cp consults

[Enkidu]

Other than transfusion, which situations do clinicians need to consult clinical pathology? When the lab values actually don't make sense? Does anybody have examples of how clinicians have consulted cp and changed their management/diagnosis based on the input?

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[mlw03]

i saw the hem/onc people come down to discuss cases a lot, if you wanna count that.

 

[yaah]

Other than transfusion, which situations do clinicians need to consult clinical pathology? When the lab values actually don't make sense? Does anybody have examples of how clinicians have consulted cp and changed their management/diagnosis based on the input?

When lab tests don't make sense or fit the profile (i.e. is it a mistake or is there something they are not understanding)

When they are having trouble interpreting a panel of tests

When they don't know what test to order or how to order it

When they want to know which test is the best one

When they want to go over a subjective test (like a smear or something)

If something is interfering with the test or might be

Stuff like that.

 

[Euchromatin]

While we're on the subject of CP consults, does anyone else have to cover these types of issues while on CP call?

Most common type of page-
Nurse or phlebotomist calls us to ask how they should draw an aPTT on a pt. with a DVT/lymphedema/grievous wound in one arm, an IV running heparin in the other arm (usually in the hand/wrist), DM (so no foot draws), and they are a "hard stick."
Because I, as a pathology resident, am obviously the most knowledgeable and experienced person in the hospital to advise nurses about appropriately drawing labs (note HEAVY, HEAVY sarcasm). I usually end up telling them that if they can't move the IV up and draw the lab distal to it, they'll have to page the clinician who is actually taking care of the patient to get alternative access, like a art stick or central line.

Second most common type of page-
Med tech from our hospital's outpatient reference lab calls at 2 or 3 am to dump a critical lab value in our lap if they weren't able to contact the physician who ordered the test. Then we get to repeat all of the med tech's work trying to contact the ordering physician and then, assuming the clinician is inaccessible, decide if we should try and contact the patient directly to send them to the ER (or whatever). Usually these are outpatients with little to no history to look up in our EMR, so you really have nothing to go on but whatever labs were ordered.

We also cover more standard stuff like yaah mentioned above (i.e. questions about what tests to order, approving send out tests, reviewing peripheral smears with new acute leukemia/lymphoma diagnoses after hours ,etc.).

 

[mlw03]

I got these regularly in my residency, probably about 1 every 2 nights on call, fortunately usually around 10pm, not 2am. I found google a good resource in these cases, in getting phone numbers for clinics, and then talking to the answering service to have them page their on-call physician. For truly emergent values, I did contact the patient directly a few times, after discussing the plan with the attending on call.

Second most common type of page-
Med tech from our hospital's outpatient reference lab calls at 2 or 3 am to dump a critical lab value in our lap if they weren't able to contact the physician who ordered the test. Then we get to repeat all of the med tech's work trying to contact the ordering physician and then, assuming the clinician is inaccessible, decide if we should try and contact the patient directly to send them to the ER (or whatever). Usually these are outpatients with little to no history to look up in our EMR, so you really have nothing to go on but whatever labs were ordered.

 

[Enkidu]

When lab tests don't make sense or fit the profile (i.e. is it a mistake or is there something they are not understanding)

When they are having trouble interpreting a panel of tests

What type of tests do clinicians have trouble with and can pathology usually provide a good answer?

 

[yaah]

What type of tests do clinicians have trouble with and can pathology usually provide a good answer?

Hepatitis serology, EBV serology, autoimmune stuff, esoteric tests, persistently abnormal tests despite resolution of clinical symptoms, tests which might be falsely wrong, and a lot of them are just trying to make sense of a bunch of data which often seems to have to do with the liver. I'm sure many clinicians just call other clinicians about these questions but we get calls too.

 

[KCShaw]

Outpatient criticals: Generally the on-call pathologist/path resident shouldn't have to be called about these, depending on your in-house SOPs. There's nothing the path/resident can do about it; unfortunately sometimes the SOP demands that a practitioner (nurse or physician) be notified, and you end up being it. An efficient SOP should include some series of phone calls to make concluding with documentation, and a protocol for follow-up in the case of being unable to speak with someone at 3AM. It's up to your SOP whether a tech must call you to decide if the critical is "bad enough" to call the patient. However, that patient may well be a known leukemia patient getting the only good night of sleep they've had in the last 6 months when you call to tell them it looks like they have leukemia (or "you really need to go to the ER" if your SOP/hospital won't let you give a diagnosis to a patient directly).

That said most of my calls from either techs or clinicians were blood bank related, with one maybe every other month or so about something else, usually esoteric enough I had to call my boss, and sometimes just administrative. During the regular day a lot of calls would go directly to the lab and be forwarded past the resident to the attending; a lot about the more esoteric coagulation studies, and pretty much anything not on an everyday CBC/chemistry panel. Usually good questions, too, from experienced consultants.