Notations and Normative Values in Human Lab Values

Previously, I had posted on my thoughts on lab values and its integration in clinical PT practice. There are subtle issues within this. In non-electronic formats, i.e. paper charts, labs are commonly denoted in shorthand that the residents are trained to use and read, as second nature. Unfortunately most PT students and even mature clinicians do not find it easy to read notations, less interpret it. While there is a plethora of web references in lab values, there is surprisingly, a lack of easily found reference to notation style, even on a Google search. The purpose of this post is therefore to provide a handy reference to lab value notations and normative values of common work up.



Common Lab Tests Reference Range for Adults -

1. http://web.missouri.edu/~proste/lab/

2. http://www.bloodbook.com/ranges.html#BLOOD

Here is to more astute PT practice....

Cheers,

Acute PT

Consults vs. Orders

A few weeks of break and my apologies. Took the family through the Big Apple and the DC area. In the meantime, some interesting posts on the Acute Care listserv, and a big win for healthcare in Congress. You must have heard of the news on HR 6331 - the Medicare Improvements for Patients and Providers Act. Or you can read all abou it here: Congress Overrides Presidential Veto. But this post is about a pet peeve of mine: Consults or Orders: what is the right wording?

There is this talk in acute care circles; of a paradigm shift in physical therapy practice. How physician referrals are to be worded: Consults vs. Orders, is a matter of indignation among therapists. There are those who are proponents for Consults - a new conceptual framework, that allows the rightful allocation of respect for the expertise, opinion, and overall collegiality among parallel medical professionals. Then those who are detractors. Really. These group of individuals cherish being "told" what, how, when, and those tiny other details, that has long been the "way" to do things in the PT world. Finally, there is what I like to think of the existential group. These group of professionals are just glad to exist. They do not really care what the wording are, as long as they have met their 9-5 commitment. And the next paycheck is in the bank.

One recent post on the acute care list serv stated, how they have been attempting to change this mindset of being "ordered". How referrals to our specialty need to, and should be worded as "consults". I cannot agree more. PT is a specialty practice. In any setting. In the acute care, we are just another consulting service. We do not exist to lift, or move, or kowtow to nursing. No our role is to evaluate and interpret movement dysfunction, and fix the cause. We need to advice, and, as needed intervene in manners appropriate to the physio-pathological state of a condition, in a manner that can be backed by evidence in literature.

We need to educate physicians along these lines. And in my experience, one has to just use rational knowledge of pathophysiology to get the attention of these physicians. Why we need not have to lift to provide appropriate care. It is not an easy task, but to achieve this goal, we will have to rid ourselves of our own internal inertia, and bring our own dissident kind to the same table from where the think-tank are speaking. Until we get this unity, we are only giving adage to the "divided, we fail".

Until next time....

AcutePT

Interesting Blog from a Radiologist

Just came across this site. I really enjoyed reading through. Iphone users listen up...

Cheers.

Board Specialty in Acute Care PT Practice

IMG_4628
Originally uploaded by AcutePT

Hello All,

Just wondering if you all are aware of the ongoing effort to get a Board Certified Specialty in Acute Care PT practice? This is not brand new news. Something the Acute PT community has felt strongly about for a really long time. The Acute Care Section of the APTA has a task force working on this. How do you all feel about this possible Newest specialty area on the block? Would you pay $1200 to $1800 to obtain such specialist certification? What kind of compensation, monetary or otherwise, would you deem as reasonable motivation for this certification?

Please reply via comments to this thread.

Cheers and a very good night.

Thoughts on Lab Values in Clinical Practice

I came across a mention on Lab Values and its significance in clinical practice pertaining to PTs. Some thoughts and observations, and hopefully a guide.

I agree whole heartedly with my esteemed colleagues, about the value of lab values. However, my personal observation of a vast majority of PT practitioners in the application of this knowledge base, has been less than optimal.

I see multiple threads of discussion of the use, applicability, and other utility of lab values. Yet, a vast number of PTs in clinical practice, even now, barely glance, if at all, far less understand significance of the various numbers representing the clinical lab work. Even less, understand the notations associated with documentation of lab work. Why is this breakdown between academia and practice? For those astute individuals who are routinely using this information, how are they different from the others?

