management/administration

Faculty Insights: Teaching Medical Laboratory Science in a Blended Learning Format

Thus far, we’ve talked about the structure of our blended model of curriculum delivery and the learner experience, but what about the instructor experience teaching in this format?

I surveyed a few of our faculty members about their experience teaching in our Medical Laboratory Science (MLS) Program, and their comments about our blended model of curriculum delivery fell into a few themes:

Benefits of the “flipped classroom” model

“Having students complete the lecture content as homework and then meeting with them for the hands-on ‘face-to-face’ learning adds another layer and more reinforcement of key concepts. If learners can’t understand what they’ve read or interacted with in the online component, they’ve got another chance to hear a short review of the material and actually perform a hands-on, real-world lab activity to reinforce again what they have learned. This is what makes blended learning so effective—read, learn, see, do—it hits the learning from every angle.”

“I believe the blended learning style with the online component is very effective, and I would bet that students retain more information and retain the information longer than in traditional formats. It’s all about reinforcement.”

Role of the instructor from “Sage on Stage” to a facilitator of the student’s knowledge acquisition and enhanced student learning

“As an instructor, I am no longer required to be the “Sage on the Stage,” and the questions from our students tend to be more specific, in that they come into the classroom prepared, having some base knowledge of the content.”

“I love teaching with a blended format. Having the online component allows the student to review the learning content prior to coming to lab where we meet face to face. The online blackboard format allows for several different ways to attack the learning, which is nice for the variety of students that we have (age, gender, and background), as well as a variety of learning styles.”

“Teaching with the online component allows for embedded written lessons, recorded lectures, PowerPoint handouts, images, YouTube videos, interactive activities such as a discussion board and wikis, and online worksheets—all at which the student can work through as fast or as slow as needed. Online learning allows for multiple levels of reinforcement to help make the information stick. It also helps learners be in control of their own learning. Access to information is not just a one-time shot in a live lecture. It’s there to use and review as much as needed.”

More time for instructor-led hands-on activities

“Time is another factor. We are only given so much time with the MLS students, and if we had to present all the lecture material in the classroom, we would not have time for all the laboratory activities that we have developed.”

“I like the fact that it puts the onus on the learner to engage with the material ahead of time, which allows for more hands-on learning in the classroom. The blended format makes it extremely conducive for a laboratory-based class.”

“When teaching morphology of cells, I like to use online question ‘banks’ with images of cells, crystals, casts, etc., for the students’ practice. They can review these question banks as much or as little as needed outside of the classroom. They can practice morphology identification at home, outside of class—all without the need of a microscope. Not only do they come into the classroom/lab knowing their cells, but they can work more efficiently and progress more quickly to advanced case studies.”

“I think the flipped model we implement is a great way to enhance our students’ reading skills and comprehension, while holding them accountable for completing the required assignments.”

“The blended approach allows us to address more difficult concepts. While the students may be able to grasp the concepts from their online reading, they also need talking points to confirm that they actually understand and can apply the concepts. We have found that giving the students the task of learning the online concepts can only really be successful if we follow up with them the next day, starting with a discussion about their online homework. We also give quizzes and have designed laboratory activities that apply the online concepts.”

Varied thoughts about course maintenance

“While the time to develop online content can be extensive, once it’s built in this format, it is easier to update and maintain on an annual basis.”

“It is not so easy to maintain the details in the online course. It takes a lot of time and effort to update all of the dates for assignments and other activities for each class section. Once the core components are built, one can easily add to the content. However, if one is building a new module or lesson, it can take a lot of time. It seems that the time to maintain an online course is similar to the time it takes to keep materials up-to-date in a traditional course.”

“At first, it took some getting used to grading assignments online, but I am used to it now and actually prefer it. It’s so easy for a student to do a “copy/paste” when filling out an online worksheet, so I do question typing (copy/paste) vs. writing things out on a worksheet and how well the information is sticking. With the intensity of our program, time is of the essence. I like that as soon as students submit their online assignments, I can grade it. Some students like to work ahead, and some turn things in at the last second. With the online submissions, I can grade as they come in, instead of getting hit with 24 assignments at once, which is a big time-saver for me.”

Repurposing

“One of the greatest positives with [the software] Blackboard Learn is that we can use the system with multiple learners. The learner has easy access to the course once he/she is added to system. One cannot always say that with traditional classroom teaching/learning. Unless the content/didactic is recorded, there is not easy access to the materials.”

In summary, I would stress the following key points as benefits of adopting a blended approach to curriculum delivery:

Increased classroom time for hands-on activities that are more closely aligned with what the students will actually be doing once they graduate, get jobs, and go to work.
Increased instructor satisfaction.
Students are more prepared for the classroom activities.
Increased ability to engage students with higher-learning concepts.
Course maintenance is more efficient, and learning tools are enhanced.
Time and cost savings are realized, related to repurposing of curriculum across different learners.

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-Susan M. Lehman, MA, MT(ASCP)SM graduated from the University of Wisconsin-Madison in 1983 with a BS in medical technology. She is program director for the Medical Laboratory Science Program and course director for Clinical Microbiology I and II; her areas of interest include distance education and education methodology.

Transparency in Injury Reporting

Susan was getting ready to work in the microbiology lab. She sat down after donning her lab coat, but before she put on gloves, she picked up some reports that were on the counter. As she picked them up, she noticed she got a small paper cut on her finger. Thinking nothing of it, she put her gloves on and went to work.

Chuck opened the door to walk into the back of the main lab. A cardboard box was in the walkway, and Chuck hit it with his toe and fell to his knee. He figured he wasn’t hurt, so he didn’t say anything since filling out paperwork was such a nuisance- and no one saw it happen.

Jean was walking into the hospital during the ice storm to get to work. Shortly after she closed the car door, she slipped and landed on her wrist. It hurt a little, but she figured it would be fine, so she didn’t say anything.

Accidents happen often in the laboratory setting, and many of them go unreported. The first thing that should occur after an injury is first aid. Then the incident needs to be reported. That may mean telling someone in charge in the department- a lead technologist or a manager. That can vary depending on the department and the time of day. Next, the incident should be reported to an institutional Occupational Health department or to a designated authority (such as the emergency Department) if the Occupational Health office is closed. This step is vitally important.

Make sure the details of the incident are recorded accurately, and that any witnesses are identified. Some facilities use an electronic reporting system, and others require a nurse to fill out the forms. Good communication is important here so that a thorough follow-up by the lab safety professional can occur later. The fewer details left out, the better.

We are human, and accidents happen, but the route to a better safety culture in the department is transparency. All injuries at work need to be reported. There is no shame in an injury, and there should be no reprisals, and reporting leads to prevention of injuries. The communication about the event is crucial- the reporting may prevent someone else from being injured in the same way. In some labs there have been serious injuries that occurred because no one reported a previous similar event. That can and should always be avoided. There are other reasons to report injuries as we – those stories at the beginning of the article did not have a happy end – because they were not reported.

After a week, Susan noticed that her little paper cut had become red and swollen. She made an appointment with her physician who prescribed an antibiotic. The antibiotic didn’t work, and after a serious bout of septicemia, Susan had to have part of her hand amputated to prevent the spread of the rare bacterial infection.

A day after Chuck tripped, Elaine walked into the lab and tripped on the same cardboard box. Elaine fell hard and broke her hip. She needed immediate surgery. She would have retired in another month.

Two weeks after her fall in the parking lot, Jean decided to go to the urgent care since her wrist was still hurting. An x-ray revealed a fracture that would need a surgical repair. Jean went to the Occupational Health office to report the event. Because there was such a delay in reporting, the compensation department decided they could honor the claim, and Jean’s medical follow-up was not covered.

There are many reasons to report an injury at work. The first one is about you- protect your own health and your future- that’s worth a few minutes of paperwork and a short visit to the Occupational Health office. The second reason to report is about everyone else. If something is unsafe in your environment and it has caused an injury, let someone know. That sort of communication and transparency is important to the entire team. Accidents happen, but even when they do, we can respond quickly and communicate so that safety improves after the event. As a lab safety professional, make sure you talk about accident transparency, and make sure it is something practiced by the entire team.

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–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.

