Tuesday, April 30, 2019

The thing called love (Musings on folks who work in medical labs)

Last updated: May 3, 2019 (See ADDENDUM)
Another short blog, this one about National Medical Laboratory Week (NMLW), April 21-27, 2019. My story is one that's hardly ever told because oldsters like me don't normally write blogs,

Folks, I came to work in a clinical lab by an atypical route. To test myself, as an individual who was terrified of being asked a question in high school, I followed some of my pals into unusual UManitoba teacher training. We were to spend several summers in Faculty of Education and get BEd.

My most vivid memory was the Dean telling me I'd never be a good teacher because my handwriting was poor. Hard to believe but the dude said it to my face. Regardless, after the first 3-month summer session I was hired by a HS in Baldur, MB. That experience was wonderful and I'll never forget it. Many students were older than 20-yr-old me and their parents totally supported teachers.

However, when the opportunity arose to move back to Winnipeg and be near to my family, I took it. The opportunity came from a university pal who told me that Canadian Red Cross Blood Transfusion Services (CRC-BTS) hired BSc grads. In retrospect that was crazy as folks like me knew nil about blood and laboratory medicine.

Note: Winnipeg's CRC-BTS was unique in Canada, a combined blood centre and transfusion service for Winnipeg and the province of Manitoba and beyond into northern Ontario. BSc grads were hired because training for med lab technologists in Winnipeg was poor. CRC-BTS was the only show in town and the training community college students received was inadequate. Most were afraid to work in transfusion labs. Hence they hired untrained innocents like me.

Fact: When hired in 1964, I well recall asking CRC-BTS colleagues what the yellow stuff was after the whole blood donation had settled. My knowledge was NIL. Today I would never be hired and that's a good thing.

ADDENDUM
To flesh out the above tale of my start at CRC-BTS an excerpt from a 2014 blog, Bridge over troubled water (Musings on what to be thankful for as TM professionals):
The reason Canadian Red Cross Blood Transfusion Service hired BSc grads because most med lab tech grads from Red River Community College (RRCC) were afraid to work there.' 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. 
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 mentioned in the paper):
Which is why I'm so privileged to have worked in transfusion for more than 50 years. Why I love my kind Med Lab Sci colleagues at the University of Alberta who overlooked my weaknesses and generously taught me what I didn't know. Why I love my students, who were smarter and more knowledgeable than I was, who tolerated me calling them 'kids.' And so many went on to become leaders in many areas.

FOR FUN
Chose Bonnie Raitt ditty because I'm a fan and it's how I feel about medical labs, especially transfusion services.
As always, comments are most welcome. See some below.

Sunday, March 31, 2019

I heard it through the grapevine (Musings on value of Twitter)

The idea for March's blog was stimulated by 'Social media use for pathologists of all ages' (Further Reading). The article begins as follows:
Pathologists have shown an increasing acceptance of professional social media use in recent years. There are currently more than 4700 pathologists and pathology-related accounts on Twitter per an online list maintained by one of the authors.
Based on personal experience, my guess is that few medical laboratory technologists are on Twitter, especially those working in transfusion. Perhaps because it came after Facebook (founded 2004), Twitter (founded 2006) is a mystery to many. Find that sad but understand why. Blogged on Twitter before (Further Reading). 

Back in 1994 I founded a mailing list (MEDLAB-L),early social media. Delighted that many med lab technologists and physicians from all over the globe subscribed.  
Blog's title derives from 1966 ditty recorded by Marvin Gaye and later Creedence Clearwater Revival. 

UNDERSTANDING TWITTER
Signing up on Twitter is easy. Tidbits:
  • Language: Twitter is the software platform. You are a tweep. When you post a message, it's a tweet. 
  • If not on Twitter when accessing a tweet and asked to join, just click on another part of the screen and you can see direct tweets. 
  • Be aware you don't need to tweet. Just as on earlier mailing lists, you can lurk.  
  • By being on Twitter you can see the replies given by tweeps to other tweeps. If not, you can see only their direct tweets (not replies). 
  • Twitter gives you quicker access to important professional events and issues, allows you to share resources with colleagues.  
  • As a citizen Twitter is the place to be because you get news about anything well before it appears on mainstream media, e.g., disasters, latest weather, political events. All media and reporters are on Twitter.
  • Twitter hashtags are key (Further Reading) For example, they can be used to identify who to follow. And you can also see who others follow for more suggestions.
As always, comments are most welcome.

FOR FUN
Chose this ditty because Twitter is a good grapevine,
FURTHER READING
Gardner JM, McKee PH. Social media use for pathologists of all ages. Arch Pathol Lab Med. 2019 Mar;143(3):282-6.

Twitter hashtags | Transfusion hashtag

Prior TM blogs about Twitter

My Twitter accounts

Tuesday, February 26, 2019

Always on my mind (Musings on infected blood inquiries)

Stay tuned - Updates likely to occur

The idea for this blog has roots in the UK Infected Blood Inquiry now in the news and the CBC's Unspeakable, an 8-part television series (Jan. 9-Feb. 27) about Canada's 'tainted blood scandal' of the 1980s-90s.

I will not go into too much detail as some topics discussed are emotional minefields for folks, eliciting strong opinions. The purpose is to offer food for thought and leave it to you, the reader, to think about the issues, according to your background and experience.

The title derives from a 1969 ditty that Willie Nelson covered with much success in 1982.

As you read, please monitor your reactions, since what we think and how we react to events largely depends on the emotional baggage we each carry. As one example of many, my reaction to blood inquiries is shaped by having worked for Canada's first blood supplier (Canadian Red Cross) for 13 years and for decades as a transfusion science educator. Also my views are shaped by being a bit of a contrarian who tends to challenge orthodox opinions of transfusion medicine's 'biggies' (thought leaders).

PURPOSE/PRINCIPLES OF INQUIRIES
First, inquiries into infected blood tragedies are not concerned with criminal or civil liability. Supreme Court Decision of Canada (Attorney General) v. Canada (Commission of Inquiry on the Blood System) specifies
Second, the same Supreme Court decision specifies
Note that inquiries can make findings of misconduct if they fall within the inquiry's terms of reference. If the same is true for the UK's inquiry, then folks looking for criminal and civil blame to be assigned will be disappointed. But misconduct that occurred or actions that failed standards of conduct will be identified and open to further investigation by the justice system.

Given that memories fail and records disappear over time, especially sensitive ones, and self-interest makes few reveal their errors, based on Canada's experience, criminal prosecution is next to impossible. But civil suits, requiring a lower standard of proof beyond a reasonable doubt, may succeed.

As in most legal matters, credibility of witnesses is crucial where no hard evidence exists. It's complicated because of self-interest. Few,if any, admit, 'I screwed up and made a bad decision, I'm partly to blame. Forgive me.' Those involved are far more likely to say, ' I did the best I could under difficult conditions. I didn't know all the facts or what would happen. No one did. Hindsight is 20-20.'

From Canada's experience, an added key factor is that so many different players are involved, sometimes operating in silos, with no one ultimately responsible, that it's easy to claim, 'Not my responsibility.' All very convenient and I suspect Canada's blood system still has this fatal flaw despite its transmogrification, post-Krever.

PURPOSE/PRINCIPLES OF CRIMINAL JUSTICE SYSTEM
Not being a lawyer, I hesitate to include this section but include it as food for thought. Here's how I see Canada's justice system, its purpose and principles. Note: My opinions may well differ with those of many Canadians, particularly regarding incarceration and punishment.
  • Ensures public safety by protecting society from those who violate the law. Defines unacceptable behaviours and the nature and severity of punishment for a given offence. 
  • Presumes innocent until proven guilty and those charged have the right to legal representation and a fair trial. Burden of proof is on the prosecution and defendant must be proven guilty beyond a reasonable doubt. 
  • Acts as a deterrent to criminals, with incarceration being the last resort, reserved for the most serious offenses and where mitigating factors do not exist.
  • Purpose is not to punish offenders but to act with compassion and rehabilitate, if possible. Fact: Most people who come in contact with criminal justice system are vulnerable or marginalized individuals who struggle with mental health and addiction issues, poverty, homelessness, and prior victimization. (See 'What we heard - Transforming Canada's criminal justice system,' Further Reading)
TIDBIT: When I read news items or information on the UK Blood Inquiry, it's my impression, rightly or wrongly, that, as in Canada, many victims and their families are out for blood so to speak. They clearly want those whose professional misconduct and negligence  - unproven but it's how they see it - led to loved ones being infected brought to justice and punished. In other words, the NHS and its medical professionals and officials seem to have been prejudged as guilty. (Further Reading)

ANALOGIES
Analogies are offered to stimulate thought.

#1. Tragic Humboldt bus crash (Further Reading)
On April 6, 2018 sixteen people were killed and thirteen injured when a bus carrying members of the Humboldt Broncos, a Canadian junior hockey team, struck a semi-trailer truck. The driver passed four signs warning about the upcoming intersection yet the semi-trailer went through a large stop sign with a flashing red light.

The driver of the semi-trailer, 29-year-old Jaskirat Singh Sidhu was charged with 16 counts of dangerous operation of a motor vehicle causing death and 13 counts of dangerous operation of a motor vehicle causing bodily injury.On January 8, 2019, Sidhu pleaded guilty to all charges.

The Crown is asking for a sentence of 10 years with a 10-year driving prohibition. Sentencing is March 22, 2019. It's possible Sidhu could be deported after serving his sentence.

Sidhu followed his girlfriend to Canada in 2013 and is now a permanent resident. He's a newlywed who grew up on a farm in India and earned a commerce degree. He worked at a Calgary liquor store before he started driving a truck. He started work at a small trucking company only three weeks before the crash, after undergoing a week of training and spent two weeks driving a double-trailer with the owner before driving on his own.

Canada and its provinces, except for Ontario, have no compulsory training for new 'class 1' truck drivers and no mandatory training standards.

TIDBIT: Sad but it seems Sidhu will take the full blame for his horrific error, despite mitigating circumstances, namely the entire trucking driver safety system failed. Trucking companies and governments now say they'll do better, but they suffer no consequences, only the ill-trained driver of the truck. Sidhu is the scapegoat.

Reminds me that Canadian Red Cross was the scapegoat of Canada's 'tainted blood tragedy.' The newly created CBC and Héma-Québec operated with many of the same transfusion professionals because you cannot educate and train new experts overnight.

Truck companies can save money by offering minimal training and put unsafe drivers of large semi-trailers behind the wheel. Only one provincial government required mandatory training or considered standardized training. Of course, now some provincial governments have but it will be a pathetic patchwork, ignoring that semis regularly drive across provincial borders.

Did the justice system provide a deterrent to prevent a tragedy like the Humboldt bus crash from happening? If a similar tragedy occurs, will it all fall on the driver again?  Will the justice system rehabilitate the dysfunction system that played a key role in the crash?

#2. Sexual abuse by Roman Catholic clergy (Further Reading)
Happened globally in 20th and 21st centuries, and likely for centuries before that. Scandal is so well exposed it needs no documentation, though see Further Reading. Clearly a systemic problem, yet who is held accountable?

Bishops transferred known offending priests to other jurisdictions to abuse more children. Everyone in the Church worked to protect the Church at the expense of children, and now it turns out, even nuns were abused.

