Always on my mind (Musings on infected blood inquiries)

Stay tuned - Updates likely to occur

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

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

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

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

PURPOSE/PRINCIPLES OF INQUIRIES
First, inquiries into infected blood tragedies are not concerned with criminal or civil liability. Supreme Court Decision of Canada (Attorney General) v. Canada (Commission of Inquiry on the Blood System) specifies

• Intent of the Krever Inquiry (Hearings1993-5; Report1997)

Second, the same Supreme Court decision specifies

• Principles applicable to inquiries ~Krever's 

Note that inquiries can make findings of misconduct if they fall within the inquiry's terms of reference. If the same is true for the UK's inquiry, then folks looking for criminal and civil blame to be assigned will be disappointed. But misconduct that occurred or actions that failed standards of conduct will be identified and open to further investigation by the justice system.

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

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

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

PURPOSE/PRINCIPLES OF CRIMINAL JUSTICE SYSTEM
Not being a lawyer, I hesitate to include this section but include it as food for thought. Here's how I see Canada's justice system, its purpose and principles. Note: My opinions may well differ with those of many Canadians, particularly regarding incarceration and punishment.

• Ensures public safety by protecting society from those who violate the law. Defines unacceptable behaviours and the nature and severity of punishment for a given offence. 

• Presumes innocent until proven guilty and those charged have the right to legal representation and a fair trial. Burden of proof is on the prosecution and defendant must be proven guilty beyond a reasonable doubt. 

• Acts as a deterrent to criminals, with incarceration being the last resort, reserved for the most serious offenses and where mitigating factors do not exist.

• Purpose is not to punish offenders but to act with compassion and rehabilitate, if possible. Fact: Most people who come in contact with criminal justice system are vulnerable or marginalized individuals who struggle with mental health and addiction issues, poverty, homelessness, and prior victimization. (See 'What we heard - Transforming Canada's criminal justice system,' Further Reading)

TIDBIT: When I read news items or information on the UK Blood Inquiry, it's my impression, rightly or wrongly, that, as in Canada, many victims and their families are out for blood so to speak. They clearly want those whose professional misconduct and negligence  - unproven but it's how they see it - led to loved ones being infected brought to justice and punished. In other words, the NHS and its medical professionals and officials seem to have been prejudged as guilty. (Further Reading)

ANALOGIES
Analogies are offered to stimulate thought.

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

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

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

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

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

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

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

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

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

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

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

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

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

BLAME GAME
Healthcare, including transfusion medicine, supposedly has adopted a quality system that promotes a blame-free culture where individuals are able to report errors or near misses without fear of reprimand or punishment. (Further Reading, Culture of Safety)

"The culture of individual blame still dominant and traditional in health care undoubtedly impairs the advancement of a safety culture. One issue is that, while "no blame" is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile the twin needs for no-blame and appropriate accountability, the concept of just culture is now widely used.  

A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (e.g., slips), at-risk behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. " 

Yet the blame game still exists in medicine, as exemplified by the Dr. Bawa Garba case in the UK (Further Reading), although the injustice was ultimately rectified.

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

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

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

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

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

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

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

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

• Always on my mind (Willie Nelson)
• In particular, note these words 

COMMENTS: As always, your comments are appreciated and welcome. See below.

FURTHER READING
Canada's blood scandal 
If you view only one resource, make it this one. From Canada's blood tragedy: Tragedy of Factor VIII concentrate (19:14 mins. well worth watching. See Randy Conners words at 18 min. mark)

• Acquittal in tainted blood scandal outrages survivor
• Nova Scotia compensates victims for 'tainted blood'

Criminal Justice System Purpose

• Transforming Canada's criminal justice system

UK Infected Blood Inquiry News 

• Latest here

Humboldt Broncos bus crash

• Included more links as case may be unfamiliar to many outside Canada
• Only Ontario requires truck driver training, but Humboldt crash could change that
• Semi-driver in Humboldt Broncos crash a newlywed with business education
• Crown wants truck driver sentenced to 10 years in Broncos crash
• Semi-driver in Humboldt Broncos crash will likely be deported, says immigration lawyer
• Sidhu apologizes to families as Crown asks for 10-year sentence in Humboldt Broncos bus crash
• Semi-driver in Humboldt Broncos bus crash had 70 regulation violations

Catholic Church Sexual Abuse

• Sexual abuse and the culture of clericalism
• Sexual abuse cases

No Blame Culture

• Culture of Safety

Bawa-Garba Case

• Dr Hadiza Bawa-Garba wins appeal against being struck off (13 Aug. 2018)

The Sound of silence (Musings on transfusion professionals use of Twitter)

Updated: 25 Sept. 2016 

September's blog takes its theme from Twitter activity on my @transfusionnews Twitter account. The blog is shorter than usual (a good thing), but something I feel passionate about. 

The title is from a 1964 classic by Simon and Garfunkel.

