Under the Hood

I like to keep some humor in the lab so when I see a technologist with a panel off a machine trying to troubleshoot an issue I will say “Uh-Oh, why do you have the hood up?” It’s a little tension breaker, especially if they are stressing about having their instrument down. It also acts as a little reset button so I can go through the troubleshooting steps with them. As technologists, we are modern day mechanics. We use instruments much more than we perform manual testing, and we are expected to be able to troubleshoot instruments that are more complex than the current day automobile.

Acquiring new instrumentation can be a lab changing experience. Each instrument has its quirks and special requirements. The vendors usually offer on site or even off site training for staff once the instrument is purchased. Who you send to these training sessions is just as important as the quality of training they receive. These sessions are where your staff will learn maintenance, operation, and most importantly troubleshooting. When your shiny new analyzer goes down, and it will, the time it takes to get it back up and running affects productivity, turnaround time, and staff morale. Nothing is more detrimental to a staff’s morale then coming into work and the first thing they hear is that the instrument they are on that day is already down. Having experienced that exact thing I can tell you it takes the wind right out of you.If it happens consistently you will see a decreased engagement by staff.

Whom should you send for analyzer training? You should have a good mix of talent and maybe some of the lower performing staff. This assures that you are keeping your talented staff engaged and shows weaker performers that you are invested in building them into a top performer. The question becomes, how do I make sure that the people I send get the most out of their experience? Let them know they will be responsible for presenting the material they learned to the rest of the staff once they get back from training. If any of your staff have an issue with that they are not the ones you should send. These small presentations will help with team building as well as solidifying the information for the key operator.

As leaders we must pick our key operators very carefully. When these choices become important is most likely when we won’t be in the office. Observe the staff that likes to troubleshoot instruments or that keep a level head once instruments are down. You want to make sure that once the hood goes up you have the best mechanic for the job.

-Matthew Herasuta

Lab Product Friday-UniCel DxH800

The common maxim when buying laboratory equipment is “Fast, accurate, or cheap; pick two.” The perfect analyzer would have all three qualities, but as the saying suggests, it’s hard to find those instruments. Enter Beckman Coulter. Their website suggests the UniCel DxH800 is designed to meet these demands by improving productivity, decreasing turnaround time and reducing overall cost.

Recently Lab Medicine published a paper evaluating the performance of Beckman Coulter’s Unicel DxH800. The authors of the paper found the instrument to be accurate and efficient. They also commented that for larger facilities, this analyzer could improve productivity and turnaround times when compared to the older model (LH 750). Notably, the authors don’t mention cost, quality control, or maintenance concerns.

Does your laboratory have the DxH800? Is the maintenance easy to perform? Has this analyzer improved turnaround times in your lab? Let us know in the comments.

 

ASCP Annual Meeting: Training Residents in Genomics Workshop

I wanted to devote this blog to my experience at the recent Training Residents in Genomics (TRIG) one-day workshop at the ASCP Annual Meeting in Chicago. I admit that I am biased since I had ten years molecular and cell biology and transgenics research experience prior to medical school and enjoy all things molecular. But I really I do think that TRIG is an idea whose time has come.

TRIG is a group of molecular pathologists, medical educators, and geneticists who came together in 2010 with the goal to create a standardized, high quality genomics curriculum and to promote adoption at >90% of pathology residency programs by the end of their 5-year grant period. A 2010 survey of 42 pathology residency program directors found that only 93% confirmed molecular pathology as a part of their training and only 31% had established curricula on relevant topics. So, TRIG plans to provide online resources, lectures and workshops, and to assess the efficacy of genomic medicine curricula at residency programs through RISE performance. From speaking to other residents I’ve met over the past year, I know that the teaching of molecular pathology at each program can vary significantly.

The TRIG workshop had four sessions that followed the case of a woman with newly diagnosed breast cancer while applying specific hands-on skills related to the genomic related elements of her case. I missed the first session so I can’t say too much except that they discussed single gene testing and assessment of BRCA mutations of unknown clinical significance. Session two covered the assessment of prognostic gene panels (Oncotype DX) and compared them versus the standard breast IHC panel. We also learned to plot Kaplan-Meier survival curves based on a patient’s genomic profile on a publicly available website.

After lunch, session three dealt with the selection of genes to design a breast cancer multi-gene assay for this patient. Questions considered were the availability of targeted drug therapy for specific somatic mutations, the strength of association of selected genes with breast cancer, frequency of these variants, reimbursement, and choice of PCR based genotyping versus next-gen sequencing. The final session focused on the creation of a genomic pathology report for this patient after analyzing the clinical significance of each result from multi-gene mutational analysis using free web-based tools.

This workshop was a great introduction for the genomics neophyte (especially if one’s residency is weak in this subject or doesn’t have a molecular pathology rotation) and even someone with some experience like myself, learned how to use some new tools and applications even though the concepts were not new to me. As I mentioned in previous blogs, I learn more from having to tackle issues hands-on and being able to participate in a bidirectional discussion about a topic versus reading textbooks or attending lectures. The workshop was a good intro albeit too short to learn to apply these skills comfortably and effectively…but it is definitely a step in the right direction and I expect to see more great things coming out of the TRIG Working Group. More info about TRIG is at www.ascp.org/trig.

-Betty Chung

The Case of the Rogue Suitcase

“Adventures in Travel” is one constant you can count on as an international consultant. Some things always work well and some not so well, and I seem to attract all the fun. As promised, in my next few blogs I’d like to share some stories that may help you avoid your own personal “travel adventure”. Or, at least, it will make you smile!

It was January, (translation: Dr. Zhivago weather in Siberia…) and I was challenged with a very complicated schedule for visits to two different countries on two continents for 3 weeks. Just packing for that adventure was not for the faint of heart. My first two weeks were to be on the Siberian border, (yep, in January) followed by a week in sub-Saharan Africa which was summer time for them. I have a history of losing luggage, so wise travel gurus might suggest carry-on. Now, how does one pack carry on for 3 weeks for a business trip in two climates, you might ask? Well I did it, and proudly boarded the plane with a carry-on and briefcase, with a pair of boots and all the sweaters, coats, sandals and light blouses one could possibly cram into them. It was a fait’ accompli to be sure. Smiling at the stewardess, I boarded the plane in San Diego headed for Atlanta where I would catch the international flight. At the cockpit she said, “We’re very full with overhead carry-on for this flight, I will need to take your suitcase here, and you can pick it up on the ramp in Atlanta.I didn’t have a choice, but that was my first mistake.

In Atlanta, I was told my suitcase had been taken to the ticket desk because the plane to Kazakhstan had been cancelled. After much wrangling with the airlines, they told me to “run like the wind”, to another terminal, they would reroute me but I would get there. I told them my suitcase drama and they made a quick phone call and said “we’ll get it on the London flight for you, no worries”.  I “ran like the wind” and seriously out of breath, boarded the plane to London just as they closed the gate. My suitcase of course, headed for Amsterdam.

In London, no suitcase, and a 12 hour layover convinced me I should buy a bit of makeup and maybe a sweater. Now you may not know, but Heathrow airport has some of the most expensive shops on the planet next to Paris or Las Vegas, so I opted for makeup and chocolate and headed for the lost luggage counter. The nice man with an oh-so-British accent ASSURED me that my suitcase was logged and tracked in the computer, and would be loaded on my next flights to Kazakhstan—no worries, it would be there with me. I decided at that point there was little I could do to affect the outcome, so I ate the chocolate.

Later…after way too much time in the airport, I boarded the plane and chased the chocolate with red wine, and settled in for a flight nap. Of course, a “flight nap” is different than a regular nap, and requires at least one glass of red wine, half an Ambien, and is only complete if you have a sharp pain in your neck and shoulders and cramps in your legs when you wake up. The pilot announced we were landing and the temperature outside was -30 degrees. That was minus 30. Passengers began to shift and stir and I noticed everyone getting out down coats, scarves and hats, pulling boots out of their carryon, and getting ready to disembark the plane. My coat was stuffed in my rogue bag in the outside pocket, ready for grabbing as needed…so all I had was what I had on—a fleece vest, cargo travel pants, socks (thankfully!) and luckily, a pair of boots that happened to be packed in my over-stuffed computer bag, so I put them on and pretended to be warm.

The plane landed in a field of snow and we climbed down a ramp and walked 200 feet through snow and ice into the terminal. It was 3AM, and the scene was surreal, and my ungloved hands froze to the handle on my computer case. This was a plane change layover—and the terminal wasn’t heated! I opted for coffee this time, burnt my mouth and spilled it all over my shirt while shivering, and stood in a corner out of the icy breeze shifting from one foot to the other in a sort of dance to stay warm. No one was in the lost luggage office at that frozen hour so I watched people, and had an acute attack of coat envy….there were beautiful long down coats, furred collars and hoods, sweeping full length furs with mittens and muffs and hats, and I coveted them all shivering in my corner with hands cupped around a rapidly cooling cup of very bad coffee. When they called to board the final flight to our destination city in northern Kazakhstan, I had expended all my energy shivering and was all too ready for a shower and a shopping trip to buy a coat, hat and gloves!

Next time I’ll finish the story…my rogue suitcase had a mind of its own, and this was just the first 36 hours! In the meantime, if you happen to be in the Almaty, Kazakhstan Airport Terminal, I recommend NOT trying the coffee, go for the hot chocolate instead.  And hopefully it won’t be 3AM and minus 30!

And if you want a great coat recommendation, send me a note at bsumwalt@pacbell.net. I’ve seen them all!

Cheers, Beverly Sumwalt

Reference Intervals vs. Reference Change Values

If we didn’t use reference intervals (RI), how would we know whether a person is “normal” or not? Or more accurately, how would we know whether a lab test result indicated health or disease? Reference intervals have been around as long as lab tests and they help clinicians diagnose and monitor a patient’s disease state. .

Most RI are developed using a specific patient population and should be used only with that population. However, some RIs are “health-based,” such as cholesterol and vitamin D. Both these analytes have RI that indicate what amount of the analyte should be present in a healthy individual, not how much is present in your specific population of patients. In general, health-based RI can be utilized in all populations, as long as the analyte assays are commutable. Thus these type of RI are often more useful than population-based intervals.

But should we be using reference intervals at all? One problem with population-based RI is that any given individual’s values may span a range that covers only part of the population RI due to biological variability. For example, an individual’s creatinine may be 0.6 – 0.9 mg/dL regularly. Since the RI for creatinine for his population is 0.4 – 1.4 mg/dL, a value of 1.2 mg/dL would not be flagged as be abnormal. However, 1.2 mg/dL may very well be an abnormal result for this individual We need to consider using reference change values (RCV) in addition to RI.

Reference change values are calculated values that are used to assess the significance of the difference between two measurements. Essentially, a RCV is the difference that must be exceeded between two sequential results for a change to be a significant change. The calculation requires knowledge of the imprecision of the analyte assay (CVA) and the biological variation (CVI) of the analyte. The formula for calculating RCV is: RCV=21/2 · Z · (CVA2 + CVI2)1/2 , where Z is the number of standard deviations for a given probability. Luckily, labs know the imprecision of their assays and there are tables available for biological variation.

It’s very likely that neither RI nor RCV by itself is adequate for interpreting analyte results. Using both may be a better alternative, especially using RCV for monitoring disease progression or therapeutic efficacy. Flagging sequential values that exceed the RCV—and reporting this change—should be considered.

-Patti Jones

Decisions, Decisions–Part 1

I’ve been reading a book called Leadership and Medicine by Floyd D. Loop. In it, he writes about decision making and its importance in leadership in all industries. In laboratory medicine, choices must be made quick and definitively. This skill can be observed early in a technologist’s career, often even as they train during their clinical rotations. As leaders we can pinpoint the quick thinkers and those who will have what it takes to make the larger decisions once they become leaders themselves. As leaders our decisions have more impact as we work our way up the ladder until the decisions we make affect entire organizations. Decision making at the executive level can be daunting and seal your fate as a success or the figurehead to blame.

The most important decision a leader can make is choosing their team members. Selecting a team that is similar to you may not always be the smartest decision. If you surround yourself with likeminded people, you will miss information and make ill-informed decisions. Contrary thinking will bring different sides of an issue to light. It can be hard to interview—let alone hire–someone you know doesn’t think like you, but their alternative view could strengthen your team. When I interview for leadership positions one of my first questions is, “Is this your first round of candidates or have you passed on any candidates?” If they have re-posted or passed on candidates they are not afraid to wait to find a person who fits their needs.

Most people make lists for projects that need completed. Ever write down a list of decisions that need to be made and their deadline? Former CEO of The Cleveland Clinic Dr. Loop writes, “Some leaders believe that all decisions must be grand in scope. The facts are that most decision making involves small details that add up to a larger goal.”

All of these decisions are null without one thing, trust. Trust in yourself as a leader as well as trust that you are a good decision maker from the people you lead. Decision making is at the heart of any organization and as leaders we must look for team members that can complement our weaknesses and build trust as we lead. With those two in hand you will find yourself making better decisions.

-Matthew Herasuta