Something to Remember...

Sometimes, in my line of work as a low-level hospital worker, I learn things that disappoint or shock. The latest discovery is related to time-dependent blood tests. I would say that at least 75% of the people who work in the laboratory drawing blood do not have education beyond high school and vocational training - those who do have more education are usually working toward getting into a nursing program. For those who stay in the lab, sometimes the vocational training is not thorough enough and common sense just does not exist. The following case demonstrates how important it is for all people in the medical field to have a basic understanding of medicine; they need to understand why they have to do the things a certain way and the consequences if they do not follow instructions.

Some phlebotomists, particularly on the graveyard and night shifts when it is not very busy, do not want to waste time going up to get multiple samples of blood from the same patient. This is understandable if the person is a hard stick and there will be no difference if the blood is drawn at that time, or at two different times. However, some tests are measuring a person's metabolism of certain medications, and are supposed to be drawn right on time, sometimes as often as every two hours. Vancomycin is one of the common antibiotics which requires blood tests to determine the trough and peak levels of the medication. Learning that some lab assistants draw all the tubes at the same time and then write fake times (as in, they draw a tube at midnight but write that they drew it at 2:00 am) is rather alarming. If I were a patient's doctor and I thought their trough and peak levels were lower than in actuality, I would have to increase their medication and possibly cause harmful side effects. The ramifications of giving doctors incorrect information can be fatal - hearing this almost makes me want to draw all of my future patients' blood samples myself! Alas, it is not feasible, but it will at least make me think twice when I get back unexpected drug level reports.

Spider Bites

The most infamous spiders in the United States, as far as being dangerous to humans, are the brown recluse and the black widow spider. The brown recluse is understandably dangerous, as their toxin causes necrosis, and a chunk of flesh as large as a softball in diameter eventually rots away unless there is early intervention. However, I am going to discuss the black widow. I shot some photographs recently, and recalled discussions in Neurobiology of Cognition about latrotoxin (named after the genus of the black widow, latrodectus).

Latrotoxins are the active ingredient in black widow venom which causes symptoms, known as latrodectism, in humans. The toxins are large molecules, and the most studied of the latrotoxins, alpha-latrotoxin, acts presynaptically to stimulate the release of neurotransmitters. The toxin forms a tetramer, so four alpha-latrotoxin molecules group together and form an ion pore. When the tetramer enters the cell membrane, the pore allows an influx of calcium ions, which results in neurotransmitter release. At nerve endings, it causes muscles to remain contracted, resulting in muscle cramps and pain - particularly in the abdomen. Rarely, people with heart problems can suffer complications. Luckily for us all, antivenin is readily available and there has not been a death since the 1940s.

Bilirubin Babies

Every day that I work in the lab, I usually end up drawing blood from a newborn or a child under 10 years old. The children are pretty easy if they are over 1 year old, since you only have to hold them down screaming and finish it fast. If you work quickly and confidently, the parents can handle it pretty well. Of course, I realized today that now when I see children ages 1-10, I feel guilty/apologetic because I am used to thinking that I am about to inflict pain upon them and see that terrified, betrayed look in their eyes. I'm talking about when I am not even in the laboratory - just seeing a cute five-year old girl in an elevator makes me feel bad because I "know" that in a couple seconds those curious, happy little eyes will change. I'm pretty desensitized in the lab, but out of the lab when I attempt to look at a child happily, I feel like I am a wolf in sheep's clothing.

At any rate, I also draw blood from newborns. 95% of the time, the purpose for the blood draw is that it is a bili baby. A bili baby is a newborn with elevated levels of bilirubin (hyperbilirubinemia). The most obvious symptoms are jaundice, or yellowing of the skin and the whites of the eyes. Prolonged exposure to such high levels of bilirubin can cause brain damage, hearing loss, eye muscle problems, physical abnormalities, liver damage, and death. There are two reasons a baby may have hyperbilirubinemia. One is increased destruction of blood cells, usually caused by antibodies from the mother if the baby and mother have different blood types. The other is accumulation of bilirubin because the newborn's system is not excreting as much as it produces - primarily because the liver is immature and unable to process the bilirubin. For this reason, preterm babies are more likely to suffer hyperbilirubinemia: their liver is not as developed.

