Tuesday, October 01, 2019

Both sides now (Musings on humans vs technology in transfusion medicine)

Stay tuned: Revisions are sure to occur

There's much transfusion news these days on artificial intelligence (AI), big data, drones, innovations, new technology, precision medicine. In a way this blog is a follow-up to the prior one, 'Get back' (Musings on transfusion medicine's future).

September's blog (albeit published Oct. 1) was stimulated by a weekly feature ('Workplace column') on a local radio program I heard this morning (Further Reading). Also, because as an oldster I want a record of events I've experienced in the hope they will resonate with some and influence others to do similar. Otherwise when we oldsters croak, they're gone forever.

The blog's title derives from a song by Canada's Joni Mitchell.

As you read the blog, regardless of your health profession, please consider the challenges you faced if you have held a management position and, if not, think about the strengths and weaknesses of managers you have had. Also, consider the impact you as a manager have had on colleagues and the influence your managers have had on you and your career. 

Specifically, the radio column was on moving into management, generally viewed as a promotion with a higher salary. The columnist (@sandbaryeg) gave tips on becoming a manager for the first time. Her tips made me recall when I took a giant leap from a long career as a transfusion educator of medical laboratory technologists/biomedical scientists to become a lab manager at CBS ('assman' as the centre's QA department addressed my mail). True, I'd been lab supervisor in my 13-yr job before teaching, but with none of the responsibility the 'assman' position entailed.

Indeed, as I only learned later, although I managed the patient services lab at the blood centre, the position had been downgraded to 'assistant manager' in order for the centre (and perhaps head office?) to retain more control, especially over salaries. Also, I hadn't realized (bit stunned of me) that the person who had been an assistant to the prior manager and perhaps (just a guess) had applied for the job I was recruited for, and was the acting manager when I came. She was a prior student of mine, in fact in the first Med Lab Sci class that I taught all the way through, who I was and still am exceedingly fond and proud of.

My take on the consultant's 5 tips for new managers. How to
1. Run meetings, something many dread;
2. Give effective feedback;
3. Foster a team environment;
4. Attract & recruit the staff you need vs filling an existing job;
5. Manage your own time effectively.

Promotion: First, I'll note that in my experience (historical, I know, dating from 1960s-2000) often the folks who get promoted in the lab are ace technologists. If all factors are considered more or less equal, seniority may play a role. To me, that's not an effective process, but it's likely the easiest.

How often do fabulous footie players (soccer in NA) or hockey players become great managers? Not many. Why? Because the skills needed are quite different.

Needed skills? More recently, not only med lab techs/scientists but also physicians (perhaps nurses?) tend to get Masters of Business Administration (MBAs) as lab medicine and transfusion have become more and more a business. Presumably these degrees help in a new career as a 'suit' whose prime concern is the bottom line, though patient safety is always touted, given first place in communications.

I'll discuss the 5 tips in various ways based on my experience.

Decades ago as an educator I'd experienced many ineffective meetings, including those run by MDs at the departmental (Lab Med & Path) & Faculty of Medicine levels. Some dept. meetings were info-only unneeded sessions. Few required active participation. And often the minutes were totally useless to anyone not attending.
  • My experiences motivated me to write a resource for TraQ in 2009 on running meetings (Meetings as Time Wasters, Further Reading).
On running meetings in my brief career as 'assman' I was fortunate and smart to designate my prior student to run many meetings. She was experienced in the task and did it much better than I ever could. Only time I ran meetings was when it came to getting staff on board with changing almost all pretransfusion testing methods in the lab. That came easy as it was right up my alley as an educator.

In a similar vein, I was glad I'd insisted on a whiteboard for my 'assman' office as it was well used when meeting with supervisors in the various sections of the patient services lab.

As an educator I had to give feedback over decades and some was difficult. For example, telling foreign students (English as a second language), whose parents had struggled and worked hard to send them to Canada that they were not going to pass their clinical rotation. For such students it was a total disaster, an incredible loss of face and shame. Frankly, it broke my heart and I know that whatever I said to lesson the blow (e.g., they could have great success in another career) wasn't heard and didn't lesson their reality in any way.

