In My Blood

In most other workplaces, a blood-spattered desk would be cause for a police investigation.

For me, it was just Friday.

Let's just say that if blood or other bodily fluids and excretions bother you, you probably don't want to pursue a career as a medical laboratory scientist.

But maybe you do want to pursue that path. Maybe you love medical science but aren't masochistic enough to put yourself through medical school. Maybe you love helping sick people but don't want to be anywhere near them while you do, because, frankly, they're a little needy. Maybe you love biology and lab work, but don't want to spend a lifetime begging for grant money to keep your cell cultures or graduate students fed. There's hope for you yet! Stay tuned to find out how you too can have a vibrant healthcare career!

I know, I'm a ridiculous infomercial, but I feel like it's my duty to promote my profession, because there are too few of us out there, and we're not well understood or respected. I want that to change. Everyone knows about doctors and nurses, but the third vital side of the healthcare triangle, the medical "techs", live in relative obscurity.

The Board of Certification for medical technologists here in the US changed things up a couple of years ago and tried to give us more respect by changing our title from "Medical Technologist" to "Medical Laboratory Scientist". It was a lovely gesture, but it didn't really help. I mean, I didn't get a raise or a talk show or anything, and I still get a blank stare and polite nod when I tell folks what I do. Although I think people picture a lab coat and some test tubes now, which is a little closer to right.

I write about my work sometimes on this blog, and last year, I wrote a series of posts here for Medical Laboratory Professionals Week. Some of them explain the science and techniques behind laboratory tests, and some of them are about my experiences in the various labs I've worked in. I would very much like to do that again this year as a way to raise awareness about the profession. I never heard about medical laboratory science careers until I was already through university with a Bachelors in Physiology and couldn't find much to do with it. I hope that by writing about it here, I can make the profession just a little more visible, and maybe inspire someone to look into it as a career.

Even if I can't inspire anyone to get into a lab career, maybe I can help people understand what the job is about. Why do you only have to fast sometimes before a blood test? What happens to a blood donation? How does blood tell the doctor how sick someone is? I'd love to make Medical Laboratory Professionals Week into a sort of Q&A session, but for that I will need your help. Does anyone have any Qs that I can A?

What do you think the job is? Have you ever heard of it before? What would you like to know about labs, blood, and medical tests? I'm getting started early this year because I want to collect questions and get to work answering them well. I want to give myself time to draw diagrams and take pictures and maybe even interview folks in different types of lab positions, so I can really do right by my profession and show off my colleagues as the caring, intelligent, dedicated people they are.

So, hit me with your questions, and I'll do my best.

Lab skills or life skills?

Considering how many hours I have spent working in laboratories, I suppose it was inevitable that lab experiences would begin to influence my everyday life.

The rinsing principle

Let's say I'm going to wash up a unit of red cells to use in a procedure. First, I have to cut the bag open and pour the blood into a big centrifuge bottle with some saline solution, which is a messy process. But no matter how hard I shake it, there are always some red cells left clinging to the inside surfaces of the bag. I want to get as much of that into my bottle as possible, so I squirt in some saline from a squeeze bottle and swish it around the almost-empty bag to get all the good stuff out.

This is a remarkably useful process to bring into real life. For example, when I get to the end of a carton of coffee creamer, I spoon some coffee into it and swirl the carton to clean off its insides, then pour it all back into my coffee cup. I've also been doing it with jars of spaghetti sauce, because I can never get all of it out, even struggling with a spatula. I dump the jar out onto one side of the pot of cooked pasta, then I scoop up some of the uncoated noodles, pop them into the sauce jar, shake it up good, and then dump the noodles back into the pot. Less waste!

Butt-operated doors

Gloves and door handles aren't supposed to meet, since gloves are potentially covered in nasties. I've developed a butt-first approach to swinging lab doors that really works for me. Back into the door, gentle shove with my butt, and I'm through. I do this more often in non-lab settings than I'd like to admit, probably to my husband's embarrassment. If the door has a lever-style handle, I can navigate that quite easily by adding my elbow to the procedure. I lean down, push with my elbow, and then bump the door with my hip to get through.

It's somewhat more complicated when the door opens towards me, but I've recently been practising and can often use my elbow to get the door opened wide enough to stick my foot into the opening and swing it the rest of the way. Very useful in public bathroom situations.

Regular round doorknobs have thus far remained beyond my skill level.

The microbiology grip

You're supposed to keep things sterile in microbiology, because one tiny mold spore or bacterium getting into your culture medium can ruin everything. That's why microbiologists do most of their work with their arms inside special biological safety cabinets whose airflow and HEPA filters minimize the possibility of contamination. Still, sometimes you've got to unscrew the cap on a tube of media you want to inoculate, and you can't just put it down on the desk. Solution: the Microbiology Grip.

It can be accomplished with the pinky finger of the dominant hand:

Pinky technique - image from eplantscience.com

Or, if one absolutely needs the strength or dexterity of the thumb and index fingers to unscrew the cap, one can try the claw grip, but the inoculation wire or loop ends up being held awkwardly, and I think there is less control with this method.

