Sunday, May 31, 2020

For the times they are a-changing (Musings on COVID-19 global news)

Stay tuned: Revisions are sure to come
What to write about during COVID-19? It initially stumped me. Possibilities I considered include how coronavirus has impacted the blood supply worldwide and increased pressure from paid plasma advocates to promote paying for all plasma and other body tissues. 

Finally settled on a mini-survey of coronavirus news featured in May's TraQ's newsletter to see what, if anything, that might reveal..

The blog's title is based on a 1965 ditty by Bob Dylan, and yes, it can be read many ways given the news.

INTRODUCTION
The mini-survey is based on news items I selectively collated for TraQ's newsletter during March, April, and May 2020. As past blogs will show, the blogs are mine alone and reflect my personal biases. 

For May's blog I arbitrarily organized COVID-19 news items into four topics, which have some overlap:
  • General (Information, industry news, search for treatments and vaccines)
  • Blood supply (Risk of shortages)
  • Convalescent plasma
  • Journal articles
SUMMARY 
Results of TraQ's March to May survey:
TOPIC 
MAR.
APR.
APR.
TOTAL
General 
0
13
8
21
Blood supply
6 3 4 13
Convalescent plasma
6 14 7 27
Journal articles
0 23 1538

Limitations
I could have calculated results incorrectly. My search alerts may not have identified all possible news items in each category. Also, in May the number of convalescent plasma news items soared and I decided not to include  many in the newsletter, as they often involved only a few people and were repetitive of earlier news. It's possible I haven't yet been alerted to the existence of more COVID-19 research articles published in May. 

LEARNING POINTS
So, as I recall from the 1966 film Alfie, it's time to ask, 'What's it all about Alfie?' Or as I once told my Med Lab Sci students, you should try to identify the 'so what' message of research papers. So too should blogs have a point. My biased musings on the results:
  • So much money is being poured into research for a vaccine and improved COVID-19 testing. It's a race to get there first among nations, including to have the vaccine manufactured in a country, as presumably that would give priority access to its citizens. 
  • Seems a rush to strike gold first. Potential for industrialized nation to get priority access and developing nations to be left out as often is the case. Think of recombinant FVIII being unavailable for ages in developing nations. Also countries like India where blood banks still use ELISA to test for HIV, Hepatitis B and C, rather than NAT.
  • Convalescent plasma is the flavour of the year of COVID-19. Results look promising but final results not in yet. More troubling is the notion that having antibodies allows you to return to work as you are protected. But scientists don't know yet whether people who've been exposed will be immune for life, as for measles, or if COVID-19 can return again and again, like the common cold. 
  • Big Pharma wants mega-money up front to fund COVID-19 research (Further Reading). Quote from article:
    • Particular concern over poorer countries’ access to medical supplies was highlighted by G20 health ministers’ failure at the weekend to issue a declaration of solidarity after this was blocked by the US
FOR FUN
I chose this Bob Dylan song as it reflects what's called the 'new normal' during COVID-19 and also reflects the current protests happening in the USA over the killing of a black man by a police officer. Somehow I suspect, with zero evidence, that the protests may be stronger and more widespread because of the coronavirus lockdown. Or perhaps because murder of black people by police has become all too common in America?

Chose Joan Baez to sing it for several reasons, the most important being she has a much better voice than Dylan. Also this version has the song's lyrics. Tidbit: Joan and Bob were once an item (Further Reading).
As always comments are most welcome.

FURTHER READING
TraQ's newsletters
Big Pharma calls for ‘billions’ in upfront coronavirus funding (20 Apr. 2020)

Joan Baez finally gets her public apology from Dylan (21 Sept. 2009)

Thursday, April 30, 2020

Could I have this dance (Musings on a love affair with transfusion medicine for NMLW)

Updated: 3 May 2020 (Fixed typos)  

INTRODUCTION
Because it's National  Medical Laboratory Week, for April's blog I'll share brief anecdotes from the labs of the blood suppliers and transfusion services I've worked for, including when an educator. These are the personal anecdotes of an oldster and I hope that some of them give a chuckle, albeit a wry one.

