Not Your Grandmother’s Hematology

Last month we celebrated Lab Week, to recognize and show appreciation for Medical Laboratory Scientists and Technicians. Lab week is also a time to reminisce, and tell stories of the lab “in the old days.” I have worked with many technologists who have now been in the field for more than 50 years, and some who have worked in the same hospital all that time! Lab techs love to share stories about their experiences over the years, the days without computers, old methodologies, ancient lab equipment and manual testing. Listening to these stories always makes me think about just how far we have come in the field in the last 50- 60 years, and gives me a true appreciation for modern technology. It causes me to reflect on all the changes and developments that enable us to give physicians a wealth of knowledge that was previously unavailable.

During the first half of the 20th century, the complete blood count (CBC) was performed using exclusively manual techniques. Blood cell counts (erythrocytes, leukocytes, thrombocytes) were performed under the microscope using diluted blood samples and a hemocytometer. For each specimen, a technologist spent about 30 minutes at a microscope manually counting the cells and calculating the total count using a mathematical formula. A spectrophotometer was used to perform the hemoglobin by the cyanmethemoglobin method, and a spun hematocrit was performed. Indicies were calculated. A manual smear was made, stained, and cells were counted and differentiated under the microscope. To complete a CBC, all these procedures had to be performed individually, with duplicate testing and applying mathematical calculations, and could take over 2 hours. After all these tests were performed, results were reported on paper and sent to the patient’s doctor or the nursing floor.

In 1953 Wallace Coulter patented the Coulter Principle for counting and sizing microscopic particles. The Coulter Principle can be used for measuring any particles that can be suspended in an electrolyte solution, and has been used in the food and drug industry, in beer making, in the manufacture of construction materials and thousands of other applications. However, probably the most important application has been in the medical field where it has revolutionized the science of hematology. Coulter suspended red blood cells in a solution and, with an electrical current flowing, passed the solution through an aperture. As the cells pass through the current, the impedance between the terminals changes, and this change can be measured as a pulse. The first Coulter Counter measured the number of cells by counting the number of these pulses. The first Model A Coulter Counter was sold in 1956, manufactured in Coulter’s basement in Chicago. The Model A counted red blood cells in a sample in 10 minutes, a marked improvement over manual counting! The Coulter Counter was hailed for its speed, accuracy, and opportunities for reducing human error, tedium and eye strain.

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Image 1. Model A Coulter Counter, 1956. https://www.beckman.com/resources/discover/fundamentals/history-of-flow-cytometry/the-coulter-principle

During the 1960’s, an improved Model B Coulter Counter was developed and Model A and Model B were used to count both leukocytes and erythrocytes. Other Coulter Counter models soon followed, and competitors entered the market with their versions of cell counters. Within a decade, nearly every hospital in the United States had a Coulter Counter, and the new, advanced Coulter Model F was widely used. In 1968 the first fully automated hematology analyzer, The Coulter Counter Model S was introduced, and could perform a seven-parameter CBC. The Model S could perform not only WBC and RBC counts, but also reported Hemoglobin, Hematocrit, Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH) and Mean Corpuscular Hemoglobin Concentration (MCHC).  In 1955 it took one or several technologists 2 hours to perform a CBC, and in 1969 an automated hematology analyzer could analyze a sample in under 2 minutes.

Image 2. “Woman Using a Model F Coulter Counter Cell Counter,” 1969. Beckman Historical Collection, Box 58, Folder 94. Science History Institute. Philadelphia. https://digital.sciencehistory.org/works/736664585.

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Image 2. “Woman Using a Model F Coulter Counter Cell Counter,” 1969. Beckman Historical Collection, Box 58, Folder 94. Science History Institute. Philadelphia. https://digital.sciencehistory.org/works/736664585.

As these improvements and advancements continued, and Coulter patents expired, new manufacturers entered the field. Technicon Instruments Corporation, Ortho Diagnostics, Instrumentation Laboratories and Toa Medical Electronics, (presently Sysmex Corporation) were among the first Coulter competitors. From a simple automated blood cell count, to the first seven-parameter CBC, we saw hematology changing before our eyes. More reliable automated platelet counts were added in the 1970s. In the 1980s we saw the first hematology analyzers that could perform automated differentials and the first automated reticulocyte analyzers. In the late 1990’s, we saw the advent of digital cell images and automated manual differentials.

Today, modern automated cell counters sample blood, and quantify, classify, and describe cell populations. These instruments use optical light scatter, impedance methods based on the Coulter principle or a combination of both optical and impedance methods. Progressive improvement in these instruments has allowed the enumeration and evaluation of blood cells with great accuracy, precision, and speed, at a very low cost per test. The latest descendant of the Model A Coulter Counter, the LH 750, can determine 26 reportable hematological parameters. The Sysmex XN-9100 with four XN analyzers reports 30 parameters and has a throughput of up to 400 CBCs and 75 smears per hour. Today’s analyzers can accomplish more and more routine diagnostics, and the role of the hematology technologist continues to evolve and expand.

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Image 3. Sysmex XN-9100™ Automated Hematology System
https://www.sysmex.com/us/en/Brochures/XN9100ScalableAutomationBrochure_mkt-10-1177_10252017.pdf

This is not your grandmother’s hematology! We’ve truly come a very long way in 60 years. Modern hematology instruments not only perform a CBC, but they give us next generation diagnostics as well. Many give us advanced clinical parameters and other new parameters which provide physicians with additional information about the state of blood cells. We can report out immature granulocytes with every differential, automated nucleated red blood cell counts, immature platelet fractions and fluorescent platelet counts, and report the amount of hemoglobin in reticulocytes and the immature reticulocyte fraction. Future directions of hematology instrumentation include the addition of even more new parameters. In upcoming Hematology blogs I will be presenting case studies that highlight each of these advanced clinical parameters and discuss how physicians can use this new information in making diagnoses.

 

References

  1. Beckman Coulter, Inc. History http://www.fundinguniverse.com/company-histories/beckman-coulter-inc-history/
  2. https://www.beckman.com/resources/discover/fundamentals/history-of-flow-cytometry/the-coulter-principle 
  3. Clinics in laboratory Medicine. Development, history, and future of automated cell counters Green RWachsmann-Hogiu S. Clin Lab Med. 2015 Mar;35(1):1-10. doi: 10.1016/j.cll.2014.11.003. Epub 2015 Jan 5. March 25, Vol 35, Issue 1, p1-10
  4. Cytometry: Journal of Quantitative Cell Science. Wallace H. Coulter: Decades of invention and discovery Paul Robinson First published: 17 April 2013 https://onlinelibrary.wiley.com/doi/epdf/10.1002/cyto.a.22296
  5. J.clin.Path. An assessment of the Coulter counter model S P.H.Pinkerton,I.Spence, J.C. Ogilvie, W.A Ronald, Patricia Marchant, and P.K, Ray. 1970,23,68-76 http://jcp.bmj.com/content/jclinpath/23/1/68.full.pdf
  6. SLAS TECHNOLOGY: Translating Life Sciences Innovation. The Coulter Principle: Foundation of an Industry. Marshall Don, Ph.D., Beckman Coulter, Inc.. Volume: 8 issue: 6, page(s): 72-81. Issue published: December 1, 2003 https://doi.org/10.1016/s1535-5535(03)00023-6
  7. Medical Electronic Laboratory Equipment 1967-1968. G.W.A Dummer and J. MacKenzie Robertson. 1967 Pergamon Press

 

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-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.

Shout it from the Mountaintop

Even after working in the laboratory field for twenty years, I’ve always thought that one of the more interesting things I come across is how few people really know what we are and what we do. Laboratory Professionals Week is not only a chance for us to celebrate ourselves and the outstanding job we do every day, it can also be a prime opportunity to begin changing that worldly lack of knowledge about us. It’s a chance to Get the Word Out!

Here in Dallas we get creative every year for Lab Week. Each section of the Lab creates a poster board depicting what they do in their section. Usually we try to include both the usual, common things, as well as the things that non-laboratorians might not be aware of. Each part of the lab/pathology creates one. So we have not just Chemistry, Hematology, Microbiology/Virology and Blood Bank. We also have poster creations from our Metabolics Lab (inborn errors of metabolism testing), Client Services/Accessioning, Sendouts, Phlebotomy, Histology, Electron Microscopy and Advanced Diagnostics, our molecular diagnostic lab.

As those of us in the laboratory field know, laboratory professionals are really creative. We always end up with at least ten colorful and eye-catching posters depicting the whole range of services provided by the Laboratory/Pathology departments. During Lab Week, those posters are hung in the hallway coming into the Hospital. They are viewed daily for that week by hospital personnel and the public alike. It never ceases to amaze me when I walk past them, how many versions of “I had no idea they did that!” I hear, and how many times I hear it.

In our current healthcare climate, the Laboratory can no longer afford to be a hidden profession. With healthcare dollars becoming increasingly dear, we must make our worth known to other healthcare professionals and to the public. We need to keep ourselves situated as prominent and important players on the healthcare team. Laboratory Professionals Week can provide a wonderful time and place to begin working on those goals.

 

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-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

Think Globally, Act Locally

National Laboratory Professionals Week is April 20-25, 2014—and this year during the same week is Earth Day, on April 22, 2014. That is an interesting combination of things we should take time to contemplate—what does Earth Day have to do with laboratory medicine? Or vice versa?

Well, a number of things come to mind:

  • As laboratory professionals, we are committed and dedicated to being part of the healthcare team that discovers and cures peoples’ health and promotes well-being.
  • Laboratory professionals are also committed to using supplies efficiently and effectively, saving costs, and using/disposing of hazardous materials safely which parallels a strong commitment to our environment.
  • The health and well-being of the planet is directly proportional to the health and well-being of the inhabitants of the planet.

It seems to me there is a directly proportional relationship here; and a link to our present and future state, as we pursue health for both the people of the world and the planet we all occupy.

Laboratory professionals the world over act locally to take care of the patients who are our neighbors and friends and family in our communities…and we think globally to support the needs and resources and collegial relationships that take care of the patients and neighbors and friends on our planet. What better combination to celebrate, support and call world-wide attention to than National Laboratory Professionals Week and Earth Day? If your laboratory is doing something special that illustrates “thinking globally, acting locally,” please send me a note about your Lab Week Celebration Activities at bsumwalt@pacbell.net . I would love to consolidate and share those ideas!

Wishing everyone in the field and industry of Laboratory Medicine a great Lab Week—both locally, and globally!

 

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Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.