September 30th (Thursday) - Iron Deficiency

A textbook case of iron deficiency. Clearly three years ago the patient was haematologically normal.

FIENDISH,GRIMLEY                                                  DOB  13/08/1949 Sex M Pat No 973146       Source    G.P.     Address   PLANET EARTH                        Clinician CRIPPEN     Date 30/09/2010 29/08/2010 13/05/2010 06/11/2008 28/10/2008 12/01/2007   Time u/k        10:25      07:06      u/k        10:03      11:16       Spec AM918276P  AW184950Q  AW289967S  AM842670E  AM830095R  AM777490D Test HB     9.0        9.4        11.6       16.2       16.0       16.5     WBC    5.2        5.4        7.9        7.2        5.7        6.3    PLT    413        326        278        194        192        157  RBC    4.68       4.59       4.40       5.15       5.13       5.24 HCT    0.343      0.340      0.380      0.463      0.465      0.481 MCV    73.3       74.1       86.6       89.9       90.6       91.6 MCH    20.9       20.5       26.4       31.5       31.2       31.5 MCHC   28.6       27.6       30.4       35.0       34.4       34.4 NEUH   2.5        2.8        4.4        3.5        2.7        3.6  LYMPH  1.9        1.7        2.4        2.7        2.3        2.1 MONO   0.6        0.7        0.9        0.7        0.6        0.5 EOS    0.1        0.1        0.1        0.1        0.1        0.1   1 View   2 Graph   3 eXit  X                             Cursor Down for more

In the intervening three years the chap has obviously “sprung a leak” somewhere and his haemoglobin level has slowly fallen as the platelet count has risen. And as is expected the haemoglobin fell before the red cell volume did (see result of 13 May 2010). The blood film shows the characteristic hypochromia and microcytosis as well as pencil cells.

In the first instance a course of ferrous sulphate would deal with the symptoms, but clinical investigation to find the leak would be a sensible course of action.

And such reflection isn’t really fooling anyone: I’ve been doing this job for years. It’s not really news to me at all. But what is good about it is that it illustrates all the features of a chronic blood loss which causes an iron-deficiency anaemia. Such so-called “textbook” cases aren’t actually that common. Most get picked up by the patients presenting much earlier and long before the changes evident here have set in.

I’ve been looking for various case studies for the website of advice I’m compiling for people doing the specialist portfolio. This will do nicely. Mind you, I really need to revisit that website and do something with it. I haven’t touched it in ages…

September 29th (Wednesday) - Cardiomyopathy

Today's lunchtime seminar was on the subject of cardiomyopathy. We started with an overview of cardiac anatomy and physiology, and then covered the three most common cardiomyopathies.

A useful revision of basic cardiology which I hadn't really reviewed for over twenty years, and then the discussion on the disease states pulled together various threads I'd picked up over the years. A really useful session….

September 28th (Tuesday) - West Kent Skills Fest

A few months ago I had an email from the boss asking if any of our staff fancied manning a stall at the West Kent Skills Festival. I forwarded the email to my immediate colleagues. No one seemed keen on the idea, so I volunteered myself. A day sitting around talking to students about what I do for a living seemed a somewhat more attractive proposition than a day spent actually doing that living. Funnily enough, as I collected posters and exhibits for our stall during the preceding week, people seemed to be somewhat jealous about my forthcoming day out. All I can say is that maybe this is God’s way of saying read your emails next time (!)

I met up with a colleague from the Margate hospital, and we soon arrived in Tonbridge. Finding the Angel Centre was tricky, but we eventually found our reserved place. The idea of the day was to provide career choice information to local schools and colleges, and we were putting on one of seventy five stalls. We were next to a stall manned by staff from a nursery school on one side. On the other side we had an engineering firm who were offering students the chance to make and float Lego boats. Opposite us was a stall from Charlton Athletic football club (!) and nearby were stalls from Leicester University’s science department, Kent University’s maths department, Kent Highways, Kent police, the Army, and one featuring some rather foxy sailors (woof!). Also present were several other engineering firms, the Royal Air Force, my leccie provider (who gave me a free key-ring), and pretty much everybody and anybody. I don’t think the day could have been bettered for careers ideas

We set up our stall rather quickly, and we soon found ourselves faced with hoards of schoolchildren. At first I wondered if we would be able to hold our own against the competition, but in retrospect I think we gave a fair accounting of our profession. My colleague spoke very knowledgeably about the intricacies of blood groups and the excitement of urgent emergency blood transfusions. I spoke rather loudly, noisily and grossly about the fascinating subject that is human parasitology. (Students like that!) To illustrate my witterings we had a microscope rigged up to show microfilaria (the small blood-borne worms that cause sleeping sickness) and a foot-long dead round worm in a sealed pot (actually retrieved from a real patient’s bum). Between us we also touched on the automated analysis of blood, haemophilia, clinical (and other) uses of warfarin, antibiotics and bacteriology, cervical cytology, and histological examinations. I think we did ourselves proud – before long the students were telling their mates about us. Newcomers to the exhibition were asking the centre management where they could find the “Extreme Biology” stall. I quite liked being regarded as an “Extreme Biologist”.

We were told that there were over two thousand students who came to the exhibition. I don’t think we saw them all, but those that we did meet left our stall actually knowing what a biomedical scientist does and (I’d like to think) with some respect for the hospital biomedical scientist.

Or perhaps it’s fairer to say that most of them did. There was a small minority who flatly refused to even come near the stall because of the inherent squeamishness provoked by the subject matter. There was one young lady who was rather disparaging about the entire concept of biomedical science. She announced (rather patronisingly) that she intends to study at University to find out why people die.

And there was another blossom who asked (in a very shy voice) if she could be an air hostess. Bless….

Next time…  I’d not take so many microscope slides. We took hundreds and used one. I’d take a laptop with a looped presentation running. And I’d have some fliers about becoming a biomedical scientist. So bearing in mind there’s another of these in a few weeks time I’d better get working on the looped presentation and see about scaring up some recruiting information…

September 27th (Monday) - C.P.A.

Last Thursday I mentioned compiling a set of questions about the IBMS for the students pre-registration portfolio website. I got half way through preparing something this evening when I had a quick look at the actual standards of the portfolio. There’s not actually any requirement to do anything about the IBMS. That was a waste of my time.

Instead I revamped some questions I’d done a couple of years ago about the role of the CPA.

Like the questions I revised last week, these questions now seem to actually mean something, rather than just being the gibberish they once were. I suspect that all fifteen of the lists of my set questions could probably do with some revision.

September 24th (Friday) - Air Travel

The latest BCSH guidelines on travel-related venous thrombosis have been issued. They don’t really say anything new that I can see. With a risk of developing thrombosis on an aeroplane being of the order of one in a million, I can’t help wondering if the whole thrombosis/air flight story is pure scaremongering to sell less reputable newspapers…?

September 23rd (Thursday) - The H.P.C.

This evening I spent a few minutes (ten) of my own time revising the set questions on the role of the HPC which I’ve offered as a suggestion as evidence for portfolio section 1a.1 over on my website of advice for students who are tackling the pre-registration portfolio. 
I didn’t like the layout I’d used, and I don’t think I’ve actually seriously revised the questions since I blagged the idea for them from a microbiologist some five years ago.

On re-reading them I had no idea what I was actually asking. I pity the poor students who’ve actually tried to make head or tail of them (!)

Having had a look through and re-worded most of them, I still don’t like the layout, but at least I think I know what I’m getting at with each question. Mind you I now can’t help but feel I should have a suggestion for a set of questions on the role of the IBMS too. I’ll do that later…

September 22nd (Wednesday) - Cardiolipin

After last week’s hiccup with the software we’d practiced beforehand to make sure it all worked. Today’s talk was on anticardiolipin and the antiphospholipid syndromes. I learned loads. Which to my mind demonstrates the usefulness and validity of the entire concept of CPD.

