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ED 013 321 VT 002 2L4 ASSISTANT, A SUGGESTEDGUIDE FOR A TRAINING PROGRAM. OFFICE OF EDUCATION, WASHINGTON, D.C. REPORT NUMBER 0E-87017 DATE 66 EDRS PRICE MF-$0.50 HC-$4.92 123P.

DESCRIPTORS-. *MEDICAL LABORATORY ASSISTANTS,TEACHING GUIDES, *PROGRAM PLANNING, PROGRAM DEVELOPMENT,*CURRICULUM GUIDES, CURRICULUM, *HEALTH OCCUPATIONSEDUCATION, POST SECONDARY EDUCATION, MDTA PROGRAMS,

INFORMATION IS GIVEN TO ASSIST IN ORGANIZINGAND ADMINISTERING A TRAINING PROGRAM FOR MEDICAL LABORATORY ASSISTANTS IN A VARIETY OF SETTINGS AND TO PROVIDEGUIDANCE IN ESTABLISHING NEW PROGRAMS AND IN EVALUATINGEXISTING ONES. THE MATERIAL WAS PREPARED UNDER THE DIRECTIONOF THE NATIONAL COMMITTEE =OR CAREERS IN MEDICAL TECHNOLOGY.PATHOLOGISTS AND MEDICAL TECHNOLOGISTS PARTICIPATEDIN THE ORGANIZATIONAL AND DEVELOPMENTAL STAGES. ALL MATERIAL WAS REVIEWEDBY A REPRESENTATIVE NATIONAL GROUP OF EXPERTCONSULTANTS IN THE FIELD OF LABORATORY . THE 12-MONTH PROGRAM WAS DESIGNED FOR HIGH SCHOOL GRADUATES OR THEIREQUIVALENT TO SE ADMINISTERED BY A TEACHING STAFF COMPOSEDOF A NATIONAL DIRECTOR, A. TEACHING SUPERVISOR, ANDINSTRUCTORS. AN OUTLINE OF INFORMATIONAL MATERIAL TO BE PRESENTEDIN THE CLASSROOM, LABORATORY PROCEDURES TO BE DEMONSTRATEDAND THEN PERFORMED AS DIRECT EXERCISES BY THE STUDENTS, AS WELLAS RELEVANT BIBLIOGRAPHIES, AUDIOVISUAL AIDS, AND STUDYQUESTIONS ARE PRESENTED FOR THE FOLLOWING UNITS (1) ORIENTATION TO THE CLINICAL LABORATORY,(2) BACTERIOLOGY,(3) , (4) ,(5) , (6) ,(7) BANKING,(8) ROUTINE ANALYSIS, AND (9) BASAL METABOLISM -- ELECTROCARDIOGRAPHY. THIS DOCUMENT IS AVAILABLE AS GPO NUMBER FS 5.267-07017 FOR 60 CENTS FROMSUPERINTENDENT OF DOCUMENTS, U.S. GOVERNMENT PRINTING OFFICE,WASHINGTON, D.C. 20402. (PS) cir 02281 "2=10. EDO 1. 3321

Op tc54: iNNiar " 11, U.S. DEPARTMENT OF HEALTH, EDUCATION &WELFARE OFFICE OF EDUCATION 0E-87017

THIS DOCUMENT HAS BEEN REPRODUCED EXACTLYAS RECEIVED FROM THE PERSON OR ORGANIZATION ORIGINATING IT. POINTS OF VIEW OROPINIONS STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICEOF EDUCATION POSITION OR POLICY.

MEDICALLABORATORYASSISTANT (D.O.T. Occupational Code0-78.381) A SUGGESTEDGUIDE FOR A TRAININGPROGRAM

OFFICE OF EDUCATION/U.S. DEPARTMENT OF HEALTH,EDUCATION, AND WELFARE' HAROLD HOWE II, Commissioner JOHN W. GARDNER,Secretary

Manpower Development andTraining Program DISCRIMINATIONPROHIBITEDTitle VI of the Civil RightsAct of 1964 states: "No person in the UnitedStates shall, on the ground ofrace, color, or national origin,be excluded from participationin, be denied the benefits of, or be subjectto discrimination under anyprogram oractivityreceiving Federal financial assistance."Therefore, any program or activity makinguse of this publi- cation and/or receivingfinancial assistance from the Departmentof Health, Education,and Welfare must be operatedin compliance with this law.

Developed and first published pursuant to a contract withthe U.S. Office of Education by The National Committeefor Careers in MedicalTechnology

For sale by the Superintendent of Documents, U.S.Government Printing Office Washington, D.C., 20402Price60 cents U. S. GOVERNMENTPRINTING OFFICE WASHINGTON : 1966 FOREWORD assistants areurgently neededtoday in commu- COMPETENTLY TRAINEDmedical laboratory tests andprocedures fordetecting nities across the countryto help performvital life-saving its and womenwith a highschool education or disease and safeguardinghealth. Young men skills through and medicine, canlearn the necessary equivalent, who have aninterest in science publication and helpto meet the medically supervised programsuggested in this the 12-month clinic laboratories. great demand fortechnical manpowerin and technologist, and work under thedirect supervisionof the medical Laboratory assistants routine proceduresin bacteriology,blood other qualifiedphysician, performing employed pri- a pathologist or serology, andurinalysis. They are banking, chemistry,hematology, parasitology, available in publicand privateclinical laboratories, butopportunities also are marily in hospital and industrial orpharmaceutical medical laboratories, 'offices, publichealth agencies, adequate to assistthe pro- shortage of individualswith knowledgeand training laboratories. The laboratory makes itprobable thattraining programs sugr fessional medicaltechnologist in the to coast. might be establishedin manycommunities from coast gested in this guide set up undermedical auspicesto meet the With the rapidgrowth in training programs providing comparable assistants, this guideshould prove tobe useful in need for laboratory the country andshould enable themto per- instructions and skillsto young peoplein all parts of form their taskscapably and efficiently. material to bepresented in theclassroom, This guide provides anoutline of informational direct exercises to be demonstratedand then performed as together withlaboratory procedures aids, and studyquestions.Also well as relevantbibliographies, audiovisual program formedical by the students, as organizing andadministering a training included is informationto assist in guidance in establishingnew programs, laboratory assistantsin a variety ofsettings, to provide and in evaluatingexisting ones. for Careers in prepared under thedirection of theNational Committee The material was the Division ofVocational and Tech- under a contractualarrangement with most of whom Medical Technology Pathologists andmedical technologists, nical Education,U.S. Office ofEducation. participated in the with laboratoryasristant training programs, areprofessionally associated reviewed by arepresentative national developmental stages.All material was organizational and laboratory medicine. group ofexpert consultantsin the field of WALTER M. ARNOLD, Assistant Commissionerfor Vocational andTechnical Education.

ill

44.1.00. *AM ACKNOWLEDGMENTS THE NUMBER of individuals and committees that assistedin the preparation and reviewof this guidewas considerable; each performeda distinct function in assisting the mittee for Careers in National Com- Medical Technology to putthe material into its presentform. Much time and effortwas given by many professional peoplein outlining, advising, ing, and criticizing drafts reviewing, reorganiz- of the material preparedby the authors.The assistance of all these persons is acknowledged with gratitude:

