April 28, 2011 (Thursday) - Dichroic Mirrors

A couple of weeks ago I had a tutorial with my specialist portfolio students on the subject of automated blood counts. While discussing flow cytometry we touched on the subject of dichroic mirrors. A dichroic mirror is a sheet of material which allows light of certain wavelengths to pass through, which reflecting light of other wavelengths.

The use of a dichroic mirror is crucial in the operation of the flow cytometer, but for our purposes it is sufficient that the mirror is there and that it reflects some light and allows other light to pass. During the tutorial I explained that it was operated by magical pixies, and left it at that.

For some areas of science a biomedical scientist needs to know absolutely everything. However one cannot possibly be expected to know everything about everything. The physics of waves is something about which (up till now) I didn’t know very much. But some of my students have looked dichroic mirrors up. I now know that they operate by the principle of Fabry–Pérot interferometry.

 It would seem (from wikipedia) that dichroic filters use the principle of thin-film interference, and produce colours in the same way as oil films on water. When light strikes an oil film at an angle, some of the light is reflected from the top surface of the oil, and some is reflected from the bottom surface where it is in contact with the water. Because the light reflecting from the bottom travels a slightly longer path, some light wavelengths are reinforced by this delay, while others tend to be cancelled, producing the colours seen.

In a dichroic mirror or filter, instead of using an oil film to produce the interference, alternating layers of optical coatings with different refractive indexes are built up upon a glass substrate. The interfaces between the layers of different refractive index produce phased reflections, selectively reinforcing certain wavelengths of light and interfering with other wavelengths. The layers are usually added by vacuum deposition.

By controlling the thickness and number of the layers, the frequency of the passband of the filter can be tuned and made as wide or narrow as desired. Because unwanted wavelengths are reflected rather than absorbed, dichroic filters do not absorb this unwanted energy during operation and so do not become nearly as hot as the equivalent conventional filter (which attempts to absorb all energy except for that in the passband).

Clear as mud?

For the purposes of counting blood cells it's probably good to know about interferometry in principle, but I don't pretend to understand it. I shall give the students a reference on the subject, but I for one will continue to describe a dichroic mirror as being operated by a magical pixie. And when assessing students I shall not expect any more explanation than that on the subject….

April 24, 2011 (Sunday) - Crackpot Quackery

I’m going to rant today. I was going to apologize for doing so, but on reflection I will instead ask that the next time any of my loyal readers are feeling ill and avail themselves of any of the wonders of today’s medical wonders, then they might spare a thought for this rant…..

From http://www.ehow.com/facts_7313433_chlorine-dioxide-scam.html “Miracle Mineral Solution (MMS), an alternative medicine advertised as a panacea, is a solution of chlorine dioxide. Chlorine dioxide is a poisonous substance, and the FDA considers the marketing of chlorine dioxide as a medicine to be fraud.”

I was ranting elsewhere on the internet about crackpot quackery, and someone whose opinion I (usually) value greatly was speaking in favour of crackpot quackery. My mother once told me it was bad form to engage in a battle of wits with an unarmed man…. He said on the subject of crackpot quackery: “Whatever works for you is OK - just let me have the choice is all I ask”.

An admirable sentiment, or is it?

Should people be allowed the choice? Or should they be stopped from eating bleach? Or are people big enough to take responsibility for their own actions?

And how can health care professionals expose this quackery in a way that people who’ve been scammed will realise that they’ve been scammed?

Alternative medicine….. What can I say……? How on Earth does crackpot quackery keep going in the twenty-first century? I can't understand how intelligent people are against modern therapeutic drugs which are tried, tested and understood, but prefer crackpot remedies which are based on nothing but hearsay, old wives tales and commercially vested interests.

What these crackpots fail to realise is that both “herbal” and “proper” medicines work because of active ingredients. There is something in both which has a medicinal property. In “proper” medicine that active ingredient is investigated, isolated, and therapeutic dosages determined by proper controlled experimental trials.