Claw-style - image from ndsu.edu

And where, you may ask, am I finding a use for such a grip? Toothpaste. Not because my sink is so disgusting that I don't dare put down a toothpaste cap, but because my hands just do it anyway. Muscle memory is no joke. I hold my toothbrush like an inoculation loop in my right hand, then pick up the toothpaste tube in my left, bring my hands together, and unscrew the cap by gripping it with my pinky and then twisting both hands in opposite directions. I keep the cap firmly in my pinky grip while I apply toothpaste to my brush, and then I recap the tube and brush my teeth.

Laugh at me if you wish, but I can be confident that there are no mold spores in my Crest Complete with Scope.

Lab Week Q&A - Bar Codes

 Part two of yesterday's question was about bar code labels.

Wait, are the colors of caps consistent across labs? I seriously always just figured it was an internal thing, and the bar codes on the sides were the important parts of communicating info to other labs if blood had to be sent out there.

 

While the cap color is extremely important in blood collection, because the quality and usability of the specimen depends immensely on how it was collected and stored prior to testing, it doesn't tell the lab what tests to run. The bar code, tied into the Laboratory Information System (LIS), has that job. The way it normally works is that a test is ordered by a physician (usually physically entered into the computer system by a nurse or a member of administrative staff working at the nurses' station), the computer puts that information into a bar code format, which is printed out and brought to the patient's side so the blood can be drawn and the tubes labeled with those bar codes. The bar codes usually list the test and the approved tube color in human-readable language, which is helpful for the staff acquiring the specimens.

Once a tube gets to the lab, the bar code is scanned, acknowledging receipt of the specimen. This time stamp is important because hospitals take turnaround time, or the time it takes from receipt of the specimen to release of a result, very seriously. The scanning is sometimes done manually by an accessioning tech, and then brought to the appropriate area of the lab, but in most larger hospitals, tubes are brought to an automated track system, where they are scanned, sorted, centrifuged if necessary, and brought around the lab where they're sampled directly off the track without a tech ever needing to touch the tube.

Automated track system (Beckman Coulter)

An automated system like that is great for many reasons. It can improve the speed and throughput of the lab, because nothing needs to wait for a tech to bring it to the next instrument. It's good for safety, because any time you can eliminate contact between a person and a blood specimen, you've eliminated a chance of exposure to a bloodborne pathogen like HIV or Hepatitis B. It's got its drawbacks, however.

One big issue is that the instrument doesn't look at the tubes. It only sees bar codes. If a specimen somehow sneaks by without getting de-capped, the specimen probe on the instrument will smash into the cap, expecting a clear path to the serum. The probe has a liquid sensor, and only starts aspirating serum when it feels the top of the liquid. It's expecting the tube to be full - if it's a very short draw, there's a risk that it will keep going and suck up the gel separator in the tube, gumming up all the tubing in the instrument and shutting it down for cleaning. That's why our lab had this sign posted by the inlet of the automated track:

Inlet of the automated line, with warnings!

Also, because all the instrument knows is the bar code, if someone puts the wrong label on a tube, there's no easy way to know unless someone is very careful about checking every tube before it gets put on the line. Ideally, they would all get a check, but when the workload is very high, some can get missed. Normally a label error is immediately apparent, like when a lavender tube, which is supposed to be diverted to hematology, chugs along the track towards the centrifuge to be spun - it's easy to spot because it's shorter than the chemistry tubes. If it gets all the way to the instrument without raising suspicions, say, if a tall pink top is labeled with a Chem-7 bar code, the results will cause the tech to pull the tube off the line and have a look at it. The potassium will be so high as to be incompatible with life!

Bar codes make it easier for the lab staff, because it saves us the trouble of having to program all the tests in manually for every single specimen. It saves us a lot of time when the instrument can read the orders and get the tests done. However, when specimens are sent out to other reference labs for more esoteric testing, they can't read the barcodes produced by our internal computer system. We have to fill out paper requisition forms and then send the tubes off (or poured-off serum) in special packaging, sometimes on dry ice, sometimes at room temperature, whatever the reference lab requests. Some hospitals have the system computerized and can fill out online requisitions and print out reference-lab-specific bar codes for the specimens - because the reference lab will have their own computer system and won't be able to use the original bar codes. It's like our bar codes are in German, but the other lab needs them to be in Finnish. We can either give them all the information on paper and they'll make their own Finnish labels when they get the specimen, or we can use their software to do that ourselves. That requires a special arrangement between the two labs, and not everybody has the resources to do it.

Even with the help of the bar codes, we still need to order things manually sometimes when tests are added on later, or if tests need to be repeated, but the only time the lab does everything manually is when the computer system goes down.

Two bad things can happen with the computers. The hospital system can go down, or the lab system can go down. In our facility, it was two separate systems, so although they could speak to each other, either one could die independently, leaving us with two different kinds of messes. If the hospital system goes down, the floors send down the tubes with patient-information labels that look like the patients' hospital armband. They include a "downtime" order form where they can check off all the tests they want run. Then we can order the labs on our end, getting bar codes, sticking them over the other labels, and proceeding as usual. The instruments still know what to do, the results still come onto our computer screens for analysis, and we can call, or print out and fax, the results to the floors. That's tedious, but not terrible. When the lab system goes down, it's chaos. We log receipt manually and program tests manually. We keep reference sheets handy to confirm panic values and normal ranges, and we fend off calls from the floors asking why everything is taking so long. We keep piles of instrument printouts so we can later manually enter everything into the computer. Some instruments will allow you to re-send the data once the system is back up, but not all of them. We love bar codes and computers. Very, very much.

Lab Week Q&A - Color coded blood collection tubes

As much as lab week is about celebrating the work of laboratory professionals, I see it as an opportunity to educate people about what happens in a lab. You get blood drawn, and you get results back, but what happens in between? I hope that I do a good job explaining things - please let me know in the comments if there's anything I missed or that you'd like to know more about.

The question for today is:

Wait, are the colors of caps consistent across labs? I seriously always just figured it was an internal thing, and the bar codes on the sides were the important parts of communicating info to other labs if blood had to be sent out there.

I'm going to break this into two parts, about tube colors and bar codes, and address each one in a separate post. I'll start with the colors.

If you've ever had lab work drawn, whether at a doctor's office, a hospital, or an external collection site like LabCorp, you may have noticed that when they take more than one tube of blood, the caps on the tubes are usually different colors. That's because there are different requirements for how the blood is treated and transported before it gets tested.

Common tube colors - from bd.com

Cap color is indeed consistent across labs. More accurately, you could say that it's consistent among the major manufacturers of blood collection tubes. It's possible that the manufacturers are doing this voluntarily, but I suspect there may be a federal entity like the Food and Drug Administration (FDA) involved, since it could hugely affect patient safety. Even if there is no official rule about cap color in the Code of Federal Regulations, I suspect that someone trying to market an EDTA tube with a green cap would find a very grumpy FDA inspector on their case.

Now, EDTA (ethylenediaminetetraacetic acid) probably doesn't mean much to you, yet. I'm here to tell you that it's an anticoagulant, one of many, used in blood collection tubes. Depending on what test is being run, we want the blood to act in different ways. I'll go over the most commonly used tubes and explain what the cap colors mean and what sort of tests each type is normally used for.

Pink or Lavender - EDTA

EDTA tube - from bd.com

Both pink and lavender tubes contain EDTA, which is a chemical that binds with and ties up calcium ions. Because blood needs calcium ions present in order to initiate the clotting process, blood that is collected into a pink or lavender top tube (and well mixed) will remain liquid.

Lavender tubes are generally used for complete blood counts (often shortened to CBC), which includes things like white cell and platelet count, and hemoglobin. This makes sense - if we're trying to do a platelet count, we need the blood to remain liquid, since a clot is going to tie up a bunch of platelets. If a number of blood cells are tied up in a clot and unavailable for the instrument to count, then the count will seem a lot lower than it really is. A CBC is one of the most commonly ordered tests, because it can tell a doctor about infection (high white cell count) or anemia (low red cell count), which are common reasons for doctor visits. You're very likely to have a lavender tube drawn if you're getting lab work done.

The main difference between the two colors is that the pink top tubes are generally bigger, and get spun down in a centrifuge to separate the plasma from the cells. The pink tubes are primarily used in the blood bank, because we run tests on both the cell part and the plasma part of the blood. We could use lavender top tubes, but we like to have a bigger volume of specimen to work with, in case we need to start cross-matching blood for the patient, which will use up the plasma. Also, the rules for labeling blood bank specimens are usually more strict, and having a bigger tube leaves more room to write out the patient's information.

Light Blue - Sodium Citrate

Sodium Citrate tubes - from bd.com

Blue top tubes are used primarily in coagulation studies, like monitoring heparin or warfarin therapy, or looking for clotting disorders before a patient goes to surgery. Sodium citrate, like EDTA, also prevents clotting by tying up calcium ions, but it's better than EDTA in preserving the rest of the blood's clotting factors. The tubes are always the same size, and contain a set amount of sodium citrate. Most coagulation tests start by adding some calcium back in and seeing how long it takes for the blood to clot, so it's extremely important to fill the tubes all the way. An underfilled tube will have an excess of sodium citrate, which will tie up some of the calcium the instrument is adding in, which will make it look like the blood's taking a very long time to clot. If you aren't on blood thinners, and you're not showing signs of a clotting disorder, you aren't likely to see the phlebotomist pull out a blue tube.