Who is ever held accountable other than the odd defrocked clergyman? Who in the Catholic Church's patriarchal hierarchy should be held accountable and what would justice for victims, providing a deterrent to future crimes, and making the public and society safe entail?

Does 'We did the best we could in difficult circumstances, wanting to protect both the perpetrators and victims equally' cut it, because there's good people on both sides (to use a Trumpism)?

BLAME GAME
Healthcare, including transfusion medicine, supposedly has adopted a quality system that promotes a blame-free culture where individuals are able to report errors or near misses without fear of reprimand or punishment. (Further Reading, Culture of Safety)
"The culture of individual blame still dominant and traditional in health care undoubtedly impairs the advancement of a safety culture. One issue is that, while "no blame" is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile the twin needs for no-blame and appropriate accountability, the concept of just culture is now widely used.  
A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (e.g., slips), at-risk behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. " 
Yet the blame game still exists in medicine, as exemplified by the Dr. Bawa Garba case in the UK (Further Reading), although the injustice was ultimately rectified.

A key part of human nature is to want to know and understand why things happen. Humans (we Homo sapiens) have done it since we emerged as Great Apes, along with orangutans, gorillas, and chimpanzees. Later in our history it's one reason astrology emerged.

If bad things happen, it's natural to assign blame. Take footie (soccer in NA). If a team loses 1-0 because of a goal from a penalty kick due to the referee penalizing our player, many fans see it as the refs fault, it wasn't a penalty, the opponent dived. Definitely not that our club couldn't score even one goal.

And it's much more satisfying and easy to grasp if we can assign blame to fellow humans as opposed to some amorphous system failure. Another factor at play: if we look for something, we often find it. For example, can be as simple as being a new VW Beetle owner and suddenly noticing them everywhere. Or more relevantly, if I suspect that a person is a misogynist, I may interpret their perhaps innocent words and actions as misogynistic.

REVENGE 
When I told a good pal that I considered writing this blog, she encouraged me (as she always does) and suggested I include what a desire for revenge does to a person.

Good example exists in the CBC's Unspeakable series, in the character Ben Landry, to me a fictionalized version of one of two book authors (along with Krever Report) the series is based on: Vic Parson, who wrote Bad Blood: The Tragedy of the Canadian Tainted Blood Scandal. In the fictionalized version, Landry's behaviour drives away his wife and son with hemophilia and misses out on celebrating the birth of his grandson.

It's a given that hatred and the desire for revenge eats away at people and can destroy their lives if left unchecked. Know this from personal experience of a relative who physically abused his wife and sexually abused many children. Revenge seldom, if ever, gives the solace we need.

LEARNING POINTS
Just want folks to think about what would constitute justice for victims of infected blood scandals around the globe. Are thousands of deaths from HIV and HCV the fault of no one, just a system failure that no one could prevent? No one can be faulted for decisions because they didn't know enough? If preventable errors were made, what does justice look like?

FOR FUN
Chose this ditty because it fits how I feel about the blog's issue. To me, transfusion professionals always had patient well-being on their minds yet they failed them, as the lover admits in this song:
COMMENTS: As always, your comments are appreciated and welcome. See below.

FURTHER READING
Canada's blood scandal 
If you view only one resource, make it this one. From Canada's blood tragedy: Tragedy of Factor VIII concentrate (19:14 mins. well worth watching. See Randy Conners words at 18 min. mark)
Criminal Justice System Purpose
UK Infected Blood Inquiry News 
Humboldt Broncos bus crash
Catholic Church Sexual Abuse
No Blame Culture
Bawa-Garba Case

Saturday, February 02, 2019

I've been everywhere (MLS grads in the Klein era)

Updated: Feb. 2019 (Major re-write)

Folks, the article below by a University of Alberta graduate in Medical Laboratory Science (MLS) was written 22 years ago. I have her permission to include it in a blog. I think it's timely because it documents -using one example- what happened to Alberta's health professionals under Ralph Klein in the 1990s, now touted as a fiscal hero by UCP's Jason Kenney.

IMPORTANT: I alone am responsible for the blog. The MLS grad agreed I could use her article in a blog, whose content was unspecified.

Although somewhat political, I decided to include it in the 'Musings on Transfusion Medicine' blog series as it relates to one of several students who got work in New Zealand's Blood Service and to education for medical laboratory technologists/scientists.

BACKGROUND
The student in question was lucky in her decision to get a university degree in MLS because it gave her international mobility. So many  of Alberta's excellent medical laboratory technologists with diplomas did not have that option.

As someone who was asked by many with diplomas what their options were when jobs in Alberta all but disappeared under Klein, it was hard to tell them the reality. Many were experienced and talented but it mattered not. Unlike MLS grads, the USA wasn't possible because of NAFTA requiring a BSc in jobs the USA needed. To work as a technologist you also needed to be certified by ASCP or similar. In contrast, most MLS grads had opted to obtain ASCP certification upon graduating so had no USA barriers to employment for what they were educated and trained to do.

Getting MLS grads accredited to work in NZ and qualified for work visas was difficult. First, I sent the entire MLS curriculum to the NZ certification body to prove the program was equivalent to NZ's, which had adopted a university entry level and called graduates medical laboratory scientists or biomedical scientists. Getting MLS's program accredited was the easy part.

Second, the job had to be on a skill shortage list, plus candidates needed a job offer from a recognized employer, in this case the NZ Blood Service. Other criteria were age, health and character requirements. Much more was required, including booking plane flights before acceptance by the NZ Canadian embassy was guaranteed. I well recall the incredible bureaucratic nightmare the MLS students endured to go Down Under.

These MLS grads, my 'kids' as I call them,were brave pioneers, undertaking a grand adventure. Thanks to PC Premier Klein, dozens of other grads uprooted them selves from their homes and families and moved to the USA where they were treasured as fabulous health professionals.

For example, out of the blue I was contacted by a maker of blood bank software (Wyndgate, now part of Haemonetics) who explained they'd done a software demo for the NZBS and were so impressed by the Canadian MLS grads, they hoped other grads would be willing to travel to California to work for them. As it turned out two MLS grads did, including this graduate, a grad of the post-diploma BSc program.

LEARNING POINTS
1. Having experienced Klein's health care cuts in Alberta, which we still are recovering from, I'm no fan of politicians like UCP Kenny who bow down to the god of decreasing a deficit. Especially when they put that above the welfare of health professionals and diss them for being pampered public service workers.

2. Seeing the fossil fuel energy sector whine about lost jobs and decreased profits, after so many good years of mega-profits, makes me chuckle at the irony. Yes, I have empathy for those who have lost their jobs. In the good years many folks, regardless of education level, earned $100K+ in the oil patch, worked hard, long hours and lived the good life.

Medical lab technologists spent much effort, time and big-$ to get an education. Oil-patch dudes, who portray themselves as pull-themselves-up-by-the-bootstraps macho-men and now whine, are portrayed as victims of the governing Alberta NDP of all things by the opposition UCP, not victims of the glut of oil and falling prices.

Meanwhile, in the 1990s public sector workers like my young MLS grads just got on with making the best of a bad situation at great personal trauma and expense. Yet the conservative UCP refers to health care professionals and others in the public sector as pampered, spoiled elites. Really?

3. To me, the most important lesson is please get the most education you can. Because it not only opens your eyes and mind, it gives you the opportunity to be the best you can, to contribute the most you can, and to be prepared when disaster strikes. As it did in Alberta in the Klein years.

REFLECTIONS ON A DEGREE-COMPLETION PROGRAM

My name is Kathy Swainston. I graduated from the Medical Laboratory Technology program at NAIT in June of 1989. Over the next three years I worked in both a small hospital setting in Jasper and in a larger centre, the Red Deer Regional Hospital. It was while I was sharing the Student Supervisors position in Histology at RDRH that I decided that I needed to return to school. I had attended university for two years before going to NAIT and I felt that I needed to complete my university degree.

At first I explored the post-diploma degree that UBC offers, before I realized that [Med Lab Sci at] the University of Alberta could offer me the same option much closer to home. I had already made the decision to leave my job, even though the future of health care in Alberta was very much up in the air at the time. In September of 1992, I was once again enrolled in university. The next two years involved a lot of hard work, but it was worth it.

The first year was tough, but not as tough as for the four year university student. Because of my training at NAIT, I was given credit for the labs that accompanied most of the courses that I took that first year. That first year got me back up to speed in all of the five disciplines of laboratory work. It also introduced me to a first year biochemistry class, which I thoroughly enjoyed and an introductory statistics class, which I endured.

As part of the degree you are required to complete a 3-or-6 credit research project. I found the experience extremely valuable. I chose to do a 6 credit pro- ject titled 'Characterization of the gene(s) that allow avirulent phase Ill Bordetella pertussus to grow on nutrient agar.' I enjoyed my time in the laboratory working on my own and learning to troubleshoot the problems that arose. I was able to experience first hand what it would be like should I decide to pursue graduate studies.

We were also required to take a course called 'Communication and Analysis of Biomedical Information.' It was set up in two stages; one part involved the research and presentation of a medical case-study to my peers. This gave me the opportunity to present my findings as a lecture to classmates and instructors. It was a great way to practice speaking in front of a group of people, which is harder than it appears.

The second part of the course involved doing a literature review of a selected topic relevant to laboratory medicine and writing a review paper in a format suitable for publishing in a scientific journal. This entailed lots of time in the library looking through journals and using on-line services such as Medline to search for articles. l chose to review 'Extraction, Amplification, and Study of Mitochondrial DNA from Ancient Remains.'

In the second year you could take advanced courses in the disciplines you most enjoyed. Some courses gave an in-depth look at instrumentation and troubleshooting, very valuable in today's laboratory. We had the opportunity to examine the management side of things, which was an eye-opener. We were exposed to the latest techniques in genetic testing and other technologies, such as flow cytometry. All in all received a very well rounded education.

l graduated in the Spring of 1994 with a BSc in Medical Laboratory Science. In the end pursuing a post- diploma degree has given me more knowledge and confidence in my work. l am more confident in conveying my ideas and knowledge to others and am a better technologist because of my experience.

Having a BSc in Medical Laboratory Science has allowed me the opportunity to explore the job market in the United States, Saudi Arabia, and other Commonwealth countries. Because of the degree and the generous help of the staff in Medical Laboratory Science at the U of A, l am now living and working in New Zealand along with five other MLS graduates.

The instructors in Medical Laboratory Science not only teach, but provide valuable help when searching for a job post-graduate. l would like to take this opportunity to praise their effort and thank them all.

For technologists looking to further their education, l would definitely recommend the post-diploma degree at the University of Alberta.

l would like to thank Pat Letendre for her help in editing this article.

Kathy Swainston, RT, BSc (MLS) Hamilton, New Zealand
Published in the ASMLT Spectrum, Jan. 1997

FOR FUN
Decided to use very old ditty by Canadian legend Hank Snow. What happens to health professionals when politicians value money above people. Tragedy is a career killer for those without international mobility. For those with mobility it's still traumatic.
As always comments are welcome. See those below.

Thursday, January 31, 2019

Unforgettable (Musings on the CBC's Unspeakable about Canada's 'tainted blood scandal')

Updated: 9 Feb. 2019 (New videos,comments +at blog's end)

January's blog was stimulated by two ongoing current events: UK's Infected Blood Inquiry and Unspeakable, a television series based on Canada's 'tainted blood scandal.' The blog's purpose is to provide those interested with a range of selective (not all inclusive) resources in one place. (Further Reading). 

The blog's title derives from a song recorded by Nat King Cole in 1951. Surely, these blood scandals must stay unforgettable forever. But in Canada a recent survey showed 61% of Canadians were unaware of the Krever Inquiry and the Canadian 'tainted blood' tragedy of the 1980s and '90s that led to establishing a new blood system.

Unspeakable has caused a bit of a stir. For example, the series resulted in Graham Sher, CEO of Canadian Blood Services, writing this oped:
As someone who lived the scandal and its antecedents while working in Canada's blood system, I know all the real-life physicians in Unspeakable. Also read the three volumes of the Krever Report, all of which gives me an advantage in following the series.

Also knew hemophilia patients Barry and Ed Kubin (teenagers at the time) when working for Canadian Red Cross Blood Transfusion Services in Winnipeg in the 1960s and '70s. They'd come to the blood service to pick up cryoprecipitate and later the Factor VIII concentrate that was to kill them. Ed died from AIDS in 1996, his younger brother Barry before that. Human interest news feature:
Some of the characters in the TV series are fictionalized. I'm guessing that the bigger-than-life character in episode 4 (29 Jan. 2019), a hemophiliac from Manitoba, who carries a rifle around, is a take-off on Ed Kubin.

I may add to the blog as the series progresses. Hope you find the resources below useful.

FOR FUN
Believing these blood scandals must stay unforgettable forever, I chose this oldie-goldie.
  • Unforgettable (Natalie Cole with video recording of her late father Nat King Cole)
As always comments are most welcome. See those below in Comments section and this one in the text of the blog.

ADDENDUM - REPLY to Dr. Neil Blumberg (8 Feb. 2019)
...Must admit it's a complicated business and at my advanced age I'm trying to stick to the BIG PIC. Easy to get wrapped up in the trees and forget the forest. First I'll deal with HCV, then HIV and FVIII concentrate/ cryoprecipitate. Appreciate Neil taking the time to present alternative views to mine. Hope readers appreciate his contributions to the ongoing discussion. 

There is no doubt in my mind that Justice Horace Krever got it right in his extensive 'Royal Commission of Inquiry on the Blood System in Canada' (1993-7), culminating in the Krever Report, 26 Nov. 1997, after which Canada got a new blood system (CBS and Héma-Québec).

Open Letter to the Honourable Commissioner Judge Horace Krever (retired) by CBS CEO Graham Sher (23 Nov. 2017):
"Sadly, an entire generation is largely unaware of the extent to which the system failed, and perhaps more significantly, why and how it has been rebuilt. In a recent poll conducted by Ipsos on our behalf, fewer than half of Canadian respondents indicated some level of awareness of the Krever Inquiry and its findings."
1. NON-A, NON-B HEPATITIS (HEPATITIS C)

The gift of death: Confronting Canada's tainted-blood tragedy
Source: Canadian Encycopedia (Time Line)

1981:Canadian Red Cross rejects "surrogate" tests (meaning testing not for a condition itself but for indicators generally associated with it) being developed for non-A, non-B hepatitis in blood. It cites controversy over their reliability and the lack of Canadian data, but no Canadian studies are undertaken.

1985:Canadian Red Cross starts screening blood for HIV, the AIDS virus.

1986:U.S. blood banking organizations start surrogate testing for non-A, non-B hepatitis based on research indicating it can drastically reduce the incidence of transfusion transmission. Canadian Red Cross remains unconvinced, estimating surrogate testing would prevent only a small number of cases, at a cost of up to $20 million in the first year.

1990: Canadian Red Cross (and U.S. organizations) start direct screening for hepatitis C virus. But unscreened plasma in blood products still reaches some patients, possibly for as long as two years.

1993: Federal government appoints Ontario appellate court Justice Horace Krever to investigate the contamination of the public blood supply in the 1980s.

Nov. 21, 1997: Krever releases his report, slamming the Red Cross and governments for ignoring warnings and acting irresponsibly as HIV and hepatitis C transmissions continued. He calls for prompt no-fault compensation for "all blood-injured persons." Krever concludes that 85 per cent of the approximately 28,600 hepatitis C infections from the blood supply from 1986 to 1990 could have been avoided.

Feb. 12, 1998: The RCMP launches a criminal investigation into the tainted blood scandal.

March 27,1998: Federal Health Minister Allan Rock and his provincial counterparts announce a [HCV] compensation package of $1.1 billion ($800 million from Ottawa, $300 million from the provinces), available only to those infected between 1986 and 1990, when screening could have been in place. Details of individuals' compensation are still to be worked out.

