Clinical Laboratory Procedures under Austere Conditions: Part I – Introduction

The following post on clinical laboratory procedures is contributed by Pete Farmer,  who holds advanced degrees in research biology and history, and is also an RN and EMT. 

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Among the many unsung heroes and heroines of modern medicine are clinical laboratory scientists, the pathologists, histologists, microbiologists, med technicians and others who perform the myriad tests required by physicians and nurses in the diagnosis, treatment, and care of patients. They collect and analyze tissue samples (including blood, urine, synovial fluid, cerebrospinal fluid, organ and other tissues) for the presence or absence of pathogens, identification of disease causative agents, antibodies, blood cell type and number, electrolytes, and much more. They perform qualitative (detection, separation, and identification) and quantitative (determination of concentration or amount) analyses, together or separately. The clinical lab of a large hospital or a stand-alone clinical laboratory service (such as Lab Corp) may perform hundreds of tests on a routine or semi-routine basis; if non-standard tests are counted, these labs do thousands of different assays, procedures, and tests annually on huge numbers of specimens from millions of patients across the healthcare system. 

Despite years of sophisticated training, doctors and nurses involved in direct patient care are, in effect, blind without clinical lab data upon which to act. Reflective of the complexity and importance of the clinical lab sciences, physicians may specialize in pathology, and there are also doctoral (Ph.D.) degrees in the field, as well as related ones, such as toxicology.  Clinical diagnostics is a multi-billion dollar business for pharmaceutical, medical device, and healthcare companies.  The field is mature, technologically-sophisticated, and enormously complex.

The medical professional practicing under austere conditions is thus faced with a dilemma: how to obtain the necessary lab data for diagnosis, treatmen,t and care when the normal clinical lab infrastructure may be absent, inoperative, functioning at reduced capacity, or swamped with too many tests to handle? There are several methods available to us to handle this problem; let’s examine some of them.

First, forewarned is forearmed. Plan ahead and lay in the necessary equipment and supplies for doing as many tests on-site as possible, and acquire the knowledge (or hire someone who has it) necessary to perform them.  Circumstances permitting, have enough inventory on hand to permit normal operations for an extended interval without access to outside supplies; the “just-in-time” system won’t cut it here. Disaster relief organizations like Doctors without Borders are a useful model , as are military healthcare professionals; they practice expeditionary – or operational – medicine, and are prepared to function independently or semi-autonomously for extended periods in remote locations where there isn’t a pathology lab, MRI, supply room or pharmacy around the corner. They know if they don’t bring it with them, they will have to do without.  Special operations medics are trained to function in this manner, as are some army medics and navy corpsmen.  Because the armed forces are often short of full-fledged physicians, they have learned to train ancillary personnel to a high standard – and then use them as the first echelon of care in the field in remote locations. 

A properly-equipped special operations medical sergeant can set up and run a basic primary care clinic in the field, and will have the ability to perform basic laboratory tests using easily-transportable, portable equipment. Even if one is not a soldier, the operational/expeditionary mindset provides a useful means of framing the problem, and can lead to greater independence and resiliency in a crisis situation.

The Special Operations Medical Handbook (U.S. Government publication, ISBN # 9780160808968, 2nd ed., 2008), the standard field reference for SOF medical personnel, includes the following laboratory tests which may be done in the field: UA (urinalysis), gram stain, brucellosis stain, Wright’s stain, Gemsa stain, Tzanck preparation, fecal analysis (microscopic and fecal occult blood), CBC (complete blood count) and cross-matching and typing. These and similar techniques offer a good jumping-off point for our examination of lab tests in the austere environments, and will be covered in subsequent installments of this series.

 Copyright © 2011 Peter Farmer


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About Cynthia J. Koelker, MD

CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
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