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|While on the subject of crackles, rales and missed diagnosis of pneumonia, how about the ubiquitous culture report, "Normal Flora"? What does it mean, normal flora? First you have got to ask yourself, why did someone order a culture? It was surely because they suspected a bacteria, fungus or TB based on the color, consistency and appearance of the sputum from a productive cough. When the lab reports normal flora and if questioned, offers, "probably a virus," you think, why bother and enter the diagnosis as community acquired pneumonia -- a total cop-out.
Part of the problem is us. We are no longer willing or able to look through a microscope. Medical schools no longer teach microscopy, HICFA or some great bureaucracy in the sky outlaws doctor's office laboratories as unsavory profit centers or dangerously unlicensed in-competencies. We relegate the microscopy to the hospital lab where economics holds a higher priority over patient care. A simple gram stain would usually identify the organism beforehand giving the microbiologist greater motivation. Normal flora does not cause leukocytosis in sputum or the blood count. Many gram stain reports -- you probably have to order it specifically -- numerate gram positive cocci and rods along with numerous gram negative rods and cocci with a conclusion of normal flora; it raises a question of credibility. With multiple forms of Neisseria on the culture plate the same interpretation might be forthcoming 24 hours later.
A serious look at the gram stain can alleviate much of the frustration if the physician will just insist on viewing the gram stain. The presence of intracellular bacteria is the first clue. What are the WBCs having for dinner? Is the slide covered with eosinophiles? It takes only a minute to splash on a Hansel's stain or for that matter KOH for a fungus. An acid fast is easy as well. What is the predominant organism? --- Infectious disease physicians and hematologists should have access to a well-equipped shared laboratory bench.
In the future, one might think that it would be in the hospitals financial interest to accurately identify a specific etiology for the pneumonia rather than the generic community acquired code. The diagnostic related group (DRG) reimbursement is far greater for a specific diagnosis. Fluorescent microscopy would go a long way towards specificity and a sharper image as well. Today polymerase chain reaction (PCR) can identify almost any bacteria, virus or parasite. It would serve the hospital laboratory well to invest in leading edge real-time definitive diagnosis of infectious disease. If not, the PCR belongs in the doctor's office.
Part of the problem is us. We are no longer willing or able to look through a microscope. Medical schools no longer teach microscopy, HICFA or some great bureaucracy in the sky outlaws doctor's office laboratories as unsavory profit centers or dangerously unlicensed in-competencies. We relegate the microscopy to the hospital lab where economics holds a higher priority over patient care. A simple gram stain would usually identify the organism beforehand giving the microbiologist greater motivation. Normal flora does not cause leukocytosis in sputum or the blood count. Many gram stain reports -- you probably have to order it specifically -- numerate gram positive cocci and rods along with numerous gram negative rods and cocci with a conclusion of normal flora; it raises a question of credibility. With multiple forms of Neisseria on the culture plate the same interpretation might be forthcoming 24 hours later.
A serious look at the gram stain can alleviate much of the frustration if the physician will just insist on viewing the gram stain. The presence of intracellular bacteria is the first clue. What are the WBCs having for dinner? Is the slide covered with eosinophiles? It takes only a minute to splash on a Hansel's stain or for that matter KOH for a fungus. An acid fast is easy as well. What is the predominant organism? --- Infectious disease physicians and hematologists should have access to a well-equipped shared laboratory bench.
In the future, one might think that it would be in the hospitals financial interest to accurately identify a specific etiology for the pneumonia rather than the generic community acquired code. The diagnostic related group (DRG) reimbursement is far greater for a specific diagnosis. Fluorescent microscopy would go a long way towards specificity and a sharper image as well. Today polymerase chain reaction (PCR) can identify almost any bacteria, virus or parasite. It would serve the hospital laboratory well to invest in leading edge real-time definitive diagnosis of infectious disease. If not, the PCR belongs in the doctor's office.
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