Keep in mind that I last had a real job working in a clinical laboratory 20 years ago. But I taught many students who still work and we keep in touch. Plus I manage a transfusion mailing list for the Canadian Society for Transfusion Medicine and an educational transfusion website, so keep up-to-date in the field.

The blog's title is based on a 1980 ditty by Canada's Anne Murray, and yes, it's an allegory for what I want to convey in this blog.

1. CRC-BTS [Canadian Red Cross Blood Transfusion Service] 
CRC-BTS in Winnipeg, MB, Canada is where I began my career in 1964. It was a combined blood donor centre and central transfusion service for the city and outlying areas of Manitoba and northwest Ontario. In those days Winnipeg hospitals did not have blood banks per se but functioned merely as distribution centres of blood, whose 'blood banks' were managed by hospital RNs. 

As I've written before, today I would never be hired as I had a general BSc (not when hired, though), and no med lab training. My knowledge of blood was close to nil. Nonetheless, CRC-BTS became my family for 13 years and I thrived. Fact is, I loved coming to work each day as I never knew what it would entail and what else I'd learn.

I decided to read the current immunohematology bibles (textbooks and journals) and eventually wrote the CSMLS (then CSLT) subject exam in immunohematology (now transfusion science), which no longer exists as a subject exam. 

Tidbit: As a subject blood banker, I'm a dinosaur who no longer exists in Canada. At one point I took offense when the then CSLT President said those with subject certification were only good for chopping liver. Think I wrote a letter to the Society's newsletter in rebuttal. 

Then I became the clinical instructor for med lab students from Red River Community College (now Red River College), new CRC-BTS lab staff, and any trainee physicians who wanted to learn about the transfusion service. 

Teaching was a natural as after the science faculty, I took a short session in the Faculty of Education and taught high school in rural Manitoba for a year. Yes, the school I taught in was so desperate for teachers they took someone without a BSc and 3 months education training. Main subjects taught were chemistry and maths but many more as it was a 4-room high school. 

Same with CRC-BTS, they hired me without a BSc (I'd goofed off and failed physics in my first year). Eventually after 3 years, management pressed me to get the BSc and I obliged with a night course in what I recall as the 'new algebra'.   

Anecdote #1 
There were no SOPs at CRC-BTS, and before I became the clinical instructor, what students and new hires learned depended on which technologist trained them on-the-job. You can imagine what fun that was for trainees. Today, med lab training is based on competencies and students are evaluated daily, but not then. 

Finally, I decided to write SOPs for the transfusion service (TS) part of the operation on my holidays at a local lakeside cabin. Whatever possessed me? This was before I became the clinical instructor. So why did I do it? Lo and behold, the crossmatch lab used the SOPs I'd written. The SOPs weren't validated, we were in a wild west world where anything goes. 

Anecdote #2
At one point a new hire with a general BSc had a disability that included having deformed hands. She could do all laboratory tasks well (TS wasn't automated and everything was done by manually pipetting) but when it came to her compulsory medical done a few months into the job, the physician said she could not do the job and should be let go. 

After I spoke to other medical lab technologists, we unanimously agreed that we should all sign a letter to management saying she could do the job and we did. So why did we do it? Bottom line: She was kept on and stayed in the job for decades, eventually becoming a supervisor/manager. 

2. MLS [Medical Laboratory Science, University of Alberta]
In late 1977 I was hired as an MLS instructor to teach introductory transfusion science, with a joint appointment as the clinical instructor for the University of Alberta transfusion service (UAH-TS). I was sad to leave my pals and family in Winnipeg but excited to move to Edmonton and meet the challenge of teaching at a university. Yes, in MLS I loved coming to work each day as you never knew what it would entail, students being students, and what else I'd learn.

Anecdote #3
As the prior transfusion instructor had unexpectedly left after attending an AABB conference and meeting a young man 😂, the position was temporarily filled by an experienced med lab technologist from the UAH-TS. Indeed, she had applied for the job but did not get it as she lacked a BSc.

This technologist became a dear, close friend, showed me the ropes, how to navigate the hospital, and introduced me to the local blood bank community, which became my new family. She also got me involved in the CSMLS in several ways, including recommending me for the Certification Board, a 3-year appointment. So why did she do it?  

