The MLA came rushing in. I was in the middle of looking at a blood film for a patient whose platelets had unexpectedly plummeted. “Simba isn’t giving diffs,” she said.

The haematology full blood count analysers were named after Lion King characters. The previous set were named after the dwarves from Snow White and lived up to their names of Dopey, Sleepy and Grumpy. Simba was just as much of a pain. The full blood count, as the name suggests counts the numbers of blood cells; namely the red cells, the white cells, the platelets as well as the haemoglobin concentration. It also provides the red cells indices, a mix of measured and calculated parameters that provide information about the size and haemoglobin concentration within the red cells. The numbers of each can go up or down in response to different things and can highlight issues such as infection, bleeding, or anaemia. The differential count refers to the numbers of the five different white blood cells (neutrophils, lymphocytes, monocytes, eosinophils and basophils).

There were only two hours left in the late shift with the main bulk of the samples from the GP surgeries hurtling through. Hundreds of samples. Luckily nothing too abnormal as of yet. The day team had cleared most of the blood films with only five on the hand-over. I had added another 10, mainly quick checks. But I hadn’t had a chance to look at any of them. The validation queue was just too long creeping closer and closer to 50 samples. Check the results, determine their validity, decide if they needed checking and or a film to be made, or phoning to the clinical team and then release them to the patient’s chart. And repeat. Sounds pretty simple right? But some of them could be difficult. A post-operative patient whose platelets dropped from 100 to 80 wasn’t much of a concern but this inpatient, whose count had hovered around the same was now in single digits set the alarm bells ringing.

“How long has it been going on?” I asked her. She was relatively new to the team but had picked up things quickly. I knew I wouldn’t have to worry about the analysers or processing of samples because she was on top of it. All for the best really as I had too much to do.

“About five minutes. I’ve already loaded all the samples missing their differential counts on another machine,” she explained.

“Excellent. So why do you think it isn’t doing the diffs?” I asked.

“Well I’ve checked the mode is correct; it’s on CBC and Diff.” In the UK, the full blood count is always reported with the differential count, either automated from the analyser or manually if it is done by counting cells on the blood film. The analyser was giving the red cell count and indices and also the platelets but not differentiating the different populations of white cells.

“Good start, what else?”

When it comes to solving problems or issues, I like to give people the opportunity to think for themselves, to put into practice the theory they learn as part of their training and apply that knowledge for troubleshooting. It helps them understand better rather than just giving them the answer.

“Where are the white cells measured?” I asked.

“The apertures?” she said without much confidence.  Almost seemed like she was asking the question.

“Nope, try again.”

The phone rang.

“Let me answer this call and you can have a think. I’ll come over afterwards.” I said and she went back into the lab to continue with the work.

“Hi, this is the haematology lab, how can I help?”

Before the voice could answer, I tried to type the film report with my index finger; ‘clumps seen on film, please send a citrated platelet count if appropriate.’ I had spent time on this report and wanted to finish it before changing the screen, otherwise all that typing would have been lost.

“Hi, I’m calling from A&E. I’m one of the nurses.”

“What’s up?”

“I sent samples for a patient about 25 minutes ago, and it still doesn’t show whether they have been received.”

“No worries, let me check for you. Do you have the details?”

I typed in the patient’s hospital number and pressed enter. He was right, both samples for the full blood count and biochemistry tests were still not in the lab.

“You’re right, they aren’t here yet. If you want, I can check in specimen reception for you and give you a call back?”

“Sure, that would be great,” he replied and left his name and extension number.

I walked briskly towards specimen reception and realised I was sweating. There was an endless list of things to do but some things are worth making time for.

“Everything okay?” asked my shift partner covering transfusion. It was the first time we had gotten a chance to speak all evening.

“Yeah, just looking for a sample,” I said.

It wasn’t there. I checked the two or three pods waiting to be unpacked from the pneumatic chute that came from different locations in the hospital including A&E. Nothing. There was the box of samples waiting to be booked in. Not in there either. I rushed back to my desk to see whether the sample had been accidentally filed away before being processed. Once again, nothing.

I called the nurse in A&E, “I’m really sorry but we don’t seem to have the samples here.”

He wasn’t impressed, I could hear the loud sigh, “Have you checke…”

“Yes,” I interrupted. “I’ve checked the pods in specimen reception, I’ve checked all pending samples waiting to be booked in and have also looked in the lab. We don’t have it here yet. I’m sorry.” Did I even need to apologise?

“Where has it gone then? I podded it myself half an hour ago.”

“I don’t know. Had it come to the lab I’d have taken responsibility for it but as it hasn’t even arrived, can you just have a look to see it’s not waiting by the pod chute on your side?”

“It’s NOT!” he retorted.

“The only thing I can suggest is you to re-bleed the patient if possible,” I said. Probably shouldn’t have done so as the response was extremely unexpected.

“Okay. I know it’s not your fault, but I am going to tell the patient you lost the sample.”

I opened my mouth to reply, but the line went dead before I even got a chance to do so.

In the heat of the situation people say all sorts, but nothing prepared me for that nonchalant yet cowardly comment. There is already very limited understanding amongst the public and patients about the role of laboratory staff as it is and when staff tell them such things it undoubtedly tarnishes what little they may know. We all have a duty of candour to our patients. What could I do? Not much.

I went outside the film room into the main lab and saw the MLA flushing the flow cell on Simba. She had worked out that the flow cell in the analyser measures the numbers of different white cells. Sometimes it can get blocked and so gives erroneous results and or fails to give anything at all. I smiled. Another quarter of an hour later, the missing samples came through the chute and landed in specimen reception.

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Laboratory image from personal photography