Advisory Committee to theNational Committee forCareers in Medical Technology Richard E. Palmer, M.D.Alexandria Hospital,Alexandria, Va.Chairman Sister M. Rosarii, M.S.,MT(ASCP)Little Company of Mary Executive Editor Hospital, Evergreen Park, Ill. Frances Anderson, MT(ASCP)Fairview Hospital,Minneapolis, Minn. Brig. Gen. Joe M.Blumberg, MC, USATheDirector, Armed Forces Institute Washington, D.C. of , Donald Brown, M.D.HackensackHospital, Hackensack, N.J. Patisue Jackson, MT(ASCP),Georgia Department of PublicHealth, Atlanta, Ga. Nellie May Bering, MT(ASCP)Teaching Supervisor,School of Medical Technology, Hospital, Washington, D.C. Doctors' Grace Mary Ederer, M.P.H., MT (ASCP) AssistantProfessor, Assistant to Director,Division of Hospital Laboratories,Department of LaboratoryMedicine, University of apolis, Minn. Minnesota, Minne- John L. Goforth, M.D.Chairman, Board of Certified LaboratoryAssistants, Dallas, Tex. Margaret Ohlen Hanson,MT ( ASCP) Former Coordinator,Medical Laboratory Assistant University of Minnesota. Course, Robert Haukohl,M.D.Evangelical DeaconessHospital, Milwaukee, Wis. Ruth F. Hovde, M.S., MT(ASCP)Professor, Director, Division ofMedical Technology, Depart- ment of Laboratory Medicine,University of Minnesota,Minneapolis, Minn. Laurin J. Kaasa,M.D.Memorial Hospital of WakeCounty, Raleigh, N.C. Eileen M. Lavine, M.S.Managing Editor of GIST,National Committee for Careersin Medical Technology, Washington, D.C. Jean Jorgenson Linne, MT(ASCP)Coordinator, Medical LaboratoryAssistant Course, Univer- sity of Minnesota,Minneapolis, Minn. Lt. Col. John M. Lukeman, MC, USADirector, Departmentof Pathology & LaboratoryScience, Medical Field Service School,Brooke Army Medical Center,Fort Sam Houston, Tex. Elizabeth Lundgren, MT(ASCP) Instructor, MedicalLaboratory Assistant Course,University of Minnesota, Minneapolis,Minn. Franklin J. Moore,M.D.Little Company of MaryHospital, Evergreen Park, Ill. Eleanor Morrison, MT(ASCP)Division of BiologicStandards, National Institutes Bethesda, Md. of Health, Hamil Murray, M.D.NorthGeorgia Technical & Vocational Verna Rausch, M.S., School, Clarksville, Ga. MT(ASCP)Assistant Professor, TrainingCoordinator, Department of Laboratory Medicine, Universityof Minnesota, Minneapolis,Minn. Karen Ringsrud,MT(ASCP)Instructor, MedicalLaboratory Assistant Course, Minnesota, Minneapolis, Minn. University of Barbara J. Schick, MT (ASCP)Coord!nator, MedicalLaboratory Assistants Course,North Georgia Technical &Vocational School, Clarksville,Ga. George F. Stevenson, M.D.Deputy Commissioneron Medical Technology, American Societyof Clinical Pathologists,Rockville, Md. Merlin L. Tr-Mtull, M.D.Baptist Hospital,Memphis, Tenn.; Commissioneron Medical Tech- nology, American Societyof Clinical Pathologists Connie Van Benthem, MT(ASCP)Chief Medical sack, N.J. Technologist, Hackensack Hospital,Hacken- Thelma Wilson,MT(ASCP)Teaching Supervisor, W. Va. Appalachian Regional Hospital,Beckley, Acknowledgment is also made of contributions of picturesby Medical Tribune (coverand p. 61), and St. Francis Hospital,Wichita, Kans. (pp. 12,20, 37, 38, 80, and 141).

vi 4"::;.. Y4' CONTENTS FOREWORD. ACKNOWLEDGMENTS INTRODUCTION Standards of the Program Fund_ s of the Medical LaboraoryAssistant Places of Employment LahOratoryStaff Organizationand ItelationohipS.. Organizational Mari PLANNING AINING PROGRAM f.'-ailiza,tional; Patterns Staff Composition, 110444 anthDiiftes FJtes

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Unit H Unit HI Unit IV Unit V Unit ;VI Unit ill Ji3lodd,.an Unit VIII Routine. Anal, Unit IX Basal Ietabolii lrocardiá APPEN A.Requirements.",:6 Boardlf Laboratory Assistants ofthe and B.Training L oxatoryin Hospital P C.Training Lah9ratory'in Votion D.Equ Meat for Traig -

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- INTRODUCTION gists and the American Society of Medical The tremendous advances in modern medicine Technologists. As of February :966 the Board have resulted in an ever-increasing demand for had approved 112 programs throughout the vital diagnostic laboratory tests.These tests country.Requirements of the Board of Certi- are often the final determining factor as to the fied Laboratory Assistants are given in Appen- presence and extent, or absence, of cancer, dix A. tuberculosis, diabetes, poliomyelitis, and other In addition, the Board administers national diseases. The complexities of laboratory science certifying examinations for graduates of ap- today require a trained staff at various levels proved laboratory assistant programs.Those of knowledge and skill to carry out both the who pass this examination are entitled to use simple and the intricate analyses which often the designation Certified Laboratory Assistant spell life or death to the patient. (CLA) after their names.Such certification Organizational echelons have developed in the represents proof to a hospital or other medical laboratory in recent years, similar to those for laboratory that the laboratory assistant seeking nursing services, to facilitate the orderly and employment has received adequate basic train- effective handling of the multitudinous labora- ing to perform routine laboratory procedures tory procedures. Under the direction of quali- under the direct supervision of the medical fied physicians, the laboratory staff includes a technologist and the pathologist or other quali- department chief,specialists,generalduty fied . medical technologists (corresponding to gen- It is important that the training program be eral duty nurses),laboratory assistants (corre- orientedtopatientcare,withcompetent sponding in some ways to the practical nurse), medical control and direction. Every program and sometimes laboratory attendants or aides should be developed within a framework that (operating on the level of nurse's aides). has access to the actual equipment of a labora- Each of the echelons in the medical labora- tory as well as to a wide variety of patients toryfrom the pathologist-director with 13 providing varied clinical specimens. years of professional training, and the medical From the beginning, the director of a train- technologist with four years of college science ing course for laboratory assistants should set and hospital training, to the laboratory assist- high standards for quality performance.It ant with 1 year of post-high school study is essential for students to learn a sense of has one objective in common with the others : responsibility toward the patient, the need to the patient's welfare. No matter how difficult cheCk and recheck, to ask questions Alen any or how simple the tasks performed by each doubt arises, and to forego the urge to take on member of the laboratory team may be, they responsibilities or decisions beyond their level all affect the well-being of the patient. of training. The upper echelons of the medical laboratory This is why professional ethics require that teamthe pathologist and the medical tech- medical technologists work under the super- nologistare trai-,ed in approved schools under vision of a pathologist or other doctor of medi- curriculums stanuardized by the Council on cine, and why the laboratory assistants need to Medical Education of the American Medical be guided and checked by the medical tech- Association.The program suggested in this nologists whose broader scientific knowledge manual will provide similar standardized train- and training enable them to grasp the implica- ing for personnel necessary to fill the key lower tions of clinical laboratory procedures and tests. echelonthe laboratory assistantwho can In this day and age, the gap between laboratory perform many of the simpler diagnostic tests procedures and scientific theory is not very and procedures in the laboratory. great. A subtle difference in test results that might be observed but discounted by the STANDARDS OF TIC; PROGRAM scientifically uninitiated can, when fully under- Standards for this type of training have been stood, make a major difference in the.handling established by the Board of Certified Labora- of the patient. For this reason, it is important tory Assistants, which was organized in 1963 that laboratory personnel at each level work by the American Society of Clinical Patholo- within their frame of scientific reference.

