Take Me Out to the BAL Game!

I first want to thank everyone who voted in the poll in my last blog post.  There has been a total of 266 votes thus far, and since I love statistics and analytics like every other scientist, here are the current totals:

Question: What do you think about the DCLS?

48.65%     I love it and want to be one! [Awesome!!!]

22.52%     It’s interesting but I don’t know if it will work.

21.62%     I love it but it’s for someone else and not me.

3.6%         I’m not entirely convinced but I am not entirely against it.

3.6%         I do not work in the medical laboratory [Thank you muggles … and other non-laboratory healthcare professionals!]

 

My residency is really starting to ramp up and I would like to share with you all an experience I had this week.  I am finishing up a rounding rotation with the cardiology service and we had a patient who has been on long time ventilator support through a trach tube.  When he was admitted he had suspected pneumonia but was also diagnosed with ventricular tachycardia.  When he presented in ER a trach aspirate culture was obtained as were blood cultures.  A BAL culture (bronchoalveoar lavage or where a tube is put down in the lungs, fluid is swished in the lungs, and then the fluid is sucked up through the tube) was obtained prior to the patient being put on a 14 day course of antibiotics. [OK – you might think “that is horrible to do to someone” and you would be right.  Normally we would obtain a sputum culture and call it a day.  Sputum is the thick green stuff you cough out of your lungs when you have pneumonia.  However, he has been on a ventilator for a really long time and is incapable of coughing up sputum.  Obtaining a BAL is the best specimen in this case to determine if this patient truly has pneumonia and what is causing it.]

By 36 hours the patient’s cardiac condition was stabilized with medication and his fever dissipated. By 48 hours the trach aspirate culture grew a light growth of MSSE (aka methicillin-sensitive Staphylococcus epidermis).  Infectious disease went ahead and started him on a 14-day course of antibiotics. By 72 hours the BAL culture was reported as no growth.

Fast-forward 7 days: The patient has been medically stable yet necessitates the implantation of a defibrillator to maintain post-discharge stability for the ventricular tachycardia.  The cardiac surgeon, however, is reluctant to perform surgery if the patient has pneumonia.

Here is the issue: The clinical PharmD on the rounding team pointed out that a 14-day course of antibiotics for MSSE is extreme overkill, especially since the BAL culture had no growth.  The attending physician then asks me: “Do you think he really had MSSE pneumonia and necessitates 14-day course of antibiotics?”

I then explain that trach’s are frequently changed because of the biofilm that grows on them of common skin flora, which includes MSSE.  The BAL culture, which is the “gold standard”, had no growth, and the patient has had no symptoms of an infection since 36 hours after admission, this confirms that the patient does not have pneumonia.

What the attending physician did next was the highlight of my day: She then said “OK, we will do this democratically.  Who thinks we should D/C [discontinue] the antibiotics and let the patient get his defibrillator tomorrow, raise your hand.”

I watched the attending physician, the cardiology fellow, all three residents, and the clinical PharmD raise their hand.  I, not having been on the rounding service very long, didn’t raise my hand.  You see, I am trying to start the actual practice of a new profession and do not want to do anything that could be viewed as presumptuous.  I want to contribute but I do not want to overstep my bounds.  Then the attending looked at me, after I had just made the case that this patient did not have pneumonia, and said “you’re in this, too!” … so I raised my hand.  🙂

The attending then said, “Well then.  That settles it.  D/C the antibiotic.”

Yes, everyone, I have fully integrated into the healthcare team. [Happy Dance!]

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4 thoughts on “Take Me Out to the BAL Game!

  1. That’s so awesome!!! Love reading these blogs, I was interested in this degree when it first came out but at the time felt I didn’t have the experience to start something so new. Now this is my goal and I’ve started taking the steps to becoming a DCLS.

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  2. Thank you for taking your time for sharing your experiences here…I used to be a generalist and now work in the quality management department. I am currently enrolled in the DCLS program at UTMB, planning on taking classes starting September. After reading your posts, I feel like it’s a lot to learn and catch up especially due to the fact that we generally don’t have exposure to up front patient care. I am not familiar with a lot of medical terms that they use on the floor 😦 hopefully I will feel confident enough to be a part of the diagnostic management team.

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