For readers who choose not to read the full blog, here's the executive version. The blog's aims are to

• Showcase prolific transfusion-focused tweeps from the English-speaking world - those who clearly believe in the power of social media like Twitter to engage and educate about transfusion.

• Interest you in joining Twitter (even as a 'lurker' who reads but never posts, as so many were and are on mailing lists) or, if that's a bridge too far, at least bookmark one of the Twitter accounts (maybe mine?), and periodically read the latest. You can do so without being on Twitter. 

Bottom line: Being a transfusion professional is a career not a 9-5 job. Learning what's happening around the globe enriches and broadens our experience. And we can use Twitter tidbits to interest our students and inform our practice. That's a good thing. Note that I resisted saying we could leverage Twitter. 

Recently, while helping a friend with a project she did for the BC PBCO, international colleagues I met only on Twitter took time from their incredibly busy schedules to go away 'above and beyond' to assist. Being on Twitter is like having an amazingly diverse family whose members generously share knowledge and expertise.

TRANSFUSION TWEEPS OF NOTE
From my experience, here are the transfusion professionals, individuals who regularly distribute transfusion news via Twitter. I've not included blood suppliers like Canadian Blood Services (@itsinyoutogive) or professional associations like @aabb, @BritishBloodTS, and  @CanSocTransMed.

To my knowledge, these are transfusion medicine's prolific tweeps (number of tweets in brackets). The list is not all inclusive. I follow many valuable transfusion tweeps with fewer tweets and others with 1000s of posts but many unrelated to transfusion. 

AUSTRALIA (2)

Haemovigilance Guy @Haemovigilante (1300+) 

Dr Sandy Minck @DrSandyMinck (1,000+)

IRELAND (1)
Gerard Crotty @gmcrotty (18,000+)

GREAT BRITAIN  (8)

Sylvia Benjamin @Gogmum (6,500+) 

Tony Davies @Dobbysdad (1,800+) 

HarveysGang @Laird_Admiral (6,000+) 

Dr. Suzy Morton: @TransfusionWM (1,900+)

Kate Pendry @KatePendry  (4,000+)

TeamHaem @TeamHaem (6500+) 

Dan Smith @Dan1763 (3,900+)

CANADA (4)

Jenny Ryan @JRyanCS (5,300+) 

Elianna Saidenberg @ESaidenberg (2,600+) 

Cyber Bloodbanker @transfusion news (2,000+) - Me 

Ron Vezina @Vez_says (1300+)

SUMMARY
Did you notice that the Brits are the transfusion rock stars on Twitter? Why is that, I wonder? If I've missed any 'tweetaholics', please let me know. 

To discover who to follow on Twitter, use hashtags such as 

• #transfusion 
• #bloodeducation
• #blood

The last may produce unexpected results.
And when you find someone you like, see who they follow and who follows them.

FOR FUN
The blog's theme reminded me of a 1964 ditty by Simon and Garfunkel. Seems the transfusion twittersphere sadly suffers from the Sound of Silence, especially in Canada and the USA. Let's be disruptive and break the silence more, folks.

• Sound of Silence (Simon and Garfunkel) 

As always, comments are most welcome.

If you could read my mind (Musings on blogging to share TM experiences)

Updated: 23 June 2016

June's blog is a follow-up to an article I wrote for the April issue of the BBTS magazine, BloodLines. In the BBTS piece I speculated on why so few health professionals, working or retired, blog. I'll expand on some of these ideas in the hopes that more transfusion professionals will be encouraged to give it a go and blog for CSTM or BBTS or any professional association in any country.

Now before you rapidly exit ('Blog? Not me!'), please take a chance and at least skim the blog. It's you I'm hoping to reach by planting a seed that maybe, just maybe, you could make a real difference by sharing your experiences with colleagues.

You don't need to be a 'big wheel' to blog. We tiny cogs in the wheel also have much to share. Perhaps we haven't published or presented at conferences. But we've all had unique experiences in our transfusion lives and, in years to come, no one will know if we don't tell our stories.

The blog's title comes from a 1970 song by Canada's Gordon Lightfoot, one of the most covered songs in pop music history. 

OBSTACLES

So why don't more transfusion professionals blog? There are many reasons, but here are my top three. 

1. No time
Most obviously, and likely the biggest obstacle to blogging, is lack of time. Like many continuing education opportunities these days, folks would need to blog after-hours on their own time. 

With internet and cell phones, many employees may already resent being connected 24-7. When work-life balance is out-of-whack, leisure time with friends and family, as well as time for yourself, becomes even more precious. 

And if you feel devalued by your employer, you may lose the enthusiastic puppy persona you had at the start of your career. Instead of a career, you may see your professional work as just a 9-5 job to earn money, not to gain fulfillment.

2. No incentive
Another obstacle to blogging is folks tend to get no credit for blogging. Indeed, blogs may even be dissed by the 'old guard' as not evidence-based, just opinion. Well, yes! Blogs offer OPINIONS on events, issues, and challenges of the day.

But blogs can offer evidence and present logical arguments. In some ways blogs are akin to editorials. Opinions by experienced health professionals can summarize issues, pro and con, and offer food for thought. 

3. Fear of ridicule

Every time you 

• Open your mouth
• Give a presentation
• Put pen to paper
• Write an e-mail message 
• Participate in social media of any kind

you may say something silly or indefensible and risk being thought a fool. Been there, done that. Indeed, you may even open yourself up to abuse by pompous academics or online trolls.

But to me the opposite is even worse:

• To avoid criticism, say nothing, do nothing, be nothing. (Attributed to...) 

ADVANTAGES

So, why blog, given its risks? Here's where I'll need to self-edit for brevity because I'm definitely a true believer in the merits of blogging.

Given that blogging is an enterprise done on your own time, why do it? 

Why I blog
I blog for 6 key reasons. Blogging...

1. Is a priceless opportunity to comment on issues of the day and try to shape opinion. One example from "Musings on Transfusion Medicine' - my likely futile attempt to shape opinion on paid plasma:

• Simply the best (Musings on paid plasma and TM colleagues I've know)

2. Allows us to celebrate colleagues who have made a difference and to record transfusion medicine history through the eyes of those who lived it, the good, bad, and ugly. See, for example, the Canadian Society for Transfusion Medicine (CSTM) blog series, 'I will remember you' (scroll down to see the 6 blogs to date).

About history, Australia and new Zealand offer a great example of how to preserve our past:

• ANZSBT 50th Anniversary (1964-2014)
• Reflections of Past Presidents 
• Fun presentation of 1964 news

3. Makes you a better thinker and writer. It's simply a case of practice improves performance. As noted in my first BBTS blog, 'Born to be Wild', key points to any writing, even e-mail, include

• Don't bury the lead - reveal blog's aim up front;
• Make it easy to read by using bullets and short paragraphs;
• Be as brief as possible;
• Include a 'so what' statement.

I confess that my blogs are too long. Please don't take them as a model of suitable length. A blog can be short and deal with a single issue or experience. 

4. Creates a record of important experiences and allows others to learn from them. 

EXAMPLE:

I could write a blog about a student I once taught who, during her clinical rotation, missed adding patient plasma to an antibody screen test, causing it to be falsely negative, with the patient receiving incompatible blood by electronic crossmatch. The elderly patient suffered a severe hemolytic transfusion reaction and subsequently died.  

This true episode makes an interesting story of what happened, including the involvement of the hospital's lawyers, the reaction of the supervising technologist and transfusion service medical director. Much to be learned from a single experience, a story worth writing that would be lost forever if not recorded. 

5. Gets your name out there and furthers your career. Of course, blogging requires taking a risk, the risk of opening your mouth and being thought a fool. No big deal. I have a T-shirt from LSOFT:

• "He Who Dares, Wins" (motto of the British Special Air Service)

6. Is great fun. Fact is, I enjoy poking the powers-that-be and sending up the absurdities in our professional lives. Someone has to do it.

SUMMARY
Expressing opinions on current issues and examining the past are valuable ways to spend one's time. So seldom today do we get the opportunity to reflect. And blogging invariably serves as informal continuing education because bloggers need to check they're not spouting total B.S.

Some claim that in today's milieu, folks no longer have the time, no longer care to spend free time on their careers. Please, let's prove this judgement wrong.

My take on blogging: It's a blast! I maintain three blogs, two professional and one personal where I pretty much rant about whatever bugs me at the time. The personal blog is therapy that keeps me sane. 

The professional blogs are my way to try to influence opinion, to motivate colleagues to think differently and challenge orthodoxies. You can too! We're here for such a short time. Why not try to make a difference?

Plus we need to create a historical record of our stories or they will be lost forever. See, for example,

• Life as a blood eater

Making colleagues smile also serves a valuable purpose. What struck you as silly recently? Why not blog about it? If you want to try blogging for CSTM, I'd be glad to help by offering my 2¢ worth (make that 'nickel's worth', as cent coins/pennies don't exist in Canada any more).

To inquire about blogging, please e-mail

• CSTM webmaster
• BBTS

Finally, I encourage bloggers to write their passions and will end with this quote by Canada's Margaret Laurence (click to enlarge):

FOR FUN

Lightfoot's 'If You Could Read my Mind' seems right for this blog. Fact is, no one can read our minds. If we don't spill the beans and blog about our experiences, no one will ever know. 

• If You Could Read my Mind (Gordon Lightfoot, live TV performance)

If you could read my mind, love,

What a tale my thoughts could tell.

Just like an old time movie,

'Bout a ghost from a wishing well.

In a castle dark or a fortress strong,

With chains upon my feet.

You know that ghost is me.

And I will never be set free

As long as I'm a ghost that you can't see. 

                                        

If I could read your mind, love,

What a tale your thoughts could tell.

Just like a paperback novel,

The kind the drugstores sell...

As always, comments are most welcome.

Sweet dreams are made of this (Musings on personalized medicine)

Updated : 28 July 2020 (Fixed song's link)

September's blog derives from increased marketing of medical treatments and clinical laboratory tests as personalized medicine tailored to the individual characteristics and needs of each patient. Seems like a great idea, right?  

After all, in the age of 'selfies' it's all about me. 

The title is from a 1983 ditty by the British duo, the Eurythmics (Annie Lennox and David Stewart). 

PERSONALIZED MEDICINE
'Personalized medicine' is a term that drives me nuts.  This April I blogged about molecular blood typing being marketed as personalized medicine:

• While my guitar gently weeps (Musings on the seduction of technology) [Further Reading]

Five years ago I had sniffed its perfumed allure with the blog

• Snip, snip the party's over (Musings on the seductive rise of DNA typing of blood groups) [Further Reading]

WAIT, THERE'S MORE
Now a new variation has arisen, the latest and greatest 'term du jour' ('term d'année?') is Precision Medicine:

• Red blood cell transfusion. Precision vs imprecision medicine  [Further Reading]

One sentence in the article stood out as a red flag:

'Although currently not practical, providing extended antigen matching by molecular techniques to all patients should improve typing accuracy and reduce alloimmunization.'

If past is prologue, even if impractical and relatively expensive, eventually molecular genotyping will be done for all transfusion recipients. After all, who can resist the sales pitch of personalized and precision medicine?

BANDWAGON
Certainly the United States, with its private health care system, cannot resist and has jumped on the bandwagon. Similarly, so has Canada, UK and other industrialized nations. 

As to the developing world, well they're stuck making do with 20^thC medicine, un-personalized and un-precision.

Of course, a genuine case can be made to tailor tests and treatments to individuals, especially those with special needs such as blood group genotyping for sickle cell and thalassemia patients. 

But why the rush to personalized / precision medicine as embodied by molecular blood genotyping? It's likely because of the reasons cited in 'While my guitar gently weeps':

• To be seen as 'with-it' hipsters on DNA's bandwagon vs being old-fogeys who resist change; 
• Way for TM organizations to develop business lines and increase earnings in age of blood conservation; 
• Self-interest for those who specialized in molecular technology; 
• No humans interpreting serologic test results must be safer; 
• High-throughput automation decreases costs by eliminating staff, with their salaries, benefits, and pensions.

Plus it's good for private enterprises that develop and market test systems and health profession leaders who want to be seen as in the real world of business efficiency. 

ANATOMY OF A SALES PITCH 
Today, many businesses promote and sell stuff that we do not  need. The aim is to trick us into thinking we need the latest and greatest. 

Consider Apple's iPhone. The premise is that potential buyers don't even know what they want until Apple tells them. They don't really need to market it because all geeks know they must have one to be part of the in-crowd. 

• It's the same reason why all TM docs know their facilities must do molecular typing.

Apple builds beautiful products and justifies price with features and benefits no one else can match. Whether you need the features is another matter. But once you've seen them, Apple will make you think you do. 

• Similarly, serologic blood typing cannot match molecular typing. Whether you need the benefits of molecular typing is a moot point.

Apple built one of the most hardcore fan bases of any product, called Apple fanboys/fangirls and, before the iPod/iPad/iPhone revolution, macophiles. I was one and would show disdain for Windows every chance I got. 

• Today, molecular red cell genotyping fans abound and can barely suppress a sneer when mentioning serology and immunohematology. The fan base of influential TM leaders is hard to combat and develops a momentum all its own.

It's worth recalling that whether selling an iphone, tablet, used car or botox, a good sales rep will FOCUS ON

1. BENEFITS and VALUE, NOT PRICE
Some examples [My comments]: 

Before molecular genotyping transfusion service labs had to use inefficient, labor-intensive serologic assays. ²

[PL: Red cell serology is passé, based on inefficient testing that costs more because of paying laboratory technologists for their time.]

Now in the 21st century and with the emergence of precision medicine, inexpensive molecular typing paired with powerful bioinformatics has enabled mass-scale red blood cell genotyping. ²

[PL: Get with the 21^stC. Molecular typing is cheap (really?) and it's twinned with bioinformatics. Bioinformatics sounds pretty darn impressive. We've got datasets coming out the wazoo.]

Web-based data storage and analytics are revolutionizing the provision of antigen-negative blood with an efficiency scarcely conceived of just a decade ago. ²

[PL: You'll be on the bleeding edge and very, very efficient. Plus it's analytics, for gawd sake. And 'analytics leverage data in a particular functional process (or application) to enable context-specific insight that is actionable'.  

Wowsa! Leverage,data, process, context-specific, and actionable in the same sentence. I'm in jargon heaven. Gotta love analytics.]

2. EMOTIONS, NOT REASON
Blood incompatibility remains a significant problem with lifelong consequences that adds to the burden of healthcare delivery and may result in life-threatening delays in care.³

If an antigen-negative patient receives blood from an antigen-positive donor, it could trigger an immune reaction, where the blood recipient’s immune system develops antibodies that can attack and reject the donor RBCs.³

[PL: If you buy our product you will prevent the dreaded immune response and save patient lives. You don't wanna kill folks, do you buddy?]

With today’s dual focus on improving health outcomes and lowering healthcare costs, preventing alloimmunization is the ultimate goal in transfusion medicine. Accordingly, a best practice for the hospital or transfusion center is to create a patient phenotype profile with the PreciseType test before a patient receives his or her first-ever transfusion.³

[PL: Do you dig what TM's ultimate goal is? It's about preventing alloimmunization. (Who knew!) Are you into best practices, a thought leader? Because if you are, you better buy our kit right now, before some patient gets immunized!]

NAYSAYERS
There are those who question the orthodoxy of personalized / precision  medicine and caution against potential pitfalls.  Two examples that examine personalized medicine from a broad perspective:

1) 'Why you shouldn't know too much about your own genes.' [Further Reading] Sample quote: 

• Here is the under-appreciated corollary to the new age of personalized medicine: just because you can do a genetic test, doesn't mean you should.

2) Juengst ET, Flatt MA, Settersten RA, Jr. Personalized genomic medicine and the rhetoric of empowerment. Hastings Cent Rep. 2012 Sep-Oct; 42(5): 34­40. [Further Reading¹] Sample quote: 

• 70 million Baby Boomers, now or soon-to-be over age 60, seek to live not just longer, but healthier and more productive lives. 
• When they fully understand and embrace personalized medicine, it will create an unprecedented level of consumer demand. 
• When physicians feel they may incur liability for not offering a test that provides information on optimal care, the impetus toward adoption will be even greater.

LEARNING POINTS
Eventually, everywhere in the developed world, red cell matching of patient and donors will routinely be done by molecular blood typing. It will be precision medicine, personalized medicine done using kits supplied by foreign companies and performed by minimally trained, inexpensive local staff supervised by a well educated lab professional.

If employers plan wisely, staff can be hired part-time or casual so they won't need to worry about benefits and pensions. 

In Canada government health care money will flow abroad, giving sustenance to anonymous investors of Immucor, et al. They'll leverage our health care dollars where they WON'T do the most good for our communities, all in the name of efficiency and safety.

POSTSCRIPT
Am I similar to 19^thC Luddites, protesting against new labour-economizing technologies? Maybe, though I'm not against technology per se and have embraced computers and the Internet from the get-go.

But, hot damn! I'm gonna get my genome profile done because it's all about me. And I can get it done for $199 CDN by 23andme...not that I really want to know.

And if I ever need a blood transfusion, I'm not into being second class and will demand complete molecular antigen typing with donor blood. Not that I'll get it now but definitely one day. None of that passé serology for me!

FOR FUN
A great song, one of my favorites, that highlights the allure of molecular blood typing and personalized / precision medicine. 

• Sweet Dreams [are made of this] (Annie Lennox, Live 8, Hyde Park, London, 2005)

'Sweet dreams are made of this
Who am I to disagree?'

As always, comments are most welcome.

FURTHER READING

1. Juengst ET, Flatt MA, Settersten RA, Jr. Personalized genomic medicine and the rhetoric of empowerment. Hastings Cent Rep. 2012 Sep-Oct; 42(5): 34­40. (Free full text)
2. Klein HG, Flegel WA, Natanson C. Red blood cell transfusion. Precision vs imprecision medicine. JAMA. Pub online 10 Sept. 2015. (Free full text)
3. Immucor: PreciseType™ HEA Test 

Other
Carolyn Johnston. Why you shouldn't know too much about your own genes. (Washington Post, 11 Sept. 2015)

USA FDA: Paving the way for personalized medicine. FDA’s role in a new era of medical product development  

US News & World Report. Personalized medicine

USA White House. Next steps in developing the precision medicine initiative

Prior Related Blogs
While my guitar gently weeps (Musings on the seduction of technology) |  April 2015

Snip, snip the party's over (Musings on the seductive rise of DNA typing of blood groups) | Dec. 2010

The early days (Musings on educating young TM professionals)

Updated: 18 Aug. 2015

August's blog was stimulated by the UK's Annual SHOT Report, which  has featured in past blogs many times. SHOT has long been the best hemovigilance program anywhere and is a treasure trove of educational goodies we can all learn from.

Since it's summer in the northern hemisphere, when many transfusion professionals will be enjoying the outdoors of our all too short summers (at least in Canada) the blog will consist of selected mini-musings on 2014 SHOT.

The blog's title derives from a song by Canadian folk singer/song writer, Chris Luedecke, known professionally as 'Old man Luedecke".

2014 SHOT - SELECTED HIGHLIGHTS
For perspective, in 2014 there were 2,663,488 blood components issued in the UK (74% RBC). SHOT received reports of 3668 cases or 13.8 reports per 10,000 blood components.
The following are but a few of my personal highlights. See Further Reading for the full SHOT Report.

Overview (What causes adverse events?)
In 2013, 77.6% of all incidents reported to SHOT were caused by errors & it's similar in 2014.
There is increasing concern about the impact of reductions in numbers and seniority of staff in the NHS.

SHOT 2013 reported that many, often multiple, errors are made during the transfusion process and data from 2014 were analysed similarly. As well, adverse events are grouped into 3 main categories. Failures relate to

• Patient identification 
• Communication 
• Documentation 

Deaths (Worst transfusion-associated adverse event)
In 2014, there were 2 deaths definitely attributed to transfusion, 1 hemolytic transfusion reaction and 1 transfusion-associated circulatory overload (TACO). Delayed transfusion contributed to 3 deaths.

ABO-incompatible RBC transfused (Key because ABO mismatches can lead to patient death, major morbidity)
N=10 (0 deaths, 1 major morbidity). This compares to 9 in 2013 and 12 in 2012. All were due to clinical (not laboratory) error.

Near misses (Avoiding major patient consequences often due to luck)
Wrong blood in tube accounted for 686/1167 (58.8%) of all near misses, where a near miss is defined as,

"Any error, which if undetected, could result in the determination of a wrong blood group or transfusion of an incorrect component, but was recognized before the transfusion took place."

MUSINGS
Below are musings on a few highlights in SHOT 2014 (edited for brevity). Some caught my imagination because they were odd, and some involved serious adverse events.

#1. False Identity (p. 45) describes several cases where the 'patient' is responsible for giving false identity. For example:
Case 2: Staff member involved in deliberate identity fraud
A blood group did not match the patient's historical record. Concurrent Haematology and chemistry samples were rejected and repeats of all samples requested.
Investigation revealed that test requests were initiated by a staff member. Samples were from a family member but labelled with the staff member's own details. The staff member returned to work after suspension and re-training.

Musings: A similar case occurred years ago at UAH in Edmonton, where a medical resident labelled his own blood sample as that of a patient in order to discover a particular lab result. To my knowledge he was given a bollocking and educated on why this was NOT a good idea.

Case 3: Pregnant woman conceals her identity

•  A 24 year old woman had an ultrasound scan at a hospital where she was advised to terminate a pregnancy. 
• The patient attended another hospital giving a friend's name for identity but her own father as next of kin. 
• She had a surgical termination which was complicated by 
• Massive haemorrhage requiring transfusion with RBC, FFP, and cryoprecipitate; 
• Emergency intervention and uterine artery embolisation; 
• Followed by admission to the intensive therapy unit , all at the first hospital. 
• When her father was called in he confirmed she was his daughter but that the name on her wristband was not hers.

Musings: Years ago, when I worked in Winnipeg for the then Red Cross centralized transfusion service/blood centre, a similar case occurred. I crossmatched blood for a young woman having a therapeutic abortion. She had assumed the identity of her friend, who just happened to have a blood group on record.

Interesting that patients providing false identity still exists. It likely occurs much more often than we know because we only catch the ones where the 'false patient' has a prior blood group record or the real patient requires blood in the future. 

I also wonder about false identity in the USA where universal health insurance doesn't really exist yet. Do people who lack insurance for a needed procedure use a friend's identity?

In Canada it's now standard practice for physician offices to require photo ID, not just a provincial health care card. 

#2. ABO-incompatible red cell transfusions (pp.23,44)
As noted earlier, of 10 ABO-incompatible red cell transfusions, all were caused by clinical (not laboratory) errors.

• In 7/10 cases there was a failure in correct patient identification, with no bedside checks performed. 
• Actions taken varied but in one case 2 nurses were dismissed, in others staff were supported, retrained and their environment modified. 

SHOT gathered evidence that staff do not follow protocols and procedures and needs to investigate why.

• In 7/10 clinical errors, group A RBC were transfused to group O patients
• 2 were transfused in emergencies, 3 others were 'urgent'
• One event occurred in a young woman during a liver transplant. The group O patient was bleeding and a new anaesthetist, who was an observer, 'helped' by taking the unit of blood from the refrigerator and transfused it. It was group A blood. 
• The OR practitioner noticed the error when less than 50mL had been transfused. 
• The patient died from complications following respiratory arrest. 
• Root cause analysis resulted in several changes to surgical procedures.

Musings: It's amazing that 7/10 wrong ABO transfusions involved failed patient identification, with no bedside checks performed by clinical staff (presumably mainly RNs but including Drs, as in the case of the anesthetist described above). Unsurprisingly, most (5/7) occurred with urgent transfusions.

In the one case where 2 nurses were dismissed, I wonder if their errors were the final straw in a list of major errors. Because firing staff does not fit with today's no-blame culture of support and retraining, as occurred in other cases.

As SHOT notes, when health professionals do not follow established procedures and protocols, we need to identify why to prevent future occurrences.

#3. Most adverse events caused by error
SHOT documents that in 2013 and 2014 more than 75% of all incidents were caused by errors and expresses increasing concern about the impact of reductions in numbers and seniority of NHS staff.

Musings: Cutbacks and increasing numbers of senior staff retiring are concerns worldwide. Remaining staff are overworked and often lack needed experience and expertise. 

Unfortunately, few senior staff exist to mentor them and share the practical knowledge and skills absent in journals and textbooks. That's if remaining staff even have time to read and consult them.

FOR FUN
Although Canadian Chris Luedecke's touching song 'The Early Years' is about his children and family life, it resonates with me from a professional perspective. Listen to the lyrics. They're delightful.

In today's health care environment, despite many obstacles, educators must lead by example and take time to educate and train young transfusion professionals to instill values that ensure the next generation puts patient safety above all else. Knowledge and skills, of course, plus clear rationales for all those pesky 'rules' are key.

But ultimately it's DNA-ingrained ethics that protects patients so that even overworked, busy health professionals meticulously follow established SOPS such as routinely and always checking patient identity. 

Fact is, those early days when we train the next generation, they don't last. We must get 'em while the gettin' is good.

You got to hold on,
It goes so fast
These early days, well,
They don't last.
You got to enjoy [train] them.
They go so fast.
The baby days, well, they don't last.

• The early days (Old Man Luedecke)

FURTHER READING

• SHOT 2014
• Full SHOT Report

As always, comments are most welcome.

While my guitar gently weeps (Musings on the seduction of technology)

Updated: 13 April 2015

April's blog focuses on news items from TraQ's latest newsletter that have a commonality. 

• The main item deals with a molecular assay to identify 35 red cell antigens from 11 blood groups. 
• The other, included to illustrate the blog's theme but mainly here for fun, focuses on the clinical uses of platelet-rich plasma (PRP). 

I'll leave it to readers to ascertain what the stories have in common. The blog's title derives from a 1968 George Harrison ditty in the Beatles 'White Album'. 

 NEWS ITEMS

• Boston Children’s Hospital ends bad blood between donors, patients (24 Mar. 2015)
• Hospitals aim to better match blood donors and recipients (19 Jan. 2015)
• Dubai plastic surgery boom includes PRP facial rejuvenation (6 Apr. 2015)  
• Can PRP penis and vagina injections give a better sex life? (14 Mar. 2015)
• See Further Reading below for more information.

MUSINGS on MOLECULAR BLOOD TYPING 
Typing of blood group antigens at the molecular level has been in the works for years. Now it's moving beyond its original special uses because of technological advances, decreasing costs, and lobbying by vested interests. 

However, its cost-effectiveness is still unproven. Immucor's PreciseType^TM HEA test costs ~$350 USD but that likely varies significantly depending on individual contracts. And any cost study I've read in journals like AABB's Transfusion is so dependent on assumptions as to be almost meaningless and needs to be read carefully and critically.

Also, molecular blood typing is not the be-all, end-all for the 100s of blood group antigens that exist, since not all are DNA-defined. But the list of antigens covered is impressive and includes nearly all clinically important blood group systems (see Further Reading). 

Regardless, molecular blood typing has no end of proponents, mild and strong. For example:

• Joint UK Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC) thinks it's inevitable. 
• AABB, on the other hand, perhaps seeing a money-making opportunity for its publications and consultant branch, developed 'Standards for Molecular Testing for Red Cell, Platelet and Neutrophil Antigens'. 
•  AABB actively promotes DNA typing, even to the point of petitioning the US government to fund testing (Nov. 5, 2014). 

I wrote a blog on this topic years ago: 

• Snip, snip the party's over (Dec. 2010) 
• Suggest you read it later, if the mood strikes. My predictions have come true but they were no-brainers. 

Me Medicine

Now molecular blood typing is being marketed as personalised medicine, ie., the tailoring of medical treatment to individual characteristics of each patient. The idea derives from the 13-year, $3 billion Human Genome Project. For example, Immucor advertises PreciseType this way:

• Molecular Technology Personalizes Donor/PatientCompatibility

Makes it seem that anything less is substandard. Get with the program, health care providers, because it's all about me.

But many experts like Donna Dickenson, emeritus professor of medical ethics and humanities at the University of London and research associate at the HeLEX Centre, University of Oxford caution that

• 'Me medicine' could undermine public health measures (New Scientist, Sept. 2013)

MUSINGS: PLATELET-RICH PLASMA (PRP) 

I'd read several news items over the years about PRP's use in orthopedics, particularly for athletes:

• Clinical use of platelet-rich plasma in orthopaedics 

And recently the owner of a local restaurant I frequent mentioned that she had her own plasma injected into her knee but had to pay for it as it wasn't covered by Canada's universal health care system, at least for her. She said her knee caused a lot of pain (she's a 50-something server in the restaurant) but apparently it wasn't bad enough to be operated on yet. 

With that as background, recent news items on PRP's expanding clinical uses caught my attention. Medical tourism grows daily, at least for the rich. Seems Dubai now has more plastic surgeons per capita than any other city in the world and hopes to attract half a million medical tourists by 2020. 

The penis and vagina PRP nonsense was included just for fun. But really, Academy Award nominees got a coupon for a Priapus Shot? You cannot make this stuff up. 

BOTTOM LINE 

Okay, I lied because I'm sure you've gotten the blog's theme by now:

• Where there's a buck to be made or an agenda to be advanced, clinical uses of diagnostic tests and products will inevitably expand well beyond what's evidence-based. 

TM poster-child for phenomenon? Intravenous immunoglobulin (IVIg). 

But what's surprising, at least to me, is how few voices, especially in the TM community, question the *expanded use* of innovations like molecular typing of red blood cell antigens under the guise of me-medicine. Particularly since our so-called 'thought leaders' are so into evidence-based these days. 

I understand why advances that help solve real TM problems are celebrated. But why the uncritical approach? Is it because blood typing at the molecular level is 

• A marvelous innovation and all want to be seen as 'with-it' hipsters on DNA's bandwagon? Versus being old-fogeys who resist change? 
• Way to develop a business line and maximize earnings in a shrinking field like TM in age of 'blood conservation 'über alles', e.g., AABB? 
• Outright self-interest for those who specialized in molecular technology and need to maximize their career's life-span?  
• Seen as eliminating humans from the equation, such as interpreting serological test results, thus must be good? 
• High-throughput automated innovation, another way to decrease costs by eliminating those pesky creatures, aka staff, with their costly salaries, benefits, and pensions? 
• Better to give money to international companies than keep staff, aka tax payers and community builders, employed at home?
• Plus many staff are probably contemplating retirement anyway and eliminating their jobs will help make that decision easier? 
• Viewed as best thing since sliced bread, not just a significant innovation with specific uses, motivating proponents to abandon whatever critical thinking skills they ever had?  

BOTTOM LINE 

Personally, I wholeheartedly agree that molecular blood typing is a useful, indeed marvelous, advancement that will make blood transfusion safer for many. Celebrate its potential but please don't promote it beyond clear clinical uses so that anything else seems sub-standard, as in this over-the-top headline: 

• 'Boston Children’s Hospital ends BAD BLOOD between donors, patients' (Emphasis is mine)

FOR FUN 

'While My Guitar Gently Weeps':

• #136 on Rolling Stone's "The 500 Greatest Songs of All Time"
• #7 on its list of 100 Greatest Guitar Songs of All Time
• #10 on its list of The Beatles 100 Greatest Songs. 

While my guitar gently weeps (Paul McCartney and Eric Clampton tribute to George Harrison, Queen's Golden Jubilee, London 2002) 

I don't know why nobody told you 

How to unfold your love 

I don't know how someone controlled you 

They bought and sold you. 

I look at the world and I notice it's turning 

While my guitar gently weeps 

With every mistake we must surely be learning 

Still my guitar gently weeps 

As always the views are mine alone and comment are most welcome.

FURTHER READING 

References for those who want to delve further into the blog's topics. 

Molecular blood typing

• PreciseType^TM HEA, first blood compatibility molecular assay used in transfusion medicine approved by FDA (Press release, 22 May 2014)
• Immucor's website (See blood group antigens that can be typed)
• Explanation of how PreciseType works
• Molecular typing for red blood cell antigens (AACC's Clin Lab News, 1 Mar. 2015) 

Nice overview: Denomme GA. Prospects for the provision of genotyped blood for transfusion. Brit J Haem 2013 Oct;163(1):3-9.

For molecular blood typing in detail, see these papers from 2009. Info overload but fascinating insight into predicting the future (All papers free full text): 

Molecular blood group diagnostics.Transfus Med Hemother. 2009 Jun; 36(3): 154–155.(editorial) 

Five expert opinions on the question ‘Will genotyping replace serology routine blood grouping in the future?’ 

Interpretations are mine. (Author origins refer to where they worked then, not necessarily nationality.) 

• Opinion 1: Only partly. Unlikely unless... (Germany) 
• Opinion 2: Probably (Switzerland) 
• Opinion 3: For some applications (Austria) 
• Opinion 4: Personalized versus Universal Blood Transfusions – Combining the Efforts: Probably but in combination with enzymatic conversion (ECO) to remove A and B antigens (Sweden) 
• Opinion 5: Yes (Netherlands) 

Platelet-rich Plasma 

• Power of platelets (Nov. 2014) 
• Plasma fraction market - Global industry analysis and forecast 2014-20 (Press release, 6 Apr. 2015) 
• Platelet rich plasma market to treat orthopedic injuries, cosmetic surgeries expected to grow (23 Mar. 2015)