Thirteen Things This Lab Scientist Wishes Every Nurse Knew

To quote the uncyclopedia’s entry on the medical lab scientist the nurse is the lab scientist’s “arch-nemesis.” This seems rather strange, seeing as we actually work hand-in-hand a lot, and we are both concerned for the patient. However, nurses hate us. And in turn, we are bitter towards nurses. This isn’t to say that there aren’t good nurses. Actually, in my experience, there are two types of nurses: 1) those who as you watch their expertise, skill and abilities, you are in awe of them. They are perfect superheroes to be frank. 2) Those who you watch and say, “If I am passed out on the floor, can you please leave me there? I think I have a better chance of survival if you leave me alone.”   There doesn’t seem to be much middle ground.

But I get it. A main part of a nurse’s job is to take care of the patient’s pain management and managing their anxieties. And our main job is to figure out what is wrong with them, and patient comfort be darned. That isn’t to say we enjoy when they have to be drawn again or something like that, but in our perspective, it is more important that they get healed eventually than them being comfortable now.

However, as many of you may know, I believe that dislikes generally are rooted in misunderstanding. So, here are thirteen things that, if nurses knew, I think would eliminate a lot of contention. I’m sure this goes both ways, but, I happen to be a lab scientist. I, by definition, do not know the things nurses wish I knew, and am therefore not equipped to write that post.  If any nurse friends want to write it, I will post it, actually.

1.       Clotted and Hemolyzed are different

If a specimen is clotted, that means that the coagulation cascade was activated, the platelets aggregated and the same is now, essentially, jello for Edward Cullen. If a specimen is hemolyzed, it means that the blood cells got shredded—usually on their way out of the vein or into the needle. They are different. Clotted specimens cannot be read for some testing, most notably blood cell counts, platelet counts, and coagulation testing. Hemolyzed specimens can interfere with the reading of some tests, notably some chemistries (especially Potassium and direct bilirubin), and in extreme cases, hemoglobin. These are not the same, and a lot of times I’m having conversations with nurses where it becomes obvious that they don’t know the difference. I keep thinking of the Studio C characters, the Good and Well Twins (see below).

For the record, the main way to avoid clotting is to thoroughly mix the tube after draw. The main way to avoid hemolysis is by not yanking back on the syringe (for a line draw or a syringe draw), and not beveling the side of the vein.

2.       Arterial blood can clot

If I had a dollar for every time a nurse responded to my, “It clotted” with “Well, that’s impossible, it’s arterial blood.” And that matters because? Granted, arterial blood is much less likely to clot, mostly because arterial blood is generally drawn from a line, not by puncture. However, arterial blood is certainly capable of clotting. If it wasn’t, every single time you place an arterial line, you would be committing murder, and arterial lacerations would be deadly. Always. Many times, I am actually aware that it's arterial. But even if I’m not, it changes nothing. This information does not unclot the sample.  If I am telling you that it’s clotted, I have evidence for that (either there are little clots that I can see with my microscope, or I pulled a blood-booger out of the tube). And the fact that it came from an artery, doesn’t really change my evidence.

3.       Things don’t clot because they “sit too long.”

Oh how often I hear, “You let it sit. That’s why it clotted.” Or “Run this fast before it clots!”

Let me explain how clotting works, and how blood collection tubes work. When you puncture a vein, two things happen that will cause the body to respond to the “leak.” First,  you go through all the tissue, releasing tissue factor. This tissue factor then activates the Extrinsic Pathway, starting with Factor VII. Factor VII activates Factor X. With the help of Factor V, Factor X activates prothrombin to make thrombin, dependent upon the presence of calcium. Thrombin changes fibrinogen to fibrin and you have a clot.

Second, since you exposed the walls of the vein, the Intrinsic Pathway is also activated. Factor XII is activated (and Factor VIII), which then activates Factor XI, which activates Factor IX. Factor IX and Factor VIII team up to activate Factor X. Factor X, once more, with Factor V, activates prothrombin to make thrombin, dependent upon the presence of calcium (the Ca2+ will be important later). Thrombin changes fibrinogen to fibrin and you have a clot.

