Sunday, July 08, 2012

Got a feeling (Musings on blood doping)

Last updated 10 July 2012

This blog's idea arose because the Olympics is almost upon us (2012 London Olympics, 27 July - 12 August) and there is much talk about the latest laboratory tests to detect cheats. 

Moreover, this year Big Pharma is involved with much fanfare and the specific giant pharmaceutical company (GlaxoSmithKline) has been in the news recently for quite a different reason (more below).

The title comes from a song by the US / Canadian group, The Mamas and Papas.

BLOOD DOPING
The London Olympics has revived news about drug cheats and blood doping, e.g., How do the sports compare.

Blood doping has also been in the news because Lance Armstrong, 7-time Tour de France winner is charged with doping by the US Anti-Doping Agency (USADA).
Blood doping boosts the number of RBC to enhance athletic performance and is rampant in endurance sports such as long-distance cycling and cross-country skiing. It's been done using erythropoietin (EPO), homologous and autologous blood transfusions. Autologous blood doping has been hard to detect because dopers receive their own red cells.

MUSINGS
As long as sports is big business with mega-bucks on the line for winners, cheating will exist. Cheating at the Olympics seems particularly odious given Olympic values.

But winning a Gold Medal is often worth $millions to athletes in commercial endorsements and sponsorships.
In contrast, the money that some athletes earn from their countries is small change.
Canada is late to the game and a cheapskate:

But the $millions in endorsements help explain why some athletes cheat and risk detection, e.g., Canada's sprinter Ben Johnson, who was stripped of his gold medal at the 1988 Seoul Olympics and whose physique revealed all.

As to professional athletes like US baseball slugger Barry Bonds,  you only need to look at their physiques, especially before and after photos to know who the steroid cheats are, as well as the 'steroid rage' that some players exhibit. 

Same with USA NFL football. Some of those dudes look loaded with steroids or human growth hormone and tests should detect the cheats. Also see


As a soccer fan (aka football outside NA), I've wondered if players take performance enhancing drugs but evidence suggests otherwiseespecially for players like Fernando Torres, whose physique hardly screams performance enhancers like steroids or HGH. 

Not necessarily true for 'recreational drugs' like cocaine, though. With young footballers earning mega-millions in salaries and sponsorships, it's bound to happen.
LONDON OLYMPICS 'BOFFINS'
But back to The Olympics. The London Olympics will showcase the ongoing battle between the cheats and those who aim to catch them.
It turns out that laboratory equipment for the new Olympics testing facility was supplied by GlaxoSmithKline (GSK) at a cost of £20 million:
This King's College London site features complimentary words on GSK by David Cowan, Director of the College's Drug Control Centre and a video by GSK:
Here's the top boffin explaining a term that many countries have implemented to help prevent cheating:
Interestingly, GSK was in the news last week for a very different reason, settling the largest health care fraud case ever:

...[GSK]... admitted to misbranding the antidepressants ...and marketing them for uses not approved by the ... FDA, including the treatment of children for depression and the treatment of ailments such as obesity, anxiety, addiction and ADHD.
In some cases, the company did so despite warnings about possible safety risks from the FDA, such as an increased risk of suicide for children under 18 taking antidepressants.
It also admitted in the settlement that it did not provide the FDA with safety information that indicated its diabetes drug ...might cause heart problems. The drug was eventually pulled off the shelves in Europe and its sale restricted in the U.S.
Its CEO says GSK instituted reforms & learned from its mistakes. 
Seems everything is spin and PR these days, certainly in politics, but also in the world of Big Pharma. Good publicity from Olympics testing lab will help put a shine on GSK and erase last week's deadly headlines about the company's incredible, unethical proven past actions.

Bottom Line
As a bloodbanker I especially hope that autologous blood doping can be stopped. And as a football / soccer fan, whose players run up and down the pitch for 90+ minutes, I hope that none are into blood doping or other cheating.

But I've got a feeling....

FOR FUN
How I feel when my sports heroes are caught out by drug tests:
  • Got a Feeling (Mamas and Papas) Somewhat ironic as this group, whose songs I love, were into drugs as were many in the 1960s.
  • Dancing in the Street (Because I like the song and Mama Cass's voice, and it's summer in the northern hemisphere)
FURTHER READING
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. 


Friday, June 08, 2012

Take a chance on us (Musings on mentoring)


Canadian TM professionals may be aware of Bloodtechnet's learning competition but others may not.

Briefly, Bloodtechnet is a program sponsored by Canada's national blood supplier, CBS, that funds educational projects. One neat thing is that winners are determined by votes by Canada's medical laboratory technologists.

For the 2012 competition I submitted a proposal on mentoring that was lucky to be one of the winners:
  • 'I will remember you. Once in a lifetime mentoring opportunity'
The proposal was later renamed to more closely describe its goal:
This blog briefly describes the mentoring proposal. Its purpose is to encourage submissions to the 2013 competition because those submitting proposals in 2013 will participate in the mentoring project.

The blog's title 'Take a chance on us' is a take-off on a 1978 ABBA hit, 'Take a Chance on me'.

Will the project be able to fulfill its goal of creating a global mentoring community that can facilitate succession planning? Only time will tell.

Currently, the most exciting news is that many mentors from across the globe have already generously agreed to participate:
  • Australia
  • Canada
  • Ireland
  • Switzerland
  • UK
  • USA
The mentors have illustrious careers and we are so lucky to have them.

As well, mentors are interdisciplinary: medical laboratory technologists, nurses, and physicians.

Fortunately, Shanta Rohse, who manages Bloodtechnet for CBS and transfusionmedicine. ca is a key collaborator in the mentoring proposal and will take the lead.

The Bloodtechnet website that Shanta manages for CBS will be upgraded to facilitate mentoring.

BACKGROUND
Increasingly, MLTs require a complex set of transferable skills but suitable continuing education (CE) resources are few:
  • communication
  • leadership
  • networking
  • problem solving
  • project management
  • team work
  • time management
The 2010 bloodtechnet survey noted:
"We often see learning as a solitary, independent pursuit, one of accumulating facts and information. On the contrary, learning is also a deeply social activity and there are a number of reasons why learning from and with others is a foundational part of continuing education. First, individual learning is supported by being exposed to and reflecting on how others think....."
Mentoring is a social way to foster transferable skills and professional development. Mentoring also supports succession planning of one generation to another.
What is mentoring?
Many definitions of mentoring exist. Regardless of definition, mentoring is a partnership between colleagues, a bond of mutual respect and trust from which everyone gains valuable insights and personal satisfaction.

This project will develop a network of informal mentors drawn from transfusion professionals within Canada and beyond and a framework with guidelines to support mentoring.

BOTTOM LINE
To all volunteers who have agreed to participate, heartfelt thanks. You are busy professionals whose time is consumed by professional and family obligations. The mentoring project is a grand experiment with much unknown.

Your willingness to give this project a chance is admirable. You are truly the 'good guys' who deserve the kudos of colleagues.

Canadian TM professionals

Please consider submitting a proposal to Bloodtechnet's 2013 competition. You will have the advantage of interdisciplinary and international mentors. Many opportunities to meet colleagues worldwide. Who can resist such an opportunity?

All those interested can keep track of the project's progress on twitter @TransMedmentors

Finally, thanks to CBS for sponsoring such an innovative endeavour. I know of no other like it worldwide. With Bloodtechnet you got it right.

Readers are encouraged to browse Bloodtechnet to get a sense of what it's about.

REQUEST
If you have ever been a mentor or a mentee, please comment below on what you think are the most important characteristics of each. 
Or let us know if there are similar opportunities in your country to compete for funds to create CE for medical laboratory technologists and others.  
FOR FUN
And a favorite song (You may have guessed I'm partial to the Beatles)
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, May 10, 2012

I've been everywhere, man (Musings on fast-tracking those with foreign credentials)

This blog is a revised version of a recent personal blog, 'Want to work in Canada as a medical technologist? Forget it!'
Last updated: 16 May 2012 (see Addendum below)
 As a promoter of international job mobility, it has long saddened me that foreign-trained medical laboratory technologists from English-speaking nations such as Australia, NZ, and the UK face so many obstacles when seeking work in Canada. 
Do physicians and nurses face similar obstacles? Perhaps not, because everywhere in Canada, I hear physicians with British, New Zealand, South Africa, and Aussie accents. And since 'Down Under' countries are always holding job fairs in Canada for nurses, I suspect that mobility may be reciprocated, i.e., Aussi and Kiwi RNs can work in Canada without too much difficulty. But for medical technologists, it's a different story. Working in Canada is onerous, indeed.
If you are a physician or nurse, I encourage you to read (even skim) the technologist-related details below to assess how job mobility for your profession compares.
This blog derives from a Dark Daily report: "Medical laboratory technologists with foreign credentials to get fast-track acceptance in Canada."

Its title derives from an old Hank Snow ditty, I've been everywhere, man.

I love Dark Daily, but its headline and article are misleading. If I were asked about foreign-trained medical laboratory technologists from AU, NZ, UK, and USA, where English as a second language is a non-issue, and where education and training are world class, my response would be:
  • All the fast-tracking in the world won't help.
As background, Canadian employers (mainly government-funded health regions) are always moaning and groaning about the shortage (soon to become worse with impending retirement of baby boomers) of nurses and physicians, as well as other health professionals such as medical laboratory technologists and diagnostic imaging technologists. In response, governments have created various fast-track schemes that supposedly will allow faster immigration and employment of qualified needed health professionals. 

USA GRADS
First, USA grads do not qualify because their general certification does not include histotechnology. In Canada, besides clinical chemistry, hematology, clinical microbiology, and transfusion science, general certification requires education and a clinical rotation in histotechnology.

Second, obtaining subject certification for USA grads in the other 4 main disciplines is out because Canada offers subject certification only in clinical genetics and diagnostic cytology.

Reasons that CSMLS does not offer subject certification in other disciplines include
  • Cost (subject exams are costly to maintain) 
  • Employer preference for flexible grads who can work in all disciplines
  • Fear that employers may use those with subject certification to work in lab sections for which they are untrained
Accordingly, the path to employment in a clinical laboratory for a USA-educated and trained medical technologist / clinical laboratory scientist is a torturous path:
  • Step 1: Attend an educational institution (Canada or US) and take a course equivalent to an histotechnology course taught at Canadian institutions. For example, see MLS 250 at the University of Alberta.
  • Step 2: Convince a potential employer to provide a clinical rotation in histotechnology. In Canada this is ~4 weeks. And it's next to impossible because employers can barely offer clinical rotations to Canadian-trained students.
  • Step 3: Apply to CSMLS for a 'Prior Learning Assessment'.
  • Step 4: If eligible, arrange to write the CSMLS general certification exam (based on a competency profile) covering the five disciplines specified on the CSMLS website.
AUSTRALIA, NEW ZEALAND, UK

Background
In my experience, education and training 'Down Under' and in the UK are excellent and in some ways exceed that of the typical Canadian graduate, since Canada rejected the BSc as entry-level several years ago.
This decision created barriers for Canadian medical laboratory technologists to work outside Canada. 
People who did not support the BSc were employers and bureaucrats in provincial government departments of health. Reasons for rejecting the BSc varied but included:
  • They perceived the BSc as entry level for nurses  as credential inflation leading to increased salaries without sufficient return on investment and they were determined to stop this happening for medical laboratory technologists.
  • Employers wanted the cheapest possible medical laboratory technologists, those who could be 'turned out' as quickly as possible and paid as little as possible. 
  • In their short-sighted view, with the move to increased laboratory automation and centralized testing, who needed a technologist whose education and training took 4 years?
Exception
Canada has two programs that provide both a BSc and professional certification by CSMLS:
All other programs are 2- or 3-yr diploma programs at technical institutes or community colleges (equivalent of USA 'associate degrees').
For interest, UA MLS grads enjoy international job mobility. They are eligible to write the American MT(ASCP)* exams and many have. (*To change once the ASCP's Board of Registry and NCA merge to form a single USA certification agency.)
This allows UA MLS grads to work in the USA and many did during the mid-90s when laboratory jobs greatly decreased in Canada and many educational programs closed.
As well MLS is the only Canadian program whose grads are eligible to work in NZ without writing certification exams. 
What about job mobility for technologists trained in other English speaking countries besides the USA? Can university educated and trained UK, Oz, and NZ grads easily work in Canada as med lab techs?;

Unfortunately, no. The main reason is that programs in these countries, while providing education in the 5 basic disciplines, do not require clinical rotations in all 5 disciplines.

For example, NZ graduates of university programs  are ineligible to work in Canada because they may do a year's rotation in only 2 disciplines, e.g., 6 mth clinical rotations in their 4th year in each of 2 disciplines (e.g., hematology and transfusion science or clinical chemistry and hematology, etc.), as in the Massey University program.

In contrast, a typical Canadian grad may spend 3 mths in a hematology lab and one month in a transfusion service lab, only one-third of the total time spent by NZ grads in these labs, and in the case of transfusion science, one-sixth as much. But NZ MLS grads are not eligible to write the CSMLS general certification exam without obtaining equivalent clinical rotations in all 5 disciplines.

Is this not nuts, given that NZ MLS grads clearly have more basic education than most Canadian grads, as well as more practical experience in at least 2 clinical laboratories?

OZ and UK grads are similarly stymied if they want to work in Canada because graduates of Australia and UK's university programs can specialize. Examples:
Why do these medical laboratory technologists face significant barriers to working in Canada? Is it all about protecting public safety by ensuring medical laboratory professionals meet Canadian standards of education and training? Or is it about protecting Canadian jobs for Canadians?

And why do graduates of Oz, NZ, UK, and US programs who are certified by their county's professional body and have worked for years in one or more areas of a clinical laboratory, need to write the CSMLS general certification examination covering all 5 disciplines to work in Canada? Beats me.

CSMLS CERTIFICATION
If the educational programs of foreign-trained technologists are deemed equivalent to Canadian programs (or better), foreign-trained candidates must still write the CSMLS general certification exam to work in almost all Canadian medical laboratories.
Most Canadian provinces have regulatory bodies that de facto require that medical laboratory technologists be certified by the CSMLS as a condition of employment in a clinical lab that performs diagnostic tests on patients.
For lab professionals with experience (e.g., those who trained 10-15 yrs ago), and who have likely worked in one discipline (perhaps two) for years, writing an exam covering knowledge and competencies in 5 disciplines is not easy. And getting clinical rotations in Canadian labs is pretty much impossible.
MUSINGS
I personally know NZ-, UK-, and USA-trained lab professionals who are better educated and trained than many Canadian grads, have ample current experience, and would make valuable contributions to Canadian labs and be exemplary employees. But they cannot work here, despite the fast-track 'BS' of our governments.

True fast-tracking would allow
  • Different routes that don't require candidates to re-learn  specific disciplines (e.g., histotechnology), which they will never work in;
  • Restricted licenses to practice and work only in the area or areas for which they are well qualified.
The situation is different for those for whom English is a second language:
Besides becoming fluent in English, these technologists often need to upgrade their education and training to Canadian equivalency. As but one example, in transfusion science, the association of the Rh blood group system with severe hemolytic disease of the fetus and newborn would not have been taught in Asian countries where almost everyone is Rh positive.
Upgrading programs are rare but exist. If candidates pass English language competency tests, successfully complete whatever minimal upgrading is deemed necessary, write and pass the CSMLS general certification exam, they still may not be hired if their English remains weak. That's the reality of today's clinical laboratories where staff are stressed to the max, mainly due to under-staffing.  
If asked, I often advise foreign-trained grads to enroll in a Canadian medical laboratory technology program. It's a tough sell because they have to support themselves and their families. But in the end, this route can prevent much grief and frustration.

Not a pretty picture....

Talk of fast-tracking foreign-trained medical laboratory technologists / medical lab scientists / biomedical scientists is largely smoke and mirrors.

Your thoughts and experiences are valued. Please offer feedback anonymously (or provide your name in the body of your response) by commenting below.

 Whether medical technologist, nurse, or physician:
  • Is there an impending shortage in your country that would benefit from greater international job mobility?
  • Does international job mobility of needed health professionals work well in your country? 
  • Do foreign-trained workers face significant barriers? 
  • Is fast-tracking a reality? 
Similarly, have you tried to work in another country and what obstacles, if any, did you face?

For fun
'Golden oldies' by Canada's inimitable Hank Snow
And just because I love it:
 As always, the views are mine alone.

ADDENDUM (16 May 2012)

Thanks to 'Anonymous,' who left a comment but perhaps withdrew it:
Well, it seems that both nurses and doctors have to sit exams in Canada in order to work here.... I wonder if it is possible to flood the ears of those desperately in need of lab staff with credentials of American or Australian or New Zealand educated professionals, so that the potential employer is motivated to seek change in the requirements.
The comment motivated me to suss out the following info on foreign-trained physicians and nurses wanting to work in Canada.

PHYSICIANS
Source: Global Medics
The basic core requirements for medical registration in Canada: 
A medical degree from any country that is listed in the International Medical Education Directory (IMED)
GP or specialty training that has been completed in Australia, Canada, Ireland, New Zealand, UK or USA
Authentication of medical certification by the Physicians Credentials Registry of Canada (PCRC). 
Some provinces require full verification before they will issue your license. Others will allow you to complete PCRC verification after starting work in Canada. Most provinces also require completion of the Medical Council of Canada Evaluating Exam (MCCEE).
Before taking the MCCEE, internationally-trained physicians must apply to the Physician Credentials Registry of Canada (PCRC) and send a certified copy of your final medical diploma. The MCCEE is a computer-based examination available at 500 test centers in 72 countries. 
Also see Info for foreign-trained medical doctors

NURSES

See Info for foreign-trained nurses

Process is similar to that for medical technologists (assessment, national exam). Exam info:
Canadian Registered Nurse Examination

More....





Sunday, April 08, 2012

While my guitar gently weeps (Musings on CBS's ongoing behavior)

Updated: 26 Jan. 2018 (Fixed broken links) 

Wow! After writing a blog about claims of CBS arrogance in closing its blood component production and distribution centre in Saint John, NB
Canada's national blood supplier seems to have 'done it again' with its decision to close a plasma collection centre in Thunder Bay, ON.

By done it again, I mean badly communicated a business decision and alienated an entire community.

Non-Canadians may find the details interesting as it deals with how national blood suppliers manage change and treat staff, volunteers, and donors.

The blog's title is from a 1968 Beatles ditty by George Harrison, While my guitar gently weeps

While it's too early to determine what actually happened in Thunder Bay, here are the facts as documented on the CBS website and as yet unsubstantiated allegations reported in the media:

FACT: CBS announces closure of Thunder Bay Plasma Centre effective April 12, 2012. (29 Mar. 2012). 
 "All Canadian Blood Services employees in Thunder Bay - 28 full-time and part-time employees combined, and two contract physicians - will be affected and were informed earlier this afternoon."
The above was removed from CBS website. See instead Open Letter to Thunder Bay Donors, Volunteers, and Community Partners (29 Mar. 2012)
MUSINGS
Sounds like they gave staff 2 weeks notice. Sound fair? On this point, a letter to the editor from a plasma donor notes:
I'm very disappointed with the way this closure was mishandled. Announcing the closure just weeks before it was to occur is wrong and irresponsible. Canadian Blood Services must have made these decisions many months ago and chose to spring it on everyone.
Their reason for not informing anyone earlier? Coun. Larry Hebert said CBS officials told him "it would be better for staff."
Not telling staff about impending bad news rings bells with me because this was the paternalistic modus operandi of the powers that be (health region physicians and administrators) when ~ 40% of Edmonton's laboratory technologists lost their jobs in the early to mid 1990s.

Of course, the main reason for keeping staff in the dark is typically so they do not make trouble (become a nuisance) for decision makers and loyally keep slaving away until they are jettisoned.

2. ACCUSATION: CBS is accused of deceit in citing reduced demand without mentioning buying plasma from USA

In a notice on its website about the closure of the plasma centre, CBS states:
Over the past two years, new replacement products and a decline in hospital demand have led to a decrease in the need for plasma for transfusion. Based on current projections, Canadian Blood Services must plan for a reduction of approximately 10,000 units to our plasma collection program this year.
Others claim this was deceitful, i.e., a convenient lie, and that CBS chose to save $ by buying plasma from the USA, a practice documented in a 2011 report

Source: CBS Financial Report March 2012 (p32)
Demand: Plasma is shipped for transfusion or fractionation and is collected through the apheresis program or recovered from whole blood collections. In 2010/11 total litres shipped for transfusion fell 11.2% as demand shifts to synthetic products within the plasma protein products business line. 
In 2010/11 Canadian Blood Services started a pilot program to purchase surplus recovered plasma from the United States (collected by organizations with an FDA licence) which will continue in 2011/2012.
MUSINGS
So, what's the scoop? CBS needs less plasma OR CBS needs less Canadian plasma because operating a Canadian plasma centre is more expensive than buying surplus plasma from the USA? If true, why not just say so?

Is the need for plasma derivatives on the wane? Provinces spend much effort and money on controlling utilization costs for IVIG, etc., e.g., BC PBCO and Transfusion Ontario. And it's an on-going challenge.

Regardless, if we need less plasma, why are we outsourcing  plasma collection to the USA? If it's all about cost, soon CBS may outsource much more to our friends to the south.

And what ever happened to Canadian plasma self-sufficiency? Has it been abandoned because it's too expensive?
This year, we also re-introduced the collection of source plasma at our existing plasmapheresis sites across the country, laying the foundation for Canadian Blood Services to improve our plasma sufficiency - one of the basic principles of the blood supply as outlined in Justice Krever's report.
Take home message

I literally grew up at Canadian Red Cross BTS and later worked in several capacities for its successor, CBS.  Like all health professionals, I wanted to be proud of my employer as its behavior reflected on me.

Has CBS behaved arrogantly or deceitfully in its recent business decisions? That's for time to tell and you to assess.  Here's how I feel about CBS today:
Some lyrics unused in the final version that caught my fancy:
I look at the trouble and see that it's raging,
While my guitar gently weeps.
As I'm sitting here, doing nothing but ageing,
Still, my guitar gently weeps.
Another unused line:
The problems you sow, are the troubles you're reaping,
Still, my guitar gently weeps.
FURTHER READING

Saturday, March 03, 2012

Blood donor questions about heterosexual sex (Musings on cultural differences in predonation screening)

Another blog that's a short snapper


Normally I would not read a research paper about blood donors in Brazil, but the following paper in January's AABB's Transfusion caught my eye:
Brazilian blood centers ask candidate blood donors about the number of sexual partners in the past 12 months. Candidates who report a number over the limit are deferred. The authors studied the implications of this practice on blood safety.
    Who can resist a paper involving sex? In a prior life as an instructor, including sex in lectures always increased student interest, e.g, discussing the so-called 'patient zero' in the AIDs tragedy, Air Canada fight attendant Gaëtan Dugas.


    In two Brazil blood centres (São Paulo and Recife), the question about sexual partners during predonation interview is: 
    • “How many sexual partners have you had in the past 12 months?” 
    In another (Belo Horizonte), the question is: 
    • “Have you had more than one sexual partner in the past 12 months? (If yes) How many?” 
    Current criteria to defer donors are more than 6, 3, and 2 heterosexual partners in the past year in São Paulo, Recife, and Belo Horizonte, respectively.


    Can you imagine blood donors in Australia, Canada, NZ, UK, or USA answering such questions about their sex life? I cannot. 


    The Brazilian study is summarized in the ABSTRACT. As would be expected, the number of recent heterosexual partners was associated with HIV positivity and overall rates of serologic markers of sexually transmitted infections. 

    Interestingly, in two centres, first-time, younger, and more educated donors were associated with more recent sexual partners (p < 0.001). 
    • Younger donors having more sex contacts seems reasonable as sexual activity tends to decrease with age, at least before Viagra. <8-) 
    • First-time donors having more sex may be related to them being younger. But researchers suggest it's also related to donors learning on subsequent donations to lie about sexual history once they know that a history of multiple sexual partners will defer them.
    • About more educated donors being associated with more recent sexual partners, that's interesting. Could it be that more educated donors are younger? (Presumably researchers controlled for that variable.) Or perhaps educated donors have increased opportunities for more sexual partners?
    Precautions
    Studies that rely on participants honestly answering questionnaires inherently have limitations. 


    When sex is involved, limitations increase exponentially. Think of surveys where men invariably report a more active sex life than women. 


    Bottom Line
    If you are a blood donor and were asked about recent sex contacts (heterosexual contacts):
    • Would you be offended at the invasion of privacy?
    • Would you answer honestly, especially if you knew that 2 or 3 or 6 or more would defer you?
    Regarding answering predonation questionnaires, are Brazilian donors any different than you?

    For Fun
    Sexy songs by Canadians? 
    As always, 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. 

    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:
    RATIONALE
    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?


    NITTY GRITTY
    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.
    CONCLUSION
    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. 
    MUSINGS
    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
    FOR FUN
    • 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.

    EXAMPLES - INTERACTIVE RESOURCES


    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?


    WHY THE LACK OF PARTICIPATION?
    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?"  


    FOR FUN


    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. 

    Thursday, January 12, 2012

    Stand by me (Musings on bullying by heath professionals)

    Last updated: 22 Nov. 2018 (Updated links)

    Bullying has always occurred in the schoolyard and workplace. Lately much news has focused on bullying in schools and cyber-bullying that sometimes leads to suicides by young people.

    But I wonder if many people realize that lack of respect and bullying happen all the time between supposedly caring health professionals. Such bullying seldom leads to tragedies like suicide but has serious consequences.

    Indeed, bullying among physicians, nurses, medical technologists and other health care providers has significant impacts and 'long tails' in terms of intra- and inter-professional cooperation and ultimately patient care.

    Granted the vast majority of health professionals do not bully, but enough do to make it common. And it's so endemic, even entrenched, that we have come to accept it as normal. How sick is that? Even more so, because we are health professionals. 

    The title of January's blog comes from the wonderful Rob Reiner film of 1986 with the same title (which took its name from the Ben E. King song). (See if you can pick out the Canadian star of 24 at ~ the 1:28 mark.)

    The blog has several origins:
    1. Last week I briefly chatted with a technologist working in a transfusion service. She reported an incident whereby a physician verbally abused the lab's technical staff and a medical director intervened.


    Such abuse was all too common historically, but apparently still occurs in an era where inter-professional team work and respect are promoted.

    2. A survey on subject certification for Canadian medical laboratory technologists by the CSMLS found that many technologists with general certification held extremely low opinions of those with subject certification calling them "dead weight" and similar derogatory opinions.
    Some respondents were even miffed that those with subject certification were paid the same as them, apparently unaware that most with subject certification invest more time and money in their education than those with general certification.

    Having subject certification, the report naturally caught my eye. And I wondered how technologists with general certification who hold such views treat "dead weights" with subject certification. Does workplace bullying occur, however subtle it may be?

    While working in a combined transfusion service / blood centre many moons ago, I never experienced bullying, but the lab consisted mainly of technologists with subject certification. 

    3. Being the founder and listowner of MEDLAB-L, a multi-disciplinary mailing list for medical laboratory professions at all levels, I am periodically struck by ongoing tensions between lab and nursing staff, suggesting a systemic lack of respect between the two groups.
    According to laboratorians, nurses
    • Just don't 'get' quality control or anything with numbers (only slightly facetious )
    • Cannot be trusted to perform point-of-care laboratory tests without laboratory supervision because they don't understand what can go wrong (legislated in some locales)
    Conversely, anecdotes abound on how clinicians (nurses and physicians) think lab staff are anal with their insistence on matching patient identification on blood samples and transfusion requisitions. 
    • "What? You need another sample because the sample reads 'Jonathan Smith' and the requisition reads 'Jon A. Smith'?
    REQUEST
    I ask readers to review a few resources on respect and bullying among health professionals and assess what, if anything, resonates.
    1. Do doctors and nurses hate each other?
    Medical laboratory technologists - Can you see parallels between physician - technologist relationships, made worse because historically technologists were the troglodytes in the basement?

    2. Bullying in the lab: Have you been a victim?
    Check the comments beneath the article. Just negative griping?
    I've seen physicians regularly bully lab technologists in the transfusion service, and lab technologists in positions of power routinely bully subordinates.

    Such bullying takes many forms, e.g.,
    • Clinician calls the lab and rants about lab incompetence (often leading to a longer delay in providing the requested blood component).
    • Some lab supervisors bully indirectly, i.e., they undermine staff by 'dissing' them to other staff. These supervisors don't comprehend Stephen Covey's common sense dictum that you build trust by being loyal to those who are absent.
    3. Doctors, being at the top of the health care pecking order, have a long tradition of bullying nurses, medical technologists, just about anyone.
    4. Nurse bullying show - "Nurses eat their young" (Dr. Brian Goldman's 'White coat, black art' on CBC)
    If nurses eat their young, do some pathologists "eat" their students and newbie colleagues? Definitely yes. Same for medical technologists.

    ANECDOTE
    Fortunately, I've had incredibly supportive colleagues (medical technologists, nurses, and physicians) throughout my career. I could name these treasured gems but won't in the interest of privacy. They know who they are.

    The one exception involved a somewhat paternalistic  physician who had a habit of glaring at subordinates menacingly in an effort to bully them into complying with his views. The tactic was comical (See Dilbert example) but it scared the bejeesus out of staff unfortunate enough to experience it, including me.

    My incident involved having failed a student on a research project. Being young, I was intimidated and never did that again. I got the message. 
    If something similar happened today, who knows? I'd like to think I'd resist being intimidated but you have to pick your battles carefully with those who have the power to make your life miserable.
    For some levity, one of my favorite Dilbert cartoons on bulllying.

    BOTTOM LINE
    What can be done about bullying among health professionals? Given that it's usually practiced by those in positions of power, probably not much. Some would argue, "No big deal. We're strong and can handle it."
    Still, it's worth a try, isn't it? Does anyone need to take such crap? Shouldn't we try to stop bullying in all its forms?

    Many strategies exist, including
    MUSINGS
    Will reporting bullying be effective, even if a report framework exists? It's a challenge, especially if only only one brave soul does the 'blowing'. Whistle blowers are typically discounted, gain a reputation as trouble makers, and lose their jobs as soon as conditions allow it to be done surreptitiously under the cover of a surrogate reason.

    Usually, persistent abuse on the part of one individual to another stops only when many (almost all) subordinates rebel. Systemic abuse by powerful health professionals to another group lower on the pecking order continues relatively unabated despite extensive education.

    Of course, it's individuals who bully. Colleagues who see bullying may offer a sympathetic ear but typically do little to stop it, mainly because they cannot see how to help. 

    Does it matter? Unfortunately, workplace bullying leads to many consequences, including 
    • increased absences
    • decreased productivity
    • mental health issues
    • job dissatisfaction
    • increased job turnover
    On a personal level, it can devastate those experiencing it. Many learn to cope (albeit at a price), but some do not.
    I encourage you to identify the bullying (minor, moderate, severe), whether intra- or inter-disciplinary, that routinely occurs in your transfusion service or blood centre. Then do something

    If prevention and complaint resolution processes on bullying don't exist, develop them. If existing policies are ineffective, improve them. Don't be content with lip service - make the system, especially its leaders, walk the talk.

    CBS has a donor slogan, "Blood, it's in you to give." The last part is the key - It's in you to give. You can make a difference.
    As Margaret Lawrence said,
    Know that although in the eternal scheme of things you are small, you are also unique and irreplaceable, as are all your fellow humans everywhere in the world.
    In the worst cases, there's always hope of retribution, although this successful example is no doubt complicated by race:
    FOR FUN
    What music comes to mind?
    • 'Stand by me" by Ben. E. King ( Support colleagues who experience bullying. It could be you next.)
    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. 

    Addendum (23 Feb. 2012): 
    Further Reading
    Nice series on physician and nursing relationships with the laboratory (full free text on PubMed Central):
    1. Butterly JR, Horowitz RE. Controversies in laboratory medicine: a series from the Institute for Quality in Laboratory Medicine. MedGenMed. 2006; 8(1): 47. 
    Two parts, each with responses:
    • Top 5 issues that irritate physicians about the laboratory  
    • Top 5 issues that irritate the laboratory about physicians
    2. Kurec A, Wyche KL. Institute for Quality in Laboratory Medicine Series - Controversies in laboratory medicine: nursing and the laboratory: relationship issues that affect quality care. MedGenMed. 2006 Aug 30;8(3):52.
    Three parts:
    • 5 nursing concerns as viewed by the laboratory
    • 5 nursing concerns as viewed by [nursing] 
    • Beyond the complaints: working together to improve laboratory testing and services
    Updated 14 Jan. / 17 Jan.  / 24 Jan. 2012 / 23 Feb. 2012