Wednesday, February 29, 2012

The sound of silence (Musings on blood safety regulations)

This month's blog is a short snapper. I've meant to try this for awhile, since some say that blogs should be relatively short, i.e., 250-500 words. Mine are typically much longer and it no doubt takes dedicated readers to read them. 

The blog's title derives from an old Simon and Garfunkel classic.

The blog is a personal synopsis (with musings) of this paper, available as free fulltext from the Jan. issue of Transfusion:
Why the paper appealed: 

1. It gets at the craziness that characterizes so many of the 'rules' governing transfusion medicine;

2. Away back when, circa 1974, having just been promoted to clinical instructor at the Winnipeg Red Cross Blood Transfusion Service* (now CBS), I went to a multi-day workshop sponsored by Ortho in Don Mills, Ontario, just outside Toronto. 
*Winnipeg BTS was a combined transfusion service (serving all of Winnipeg and environs, stretching into NW Ontario) and blood centre, still the only one in Canada.
One of the required workshop tasks was for each attendee to research a topic and present it to the group. The topic I chose was the 'storage lesion.' 

Pretty sexy, eh? I knew nothing about it, so thought may as well learn something. Who'd have 'thunk' ATP and 2,3 DPG would still be current 35+ years later?

As background, AABB and the U.S. FDA require RBCs to be stored between 1 and 6°C for up to 35 or 42 days depending on the anticoagulant-preservative solution. However, RBCs can be transported in containers that keep the temperature between 1 and 10°C. 

The U.S. FDA recently clarified storage vs transport: RBCs issued in coolers to an OR are in storage and not transport, hence must be kept at 1 and 6°C.

Other countries have similar distinctions for storage vs transport. The origin of the different temperatures ranges for RBC storage and transport is unknown.

Imagine this scenario:

1. Unused RBC units are returned from the OR to the transfusion service at 8°C and are discarded since they exceed the 1 to 6°C storage range.

2. RBC units from the blood supplier arrive at the transfusion service at 8°C and are placed into inventory since they adhere to the 1 to 10°C for transport.

Say what? Difference makes little sense. As the authors write [paraphrased]:
(1) Differing temperature ranges likely do not increase patient safety and should be reconsidered, since improved utilization and cost control of all hospital services is essential. Increased wastage of an already scarce resource can lead to low blood inventories, putting patients at risk.
(2) The change from OR fridges to coolers was to reduce incompatible blood transfusions associated with using shared refrigerators for several ORs where blood for patients of different ABO groups were stored. But the cost of improved safety has been increased blood wastage to comply with temperature regulations that lack scientific verification.
The authors' conclusion (paraphrased):
Data show there may be no detriment to increasing the storage temperature range to 1 to 10°C for a few hours, such as while RBCs are in a cooler in the OR. But data are incomplete and may not apply to storage with current materials. Research on differences in metabolite formation, biochemical changes, and microbial growth between RBCs stored at 1 to 6°C and 1 to 10°C would help demonstrate the most appropriate storage temperature range. 
Kudos to the authors for tackling this issue. In a way it's sad that the authors use cost constraint as a major motivator for re-thinking the regulations. No doubt money 'makes the world go around.' But why weren't such rules challenged a long time ago on science alone?

Wouldn't it be great if more iffy, nutball regulations (those lacking scientific evidence) were challenged?

Perhaps the 'powers that be' could develop a mechanism for trench workers in various countries to suggest which regulations may not be warranted? Then research could be done that clarifies the issue.

Suitable challenges would involve regulations that 
  • Seem arbitrary (unrelated to safety) 
  • Are inconsistent with other regulations
  • Cause increased work / money without apparent justification
  • Sound of silence (Simon & Garfunkel) The song title fits behavior in the TM community about iffy rules and regulations. But mainly it's included because I love the tune, lyrics and artists.
As always, the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

Thursday, February 09, 2012

Wasted Days & Wasted Nights? (Musings on transfusion professionals use of the Internet)

This month's blog muses on whether the Internet for health professionals is over-hyped. I'm particularly suspicious of applications that are meant to be interactive, not just users passively consuming information provided by others. 

Today's Internet is presumably about the interactive sharing of experiences that supposedly happens on blogs like this one, as well as on discussion forums and mailing lists. 

The blog's title comes from a 1959 song by Freddy Fender.

Based on my experience, Internet users  - meaning you - are definitely passive. Me too when visiting other blogs but I try to participate, at least occasionally, since working in cyberspace is a lot like this cartoon illustrates.


1. Musings on Transfusion Medicine: This blog is written just for fun. A review of comments made on earlier blogs reveals very few, and mainly by kind-hearted colleagues who take pity on a friend. (Bringing out a big hanky now....)

Even the controversial blogs specifically designed to stimulate thinking get few, if any, comments, e.g., the last two on bullying and calling Canada's blood supplier vain. Yet, 1000s of transfusion professionals know about the blog via TraQ's monthly newsletter.

2. AABB's "Communities" open to members only (previously AABB forums): Just took a look and there's little activity and often by the same people. Why? AABB  has 1000s of members.

3. Canada's Transfusion Safety Officer "transfusion" mailing list: 200+ subscribers but few post questions.

4. CBBS e-Network Forum: Over the past year, discussion on e-Network Forum, a truly quality resource, has decreased significantly. 

Also, there's a request for new Associate Editor/Moderators, which suggests that long-time editor and founder Ira Shulman may have retired or is about to. 

5. BloodBankTalk - BB Talk is an active discussion group based in the USA. Unfortunately, participation is limited to a core of contributors, including an active UK contingent, whose contributions are uniformly of high quality.

OTHERS? If other web-based forums or mailing lists exist for transfusion medicine physicians or nurses, I'm unaware of them. Why don't they exist?

About mailing lists and web-based discussion forums, many possible reasons exist for the lack of participation. Some of the most obvious include

1. Too busy to use Internet resources for work purposes (most health professionals are stretched to the max). But we still spend time on Facebook, on conducting marginally productive Internet searches, on watching sports, and the like.

2. Fear of revealing weakness about not knowing. I suspect this is a biggie. Some may feel embarrassed to request help, thinking, "I should know this." Others may feel their employers may not appreciate an external request for advice.

3. Prefer to network privately since it offers more privacy and less risk of public exposure.

4. Distrust of sources whose qualifications and experience may be uncertain (even though many acknowledged experts now offer help via the Internet).

5. Lack of confidence in computer skills to use Internet effectively (perhaps more prevalent in older professionals?).

6. Boring content, not stimulating enough interest to participate.

If you can suggest other reasons, please add them in a comment below.

So the question arises, "Is today's Internet past its prime as a mechanism to ask and answer questions and participate in as a community?"  


As I muse about why the silence, the song that comes to mind from a personal perspective is 
If you read this blog, please suggest topics to cover, keeping in mind that content should appeal to technologists, nurses, and physicians working in transfusion medicine. Controversy is okay and ideally should be food for thought. 
As always, comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice.