Bands no longer important

[RATM2010]

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Hi guys and gals,

I just learned yesterday that the clinical laboratory specialists at my hospital were reviewing teh clinical signifigance of bands. Apparently there is a article out that says that they are no longer of clinical importance. Has anyone heard of this or know anything about this? If so, what do you think if bands are no longer included in the manual differential?

 

[ccfccp]

Real bands haven't been important for a while. Everyone just lip syncs anyway. 🙂

 

[RATM2010]

ok.....

 

[McGillGrad]

We have no idea what you're talking about.

 

[Entgegen]

Neutrophilic bands/left shift on a CBC w/ diff.

 

[McGillGrad]

Neutrophilic bands/left shift on a CBC w/ diff.

Nice catch.


As for the OP, the lab guys don't have the medical background to understand the significance of the measures they record for the physicians.

Just like every other lab result, the interpretation is dependent on many factors, including the patient's history and physical (and current observations).

Thus, it is ignorant to assume that any clue could be useless clinically. It serves a purpose in some cases and no much in other cases. Just like WBC counts are not very useful in neonates, but very useful in adults.

That's why there's 4 years of medical school and 3-5 years of residency spent on learning physiology and pathology. It is dynamic application of variables. Not just reading some lab results and cut-and-pasting a result.

 

[cyclohexanol]

Hi guys and gals,

I just learned yesterday that the clinical laboratory specialists at my hospital were reviewing teh clinical signifigance of bands. Apparently there is a article out that says that they are no longer of clinical importance. Has anyone heard of this or know anything about this? If so, what do you think if bands are no longer included in the manual differential?

I have no idea what you're making reference to, it would help if you had some kind of information regarding your reference. In a quick search the only thing I came up with was this:

http://www.ncbi.nlm.nih.gov/pubmed/20970296

Notwithstanding the statistical problems with the study (single center study, low n, etc..), their conclusion is that degree bandemia doesn't predict mortality.

This does not mean that bands are 'no longer of clinical significance', bands are used together with multiple other metrics and the clinical picture in order to guide further diagnostics and therapeutics.

 

[Venko]

Nice catch.


As for the OP, the lab guys don't have the medical background to understand the significance of the measures they record for the physicians.

Just like every other lab result, the interpretation is dependent on many factors, including the patient's history and physical (and current observations).

Thus, it is ignorant to assume that any clue could be useless clinically. It serves a purpose in some cases and no much in other cases. Just like WBC counts are not very useful in neonates, but very useful in adults.

That's why there's 4 years of medical school and 3-5 years of residency spent on learning physiology and pathology. It is dynamic application of variables. Not just reading some lab results and cut-and-pasting a result.

I would be careful with this.

Many of the labs are run by very intelligent people who probably understand the shortcomings of their tests sometimes better than the clinician. For example when a urine tox screen may falsely show a positive result and then combining with the local prevalence / incidence of disease how meaningful the result they are posting is. Sometiems the labs are run by pathologists or other specialties who can help train the folks to be very knowledgeable. Be careful, sometimes the people who work in a specific part of the hospital truly are an expert in that part....i.e.the lab folks may know about the labs they are reporting 😉

Does this mean they are right on this issue, no, just that the idea that as a uniform rule the lab is not necessarily less knowledgeable and should be discounted.

Also, I'll say that maybe its just my ignorance but the MCHC, monocytes etc have not to my recollection altered my decision making process. Some tests don't help make decisions....some argue the WBC entirely does not alter your decisions when practicing truly evidence directed care....

 

[McGillGrad]

I would be careful with this. Many of the labs are run by very intelligent people who probably understand the shortcomings of their tests sometimes better than the clinician. For example when a urine tox screen may falsely show a positive result and then combining with the local prevalence / incidence of disease who meaningful the result they are posting is. Sometiems the labs are run by pathologists or other specialties who can help train the folks to be very knowledgeable. Be careful, sometimes the people who work in a specific part of the hospital truly are an expert in that part....i.e.the lab folks may know about the labs they are reporting 😉

Fair enough.

Although, it kind of cute when the lab guys leave little notes on your results questioning why you are re-running this or that.

