Hematopathology Case Study: An 83 Year Old Man with an Elevated PTT

Case History

An 83 year old man with rapidly growing squamous cell carcinoma of the left temple and scalp underwent workup prior to surgery which showed an elevated PTT and a slightly elevated PT. The patient denied a history of abnormal coagulation tests or excessive bleeding or bruising. He also noted that he had previous surgeries including dental procedures without excessive bleeding. In addition, he did not have a history of clot formation.

Lab Values

Differential Diagnosis

At this point, the differential diagnosis for a prolonged PTT included the presence of an inhibitor (specific factor inhibiter vs. non-specific lupus anticoagulant) vs. reduced levels/activity of intrinsic pathway factors that would prolong the PTT, but would not significantly affect clot formation. This would include factors XI and XII. 

Additional Testing

An inhibitor screen/mixing study was performed and was positive. An inhibitor screen is performed by mixing the patient’s plasma with pooled normal plasma and running a PT or PTT.  If the PT/PTT corrects than the screen is negative. This means that a factor or factors were deficient in the patient’s plasma and were replaced with the pooled normal plasma resulting in a correction of the PT/PTT. In this case, a PTT at time 0 of 68 seconds and a PTT at 2 hours of 66 seconds was a failure to correct and indicated that an inhibitor was present, thus a positive result was entered.

The dilute Russell’s viper venom time (dRVVT) was used to test for a lupus anticoagulant. The screening test is performed by adding Russell viper venom, which directly activates coagulation factor X in the presence of calcium and a phospholipid poor reagent to the patient’s plasma and calculating time to clot. The confirmation test is the same assay with added excess phospholipid. In the presence of phospholipid dependent antibodies, the time to clot will be shorter for the confirmation test. The screen and confirmation ratios are normalized ratios (NR) of the patient sample result in seconds divided by the mean of the normal range in seconds. If the screen is <1.20, the confirmation test will not be run. If the screen is greater than 1.20 as seen here, the confirmation test will be run. The end result is reported as a normalized ratio of the screening test over the confirmation test. If the NR is greater than 1.20, than a lupus anticoagulant is reported as present.

Specific factor assays are performed by mixing the patient’s plasma with substrate plasma that is severely deficient in the factor being measured. Factor deficient plasma would be expected to give a prolonged clotting time. When patient plasma is mixed with factor deficient plasma, the clotting time will shorten and the degree of correction is proportional to the factor level in the patient’s plasma. The clotting times for the patient sample are compared to a reference curve. The reference curve is made with dilutions of normal plasma (containing 100% factor) added to factor deficient substrate plasma. All tests are run with 3 dilutions at 25%, 50% and 100% and curves are checked for parallelism errors, which might indicate the presence of an inhibitor. For this patient, factor XI was initially resulted as 1%, which would indicate a factor deficiency.

This is an example of a factor assay that shows parallelism. The reference plasma calibration curve and the patient plasma are parallel lines. 1

Analysis

From the results, it initially appeared that there was both a lupus anticoagulant and a factor XI deficiency. However, it would be odd for a patient with no reported coagulation abnormalities to suddenly have both a lupus anticoagulant and a factor XI deficiency. The raw data from the factor XI assay was obtained.

Upon review, the factor XI assay did show parallelism errors. Parallelism is tested by performing serial dilutions of a standard with known normal concentrations of factor and recording the time to clot. This line is shown with the red arrow. In contrast, the patient sample appears to be a flat line that is not parallel to the calibration curve. Parallelism errors were flagged because from the 50% to 25% dilution, the corrected results more than doubled. If there is a >20% change between dilutions, this indicates possible interference and additional dilutions should be run to dilute out the inhibitor. The 25% dilution had a corrected result of 2.9, which was greater than a 20% increase from the 50% dilution result of 1.3. Once more dilutions were performed; the Factor XI level was ultimately close to 100%.

Additional factors were checked to see if they also increased with dilutions. This would add support to the theory of a non-specific inhibitor (lupus anticoagulant) that was affecting all of the factor levels, rather than a specific factor XI inhibitor or a concurrent factor XI deficiency. The curve from factor IX (below) showed a similar phenomenon. As the sample underwent additional dilutions, the corrected result increased significantly (from 12.8 at 50% to 26.8 at 25%). Ultimately, the factor level was close to 82%.

The curve from factor VIII also showed low results to begin with and ultimately normal levels with additional dilutions. Altogether, this supported the presence of a strong lupus anticoagulant that was non-specifically interfering with all of the factor levels and prolonging the PTT.

Discussion

A prolonged PTT can be caused by many factors. In a patient without a bleeding history, lupus anticoagulant and certain factor deficiencies are high on the differential. The most common specific factor inhibitors are to FVIII and FIX. These generally arise in hemophilia patients treated with factor concentrates. It is very rare for a patient to develop an inhibitor to factor XI or XII.

Factor XI acts in the intrinsic pathway of the clotting cascade and is important for hemostasis. Deficiency of factor XI is rare and mainly occurs in Ashkenazi Jews. Generally, it does not cause spontaneous bleeding; however excessive blood loss can occur during surgical procedures.

Lupus anticoagulants are directed against proteins that complex with phospholipids. Although they prolong the PTT, they are associated with an increase in thrombosis rather than bleeding. In addition to interfering with the PTT assay, lupus anticoagulants may interfere with individual factor assays and result in non-parallelism (patient curve is not parallel to calibration curve) as seen in this patient. With increasing dilutions, the lupus activity will be disproportionately neutralized and the coagulation factor activity will increase in a non-parallel manner. 1

In a letter to the editor by Ruinemans-Koerts et al., they performed a set of experiments to investigate whether lupus anticoagulants vs. individual FVIII and FIX inhibitors can cause non-parallelism in the one-stage factor assay.  Non-parallelism was only detected using lupus sensitive reagents in plasma with high titers of lupus anticoagulants. The FVIII and FIX inhibitor containing samples both resulted in curves that were parallel to reference sample.

This curve shows that the factor IX inhibitor line is parallel to the reference plasma, while the lupus anticoagulant line is not. 1

Ultimately, this demonstrates the importance of running dilutions and being aware of parallelism errors when performing factor assays. This is especially important in patients with known or suspected lupus anticoagulants. In this case, the unlikely presence of a FXI deficiency with no previously reported coagulation testing abnormalities or bleeding history raised the suspicion of an inhibitor interfering with the factor assay. With a concurrent positive inhibitor screen and lupus anticoagulant test, as well as interference demonstrated with multiple factor assays, the best unified conclusion was a strong lupus anticoagulant. 1

References

  1. Ruinesman-Koerts, J., Peterse-Stienissen, I, and Verbruggen, B. ”Non-parallelism in the one-stage coagulation factor assay is a phenomenon of lupus anticoagulants and not of individual factor inhibitors. “ Letter. Thrombosis and Hemostasis, 2010, p.104.5.

Chelsea Marcus, MD is a Hematopathology Fellow at Beth Israel Deaconess Medical Center in Boston, MA. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.

Proficiency Testing (PT)Part 1: Are You Doing it Right?

Every laboratory knows that they must participate in proficiency testing (PT) for all of the regulated analytes they report. But did you know that there is more to it than simply checking your overall score in each survey you participate in? Whether you utilize samples from the CAP, API, or have developed your own in-house blind sample testing algorithm, there is a lot of data available to help you assess the quality of your laboratory program. In the first of this 3-part series, we’ll review why PT testing is important and the rules that must be followed. In part 2 we’ll discuss how to properly perform an investigation when scores are <100%. Lastly, in part 3 we’ll look at how to review your results so that you get the most out of them for a successful quality laboratory.

Why participate? Well frankly, because you have to. It is a CLIA/CMS requirement, and if your lab has additional accreditations, those agencies will have their own rules and requirements as well (we’ll get to the rules in a little bit). But outside of the regulations stating you must participate; all labs should want to participate. It’s an opportunity to check your accuracy against peers who are using the same instrumentation as you. Similar to utilizing an affiliated QC report, this is a way to see what the “real” value is supposed to be (despite what a manufacturer may claim it to be), and how close/far off your lab is to that true value. It can help you identify potential problems before they become huge problems with patient values being affected, and it’s also a great way to satisfy competency requirements for your staff.

The rules:

  • Participation: For every regulated analyte being tested under your laboratory permit1, you must participate in a CMS-approved PT program2.

Key things to note: This only applies to testing performed using non-waived methodologies. Waived testing is exempt from PT requirements; although it is still recommended that participation occur if an evaluation program is available. Additionally, this only applies to your primary instrumentation. For example, if you have an automated urinalysis reader and your backup methodology is to read dipsticks manually, you are only required to participate in PT for the primary methodology. (Your backup method would then be evaluated for accuracy through semi-annual correlation studies.)

  • Routine Analysis: Unless otherwise instructed by the provider of your PT samples, PT samples are to be treated the same as patient samples. Meaning they are handled, prepared, processed, examined, tested and reported the same way you would perform patient testing; AND by the same staff who would handle patient testing.

Key things to note: If nursing staff perform a particular test within their unit (for example, ACT testing in the cardiac cath lab), it is those nursing staff members who must run the PT samples. You cannot have the laboratory perform PT testing unless the laboratory also performs the patient testing. Additionally, PT samples should be rotated among all staff members who perform patient testing. Meaning all shifts, and all days of the week that the test is performed – don’t let the day shift get all the fun.

  • Repeated Analysis: Similar to rule #2, unless you routinely perform duplicate testing on your patient samples, you cannot perform duplicate or repeat testing on your PT samples. You cannot run a PT sample in duplicate “just to make sure.” Patient samples are just as important to be accurate as a PT sample, which is why we participate in a PT program in the first place.

Key things to note: After the date that laboratories are required to report results back to the PT provider, you are then allowed to use the samples for repeat testing. This can be used to check for uniformity in grading of reactions among staff members, and to assess annual competency. But only after the submission date has passed.

  • Interlaboratory Communication: You cannot discuss the results or samples from a PT survey with any other laboratory (or Facebook user group) until after the results submission deadline has passed. Doing so before that time would be considered cheating. The point of PT testing is not to see how good your networking skills are, but to ensure accuracy of your own results. Plus, the other lab may not be as good as you think they are.

Key things to note: If your laboratory is part of a larger integrated health system, be careful that you have separate designated staff assigned to enter results from each location. Entering results for more than one permit number by the same person would be considered a violation of the interlaboratory communication rule as they could compare results from Lab A to Lab B prior to submitting. Also, be mindful of what you put on social media. User groups are a great networking resource and learning tool, but you still need to follow the rules. Violating them in a public arena such as Facebook for all the world to see would put yourself and your organization in great jeopardy if you were caught. 

  • Referral of Samples: You are not permitted to forward or share your PT samples with any other laboratory until after the result submission deadline has passed. Similarly, if your laboratory has received PT samples from another lab, state regulations may require you to notify your local Department of Health to inform them of the violation.

Key things to note: The intended purpose of performing PT testing is to verify the accuracy of your own laboratory testing. If you would routinely send a positive sample to a reference lab for additional confirmation testing, you would not do so in this case. Simply report out the values for the tests that your laboratory performs only. The reference laboratory will have their own PT samples to check accuracy for the confirmation testing they perform for you. Ensure your testing menu is up to date and accurate so that your PT provider is not expecting values for a confirmatory test if you do not physically perform it in-house.

  • Records Retention: Ensure that all records and documents related to the testing of PT samples are saved for the amount of time required by your regulatory agencies (typically 2-5 years). This includes instrument print outs, LIS chart copies of the filed results, QC records for the day of testing, and any associated worksheets used to document your results.

Key things to note: Retaining a copy of the instrument maintenance logs and QC records along with the actual PT results will help you investigate any scores that are less than 100%.

  • Attestation: Both the laboratory director and all personnel performing testing must sign the included attestation statement. This is not just a way to track who performed the test, but is a legal binding document assuring that testing was carried out appropriately as per the rules defined above.

The penalties for labs that are caught violating the rules (whether intentionally or not) can be quite severe. These penalties can include the revocation of your CLIA permit; a ban for the laboratory owner and laboratory director; as well as possible financial penalties and fines.

Coming up in the next blog we’ll review the rest of the rules related to evaluation of your scored PT results, and how to perform a thorough investigation into any unsuccessful survey events.

1: https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/cliabrochure8.pdf

2: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/ptlist.pdf

-Kyle Nevins, MS, MLS(ASCP)CM is one of ASCP’s 2018 Top 5 in the 40 Under Forty recognition program. She has worked in the medical laboratory profession for over 18 years. In her current position, she transitions between performing laboratory audits across the entire Northwell Health System on Long Island, NY, consulting for at-risk laboratories outside of Northwell Health, bringing laboratories up to regulatory standards, and acting as supervisor and mentor in labs with management gaps.

Blood Bank Case Study: A 54 Year Old Woman with Lethargy

The patient is a 54 year old woman, presenting to the Emergency Room with complaints of abdominal cramps and feeling lethargic for the past few days. She also reports her stools have been black and sticky.  Her chart reveals a history of ulcers and GI bleeding.  She was transfused with 2 units packed RBCs 2 months ago for the same symptoms. CBC results are shown below.

The patient was admitted to the hospital and four units of blood were ordered. The patient is type A pos with a negative antibody screen. One unit of packed red blood cells would be expected to raise the Hgb by 1g/dl. Because the patient was actively bleeding, 4 units were crossmatched and transfused.

Two days later, the patient was discharged, with orders to follow up with her GI doctor for further testing and treatment. Three days after discharge she still felt weak and returned to the ER. On examination, it was noted that the patient’s eyes and skin appeared jaundiced. The patient had a fever of 100F. Repeat lab results are shown below.

The Physician ordered a type and crossmatch for 2 units of packed red blood cells. The patient’s antibody screen was now positive. A transfusion reaction workup was initiated

Transfusion workup

Clerical Check- No clerical errors found.

Segments from all 4 transfused units were phenotyped for Jka antigen. Three of the four units transfused typed as Jka positive.

A transfusion reaction is defined as any transfusion-related adverse event that occurs during or after transfusion of whole blood, or blood components. Transfusion reactions can be classified by time interval between the transfusion and reaction, as immune or non-immune, by presentation with fever or without fever, or as infectious or non-infectious.

A delayed transfusion reaction is defined as one whose signs or symptoms typically present days to several weeks after a transfusion. In Transfusion Medicine, we do not want to give the patient an antigen that is not present on their red blood cells. However, we do not routinely phenotype patients, so, in the patient with a negative antibody screen and history, it is always possible that the patient receives units with foreign antigens. The more immunogenic the antigen, and the greater number units received that expose the patient to this antigen, the greater likelihood that the patient will develop an antibody to the foreign antigen. Therefore, this type of reaction would also be categorized as immune.

In a delayed hemolytic transfusion reaction (DHTR) investigation, the units transfused would have appeared compatible at initial testing. This type of adverse event is fairly common in patients who have been immunized to a foreign antigen from previous transfusion or pregnancy. The antibody formed may fall to a very low level and therefore not be detected during pretransfusion screening. If the patient is subsequently transfused with another red cell unit that expresses the same antigen, an anamnestic response may occur.  The antibody level rises quickly and leads to the DHTR. In the transfusion reaction workup, this antibody can often be detected when testing is repeated. However, in some cases, particularly with Kidd antibodies, the levels again drop off so quickly they may not be detected!  The diagnosis of DHTR is often difficult because antibodies against the transfused RBCs are often undetectable and symptoms are inconclusive.

This case is a classical example of a DHTR.  Kidd antigens are notorious for causing DHT because their levels can drop off quickly and disappear, making them difficult to detect in screening. In this case, the transfusion two months earlier exposed the patient to the Jka antigen and the patient produced the corresponding antibody. The levels then dropped quickly, as elusive Kidds are known to do! When the patient returned to the ER in crisis, the antibody levels had dropped below detectable levels and the antibody screen was negative. The patient was given 4 units and returned to the ER five days after transfusion. This patient did exhibit mild jaundice and a low-grade fever. However, often, the only symptom of a DHTR is the unexpected drop in Hgb and Hct, making them even more difficult to diagnose.

The new antibody screen, sent to the Blood Bank on day 5, detected anti-Jka. The DAT was positive mixed field due to the transfused cells. Elution was performed and anti-Jka was recovered in the eluate. In the DHTR, only the transfused cells are destroyed. Phenotyping segments from the transfused units can estimate amount of transfused RBCs that may have shortened survival. Management of this case patient would be to provide antigen negative units for all future transfusions.

Kidd  (Anti-Jka and Anti-Jkb), Rh, Fy, and K have all been associated with DHTR and occur in patients previously immunized to foreign antigens through pregnancy and transfusion. These types of reactions are generally self-limiting but can be life threatening, especially in multiply transfused patients, such as those with sickle cell anemia. Antigen negative blood must always be given, even if the current sample is not demonstrating the antibody in question. For that reason, it is vitally important to always do a thorough Blood Bank history check on all samples!

-Becky Socha, MS, MLS(ASCP)CM BB 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 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

The Educational Audit

The Lab Safety Officer (LSO) had years of experience, and he was proud about how far he had advanced the lab safety culture. He had focused on fire safety for a long time because when he started, very few staff members knew how to respond to fire drills or alarms. He studied fire regulations and educated staff about them. He performed safety audits, looked for and corrected potential fire safety issues, and overall felt fairly certain that he had learned all there was to know about fire safety.

When the hospital accreditation inspector walked through the laboratory, the safety officer accompanied her. The inspector opened a freezer containing patient specimens in one of the specialty labs. The safety officer had opened that freezer many times during audits, but this time the inspector asked a staff member if anything other than serum was stored in the specimen tubes. The staff member stated that there was methanol and other reagents added to the tubes. The inspector turned to the lab safety officer and stated she would need to cite the lab for inappropriate storage of flammable materials. According to NFPA-45, a national fire code for labs using flammable materials, these specimens need to be stored in a freezer that is designated as explosion-proof. In all his years, the LSO had never seen that regulation. Upon further investigation, he also learned that every laboratory refrigerator needs to be labeled as to whether or not it is capable of storing flammable materials.  

Later during the accreditation walk-through, the inspector noticed that the flammable cabinets in the laboratory did not have self-closing doors. The LSO asked if that was a requirement, and if so, where was it stated. The inspector said that self-closing doors was a requirement of the International Fire Code (IFC), and it was required if the state adopted the code. Again, upon further study, the LSO learned that 48 U.S. states had adopted IFC, and he now needed to consider replacing his flammable storage cabinets with self-closing units.

When the auditor reviewed the lab’s Exposure Control Plan, she asked how education about Bloodborne Pathogens was given to the staff. The LSO was happy to show the inspector staff education records which showed that every employee viewed a mandatory computer-based training program which covered all aspects of bio-hazard education. When the inspector asked how employees could inter-actively ask questions about bloodborne pathogens as required by the standard, the LSO could not answer. When he researched the OSHA standard, he found the requirement, and he told the inspector he would work with the hospital to figure out how to make the changes to their annual education.

As you might imagine, the safety officer wasn’t feeling quite as proud of his lab safety program after this inspection. In fact, he felt more than a little surprised that after so many years in the field that there was so much he still had to learn about lab safety regulations. He was disheartened, but he was able to turn that feeling around into a resolve to make the necessary corrections, to learn more about the regulations, and to continue to make improvements to the lab safety program.

One of the benefits of having an outside auditor come through your lab is having that new set of eyes in an area that you may see every day. Maybe the inspector has a very different background- perhaps they were a fire inspector previously – and they can enlighten you about specific regulations you hadn’t considered before. Be sure to look at audits as an educational opportunity, even if (or especially if) you receive several citations you were not expecting. The world of safety is always changing, and there will be changing regulations and other regulatory agencies you just didn’t know about. Take that as an opportunity to learn, to grow, and to always be working to improve your lab’s safety culture.

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.

Tired Traveler Travel Tips

When I was considering the Chief Medical Officer role at ASCP, there was significant travel on the table. Prior to ASCP, I was already a seasoned traveler, having been to every continent except Antarctica. I had a few travel tricks up my sleeve. However, the nearly 2 weeks per month that I find myself out of the ASCP offices have evolved my travel skills from seasoned to ninja. For your enjoyment, here are some of my best tips.

Join and explore a loyalty program. We all have frequent flyer miles with one or more airlines; however, consistent use of a single airline or group of airlines (Star Alliance, Sky Team, etc) will rapidly add up and provides perks and benefits you may have to research a bit. Most importantly, don’t get discouraged by one bad flight and switch! They are called loyalty programs for a reason. In addition to upgrades, lounge access, early boarding, and free premium snacks, perks like premium economy for the same price as economy make a huge difference as planes seats get tighter.

Book economy, fly business. Economy non-refundable tickets are the least expensive typically, especially when booked on a Tuesday. If you’re booking a common business commuter flight (Chicago to NYC, Boston to DC), make sure you’re staying over a Saturday and watch prices to book effectively over time. Typically, business customers book last minute (paying highest prices) so prices are lower when booked very early; however, commuter flights are often packed with business travelers so booking early may not always be cheapest. When you get to the airport, ask if upgrades to business are available when you check in but be patient! Booking the upgrade at the gate desk is often significantly cheaper. Set a limit for yourself. “I won’t upgrade unless the cost is less than $XXX.” This will keep your personal budgeting in check and not let your exhaustion or irritation with your last economy leg lead to something rash. 

Plan ahead. If you’re planning a vacation, especially a long flight (not a typical business flight), research prices way ahead of time and watch them for some time. There are websites into which you can load your favorite flights and received pricing alerts. Even if you’re a business traveler (for example, attending conferences), you’ll likely know the dates early and be able to do the same. The earliest flights of the day are often the cheapest but remember the opportunity cost to you of having to get up extra early (especially if hauling little ones!).

Carry on. Don’t check a bag. There are exceptions but, for the most part, don’t check a bag. Consider the laundry services at your hotel or access to laundry machines. When you are packing, lay everything out and ask yourself, “Am I going to die if this is not with me?” If the answer is “no,” move to the “maybe” pile. If you’re bringing gifts, carry them in a reusable sack as your personal item. Speaking of reusable sacks, organizing your back pack with a few of these means you can pull out “computer” or “clothes” or “other” quickly and replace them easily (it’s like file folders). If you are going on a big trip and just can’t do without a checked bag, try to fly direct and/or make sure you have a full one hour (domestic) or two hour (international) layover between flights— both will increase the likelihood of your luggage arriving. If you are a business traveler, INVEST in a very good carryon bag. Because carryon luggage at the low end of the scale is assumed to never be checked, one bad flight can destroy it. 

Toiletries. I know you have a strict beauty regiment with 12 products you can’t live without but consider lightening your load when possible. All hotels provide basic toiletries and there are stores everywhere (clearly, if you’re vacationing or working very remotely, there may be limitations, but remember context and consider the essentials). Most large format toiletries have to be checked and that’s adding challenges you don’t need. Some of my pro-travel colleagues who MUST have their complete hygiene system check bags but always use the suggestions I mention above about checked bag security. A clever, lovely friend of mine once said (when I asked why she was wearing only mascara in the middle of Africa), “If I just have this one thing I do every morning, I feel normal.” Sound advice.

Security. There is general anxiety about going through security but there doesn’t have to be. First, it’s for your safety and, unless you are a criminal or a terrorist, the security people are there for your protection and they are quite nice. Second, if you get TSA pre-check, know the drill. Nothing infuriates fellow travelers like a confused passenger in the TSA pre-check line disrobing and regurgitating the contents of their bag into a bin. If you’re not TSA pre-check, be ready to remove coats, shoes, laptop, belt, all pocket contents, and sunglasses. You can do all of that during your 10 + minute waiting in line. You should not do it when you get to the table—that’s why the line is so long. Third, when you travel internationally, the rules are always different but the security agents are still just human beings doing their job. Politeness and paying attention will make all the difference. Fourth, some of us are more likely to experience friction with security because of the way we look, our clothes, or even our perceived attitude. It’s not right, it’s not fair, and it’s annoying… but we know this and can prepare for it. Displaying courtesy and politeness at all points in the airport will get you through security quickly. If you happen to have a difficult experience, I encourage you to send a strongly worded, formal letter later (you can write it on your smartphone on the plane… just don’t send it until you are back home). There is no point in ruining your trip over someone else’s potential unfounded fear or ignorance. Lastly, I understand the world is liberated (being liberated) and we all think we have the freedom to do as we wish l; however, showing up to a security check point drunk or stoned or reeking of pot will get you heavily screened and searched. The rest of us enjoy the show but not the delays.

Boarding. The bin above your seat is not assigned to you. The space under the seat in front of you is. The bin above your seat is determined to be full by the crew, not by you. Other peoples’ bags are going to touch yours. The crew can and will place your bag correctly in the overhead bin. When you find your seat, quickly store your bags and sit quietly with your seatbelt unfastened and your hands in your lap. Don’t pull out your laptop. Don’t have 5 things in your hands and in the seat pocket. Your personal item under the seat in front of you should contain anything you’ll need during the flight. Organize yourself at home before you depart—not while the rest of the plane is trying to board. People will like you. The crew will like you. 

Seat selection. If you know you get up frequently to use the restroom normally, book an aisle seat. If you pass out on airplanes at takeoff and wake up at landing, book a window seat. If you are in a middle seat (someone has to be), it’s frustrating but it does not entitle you to more space than the people on either side of you. Booking early and checking in early is the best way to score a window or an aisle. We are all trapped on the same plane and courtesy wins the day. If you are rude or discourteous, the crew will notice and you will have a miserable flight.

Jet lag. It happens. It’s terrible. It can take you out for a day or more of your trip. There are apps and websites that explain how to avoid, reduce, or beat jet lag. But each person’s physiology is different and these remedies may fail. Common chemicals used include melatonin and caffeine. You’ll have to find your own way of coping but, for fun, here is mine. First, sleep when it’s dark and stay awake when it’s light. Avoid napping during the day. Second, if you are on an overnight flight to an earlier time zone (US to Europe), do your best to sleep on the plane. I don’t recommend drugging yourself but earplugs and an eye mask can do the trick. Lastly, the first night you are in your final destination and about 1.5 hours before bed, run a hot bath and drink a very cold beverage (beer is my preferred coolant but anything cold, with calories, and no caffeine will work). Turn the AC down to a low setting so the room is chilly (even if it’s winter).The hot bath relaxes your muscles, shifts your blood flow, and tells your brain to cool down your body. The cold liquid helps do this. Why? We are naturally diurnal and our bodies are warmer when we are awake than when we are asleep (and the switch is related to light cycles and perceived time of day). After the bath, don bathrobe or towel and sit in the cool room for 15 to 30 minutes so your body dries with water on it (more cooling effect!). Now that you are chilled, crawl in bed and sleep. As I said, this works for me and it may not work for you. And, of course, it requires a bathtub.

Consumption. Drink plenty of water. Deep vein thromboses are no laughing matter. Being well hydrated and getting up to use the restroom a few times is actually good for you. Don’t drink tea or coffee on an airplane (google it to see why). If you’re on an international flight and the alcohol is free, pretend you’re at your grandmother’s house. A glass of wine or a cocktail are fine but becoming inebriated will do you no favors. It can also cause you to sleep when you shouldn’t and it dehydrates you. Make your own choices about eating food on the airplane. It’s often hit or miss so my decisions are made in real-time.

Here’s some self-explanatory one-liners to wrap up:

  1. Wear comfortable, slip on shoes
  2. Loose fitting pants (with belt)
  3. Leave you giant pillow at home
  4. Headphones! No exceptions
  5. Ziplock bags to organize electronics
  6. Always have a pen
  7. Seats are for people, not bags
  8. Understand time zones in advance
  9. Learn “Hello” and “Thank you” in the local language
  10. Carry at least two universal travel adapters
milner-small

-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.

Working with Gen X: How Other Generations Can Adapt

Generation X is sandwiched between the two largest generations alive today: Baby Boomers and Generation Y/Millennials. This means that Generation X will never be the largest generation at the workplace, but even so, their impact is significant. Gen Xers are in a unique position as they started their careers relatively recently and can understand the challenges Millennials face, while also starting to enter leadership positions and can therefore relate to Baby Boomers.

One of the things that make Generation X stand out from other generations is that many of them have young children and aging parents. This means that having a work-life balance is important to them as they often have responsibilities to take care of their family members. They typically also prefer a divide between their personal and work lives. This is not to say that they do not make friends at work or not hang out with colleagues after work, but they tend to have a “business first” approach to their work relations.

When working with Generation X, note that they appreciate it if you use their time efficiently. When presenting an idea of have a meeting with them, make it as productive as possible and focus on what is in it for them. Gen Xers value brevity, fast turnarounds, and efficiency. This is a stark contrast with Baby Boomers, who focus on interpersonal relationships before getting a task done. Making your communication, whether it is in-person, over the phone, or via Gen X’s preferred mode of communication (email), as concise and to the point as possible will increase your effective collaboration with this generation.

As leaders, Gen Xers dislike micromanagement, both as a leader and as a follower. Their leadership style revolves around trusting others to get the job done and they expect the same courtesy in return. They value people doing what they say they are going to do, so do not promise Gen Xers that you will do something if you know you cannot. Their leadership style is therefore quite informal as they expect people to follow deadlines and get the job done, while giving their workers a high degree of freedom.

Generation X is an efficient generation who hate wasting time with empty words, promises, and incompetence. They appreciate immediate actions, a focus and straightforward approach to work without long social interactions. They respect child-friendly environments, such as being able to have a flexible schedule that allows them to accomplish their professional tasks while also taking care of their family members. They can brief and blunt, but they have an authentic and results-orientated approach to work. If you work with a Gen Xers, give them freedom to do their work and explore and only make promises you can keep. Keep your emails and interactions to the point and follow up quickly after a meeting. Having an efficient but friendly approach will take you far with this generation.

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-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.


So what does working with a Gen Xer really mean? Does it only apply to the laboratory, or do we work with people outside of the laboratory? Hmmm. How about our family, friends, social and community relationships? That said, I took this question to the streets as well as the laboratory and asked these questions.

Boomers, what’s it like working with a Gen Xer?

Gen Xers have a good work ethic; however, their family often ranks higher than their job. Boomers pride themselves in their work ethic. The Gen Xers are still so busy taking care of their aging parents, as well as, their kids, even when they’re off at college. They are the “Sandwich Generation.”

Millennials, what’s it like working with a Gen Xer?

I took this question to the classroom where I teach. My students are all working on their Masters Degree, and by the way, I have three Gen Z students in my class. Both the Millennials and Gen Z students found that the communication with a Gen Xer is different. The stated that the Gen Xers use email, messaging and Slack. As a Boomer, I didn’t know what Slack was! The Generation Y and Z students felt that the Gen Xers were resistant to change and to some technology.

One Millennial by the name of Erika shared that she found Gen Xers relatable and at ease. I found her most profound statement to be that she said the Gen Xers seemed like they were in-between and strike a balance between the Boomers and the Millennials. Hmmm…. They are known as the “Sandwich Generation” because they are often taking care of their parents and their children, but it’s interesting Erika saw them “sandwiched” in a different way.

Time to hear from our Gen Xers and how they feel about working with the Boomers and Millennials.

Gen Xers, what’s it like working with the Boomers and Millennials?

My first Gen X interview came from a regional director of a Beverage Company. As a Gen Xer, he felt that he was more effective working with the Boomers when the communication was face to face, or on the telephone. Emails worked, but he definitely noticed the Boomer preference. On the other side of the coin, this Gen Xer found that the Millennials who worked for him or with him preferred the technology communication.

The Gen X laboratory professional I interviewed found the Boomers resistant to change. This was interesting because this is how the Millennials felt about the Gen Xers! Again, is this the “Sandwich Effect!” Overall, this Gen Xer appreciated the depth and vast knowledge of the Boomer and how they wore that hard work as a badge of pride.

Lastly, on a high note, the Gen X laboratory professional really appreciated the Millennial’s enthusiasm. The grass doesn’t grow under their feet in the work place. If they perceive there’s no place to climb the ladder, they’re off and running. The Gen Xers let go of the “Boomer Job Loyalty Program,” however, they are more stable than the Millennials in the work place.  Again, they possess the gifts from the Boomers and Millennials. They are “The In-betweeners!”

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-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.  

Dead Wrong About Forensic Pathology

(•_•)         ( •_•)>⌐■-■       (⌐■_■)

[Puts my sunglasses on dramatically]

[Won’t Get Fooled Again by The Who plays]

Image 1. Looks like this medical lab science blogger made quite the … shady… joke. CSI: Miami’s Lt. Horatio Caine (played by David Caruso) donned his shades at pivotal plot times. (Source: CBS)

Okay-okay, I couldn’t resist that. How many times have you just wanted a CSI-style joke on here? No? Just me? That’s fine…

Hello again everybody! Welcome back! Last month I talked a bit about “Just Culture,” a sort of bridge between the values we tout as clinical leaders in our laboratories and the medical culture’s evolving and value-informed paradigm shift. There was a little in there about the lessons paralleled in LMU and the benefits of interdisciplinary teamwork. This month, on the subject of interdisciplinary collaboration, I’d like to talk about our colleagues who often are secluded or in more remote areas in our hospitals, offices, and academic centers. Not here to stereotype; I’m talking about our friends in forensic pathology!

Before I get there, let me go back a bit. I’ve already written several times about the stereotypes that surround our field of lab medicine and there are two times when that is glaringly present: when you’re a medical student or when you’re in forensics. I got the chance to meet someone who falls into both categories.

I’ve just finished up my OB/GYN rotation. But before my last day, I went to the lab at our hospital and followed up on some pending biopsy results. Okay, I can’t lie to you guys: they wanted me to see if I could rush “my lab friends” to expedite the process of fixing, setting, cutting, staining, and reading/reporting—because that’s possible. So, I went to the lab and had a pleasant chat with the staff explaining the situation and they were happy to help. While I was there, however, I happened to see another short white coat (ironically from my same school) who was helping some lab personnel with some grossing. Turns out she wants to match into a pathology residency—just like me—and specifically was interested in forensic path, a field which I don’t know much about. After talking more, I asked if she’d like to share some information. Here’s my conversation with Kyla Jorgenson, a 3rd year medical student at AUC-SOM from Toronto, Canada:

I get lots of hassle when I say I want to become a pathologist. People often ask me, “what’s your back up choice” or “don’t you like patients?” It can be a challenge. What’s your experience been like?

You want to do autopsies, so you want to be a mortician, right? Not quite. Many times, I’ve been faced with blank stares when I say I want to be a forensic pathologist. Other times I get the other end of the spectrum, that’s so cool! Clearly, they’ve seen a few crime-shows and think that I’ll get to go to crime scenes in stiletto high heeled shoes with a song by The Who playing in the background as I arrive. Even today when talking with a dermatopathologist I got a, “well when you realize that hanging out with dead bodies every day isn’t the greatest, you might consider surg path.” Then after hearing my experience as an autopsy assistant and that I’m sure this is what I want to do it was the resigned sigh signalling that I was a lost cause already.

A “lost cause,” that’s frustrating. A lot of specialities rag on other ones, it seems to be part of the culture of medicine—hopefully not forever, but still can’t we all just get along?

So, my background leading to pathology involved me working for several years between college, graduate school, and medical school; in hospitals of various sizes. I have personal experiences in these fields and sort of feel “at home” when I’m dealing with hematopathology, transfusion medicine, cell therapy—that sort of thing. What piqued your interest in forensics?

I started my undergraduate degree in forensic biology at the University of Toronto in the fall of 2008 just as a major review of pediatric forensic pathology in Ontario was being released. After numerous issues came to light, the inquiry looked at policies, procedures, practices, accountability and oversight mechanisms, quality control measures and institutional arrangements within the field in Ontario from 1981 to 2001. Ontario Court of Appeal’s Honourable Justice Stephen T. Goudge developed 169 recommendations on how pediatric forensic pathology in Ontario needed to address and correct its systemic failings to restore public confidence.

(Read more about these inquiries here: https://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html)

After studying the cases that prompted the inquiry and its recommendations in class, what left the greatest impression was the importance of having medicolegal autopsies performed by those trained in not just pathology, but specifically, forensic pathology. What I took away from the cases of accidental deaths falsely attributed as homicides due to lack of experience on behalf of the pathologist and other such issues, is that forensic pathology isn’t something to be dabbled in. While our patients are no longer alive, there are lives that can be affected by the work we do. In Ontario, false convictions not only stemmed from “junk science” but also from inadequacies in the training of pathologists working in a forensic capacity and also a general shortage of forensic pathologists.

Seems like a lot of us (of the few of us) who enter medical school knowing we want to go into pathology have to sort of wait their turn, as it were, collecting experiences which help make us competitive for residency matching—what keeps your “commitment algorithm” going?

Since discovering that forensic medicine is a career path as a high school student, I’ve geared my education towards training in forensics. First my undergraduate degree and then a side trip for my master’s degree in Forensic Death Scene Investigation and a job as a pathology technician at the Medical Examiner’s office on my way to medical school. I have in each step along the way, confirmed that both medicine and forensics fascinate me. Scroll through my Netflix account and you’ll find crime dramas (with the British shows being my favourite) or my podcast app filled with true crime shows; I am enraptured using science to figure out what happened.

Sidebar: at this point Kyla showed me a first-author published piece in the Journal of Forensic Sciences from 2017 that talked about law enforcement-involved firearm related deaths in Oklahoma, where she worked at the time. Basically, it showed through metadata analysis that gun-related deaths were on the rise. Not just over time, but number of times being shot. Remember when we talked about pathology’s role in the #StayInYourLane/#ThisIsOurLane discussion? Well which pathology speciality do you think works with this stuff directly? Chemistry? Cytology? Last time I checked GSWs don’t get screened for lead poisoning and you can’t FNA a bullet. Forensic pathology has often been tasked with seeing trends in morbidity and mortality and translating that to effective social and public health change: think seatbelts, stents, and maybe someday gun-related legislation changes.

Image 2a. Monthly aggregates of gun-related deaths over a 16-year period in OK. (Source: Jorgenson, K et al (2017) Trends in Officer-Involved Firearm Deaths in Oklahoma from 2000-2015, Journal of Forensic Sciences, doi: 10.1111/1556-4029.13499)
Image 2b. Number of gun shot wounds per victim over time. (Source: Jorgenson, K et al (2017) Trends in Officer-Involved Firearm Deaths in Oklahoma from 2000-2015, Journal of Forensic Sciences, doi: 10.1111/1556-4029.13499)

I was interested when I shadowed at the Cook County ME’s office a few years ago—I saw some cool things. I also remember learning a lot from the first real autopsy I saw in a hospital, ultimately it seems like a totally different field that maybe gets underappreciated even within the pathology umbrella. AP/CP residents have to do a certain number of autopsies to graduate, but the attitude I’ve noticed around the topic is a “necessary evil” and most are working towards not having to do that. So let me ask you definitively, why forensic pathology?

Medicine is science being applied to find out what happened in the body and how we can change or manipulate those variables to diagnose, prevent, treat and manage disease. Each diagnosis is solving a crime occurring within the cells in the body, if you will. In forensic medicine, not only do you get to do all that but add in the crime solving element and you get to be “Dr. Nancy Drew.” While medicolegal systems are different all over the US and Canada, chances are that as a forensic pathologist you won’t only be working on your stereotypical “forensics” cases, the gunshot wounds, stab wounds and other nefarious causes of deaths many associate with that term. You could get the generic, “cause of death atherosclerotic cardiovascular disease, manner of death natural,” for a large proportion of cases.

It’s not glamorous, you could spend your day with a two-week-old decomposing decedent that has a pulsating maggot mass devouring its torso or documenting 51 stab wounds or signing out your cases after reviewing your histology and toxicology reports or testifying on a homicide case you worked on. But for me, those all sound like pretty interesting ways to spend the day, sign me up. As a pathology technician assisting with the autopsies and external exams, I was never required to think about what was happening in the body, but I wanted to understand it all. Now as I progress through medical school and look towards residency and fellowship, I eagerly await the chance to perform my first autopsy as a physician, to put all the knowledge and experience I’ve gained towards helping move Ontario and forensic pathology forward.

Image 3. Kyla M. Jorgenson is a 3rd year medical student at the American University of the Caribbean School of Medicine with prior undergraduate and graduate studies in the field of forensic pathology, professional experience as an autopsy technician, as well as a vested interest in pursuing a career in the field moving forward in residency and fellowship. (Source: Kyla M. Jorgenson)

I’d like to thank Kyla for her time in talking with me and her willingness to share her insights with all of you. I wish her all the best of luck as she continues through her training with electives and core rotations both in the UK and state-side. If you have any questions to relay to her, please feel free to comment below and I will forward appropriately. And as always, don’t forget to share with your colleagues across every discipline!

Thanks for reading, I’ll see you next time where I’ll be writing from the Mayo Clinic Hospital in Rochester, Minnesota, conducting a formal rotation in Anatomic and Clinical Pathology! Don’t miss it, I’ll have lots to share while learning at one of the nation’s top institutions!

Until next time!

–Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student actively involved in public health and laboratory medicine, conducting clinicals at Bronx-Care Hospital Center in New York City.