1 While educational requirements andtechnical tial count limited to normal pattern; prepares skills may vary widely for thedifferent levels, and stains bloodsmears; performs hemoglobin all laboratory personnel must bededicated to a determinations; performs tests to determine career of service in the fullest sense.Such a Heeding tiine,, coagulation time, sedimentation philosophy should be inculcatedin the labora- rate, and prothrombin time; and performs tory assistant trainingprogram, and all appli- hematocrits. cants should be screened carefully with this in Clinical chemistry. mind. A sense of duty is the keyto success. Performs tests for With it, all thingsare possible.Without it, nonprotein nitrogen partition (NPN and/or the finest organizational structures BUN, creatinine, uric acid) ;.performs protein are mean- partition by a chemical method; and performs ingless and the most excellenttraining may be worthless. glucose, amylase, and flocculation tests for liver function. FUNCTIONS OF THE MEDICAL . Performs slide and test-tube LABORATORY ASSISTANT procedures for ABO grouping and Rh typing; The medical laboratory assistant,as defined performs routine crossmatching and Coombs in the Dictionary of OccupationalTitles (U.S. testing; prepares donor for ; main- Department of Labor), third edition,"per- tains blood bank records; knows how to use forms routine tests in medical laboratoryfor reference laboratories. use in treatment and diagnosis of disease: Pre- Routine analysis. Performs routine analy- parestissue samples for PATHOLOGIST, sis of urine, including centrifugiag urinesam- takes blood samples, andprepares vaccines. ples, preparation for microscopic study, and Executes such laboratory tests as urinalyses examination of stained and unstained sediment; and blood counts, using microscopes,microm- titrates aspirated gaitric fluid for acidity; per- eters, and similar instruments.Makes quan- forms test for increased globulin concentration titative and qualitative chemicaland biological in body fluids; performs cell count in cerebro- analyses of body specimens, undersupervision spinal, fluid ; and detects occult blood andneutral of MEDICAL TECHNOLOGISTor PATHOL- fat in . OGIST." Specifically, the medical laboratoryassistant Basal metabolism and electrocardiography. performs laboratory proceduresin any or all Uses and maintains machines used inthese of the followingareas : tests; prepares patibnt and performstests; and detects and correctserrors. General laboratory services. Keepsaccu- rate records ;identifies specimens properly; PLACES OF EMPLOYMENT uses microscope and basic tools of the labora- tory proficiently, includingcentrifuges, incu- Hospitallaboratoriesare the largest em- bators, spectrophotometers andbalances ; steril- ployers of medical laboratory assistants.Op- izes instruments;prepares basic laboratory portunities also are available in publicand solutions and media; prepares histologic and private clinicallaboratories ;in physicians' cytologic specimens for processing;and per- offices ; in public health agencies at local, State, forms venipunctures and fingerpricks. and Federal levels; and in laboratories main- Bacteriology, serology, and parasitology. tained by industrialor pharmaceutical firms. Prepares and stains slides forbacteriologic study; applies sensitivity discsto culture plates LABORATORY STAFF ORGANIZATION and records results; prepares stool specimens AND RELATIONSHIPS for parasitologic study; performs flocculation The type and extent of departmental screening serological tests forsyphilis; and organ- prepares bacteriologic and serologic specimens ization in a laboratorymay vary from situation for mailing. to situation.If laboratory personnel are rela- tively homogeneous with respect tobackground Hematology. Collects and performscom- and training, a clear-cut organizationalstruc- plete blood count, with reading ofthe differen- ture may not benecessary, particularly if the 2 laboratory is small. Asthe work load increases, scientific knowledge and training needed for however, the need fororganization becomes professional judgment in certainareas. Labora- more evident. Areas of activity must beclearly tory assistants should not be expected to partic- defined and patterns ofresponsibility estab- ipate in development, extensive quality control, lished.Without a well-delineatedadministra- or the performance of technically complicated tive structure and definitivejob descriptions, procedures ; they do not delegate responsibility the duties and responsibilitiesof the various nor do they supervise or teach. Their role is to echelons become lost ina sea of chaotic in- perform the less complex but equally essential efficiency.Confusion and misunderstanding tasks which are necessary to complete the total may develop into antagonism and insecurity. service function. In the interest of good patient Ultimately, patientcare suffers. care it is mandatory that the tasks assigned to The director of laboratories,in most hos- laboratoryassistantsdo not exceedtheir pitals, is a physician trainedin pathology. As capabilities, as clearly set forth in the job a chief of service, his administrative position is description. related to the board ofgovernors, the medical Other technical personnel may be fitted into staff, and the laboratory staff. Heis responsible the organizational structure as best suits their for the total operation of theservice, teaching, education, experience, and training. The need and research activities of thedepartment. of the institution for such personnel depends Immediately below the M.D. staffcomes the on such factors as size, location, specialization, M.T.(ASCP) staff, that is, medicaltechnolo- and availability of other staff.Nontechnical gists certified by the Registry ofMedical Tech- personnel include the clerical staff, dienerper- nologists of the American Societyof Clinical sonnel (men of all work), and inmany hos- Pathologists.This staff may be divided into pitals, an intravenous team. three echelons : chief technologistand teaching supervisor, section chief, andgeneral duty ORGANIZATIONAL PLAN technologist. The chief technologistand teach- ing supervisor usually havedepartment head The organizational plan of the laboratoryis status in the hospital's organizationplan, in usually in writing, and appropriate changes order to deal effectively with otherdepartment are made from time to time as necessary. An heads. example of such a plan is : The section chief, like the headnurse, is re- sponsible for the fiscal and technicaloperation of the section.Delineation of sections varies Director of Laboratories, M.D. from one laboratory to another, but,in general,

they consist of chemistry, hematology,blood M.D. Assoc.

bank, , bacteriology, andBMR-EKG. LI* MOW =1. No .101 Serology, , urinalysis, and radioisotope Clerical & Auxiliary sections may be included under the Chief I Teaching above divi- Personnel Technologist sions or may constitute separatesections.If Supervisor a section is sufficiently large, an assistant Blood sec- Histology tion chief or additionalpersonnel may be Boni( needed. The solid lines represent the usual chain of General duty medical technologistsconstitute command. The dotted lines representthe rela- the backbone of the service force.Because of tionship of the teaching supervisor ofthe specialized knowledge and skills,the medical laboratory assistant trainingprogram with the technologists may be utilizedmore efficiently section heads for the didactic andthe practical and effectively by delegatingmany of the aspects of the training. The chief technologist simpler procedures to the laboratoryassistants, may also be the teaching supervisor. who come immediately below the M.T.(ASCP) All echelons and categories shouldhave staff. Laboratory assistantsarespecifically written job descriptions, witha full exposition trained to perform these simplerprocedures, of economic details, includingstarting salary with due consideration for their lack ofthe with proper salary differentials forvarious 3 categories, scale of increments, vacation and PLANNING THETRAINING PROGRAM sick leave specifications, and delineation of fringe benefits such as hospitalization and re- Training programs for laboratoryassistants, tirement. A sample job description form (filled who will be eligible forcertification upon out for a laboratory assistant and excluding graduation, should be planned underthe guid- economic item) follows : ance of an advisorycommittee) including among its members pathologists andregistered med- Job Title : Laboratory Assistant ical technologists.These programs may be Dept. : Laboratory established in educational institutionssuch as vocational and technical schools,technical in- Prepared by : stitutes, 2 and 4 year colleges, anduniversities, Date : in affiliation with accredited ,approved Approved by :* medical schools or other acceptablelaboratories (Dept. Head) endorsed for such training by the Boardof Admin. Certified Laboratory Assistants of theAmerican Society of Clinical Pathoiogists and theAmer- Main function: To collect blood specimens from ican Society of Medical Technologists.Or the patients and to perform certainspecific programs may beestablished in these labora- laboratory procedures which are not complex tories themselves. in nature. Federal funds used to support training pro- Reports to: Medical Technologist. grams for laboratoryassistants are provided Dutiesand responsibilities:Performsthe by annual appropriation under the vocational following tasks in any one or all areas (list education acts and the Manpower Development specific tests,etc., as noted earlier under and Training Act of 1962.The funds are ad- "Functions of the Medical Laboratory Assist- ministered by the State Boards of Vocational ant"). Education. Education: High school graduation, plus com- A Guide Book for an ApprovedSchool of pletionof approved laboratory assistant Laboratory Assistants may be obtained from training course. the Secretary, Board of CertifiedLaboratory Experience:Certification as Laboratory As- Assistants,445 North Lake Shore Drive, Chicago,Ill.,60611.Also availableis an sistant. application form for securing approval of the Contacts :Patients, nurses, physicians, and training program by the Board. laboratory personnel. Physical demands:Moderate to intense con- ORGANIZATIONAL PATTERNS centration required in using test equipment; The program for laboratory assistants can good vision ; manual dexterity. use combined academicand clinical training Workingconditions:Noise,odors,fumes, facilities in one institution, or can be set up as blood,excrement, communicable diseases ; separate sections in 'different institutions, pro- may work weekends, nights, orholidays. vided that in either case the institutions in- Hazards: Burns from concentrated acids and volved meet minimum requirements with re- alkalis ; exposure to infectious diseases. spect to staff and teaching facilities. Consequences of error:Inaccurate work may invalidate test results, causing supervisors In one institution to make decisions on false information and There are several patterns that may be used possibly resulting in injury to patient; care- for a program set up within one institution : less handling of chemicals and equipment Concurrent Classroom and Clinical Schedules. may result in injury toself or others in im- The classroom and the practical training sched, mediate area and may destroy specimens, ules can run concurrently throughout the period thus causing delay in patient's treatment and 1 King, Sam W., Organization and Effective Use of Advisory subjecting patient to additional discomfort Committee, U.S. Office of Education, Washington :U.S. Govern- in collecting new specimens. ment Printing Office, 1961. 4 of training.The plan used to coordinate the An affiliation can be established between a two phases depends on the size of the institu- clinical training institution and a college or uni- tion and the staff, as well as the student load. versity. The student might take regular college In most instances, it will be practical to have courses (usually limited to one or two basic the schedule arranged so that the student starts science subjects) to give him a better back- academic instruction in a subject before any ground for the material to be covered in the clinical practice in that subject.Under this clinical laboratory, or special courses might be arrangement, the orientation period should be set up especially to fit into the laboratory as- concentrated in the first 8 to 10 weeks of the sistant's training course.In both instances, year and be extensive enough to give the the institution giving the clinical training will student a good introductory background in all have to supplement the practical work with subjects. This procedure will enable the student some academic instruction.Unless the student to understand the more basic material pre- qualifies as a regularly enrolled college student sented in either the classroom or the laboratory under the education laws of the State and of the without first having had the other phase of that college, no credit is reserved for his college subject, and it will permit gradual introduction hours, and they cannot be applied to future to laboratory work as the more advanced academic study. academic phases are completed. Concurrent Schedules Using Student Labora- 2. Extension or Adult Education Division of tories.Another way to operate the academic College or University.Another type of affilia- and clinical phases concurrently would be touse tion possible is for a college or university to student laboratories for all practical instruc- establish a laboratory assistant course on a non- tion.To reach the recommended minimum collegiate level, as an extension or an adult total of 100 class hours, at least two academic education division. Under this plan, the school presentations would have to be given per week gives concentrated academic training to the for 50 weeks. The students would spend the student, usually for a 6-month period, covering rest of the week in a student laboratory per- all the areas of training. A student laboratory forming the practical exercises relating to the usually is provided for practical training.In- academic material.This plan presents a dis- structors are medical technologists who also advantage in not exposing the student to the qualify as teachers under the staff requirements actual working conditions in a clinical labora- of the university or college.For their clinical tory. _training, the students are sent to affiliated Concentrated Academic Period Preceding medical institutions, with a member of the Clinical Period.Classroom material can be university or college staff acting as coordinator. concentrated into one period of the training College credit is not earned by the student year, i.e., 3 or 6 months, with the remainder of under this program. the year spent in clinical training.The con- 3.Affiliation with Junior College. A com- centrated academic period will be moresuccess- paratively new type of affiliation is being estab- ful if a student laboratory is available,so the lished in some areas by junior colleges and student can receive practical instruction and/ clinical centers.The college and the clinical or demonstrations coordinated with the aca- laboratory are approved jointly for a laboratory demic material presented. assistant course, with the college assuming re- sponsibility for coordinating and supervising Separate academic and clinical training the program. The first year of the 2-year plan The training program can be divided into is spent as a full-time student in the college, separate academic and clinical training phases, with a general academic curriculum to broaden with different institutions assumingrespons- the student's educational horizons.For the ibility for each phase. second year, the student transfers to the med- Academic Phase. The academic instruction ical laboratory for training as a laboratory can be presented in several types of institutions. assistant ; the college faculty may assist the laboratory training staff' in some of the aca- 1.Affiliation with a College or University. demic instruction.Upon successful comple-

5 tion of the secondyear, the student is granted must be available; and the clinical material an associate of arts degree from thecollege. An must be adequate in each specificarea of train- incentive for the studentto continue his educa- ing. tion beyond the level oflaboratory assistant is A student may receive all of the possibility of applying the clinical credit earned during training in one institutionor in several.Care- the first year toward futurestudy in a 4-year ful evaluation of the clinical materialand in- college course. struction available in differentareas of a 4. TechnicalorVocationalSchool.The specific laboratorymay indicate a need for academic trainingcan be given in an area tech- rotating students among hospitals inorder to nical or vocational school,where the teaching achieve more comprehensive training.In such supervisor usually isa registered medical tech- programs, the teaching supervisor for theaca- nologist employed by thearea Board of Educa- demic instruction should be thecoordinator for tion. He is directlyresponsible for seeing that the clinical training, travelingbetween partic- all academic instructionis presented to the ipating hospital laboratories,conducting fre- student and that the practicaltraining is pro- quent conferences with students andinstruc- vided in a studentlaboratory. A student- tors, helping to solve problems whichmay arise, teacher ratio of 10 to 1 isapproved for the and maintaining school records. academic phase of training,as contrasted with If the clinical training ofthe entire class a ratio of 2 to 1 for clinical training.The takes place inone institution, the teaching academic phase is usuallyallotted one-half of supervisor is needed to coordinate itwith the the total time of the entireprogram and taught academic training.In addition, he usually de- at the vocational school.However, this train- votes some time in actual participationin the ing can be doneon hospital premises if there clinical training program. are better facilities andmore space for instruc- tion.In either situation, theteaching super- STAFF COMPOSITION,QUALIFICATIONS, visor occupies thesame position. AND DUTIES An adequate, 5. Academic FacilitiesProvided bya Group interested,and well-qualified of Hospitals.Within one locale, itmay be to teaching staff is essential fora laboratory as- the advantage of twoor more hospitals or sistant trainingprogram.In a school where clinics to combine facilitiesin offering the the facilities are inone institution, the desirable separated academic phaseof a laboratoryas- maximum student-teaching staff ratiois 2 to 1 sistant program.Selection ofone of the par- for the clinical training.In other words,a ticipating institutions tobe used as the center school with a director,a teaching supervisor, of academic trainingmay depend on a central and two instructors ideallyshould have no location, concentration ofinstructors, better more than eight students.Because proper equipment, or more adequatespace.Another student instruction is time-consumingfor the possibility is to divide theacademic instruction teaching staff, the laboratory musthave ade- into separate sections,with appropriate quate additional personnel for workperform- sec- anc.e. At no time should tions taught in separatehospitals according to the number of students their specific facilitiesand/or instructors avail- exceedthe number offull-timetechnical able. workers in the laboratory. For the school having separate facilities Clinical Phase. for The clinical training period the academic and the clinical trainingphases, a of a program providingseparate academic and different ratio may be set clinical training up for the academic can be taught in a hospital phase, with a recommended10 to 1 maximum. laboratory or its equivalent,such as a labora- However, the 2 to 1 student-instructor tory serving a large clinic ratio in or group of doctors. the clinical training phase should bemaintained One or more laboratoriescan be used, with the closely.It is felt that these following factors guiding recommendations selection of the in- will assure adequate and constantsupervision stitutions : instructors ineach section must be in both types of qualified ;student-instructor programs. Students should at ratio must not no time be allowed to give any type ofinstruc- exceed 2 to 1; goodfacilities and equipment tion. 6 The teaching staff should be composed ofa ing constantly among the students in the medical director, a teaching supervisor, and various sections of the laboratory. instructors. Keeping permanent files and records on all students and on school activities and programs. Medical director The medical director should be a graduate of Instructors a medical school who is certified by the Amer- Personsservingasinstructorsshouldbe ican Board of Pathology or who has had accept- qualified to teach according to State certifica- able training and experience in clinical pa- tion requirements and should have an interest thology.The director is responsible for the in the training of laboratory assistants. training program and should be in daily attend- Educational Requirements.Instructors ance for a sufficient length of time to see that should be graduates of AMA-Approved Schools it is operating satisfactorily.In a program of Medical Technology and registered as M.T. conducted by a junior college, or an area tech- (ASCP), ortechnologists with equivalent quali- nical or vocational school, the medical director fications.Specialists in the various laboratory might be designated as medical coordinator or areas, or persons possessing Master's or higher advisor. degrees, are valuable members of the staff.In- formation on certification requirements and Teaching supervisor availability of teacher education courses may be obtained from the State Supervisor of Trade The teaching supervisor is the person most and Industrial Education or the Head Teacher responsible for the success of the training pro- Trainer in the area. gram. He should be a person qualified to teach, Clinical Ethperience.Instructors should have and should have a keen interest in developing at least 1 year of clinical laboratory experience. well-trained laboratory assistants. Duties.Theinstructorsusuallypresent Educational Requirements.Theteaching some of the classroom material and are re- supervisor should hold a baccalaureate degree sponsible for the practical or bench work in from a recognized school of higher learning, their respective areas.Their duties include should be a graduate of a School of Medical giving proper instruction in the performance of Technology approved by the American Medical laboratory procedures ; giving written, oral, and Association, and should hold certification by practical examinations ; keeping records of tests the Registry of Medical Technologists of the performed ; and evaluating the students' work. American Society of Clinical Pathologists as Staff conferences and evaluation M.T. (ASCP). Clinical Experience.The teaching super- The teaching staffshould conduct regular visor should have no less than three years of conferences to compare notes on the progress of the program and problems to be solved.Com- practical experience in the clinical laboratory, plete records should be kept of these confer- including some teaching experience and service ences, and these records should be evaluated in in a supervisory capacity. setting up the program for each new class of Duties.The teaching supervisor's primary students.Periodical meetings by the director, responsibility is to supervise the instruction teaching supervisor, and instructors with the and coordinate the activities of the program. students also are valuable to help evaluate what Some specific duties include : the students have learned and the teaching Reviewingapplications,corresponding effectiveness of the instructors. with applicants, and assisting inselection of students. TRAINING FACILITIES Interviewing prospective students. A well designed and equipped physical facility is basic to the effectiveness of the laboratory Planning and scheduling classroom peri- assistant training program. Training facilities ods, examinations, and rotation of students. apart from the regular laboratory should be Teaching some of the courses and circulat- provided for the instructional program.