Anecdote #4
As mentioned earlier, I lacked education and training in medical laboratory science and managed to learn transfusion in-depth through reading and broad practical experience in a busy joint blood centre and transfusion service. In MLS most colleagues were graduates of MLS and they too befriended me, put up with my many deficiencies, became my family, and generously taught me the key things I needed to know in other clinical lab disciplines. I'm forever grateful. So why did they do it? 

3. CBS (Canadian Blood Services, Edmonton)
After MLS, I was lured to take a job at CBS as an assistant lab manager, where I was in charge of the patient services laboratory (PS lab): pretransfusion testing, prenatal testing. Not quite the job I expected, as it was promoted as having a significant teaching component. I refer to it as my 'assman' job as that's how the QA dept. addressed my correspondence. Again, I loved coming to work each day as I never knew what it would entail, more specifically what new knowledge and skills I'd learn. 

Anecdote #5
The person who had been running the lab on a temporary basis was in the first MLS class I taught all the way through, one of my 'kids' as I call them. She was an assistant to the person in the manager job prior to me. She should have gotten the job I now had, but nonetheless, she kindly showed me the CBS ropes and performed any function I asked her to do. So why did she do it? 

Anecdote #6
All of the PS lab staff (supervisors, technologists, lab assistants, clerical) generously welcomed me, a rank outsider. One of the big projects we had was being the Canadian pilot site for a new CBS computer system (Mak Progesa). In conjunction with the new lab information system, I decided to change most of the PS lab's serological and policy SOPs to update them, including instituting the electronic crossmatch. 

Despite what must have been stressful, all staff pitched in, performed above and beyond, and did so as a team with great camaraderie. In retrospect, I suspect we had a lot of fun meeting the training challenges. So why did they do it?

4. PLC [Consulting career]
I won't go into the many adventures I had in a consulting career as that's another blog. 

SUMMARY
So the questions above ask why did I, she, they do it? The answer is the same for all. 

My experience is that medical lab technologists (biomedical scientists) who work in transfusion, and I suspect all clinical laboratories, are a close-knit family dedicated to protecting patient safety. Why do I say family? Because just like a biological family, the medical laboratory family has little to nil to do with ancestors and genes and everything to do with love, compassion, and support for members of the team.  

Perhaps transfusion is even more so a family, because we are a comparatively  small group. For example, when I was active in the profession I knew many med lab technologists in blood centres and transfusion services across Canada. When the Internet made international mailing lists possible, the family grew to include lab professionals from around the world. 

For all the positions I held throughout a long career, members of the family became lifelong pals. I think of my career and those of my colleagues as a long love affair with transfusion medicine and laboratory medicine that's never ended. I hope that those who work as med lab professionals in any discipline are lucky enough to feel the same, indeed, workers in any field. That I lucked out with my career is an understatement and I'm sure many of my transfusion colleagues over the years feel the same way.

Happy National Medical Laboratory Week (April 26 to May 2, 2020 in Canada). Though largely hidden from the public and working behind the scenes, we in clinical laboratories play a crucial role in diagnosing and treating diseases. 

FOR FUN
I chose this song as a allegory for how so many medical laboratory technologists (biomedical scientists) feel about transfusion, myself included. 
Could I have this dance for the rest of my life?
Would you be my partner every night?
When we're together it feels so right
Could I have this dance for the rest of my life? 

As always, comments are most welcome and appreciated. See some below.

Tuesday, March 31, 2020

We are the world (Musings on COVID-19's impact on the world's blood supply)

Stay tuned: Revisions are sure to occur
March's blog derives from the ongoing worldwide shortage of blood due to the coronavirus (COVID-19). Of course, because this is a transfusion medicine blog, I'm preaching to the converted. But I hope it gets wider distribution among all healthcare colleagues and the public beyond. 

Specifically, I ask all transfusion heath professionals to speak to colleagues, family, friends, neighbours about the ongoing need for blood donation, made even more crucial because of the COVID-19 pandemic. 

The blog's title is based on a 1985 song written by Michael Jackson and Lionel Richie for  'USA for Africa.' 

BLOOD SHORTAGES
For TraQ's newsletter, I've collated some of the ongoing blood shortages across the globe (Further Reading). Fact is, the need for blood transfusion is ongoing despite the COVID-19 pandemic. Yet blood donation has dropped off significantly in many nations for numerous reasons explained in the news items in Further Reading. 

TRANSFUSION NEEDS
Despite the ongoing efforts of the Transfusing Wisely initiative (Further Reading), implemented in many nations, regular need for transfusions still exits for many patients. Transfusing Wisely's general goals: Reduce the rate of unnecessary blood transfusions with the goals of lowering the risk of complications for patients and supporting the judicious use of valuable resources. 

For the general public, just some of the ongoing needs for blood transfusion include the following (not all inclusive):

Patients who need blood transfusions
  • Mothers who incur significant bleeding during delivery, including those with placenta previa
  • Gastrointestinal bleeding (if massive can be life threatening) with many causes such as hemorrhoids, peptic ulcers, tears or inflammation in the esophagus, diverticulosis and diverticulitis, ulcerative colitis and Crohn's disease, colonic polyps, or cancer in the colon, stomach or esophagus  
  • Kidney disease, sometimes secondary to type 1 diabetes, that requires dialysis
  • Any surgery that involves significant blood loss
  • Trauma patients including those in car accidents who experience blood loss and victims of knife attacks or gun shot wounds
  • Blood disorders, including
    • Thalassemia major patients need regular red blood cell transfusions to raise their hemoglobin level and deliver oxygen to body tissues
    • Sickle cell disease patients need regular red blood cell transfusions to provide normal red blood cells, lessen anemia and reduce the blood's viscosity, allowing it to flow more freely and ease disease symptoms and prevent complications
    • Leukemia patients who develop thrombocytopenia need platelet transfusions to control bleeding 
The need is real and ongoing. Please encourage colleagues, family, friends, and neighbours to donate blood and save a life. It's one thing folks can do during the pandemic. Further Reading includes questions about donating in Canada and blood systems in all nations have similar information. 

FOR FUN Naturally, I chose We Are The World, originally written for 'USA for Africa' in 1985 by Michael Jackson and Lionel Richie, produced by Quincy Jones and Michael Omartian, and sung by many fabulous American  artists.  
We are the world
We are the children
We are the ones who make a brighter day
So let's start giving...

As always, comments are most welcome and appreciated.
FURTHER READING
Australia: In the face of coronavirus pandemic, Australian Red Cross Lifeblood’s stocks are threatened (24 Mar. 2020)

Canada: Top doc says Canada still needs people to give blood amidst social distancing (17 Mar. 2020)
      Canadian Blood Services: Message by CEO Dr. Graham Sher
      CBS answers COVID-19 blood donation questions

Pakistan: Experts urge volunteers to donate blood as thalassaemia patients face shortage (22 Mar. 2020)

Spain: In COVID-19 emergency blood bank stocks in Costa Del Sol hospitals are alarmingly low (18 Mar. 2020)

UK: Blood donors needed after 15% drop, says NHS (23 Mar. 2020)

USA: Coronavirus fears threaten America's blood supply (12 Mar. 2020)

Transfusing Wisely Canada

Saturday, February 29, 2020

You don't own me (Musings on questioning Dr. orders)

 Updated: March 1, 2020
February's blog derives from another TraQ case study from decades ago that discusses a topic not often included in online transfusion medicine cases but is still relevant. This case was based on a case study used to teach nurses at the McGill University Health Centre (MUHC) in Montréal, Québec. Because of this blog, I've revised the case to update all links. 
  • The blog's title derives from a 1963 ditty first recorded by Lesley Gore.
Case Study O6: Transfusion Reaction Coincidental with Failure to Disobey Physician Orders
This case was suggested by an RN and, because I'm not a nurse, several helped me with the case, also medical laboratory technologist pals from Hamilton and a physician (whom I taught when she was in Medical Laboratory Science at the University of Alberta). 

CASE SUMMARY
This case study presents a scenario in which a nurse did not follow several key transfusion protocols and procedures, including adhering to the time limit for transfusing blood, monitoring vital signs throughout a transfusion, and questioning orders that contradicted hospital policies and procedures.

It began when the nurse called the attending physician to explain the situation and charted the conversation as follows:
  • The Dr. was made aware; he ordered to continue transfusion even if it takes all day.
What happened to the patient? Based on laboratory results and a multidisciplinary discussion, staff concluded that a febrile non-hemolytic reaction had likely occurred after the second PRBC and had triggered subsequent events:
  • Increased temperature and chills increased intracranial pressure (the drain had been closed the previous day), leading to
  • Seizure and convulsions (treated by medication, induced coma, and intubation)
Analysis of the incident revealed that the nurse in question required remedial training related to resolving slow running transfusions and critical thinking in general, and also required re-training for how to monitor and document transfusions.

A more systemic problem was identified regarding the responsibilities and related skills of health professionals to provide checks for patient safety as part of the healthcare team. In other words, she should have questioned the physician's orders and taken it further, though that would be difficult.

Further analysis resulted in individual re-training and a system-wide education program on responsibilities and skills for providing interdisciplinary checks to ensure patient safety.

Key learning points include:
1. Clinical staff who administer transfusions must be trained and assessed in blood administration.

2. Monitoring and documenting vital signs must be done for each blood component transfused before, during, and after transfusion according to established policies and procedures.

3. Scopes of practice ensure that health professionals have the required education, training, and professional qualifications to perform their duties competently and safely.

4. Within their respective scopes of practice, members of the health care team collaborate in providing patient care.

5. Perceived loss of autonomy is considered to be a major obstacle to collaboration and open questioning within health teams.

6. Nurses and allied health care professionals such as medical laboratory technologists have a duty to question physician orders that are inappropriate or unclear.

FOR FUN 
Yes, I'm being facetious with the title and song, having some fun, but I couldn't resist. Decided to use the version with Bette Midler, Goldie Hawn & Diane Keaton as in the 1996 film, The First Wives Club. Yep, love these actors.
As always, comments are most welcome.

FURTHER READING
Case Study O6: Transfusion Reaction Coincidental with Failure to Disobey Physician Orders (Links are fixed) 

Davies C. Getting doctors and nurses to work together. BMJ 2000 Apr 15;320:1021-2. [Changed title]

Mancini ME. Performance improvement in transfusion medicine. What do nurses need and want? Arch Pathol Lab Med 1999;123(6):496-502.

Poerto G, Lauve R. Disruptive Clinician Behavior: A Persistent Threat to Patient Safety (July /August 2006, Patient Safety & Quality Healthcare)

Salvage J, Smith R. Doctors and nurses: doing it differently. The time is ripe for a major reconstruction. BMJ. 2000 April 15; 320(7241): 1019-20.

Friday, January 31, 2020

Stand by me (Musings on transfusion medicine errors)

Updated: 1 Feb. 2020 (Learning pt. 5, Further Reading)
To begin the new decade, I'll muse on a TraQ case study from decades ago that discusses a topic not often discussed by educators in class or included in online cases* but is still relevant and merits airing. 

*Online transfusion cases often involve antibody identification or making a diagnosis using lab and other diagnostic tests, in other words, cases with clear evidence-based results: yes and no answers that require factual knowledge and experience but not much reflective thinking. You may disagree, that's okay too. 

This blog's case study involves a student whose error resulted in a patient dying prematurely but, given another patient, could easily have been THE cause of death. Frankly, I shudder to think what the headlines may have been if local media had gotten hold of the story and were anything like the UK's tabloid press. 

The blog's title derives from a 1961 ditty by Ben. E. King.

CASE A8: Severe Hemolytic Transfusion Reaction Involving a Student
This case involved me directly as I was the clinical instructor of the student and transfusion service (TS) involved. As the clinical instructor I taught the student in a 2-week student lab (involving wet laboratories and small group tutorials) followed by a 4-week internship in the clinical transfusion lab where students were supervised by medical laboratory technologists. All the details of the case are in Further Reading. 

CASE SUMMARY
The student was supervised by an experienced, respected technologist  who was also responsible for working on the bench and processing routine work. The TS laboratory performs antibody screens using gel technology followed by an electronic crossmatch for patients who lack clinically significant antibodies.

The lab's policy is to initially supervise students very closely and then, depending on performance (which is documented daily),  to gradually allow students to perform with less supervision. Regardless of the intensity of supervision, the policy requires that supervising technologists always read the results of student tests.

