New BB tech - need some comforting words

[DaBears]

.,

Edited November 16, 2015 by DaBears

[Sko681]

I call that the "baptism of fire".  Just remember that experience is the best teacher.  If you find yourself in such a scenario where you do not feel comfortable or need help with a decision, is there a supervisor or on call person that you can reach out to?  As a newbie there really should be some kind of support for you in these situations. 

 

Just a battle story to share....  we are not a trauma center either and a while ago when I was new,  we had a patient that came in as a trauma and they wanted emergency release.   Blood was issued and then we found out the patient had multiple antibodies.  I believe that one was a Kidd.  Of course, the units that the patient was given were incompatible.  Because "universal donor" is really kind of a misnomer in scenarios like this. I had obviously never been in a situation like this.    I learned a few things after that incident- the first is that we aren't a trauma center. Almost always the patients that we get are not stable enough to go to another hospital which leads me to my next tidbit... if the patient is bleeding so bad that they cannot wait for crossmatching and antigen typing- the immediate risk to the patient of not getting blood is greater than a potential transfusion reaction.  They just need the oxygen. 

 

Since that time we have had this happen on occasion and while it still makes me nervous it isn't that drop in the pit of my stomach anymore.  Don't be discouraged, you will gain the knowledge over time to be confident in your decisions! 

[DaBears]

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.

[Emelie]

Where I work we're alone during nights and weekends, so situations that would have been perfectly fine daytime with a couple colleagues around can easily get quite overwhelming with only a doctor on call-duty to discuss with. Like when there's a traffic accident or some other trauma with several badly injured victims and one of them turn out to have a pos ab screen - it can be quite stressful to set up an ab panel while simultaneously handing out lots of blood and keeping up with the thawing of FFP, and if our stocks are getting low, managing the transfer of blood and platelets from other hospitals to our own. I rarely encounter those extreme situations, but I had a slightly annoying weekend a couple months ago, working alone, when an ER patient needed a lot of blood acutely and of course she had a pos ab screen with several ab's. There wasn't a chance for me to identify them properly so I phenotyped her thoroughly and cross-matched units. I tested her against more than 20 units that fit her phenotype as far as I knew (Rh, K, Fy, Jk, MNS) and still only found 2 that were compatible. She received a lot more units of rbc's that weekend and we do all xm manually, but the most frustrating thing was when our primary "help-lab" sent back the results from her blood work marked as "Un-identified antibodies"... and it's not a one-time only patient, this one was at the hospital for quite some time getting several more transfusions and will most likely be back. We've sent new samples to a ref lab and hope for more exciting answers this time

In my opinion, it's important to always double-check with the medically responsible doctor before doing anything when you're uncertain, rather ask for expert advice one time extra than one too little, and document everything they say in order to keep your back free. As a blood lab tech I am not qualified to make decisions regarding patients, no matter what opinions I harbour (though it's obviously important to always give sufficient info about ab's and other findings to the patient's doctor to help them make proper decisions).

And, of course, always do a background check on a patient when something seems really odd, bm transplants and recent transfusions at other hospitals can mess things up, and there might be important information to be had

[goodchild]

I call that the "baptism of fire".  Just remember that experience is the best teacher.  If you find yourself in such a scenario where you do not feel comfortable or need help with a decision, is there a supervisor or on call person that you can reach out to?  As a newbie there really should be some kind of support for you in these situations. 

 

To extend this point, it's not only a "there should be" kind of situation, it's actually federal law that there's support for testing personnel in problem scenarios (obviously this standard can be widely interpreted):

 

CLIA Subpart M

§493.1463   Standard: General supervisor responsibilities.

The general supervisor is responsible for day-to-day supervision or oversight of the laboratory operation and personnel performing testing and reporting test results.

(a) The general supervisor—(1) Must be accessible to testing personnel at all times testing is performed to provide on-site, telephone or electronic consultation to resolve technical problems in accordance with policies and procedures established either by the laboratory director or technical supervisor;

Edited May 27, 2015 by goodchild

[Karrieb61]

You can have it from me- You did a great and thorough job from what you are telling us! Good for you! I don't think the pit in the stomach ever really goes away and I think having that keeps you on your toes, keeps you from getting complacent and potentially miss something. So you had a rotten situation, did all the right things, and it worked out- again good on 'ya!!

I can't think of an antibody situation offhand that I was witness to, but I have "fond" memories of working alone overnight when a newborn was in crisis and the MD came flying into the Blood Bank begging me for blood, no time for any paperwork, just PLEASE let him have one of the Oneg Pedi units off the shelf. He grabbed one as I opened the frig and out the door he flew. That one has stayed with me for 40 years.

Oh yeah, about 15 years ago there was the actively gushing patient on the OR table with 5 antibodies and the surgeon came rushing in begging for "ONeg blood, that's all we need" and I had to 1) try to explain to him (calmly so he wouldn't hear my heart beating very loudly) that ONeg wasn't the solution to multiple antibodies 2) make the BB tech who was screaming at him "you're gonna kill the patient" sit down and shut up and 3) pray as we waited for delivery of several screened units from the Blood Center next door.  We got the units, out he went and the patient did well.

So your future events will likely happen. Try to read up on problem situations when you can to keep fresh, including any online teaching tools you can use from your vendor or here in the wonderful PathlabTalk. We are here for you!

[Joanne P. Scannell]

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.

[Dr. Pepper]

Ditto to all the above. You did a fine job. A few thoughts:

1. Your BB should have some procedures regarding "what if" situations (uncrossmatched blood, uncrossmatched blood with antibodies, etc). An emegergency release form with several check boxes for different scenatios is helpful; there was a thread a few months ago where someone had added the relative risks of hemolytic reactions under those scenarios. If you don't have those in place, and you've got a decent relationship with your supervisor, you could gently suggest that they could be very helpful to a newbie (as well as everyone else).

2. Practice your emergency issue scenarios. The Boston Mathathon bombing victims did very well because the hospitals treating them had active trauma units and held frequent drills.

3. Someone should always be available to give a helping hand, for both benchwork or advice.

4. Someone exsanguinating bleeds out their antibodies, too. Your patient may have a delayed reaction down the road but at least they'll be alive to do so!

 

Worst I had it was years ago with a ruptured AAA who had anti-K. The anti-K antiserum used an indirect AHG test in those days, so there was a time constraint. My coworker and I kept ahead for about 25 units, then ran out of screened, crossmatched blood. The OR called and said if we don't get 10 units RIGHT NOW the patient will die. So we grabbed 10 units, stuck a segment from each onto the counter with a bag sticker, tossed them in a pile on the dumbwaiter and sent it up a floor to the OR. And did this again. We eventually caught up, and the patient did indeed die, but not from a reaction or lack of blood.

[David Saikin]

All of us Blood Bankers (and you are now one of us) have had to deal with scenarios that helped us develop both our knowledge and technical abilities in Immunohematology.  If you stay primarily in the BB you will develop the knowledge and with that the confidence to handle the stresses of those providing direct patient care.  Most docs don't care about the nuances of Blood Banking, they care about getting the components they need and they usually need them NOW!  Eventually you will experience most of the scenarios described by the very experienced folks who have responded to your post.  As intimated above - in dire situations getting the patient ABO compatible rbcs is the most crucial consideration - exsanguination cannot be cured, almost everything else can be dealt with after the fact.  NEVER let the docs compel you to break policy (eg reducing incubation times or sending the plasma frozen to them to "melt") - your facility should have a policy to deal with outlying situations - become familiar with it.  In my experience most crises do not occur on the day shift.  Best of luck!

 

Decades ago I was the night guy in a tertiary care university hospital.  My Medical Director told me many times he liked me working nights 'cuz I wasn't afraid to say "no".  That is the type of confidence you will develop if you stay in the field.

 

I have found that common sense really helps when the going gets rough. 

Edited May 27, 2015 by David Saikin

[kirkaw]

In my opinion,knowledge is power. If you have access to a Technical Manual or some other Immunohematology-type text book, just start reading. Sometimes, lack of knowledge in theory and hamper your critical decision making skills, as maybe happened with your anti-M. Also, if you get a chance, spend some time on day shift and see how those folks handle antibodies and emergencies. Granted, it will be different on evening shift, but at least you can observe their thought processes and process flow. 

 

I am a supervisor at a non-trauma center community hospital and my techs call me at night, on weekends and when I'm on vacation. I'm more knowledgeable on day to day stuff than our pathologist. But I also TALK to people and see if there's any learning opportunity that they need to make them more confident, whether that's doing an in-service with me, having me work with them for part of a shift or having them join us on day shift. It's a coordinating effort but well worth it. I want my techs to be confident and one of the better ways to do that is teach them where to find the information they need and how to make good decisions.

[DaBears]

Thanks for all of the responses and advice! I have a list of things I am going to discuss with my supervisor when she returns.

I appreciate all the words of wisdom and pointers. I'll keep ya posted and definitely going to browse this forum A LOT!

[Auntie-D]

There's a lot of talk here of waiting for antigen negative units - all I can say to this is that this in itself can kill the patient in a massive haemorrhage scenario. You have to weigh up the risk to the patient of a delayed transfusion reaction v/s the very real chance of the patient bleeding to death. This happened to a new tech I new on his first week

 

In this situation I would contact the medic in charge and find the status of the patient and find out just how long they can wait. With multiple antibodies I would give rhesus and K compatible blood (ie c-neg E-neg D-neg K-neg) and happily give it them uncrossmatched if the patient is bleeding out. If they could wait for a full crossmatch but not for antigen negative units I would empirically crossmatch (10 units at a time) and suggest they use a blood warmer (to combat the possibility of cold IgM anti-M).

 

I have been in this situation with a thalassaemia patient who was in a car accident. They had anti-c and anti-E (older patient before phenotyping happened). The patient was B Pos. I gave them B Pos c-neg, E-neg, K-neg units until these had run out, I then swithched to B neg, then to O Pos by which time the blood order had arrived and I could give B pos. The patient had a cannula in both arms and both legs whilst the anaesthetist was trying to get a central line in and they were giving 4 units at a time.

[Auntie-D]

You did bloody good anyway! It's awful isn't it? If it makes you feel any better my first night was a favour I had offered to do as I was due to go on but hadn't yet shadowed anyone. They promised me as it was a Tuesday it would be quiet - it wasn't!

 

I had a 4 unit crossmatch on a patient in A&E who had been in a car accident (plus all the samples on everyone else who had been involved - 4 cars and 9 people), a 6 unit obstetric haemorrhage, a 10 unit AAA crossmatch and a CSF on a kiddy for microbiology and chemistry (I was everyone!). I cried... I phoned my supervisor and he helpfully said 'prioritise who will die first'. So I did (whilst crying) thinking they were all going to bloody die! My supervisor did come in but by the time he had, everything was cleared and everyone survived. I told him if this was what nights were like I didn't think I could cope and didn't want to do them. He told me it would be a once in a lifetime type shift and said I did brilliantly - he also apologised for his flippancy as he had assumed it was first night nerves and not a real crisis like it was.

[tbostock]

Sounds like you made really good decisions but I agree with a couple things the other folks above talk about:

1. As a new BB tech, you'll need more backup and support.

2. Keep learning; knowing that Anti-M is usually not a big deal could have been a little calming for you.

3. When someone is truly exsanguinating, you can safely ignore antibodies until they stop bleeding. As they say "incompatible blood can be fatal, but death is always fatal".

If you never have knots in your stomach again, you may not be a good Blood Banker. We will never be perfect, and it's the adrenaline rush that you get with cases like this that keep you learning and also remembering why you work in this crazy field. Not too many people get to go home and say "I helped to save someone's life today".

[Malcolm Needs ☆]

I agree wholeheartedly with everything everyone has said in their above posts - but I just LOVE David Saikin's comment, as it is so true - YOU ARE NOW ONE OF US!!!!!!!!!!!

[John C. Staley]

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.