I can remember when I was first employed as a Junior ”A” Grade M.L.S.O. back at the Sussex Infirmary for Distressed Gentlefolk. The senior staff there were about as old as I am now, and it was quite obvious that the knowledge base of many of these senior people was hopelessly out of date.

Being first described in the mid 1980s I never touched on today’s subject matter when I was doing formal work-related study. And without something like CPD it would be possible for me to have continued in my ignorance. On reflection I’m quite grateful for today’s session.

September 20th (Monday) - Batten's Disease

BUNDY,T.F.                   DOB  10/07/1994 Sex F Pat No 999             Received  13:47 Address   HIS HOUSE                               20/09/2010 Diagnosis known battens disease on phenytoin Specimen No   :  AW147418M                 HB     12.7   Q000 MONO   0.9    Q000                    WBC    14.4   Q000 EOS    0.0    Q000  PLT    197    Q000 BASO   0.0    Q000  RBC    3.95   Q000 ~F1   ^LS     Q008  HCT    0.380  Q000 ~F2   ^FILMW  Q008  MCV    96.2   Q000  MCH    32.2   Q000  MCHC   33.4  Q000  NEUH   11.4   Q000  LYMPH  2.1    Q000

Batten’s disease is a new one on me. Further investigation shows it’s a disease of a malfunctioning lipid metabolism, and consequently lends itself to being diagnosed by histological staining. Which is sometimes the problem in my line of work. Such glib statements tend to overlook the fact that children with Batten disease become blind, bedridden, and demented before dying much sooner than they otherwise would.

One lives and learns…

September 17th (Friday) - Committees

There’s no denying that the bit of my job I like the best is being very involved with the training.

I’ve currently got six trainee biomedical scientists under my wing. Help, advice and guidance from my sage experience on a daily basis, and an occasional firm kick up the bum when needed. I have to admit that work does support me in this respect; I’m given time to spend with trainees (not as much as I’d like, but then there are other things to do…), and I’m given time to go to other hospitals to assess their trainees and time to go to the university for all sorts of reasons. Over the last few years I’ve got to grips with the pre-registration portfolio and am seen as something of a leading light on it, and I’m happy to be so.

I’m also worrying about four qualified biomedical scientists who are studying for their specialist portfolio and a lab assistant who is studying for the biomedical science foundation degree. I’d like to do more with them, but I’m not quite sure exactly what I should be doing.

And it’s no secret that I’m dead keen on continuing professional development (hence this blog). As well as spending much of my every working day pointing out CPD opportunities to all and sundry, I (try to) run a formal series of seminars on Wednesday lunchtimes.

There is always a flip side to anything good. Being seen as an educationalist is one thing. Being formally recognised as such is another. And having been formally recognised, I’m a member of the work’s Education and Training committee… I’m not going to run down this committee, or my work’s management. That is neither reflective nor constructive.

The problem lies with me. I need to accept that management have decided that they will operate by committee. In my time I’ve been on so many committees, both at work and in various voluntary personal capacities. I really should realise and accept that some people really do like the “committee way” of doing things. They really can spend hours considering the intricate ramifications of obscure legislations. Some people really do enjoy the confrontational challenge of civilised debate, and can spend hours politely discussing obscure points of semantics. Others go along to have a “who’s the busiest, you or me” argument and really cannot see that if they actually were as busy as they claimed to be, they’d not have time to be at the committee meeting.

My problem is that I am not a committee animal. I don’t understand the need for it and I don’t speak the language. At a very fundamental level I don’t think I agree with the concept of democracy as exemplified in committees. I’d far rather be given orders and spend the precious time I would have spent in committee getting on with those orders. Today was a classic case in point. I spent two hours  sitting in a committee meeting occasionally offering opinions of dubious merit whist fretting about the work that I felt I should be doing.

The failing is on my part, I’m sure…

September 16th (Thursday) - Glandular Fever

An interesting case

Specimen Results Entry HONORAMA, FLETCHER                                                     Queue  DOB  07/04/1992 Sex F Pat No 666          Source    G.P.   Received  18:23 Address   HER HOUSE                       Clinician JECKYLL              16/09/2010 Diagnosis SORE THROAT Specimen No   :  AW126536J               Selected Auth Level : S  HB     13.7   Q000  MONO   1.6    Q000                     WBC    11.1   Q000  EOS    0.0    Q000                     PLT    168    Q000  BASO   0.4    Q000                     RBC    4.87   Q000  E      5      Q000                     HCT    0.420  Q000  G      +      Q000                     MCV    85.2   Q000  ~F1   ^ATM    Q008                     MCH    28.1   Q000  ~F2   ^FR     Q008                     MCHC   33.0   Q000                                        NEUH   2.7    Q000                                        LYMPH  6.5    Q000                                        1 Auth'd   2 Unauth'd   3 Nomin'd   4 Change   5 Reject  6 Options  7 eXit> U  Disc: CLIN    Sect: HAEW          The Author

Note the reversed neutrophil/lymphocyte ratio and the appearance of atypical mononuclear cells in the blood film.

Bearing in mind the diagnosis of “sore throat” and the patient’s age, I suspected this to be a case of glandular fever. I added the test for glandular fever to the request, and my educated guess was right. And in doing this I’ve saved time in the diagnostic process.

And then I found two more almost identical cases. Is there an outbreak?  And then I remembered – schools and colleges are back in session…

September 15th (Wednesday) - Lunchtime Presentation

The plan was to have a lunchtime CPD presentation today. Having got to grips with the presentation apparatus last week I had been looking forward to today's talk. But we had a minor hiccup with today's CPD presentation which has illustrated an important point....

People prepare CPD talks in their own time, much as I write this blog. And people do it at home where they (generally) have a far better and more modern P.C. and/or laptop than is available at work. So when today’s speaker brought in her presentation, the Office 2003 software didn't recognise the *.pptx files.

So I've asked people that when preparing a PowerPoint talk for CPD purposes, if they've created the thing at home on more modern versions of MicroSoft Office, could they use the "Save As" option rather than "Save", and to save as an office 2003 compatible file if they are going to bring it in on a stick.

Alternatively they might bring in the presentation on a laptop which we could plug directly into the presentation apparatus.

On a similar theme, yesterday a colleague asked what happens to the CPD PowerPoint files after they are presented. He said he’d like to be able to see the PowerPoint presentations of the sessions that he’d missed. My immediate reaction was that in four years of doing these talks no one had ever asked that before, but he got me thinking. And after a little bit of mucking about, I’ve obtained the use of a gigabyte (or so) of webspace where I shall form an archive of CPD presentations. Provided of course the speakers are happy for me to have their work. This archive is a bit empty at the moment. I’m hoping it will grow with time.

September 14th (Tuesday) - Some Mentoring

For once I actually had some time for the trainees, and had a couple of one-to-ones today. One of them has all but completed his pre-registration portfolio. I’m feeling a sense of completion, but probably nowhere near as much as he is.

The other is just about to embark on his pre-registration portfolio, and so over on another CPD project of mine I have a PowerPoint presentation designed to give such students an introduction into what they can expect when doing this portfolio. It’s only a year since I put that PowerPoint presentation together, and already it’s rather out of date. When I get a minute or two I shall put it right. Putting the PowerPoint presentation right is easy. But getting that revised PowerPoint presentation into the website…. I can’t remember how I did that…..

Moral of the story – this website will never be a finished product. It’s always going to be a work in progress. Which, for my personal CPD purposes, is ideal provided I actually keep up the work.

September 13th (Monday) - A Case Study

MOUSE,MICKEY                                            B+       Queue DOB  10/04/1932 Sex M Pat No 654321       Source    HOSPITAL  Received  11:58 Address   DISNEYLAND            Clinician KILDARE                    10/09/2010   Date 10/09/2010 14/07/2010 30/06/2010 23/06/2010 09/06/2010 09/10/2007         Time 11:28      09:30      10:05      10:00      10:00      u/k                Spec AW117471J  AW215069M  AW170145Q  AW146255Q  AW380100H  AW188183G                HB    7.6        10.5       12.2       11.2       12.9       14.0             WBC   9.3        3.9        7.2        4.1        7.1        6.0              PLT   264        124        135        145        129        165              RBC   2.76       3.50       4.18       3.94       4.50       4.78             HCT   0.260      0.320      0.360      0.350      0.380      0.423            MCV   94.2       90.3       85.4       89.1       85.3       88.5             MCH   27.5       30.0       29.2       28.4       28.7       29.3             MCHC  29.2       33.2       34.2       31.9       33.6       33.1             NEUH  5.9        1.6        4.6        1.7        4.8        3.71             LYMPH 2.6        1.8        2.2        2.1        1.9        1.49             MONO  0.7        0.4        0.3        0.4        0.3        0.50             EOS   0.0        0.0        0.0        0.0        0.0        0.24                                         Cursor Down for more                         Disc: CLIN    Sect: HAEW          THE DIARIST       SRE/APEX

An interesting case. Consider the historical record. The patient has been haemodynamically stable, with haemoglobin and platelet levels toward the lower end of the reference ranges for at least three years.

He’s developed a gastrointestinal bleed which is evidenced by the drop in haemoglobin level. However the interesting parameter is the platelet count. It has effectively doubled (which is expected in such cases), but such doubling isn’t immediately noticeable because the number is now in the middle of the reference range.

Moral of the story – look at changes in values, not the values in isolation.

September 12th (Sunday) - Reflection

In the four days since I created this reflective diary, it’s been accessed over a hundred times (and I’ve set the tracking software not to record when I call the thing up myself!). When I set it up I never intended it to be primarily something that other people would read or use, it was (and is) intended to be an archive for myself and the HPC-appointed CPD inspector.

But if others like reading it, that’s fine by me. And to that end I’ve added a couple of pages (see above) to this reflective diary. One to give hints and tips about what CPD is all about, and one to help other biomedical scientists to set up their own reflective diary. I wonder if anyone will…?

Speaking for myself, I’ve now managed to do some CPD every day for a week. And more importantly to record that I’ve done so. I hope I can keep this up…

September 11th (Saturday) - Swear Words

I spent a little while fiddling with my pre-registration website today. I’ve recently discontinued updating the first draft of this website. A lot of it was done in work’s time, and so I’ve left the first draft elsewhere on the Internet. If work want it, they can have it. The revised version is mine!

Which has given me something of a dilemma. This pre registration website of mine is supposed to be a serious one; intended to give advice for students applying to become State Registered biomedical scientists. Today I added a section of advice on the subject of “Reflective Practice”. Am I wrong to use the word “b*ll*cks” in that advice?

September 10th 2010 (Friday) - Another Urgent Queue

The problem – identifying samples from wards which would require attention before samples from less urgent souces.

The solution – queue them, in the same way I queued samples from the most urgent locations (a few months ago)

Queue Summary Queues requiring attention :- Queue Queue name No. of specimens Date Time User -------------------------------------------------------- Urgent - General Queues URGENT One-hour turnaround samples 29 10/09/2010 19:40 0 WARDS Four hour turnaround samples   1 10/09/2010 19:35 0 Routine - General Queues GF GF tests to be done 11 10/09/2010 18:43 0 VITP B12s awaiting authorisation 16 10/09/2010 17:41 0 ZHB1 Hb-opathies awaiting analysis 16 10/09/2010 19:18 0 ZHB2 Hb-opathies sent to Somewhere 37 10/09/2010 09:40 0 -------------------------------------------------------- 1 Process queue 2 List 3 Update 4 eXit : P Disc: CLIN Sect: HAEW QMON/APEX Overtype

Firstly I created a list of wards the results from which needed to appear on the four hour turnaround samples.

Then I made a rule:

• If it’s on a queue already then quit else continue
• If it’s not one of our samples (AW succession number) then quit else continue
• If it’s on the list of wards then queue the result else quit.

"WARDS" (in red) is the new queue - let’s see if it works