Treatment for hyperbilirubinemia is phototherapy. Light is absorbed through the skin and helps convert the excess bilirubin into a more excretable form for the infant. In extreme cases, blood transfusions are necessary. For babies under 7 days old, the average acceptable level of bilirubin in the blood is 10 mg/dL, 6 mg/dL for babies less than 24 hours old.

Circumstances

Today at work I encountered a woman who was getting tested for various things, and her entire hand was inflamed from a bee sting. She told me how she had been stung once before and had not had a reaction to it, but this second time it was progressing up her arm. I recalled that years ago I had been stung in a pool, and because my skin was so cold from being in the water, as was the bee's venom gland, I did not have any lasting reaction from the sting. I suspect it is because the fluid was not warm enough to diffuse into my skin, my skin was taut from being cold, and my flesh was cold so the venom that did get into my skin did not permeate very far.

With that in mind, I asked her about the circumstances of her first sting, since a lot of people get stung in or around pools. Sure enough, her first sting was in a pool. After a little research, I found that there are a lot of factors that affect a person's allergic reaction to something like a bee sting, including temperature and a person's emotional state (panic can cause a chain reaction that makes the patient worse). Another thing to consider is that the first time a person is exposed, she may not react at all, but after that point the body may build antibodies and recognize the allergen when exposed a second time. It is very possible to develop allergies after previous exposures, such as health workers developing an allergy to latex. The second time this woman was stung, she was riding a motorcycle with her significant other, on a hot day, and panicked because they were on a freeway and couldn't stop for her to examine the situation. I imagine that tiny details such as these can make huge differences when evaluating a patient history.

Relishing the News

I have gradually grown to oppose dietary supplements, culminating in my history of medicine paper documenting the history of the industry (which is quite interesting). I rarely do double posts on the medical blog, but felt compelled to share a recent article. In this article, it has been found that those who take vitamin C and E supplements do not receive some of the benefits of exercise, such as increased resistance to oxidation and better control of insulin production. To spare the nitty gritty, it stems from vitamin C and E neutralizing the oxygen radicals produced from muscles respiring. As a result, the body does not receive damage from the radicals and therefore does not launch a response to the oxidation - the vitamins took care of the problem. This is not to say that antioxidants are bad, but just that megadoses of vitamins C and E is not a good option.

This is just one of many recent studies disproving the long-term health benefits of vitamins C and E in preventing heart attacks and cancer, as well as the lack of long-term benefits from taking a daily multivitamin. Like with weight loss, people always want fast, easy solutions to difficult problems, and the artificial solutions are almost always worse than the natural solution. Want to lose weight? Take ephedrine or hydroxy-cut and get a heart attack. Want to eat what you want without gaining weight? Binge and purge, while your teeth rot out. Want to eat more junk food and less fruits and vegetables? Pop a multivitamin and lose money and the benefits conferred from actual food. When it comes to one's long-term health, there is no magic solution, and people seem to refuse to acknowledge that. In an age of instant-gratification, perfect health is still unattainable at the click of a button.

Obesity

There are times when I feel like medical research is somewhat unnecessary, such as when it proves something already widely acknowledged as true. With obesity, the number of "studies" about the health and social effects of obesity is quite staggering, and the results unsurprising. Here is a sampling of the recent findings relating to obesity.

Being obese will...increase the chance a child will have allergies, lower a man's marriage chances, decrease one's productivity, worsen asthma symptoms, lower chances of receiving a raise or promotion, increase women's chances of pelvic disorders and decrease quality of life in old age, increase the chance a child will suffer lower body injuries, hide fetal abnormalities during an ultrasound, and raise the chance of being disabled in general.

This is supposedly new data, compared to the old data linking obesity to breast cancer, high blood pressure, shorter life span, cardiovascular disease, heart attacks, diabetes, sleep apnea, gastroesophageal reflux disorder, back problems, and steeper decline in mental faculties after the onset of Alzheimer's or dementia. I don't understand why we need more proof that being overweight and obese is a serious health problem. If being told that they will get their feet amputated if they don't lose weight does not motivate them, then how will information about pelvic disorders sway them more? We also do not need data to prove that being obese makes one less desirable in general, everyone already recognizes that fact. It is mostly a superficial problem, but it is hardwired in our being to be repelled by the unhealthy. Unfortunate and discriminatory from a humanistic stand point, but logical and fair from an evolutionary view, where the population, not the individual, is most important.

To play devil's advocate, knowing definitively that something is caused by a person being obese could help physicians treat problems - they could abstain from prescribing medications they would give a non-obese person, if the potential benefits of the medicine would certainly be curtailed by the person's obesity. After all, a non-obese person may have an underlying cause for a disorder which is treatable, while the obese person may have the problem simply because of excess weight. I have been tempted to write about obesity before, and finally felt compelled by the many unnecessary "studies" posted in Yahoo!'s Weight Loss News. If nothing else, one can at least be impressed by the sheer number of health complications from being excessively massive.

The Hospital

So, I get to work tomorrow at the main hospital. I tend to avoid shifts at the main hospital, as there are more supervisors, there is stress because it is a very busy place, there are more doctors, and more complicated procedures since they have the equipment to deal with more than clinics. For example, at clinics one cannot do a blood test for deep-vein thrombosis or lactic acid. Also, the hospital is a very clique-y place. I am not sure whether it is like this outside the United States, but at most hospitals we have a large proportion of Filipino nurses and laboratory workers. I have no problem with Filipinos, but they do tend to group together and establish a hierarchy within themselves. Also, they are very communal and every lunch/dinner break becomes a potluck, which can make a person feel awkward if he only brought a meal for himself.

Politics aside, I prefer not to work within sight of my manager - since the hospital is more stressful, she is always more stressed. Even though I have a very strong union and know it takes a lot to be fired from Kaiser, I can't help but feel nervous for my job any time she brings up a single negative about my performance. Honestly, you can only be fired for something close to criminal, like compromising patient confidentiality or misidentifying a blood donor and potentially killing someone. Nothing like the good 'ol depression days where if a man doesn't work fast enough he is fired and one of the 100s of people waiting outside runs in to take his place for a penny less per hour. At any rate, it is a small comfort knowing I will be leaving in 2 months and not have to work in the laboratory again.

Chagas Disease

I recently collected an insect from the family Reduviidae, or assassin bugs, ambush bugs, and thread-legged bugs. Why is this medically relevant? Insects of the genus Triatoma, or bloodsucking cone noses, are the vector for Trypanosoma cruzi, the parasite which causes Chagas disease. It is found in South America and Mexico, and cases of Chagas disease have occurred along the southern border of the United States. The insect likes to hide in thatched hut roofs during the day and then emerges at night to feed on human blood. It is approximately 3 cm long. The insect transmits the virus through its feces, not its bite, however scratching a bite can contaminate it with the feces, and thus the parasite.

T. cruzi can also be transmitted via contaminated food, blood or organ transplants, and from mother to fetus. The disease progresses initially with swelling at the site of infection, if from a bite, and fatigue, fever, rash, headache, vomiting, etc. The most telling acute symptom is Romaña's sign: swelling of the eyelid on the side closest to the bug bite. Immunocompromised individuals or children can die from inflammation of the meninges (meningitis) or heart muscles (myocarditis) in the acute phase. The illness then proceeds to the chronic phase if untreated, and its eventual symptoms include heart disease and intestinal malformation. It is estimated that 8-11 million people are living with Chagas disease, most without knowledge of it because the acute symptoms are short-lasting and can be falsely attributed to other medical problems. It is now routine to test all donated blood for Chagas disease in addition to other blood-born diseases. There is no vaccine or drug to use as a preventative measure, so the only guideline is to avoid poorly constructed housing and to use bug nets and insecticides.