If you need a visual for the above concepts, imagine either the Beacon of Gondor from Lord of the Rings, or the scene in Grease where they pass the message down the cars about Rizzo being “knocked up.” (See below).  And for your information, yes, I do see science concepts things in everyday life and movies.  I also see the Battle of Helm's Deep as the perfect representation of a left shift.

Anyways, in order to keep blood from clotting, blood collection tubes often have chemicals that impede these processes. The most common types of tubes are EDTA tubes, citrate tubes, and heparinized tubes. EDTA and citrate tubes work in roughly the same way. EDTA and citrate both chelate calcium, meaning they kind of eat it and hold it in their mouths. If EDTA and citrate eat the calcium, then Factor X cannot activate prothrombin to thrombin, and the whole thing is stopped. Heparin, on the other hand, inhibits thrombin. You can change the prothrombin to thrombin, but then thrombin gets whacked over the head and forgets what to do next. So, the key to a tube not clotting is getting the blood to the ANTI-COAGULANT before it gets to the corresponding step in the process. If the blood is in the presence of the anti-coagulant, it will not clot. The blood can sit there for a week, and still not clot. So long as it got to the anti-coagulant in time.


Granted, it is technically true that if we ran it fast enough, it wouldn’t have clotted. However, in a normal person, the extrinsic pathway takes about 12 seconds once activated (which is pretty much as soon as you start to draw it). The intrinsic pathway, in a normal person, takes about 30 seconds once activated. So, yes, technically, if you got it to the lab in 15 seconds, we could run it before it clotted, even if the anti-coagulant screwed up, but really, 15 seconds?

So no, in conclusion, no. It was already clotted. If it was a delay problem, it was that it was in the syringe too long before going into the vacutainer. Or you didn’t mix the blood after putting it in the vacutainer and so it was delayed getting to the anti-coagulant, not a delay getting to testing.

4.       We know what we’re doing

I didn’t just graduate from high school to do this job. I don’t just press buttons. In fact, where many registered nurses have associates degrees, every single one of us in our lab has a bachelor’s degree. There is such a thing as an associate’s in lab science.  They are called medical laboratory technicians--and we don't have any full-time ones in our lab, but they exist. We, as laboratory workers, had to take physics classes, physiology classes, organic and biochemistry, biology, anatomy, molecular biology, infectious disease, microbiology, immunology, parasitology, genetics and more, on top of classes in laboratory technology, clinical technology, blood banking, and technique classes to do what we’re doing. We are trained in phlebotomy, cellular analysis, microbiology, chemical testing, laboratory technique, blood banking, and more. And we sat through a nasty, gross national exam, just like you did. We know what we’re doing.

5. I don’t tell you how to do patient care. Don't tell me how to do lab work

You are a nurse. That’s a wonderful thing. There are many things that you know that I don’t know. But the converse is also true. Don’t be condescending about lab work, especially when you’re wrong. I wouldn’t try to tell you how to do patient care. Why do you try to tell me how to do lab work? Usually when it’s something you don’t know, I don’t think badly of you. And if you don’t know something, just ask. I’d be happy to tell you. I sometimes am trying to work something out and have to ask you, “I’m not familiar with that. Could you explain it to me?” There is nothing wrong with that. You know patient care. I know lab. And when I give you the critical value of schistocytes, believe me, most nurses don’t know what those are, and there’s no shame in asking.

That being said, I won’t shame you for your lack of knowledge, until you try to act like you know more about it than me. I once called a nurse to tell her the coags had clotted. She told me, “That’s impossible. Coag tubes have heparin in them.” I usually wouldn’t care that a nurse doesn’t know that light blue tops have sodium citrate in them (my job to know that, not necessarily the nurse’s), but when you take that tone with me, I won’t hesitate to say, “Actually they have sodium citrate, and I have a big chunk of goop that says otherwise” (politely, of course).

