In microbiology we learn to use the Gram stain results of a direct smear to check specimen quality (usually by a count of squamous epithelial cells) and any predominating organisms (e.g. lancet shaped Gram positive cocci on a sputum) that suggest what to work up.
All good micro techs use the Gram stain. Intracellular organisms are an immediate clue of what’s causing an infection. If an organism is seen on the Gram stain and not seen on the plates, it could indicate that the patient is being treated, making the organisms non-viable. Gram staining urine specimens can give hints of certain organisms, such as Aeromonas. It’s one of the first steps in the detective job of the microbiology tech, to tell the doctor what’s causing an infection and how to treat it.
But the Gram stain can also be used to educate and connect with other front line staff. It can be used to elevate our profession and status as a clinical resource, instead of being seen as button pushing phlebotomists.
When a wound culture direct smear shows many squamous epithelial cells and what appears to be mixed skin flora, it’s a chance to talk with the nursing staff about how the specimen was collected. It’s a chance to talk to the pharmacy about how the patient may already be treated. And it’s a chance to check the chart and talk to the physician about why the culture is important e.g. MRSA.
I reviewed a chart of a suspected pneumonia patient, and in the H&P the physician had noted “Gram stain shows many white cells and Gram positive organisms.” This was correct to a point; the reason I reviewed the chart is because the plates were being worked up for Haemophilus. The Gram stain report also reported intracellular organisms and many Gram negative cocci. Why didn’t the H&P accurately reflect the recent report? Why didn’t the admitting doctor see this original report and notice the discrepancy?
All good chances for us to use the Gram stain to improve patient care.
NEXT: We Are IT
According to one Fox affiliate contributor, Ben and Jerry’s has a special nap room for employees. If you get too tuckered making Chunkey Monkey, you can bag a few zees. The National Sleep Foundation reports that sixteen percent of employers have similar napping rooms. One sleep expert comments, “Just one 26-minute power nap can increase your cognitive skills by 40 percent.” That sounds like a good, low-cost solution to fighting exhaustion, maintaining productivity, and showing a human side as an employer. It’s less fattening than a bear claw washed down with a Red Bull, too.
But sleeping is non-productive time in the view of less progressive, more conservative organizations, many hospitals included. “You aren’t paid to sleep!” is rooted in our culture; napping means immediate dismissal. This is unfortunate for patients, since healthcare workers need “cognitive skills” as much as anyone. One would think we’d get it before Ben and Jerry’s, but they get to make their dessert and eat it too, I suppose.
And that’s just day to day exhaustion. Career burnout is very real in our profession. It’s tough to enjoy a job that is physically and emotionally exhausting. If your employer isn’t savvy enough to give you a nap room, here are a few suggestions to recharge and renew your energy:
- Exercise - a study at the University of Georgia reported by The New York Times shows that regular, low-intensity exercise (leisurely walks) can fight fatigue, increasing energy more than higher intensity workouts.
- Diet - WebMD suggests watching what you eat -- such as foods that cause heartburn in the middle of the night that will disrupt sleep -- and going easy on caffeine and alcohol.
- Stress - as the site LiveStrong points out, “a job that you don't enjoy can make you feel tired and downtrodden.” The last thing you need on top of it is more stress, aggravation, and annoyance. Don’t agree to extra projects, extra shifts, and adjust your workstation to fit your needs.
Talk to your boss. Unless he uses his office as a nap room, you’re in good company.
NEXT: Use the Gram Stain
Repetitive motion injuries are commonly caused by cumulative trauma to musculoskeletal joints such as thumbs, elbows, and shoulders. These have always been common in
workplaces but there is greater awareness during these long days of people sitting at computer terminals. Hours of restrictive movement using the same muscles that involve
fine motor control e.g. mouse clicking and keyboard typing can cause injury.
WebMD points out problems related to ergonomic issues,
- Bursitis - the bursa is a sac of fluid cushioning or lubricating an area where tissues rub against each other; inflammation can be caused by repeated or prolonged
pressure, twisting, or rapid movement.
- Carpal tunnel syndrome - caused by pressure on the median nerve in the wrist; symptoms include tingling, numbness, weakness, or pain in the fingers, thumb, hand, and
- Muscle strain - pulled muscles are caused by overstretching, and can be minor or severe; recovery time varies.
