A Dull Day At Work...?: July 2024

29 July 2024 (Monday) - Learning Monday

#LearningMonday. Looked like hairy cells to me.

It was.

Usually there’s a link about the subject matter. There wasn’t this time.

28 July 2024 (Sunday) - IBMS Newsletter

The IBMS sent their update today. You can read it by clicking here. One article caught my eye. Click here to read it. Rather than taking a blood sample from a patient and sending it to a state of the art diagnostic laboratory, it is being claimed that it is far better to have some tin-pot near patient testing device on hand for an immediate result. Or is it being claimed that *some* results can be obtained from a near patient testing device far quicker than they can from a distant laboratory and in some situations this will speed up the patient’s ultimate outcome?

Which is it?

I really don’t know.

Had the article been written in English rather than some strange collection of management catch phrases then I might have had some chance of understanding.

28 July 2024 (Sunday) - Mistakes (Honest and otherwise)

I’ve signed up to the mailing list of “The Mislabelled Specimen”. A lot of their postings are somewhat flippant, but so am I.

Here’s a post about a case of massively high potassium because a nurse took the blood into the wrong sample bottle and tipped it over. Things like this happen from time to time. However what boils my piss (I said I was flippant!) is the attitude from the one making the mistake who was quoted as saying: “I hate drawing blood for this reason. You guys are always picky with your tube colors. I drew it in a tube with a purple cap. My supervisor told me that I drew the wrong tube. So I transferred it to a green tube. I can’t see how it would affect her potassium level!”

Fortunately this error was spotted before any harm was done.

There was a post which was not entirely dissimilar on the Facebook “Blood Bank Professionals Group” this morning in which a clinician ws in a hurry to get blood for a patient with a haemoglobinopathy, and rather than getting phenotypically matched blood he wanted O Neg as everyone knows that’s a universal donor (!)

Slightly (much) more serious was a case I heard about in a hospital fifty or so miles from where I lived at the time in which a child had been born with HDN due to anti-K. Apparently the lab (not mine!) had been constantly telling the ante-natal clinic about the matter, but the consultant obstetrician had declared that because he had never heard of anti-K it couldn’t be important.

Cases like this occur from time to time. But what do we do about them? Ideally one of two things. We should use them as a learning opportunity. And if nothing is learned then they should be reported to the appropriate regulator as a clear and present danger to patient safety.

But we don’t do we? We roll our eyes, don’t record any of the specifics, and let the episode pass into the lore of “Well, the other day…”

Here’s a job for the Quality Management teams…

And then just as I was about to post this I had a thought. Of these three cases only one is of my personal experience, and that was from over forty years ago. The other two are from the USA. Do we in the UK still get these sorts of things happing. On reflection nowhere near as many as used to happen.

Quality management in action, maybe?

26 July 2024 (Friday) - At A Loose End

With my car in for service and what was supposed to be a two-hour service now taking all day, and everything I had planned for the day needing a car I thought I might as well do a BTLP-TACT exercise.

I was presented with two cases.

93476 – a sixty-year-old chap in A&E needing group & save for a fractured neck of femur.
He grouped as AB Rh(D) Negative with antibody screen positive in cells 1 and 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 1, 2, 3 and 4 which corresponded with anti-C and anti-D but didn’t exclude anti-Cw

86139 – a thirty-two year-old chap in the haematology clinic needing two units of irradiated blood within the hour.
He grouped as O Rh(D) Positive with antibody screen positive in cell 2. I requested antibody panels. The IAT and enzyme panels were positive in cells 3 and 5 corresponding to anti-E.
I selected two units of irradiated O Rh(D) Positive E Negative blood

I got the green light.

23 July 2024 (Tuesday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I had two cases:

28671 – a forty-six year-old woman in the maternity unit needing four units of CMV-negative blood for tomorrow. She grouped as A Rh(D) Positive with a negative antibody screen. I selected four units of A Rh(D) Positive K-Neg CMV-Neg.

98423 a fifty-five year-old chap in the orthopaedic department. Recently transfused he needed four units of blood for today. He had an inconclusive ABO group presumably an AB person having been given O blood, and his Rh group was negative. However his antibody screen was negative. I selected four units of O Rh(D) Negative

I got the green light.

22 July 2024 (Monday) - Learn Haem

Whilst rummaging about on the Internet whilst I should really have been doing proper work I discovered this web site. There’s all sorts of tutorials and lectures on there, complete with quizzes.

I did one, and learned quite a bit. Hepcidin was only discovered twenty years ago.

I shall do more of these.

22 July 2024 (Monday) - NEQAS 2403 DM

The results of NEQAS DM 2403 became available today. I thought the case was a case of Hb SC disease with an utterly unrelated lymphoproliferative condition – probably a myeloma.

I would seem to be in agreement with the consensus. I’ll take that.

21 July 2024 (Sunday) - In The Future

Here’s something that made me think. What will the effect of AI be on what we do?

When I first started in this game forty-three years ago I spent a few months in each part of pathology to get a feel for what I might like to do.

At the time I was told that clinical chemistry was ripe for automation but it would never happen with haematology. I’m reminded of Arthur C Clarke’s comments about the failure of imagination; the people with whom I worked all those years ago wouldn’t recognize where I now work.

I’m not saying that AI will wipe out biomedical scientists.

I’m not saying that biomedical scientists will be safe from AI.

I am saying that the future won’t turn out anything like we imagine it will.

As the Hitch Hiker’s Guide to the Galaxy said about grammar in the future, “the term "Future Perfect" has been abandoned since it was discovered not to be.”

18 July 2024 (Thursday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was presented with two cases:

87818 – a fifty-year-old chap in the outpatient department needing group & save.
The ABO group was inconclusive, but the RH(D) group was negative.
The antibody screen was positive in cells 1 & 2 so I requested antibody panels. The IAT and enzyme panels were positive in cells 1, 2 and 3 corresponding with anti-D but not excluding anti-Cw.

48596 – a fifty-one-year-old woman also in the outpatient department needing two units of blood. Sadly the NHS number on the blood sample was completely different from that on the accompanying form so I rejected the request.

I got the green light.

Mind you, I find myself wondering just how much use this simulator is to me. It doesn’t really simulate what I do at work on a daily basis. If I make a mistake at work (which we all do from time to time) I would be mortified, and fret about it for weeks. However I get this thing right with a sense of serious achievement and amazement.

18 July 2025 (Thursday) - Oncology Central Update

The most recent Oncology Central newsletter appeared in my in-box this morning. You can read it by clicking here. I had a wry smile at the bit about acupuncture having a role in modern medicine. Back in the day this would have been laughed out. Nowadays people would seem to be doing what science should be about – seeing that something happens and finding out why rather than just laughing because it doesn’t fit the theory.

To be honest this is something of which I am guilty. We all know that dowsing is a load of rubbish and has absolutely no basis in science… it really annoys me that I can do it.

17 July 2024 (Wednesday) - Auer Rods

I was mooching about on the Facebook Haematology Interest Group when I found their archive of case studies. Here’s an interesting one – a particularly strange case of AML with Auer rods in the mature neutrophils.

15 July 2024 (Monday) - BTLP-TACT Exercise

Time for another BTLP-TACT exercise. I was presented with two cases:

62583 – a forty-nine year-old woman in out-patients needing a pre-operative group & save.She grouped as A Rh(D) Positive with a negative antibody screen
11943 – a twenty-four year-old chap in A&E needing two units of blood within the hour. He grouped as O Rh(D) Positive with antibody screen positive in cells 1 & 3. I requested antibody panels.

The IAT panel was positive in cells 1, 3, 6, 9 & 10 corresponding with anti-Fy(a) but not excluding anti Cw or anti-Lu(a). The enzyme panel was negative throughout. According to BTLP-TACT this excludes anti Cw or anti-Lu(a)

I selected two units of ORh(D) blood that were Fy(a) negative

I got the green light.

15 July 2024 (Monday) - Gaucher's Disease

#LearningMonday… continuing being a reactionary old fart, I hate hashtags. But I do like the Learning Monday idea. This one was a good one… which is the most unlikely diagnosis. Initially I plumped for PNH as it is a disease of older people.

But… Gaucher’s disease… what’s that?

There’s a Wikipedia entry on the condition here. I know that proper science sneers at Wikipedia, but as a starting point it is hard to beat. Apparently Gaucher’s disease is one in which glucocerebroside accumulates in cells and certain organs… one of the places it accumulates is in macrophages which have a distinctive appearance in bone marrow smears… and to complicate the issue there are also pseudo-Gaucher cells.

I learned something here…

12 July 2024 (Friday) - UKAS Update

The nice people at the UK Accreditation Service sent their update today. You can read it by clicking here. On the one hand the reactionary old fart in me thinks it is a load of blah-blah-blah. On the other hand I realise that regardless of what I might think, UKAS has a bigger bearing on my professional life than any other body. Like it or lump it, this is the way forward. And like it or lump it I am better off being aware of what they are up to and what they are suggesting.

The biggest problem with their updates is that they say a lot without saying very much. What exactly is an ISO standard, and what is a mistaken interpretation of an overworked assessor?

The cynic in me would take them far more seriously if they openly published their standards rather than demanding one hundred and sixty quid for a copy of them.

10 July 2024 (Wednesday) - IBMS Update

The IBMS sent their newsletter for members today. You can read it by clicking here.

It made me think. Though not about that which CPD should make me think. The whole point of CPD is that I learn something new, or find that what I thought was good practice isn’t.

