Lab Work

I wish I had learned more in medical school.

I did learn, what should have been a very valuable lesson, quite early on during the laboratory medicine part of our pathology course. What I was taught was:

Don't order any investigation where the result (positive or negative) will have no influence on the management of the patient.

With that knowledge in hand out I went into the world.

I learned another thing along the way.

If after talking to and examining the patient, you have not the foggiest what could be wrong, no lab test is going to help you.

Now if you read this blog, you will know that collecting blood for the lab was one of my most favourite parts of internship. Through sheer stupidity I actually used elective time to do orthopaedics thinking I would actually learn something useful. Now on ortho, every admitted patient (and back then there was very little day surgery and no same day admission) whether he was 19 or 90 got a laboratory panel of 24 tests known as the SMAC. This required 5 tubes of blood to be collected. So on my first or second day, I asked the resident, "why do we do so many tests on apparently healthy patients?". He looked me in the eye and said, "Anaesthesia wants them". Naturally all these patients were admitted after 1500 when the lab blood collection went home, which left the blood collection to the interns.

Of course "normal" results are in fact the range that 95% of healthy assymptomatic patients fall into. This means that 5% of otherwise normal patients will have an abnormal result to a test. If you order 24 tests, there is an absolute certainty that at least one will be abnormal. These abnormal tests have to followed up on which of course means more blood work.

Now did "Anaesthesia" really want them. Apparently not as I learned a few years later when I read the guidelines for routine lab work. Here are the current ones:

Now I was able to find these in about 30 seconds because I know where to look for them. If I had googled pre-operative blood work it is little more complicated but by simply looking up the guidelines of your national anaes. society, it should be quite easy. Or you could ask your anaesthesia department.

But why do I even give a shit?

1. I pay taxes

Most healthcare is publicly funded in Canada. A significant amount is publicly funded in the US. I want my tax dollars spend on treating patients not on lab work! As an aside, much of the blood work in my province is done by a private company. Do you thing they have any interest in reducing lab work?

2. Healthcare is a zero sum game

Even in the US, there is a finite amount of money that can be spent on healthcare. That means money spent in one area is money that will not be spent in other areas. Every dollar spent on unnecessary lab work is a dollar that could be spent on something useful like chronic pain.

3. It holds up things.

How often has your day in the OR been disrupted by a cancellation or postponement due to an abnomral lab test that shouldn't have been ordered that has absolutely no bearing on the patient's ability to tolerate surgery. Just the same, you have to cancel the case, or wait while the test is repeated or the necessary follow-up tests are done. Many years ago I saw a patient who had been cancelled a month ago because of an abnormal gamma GT that someone had ordered pre-op. It was elevated so she was cancelled, went for the million dollar work-up which was of course normal and was re-booked. Of course somebody ordered the gamma GT again which was still elevated. Remembering from my time in family practice that this test is a marker for alcohol abuse (or use?) I asked her if perhaps she might have had a glass of wine the night before her testing and lo and behold she said yes. I put her to sleep and she survived despite her abnormal lab test.

4. It delays necessary lab work.
A classic example is the PT/PTT. Nobody would deny the benefit of these tests in following response to anti-coagulant therapy. There are also important in the management of an evolving coagulopathy or in monitoring whether a patient has been off his anti-coagulants long enought to do surgery or stick a needle in. Except...when you order the stat PT/PTT you really need, it is going to be queued up behind all the "baseline" PT/PTTs that have been ordered. Therefore you are going to get back your PT/PTT long after you have already bit the bullet and given the FFP your patient may or may not have needed.

5. Nobody looks at it or does anything about it
Sadly, that is the case. We order all this stuff and it gets filed in the chart and nobody looks at it. This includes abnormal lab work which frequently isn't followed up on. Chest X-rays are the classic which are often ordered pre-op and reported on post-op. As I found out as a resident, actually going to X-ray and looking at the CXR is no help. The one and only time I tried that, the tech at the film library laughed at me. Actually at our hospital, CXRs are available on-line now if I could just find the time to fill out the stupid form, make up a password etc. EKGs of course go off to be reported by the cardiologist which means they sit on someone's desk until look after the surgery.

6. Surgeons actually think lab work is a substitute for a proper history and physical.
The last time I cancelled somebody as medically unfit, the surgeon's whine was, "But I ordered a cardiogram". Further people think that lab work is a static thing, like the fact that the patient's K was normal on admission, means his K is still normal after he's been vomitting for 3 days.

7. Politicians know we order too much lab work and use it as a stick to beat us on the head when we complain about lack of funding in other areas. "The ER is full of patients waiting to be admitted?. That's because you doctors order too many blood tests".

8. It leads to more unnecessary testing and interventions

I have a personal story here. My first born was born at term after an uneventful labour and was normal size for gestation. Despite this somebody decided he needed to have a blood glucose done. It was something like 3.0 which would be low for an adult but normal for a full-term neonate (because of this episode the normal range for neonates of 2.5-3.5 which of course I had to know for my recently completed written exams has stayed in my mind). Of course the lab reported that number as low using the adult range, so the first thing the nurses did was to feed him some glucose and water. This meant when my wife woke up a few hours later with swollen boobs, our son didn't want to feed. It also meant he got an extra heel prick the next day to see if his blood glucose was still "abnormal".

Death on the table

We recently had a death in the OR. Actually the patient died in the ICU afterwards but it was essentially a "table-death". This was a laparoscopic gall bladder in an octagenarian. She had an uneventful OR and then arrested in the recovery room. I didn't do the case but responded to the alarm, stayed for while until I figured there was enough help, so went on my way. Anyway she had a complex but no pulse which lead me to think she might be bleeding. After some rescuscitation they took her back to the OR where there was bleeding in the retroperioneum around the pancreas that nobody had noticed. She as I mentioned later died in the ICU.

This reminded me of a few things.

The first thing that came to mind was something that happened to a staff anaesthetist where I trained. This individual was not a very good anaesthetist. He however felt that he was the best anaesthetist around. This is a bad combination. He wasn't really fun to work with as a resident. (Aside from being a pompous twit, he had a nasty habit of poking you in the shoulder to make his point; nowadays laying hands on a resident would land you in the Dean' office.)The event in question however happened about 2 years after I finished. By that time I gather there had been a few other episodes.

He was doing a laparoscopic cholie around the time that surgeons started doing laparoscopic cholies and those of us who worked in that era remember what a dark time that was(3 hours of farting around followed by an open cholie). I gather during the case, the blood pressure continued to fall and fall. He asked the surgeon if there were any problems and of course the surgeon said no so on they went until the patient died.

My former "mentor" was told soon after that it was time he retired. This was before the autopsy showed a belly full of blood which the surgeon had failed to notice. Unfortunately my mentor had to keep retired while the surgeon is to my knowledge still working and hopefully learned something that day.

I have unfortunately over the years had a few deaths in the OR and few people that expired shortly after. Most of these have been predictable, ruptured aneurysms of both types, traumas and of course the ICU cases sent to the OR to be euthanized (this patient is going down the tubes and we can't think of anything to do so lets operate on him). Self flagellation comes naturally to anaesthesia and we always wonder if there was anything we could have done differently and looking back over the years, I don't think there was except maybe I could have run away.

The wierdest thing about a table death is that you usually have to start another case right after. Either you are on call or this case bumped into your elective list or it was in the middle of your elective list. So after an hour or so to clean up the mess and do the paper work, back in the saddle. Strange.

Several years ago, we had a province wide committee on peri-operative deaths and it was an interesting exercise. Essentially if a patient died within two weeks of surgery you had to come down to medical records, review the chart and fill out a form. Many of these were of course patients you knew died or you thought were going to die but you got the odd patient who just happened to die a few days post-op for no apparent reason. As I say it was interesting (and easier than reading the obits and looking for names you recognize.) This initiative stopped during our time of health care reform and downsizing in the mid 1990s when the province and hospital admins got worried that death might be attributed to their restructuring efforts.

Anonimity

It is nice to know that somebody actually reads my blog as I got an email last month regarding my posts regarding RateMds.com. The emailer expressed some disbelief that an anaesthesiologist would even be rated on such a site as nobody really knows who their anaes is.

That is quite correct and in fact the posts of RateMds relate to my work in the chronic pain field.

Anaesthesiologists are two-faced about the anonomity that comes with the profession. On the one hand, the lack of sustained patient contact is a significant factor in drawing many of us to the specialty. At the same time we resent the lack of recognition we get for the miracles we daily perform in the OR, we get really upset when nurses on the floor announce "anaesthesia is here" rather than Dr. BH is here, when we read about the latest surgical miracle in the hospital which mentions every member of the team except the anaesthesiologist etc etc we get really pissed off.

When I was a GP in small towns, you were very visible and people got to know you after a while. You were occasionally stopped on the street and asked for advice. On the other hand, you couldn't throw temper tantrums about bad service and you had to be very careful about drinking in public.

I always remember how in one small town, I treated a small child for what I felt on examination was a URTI, so I prescribed the usual nostrums. The child did not get better as most URTIs don't in the short term so the mother took the child to another doctor who informed her ( as doctors unfortunately do), "this is is the worst case of pneumonia I've ever seen and this antibiotic will cure it". So the child was sent home on antibiotics and got better as most URTIs eventually do. I will not even discount the possibility that the URTI may have developed into pneumonia.

At any rate, I obviously never learned of this developement until a couple of days later I was eating lunch with my wife in a somewhat cozy restaurant and heard the entire story from the next table complete with a description of how stupid the new doctor was. The lady then got up, saw me and turned beet red.

When I went into anaesthesia somebody told me that it was a good idea to make post-operative rounds on your patients. I actually tried that. One day I located all the patients I had done the day before which involved phoning admitting to find their locations and tried to visit them. This was in addition to the number of pre-operative visits I had to do in those days before same day surgery. I went into each patient's room introduced myself as Dr. BH who had put them to sleep the day before and "how are things going". And I got a lot of blank "who the hell are you" stares. Needless to say I have never made post-op rounds since.

Anyway our licensing body a few years ago decided that we needed our competency and other issues examined. Therefore presumable at great expense (using our dues) a program of assessing our fitness as physicians was initiated. So about two-three years ago I received in the mail a number of surveys about my abilities and personality as a physician. I was supposed to name 10 other physicians to evaluate me as well as 10 non-physicians. I must say I had a little trouble finding 10 surgeons who weren't pissed off at me but I did find 10 names. The 10 non-physicians (nurses) was a little more difficult but I found 10 names.

What was really difficult was that I was given 30 questionnaires that I was supposed to give to patients. I had about a month to do this. Now at the time I was working at the centre of excellence and typically did about one long case a day usually on a patient having some type of horrendoplasty. I thought to my self, these patients are not about to be able to complete a questionnaire about my bedside manner plus I don't do thirty cases in a month. Now at that time I worked 1-2 days a month at a community hospital doing day surgery. So I phoned up the survey company and explained my dilemma. After some negotiation, I was given extra time and over 2 months I was able to get rid of the 30 questionnaires.

Not a single one was returned!

As one of my non-physicians I named on the orderlies that I had befriended. One day, he pulled me out of the hall and said "Hey are you in trouble, I just got this questionnaire about you". I assured him I wasn't in trouble yet.