In “herbal” medicines it is found that (for example) eating turnips has once cured piles. However that is all that is determined. No one knows how or why it works, or gives any thought to the fact that (whilst curing your piles) eating turnips might give you guts ache as well. And herbalists tend to gloss over the fact that the amount of pile-curing ability varies terrifically from one turnip to the next. One turnip will cure whereas a field of different turnips might just achieve mild relief at best.

For an example of this, take the old wives tale that if you get stung by a stinging nettle, rubbing the wound with a dock leaf gives pain relief. I’ve tried this many times. Sometimes it works, and sometimes it doesn’t. Depending on the individual dock leaf. Much the same is true of a cure for jellyfish stings. Dousing the wound in urine sometimes eases the pain. But only sometimes, depending on exactly what the person producing the urine has been eating and drinking recently.

Or take malaria. For years those suffering from malaria found the symptoms were alleviated by having a gin & tonic. Sometimes alleviated better than others, depending on the brand of the tonic water used.

Or from a non-medical viewpoint I might suggest the reader go to Hastings Old Town High Street. There’s a pub there called the FILO. Have a pint of the home made ginger beer. It’s made on the premises; each batch to the same recipe. And then go back and repeat this a month later. You’ll find that the strength of the ginger taste varies dramatically from batch to batch. Sometimes it’s barely noticeable; other times it’s overpowering. Why is this? – It’s because they are chucking in a measured lump of ginger root each time, but not measuring the active ginger taste. (I know this because I’ve watched it happen!)

In all these cases (and in thousands of others) the old wives tale has a nugget of truth in it. What modern medicine does is to investigate these tales; find out exactly what the active ingredient is that is causing the medical effect, and then produces that element as a modern drug.

The clever bit lies in finding out and *proving* the active ingredient. This is where the entire concept of clinical trials comes into play. 
I had a burst blood vessel in my eye a few weeks ago. It’s now better. Using the “herbalist’s argument” I might claim this as a resounding success for the application of excessive amounts of ale. But I won’t because we know from experience that it would have got better anyway.

This is the problem with many illnesses. Lots of them get better anyway. I once read the biography of a general practitioner who felt that ninety per cent of his patients would recover from their maladies regardless of any cures he might have offered. Also, a lot of illness is psychosomatic – “in the head”. I once took a blood sample from a little old lady with a persistent sore throat. She walked into the clinic looking like death warmed up. I stuck a needle in her arm and drew some blood, and she visibly recovered. Medically it was a nonsense, but the blood drawing cured her. She’d decided that the cure she needed was a blood test, and it worked.

Clinical trials are designed to get round these effects. They take a thousand (or more) people with piles. Five hundred are given blue pills containing turnip extract. Five hundred are given blue smarties. And no one (including those giving the pills) knows which is turnip and which is smartie. The recovery rates are compared and if the drug works (without too many side effects) then it becomes readily available.

This has been going on for years. It’s called “modern medicine”. It’s a multi-billion pound industry. There’s money in making new drugs, so research is fierce. The crackpot fringe claim that the pharmaceutical industry actively clamps down on the herbal remedies. This is not the case at all – it’s the investigation of these herbal remedies that keeps the pharmaceutical industry going.

(And as an aside, compare the price of herbal remedies to the prescription charge too….)

I could be wrong, but with the intensity of research, there can’t be many herbal cures left that haven’t been scientifically investigated. Apart from the crackpots who refuse to allow their so called cures to undergo rigorous investigation. And most of those who tout these crackpot cures these days (and there’s a lot of touting going on) refuse to allow any trials of their so-called cures.

So the next time you have a headache and you are offered a lump of tree bark to suck on, it may well cure your headache. But you’d be far better off having an aspirin that was made from that tree bark.

Remember that quackery is not so much “alternative medicine” as “an alternative to medicine”… But then I’m sure that most readers of this blog know this anyway. But how can health care professionals expose this quackery in a way that people who’ve been scammed will realise that they’ve been scammed?

April 20, 2011 (Wednesday) - Modernising Scientific Careers

Today’s lunchtime seminar at work was on the latest Government’s initiative “Modernising Scientific Careers”. This is something with which I’ve been trying to get to grips for some time. The talk went on for the best part of three quarters of an hour, and in retrospect I can’t honestly say that I’m any the wiser.

But from what I can discern (and I could have this wrong), apparently there is a need to standardise scientific training in the health care professions and this will take place in conjunction with a rather radical overhaul of the jobs that we do in the laboratory. Historically we’ve (effectively) had four tiers of staff in the average path lab.

• Workers who do all the mundane hard work (where I started!)
• Technical bods who do the scientific stuff that needs a bit of understanding (like me!)
• Managerial types who run the show (like I used to be!)
• Consultant-clinical types who liaise with the doctors (like I chose NOT to be).

This is all to change. Effectively the managerial types will be out on their ears, and with the advent of modern robotic blood testing technology there will a major expansion of the role of the worker grades at the expense of the technical bods (like me!)

Those technical bods remaining (like me!) will in future be greatly reduced in numbers and will be trained alongside medics at a small number of nationally recognised institutions and will operate in a far more patient centred manner.

Or that’s the theory. And it has to be said that this is a theory with a lot of unanswered questions. Exactly what was wrong with the current condition of the workplace was never made clear. Who (exactly and specifically) will run these labs of the future? How exactly does a blood-tester work in a far more patient-centred manner? How do we encourage these clinical-scientists of the future to relocate to district general hospitals when we currently struggle to recruit staff at the equivalent pay bands? What would I personally do in this lab of the future?

What will actually happen in practice is anyone’s guess. My personal (and rather cynical) view is that it will go one of two ways.

Either the whole thing will be abandoned in favour of another crackpot scheme hatched by a different politician to the one who thought this one up.

Or it will take so long to implement that I will be safely retired before the consequences of the change affect me personally.

April 19, 2011 (Tuesday) - The ESR

The International Committee for Standardisation in Haematology has released new guidelines for performing the erythrocyte sedimentation rate. Fortunately the new international guidelines correspond exactly with our current practice.

I’m amazed that in today’s high-tech medical laboratory there is any place for the ESR. Suck blood up a tube, leave if for an hour, and see how much it settles. The more it settles, the more ill the patient.

But I suppose the secret of its success is its simplicity. Rather than performing a battery of very specific tests, the GP has a one-stop test to weed the workshy from the genuinely ill. Having determined a patient is really ill with an ESR, more specific testing can be performed.

Quite fortuitous that I should have found that link today, as over lunchtime I had a tutorial with some of the specialist portfolio students on the topic of ESRs.

April 18, 2011 (Monday) - What's in a Name?

A new diagnosis – Aase syndrome. It turns out that aase syndrome is a disease in which there are a range of physical problems and an anaemia caused by an underdeveloped bone marrow. The anaemia can be cured by bone marrow transplantation.

This got me thinking: I know of other anaemias which are only cured that way, one of which is Diamond-Blackfan syndrome. However on further research it seems that aase syndrome is actually the same medical condition as Diamond Blackfan syndrome. All that differs between the diseases is the viewpoint from which you are considering them. Aase syndrome when one considers the physical deformities, Diamond Blackfan syndrome when one considers the anaemia.

I wonder how many other conditions with which I am familiar go by different names when considered by other medically-related professions…?

April 17, 2011 (Sunday) - ESR & GF

I’m intending to give a couple of talks to the specialist portfolio students this week. The schedule calls for talks on the ESR and on glandular fever. So I spent a few minutes (an hour) on the on-line material for the relevant sections (7.1b & 7.1d): reviewing and slightly amending the set questions, and reorganising the PowerPoint presentations.

There are probably (hopefully!) some students who’ve already done the set questions as they were written before today’s revisions. That’s fine: the websites of advice are designed to be evolving things.

If only I could spend as much time actually hands-on with the students in the workplace as I do working on the on-line advice I prepare for them!

April 15, 2011 (Friday) - A Progress Review

Most Wednesdays at my place of work there is a lunchtime lecture on a subject of professional interest which I then write up on this blog. I’ve been asked why I’ve not written up the most recent one….

The reason is I’ve been reflecting on it.

The reason why I write this blog is that I have to. In order for me to retain my professional registration with my profession’s governing body I have to be seen to be performing continuing professional development. And every two years one out of every twenty biomedical scientists are called upon to show what CPD we’ve done, and explain how it satisfies the regulations. The last time people were audited, one of my colleagues was called up, and last Wednesday he talked about his experiences. So I thought that following on from that talk, and bearing in mind I’ve been doing this blog for eight months, now might be a good time to pause and look back on how I might fare if my CPD efforts were audited.

(the full wording of the CPD criteria are listed by clicking on the link “The CPD Requirements” at the top of the page)

CPD Standard #1

There are a range of ways I can do this, but for me, an on-line blog seems to work well.  This blog is a continuous, up to date and accurate record of what I’ve been up to.

CPD Standard #2

A mixture of learning activities – I think so. Looking at the labels I’ve assigned to the various blog entries I see that so far I have

• reflection (28)
• cpd talk (27)
• case study (21)
• Service Improvement (18)
• pre reg website (10)
• pre reg portfolio inspection (8)
• specialist website (6)
• mentoring (4)
• HPC Newsletter (3)
• I.T. (3)
• journal review (2)
• on-line morphology (2)
• specialist portfolio inspection (2)
• specialist portfolio tutorial (1)

CPD Standard #3

What have *I* got from my CPD? I think I’ve learned lots. I think that the twenty-eight reflections and twenty-one case studies will bear me out on this.

CPD Standard #4

This is the tricky standard to prove. What have my service users got from what I’ve done? I suppose it depends on what I define as “my service users”.

• I’ve organised a series of weekly lectures and produced an archive of presentations used at those lectures.
• I’ve produced (and maintained & improved) a website of advice for candidates (and their mentors) for the IBMS Pre-Registration Portfolio
• I’ve produced (and maintained & improved) a website of advice for candidates (and their mentors) for the IBMS Specialist Portfolio in Haematology
• Together with a colleague I’ve made a start on compiling an atlas of haematology

And on a broader scale I’d like to think that in reading this blog, the reader is somehow enriched. With over twenty hits a day, and regular readers across the world, this blog is far more popular than I ever imagined it would be.

CPD Standard #5

I haven’t done anything for this yet – the regulations say that standard 5 requires me to give a written explanation of who and what I am, and how the CPD that I have done is relevant to me. But I am only required to do so when specifically asked to do so.

I haven’t been asked (yet). Perhaps I might make a start on doing so anyway….

On Wednesday my colleague explained that he was horrified when he was selected for audit of his CPD activities. How would I react if I were called up for audit next September? At the risk of appearing smug, I’d have to say I would be quietly confident.

April 12, 2011 (Tuesday) - Pre-Reg Portfolio Section 3a.3

When I verify pre registration portfolios I am usually rather unimpressed with the health & safety aspects of the portfolios that I assess. Being the last standard in the portfolio it’s plain that by the time people have come to address that standard, they are heartily fed up with the whole portfolio idea.

Which is a shame because by the time students come to address the last standard they have probably already provided plenty of evidence for that standard in the work they have done - without realising that they have done so.

I’ve added a section to my website of advice for the pre-registration portfolio specifically for the Health & Safety section. Hopefully just one A4 sheet listing the other evidences where H&S matters are covered will provide adequate evidence for section 3a.3.

I’ve suggested to two of my students that they try this approach. Let’s see if it works….

April 11, 2011 (Monday) -Behcet's Disease

Today we had a diagnosis which was new to me....

Behçet's disease (Behçet's syndrome, Adamantiades’ syndrome, or "silk road disease") is a rare, systemic, form of vasculitis that often presents with mucous membrane ulceration, and ocular problems.

As a systemic disease, it also involves visceral organs such as the gastrointestinal tract, pulmonary, musculoskeletal, and neurological systems.

This syndrome can be fatal; death can be caused by complicated rupture of the vascular aneurysms, or severe neurological complications, and therefore immediate medical treatment is necessary.

The syndrome is rare In the UK, it is estimated to have about 1 case for every 100,000 people, but is common in the Middle East and Asia, suggesting a possible cause endemic to the tropical areas.

It is not associated with cancer, and links with tissue-types are not certain but are under investigation.

It also does not follow the usual pattern for autoimmune diseases. However, one study has revealed a possible connection to food allergies, particularly to dairy products.

