Monday, March 16, 2015

I will remember you (Musing on retiring TM professionals & their patients)

As always, stay tuned for revisions 
This month's blog was triggered by ongoing retirements of longtime colleagues, medical laboratory technologists (clinical lab scientists) who work in transfusion services, blood centres, and Canada's provincial blood coordinating offices. The retirements come to my attention because I manage a mailing list ('transfusion'), whose subscribers are mainly Canadian and include laboratorians and nurses.

Because I've blogged about similar themes before, I decided to keep it short and add a few related news items from TraQ.

The blog's title derives from a memorable song by Canadian Sarah McLachlan, one that I've used before and love.

RETIREMENTS
We have known for ages that all health professions have an ageing workforce and that many would retire shortly, presumably leading to significant staff shortages.

Another long-standing concern is an impending brain drain. The loss would be especially acute in the laboratory 
due to automation, regionalization, and centralization, once the few remaining transfusion specialists retire with insufficient knowledge transfer to the next generation. Succession planning has not been a priority in health systems where staff barely have enough time to perform routine tasks needed for safe patient care.

As noted, over the past couple of years, many transfusion colleagues whom I've known for decades have retired, or are about to. They worked from coast to coast to coast in Canada and made incredible contributions to our transfusion medicine system. They seldom, if ever, get the national credit they deserve upon retiring.

Just a thought. Perhaps the CSTM would consider celebrating some of these wonderful transfusion professionals on its website as an ongoing feature?

NEWS ITEMS
1. Israel: Health system faces severe shortage of medical laboratory workers . Key points:
  • Close to half of Israel's lab workers are 55 or older
  • Lab worker with a doctorate and eight years' seniority gets 34 shekels ($8.80) an hour, similar to a hospital orderly
  • As expected, graduates prefer to work in other sectors
That low wage is pretty incredible.

2. Canada: CBS Regina component production lab to close in 4-5 years, as production moves to Calgary 


CBS's long-term plan is to regionalize blood component production to a few centres the way it regionalized blood donor testing earlier. Employees who find themselves without a job transfer to other positions (if available), move to other locations (impossible for many), or leave the organization.

The strategy is to innovate, mobilize knowledge, be on the leading edge of best practice, rightsize, leverage business lines, and be a leaner organization. 
Translation: Put safety first in all communications because it makes us look good but get rid of as many staff as possible, hire cheaper ones, save money. 

3. Scotland: Infected with hepatitis C via transfusion, woman charts her journey back to life

Interesting report of a Scottish woman who contacted transfusion-associated HCV ~27 years ago when she gave birth to a child and received 4 blood transfusions.

The UK experience with compensating people infected with HCV via transfusion is messy.

We need patients to remind us that, when the blood system gets it wrong, as it so tragically did with HIV/AIDS and HCV, people may die. And if they survive, they suffer for a long time and in many ways.

MUSINGS

  • Let's not forget our retired transfusion colleagues who dedicated their careers to helping others. We owe them a lot, not the least of which is friendship, mentoring, support, and many a shared laugh at meetings. For a chuckle see this conference cartoon via @academicssay on Twitter
  • To refresh the profession, we need to pay people a competitive salary, i.e., competitive to what health professionals with similar education and training earn. 
  • Leveraging and other management jargon, ubiquitous in our transfusion leaders' communication these days, fools no one. It's about the cost savings, stupid. 
  • Our transfusion 'thought leaders' (how's that for jargon?) continue to brag that the system is the safest it's ever been. And it is. That cocksure confidence was what led to the HIV/HCV tragedies. I'd prefer a little less braggadocio, a little more humbleness.
  • Let's never forget the patients in our care whose lives were harmed because our transfusion medicine leaders - caring and dedicated and extremely bright - nonetheless screwed up.
FOR FUN
Only one song fits this blog's theme:

And I will remember you
Will you remember me?
Don't let your life pass you by
Weep not for the memories. 

As always comments are most welcome.

Saturday, February 07, 2015

Islands in the stream (Fun musings on TM's crusade to cut costs - there's an app for that!)

Updated: 14 Feb. 2015

This blog derives from an article in the Jan. 3, 2015 issue of The Economist:
The blog is a follow-up, a sidebar in newspaper parlance, to a blog I wrote for TraQ's January newsletter:
The earlier blog discusses the rancor and over-the-top claims that can occur during contract negotiations, especially when employers such as national blood suppliers consistently opt to cut costs by hiring cheaper, less educated staff.

The current blog muses on HR 'what ifs' related to saving money by using outsiders and training remaining staff 'on the cheap' using apps. The tone is irreverent, the content tongue-in-cheek. If you're offended, don't be.

The blog's title derives from a 1983 Bee Gees song. The Bee Gees were the brothers Gibb, born on Isle of Man, who sold more than 220 million records worldwide.

#1. What if...
CBS, Canada's national blood supplier, expanded its Donor Care Associate initiative ('multi-skilled clinic employees' perform all clinic functions, from venipuncture to donor screening, tasks previously done by RNs) beyond nursing to transportation?

In northern climates I envisage 'Transport Care Associates' working for blood suppliers such as BFDC ('Blood Fluids Dot Ca').

In tropical climates, perhaps turtles, slow but steady and reliable?