In giving more routine feedback, as a med lab technologist with an MEd, I knew the characteristics of effective feedback. On a personal level I believe that often what shapes us for good and bad in life are 15-60 second interactions with others. For example, I'll never forget the powerful effect of my Dad saying, 'Pat, don't be afraid to be different.'

As a teacher of med lab students I always kept that in mind when giving feedback. Meant I treated struggling students the same as high achievers. And in retrospect I see that many of those who struggled have gone on to be high achievers, leaders in their field. Why? Suspect it's because success depends on many factors, not necessarily getting the highest grades.

A good pal is a standardized patient at the University of Alberta and they have a particular take on feedback, called CORBS (Further Reading):

CLEAR – Give information clearly and concisely
OWNED – Offer feedback as your perception, not the ultimate truth. Talk about how something made you feel. Use terms such as “I find” or “I felt” and not “You are”
REGULAR – Feedback is offered immediately, or as soon as possible after the event
BALANCED – Offer a reasonable balance of negative and positive feedback. DO NOT overload with negative feedback.
SPECIFIC – Feedback should be based on observable behavior and behaviors that can be modified.

Not much to say. Health care teams are similar to politicians kissing babies. Everybody does it as it's the reigning orthodoxy, the cliché of how we love to see ourselves. Again, University of Alberta has a course on it. INT D410 - Interprofessional Health Team Development.

Like to think I've been a member of many teams in health care (my transfusion families over the years) but must admit that many who promote it most publicly do not walk the talk.

Will only speak to my recruitment to be 'assman' 21 years ago. Fact was the job was not quite as advertised. In retrospect I thought they portrayed part of the job almost as if it was what became hospital liaison specialists. I totally dug the part about the centre being the pilot site for a new information system and found it a worthwhile challenge.Our talented team of med lab professionals did a wonderful job in implementing the new IS.

Similarly, I loved the opportunity to change outdated lab methods, though don't think they hired me for that. It was just my 'value added' to the job I held for all of 9 months. When I tendered resignation I explained why in exit interview. They understood more money wouldn't make a difference and admitted they could not change what I thought needed changing most (head office, though it's more complicated than that).

So did CBS recruit the right person for the job? Yes and no. Yes, because I led the talented patient services lab team successfully through a difficult time of incredible change. No, because after years in academia at a university where dissent and free speech are cherished, I didn't fit in a national organization where adhering to head office directives was paramount. That's what made you a valued team member.

The radio consultant pointed out that managers need to prioritize their tasks and serve as role models for staff as they cannot work to 10 pm over the long term. I don't have much to say except that you obviously cannot help others if you're exhausted. See it as a Buddhist concept that you need to love yourself, be okay with who you are, in order to love and help others. Over my entire career I was often the first in and last out daily but that's another story.

Are AI, big data,new technology, precision medicine all important to health care and more crucial than the qualities of people in leadership positions? Perhaps. But not to me. As a human being on plant earth, I'll always value the human condition over technology. See excerpt from 2001, a Space Odyssey (Further Reading).😁

Chose this song because I've lived long enough to see transfusion medicine evolve from being people-focused to technology-focused. As  early adopter of technology (not a Luddite), I doubt we're on the right track (Further Reading). Also, admit that I love the songs of Canada's Joni Mitchell.

Saturday, August 31, 2019

Get back (Musings on transfusion medicine's future)

Updated: 1 Sept. 2019 (Learning pt 4, Further Reading)
August's blog was inspired by a blog I saw on the UK's BBTS website:
  • Transfusion 2024: What did we learn and where will we be? (Further Reading)
To me Dr. Nicholas Watkins' blog had 3 related themes:
  • How to replace retiring staff (and their experience) with new staff, including retaining them.
    • Innovation and technology can help 
    • As can big data (electronic donor and patient records)
The blog's title comes from a 1969 Beatles ditty.