One lives and learns….

April 10, 2011 (Sunday) - HPC Newsletter

The HPC have just released their latest newsletter. I wasn’t too impressed with the last two, but this one has one or two bits in it that made me think.

I don’t like the idea of the health self-declaration. Previously before anyone could be HPC registered they needed a doctor to certify that their health (both mentally and physically) was up to par. Now potential applicants can just announce they are healthy enough and off they go. Surely if someone has spend five years or more trying to obtain HPC registration (a not unreasonable estimate of time from commencement of degree to portfolio verification) they are hardly going to then announce they aren’t up to it, are they?

I’ll leave aside the whole tangled mess of what medically unsuitable registrants might get up to….

There was an article about exactly what a registrant can and cannot mention about work on social networking websites. There are websites out there that are good – take for example “I am a Biomedical Scientist” on Facebook. Or look at any of the links in the panel on the right hand side of this page. These are good examples of professional use of social networking. I aspire to be that good. I try – but there’s no denying that a few of my rants have got close to the line recently, but I do take care to follow the HPC guidelines when I’m blogging on this website.

It annoys me that others do not. Take for example the Facebook group “The Hospital Lab Biomedical Scientist”. I’ve “unliked” that page – do we as health care professionals really want to be associated with such quotes as “just so cannot be arsed to look at anymore smears... make it up time methinks!”. And some of the stories related on that website make me cringe. I can’t pretend that the medical profession is perfect, but there’s something frankly idiotic in openly broadcasting failures to the world in the worst possible light. Look at the post from last Thursday at 13:39 and ask yourself what your employer would do if you’d posted that.

There was an advert: “We are seeking to recruit registered professionals to fill vacancies for the role of Visitor. Visitors make recommendations about education and training delivered (or proposing to be delivered) by education providers.” I would have applied, but they didn’t want biomedical scientists (this time).

The newsletter ended by saying that the HPC is now on Facebook. I’ve “liked” it – but bearing in mind some of the other work-related Facebook pages, I wonder how that page will pan out…

April 7, 2011 (THursday) - Specialist Portfolio (Again)

I received a certificate through the post today. Our lab is now certified to deliver training for the Specialist Portfolio. I’m personally very pleased about this, and I’m taking it as a personal success, and a vindication of my way of tackling the specialist portfolio.

Something on which I am very poor is actually spending time with the students to monitor progress. Whilst my entire philosophy is that I give them all the information on a website and let them get on with it, I am very conscious that I do need to actually spend some time with them. I’ve had words with the boss – an hour is to be allocated to me twice a week, which is probably just as well as I have eight (soon to be nine) students working on that portfolio. So (hopefully) I should have one session per student per month.

In the meantime I’ve revised my pro-forma for recording what happens at these monthly reviews.

I just need to make sure these meetings actually happen!!!

April 6, 2011 (Wednesday) - Mistaken Identity?

Being Wednesday we had the traditional lunchtime seminar - a fascinating lecture and subsequent discussion: how can we be certain of the origin of any blood sample with which we are presented. Does the name on the bottle bear any relation to the person from whom the blood was taken?

Was the person who collected the blood sample meticulous in confirming the patient's identity?

I've seen a case (admittedly a long time ago and in another hospital) where a retired gentleman arrived at the phlebotomy station with the blood test form of an antenatal teenager. Said retired gentleman insisted that the details on the form were his details. I asked the chap if his name was Susan, was he nineteen years old and pregnant to which he answered a most emphatic YES!!!

Also how do we know that the patient is who they claim to be? How do we know they aren’t actually lying and making that claim for nefarious reasons of their own?

I've seen cases where patient’s blood groups and haemoglobinopathy statuses have apparently (and impossibly) changed because illegal immigrants have had medical treatments using the alias of legal immigrant friends.

And given that a blood test is labelled as being from Fletcher Honorama with d.o.b. 30-2-64, how do we know that this patient is the same Fletcher Honorama with d.o.b. 30-2-64 that exists on the laboratory computer? Seeing that the name is rather obscure, this is *probably* a safe bet.  But only *probably*. How can we be sure?

