[Lab in the News] BC Children's Chemical Spill

This week, our BC Children's Hospital was treated to a Code BROWN, or major chemical spill of parafromaldehyde. Para-formaldehyde can cause skin and eye irritation, and can be harmful if inhaled. It is also highly flammable.


http://www.cbc.ca/news/canada/british-columbia/bc-children-hospital-chemical-spill-1.3259740

Each hospital drills every year in case of this occurrence, and the procedures in place seem to have been followed to the letter. No one was reported hurt, and the spill was contained in under two hours.

Just in case you aren't familiar with common protocol, each hospital usually has a color coded to indicate that a chemical spill has occurred to the staff without alarming patients or visitors. Once a Code Brown is called, there are processes in place to do some or all of the following:

- Summon security or someone trained to address the spill.
- Evacuate anyone who could come into contact with the spill, or fumes from the spill.
- Call in a HAZMAT team or fire fighters to address more dangerous chemicals.

That's all well and good, but when is a Code Brown called, and what should lab staff do directly after a spill?

First, lab staff need to determine if they should be calling a Code Brown, or cleaning it themselves. Questions to ask include:

Do you know what chemical was spilled?
What volumes are involved?
What are the hazards of the chemical that was spilled (Found in the MSDS kept on site by law)
Is there a Chemical Reaction or hazard present, and can the area be cordoned off?
Do you know where the spill kit is, and how to use it?
Make sure to inform your supervisor and close by staff about the spill before attempting to clean it up.

ALWAYS CHECK AND WEAR APPROPRIATE PPE BEFORE APPROACHING THE SPILL.

Some spills you will need breathing equipment, or special gloves. Do not make assumptions; always check the MSDS.

A Code Brown is called if there is a spill over a certain volume of chemicals or matter deemed low risk, or any amount of spill of high risk chemicals or gases. Each facility will have it's own categories.

Low Risk Spills: (Dealt with by lab staff, not HAZMAT/Code Brown)

This tends to include a chemical spill less than 500 mL of a known chemical that shows no visible chemical reaction (bubbling, hissing, gases emitting when in contact with surface spilled onto).

Example: Spilling 10 mL of 0.1M HCl onto a bench surface.

Intermediate Risk Spills: (Dealt with by security and lab staff, Code Brown called)

This includes chemical spills that are large volume and can't be handled by lab staff alone, that are not reacting with the surface spilled onto, and also are not emitting fumes. You would call a Code Brown in this case, and security would come and help you keep people off the area, and clean it up.

Major Risk Spills: (HAZMAT, Security, Lab Staff work together, Code Brown called, Evacuation)

Either the substance spilled is unknown, the volume of the spill is unmanageable, the chemical fumes/contact is dangerous, or there is known/visible reactions that are happening between the chemical and the spill surface.

This is where parafromaldehyde lies, if dealt with outside of a fumehood. It is both highly flammable and emits fumes that are harmful to humans if inhaled. It makes sense that the evacuated the hospital, and ensured no harmful fumes/risk of fire was transfered to staff and patients.

 

Link: CBC Article on 2015 Research towards the universal blood type

http://www.cbc.ca/news/canada/british-columbia/ubc-researchers-step-closer-to-creating-universal-blood-type-1.3056650

Too much Iced Tea causes Kidney Failure - NEJM Article

Case Study: A man with kidney failure caused by oxalate toxicity from drinking a 16 glasses of black 

iced tea a day... (Iced Tea has about 500 to 1000 mg of oxalate per litre; overloaded kidneys)



This is a short (but sweet!) case study involving both pathology and chemistry; patient comes in with weakness and body aches, initial blood work up shows high serum creatinine and a high number of calcium oxalate crystals in the urine.

Followup testing showed 24 hour urine oxalate excretion to be elevated; also a kidney biopsy showed oxalate crystals. Patient history revealed none of the usual causes for this (hx of gastric bypass, ethylene glycol poisoning, 'juicing', or vitamin C overdose), but above detailed habit of iced tea.

Interesting!

[Urinalysis] Sperm

                                          Image by Cooldesign, from FreeDigitalPhotos.net

When we take a look at urine under the microscope, there are things we tend to look for. Most of them seem pretty clear cut on why they are reportable - they are signs of infection or conditions that the doctors can then treat. Bacteria, and WBC are both obvious signs of urinary tract infections; yeast signal a yeast infection. White cells casts can predict pyelonephritis, and red cell casts glomerulonephritis.

 But what about sperm?

Shouldn't sperm be something we see in every male midstream sample?

Nope.

Spermatozoa are only normal if the sample isn't midstream, AND the patient has had sexual activity within five hours of collection. As collection protocol for urinalysis is midstream, we should not expect to see sperm in sample.

Sperm is seen in midstream urine when the bladder sphincter fails to produce the usual tightening before ejaculation. The sperm then travel into the bladder instead of out of the body, and are excreted during urination. This condition is called retrograde ejaculation, and can be due to nerve damage, diabetes, medication side effect, post bladder/prostate surgery, or weak muscle condition. This is one of the more common causes of male infertility, and can be treated.

Another reason sperm may be seen in male patients' urine is prostatitis. When the prostate is swollen with fluid, it can block off the paths that sperm would normally travel, causing a redirect. This can be due to prostate cancer, recent surgery, bacterial infection of the prostate or urinary system, or arousal without ejaculation. Sometimes this is also seen when methods to avoid mess are used in sexual expression; the interference (or application of Hughes Method) to prevent ejaculation can cause backflow into the bladder. Unless other symptoms are present, treatment is generally unnecessary.

Reporting sperm in male urine can be a real clue to infertility patients

.What about females and children though? You should never see sperm in a child's urine. If you do, you must report it; that child could be sexually abused. I would advise confirming with a second sample if you can, to ensure there are no mistakes. Know that you cannot be sued for bringing this to your hospitals' attention so they can follow up; this is part of your duty to report as a technologist. In one case, the parents attempted to sue, but failed. Seeing sperm in an adult female's sample is a non-clinical finding.

[Hot Topic] CBS Blood Donation Policy, Update

Last year, the big news was Canadian Blood Service's attitude change towards accepting blood donations from gay men. Previously completely banned, gay men can now donate blood if they have had no same sex sexual activity for the past five years.

This is a huge step for Canadian Blood Services.

Last year, they had still not quite ironed out how this change would echo through the rest of their policies.

For instance, what about women who had had sex, even once, with a man who had had a male sexual experience? Up until last May, they were also still excluded from giving blood. Even last May, when I called and spoke with a CBS associated nurse, they were still excluding those women from giving blood, as they "just didn't know" how things would play out.

I called back this year and clarified. Now the question for women has been changed from

"Are you a woman, who has had, even once, had sex with a man, who has had sex with a man?" 

to,

"Are you a woman, who has had sex with a man, who has had sex with a man, in the last five years?"

I.e. if the same sex sexual experience took place greater than five years ago, then you can donate.

This is particularly applicable for bisexual men and women, or partner's of those who "experimented" in college. Previously, if they were aware of their partner's past, they would have been permanently deferred. Now, if it has been more than five years since the MSM encounter, women are eligible to donate again.

As always, if you have questions about your eligibility to donate blood in BC, call the donor line at 1888- 2DONATE, and ask for the nurseline. They will be able to help address concerns about whether you are a good fit for a donor.

CBS continues to collect data to see if it can relax it's deferral policies in the manner any further.

It will likely be at least ten years of data collection though before we see any more change. One step at a time though is all we can do.

Hopefully, the screening process will continue to move more towards an actual sexual-risk based policy based on number/frequency of sexual partners rather than the sexual orientation of the donor.

[Acronym of the Day]: DAP

Acronyms are certainly part any workplace's jargon; the lab is no different in that respect.

One of the more important ones to know about is DAP.

What is DAP, and what does it do? The Diagnostic Accreditation Program, according to the DAP website:

"sets accreditation standards for best practices that are evidence based, outcome focused and aligned to the principles of continuous quality improvement. The accreditation standards are comprehensive and address medical, technical, and management aspects of service delivery."


Since 1971, each facility in British Columbia that performs laboratory testing must be DAP reviewed, public or private.

What this boils down to is every four years, an outside team of your profession/stakeholders comes in and goes over your work with a fine toothed comb to ensure you are meeting standards in patient care, quality, and safety. It sets an external standard of trust in the system, and encourages vigilance in maintaining current methods, up to date safety procedures, and overall evidence based best practice.

DAP also produces a line of external quality control samples, or blind controls, to ensure your results are accurate. They are released quarterly, and laboratories that do not meet standards are held accountable.

The DAP is headed by some of the top minds in each discipline in the province; there are representatives from the management, educational and the vocational views on each board. They in turn supervise DAP teams, each formed depending on the facility and disciplines necessary in review.

If you have a chance to participate in a DAP review of another facility, take it; it's a great way to learn from the ground up.

New in Serum Osmolality: Zander's Formula

Serum Osmolality and OGAP... two of the formulae chemistry techs can do in their sleep. We all know the standard textbook Worthley et al equations;

Serum Osmolality (all in mmol/L):

2 Sodium + Urea + Glucose + 1.2 Blood Alcohol

Osmolar Gap  

Measured Osmolality - Calculated Osmolality

To make it easier for doctors or nurses without a lab handy, many websites/apps are even set up to do the math, with the reference ranges and criticals on the side. We've used the same formula for more than twenty-five years.

Last year, 2013, Zander's Formula was released as a "better, more useful calculation" for osmolality.

Zander's Osmolality (all in mmol/L): 

(Sodium + Urea + Glucose + Potassium + Bicarbonate + Lactate +6.5)x0.985

How is it better? Not only does it show a much better correlation between calculated and measured, it also has the closest 95% limits of agreement, when compared to 36 other possible formulae, (including the Worthley.) 

This new formula also only uses analytes commonly found on a blood gas analyzer panel. This will enable, in the future, a calculated osmolar gap to be added on automatically to trauma panels, giving the clinician one more piece of the puzzle in differentiating metabolic acidosis.

This is important because with such improved accuracy of OGAP, we would reduce the necessity for follow up methanol or ethylene glycol testing on many of our trauma patients who present with elevated gaps due to renal failure/shock/lactic acidosis, thus speeding diagnosis. (Remember though, the measured osmolality MUST be done by freezing point method if looking for any types of alcohol, as vapour pressure methods don't detect volatile solutes such as ethanol/methanol)

That said, Zander's is built to be used broadly; it doesn't include ethanol contribution as a matter of course; you would have to add the 1.2(ALC) yourself, to rule out/confirm any gap being due to ethanol rather than methanol, mannitol, or any of the other usual suspects. Depending on your population and preferred use, it could do with some tweaking.