Be aware I've worked in transfusion for decades. My views are biased by long experience as are the opinions of everyone.

In the 1990s I saw how regionalization and centralization of hospital transfusion service laboratories affected staffing, along with semi-automatic instruments. In Alberta, Canada (perhaps everywhere?) that meant many transfusion labs required fewer knowledgeable specialists and could get by with mostly medical technologists who were generalists,  plus lab assistants. Another factor was an AB conservative government that removed 40% of the province's lab budget to decrease a budgetary deficit.

Similar changes across Canada resulted in all medical lab educational programs closing in Western Canada except for the two in Edmonton, NAIT and the University of Alberta's MLS. I taught in MLS but as the University of Alberta Hospital's transfusion service clinical instructor I also taught  NAIT med lab students.

Automation came much earlier to blood supplier donor testing labs. In effect donor testing labs could be mostly staffed by technologists experienced in highly automated clinical chemistry labs.

Learning point #1:
To me, these events meant a huge loss of laboratory transfusion expertise in immunohematology. In Edmonton, Alberta, for example, experienced technologists had to compete for the few remaining jobs based on seniority and many left the field. Those with a BSc in Med Lab Science (who wrote ASCP exams) were able to move to USA (and overseas to countries such as NZ) and work for years.

I don't see 'innovation and technology' as truly helping the loss of expertise except in the sense it means:
  • Med lab profession can be 'dumbed down.' With increasing technology no one needs much expertise to perform routine tasks. And I don't mean generalists and lab assistants are 'dumb', I respect them for their skills, just that their lack of transfusion expertise is the new normal in many labs. 
  • We can only hope so long as serology survives, there's a safety net in all workplaces where the few knowledgeable staff catch any errors.
Learning point #2:
Today the biggie is molecular testing, which means immunohematology expertise will eventually become passĂ©. Presumably, if biotech manufacturers succeed with marketing campaigns that promote matching blood donors and transfusion recipients for antigens with known genes, not just in multi-transfused patients but as the gold standard for ALL transfusion recipients, serologists will no longer be needed.

Transfusion recipients will no longer develop alloantibodies from transfusion, except for ones the DNA PhD gurus haven't identified. But let's hype the hell out of precision medicine to increase profits of commercial interests.

Sounds like a perfect world, no? Local med lab staff numbers shrink to a precious few. Their pesky staff benefits are greatly reduced as an employer cost. Instead of supporting a local economy, money is funneled to foreign biotech companies, who thrive by pleasing their shareholders who grow richer and richer.

Big Data
Yep, big data can provide insights and feed into artificial intelligence (AI) to further remove error-prone humans from healthcare decisions. The downsides include patient privacy and the reality that machines make mistakes. GIGO rules and AI is only as good as human input.

Learning point #3: Privacy is big data's greatest challenge and if it fails (as is likely), big data will become just another failed trend. As to AI, I suspect it's decades away from filling the skilled worker shortage in the transfusion world. But it's already got niche roles in medicine (Further Reading).

Learning point #4: Presumably one day in the distant future AI, automation, and robotics will make human work passĂ©. It's already started and not just on car manufacturing assembly lines. Have you seen the Android robots from Japan or those providing robotic nursing care? With an aging population and worker shortage, robots can fill the bill. (Further Reading)

My vision for the future includes humans who cannot communicate with other humans by talking and have developed enormous thumbs for texting and perhaps sexting. 😉

Choose this Beatles ditty for blog's title song
  • Get back (Paul McCartney, Live in Lisbon 2004)
It's my attempt at a joke as we can never get back to the days where oldsters like me once belonged. 😄

As always, comments are most welcome. And there are some - see below.


Wednesday, July 31, 2019

Look what they've done to my song Ma (Musings on invisible health professionals)

July's blog, another short one, was stimulated by an editorial in the Archives of Pathology; Laboratory Medicine, August 2019: Emerging From the Basement: The Visible Pathologist. (Further Reading)

The editorial reminded me that a hematopathologist I once worked with told me, "Pat, just like medical laboratory technologists/scientists (biomedical scientists in UK, Australia, NZ) feel invisible, at the bottom of the health professional pecking order, so do pathologists of all specialties."

