As a transfusion medicine physician, I must know if I can trust my staff’s interpretation of immunohematology testing.  I may be called at night and they will provide me with results and I must use these to make a medical judgment.  If their interpretation is flawed, I might make a decision that harms the patient.

I really don’t like multiple-choice questions, but nowadays this is often the norm.  For my staff, especially senior staff and those who want to be promoted to senior staff, I have developed a series of projective exercises to help me understand their thought processes.

Here is another exercise, usually given to physicians.  I give them the following scenario:

There is a major trauma on an unidentified young adult male patient.  We do not know the transfusion, medical, or medication history.  They need six units RBCs STAT.

What blood type do you select?  How do you release the blood?

You give the 6 units and receive a specimen back.  The patient’s typing reactions are:

Forward type:  Anti-A, anti-B both negative

Reverse type:  4+ reaction with A1 and B cells

About 15 minutes later, your technologist tells you that the antibody screen is 4+ in all cells and all panel cells react 4+ both at AHG and enzyme phases.  What do you tell the treating clinician?  What do you do?

The technologist in panic has been performing AHG crossmatches but all 4+ incompatible.

Here is the panel:

I have them review this panel and tell me to interpret it

1. What further testing would you do, if any?
2. What blood type do you release now?
3. What is the significance of the negative autocontrol when there is panreactivity?
4. What if the enzyme panel results are all negative?
5. What if the autocontrol is 4+?

The smart ones will ask for a full extended phenotype (e.g. Diamed/Biorad’s three profile cards) and for anti-H.

I tell them the clinician is very angry and demands you release more group O blood immediately?  How do you respond?

5/9/20

Objectives:

1. Theoretical:
   1. ABO system and discrepancies
   2. Rh system and discrepancies
   3. Other blood groups (Kell, Kidd, Duffy, MNSs, Gerbich)
   4. Direct antiglobulin test
   5. Comparison of gel and tube methodologies
   6. Transfusion reactions
   7. Drug-related hemolysis
   8. Inventory management
   9. Emergency blood release
   10. Massive transfusion
   11. Hemolytic disease of the newborn
   12. Transfusion-transmitted diseases and look-back
   13. Filtration
   14. Irradiation
2. Practical:
   1. ABO/D typing
   2. Antibody screen
   3. Crossmatch
      1. Immediate-spin
      2. AHG-phase

2. DAT
3. Elution
4. Antibody identification
5. ZZAP

Clinical Responsibilities (after proven competence):

1. Evaluation of DAT results
2. Evaluation of antibody workups
3. Transfusion reaction workups
4. Component substitutions for inventory management (excluding Rh-incompatible)

Assessments:

1. ABO typing and discrepancies
2. Rh(D) typing and discrepancies
3. Antibody identification
4. DAT and drug-related hemolysis evaluations
5. Transfusion reaction assessments
6. Post-training

Working Hours:

1. 0900-1700, Saturday through Wednesday
2. Must carry pager for clinical responsibilities

Original Date:  26/6/06 for NGHA Riyadh, Reviewed 27/8/20

As a transfusion medicine physician, I must know if I can trust my staff’s interpretation of immunohematology testing.  I may be called at night and they will provide me with results and I must use these to make a medical judgment.  If their interpretation is flawed, I might make a decision that harms the patient.

I really don’t like multiple-choice questions, but nowadays this is often the norm.  For my staff, especially senior staff and those who want to be promoted to senior staff, I have developed a series of projective exercises to help me understand their thought processes.

Here is another exercise, usually given to base medical technologists.  I have the staff review this panel and tell me to interpret it:

You just can’t solve this without the enzyme panel.  Will the staff member ask for this?  Will he note that the one cell reacting is homozygous for E?  Will he ask for extended antigen typing (the patient is R1R1)?

As a transfusion medicine physician, I must know if I can trust my staff’s interpretation of immunohematology testing.  I may be called at night and they will provide me with results and I must use these to make a medical judgment.  If their interpretation is flawed, I might make a decision that harms the patient.

I really don’t like multiple-choice questions, but nowadays this is often the norm.  For my staff, especially senior staff and those who want to be promoted to senior staff, I have developed a series of projective exercises to help me understand their thought processes.

Here is another exercise, usually given to base medical technologists.  I have the staff review this panel and tell me to interpret it:

Everyone reports this is anti-S, enzyme-labile, but relatively few bother to ask for the S phenotype.  All were trained to check the phenotype as part of the workup.  I also had a version of this examination in which I only showed the AHG results.  Many did not ask to perform enzyme.

The proper answer was probable anti-S, enzyme-labile, but request S phenotype. If the enzyme had not been performed, then the enzyme panel results should be requested.

As a transfusion medicine physician, I must know if I can trust my staff’s interpretation of immunohematology testing.  I may be called at night and they will provide me with results and I must use these to make a medical judgment.  If their interpretation is flawed, I might make a decision that harms the patient.

I really don’t like multiple-choice questions, but nowadays this is often the norm.  For my staff, especially senior staff and those who want to be promoted to senior staff, I have developed a series of projective exercises to help me understand their thought processes.

Here is another exercise, usually given to base medical technologists.  I have the staff review this panel and tell me to interpret it:

Many staff called this anti-E and anti-c.  They did not note that there is no E-positive c-negative cell.  Also, many did not see that one c-positive cell had no reaction—they did not notice that the c was heterozygous (C+c+ not c+c+).

A medical technologist must not be sloppy, but rather very meticulous.  If there are discrepancies in the panel, they must rule out dosage, zygosity, etc.  They should not name an antibody specificity with only one antigen-positive cell.

To Be Continued:

22/8/20

As a transfusion medicine physician, I must know if I can trust my staff’s interpretation of immunohematology testing.  I may be called at night and they will provide me with results and I must use these to make a medical judgment.  If their interpretation is flawed, I might make a decision that harms the patient.

I really don’t like multiple-choice questions, but nowadays this is often the norm.  For my staff, especially senior staff and those who want to be promoted to senior staff, I have developed a series of projective exercises to help me understand their thought processes.

Here is a sample exercise.  I have the staff review this panel and tell me to interpret it:

Most of them answer that this is an anti-Cw without hesitation.  However, they are basing that on only one Cw-positive cell.

More astute ones indicate it might be anti-Cw but ask to test additional Cw-positive cells and perform an enzyme panel.  These are the ones that I will consider for promotion now.

This is an updated version of a presentation given to the Saudi MOH several years ago. I have included statements about pathogen inactivation and platelet additive solution which were not used on the original date.

This is the third part of this Saudi Ministry of Health presentation that I gave several years ago and looks at TRALI/TACO pathophysiology.

To Be Continued

13/8/20