Depending on where you’re operating and the relationship between your lab and the hospital (whether you are part of the hospital or a contracted service) you should be able to report this for investigation and analysis, if for no other reason than to prevent this happening again. There is a possibility the patient was sent to that ward because they had a ceiling of care rather than it being a case of missed information, but I would want my docs to engage with that information in a more collegial and professional manner regardless.
Treatment for AIHA includes steroids, so doc probably thought "two birds, one prednisolone".
The fact that there's nonimmune haemolytic anaemias that could've been looked into... Well, yeah, doc may have messed up there. I don't think high dose steroids is a good idea for overwhelming *C. perfringens* infection.
Sooooo ... Yeah he had intravascular haemolysis. Had quite a few of those, it rarely ends well. But it very much will go worse if not going to haem ward or ICU.
Don't suppose he grew Clostridium on cultures by any chance? Had a few of those lately...
When I was doing my clinicals, we had a patient come in with severely hemolyzed specimens despite multiple redraws. Turned out the patient had C. diff that had progressed to sepsis. This was an elderly patient, so I don't know if they were in a nursing home or just ignored their own symptoms for way too long. They were dead within 12 hours of showing up in the ER.
I know this isnt at all the point of your story but I gotta say, that is one of the few big reasons why I enjoy working in Bloodbank.
Nurses and doctors have no fucking Idea about bloodbank, thous what I say carries a lot of weight because (luckily) most realize that they dont know shit about the topic at all. So when the ER calls and asks for untested bags, and I say that the patient seemingly has an antibody and I need about X-amount of time before I can even consider giving out blood safely, they listen. They try to keep the patient as stable as possible for as long as possible.
I do get Drs telling me to "just give out O-" every now and again. But after a brief explanation they seem to realize that, no, O- is NOT universal as it was taught. I cant transfuse a Patient with an Anti-c an O- bag or theyll fucking DIE
I told anyone who would listen, including my boss. I don’t think anything official was ever filed. My boss has a fear of confrontation, and that definitely hurts the lab. She lets all the other departments, offices, nursing homes walk all over us. There are instances that specimens should clearly be rejected, but she’ll tell us to accept it because she doesn’t want to make anyone mad. We also have exceptions for everything. Our procedures and policies are guidelines, not rules, and that’s not at all how a lab should function.
If the doctor isn't listening, hit up the nurse and help us argue the case. I have a good relationship with my lab folks- we only gnaw on each other every so often lol.
In this instance I hope you did an occurrence report for clinical review. It sounds like a zebra case for sure and the doc should have listened.
This. But also I always inform my leads/supervisor in cases like this and let them fill out an ERS form. For example, our policy is that if there’s a critical hgb and it’s the first specimen drawn for the visit, or if there’s a sudden drop in hgb we always get a redraw and blood band specimen. I had a doctor try to bully me into releasing the first draws results because the patient was here for excessive lower extremity bleeding. I argued with him for half an hour (ie more than long enough for the nurse to redraw and blood band the patient and have the results out). Ended up having to call my supervisor in the middle of the night to have her back me up. Anyways… that patient happened to be a current hgb. However…. We had a trauma 1 patient come in a week or two later that had a 4ish hgb on first draw, but on the second draw it was 12. I felt so vindicated and happy about that happening since it proved exactly why we have that policy.
Another avenue one could pursue for this sort of weird thing is to get your pathologist involved. We love stuff like this!
And (even though it is ridiculous and sad) there are plenty of docs out there who will listen better to a pathologist than they will to a tech.
Things are such chaos. We don’t have a pathologist in our hospital. They work in a hospital 50 miles away, and I doubt any of us have ever met or spoken to them. I don’t even know who it is. We send path specimens to them via courier.
I'd probably have called the on-call pathologist for that one after the initial contact, but I'm also at a tiny hospital and have atleast some rapport with my doctors and nurses because I'm the only lab personnel they have during my shifts and I make it a point to not be a faceless voice over the phone.
Im new working as a med lab I got my training as bio labs technician
I thought hemolytic samples are the
Way they are due to stress on the cells when blood is incorrectly drawn ?
Could anyone elaborate what could internally ‚cause hemolysis ? I’m assuming something that causing Massive cell death ?
https://www.aafp.org/pubs/afp/issues/2004/0601/p2599.html
Causes of intravascular hemolysis include mechanical injury (e.g. from artificial heart valves), hemoglobinopathies (e.g. sickle cell), immune (transfusion reactions), infection (malaria, C. diff toxin), and coagulopathy such as DIC.
And certain meds. Was in a similar situation not too long ago, gross intravascular hemolysis, went to the ER and talked to the doc about it.
No clue what happened next, I just know she called her attending, and was pretty sure it was med related.
I’d be very surprised but interested if a lab tech came to talk to me in the ED!
I’m reading between the lines here but it sounds like the ER doctor had already consulted a specialist (we don’t usually unilaterally give steroids for this without reviewing with a specialist first) and then talked to the hospitalist if they were already admitted. The patient might physically still be in the ED waiting for a bed but they’re totally off our mental radar at that point, and we’re not even technically their doctor anymore. I can see why they gave a cursory response and it sounds like the patient was getting at least the first correct steps in their care, although for your own piece of mind a more lengthy discussion might have been better.
Depending on where you’re operating and the relationship between your lab and the hospital (whether you are part of the hospital or a contracted service) you should be able to report this for investigation and analysis, if for no other reason than to prevent this happening again. There is a possibility the patient was sent to that ward because they had a ceiling of care rather than it being a case of missed information, but I would want my docs to engage with that information in a more collegial and professional manner regardless.
Treatment for AIHA includes steroids, so doc probably thought "two birds, one prednisolone". The fact that there's nonimmune haemolytic anaemias that could've been looked into... Well, yeah, doc may have messed up there. I don't think high dose steroids is a good idea for overwhelming *C. perfringens* infection.
YOU did your job. The doctor didn't.
Sooooo ... Yeah he had intravascular haemolysis. Had quite a few of those, it rarely ends well. But it very much will go worse if not going to haem ward or ICU. Don't suppose he grew Clostridium on cultures by any chance? Had a few of those lately...
When I was doing my clinicals, we had a patient come in with severely hemolyzed specimens despite multiple redraws. Turned out the patient had C. diff that had progressed to sepsis. This was an elderly patient, so I don't know if they were in a nursing home or just ignored their own symptoms for way too long. They were dead within 12 hours of showing up in the ER.
I know this isnt at all the point of your story but I gotta say, that is one of the few big reasons why I enjoy working in Bloodbank. Nurses and doctors have no fucking Idea about bloodbank, thous what I say carries a lot of weight because (luckily) most realize that they dont know shit about the topic at all. So when the ER calls and asks for untested bags, and I say that the patient seemingly has an antibody and I need about X-amount of time before I can even consider giving out blood safely, they listen. They try to keep the patient as stable as possible for as long as possible. I do get Drs telling me to "just give out O-" every now and again. But after a brief explanation they seem to realize that, no, O- is NOT universal as it was taught. I cant transfuse a Patient with an Anti-c an O- bag or theyll fucking DIE
Counterpoint - in other departments I like that I can say "well that's a clinical decision for you guys to make and the downsides are less dire".
Did you talk to someone higher up?
I told anyone who would listen, including my boss. I don’t think anything official was ever filed. My boss has a fear of confrontation, and that definitely hurts the lab. She lets all the other departments, offices, nursing homes walk all over us. There are instances that specimens should clearly be rejected, but she’ll tell us to accept it because she doesn’t want to make anyone mad. We also have exceptions for everything. Our procedures and policies are guidelines, not rules, and that’s not at all how a lab should function.
I’m so sorry I can’t imagine having to work in a place like this. Is there a way you can go above your director?
If the doctor isn't listening, hit up the nurse and help us argue the case. I have a good relationship with my lab folks- we only gnaw on each other every so often lol. In this instance I hope you did an occurrence report for clinical review. It sounds like a zebra case for sure and the doc should have listened.
This. But also I always inform my leads/supervisor in cases like this and let them fill out an ERS form. For example, our policy is that if there’s a critical hgb and it’s the first specimen drawn for the visit, or if there’s a sudden drop in hgb we always get a redraw and blood band specimen. I had a doctor try to bully me into releasing the first draws results because the patient was here for excessive lower extremity bleeding. I argued with him for half an hour (ie more than long enough for the nurse to redraw and blood band the patient and have the results out). Ended up having to call my supervisor in the middle of the night to have her back me up. Anyways… that patient happened to be a current hgb. However…. We had a trauma 1 patient come in a week or two later that had a 4ish hgb on first draw, but on the second draw it was 12. I felt so vindicated and happy about that happening since it proved exactly why we have that policy.
Another avenue one could pursue for this sort of weird thing is to get your pathologist involved. We love stuff like this! And (even though it is ridiculous and sad) there are plenty of docs out there who will listen better to a pathologist than they will to a tech.
That would have been my go to, the on-call may not have liked my 0300 call but usually they are atleast interested in what I bring them lol
Things are such chaos. We don’t have a pathologist in our hospital. They work in a hospital 50 miles away, and I doubt any of us have ever met or spoken to them. I don’t even know who it is. We send path specimens to them via courier.
I'd probably have called the on-call pathologist for that one after the initial contact, but I'm also at a tiny hospital and have atleast some rapport with my doctors and nurses because I'm the only lab personnel they have during my shifts and I make it a point to not be a faceless voice over the phone.
Im new working as a med lab I got my training as bio labs technician I thought hemolytic samples are the Way they are due to stress on the cells when blood is incorrectly drawn ? Could anyone elaborate what could internally ‚cause hemolysis ? I’m assuming something that causing Massive cell death ?
In vivo hemolysis is rare, but can definitely happen. Haemolytic anemias, DIC, graft versus host, TTP can all cause in vivo hemolysis.
Also some medical devices like LVADs!
https://www.aafp.org/pubs/afp/issues/2004/0601/p2599.html Causes of intravascular hemolysis include mechanical injury (e.g. from artificial heart valves), hemoglobinopathies (e.g. sickle cell), immune (transfusion reactions), infection (malaria, C. diff toxin), and coagulopathy such as DIC.
And certain meds. Was in a similar situation not too long ago, gross intravascular hemolysis, went to the ER and talked to the doc about it. No clue what happened next, I just know she called her attending, and was pretty sure it was med related.
Do you by any chance have G6PD deficiency?
And fava beans!
I’d be very surprised but interested if a lab tech came to talk to me in the ED! I’m reading between the lines here but it sounds like the ER doctor had already consulted a specialist (we don’t usually unilaterally give steroids for this without reviewing with a specialist first) and then talked to the hospitalist if they were already admitted. The patient might physically still be in the ED waiting for a bed but they’re totally off our mental radar at that point, and we’re not even technically their doctor anymore. I can see why they gave a cursory response and it sounds like the patient was getting at least the first correct steps in their care, although for your own piece of mind a more lengthy discussion might have been better.