Short of microchipping the population (as one does with one's pets) there is no easy answer to this. But today's talk has made me think...

April 5, 2011 (Tuesday) - Nucleated Red Cell Counts

Following on from last Thursday’s seminar, it struck me that if we request nucleated red cell counts on those samples likely to have nucleated red cells in their circulation, then we would (probably) get white cell differential counts in these cases. Thereby reducing the need for manual differentials in cases in which it is difficult to perform such differentials, and also speeding up the process.

Rule Table Definition Rule Code:ZHB1  Description: Haem - count with Hb-opathies                                                          If   %HLOC  EQ  WSCBU  AND %OC    CO  FB     AND %OC    NCO NRBC Then          ALERT Enter ALERT text Please add test NRBC to this request Confirm with f10 key [Y or N] : Y  Use as error : N  Else  CONT   Dialogue If Historical Location is EQUAL to "WSCBU" and Order Code does CONTAIN "FB"   and Order Code does NOT CONTAIN "NRBC" Then ALERT Else CONT

I therefore made a tweak to an existing rule. The idea is that the rule will now prompt the clerical staff to request an NRBC count when a child on the special baby care unit has a blood count done.

Ideally the rule would add the test automatically, but I can’t get that to work. Something for the future, maybe?

April 4, 2011 (Monday) - An International Problem

A couple of days ago I mentioned about how we are losing staff to jobs which offer less responsibility for more money. I was therefore interested to read an American journal today in which it would seem that the American financially driven model (which we are constantly being told is the way forward) isn’t working any better. Staff recruitment in the US would seem to be problematical, with the highest amount of unfilled vacancies in the blood banks (which is where the most stress is). With ten percent of staff posts unfilled, nearly twenty per cent of supervisor posts unfilled and fifteen per cent of those in post looking to retire in the near future, American blood banks are looking at a staffing crisis. And as for getting more staff, the article says: ”Changes in hiring criteria for laboratory personnel, coupled with a declining interest in laboratory medicine as a career over the past two decades has led to the closure of numerous medical technologist training programs.”

Clearly running medical labs as a business isn’t providing the best quality service. I thought the whole thrust of medical advancement these days was “evidence-based” – doing something because it is seen to work, or not doing something because it demonstrably does not. I am reminded of the Serenity Prayer: “God, grant me the serenity to accept the things I cannot change, Courage to change the things I can, And wisdom to know the difference”.

It is difficult to be serene when one is watching one’s chosen profession going down the pan….

April 2, 2011 (Saturday) - A Pay Freeze

For all that I whinge about my job (from time to time) it’s not a bad old life. It could be a lot worse. And I’m desperately hoping that government policy won’t make it worse.

My wages have been frozen for two years. I won’t get a pay rise in that time. And nor will my colleagues. Perhaps it’s rather self-seeking of me to worry about pounds and pence in what I originally intended to be a professional and reflective blog, but what will the effects of that pay freeze be? For myself it’s rather obvious. I shall have one pint of beer less every time I’m in the pub, and I might occasionally whinge about the rises in the cost of living outstripping my wages. But will everyone else have the same attitude?

I’ve been told by one of our support workers that he’s resigned and is soon to take up his new position. He’s found that bar work pays better than lab work, and is off to earn a crust by pulling pints. We will miss this chap when he goes. He’ll be replaced, and six months down the line he’ll be but a happy memory. Five years from now and no one will even remember his name. But what worries me is the (potential) legacy of this chap’s departure. What will be the reaction of all the other support staff?

After all, if you make a mistake at work, what happens? If there’s a mistake made in the hospital lab then there are potentially dire (and possibly fatal) consequences. If there’s a mistake made with a drinks order in the pub, then it can be put right in a matter of seconds. How long will it take people to realise that they could do a job with less responsibilities and earn more money?

Five years from now no one in the lab will remember the name of the bloke who resigned yesterday because in five years time we might all have got ourselves better paid jobs and there might be no one left in the lab.

One of the stated purposes of my doing C.P.D. (and this blog) is to improve the service I provide. It’s very difficult to do so when I’m being actively undermined by HM Government.