Section: Special Hematology

Duration: 1 month

Goals & Objectives

The goal of these rotations is to provide residents with the opportunity to increase their knowledge base and skills in the interpretation of a wide range of hematologic abnormalities. Through regularly scheduled sign-out sessions with the attending pathologists, the residents should gain a great deal of practical experience in how to approach potential diagnoses of hematologic malignancies, systemic disorders affecting bone marrow, lymph nodes and other organs; bleeding abnormalities and thrombotic conditions; hemoglobinopathies, thalassemias, anemias; and a varied array of other hematologic abnormalities presenting in both the inpatient and outpatient populations. A major goal of the rotation is that the resident gain sophistication in the appropriate choice of laboratory tests for a given clinical situation. While the achievement of technical proficiency in laboratory procedures is not a specific objective of this rotation, sufficient familiarity is required such that the resident can appreciate the intrinsic limitations of the procedures, as well as recognize unlikely individual test results that might reflect technical artifact. During this rotation, the resident should also learn how quality control is maintained for hematologic procedures. In order to maximize achievement of these objectives, residents on this rotation are strongly advised to establish close working relationships with technologists and supervisors in the laboratories - a number of whom are truly expert in the field.

Duties & Responsiblities

Become credentialed to take histories on all referral patients for hemostatic workups. Select studies most appropri-ate to evalu-ate the patient's disorder. Before the patient leaves, review the history and proposed tests with the attend-ing pathologist.
Sign out:
Hemostasis evaluations: Work with the technologists and attending pathologist to determine the appropriate tests to be performed. Sign out interpretation with attend-ing pathologist and contact referring physician to discuss future diagnostic and follow-up testing and proper thera-py.
Hemoglobin/thalassemia evaluations: Work with the tech-nologists to determine the appropriate tests to be performed. Check the Wright-stained blood films. Procure further clinical information as indicated. Write interpretation and sign out with the attending pathologist.
Osmotic fragility determinations: Work with the technologists to determine the appropriateness of an osmotic fragility determination, in consideration of the clinical history and, if available, the peripheral blood film. Write interpretation and sign-out with the attending pathologist.
Evaluate requests for bleeding time determinations in the following circumstances: · If the request is received during the second or third shifts when the laboratory staffing is decreased. · If the technologist has a question about the appropriate-ness of the ordered bleeding time. · Become familiar with all procedures. These include instrument checks, calibration and quality control. During the month that this rotation is combined with the rotation in Clinical Chemistry, the resident will spend one week focusing not only upon testing performed in the special testing section, but also upon testing performed with high volume and more automated instrumentation.

Instrumentation (principles and maintenance)

The microscope
Microscope illumination
Blood diluting procedures
Abbott Cell-Dyne 4000
Diabnostica Stago. STA Coagulation Instrument
Hemoglobinometry
Calibration
Maintenance of spectrophotometers
Phase microscopy and patelet counting
Centrifuges
Standard
Microhematocrit
Platelet lumi-aggregometer and whole blood aggregometer
Bechman and Sebia electrophoresis apparati
Isoelectric focusing apparatus
Bio variant HPLC apparatus

Preparation of reagents

Wright's stain
Cytochemical methods
Blood-diluting fluids
Use of anticoagulants: Citrate, Heparin, EDTA
Buffer solutions

Quantitative evaluation of laboratory data

Quality Control statistics
Factor assays, inhibitor assays, etc.

Economics and administration of hematologic laboratory Hematologic procedures

Obtaining blood: Capillary, Venous, Various sites
Counting of erythrocytes: Abbott Cell Dyne
Preparation of blood films: slide, coverslip
Staining of blood films: Wright's stain, Special stains
Reticulocyte counts
Platelet counts: Phase-microscopy, Abbott Cell Dyne
Hematocrit: micro, Abbott Cell Dyne
Red cell indices
Review, interpret blood cell histograms from Abbott Cell Dyne
Westergren Sedimentation rates (ESR)
Automated erythrocyte sedimentation rate (Vesmatic)
Eosinophil counts
Osmotic fragility of erythrocytes
Autohemolysis
Sickling determinations
Hemoglobin electrophoresis - alkaline electrophoresis, acid electrophoresis, isoelectric focusing
Sucrose hemolysis test
Acid serum hemolysis test
G-6PD screening tests and assay
Unstable hemoglobin: heat denaturation; isopropanol solubility
Hemoglobin A2 assay (this is a part of the HPLC method - no manual method
Acid elution (fetal hemoglobin)
Heinz body preparation
Hemoglobin H Preparation (brilliant cresyl blue)

Coagulation and Platelet Procedures.

Obtaining blood (special techniques, such as two syringe tech-nique)
Bleeding time - Simplate II
Partial thromboplastin time, Thrombin time, One-stage prothrom-bin time
Platelet aggregation and release reaction studies; imped-ance aggregometry
Clot retraction
Platelet count
Procoagulant factor assays
Fibrinolysis - Euglobulin lysis time
Screening Test for fibrin degradation products: D dimer tests
Fibrinogen assay
Circulating inhibitors - Lupus-like inhibitor test battery - Factor VIII inhibitor (Bethesda) - PFA-100
von Willebrand Factor Antigen, Activated Protein C resistance
Ristocetin cofactor
Factor XIII screening test (urea solubility)
Platelet-associated immunoglobulin, anti-platelet antibodies
Chromogenic assays - Protein C activity, Antithrombin III activity Heparin levels, etc.

Hematology, Abnormal Results Standard Operating Procedure

The Hematology technical staff will call the patient's physician immediately to report any of the following:

Hematocrit < 25 or > 55% WBC < 2 x 103/?L or > 30 x 103/?L
Platelet < 50 x 103/?L or > 1000 x 103/?L
Prothrombin time > 30 sec
Partial Thromboplastin time > 90 sec
Thrombin Time > 40 sec
Bleeding Time > 12.0 min.

Unexpected differential findings, including blasts in a new patient or leukemic patient in supposed remission will also be called. These findings will be confirmed with the Hematology Supervisor, the Clinical Pathology Bone Marrow Resident (or resident on-call), or the Attending Pathologist.

In the case of a clinically important unexpected finding (such as blast cells in a new patient suggesting the diagnosis of leukemia), the Hematology Supervisor will consult the Clinical Pathology Bone Marrow resident. The resident will confirm the finding, checking with the hematopathology fellow or attending pathologist as necessary, and call the clinical physician to report the finding and inform the clinician of its implications.

Evaluation

Global Rating of Live or Recorded Performance: A rater judges general categories of ability (patient care skills, medical knowledge, interpersonal and communication skills) and the ratings are completed retrospectively based on general impressions collected over a period of time (end of rotation) derived from multiple sources of information (direct observations or interactions); input from other faculty, lab technicians and residents and review of work products or written materials. Evaluations will be based on the above objectives.