Saturday, January 11, 2014

Mommas, don't let your babies grow up to be lab techs (Musings on what TM journals imply about med lab technologists/scientists)

Last updated: 3 Feb. 2014 ('Tweeks' +ADDENDA below)
Happy New Year, everyone. January's blog is a crude attempt to identify the state of transfusion medicine in developed nations in 2014 and, particularly, where my medical laboratory colleagues (vs nurses and physicians) fit in the grand scheme according to TM journals.

The title is a take-off on a song covered and made famous by Waylon Jennings and Willie Nelson.

To be clear, I and most of my cohort had wonderful careers as medical laboratory technologists working in transfusion medicine. We experienced the glory years where our specialty, immunohematology (blood group serology) was exciting and rewarding. But, my friends, the times they are a changin', and have been for a long time.

At the start of a new year, I wondered if transfusion medicine journals had become more relevant to working medical laboratory technologists / scientists and decided to use the January 2014 issue of the AABB journal Transfusion as an indicator.

The same challenge faces TM nurses and physicians - of all the knowledge needed to keep current, how many papers are truly useful? (What RNs and MDs would read of direct relevance won't be dealt with here, mostly because it's beyond my pay grade.)

Also, I wondered if the New Year issue would identify what's hot, and not hot, in TM.

It's a thought game I play with every issue of the TM journals I read. With a background as a medical laboratory technologist and educator, what would I read? Frankly, I read many papers just for fun, out of curiosity and as bathroom reading. (Easily beats People magazine and edges Canada's Macleans.)

But most adult learners, including busy TM professionals, want immediate usefulness. They tend to take time to read resources that they can apply instantly and directly in their jobs.

So, specifically, what would I read in January's Transfusion that is of immediate relevance to me, assuming I still worked as a frontline worker, instead of playing around on the Internet, looking for resources to share with all involved in transfusion medicine?

My assessment for practical relevance includes several factors:
  • How closely does the author's locale fit my situation?
  • Do I know the authors personally or by reputation as thought leaders?
    • Love this buzz word, meaning influential
    • How many colleagues would you name as thought leaders?
  • Does the paper deal with something I have some control over and can evaluate and implement?
  • Who funded the research? 
  • Which competing interests do authors identify?
As an aside, one thing I noted in the Jan. issue was how only the editorials (10 pp.) and letters (3pp.), i.e., 5% (13 of 258 pp.) of Transfusion's January pages, were new. The rest were published and available online mainly in April-June, 6-8 months earlier.

Does Transfusion's publisher, Wiley, need to continue to cut down trees for 5% of new content? How about asking AABB members and other subscribers if online access suffices?
After all, how many TM professionals exist who cannot access the Internet? No doubt some in developing nations, but even there, electronic copies may be easier to access than paper ones.
MY WINNERS (Transfusion, Jan. 2014)

1. The 'Transitions' editorial, only because the title is irresistible. Transitions of what? AABB, the journal's focus, or even TM itself? I had to know.
Turns out the editorial was about changes to Transfusion's editors.Of special note to me was the retirement of George Garratty, PhD as associate editor of the Immunohematology section after 31 years of service promoting papers on red blood cell serology. His successor is Connie Westhoff, SBB, PhD, who also handles Blood Group Genomics. Garratty will continue to serve Transfusion as a member of the editorial board.
George is an icon to TM medical technologists - see this interview, similar to these 'dudes' and others:
Over the years I've noticed how some physicians, at best, patronize PhDs and, at worst, denigrate them for their lack of clinical expertise (usually among fellow physicians, almost never to their face). Which is why this sentence on George Garratty from the Transfusion editorial struck me:
'Even though he is not a clinician, he demonstrated a remarkable ability to marry the serologic aspects of manuscripts with clinical implications, adding value to this section for laboratory technologists, immunohematology researchers, and laboratory directors who supervised technical activities and who are required to interpret these findings for practicing clinicians.'
Patronizing? I can only imagine what the author thinks of medical laboratory technologists. Can we ever have 'remarkable ability to marry the serologic aspects of manuscripts with clinical implications' or marry anything to the be-all and end-all supremacy of clinical? And if not, are we lesser beings in the TM pecking order?

And what about nurses? They're clinical but do they cut it with docs for their clinical expertise or are they forever designated as handmaidens to physicians? Just asking, you do your own answering.

2. Transfusion Medicine Illustrated. Who doesn't love neat photos?
An unusual cause of red plasma: Due to concern for cyanide exposure, a burn patient was treated with hydroxocobalamin. Red discoloration was subsequently seen in her plasma, urine, and wound dressing. 
Many causes of discolored body fluids exist (e.g., ingesting food coloring, rapid hemolysis), but in this case the clinical scenario suggested it was due to the dark red color of hydroxocobalamin.
 Is it similar to red pee after eating beets? <;-)

3. 'Hospital-based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient transfusion safety' and not just because its authors are Canadians but because we all need to know what errors are made in order to prevent them. From the abstract:

During 5 years at Sunnybrook in Toronto, errors occurred at every point in the transfusion process, with the greatest potential risk of patient harm resulting from inappropriate ordering of blood products and errors in sample labelling. Specifically:
  • 15,134 errors were reported, a median of 215 errors/mth:
    • 9083 (60%) on the transfusion service (TS) 
    • 6051 (40%) on the clinical services 
  • 23 errors resulted in patient harm:
    • 21 on clinical services and two on the TS 
    • 21 of 23 harm events involved inappropriate use of blood 
  • Errors with no harm were 657x more common than events that caused harm 
  • Most common high-severity clinical errors:
    • Sample labeling (37.5%) 
    • Inappropriate ordering of blood (28.8%)
  • Most common high-severity error in TS
    • Sample accepted despite not meeting acceptance criteria (18.3%) 
  • Cost of product and component loss due to errors: $593,337
4. 'Record fragmentation due to transfusion at multiple health care facilities: a risk factor for delayed hemolytic transfusion reactions.' 
The paper deals with errors due to record fragmentation, a risk that exists whenever people are treated in regions without a common information system for patient records. With increasing mobility of the workforce, the risk is ever-present and widespread.
From the abstract:

Multisite transfusions were common. For patients seen at both of two nearby hospitals, antibody records were frequently discrepant. Findings support the need for interfacility sharing of transfusion records, particularly at the regional level. More specifically:
  • Antibody discrepancies occurred in 64.3% (27/42) of cases 
  • Most common discrepancy was failure of one facility to detect an antibody
5. 'Successful management of severe hemolytic disease of the fetus due to anti-Jsb using intrauterine transfusions with serial maternal blood donations: a case report and a review of the literature.'
The authors are from Muscat, Oman but a case report dealing with HDFN is a magnet to most techies because some immunohematology and other laboratory data are sure to be present.

The case was notable because anti-Jsb is an extremely rare antibody. 100% of Caucasians and 99% of blacks are Js(b+) and maternal blood was used for 4 intrauterine transfusions.

#1. Besides the editorial and TM illustration, as a busy medical laboratory technologists/scientist who worked in a large tertiary care facility and earlier in a combined transfusion service-blood centre, I would probably have read three papers comprising 19 useful pages of 258 (~7%) of January's Transfusion.

Keep in mind I would have read more out of curiosity as a bench technologist and because, after becoming an educator, I wanted to be at least familiar with all aspects of TM, even if it was in the purview of nurses and physicians.

Think for a moment: How many of today's med lab techs in the transfusion service, especially cross-trained ones who rotate in the blood bank, hematology, and clinical chemistry - but also TM specialists - would read any of these papers?
First, even specialists would lack access to Transfusion unless they were AABB members or had journal clubs that discussed published research or were at university hospitals where staff were given access. Not many.  
Experiment: Ask your TM colleagues (medical technologists, nurses, physicians):
  • How many read Transfusion (or the equivalent specialty journal in your country)?
  • If a medical technologist, assuming they're members and receive a journal as part of membership, how many read even a few articles in their general professional journal? Ex:
    • AJMS in Australia
    • CJMLS in Canada
    • IBMS Newsletter in UK 
    • Lab Medicine or Clin Lab Science in USA
2. Transfusion complications and errors continue to be a concern. Besides papers 3 and 4 above, three other papers deal with transfusion complications and risks (See TOC below).
To Ben Franklin's famous quote, 'In this world nothing can be said to be certain, except death and taxes,' we can surely add, 
Nothing is more certain that transfusion errors and complications will occur despite our best efforts. [See UK's SHOT]
3. What's hot? Looking at the Table of Contents (TOC), Transplantation and Cellular Engineering and Transfusion Practice have the most papers (6 each).

The first section (sounds oh so important - love use of engineering) fits with AABB's attempt, and transfusion medicine in general, to move from blood transfusion (waning in an era of transfusion complications and blood conservation) to a more viable, emerging field like stem cell transplantation.

Kinda like dentists expanding their practices by promoting teeth whitening for all and braces for more and more kids?

The second (Transfusion Practice) validates AABB and transfusion MEDICINE in general as mainly in the control of physicians. Doh!

4. What's not hot? Immunohematology and Immune Hematologic Disease (the anti-Jsb case study) has the fewest papers (1 each). And even there, I wouldn't read the Immunohematology paper as it deals with basic research using mouse red cells ('Transfusion of murine red blood cells expressing the human KEL glycoprotein induces clinically significant alloantibodies').

All I can say on what's hot, what's not, is Plus ça changeplus c'est la même chose. [If needed, a translation]

You may disagree with my assessment of read-worthy papers for medical lab technologists/scientists in Transfusion's Jan. 2014 issue. If you agree or disagree, please let me know in Comments section or by private e-mail.

As noted, I cannot evaluate the articles from the perspective of busy TM nurses and physicians. Decide for yourself (Transfusion TOC in Further Reading below) which of the papers' titles would motivate you to read them.

#1. (12 Jan. 2014) In reply to Roger (see Comments below): Thank gawd for ARC's journal, Immunohematology. One place where those of us in the lab can still enjoy and learn about blood group serology, a dying art.

#2. (13 Jan. 2014) In reply to Robina (see Comments below):

Robina, I agree that a significant reason for so few 'serological studies' being published is that routine blood group serology is not as innovative and ground-breaking the way it was, especially in the 1960-80s.

Soon thereafter, and extending into the 21st C, red cell serology papers were often comparisons of various automated systems with manual techniques and then with each other.

Other factors abound, including:

1. Waning of serologic studies as pretransfusion testing became assessed for clinical relevance. Ex:
2. With the invention of PCR and DNA sequencing, blood group discoveries began to focus on DNA analysis to determine blood group inheritance. For example, see Willy Flegel's
  • Rhesus site at the University of Ulm (static since 2009)
3. Molecular genotyping. Applying DNA analysis to typing blood group antigens started in the early 1990s and continues to make inroads into routine use. I blogged about this in 2010:
4. Shifting priorities.
-As labs became more automated
-As regulation extended beyond blood centres to transfusion services
-As governments instituted cutbacks on health care funding,
research into the following became higher priorities:
  • Competency training, assessment, and audits for compliance
  • Reducing errors in patient identity, blood administration and blood ordering
  • Improving blood utilization, especially for plasma derivatives like IVIg 
As well, the funding of transfusion safety officers to help with the above meant that blood group serology all but disappeared from the research radar.

Besides the above factors, secondary causes for the paucity (sorry, cannot resist the word) of published papers on red cell serology include the nature of the TM workforce. The following are my views and I could be wrong.

Olden Days vs Today
1. Once medical directors of transfusion services and blood centres had sufficient budgets and staffing to allow a lab technologist to work part-time on a research project under supervision and with support.

Today, this is generally untrue. Staffing is stretched to the max just to get the real work done.

Research projects exist in a few places but typically dealing with new priorities and where the medical director has access to research funding or to students in a local university CLS/MLS program. And also where, because of affiliation with a university, medical directors have an incentive to publish papers as it earns prestige, promotion and salary increases, no matter how minimal. 

2. With the advent of regionalization, centralized testing and automation, it's possible to operate transfusion services with fewer staff, and less well trained ones. The few existing transfusion specialists are swamped with administrative, education, human resources, and management issues.

As for the 'trench workers', regardless of education and training, they often feel less valued by employers (knowing they are disposable if the right technology comes along) or, in the case of blood centres, if the right 'care associate' can be trained to do their job. See my joke on the practice.

Hence, many have evolved into 9-5ers, taking pride in their daily job, but unlikely to put in the extra hours that goes invariably with research. Of course, some do want to excel and go above and beyond, but the numbers are small.

Well, these are a few stream-of conscious ideas for why blood group serology papers are increasingly rare in major TM journals.

Please see Robina's follow-up comment below about the situation in the UK.

#3. (3 Feb. 2014) In reply to Anonymous(see Comments below):

Yes, the Globe & Mail article on paid plasma clinics in Canada is interesting. Health Canada is into its second year of deliberating whether to license the clinics and notes that each province can decide to allow paid plasma clinics (or not).

The CBS quotes are interesting. Most notably, Graham Sher, CBS's CEO seems to have shifted ever so slightly in how he presents the CBS position.

For example in a commentary he authored in the Toronto Star in March 2013 ('Prohibiting pay-for-plasma would harm patients'), Dr. Sher wrote (summarized by me):
  • On Safety
    • Manufacturers must be licensed and meet stringent quality and safety standards.
    • Safety procedures built into fractionation are extensive, and include donor screening and testing, plasma quarantine, technology that inactivates viruses, and purification steps. 
    • These products are extraordinarily safe. 
    • Many studies show plasma products from paid donors are as safe as those manufactured from volunteer donors.
  • On Security of Supply
  • A safe system must ensure security of supply. 
  • 1000s of patients depend on life-saving fractionated products (plasma derivatives).
  • Prohibiting paying donors for plasma would deny patients access to these products, both here in Canada and around the globe. 
In the Globe and Mail piece, Marc Plante (CBS Communications Specialist) reiterates Dr. Sher's March 2013 commentary, whereas Sher is quoted as telling a panel audience at an October 2013 production of Tainted:
  • “Would I be happy if they [paid plasma clinics] never opened their doors here? Never did business here? Absolutely.”
Perhaps an attempt to modify his earlier statements where he seemed to to come across as an advocate for paid plasma?

I also thought it interesting that the Globe and Mail quoted Janet Conners. Also see
Comments are most welcome.

And just because I'm in a 'Willie Nelson frame of mind':