The student did gel antibody screens on a batch of 5 patients in the late afternoon.

One of the 5 patients had a positive (3+) antibody screen ("Patient A") but, because blood was not ordered and unlikely to be required for the type of surgery, the patient specimen was set aside for antibody identification the next day.

One of the 4 patients with a negative antibody screen ("Patient B" - an 70-year old male scheduled for liver resection for metastatic colorectal cancer) had an electronic crossmatch performed for 3 units of RBC.

Early the next morning Patient "B" was transfused with 2 units of RBC.
When the morning shift began in the laboratory, an antibody identification panel on Patient A was unexpectedly negative, as was the repeat antibody screen. Antibody screens were then repeated for all patients in the batch and one (Patient B) was positive. Patient B was later found to have an anti-Fya and anti-c.

Immediately upon discovering the mix-up and positive antibody screen on patient B, the ward was contacted to stop any transfusion in progress, to inquire about Patient B's condition, and to monitor him for signs of a possible hemolytic transfusion reaction (HTR). Subsequently, Patient B was found to be experiencing a severe HTR and the TS medical director was consulted to help manage it. 

The student and supervising technologist were questioned in private, both individually and together, by the medical director and laboratory supervisor. The student could not recall making an error and thought that patient plasma had been pipetted correctly for each patient. The supervising technologist recalled not seeing the student actually pipette patient plasma into the gel cards but did read the results of all indirect antiglobulin tests (IATS) in the batch.

By chance, staff were able to retrieve gel cards from the biohazard garbage and identify that Patient B had less volume than usual in the antibody screen tests, consistent with no plasma having been added. The conclusion was that there was a pipetting error in which Patient B's plasma was not added to Patient B's gel antibody screen cards but rather to Patient A's tests.

Patient B died the day following transfusion.

The hospital's Risk Management Office was contacted and the chief counsel discussed the case with the TS medical director and Patient B's physician.

A series of group meetings were held by the lawyer from Risk Management with the TS laboratory supervisor, student, supervising technologist, and TS clinical instructor (me) all being present.

The Chief Medical Examiner was notified and investigated the death.

The TS medical director openly disclosed and explained what had happened to the patient's family. We waited for 2 years suing limitation but the family never decided to sue. 

The supervising medical technologist left the lab and began a career in a related field.

My personal learning points from the case:
1. When medical technologists in a busy lab supervise students, they can't watch every student move. Student errors may happen and supervising technologists are devastated, as in this case. Suspect this may be true for other health professionals supervising students who make serious errors too. 

2. The group sessions with the hospital's Risk Management lawyer were enlightening to me. She stressed that anything said in our meetings couldn't be used in court because of attorney-client privilege.

3. Our TS medical director was exemplary in her transparency to disclose the error to the patient's family. Perhaps ahead of her time?

4. I suspect many lab errors are latent errors (aka systems errors as well documented by UK's SHOT) caused by flaws in the system, i.e., errors that lead to human (operator) errors and whose effects typically lie dormant in the system. (Further Reading) 

5.The student in Case 8 thought she'd added drops to the antibody screens correctly. Many times in the student lab when students get incorrect results they'd almost always say, 'But I did it right. I know I did.' Then I'd gently remind them that it was, of course, normal to think that.If they knew they were adding the wrong drops, following the wrong procedure, they'd not have done it. 

Being human we make all sometimes make mistakes.What's key is to learn from them and realize the clinical laboratory has a culture of no blame that enhances patient safety. The worst thing would be for them to be spooked and frightened of making mistakes in the clinical lab (self-fulfilling prophesy) where patient safety is at risk. 

6. Reminds me of the reality that transfusion med lab technologists / scientists are often the last barrier between a patients and possible death. The transfusion service is different from many other med lab departments (not all) where unusual results are often repeated before reporting. 

I knew this as early in my career I'd crossmatched group AB blood for a patient who died because she was group O and had a wrong group AB sample sent to the off-site transfusion service where I worked. 

As always comments are most welcome. 
FOR FUN
Chose this song because I think all health professionals need to stand by colleagues and students when human or systematic errors occur because there, but for the grace of gawd, go I. 
FURTHER READING