#2. What if...
An equivalent to Amazon's 'Mechanical Turk' existed for transfusion services?  Why not a global blood bank work force where transfusion medicine specialists 

  • Work from home
  • Choose own work hours
  • And no one needs to pay for their benefits except them
  • National blood suppliers would crow to government paymasters, 'Look how we've decreased costs.'
  • Not mentioning on whose backs savings were realized and probably increasing the CEO's salary for his great work
Let's call it 'BB-a-Go-Go' with these business lines:
  • BBaGG-IH: Want expert help with an unexpected crossmatch incompatibility, complex antibody identification, blood grouping conundrum, any immunohematology challenge? 
    • Get these IH folks fast as they're a dying breed.
  • BBaGG-Scribe: Need experienced SOP writers or help creating a blood contingency plan to deal with severe blood shortages from pandemics and other disasters? 
    • They'll create e-text files. Bonus: Older Scribe staff will produce notes in readable cursive writing in the margins of existing documents. Yes, really!
  • BBaGG-Consultants: Looking for 'suits' to down-size the organization or decimate it by out-sourcing tasks to for-profit firms, then flee the ugly aftermath? 
    • Our 'suits' don't clean up the detritus of the 'past civilization' but we can supply grief counsellors for a fee.
  • BBaGG-RN: Seeking advice for how to tame and educate pit-bull nurses refusing to re-draw mislabelled specimens? Typically, the RN's dialogue proceeds as follows:  
    • 'I know I took blood from the right patient.'
    • 'Don't you know you're risking the patient's life with your stupid lab rules?'
    • 'The poor patient has been "stuck" 4 times today already!'
For an extra fee, we offer the online RN-tailored course, 'Quality Control, what's it all about, Alfie?'
  • BBaGG-Dominatrix: Desperate to neuter abusive docs who insist on blood now, who don't care about your 'bloody positive antibody screen nonsense', just want group O RBC NOW, because they were told in med school group O was the universal donor, safe for all?
    • With Dominatrix Plus, the physician gets a safe word or phrase to indicate they cannot take it any more. We suggest 'Lab uber alles' or 'I'm lab's poodle'.
Other 'BB-a-Go-Go' business lines are possible. Feel free to suggest some in Comments.

#3. What if
A smartwatch app existed that included all the pre-administration checks that a nurse must do before administering a transfusion? Let's call it 'Last Chance':

  • The watch has a camera that monitors the checks, and beeps if one were missed, identifying the missed detail. 
  • A nursing manager  - for fun, the spitting image of Nurse Jackie - pops up on the watch's screen and gives a video message about what to do next and why you better do it NOW. 
  • The bedside nurse can reply and ask questions with a video message in return. 
The app could also include built-in alerts to check the patient during and after the transfusion.

With bulk purchases, buyers get the add-on, 'Doomsday Clock', which shows how close to midnight it is, indicating how close the nurse came to an OMG! patient disaster.

#4. What-if
An app existed that allowed instant access to transfusion medicine experts, 24-7? 


Say you're a hematopathology/hematology resident on-call and the biomedical scientist / lab technologist calls with an issue you've never heard of. Chances are she or he knows more than you but you can never admit it.

You could call the transfusion service medical director, yet again, further digging your own grave, or you could use this 'killer app',  PMA ('Protect My Ass') for medical residents. Currently, versions exist only for Blackberry and iOS phones, plus iOS tablets.

Wait, there's more! PMA includes a simulation of how residents can learn to be obsequious to RNs on the wards, bowing to their superior knowledge and experience, and learning from it.
SUMMARY
The Economist's piece expertly analyses the pros and cons and obstacles to the ongoing trend of on-demand freelancers who work without job security, without benefits, without pensions.

That's where national blood suppliers like Canadian Blood Services are heading. It's a trend everywhere.

My view is the trend is inevitable but not progress, not admirable. And, as The Economist points out, a freelance work force doesn't contribute to happy staff who consistently give their all for employers they love and respect, and whose success is tied to theirs.

BUT the trend exists because .... [you fill in the blank] 


Wish List: I'd like to see an app that translates management's weasel words into what they're really saying. One example: 
  • 'We're pleased to report a "cost saving" of ...' probably means,
    • We've eliminated expert frontline staff;
    • Replaced them with less educated, cheaper staff; 
    • Perhaps replaced them with automated equipment, likely sending money to a foreign international company rather than hiring local staff and keeping wages in the community;
    • And given execs a bonus and pay raise for their brilliance in decreasing costs.
FOR FUN
This duet of the Bee Gees song is perhaps the best country duet of all time. One of my favorites, the song fits what I see the transfusion medicine community should be but isn't. The lyrics also suit upcoming Valentine's Day.

Islands in the stream
That is what we are
No one in between
How can we be wrong
Sail away with me
To another world
And we rely on each other....

Not a disco fan but this Bee Gee ditty from 'Saturday Night Fever' with John Travolta is irresistible. Also relates to TM workers in era of cost restraints:
As always the views are mine alone and comments are most welcome.

Friday, January 09, 2015

All you need is love (Musings on national blood supplier HR woes)

Updated: 11 Jan. 2015

January's blog derives from news about unionized employees of Canadian Blood Services in Ontario considering strike action and the public rancor that occurred between employer and employees. The strike is apparently off, as is often the case, but what happened bears comment.

Suspect no matter where you live, what your transfusion health profession, staffing issues in blog are relevant. Do you think your employer focuses on decreasing costs? Saves money by hiring less well educated and trained staff? Cares more about the bottom line than staff welfare? But spouts rhetoric to the contrary? Then this blog's for you.

The blog's title derives from a 1967 Beatles ditty, All you need is love

Disclosure: I worked for ~13 years as a medical technologist, supervisor, and clinical instructor for CBS's predecessor, Canadian Red Cross, before becoming an instructor in MLS, University of Alberta and since then have been hired by CBS as a consultant on many projects.
BACKGROUND
1. Ontario's CBS employees, belonging to the Ontario Public Service Employees Union (OPSEU), claimed the CBS management wanted to lay off skilled health-care professionals and replace them with lower-paid workers:

2. The union wrote a letter to CBS staff about CBS's intention:
3. OPSEU published ads in 14 newspapers across Ontario and made videos that claimed that CBS's HR policies threatened the safety of Canada's blood system, as in the earlier AIDS/HCV tragedy:
4. CBS strikes back in the form of Ian Mumford, CBS's chief supply chain officer's e-mailed statement:
MUSINGS
Be aware that I am a staunch union supporter, despite their shortcomings. Love Pete Seeger and all he stood for.


Was in a union as a tenured professor at University of Alberta. Yes, it was the Association of Academic Staff, but a union all the same. 

When I worked for Canadian Red Cross's Blood Transfusion Service (BTS) in Winnipeg, we worked ridiculous hours at low pay. When I mentioned staff couldn't continue to work long weekend shifts (~24 hrs) and whatever it took to process huge blood donor clinics, the medical director, a man I respected until then, kindly said the equivalent of, 'You can always quit. I'll be glad to supply a reference.'

Also, I believe that CBS has a policy to hire the cheapest possible staff, to train them for specific jobs, and claim they're 'safe' with documented competency assessment.

This is exemplified by CBS's 'donor care associates' program, approved by Health Canada:

Of course, CBS's 'cheapest staff' policy was vetted by Health Canada.  Why the cheapest possible? Because the federal government and its regulatory agency, HC, as well as the provincial governments responsible for Canada's healthcare system, are invested in reducing costs. I've blogged about this often.

And I well understand, but strongly disagree with, how public health and government employers under cost constraints prefer to hire casual and part-time staff. I lived it in the 1990s when the Alberta government cut ~40% from the laboratory medicine budget.

The result was massive lab technologist job losses, followed by years of casual and part-time employment, all so employers did not need to provide various staff benefits. Despicable. Also, many transfusion medicine experts lost jobs as transfusion services hired 'generalist' technologists who were supervised by fewer and fewer transfusion specialists.

Many transfusion medicine laboratories face succession planning issues as older transfusion specialists retire. The crunch may occur in 10-15 years when more and more specialists retire.

BUT....
To me the OPSEU ads are over-the-top and do the cause more harm than good. CBS's hiring practices are NOT admirable. Hiring less well educated staff and training them on-the-job puts more of a burden on busy, well educated and trained staff. Hiring practices that lead to long-time staff being without benefits are despicable.

Indeed, current CBS HR policies create real potential safety issues, to say nothing of staff discontent and workplace resentment. I suspect nobs like CEO Graham Sher and chief supply chain officer Ian Mumford do not have a clue about how staff in the trenches feel. And maybe those earning mega-bucks don't even care. 

But to imply CBS hiring policies threaten the safety of the blood supply, like the HIV/AIDS and HCV tragedies of the 1980s and 1990s did, is nonsense. Such claims make it easy for CBS to dismiss real concerns about their business plans that put cost above all else.

And yes, Canada's blood system has morphed into a business, not healthcare. None more so than Canadian Blood Services. CBS is not patient-centred, it's cost-centred. And staff is one of its biggest cost-centres. CBS gets rid of staff without a thought. Indeed, CBS congratulates itself for how much it cuts costs on the backs of staff.

But, please, those concerned should analyse each CBS policy rationally. Its policies may be sh*t on many levels, but they're NOT equivalent to the 1980s AIDs tragedy. 
False arguments that make it easy for CBS to dismiss legitimate concerns don't help.

My career path with two major employers (blood supplier, university med lab science program) seems antiquated. [I don't count consulting because it's a hodgepodge of 'jobettes'.] In contrast, today's workers can expect many employers with little job security.  

But despite conflicts, I considered both employers my family. I loved the organizations and believed we were on the same side, wanting to help and serve others. Canadian Red Cross BTS is where I grew up, literally. Teaching transfusion science in MLS at the University of Alberta was the best transfusion-related teaching job in the world. Hands down!

Reading the CBS-OPSEU rancor, makes me glad I'm a dinosaur of sorts. Are such HR issues between national blood suppliers and staff relevant elsewhere around the globe? You tell me.

FOR FUN
Always sorry to see animosity between union and employer (CBS) but I understand why. Yet to me, life is too short to be opponents. Surely, cooperating and understanding are better. My experience puts me on the union's side, despite its faults and hyperbole on blood safety. But I prefer cogent arguments to over-the-top claims, easily dismissed. 


Perhaps kumbaya, but I love this Beatles song:

  • All you need is love (Paul McCartney, Stewart, Joe Cocker [now deceased], and many rock n' roll legends, Party at the Palace, 2002)
My edits to Lennon-McCartney lyrics:
There's nothing you can do that can't be UNdone
Nothing you can sing that can't be UNsung
Nothing you can say that can't be UNsaid
But you can learn how to play the game
It's easy... Love is all you need. 
As always, comments are most welcome.

Wednesday, December 10, 2014

Angel (Musings on communication errors in TM)

Updated: 13 Dec. 2014

This month's blog derives from news items appearing in TraQ's monthly newsletter involving Jehovah's Witnesses in NZ and the UK, and the availability of online legal summaries.

In particular, the blog features a case from NZ in which communication failures led to a woman's death. Her death likely could have been prevented if the surgeon had known that she was a Jehovah's Witness and had refused to be treated with blood and blood products.

The case is all the more tragic because her surgery was routine, elective laparoscopic cholecystectomy. Even with 'open surgery,' transfusion may be required but seldom is. For many years, transfusion services have done only a type and screen, just in case blood is needed.

So, although involving a Jehovah's Witness, the blog is about communication and how critical it is to patient safety.

The title derives from a 1997 much-covered song by Canada's Sarah McLachlan.

BACKGROUND
UK SHOT Reports always feature cases that emphasize the importance of communication to transfusion safety. Musings on communication failures and examples from SHOT follow the NZ report.

NZ CASE
Below is my edited version of key case details as described in the report. I've kept the NZ spelling (with the diphthong 'ae' used in many former British colonies,though not so much in Canada with our proximity to the USA).

1. Ms A was seen by a surgeon at an outpatient clinic (Hospital 1). A surgeon confirmed gallstones and she was put on a waiting list for an elective laparoscopic cholecystectomy.

2. Later Ms A attended a nurse-led pre-admission clinic, where she confirmed that she did not consent to the use of blood and blood products.

3. Ms A was admitted for surgery. Surgeon Dr C and anaesthetist Dr D met with her to discuss the operation and to complete the process of obtaining informed consent.

4. When the surgery began Dr C was unaware of the patient's views on blood transfusion. The matter was not raised during the surgical 'Time Out', when any issues of concern are brought to the attention of the OR team. (See below for info on surgical 'timeouts'.)

5. Surgery began at 9 am. Because of difficulties, at 9.50 am, the laparoscopy was converted to open surgery. Ms A's gallbladder was removed and the operation ended at 11.15 am.

6. Bleeding occurred during surgery, but not enough to cause concern. Ms A was transferred to the Recovery Unit at 11.25 am.

7. There were concerns about Ms A's condition from about noon. Initial measures were unsuccessful and it was thought that she was probably bleeding internally.

8. Dr C instructed that Ms A was to be transfused, at which point he was advised of her blood product refusal.

9. Dr C determined that further surgery was needed to identify and address the cause of the bleeding. Ms A, still partially sedated, confirmed that she would not accept blood.

10. Permission was sought from Ms A's mother to override Ms A's directive but she said she could not do this.

11. Ms A was returned to the OR and surgery began at 2.55pm. Because no obvious bleeding point was identified, Dr C determined that the best course of action was to pack the liver bed and close the abdomen, so that Ms A could be transferred to a facility better able to manage her condition.

12. Arrangements were made to transfer Ms A by helicopter to Hospital 2. When the helicopter crew arrived, it was decided that transfer was inappropriate due to likely hypoxic brain injury. Ms A was confirmed dead at 6.59 pm.

SUMMARY
For more information, and key findings, I encourage you to read the full report below. 62 pages is a lot but many are appendices, plus it's fascinating. Documented tidbits include
  • At 2.29 pm, prior to the second surgery, Ms A's Hb was 45 g/L
  • At 3.26 pm, post second surgery, Ms A's Hb was 11 g/L 
A physician at Hospital 2, where she was to be transferred, said about the second surgery:
"Pre-operatively her haemoglobin level was 45, which in a Jehovah's Witness who refused blood product transfusion I felt was life threatening. Post-operatively her haemoglobin was 11 which is almost incompatible with survival.

At some stage I suggested using concentrated factor VII, which if used early enough before severe dilutional anaemia has occurred might control the bleeding. I thought [Ms A] was almost certainly going to die..."
Recommendations and Follow-up actions are on pp 42-3 of the Report and include mandating that 
  • Those involved review their practices and apologise to Ms A's family in writing.
  • Appropriate medical colleges be sent a copy of the report, and advised of the names of Drs C and D.
MUSINGS
The communication failures in the NZ case highlight a long standing issue in transfusion medicine. Communication errors are common causes of adverse events.

Patients with special transfusion needs such as those requiring irradiated or CMV-negative blood components are particularly at risk when communication fails.The spectrum of communication deficiencies includes:
  • Physicians failing to communicate with nurses, technologists, pharmacists, and other health professionals and vice versa
  • Attending physicians failing to communicate with residents and interns
  • Staff from one unit failing to communicate with those from others
  • Staff on one shift failing to communicate with those on the next shift
  • Documentation failing to accompany patients from facility to facility
  • Health personnel failing to listen carefully to patients
Common tools to prevent communication errors include mistake-proofingaka as the politically incorrect 'idiot-proofing'.

Error proofing is  ubiquitous in society, e.g., beeping alerts when keys are left in cars or headlights are left on. Non-communication transfusion-related examples include
  • Colour-coded ABO typing sera, 
  • Pretransfusion nursing checklists 
  • Cross-checking work done by others
  • Eliminating identification errors via technology, e.g., barcodes, RFID
Preventing communication errors between TM professionals is more onerous because it involves complex, long term strategies such as
  • Developing standard operating procedures and tools (forms, letters, patient cards) to facilitate intradepartmental, interdepartmental, and inter-facility communication
  • Implementing methods to train and retrain health professionals to value effective communication and teamwork
  • Fostering a culture that eliminates communication barriers such as hierarchies within and between professions, and boundaries between departments
  • Developing information management systems to facilitate information transfer
SHOT REPORTS
Below is a small selection of communication issues documented by SHOT over the past decade (most recent first). (I've sometimes edited the original text.)