Light Green - Heparin

Heparin tube with gel separator - from bd.com

These were the most commonly used tubes in the chemistry section of the hospital lab. They're used for glucose (blood sugar) testing, electrolytes like sodium and potassium, and other important analytes like cholesterol, liver enzymes, and cardiac markers that can indicate a heart attack. This anticoagulant is usually a Lithium-Heparin salt, instead of a potassium or sodium salt, because most basic metabolic profiles (you'll sometimes hear them called a Chem-7 or Chem-some-other-number on TV medical shows) will measure potassium and sodium, and we don't want to falsely increase those numbers with our anticoagulant. We also can't use EDTA, because the calcium would look too low. 

Because chemistry testing is focused on the plasma, the blood is centrifuged to get the cells out of the way. Some tubes go an extra step with a built-in gel barrier, which keeps the cell portion trapped below so that even if you invert the tube, the cells stay put. This makes it easier to aliquot the sample (take small volumes from the main tube for other testing) without disturbing the cells and making it necessary to spin the tube again.

Gold - Gel Separator, No Additives

Gold tube, no additive - from bd.com

In situations where it's okay for the blood to be clotted, a gold top tube can be used. It has no anticoagulant, so after the blood has been in the tube for a few minutes, it will form a nearly solid clot. Once spun, the tube will have cells and serum separated by a gel barrier, which makes it easy to pour the serum off into other tubes for separate tests. These tubes are often used when the serum is to be sent to an outside lab for special testing (anything not done at the lab where it's drawn), because it's easier to pour the serum into transport tubes for refrigeration or freezing, and they're a little cheaper because they have no additives. 

Many labs use these as their workhorse tubes, accepting them instead of heparin tubes for chemistry workups. I don't actually know why the lab I was working in used the green tubes for most of the chemistry - a lot depends on the instruments being used in the lab and whether they have specifications for the test material. If your test's instructions say it needs to be a heparin tube, then that's what you should use, because the results may not be reliable if you use something else. Also, it's better for the patient if we can run several tests off of one tube, and not just to keep costs down. Repeated blood draws can lead to bruising, and if excessive, to phlebotomy-induced anemia. So, if you can choose to use either a green or a gold tube for a certain test, because both are allowed by the instrument's specifications, but another important test in the lab needs to be on a green top, it may make sense to bundle those tests together onto one tube.

Other - Special Cases

Some other colors are out there, but they're used infrequently and you're not likely to see them unless you're having fairly rare tests done. In our lab, dark blue tubes were used detection of heavy metals like copper or lead, because the tubes and interior of the caps were free of trace metals. Red top tubes had no additives, like the gold tubes, but contained no gel separator, so they could be used for some therapeutic drug levels - the gel has a tendency to absorb some drugs over time, so a red top would be more accurate in those cases. Gray tubes were used for lactic acid levels, but some places use them for glucose, because the potassium oxalate anticoagulant in the tubes stops the red cells from using it all up.

While different labs will use the same tubes for different tests, depending on their methodologies, a lavender top tube in one hospital will contain the same additives as one in any doctor's office. It's common sense, really - you don't want a part-time employee who works at two different facilities to get confused and use the wrong tube for a specimen collection, because it's what he's used to at the other job. Yes, it gets looked at in the lab, but we're all human and sometimes a wrong tube can go on an instrument, and since all the instrument does is read a bar code and perform the tests it's instructed to, you'll still get a result, and it may be very wrong. Consistency is key to medical and laboratory safety.

Become a Bone Marrow Donor

No, I'm not asking you to run to the hospital and offer up your hipbone for a bone marrow extraction. You'll probably never get a call, never get a chance to save a life with such a gift, and never have to think about it again. But what if? What if you're a match for someone dying of leukemia?

I saw a post from Wil Wheaton on Facebook, about a wonderful idea someone had to put a bone marrow registry kit inside a package of bandages, making it easy and simple for people to send in a sample for testing - they're already bleeding!

I've considered joining the registry before, but never got around to it. The main thing that held me back, I'm ashamed to say, is that it wasn't free. Sure, I would like to help out, but to go to the trouble of sending in some swabs or blood and have to pay for it, so that ten years from now they can call me and suck bone marrow out when they need it? No wonder so few people are registered bone marrow donors.

When Wil posted the link, I was curious to see who was going to pay for all that expensive genetic testing, so I followed a tree of links back to DKMS Americas, a bone marrow donor center and registry with over 3 million registered donors worldwide. They are the ones behind the bandage kits, and they also offer a much-less-bloody option of mouth swabs for testing. Also, these great folks will send you a registration kit for free.

I like free.

I gave the website my information and I received my donor kit in the mail within a week. The process was remarkably easy. The package contained a set of sterile swabs and a special envelope to seal them in, a donor card, a letter of thanks, and a return envelope. A postage-paid return envelope. Getting yourself on the bone marrow registry won't even cost you a stamp.

I rinsed my mouth out with water, swabbed the inside of my cheeks for ten seconds, let the swabs air-dry in my hand for a minute, and then sealed them up in the envelope before putting it into the return envelope. It took me longer to write this paragraph than it took me to do the work.

Now, honestly, I'm not sure how helpful I will be to the bone marrow registry. I'm Caucasian, from a long line of Caucasians with mostly Western European ancestry. Most registered donors are of a similar background. But people of every mix of ancestry get leukemia, and that's the problem. You see, as much as everyone is equal, no matter where they come from, certain sets of genes vary quite a bit among different populations. A Pacific Islander will have a different pattern of genes than a Hispanic person, which means that donors and recipients usually need to have similar ancestry in order to have their genes match up well. The hardest patients to find donors for are ones with two parents from different populations. A child who is half-Chinese and half-German will have a very hard time finding someone whose bone marrow can save his life.

But it doesn't matter what you are. I'm doing this because I've seen too many of my friends and family fighting cancer and genetic diseases, and if there's a chance I can help anyone else fight their disease, I'm going to do it. Follow my link and head to the site so you can read up on bone marrow donation. If you want to do it, that is fantastic and makes me very happy. If you would prefer not to take the chance of having to donate bone marrow sometime in the future, that's okay too - I'm not trying to guilt anyone into doing something they don't want to. But if you're not going to do it, please spread the word to someone who might. Share my post, or like DKMS Americas on Facebook. Even better, you can make a donation to DKMS through their website. If you don't want to get tested, your donation can still help them pay for someone else's registration kit and testing.

Thanks for listening.

Blood bank lesson: blood group antigens

I've been at the new job for a week now, and I'm thinking it's going to work out. I've been asked what exactly I'll be doing there, and I would like to explain, but first you'll need a blood bank lesson or two.

You've got stuff on your red cells. They're little nubbins of proteins and sugars, and we blood bank types call them antigens. They're genetically determined and you inherit them from your parents, so what's on your red blood cells will be a mix of what's on your Mom's and on your Dad's. You're probably familiar with the A and B antigens, since they determine blood type, and the D antigen is the one that makes you "Rh positive". Those were the first ones discovered, a long time ago, and since then there have been dozens more, if not hundreds, added to the list. Scientists, having a deep-rooted need to sort, classify, and name everything, have sorted, classified, and named them all. For some people, these antigens become an issue.

When you get a blood transfusion, you're exposed to a mix of antigens from the donor's cells, and your immune system might decide to make antibodies against the ones it's not familiar with. The same thing happens in pregnancy, because the baby's cells will have some antigens from the father's side, which the mother's body has never seen. There's no guarantee that you will develop an antibody if you're exposed to something new, but once you've made an antibody, we have a problem.

Let's say you get a blood transfusion from someone who's got the Kell antigen on their cells. It's a common one - about 90% of people have that one. If you're in the 10% of people who are Kell-negative, you might make an antibody in response to your exposure. Next time you go to the hospital and need a transfusion, the blood bank will find the antibody in your blood when they do a "type and screen". Once they've done their investigative magic and figured out the identity of your antibody, they will have to find you some blood that doesn't have the corresponding antigen on it, because now that you've got those antibodies in your system, if you see the Kell antigen again, your antibodies will destroy those transfused cells and all the red cell guts will be free in your blood and that's a bad thing.

How do they find the Kell-negative blood for you? With antibodies! There are commercial preparations of purified Anti-Kell (and anti-pretty-much-everything) that the blood bank can buy and use to test blood units. So they'd take a little drop of cells from the donor units, and mix them with this antibody solution, and see if the cells clump up. If they do, the cells are positive for the Kell antigen, and you can't have those. The ones that don't clump up are safe for you, because if this Anti-Kell solution doesn't clump up the cells and destroy them, neither will the Anti-Kell you've got floating around in your plasma (the liquid part of your blood).

Recap: Blood group antigens are on your cells. When you're exposed to a foreign antigen, you can make an antibody that will remain in your plasma, which can make subsequent exposures dangerous. Blood bankers use antibody solutions to test blood for specific antigens, when necessary, to be sure to avoid that situation.

Questions from the class?

My Blood Donation

The hospital blood drive was Monday, and I decided to put my money where my mouth is and roll up my sleeve to donate a unit myself, instead of just recruiting others to do it. I had a bad experience at my last donation a year ago, and I was reluctant to try again, but I've been feeling like a hypocrite, thanking everyone for their donation while sitting at the juice counter with a magazine. It wasn't difficult at all and I feel much better about myself now that I've done it.

I'll describe the whole donation process for you, from sign-in to cookies, and maybe it will take some of the mystery out of it and encourage some people to try it for the first time.

Mr Bill, the Red Cross volunteer, checked me in at the front desk and gave me a big sticker with my name on it so everyone would know who I was and could call me Jen instead of "miss" or the dreaded "ma'am". I signed in at the computer (touch-screen, fancy!) and then I read a small booklet of information before going in to wait for my interview. The booklet contained some general guidelines about donation, so people who might not qualify could find out right away and not waste their time - there was a page about mad cow disease and the countries on the exclusion list, along with information about age, weight, and health requirements. There was a list of excluded medications, and a description of what would happen to your donation once it was taken. If you read all that and still feel like you're eligible and ready to donate, then you head to the waiting area.

I only waited a few minutes before a booth opened up, and a Red Cross employee called me over for the physical and interview. I handed over my ID and confirmed my name, address, and date of birth, and then she took my pulse and blood pressure. Once all that checked out, she measured my hemoglobin level with a little machine that looks like this and takes a drop of blood from a fingerstick. If you know anyone who checks their blood sugar for diabetes, it's almost exactly the same process, except it measures hemoglobin instead of glucose.

Fun fact: they're not measuring your iron level. Hemoglobin level is related to how much iron is in your blood, but taking an iron pill the day before a donation will not boost your hemoglobin level, because red cells take days to form, and they take up iron to make their hemoglobin early in that process. Hemoglobin is a protein packed into your red cells, and it contains iron and transports oxygen. In this context, it's a quick and dirty way to check how many red cells you have, to see if you've got enough to give.

My hemoglobin level was spectacular, so I was cleared to donate, assuming I passed the questionnaire portion of the interview. They no longer sit beside you and read you the questions - I guess maybe they found that people were more likely to lie if someone was right there. It's all done on computer now, with a series of yes/no questions about sexual activity, drug use, health, and travel. It's a smart system - if you say no to travel outside of the United states and Canada, it skips the questions about travel to the UK or Mexico or any other potentially problematic places. Having never traded money for sex or enjoyed a wild night of intravenous drug use, I passed with flying colors and was brought over to the donation chairs.

The phlebotomist (big word for the day, it means "health worker trained in drawing venous blood for testing or donation") handed me a little squeeze toy and then pumped up a blood pressure cuff on my arm to make a vein pop out. Once she found a vein she liked, she swabbed my arm with a squishy iodine swab for 30 seconds, told me to get ready, and then poked the needle in. It hurt a little, because, hey, it's a needle. But it wasn't too bad. She covered it with a little square of gauze so I couldn't see it, in case I was one of those fainters, and then she got to work on the blood unit.

As the blood came out of my vein, it went through some tubing into a small pouch, from which the phlebotomist took samples into a handful of tubes for testing. They need to check my blood type, obviously, but also check for all those communicable nasties like HIV, hepatitis, and West Nile Virus. After that, the blood zipped past the pouch into the big collection bag, which was hung from a hinged pole so that it would be obvious when it was full enough - the bag reached the target weight, the hinge dropped down, and one of the techs came to seal it up and unhook me. The actual bleeding part of the donation process lasted about 10 minutes.

Once the needle came out of my arm, I pressed a ball of gauze against the site for a full minute with my arm above my head, to be sure my platelets had time to do their thing and plug the hole from the inside. The tech wrapped a stretchy bandage around my arm and thanked me for my donation, and then I was free to raid the canteen. They have Keebler cookies now, which is awesome. I had some rainbow chocolate chip cookies and a can of orange juice, and then I was back out at the front desk helping Mr Bill with his computer and thanking everyone who came in to donate.

A day later, I'm feeling a little tired and worn out, but I'm not sure how much of that is from the blood loss and how much is due to working a 14-hour day, not getting enough sleep, and then getting up too early.

We got 29 units out of this drive, which isn't bad but I would really like to see us get above 30, especially considering we give out 500 units of blood to our patients in an average month. We actually had 39 people show up and try to donate, but 10 of them were deferred because of low hemoglobin levels, travel, or illness. I'm encouraged by the turnout and I'm looking forward to the next drive. Nine laboratory employees donated, which is a record and something to be proud of.

Go donate blood! If a wimp like me can do it, so can you!

Can I give blood?

Another blood post! I'm really trying to increase the percentage of posts about the lab tech life, because I know some of my regular readers are interested, and I also think it's important to boost awareness about the profession.

I think I've mentioned this before: I am the hospital's recruiter for our regular blood drives. This means I wander the hospital, clipboard in hand, and ask people if they would like to make an appointment to donate blood. Some people avoid eye contact, as though I worked for that irritating booth at the mall where a young employee chases you down with hand lotion samples. Made with real Dead Sea kelp! Some people will answer me with a shake of the head and little more, but often I will hear reasons why they cannot or will not donate.

Some people are afraid of needles. And you know what? I don't push them. A fear is a fear, and I'm not going to get aggressive and call them sissies (well, ok, it depends how well I know them) because they have a terrible fear of needles. I sometimes take a second and reassure them that it's not painful beyond the hemoglobin check, for which they prick your finger, and the insertion of the needle in your arm. Once it's in, you don't really feel any pain. But if you're going to faint or scream when the needle comes at you, then you've got a good excuse to not come by. Maybe send a friend in your place, though? One who's not a chicken? I kid, I kid...

A lot of people say they'd love to donate but they just got a piercing or a tattoo. The rules were fairly recently revamped on that front, so if you had the work done in a state where tattoo parlours and piercing shacks are regulated, you're good to donate immediately. If unregulated, it's a twelve-month wait before you're allowed to donate again. The wait is because of the risk that you may have been exposed to hepatitis through used equipment, and twelve months is long enough for you to have gotten sick and found out about the exposure, or for the virus and/or antibodies to be present in your blood so they can show up when it's tested.

Travel is another big reason for deferral. You need to wait twelve months after visiting any area where malaria is endemic (normally present), which, unfortunately, is a whole lot of fun places to visit, including a lot of Asia, Africa, and Central America. So that Caribbean cruise to Mexico will take you out of the donor pool for a year.

Note: these criteria apply to the United States, more specifically the American Red Cross eligibility criteria. I do not claim to be an expert on these rules, so please refer to the ARC website for clarification. There's a phone number you can call if you have more specific questions.

It might happen that you study these rules carefully and decide you're eligible, and you show up to a blood drive, and a Red Cross employee tells you that you are actually ineligible. Maybe they're right, maybe you overlooked something. But they're human too, and there are a lot of rules to keep straight, and it's possible that they're wrong. Take the example of a person with a chronic medical condition, like Crohn's disease. The website says that well-managed chronic medical conditions, in general, are not reason for donation deferral. It's possible that a medication you're taking, or a medical procedure you've had recently, is what's actually taking you out of the pool, but maybe the Red Cross tech has never encountered Crohn's before and is trying to err on the side of caution.

This happened to a friend of a friend who had donated several times in the past with no problems, and I was asked what he should have done in this situation. I would have asked to speak to a supervisor and to see the eligibility criteria and I would want to know what about my condition made me ineligible. Was it out of possible risk to the recipients of my blood or was it because of apprehension about what a donation would do to me, someone with a chronic condition? Either way, I would have pressed the issue a little, because I know how valuable a blood donation is. It might make sense, if you're encountering problems like this, to try donating at a blood center instead of a random blood drive, because you're more likely to have access to a supervisor there.

So, go read the eligibility criteria! Get educated, and go give some blood!

Blood Bank Regulars

Someone mentioned to me that I need to post more about work and the blood bank, so I'm going to try. I'm not sure what people are interested in, and I don't know how technical to get before they give up and get frustrated and go look for videos of cats on Roombas instead, but I'm going to start somewhere and hope that people comment to guide me.

We have regulars at our blood bank. Safe in the basement of the hospital, where all good med techs belong, we crack jokes about them needing loyalty cards - get a punch for each unit of blood transfused and the tenth unit is on us. We never see the patients - we get their blood, type it and check for antibodies, crossmatch some suitable units from our supply, and send the blood up to the infusion center, the emergency room, or the hospital floors. But even without meeting these patients, we get to know some of them, whether we want to or not, especially those who have chronic conditions that bring them back week after week for scheduled transfusions. Or those with "problems" that make it hard for us to find them safe and compatible blood - when we see an order print down in the blood bank, and we recognize the name, it's not usually good. Impending doom is probably how I'd describe the feeling.

Like Mrs. B, who's up to 550 units over her lifetime and still going strong. She has a bleeding disorder, and her own body can't keep up with the blood loss, so she comes in for weekly transfusions. Because of all of these exposures to foreign blood, she's developed a couple of antibodies, and because of the specific ones she's developed, we need to get her special compatible units from the Red Cross. Sometimes she has a bad bleeding episode and comes in through the emergency room because she can't wait until her appointment, so we always make sure to have at least two units aside in the blood bank, tagged with "Save for Mrs B", so that in a crisis we can at least get her started with something while we get more shipped in from the Red Cross.

Or Mrs. M, who has such strong auto-antibodies that her cells clump together as soon as they come out of her body into a specimen tube, making it impossible to discern her blood type. We have to give her Type O blood because we just can't tease her blood type from her cells and plasma. We tried asking the nurses to preheat the specimen tubes and to bring them to the blood bank on a warmer or in a cup of hot water, but even that hasn't been enough to fix the problem.

One of our regulars passed away recently, and it depressed all of us. We'd been supporting her through regular transfusions for over two years. Over the course of those years, she developed more and more antibodies, making her case a complex one requiring a few hours of work from a dedicated tech each time she'd come in, and specially-typed units from the reference lab at the Red Cross for transfusion. We'd all grumble when we saw her orders come across the printer, and argue a little over who worked on it last time and whose turn it was, but we were all glad to be doing something to help this woman enjoy more time on this Earth with her family. Hearing that she was never coming back was a little hard on all of us.

We don't always find out what happens to the patients, because of privacy rules. Sometimes we suddenly stop seeing a patient, and we don't know if it's because they got better, got transferred, or passed on. It's very hard sometimes to have worked hard in the blood bank to help keep someone alive, and then not know if it succeeded. But by the time you start worrying about it, another patient comes in, so you just keep going.

Public Service Announcement - Blood Donation

You need to donate blood.

Blood is, so far, not something we can manufacture in a lab. We've come a long way in reducing the need for blood transfusions, with new surgical innovations to minimize blood loss in the operating room, and drugs to help a body boost its own blood cell production, but in the end, many patients can only be helped by a blood transfusion.

When your bone marrow stops making new cells, because of disease or because the chemotherapy for your cancer has killed your production system, you need a transfusion. If you have a clotting disorder or you've overdosed on heparin and are at risk of bleeding to death, you need a blood transfusion. If you're having heart surgery, you need a blood transfusion. If you've been in a crash and you left half of your blood at the scene, you need a blood transfusion. If you're born premature because your mother's antibodies were attacking your blood cells in utero, you need a blood transfusion. If your peptic ulcer, colon cancer, or intestinal polyps have been bleeding undetected, and you're fainting because your hemoglobin levels are so low, you need a blood transfusion.

At my hospital alone, we're transfusing almost 700 units of blood, platelets, and plasma every month. And that's with careful guidelines in place to make sure only those who really need this blood are getting it. We hold a blood drive every two months, and we rarely collect over 30 units of blood. The American Red Cross donor centers do better, but sometimes it's hard for them to keep up with demand. Right now levels of all Rh-negative blood are so low that we may have to contemplate putting off some surgeries in case we can't supply the blood the surgeon needs.

I know some people have moral issues with the Red Cross, specifically with their deferral of all male donors who have had sex with other men. Excluding gay men from the donor pool is not a decision that I personally agree with, but I don't think that my dislike of the Red Cross' rules should be enough keep me from donating blood and helping someone. I can show my disagreement with that rule in other ways, so why boycott the Red Cross and refuse to donate, when my blood might make a difference?

I'll be wandering the hospital today, trying to encourage nurses and doctors and everyone else to roll up a sleeve on Monday for my hospital's blood drive and give an hour of their day and a pint of their blood for someone who needs it. It's a thankless job - most people try to avoid eye contact and I end up feeling like a telemarketer. But in the end, every person who shows up to donate is a hero, so I'll put up with the discomfort and do my part to help get people giving.

Please donate. Anytime. Whatever your blood type. You can find donor centers and blood drives near you with this link, and you can learn more about blood and the donation process here. Please share this information, because the need for blood is constant - and every donation helps.

Public Service Announcement

If you or a loved one is ever in the hospital and is scheduled for surgery, please ask your nurses and doctors whether the blood bank has an in-date specimen in case you need blood.

Most surgeries won't even be big or bad enough to need blood, and most of the time everyone's on top of things and the blood bank has a "type and screen" on surgical patients long before they make the trip down the OR hallway. But sometimes, especially when it's a patient who's been in the hospital for a few days already, they can end up on the OR table, needing blood, and the blood bank has to tell the surgeon they can't have it immediately because the old specimen is expired. Trust me, that's no fun for anybody. Least of all the poor patient.

And when I say a specimen is expired, I don't mean it's gone moldy or anything. But your body is not static. Every single unit of blood you get challenges your immune system, and increases the chances that you'll form an antibody against a foreign protein on donor cells. So we ask for a new specimen to be drawn every 3 days, so we can catch any changes and detect antibodies before we give you incompatible blood. Blood that was fine for you three days ago might not be fine for you now, if your immune system made an antibody against something in it.

Antibodies aren't necessarily a big deal. In the majority of cases, we can still find compatible blood pretty easily, but the problem is time. A normal type and screen, where we confirm blood type and screen for antibodies to red cell proteins, takes a little over 30 minutes. Once we have that done, adding on units of blood takes 5 minutes. It's really that fast - once the OR calls to ask for blood, we have it ready before the tech shows up at the door to pick it up. But in a situation with a new antibody, even the simplest work-up will take over an hour, and most of the time it's a little more involved. We have to test the plasma against a panel of known donor cells to figure out what specific antibody is present, then we have to pull units from our supply and type them for the corresponding antigen - only those that are negative for that antigen will be safe for the patient with that antibody. That can take up to a half hour. If there's more than one antibody present, the typing takes longer, and sometimes we need to ask the Red Cross reference lab to check their rare donor stash to find us some blood and send it to us, which takes hours. Once we have the right kind of units, the crossmatch itself takes 20 minutes.

Imagine trying to do that, under pressure, knowing the patient needs blood now. When we have advance notice and get the specimen early enough, we always set up extra blood on antibody patients so it's there quickly if it's needed. In a desperate situation the doctor can opt for uncrossmatched units, which can be risky, but the doctor weighs the risks of not transfusing vs the risk of the patient having a reaction, and makes that call. Obviously, we all hate the idea of uncrossmatched blood in principle, and we try to only give patients the safest blood possible after crossmatching it. So we like to avoid unnecessary surprises, like when a patient gets all the way to the operating room for a major surgery without anyone checking on the blood bank.

Be your own advocate, and ask. Worst case, you'll irritate a nurse or doctor. Best case, you'll be sure you won't get in trouble mid-surgery because the blood bank needs a couple of hours to find safe blood for you under pressure.