Letters from Maine

Just a drop will do


Some of the darkest hours during my house officer training (and there were more than a few) came when it was my job to extract a blood sample from a young child or infant, or even worse, a preemie. Those were the days before multiport indwelling catheters had been invented. Finding an unused vein could take an hour. Eventually, one might resort to a femoral stick or the infamous internal jugular approach.

Even in hospitals devoted to the care of children, laboratories often asked for samples that if successfully obtained would result in an iatrogenic anemia or exsanguination. For house officers, the three most dreaded letters were Q-N-S on a lab slip.

Some tests had been successfully miniaturized, but even getting a free-flowing finger or heel stick in a sick infant isn’t easy. Heavy-handed attempts at getting blood out of one of these little turnips often resulted in a useless hemolyzed sample.

It’s not surprising that pediatricians in my demographic are often loath to order lab tests. Posttraumatic stress can be a potent behavior modifier. But, I’m sure that despite advances in lab diagnostics and phlebotomy techniques, those of you who were trained in the last 20 years have also had your share of frustrating experiences getting blood from your smallest patients.

However, it appears that the next generation of house officers isn’t going to have any phlebotomy war stories to share. The woman who promises to put an end to this bloodletting torture that my patients and I endured is a 29-year-old who dropped out of Stanford at 19, cashed in her parents’ education trust, and started her own bioscience company, now known as Theranos.

After 10 years of research and development Elizabeth Holmes says she now has a system that can provide accurate results for more than a thousand tests on a blood sample the size of a raindrop. And, the results will be ready "in as little as 2 hours" ("Elizabeth Holmes: The Breakthrough of Instant Diagnosis," by Joseph Rago, Wall Street Journal, Sept. 8, 2013). And, she claims the results will be more accurate than current lab techniques, in part because of reduced bench and handling time. And, and ... there’s more. The tests will be half the cost and could save Medicare and Medicaid $150 billion over a 10-year period.

Ms. Holmes has already entered into an arrangement with Walgreens to develop in-store sample collection centers. Her long-term goal is to provide her service "within 5 miles of virtually every American home."

Hmmm. Maybe it’s time for us to pause and take a breath. Listen. Is that creaking sound I hear the rusty hinges of Pandora’s box opening? It’s hard to argue with cutting health care costs, improving accuracy, and shortening the anxiety-provoking wait that many patients endure waiting for their lab results to reach them. But, this "breakthrough" sounds like it has the potential for creating a tsunami of TMI (too much information).

Physicians already order too many lab tests, in many cases a defensive strategy. Often physicians don’t know what to do with borderline results. The temptation is to retest, and soon the doctor finds herself in unfamiliar waters chasing an elusive school of red herring. The Theranos technology promises to make ordering blood tests cheaper and easier, and, predictably, physicians will respond by ordering more of them.

We know that pathologists and the folks who run for-profit laboratories are going to balk at this new system. But, the rest of us will need to figure out how we can deal with the glut of data and help our patients benefit from what promises to be a significant upside of this breakthrough technology.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at pdnews@frontlinemedcom.com.

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