A Day in the Life: Transfusion Medicine as Team Sport

Justin Kreuter, MD
Consultant and Instructor of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota

In this edition, Justin Kreuter, MD, takes a break from teaching and clinical duties to walk us through a typical day in the life of a pathologist specializing in transfusion medicine.


Justin Kreuter, MD

Institution:
Mayo Clinic, Rochester, MN

Specialty:
Transfusion medicine

Years practicing:
8

Transfusion medicine is the clinical application of immunology and coagulation principles – but most of all, it’s a team sport! As a pathologist at Mayo Clinic, I have a subspecialized practice in transfusion medicine and transplant compatibility testing, which includes human leukocyte antigen (HLA) compatibility for hematopoietic stem cell transplantation.

Constant communication and coordination with colleagues across teams is crucial. One of my areas of interest is developing professional learning communities in the digital environment and, since the COVID-19 pandemic hit, I’ve adapted to bouncing back and forth between in-person meetings and teleconferencing.

Here is how I spent a recent workday:

6:00 a.m. I wake up and spend 30 minutes on the rowing machine while listening to the latest Key Literature in Medical Education (KeyLIME) podcast, which is released weekly by the Royal College of Physicians and Surgeons of Canada.

7:00 a.m. I join a Zoom call with colleagues from Karolinska Institutet in Sweden to finalize the write-up of our upcoming project – facilitating the annual Mayo-Karolinska research meeting in the digital environment.

8:00 a.m. I arrive at the hospital with a few minutes to spare, so I scroll through Twitter. Transfusion medicine is a team sport, so I like to see what my clinical colleagues are talking about. This morning, my anesthesia colleagues are discussing a new patient blood management article. I email myself the link to read later.

8:30 a.m. I attend the transfusion medicine morning conference. It’s equal parts chart rounds for our clinical service and education for the learners from outside pathology rotating with our service. Today, we have two anesthesia residents, one hematology/oncology fellow, two pathology residents, one transfusion medicine fellow, and eight medical laboratory science students doing their clinicals. Because of COVID restrictions, the conference is broadcast on a web meeting platform. Only my pathology residents are physically present with me in the conference room, so I need to be mindful of including the virtual learners in our conversations. At the beginning of the pandemic, this was a significant challenge; now I keep a notecard in front of me with their names and training programs.

We start the conference by reviewing our inventory of blood products. This morning, we are short on O+ red blood cell (RBC) units. We have been worried about this shortage for a week or two. Our blood suppliers do not currently have additional units to send us, so we need to keep an eye on the situation.

Next, we discuss patients who our service is following: three patients are refractory to platelet transfusions, three have acquired coagulopathies, two have multiple RBC antibodies (which makes it challenging to find compatible blood products for them), and one has a congenital coagulopathy (we are coordinating this patient’s care with the hematology/oncology team). Finally, we review new antibody workups, transfusion reactions, and stem cell infusions.

9:30 a.m. I spend the last half hour of the conference playing a coagulation game with the learners: I pretend to be stabbed and the learners have to build the thrombus that saves my life. We use playing cards to represent coagulation factors and poker chips to represent platelets. The gameplay is fun today, with everyone freely participating. They build the thrombus, but we have to save the discussion of endogenous anticoagulants and fibrinolysis for another day. We conclude with a reflection on the clinically significant points they learned from the game.

Blood units running low on the O positive shelf.
A learner playing Dr. Kreuter's coagulation game during the morning conference.

10:30 a.m. I attend a weekly meeting with my colleague from the HLA lab. We discuss a few patients who are coming for bone marrow transplant soon and share ideas about improving our testing workflow for solid organ transplantation.

12:00 p.m. I chair our medical school social media committee via web meeting. This is the highlight of my day – an opportunity to participate in the formation of these medical students’ professional digital identities! When they begin medical school, they are using personal social media accounts, and by graduation, they have evolved into professional accounts. Since we also give our students access to our official school accounts, we have interesting conversations about how their voices on the institutional account differ from that of their individual accounts.

1:30 p.m. I supervise our therapeutic apheresis conference, also via web meeting, where I am joined by our pathology residents, transfusion medicine fellow, and apheresis nurses. The nurses begin by reviewing the procedures so far. Typically, our mornings and afternoons focus on stem cell collections and therapeutic procedures, respectively. Next, one of the pathology residents reviews tomorrow’s apheresis schedule.

After the meeting, I focus on administrative work, including eligibility determinations for potential convalescent plasma and stem cell donors, charting stem cell infusion reactions (or lack thereof) in the medical record, and co-signing the pathology resident’s transfusion reaction notes. I walk back and forth to the resident/fellow office a few times to discuss the notes.

6:00 p.m. I get a text letting me know it’s time for dinner. My wife and I have two daughters, who are getting hungry. I am grateful for the reminder that I’m a husband and dad. I pack my backpack and drive home.

8:00 p.m. As the on-call pathologist tonight, I get paged about a bleeding patient and go over my thought process and strategy with the resident. When I finish the call, I go back to reading bedtime stories to my youngest daughter. Afterward, I call our blood bank to check in about the bleeding patient and get an update about the current O+ RBC inventory. The patient’s bleeding has stopped, which is good for both the patient and our hospital’s blood inventory.

Dr. Kreuter with his wife and daughters at Mount Washington State Park in New Hampshire.

10:30 p.m. It’s my bedtime. I like listening to an audiobook while I fall asleep, although I suspect that it is not great for sleep hygiene.

2:00 a.m. I am paged into a group call. My ICU colleagues have been asked to accept a transfer from an outside hospital that doesn’t have compatible blood for the patient. I excuse myself from the call and contact the outside blood bank directly to understand what testing has been performed and the results. Then I call my ICU colleagues back and we talk about how to support this patient. We accept the transfer.