Why is it Important to Learn About Generations?

Understanding and appreciating different generations is critical for effective and productive teams, departments, and companies. Currently, there are five different generations in the workplace: Traditionalists, Baby Boomers, Generation X, Generation Y/Millennials, and Generation Z. A wide variety of experiences exist between these generations. For example, most traditionalists grew up without television, while almost all Generation Z’ers have a cell phone. If we look deeper, however, we can see commonalities between Traditionalists and Gen Z; both grew up during economic strife (The Great Depression and the Great Recession, respectively). Understanding each other’s views and values will allow different generations to increase their appreciation of one another. This, in turn, will lead to better communication and collaboration because people are now talking from a sense of appreciation and acknowledgement. When people feel heard, understood, and valued, they are more likely to invest time and energy into their projects and jobs and they are more likely to stay at an organization. Truth is, we need people of all generations to make organizations effective. You want the “getting the job done” attitude of the Traditionalists, the teamwork skills of Baby Boomers, the self-reliance of X’ers, the multitasking abilities of Millennials, and the entrepreneurship of Generation Z. Combined, these qualities create a powerful workforce that is able to handle any challenge that comes its way.

It is important to remember that learning can, and should, go both ways: newer generations can pay attention to the older generation’s lessons and knowledge, while older generations can learn a lot from the younger ones (and not just about how to use technology). Each generation has its own unique perspective, challenges, and contributions, and we can all grow by listening to and learning from people who are different than us. Generational diversity is one way to strengthen your team.

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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.

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The differences are many and yet so few. This is stated so clearly by Gretchen Gavett when she wrote in the Wall Street Journal:

“Baby Boomers, Gen Xers, Millennials, the Gen Z up-and-comers – we all want the same things, (income, sure, but also purpose, and to feel valued) just in slightly different ways. The challenge is to look past the stereotypes and listen to one another so that good work gets done efficiently and humanely.”

Let’s begin with the GI Generation. The youngest of this generation are in their early 90’s so they are almost non-existent in the workplace. They are our oldest living generation and were born at the beginning of the 19^th century. Most of the soldiers during WWII came from this generation.

Traditionalists make up 2% of the current workforce which is the smallest percentage. However, they represent the institutional memory of a workplace. They know and remember the organization’s past and founding goals. Typically born between 1927 and 1945, they went through their formative years during the Great Depression and its aftermath.

Baby Boomers are currently the largest generation at approximately 77 million people in the United States. (Generation Y runs a close second.) Born between the years of 1946 and 1964, they are the post-World War II generation. The Baby Boomers represent about 29% of the workforce; that number is declining by the day.

Generation X is bookended by the two largest generations, Baby Boomers and Generation Y. They are born between 1965 and 1980. They make up approximately 23% of the workforce.

Generation Y, also known as the Millenials, are born between 1981 and 2000. The Millenials are currently about 42% of the workforce, which makes them the largest working generation. They have their own values and characteristics (as do the other generations) their numbers make them a force to be reckoned with.

Generation Z is our newest generation. They’re currently around 4% of the workforce and growing. They grew up during the great recession after the early 2000’s. We are learning about what the Generation Z’s value and their characteristics as each day passes.

The challenge we all face: how can we connect, communicate, and collaborate most effectively in the workplace and outside of the workplace?

Source: https://hbr.org/2009/10/are-you-ready-to-manage-five-g

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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.

Synergistic Decision Making

Contrary to common belief, the group is NOT as strong as the weakest link. Instead, a group is as strong as its capacity to compensate for the weakest link. We have all experienced this when, for example, a colleague does not do their share for a presentation or project. This does not mean that the project or presentation fails; it means that other team members will compensate and do additional work that was initially assigned to the unproductive team member. The group thus does not sink to the level of the unproductive member. Instead, it rises to the level of how well others can do that members’ job.

When teams reach synergy, they reach a high level of effectiveness and productivity. In order to find out if your team is synergistic, this course conducts a simulation. The team-building simulation, designed by Human Synergistics International, revolves around some type of emergency situation: people are stranded in the desert, a tsunami is coming, they are surrounded by incoming bush fire, there is a severe snowstorm on the way, or people are stranded on a float plane in the middle of the subarctic. Through a video story, participants of this course are introduced to their situation and then asked to rank available items in order of importance. This is first done individually and then with a group while being observed by one person who is assessing their discussion. Once the correct ranking is revealed, participants will see the difference between their individual and group scores and they receive insights about how effectively they worked together.

Understanding the challenges of a team and how to move ineffective behaviors to productive ones is essential for team synergy. This course follows the Human Synergistics circumplex, explained in more detail in the Organizational Savvy and Reacting to Change course blog. In short, this circumplex indicates which behaviors are constructive, passive/defensive or passive/aggressive. Awareness of the constructive and ineffective behaviors will increase a team’s synergy. The idea behind this model is that when a team adopts constructive behavior, their collaborative results will produce greater results than the sum of their individual efforts. These groups are not as strong as their weakest link, nor are they as strong as their capacity to compensate for the weakest link. Rather, these groups are as strong as their syngeristic capacity.

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“Doctor! We need your help STAT … in Antarctica!”

As a pathologist based in Denver, Colorado, I can easily say this is not a statement I ever expected to hear. Because of my sub-specialty expertise in surgical and cytopathology, and my role as chairman of the pathology department in a tertiary care facility, it was not unusual for colleagues, staff and administrators to stop by my office or to phone me for a matter in need of immediate attention. The conversation would usually start with, “Doctor Sirgi, we need your help as soon as possible with …”. I always welcomed these opportunities to assist with whatever matter needed attention, knowing full well the ultimate beneficiary of these calls would be a patient or an anxious family member. However, I could not hide my surprise when I heard the second part. “You need me where?!” I asked, thinking I had misheard the latter part of the phrase. It turns out my assistance really was immediately needed in Antarctica!

That moment in June 1999 I learned the headquarters of Antarctic Support Associates (ASA) is based in Englewood, Colorado (a suburb of Denver). ASA is contracted by the National Science Foundation to provide science support to the United States Antarctic Program (USAP), based at the Amundsen-Scott South Pole Station (ASSPS). The ASA director told me they had received a desperate call from the scientific team deployed in the South Pole informing them their only medical doctor on site, Dr. Jerri Nielsen, had discovered a breast lump worrisome for cancer during self-palpation. Considering Antarctica was in deep winter, with outside temperatures hovering around negative 85 degrees Fahrenheit evacuating the doctor for medical tests and treatment was completely impossible. This was a full-fledged “Houston we have a problem!” kind of situation.

As soon as I arrived at ASA, a videoconference was established with the afflicted doctor and a few non-medical scientists on site via satellite link-up; the first order of business was to understand the elements of the problem and offer a potential course of action. We only had a few precious minutes of satellite connection before lost of signal. We learned the following:

The doctor had self-detected a sizable breast mass of hard consistency.
Nobody around her had any experience at performing a biopsy or fine needle aspiration, let alone surgery.
There was no laboratory facility or expertise to offer pathology examination, should a sample be obtained.
There was no mammography or ultrasound equipment adequate for the evaluation of a breast mass.
There was no adequate medication, should a diagnosis of malignancy be established.

With the possibility (or the wishful thinking) that we could still be dealing with a benign lesion, I recommended that we first focus our efforts on securing a diagnosis. Luckily, the rudimentary equipment available to Dr. Nielsen included needles, glass slides, Giemsa stain, an antiquated microscope (with no camera attachment), and a medium resolution digital camera borrowed from scientists working in another area of the research facility. I explained in detail to Dr. Nielsen and her team of worried volunteers how to use these seemingly unrelated pieces of material and equipment. Keep in mind that all this happened at a time when digital pathology was still in its infancy (if not fetal stage), and a hefty dose of DIY had to be improvised on the spot.

I had brought a needle, an orange, a couple of glass slides, and three jars filled with the fluids needed for a quick staining of the material obtained. Dr. Nielsen had herself and her crew of non-medical scientists. I demonstrated how to perform a fine needle aspiration, smear the material obtained on a glass slide, and how to properly stain it for microscopic examination.

These were but the very first steps of a long journey toward obtaining a diagnosis. Considering Dr. Nielsen had no expertise in the examination of pathology material, she needed to follow steps completely unfamiliar to her in order for me (and other experts mobilized around the country) to establish a diagnosis:

Perform a medical procedure she had never performed before … on herself!
Prepare smears of the material aspirated from the mass
Have those smears stained
Use a microscope to identify areas of cellularity on the slides obtained
Use a camera to take pictures of these areas
Load the pictures in an email
Transmit an email “heavy in data” across the planet, on a very slow satellite linked connection

Dr. Nielsen performed the procedure on herself the next day. The pictures I received a day later were impossible to interpret because the slides had been improperly stained; areas photographed had abundant red blood cells but no breast epithelial cells to evaluate. The team was understandably quite discouraged when they received our feedback. I sent them an email commending them on their efforts and further guiding them on:

Troubleshooting the staining process
Focus on the best areas to take pictures, using a breast cytopathology atlas as a visual aide

Their second attempt was much improved and allowed us to unequivocally establish a diagnosis of malignancy affecting Dr. Nielsen’s breast. Reaching a diagnosis was good; however, the tragic reality still remained that the patient had cancer and it was completely impossible to evacuate her from her current location.

The “home team” (anybody not based on the other end of the world) immediately started mobilizing resources from different areas of expertise to:

Get Dr. Nielsen the treatment she needed while stuck in Antarctica
Get Dr. Nielsen out of the South Pole as soon as meteorological conditions allowed

The following immediate priorities were then identified and acted upon:

Per the oncologists consulted, adequate chemotherapy could not be started in the absence of knowing the tumor’s biomarkers status
To establish this status, better tissue was needed for further immunohistochemical testing
Each medical specialty involved with the rescue effort made recommendations for the type of equipment and material that needed to be transported to the South Pole (including specialized medical atlases, ultrasound equipment, newer microscopes equipped with high resolution digital cameras, regular and immunohistochemical stains with appropriate easy to use instructions, various chemotherapy drugs for different treatment possibilities).

The equipment, with duplicate units of everything sent, was placed in crates and flown to the US Air Force base in New Zealand. Ace pilots volunteered to drop the equipment over the Amundsen-Scott South Pole Station, despite terrible weather conditions, zero visibility over the drop zone, and no chance of landing or refueling during the mission. Ultimately, a couple of attempts were necessary to successfully drop the needed equipment over the area. The station personnel worked for hours in negative 85 degrees Fahrenheit temperatures and near zero visibility to collect the dropped material, much of it severely damaged, and transport the surviving equipment back to the base.

Treatment began, the tumor was stabilized, and Dr. Nielsen returned to the U.S., where she continued treatment as soon as weather allowed it. Unfortunately, she succumbed to her illness several months later.

What started as a “Dr. Sirgi, we need your help STAT … in Antarctica” developed into a medical rescue mission of monumental proportion. Ordinary people from different walks of life and medical expertise worked synergistically to develop on-the-fly life-saving solutions that had never been tried before. In the end:

A heroic doctor performed diagnostic procedures on herself and braved all kinds of challenges in an attempt to survive.
A staff of scientists with limited to no medical experience rose to the occasion to act as capable and devoted medical assistants.
Physicians and medical technologists from around the country, who were previously strangers, synergistically worked together to coordinate efforts to save a colleague who was trapped in some of the harshest conditions in the world.
Administrators of the Antarctic Support Associates (ASA) organization worked day and night to secure any and all expertise and needed equipment for the rescue mission.
Air Force pilots voluntarily risked their lives to rescue a fellow human being.

No one involved woke up on that first day thinking they would be called for such a noble endeavor. All parties involved were ordinary citizens, and every single one tapped into his or her infinite leadership potential to collaborate with colleagues in order to resolve an almost impossible situation. Although There were many links of uncertain strength in this effort due to lack of experience or expertise, the common resolve and demonstrated leadership of all players involved created an indestructible chain of potential and led ultimately to the mission’s resounding success.

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-Karim E. Sirgi, MD, MBA is board certified in anatomic and clinical Pathology, with additional board certification in cytopathology. He is active as an independent healthcare consultant, and is the current president of the CAP Foundation. Additional biographical information can be accessed at www.karimsirgimd.com

Time Mastery

One of my favorite song lyrics is from “When I Find Home” by Cody Chestnutt: “I only got time to think about the time I don’t have” I like this lyric, because when I get really busy I sometimes enter this “freeze” moment, where I am stuck thinking about all the things I have to do without being able to do any of them.

As our work continues to get busier and busier, it is becoming more critical to have good time management skills. However, to actually master time, people need more than To-Do lists. This course focuses on twelve different categories of time mastery and participants assess their skill level in each of these areas:

Attitudes
Goals
Priorities
Analyzing
Planning
Scheduling
Interruptions
Meetings
Written Communication
Delegation
Procrastination
Team Time

However, not all of the categories are equally important in a current position. I might have no direct reports, so even though I might score low in that category, it is not really important in my current job. Based on participants’ answers, the assessment automatically creates a Skills Gap Analysis, a table in which the categories are organized according to two axes: less important to important and less skill to more skills. These tables gives participants a quick overview of which categories they have marked as more important, but have less skill in. In other words, these are the areas of development.

Mastering time and moving away from thinking about the time that I do not have, has allowed me be more proactive about my time and schedule. My written communication and meetings are more productive and better organized; I am clearer in my delegation and define authority levels; I follow my yearly goals more closely and I take the time to analyze when and why I am interrupted or interrupting, to understand what could have been communicated better. Mastering time has allowed me to rarely experience stress while at the same time being more productive. I only got time to think about the time I do have.

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When many of us are asked if we would be interested in learning more about improving our time management skills, our response, maybe “Yawn, I got this, after all, I am a busy professional.” What we often don’t realize is that getting to the goal, no matter how hurried or rushed, is not just often about you. Our work pace impacts others in the workplace and if we want to become a true leader, we need to master ourselves first. The first place to start on this is how we manage our time.

We have an expression in our family: “we’re always working for the farm.” When you are running a farm, you don’t get to choose your own timing or schedule in the projects that must be done. The seasons come and go and there is planting and harvesting to be done on nature’s time. There are animals to be fed and fences to be mended on nature’s time. Understanding some of these basics help us to realize that there is time in one’s schedule that we can control and time in one’s schedule that we don’t control.

As for the time you can control at work, you can select when to answer your emails, and when to have “that open door” for workplace issues, and when and how to prioritize your projects. In some cases, like the farm, you will not get to always control your own schedule and choose when important events or meetings happen. So to help with this, we can paraphrase Mark Twain: “Eat your frogs early.” This means doing your biggest and hardest task first thing every day so that you prevent procrastination and free up time in case other urgent situations emerge. For some, that may be a phone call dealing with a patient or employee complaint; for others, it may be tackling an unresolved operational issue that needs to be urgently addressed. Whatever it is, go at it first and efficiently and get the job done.

When we look to improve how we master time, we need to have an understanding of what is urgent and important and what is important, but not urgent. The best advice for time management is to work more on what is important, but not urgent, to prevent everything from becoming a last minute urgent need. If you are often focused on urgent issues every day, you are simply putting out the fires at work and never getting to the optimal operational efficiency in your area. You can begin to master this by simply blocking out a time every day that you will work on these important projects. This will soon become part of your habitual schedule and that job will get done over time by breaking these projects up into smaller blocks of time. The most productive writers often say that they sit down with their computer to write during a certain time of day, whether they feel like it or not, and much to their surprise they are able to make progress. Yes, this even works for the great story tellers of our time, such as Earnest Hemingway, who sat down every morning at the same time to write.

One of the best ways to become a time master is to understand your own biases, strengths and weakness about time management. Are you good at delegating tasks that can be performed by others? Do you lose track of time when you are interrupted in your office? There are tools that you can use to assess your time management skills, and help you work to develop better habits for improved productivity and better balance. As you begin to become more proficient in time management, you will find that your overall work place and life stress will also decrease, as you find more “time” to take on more of those projects that bring balance and joy into your work and life.

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-Dr. Deborah Sesok-Pizzini, MD, MBA is a Clinical Pathologist at the University of Pennsylvania, Perelman School of Medicine, who specializes in Blood Banking and Transfusion Medicine at the Children’s Hospital of Philadelphia. She has a strong interest in resident leadership development, patient safety and quality, and is currently serving as a member on the ASCP Fellow Council. She is a graduate of the ASCP leadership institute certification program and has an MBA from Villanova University with a concentration in finance.

Packing for the Trip

If you are sending specimens outside of your lab for testing or for other purposes, there are many things to consider. Not just anyone in the laboratory should prepare the specimens for shipment, specific training is required. Staff needs to have knowledge about packing procedures, specimen safety considerations, and how to fill out the necessary paperwork.

The safe transport of laboratory specimens is regulated by at least four different agencies. The United States Department of Transportation (DOT) generates specimen packaging and shipping regulations and updates them every October. They become effective on April first of the following year. The International Civil Aviation Organization (ICAO) provides technical instructions for domestic and international air shipments. Dangerous Goods regulations are published by the International Air Transportation Association (or IATA). These annual updates take effect every first of January, and they comply with ICAO instructions as well. The fourth regulatory body affecting specimen shipping is the United States Postal Service (USPS). The USPS regulations are synchronized with those of both the DOT and IATA. In fact, most of these regulatory agency’s shipping regulations are similar because they have been harmonized with the United Nations Model Regulations.

Dangerous Goods are categorized under classes and divisions, and laboratory specimens fall under Class 6, Division 2; Infectious substances. For the purposes of shipping, these infectious substances are further divided into Category A (specimens known or reasonably expected to contain pathogens) and category B (human or animal specimens which do not contain pathogens). Very specific training for lab staff is required for those who will package and ship these types of products. A laboratory that sends such specimens is considered the shipper, and shippers are viewed in the eyes of the law as responsible for the package until it reaches its final destination. That responsibility involves proper and regular training, specific packaging instructions, and management of shipping paperwork.

Dangerous Goods packing and shipping training includes General Awareness information. This includes an overview of the various regulations surrounding specimen shipment as well as enabling the trainee to recognize and identify the hazardous materials that fall under the regulations. Function-Specific training is general instruction on how to package dangerous goods, how to properly label parcels, and how to fill out the required paperwork. Training shippers about Safety is also required. Staff must be given information about the hazards associated with handling dangerous goods, and there must also be training given about how to handle emergencies such as accidents or spills. Lastly, Security training is required because the materials being shipped could be misused in a way that could cause harm to others (i.e. a terrorism event).

The paperwork that must be filled out and that must accompany the package is called a waybill or a shipper’s declaration. A lab must have two original completed and signed forms. Two of the signed forms travel with the shipment to its final destination, and one will be retained by the carrier. There are very specific instructions about how to fill out a shipper’s declaration, and only those trained should do so.

Not all specimens and chemicals shipped by a lab are considered Dangerous Goods, and they may not fall under the regulations for labs that transport them. The DOT designates some items as “Materials of Trade,” and they are not regulated under transport laws. Material of Trade are those items which are carried on a motor vehicle to directly support a principal business of a private motor carrier (such as a private courier). That means that many diagnostic specimens and some hazardous chemicals (under 8 gallons depending on the chemical) may be transported without shipping papers, emergency response plans, and specialized training.

Proper training for those shipping Dangerous Goods takes time, and the information included in the training is much more in-depth than what has been discussed here. Those who are trained should be tested on the information taught, or they can provide a demonstration of proper packaging and paperwork management. Each successful trainee should be given a certificate of completion, and that record needs to be retained for at least 36 months. Training should be repeated every two years in order to satisfy the requirements of all regulatory agencies.

Laboratories across the country package and send diagnostic specimens for testing or for other purposes. Sometimes, depending on how and where those specimens will be transported, very specific regulations will apply, and specialized staff training will be required. Before you get those samples packed and ready for their trip, make sure your lab is following the regulations that will keep your staff (and those who will transport and receive the packages) safe from harm.