7 Classroom A photograph of this laboratory, located at. Schwerter School, Wichita, Kans., is shown A classroom is necessary and should be avail- below. able when needed.It should contain a chalk- Ideally, the training laboratory should have board, ample seating and lighting, and pro- approximately 100 square feet of space per visions for audio-visual instruction. student, including at least 3 lineal feet of work- bench space per student.There should be an Training laboratory adequate number of electric and gas outlets, a fume hood,adequatelighting,fire-fighting In a hospital training program it is advan- equipment, and at least 1 sink per 10 students. tageous to have a separate training laboratory To help determine adequate space, lighting, available to provide students the opportunity facilities,etc.for the laboratory, referto for laboratory practice away from the rush of "Manual for Laboratory Planning and Design," the busy hospital laboratory. A sample Layout Arthur E. Rappoport, M.D., published by the for a Training Laboratory in a Hospital Pro- College of American Pathologists, 230 North gram is shown in Appendix B. In the academic Michigan Avenue, Chicago, Ill., 60601. phase of a program conducted in a separate in- Every precaution should be taken to prevent stitution, a training laboratory containing all any health hazards in the laboratory.In the necessary equipment and facilities is essential. event any injuries occur, immediate treatment Appendix C shows a Sample Layout for a should be provided.Hospitalization insurance Training Laboratory in a Vocational School. for the students is recommended.

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8 Library Manual dexterity necessary for working A library with up-to-date references, latest with precision instruments. editions of textbooks, and scientific journals Ability to understand and follow instruc- pertaining to the clinical laboratory should be tions carefully and completely.(Inaccurate maintained andreadilyaccessibletothe work may invalidate test results, and careless students. handling of chemicals and equipment may re- sult in injury to self and others.) Office and other adjacentareas Ability to work with others, including It is advantageous for the trainingarea to patients, physicians, nurses, and other labora- have available an office for the teachingsuper- tory personnel. visor, a specimen collectionor bleeding room, and restrooms or lounge. Integrity and intellectual honesty, with the realization that there are no shortcuts in the Laboratory equipment laboratory where tests vitally affect the lives of Equipment for a Laboratory Assistant Train- human beings. ing Program is listed in appendix D. Suggested Since many laboratory tests can be performed supplies are given in appendix E. sitting down, even in a wheelchair, laboratory work offers a unique opportunity for students Clinical material with physical disabilities.A number of in- Adequate amounts andkindsofclinical dividuals who are deaf, or who have been material are required to assure proper practice crippled by polio or suffer from other handicaps training.There should be available material which do not limit their activities unduly in a equivalent to that provided bya hospital of laboratory situation, have discovered bright new 100 beds, having 3,000 yearly admissions and horizons to reach for in this work.Often, a minimum of 50,000 clinical laboratory tests government funds or grants from health agen- a year, with sufficientdistribution of the cies are available to provide vocationalre- material in order to provide adequate technical habilitation training in laboratory work for training in the various laboratory divisions. such individuals. Demonstration material, including bloodsmears which emphasize the normal pattern,as well Admission procedure as color transparencies and filmstrips illustrat- The procedure for admitting students should ing various techniques or test results, should be include consideration of the application form available for lectures and demonstrations. with accompanying records and references, STUDENT SELECTION aptitude testing, and a personal interview. Application Form.Each training program Selectionof students should be basedon should have its own application form, withper- definite criteria established by the school and sonal data such as name, address, telephone, made by a scholastic committee of teaching and name and address of parent or guardian, date supervisory personnel. and place of birth, marital status, educational Educational prerequisites background, past employment, military service record ; possibly a brief statement of the appli- Students should be graduates of accredited cant's reasons for wishing to becomea labora- high schools, or have certificates of equivalent tory assistant, and a listing of general interests, training, preferably withcourses in the bio- hobbies, and extracurricular activities in high logical sciences, chemistry, and mathematics, school. including algebra and geometry. Acourse in High, School. Record. A transcript of the elementary physics also would be helpful. applicant's high school record should bere- quired, including all courses and grades, with Desirable characteristics of trainees an explanation of the school's marking system, Good vision, needed for the delicate testing applicant's rank in class, andscores on any required in the use of the microscope and other specialized tests administered by the school. sensitive optical instruments. Health Record.The student should submit 9 evidence of good health through a physician's that the school may send him relevant literature statement and report of a roentgen examina- and information about new job opportunities tion of the chest, or on a printed form included and keep in touch with the graduate. Former 6 with the application form to be filled out by a students may provide the school with interest- physician. ing clinical material from their laboratories Character References.Appropriate refer- for use in classroom and practice demonstra- ences should be obtained for all applicants. A tions. prepared form may be sent to persons given as Attendance records references, asking for opinions on specifically stated 'points.Most satisfactory would be Records of student attendance must be kept references from : accurately day by day, so that specified hours in each phase of the course are completed. A high school science teacher, who would be queried as to the applicant's interest in Hours lost by tardiness or absence must be made science and laboratory work, his ability to up by the end of the course. follow directions and to understand basic con- Achievement records cepts of laboratory procedures, his manual Records of achievement should be kept for dexterity, his study habits, and an appraisal of both phases of trainingthe didactic or theory, 11 his general intelligence. and the practical or manipulative. A student Former employers, youth group advisors, ranking at the 90th percentile in theory might clergymen, or other similar sources as to the possibly have to be eliminated from the course applicant's ability to get along with others, because of inability to perform the required general state of health, initiative, judgment, laboratory tasks accurately and skillfully. emotional maturity, reliability, and honesty. A conventional school roll book is used to Aptitude and/or Interest Tests.It may be record daily quiz grades and performance tests. desirable to utilize aptitude testing services in A great part of the proficiency rating of the the selection of students.General Aptitude student is made through close observation by Test Battery scores may be provided by the the instructor.Each examination score is re- local State Employment Service.In some in- corded in the roll book, with a final grade in stances, high school transcripts may include re- each section, and for the entire course. sults of aptitude and interest tests. Record of laboratory tests performed Personal Interview. A personal interview is an important part of selecting students.Dur- In each learning situation, the more a student ing the interview with the medical director, performs the various laboratory tests, the more teaching supervisor, and possibly an instructor, accurate and skillful he will become.Care judgments can best be made in regard to neat- must be taken to record the number of tests ness, , ability to communicate orally, each student has performed in each of the train- degree of maturity, and the individual's motiva- ing areas.Equally important, the results of tion and suitability for laboratory work. the work done must be recorded and compared along with standards or controls and the STUDENT RECORDS student graded for accuracy and precision. A sample Tally of Tests Performed is given in A personal file should be maintained for each appendix F, and a sample Tally of Test Results student, including previous scholastic record, in appendix G. (Details on laboratory record personal references, health records, evaluations forms are given in appendix N.) of personal factors, and,desirable, the results of aptitude tests.The file should consist pri- Rotation assignments chart marily of a continuing record of the student's In orthr to plan the year's work and instruc- progress through the course, with test scores, tional material, the instructor must chart the teacher evaluation, etc., from the time of appli- course of study for the coming months.Once cation to the completion of the training pro- a satisfactory pattern is established it may be gram.It is valuable to continue the student's used for ensuing classes.A chart displayed file after completion of the training in order for the benefit of the teacher and student not

10 only tells the sequence of departmental study, test may be given to evaluate theirknowledge but also keeps them bothaware of the student's of basic chemistry. progress. For those who needmore preparation inscience before starting the Evaluation andprogress records regular curriculum,a related Basic Science A student'sprogress often can be followed Unit in chemistry and/or biologymay be offered through periodic evaluationsheets filled out by either preceding the start ofthe regular pro- the instruction staff. Asample of a Weekly gram or concurrently with it.In some in- Report of Laboratory Proceduresand Assign- stances, students alsomay lack sufficient back- ments Completed is in AppendixH. A Monthly ground in laboratory mathematics; the outline presented in the Orientation InstruCtional Report of Training is givenin Appendix I, and Unit a sample Departmental StudentReport is for this topic may be offeredat the start of the shown in Appendix J.Some items, such course to supplement the Basic ScienceUnit. as This science unit personality traits, personalhygiene, work atti- can be adapted to the needs of tude, capabilities, etc.,are important for the the students ;in chemistry, for example,it student and staff to know.A Student Progress might include definitions anda brief outline of Report containing detailsof these items is the following subject matter: shown in Appendix K.A sample ofa Final Fundamental concepts of chemistry. Evaluation Record is givenin Appendix L. Atoms and molecules. Placement file card Valence and chemical equations. Oxidation and reduction. A program witha good method of record- Physical and chemical propertiesof mat- keeping has at its fingertipsfiles on all presently ter. enrolled students, as well as past recordson Gases, liquids, and solids. former students.Perspective employersmay Water. write for referenceson a particular graduate, and a single file card Solutions. similar to the File Card Acids, bases, and salts. on Graduates of Training Programshown in Appendix M Electrolytes and ionization. can be used to provide theem- Brief survey of organic ployer with thenecessary information about chemistry. the graduate. For example, Hormones, the student might Electrochemistry. have been particularlyinterested and adept in chemistry or weak insome other area ; the card A helpful text andreference book for this willindicate his classstanding,hisfinal basic course is Principlesof Chemistry by average, and any pertinentobservations or Joseph H. Roe (9th ed.,St. Louis, Mo., C. V. comments whichan instructor might otherwise Mosby Co., 1963). Students mayuse only the forget as timepasses. How a person achieves relevant chapters. and performs in theclassroom and especiallyin a practice laboratory isa good indication of Class schedule how he will performon the job. In programs where theacademic phase is presented for the first 6 DEVELOPMENT OF months, the daily CURRICULUM schedule usually includeslectures, discussions, Instruction in the, trainingprogram should demonstrations,laboratorypractice,exami- follow a planned curriculum,based on the unit nations, and field trips; the second 6 months outlines given in the next section of this manual, are devoted to the clinical laboratoryphase. including lectures, discussions,demonstrations, Where the academic andpractical programs supervised laboratorypractice, and practical run concurrently, for the first10 weeks of clinical experience,supplemented by audio- orientation, all studentsmay follow one sched- visual aids and reading assignments. ule from 8:30a.m. to 5 p.m.During there- Basic science unit mainder of theprogram, the class may operate under a two-section rotationsystem, with half Students entering the trainingprogram may the students startingat 8 a.m. to have varied backgrounds in accompany the science. An initial blood collection team andending their day at 11 4:30 p.m., while the other halfstarts at 9a.m. andcontinues and scope of thefollowing listedactivities de- on the regular scheduleuntil pend upon the 4 :30 p.m.,when they remainfor a final hour imaginationand ingenuity ofthe devoted to individual teaching supervisor,as well as on the level of review with theinstructor ability and particular and specialprojects. Thetwo sections usually needs of the students. are rotated The supervisormay expand and adapt theideas every 5 or 10 weeks.A sample or formulate different daily schedulemight beas follows : avenues of approach consistent with localsituations. 8-9 a.m. Bloodcollectionassistance Field TriQ.Suggested visits include (for half the class). : 9-10 a.m.. Lecture. Community healthcenters :Board of 10-11 a.m. Demonstration,toillustrate healthspecial emphasison proper prepara- or augment lecture. tion of bacteriologyand serologic specimensfor 11-12 noon Practice exercise. mailing; Communityblood bankpreparation 12-12:30p.m. Lunch. of donor, records, 12:30-4:30 use of reference laboratory; p.m. Practical work in studentlab- Social welfare oratory. agencies, etc. 4:30-5:30 Other hospitals. p.m. Individual reviewor special projects(otherhalfof Medical exhibits,museums. class). Industrial health clinic. Examine lions Libraryorientation tocatalog system. Hospital supplycompany. Writtenexaminationsshould be givenat fre- Doctor's officeor clinic laboratory. quent intervals,covering academicmaterial Laboratory assistanttrainingprogram in presented in theclassroom, and thesolution of another hospitalor school. practical dailyproblems. Studentsin a labora- Mental institution. tory assistant training program must assimilate HospitalTours. Participationofpara- a considerable amountof knowledge ina rela- medical and nursing tively short periodof time. personnel in conducting Straight recall of inservice hospitaltours pro videsan effective material inan examination is notsufficient, way of exposing the students however. The students to different phases must havesome under- of patientcare.Visits may be made standing of whatthe knowledge to : means in a Dietarydepartment,explanation ofuse clinical situation inorder to apply it ina work- of special diets. ing situation.Instructors interestedin detailed information Psychiatric unitorientationto andpre- on preparing variouskinds of cautions in handlingthe mentally ill. items to test thistype of knowledge, under- unitdemonstrationof isolation standing, andapplicationare referredto technique. Bulletin on Classroom Testing, Numbers1-12, Radioisotopelaboratorydemonstration Bureau of InstitutionalResearch, 211 Burton of technique. Hall, Universityof Minnesota, Minneapolis, Intensivecare unitemphasison emer- Minn. ($3 forentire set). Also usefulare gency procedures, especiallyas they relate to Numbers 1-3, Vol.111, of TeachingTech, the laboratory. edi red by Verna Rausch, M.S., M.T.(ASCP), X-rays,rehabilitation,etc.demonstra- American Societyof MedicalTechnologists, tions. Hermann ProfessionalBuilding, Houston,Tex., 77025. Surgeryobservation (ifpermitted). Laboratory Demonstrations.These might Supplemental projects include : Autopsy (optional). In addition,supplemental projects can be use- Use of specializedequipment such ful teaching devicesto augment thecurriculum as auto- and add background matic cell counter,flame photometer,gas analy- information to helppro- sis machine,autoanalyzer, etc. mote a sympatheticunderstandingamong the students for other Grosstissueexaminationandtissue paramedicalgroups and their preparation. contribution to totalpatient care. The nature Use of fire-fightingequipment. 12 Student Projects. Some possibleassign- tion time is needed togive adequate academic ments might be toprepare a procedure note- preparation in certain subjects.Accordingly, book or to undertakea project related to the total hours are given, without student's special interests. a breakdown for classroom and practicelaboratory time.The 1. Preparation ofprocedure notebook. The hours can be shifted to meetthese needsas long student is asked toprepare his own reference as the necessary basic materialis covered manual in notebookform, incorporating each thoroughly and includesfundamental principles new procedure to which he isintroduced. The in each subjectarea, with special emphasison following format isused to insure inclusionof a thorough understanding ofcalculations, the all necessary informationin reference to each necessity of acquiring technicalaccuracy, and technique : the limitations of thislevel of training. Department in which testwas done. A suggested allotmentof time for the full Name of the test. 12 months follows: Reagents needed. Chemicals necessary tomake reagents WeeksTotal Hours Chemical grades and brandnames where Orientation to Clinical pertinent. Laboratory 10 400 Necessary equipmentfor performance of Bacteriology, Serology, test. Parasitology 8 320 Principal reaction involved. Procedure. Hematology 10 400 Calculations. Clinical Chemistry 10 400 Precautions or notes. Controls. Blood Banking 6 240 Normal values. Routine Analysis 6 240 2. Special interestprojects.These may be Basal Metabolism, Electro- elective or assigned inaddition toor in place cardiography 2 80 of any of the above suggestions. They should Total 52 2,080 be consistent withthe student's ability andthe limitations of hisbackground.In no way should theseor any other extracurricularproj- In practice, most of thehours for the orienta- ects be allowed to interferewith the fulfillment tion subjectsmay be utilized for lectures, dis- cussions, demonstrations, of the curriculumof necessary clinicalex- audiovisual aids, and perience.Examples of simpleprojects which special field trips, since fewlaboratory exer- may be made available to thestudent are : cises are involved. Theschool may reduce the total time inone or more subject areas to allow Work with special stains. for vacation periods. Medical photography. Preparation ofa hematology slide collec- tion.

Suggested time allotmentsfor instructional units Hours to be scheduledfor each subjectmay vary from school to school.Special timemay be needed for supervisedstudy, additional test- ing, and review, and2 weeks usuallyare re- A* served for a vacationperiod.Students may need more preparationor training in one area than in another,or the teaching supervisormay find that additionalclassroom and demonstra-

13 INSTRUCTIONAL UNITS schedule is left up to the discretion of the teach- ing supervisor. However, because of the nature Unit I Orientation to the of the first six topics, they should be presented Clinical laboratory during the first few days. The first four topics acquaint the student with his strange surround- Suggested time: 10 weeks; 400 hours. ings.The next two attempt to stimulate good study habits and professional attitudes.The Introduction remaining topics may be placed in the most ap- propriate positions.Several may be combined The responsibility of the laboratory assistants for an hour lecture. The length of time spent training program to the student is twofold : on each will depend on many factorsthe in- first, to help the student acquire limited medical structor, the facilities, the interest shown by knowledge and certain skills in laboratory tech- students, the availability of related institutions niques, and second, to help him gain an under- and facilities (state health departments, med- standing of the role he is to play on the labora- ical schools, institutional hospitals, etc.). tory team.Because of the type of student Demonstrations, practice work, tours, audio- entering this program and the vast amount of visual aids, reading assignments, and special material to be covered in a year's time, a de- projects may be included. However, these are tailed and thorough orientation course is neces- not detailed specifically in this section, except sary. for a general listing of reference and textbooks, Much of the basic knowledge necessary for booklets, films, and filmstrips riven at the end. laboratory work will be acquired during the Laboratory exercises and study questions on orientation program.The attitudes, impres- this orientation material would be determined sions, and abilities developed by the student by the school's own policies and procedures and during the course are important and should be could follow the relevant lecture material out- guided and guarded by the medical technologists lined if desired. responsible for his training. The educational level of the laboratory assist- Unit content ant student, as well as the quantity and level of information to be acquired during the year's A.The Scope of the Medical Laboratory Field. course, present a need for flexibility in the B.The Training Program for Laboratory sequence of instruction during the orientation Assistants. program. In some schools, the teaching super- C.The Clinical Laboratory. visor may wish to spend 10 weeks at the D.The Hospital. beginning on orientation subjects, all didactic E.Library Facilities and Suggestions for or possibly with some practical and laboratory- Study. demonstration sessions.In other schools, the F.Medical Ethics and Conduct. teaching supervisor may spend a few hours G.Introduction to Medical Terminology. each week on introductory subjects and at the H.Laboratory Requisitions and Reports. same time also initiate training in specific sub- I.Basic Anatomy and Physiology. ject courses. This is being done in a variety of J.Handling, Identification, and Care of Lab- ways in already established schools.It is essen- oratory Equipment. tial that this material be covered at some point K.Aseptic Technique and Methods of Steril- in the training program. However, the timing ization. can be determined most effectively by the L.Basic Laboratory Mathematics. teaching supervisor, depending on the total M.Basic Elements of Quality Control. program E cheduI, and the setting in which the N.Handling ofHistologic andCytologic program is taking place. Specimens. The following is not outlined by specific lec- 0.Fire Safety and Disaster Planning. tun but is an outline of material that should P.Instruction in Blood Collection Techniques. be presented during the training program. The Q.Introduction to Departments of Clinical placement of thematerialinthelecture Pathology.

14 Unit outline (b) ASMT Representativesfour. A.The Scope of the Medical Laboratory Field. (2) Definition of an Approved School 1. Explanation of clinical and pathological of Medical Technology. laboratory : c. History of Board of Certified Labora- a. Role of laboratory in studying patho- tory Assistants: logical changes (disease) : (1) Composition: (1) Clinical laboratory findings as a (a) ASCP Representativesfour. diagnostic tool. (b) ASMT Representativesfour. (2) Anatomical laboratory findings as (2) Requirements for certification and a diagnostic and prognostic tool. approval of training programs. b. The laboratory team according to the B.The Training Program for Laboratory laboratory organization chart : Assistants : (1) The role of the pathologist : 1. Organization and approval dates of this (a) Director of laboratory. program: (b) Doctor's doctor. a. Explanation of organizational chart of (c) Duties and responsibilities. program. (d) Professionalorgonizations b. Introduction of faculty members : American Society of Clinical (1) Pathologist. Pathologists ; College of Ameri- (2) Teaching supervisor. can Pathologists. (3) Instructors. (2) The role of the medical technologist : 2. Policies of training program : (a) Primary and pivotal laboratory a. Curriculum: worker. (1) Class schedule. (b) Educational requirements, train- (2) Rotation schedule. ing and registration. b. Fees and textbooks. (c) Duties. c. Sick leave. (d) Professional organization d. Health program. American Society of Medical e. Vacation. Technologists. f. Stipends, scholarships, etc. (3) The role of the laboratory assist- 3. Explanation of personnel policies of the ant: affiliated hospital as related to stu- (a) Outline of program, objectives dents. and outcomes. 4. Student experience records: (b) Laboratory assistant's capabili- a. Distribution. ties and limitations. b. Purpose of recording experiences. (c) Certification by Board of Certi- c. Directions for recording experiences. fied Laboratory Assistants as 5. Methods of evaluation : CLA (see below). a. Class materialexaminations. (d) Possible future opportunities in b. Practice workquizzes. medical technology. c. Personal development. (e) Opportunities for further educa- 6. Student notebooks: tion and training. a. Class notes. 2. Medical recognition and certification : b. Test procedures. a. History of Board of Registry : c. Special projects. (1) Composition : (a) ASCP Representativesfive. C.The Clinical Laboratory: (b) ASMT Representativesfour. 1. Organizational chart of laboratory. (2) Types of certification and require- 2. Scope of services: ments for examination. a. Inpatient. b. History of Board of Schools : b. Outpatient. (1) Composition: c. Private physicians. (a) ASCP Representativesfive. d. Charity.

15 e. Research. 3. Policies and e. Personalitymanners, poise, voice,con- standard operating proced- versation. ures of the laboratory: 3. Patient relationship: a. Work schedule. b. Work hours. a. Specimen collection. c. Personnel. b. Answering inquiries by patientsabout d. Vacation. tests and test results. c. Handling special categories : e. Sick leave. (1) f. Holidays. Psychiatric patient. (2)Pediatric patient ; newborn infant. 4. Use of departmentalprocedure manuals. 5. Student manuals. (3)Geriatric patient. (4)Uncooperative patient. 6. Responsibilities ofthe laboratory assist- Drunk patient. ant student. (5) (6)Patient of oppositesex. D. The Hospital: (7)Comatose patient. 1. Hospital organizationalchart. (8)Patient with communicabledisease. 2. Interdepartmentalrelationships. 4. Responsibilities of the laboratoryassist- 3. Tour of hospital; introduction to depart- ant : ment heads and explanationof serv- a. To the patient : ices. (1) Thorough understandingof orders. E. LibraryFacilitiesand Suggestionsfor (2) Respect for confidentialmatters. Study : (3) Kind and courteoustreatment. 1. Library facilities: b. To his superiorsMedicalTechnologist, a. Clinical laboratory library. Pathologist, Administrator: b. Hospital library. (1) Cooperation. c. Medical school library. (2) Reliability. d. Community library. (3) Respect. 2. Library orientation: 5. Importance of laboratorywork : a. Location and hours. a. Confidential nature : b. Use. ( 1) Unethical to discussreports and c. Regulations : findings outside the laboratory. (1) Card file system. (2) Legal aspects involvedin issuing (2) Check-out system. laboratory results to unauthor- d. Tour of libraryfacilities. ized persons. 3. Suggestions forstudy : b. Accuracy and validity oflaboratory re- a. Budgeting time. sults : b. Proper conditionsfor study. (1) Quality control. c. Good study methods. (2) Care of equipment andreagents. d. Incentives andmotivations. (3) Professional honesty. e. Note-taking. G. Introduction to MedicalTerminology : F. Medical Ethics and Conduct: 1. Major Latin and Greek 1. Introductory adjustments roots, prefixes : and suffixes (given early incourse). a. Professional field and ethics. 2. Abbreviations. b. Certificationexamination andnational 3. Applications to terms. recognition. 4. Request slip terminology. 2. Personal adjustments (Items 2, 3, and : 4 may be given a. Personal cleanliness. as students are ex- posed to them in the variousdepart- b. Good grooming. ments.) c. The uniform. d. Characterhonesty,integrity,accu- H. Laboratory requisitionsand reports : racy, dedication, self-control,endur- 1. Types of requisitionforms used in the ance, kindness, loyalty. laboratory : 16 INIaorA,nn