- Tendon injuries - tendinitis (inflammation) and tendinosis (tearing) are two common injuries of these tough, ropey fibers connecting muscle to bone. Caused by any
activity requiring twisting or rapid joint movement.
If you’re a laboratory generalist, you may be less prone to carpal tunnel than specialists. You may not sit at a microscope long enough, for example, to accumulate
injury. But there are plenty of chances to twist, lift, and jerk when moving supplies. A 20 liter cube of hematology diluent, for example, weighs 44 pounds and is
difficult to lift and maneuver, even for people in good shape.
For a technologist assigned to one department, the chance of performing the same tasks over and over is much more likely. Repetitive motion also seems likely. Paying
attention to ergonomic issues is a must in these settings. You’ll want to avoid long periods of pressure, strain, or rapid fine motor movement. “Repetitive” really means
cumulative, and in some cases this means years of activity that flares up.
If an ergonomic related injury has happened to you in the workplace, how did you discover it? Was it brought on by a specific workstation or just years and years of the
same activity? Please share your stories.
NEXT: Recharge and Renew
When we renovated our lab design, moving walls, equipment, and refrigerators, one of the techs joked the newly opened space made it “walker ready.” “We aren’t getting
any younger,” she said. That seems to be a theme these days. I’m not sure we’ll be working with walkers -- I hope not -- but ergonomics and exhaustion seem to bedevil us
at every turn.
The Occupational Safety and Health Administration (OSHA) has this to say about ergonomics:
“Ergonomics is the science of fitting workplace conditions and job demands to the capabilities of the working population. Effective and successful ‘fits’ assure high
productivity, avoidance of illness and injury risks, and increased satisfaction among the workforce.” Risk factors include repetitive motions, prolonged exertions, heavy
lifting, pulling, or prolonged and awkward postures. Conditions that affect these risks include intensity, frequency, and duration.
Thus, sitting at a microscope could cause injury if it involved prolonged and frequent motions involving hyperextending, reaching, bending the neck, etc. In other words,
the kinds of things we all did at twenty five and felt good enough to party at the end of the day. We are living in a different world, it seems.
The second factor -- exhaustion -- may be worse in our modern electronic age. According to CNN Health, probable causes are “a move to a 24/7 work culture, more time spent at our desks due to over-reliance on email and a more
contract based, short term work force that feel insecure in the workplace -- and thus less likely to take breaks.” One UK newspaper reports an “exhaustion epidemic,” citing
a study finding 42 percent of people saying lack of sleep is their biggest concern.
Exhaustion caused by stress leads to more stress, more worry, depression, and eventual burnout in a downward spiral that can be hard to break free of. It takes energy to
fight exhaustion, a cruel irony. Doing more with less, worrying about changes in our industry, and fighting the general fatigue that can come with age all add to the
What can we do? Next, I’ll first consider ergonomic issues.
NEXT: Move Smarter
Pardon the pun, but it’s an old story. According to the Hospital Council of Northern & Central California, “The average age of a CLS in California is above 50. There are not enough new CLSs in the pipeline to equal the numbers currently working but planning to retire,” which says it all. We are all getting older.
Our laboratory has a pretty good cross-section of laboratory ages: most of us are in our mid-fifties, a handful are in their mid-forties, one or two are in their mid-thirties. We are fortunate to have a technologist who is in her mid-twenties, a rarity these days.
It’s cliche for “old folks” to be ridiculed and stereotyped for attitudes about computers, technology, work habits, acceptance of change, etc. But the fact is we are the people who created the technology, have the experience, and know what change really means to an organization. Being around the block a few times means finding cracks in the sidewalks, assuming one still have good eyesight and a working memory.
That’s not the kind of ageism this blog is about. It’s easy to deride older workers when they are in a minority, harder when they are the bulk of the workforce. These days, reverse ageism happens more often, I suspect.
Younger workers are more at risk for layoffs, based on a “last one in, first one out” labor practices. Older workers with families may be perceived as getting special treatment. According to a writer in The Atlantic, “That was certainly the case ... 20- and 30-somethings were regularly sacked at greater proportions, despite being generally more productive than older employees and much less expensive due to smaller salaries.”
Attitudes have shifted, perhaps, in the way younger workers are treated in the workplace. As a minority, younger workers may be treated with more impatience than necessary. “She’s too rude!” “He never finishes his work!” “She was out partying all night!” Sometimes, when I listen to complaints about younger workers from much older workers I’ll gently ask, “Aren’t these sins of age?”
We were all young once. How soon memory fades.
NEXT: Ergonomics and Exhaustion
It’s easy to make solutions more complicated. When there are holes in a schedule, one can create multiple rotation lists with conditional rules. When quality control is out, one can apply more Westgard rules than are needed. And when microscopic cellular elements are evaluated, one can apply criteria that are too detailed to be practical.
Laboratory professionals are a pragmatic and dogmatic lot, generally, trained to follow stepwise instructions. Many times I’ve heard, “I don’t run that test very often, but I can follow a procedure.” But we tend to follow the complicated as readily as the simple. This doesn’t mean we don’t prefer the latter over the former. We all want simple solutions.
In my last blog, I theorized that we take the shortest route to solve any problem. I wonder how many times this is a desire for simplicity. Given a choice, techs want an easy, fair scheduling process, quality control troubleshooting with as few rules as practical, and microscopic criteria that are easy to remember and reproduce. The simplest solution is often the most expedient. Less work is simpler.
Simpler is probably better, too. A philosophical principle called Occam's Razor, after a 14th century monk who popularized the idea, states “Entia non sunt multiplicanda praeter necessitatem” -- entities should not be multiplied unnecessarily -- and other ways of saying that simpler is better. For scientists, this means that if two theories explain the same observations, the simpler is probably correct.
Thus, of two methods to rotate people through shifts on a schedule, the one with fewer rules is probably better all around; applying one or two Westgard rules as points of failure and revamping a review process is better for techs on the bench; fewer criteria e.g. less than or greater than 10 per field, is reproducible while giving physicians the same information.
Of course, Occam’s Razor isn’t always applied. Management geeks and policy wonks smell job security in keeping processes wild and woolly in the nonsensical notion that infinite complexity eventually improves patient care. But that’s another blog.
NEXT: Ageism in the Laboratory
Corrective action is a beautiful thing. When quality control is out of limits, running a fresh control that is acceptable saves time, avoids an irritating sample look back, and reassures the tech. When a weak blood bank reaction in all tubes disappears by recollecting a sample and letting it clot in the refrigerator, a simple fix is found. And when an instrument problem is identified and repaired before a service call, everyone is happy.
Corrective action should always be this easy, but I’ve seen QC problems ignored, instruments run despite problems, refrigerator temperatures ignored, expired reagents and controls run, and out of control values repeated multiple times until they just squeak in. I suspect this is common in all labs to some degree.
One solution is for any laboratory instrument to lock out the operator if conditions aren’t met, similar to bedside glucose meters. This is possible with information systems, too. I don’t know why that doesn’t happen. In the CPSI system, for example, one can post unacceptable quality control and still report patients. That seems to me a trivial software engineering problem.
But the problem is not just engineering. We all naturally take the shortest route to the finish, which explains why nurses will hoist a person in bed and get a back injury instead of using a lifting device, why people arrive at work in the winter in high heels and walk down an icy hill around a dumpster, and why lab techs repeat a control three times until it is within limits. Most of the time, this kind of behavior doesn’t cause a problem.
“Near miss” behavior is the darling of quality geeks, who think if we can eliminate it errors will never happen. There won’t be lifting injuries, there won’t be falls, patient results will be improved, and we’ll all save money. Of course, these are the same people wearing the heels, eating the fast food, typing with the keyboard on top of a bookcase, etc. We are all carelessly expeditious.
What we need is corrective action to fix corrective action. Any ideas?
NEXT: We All Want Simple Solutions
A million monkeys on a million microscopes probably couldn’t bang out an accurate WBC differential in a million years, but a lab tech could teach a gibbon to run a
chemistry analyzer in about ten minutes.
I’m kidding. But the subjective variability of microscopic analysis versus objective reliability of engineered automation is known. WBC differential, abnormal cell
identification, manual cell count, cell count estimate, crystal analysis, urinalysis, or Gram stain often have significant variation. It’s the nature of the primate.
Reliability combines accuracy and precision; let’s briefly consider both.
A reason for inaccuracy is confirmation bias, described by Science
Daily as “a phenomenon wherein decision makers have been shown to actively seek out and assign more weight to evidence that confirms their hypothesis, and ignore or
underweigh evidence that could disconfirm their hypothesis.” In other words, we tend to find what we’re looking for.
For example, if we glance at a report and see the patient MCV is 75 fL, our confirmation bias will seek microcytes on the peripheral smear. Techs who don’t know the
instrument MCV may or may not see microcytosis.
A reason for imprecision is our tendency as scientists to seek a greater degree of precision than necessary. We think in procedural, stepwise fashion and not
For example, in urinalysis we may report white cells as 0-4, 5-10, 11-15, 16-20, 21-30, etc. It’s difficult to imagine a laboratory can reproduce this suggested
precision given the significant variation that exists in spinning the sample, preparing the slide, time under the scope, etc. I’m not sure it matters to a physician.
While we can’t always prevent confirmation bias, we can change our microscopic criteria to be reproducible. One approach is to base grading around significant cutoffs.
In urinalysis, we might report squamous epithelial cells as less than or greater than 10 per LPF, for example, a decision limit to determine contamination.
Choosing reproducible cutoffs may not help a million monkeys read a differential, but it might keep us techs from going bananas at the scope.
NEXT: Corrective Action
An acronym pulled from the alphabet soup is CQI, or Continuous Quality Improvement. Managers and quality improvement people use this to show that everything can be improved, even processes that work. Continuously trying to improve quality generates incremental improvements; rather than completely redesigning a process, it is changed in response to data collected, often in a PDCA (Plan-Do-Check-Act) cycle.
A good example of where this idea can be applied is your criteria to review blood smears in hematology. Your criteria to perform a smear review or manual differential are likely based on CBC parameters such as white blood cell count, absolute counts, instrument flags, etc.
Assume, for example, that all smears are reviewed if the white blood cell count is above 20 thousand. Taking a quick look at the smear can reveal signs of sepsis and other acute conditions. But a white count alone is nonspecific. If this limit is strictly obeyed, you’ll also end up screening a lot of negative smears as well as looking again at patients with certain disorders (e.g. CLL) that typically have very elevated counts.
There isn’t anything wrong with reviewing more smears than necessary, except that it costs time and money that could be better spent doing other things. Techs who spend time reviewing more normal smears could miss abnormalities elsewhere. And turnaround time is always a factor with ED patients or continuous flow work models. Too much busy work is never a good thing.
A few ideas:
- Consider absolute differential counts instead of a total white count, if a differential is performed by the instrument.
- Include a delta check limit (if the count has remained with certain limits for so many days, etc.) in your criteria.
- Review “first time” reviews, looking for significant changes over time.
Each of these improvements can be implemented using PDCA: plan specifics, make the change, measure the impact, and adjust if needed. Your performance improvement can be tracked in a number of ways: number of smears reviewed, turnaround time, etc. CQI is one case when alphabet soup is good for patients. Let’s hope it’s low sodium, too.
NEXT: Reproducible Cutoffs
Each day, I see people arrive for work after they have had breakfast at home. They sometimes arrive with coffee. Within two hours or so they go to morning break and eat a muffin, fruit, or some other snack, often with more coffee. Two hours later they have lunch, and so on. Our days are one long glucose tolerance test.
Yet we require that patients fast eight to fourteen hours before measuring substances commonly found in all these foods and drinks. The Quest website puts the reasoning succinctly: “If you don’t fast, or fast for a shorter time than prescribed, your tests could give inaccurate results, meaning you’ll likely have to repeat the test.” In the context of lifestyle related testing, “inaccurate” means your results will not compare accurately to other fasting patients, not in the sense of reflecting what’s usually happening in your blood.
“Fasting” is useful for clinicians to make a diagnosis, but it still seems odd to me to ask patients to fast. And in fact, there are guidelines for a random plasma glucose (greater than 200 mg/dL); US News and World Report reported last November that fasting may be unnecessary for cholesterol testing, too. In this study, fasting and non-fasting values varied little, only suggesting a need to repeat triglyceride testing in some instances.
Fasting testing might be unnecessary in some cases. It may have to be, since we never really know how compliant patients are. If many people in work settings don’t last more than a few hours without another sugar, fat, or caffeine load, it’s easy to imagine the torture of a fourteen hour fast. Countless times patients have asked me, “I’m supposed to be fasting, but I just had a ____ and ____,” -- fill in the blanks -- “is that Ok?” I suspect a large number of patients are not fasting. Some probably modify their eating slightly before the test. I’ll bet clinicians know that, too.
Perhaps, cheaper or more reliable testing will allow enough data to be collected to reflect patient habits in a meaningful way. We’ll be fasting a while longer.
NEXT: Improve Your Criteria
The other day after I explained a change in microbiology an employee told me, “That’s three times you’ve used the word ‘exciting.’ That’s not a word I would use.” This was said in good humor, but the point is valid. Slogging out results day in and day out, thousands a year, can be tedious. How do we keep benchwork exciting?
While the question is closely related to motivation, camaraderie, culture, and other workplace conditions, it’s much simpler. It boils down to what keeps the hands on work of producing lab results exciting. A love of medical technology seems like a prerequisite to me.
Other than loving technology, it’s difficult to speculate why someone would find labwork exciting after years of doing it. And in fact many don’t. Techs get burnt out,exhausted, fed up, and ultimately disillusioned enough to quit the profession. But I’ve stuck with it for many years and like my colleagues still find a lot to be excited about.
Here are a few ideas to keep benchwork exciting:
- Read. Textbooks, trade magazines, websites, and resources like UpToDate are good sources of continuing education. The more you know about the technology and how it’s applied, the better.
- Get involved. Other professions are a good source of interest. It’s helpful, for example, to audit nursing when they administer blood to learn the care side of transfusion medicine. This kind of information can help improve your processes and improve patient care.
- Look beyond. I’ll admit, it can be tedious to churn out CBCs all day, but you can always look beyond a single result. Values and smear reviews can be correlated with information from other departments or a diagnosis. You can always dig a little deeper to find out more.
But that’s just me. I lean towards a curiosity and desire to improve things. I can easily imagine other factors: helping colleagues, personal productivity, multitasking. I know a tech who whistles while she multitasks, happiest when she has three or four tests cooking at once. Is that exciting? Perhaps.
How about you? What keeps your benchwork exciting?
NEXT: Why Fasting?
Stress is big trouble in all our lives. It seems to me that we can handle stress at work or home but not both. Life being what it is, stress seems to jump from one to the other and seldom sits still. At home, family can help us cope with stress. Does a work family do the same thing?
Many employees have told me, “We’re like family here. We help each other all the time.” This makes sense, if we admit to not being able to hide ourselves for very long. Not many of us can completely hide emotional pain, and we need each other to cope with stress. We all understand that things happen beyond our control, inside or outside work’s doors.
I’ve seen people support each other through child troubles, illness, cancer, family deaths, and marital troubles. It’s hard not to be emotionally attached to people who share these kinds of problems, and this kind of involvement naturally makes them important. Doubtless most of these individuals have family at home, but life doesn’t just stop happening at the doors to the laboratory. A “work family” can be just as important.
Maybe it’s the man in me, but I wonder.
Becoming emotionally vested in a workplace and dependent on the support of coworkers who are otherwise strangers is a choice that some will not take. The alternative is to view work as work, a means to an end and nothing more. It’s just as healthy to see our problems as unwanted invasions into the emotional worlds of others and keep our private lives private. Most of us understand when someone makes this choice.
Thus, one might choose to say nothing, take time off, seek counseling outside the laboratory, and maintain a poker face. Chances are, he or she has a few close confidants at work to talk with, and aside from a few outward tells of stress no one is the wiser. I doubt this kind of person sees work as family.
How about you? Is your work and family different, or is work a second family?
NEXT: Keeping Benchwork Exciting
We encounter scripting all the time. When calling customer service, at the end of the call, the representative says, “Have I answered all your questions today?” In a restaurant, a waiter will say, “My name is Matt, and I’ll be your server.” And at the supermarket the checkout person will ask, “Did you find everything you were looking for today?”
While some of this sounds robotic, it all does what is intended: build an expectation in the mind of the customer of what happens next, no matter the employee.
Thus, every time I go to a Best Buy and start wandering around I can expect a person in a polo shirt and khakis to welcome me and ask me if I can be helped in any way. When I go to the local Hannaford supermarket I can expect people to ask me if I need help finding any items or if I found everything I need. And if I call DirecTV the person on the other end will introduce themselves and assure me my problem will be solved.
I’m never quite sure what happens when I need help and the person isn’t helpful, I couldn’t find what I needed, or if the person on the other end of the telephone makes my problem worse. This happens often enough that it leads me to believe that scripting ends with the sidewalk. Customer service often sounds robotic because it is.
All this can be applied in the laboratory, too. You can introduce yourself to a patient, ask if there is anything more that you can do, and ask doctors if they have found all the results they need. And if everyone in the laboratory does all these things, it will doubtless build an expectation of how people behave until they need to go off road when the scripting is derailed. But that’s another blog.
After experiencing scripting in various forms, I’m not convinced it’s smart business. Some customers love personality, which indicates diversity, innovation, and unique value. If that’s true, is scripting bad?
NEXT: Your Work, Your Family
A common task we are expected to perform is checking expiration dates on reagents, controls, and other dated materials. Boxes are crowded with different languages, vials are smaller, and eyesight fades with age. I remember vividly the moment when I couldn’t immediately adjust between a crossword puzzle and the wall clock.
What if we miss a date? Suppose, for example, a vial of blood bank reagent has expired a few days and the techs just misread the date, the date was covered by a received sticker, or it’s just one of those things. People are human and make these kinds of mistakes. It’s improbable that several techs in a row would make the same error of omission, but we should expect that, too.
There are three common reactions:
- Blame. It’s easy to blame the techs who didn’t read the expiration date correctly, but this ignores the inevitability of human error in a system that relies on the myth of consistent human performance.
- Oh, well, it happens. The other extreme is attributing this kind of event to human error and shrugging it off. While probably apt, it isn’t a response that prevents a future error from happening.
- Just work harder. This event can be added to a list of reminders at lab meetings, posted in a memo, or written in a policy as something to be avoided. But people don’t forget because they don’t work hard; they forget because human memory is fallible.
Tasks like checking expiration dates are subject to “self control” as I blogged recently; they depend on people developing religious habits. But a fourth possibility is using the system to help self-correct any errors of omission.
Expiration date reminders, for example, can easily be added to an Outlook calendar. These can pop up and ding at a workstation to alert the techs. (A paper calendar works, too!) The website IFTTT (If This Then That) can text, page, or email reminders that reagent will expire.
Good thing computer screens are bigger. Some of that print is wicked hard to read.
NEXT: Is Scripting Bad?
We all have moments when we lose self control, usually under stress of some kind: frustrated by highway traffic, pressed for time, shopping in a crowded store, irritated by arguing. In a similar way, stress in the laboratory can cause us to lose self control of a different kind: our own personal checks and balances in performing manual testing.
Engineers rely on different kinds of feedback loops to ensure a system is properly maintained. In a feedback loop, actual output is compared to desired output and the system self-corrected. Examples include your household thermostat or water heater. Laboratory instruments are designed to self-correct, but many verification processes accomplish the same thing. When we review a laboratory result, we decide if it’s reliable based on a number of factors: age, gender, delta checking, instrument errors, etc. If it isn’t, we may repeat the test (self-correct).
But not all laboratory tasks produce data. Manually reading blood bank test tube reactions, for example, requires concentration and attention, but it doesn’t produce data that can be checked unless another tech verifies the reaction. It is self controlled in the sense that it relies on religious habits that a tech doesn’t have to think about to be able to reliably remember with confidence the actual reaction. Developing these kinds of good work habits is a hallmark of an experienced bench technologist.
Nursing and other professions may have a perception that we are all button pushers and the instruments do all the work, but there are a remarkable number of processes that still rely on self control alone.
- Patient identification - asking the patient, reading a requisition, and “time outs” rely on manual verification.
- Specimen labeling - immediately labeling a specimen after collection is often a recreated event e.g. “I always do it this way” to verify performance.
- Specimen aliquoting - pouring off tubes and labeling the secondary tube are highly subject to self control.
- Reading reactions - any kind of manual interpretation of a reaction is variable to degrees and subject to interference from distractions, mood, environment, etc.
This isn’t to say that these tasks are performed better or worse than instruments, but there is certainly a potential for greater variation and error. Next, I’ll consider a practical example with a possible solution.
NEXT: Can You Read Expiration Dates?