running a marathon with a hard sprint up heartbreak hill...
Summer has arrived, and along with it the snowbirds and tourists. And my small, rural hospital has shifted into trauma center/emergency room. Last Wednesday was the kind of day I dread.
My shift started at 1:30pm. I checked in with the hema tech who warned me that chaos had reigned so far, with a long-winded story that boiled down to a single lab assistant known to be a space cadet. I putzed around a bit to get ready for the evening, then headed out to the cafeteria to pick up a big bottle of juice, part of my routine now to make sure I stay hydrated. The lab is exceptionally dry due to all the instrumentation.
When I came back, the micro tech was grumbling. She wanted to leave early, but the urine analyzer had just been returned from the shop and now we had to swap it out with the loaner and she couldn't get the bar code reader off the loaner. She managed to free it and we swapped them out. After we repackaged the loaner she was filling out paperwork and realize she needed the serial numbers off the loaner, so we unpackaged it and then repackaged it. I calibrated our return, then ran qc. All ok, so we were back in business. Except now she needed to re-program it, which is a royal pain because it is an incredibly stupid instrument with 3-digit codes to = a single letter. After punching away, cussing the whole time, she finished. A couple minutes later, I heard loud cussing...she had moved the instrument slightly and it disconnected. She couldn't get it on again. I fiddled with the cord at every juncture and got it going. Phew! Then we discovered all the programming was lost 
She started punching codes like crazy, and cussing like crazy, she got it re-programmed and ran for her life at 3pm on the dot
I snuck in a quick sip of water and a pee. Then the space cadet lab assistant came running to me babbling. She talks too fast, includes a ton of extraneous detail and side stories, generally starts somewhere around the middle or end and winds up at the beginning. So you have to listen to a long, long story to sort it all out before you have a clue what she's babbling about. Which is how she manages to scramble your brain and spread chaos. So I sorted out the latest mess...an outside patient waiting for type & screen for rhogam..and then the ERs started coming, and my pace picked up to a jog. There were now just 2 of us, and while the chem tech took care of QC on her analyzer, I was stuck with hema, micro and serology, jogging from one end of the lab to the other. Somewhere in there, I ran into the break room and downed half a bottle of juice in a single, long slug.
Shortly before 5pm, I ran an outside lab patient that had a critical WBC with half the instrument flags lit up. Craps, now I was running hard. It took extra time to see the patient history because the blood was such a mess the instrument couldn't do the differential, and the resulting software wouldn't let me in until I cancelled out its warning message and "NP'd" every single non-result. It turned out we had a long history on the patient, so I didn't have to race to get this one done. It also turned out the night tech had run this blood just a week earlier, so when she arrived at 5 I mentioned it to her. She responded by running to the chem lab and plunking down into that chair their so she wouldn't have to do hema. Nobody wants to do hema because it can require a lot of manual workups with room for mistakes. I slowed back down to a jog and continued working up that spec.
And then shortly after 5pm I reached heartbreak hill. Another critical patient, with half the instrument flags screaming. Holy shit...now I was running hard, and in a panicked, foggy, dehydrated, surreal state. I re-ran the specimen on a 1:5 dilution, and then re-ran an optical count on the platelets. I checked the spec for clots and made a slide. I did the math on the dilution. It didn't make sense and I called out to the other tech. She glanced over and saw that I was comparing the dilution results to the other critical patient. No wonder. I moved that pile of papers well out of my way, and set about comparing the results. The numbers were effing insane. 
I tried to look up the patient history, but once again had to NP the entire instrument diff. I printed off those results for comparison. A normal WBC runs between 4.5 and 11. 2 days ago the patient's WBC was a critical 2.0. Now the WBC was 0.08; 0.1 on dilution!!! 
Normal platelets will run in the 2-300 range. There were 10 platelets. 10. I started consolidating the results on a single page so when I called the ER with the confirmed criticals I would be reading the correct numbers off. That's when the ER doctor, the one who normally hates me and runs in screaming, came running in looking scared. He stood there looking at the pages of results laid out in front of me, and asked if he could make a copy. Of course. He took the consolidated page and ran to the copier, returned my sheet and raced back to the ER. I went back to working up the spec. I started the slide staining and went back to reviewing the RBC results so I could work my way down that tree of crazy. I then sat down at the scope with the stained slide. Scanning at 10x, I couldn't find a single white cell on the slide. None. So I made 3 extra-thick slides and started them drying. The other tech yelled I was wasting my time and said I should cytostain them. Um...I don't think so. The last time we worked together she butt into chemistry and effed me up big time. This time, I called our supervisor. Nope, cytostain won't work, make 3 extra thick slides...I told her they were already staining. She asked if I'd called the results. I told her I'd given the Dr. a copy. Then she asked me the name of the patient...and that's when I noticed the age. 
It's just a kid with cancer. She said the chemo had probably really wiped out everything. There's an old, closed nuclear plant within 30 miles or so. The first lab tech I'd talked to that day once told me that every class from the school in that town has at least one kid with cancer of one kind or another. Every single class has at least one cancer patient. 
Normally, we do manual differentials on 100 white cells. 2 days ago, with a 2.0 white count and 20 times as many white cells as I had to work with, the tech did a 50-cell diff because it's so hard to find enough cells when the counts are that low. My supervisor told me to try to do a 25 cell diff, but not to worry because "all you can do is the best you can do." It took me about 40 minutes, but I found 25 cells. Actually, 33 because the counter doesn't ding until 100, so I lost track of where I was. But I found enough. I only saw a platelet or two. I scanned quickly to confirm there was no platelet clumping. And finally could report the results.
I limped back to the break room and downed the rest of my bottle of juice, again in a single swig, and then headed back to hema. I finished working up the first critical patient, and a continuous string of EDs. I put in the orders for the lab patients from earlier in the day, labeled those specs, and ran the hemas. I sorted out the chemistries and was going to put them on, but the chem tech came back from doing the urines and said don't worry, she'd get them. I headed back to micro and plated 5 specimens and took care of a couple gram stains.
We were all caught up and at ten minutes before 9pm. I sat down and ate my dinner.
I took a benadryl to help me sleep that night. My back ached and my feet hurt like hell. But that kid's results kept running through my head. I kept going through each step, trying to figure out which one I'd effed up. All my testing and results would be reviewed by a lead tech the next day. When we make mistakes, they leave "love letters" in our mailboxes telling us everything we did wrong. I slept about 4 hours. The next morning my feet still hurt, and my legs ached. All my muscles were tired, tired, tired. I had the day off, and did very little. Couldn't sleep that night either, again the kid's numbers were all running through my head. I decided I had messed up the hematocrit because I couldn't remember the numbers. If they don't drop below a certain point, we need to do a manual crit. I couldn't remember the numbers; I couldn't remember double-checking the crit. But I know I didn't do a manual crit, which I hate, hate, hate because they are so time-consuming. I wondered how much damage a wrong crit number could do.
Yesterday I was on again. First thing I did was head to my mailbox for my love letter. It was empty. I made it. 
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