 

[EM2BE]

Pretty sure when we got a result of 68% BANDS it meant something. We never got the chance to figure out what though.

 

[alexmtr]

I would be careful with this.

Many of the labs are run by very intelligent people who probably understand the shortcomings of their tests sometimes better than the clinician. For example when a urine tox screen may falsely show a positive result and then combining with the local prevalence / incidence of disease how meaningful the result they are posting is. Sometiems the labs are run by pathologists or other specialties who can help train the folks to be very knowledgeable. Be careful, sometimes the people who work in a specific part of the hospital truly are an expert in that part....i.e.the lab folks may know about the labs they are reporting 😉

Right on 👍
My mom used to work in a lab - some of the things clinicians say/do are pretty dumb/ignorant from a pathologist's perspective 😉

 

[McGillGrad]

Right on 👍
My mom used to work in a lab - some of the things clinicians say/do are pretty dumb/ignorant from a pathologist's perspective 😉

Well at least you're unbiased.

 

[Zback]

While working in the rural environment during under-grad I was amazed by some of the questions that the physicians were asked by the lab.

 

[WilcoWorld]

Right on 👍
My mom used to work in a lab - some of the things clinicians say/do are pretty dumb/ignorant from a pathologist's perspective 😉

The key word here is perspective. I'm sure that some of the tests the ED orders seem ridiculous from path's perspective, but some of the things my lab does strike me as ridiculous as well. The truth is that everyone thinks that his thinking is logical, it's everyone else who is wrong. I think an environment of mutual respect is what's best for everyone, even if it is rarely achieved.

 

[Birdstrike]

A band count is and always has been very non-sensitive and non-specific. If you're relying on a band count to tell you if someone is sick or not sick, you're lost. We usually use such tests to tell us what we want to hear which can be a source of errors. The only value such a test has is as "consultant bait"....ie, "I know everything else is negative but this kid sure does look sick and you know, that bandemia really bothers me. You know last last kid I had that bounced back with sepsis...the only thing he had was a bandemia". I'm going to write book, it's going to be called, "The art of admitting patients who aren't even remotely sick", by Birdstrike. I could get a vegan low fat organic salad admitted to the hospital if I needed to. A high band count just might get it done.

 

[roja]

1. No test is EVER perfect.
2. This doesn't mean that in the context of building a picture of a patient that it is useless (see physical exam)
3. ONE article NEVER proves anything. ever.
4. There are stupid, idiotic people at all levels. No one has a monopoly on it.
5. If you haven't examined the patient and aren't legally responsible for the patient, you should realize you are operating under a serious handicap. Doesn't mean the person who is is absolutely correct, just that you might want to keep that in mind.
6. I can't think of a single 'test', in isolation, that I would make a decision on for a patient

 

[gutonc]

6. I can't think of a single 'test', in isolation, that I would make a decision on for a patient

I can think of a bunch of "tests" (biopsy, cardiac cath, endoscopy, CTA chest, etc) but very few of them that you can get in the ED so your point is still valid.

 

[alexmtr]

Well at least you're unbiased.

Yep. I just assume that all clinicians (including my future self) are stupid because that's what my mommy told me.
...or perhaps it is all about perspective and realizing that being smart/educated in one area (like being an EM doc or something 😉) doesn't mean you know everything. It is like arguing about the importance/difficulty of different medical specialties - even if something sound like a "simple job", if it requires years of education and training, it is usually safe to assume the people doing it know more about it than you do....

The key word here is perspective. I'm sure that some of the tests the ED orders seem ridiculous from path's perspective, but some of the things my lab does strike me as ridiculous as well. The truth is that everyone thinks that his thinking is logical, it's everyone else who is wrong. I think an environment of mutual respect is what's best for everyone, even if it is rarely achieved.

👍 🙂 👍 🙂

 

[McGillGrad]

Yep. I just assume that all clinicians (including my future self) are stupid because that's what my mommy told me.
...or perhaps it is all about perspective and realizing that being smart/educated in one area (like being an EM doc or something 😉) doesn't mean you know everything. It is like arguing about the importance/difficulty of different medical specialties - even if something sound like a "simple job", if it requires years of education and training, it is usually safe to assume the people doing it know more about it than you do....

Well, at least you're professional about it.

 

[alexmtr]

Well, at least you're professional about it.

Well, at least you focused on the most relevant sentence in my post...
Seriously - is this a cat people vs. dog people argument? 😉 Because it is really about nothing meaningful as far as I can tell 😛

 

[microscp2]

Nice catch.


As for the OP, the lab guys don't have the medical background to understand the significance of the measures they record for the physicians.

Just like every other lab result, the interpretation is dependent on many factors, including the patient's history and physical (and current observations).

Thus, it is ignorant to assume that any clue could be useless clinically. It serves a purpose in some cases and no much in other cases. Just like WBC counts are not very useful in neonates, but very useful in adults.

That's why there's 4 years of medical school and 3-5 years of residency spent on learning physiology and pathology. It is dynamic application of variables. Not just reading some lab results and cut-and-pasting a result.

You are very wrong at assuming the medical lab specialist doesnt have the medical background, but you are not alone, it is the biggest misconception in the medical field. I am an intern today, but was a clinical laboratory specialist until the day before went to med school, ASCP certied(American society of clinical pathologist) Pathology was sooo easy for me because I already had it, a condensed version of it, but broad enough.Also hematology, blood bank , clinical biochemistry, immunology , microbiology, etc. , thechnically all except pharmacology and neuro.I finished basic sciences with straigh A , thanks to my preparation as a clinical laboratory specialist, and like the guy at your hospital, I had to take the same pre med as you did, all the general and organic chemistry,all the physics and biochemistries and biology courses, reason why when I finally decided to apply to med school, I already had all the required classes plus more !
The people that answer the phone at the lab, are not the lab specialist, they are busy working. Usually are the phlebotomist or lab assistant, who are people with high school diploma and no knowledge, so give the bad reputation that the lab gets.

 

[McGillGrad]

You are very wrong at assuming the medical lab specialist doesnt have the medical background, but you are not alone, it is the biggest misconception in the medical field.

So what you're saying is that you would trust a lab tech to diagnose and treat your family?

 

[Rendar5]

So what you're saying is that you would trust a lab tech to diagnose and treat your family?

For all that sarcasm, I don't think you comprehended what he wrote. You just responded to what you wanted to think he wrote.

 

[McGillGrad]

For all that sarcasm, I don't think you comprehended what he wrote. You just responded to what you wanted to think he wrote.

No, I understood the tone of his response. He said he had the medical background of a pathologist without all those annoying details we learn in medical school. He illustrated his point by making sure we knew he aced everything in med school and is apparently a better intern because of his lab background.

Reading between the lines is not everyone's strength, so I can see how you were confused.

 

[Rendar5]

No, I understood the tone of his response. He said he had the medical background of a pathologist without all those annoying details we learn in medical school. He illustrated his point by making sure we knew he aced everything in med school and is apparently a better intern because of his lab background.

Reading between the lines is not everyone's strength, so I can see how you were confused.

Ah again such lovely sarcasm. I can see you're not that interested in that mutual respect thing mentioned before. Sure he's egotistical--this was inherent in his post (as it was in yours in different manner), but his point was that the people in charge of the lab aren't idiots. If you'd rather go off on his personality than his intent, be my guest.

 

[deleted109597]

I would argue that the people in charge of my lab are idiots. As are the people in charge of my ED, my cafeteria, my radiology department....

 

[EM6771]

McGill,
I am assuming you are interested in EM given that you are in this forum. If not, disregard this advice however I strongly recommend you change your attitude about the ancillary services you will use everyday if you want to be successful as an EP. This is a field that takes teamwork and mutual respect if your practice is going to run smoothly. In the end it will make your life a lot easier and your patients a lot safer if you incorporate all the services at your disposal. Noone wants to help the pompous a** physician.

 

[SoCuteMD]

.

 

[EM2BE]

One big thing I have found is that losing a troponin is not a good thing. Or not seeing the order. Not acceptable.

 

[caffeinegirl]

Wow. Quite an eye-opening thread, that starting about a study of bands and has devolved into "my lab sucks."

As a pathologist, I recommend that if you get weird crap from the lab (ie. canceling the CBC due to PV), then ask to talk to the lab supervisor and/or your friendly neighborhood pathologist. In the vast majority of labs, the medical director is a pathologist (MD, board certified, etc etc). Lab supervisors and the medical directors are here to help. If you just call the lab and speak to the clerk (who doesn't have a medical background most of the time) it won't get you anywhere.

And if your lab is losing specimens willy nilly and not reading orders, then there's an inherent problem in the system, which needs to be addressed ASAP.

 

[alexmtr]

So what you're saying is that you would trust a lab tech to diagnose and treat your family?

🙄...either you are too preoccupied with generating your passive-aggressive wanna be funny responses or you really don't get it...

This is a field that takes teamwork and mutual respect if your practice is going to run smoothly. In the end it will make your life a lot easier and your patients a lot safer if you incorporate all the services at your disposal. Noone wants to help the pompous a** physician.

One person I definitely wouldn't trust with anything at all is a pompous a** physician. Too much confidence is usually a result of not enough knowledge and experience to recognize (and admit!!) one's own limitations - obviously dangerous. You can flaunt your MD at parties and on dating sites all you want, but when it comes to taking care of people we are (important, sure, but) a rather small part of a community of intelligent educated people who make it all happen.

 

[tkim]

McGill,
I am assuming you are interested in EM given that you are in this forum.

He does mention elsewhere that's he's a 4th year this year so I assume he matched. Or not.

 

[McGillGrad]

He does mention elsewhere that's he's a 4th year this year so I assume he matched. Or not.

Yup, matched. And I am not sure what the guy was reading, but it wasn't my posts because...as long as everyone knows his/her role in "the team," then everything flows smoothly.

I don't go into the lab and start spinning my own samples, so I expect the lab rats to avoid playing doctor.

 

[tkim]

Yup, matched. And I am not sure what the guy was reading, but it wasn't my posts because...as long as everyone knows his/her role in "the team," then everything flows smoothly.

I don't go into the lab and start spinning my own samples, so I expect the lab rats to avoid playing doctor.

Congrats on matching!

 

[alexmtr]

I don't go into the lab and start spinning my own samples, so I expect the lab rats to avoid playing doctor.

(...Is there a facepalm smilie?)
Mutual respect (definite) FAIL


Good thing you matched - residency, being a pretty humbling experience, will be good for you (at least I hope so…😱)

 

[roja]

I'm just going to go out on a limb and recommend that people stop pissing on the flames here and either let the thread die or move to a more productive conversation.


medical myths (wbc meaning something for appy, bandemia)
decision making process
Testing in medicine

 

[microscp2]

So what you're saying is that you would trust a lab tech to diagnose and treat your family?

you know the answer, nobody is even saying a pharmacyst shoud diagnose and treat your family, not a nurse, not the radiology tech. The issue here is saying the laboratory specialist has no medical knowledge, I was giving my 2 cents about the comment you made. A physician diagnose and treat, reason why you and me went to medical school.😳

 

[Rendar5]

well back to bands then. Interestingly, had a lady with a early pyelo v. kidney stone story. urinary frequency, discomfort, and urgency, chills, and transient left flank pain, benign abdominal exam x24 hours. no RLQ pain or tenderness. looked fantastic, not at all sick. plan was for u/a, basic labs, d/c.

Then the urine came back as an iffy UTI - 3 reds, 6 whites, small LE, neg. nit
WBC ~20, 25% bands...
lady still looked well, decided to CT cause something seemed off with the overall clinical picture.

Appendicitis, Diverticulitis, and Left sided pyelonephritis. Re-exam showed the start of RLQ tenderness.

a freak case honestly, and if there were a negative CT I'd have d/c'd the pt with antibx. But nonetheless, I will say the white count and the band influenced my decision to order the CT.

 

[alexmtr]

On my heme/onc rotation in severely leukopinic patients (no real WBC elevation, not too many symptoms) a lot of attention was paid to bands....

 

[roja]

Croskerry

2002: Achieving quality in clinical decision making:
cognitive strategies and detection of bias
2002: Cognitive forcing strategies in EM
2003: The importance of cognitive errors in diagnosis and
strategies to prevent them
2003: Achilles heels of the ED: delayed or missed diagnoses
2009: Clinical cognition and diagnostic error: applications of
a dual process model of reasonin

 

[RATM2010]

Favorite conversation with the usually excellent lab at our community hospital

Me: Hi, I'm calling to see why a patient's CBC was cancelled.
Lab: It was canceled for possible contamination.
Me: What would make you think it was contaminated?
Lab: The abnormally high RBC count.
Me: The patient has polycythemia. Please result the CBC.

W...T...F? A) If the ONLY abnormal value is a high RBC count, then how is it possible that the sample could be contaminated? I can only assume that this brilliance resulted from some laboratory scientist's genius and a resulting policy, as the lab is not allowed to cancel results willy-nilly.

you made this convo up. No lab tech would do this. They would not say RBC is contaminated. Main reasons for lab cancels CBC are as followed:

1. short draw
2. hemolyzed
3. IV contamination

Again, please don't make up imaginary conversations to make lab techs sound like idiots, like you do in this post.

 

[tkim]

you made this convo up. No lab tech would do this. They would not say RBC is contaminated. Main reasons for lab cancels CBC are as followed:

1. short draw
2. hemolyzed
3. IV contamination

Again, please don't make up imaginary conversations to make lab techs sound like idiots, like you do in this post.

Were you there?

 

[RATM2010]

Were you there?

Don't have to be.

 

[Dwindlin]

Don't have to be.

So it is entirely out of the realm of possibilities that there in fact exists a lab tech who is also an idiot?

 

[HankReardon]

So it is entirely out of the realm of possibilities that there in fact exists a lab tech who is also an idiot?

Bam! Lawyered!

 

[wholeheartedly]

As a clinical lab scientist I can say without hesitation that there are people who, um, should never have graduated in pretty much every field I've encountered in health care. Unfortunately it's the negative encounters that stand out in people's minds. The vast majority of us do have pretty solid medical knowledge, but wouldn't consider ourselves qualified to diagnose and treat patients.

I hadn't heard that about bands. Would be nice if the article was posted.

 

[KYTNOH]

Nice catch.


As for the OP, the lab guys don't have the medical background to understand the significance of the measures they record for the physicians.

Just like every other lab result, the interpretation is dependent on many factors, including the patient's history and physical (and current observations).

Thus, it is ignorant to assume that any clue could be useless clinically. It serves a purpose in some cases and no much in other cases. Just like WBC counts are not very useful in neonates, but very useful in adults.

That's why there's 4 years of medical school and 3-5 years of residency spent on learning physiology and pathology. It is dynamic application of variables. Not just reading some lab results and cut-and-pasting a result.

Any decision about this is not being made by the lab tech. It is being made by the clinical pathologist who did go to medical school, did complete a residency, and did complete a fellowship.

I had an experience the other day that highlighted this. At my hospital we use PCR for C. diff. I had a patient in the ICU that had completed a course of PO vanc and IV flagyl and had improved. The patient began having mild diarrhea again so I ordered a repeat PCR. The order was cancelled by the lab, which made me mad. I called them up ready to yell at them and then they gave me a very good, evidenced-based reason for cancelling the order. It ends up that repeat PCRs within three weeks of treatment being completed will often give a false positive. It would be a completely wasted test because there's no way that it would help my in my treatment.

I guarantee you that the lab tech didn't just decide to do that. That came from the residency and fellowship-trained pathologist.

I would also urge you to actually look into the utility of the CBC when it comes to working up inflammation or infection (appendicitis, diverticulitis, pancreatitis, etc, etc, etc). Despite the position held by many surgeons, evidence-based medicine actually says the CBC is an almost completely useless test because it doesn't change out management. And if the WBC isn't important clinically, then the band count certainly isn't that important. Our hospital has actually stopped reporting bands and segs unless specifically asked for.

 

[ccfccp]

Bam! Lawyered!

Okay, this is a couple of weeks late, but this quote made me laugh so hard I almost spit up breakfast. Nice.