In this episode of End of Shift, Eric and Joe continue their discussion with Dr. Shannon Jackson, talking about blood types and donation as well as sickle cell disorders.

ONCE AGAIN, call 604-682-2344 (St. Paul’s Hospital) and you can reach a hematologist 24/7.

Most hospitals carry: pRBC, FFP, platelets and cryo. The Canadian Blood Services knows where all the products are, and the central transfusion registry in BC circulates products to areas of need and does so with minimal wastage. 

FFP is made from plasma which is separated from donor blood and frozen to minus 35°C to preserve it. Cryoprecipitate (cryo) is made from FFP which is frozen and repeatedly thawed in a laboratory to produce a source of concentrated clotting factors including Factor VIII, Factor XIII, von Willebrand factor and fibrinogen.

FFP can reverse the effect of warfarin because it contains substantial levels of vitamin K dependent clotting factors (II, VII, IX, X and protein C/S). FFP is indicated when a patient has MULTIPLE factor deficiencies and is BLEEDING.

Cryoprecipitate is indicated for the treatment of acquired fibrinogen deficiency or dysfibrinogenaemia, due to critical bleeding, an invasive procedure, trauma or disseminated intravascular coagulation (DIC). It’s not ideal for specific factor replacement.

If you have no factor available, you can use FFP/cryo.

DONATE DONATE DONATE!

There is never too much blood – donated blood can also be used for non-clinical research.
You can donate every 8 weeks! There are very few exclusions to donating.

Go to Canadian Blood Services - www.blood.ca - to book your donation.

Dr. Shannon Jackson is a clinical hematologist and the medical director of the Provincial Adult Bleeding Disorder program based out of St. Paul’s Hospital in Vancouver.

Related Clinical Resource:
Treatment of Persons with Inherited Bleeding Disorders (PwIBD) in the Emergency Room
by Dr. Shannon Jackson, Michelle Bech

The older ED crowd will remember this classic Supertramp track from the 1974 album, Crime of the Century. It's our springboard to talk about bleeding disorders.

Dr Shannon Jackson is a clinical hematologist and the medical director of the Provincial Adult Bleeding Disorder program based out of St. Paul’s Hospital in Vancouver.

The program deals primarily with inherited bleeding disorders: Factor (VIII and IX) deficiencies, von Willebrand disorder, platelet disorders and undefined bleeding disorders. 

This is episode 1 of 2 with Dr. Shannon Jackson.

Factor VIII or IX deficiency:

• VIII deficient: hemophilia A, 1 in 10,000 people and IX deficient: hemophilia B, 1 in 50,000 people
• X-linked recessive disorders, males have phenotypic disease, females can be obligate carriers from their fathers – but one third of emerging cases are NEW MUTATIONS
• 30% patients are SEVERE, with < 1% of normal factor
• 10 % are MODERATE, with 1 – 5 % of normal factor
• Rest are classed MILD, with < 40 % normal factor

Von Willebrand disorder:

• Autosomal inheritance on chromosome 12, 1 in 100 people
• Type 1: low antigen amount, so low activity – 70 % cases
• Type 2: defective antigen, so poor activity – 15% cases
• Type 3: no vWF

FEARED bleeds are intracranial, GIB, iliopsoas, vaginal, medial forearm, anterior calf

Patients are usually very well informed - perhaps more than you.

They carry Factor First cards, identifying their disease, appropriate doses of factor for treatment and thankfully – the contact information for the on-call hematologist.

Steps in the ED? Reverse order!

• Order factor first (or ddAVP if fVIII unavailable)
• Then imaging,
• Then history.

Tranexamic acid also a useful adjunct – UNLESS gross hematuria (can trigger renal and ureteric concretions)

Related Clinical Resource:

• Treatment of Persons with Inherited Bleeding Disorders (PwIBD) in the Emergency Room
  by Dr. Shannon Jackson, Michelle Bech

Conventional medical school and residency curricula glossed over nutrition for patients and certainly made no mention of how to look after oneself on shift.

Eric and Karine discuss the roles that caffeine, hydration and nutrition play when working in emergency medicine. They look at some good and not-so-great strategies and provide some advice for shift performance enhancement.

Coffee:

Caffeine is the most widely consumed CNS stimulant, and coffee is the world's 3rd most popular beverage. If you drink coffee, you can probably do stupid things faster and with more energy but ... 

Seriously, caffeine has beneficial effects on reaction time, vigilance, and attention, but there is less to suggest that it improves decision making and problem solving.

• Caffeine is an ADENOSINE blocker. It counteracts the CNS depressant activity of adenosine.
• 2 to 3 cups are likely the ceiling of beneficial effect. Restrict caffeine the to the first half of your shift.
• Try a coffee nap:  have a cup or a shot some time prior to your shift, IMMEDIATELY lie down and rest/sleep/doze for 30 minutes. When you wake, the caffeine will be starting to have effect.

Hydration:

• Dehydration of 2% can affect decision making and cognitive performance.
• 1 to 1.5 litres of water over a shift is about right.
• Caffeine does NOT dehydrate you.
• PEE before you put on your PPE (prior to a procedure, critical care etc.)
• Urine colour is a reliable marker of hydration status, so if you are yellow, have a glass!

Nutrition:

• Shift working (especially night shift working) affects circadian rhythms which has detrimental metabolic effects.
• Night workers tend to choose sugary snacks, often out of convenience. Sleep deprivation makes you choose calorie dense carbs and salty snacks. 
• Aim for euglycemia, so avoid high glycemic foods (candy, donuts, fruit juice). Stick to balanced meals with roughage and high protein sources. Snack on fruits, vegetables, yoghurt and nuts.
• Avoid where possible processed foods.
• Eating at end of shift before sleeping? On one hand, you are less likely to wake up ravenous, but some data suggests that the increased body temperature generated after eating can impair sleep.
• Eric and Karine were unable to agree on the concept of comfort food at 0200 hrs being beneficial. You must decide whether a handful of jujubes will prevail over 4 carrot sticks.