More Blood

Warning: Don’t read this if you’re squeamish.

THIS MEDICINE MAY REDUCE THE NUMBER OF BLOOD CELLS WHICH ARE NEEDED FOR CLOTTING.

We’ll see what my lab report says, but based on recent events, I think it’s safe to say that this is one medication effect that I’m definitely experiencing.

I saw my rheumatologist Friday, and of course she ordered more blood tests.  Because of my recent experience with the cut, I was extra careful to make sure that I held pressure on the teeny-tiny little hole out of which my blood was drawn.

It looked good and seemed to be fine, so I headed out to my car.  Once there, though, I looked down and discovered that the absorbent gauze that had been taped to my arm was saturated.  Having overflowed the gauze, there was nowhere else for my blood to go, so this bright red, life-sustaining fluid was spreading across my arm.  Outside, all over the skin, not inside the veins where it belonged.

I clamped my hand over the mess as best I could and held my arm up in the air (not hanging down and swinging at my sides as one normally walks) and returned to my doctor’s office.

The ladies at the front desk looked up questioningly when I opened the door, saw my arm, and immediately whisked me back to get cleaned up.

All this has me a little scared.  I’ve been taking NSAIDs daily for three years.  I’m very careful to take my pills with food to minimize the chances of there being a problem, but to tell the truth, I haven’t been too concerned about it.  If the NSAIDs caused an ulcer despite my precautions, I could stop taking that particular med and give my stomach time to heal.  Now I’m not so sure.  Seeing how much bleeding there was from the tiny little hole from which blood was drawn, I’m thinking that a bleeding ulcer could be a serious problem.

I’m wondering if this will concern my doctor as much as it concerns me, or if I’m making much ado about nothing.

So I wait for my lab results, glad that my doctor has the lab send me a copy.

Labs

I don’t know why I continue to be shocked at the shenanigans pulled by some insurance companies.  Dr. Wes recently wrote Lab Wars and the Doctor-Patient Relationship, wherein he tells the tale of an insurer who is trying to dictate which lab facilities his patients use.  If I read the letter correctly, the insurer claims that the doctor is not supposed to be using his employer’s lab, even though the results feed directly into his EMR.  Instead, he’s to send patients somewhere else.  Somewhere that requires extra hoops - extra time – to obtain the patient’s lab results.  

Isn’t the goal to get the required data so that diagnosis & treatment decisions can be made in a timely manner? 

No, I guess not.  That’s the doctor’s goal.  The insurance company has different goals. 

 

I didn’t realize it mattered which lab is used.  I go wherever it’s most convenient for me. 

My PCP uses Lab A.  I can be drawn right there in his office, and he gets the results promptly.  If the lab tech isn’t there, I can go next door to a different doctor who also uses the same lab and have that tech draw me.  

My rheumatologist uses Lab B.  I can be drawn right in her office and the results show up in her EMR.  If there’s nobody in the office to do the blood draw (or the person looks at my arms and doesn’t even want to try), there’s another place in the same building that I can go to be drawn.  

This works great when I’m at the doctor’s office and labs are ordered.  However, hard as this may be to believe, I do not live at either doctor’s office.  I have a life outside of seeking medical care.  

red flags = labs

 

Have I mentioned that I live in the middle of nowhere?  It takes me nearly an hour to drive to my PCP’s  office, and another five minutes beyond there to my rheumatologist.  If I’m at a doctor’s office and blood work is ordered, I just pop into the lab and let them stick a needle in my arm.  No problem.  But if I’m at home with a lab slip, I’m not going to drive an hour for a two minute procedure, then turn around and drive another hour to get home.  

There is a different lab, not affiliated with either of the others, within reasonable driving distance of my house.  A bonus is that while the other places close at 4:30, this one is open until 8 p.m.  That’s where I go for lab work in between doctor’s appointments.  Lab C has never cared that the doctor’s order is written on a different lab’s form, and my rheumy is okay with those results not going straight to her EMR if it saves me two hours on the road.  

It never even occurred to me to be thankful that I can pick my own lab.  

