To set the scene, me and an australian lab scientist, Kristy, are collaborating to develop a training package on laboratory requesting and how to interpret results. In our discussions it came up that doctors often only ask for a white blood count but the haematology machine does a complete blood count on every sample sent. However if the doctor has not requested a Haemaglobin, haematocrit & platelets the lab staff will not write this information on the result sheet - even if they are abnormal & significant to patient management.
We concluded that I could inform the doctors about the machine & advised them to request a full blood count as it is being done anyway and the information is often diagnostically helpful.
Location of conversation - sat around table in staff room of ICU medicine ward.
Participants of conversation - me, Dr L, Dr O, my VA
Focus of conversation - 28 year old man with an alcohol problem, has frequents fits and is now complaining of headache, no neck stiffness, low grade fever, has just had a very traumatic lumbar puncture and now needs blood tests doing.
Me: "What blood tests are you going to do on the patient with the headache?"
Dr O via my VA; "White blood count, malaria screen, calcium, glucose"
Me: "Did you know that the machine in the lab does an Hb, haematocrit & platelet count on every sample anyway? So you may as well ask for of all them!"
Dr O via my VA (who is growing increasing bored & disinterested - I think he thought there would be more saving lives & less sitting); "Why would I need a Hb or platelet count?"
Me; "Well you have malaria as a differential diagnosis and the patient comes from Pailin" (home of Pol Pot & falciparum - two killers)
Dr O (not even waiting now for my VAs translation); "IT IS NOT MALARIA - the man has meningitis!"
Me; "But you have requested a malaria smear, surely knowing a Hb and what his platelets are would be a useful thing & the test is being done anyway in the lab. The test is run as a complete blood count not just white cells."
Dr L (in english & with his best condescending tone); "The patient has meningitis, he does not have malaria, there is no need to demand an Hb."
Me; "But if is being done anyway why not? The machine in the lab runs a full blood count" to my VA "Do they understand what I am saying? Could you translate it for me?"
My VA *silence*
Dr L (in english and increasingly withering); "There is no machine in the lab, there is NO MACHINE & no reagent"
Me; "There is no machine that works for electrolytes and no reagent for that at the moment it is being fixed BUT there is a haematology machine, I spoke to the lab about it today"
Dr L (his back to me - talking now to my VA in english) "Tell her there is no machine, there has never been a machine"
Me (to my VA) "But there is a machine, we saw the machine this morning, we spoke to the lab scientist about it and we are going to do training, could you perhaps translate that?"
My VA *silence* (he doesn't like disagreeing with doctors unless they are female and foreign)
Me; "Well OK then, I'll leave you in peace & I'll come back later to see what the results of the LP & bloods are - Lea Hai!"
I had to go back to the lab to check with Kristy that I wasn't imagining a machine, like an oasis mirage in a resource poor setting. When faced with such fervent belief that there is NO MACHINE the high levels of self doubt kick in. Kristy reassured me that there was and even made me take a photo of it on my phone so if I ever doubted its existence again I had proof.
Five hours later I went back to the lab as the results weren't in the notes, they were in the pigeon hole waiting to be collected my a ward nurse, they will be waiting a while as the nurses were all at a wedding. The white count was normal as were calcium & glucose and the malaria screen was negative. As for the Hb & platelets we will never know as the lab staff didn't write the result down because the doctor hadn't ticked the box.
The LP was grossly abnormal - I questioned it with Kristy as it made no sense to me. Kristy re-did microscopy. The 750 reported lymphocytes were in fact 750 red blood cells - small cells with no nucleus as opposed to larger cells with a big nucleus AKA lymphocytes, capacity building the lab staff is her problem not mine!
My conclusion was this patient does not have meningitis (gram stain negative, glucose high normal, protein normal) but if I said the sky was blue the doctors would say it was green, so I told the family (who had no communication with any staff & just wanted to know what was going on with their relative) that he was being treated for infection & I'd ask the staff for some paracetamol for his headache.
I hope his headache wasn't too bad though, I'm pretty sure that my request on his behalf for analgesia meant the staff would do the complete opposite. (They did argue the toss over the dose of paracetamol - I swear they can't help themselves)
 |
| The mythical haematology machine |
And so not inexplicably but still very irritatingly, all day I have been singing these lyrics -
"Just as I thought it was going alright
I find out I'm wrong, when I thought I was right
s'always the same, it's just a shame, that's all
I could say day, and you'd say night
tell me it's black when I know that it's white
always the same, it's just a shame, that's all
I could leave but I won't go
though my heart might tell me so
I can't feel a thing from my head down to my toes
but why does it always seem to be
me looking at you, you looking at me
it's always the same, it's just a shame, that's all"
GENESIS AND PHIL COLLINS GET OUT OF MY HEAD!
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