Also on the local scene in Alberta, Canada, a new provincial government just cancelled a needed planned hub lab in Edmonton, with the new government implying they wanted to concentrate on patient care (as if clinical laboratories didn't affect patients) and the centralized superlab/ hub lab was a waste of money best spent elsewhere. The new Premier Jason Kenny argued the changes (new consolidated hub lab) would do nothing to improve patient services.

The blog's title derives by a 1970 song by Melanie Safka.

My take has always been that most folk don't have a clue what medical laboratory technologists/ biomedical scientists do. Suspect they assume we are merely the vampires/blood suckers who draw their blood samples for lab tests. Generally, folks do not realize we are highly educated and trained professionals who play an critical role in assisting physicians to diagnose and treat patients.


Fact is med lab science and clinical labs need to be more visible to the public. In this section I'm going to include tweets of colleagues and former students (my beloved 'kids') who are using Twitter to promote med lab science and make the case for why clinical labs merit respect as playing an as important in patient care.

Tweets and News

Folks you can see tweets without being on Twitter. If you are asked to join, just ignore the dialogue box asking you to join and click on the tweet off the dialogue box. All tweets are short, please read them.

1. Thanks to all who came out to the CSMLS open forum last night

2. AHS Newborn Metabolic Screening program

3. Cancelling superlab undermines foundation of patient care

4. Finally - someone took a look at what's going on

5.  Short-sighted decision to halt ongoing construction of the Edmonton Clinical Lab Hub

6. Yet another example of the importance of lab medicine

7. Pictured here are very passionate medical lab professionals seeking to educate Albertans of the critical role med lab plays in quality patient care 

8. Clinical labs save lives. We have no space & aging equipment. Cancellation of Northern AB Hub Lab leaves us wondering how will this crisis be addressed?

9. Thank you for helping champion the voice of the medical lab profession and its critical role in effective quality patient care.

I chose this song because I'm disappointed that medical lab technologists (biomedical scientists) still have to fight to be visible to the public, including some politicians, after all these years. I came to the med lab science field by a non-traditional route 55years ago and still we face the same challenges.
Look what they've done to my song, Ma
Look what they've done to my song
Well, it's the only thing I could do half right
And it's turning out all wrong, Ma
Look what they've done to my song

Harrold IM, Bean SM, Williams NC. Emerging from the basement: the visible pathologist. Arch Pathol Lab Med. 2019 Aug;143(8):917-8.

Health Quality Council of Alberta: Provincial Plan for Laboratory Services in Alberta (February 2017)

Leaning into the challenge of medical science (4 June 2019)

The UCP government scrapped Edmonton's 'superlab'. Medical experts say Alberta needs an alternative and fast (24 July 2019)

Medical lab group pushing Alberta government to address gaps after cancelling superlab (24 July 2019)

Alberta government keeps promise to cancel construction of medical superlab (20 June 2019)

Lab Tests Online: For anyone interested in what medical lab professionals do and information on your lab tests results

Sunday, June 30, 2019

I will remember you (Musings on Marion Lewis, an extraordinary Canadian)

On June 27 Julie Payette, Governor General of Canada, announced new appointments to the Order of Canada. Included in the honours was Marion Lewis of Winnipeg, who at age 93 was named an Officer of the Order of Canada (Further Reading).

As my early career was in Winnipeg I was well familiar with Marion Lewis and Dr. Bruce Chown. In 1944, she and Dr. Bruce Chown opened the Rh Laboratory to study and eradicate Rh hemolytic disease of the fetus and newborn (HDFN).

The blog's title is based on a 1995 ditty by Sarah McLachlan.