1. SHOT 2012 has 50 'hits' for 'communication'
One example (p.16, under 'Human factors in hospital practice'):
  • The errors described in this SHOT report consistently demonstrate failures in communication and handover that lead to adverse incidents, some life-threatening, in transfusion practice.
  • Failures of 'handover' (communication errors) may occur as the patient travels between wards and departments within a hospital, between clinicians in different hospitals, and between hospitals and community settings. 
  • Why? Often it's because of the human tendency to assume that someone else is responsible
2. SHOT 2013 has 48 'hits' for 'communication'
One example (p. 42 under 'ABO incompatible transfusions n=12'):
  • This shows the importance of communication between clinicians and laboratory staff in an emergency. There was no historical record available for the patient and laboratory staff issued FFP based on the misleading grouping result.
3. SHOT 2003 has 21 'hits' for 'communication'

Fewer 'hits' mean nil because the report includes 107 cases in which patients with special needs were transfused with the wrong blood. Of these, 81 involved patients at risk of GVHD for whom there was a failure to provide irradiated components.

The following three examples from SHOT 2003 (p. 23) illustrate the issues (italics not in original):
Case 10. Lack of awareness of guidelines puts patient at risk. A 66 year old male patient received fludarabine for chronic lymphatic leukaemia. The ward staff were unaware of the indication for irradiated blood components and so the laboratory was not informed.

Over a 5 month period the patient received 13 units of unirradiated red cells. 
Case 11. Failure of communication in shared care. A 14 year old male was admitted for an open lung biopsy following which he bled and required transfusion. He had previously received a stem cell transplant in another hospital in the same Trust, but there was no facility to link the two transfusion laboratory computer systems and the requester was not aware of the previous history.

Non-irradiated red cells were given. 
Case 12. No notice taken of an informed patient. An elderly male patient was admitted to hospital A with an ischaemic foot. He informed the ward staff that he required regular transfusion with 'special blood' at hospital B.

The ward confirmed with the transfusion laboratory at hospital B that he had an anti-ANWJ but this information was not passed on to the laboratory at hospital A who were undertaking pretransfusion testing.

The antibody screen was negative and 3 units of red cells were issued electronically and transfused. The patient had a rise in temperature and a raised bilirubin, and died 8 days later from bronchopneumonia.
As documented by SHOT, communication failures continue to happen because they involve humans, and 'to err is human'.

BLOG's TITLE SONG
Sarah McLachlan's 'Angel' (often mistitled 'In the arms of an angel') has been used so often as a song of comfort that it's almost become a cliche. To me it fits a blog that describes a series of communication failures that resulted in a tragedy that need not have happened.This performance with iconic guitarist Santana is a 'oner'.
  •  Angel (by Sarah McLachlan with Carlos Santana)
In the arms of the angel fly away from here
from this dark cold hotel room and the endlessness that you fear.
You are pulled from the wreckage of your silent reverie.
You're in the arms of the angel, may you find some comfort here.
You're in the arms of the angel, may you find some comfort here.
The song's origin is not at all what it's come to symbolize: Sarah says it was inspired by articles about musicians turning to heroin to cope with the pressures of the music industry and subsequently overdosing.

FURTHER READING
1. 'Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery', including
1. A pre-procedure verification process
2. Surgical site marking
3. Surgical "time out" immediately prior to starting the procedure
2. A Report by NZ's Health and Disability Commissioner (30 June 2014)
Nelson Marlborough District Health Board
General Surgeon, Dr C
Anaesthetist, Dr D 
3. News item: Jehovah's Witness dies after refusing blood transfusion (20 Oct. 2014)

Monday, November 10, 2014

To dream the impossible dream (Musings on TM research)

As always, stay tuned for updates

November's blog is based on an abstract from AABB's 2014 meeting in Transfusion. I always read 'Education and Training' abstracts (one of the smaller sections - go figure!), and this one caught my eye:
  • A14-030D: ChargĂ© SB, Walsh GM. Bridging the gap: knowledge mobilization and transfusion medicine research. Transfusion 2014 Sept;54(2S):231A. 
The authors are from CBS's Centre for Innovation. 'Leading edge' on the Centre's website grates but at least it isn't 'bleeding edge.' As soon as I read 'knowledge mobilization' in the abstract I thought, 
  • 'OMG, not more management bafflegab by Canada's national blood supplier!' 
  • If there's a new buzzword out there like knowledge mobilization, you can bet CBS management will jump on it. 
That said, reading the abstract, I lost my skepticism, well at least some of it. The project to educate front-line CBS staff about the organization's research initiatives and research team is admirable.

The blog's title derives from the principal song of the musical 'Man of la Mancha' based on Cervantes' 17th C classic, Don Quixote. I hope that transfusion professionals the world over can relate to the blog's musings on the nature of research.
ABSTRACT 
Here's my version of the CBS research initiative. (Read full abstract for more details) 

Title: Bridging the gap: knowledge mobilization and transfusion medicine research
Why do it?  To transfer knowledge generated by basic and clinical research to those whose work it may affect. Unfortunately, journal publications and conference presentations have limited access.
What did they do? CBC developed these tools:
  • Summaries in plain language of notable publications were published online monthly and aimed at all stakeholders, including donors.
  • Knowledge to Munch OnInternal follow-up to major conferences, inc. 
    • Displays of conference posters
    • Distributing an electronic conference report
    • Lunch and Learn national webinars highlighting conference presentations. 
What did they find? Summaries in plain language: Between March 2013 and March 2014, 10 Research Units were online and downloaded >1100 times.

Knowledge to Munch On:
  • 66 conference presentations were available to staff who couldn't attend conferences
  • 3 electronic conference reports were downloaded 747 times in the 3 months after publication
  • Lunch and Learn: 8 presentations were attended by 263 staff.
    •  96% agreed with, 'This event enhanced my knowledge.' 
    •  76%felt that the knowledge was applicable to their practice.
What did they conclude? The programs' impacts are measurable and need more developing and monitoring to achieve a greater impact.

