noun. Indeed, touch is a physical contact between one or more surfaces, but it is also transmitted by non-physical means. Touch is so crucial in osteopathy because it can be used in diagnosis and treatment, especially when applying principles of osteopathic manipulative treatment and while compounding as a method to communicate with the patient and better understand the underlying condition.

The art of touch whether physical or non-physical is a skill that will take many, many years of practice and will be continuously refined throughout the career of osteopathic physicians. However, I have recently come to realize that the concept of touch is best exemplified by the musicianship of piano playing and I have used this analogy in my study of osteopathic manipulative treatment as a first year medical student.

In terms of physical touch, there are different degrees and levels of contact. We can simply put our hands on the patient to touch them and do our examinations. We can simply lay fingers on the piano and produce a sound. But when we begin to analyze just how we put our fingers on the piano, this produces more than just a sound- it creates more specific sounds, tones, volumes, colors: music. When putting your fingers on the piano, there are more variables than one might imagine. Just in the first note, there is so much to consider. The pianist must consider the attack- how does one approach the keys? In a shy, quiet piece of music, the fingers must slowly and sneakily slip onto the keys; in a boisterous fanfare piece, the fingers must quickly and boldly strike the keys. In essence, in the simple act of putting hands on the piano keys for the opening note, we have already considered, speed, attitude, and force in just that one touch.

Such thoughtful touching is similarly applied in osteopathy. It is possible for the physician to lay his or her hands on the patient with a coordination of speed, attitude, and force. The result is that this becomes more than a touch and can be sensed by the patient. Not only does sincerity convey a more comfortable environment for the patient, but it also establishes a sense of trust towards the physician. This closer connection improves doctor patient communication and relationships. Putting thought into physical contact also prepares the physician; the act of thinking about the contact stimulates a patient centered approach. Even before touching the patient, the physician would have already considered the general state of the patient while determining the components of the first approach to touching the patient. The physician will have evaluated whether to approach the patient more lightly or with more boldness. I believe that this consideration and thoughtfulness in the initial approach to the patient best sets the stage for patient care. Perhaps if physicians do not consider as much, they will simply lay their fingers on the piano and produce a sound that is not music.

Featured image:
Piano Solo 2 by j_arlecchino

Categories
General Lifestyle

Torn Between a “To Do List” and a “Social Life”

I have always been an overachiever, no doubt about it; always wanting to be one step ahead of the rest, always ahead of the game. For example, if I finished a school assignment by 7 o’clock in the evening, instead of taking the night off, I’d start on another assignment I knew was coming up. This was the motto I lived by all my life, until I finished my 1st year of medical school, that is. As a pre-med and 1st year medical student, I constantly told myself I’d fill my summer up with resume-building extracurriculars. But people kept telling me, “It is your FINAL summer off for years to come, enjoy your time!” Me?! Taking time off? Not being productive? I couldn’t even bear the thought. By midway into my 1st year, I already had research for the summer set up, in addition to potential shadowing opportunities in fields of interest to me. I factored it all into the schedule for my seemingly lengthy, but in reality limited, 6 weeks of summer: research, volunteering, shadowing, studying for boards. My plan was to complete all my research and volunteering positions throughout the days, and study a few hours for Boards at night.

Today, 2 days into my official summer vacation, I realized I had failed to factor some crucial aspects into my schedule: my family, friends, & outright sanity! I have worked too hard all year not to enjoy a few weeks of bliss. I deserve to wake up to a day filled not just with endless studies and a “To Do” list the size of my Grey’s Anatomy textbook, but rather to a day of, yes, some work and productivity, but also some well-deserved fun! Since this realization, I have altered my schedule drastically, allowing myself to live the next 6 weeks with this new mindset. On top of everything, my sister is tying the knot the last weekend of my summer, an event I underestimated in terms of the time and effort it would take to plan for. These happy times with family and friends will be memories I will cherish forever. Ok, so you can’t exactly add “planned sister’s wedding and hung out with friends and family” to your resume, but one cannot compare the value of building those precious memories with a completed “To Do” list. I know I will regret it down the line if I don’t allocate some time during the summer for my loved ones.

Of course, I am filling my schedule with productive, career-building endeavors; however, I am not overwhelming my life with these plans. I plan to enjoy my time and to experience exciting pursuits with my loved ones. I am extremely satisfied with the decision I’ve made: the decision to have a summer I can remember for the rest of my life, yes, but one that also includes a realistic amount of academic accomplishments.. I mean, after all, how much of my Boards studying am I REALLY going to remember? Five percent, if I’m lucky. And at the end of it all, I know one person who will be the MOST thankful and excited about my decision: my loving sister. I can spend some quality time with her, helping make the happiest time of her life one to cherish forever. For those of you who wish to fill your summers with career-building activities (a.k.a. my fellow overachievers), below I have listed some things that were on my list to achieve this summer. I hope they spark some inspiring ideas and fuel motivation that may have dwindled if you are anywhere close to the state of mind I am in after a year of hard work! Good luck to you all!

  • Volunteer at a Hospital around your area, or school’s area, or where you plan to apply for residency. It is never too early to get your foot in the door and start forming connections with program directors in residency programs you will be applying to in a couple of years! You can even find individual doctors in departments of interest to email and ask if you can shadow.
  • Volunteer for a humanitarian project. I am personally volunteering for the 2015 Special Olympics World Summer Games in Los Angeles, California. Any small gesture to give back to our community, preferably using the knowledge we have learned thus far, would be more than enough. A little help from a lot of people combined turns out to be surprisingly impactful!
  • Do research at your school. By finding a project at your school, you will be able to continue the research throughout the following year if the project extends past the summer. This shows longitudinal dedication, without adding an unmanageable workload on top of your coursework.
  • Light Boards studying. Key word: LIGHT. We are probably not going to remember much for the Boards from this summer. Maybe look over some drugs and bugs. Maybe Pathoma or Kaplan videos, focusing on topics that particularly confused you during your 1st year or that you were never able to grasp.
  • Pursue your hobby, and do it in a way that is applicable to medicine. Residency programs do look for a well-rounded applicant, after all. For example, I thoroughly enjoy writing, and now blog for the MSPress. This allows me to relish in my hobby, while giving me a solid accomplishment to add to my resume. For those of who might like to paint, paint a medical scene!

There are many many more, these were just a few. Above all, remember to always update your resume (you will regret it if your achievements pile up and you forget the details), and remember to enjoy life!

Featured image:
100! ;D by Abdulrahman AlZe3bi.

 

Categories
Clinical Reflection

Working Miracles With Gravity

Before medical school, I worked as an assistant at the clinic of a physical therapist. Half of the physical therapist’s business was bread-and-butter physical therapy, but the other half was vestibular rehabilitation. The therapist specialized in diagnosing and treating balance and dizziness disorders of the inner ear. And guess what? Most of his patients were there as a last resort, because the doctors and their drugs weren’t working. They had fallen through the cracks, and the tragedy is that the most common cause for their dizziness is easily treatable, in 5 minutes, with only a table and some body positioning.

Benign paroxysmal positional vertigo, or BPPV, is caused by rogue calcium carbonate otoliths. These otoliths escape from the utricle of the inner ear and make their way into the semicircular canals (usually the posterior semicircular canal). These otoliths cause aberrant movement of the fluid in the semicircular canals with changes in head position, confusing the brain, which is getting mixed signals about the body’s orientation in space from the right and left semicircular canals. Predictably, the brain’s confusion manifests as vertigo, which  defines as “an illusion of self or environmental motion.”

Patients with BPPV suffer from sudden dizzy spells triggered by changes in head position, usually lasting 15-20 seconds. Movements like looking up, rolling over in bed, or getting up out of bed in the morning set the world spinning, often with an accompanying nausea. As you can imagine, these patients do everything they can to minimize their head motion. They move in a characteristically rigid fashion, keeping their heads as still as possible in order to avoid repeat attacks. Clearly, this is an extremely unpleasant condition; one that is experienced at least once by 2.4% of the population. The good news, however, is that it is easily treatable, as long as it is recognized.

A certain amount of diagnostic finesse is required to rule out central nervous system problems, but once the proper neurological exams have been performed, BPPV should be high on the differential for patients with the symptoms described above. The test for BPPV is called the Dix-Hallpike Maneuver, in which the practitioner provokes a dizzy spell by changing the patient’s head position and observing the eyes for nystagmus.

Once a diagnosis has been made, treatment consists of The Epley Maneuver, which is nothing more than a simple series of head and body positions designed to use gravity to reposition the rogue otoliths into the utricle where they can no longer confuse the brain by moving semicircular canal fluid inappropriately. When the patients I saw were cured of their vertigo so quickly, with such a simple technique, they wasted no time in hailing the physical therapist I worked for as a miracle worker. They had been miserable for months, and that’s all it took to fix it?? In these situations, the patients were always ecstatic. I couldn’t help but smile.

As we go into rotations, residency, and practice, I hope we will be able to catch these patients before they fall through the cracks. My purpose in writing this article is to get the word out , because it is so easily treatable without the use of expensive, ineffectual, toxic medications. All we have to do is recognize it when we see it. As an added benefit, maybe someone will call you a miracle worker one day.

References
http://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo
Harrison’s Principles of Internal Medicine, 19th Edition, Chapter 28
http://www.neurology.org/content/70/22/2067.long

Featured Image:
Vertigo by Diana Mehrez