In 1943 Marion Lewis graduated from high school and trained as a 'medical technician' at Winnipeg General Hospital (now Health Science Centre). In those days there were no post-secondary institutions training what today we call medical laboratory technologists/scientists ('biomedical scientists' in UK and Down Under). As noted, only a year later she was at Winnipeg's Rh Laboratory with Dr. Bruce Chown.

With a Bachelor of Arts degree she became a Full Professor in the Dept of Pediatrics and 2 years later a Professor in  Dept. of Human Genetics. Normally that's reserved for those with MD or PhD degrees. In 1971 Marion shared AABB's Karl Landsteiner Memorial Award with Dr. Bruce Chown in 1971. To me, it's AABB's most prestigious award. And it's not the only AABB award she received.
  • Karl Landsteiner Award
  • Past recipients (Check these TM giants out: Levine, Wiener, Race, Sanger, Morgan, Watkins, Mollison, Dausset, Blumberg, Crookston, Bowman, Issitt, Gallo, Montagnier, et al.)
It's fascinating that in 1950-51 Marion Lewis needed a break and spent four months at an Italian university studying Italy's language and culture. Then she spent another three months studying in London with Dr. Robert Race and Dr. Ruth Sanger of 'Blood Groups in Man' fame. In 1951 Marion returned to Winnipeg and the Rh Lab. And the rest is history (See her University of Manitoba biography in Further Reading).

Please read Further Reading for Marion's unique career.

Of course, I knew Dr. Jack Bowman of Winnipeg's Rh Lab well as he was the Medical Director of Winnipeg's Can. Red Cross BTS while I still worked there. Wrote a blog when he died in 2005 (Further Reading).

Chose this Sarah McLachlan song because I will always remember transfusion medicine giants and especially folks like Marion Lewis who rose from humble beginnings to great accomplishments on the strength of intellect, skills, and hard work.
As always, comments are most welcome.


Saturday, June 01, 2019

We can work it out (Musings on transfusion association annual meetings)

Last revised: 2 June 2019  (See ADDENDUM below)

As the CSTM annual conjoint meeting with CBS and HĂ©ma-QuĂ©bec is now on May 29 to June 2, I thought I'd muse on annual meetings in general. As readers of this blog will know, I've had a long career in transfusion starting at the bottom without qualifications but being incredibly fortunate in my employers.

I'm an outlier of sorts with atypical views and being an oldster gives me the freedom to say things that colleagues likely would not. Perhaps many may disagree with me on this blog's points. That's okay too as I'd be concerned if all, even most, agreed with me. Included are tidbits I think contribute to quality presentations at meetings.

Professional associations exist to serve and represent the interests of their members, which applies to the three associations I belonged to during my long career as a medical lab technologist turned educator: AABB, CSMLS (includes IFBLS membership), CSTM. The latter two are Canadian organizations, the first American but AABB has branched out to become international, though its headquarters remains in the USA as does its primary focus.

The blog's title is based on a 1965 Beatles ditty, We Can Work It Out.

Over the years I've attended many meetings, aka conventions and congresses. With a few exceptions most of all those attended were held in Canada by CSMLS or CSTM. One memorable one (IFBLS) was held in Oslo in 1996. Why memorable? Most of all it was because I met a Norwegian med lab technologist who worked in transfusion and we've been good pals ever since.

To me, that's Lesson #1 of what's important at annual meetings. It's not so much the scientific presentations you hear and what, if anything, you learn from them (commit to long-term memory). Face it, if you read professional journals you're pretty up-to-date on the latest and greatest. During my career the AABB journal Transfusion and similar were kept in the bathroom as a welcome distraction or read while basking outside in Canada's all too short spring, summer, fall.

Of course, I suspect not many transfusion technologists and nurses in the trenches regularly read journals. Take a peak at the index of Transfusion 2019;59(5). How many articles would you read let alone understand?

Today, keeping current also applies to those on social media platforms like Twitter where journals and associations alert folks to the latest developments. But how many of you use Twitter?