Now don't get me wrong. I like the notion of evidence in practice. And towards this end I find a lot of PTs looking to integrate knowledge of lab work into clinical reasoning. However, there are also those, who are still trying to find justification or evidence, for rationalizing the utilization of labs in PT practice. It does not make sense why an integral part of the evaluation of physiological homeostasis is being debated for clinical relevance, as if it is a separate entity.

Let me digress for a moment. Much as we focus on the unique body of knowledge in PT, one undeniable fact in the realm of evidence-based practice of physical therapy remains the allopathic philosophy, which we commonly share with the general medicine body as well. The science of PT practice is based on the same cause-effect relationships that govern modern medicine. Obviously, here is our trump card over some of our so-called "competitors" whose philosophy may be rooted "elsewhere" (read: spinal misalignment OR, bone misalignment).

Using the philosophy of allopathy, we need to able to ascertain how the pathology (cause) is affecting (effect) homeostasis and vice versa. Obviously, labs are adjunct investigations. But these help in setting the baseline understanding of the development, progression, and prognosis of disease. With specific reference to Acute PT practice, but may equally be broadened to include any setting, we need to understand how pathology and lab values are integrally tied. And to try to treat a condition without an integral understanding of the pathologic homeostatic mechanism is truly not wise.

Which brings me to a question. Why do we need to have to find evidence, just to support the use of lab values in our practice? It may be poor analogy to some, but to me, it is like trying to find evidence of the need to do a history review, or, a chart review, for purpose of evaluating a patient. I have never, ever, seen anyone asking the relevance, or evidence, of history taking, for instance! Then why do we need to do that for integrating knowledge of lab values ?

Well, I think I can partially guess why. And I will try to hazard a complex thought with the hope that I write it right. We are rapidly approaching a new era in PT practice. Something we refer to as autonomous practice, or simply, Vision 2o2o. As we progress towards our goal, we have awakened to the higher calling of practice. We are expanding our practice turf and hopefully advancing our level of responsibilities to the point where we may possibly serve as healthcare gatekeepers of our own specialty. At this time, progressive professionals are trying to catch up with the missing pieces of the puzzle of complex medical syndromes and how they impact what we as PTs can offer; and academics, on their part, are trying to integrate that knowledge base into coursework of future professionals.

However, from my own vantage of teaching scores of students in clinical rotations, I find them poorly prepared to integrate classroom knowledge with practice philosopy for one MAJOR reason. And that is the flaw in the method this lab work teaching is engineered. Many of the current students, as well as well meaning PTs in practice, are attending weekend courses and seminars, as a continuing education in lab values. And I admit, there is value to this as no knowledge ever goes waste in my philosophy. However, using this method, it will be years before a clinician can become adept, far less astute in assessing significance and application in practice. Indeed, if my thinking is right, there needs to be a paradigm shift in how this piece of knowledge should be integrated into education.

And that would require three components:

1. Revamping and retooling the packaging of the knowledge;


2. Residencies - in appropriate settings, with worthy mentors;
   


3. Teachers that can get out of the handout mode and REALLY teach the integration of this knowledge base without asking guest doctors to superficially skimp through the information.

Having stated this, I will write a brief on my take on Lab values and how they should be packaged as a larger piece of the puzzle. So, read on...

Lab work is part of a larger Science: Lab Medicine. Lab medicine may be defined as the study of the molecular and cellular constituents of blood and other body fluids for the diagnosis and management of illness and for the investigation of the mechanisms and pathogenesis of disease. Each subtle variation of lab values are integral to the pathologies that they are associated with. We may know the relationship, which is when we can make good judgments. And we may not know the relationship, where we may miss making optimal judgments.

The best way to assimilate this is by understanding the basic pathology and its physiopathologic basis by which a disease is known to alter normal homeostasis. Thus, the best method of interpreting lab work, is to integrally package the knowledge of the pathologic basis of disease, and how it affects processes, altering normal homeostatic mechanisms as a composite study.

I appreciate your patience in reading this long post.

Have a great time folks. Good to have you as a valued reader.

Until next time....

Cheers,

AcutePT

A Very Sad Announcement

I am deeply saddened to be bearer of bad news. A brilliant mind and an indispensable colleague, has passed away. In an announcement via the Acute PT and the CardioPT Listservs, I am informed of the passing of Rebecca (Becky) White, PT CCS. She struggled for years with Eisenmenger' s syndrome and was waiting for a heart-lung transplant in Pittsburgh when she died.

A very respected, astute and eloquent lady, Ms. White was a cardio-respiratory specialist physical therapist at the University of Michigan. Some years back, I had the opportunity to interact with her briefly and I came away with a really positive impression of a colleague in advanced PT practice.

I am posting a link to her obituary here: http://www.legacy.com/ToledoBlade/Obituaries.asp?Page=LifeStory&PersonID=111162297

And a Link to the Toledo Blade GuestBook: (Will remain open and available online upto July 8, 2008): http://www.legacy.com/ToledoBlade/GB/GuestbookView.aspx?PersonId=111162297

Becky will be greatly missed by the PT community in general and those who had a chance to interact with her. Please keep her and her family in your prayers.

Sincerely,

AcutePT

Acute PT and the Physiatry Conflict..Brewing Trouble.

There is this patient under my care with classification of non-solid tumor of the hematopoeitic system. As is well known, these patients are particularly vulnerable to severe deconditioning, with high levels of morbidity in the adult population. What is worse, a significant number of these patients are too sick for traditional physical rehabilitation. I have been involved with the care 0f this patient through some critical illness, during course of this hospitalization. Fortunately, as of yet, this patient has been progressing reasonably, though, still with significant medical issues.

Physical therapy in the acute inpatient setting is progressively consultative, with limited hands on intervention. I am not even going to begin extrapolation on this. However, with less than 5 FTEs' serving a larger than 350 bed population, a frequency of no more than 2-3 visits a week is inevitable, sometimes even less. After all, the patients are in the hospital for a critical illness first. If they are truly in full rehab mode, it would be so much more appropriate to be in a rehabilitaiton setting that could accord much more directed care consistent with their philosophy. In this case, it just made good clinical sense to get this patient over to an inpatient rehabilitation unit (IPR) as soon as medical stability was achieved. Given the acuity of this patient's status, a sub-acute IPR seems most logical. However, owing to a complex referral relationship (more of preference/convenience, than necessity), the primary heme-oncology service is favorable to send these patients to acute inpatient rehab setting whenever feasible.

Acute IPR is a hospital. Traditionally, in the grand scheme of things, PM&R and the medical body have reserved privileges for admission under their own control. While I have nothing against their admission privileges, it is highly insulting for our PT community to be dictated on, concerning our therapeutic judgment and decision making. Much as I anticipate colleagues denying this, I know for a fact the MO (of how PM&R sweetly circumvent criticism for writing out explicit details of intervention management in the IPR setting - as if, we have no idea of how to evaluate for, or set plan of care!). Yet for sake of immediate patient need, I requested physiatry to be consulted and be on board. Interestingly, I always have my doubts of such patients being either appropriate, or be accepted for acute IPR admission.

PM&R did come on board the case, late as usual. They had no helpful input, just as usual, instead, focusing on the Physical Therapy consultation as their pivotal criteria. And from the word go, decided against accepting the patient, just as I had suspected. At this point, consider the facts. The patient has been mine as a consultant, first. I got PM&R on board. As stated, they have no useful input. Yet the PM&R resident remarks in his notes, "recommend Physical Therapy daily", as their only suggestion.

I am astounded by their presumptive superiority complex. They dare refer my own patient, back to me! When I was the one suggesting them to come on board. And if they had no useful input (primarily to accept the patient), I guess, I have enough clinical acumen to keep my own advice of when and how to see my own patients. Frankly speaking, physiatry in the acute care consultation service, rarely do have any unique examination method, or recommendation, that would be above and beyond what an expert acute PT provides. I hear echoes of this thought from scores of internists and surgeons, who cannot even begin to fathom how it would be helpful to even get physiatry on the case, since they cannot ever make a recommendation, sans the PT recommendations!

Which brings me so often to the point of whether it is at all a necessity to have physiatry be involved in hospital inpatient settings? The PTs are already providing the last detail of the patient diagnostics and status on the neuro-musculo-skeltal status on these patients. The medical piece that these rehab doctors introduce in their consultations are purely copies of the internist documentation and the H&P. The musculos-skeletal/neuro exam, is frequently the copy of the neurologist or PT documentation. And for heaven's sake, I do not understand how a rehab physician does not know how to do a functional status exam! I do concede to their ability to organize the information that they compile from all sources, but where is the novelty of their specialty in that? Don't PTs do that as well?

And insurance companies for once, have wizened to the fact that PT impressions are pivotal in authorizing for inpatient rehabilitaiton. That leaves just about no role for a physiatrist in a hospital rouding role. I propose that we as PTs should capitalize on our strengths and gain the recognition for our expertise in the acute care setting. Acute care PTs are already neck deep in the responsibilites and liabilities of being primary care for the neuro-musculo-skeletal health of our paitents. We should therefore be able to command the salaries that these Physiatrists are getting, and at least not have to copy the notes of other professionals!

In closing, I hope these PM&R mean well where patient care is concerned. But the high road they are travelling to keep PTs from usurping their own practice is blatantly self-serving. They have deep pockets and strong lobbies. But the power of truth is larger than just deep pockets. They have the nerve to suggest that they make the decisions when we provide the logistics? PTs are not the messenger people for physiatrists. The sooner they recognize this the better. Otherwise, I am looking forward to their conceit being their nemesis, at least in acute care practice. What do you, my readers, think? Stay tuned for more on this....

Cheers all.
AcutePT

Professional Parity between PTs and Doctors: IAP on track - way before APTA!

Just signed on to the hospital EMR. I am reviewing a patient that I am consulted on for opinion. The system asks me to establish my relationship with the client. The options for me are: "Ancillary Services, Chart Review, and Clerical". I smirk at this distinction.

Which brings me to the Holy Grail of autonomos practice. The concept of "Autonomous Practice" - or "Direct Access" has been floating around in the US for the better part of at least, the last 2 decades. Much has been done in this regards, but true implementation has been lagging.... Which I define in terms of reimbursement, social status, and be able to control our own specialty, without being considered "under direction of a physician".

In context of Direct Access, the focus of the American Physical Therapist Association (APTA) and the majority of the proponents, has been, and continues to be in the out-patient domain. This is unfortunate. Expert physical therapists in the medically complex, acute care setting, have already set a trend of practice that can easily be construed to be the closest descriptor of autonomous practice as conjured up in Vision 2020 of the APTA. So much so, that there are discussions in the acute care section of creating the latest (and Greatest?!) board-certified specialty in acute care practice. Acute PTs are not just helping diagnose patient problems, they are instrumental in directions for work-up, disposition, and placement for patients in that domain.

A patient may not be admitted or transferred to a rehabilitaiton hospital without the PT consenting to a clinical need (save Medicare enrollees). The orthopod and the PM&R physician very rightly do not have privileges to influence disposition of privately insured individuals unless PT is on board. It is extremely interesting how these PM&R physicians make it seem that they are waiting for the PT input in making their decision, all the while basing their entire evaluation off the PT consultation report. Yet the hospital EMR system is set up to relate to us as "ancillary services"!!


The United States prides itself on the highest bastions of PT education, ethics, title protection, and consumer protection. The entry level criteria for PT practice has been continually upgraded to now the doctoral level. Yet, the APTA has been sadly unable to separate the practice of Physical Therapy from the confines of "ancillary services". This topic alone merits discussion of its own.

But this post is about seeking parity with primary medical services and how we contribute to healthcare as PTs. Just like the APTA, the Indian Association of Physiotherapists (IAP) has long been in the process of title protection, turf protection, and similar challenges. I concede that progress has been slow, but the graduates of Indian Physical Therapy schools (Physiotherapists) have been legally able to use the title of doctor, for quite some time now. Now this new development from the Indian subcontinent, is a giant step forward towards establishment of PT as a parallel medical profession, not to be construed "under direction of a medical doctor".

While we continue down the path of Vision 2020 and Direct Access for PT, we need to unshackle ourselves from the dominating domain of medicine, especially those of Physical Medicine and Rehab. But then, that is another discussion....

Cheers
Acute PT