From 'Blood officials knew in '81 of hep-C [surrogate] test, memos show' (12 Nov. 2003) by André Picard, author of 'The gift of death: Confronting Canada's tainted-blood tragedy' (1985) 
  • ...Much of the discussion focused on using a surrogate, or indirect, test for alanine amino tranferase. ALT is a blood enzyme that indicates liver dysfunction, a telltale sign of hepatitis infection.
  • The test was far from perfect. It would detect only about half the cases of HCV, resulting in the loss of about 3 per cent of blood donations, and would cost about $3 per unit of blood. But HCV was becoming such a widespread problem that the meeting concluded: "Blood-collection agencies in the U.S. should prepare to test ALT levels of all blood units."
  • John Derrick, director of operational research at the Canadian Red Cross, said testing was "premature" but blood banks in the U.S. were "gearing up" for the move. He noted that as long as the ALT test was not part of standard operating procedures, the Red Cross "can not be held legally responsible for any illness resulting from transfusion of blood with high ALT levels."
  • Dr. Derrick concluded the memo by saying there was a "general strong feeling . . . that no one should test on a routine basis since all blood centres would be obligated to test.
  • In May, 1981, Dr. Patrick Moore, director of the National Reference Laboratory of the Canadian Red Cross and one of the country's foremost experts on hepatitis, had demanded immediate implementation of surrogate testing. But his recommendation was rejected by his superiors, largely for financial reasons. They decided instead to do more testing.' 
It took the USA a long time to implement surrogate tests (ALT, anti-HBc) because of the balance between risk and benefit (Harvey Alter) and Canada never did.
Perfect example of the precautionary principle abandoned and it's not so much that transfusion physicians in the 1970s-80s were such staunch proponents of evidence-based medicine, although some were, because I must have missed that. EBM existed before but got huge impetus from McMaster University in Canada about 1992.
The precautionary principle applies where after assessing available scientific information, reasonable grounds for concern exist for the possibility of adverse effects on human health [or the environment], yet uncertainty persists. Risk management measures can be adopted, without having to wait until the reality and seriousness of adverse effects become fully known. In other words, in risk management, err on the side of human safety.
Based on the evidence of the Krever Inquiry, in Canada and perhaps elsewhere, the over-riding principle was minimizing costs at the expense of human lives. Yes, the transfusion medicine community were dealing with many unknowns about non-A, non-B hepatitis (hepatitis C), its incidence, cause and seriousness, but Canadian leaders and funders opted (conscious decision) to do nil about hepatitis C despite calls from many inside the system

Who knows how many of the estimated 20,000 cases of hepatitis C (1985-90) could have been saved by surrogate testing of the Canada's blood supply and those infected by blood before 1985. 

2. HIV and AIDS
Will try to keep this reply shorter. In reply to my comment, "But why not cryoprecipitate made from one donor not 20K+ as for FVIII concentrate?" Neil Blumberg commented, "The capacity to generate cryoprecipitate was nowhere near what it needed to be to replace all the factor VIII concentrate that was in use. Would have required a year or two (my guess) to ramp up production."

I've only a sketchy idea of what increased cryoprecipitate production would have taken in Canada. Based on my 13 years as a medical lab technologist at Canadian Red Cross BTS in Winnipeg (combined blood supplier and regional transfusion service) for Manitoba and northwestern Ontario, maybe more large refrigerated centrifuges to separate plasma from red cells, a few more blood component staff? What I don't know is what percentage of donated blood was typically processed into cryoprecipitate.

First, did CRC-BTS even try to ramp up cryo production, given it had decided to distribute its already paid-for stockpile of known HIV-infected, non-heat-treated FVIII concentrate? I think not.
Kinda reminds me of CBS's decision to close a plasma collection site because it was cheaper to buy plasma derivatives like intravenous immune globulin (IVIG) from USA. CBS has since decided that securing a Canadian supply chain for donated plasma is a good thing but to date no government funding has been announced.  
Second, some CRC-BTS centres and medical directors in Canada decided to distributed more safe heat-treated FVIII conc. and fewer HIV-infected products and also promoted cryoprecipitate, as did some hematologists, versus giving HIV-infected stockpiles to patients. To my knowledge there were no hemophiliac bleeding disasters in cities like Calgary, Edmonton, St. John's, who did so.

BOTTOM LINES [BIG PIC]
Was there a shortage of heat-treated FVIII concentrate so that hemophiliac lives could only be saved by using up stockpiles of HIV-infected concentrates, else they'd bleed to death, and most were judged as already infected?
Based on Krever, it's an open question in Canada and a bit ironic, given the product meant to save hemophiliacs killed them. I've read evidence there was no shortage of heat-treated concentrate but don't know the reality. Also, CRC-BTS made no effort to increase production of safer (one-donor) cryoprecipitate. 
Was Canada deciding not to implement surrogate tests -against the views of some of its own medical experts- justified and honorable? No. Krever presented evidence to show decision was based on limiting costs not patient safety.

Agree with Neil that hindsight is 20-20 and real time is much fuzzier. And that folks, especially victims whose lives have been destroyed, naturally play the blame game because it's hard to accept, 'Oh well, sometimes bad things just happen.'

However, I do not agree that the worldwide 'tainted blood tragedy' of the 1980s-90s was unavoidable. Instead, I agree with Justice Krever. The tragedy's effects in Canada (perhaps elsewhere) could have been significantly decreased if transfusion leaders had not been so arrogant (yes, many were arrogant in thinking, as physicians in that era often did, we know best and some still do) and focused on the value of human lives, not the bottom line (cost-savings).

One last tidbit: In the past I read that minutes of a key meeting of Canada's government funders and CRC-BTS officials were inexplicably destroyed. Cannot get the reference now but it's real and did happen. Remind you of anything, e.g., missing minutes of a Nixon Watergate tape?

That's it for this oldster. Over and out.