LESSON #1: The most valuable benefits of meetings are the interactions with peers, sharing experiences and knowledge that's not in journals or textbooks, including the friendships made. Often such interchanges are shared during a night-out over a meal or glass of wine/beer. Typically, chitchat involves practical and tacit knowledge only gained from experience.
Pretty certain that Lesson #2 will be familiar to medical lab technologists/scientists world-wide, at least those lucky enough to attend meetings:
  • So many of the presentations at transfusion association meetings are by physicians and researchers, though it's slowly changing. 
What this means is the information and research presented, though significant, is often not particularly meaningful nor of immediate use to those in the trenches, whether transfusion med lab techs, nurses, physicians without university appointments. And being able to use new meaningful learning right away is important to busy adult learners. In continuing education and professional development courses it's critical because 'adults vote with their feet' as the cliché goes.

Indeed, I wonder in the age of the smart phone how many meeting attendees during presentations  spend most of the time checking e-mail, texting and browsing. Suspect it's far too many. Best take is they're live tweeting but no, that's not it.

Reality is that much transfusion research is esoteric, of interest mainly to those involved in similar, narrow research.  Kudos to CSTM for its full day of workshops relevant to front-line professionals.

LESSON #2: Many presentations at scientific meeting are of minimal value to attendees, especially those who work in the trenches on the front-lines of transfusion, those in the lab and those on the wards. If you're a PhD or MD/PhD researcher and the topic coincides with your interests, the talks are no doubt fascinating.
Lesson #3 relates to a sad fact of life for many in the trenches. Years ago funding for CE/CPD was scaled back significantly. The result is fewer and fewer attend national meetings (unless local), let alone international ones. Today the cost of airfare and hotels is increasingly exorbitant.

Who can afford it? My guess includes
  • Physicians and researchers who get funding support or earn large salaries, along with those in senior positions. 
    • Bench technologists and front-line transfusion nurses not so much. 
  • Educators and those in health profession unions who get discretionary funds to use for CE/CPD but the funding wouldn't come close covering travel and hotel costs to attend meetings outside their locale. 
  • Some associations fund invited presenters, but not all.
  • An association's board of directors, whose members are volunteers and put in much dedicated time and a tiny perk is funding to attend meetings.
Many transfusion associations/organizations now offer local CE/CPD events across the country or provincially, including CSTM's Education Days. And thanks to the Internet, technology makes webcasts and podcasts possible.

LESSON #3: To what extent have annual meetings become a place for the 'elites' to meet and interact?  By elites, I mean those professionals fortunate to have funding or be wealthy enough to attend if the meeting is not in their locale and schmooze with other elites? It's a question to which I do not have an evidence-based answer, yet suspect it may be true.
Lesson #4 has been a pet peeve of mine for ages and relates to the quality of presentations at meetings by the biggies, the so-called 'thought leaders' of a profession. My experience is presentation quality is often awful, bordering on pathetic.

It's one reason I'm so glad that Medical Laboratory Science at the University of Alberta has a communications course that includes how to give presentations and gives students opportunities to practice the skills, including presenting their research projects.

Wish all MSc/PhD graduate and medical education programs included such a course. About physicians, my experience is, if a communication course or any professional development program, is not given by a physician, they devalue it. Apparently only physicians can teach physicians.😞

