Hematology Competencies

Department of Laboratory Medicine and Pathology

Clinical Laboratory Scientist (CLS)/ Medical Technologist Program(MT)

Pre-Clinical Hematology Competencies

The clinical hematology rotation at HCMC consists of a total of 5 weeks of practical laboratory experiences, individualized morphology studies, clinical case studies, and formal lecture instruction.

Throughout the course of rotation the student will be directly involved in the performance and evaluation of hematological specimens and procedures. It is important that we graduate students who demonstrate both technical expertise and a broad cognitive base in hematology theory.

In order for the students to master these abilities it is necessary to have the basic pre-clinical competencies taught at the college level. Our emphasis at HCMC will be on abnormal RBC/WBC morphology and disease states, hemoglobinopathies, clinical correlations, development of technical skills, instrumentation, and quality assurance programs.

NOTE: Each student is required to write out answers for all of the objectives. If the objective involves the performance of some activity, describe what you did in your college courses in order to meet that objective. These answers must be turned in to the HCMC program director on the first day of orientation. They will be evaluated for completeness by the HCMC education techs. Students will be required to review and know this material when they enter each of the rotations.

Sandy Olson, MT (ASCP) SH
Reviewed 2006

OUTLINE
I. Basic Hematological Techniques

A. Fingerstick procedure
B. Preparation of blood films
C. Wright staining techniques
D. Chamber cell counts
E. Red Cell indices
F. Use of microscope
G. Normal differential counts

II. General Theory

A. Vocabulary/medical terminology
B. Normal erythrocyte development
C. Erythrocyte production
D. Erythrocyte function
E. Erythrocyte destruction
F. Anemias
G. Granulocyte production/function

HEMATOLOGY PRE-CLINICAL COMPETENCIES

I. Basic Hematological Techniques

A. Fingerstick procedure. Reference: Brown Hematology, 5th Ed. The student will be able to describe key features of the following:

1. Patient identification
2. Selection of finger
3. Cleaning of finger
4. Puncture technique
5. Blood film preparation
6. Closing the wound

B. Preparation of blood films. The student will be able to prepare 8 out of 10 acceptable blood films. The student will be able to explain the importance of the following:

1. Cleanliness of slides and spreader slides
2. Size of blood drop
3. Angle and speed of spreader slide
4. Rapid drying
5. Identification of slide
6. Troubleshooting of poor slides

C. Staining of peripheral blood smears

1. State the components of Wright's stain and indicate the organelles or chemical constituents expected to react with each stain component.
2. Describe the steps necessary to produce a high quality stained blood film.

D. Chamber cell counts. Reference: Brown, Hematology, 5th Ed. The student will be able to accurately perform manual platelet and WBC cell counts. Points to be explained:

1. Cleanliness of equipment (counting chamber and pipette)
2. Dilution with appropriate diluent -- describe properties of each diluent
3. Loading chamber -- distribution of cells
4. Counting/cell identification (platelets, red cells, white cells)
5. Calculations and dilution problems
6. Sources of error
7. Safety

E. Red cell indices. The student will be able to calculate MCV, MCH, MCHC, state the normal values and discuss the significance of results as related to red cell morphology on a peripheral smear.

F. Proper use of microscope. Reference: Brown, Hematology, 5th Ed. The student will be able to identify parts of the microscope and demonstrate correct usage and care. Cover the following points:

1. Vocabulary and microscope anatomy - include the meaning of "parfocal"
2. Correct procedure for counting cells in counting chamber
3. Correct procedure for examining stained blood films
4. Care of microscope
5. Troubleshooting

G. Normal differential counts. The student will be able to perform normal differential counts from a peripheral blood smear demonstrating accuracy and precision within allowable limits.

NOTE: It is imperative that the student demonstrate competency in the above stated "Basic Technique" category. HCMC will provide self-instructional review units if necessary, but will not formally cover these areas again.

II. General Theory

A. Vocabulary/medical terminology. Students will be able to define/describe and/or identify the following:

acanthocyte
agglutination
anemia
anisocytosis
basophilic stippling
bilirubin
biliverdin
buffy coat
burr cell
Cabot ring
conjugated bilirubin
crenation
EDTA
erythropoietin
feather edge
ferritin
Heinz body
helmet cell
hematocrit
hemochromatosis
hemolysis

hemopexin
hemorrhage
hemosiderin
heterozygous
Howell-Jolly body
hypochromasia
hypersegmentation
Hgb A1
Hgb A2
Hgb C
Hgb F
Hgb M
Hgb S
iron binding capacity
iron stores
jaundice
karyolysis
karyorrhexis
MCH
MCHC
MCV

microcytic
ovalocyte (elliptocyte)
plasma
poikilocytosis
polychromasia
polycythemia
porphyrin
protoporphyrin
reticulocyte
Rouleaux formation
schistocytes
serum
serum iron
sickle cell
siderocyte
spherocyte
splenomegaly
target cell
teardrop form
transferrin

B. Normal development and metabolism of the erythrocyte

1. Define the word "erythron."
2. List the steps of normoblast maturation. List the features used to identify normoblast: cell size, nuclear size, cytoplasmic basophilia, chromatin clumping, presence of nucleoli, presence of cytoplasmic hemoglobin. Using these morphologic features the student will be able to identify the stages of normoblast development.
3. Describe the shape, diameter, and volume of a normal red cell.
4. List the functions of the 4 major red cell enzyme pathways: Embden-Meyerhoff pathway, Hexose monophosphate shunt, methemoglobin reductive pathway and the Luebering-Rapaport pathway.
5. List laboratory tests for evaluating red cell production.
6. State the normal life span of a red cell.

C. Production of erythrocytes

1. List the nutritional requirements for red cell production.
2. List the steps in the metabolism of iron.
3. Describe the chemical composition and structure of normal Hgb.
4. List the basic steps of porphyrin synthesis.
5. Describe the subcellular site of porphyrin synthesis.
6. Describe the structure and list steps in the production of globin.

D. Function of erythrocytes

1. List the functions of the erythrocyte.
2. Define oxyhemoglobin and deoxyhemoglobin.
3. List the hemoglobins found in newborns and normal adults and the percentages at which they occur.

E. Destruction of the erythrocyte

1. List the body sites of erythrocyte destruction.
2. List the steps in the process of normal degradation of Hgb and its mode of
excretion.
3. Diagram and list the steps of intravascular and extravascular mode of RBC destruction.
4. Define haptoglobin and discuss its role in hemoglobin destruction.
5. List the steps of hemoglobin catabolism, that is, the formation of bilirubin, its transport, its metabolism (conjugation) in hepatic cells and finally its excretion.

F. Anemia

1. Define anemia and discuss the clinical manifestations of anemia.
2. List and discuss the basic lab data used to evaluate and diagnose anemia (not an inclusive list).

a. Hematologic

1) Hgb concentration
2) Red cell indices, red cell count
3) Reticulocyte count
4) Platelet count
5) Hematocrit
6) Erythrocyte sedimentation rate
7) DAT
8) Examination of stained blood smear
9) Osmotic fragility

b. Serum/plasma

1) Iron and iron binding capacity, serum ferritin
2) Bilirubin
3) Urea nitrogen
4) Creatinine
5) Proteins
6) Red cell folate
7) Serum folate
8) Vitamin B12
9) Haptoglobin
10) Serum hemoglobin

3. Describe the morphological classification of anemias, i.e. (1) macrocytic, (2) hypochromic-microcytic, (3) normochromic-normocytic. List typical indices and describe typical RBC morphology.

a. Macrocytic Anemia - Due to folic acid and Vitamin B12 deficiencies

1) Define a megaloblastic anemia.
2) List morphologic manifestations in peripheral blood, being able to list, describe, and identify RBC, WBC, morphology in a typical case of megaloblastic anemia.
3) List three common causes of B12 deficiencies.
4) List three common causes of folate deficiency.
5) List the sources of B12 and folate.

b. Hypochromic/Microcytic Anemias

1) Define hypochromic/microcytic anemia.
2) List at list 6 causes Hypochromic/Microcytic Anemias.
3) Define iron deficiency anemia.
4) List at least 4 causes of iron deficiency.
5) Describe and identify the laboratory findings in blood and bone marrow in Fe deficiency (emphasis on peripheral blood).
6) Describe iron absorption.
7) State the normal values for serum Fe, iron binding capacity, transferrin, % saturation.
8) Define sideroblastic anemia and the anemia of chronic disease; be able to differentiate them from iron deficiency anemia on the basis of laboratory data.

c. Normocytic-Normochromic Anemias (NC/NC)

1) Define normocytic-normochromic anemia and prepare a chart containing common NC/NC anemias. Include: anemia of acute blood loss, the hemolytic anemias, anemia secondary to intrinsic bone marrow disease and anemia secondary to decreased erythropoietin secretion.
2) List laboratory tests that would aid in diagnosis of NC/NC diseases. Explain what a positive result would be.

G. White cell production and function

1. State the origins of leukocytes.
2. List all stages of neutrophil development and identify using the following features:

a. Cell size
b. Nuclear cytoplasm ratio
c. Nuclear morphology (shape, chromatin color, chromatin clumping)
d. Nucleoli
e. Cytoplasmic morphology (texture, color of granulation)

3. List the function of mature leukocytes.
4. Perform differential analysis of cells on normal peripheral blood film (minimum of 25).
5. State the normal range for white cells in both adults and children.
6. Compare and contrast relative and absolute white cell counts.
7. Describe and be able to identify the following reactive changes present in toxic neutrophils (toxic/azure granulation, Dohle bodies, and cytoplasmic vacuolation) and reactive lymphocytes (increased cytoplasmic basophilia, increased cytoplasmic granulation, and cytoplasmic vacuolation).

REFERENCES

1. Hematology: Principals and Procedures, B. Brown, Lea Febiger, 5th Edition

2. Hematology, W. Williams et al, McGraw-Hill Co., 4th Edition

3. Clinical Hematology, M. Wintrobe, Lea and Febiger, 8th Edition

4. Laboratory Medicine-Hematology, J. Miale, C.W. Mosby, 5th Edition

5. Blood: Textbook of Hematology, Jandl, J.H., Little Brown, 1987

6. Technical Hematology, Simmons, A., J.B. Lippincott, 1980

This is only a small sample of books available.

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