Monthly Archives: October 2013

“More Thumb Twiddling Required..”

People are generally very busy these days. It is almost culturally unacceptable not to be busy and to have too much time on your hands. I have come across people in my line of work who are simply too “busy” to be able to build up the important personal relationships that are required to produce effective work.

For a great article on being busy, and to read about the topic in more detail, click here.

However in the microbiology laboratory, I don’t want people to be busy every working minute of the day. If it takes 8 hours for a staff member to complete tasks A-Z then he/she will have no time to think about whether all the tasks A-Z are absolutely necessary, or whether any of tasks A-Z can be done more efficiently.

Everyone needs a bit of “thumb twiddling time” during their normal working day in order to think more clearly about what they are doing and why they are doing it. It is difficult to appreciate the bigger picture or to have a long term vision in your work if you are too busy.

Of course you need to have a balance between having a bit of downtime and standing about doing nothing all day. However I always try to emphasize the importance of quality over quantity. A person can potentially have more impact working 4 hours a day than someone working 12. I am not an advocate of people who “heroically” burn the midnight oil in the office/laboratory on a regular basis. Go home to your families and the more important part of your life.

Occasionally people can be busy because they are simply given too much work to do. However I suspect the majority of people are too busy because they are unable to say no to work that is offered or available. i.e. they simply take on more work (or do not delegate enough away) than they are capable of handling.

Personally, and being slightly lazy in nature, I never seem to feel too guilty about not being busy. I just enjoy finding ways to make myself and my colleagues less busy in the future. One could even say I do my most productive work when I am twiddling my thumbs….


p.s. Here is another good article on being busy.


“The paradox of the error free laboratory…”

A lot of people strive to make their microbiology laboratory “error free”. Whilst this could be said to be an admirable goal, maybe we need to think about what we wish for a little further..

A progressive laboratory by definition is going to make errors. You cannot introduce a new software system into the lab without making mistakes. You cannot develop a new assay without going through a teething process. You cannot develop an electronic requesting system without going through a lot of trial and error first.

Making changes to a laboratory are necessary so that the systems are of better quality and efficiency in the long-term. I would be concerned about the laboratory that believed that mistakes should be avoided at all costs.

Of course we should try and anticipate where errors might happen, as well as analysing ones that have occurred in order to reduce the chances of them happening again. Pilots, validations and quality control processes also reduce the chances of any potential errors occurring or impacting on the patient.

The same applies for complaints from laboratory users. When introducing new laboratory systems and technologies, there will always be a few users who are unhappy with the change, for various reasons, not necessarily microbiological… Part of our job is to educate users about the reasons for introducing new laboratory systems and making their expectations of the process realistic.

So maybe the next time your boss comes to you and says “Congratulations, so far this year we have had no errors, and no complaints from laboratory users”, maybe the response should be “So what are we doing wrong?….”


p.s. Note that within the website I am writing a short personal blog on my experiences and observations in Paris. Click here to access. Please feel free to have a read from time to time.

p.p.s Note that that this website is specially adapted for use on smart phones. Let me know if you have any problems.


Diagnosing CNS TB. How can the lab help?

Diagnosing Central Nervous System (CNS) Tuberculosis in the laboratory is not easy. There needs to be a balance between rejecting unnecessary and inappropriate investigations for CNS TB and at the same time making sure no true cases are missed.

Here are a few tips:

Investigations for TB in CSF should always be requested only after CSF protein and cell parameters are known. (Of course these parameters can occasionally be normal in CNS TB but knowledge of them changes the positive and negative predictive value of any future testing)

Investigations for TB PCR in CSF should always be requested by a consultant clinician. (on the assumption that a consultant has the knowledge base and experience to best select the patients where testing is appropriate, not always the case however). I have seen numerous instances of junior doctors requesting TB PCR on 0.5 ml CSF on a patient with a couple of days of headache.

Investigations for TB PCR in CSF should always be approved by a clinical microbiologist. If there is no such filter, there is the risk of testing volumes running riot and inappropiate testing occurring. TB PCR is specific but only has a sensitivity of between 50 and 70% at diagnosing CNS tuberculosis. It is important to make requestors aware that a negative result is virtually meaningless. Auditing TB PCR requesting volume and indications is always a good audit project for students.

Insist on adequate CSF volume for testing. The sensitivity of both culture and PCR tests for TB in CSF increases with increasing volume submitted. Different labs have different volume requirements for these tests. For optimal testing, somewhere around 5 ml CSF are needed for these tests, which is not an insignificant volume. That is not to say that smaller volumes should always be rejected. The clinician needs to be made very aware however that doing TB culture or PCR on tiny amounts of CSF may be of extremely limited value.

Educate the requestors. With written protocols, presentations etc TB investigations in CSF is a problem that must be faced by many clinical microbiology departments throughout the world. Better to be pro-active than reactive about what is acceptable and what is not.

For more detail on the diagnosis of CNS tuberculosis see these guidelines, which are well written and still reasonably up to date. They also highlight the importance of clinical suspicion, comprehensive imaging and empirical treatment when laboratory diagnosis is proving elusive.

In the developed world,  big laboratories will receive many hundreds of requests for TB culture and TB PCR in CSF, but will likely be able to count the number of probable or confirmed cases on the fingers of one hand. Close co-operation between the laboratory and the clinicians is required, as it is not a diagnosis you want to miss…