To me the biggest, common presentation failures include NOT doing the following, relevant to physicians, especially. BTW, the points are basic, equivalent to Presentation 101 courses.
  • Begin with a personal anecdote to grab audience attention immediately and get them to appreciate your authenticity, that you've 'been there, done that,' and dig their professional realities.
  • Explain up-front why the talk is relevant to the audience.
    • For gawd sake, don't keep it a secret.
  • Briefly outline what the talk is about, perhaps even say, if that's not what you expected, feel free to exit now. 
    • Shows you  respect the needs of audience.
  • Mention there will be time at the end for questions, if the person who introduced you did not.
  • Distribute handouts at the end and say that up front. 
    • Include your speaker notes in handouts so the audience has something substantive to take away.
    • In the early days of Powerpoint I don't know how many handouts I brought home from meetings, including making notes on each slide myself, that were all but useless and eventually tossed in a trash can.
    • Fact: If you distribute handouts at the start of a talk, the audience will concentrate on them, not what you are saying.
  • Use mostly graphics in the presentation vs bullet points. It's a way to get folks to listen to what you say.
    • If you use a few slides with bullets, do NOT use complete sentences and, regardless, NEVER read the points word for word unless you want to put the audience to sleep.
  • Forget about using any busy slides you have where the writing is minuscule and unreadable.
    • Just don't, no matter what.
    • Saves you the trouble of cynically apologizing for it being busy.
    • Because obviously you included the slide anyway, thus disrespecting your audience's intelligence. 
  • Throughout the talk refer to the experiences of colleagues and audience members you recognize, and sprinkle the presentation with their work.
    • It's not all about you, it's about those who helped you succeed.
    • Self-deprecating humour, if sincere, is appreciated by listeners.
  • Focus on key points only.
    • Though tempting, do not succumb to presenting all your data and conclusions.
    • Few viewers are as obsessed with the topic as you are.
    • The fewer key learning points, the more they will be remembered because of info overload.
  • At talk's end, briefly tell the audience what you told them and reinforce why it's significant and relevant to them. 
  • Thank the audience for their attention and thank conference organizers for inviting you.
  • With questions at the talk's end, even if you get snarky questions (yep, there are always all-about-me colleagues), try to be gracious, realizing that to most in the audience, the asker is showing themselves in a bad light and you are better than them.
    • Taking the high road always wins.
LESSON #4: Physicians and researchers, at least try to learn how to present well. I realize you could care less as you've gotten away with pathetic presentations forever and have zero motivation to change. But please try to be better because it has many rewards, adds to your reputation.
First a disclosure. Folks, for most of my career I was one of the fortunate 'elites' I referenced earlier, mainly by virtue of volunteer positions for professional associations, being an invited speaker at conferences where organizers funded travel and hotel costs, or as a perk of being an educator at a university. 

One thing I noticed in those days of yore versus today's national meetings is that now there seem to be fewer young attendees. Perhaps it's my imagination or just that all professions are aging and those in senior positions are older than before. Or maybe not.

While I hesitate to mention this, one reason could be that younger med lab technologists/scientists may not be as keen as we were in what I call the 'golden age of immunohematology.' Perhaps when considering annual fees, younger folks and many older ones too, wonder if it's worth it, questioning the benefits of membership. That is, they first ask 
  • What will the association and being a member do for me? vs
    • What can I do for my association?
    • How can I give back to my profession?
Or it could be that membership for some has become a financial burden. For example, in Canada registration with provincial regulatory colleges is compulsory for med lab techs,e.g. CMLTO annual fees. In contrast, membership in professional associations is voluntary and annual fees are a bargain in my opinion, e.g., CSTM $120 and CSMLS $167. But if you worked in Ontario and belonged to all three, the total would be $671.20. To me, that's just a tiny percentage of annual salaries and the benefits are many. 

Which brings me Julie Hendry's presentation. Julie is this year's recipient of the CSTM's  Buchanan Award, who included this slide at the end of her talk (click to enlarge - Julie's slide was tweeted by Geraldine Walsh and Clare O'Reilly on Twitter): 

Julie's challenge is a great one for CSTM members and members of all professions. We in the health professions are so lucky. 

I chose this Beatles song because its lyrics fit the blog's content.
As always, comment are most welcome (and there are some below).

Tuesday, April 30, 2019

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

Last updated: May 3, 2019 (See ADDENDUM below)
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.

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.

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. 

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.

Chose this ditty because Twitter is a good grapevine,
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).

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.

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 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)?

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.

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.

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?

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.

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.

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.

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.


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

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.

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."

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 AndrĂ© 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.

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.

For followers of the CBC's Unspeakable, I recommend these resources:
Victims outraged by tainted blood trial acquittals (1 Oct. 2007)

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

AndrĂ© 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)
For followers of the UK's Infected Blood Inquiry I recommend these resources: