64. Let’s talk tests with Let’s Talk Micro

In this episode Jame and Callum are joined by Louis, host of the let's talk micro podcast.

Listen in for a discussion on what a Biomedical Scientist is and how to become one. We explore the key details that clinicians need to add to their specimen request details; and ponder how laboratory managers can make this easier for clinicians.


How to request a test:
https://global.oup.com/academic/product/how-to-request-a-test-a-clinicians-guide-to-the-interpretation-and-evaluation-of-medical-tests-9780192866615?cc=gb&lang=en&

Let's talk micro podcast:
https://rss.com/podcasts/letstalkmicro/ 

Transcript

Speaker 1: 0:00

Hi everyone, welcome to the Idiot's podcast. That's some infectious disease insight of three specialists. I'm James, that's Callum over there's Louise, and we're going to tell you everything you need to know about infectious disease. Callum, how are you doing?

Speaker 2: 0:22

I think we need to talk, James, about what Callum, let's talk micro.

Speaker 1: 0:32

Let's talk micro, but isn't the host of let's talk micro on the line? Hey, that's me, Louise. How are you doing?

Speaker 3: 0:41

I'm pretty good. Thank you for this opportunity to be talking to you. I mean, it's actually really nice. I had a chance to you know before to talk to Callum, and so it's great that I get to talk to both of you?

Speaker 1: 0:53

Yeah, I know it's real nice to finally put a face of the name and the voice. We should introduce each other's podcasts. Louise, why don't you tell us a bit about the let's talk micro podcast?

Speaker 3: 1:04

Well, the let's talk micro podcast. I started over two years ago and it always came from this need to share information, to talk to people I always enjoy from training biomedical science students, which here we call them medical laboratory scientists. So I always had, I'm always like to talk and I always give people more information that they need and I'm pointing to people. Hey, you know, look at this package, answer or check out this book. And at some point in time I decided you know what, just let me talk about it. And I started thinking about a podcast and it seemed that it was a little bit difficult getting started. And but then it turns out that when I slowed down, I did the research and it was easier than I thought. It was. Just, you know, there are many providers out there, so it's just about recording. You know, getting some cover, art, proper equipment, and then I started and it was also about, you know, as working on the bench and seeing cultures, dan and they out.

Speaker 3: 2:02

You start microbiology. You know it's all about research and you start seeing things over and over again and then you start noticing wait a minute. You know this organism maybe is growing on this auger that is not designed for it, or you know it's like a back end, or you're short on supplies and you want to recover this but we don't have it. So what can we use? So all those little tricks I started noticing and I'm like, okay, you know, I just I want to share this with you and Luis, who's your?

Speaker 1: 2:32

who's your main audience, and do you have any idea who's who's listening and who's who's tuning in?

Speaker 3: 2:39

Well, my main audience, you know. So when I started, it was definitely mainly targeted for the, for the medical laboratory science students, you know, and professionals as well. So it's just there's so much information in this field and then working day in and day out, you know it's, it's. You know training happens quick and it's very great. A lot of times, you know you have to know all this information about this organisms. You know other flora or other pathogens and based on the source and things like that. So I just want to make sure that they had a better access to it and they could understand a little bit better. But as I went along, I find out that I'm also getting you know like directors. You know they're listening to the podcast. I have people in the industry pharmacists. I went to a micro 2023 recently in Houston. This is for the American Society for Microbiology.

Speaker 1: 3:33

Oh, yes, I saw that on on Twitter and you were rolling success, I saw.

Speaker 3: 3:38

Yes, no, it was great. I really met people presenting posters. I had little stickers with QR codes, so people go go check out the podcast and I get recognized a few times and some of those were actually people like you know. There were pharmacists and directors are like oh yeah, listen to your podcast, or are you Lewis from let's talk micro?

Speaker 3: 3:55

And that's the first time you like it felt a little right alone, a little bit of a Hollywood feel like like here I am being recognized for something I do Because you know you sit here, you record and you're not doing the live, so you don't know who's actually listening to it. So actually putting some faces to the listeners, it was a great experience and I enjoy this. I mean, even if I, if I only had one listener, I will still do it, because it just I feel like even just talking about it and doing research, you know, I'm improving myself, I'm trying to keep current with the, with the resources, with the information, and just I feel that since doing this, you know, I have grown so much, you know professionally, like my knowledge, that it just it's really great.