Over the years I’ve come to realise that I *don’t* get this from my professional body. Again the IBMS newsletter was all about what people have done and who is on what committee. This month the IBMS sent out all sorts of awards, and as I have said many times before, singling one out for praise cheapens the efforts of thousands who have done the same but gone unrecognized.

My first on-line rant about this subject was nearly eighteen years ago – click here and look up 13 September 2006, and I ranted along similar lines on 4 January 2007.

My thoughts right now are that it costs me sixteen quid a month to be a member of the IBMS and now that they don’t offer professional indemnity insurance I really have to ask what I get for my money.

There’s reflection, eh?

9 July 2024 (Tuesday) - Redeeming Myself

After yesterday’s little balls-up I thought I’d better see if I might redeem myself. I was presented with two cases:

68506 – a fifty-nine year-old woman in theatre requiring two units of blood for tomorrow.
She grouped as A Rh(D) Positive with a negative antibody screen.
I issued two units of A Rh(D) Positive blood.

54326 – a seventy-nine year-old woman with haematemesis also requiring two units of blood tomorrow.
She grouped as B Rh(D) Positive also with a negative antibody screen.
I issued two units of B Rh(D) Positive blood.

I got the green light. I suppose if nothing else this made me sit up and take notice about one feature of the software – to which patient the units are being allocated.

8 July 2024 (Monday) - Getting the BTLP-TACT Wrong (Again!)

Time for a BTLP-TACT exercise. I was presented with two cases:

54995 – a twenty-one year-old chap needing four units of FFP for the next morning

The ABO group was indeterminate being B in the cells and AB in the serum, but was Rh(D) Positive, and had a positive antibody screen in cells 1 & 2. I selected antibody panels. The IAT and enzyme panels were positive in cells 1, 2, 3 and 4 corresponding to anti-C and anti-D but not excluding anti-Cw… even though the patient was Rh(D) Positive.

I selected four units of B FFP. The guidelines said to give it

https://www.nature.com/articles/s41598-024-54379-0, and methylene blue inactivated is no longer needed for someone of that age.

https://rightdecisions.scot.nhs.uk/m/dbjpyafg/fresh-frozen-plasma.pdf

53685 – an eighty-six year-old woman needing four units of FFP and two units of cryo prior to a liver transplant.

They grouped as A Rh(D) Positive with an antibody screen positive in cell 2. I selected antibody panels. The IAT and enzyme panels were positive in cells 2 & 6 corresponding with anti-K.

I selected four units of A FFP and two units of A cryo. The guidelines that I could find on the spur of the moment seemed rather vague so I thought I’d rather be wrong for doing something than be wrong for not doing something.

I got the thumbs down. Apparently I selected all the plasma products for the second patient.

8 July 2024 (Monday) - Learning Monday

Thrombophilia wasn't something I ever formally studied so in my mind it is one of theise "new fangled" things... Which is exactly why I (and we all) need to do CPD.

I got the answer right. Which was something of a result...

5 July 2024 (Friday) - BTLP-TACT Exercise

Time for another BTLP-TAXT exercise. I was presented with one case – a nineteen year old woman in theatre.

She grouped as B Rh(D) Positive with a negative antibody screen.

I got the green light.

2 July 2024 (Tuesday) - Fritsma Factor Update

The Fritsma Factor update appeared in my in-box today. You can read it by clicking here. Unlike previous instalments this one was rather dull, but all good background reading if nothing else.

2 July 2024 (Tuesday) - BTLP TACT Exercise

Time for another BTLP-TACT exercise. I had one case – a forty-four year-old chap with appendicitis requiring group and save.

He grouped as O Rh(D) Positive with a negative antibody screen.

I got the green light.

1 July 2024 (Monday) - Learning Monday

Learning Monday…. Thrombocytopenia with apparently normal megakaryocytes in the bone marrow? Immune thrombocytopenia.

I quite like these little exercises. Especially when I get them right…

26 June 2024 (Wednesday) - Westgard QC Update

The nice people at Westgard sent their update today. You can read it by clicking here. It’s a tad dry, but it’s the sort of thing that is relevant to what we do every day.

25 June 2024 (Tuesday) - Transfusion Evidence Alert

The Transfusion Evidence Alert email arrived in my in-box this morning.

Back in the day the worst thing that you could do with a bag of platelets was to stick it in the fridge. Now this is being encouraged.

And transfusion volumes – one unit transfusions were a no-no. Now one unit is the amount most people seem to have.

One thing I’ve found over the years is that what is terrible practice at one moment becomes standard practice the next.

ARTICLE OF THE MONTH

Andexanet for factor Xa inhibitor-associated acute intracerebral hemorrhage.
Connolly, S.J., et al. (2024). The New England Journal of Medicine.
PICO Summary available

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