My take on the CBS research project
  1. Demographics: Who viewed the posters, downloaded the summaries and reports, attended and participated (geographical locale and health profession)?
  2. When were various components of the program available and accessed? During the work day vs lunch hours, coffee breaks, and after hours at home?
  3. Plain language summaries of 10 research units downloaded a total of  >1100 times over a year is NOT very much. 
  4. Was a Likert 5-point scale used to assess participant feedback? e.g., 96% agreed with, 'This event enhanced my knowledge' and '76% felt that the knowledge was applicable to their practice.'
Seems like a good start. Wonder how much time, effort, funds were spent and how committed CBS is to maintain the project, given the organization's overpowering emphasis on cost cutbacks, even related to its core business lines.

MUSINGS on RESEARCH
1. Research means being incurably curious about the world. Researchers, especially those involved in basic research, conduct many experiments year after year with failure after failure and little hope of success, until it happens, if it does. 

2. How many researcher dudes have you even heard of (and they are mainly dudes)? You may recognize the names of the luminaries who publish in leading journals and present often at conferences. 

But if you are a front-line transfusion professional, whether lab technologist /biomedical scientist, nurse or physician, you likely do not read papers or attend sessions on basic research, whose titles are often indecipherable. Even applied research gets little readership unless it directly affects us.

3. Many types of research existSee this primer on medical researchOn a simplistic level
  • Basic research is wondering if inherited traits might make different groups of people more or less susceptible to the same disease.
  • Applied research is trying to develop a screening test for HIV once we know it causes AIDS, and possibly making mega-bucks in the process.
4. It's easy for people to slag researchers as egg heads divorced from reality. These guys and gals get to attend conferences and seemingly live a charmed, stress-free life compared to those in the trenches. 

Indeed, I live in a university city where some politicians have long dissed academics as not living in the 'real world'. Anti-intellectualism is popular among populist politicians and a sure vote winner with some.

5. What the public does not see is the stress of researchers: 
  • Proving their worth annually by winning scarce research funds
  • Keeping spirits up in the face of experiments extending for years 
  • Defending criticism from peers when they publish findings
  • Facing condescension by some who perceive them as pampered 'ivory tower' dwellers.
6. Basic research, often derided, has a record of producing major scientific findings. One example:
Hepatitis BApplied research is all the rage among politicians these days, but basic research rivals it via serendipity. 
Hepatitis B kills more than 700,000 people annually. Prevalence is highest in sub-Saharan Africa and East Asia, where most people become infected during childhood and 5-10% of adults are chronically infected. Vertical transmission from mother to child is common. About half of all cases of hepatocellular carcinoma are attributed to chronic HBV infection.  
Today all blood donations are screened for HBV thanks to its discovery by Dr. Baruch S. Blumberg 
In 1976, Dr. Blumberg won the Nobel Prize for Physiology and Medicine for his discovery of the hepatitis B virus. He and his colleagues discovered the virus in 1967. 
But Blumberg began as a medical anthropologist interested in the genetics of disease susceptibility. He wondered if inherited traits might make different groups of people more or less susceptible to the same disease. The research had nil to do with hepatitis.
His research involved using antibodies from multi-transfused hemophiliac patients to test blood samples collected around the world. When an antibody from a New York hemophiliac reacted with an antigen in the blood of an Australian aborigine, they called it the 'Australia antigen', and the serendipitous path to a life-saving discovery was made. 
The Au antigen was subsequently found in the serum of many multi-transfused leukemia patients. Was it related to causing leukemia? Then Blumberg's laboratory technologist developed hepatitis B. And ultimately it became clear that the Australian antigen was the hepatitis B surface antigen
Soon a lab test was developed to screen blood donors and a vaccine was developed.
BOTTOM LINES
  • Basic research, with unknown outcomes, often trumps applied research, despite applied research being the flavour of the decade. 
  • A researcher's life is not all roses. Far from it. 
  • All health professions should get to know each other better, including the researchers who work behind the scenes and whose work can affect us all.
FOR FUN
The blog's title derives from the musical, Man of La Mancha, based on Cervantes' Don Quixote, and its song, 'To dream the impossible dream'

Like Don Quixote, researchers are sometimes seen as impractical, naive, idealist dreamers. Researchers dream the dream daily. It keeps them going. They never know when something momentous will be discovered, something to improve the lives of people, like Blumberg's Australian antigen did.
As always, comments are most welcome.
FURTHER READING
  • Baruch S. Blumberg

Monday, October 13, 2014

Bridge over troubled water (Musings on what to be thankful for as TM professionals)

Updated: 25 Nov. 2014

Apparently being thankful can improve your life. A professor of psychology at the University of California says so. It must be true (she wrote with tongue in cheek). Actually (and I hate writing or saying 'actually' after hearing a news reporter begin every sentence with it), I suspect it's true in most circumstances. Not necessarily when linked to being obsequious, though.

I had earlier written another blog for October on a topic I often blog about (two guesses - see below) but rethought it, especially since it's Canada's Thanksgiving today. Accordingly, this month's blog is about three things I feel thankful about it in the world of transfusion medicine and two that I don't.

Despite the Canadian references, transfusion professionals worldwide should be able to relate. As you read, I encourage you to think about your career and assess if any of my musings agree with yours.  Please feel free to comment.

The blog's title derives from 1970 Simon and Garfunkel classic, one of my favorites.

TOP THREE 'THANKFULS'

#1. Career in Transfusion Medicine
My life in TM began by accident and I never should have been hired. I was a high school teacher who wanted to work in Winnipeg but jobs were hard to come by for a 21 year old with a year's experience teaching in a rural Manitoba 4-room high school.

Lo and behold - a friend said, 'Pat, Canadian Red Cross Blood Transfusion Service hires BSc grads because most med lab tech grads from Red River Community College are scared to work there.' Say, what? I later learned the fear was largely because the clinical rotation was pathetic. Students spending most time labelling tubes and similar scut work in between being told by technologists to get the ABO group right or they could kill a patient. Did I mention the clinical rotation was only 2 weeks then?

Soon I started work in a large combined blood centre and transfusion lab, the latter doing compatibility testing for all city hospitals and beyond, plus prenatal testing for northwestern Ontario. At first, I did not even know what the yellow stuff was when the red cells settled. True story. Could never happen today, a good thing.

I'm so thankful for the mentoring of generous colleagues. And for wanting and needing to read the 'bibles' of TM from front to back (every word). The books were penned by such icons as Issitt and Mollison, and included the AABB Technical Manual and a 'little red book' written for Red Cross staff by Dr. B.P.L. (Paddy) Moore (and others), National Director of the Red Cross Blood Group Reference Laboratory, who died in 2011. I wrote about Dr. Moore in a 2007 blog, 'My life as a blood eater.'

I worked in Winnipeg for 13 years, got Subject certification in Transfusion Science (no longer offered) from what is now CSMLS. My last 3 years were as the clinical instructor for new laboratory staff, RRCC students, and medical residents doing a transfusion medicine rotation in the only show in town. How crazy is that?

Looking back, I'm thankful that I worked in a busy laboratory where you never knew what to expect. Besides the routine of pretransfusion testing for scheduled surgery and anemic patients, at any time 24/7 patients might need massive amounts of blood in a hurry from a ruptured aneurysm to a GI bleed to a placenta previa during delivery. Often the lab was chaotic but it was organized chaos, even if that's an oxymoron.

Moreover, I'm thankful that in those days work was mostly hands-on and issues arose daily that required problem solving. For example, I worked with Dr. John Bowman when he did the first trials of antenatal Rh immune globulin and was involved in the work that led to this paper (I'm the Pat):
Eventually the blood donor side of the laboratory got an autoanalyzer, the Technicon BG-15. We called it 'Big George' and two staff (probably closet chemistry technologists at heart) opted to become 'specialists in automation'. Can you see the irony?
For an absolute hoot, when you have some time for 'mindfulness' reading, see these articles from 45 years ago by Canadian Red Cross staff, including Dr. B.P.L. Moore. The second includes, 'The possible future role of automated tests on blood donations is briefly discussed.' (Emphasis is mine.)
As to my career, the rest is history.... I'm thankful that I lucked out getting a teaching job in Medical Laboratory Science, University of Alberta, where I had the privilege of again working with generous, talented colleagues and teaching 100s of bright, inquisitive students, who kept me on my toes and forced me to keep learning. To be honest, at MLS I believe I had the best job teaching blood bank in the entire world.

Thinking about a career, particularly in later years, makes you realize how lucky you have been. I'm thankful to have worked in the trenches of blood banking doing work that made a difference and then to have gotten a job where that knowledge and skill could be passed to others. I hope that's true for you too.

As an aside, I'm thankful that I learned how to create web sites before it was easy (and you needed to know html code), which has stood me in good stead over the years, especially after I left real work. 

#2. Living in Canada
The good points of living in Canada are obvious, but that's not where I want to go. I imagine residents of many countries feel privileged for various reasons.

Instead, in keeping with the transfusion theme, I'm thankful that today Canadians are free to criticize CBS and our blood system leaders. Goodness knows, I do plenty of that and live to write another day.

October's TraQ newsletter has examples of criticism and responses to it:
In olden days, medicine was so paternalistic that physicians had god complexes. Some still do but times have changed, not just among health professionals but between doctors and patients, as in this 2011 Maureen Dowd column in the NY Times:
In many countries criticism of perceived authority is not allowed. And in some democracies health care workplaces exist where questioning prevailing orthodoxy, especially by those lower in the pecking order, is discouraged, even risky, career-wise. I'm grateful that's not true in Canada's transfusion medicine community, at least not the one I've been fortunate to work in.
#3. UK's SHOT
The UK's haemovigilance scheme (why is everything in UK TM a 'scheme'?), known universally as SHOT (Serious Hazards of Transfusion), is a world leader in hemovigilance.
Note, I've dropped the 'ae' diphthong, which still rears its ugly head in Canada, a carryover from transplanted Brits running our blood system. (big grin).
I'm thankful for SHOT, a godsend to TM professionals globally and one of the best tools for education and quality improvement ever. As an educator, I use it repeatedly to make instruction real to students and professionals alike.

The prior blog discussed an example from the 2013 SHOT report on how errors occur and touted it as a great CE resource. 
  • Stand by me (Musings on effects of errors on transfusion professionals)
I've mentioned SHOT again in order to emphasize one of the 'Bottom Two' issues below that I'm NOT thankful for.

One of the best parts of SHOT's reports are its case studies, which detail exactly what went wrong and provide learning points. As but one example from SHOT 2013:
  • Case 3: ABO incompatible transfusion despite a robust system of warning alerts on the laboratory information management system (LIMS)
  • Search for 'Case 3' (without the quotation marks)
Excerpt:
" An ABO incompatible red cell unit was transfused resulting in a haemolytic transfusion reaction. The blood was issued using an emergency protocol on the LIMS, which was not appropriate for the non-urgent clinical situation, and the computer warning flag stating that the units were incompatible was overridden several times by the biomedical scientist (BMS).

This incompatibility was not noted at the bedside and when the patient reacted to the transfusion, the doctor who was consulted advised that the transfusion should continue without reviewing the patient. The patient developed acute and delayed haemolysis, but no long-term sequelae."
Good stuff, no?

TWO NOT-THANKFULS
To give the blog a dash of hard cold reality and move from 'Kumbaya' territory, two TM realities I'm not grateful for:

NOT Thankful For #1
Canada's lack of a hemovigilance reporting similar to SHOT, where TM practitioners and educators alike, can see how our TM system is doing. Oh wait! Instead of the usual archived SILENCE, all of a sudden, TTISS is online with  - wait for it - summary tables:
Okay, I guess we should be thankful for small mercies. We're keeping statistics, so will be able to measure improvement. And finally a public report on all the data that's been collected, even though no news media have picked it up, hence no citizens will even know. Plus, no real details, no analysis. Baby steps...

For interest, I blogged about Canada's lack of hemovigilance reporting in 2011:
NOT Thankful For #2
Health Canada's stonewalling on Ontario's paid plasma clinics. I've blogged about this many times. HC's public consultation from April 2013 has transmogrified into SILENCE as 2015 approaches. Hmmm...

The one thing perhaps to be grateful for is the hope that 'no news is good news.' Not holding my breath.

LEARNING POINTS
1. I hope all readers can say they love their careers as I love mine. In some ways the 20th C was a golden age, especially for those of us who love immunohematology.

Work is something we do, first to provide essentials like shelter and food, second to be able to appreciate the good things in life that aren't free, and third, to make a difference in the world - to make life better for each other.

TM professionals are truly fortunate to love going to work each day and to be able to question authority. For so many on the planet that's not true. Best of all is knowing we make a difference, each in our small way. It's captured by Mary Oliver in her poem, The Summer Day:
'Tell me, what is it you plan to do
with your one wild and precious life?'
2. Where we live is an accident of birth. We in the industrialized west are so fortunate. Search Google's images for 'children garbage dumps' for  1000s of examples. Or people who say homosexuality should be accepted or places where female genital mutilation commonly occurs.

3. Some national blood systems spend time, energy, and money on improving transfusion practice and generously share it with the rest of us. The best example is SHOT, funded by the UK Blood Services. Kudos to NHSBT. Wish Canada and the USA would do more of the same. Hope springs eternal...

FOR FUN
What was my original Oct. blog's topic? Two guesses (my favorite 'hobby horses'):
A. Paid plasma clinics
B. HIV/AIDS
For  clue, look at TraQ's Oct. newsletter.
Now, on to the fun music selections. On the two TM issues I'm NOT grateful for, the song that comes to mind is Simon and Garfunkel's 1964 classic, 'The Sound of Silence,' #156 on Rolling Stone's list of the 500 Greatest Songs of All Time and one of the most covered songs of the 20th C.
On the three TM realities I am grateful for, the chosen song is another Simon and Garfunkel classic, 'Bridge Over Troubled Water' released in 1970, ranked #48 on Rolling Stone's list of the 500 Greatest Songs of All Time.

Why? Mainly because I'm grateful for this song and appreciate its lyrics.
Also, because one of the best things in life is to be grateful for our friends.
When you're weary, feeling small,
When tears are in your eyes, I will dry them all.
I'm on your side. When times get rough
And friends just can't be found,
Like a bridge over troubled water
I will lay me down.
As always the views are mine alone and comments are most welcome. Does any of this ring true? What are you grateful for these days?

Added 25 Nov. 2014

In reply to Anonymous, who notes Globe and Mail article:
Another article from Toronto Star on the news:
Seems CPR will try to open paid plasma collection centres in western Canada, likely BC or Alberta [vs Saskatchewan or Manitoba, where a paid plasma clinic exists in Winnipeg, but for plasma containing special antibodies, e.g., anti-D to produce Rh immune globulin)] because of their larger populations and openness to private medical facilities.

About CPR collecting plasma for research purposes in Ontario, I agree it would be interesting to see the protocol and informed consent for such a proposal. Thanks for the comments.

Added 3 Nov. 2014

In reply to Anonymous, who writes about introducing paid plasma clinics in Ontario:
  • "Policy decisions of this nature should not be made without hearing from those who are affected the most by the legislation: that is, the recipients of plasma-derived medicinal products represented by their associations”:
For reference, PPTA is Plasma Protein Therapeutics Association. PPTA represents the private sector, collectively known as plasma protein therapies and the collectors of source plasma used for fractionation. In other words, PPTA represents a part of Big Pharma whose business involves collecting, manufacturing, and selling blood-derived plasma products.

The link provided by Anonymous is to a paper in the Fall 2014 issue of The Source, a PPTA publication:
Page's article is PRO PAID PLASMA (my interpretation): Today's products derived from paid plasma  are safe and all user groups want paid plasma because they buy the premise that, without it, their lives are at risk.

Interesting that PPTA's Fall 2014 issue of The Source includes David Page's article, as well as an article by CBS CEO Graham Sher:
Dr Sher's take home message is the same as he's espoused in Canada;
  • [Paid plasma] is an issue of public policy, not product or patient safety.
  • Pharmaceuticals made with plasma from paid donors are safe, lifesaving products for patients in Canada and around the world.
  • Canadian Blood Services remains committed to voluntary donation for its donors.
Sher's article is PRO PAID PLASMA (my interpretation): Because paid plasma is safe, to use it or not depends on government policy.Without paid plasma, people would die. But, hey, CBS is committed to a voluntary blood system. 

The PPTA would not publish articles that were anything but PRO PAID PLASMA. 

Further Reading