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A Laboratory Professional’s Perspective on the Opioid Crisis

It was in the 1980s that physicians first explored the use of narcotics/opioids for the treatment of pain associated with non-terminal illnesses, including chronic and “mild to moderate” pain. In 2012, opioid prescriptions for outpatients were common, and some states had as many as 143 opioid prescriptions for every 100 people. Today, more than 6 out of 10 drug overdoses involve an opioid. The CDC states that 91 Americans die every day from an opioid overdose. This situation has been called “the opioid crisis” and the “opioid epidemic.” It is a public health emergency.

The landscape is characterized by new trends in both the drugs involved and drug user demographics. Current data indicates that prescription opioids are not the main problem. In fact, from 2015 to 2016, prescription opioid overdoses decreased from 17,539 to 16,800. The decrease in prescription overdose may indicate that efforts to reduce over-prescribing may be working. Or, drug users may be abandoning high cost prescription opioids for illicit drugs.

While prescription opioid overdoses have been decreasing, the incidence of heroin overdose has tripled. The incidence of fentanyl overdose has increased 196%, and the incidence of overdose due to non-methadone synthetic opioids has increased by 72%. Fentanyl is available both legally by prescription, and illegally from illicit sources. It is frequently combined with or sold as other drugs such as heroin, cocaine, and alprazolam. Fentanyl is 100 times more potent than morphine, and 50-100 times more potent than heroin. Even more dangerous are the fentanyl analogs, carfetanil(yl) sufentanil, acry and acetyl fentanyl, and furanyl fentanyl, to name a few. Sufentanil is 1000 times more potent than morphine, and carfentanil – sometimes called elephant tranquilizer – is 10,000 times more potent than morphine. Opioid abuse now spans nearly all demographics. In fact, NCHS Data Brief in 2017 disclosed that the age group with the most rapid rise in opioid overdose is adults ages 55-64 years. Some of the greatest increases in heroin related deaths have been among women, privately insured, and those with higher incomes – demographic groups that historically have had low rates of heroin abuse.

Laboratory professionals can help fight this crisis by providing relevant testing, and billing for the testing appropriately. Most hospitals are ill equipped to test for the synthetic opioid analogs. For many hospitals, the drug testing capabilities consists of an immunoassay based urine drug screen. These screens can detect many of the “classic” drugs of abuse like morphine (heroin), cocaine, amphetamines, PCP, and benzodiazepines. These screens do not differentiate individual drugs in a drug class, and they can’t detect fentanyl or fentanyl analogs, even with high degrees of cross-reactivity. As our Vice President of Laboratories expressed it to me, “our emergency rooms are full of overdose patients with negative drug screens.” Unfortunately, the culprit drug is not identified until a medical examiner orders forensic toxicology. More comprehensive and confirmatory testing like mass-spectrometry based testing provides more accurate information.

Mass spectrometers are not cheap, and many laboratory professionals are challenged with obtaining funding for them. The challenge is not lessened by the bad taste left in Medicaid’s mouth by code-stacking when billing for drug testing in the pain management patient population. This practice was, unfortunately, exploited by some physicians running office-based drug testing labs. Large multi-drug LCMS based panels were used in routine monitoring of pain management testing but instead of billing per panel, the test was billed by drug (analyte) in the panel. This practice led to CMS scrutinizing the use of mass spec testing alone and recommending the limited immunoassays. Laboratory professionals have the responsibility to advocate for the appropriate use of this powerful testing, and fortunately we are doing that – the Academy of AACC in collaboration with American Academy of Pain Medicine just released guidelines for the use of laboratory tests in monitoring pain management patients. We need to be trusted to do the right test, at the right time, for the right patient.

Forensic pathologists and toxicologists also face big challenges related to the opioid crisis. Forensic toxicologists are challenged to keep up analytically with synthetic and novel drugs entering the market while dealing with the pressure of limited budgets and client frustration with long turnaround times. Forensic pathologists are challenged by the sheer volume of overdose-related deaths. The National Academy of Medical Examiners (NAME) limits the number of autopsies to 325/pathologist/year. There are currently only around 500 board certified forensic pathologists in the US and the future doesn’t look great – only 3% of graduating medical students choose to enter pathology and only 7% of those will enter forensic pathology.

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–Sarah Riley, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.