Speaker 2: 4:42

Speaking, as maybe I could be that one listener, because we were saying before we started recording that I'm revising for my part two fellowship exams which, if you are going to sit, we've got an episode about how to revise for that. So go back and have a listen to that. And I've been listening to a lot of let's talk micro as revision. It's been really useful. So thanks again for doing that and would agree with that feeling of when people come up to you and say that they're a listener. That's a really nice feeling just to know that there is somebody out there listening and that people appreciate it. So, james, what's the idiots podcast? I've not heard of that one.

Speaker 1: 5:21

Well, I'm glad you asked, Cal. The Idiot's podcast is the UK's premier infectious disease podcast. It started again two years ago. A lot of ID and microbiology podcasts seem to start two years ago for no particular reason, and we are focusing on the basics of infectious disease that a core infection trainee would want to acquire in order to be able to pass their UK exams. So our initial focus was kind of very much on doctors training in infectious disease or microbiology in the UK.

Speaker 1: 5:57

But, much like you, luis, the audience has turned out to be much greater than that. So we did an audience survey recently and it's about two-thirds doctors but one-third everything else. So anything you can imagine biomedical scientists, nurses, you name it. So we've kind of realized that our audience is a bit bigger than we had thought. It's great, the more people that know about infections and how to deal with them, the better. But our core mission is really to, at least for the first few years, is to kind of develop podcast episodes which function as resources for people to learn about all the bugs, all the drugs, and when we get bored we all talk about certain clinical syndromes or do a general club episode or just talk about a topic on infection in general. That tickles our fancy, isn't that right, callum? Yes, thank you, callum. So on to the questions. So what are we talking?

Speaker 2: 6:59

about today, callum, two main strands, and the first strand I thought would be useful to talk about, which we've not talked about in idiots, and I think you've covered on. Let's talk micro, and I guess our question would be for those who are listening, who aren't aware, who don't work with a medical lab scientists group or with biomedical scientists, or who aren't in that group what is a medical lab scientist or biomedical scientist? What do they do? How does one become that Like? What training do you have to go to get to that stage?

Speaker 3: 7:33

That is a great question and before I answer it, I just want to say that thank you for listening to the episodes and I have listened to yours and this is one of those things that we talked about a little bit about it before. But as I was looking for other podcasts and then I found yours, and as a medical laboratory scientist, and I'll talk about what we do. But we don't have much interaction with infectious disease doctors. We typically just what we see is like a request to work something up or maybe a quick phone call. So it's always interesting seeing what happens right, we work with the results and we put them out there and seeing how the treatment, the choices. For me, just connecting those two, it's great. So, just like you said, a biomedical scientist, medical laboratory scientist a lot of people are unaware of what we do and this is something that's it's an ongoing struggle. I mean you, you people typically they're already about to graduate college or they have already a degree and then they find out about this. Maybe they know someone that knows someone that completed this degree. So when you think about it, right, so you, you go to the doctor and then they collect a sample could be, you know right. So it hurts or anything that cholesterol you're getting. You know, checking your hemoglobin, so that is tested, those results you know. If they are tested, that sample is tested by a medical laboratory scientist, like biomedical scientist and medical lab scientists. So that's what we do. We process those samples and then we actually do the testing on it and we produce results. So it can be.

Speaker 3: 9:14

There are four main areas. And you have blood bank where we do the type and screen, you know, for your units, your ABO, we do anybody screens. Then you know you have hematology where you're doing a hematocrit hemoglobin, you do cell count. You move on to this clinical chemistry where you analyze glucose, cholesterol, hormones. And you have microbiology where we do, you know, we do PCR testing and we test for viruses. You know bacteria, fungi, so many as I have worked in all the other areas, but you know.

Speaker 3: 9:49

And but let me just go first with it the education. So there are some, some variation, but you can work in this. You know the main one will be a bachelor's degree in medical laboratory, scientist, sciences, and then you have different programs where maybe you do three years of undergrad with some required courses and then you finally it's in laboratory, that all you have the two and two. We'll use those two years of undergrad and then the last two years they are related to the lab, with a clinical rotation, or you can also some programs that require that you already have a degree, like in biology or chemistry, with some required courses, and then you do that one year of like didactic and laboratory. You know your. So yeah, so that is the training.

Speaker 3: 10:42

And then you know, I touch on the other areas and for me as a medical laboratory scientist, in my biology you know we do all sorts of testing, all no-transcript.

Speaker 3: 10:56

So we do, from PCR testing, any type of rapid testing, like influenza, streptococcus, pneumonia, rapid strip, pcr and group B strip. And then I concentrate heavily on working on culture. So you know those samples that are played on agar, and then we look for the presence of organisms and then, based on the source, on the organism, we produce identification and do susceptibility testing. And then we have to make the determination. You know the organism that's growing here, based on the source, you know, is it a pathogen or is it part of the commensal floor, and with the susceptibilities, make sure that that susceptibility pattern matches to the organism, do any extra testing that is required. So it's great work and I love it and I recommend it and I think that we are making progress and some medical lab sciences programs. You know they're going out there, they're going to high schools, they're going to colleges and promoting the field. So it's an exciting time.

Speaker 1: 12:04

Louisa, I have to ask at this point I've wondered this for years what is your day job Like? What are you doing day to day? Are you on the cultures benches? Are you supervising?

Speaker 3: 12:15

Yeah. So I was a supervisor for a little bit and it had good things and then these not so good things, so ultimately I ended up not being in that position anymore. So right now I am a lead medical lab scientist and I am charged with the quality control of the microbiology lab. So everything from auger, from testing, I make sure that we're compliant with the requirements that we're doing, either performing the QC, either like a lot shipment, making sure that the auger you know if it needs quality control, sterility. But I do work on the bench and I do work with cultures from pretty much all the areas, from wound cultures to hearing cultures. So I'm all over the lab and do a lot of susceptibility testing. So as of right now, I'm still heavily involved. So that will be my main job and then, as a part-time job, I work as a laboratory instructor at a medical laboratory sciences program here in Florida.

Speaker 1: 13:13

Excellent.

Speaker 2: 13:13

So thanks, I hope that makes it clear because I think sometimes, certainly as a clinician prior to training in microbiology, I don't think I really understood that aspect of the role and I think that aligns pretty well with what a biomedical scientist in the UK does. You know it's a really skilled job and you acquire a lot of training to get to the point of being able to do that and we really rely on that expertise in the laboratory. I guess the second part of what we wanted to speak about is kind of related to that. I think it's about the interface between clinicians and the laboratory and I think this is something that can be a bit tricky, because when you're asking for something, if you don't understand how the thing is done, it can be a bit tricky to know what you're asking for, if that makes sense. So I guess what I mean by that is, if you're requesting a test, if you don't understand how the test is performed and what factors changed the way in which the test is performed, you might not request the test in the right way.

Speaker 2: 14:22

I think there's a book recently published called how to Request a Test, which I saw and haven't read yet, but one of my colleagues said was really useful for this question. So I guess, luis, I would like to just talk a little bit about that part of the sort of pre-analytical phase, so how tests are requested and how that influences what happens in the lab. So I guess the first question is as a medical lab scientist, what do you look at in the specimen request details? What information are you looking at when you're going off to do, let's say, a fraud swab or some other investigation?

Speaker 3: 14:58

Yeah, all the way from the order. That's a challenge that happens in the lab and sometimes we have the issues with the laboratory information system and where sometimes we get providers that order everything or there's a catalog of tests and maybe some that are not done at our hospital, but they order that one and we have to work with that and check with them and make sure that offer the one that we do in-house or the one something else you know, to let them know and then notify them and then send that sample away. But whether it be like a paper request or you get it electronic. So we definitely want to make sure that, of course, right, the patient identifiers want to make sure that it's properly labeled, that you have the information that it needs. With the, you know the address or graphic information of the patient, you know name, date of birth, and that you know with the sample as well. We want to make sure that our sample is labeled with all that information, not just one last name. Right, it's just only one name. That's very difficult and you know if it's missing information, unless it's like a critical sample and irretrievable sample, right, if you get a three-year-old kind of label, I mean we have to call them and then we fill out a form explaining what happened and then the sample is labeled. But if it's something like, let's say, just like a blood or tube or something like that, then we just completely reject it and that sample does not get tested at all. So, proper labeling, that's the first thing that we have to make sure that we do right. We're definitely putting a result out there that's going to go to a patient's chart and that's going to affect the course of the treatment, so that results are runious. You know we're putting that patient in harm. So that will be the first step.

Speaker 3: 16:44

And then also, we're also looking at, right, what order the source of the sample. And that's a big one. You know, many times I find myself working on a culture and then it just says sample source and it just says wound. I'm like, okay, it is a wound. Right, I'm working on the wound and back and it's obviously, you know it is a wound. But I need to know where many things change depending on the source. Right, you wouldn't treat the same, let's say, a sample that's maybe from enteric area, like from another source, right, you know you have a lot of enteric bacteria. You consider that into fact, that if you start seeing multiple, you know, let's say, enterobacterialis in that area of the body versus an arm wound or something like that. So the source is very important. You want to know, right, if you have something respiratory you start seeing that, say you know, start seeing maybe like I can allow, or this type of anger. So it always. It helps you correlate that with the culture and it makes you make the proper determination. When you are working it up and for those of the listeners out there, when you call it, work it up, it's just you know you are evaluating the culture, you're doing seeing the organisms and then you're making that determination. Okay, I have here normal skin fluora or or a pharyngeal fluora or something like that. Or if you have something like, you know like staph aureus, you call like pseudomonas. So we definitely need to know the source. That's very important.

Speaker 3: 18:15

And then the other thing is, and maybe is also, you know, collection time. You know it's very important. You want to make sure that because it's just you know, sometimes you know that you have like a great example is when we used to do the cold blood, you know, test for the stool, that we used to get the three, and then they don't put the collection time or they put it on the. Just they're all like maybe like a minute apart. So well, you know that doesn't count, we're just not making the proper evaluation. It's just, you know that sample is probably from, you know from the one time. So that's also something that's very important.

Speaker 3: 18:54

And if you are suspecting anything, that's just a potential. You know that it's just an organism that normally you know like it's either a potential bio-terror agent or or you know that is very abnormal. You know, please let us know so we can start taking the proper precautions. But yeah, those are, those are the things that we looked in. And just to touch a little bit on what you mentioned earlier, you know with the biomedical lab scientists One thing, and at least here in the States, sometimes people think that you know that you just do a bachelor's in microbiology and that just guarantees you, you know, a job in the lab, and that's not the case. You know you do have to go through one of this medical lab science schools, you know, like a program, and get a certification.

Speaker 2: 19:40

Yes, it's a complex journey to get there and I think that's, you know, probably a global issue amongst every lab, isn't it that you're getting samples that are incredibly labeled, you don't know who they're from, you're having to reject them, and nobody wants to be the person that says you know, we had to reject the samples, particularly if it's a precious one, and every effort is made to try and do that. But when you're, when you're dealing with thousands of samples or you know that's not safe to process it, the worst thing that we could do is release a report and say your patients got this pathogen and they don't, so that you know it's. That could be really bad if we, if it was accepting you know poorly labeled samples. And I guess the other thing that came to my mind was you know, there's some clinical situations, I think, where actually the clinical details change. What's done in the lab and what is it? Any examples of that that the review can that can share?

Speaker 2: 20:32

The one that comes to mind for me is that that I learned about when I went and did the bench training. The brief bench training that I got to do was that I had a lot of throat swabs. So you send a bacterial throat swabs laboratory and if you put on it that the patient had recurrent tonsillitis and then it might get worked up for a different organism, or if they had long standing throat pain, then we might work up for something else. So I think it was is a fusobacterium necrophorum was one and the other one was our canobacterium. Correct me if I'm wrong there. I find that really interesting because, as the person who had previously been ordering the first swabs, I had no idea about that and I wonder if that was a little bit of a failing of our, of our our ordering system and it didn't allow you to. It didn't prompt users to say what's important. Is that something that's reflected in your area, area of practice, or is that something that isn't an issue for you?

Speaker 3: 21:26

Yeah, we had some issues and I know that there are some restrictions in place. I think it comes when, when I mentioned that, when ordering that, a cold blood test, and also when I think there's one for blood cultures as well, I think one that there wasn't a prompt and then we tried building one was for ordering parasites. You know, like like o amp exams and because we were getting so many, you know, patient with diarrhea, just collect a sample, and then we were getting a little bit of a prompt and then we build some restrictions. You know that they had to have. The physicians had to answer, like you know, like is there like a travel history and some other questions, and they were able to answer all three. Then it will let the system will let them order the test, and that worked well for a while and then we switched to another system and the restriction I guess it wasn't updated with the system and we started getting that flood again and we're working on it. Those are the two that come to mind. But as far as solid things with history, like that, it's that's mostly something that we do look out on the side, that when we're actually working the cultures, I mean as part of our standard. It'll work with a.

Speaker 3: 22:37

We check, check the history, see if the organism is the same and then, depending on the source, if it's within 48. Well, we do 72 hours, we can refer the organism to the other one and then just not perform a susceptibility on it. You just have to make sure, right that in cases like if you have staph aureus, you have to make sure that either they're both merces or they're both MSSA. You're gonna do that type of thing of referring this susceptibility. But we do. We do keep an eye on on on the history and typically if we see that there is a patient that has a history of an MDRO, we kind of just started, you know, start setting up the, the reflex ahead of time, just to save a day because you know we know it's well documented there. Or if we always see in the history there's an organism you know, we make sure that we go ahead and add an extra blade if it needs to, or maybe if it needs to be incubated longer. We do that just to make sure we don't miss it.

Speaker 1: 23:35

Luis, what clinical information would make you want to put culture in for prolonged incubation these days?

Speaker 3: 23:44

Well, one, definitely one that's big.

Speaker 3: 23:47

It's if we have, let's say, you know, the patient with like a history of nocardia, we definitely want to make sure that we keep.

Speaker 3: 23:56

Or if there's no history, I mean if we do see the gram positive, like the beta-brons, on the initial gram stain and maybe for a little bit further, for later, and I'll vary, if you know, as I talked about what we do in the lab. So right, initially we get that sample and then we put it on the auger with some nutrients and it has the conditions that the organisms need to grow, and we also perform a gram stain, which I will be the direct smear, and if we see anything like that, we just kind of make sure that we but we seal the plates and then we we notify someone and make sure that we hold them for seven days and so that's, that's a really big one. The same thing we have, and we have sometimes, you know, like a mold or make sure that you know we're kind of looking at for it if we need to an extra plate or hold it longer. So those are really the type of scenarios that we we encounter the most.

Speaker 2: 24:50

Yeah, I think them there's this whole. There's definitely a golf sometimes a knowledge between the clinician and laboratory in terms of knowing what's going to be processed, and that's not going to be the same for everybody. And I guess at points I felt like, oh well, you know, the often request details that we get is just like a blank, so just the space, or people say like monitoring, or they don't really give you that detail that we need in order to process a sample, right. But more recently, I think I've kind of changed our mind on the honest being, on the user, and actually it's kind of difficult to know when you're ordering a test if you don't understand the laboratory and it's not. I don't think it's reasonable for us to expect everybody to have a full understanding of what's actually happening, although I would love that.

Speaker 2: 25:42

So maybe the honest is more on the laboratory as a whole, to design systems that mean that when you're ordering a test, it forces you to answer the questions that we want answered. So if you're ordering blood cultures, it forces the user to say you know, ok, have they been to any areas that are sort of tropical areas? So any risk of typhoid, I guess, is what we want to know, and these are questions which are really important for the lab, but the clinician might not think to have even asked the patient or include in the specimen request. So I guess I guess, on the next question is is there like key safety information that people should be putting onto requests and if so, what is?

Speaker 3: 26:25

that, yeah, definitely. And before I move on, you know it came to mind as I was listening and you know we also before in the past. We know, with a previous blood culture system, you know we were, we were to hold them and we had physicians requesting to hold the culture. So sometimes you know 14 days to make sure that we didn't miss like a nutritionally deficient strap or attempting to hold them longer for Brusella. And one of the requests that we get a lot it's for cuted bacterium, to make sure that we hold them. You know 14 days and that's something that we do with, you know, like sources that are like from the knee, we definitely hold them for 14 days but we still get those.

Speaker 3: 27:04

As far as the blood cultures with the systems, you know some of the system out there, a lot of these organisms, they're detected very fast. So really the the prolonged incubation time is not necessary. And the pathogens, we do get them. I mean cuted bacterium. It really on a blood culture especially, you know it pops positive about day four, three to four on average. So we do, yeah, so we do get them. So those are not necessary, but we still get a lot. Sometimes, you know, we do get the request, especially if we have. Sometimes, you know, maybe I was in like all two physicians and that some times you know the order some tests, you know the way that they were before and things like that. But yeah, those are the ones that come to mind. But as far as precautions, you know there's a history or and a great example, and I talked about this before another podcast and with other people A lot of times that we had like a Brucell exposure.

Speaker 3: 28:01

Sometimes, you know, they kind of were thinking about it and no one said anything. So, and just to give them background to the listener, right, so when we're working on the plates, right, we typically so we go ahead and we try to identify them. Right, we're not getting that ID. So the next step is right, okay, well, maybe let me consult with a more experienced co worker, so you do that, and then that person looks at the plates and then, or maybe, okay, let me check with my lead or my supervisor. So, bottom of my, sometimes you know you have four or five people looking at this plate and then all of a sudden you know it's like, okay, it turned out to be Brucell and everyone has been being put on prophylaxis and and things like that and just, and then we find out that they kind of knew. So if you're suspecting anything and that comes around, right, we're taking the history of the patient and and you're thinking there's some travel history or something like that or and you think that maybe you know beyond the look, are for this, if you are able, you know, if you're thinking about that, if you're suspecting it, please let the not know Because you know it changes the way that we treat the sample Right.

Speaker 3: 29:08

So it goes back to we. You know we get the samples, we play them. Most of the plates that we work, you know, here in the micro lab, you know we, we work with them in the open. I mean we use our PPE, we have our gowns, you know we have our gloves, which should. I think some people, maybe some that have been working longer time, don't do that and I don't like that, but we definitely have that. I mean, with COVID, I think more people started incorporating where you know, wearing the mask.

Speaker 3: 29:37

So we take we take those precautions. But if you tell us you know you're thinking about that we, immediately, from the moment that we get that sample, you know, we, we go to our you know our BSL two or BSL three, and then we just go to that and we go to the BSC and then we process the sample on the hood. You know we make sure we keep everything there, we seal it, so we will handle it differently than you just having, you know, waving that plate around for three or four days and then all of a sudden it's, it's brucella. So with experience, you know, since we function as a reference lab, when we get a plate that says, you know, maybe like gram negative carcass, vasilla for ID, you know we're kind of careful to make sure that maybe go to the hood and open it there and if you see tiny growth, you know, just proceed with caution. But bottom line, you know, if we got those warnings ahead of time, if they put it on the request, it will definitely change the way that we treat the sample.

Speaker 2: 30:34

Yeah, it's hugely important. I was just as you were saying that some voice popped into my head and said don't sniff the plates and don't smell your plates, stay safe. I heard that on a podcast somewhere, so maybe, maybe you should have that on a on a on a t-shirt. I don't know if you're getting merch, but I think that whole lab safety thing is really important and I do think, jane, that maybe we or maybe you've already done this, luis is have an episode about lab safety.

Speaker 2: 31:01

In the UK we've got this group called the advisory council for dangerous pathogens and they publish a list called the approved list of biological agents and they categorize pathogens into groups one to four, with group four being the ones that are very serious and cause serious hazard to employees, that usually likely to spread to communities, no effective prophylaxis or treatment available and all organisms are categorized into one of those four groups and the way that the lab works. You know if there's risk of these group three or four organisms, then you you process a sample in a different way. So it's really important for the team to know that information and they won't know unless it's in a request detail or someone phones. So, yeah, I think that lab safety aspect is a real key consideration, as as a microbiologist in the lab or the clinician that's ordering the test. So, luis, is there anything else that you would say? Any other examples of things that you would change in the lab if the clinical details said one thing rather than the other?

Speaker 3: 32:06

Yes, yeah, definitely. Oh, you know the orders. They change from from lab to lab and there are some things that kind of just maybe remain standard, right, maybe a wound culture or there might be another phrasing to it. Some places maybe they call it like miscellaneous. And then when you think about your standard setup, you know for most of you you're in cultures, right, you do blood and you do Maconkey, and then if you have a regular culture, you do blood, chocolate and Maconkey, which you know for the listeners out there, depending on where you are, if you maybe are training or you're starting to learn, right, so it gives pretty much all the organisms a chance to grow. You know, gives the ground negatives a better chance. On the Maconkey you get, you're getting your fastidious with the chocolate and then the blood pretty much grows everything.

Speaker 3: 32:54

But if we see something like course, for example, say, there are genital cultures in the lab where they get like a limbroth or chariot for rubystr, and then there's also a pheomartin for an Assyrian gonorrhea. So if we get, let's say, a wound culture that the source is genital, then we go ahead and you know, we add that pheomartin plane A lot of times and this is not on the request. But definitely if you're working like a blood culture and we see both gram positive and gram negative, you know we throw a PEA. If we see that there's a history medium, you know we can just go ahead and add some fungal media just to kind of make sure that we're giving the organism a chance. I mean, you don't know, maybe on the Grams thing you can tell, but you don't know. You know if it's going to be like a polymicrobial infection and you might have a lot of things to replace. So at the earliest, you know you take that caution and by adding those plates you're giving those organisms a chance, if they are there, so you don't miss them.

Speaker 2: 34:00

Thanks. I think it's a really key part is like how much the details in that pre-analytical phase, like before the lab work starts, can affect what it is. Because if we don't know the clinical details then we won't know what extra plates are set up to look for organisms and you might miss something. And then the clinician gets back a result saying culture negative and they relax. And it was interesting what you were saying about some of those older school clinicians asking for specific things and maybe they're a bit of a date and they actually know what the standard lab practice is. But at least they're engaged in the process and at least they're thinking about asking the lab for extra things.

Speaker 2: 34:39

I think for me one thing that I find really helpful is there's the UK standards for microbiological investigation, the UK SMIs, which we certainly spoken about before, and just thinking of two examples so SMI 11, investigation of swab, some skin and superficial scottis tissue infections. They lay out that everybody should get blood agar and clad or mconky and then they say add in different agars for different things. So if it's traumatic wound, add a new plate for anaerobes. If it's a cellulitis from a human animal bite, add in the chocolate agar looking for a mothless If it's a burn patient or diabetic or is into trigorylparanica, add in the sabooroo agar for use in mold and etc. Like coils agar for dipheria.

Speaker 2: 35:25

And another example is in the context of SMI 17, which is investigation of tissues and biopsies from deep-seated sites. There's so many supplementary agar that they suggest and also like some of the growth conditions are different, if you're thinking about things like nocardia, artinol organisms, branching, gram positive bacilli that we did an episode on. So it's really important and I think for those precious samples there's probably someone in the lab thinking about it and there might be a clinical microbiologist looking at the patient's notes or speaking to the question and saying, like, what do you actually want done on this? So actually maybe it's even less important for those critical samples. It's more the routine ones. I don't know if you agree with this, but like the ones that just go through the lab very quickly. Maybe that's where it's more important to say if you want something specific and then the unusual specimens, then we tend to pay a bit more attention to those anyway, because they're a bit more rare.

Speaker 3: 36:22

Yeah, yeah, we do. It's something that definitely we do. Pay more attention to the unusual ones and then from the routine ones. Sometimes things do get missed or they get delayed. We get that many samples and this is something that, as we were telling the provider, make sure that you're putting all this in and then on the lab we should be able to question this and a lot of times, the moment that you get that requisition and something is missing or it doesn't match or something like that, just make sure that right away you talk to the physician, you let them know so it can be corrected.

Speaker 3: 36:57

Sometimes we catch this errors and things missing 24 hours later when we were looking at the culture on the plate. We end up delaying patient care to have all the information. So it takes the effort of everyone really, from that pre-analytical phase, from when the sample is collected and we get it, and prior to testing, and then the analytical and post-analytical. So if something starts wrong from the beginning and where it's missing, then it's just the whole thing. Time I get a little skewed and at the end it's just the one that gets affected. It's the patient, because we're delaying the results, and I said this over and over again right, micro is all about time. So something goes wrong and it costs you a day. And, yeah, it takes a lot of teamwork and communication between all parts.

Speaker 2: 37:48

It's a key point, well made, that at the end of the day, everyone's aim is to get the best result for that patient. So giving the clinical details is really key to us getting there. And the lab is often a really high throughput place and there's not time for your medical lab scientists or biomedical scientists to be chasing up every time the clinical details aren't complete. You know it's just not feasible. So if you want your as a clinician, if you want your patient to get the best possible investigation, then you really need to put those clinical details in. And I think, as lab or a lab manager, maybe you should be thinking how do we make it easy for people to provide that information? How do we mandate the questions? Because we know the questions that we want answered, but we don't know the answers to them, and the clinicians know the answers but they don't know the questions. So we need to find ways for the questions to be asked and answered.

Speaker 3: 38:41

Does that make sense? Yeah, it doesn't. Yeah, yeah, always be receptive to feedback. So if you're in the lab and you hear suggestions, you know be receptive, and the other way around. So if you feel that there's something better that can be done, yeah, but always right, don't be afraid. Just bring it up and all they can say is no, but that's it.

Speaker 2: 39:04

You don't ask, you don't get, and garbage in, garbage out that's a competing term. But yeah, if you put bad information in the beginning, then you're going to get a bad result out at the end. And, james, do you have anything to add? This is I think this might be the episode where you've spoken the least there's no one to get dropped on us, Cal?

Speaker 1: 39:21

No, no, I don't have anything to add. Luis, thanks very much for coming on the show.

Speaker 3: 39:28

Yeah, well, my pleasure. So, but definitely, you know, thank you for the opportunity and, like I said, you know I like I listen to your episodes. You know it connects what happens on the other side and, yeah, so, to your listeners, you know if, definitely, I'm always very reachable and then you know via social media or email and once you have listened to the idiots, um, uh, episodes. You know, take a look at let's Talk Micro and on Instagram, tiktok and YouTube, as let's Talk Micro and what is called now X. We're still getting used to that.

Speaker 2: 40:05

Let's talk to Micro.

Speaker 3: 40:06

One yeah, and then uh, then email, which is at Outlookcom. So any suggestions, any, you know, any feedback if you have, if you think that you have a good topic and you want to reach out to do an episode, I'm always receptive to that. So, yeah, let's feel free to reach out.

Speaker 1: 40:25

Brilliant. All right, that's what's coming on the show, my pleasure, uh. Questions, comments, suggestions. Send them into idiotspodcastingcom at gmailcom. Have a five star review in your pocket, cal, and I would love to have it. Lewis would also please drop them in your podcast. Players of choice. We X at idiots underscore pod, and if you want to donate to support the show, there is a link to do so in the description. Until next time, I'm James and Lewis.

Speaker 2: 40:55

I'm Cal. Thank you for listening to the idiots podcast, the UK's premier infectious disease podcast. We are supported by the British Infection Association, but they do not have creative control over the episode content, so please don't blame them if we get something wrong.

Speaker 1: 41:14

Questions, comments, suggestions. Why don't you send them into idiots podcasting at gmailcom? Have a five star review in your pocket, cal, and I would love to have it. Please drop it in your podcast player of choice. We tweet at idiots underscore pod and if you want to donate to support the show, there's a link to do so in the description. But until next time, I'm James and I'm Cal. See you then.

Speaker 3: 41:33

Now that the episode's done.

Speaker 1: 41:35

We hope you learn and had lots of fun. So go forth and treat people with some of what you now know. Do you have any crap puns that you didn't include in the in the show proper?

Speaker 2: 41:48

No, I've got no puns about feces, but what I would say is that after we recorded I realized that we didn't even mention that both the podcast would be supplementary to each other and they would particularly be enriching to listen to both episodes, particularly where there's overlap. Although I guess, with limited time, that people have a training, maybe you can be a little bit selective about which episodes you listen to. I think that's that's a garbingo.