I couldn’t pass the NCLEX-RN and it would be somewhat entertaining to see me try. But you know what else would be funny? Seeing you take a crack at the MLSBOC.

6.       Specimen labeling—yeah it is that big of a deal

I know. It’s inconvenient when you have to come down and relabel a specimen because the time wasn’t on it. Or because the printer wigged out and we only have a half a name. Even worse when you have to stab a child again because you have to redraw the specimen entirely because there was no label on it at all. And when you were busy in the heat of the moment, you just plain forgot to put it on. I get that. But yeah, it is a big deal. And no, I’m not being picky about it. Testing run under the wrong patient is one of the biggest sources of laboratory-based medical error. I get that it sucks. But I’m also not going to bend on this one.

A lot of times when a nurse is being fussy about this one, I explain it this way and she calms down. Imagine you were sent some IV meds from the pharmacy. What meds? I don’t know. Clear ones. It doesn’t matter for the sake of our story, and I don’t know enough about meds to choose (see item 5).  They have no label. None. No patient label. No label as to what they are. Nothing. You call the pharmacist and say, “I don’t know who these are for. I don’t know what they are.” The pharmacist says, “Oh that’s the x for Jane Doe.” Are you going to give the meds to them? No, you’re probably not going to. What is the pharmacist says, “Well, I’m really busy. Just give them those and I won’t forget the label next time.” Will you give them to them now? No, probably not. What if the pharmacist swears on all that is holy that those are what they say? Will you give them now? No, probably not. Are you starting to see my dilemma here? How can you promise me that this blood belongs to this patient? From my point of view, it looks like all other blood. And trust me, I see a lot of blood, and I still can’t tell it apart.

7.       No, I can’t give you the result without valid controls

Sometimes I have to make that stupid phone call of, “I’m sorry. I ran the testing, but I do not have valid controls for that assay. I will call you when I have them.” I hate it. You hate it. But I have to do it. A lot of times, the nurse’s response, “Well what is it?” Did you not just hear me? I can’t tell you that. I don’t have valid controls. I don’t know that this result is correct. “I won’t write it down, I just want to know.” I explain that, well, I can’t promise it’s right, so I don’t want a patient treated off of it. I have seen failed controls result in values that are critically low when they’re actually critically high. “Well, I won’t treat them, I just want to know.” If you’re not going to write it down, and you’re not going to treat off that value, then why do you need to know?

8.       If that isn’t right, I don’t even want it on the medical record ever

A lot of times, I look a test result and think, “That can’t be right.” I call up the nurse because sometimes, they drew it from a line, or above a line, and there is IV fluid in it, or saline waste, or they left it in the syringe and it separated and the purple tube ended up with all the cells, and the green tube with all the plasma. I say, “I think we should redraw this sample.” A lot of times their response, “Well, just post the result and then if the doctor questions it, we can redraw it then.” No, you don’t get it. If the result is wrong, I don’t want it on their medical record for doctors who don’t know the whole story to try to interpret their patients’ status. I don’t want that patient charged for that testing if it was erroneous. And if I put it on their medical record, it can’t come off. EVER. In the event that you call and tell us that you're doing a redraw, we can put a disclaimer on the value, but we can't EVER take it off of the medical record once it's on. Also, floors rarely tell us that it is a redraw, so if you're going to do this, at least tell us it's a redraw of the last specimen and not a separate check. Then we can put a disclaimer on the value and credit the charges.  That being said, I don’t want it there if it’s clearly wrong. If that’s what they’re honestly running, they’ll still be running it when you redraw. But before a miscommunication happens and someone doesn’t know that the lab scientist said, “I don’t think this sample is valid,” they do something like give insulin to this baby with a glucose of “632” when that’s all IV fluid, let’s redraw this sample.

9.       We are scientists. We are rule-based, evidence-driven, control-loving people

I think a main source of contention is that we are different types of people. You are nurses. You are part of medicine. Medicine is a case-study, anecdotal, experience, it-worked-once-might-as-well-do-it-again type of discipline. And I don’t say that in a mean way. That’s just how it is. And there's a hope-giving beauty to that.  We are part of medicine, but we are kind of the illegitimate love child of experimental science and medicine, and we always liked our experimental science parent best. We don’t care if it worked once. Did you have control groups? Did you have reproducibility of results? You didn’t eliminate all the variables from the equation!? Does this make us make any more sense?

10.   It may seem bureaucratic from your perspective but there's a reason. If you want to know why, feel free to ask, but don’t assume that there just isn’t a reason.

We are rule-based people (see item 9). But we have reasons behind our rules. If you don’t see the reasons for the rules, feel free to ask. But don’t just roll your eyes and say, “That’s stupid,” or tell all your student nurses, “There’s not a reason for that. They just have something up their butts.” (I heard a nurse say that once at a social when someone was talking about how they had to go back to a lab for a redraw for some reason…she didn’t know I was a lab scientist. And she didn’t say butt). Most of our rules were created after an incident, by the way. So, there is a reason behind every rule that seems stupid.

11.   We won’t lie to you. If we screwed up, we’ll say so

It has come to my attention that many nurses believe that when we say a sample is clotted, we actually spilled it. Nothing could be further from the truth. I have seen samples get spilled. Accidents happen. I’ve also seen blood get sprayed across the room when the cap opened up (not pleasant). I’ve seen a tube of blood explode in the centrifuge (literally explode. It broke and there were plastic shards all over the inside of the centrifuge). And whenever those things happened, the truth was told.

If we screwed up, we’ll own up to it. If we aren’t saying, “I screwed up,” then we most likely didn’t. We’re not afraid to admit it. Partially because the lab’s quality control system is based on the assumption that if something goes wrong, the system failed. Not the people. People are, by their definition, flawed. People make mistakes. That’s why you design a system where people’s mistakes don’t hurt anyone. So, we aren’t as punitive as nursing is (from what I hear). Not to say that you can be incompetent and not get in trouble. But the first question is “What went wrong with the system?” not “who screwed up?” For this reason, if we’re not saying we screwed up, chances are, we didn’t
.

12.   Which is worse: The patient getting poked again, or you treating an erroneous result?

See Item 8. But basically, if there’s any doubt in my mind about the sample’s integrity, identity, or validity, I want a redraw. I would much rather you put a needle in their arm one more time than they die. I know it’s not fun. And I know nobody likes it. I work in a children’s hospital. Even less fun. And I don’t want NICU babies bled dry, either. But another .5 mL of blood, verses death? I think we’re going to go with .5 mL of blood.

13.   We are all on the same team—we’re there for the patients’ best interests

As I’ve said, we’re dealing with different parts of patient care. But the fact remains that we’re on the same team. We are arch-nemeses, but we are like Captain America and Iron Man (by the way, I see us as Captain America in this equation, but you’re free to see it the other way). We don’t see things the same way, and we’re constantly bickering. But at the end of the day, we’re on the same team. We both want the patient safe, sound, and preferably at home.

Months later edit:  This post has gotten a lot more traffic than I ever expected any of my posts to get, due to LabHumor posting it on their facebook page.  I appreciate the insight from other laboratory workers.  This has brought in some thoughts from people at other labs than my own.  They would like to clarify that people who are MLTs are not lesser.  I never meant that they are lesser, but am sorry that they felt my words meant that.  However, I have to stand by my original to some degree, as I am referring to my lab, in which non-Bachelors MLSs are not present, and our MLTs only take small shifts and cannot serve all of the functions of an MLS.  The world is not fair to people with equivalent experience, and I am sure that many of these people are much better lab scientists than I am because of their life experiences, even if I have a bachelor's--I'm twenty-four. It is worth noting that the experience-route to MLS certification has been discontinued by the ASCP , and existing MLS that do not have bachelor's degrees are grandfathered, but it is no longer acceptable.  I can only speak to my experiences in a lab.  And in my lab, we don't have any of those.  I am not naive to their existence, but I am aware that they are not present in my lab.