Just For Fun

[jcornell]

We were happy to have a recently trained neonatist join the staff at our rural hospital many years ago. Upon the arrival of the first baby in distress he screamed for the transcutaneous electrodes (to measure electrolyes). I told him that unless he had brought some with him, he was out of luck.

[TimOz]

I was in a Hospital in Phnom Penh (Cambodia for the geographically challenged) recently patiently explaining, through a translator, why it was important to group the patient twice in seperate events and from seperate cell suspensions to a med tech. Out of the cornor on my eye I saw a ward nurse come in with an unlabelled blood tube, hand it to the tech on the next bench who grouped and Immediate Spin crossmatched it with a unit of blood while the nurse patiently waited. The IS crommatched (I can't make myself say compatible) unit was handed unlabelled to the nurse who flip-flopped back to the ward, undoubtably to transfuse it in the patient she may have collected the blood from.

This is in a place with no wrist bands, no real ID, often multiple patients per bed and all the while family members cooking in and outside the ward and literally hundreds of Dengue patients with drips in just wandering all over the place. Maybe grouping twice is not the priority here?

[Likewine99]

I had a surgeon ask for FFP stat and I explained it would take 30 min to get it ready. He said that was too long and he was sending someone up right now to pick it up, it better be ready.

When the pick up person arrived she said he wanted it regardless of how thawed it was so I sent it out about 1/4 of the way thawed, not even close to being slushy, big huge ice chunk still in the bag.

It came back up in about 10 minutes with the instructions from the surgeon to "thaw it all the way". I think he may have said please!

[Brenda K Hutson]

Most memorable diagnosis: "hard won't go down"

Scary scenario: Mom O pos, Anti-E, baby O Pos, positive DAT. Doctor (yes, the doctor!) calls and tells me I am wrong; the baby can't have a positive DAT because the mom and baby are the same type. I explain about the Anti-E, and he tells me that's just a minor antibody!

Had a mom with an anti-D titer>2000 at delivery, doc demanded RhoGam. It was the mom's 5th baby, 2 previous babies did not survive, and the docs did not know why. Her prenatal Anti-D titer was 16, and no one noticed. They never checked the baby's H&H, so at 5 days old, the baby was in PICU with a Hgb of 5. The pediatric hematologist thought the baby's positive DAT was due to an ABO incompatibility, but the mom was A neg and the baby was A pos.

Also, had a patient with Anti-c and 2 other antibodies. The tech did not complete the workup the night before surgery (I guess multiple antibodies confused him), so it didn't get sent to the ref lab until the next day (the day of the surgery). OR was notified, and they took the patient in anyway. Of course they needed blood super stat. I was already at home, when they called me. I told them not to emergency release any O negs....they didn't believe me and called the path. Guess what they gave? Yup, O negs!.

We also get calls about room numbers. I ask them to call back when their room number has a name.

Along the same line....I inspected a lab that had in their collection policy that the 2 independent patient identifiers were name and room number!

Wow, that is scary! I know, the Nurses always want the room#! ! Can I speak to the Nurse taking care of XYZ....Nurse; what room is he in. I don't know; we don't work on room numbers here in the Lab, we work on patients.

Brenda Hutson

[Brenda K Hutson]

I was in a Hospital in Phnom Penh (Cambodia for the geographically challenged) recently patiently explaining, through a translator, why it was important to group the patient twice in seperate events and from seperate cell suspensions to a med tech. Out of the cornor on my eye I saw a ward nurse come in with an unlabelled blood tube, hand it to the tech on the next bench who grouped and Immediate Spin crossmatched it with a unit of blood while the nurse patiently waited. The IS crommatched (I can't make myself say compatible) unit was handed unlabelled to the nurse who flip-flopped back to the ward, undoubtably to transfuse it in the patient she may have collected the blood from.

This is in a place with no wrist bands, no real ID, often multiple patients per bed and all the while family members cooking in and outside the ward and literally hundreds of Dengue patients with drips in just wandering all over the place. Maybe grouping twice is not the priority here?

Well sadly, you can almost see why things are different there....or are they? I remember a time where we called the Nurse and told her we could not accept the specimen because it was unlabled. Next thing we know, she is in our Lab with a label in her hand, thinking we are going to let her label it. So the "sharp" supervisor, went and got another specimen and tore of the label; she then put both of them in front of the Nurse and said, "Ok, which one belongs to your patient?!" Ha

Brenda Hutson, CLS(ASCP)SBB

[clmergen]

A call from the unit clerk one night while I was working in a small hospital "Hey Carrie, what was the result of that test on the patient in bed 9?" My response "Patsy, can you be more specific?"

Favorite diagnosis - "Whizzing", I think the patient was having an asthma attack.

[Mary**]

They could have asked the patient to "lick the plasma"!!

[BankerGirl]

My favorite diagnosis: Tests ordered were KOH, Wet Prep, Culture and the diagnosis was "Dog Bite". After we stopped laughing I said to a coworker that I wanted to see that dog! Turns out it was ordered on the wrong patient and all the specimens were labelled incorrectly, but we didn't know anything about this part for two days. The ward clerk in the ED just crossed out the patient demographics on the results print outs and placed them on the "correct" patient's chart. Who cares that the computer has the results and charges under a different patient, right?

My worst case Blood Bank scenario: Patient comes in with 2 known antibodies 13 days after several previous transfusions and goes to surgery with no type and screen specimen. Patient doesn't do well in surgery and Dr requests uncrossmatched blood STAT. We inform him that his patient has multiple antibodies and we don't know if the blood is compatible or not. He says patient is bleeding and needs blood and he will sign the consent for uncrossmatched blood. While she is getting the uncrossmatched blood, we work the patient up and find a total of 4 antibodies in the current specimen. The Dr insists that she is still bleeding the next day and needs uncrossmatched blood until we find compatible blood, and if we were competent in the lab it wouldn't be taking so long to get her blood (REALLY!) Long story shorter: patient ended up with a total of 5 antibodies, received 8 units of uncrossedmatched blood that wer each incompatible for atleast one antibody, developed a total bilirubin of 62 (yes, SIXTY-TWO) before she died 19 days later. Her doctor still thinks WE are incompetent. Even scarier, a similar scenario occurred with the same Dr. two months later with another patient. Obviously, he did nothing wrong!

Edited August 20, 2009 by BankerGirl

[L106]

BankerGirl - Think it's time that the doc gets a visit from the hospital's Transfusion Committee? (Or better yet, the hospital's Corporate Compliance Officer or Risk Manager?)

[BankerGirl]

We refered this case to our Risk Manager and that is the last I heard about it. We haven't heard much from him lately, but I don't want to get my hopes up.

[MAGNUM]

How about the time the young intern at one of our Military Hospitals ordered the Stat throat culture, and then called 30 minutes later complaining that he ordered it stat and he wanted it stat!! I proceeded to call him for the next 24 hours every hour on the hour to report that the patient still had no significant growth.

[MAGNUM]

Your funny diagnosis reminds me of a story that took place several years while working in a very small rural hospital where I also had to double as a ED tech. We received a phone call from a patient complaining about excessive bleeding during her mensus. The nurse trying to get a hand on the matter asked her "How's the Flow?" To which she got the response of "The flow, whats the flow got to do with it, the flows linoleum." She dropped the phone.

[AMcCord]

We had a surgeon here some years ago who could do no wrong (in his mind, anyway). He believed absolutely that all of his patients should get fresh whole blood. He would grudgingly take bank whole blood sometimes. If he had a patient in the OR or post-op in ICU, he would show up in his little green scrubs and stick his arm out, demanding that we draw a unit of blood. This was back in the days of the walking blood bank. We would, grudgingly, draw him and he would then grab the unit out of our hands, take it directly upstairs over our protests that it was not crossmatched and hang it. No tag, no labels, no testing (ever hear of hepatitis, doc?). He at least was O Pos. As to the crossmatch, he would tell us to finish it whenever we wanted, or not - HIS blood was compatible with anyone. Once when he couldn't leave the OR, he had a scrub nurse call his wife and tell her to come in and donate blood. We did get a chance to get an antibody screen and crossmatch done before someone came for the unit. Turns out that the Mrs was O Neg with a strong anti-D. Our patient was Rh Pos. They didn't get that whole blood unit. Even though we told him why his wife could not donate, he sent her in 3 or 4 more times to donate and we had to tell her thanks but no thanks. Very nice lady, just not donor material. Too bad we didn't have a pathologist with you-know-whats to stand up to him!

Edited August 20, 2009 by AMcCord
turned my perfectly nice word into *******

[QAZ]

I had a surgeon ask for FFP stat and I explained it would take 30 min to get it ready. He said that was too long and he was sending someone up right now to pick it up, it better be ready.

When the pick up person arrived she said he wanted it regardless of how thawed it was so I sent it out about 1/4 of the way thawed, not even close to being slushy, big huge ice chunk still in the bag.

It came back up in about 10 minutes with the instructions from the surgeon to "thaw it all the way". I think he may have said please!

I had an OB doctor send someone to pick up FFP "Now, no excuses" before they had even ordered any. I couldn't bring myself to hand her the bags straight out of the freezer; I had to make an excuse.

[kell23]

We have hospitalists at our hospital and one wanted blood stat on a new patient who had an unknown antibody. She wanted to give uncrossmatched blood and I told her she should let us identify the antibody, she stated the patient would die if she didn't get the blood right now. I told her she might die sooner if we give her the uncrossmatched ....so her answer to that was.... 'just give her O Neg,,,..they do that on t.v. all the time"........so my reply was "they don't have antibodies on t.v.".........

[SMW]

got used to the diagnosis of SOB (shortness of breath for those without a legend key) but a diagnosis of SOBE along with a stat request for xmatch of 6 units with a normal hemoglobin prompted a call to ER for further explanation.......SOBE = Stepped On By Elephant. Who would have guessed!!....Circus was in town, but how were we suppose to know?

As for local acronyms.....coming from a small community hospital to a urban, teritary care facility it didn't take long to learn (and sad to know there was a need for an acronym) but diagnosis of "BBB" was "beaten with baseball bat".

Some other favorites, diagnosis of Euro sepsis....

and then gangere (which is certainly never funny) but when the patient names is (I kid you not, ..) Shrek, kind of makes you step back for a minute.

And have also received the stat request from OR for fresh frozen plamsa, acknowledged request and told them to come down in 20 minutes to pick-up, OR reiterated it was stat, we reiterated acknowledgement and stated to come in 20 minutes, OR said it was stat and they were coming NOW!! When OR arrived, I handed them a frozen brick at which point they actually asked what they were suppose to do with that and how could they transfuse a frozen block of ice?.....I responsed, if they would come back in 20 minutes we would have it thawed. They left, the product was thawed and issued to the OR about 20 minutes later (but to a different transporter......... ).

[Brenda K Hutson]

My favorite diagnosis: Tests ordered were KOH, Wet Prep, Culture and the diagnosis was "Dog Bite". After we stopped laughing I said to a coworker that I wanted to see that dog! Turns out it was ordered on the wrong patient and all the specimens were labelled incorrectly, but we didn't know anything about this part for two days. The ward clerk in the ED just crossed out the patient demographics on the results print outs and placed them on the "correct" patient's chart. Who cares that the computer has the results and charges under a different patient, right?

My worst case Blood Bank scenario: Patient comes in with 2 known antibodies 13 days after several previous transfusions and goes to surgery with no type and screen specimen. Patient doesn't do well in surgery and Dr requests uncrossmatched blood STAT. We inform him that his patient has multiple antibodies and we don't know if the blood is compatible or not. He says patient is bleeding and needs blood and he will sign the consent for uncrossmatched blood. While she is getting the uncrossmatched blood, we work the patient up and find a total of 4 antibodies in the current specimen. The Dr insists that she is still bleeding the next day and needs uncrossmatched blood until we find compatible blood, and if we were competent in the lab it wouldn't be taking so long to get her blood (REALLY!) Long story shorter: patient ended up with a total of 5 antibodies, received 8 units of uncrossedmatched blood that wer each incompatible for atleast one antibody, developed a total bilirubin of 62 (yes, SIXTY-TWO) before she died 19 days later. Her doctor still thinks WE are incompetent. Even scarier, a similar scenario occurred with the same Dr. two months later with another patient. Obviously, he did nothing wrong!

I know this is supposed to be a "fun" Thread, not technical, but I just had some thoughts in reading your antibody scenario. And please know this is NOT to say you did anything wrong; I don't know all of the aspects and you may very well have done the things I am listing:

1. Did you still have the specimen from 13 days before? If Yes, was that an untransfused specimen (i.e. no

transfusions in past 3 months)?

2. If Yes to #1, could have used that specimen to perform a complete phenotype, thus seeing what the patient "could"

make. One option then would be to just try to get Antigen Negative units from your Donor Center, for any antibodies

the patient "could" have made.

3. Using complete phenotype, could also run a phenotypically similar cell; if positive, it is a High, if negative, it is

multiples (which is what you suspected anyway). But knowing what the patient "could" make, could result in a

more managable work-up (so while unable to provide blood for last minute OR order, perhaps could have had

compatible units the next day)?? So could then either focus on ruling out what the patient "could" make, or just

focus on finding Antigen Negative units based on what the patient was negative for.

Again, I don't have all of that information so you may have done all of that; but the reference specialist in me just had some thoughts as I read it.

Brenda Hutson, CLS(ASCP)SBB

[BankerGirl]

Thanks for the suggestions Brenda. I was trying not to get too bogged down in the details, but it turns out that the patient had multiple transfusions at several hospitals across our state. The Red Cross reference lab had worked her up for another institution and had her phenotype on file. They had actually identified all four antibodies previously, but the S and Jka had become non-detectable by the time she came to us. The antibodies we had identified were anti-E and anti-M, and we all know that M is supposed to be IgM and thus, not clinically significant, but in the end, she had developed an anti-M that appeared to be IgG specific. ARC had two units on their shelves that we transfused when we got them, but they had to call all around the country trying to find antigen negative units for her so we were not able to keep up with the Dr's demands. The final antibody was an anti-K that we think probably came from a unit we gave early in this catastrophe.

[lateonenite]

And have also received the stat request from OR for fresh frozen plamsa, acknowledged request and told them to come down in 20 minutes to pick-up, OR reiterated it was stat, we reiterated acknowledgement and stated to come in 20 minutes, OR said it was stat and they were coming NOW!! When OR arrived, I handed them a frozen brick at which point they actually asked what they were suppose to do with that and how could they transfuse a frozen block of ice?.....I responsed, if they would come back in 20 minutes we would have it thawed. They left, the product was thawed and issued to the OR about 20 minutes later (but to a different transporter......... ).

There once was a little rural hospital who would be the first port of call for trauma patients before they were transported to a larger (usually metropolitan) hospital for further treatment. The ED staff would ask for blood products to travel with the patient. They would duly send crossmatched or uncrossmatched blood (depending on how much time they'd had), but, not having a water bath for thawing FFP, would send the frozen blocks with the patient.

So far as I know, no-one ever complained.

(And yes, I really wish I was kidding.)

Edited August 22, 2009 by lateonenite

[lateonenite]

Well sadly, you can almost see why things are different there....or are they? I remember a time where we called the Nurse and told her we could not accept the specimen because it was unlabled. Next thing we know, she is in our Lab with a label in her hand, thinking we are going to let her label it. So the "sharp" supervisor, went and got another specimen and tore of the label; she then put both of them in front of the Nurse and said, "Ok, which one belongs to your patient?!" Ha

Brenda Hutson, CLS(ASCP)SBB

We have a manager in our area who keeps all of the unlabelled samples his lab receives in a bucket in the fridge. When the doctor or nurse rings up and says they're coming down to label it, he replies with "Sure, come down" and when they appear he duly hands them the bucket and tells them to pick out the specimen they want to label.

Always with a smile.

[donellda]

Yesterday a doctor called the Blood Bank and said that she had a patient with a very low hemoglobin in the ICU and wanted us to bring 2 units there right away. I asked her for the patient's information to see if we had anything for that patient so she promptly handed the phone to the unit clerk. The clerk said to me, "I told her to let me do my job but she wanted to call so now I'm here doing my job". We have wonderful, knowledgeable unit clerks, especially in our ICUs but administration has taken a lot of their duties away like placing orders in our HIS system. The doctors are doing it now and things really are a mess.

[RR1]

My favourite diagnosis was " unemployed " , my lab manager at the time suggested that may be we should make a blood film to look for Dohle bodies.

[L106]

We have wonderful, knowledgeable unit clerks, especially in our ICUs but administration has taken a lot of their duties away like placing orders in our HIS system. The doctors are doing it now and things really are a mess.

donellda - Welcome to the club!!

A few months ago (or a year or so??) we switched to physicians placing their own orders. Yikes!! The list of problems and things that need to be cancelled every day goes on and on. One of our biggest problems is that admitting physician, attending physician, consulting physicians, and residents don't look to see what has already been ordered, so they order duplicates (then they get mad when we cancelled their duplicate order instead of one of the other doc's order.) Plus, they figured out ways around the system, such as going to another floor and calling in the order (so they don't have to enter it into the computer themselves.) When we have to consult a physician about some confusing/ nonsensical order, we are often told "Well, you should know what I mean." (Yeah, right.) The docs are making our unit clerks look better & better!

However, I think the blame has to be shared with our nursing team who designed the screens, the ordering procedures/protocol, etc., and are responsible for training. I think what they designed is often not very logical and the training is weak.

A good unit clerk (or lab secretary) are worth their weight in gold!!!

[AMcCord]

We'll have physician ordering in about 6 months. Nursing service thinks it will be great. We think it will be veeeeeeeeeery interesting. I agree that a good unit clerk is a major asset.

[L106]

We'll have physician ordering in about 6 months. Nursing service thinks it will be great. We think it will be veeeeeeeeeery interesting. I agree that a good unit clerk is a major asset.

Ann -

Providing good, adequate training for the physicians from the beginning is crutial! If you do a quick, sloppy job of training it causes errors, bad habits, and avoidance tricks, etc. (Not you personally....you know what I mean.)

Donna