Difficult Donors

1. Difficult Donors Matthew Montgomery, M.D. OneBlood, Inc.

2. Disclaimer None of the following case scenarios are meant to be disparaging towards donors or people in the medical field Slight modifications to the cases have been made to ensure anonymity

3. Case 1 - The Mother and Child I was called on a Thursday by a branch seeking early approval for a directed aphereis platelet donation by a 48 hour post-partum mother to her thrombocytopenic infant. Suspicious for NAIT. Hgb 9.9. “Sore” but otherwise stable. Ok’d donation, informed staff to watch her closely

4. Case 1 Received call Friday from IDC notifying me that the directed unit tested positive for anti-HLA 1,2 antibodies. Normal protocol to discard product I was asked if it should be released I got contact information from the branch and called the ordering physician to discuss the situation

5. Case 1 Contact information connected me to the NICU floor and I was informed the ordering physician (#1) wasn’t present. Spoke to the covering physician (#2) and was told that the baby’s platelet count was ~70K and beginning to stabilize and improve and wasn’t sure they would be needed Informed him of the usual protocol. At the time I was unsure of the possible significance of the antibodies on the child and would defer to his clinical judgment on the necessity of transfusion I was told to allow for the discard of the unit Informed IDC to discard unit

6. Case 1 Received a follow-up call the next day that another physician (#3) on the team had some questions regarding the case I was also told that the child had received an aliquot of platelets over night Found out that the platelet count had dropped to ~20K – 30K range overnight. The post-transfusion count was ~70K, showing good response

7. Case 1 Stated that if they desired, the mother could return and attempt donation again and I’d override the discard, but that since the baby had shown good response it might be easier and safer to continue use of the dedicated unit (there was no record of known anti-PLA-1 antibodies in the mother at this time) Physician was comfortable with this course of action Officially this was the end of my involvement in the case

8. Case 1 – The Aftermath of Confusion Following my involvement, the weekend brought an onslaught of challenges Another FBS physician picked up the case and was asked to set up another directed donation that was to be delivered to the hospital that weekend Product was arranged and planned to be washed by IDC prior to shipment

9. Case 1 Due to computer complications, the time for delivery of the unit was excessively long but was delivered Shortly thereafter a nurse from the NICU called inquiring about the blood type of the unit, which didn’t match the mother (mother Bpos, unit Opos) Mother not happy with the situation and demanding to speak to the BBK physician on call around 10pm

10. Case 1 The actual maternal platelets had never finished processing in IDC Another physician (#4) asks to speak to the BBK physician The product is finally ready but would have to be volume reduced following discussion between the BBK physician and this latest physician

11. Case 1 According to one staff member, during the many calls back and forth between the BBK and the NICU, many voices could be heard, including the mother who was talking with the nurses and directing them to ask questions and get contact information for the BBK physician as well as other IDC and BBK staff

12. Case 1 More confusion – from another account of the story, an IDC employee recalls talking to a BBK staff and informing her of the progress of the unit multiple times during a shift. However the BBK staff that they thought they were talking to was not actually working at the time. Turns out that two of the nurses on the NICU floor had the same names as two of the staff in the BBK and that the connection had not been made by any of them

13. Case 1 Once this was sorted out, there was not going to be adequate time to volume reduce the unit, and the NICU nurse stated that another doctor (not named) said this was fine – this was in direct conflict with what had been previously arranged

14. So what happened? Multiple care team members unaware of what each was doing It turns out that the mother, who is a RN, had been independently calling members of the nursing staff, IDC, and all of her doctors and passing along piecemeal the information she had received from each but not a coordinated story She was very angry and all the team members were on edge

15. Case 1 Bottom line…by trying to use her healthcare influence to personally guide the procedures that were in place, and by telling each physician a slightly different story, the entire process became disrupted Add to this that there was confusion over identical names of team members of in the BBK and on the NICU floor and chaos ensued A RCA discussion was had and a conference call with the mother and her attorney were demanded And the baby was fine

16. Epilogue Turns out the same patient reappeared for another planned delivery late last year From the get go, a red alert was sent to any and every employee to be on the alert as the patient had already begun attempting to make phone calls to arrange the procedure herself The BBK physician spoke to her primary OB physician who was aware of this tendency and all agreed that the only communication was to be between him and the BBK physician on the matter and that the mother was to be kept out of the process In the end the process went completely smoothly

17. Case 1 The moral…processes and procedures exist for a reason. To try and circumvent these things for any reason can lead to unexpected delays and accidents If you are health care worker of any kind treating a patient…Follow your SOPs to the best of your ability If you are a health-care worker who happens to be a patient, let your team do their job the way they are trained to do it. In every case where I have heard of a healthcare worker trying to dictate the handling of their own care, the results have almost always been negative

18. Case 2 – The Angry Doctor I come to work one day and find a message waiting for me from an area doctor that would like to speak with me about an autologous unit collected from herself I investigate what I can before making the call She’s scheduled for an elective knee replacement and has demanded to donate 2 units autologously

19. Case 2 The first unit was collected without incident The second unit, collected near the time limit for pre-surgical collection, however, was drawing too slowly and clotted and had to be discarded There was no time to attempt another autologous collection

20. Case 2 I called the doctor ready to explain the situation The first thing I’m told is that she is extremely angry, that we are completely unprofessional, and that she wants action taken against the employee This is never a good way to start a conversation

21. Case 2 I’m told that during the collection of the second unit, the phlebotomist received a phone call that the donor believed to be “personal” and that she was “giving her a look” That if the phlebotomist had been watching the unit all along she could have kept it from clotting Upon speaking to the donor room staff, the call was a standard work-related phone call that was answered because everyone else was preoccupied and the unit had begun flowing normally, though slowly

22. Case 2 The unit continued to slow down, which was noticed by the phlebotomist, no longer on the phone Eventually the flow stopped completely though the unit was nearly complete However, there were multiple clots in the unit and it would not be able to be filtered or transfused All of this information, as well as the reasoning behind the cutoffs for autologous donation as well as sompe possible reasons for the poorly flowing and clotting of her unit, were explained calmly to the doctor

23. Case 2 I was asked to “guarantee” to the doctor that if she had to receive allogeneic blood that she would not “get hepatitis or HIV” Pause for dramatic effect I explained that that guarantee is impossible to give, just as it’s impossible to guarantee almost anything in medicine I explained the relative risks of infectious diseases, the sensitivity of the tests used, and put them in context of the myriad of other things that are more likely to happen

24. Case 2 I also explained the inherent dangers of autologous donations All in all, she was unimpressed and remained severely angry and demanded action on the employee I explained that the employee would be spoken to Her surgery proceeded without incident and her autologous unit was wasted

25. Case 3 – the sneaky teen On the way to work I receive a call to immediately proceed to an area hospital where a young teenage girl has been admitted after sustaining multiple seizures following a high school blood donation The family is of course there as well as her treatment team Not the call you want to get ever

26. Case 3 I arrive to find the donor has been sedated and is unresponsive but stable I speak to the father I inquire about past medical history The father is thankfully very calm He’s also a bit annoyed, but with his daughter, not us I do some more “detectiving”

27. Case 3 Turns out that the donor, 16, falsified her parental consent to donate in order to get out of class with her friends She had not eaten or had anything to drink It’s Florida…it was in a gym…it’s hot in Florida gyms She also failed to divulge that she has a history of seizure disorders and was currently taking Dilantin

28. Case 3 Any one of these things would have been cause for deferral I wrap up my investigation, give my regards to the family, and ask for the treating physician to please keep me in the loop regarding her condition and further tests

29. Case 3 And then it gets more interesting I receive a call later in the day that the girl is now stable and awake, is currently having to be fed via NG tube, and is having intermittent vomiting MRI and EEG are normal other than what would be expected of her condition

30. Case 3 However, her toxicology screen and Dilantin levels have come back Her Dilantin levels were through the roof Upon investigation of her belongings, the father discovered that she had taken an entire month’s worth of medication that morning

31. Case 3 • Apparently she had been in a disagreement with the family and had decided to attempt to overdose on the medication • We’re still not sure why she chose to try and donate that day • Did she have a change of heart and thought getting rid of some blood would help? • Did she think it would speed up the outcome of her original intention? • We’ll never know • Last I heard the girl recovered completely and FBS avoided a very scary potential liability issue • We also started verifying by phone when possible parental consents for young donors

32. Final thoughts Always try your best to be calm when approaching a situation where you know a donor is angry If you know a donor is angry up front, try to diffuse the situation by explaining what you believe may have happened and what you can do to try and rectify the situation rather than automatically apologizing (this will almost always be used against you if it proceeds to litigation) Know that sometimes these things are unavoidable Autologous blood is bad (with a few very specific exceptions) Not every donor reaction is due to the usual suspects – detective work often pays off.