generalist – Lablogatory

The Impact of ASCPi Certification

The world of medicine relies heavily on the skilled and knowledgeable hands of medical laboratory scientists. However, with globalization and a growing healthcare workforce, ensuring internationally trained scientists can seamlessly integrate into new environments is more critical and challenging than ever.

For laboratory scientists in developing countries, obtaining certification can be a life-changing event. Beyond the simple struggles of daily living, these individuals must overcome the obstacles and difficulties that students in the U.S. rarely (if ever) have to face. Yet still, they seek to prove their knowledge and worthiness by seeking international certification.

ASCP is at the forefront of certifying laboratory scientists in developing countries by offering the ASCPi exam. There are few opportunities for students in second and third-world countries to get the quality training and experience to pass the exam. These students come with diverse life experiences and needs but are still passionate about working in the lab.

I discussed the importance of the ASCPi certification with Marion Carrilo, MS, MLS (ASCP), the visionary founder of Trinity Blood Solutions in Trinidad and Tobago in the West Indies, about the reasons why and the need for certification and how the ASCPi is bridging the gap for international laboratory scientists.

Hi Marion, thanks for talking with me today. First, can you describe your typical student?

The typical individuals pursuing MLS ASCPi certification are experienced medical laboratory technologists/technicians. Many of them have worked in the field for at least five years. They love the profession and want more out of it.

In Trinity’s ASCPi Exam Prep, I get some MLTs who have never done an MLT program but want the theory so they can get up to speed with their colleagues who completed an MLT program. These are not typical individuals and they usually have a degree in biological science and are practicing MLTs.

Why do the students choose to take the ASCPi exam?

Reasons for taking the ASCPi exam will vary according to the region and according to the state of affairs for medical laboratory technologists. In many countries, taking and passing the MLS ASCPi is the first step to migrating to the USA as a medical laboratory tech. People migrate due to poor salaries, bad working conditions, and no or limited opportunities to advance in the profession.

In the Caribbean, taking the MLS ASCPi exam after graduating from an MLT program is not routine. Every country has its criteria for being able to practice in a medical laboratory, and in many cases, it is sufficient to graduate from a local MLT program and/or be registered with a local MLT association or board. ASCP is not yet a household name in the Caribbean, so many who pursue taking the exam do it to migrate. Others take the exam for professional advancement.

Migration to the U.S. or another developed country provides them with better opportunities for professional and personal development. In the U.S., the pathway to professional advancement is sure if you work hard. In developing nations, working hard does not guarantee good success.

Professional advancement can be a promotion to a supervisory role or being able to show the credentials of international certification. In some cases, medical laboratory technologists may have been encouraged to get certified by another colleague who is ASCPi certified.

What are the benefits to the lab of having ASCPi techs?

Whether an individual prepares for the exam on their own or enroll in an exam preparation course, they are exposed to systems and procedures not used in their country. This new exposure encourages those techs to be more conscientious in their practice. Having ASCPi techs helps to maintain laboratory accreditation because the new knowledge now gives them an appreciation for working in quality systems. It also encourages the certified tech to share what they learned through preparation with their colleagues.

What do you think the ACSP should or would like them to do to help international students achieve certification?

Recently, a certified individual told me that making the BOC page more intuitive for international candidates will make ASCPi certification info easier to find and understand.

This never occurred to me because I’ve used it for so long. I agree that the BOC page can be intimidating. An example would be displaying the routes in a table form as opposed to the drop-down menus. Have a dedicated page with only the necessary information for the international candidate. So removing newsletter, BOC eligibility Assistant, Categories of certification etc., U.S certification.

Last month, ASCPi BOC created a new Caribbean Advocacy Team. This team will help to provide ASCP BOC with information about how they can best promote certification in the region. As mentioned before, each region has a specific culture concerning the profession, so having Advocacy Teams in various regions is a great gesture.

I really appreciate you providing your experience with our readers. Do you have any final thoughts you would like to share?

It is a great feeling to know ASCP BOC is providing opportunities for techs to advance globally. Some may say they are contributing to the brain drain of a country, and I’m afraid I have to disagree. Instead, they are providing opportunities for advancement as a tech that are not available in the international candidate’s country.

Migration is an expensive process, so not everyone who becomes certified will leave, although they may have planned to do so initially. Even those who leave may return and help their country or provide assistance to their home country from their new home abroad.

Advancement cannot only be seen as moving up a career ladder; it must be seen holistically. A tech working 12 hours 6 days per week and not being paid enough to provide a reasonable level of comfort for their family stymies the work that tech will do and their mindset about the profession. ASCPi provides a way for these techs to move out of such systems and advance holistically in a profession they love.

The ASCP is doing its part to ensure that there are well-trained medical scientists in the world’s laboratories who can provide accurate and timely results for patient care. Passing the ASCPi exam can be, and has been, a life-changing event for scientists working under the most stressful life conditions worldwide. By bridging the knowledge gap and fostering a culture of excellence, the ASCPi is paving the way for a brighter future in laboratory medicine throughout the world, one well-equipped scientist at a time.

–Darryl Elzie is a Quality Consultant for Inova Blood Donor Services. He has been an ASCP Medical Technologist for over 25 years, performing CAP inspections for 15+ years. He has held the roles of laboratory generalist and chemistry senior technologist. He has a Master’s in Healthcare Administration from Ashford University, a Doctorate of Psychology from The University of the Rockies, and is a Certified Quality Auditor (ASQ). Inova Blood Donor Services is the largest hospital-based blood center in the nation. Dr. Elzie is also a Counselor and Life Coach at issueslifecoaching.com.

Happy Medical laboratory Professionals Week! A Trip Down Memory Lane

When I think of Lab Week, I think of all the Lab Week celebrations we’ve had in the past: Food, games, from “Guess whose baby picture?” to word searches and coworker trivia, and of course, more food. I’ve seen the same games over and over, but with new coworkers they’re always fun. Probably the most unique game I’ve seen, was “whose sample is this?” Smushed chocolate candy bars were stuffed into sample cups (and looked like you know what) and we had to guess which ‘sample’ came from which candy bar. Lab week also helps us remember the techs we’ve worked with in the past and the good times we’ve had in the lab and outside. And, of course, Lab week always seems to bring up reminiscing, and the question “Remember when?”

As a nod to lab week, I’d like to take you on a little trip down memory lane. Those of us who have been around for a while can laugh and add our own stories. The new techs in the lab, the younger generation will look at us and say “No way!”” or “You’re joking, right?”

I work in a lab that is very fortunate to have a few wonderful techs in their late 60’s and 70’s who still work for us part time. But anyone who has passed through our lab in the past 60 years remembers Irene, who is over 80, and has been here since 1963. That’s before many of us were born! Now Irene doesn’t work every day, or even every month, but she’s there for our students and newly graduated employees when we can use her talents for a few days. She has boxes full of teaching slides and comes in to review WBCs and RBC morphology with them and shares many stories about ‘the old days’ in the lab. Recently she was talking to a new grad and mentioned the old lab and the rabbits they kept in the lab.

“Rabbits?’ he asked.

“Yes, youngster, let me tell you about it.”

Rabbits were used for the first pregnancy tests. The first HCG tests came out in the early 1970’s, but before then, the question “Did the rabbit die?” was associated with a positive pregnancy test. Young rabbits were injected with urine or blood from a woman, and several days later, the animals were dissected to look for enlarged ovaries, a sign that HCG was present in the injected specimen, and a positive pregnancy test. So, in reality the rabbit (or mouse, or frog) always died, whether the woman was pregnant or not.

I fortunately missed the live animals in the lab era. Now that I’m working with techs who are younger than my kids (and not that much older than my grandkids!), when us ‘old timers’ talk about what the lab used to be like, we get incredulous wide-eyed stares.

“You didn’t wear gloves??”

“They drank coffee in the lab?”

“No computers?”

In my very first job out of college I worked in a hospital lab, and trained in Hematology, Chemistry and Blood Bank. It was the time of the rise in automation, and we had some great ‘new’ analyzers. We had a Coulter S in hematology, the first automated hematology analyzer. The Coulter S offered 7 parameters. In about 1 minute it could analyze and report the WBC, RBC, Hgb, Hct, MCV. MCH and MCHC. Before this we had to prepare samples, lyse RBCs to count WBCs, perform hemoglobin measurement on a spectrophotometer, and calculate the indices! If a physician wanted a differential, we stained slides by hand and counted a 100-cell diff. Platelet count counts fortunately were not ordered on every CBC because those were counted manually!

I remember training in the chemistry department with a lot of instruments which each did only one or 2 tests. Individual tests were done on single test analyzers. Which meant a lot of techs in the lab, and you could be assigned to a bench where you did just Na and K on the flame photometer or just Glucoses and BUNs on single test analyzers all day. We did have a STAT analyzer which did electrolytes, glucose and BUN, and a larger analyzer that did 12 test panels, but they were only used when the full panels were ordered. These multi test analyzers were new and exciting, but in 1980 we were still uncapping and pouring off all our samples by hand. Without gloves!

“What?? No gloves?”

No gloves. We drew blood and worked in the lab with no gloves. Analyzers had glass coils that techs changed with their bare hands, and there were accidents. Techs contracted hepatitis and in the 1980’s the fear of contracting HIV was real. It wasn’t until 1992, when the Occupational Health and Safety Administration (OHSA) published the Bloodborne Pathogens Standard. There was increased awareness of HIV, and OHSA implemented universal precautions to protect workers who may come in contact with bodily fluids. OSHA’s standard required employers to provide personal protective equipment, including disposable gloves.

I once read an article that said that medical technician/technologists were the profession that drinks the most coffee. Now, I don’t know about that because I don’t drink coffee, but what they didn’t mention in the article was that they used to drink it in the lab! Yes, the cup of coffee often sat next to the microscope while doing diffs. And remember, no one wore gloves. I remember a doctor walking through the lab smoking a cigar. And while I don’t remember if I ever saw eating in the lab, I’m pretty sure it happened. These things are so taboo to us now that sometimes we wish we were camels because we often go for hours without a sip of water! We may have been the profession who drinks the most coffee, but today we may be the most dehydrated because the closest ‘clean ‘area to get a drink is way down the hall! And we’re too busy to leave our work and go get a drink!

People often use the term ‘The Good Old Days’ when talking about the past, but in the lab, these times weren’t always ‘good’. Yes, we had good times. But there were also practices that weren’t what we would today consider safe. Besides the lack of gloves, and coffee in the lab, there was also mouth pipetting. Remember spit strings? Techs kept them in their pockets for use in mouth pipetting body fluids (shudder). We washed glassware, even literally rinsing blood out of test tubes and reusing them.

We also love to reminisce about obsolete lab tests. I remember when AST, LDH and CK were used for markers of myocardial infarction. Then we had a new test, the CK-MB, which is now designated antiquated and has been replaced by cardiac troponin I for diagnosing MI. Bleeding times were once widely used as a platelet function test. Today this rather crude test is rarely used and not even offered by many labs. Glass in the lab has been replaced by plastics from vacutainer tubes and blood bags to graduated cylinders and beakers. We no longer count platelets on a hemocytometer because our automated analyzers perform platelet counts. In Urinalysis, we used to do confirmatory tests for glucose, bilirubin and protein in urine. And so many more tests that have been replaced by newer and better testing. What is your favorite or no so favorite ‘obsolete’ lab test?

We’ve certainly come a long way in the last 60 years! Lab Week is a great time to generate new awareness and excitement about the laboratory medicine profession while having some fun with your lab coworkers. Thanks to everyone who is part of the laboratory team for your hard work and dedication. Happy Laboratory professionals Week!

DOWN
1. favorite drink to sip at the microscope while doing diffs
2. standard PPE that wasn’t so standard before 1990
3. standard set of guidelines for prevention of bloodborne pathogens

5. old confirmatory test for urine bilirubin
8. type of pipetting common in the old days
9. you probably won’t use one of these for heating in the lab today
10. historic method for testing for glucose in urine
11. animal kept in lab for pregnancy testing
12. old school test for MI
14. plastic blood collection bags have replaced these

ACROSS
4. used to draw blood before vacutainers
6. carried in your pocket as a pipetting aid
7. used for manual platelet counts
13. obsolete platelet function test
15. dark field microscopy was first test for diagnosis of this STD in 1906

-Becky Socha, MS, MLS(ASCP)^CMBB^CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 40 years and has taught as an adjunct faculty member at Merrimack College, UMass Lowell and Stevenson University for over 20 years. She has worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. She currently works at Mercy Medical Center in Baltimore, Md. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

The 3 Hazards of Hazardous Waste Management

Managing chemical (hazardous) waste in the laboratory is easily one of the most complicated areas of safety to understand. The regulations are set forth by the Environmental Protection Agency (EPA) and enforced by them or representatives of their state branches. For laboratories that are housed in hospitals or other large facilities, hazardous waste is often removed and handled through other departments like environmental services or maintenance. In the eyes of the EPA, the waste generated by the lab is the responsibility of the lab until it gets to its final disposal location. If other departments manage lab waste, the lab should routinely make sure it is being handled appropriately.

One of the most common areas where hazards occur in waste management regards storage. There are two types of chemical waste storage areas that can be designated in a facility, a Satellite Accumulation Area (SAA) and a Central Accumulation Area (CAA). Chemical waste is initially stored in a SAA which must be within the line of vision from where the waste is generated. Labs may store up to 55 gallons of waste in a SAA, and the EPA does not permit moving waste from one SAA to another. If the waste stored at the SAA is flammable, it should be kept inside of a flammable storage cabinet, but that cabinet would also need to be visible from the point of waste generation.

A second common issue surrounding hazardous waste is container labeling. In most US states, it is required that all containers of chemical waste display the words “hazardous waste.” The label must also show a description of the waste (i.e. stain waste, xylene waste, etc.). Finally, there must be some sort of hazard warning on the label. That warning may be in the form of a pictogram, a NFPA or HMIS warning label. If waste is poured into an empty reagent container, no elements from the original product label may be used, even if the waste is the same as the original reagent. Cross out the original label and place a new complete hazardous waste label on the container.

Containers placed in a SAA should not have an accumulation start date on the container. Facilities are allowed to store waste on site for specific periods of time based on the generator status selected as part of the EPA registration process. However, that storage time limit does not start until the waste is moved to the Central Accumulation Area. All waste in the CAA must be labeled with an accumulation start date.

The third hazard that crops up often in laboratories surrounds recordkeeping. Chemical waste vendors will come to the facility and they may remove waste containers from the CAA or any SAA. When they remove waste, they present a waste manifest which must be signed by a facility representative. Whoever signs that initial manifest must have a specific hazardous waste training that is required by the Department of Transportation (DOT). It is easy for a lab to monitor their own staff training, but if a different department signs waste manifests for lab waste, you need to check that those signing have the required training documentation.

Keep initial waste manifests in a file. The facility should receive final waste manifests within 45 days, and those final copies should be matched up with the initial paperwork so the lab can be sure all waste has been delivered to its final destination point. If the manifest records are kept in other areas of the facility, a lab representative should make routine checks to ensure records are kept up to date.

As you can see, it is fairly easy to make an error when managing hazardous waste for your facility. The regulations are complicated, and we only scratched the surface of them in this blog. Perform waste audits regularly, and include all storage areas and departments in the facility that may handle your waste. Reach out to the EPA or a state branch representative and feel free to ask questions. Managing hazardous chemical waste can be tricky, but it can be done so that the lab follows all regulations and laboratory staff can remain safe.

–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Letting Safety Slip

On a recent trip to my parents’ house for Thanksgiving, the second-row seat in my wife’s crossover vehicle broke. My wife and I, along with our two daughters were excited to set out for a long holiday weekend, the first in many years. We took that vehicle with three rows of seating so that when we visited my folks, everyone can fit in one car. While on vacation, we returned from a park, and my father exited the second row, followed by my daughter. The lever was flipped in order to fold the seat forward. When the lever was activated again to fold the seat back into its normal position, I noticed the pop-up indicator on the seat did not retract (the indicator lets you know when the seat is locked into place and safe for passengers). After tinkering with the lever, I discovered that the bottom right side of the seat was not locking completely into the floorboard. I immediately thought about the trip home. Our oldest child gets car sick when she rides in the last row, and our youngest’s car seat occupies the other second row seat. Should I take the risk and let my child ride in the semi-broken seat? After all, three out of the four sides were locked in place, and she would only be in danger if we got into an accident. I just had to make sure we drove extra carefully, and nothing would go wrong. The alternative was dealing with a carsick child- a very unpleasant option.

I share this story because I have seen lab staff having to make similar decisions and potentially compromising their safety. I wonder how many of you reading this blog have one piece of broken equipment in your lab that you continue to use. Maybe it is not all the way broken. Perhaps it is just a centrifuge with a broken latch or lock. It might be a drawer with a missing handle, and the drawer falls off the track when you open it all the way. There are worse scenarios. Right now there is someone working in a lab where the biological safety cabinet sash doesn’t go down all the way, and all the chairs have at least one rip in the leather. I know lab chairs are not cheap, and the company that comes out to fit the BSC costs a pretty penny, but how much do you think do you think it would cost if something catastrophic occurred because these issues were not addressed?

Sometimes we don’t think too much about broken equipment until something bad happens. Why would someone continue to use a broken centrifuge? Would you get on a rollercoaster if it were broken? Would you put your child in a seat that was not fully locked into place? I hope not. I sometimes hear managers say they are looking into fixing the issue, or they are waiting to get a quote, but they are still using the broken equipment. We should never be complacent when it comes to safety. Accidents will happen, fires will occur, and people will get injured while working in the lab. We put safeguards in place to reduce these occurrences, but when we choose to work with broken equipment, we negate all of those efforts. If you notice a piece of broken equipment, you need to take it out of service immediately and let your supervisor or manager know. Managers may not be aware of everything that happens in the department, and they depend upon staff to keep them in the loop when equipment gets damaged. Do not encourage working in an unsafe environment.

We made the executive decision to let our daughter ride in the far back row on the trip home. It was raining and we knew there would be a great deal of traffic. My child’s life was on the line, so of course I chose to do the right and safe thing. Did we have to make a few extra stops? We sure did, about three extra stops were included because she felt nauseated. We were actually about 15 minutes from home before she got sick. I knew it would happen; it was just a matter of time. I didn’t mind this time because it beat the alternative of having something happen to her if we were involved in an accident. In life we have to assume the worst will happen so we can make decisions that protect those we care about. It made the trip a little longer, a little messier, but for safety’s sake we have to be willing to take the long road, work a little harder, and maybe even be inconvenienced at times. Lab life isn’t always easy either, but it is worth the effort to protect those in our department. We should always take on the work to make sure the patients, our coworkers, ourselves, and even our loved ones are always as safe as possible.

-Jason P. Nagy, PhD, MLS(ASCP)^CMis a Lab Safety Coordinator for Sentara Healthcare, a hospital system with laboratories throughout Virginia and North Carolina. He is an experienced Technical Specialist with a background in biotechnology, molecular biology, clinical labs, and most recently, a focus in laboratory safety.

Three Safety Cultures Questions to ask Yourself, Your Staff and Your Leaders

Whether you are a newly graduated scientist or a seasoned individual starting at your fifth lab in your career, you might be surprised by the safety culture at the new facility. You could be so impressed by the safety culture at your new laboratory that you question how no one was seriously hurt at your former one. Or you could walk into the lab on your first day and immediately get a bad feeling in your gut. No matter how you feel on day one, two, or maybe day 32, just know that there are some things you can do to help understand your new perception of the culture. Any great piece of research starts with a question or two. Let’s examine some queries that can help you wrap your head around why some labs win, and others fall short when it comes to their safety culture.

First, let’s start with the why. When the safety culture does not look good, it is easy to assume that the deviant behaviors you witness are simply people taking advantage of the system. But not all bad behaviors are spawned from a desire to do harm. You need to find out what is influencing their unsafe behaviors. Most of the time, subpar safety behavior stems from a lack of understanding the consequences of unsafe actions. For example, some folks may not realize that handling their cell phone with gloved hands in the lab has the potential to transfer pathogens into the breakroom when they place that same phone on the table when they are eating their lunch. When the timing is right, you should have a conversation with the employee about what you saw and inquire if they are aware of the potential safety risks. You never know, you could discover that it was a topic skipped in safety training and you single-handedly just improved the quality of your safety training program!

The next question you should ask yourself is, are laboratory leadership aware of the safety issues present in their lab(s)? In most labs, the managers are often overburdened, spending most of their time chasing a schedule, trying to fill open positions, or putting out fires (figuratively we hope). Therefore, you should not assume that leadership is aware and allow unsafe practices to occur in the lab. Sometimes managers and supervisors are so hyper-focused on one thing, they might not be able to see a safety issue right in front of them. If you see unsafe habits, bring it up to lab leadership and share with them that your intentions are to avoid a potential harmful event from occurring. In some cases, managers are already aware of the situation and are trying to come up with solutions. Your conversation with them and perspectives about the safety concerns might be the missing piece that helps complete the puzzle they are trying to solve. So, you should feel comfortable bringing your concerns and be prepared to come with solutions to any problems you present to them.

Finally, ask yourself if the safety issues you see are isolated to a particular shift or certain individuals. Although it is the responsibility of laboratory leadership to champion the safety culture, it is up to the staff to feed and nurture its existence. When everyone works together, it is reflected positively in the safety culture, the audit results, and the injury and exposure reports. When gaps are present, there will be an increase in the negative indicators until the issues are identified and resolved. Instead of making assumptions about the safety culture of the entire lab, try to see where the gaps exist and then revisit the first question- why? It is a lot easier to coach a single individual that wears earbuds in the lab than the entire night shift crew that refuses to wear a lab coat until 5 minutes before the day shift supervisor appears. If that single person is the root of your safety concerns, don’t let their behavior go unchecked. As with negative attitudes in the department, poor safety habits can spread like wildfire. If a single individual’s behavior is not addressed, then others will soon follow suit. They will see that there are no repercussions to lax safety behaviors or worse, they will think nothing bad can come of cutting safety corners. Laboratory leaders and coworkers that normalize poor safety habits are only making the situation worse and damaging the safety culture of the lab while putting the entire staff at risk.

You should never assume a safety culture persists on its own. A good or bad safety culture is the sum of many different factors, and the reason behind the factors can be vast. So, before you are ready to write off a lab as unsafe, take the time to dig a bit deeper and find out what contributed to making the safety culture what it is today. If the lab has a great safety culture, find out why. The lab you are in today may not be the place at which you retire. Your path might lead to a different workplace that has an even worse safety culture than the one you left behind. By asking questions about what creates a great safety culture, you become equipped with the right tools and knowledge and will then be in a strong position to use what you know to improve the lives of others in your new lab.

As Laboratory Professionals, Are We Immune from Microaggressions?

Microaggression is a term first coined by Dr. Chester Pierce, a Harvard psychiatrist, in 1970, where he described the lived experiences of an African American man navigating in white predominant spaces. It took 37 years for the term microaggression to come into mainstream acceptance when it was re-introduced by Dr. Derald Sue in 2007, where he expanded the definition to include general disrespect, devaluation, and the exclusion of minorities.

I still remember my first frozen on-call as a PGY-1 AP/CP resident; I came to work at 6am to prep the gross lab. I was told to fill the big formalin container for the day ahead, log all the refrigerated patient specimens from overnight surgeries, ink to orient and then cut the specimens so they can be fixed. Then finally when I moved to change the water in the stain line, suddenly the tech walked in and asked, “Are you Muslim?” I paused and froze for a moment, didn’t have any words to answer his question. Then I said, “No!”, and he walked away. This incident set me back the whole day, because I was replaying it in my mind again and again, to see why he had asked this specific question to me. Maybe I should have answered differently. I didn’t know of the term, “microaggression” back in 2009.

Now I am equipped with this term and training my colleagues to respond in real-time to these types of instances, I wonder how empowered I would have been if I knew about microaggressions from med school/residency training. I would have been more confident in my interactions, rather than walking on eggshells.

When teaching bystander intervention, there are multiple mnemonics, so that you can quickly react to the situation rather than lack of response in the moment. The 5D’s from American Psychology Association that calls to action are: Distract, Delegate, Document, Delay and Direct. In JAMA Surgery, Dr. Nafisseh Warner introduced GRIT (Gather, Restate, Inquire, Talk It Out). In a learning environment to shift the power dynamics to the clinical learner, the visual below from Dr. Justin Bullock is helpful in breaking down each segment of bystander response: pre-brief, during and after the microaggression.

Reference: Bullock JL, O’Brien MT, Minhas PK, Fernandez A, Lupton KL, Hauer KE. No One Size Fits All: A Qualitative Study of Clerkship Medical Students’ Perceptions of Ideal Supervisor Responses to Microaggressions. *Acad Med*. 2021;96(11S):S71-S80.

When trainees come into laboratory spaces, it is essential to conduct a pre-briefsession to create a safe-learning environment. During orientation, talk to learners about the possibility of racism and bias. In medicine, the hierarchy is engrained and overemphasized within the system, so learners are hesitant to respond to microaggressions, report bias and racism. Therefore, taking the time to pre-brief will shift the power to learners to say something when being the target of racism and bias.

During microaggression, recognize and analyze it. Is it objectifying? Is it prejudice or negative attitude/stereotype? The usual response to microaggression is no response because you freeze, like I did in my scenario. The effective response is short and direct, most importantly respond in real-time. The degree of response will vary according to the situation and learner’s preference, sometimes the supervisor may bear witness or stop the interaction to create an opportunity for the trainee to exit.

After the microaggression, do not ignore what happened and move on. Supervisors should take the time to privately check-in with the learner and offer support, which is the most preferred approach. Team debriefs might invite an exhausting dialogue and may cause the target to relive the traumatic experience. Also, if there are instances of repeat microaggressions, propose the option for re-assignment.

To create a safe learning environment for our learners it is essential to prioritize psychological safety in our busy clinical services. Taking the time to pre-brief with learners, check-in and offer support to the target will promote a better work culture. Together we can support and empower each other to mitigate microaggressions at our workplaces.

-Deepti Reddi, MD, Assistant Professor of Pathology, Department of Laboratory Medicine and Pathology, UW School of Medicine; UW Medicine’s equity, diversity, and inclusion (EDI) peer trainer at the Office of Healthcare Equity (OHCE) and teaches Racism & Bias for Center for Learning & Innovation in Medical Education (CLIME) in Advanced Clinical Teaching Certificate program. She is also a 2021 ASCP 40 Under Forty Honoree.

Fright Knife

One of my favorite scary movies is the original Fright Night, a campy horror film from the 1980s. In it, the main character, Charlie, discovers he is living next door to a vampire. He realizes there is danger, so the first thing he does is research. He asks his friend “Evil Ed” about vampire knowledge and tries to get as much information as possible. He performs a risk assessment in his home and then puts into place some engineering controls (crosses, wooden stakes, windows nailed shut), some PPE (a garlic necklace), and even work practice controls (do not invite a vampire into your home). Charlie also utilizes help in the form of an out-of-work actor who starred in cheesy vampire flicks. These actions taken by Charlie make sense: he takes the time to learn about the danger, and then he prepares to deal with it safely.

As a lab safety professional, I often wonder why people who work in the laboratory do not follow the same pathway. They are educated in school and in training about the multiple dangers in the department, but many work throughout their lab careers utilizing unsafe practices. For example, it is common for staff in a histology lab to work with or near sharp blades in cryostats and microtomes without using any implements or safety guards. The number of reported cuts that repeatedly occur in these labs is shockingly high, and the number of unreported injuries is likely much higher. What is interesting is that when having conversations with those laboratorians, they are fine with accepting the risk and accepting the injuries or exposures when they occur.

The concept is the same, isn’t it? Vampire teeth can kill you, so you protect yourself. Bloodborne pathogens and sharps can also be deadly, but why isn’t there concern about the use of safe lab practices with blades? There may be a few reasons.

The use of large, sharp blades is, of course, common in histology labs. They are a part of the everyday job. Hands go near them when tissue is cut, when tissue blocks are changed, when moving the blade, and when changing the blade. In some busy cutting labs, a microtome blade can be changed up to twenty times a shift. This ubiquitousness of this item tends to create a sense of complacency about it. Yes, people have been injured, some badly, some amputations have even occurred, but in comparison to the number of tissue blocks cut, those reported injuries may seem like small numbers…unless it happened to you.

Another reason for complacency is that often, when blade injuries occur, the blade has been used with fixed (and essentially harmless) embedded tissue or when they haven’t been used at all. Many cuts are “clean” and minor, so there is no true perception of danger.

A third reason I have often heard about why blades are handled with no safety measures in place is that productivity in the lab is key. There are standards about how many tissue sections should be made during a standard shift, and using implements to move or change the blade would hinder those goals. Read that again- productivity, in the minds of some, is more important than staff safety – and that is an acceptable stance for them.

As a lab safety professional, one of my goals is to change that unsafe mindset. It does not matter in which section of the laboratory work is performed, staff should be made aware of the risks, and they should be taught how to utilize engineering controls, administrative controls, and PPE to avoid the hazards in the department. Then there should be ongoing management of the safety program which includes risk assessments, safety audits, and follow up when injuries or exposures do occur.

Train those who work with blades in the department. Show them how to work with and handle them safely by using magnet-tipped brushes and rubber-tipped forceps to change and move them. Teach them to always engage the blade guards when hands go anywhere near the blade. Talk about serious cuts and amputations that can occur when unsafe practices are utilized. Review work practices regularly to ensure staff remain safe each time they use the equipment associated with the blades. With sharp blades, the danger has already been invited into the lab. Take the next best precautions you need to make sure your blade doesn’t bite and become a “fright knife.”

Critical Update for Hispanic/Latinx Heritage Month and Indigenous Peoples’ Day

What is the data regarding the number of physicians- and pathologists-in-training who self-identify as Native American, Alaska Native, Hispanic/Latinx, or Native Hawaiian/Pacific Islander?

Among all resident physicians in ACGME-accredited and in combined specialty training programs on duty as of December 2022, there were a total of 154,231 individuals. The number of physicians in training in Pathology and its subspecialties totaled 2261 individuals. Looking at the demographic data as self-identified, the following data are striking:

Reference: Data was derived from Table 8 from Brotherton SE, Etzel SI, Graduate Medical Education, 2022-2023, Appendix to *JAMA* 2023: 330(10):988-1011.

Clearly there is an enormous gap in training of people from Indigenous and Hispanic/LatinX background in both medical training generally and in pathology specifically. The COVID19 pandemic disproportionately affected people from groups who are considered Under-Represented in Medicine (URIM), which include these groups, as well as individuals who self-identify as African American/Black, and who are also significantly under-represented in pathology and laboratory medicine.

What about the numbers for the laboratory professions?

With respect to laboratory professionals in practice and in training, I searched unsuccessfully for rigorous data to compare to the data available for physicians in training; however, even from the numbers available, under-representation is a challenge in the laboratory professions.

Please also note that Asian heritage comprises over 50 different language and ethnic groups. Within the United States, some of these groups are disproportionately affected by poverty and adverse social determinants of health. Therefore, for strategies to improve representation, future analyses should avoid simply lumping individuals into large buckets of self-identified demographic categories.

To address the adverse health impacts of the social determinants of health for patients from ALL demographic backgrounds, it will be essential to recruit actively from groups who have been both URIM and also from communities grappling with the impact of low income; lack of access to health insurance; lack of access to clean water; lack of access to sanitation services; lack of access to high, quality fresh food; residence in historically redlined neighborhoods that have been zoned for hazardous industries; lack of access to air-conditioning and shade from trees; and over-representation in hazardous work conditions.

Even without addressing these subtleties within ethnic/demographic groups, the data presented in the table convey the obvious fact that we have work to do to increase the numbers of trainees in Pathology (and, by extension, in the laboratory professions) from populations who have been historically under-represented in our training programs and workplaces. ASCP has a great opportunity for focused efforts by our Career Ambassadors, our Pathology Ambassadors, and all members to increase awareness of career opportunities in laboratory medicine and pathology. Recruitment is an important piece. Equally important is building and sustaining climates in our training programs and workplaces where people feel welcomed, recognized, invited to participate in transforming our practices to serve our patients better and considered for opportunities to advance and to be considered for leadership positions. Being hired is not enough. We all need to participate in continuous quality improvement, which means continuous engagement and active participation in decisions that will transform the ways we provide care so that we meet the needs of all our patients, now and in the future.

-Melissa P. Upton, MD. Past-President of ASCP and Chair of the ASCP Diversity, Equity, and Inclusion Committee; Emeritus Professor of Pathology, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA.

It’s Getting Hot in Here

Each laboratory is required to create and maintain a fire prevention plan. What exactly does this plan entail? A fire prevention plan should include, at minimum, the identification of potential fire hazards in your lab, your available firefighting tools, and an action plan that outlines employees’ responsibilities during a fire or evacuation.

First, it is best to determine what fire risks are present in your labs. The best way to begin would be to inventory any flammable chemicals used and stored on-site. Some flammable materials such as alcohol can accumulate quickly, and it is necessary to know how much is stored in the department and where. The Occupational Safety and Health Administration (OSHA) mandates that quantities of flammable liquids greater than 25 gallons in a single room must be stored inside of a flammable storage cabinet (1926.152(b)(2)). The National Fire Protection Agency (specifically standards NFPA 45 and 30) takes it a bit further and focuses on limits based on total square footage in the lab. The NFPA limits the amount of flammable liquid stored outside a flammable storage cabinet to no more than 1 gallon per 100 ft², or 2 gallons per 100 ft² if you use fire safety cans. This storage limit doubles if an automatic fire suppression system is in place. The limitation of flammable materials in a concentrated area enables a fire suppression system to more easily extinguish a fire if one were to occur.

Next, look at the amount of combustible items stored around the lab. Are there several boxes of paper stacked next to photocopiers? Large amounts of combustible material in a single area can help fuel a potential fire. Are items stored too close to the ceiling? Check to see that there is at least 24 inches of clearance from the ceiling so that sprinklers are not blocked. Finally, inspect your electrical equipment. Look for daisy chains or permanently placed extension cords in the lab. As part of routine physical environmental rounding, it is best to search for these prohibited situations while also seeking out frayed cords and damaged electrical equipment.

Another component of the labs’ fire prevention is having the correct tools in place to combat a fire should one occur. The local fire authority will determine how many fire extinguishers are required in the laboratory and where they should be placed. To ensure adequate operation of this firefighting equipment, extinguishers should undergo routine checks which include annual maintenance. OSHA also requires a monthly visual inspection of all portable extinguishers (OSHA-1910.157(e)(2)). Verify that staff know the locations of their nearest fire extinguishers and that they can operate the specific types provided. Is there an automated sprinkler system in the facility? Staff should be aware of the location of fire pull alarms and have education about the alarm process (including calling any emergency numbers).

Lastly, the fire prevention plan should detail information about staff response to a fire, including fire drill and evacuation training. The safest way to evacuate is to have a predetermined evacuation route and muster (meeting) location. Staff should physically walk their full evacuation route annually all the way to their muster location and back. If this route becomes impassable, there should be an alternative evacuation route. During drills, walk one route to the muster location, then walk back via the alternate route. It is also wise to outline the expectations of staff members once they reach that muster location during the drill. If a large group evacuates at the same time, using a checklist or a buddy system can help staff keep track of who is present and who is not. Encourage your staff to stay at the muster location and not to wander off. If a supervisor is taking a roll call at the muster location, a staff member might be counted as missing if they leave to chat with a buddy in a different area. The last thing anyone wants is for a rescue worker to run into a burning building to search for a person who is not even at work that day. As the laboratory grows, so should the fire prevention plan. The addition of new equipment or a change in the current procedure warrants a review of the plan. It is recommended that fire safety policies and procedures are reviewed annually, and when changes are made, communicate that information to staff quickly. Ensuring that equipment is in place, that items are stored properly, and that staff are made ready to respond can lead to much better outcomes should a real fire occur in the laboratory.

Guess Who’s coming to the Lab?

When we enter the laboratory, we know of the dangers that can be encountered. Our training tells us there could be microbes and other potential pathogens in the samples we are about to analyze. We also learned how to protect ourselves; how our behavior while in the lab has consequences. We even know how to dress properly and what engineering controls we have at our disposal to keep us safe. We put on our personal protective equipment (PPE) before we start to work and remove it before leaving the lab. For some, these behaviors are automatic, actions that are done almost without even thinking. But is this the same for all who enter the lab? Do visitors who comes into the department know what they are really walking into or how to keep themselves safe in an environment that may be foreign to them? One common question asked by lab staff regarding visitors is “do they have to adhere to the lab safety policies and if so, why?”.

On a recent safety audit, I visited a lab that happened to be getting a new chemistry analyzer installed. I noticed the vendor team, which consisted of 5 individuals, were not wearing any PPE. There were backpacks, open water bottles, and cell phones sitting on the counters and floors. The new instrument was not hidden in a back corner of the lab far away from the daily work. It was close to the area where the lab process, spins, and runs patient samples. Members of the vendor team were lying on the floor and crawling around. How does that scene make you feel?

Vendors and service representatives are regular visitors in your lab. A laboratory can have a representative on site a dozen times before you even begin to use that piece of equipment. Once it is installed, you can bet you will see them multiple times for preventative maintenance and service calls. How does your lab welcome these guests? Do you let them in and have them get right to work? If they are there to repair an analyzer you are likely eager to have them get started, but do you ask them to wear a lab coat? Did they bring one of their own that was kept in their backpack? If so, do you think that coat is clean or was it used in a different lab, packed up, and brought to your lab? Vendor compliance is a safety issue for many labs because these visitors are not lab employees, yet they are in your department and may be putting themselves and your team at risk. Often vendors are seen with drinks in labs, using cell phones or touching instruments without gloves – behaviors lab folk are told not to follow. So why is it tolerated? It shouldn’t be, and you have the right to speak up and ask them to adhere to your lab policies.

What about other potential laboratory visitors? Do pathologists come in to look at a patient slide in Hematology? Do they just sit down at your bench and look at the slide without gloves or a lab coat? Is lab staff allowed to scan a smear without PPE? Probably not, and no one else should be allowed too either. The microscope has most likely been touched with dirty gloves, and no one else should touch the same scope without gloves. Even lab doorknobs are a consideration. Staff should wash hands before leaving the department. That means no one should use contaminated gloves to open the door.

Speaking up about these safety issues to lab visitors can feel uncomfortable. A conversation with a physician about safe practices in the lab can be daunting, but the cost of not speaking up can be high. Take the opportunity to show you care about visitors and want to keep them protected. Sometimes you know who is coming to the lab, and you feel confident they have been trained and will use the best safety practices. At other times, though, those guests may be unexpected and lacking in safety knowledge. Make sure to treat them with respect, give them the safety training and tools they need so they can leave both happy and healthy.