RELATED BACKGROUND VIDEOS
FURTHER READING
CANADA
For followers of the CBC's Unspeakable, I recommend these resources:
Twitter:
Victims outraged by tainted blood trial acquittals (1 Oct. 2007)

Hepatitis C Package Controversy (The Canadian Encyclopedia, 2003, updated 2014)

André Picard tweets about Unspeakable, based in part on his book "The Gift of Death", shares some of his stories on 'tainted blood' scandal

Krever Report: Some Important Milestones: HIV and AIDS,1981-94 pp.xxi -xxviii

Krever Report: 14. The risk in Factor VIII concentrates

Capan K. There's more to Krever's report than the blood issue -- much more. CMAJ 1998;158:92-4.
  • See 'Therapeutic privilege' for lawsuit filed by Rochelle Pittman infected with HIV from husband, who got it from infected transfusion and was never told.
A systemic deconstruction of the Canadian tainted blood tragedy (Gilles Paquet and Roger Perrault. Oct. 27, 2015)
UK
For followers of the UK's Infected Blood Inquiry I recommend these resources:
Twitter

Monday, December 31, 2018

Those were the days (Musings on physicians I've worked with over a lifetime)

Significant updates: 8 Jan. 2019 (added tweets)
December's blog is about eight pathologists, hematopathologists and hematologists, I've had the pleasure to work with over a more than 50-year transfusion career. I cannot do them justice so will offer a series of brief tidbits that symbolize how I see them. Some are what folks call 'real characters,' some not, but they all have strength of character and I'll never forget any of them.

1. John Bowman (Winnipeg, Manitoba)
I've blogged on Jack before when he died in 2005:
Dr. Jack Bowman (In Memoriam)
Many tidbits to show why I respected him.

The rest are from my career in Edmonton, Alberta, Canada.

2. Lynn K. Boshkov (Edmonton)
Lynn is such an unassuming person. Loved her tenure at the UAH transfusion service. She was the Medical Director when this case happened
So respected her when she disclosed and explained what had happened to the patient's family whose loved one had died and supported the staff member involved. Lynn eventually moved to Portland's Oregon Health and Science University.

3. David Ferguson (Edmonton)
As UAH Medical Director David helped me a lot as the clinical instructor to the UAH transfusion service. He eventually moved to BC and retired in 2013. Two tidbits:

The Med Director gave oral exams to all med lab technologist doing their clinical rotation at UAH and I was present to decrease any stress. Once David asked a student which lectin acted like anti-A1. Her reply was Delicious biflorus (not Dolichos biflorus) at which point he started laughing uncontrollably. Poor kid, I tried to salvage the moment, though I had a huge grin on my face.

Second tidbit is David's reaction to feedback we got on a paper submitted to AABB's Transfusion.

Letendre PL, Williams MA, Ferguson DJ. Comparison of a commercial hexadimethrine bromide method and low-ionic-strength solution for antibody detection with special reference to anti-K. Transfusion 1987 Mar-Apr;27(2):138-41.

AABB reviewers thought we needed to change title to add 'with special reference to anti-K'. We did, of course, but I'll never forget David's venting as only he could do. In retrospect I wish all could see him as I did.

4. Ed Uthman (MEDLAB-L)
When I created the mailing list MEDLAB-L in 1994, Ed was one of the first to subscribe. He soon became a rockstar and motivated many to love the list and join. He contributed many posts and made the list a success.

Now on Twitter Ed still contributes to pathology worldwide: Ed on Twitter

5. Neil Blumberg (MEDLAB-L)
Neil also joined MEDLAB-L early on and was so generous with answering questions completely and in detail. The wealth of knowledge he has is incredible and that he's so willing to take time to share it with others.Wow!
I'll always treasure Neil's contributions and he's still at it: Neil on twitter
6. Ira Shulman (MEDLAB-L)
Ira gave talk at Edmonton conference and I got to know him. Came to my University of Alberta Med Lab Sci office to catch up on e-mail. I erred in ordering wine that was sweet at a local restaurant (horrors!) and especially funny as I prefer very dry wine. We went to the local IMAX theatre as he wasn't into a river valley walk. 


Great guy. Loved California Blood Bank Society (CBBS e-network forum) but it ended.

Once he asked me to present at AABB conference with him, but without financial support as a consultant I couldn't, especially given the US-Canada exchange rate. At ISBT World Congress in Vancouver I enjoyed his OMG comment on all the backup files I had for my Powerpoint presentation.

6. Heather Hume (Ottawa, CBS Head Office)
I worked on contract for CBS under Heather's supervision, along with colleague and friend Kathy Chambers, when Heather was executive medical director, and had the vision that CBS should do more transfusion education. Heather is special.

Together, with input from Dr. Lucinda Whitman, we created a Transfusion Medicine website [screen shot of old site] that has since transmogrified to Professional Education.

At Vancouver at ISBT 2002 Congress when, as a panel member, I noted I'd stayed at University of Alberta Med Lab Sci for 22 years but managed only 9 months at CBS Edmonton as 'Assman,' Heather quipped,~ to 'Pat always wants to end with a laugh.' I'm sure she was thinking much worse, but the classy lady gave me the benefit of the doubt.

7. Gwen Clarke (Edmonton)
I taught Gwen when she was in Med Lab Sci and got to know her better after she became a hematopathologist. In 2006 Gwen and Morris Blajchman edited Clinical Guide to Transfusion, the first to be published online and in print. Believe it or not, I was a co-author (minuscule role) of one of its chapters:
2006 Chamber K, Letendre P, Whitman L. Blood Components. In: Clinical Guide to Transfusion, Clarke G, Blajchman M, eds. Ottawa: Canadian Blood Services, 2006.
Every technologist who works with Gwen respects her. She's a oner. I hope CBS knows how lucky they are to have her on staff.

 8. Susan Nahirniak
I count Susan as one of my Med Lab Sci 'kids'. Despite all my kooky blogs and tweets, Susan never fails to greet me with a warm smile, as here at MLS 2018 reunion. I so appreciate that she forgives me my sins for old time's sake. During our talk her phone kept vibrating because her daughter wanted to be picked up, but Susan kindly ignored the phone.

In summary, I hope you enjoyed these glimpses into encounters I've had with a variety of transfusion physicians over the decades. All are very different, unique, and superb representatives of their profession.

TWEETS
Replies I received on Twitter when I posted this blog. Both have given me permission to post their tweets.
#1 By @shroon7, 1 Jan. 2019
I adored Dr. Boshkov and was @UBB [University of Alberta Blood Bank] as an LAII when she left. Dr. Clarke is also wonderful and I’m glad I still get to talk to her occasionally when she’s on call. RBB’s [Royal Alexandra blood bank] loss was CBS’s gain.Dr. N [Nahirniak] is another fave; more than a few times I’ve been very glad it was her on call. #2 By @shroon7, 1 Jan. 2019
She [Lynn Boshkov] was just so wonderfully “chill” in bone marrows. She had the best ability to keep patients distracted and at-ease during the whole procedure.
#3 By @shroon7 1 Jan. 2019
To sum up: Considering THREE fabulous hemepaths I’ve had the good fortune to work with are three of your top choices after your long career, I’d consider myself very blessed.

#1 By @DoctorCanBob, 1 Jan. 2019
Lynn was trained in McMaster and was also a superb "clotter".
#2 By @DoctorCanBob, 1 Jan. 2019
Lynn is still doing primarily clotting in Portland at OSMU. 

Also see entire thread of these tweets.

FOR FUN
Could choose many songs for this blog but decided on 'Those Were The Days' by Mary Hopkin. Her 1968 version, produced by Paul McCartney, became a number one hit in UK.
As always, feedback is appreciated. See Comments below.

Wednesday, November 14, 2018

Nessun dorma (Musings on anti-paid plasma blogs over the years)

Updated: 14 Nov. 2018

Below is a list of the blogs I've written so far on paid plasma: 23 blogs over 6 years as of 14 Nov. 2018. Some blogs focus on it entirely, others touch upon it along with related issues. In total 2004-2018 I've written 174 blogs, and paid plasma constitute about 13% of them. This blog's sequence is different than others. The main content (list of earlier blogs) will come at the end.

INTRODUCTION
The blog's title comes from a famous aria for tenors in Puccini's opera Turandot, which premiered at La Scala in Milan in 1926 after Puccini's death. Like many, I love the classic for many reasons. One is my spouse and I heard Pavarotti sing it in person in Edmonton in 1995. The face of every person on the LRT ride home from the concert radiated with joy.

I chose Nessun Dorma for several reasons. The title and first lines translate as 'None shall sleep' and builds to the final, victorious cry of 'Vincero!' (I will win!). In the battle over paid plasma in Canada, and it is a battle, I'm against paid plasma, as explained in the 23 blogs below. We don't know who will win and what the win will look like.

I hope the eventual winners (Vincero!) will be
  • Patients who need plasma derivatives and are prescribed products like intravenous immune globulin (IVIG) for evidence-based reasons, not because Big Pharma promotes it relentlessly to physicians. VERSUS patients being scared into panic by BIG Pharma, which supports their associations financially and is not beyond creating fear the world will end if paid plasma clinics cease to grow exponentially. 
  • Blood donors in financial need, who will no longer be exploited at the risk of their health by Big Pharma, which makes $billions off their body tissue. Yes, not all see themselves as being exploited, but many, if not all, are exploited and it's unethical.
  • Volunteer blood donor sector, which will recruit and be able to retain young donors, instead of having them slowly siphoned off to paid plasma, from which they are unlikely to return as they age.
  • Canada's blood supplier CBS (outside Quebec), which can concentrate on ways to encourage more volunteer young donors, perhaps with token incentives as happens in the USA system, or maybe not. Hope that CBS gets funding to open plasma collection clinics to get Canada closer to meeting its plasma needs.
  • Canada's government funders of the blood system, which should fund CBS plasma clinics, encourage voluntary donation, VERSUS now needing to spend megabucks to regulate ('police') the use of IVIG due its ever-increasing usage, as done by the BC PBCO and others, including for primary immunodeficiency
  • Health Canada should do its duty to regulate blood safety as a win-win strategy for patients and blood donors, VERSUS encouraging Big Pharma to promote endless iffy uses of plasma derivatives by supporting its exploitative paid plasma growth in Canada. 
FOR FUN
PAST PAID PLASMA BLOGS (n=23)
2018
The sound of silence (More musings on paid plasma pros & cons) 
The Boxer (Musings on HC's Expert Panel Report on immune globulin & paid plasma)
2017
Look what they done to my song (Musings on how paid plasma mirrors Rumpelstiltskin) 
Always on my mind (Musings on lack of transparency in Canada's blood system) 
The Sound of Silence (Musings on Health Canada's Expert Panel on Immune Globulin Product Supply) 
While my guitar gently weeps (Musings on recent transfusion-related news) 
We are the world (Musings on the humanitarianism of selling body tissues) 
The Boxer (Musings on lies & jests in the blood industry)
2016
Simply the best (Musings on paid plasma & TM colleagues I've know) 
Sweet Dreams (Musings on a recent transfusion-related nightmare) 
Heart of Gold (Musings on donating the gift of life)
2015
Heart of Gold (Musings on sucking $ from body tissues)
2014
Don't worry, be happy (Musings on the safety of our blood supply) 
If you could read my mind (Musings on hard-to-believe TM news) 
C'est si bon (Musings on TM news that is so good and not so good) 
Hey Jude (Musings on why paid plasma makes it worse, not better) 
I heard it through the grapevine (Musings on paid plasma's PR campaign) 
Bridge over troubled water (Musings on what to be thankful for as TM professionals)
2013
Day tripper (Musings on HC's instructions to the jury on paid plasma) 
Heart of Gold (Musings on pimping for paid plasma) 
Stop children, what's that sound (Musings on commercialization of our blood supply) 
We are the world (More musings on commercialization of the blood supply) 
Still my guitar gently weeps (Yet more musings on commercialization of our blood supply)