Nephrology

The work of kidneys goes on without much fanfare, and it’s easy to ignore them — unless something goes wrong.  Or you’re told that something might go wrong.  When my doctor wrote prescriptions and said that I’d have to have blood drawn frequently to make sure that those drugs don’t harm my kidneys, well, suddenly I had have a new respect for those little organs.

Aside from a general, “somewhere in the abdomen,” I wasn’t even sure exactly where the kidneys are located.  Now I know.

Learning where they’re located didn’t mean I knew what the kidneys do, though.

Some days I wonder if I ever learned anything useful in school!  A zillion years of formal education (with pretty good grades), and I never had to learn basic anatomy.  That seems so wrong – and is why my children are learning some basics about how their bodies work.  But I digress.

Whenever something goes into people’s mouths (steak, tofu, twinkies, salad, asparagus, ice cream…), their bodies use the nutrients they need, and sends waste into the bloodstream.  The bloodstream then flows through the kidneys, which are incredibly complex filters. 

They do more than act as filters, though.

Our kidneys analyze the stuff they’re sent and sort everything.  Electrolytes that the body needs (sodium, potassium, etc) are measured out in just the right amounts and allowed into the bloodstream.  Waste and extra water is shuffled off to the bladder for removal as urine.

It doesn’t stop there, though.  In addition to filtering out wastes, these fist-sized organs release one hormone to tell our bone marrow to make red blood cells, another that helps regulate blood pressure, and a third substance involved in calcium maintenance in the bloodstream.  When the kidneys aren’t doing their job, these things don’t get done.  The kidneys are important!

But I still had some questions.

  • Why are lab tests that check kidney function called a renal panel?
  • Why are kidney doctors called nephrologists?
  • What about those lab tests?

Slowly, I’m learning.

Renal – The Latin word for kidney is ren, plural renes.

Nephrology -  Just as the lungs are full of little air sacks called alveoli, the kidneys are full of little tubes called nephrons.  (So why do we have pulmonologists, instead of alveolologists?)

This didn’t just turn into an etymology blog, but if you’re into word origins, it’s interesting to note that νεφρός (transliterated nephros) is the Greek word for kidney.

Labs – A renal panel includes electrolytes (sodium, potassium, chloride, and bicarbonate), blood urea nitrogen, creatinine, glucose, albumin, calcium, and phosphate.  My doctor has never ordered a renal panel.  Either she orders a CMP (which includes all these tests and more), or a few select tests.

BUN - blood urea nitrogen – the normal range for this test is around 6-20 mg/dL (or 2.1-7.1 mmol/L) in adults, although there can be slight variations between different labs (my lab uses 7-23 as its normal range).  Labs usually print their reference range right on the report, which is nice because we don’t have to guess.  High numbers can indicate a problem, but can also be due to dehydration or a high protein diet.

Creatinine - according to LabTestsOnline, the normal range for this test depends on age and gender:  0.6-1.1 for women age 18-60, and 0.9-1.3 for men in the same age range are reasonable numbers.  Again, labs can vary.  My lab’s normal range for this blood test is 0.4-1.0.  As with BUN, high numbers can indicate a kidney problem, but can also be due to dehydration.  Note that creatinine can also be checked with a urine test.

BUN/CRE Ratio – some labs will also report the ratio of blood urea nitrogen to serum creatinine.  Ratios are interesting.  The individual components can fall within the normal range, yet the ratio of one to the other be out of whack (to use a technical term).

eGFR - Estimated Glomerular Filtration Rate - this is a calculation (not a separate test) based on serum creat and a bunch of other details.  The National Kidney Foundation has a handy-dandy eGFR calculator available online.  And if you wonder, as I did, where they came up with a name like glomerular, the glomerulus is one little part of every nephron.

Since these lab tests are easily affected by what people eat and how much they’ve had to drink, it’s easy to see why doctors don’t worry about fluctuations of one or two numbers.  That explains why, if something is outside the normal range, my doctor orders a re-test.  It’s the long-term trend she’s looking for, not the occasional blip caused by my steak & eggs breakfast.

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For more reading about the kidneys: