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.

lotte-small

-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!”

Stakenas-small

-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.

Lean Principles

Last month we touched on implementing lean principles to help improve efficiency within the lab, as opposed to relying strictly on physical changes. For example, purchasing a larger centrifuge as opposed to switching to a different methodology completely for your STAT testing needs. But what exactly does “lean” mean?

The overall focus of a “lean” laboratory is efficiency: optimizing delivery of results by efficiently utilizing resources, thereby reducing costs and improving speed (turnaround time). If a step or action does not add value, lean laboratories will seek to remove or minimize this perceived waste.

There are 8 key areas where lean processing can be applied to minimize waste, improve efficiency, and prevent unplanned downtime:

  1. Defects: This can apply to both your consumables (reagents, controls) as well as your instruments and equipment. QC reagents that are not as stable as the manufacturer claims them to be can lead to failures, repeats, and extra costs (and time). Older equipment may be more prone to failures and breaking down, leading to additional downtime. Ensure all maintenance tasks are completed on time to prevent these interruptions.
  • Overproduction: Performing testing that was not requested by the customer uses staff time and resources, and cannot be billed for. Evaluate your critical value policy – are you repeating and verifying every single critical result, even though the patient has been consistently running that way since admission? Consider tightening your delta check rules and only verifying values when the result is either new, or a significant change from the prior result.
  • Waiting: If a process is idle or stagnant, resources are being tied down that cannot be used to add value. There is value to batching certain tests due to QC requirements or cost (ELISA plates, electrophoresis gels); however waiting to batch CBC samples on an automated analyzer does not provide the same return value. Similarly, waiting until an instrument runs out of reagent completely before loading more on board can cause further delays if the reagent has special handling requirements (thawing, reconstituting) or has not yet been calibrated.

Evaluate your workload to ensure you have appropriate staffing levels that match your testing volume. If your laboratory receives a large drop off of samples from outpatient clinics at 5pm, consider staggering your work schedules so that you have coverage when you need it, while minimizing the amount of staff waiting for work to arrive.

  • Not engaging all employees: Your staff on the front lines are the experts – utilize this valuable resource by tapping into their creativity. Ask them what is working in your current process, and what they would like to see improved. You may be surprised by the innovative ideas they come up with, and they will have a vested interest in making the improvements work.
  • Transportation: Excessive movement of reagents or samples can lead to time wasted. Try to keep heavy or commonly used items stocked near the location they are used in. It is much easier to transfer a 5 gallon reagent cube from a storage shelf within the hematology department than to bring it up from a central supply room 3 floors below the lab. When possible, utilize automation to process samples and organize completed tubes ready for long-term storage.
  • Inventory: Determine appropriate par levels for each consumable, and avoid over ordering when possible. Excess inventory ties up capital budget, space, and depending on the product can risk wastage due to short expiration dates. For items requiring a long lead time (heavy reagent cubes traveling via ground shipping), plan accordingly to avoid excess rush delivery costs. Within your inventory management system, include all necessary information so that all staff can reorder supplies when the par threshold is exceeded: full description of the item, photo, physical location where it is stored, supplier, item #, par level, amount to order.
  • Motion/Distances: Reduce excess travel and motion of both your staff and your samples to improve efficiency. Strive to create a continuous process flow when designing your lab work areas. Work should move along the process path in a smooth and uninterrupted stream; rather than having to keep returning back to a different bench or department. If different departments frequently share specimens (CBC and HA1c on the same tube), consider colocation of these areas to reduce excess motion between them.
  • Extra processing: Performing non-value added work, having redundant paperwork, or overly complicated processing steps can lead to errors and wasted time. Focus on simplification and standardization. For example, consider implementing a barcode scanner to reduce transcription errors associated with manual entry of values.

When looking to implement lean processes within your lab, start small. Look to see which departments or processing steps are generating the most waste and focus your efforts in those areas first. Even small steps can yield a big return when executed well. Efficient labs lead to happy techs; happy techs lead to successful labs.

https://www.mt.com/us/en/home/library/guides/laboratory-division/1/lean_lab_guide.html

-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.

The Three Biggest Safety Audit Blunders

There are several potential safety indicators that can be used to help someone assess the effectiveness of a laboratory safety program. The results of a properly performed safety audit can be one of those indicators, and it can provide useful information to a lab safety professional whether he or she is new to the role or has been there for years. You’ll note, however, that the term “properly performed” was inserted, and that was no mistake. Safety audits are performed in laboratories across the world, but in some of these locations the environment remains very unsafe, and performing the audits hasn’t made any difference. Mistakes can be made when performing a laboratory audit, and those errors can lead to dangerous situations. While all audit errors need attention, there are three that can cause the most damage to your lab.

Probably the most common safety audit gaffe is a practice known as “pencil whipping.” This happens when someone quickly marks “yes” on every single item of the safety checklist without really checking for compliance. Pencil whipping occurs for many different reasons. The person performing the audit may be in a hurry, they may feel like they have performed the audit often and just know the answers, or they may just not care about the audit results. Perhaps there is no lab leadership oversight as to how the audit is performed, or maybe the person performing the audit doesn’t understand what the checklist items mean. No matter the reason, this pencil whipping of answers is dangerous. It provides false results, and it masks real safety issues in the department that will likely not have resolution. In an environment where this occurs, a preventable lab injury or exposure is likely to occur, and it could have lasting or even career-altering repercussions for the victims.

Another safety inspection misstep occurs when the person performing the audit begins going down the checklist with pre-conceived assumptions or a specific focus in mind. Some auditors have their minds made up about a lab safety culture before they start, and their version of what they see while inspecting may be skewed. That may cause them to cite a lab falsely and without enough investigation into a particular issue. Some inspectors might be so focused on one thing- chemical labeling, for example – that they miss other obvious safety issues such as trip hazards on the floor. This narrow focus or mindset can limit the effectiveness of a safety audit as it can prevent the auditor from noticing other real hazards in the laboratory.

The third safety audit blunder (and probably the one with the worst consequences) is a failure to follow up on the audit results. In a larger laboratory, a complete lab safety audit can take several hours. It may involve a procedure review, an employee file review, and a look through lab drawers and cabinets as well as a walk-through. However, even if all of the findings from that work is well-documented, it won’t mean anything if there is no follow-up. A failure to review and act upon audit results negates the entire process, no matter how well it was performed. Make sure your lab inspection method includes that final step – someone should review all results and ensure that any safety issues are addressed or resolved as soon as possible. A healthy lab safety cycle will include that review as well as repeat audits to make sure safety compliance is maintained on an on-going basis.

A properly performed audit can speak volumes about the overall lab safety program. If your audit form remains constant, it can be a good idea to train multiple people to perform the audit so the lab can be viewed with fresh eyes each time. Regardless of who performs the safety audit, make sure they refrain from pencil whipping, that their focus is not narrow, and that the person responsible handles the follow up of any safety issues discovered. By avoiding common audit blunders, a positive improvement of the lab safety culture can be assured.

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.