Subj: Re: CBC
Date: 96-03-01 21:36:05 EST
To: [log in to unmask]
Several comments from the Devil's Advocate school of EMED postings
1. There are a lot of comments about the TOTAL WBC. I can accept that WBCs
can demarginate as a result of albuterol, fever, pain, etc. and mean nothing
in terms of severity of infection. I have a harder time accepting a left
shift as meaning nothing. If I don't get the CBC I won't know if there is a
left shift or not. If there are 20% Bands and Toxic granulations present, my
simple brain says "there must be something going on". The bone marrow doesn't
just decide to rev up the neutrophil production for nothing. My personal
experience has been that the total WBC is not very helpful but the
distribution of WBC is not bad.
2. My heightened level of anxiety resulting from an abnormal CBC very well
may then transfer into a change in treatment even if that treatment is just
suggesting a little more strongly to the parents to "care for" their child
(watch closely, no smoke in the house, lots of fluids) or to arrange a little
closer follow-up or to watch them more closely in the hospital. Admit it -
you're impressed when the WBC comes back 22,000. Could it be a
self-fulfilling prophecy, then that these kids don't do worse than they do
because we our care is then pushed up a notch? These types of things are
rarely looked at in studies. I have to think, though, that those who suggest
the "Gestalt" approach to diagnosis must also appreciate the "Gestalt"
(poorly studied) approach to healing and treatment.
3. What exactly is "clinical diagnosis"? What is the specificity and
sensitivity of "eye contact"? What defines "irritable"? Can't mild
dehydration, a fever, a painful ear and being in the ED make a child look
like sh*t? Isn't our "sixth sense" really an accumulation of years of
comparing our history and physical to lab and xray studies and follow-ups?
Russ Hartung, MD
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