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I was once told by a very smart man that if you get the ABO right the rest can be dealt with. As noted above, more than once, a transfusion reaction can be dealt with, death by blood loss can not. You did fine. Could you have done something different, probably but you were the one on the spot making the best decisions you were capable of. Welcome to the club. The butterflies in the belly only get smaller they never go away.

We went live with TAR several years ago and it has made my life much easier. I think there is a way to document the vitals through TAR, but even if they don't do it that way, all of the vitals entered into Meditech end up in the same "bucket" eventually, so I had our NPR writer design a report for me that pulls all vitals entered on the patient from 1 hour prior to 15 minutes after the end of the transfusion. This can pull a lot of vitals if the patient is being monitored very closely, but I would rather have too many than not enough.

§493.1449 Standard; Technical supervisor qualifications. The laboratory must employ one or more individuals who are qualified by education and either training or experience to provide technical supervision for each of the specialties and subspecialties of service in which the laboratory performs high complexity tests or procedures. The director of a laboratory performing high complexity testing may function as the technical supervisor provided he or she meets the qualifications specified in this section. (a) The technical supervisor must possess a current license issued by the State in which the laboratory is located, if such licensing is required; and ( b ) The laboratory may perform anatomic and clinical laboratory procedures and tests in all specialties and subspecialties of services except histocompatibility and clinical cytogenetics services provided the individual functioning as the technical supervisor— (1) Is a doctor of medicine or doctor of osteopathy licensed to practice medicine or osteopathy in the State in which the laboratory is located; and (2) Is certified in both anatomic and clinical pathology by the American Board of Pathology or the American Osteopathic Board of Pathology or Possesses qualifications that are equivalent to those required for such certification. ... (q) If the requirements of paragraph ( b ) of this section are not met and the laboratory performs tests in the specialty of immunohematology, the individual functioning as the technical supervisor must— (1)(i) Be a doctor of medicine or a doctor of osteopathy licensed to practice medicine or osteopathy in the State in which the laboratory is located; and (ii) Be certified in clinical pathology by the American Board of Pathology or the American Osteopathic Board of Pathology or possess qualifications that are equivalent to those required for such certification; or (2)(i) Be a doctor of medicine, doctor of osteopathy, or doctor of podiatric medicine licensed to practice medicine, osteopathy, or podiatry in the State in which the laboratory is located; and (ii) Have at least one year of laboratory training or experience, or both, in high complexity testing for the specialty of immunohematology.

Dr Pepper has hit the nail on the head - the innate ability, initiative and interest of the worker. Regardless of education - these are qualities I look for in BB techs, whether MLTs or MTs. I've worked with SBBs who aren't worth a damn and the best BBer I ever worked with and learned A LOT from was an MLT. I think there are other recent posts which address this topic somewhere on this site.

For decades we hired only MTs, but have had to hire a few MLTs over the last couple of years due to MT shortages. I find the quality of work varies not from the number of college courses they took but the innate ability, initiative and interest of the worker. We train equally and job responsibilities are equal (although the MTLs cannot do some things, like review results etc). I had a MLT generalist on last weekend. He had a patient who got 4 units of blood the week before who now presented with anti-c and a positive DAT, weak mixed field. Pretty classic delayed reaction, except that the eluate reacted with all the panel cells. DAT was negative the week before. He dug into it and tested some more c-negative cells and found that there was also anti-Fya and -Jkb in the eluate (but not in the plasma yet). En route he tested the eluate with ficin-treated cells and PeG and ficin-treated some additional ones himself to help untangle the specificities. I did give him some phone coaching along the way, but it was an excellent job of blood banking. "Just" a MLT, but he really digs BB.

There's not much I can add to what has already been stated ... a learning experience, talk about it so you can be better prepared next time, etc. Except ... 1. Your supervisor dropped the ball here. As 'Quality Guy' quoted CLIA (and it should be a 'rule' regardless of who requires it), your supervisor should have a 'call me anytime and if you can't get me, call ____' with the phone numbers perpetually posted at every BB phone.As far as the policy about 'the patient has not been transfused so you do not need to repeat the workup' - yes, it may be a rational thing to do, but unless this exception is written in your policies, you are not free to skip the testing. That exception should be written in your procedures and you should have been informed of it during your training. Sounds like you were not trained to deal with 'unusual crisis' cases. Were you trained in what antibodies are truly 'clinically signficant'? Were you trained what to do if you have a crisis patient who has 'clinically significant antibodies'? ... or other issues like IgA Deficiency, Sickle Cell Protocol, etc.?2. "Remember exanguination is a lot harder to treat than a transfusion reaction." Keep in mind that it's up to the attending MD to decide if the patient can wait until all the required testing is done or not ... it's not the Blood Bank's responsibility. All the demands, threatening statements, and loud voices are not going to change that fact. The responsibilities of the BB Tech are: to inform the requesting MD of any additional risks (e.g. clinically signficant antibody, IgA Deficiency)to convey to the requesting MD the TIMING for filling the order (very important, they will change care plans based on what is said) and not burdening them with the details about 'how'.to do whatever tasks are necessary to get the safest blood out the door in a timely manner in accordance to whatever can be done in the given period of time, e.g. Group O RBCs vs Type Compatible RBCs vs crossmatched RBCs.to focus on those tasks, not worrying about what's happening in the ED or who's screaming on the phone or what MAY happen 'if'.Yes, it's all these things that help techs get through these tougher situations. You lucked out with this crisis, but as you are feeling, you need more support and more information ... get those things before this happens again.

Thanks for the encouragement. I think I need that right now! Maybe anyone just sharing you "baptism by fire" stories would be really helpful! The BB supervisor has told me that I can call her pretty much any time, so I know she's there. This was a fluke because she was on vacation when this happened. Our medical director is very knowledgeable and is willing to help, but she's not "warm and fuzzy" so it's hard to gauge her. I think a lot of the problem with this situation is that since the supervisor was out and the medical director is more hands off, there was no debriefing, no one to say "hey you did great with this, but next time try this" etc. . . So all I know is I did what I could to the best of my abilities and skill and fortunately, it all worked out.