a. Admission requisition androutine labor- 6. Reproduction of thehuman being the atory tests. reproductive system. b. Requisition forother tests. c. Outpatient requisitions. J. Handling Identification,and Care of Lab- d. Charge slips. oratory Equipment: 2. Identification ofspecimens : 1. General considerations: a. Information on requisitionslips. a. Precautions in handling. b. Informationon label of container. b. Breakage and repayment. c. Method of listing andnumbering of c. Expense and replacement cost. specimens : 2. Glassware : (1) Transported fromlaboratoryto a. General considerations: other institutions. (1) Kinds of . (2) Received intolaboratory : (a) Inpatient. (2) Maintenance of glasswaresupplies. (b) Outpatient. (3) Location of storageareas. (c) Mail. (4) Cleaning of glassware: (a) Methods used in d. Charting test results: laboratory. (1) Explanation of (b) Cleaning of specificitems. patient's chart. (c) Importance of thorough (2) Methods of chartingtest results. rinsing. e. Explanation of filing system (d) Spot-checking forproper clean- within ing. laboratory. (5) Plastic items f. Tabulation of testperformed : versus glassware : (1) Daily records. (a) Advantages anddisadvantages. (2) Monthly records. (b) Cost. (3) Yearly records. b. Care of needles and syringes: g. Processing reports (1) Cleaning. on "Stat" work. (2) Sterilization. 3. The Microscope I. Basic Anatomyand Physiology: : a. The compound microscope: A brief descriptionand discussion of the (1) Review of parts. various systems of thehuman body, their (2) Theory of the microscope. characteristics and functions,will be necessary (3) Use of the microscope. to acquaint the studentwith the bodyas a (4) Care of the microscope. whole. More detaileddiscussions can be given b. Special microscopes: in the various departmentsas part of the intro- (1) Darkfield. duction to the specificsubject matter. (2) Stereo. (3) Electron. 1. Introduction: (4) Phase. a. Major concepts about the body. c. Demonstration and practice inuse of b. Component units ofthe body. microscope. 2. The erect and moving body : 4. The Balance: a. The skeletal system. a. Introduction to the analytical b. The muscular system. balance : (1) Construction andprincipal parts. 3. Maintaining themetabolism of the body: (2) Care in cleaning. a. The respiratory system. (3) Proper operation b. The digestive system. and rules. (4) Weights: c. The circulatory system. (a) Use andcare of weights. d. The urinary system. (b) Periodic check 4. Integration and control on weights. of the bodythe b. Other balancesdescriptionand uses : nervous system. (1) Torsion. 5. Integration and controlof body functions (2) Trip. by hormones the endocrine system. c. Laboratory exercise inuse of balances. 17 5. Electrical instruments : 2. Precautions to take upon entering a. Centrifuges. a. Operating room. b. Rotators. b. Delivery room. c. Waterbaths. c. Nursery. d. Incubators. d. Isolation. e. Routine care: 3. Methods of sterilization : ( 1) Cleaning and oiling. a. Heat : (2) Maintenance. (1) Temperature. (3) Responsibility of personnel. (2) Time. f, Instrument failure. (3) Moisture. g. Demonstration and practice in use of (4) Pressure. instruments. b. Chemical. 6. Electronic instruments : c. Filtration. a. Introduction to instruments. d. Checking the sterilization procedure. b. Instruction manuals. c. Responsibility of personnel toward in- strument. 1. Review of student weakness: d. Replacement of parts. a. Fractions. e. Instrument failure. b. Decimals. f. Proficiency in use. c. Percentages. g. Demonstration and practice in use of d. Ratio and proportion. instruments. 2. Metric system : a. Linear measure. K. Aseptic Technique and Methods of Sterili- b. Volume. zation : c. Weight. 1. Principles of aseptic technique. (Someof d. Conversion problems. this material also is covered inse- 3. Importance of accurate glassware : rology ; it may be omitted at that time a. Bureau of Standards. or repeated as a review.) : b. Necessity for calibrated glassware. a. Definition of asepsis. c. Varieties of pipettes, tubes, flasks. b. Requirements and utilization of sterile d. Precision in pipetting. technique. 4. Solutions : c. Materials and equipment used : a. Types of solutions : (1) Syringes : (1) Normal. (a) Types and sizes. (2) Percent. (b) Reusable versus disposablead- (3) Molar. vantages and disadvantages. (4) Weight/volume. (2) Needles : (5) Volume/volume. (a) Types and sizes. (6) Weight/weight. (b) Reusable versus disposablead- (7) Aqueous, alcoholic, etc. vantages and disadvantages. b. Solution problems. (3) Vacutainers : c. Preparation of solutions. (a) Types and sizes. 5. Titrations : (b) Anticoagulants. a. pH, definition. (c) Advantages and disadvantages. b. Selection of indicators. d. Performing a venipuncture: c. Preparation and titration of solutions. ( 1) Preparation of patient. 6. Miscellaneous measurements and calcu- (2) Technique : lations : (a) Use of syringe. a. Temperature and heat : (b) Use of vacutainer. (1) Temperature scales : e. Opening an ampule. (a) Fahrenheit. f. Care of soiled supplies and equipment. (b) Centigrade.

18 (c) Formulas for conversion. a. Role of cytology in modern medicine : (2) Quantities of heat. (1) Definition. (3) Bunsen burner. (2) History. b. Calculationscommon calculationsin (3) Papanicolaou smear. the laboratory. b. The cytology laboratory and its rela- 7. Review of basic chemistry mathematics: tionship to other departments of the a. Valance and chemical equations. laboratory. b. Atoms and molecules. c. Safety precautions in handling speci- c. Oxidation and reduction. mens. d. Acids and bases. d. Preparation of specimens for mailing. e. Normality, molarity, milliequivalents. e. Recordkeeping. M. Basic Elements of Quality Control: 3. Mailing of specimens to largeror refer- 1. Meaning of quality control: ence laboratories : a. Concept of positive and negativecon- a. Collection of specimens : trols. (1) Blood smears. b. Standard solutions. (2) Bacteriological. c. Concept of variance and standard devia- (3) Parasitological. tion. (4) Serological. 2. Procedures to minimizeerrors : b. Handling of specimens. a. Correct identification of patient. c. Containers for mailing. b. Obtaining representative andadequate d. Preparation. specimens. 0. Fire Safety and Disaster Planning: c. Correct identification of specimens. d. Accurate analysis of specimens. 1. Safety program of the hospital: e. Prompt and accurate reporting ofre- a. Fire plan: sults. (1) Fire signal. f. Adequate recordkeeping. (2) Location of fire boxes. 3. Types of controlmeasures taken in vari- (3) Location, use, and maintenance of ous departments of the laboratory. fire-fighting equipment. 4. Moral responsibility of studentin this (4) Station and duties of the laboratory area, as related to : personnel in emergency. a. Patient. b. Disaster plan : b. Technologist. (1) Warning signal. c. Physician. (2) Location of shelter. d. Self. (3) Station and duties of laboratory personnel in case of disaster. N. Handling ofHistologic,Cytologic,and 2. Laboratory safety and first aid: Other Specimens: a. Precautions to be used in : 1. Introduction to : (1) Collection of specimens. a. Role of histopathology in modern medi- (2) Receipt of specimens. cine : (3) Handling of specimens. (1) The . (4) Disposing of glass, flammablema- (2) The autopsy. terials, contaminated materials, b. The histology laboratory anditsre- etc. lationship to other departments of b. Basic precautions to beobserved for the laboratory. control of chemical hazards, explo- c. Safety precautions in handling speci- sives, etc. mens. c. Safety practices in electrical mainte- d. Preparation of tissue specimensfor nance and operation. mailing. d. Safety practices in handlingother lab- e. Recordkeeping. oratory equipment especially 2. Introduction of cytology: glassware.

19 e.Reporting of accidents. f. Precautions to avoid f. errors, , Laboratory first aid and fire-fighting: etc. (1) Safety equipment available inlab- g. Demonstration and practice sessions in oratory : performing venipuncture. (a) First aid kit or cabinet. 5. Collection of capillary blood: (b) Safety shower andeye fountain. a. Materials for collection tray. (c) Caution labels. b. Site of collection. (d) Tongs for handling hotutensils. c. Steps in collection. (e) Protective coverings:coats and d. Precautions to avoiderrors. aprons ; gloves and mittens. e. Demonstration and practice sessions in (2)Fire-fighting methods and equip- performing puncture. ment for the laboratory. (3)Use of fume hood. Q. Introduction to Departments ofClinical (4)Care of sinks and drains. Pathology : 1. Bacteriology, serology, and parasitology: P. Instruction in Blood CollectionTechniques. (Some of this materialmay be covered a. Bacteriology : under Blood Banking and/or (1) Branches of microbiology: Serology (a) Bacteriology. or repeated there for review.): (b) Mycology. 1. Hospital regulationsconcerning collection (c) . of specimens. (2) History of bacteriology. 2. Review of blood-carryingorgans of the (3) Morphology and physiology ofbac- body. teria. 3. Collection of blood: b. Serology: a. Type of specimen requested: (1) Use of serological tests indiseases (1) . other than syphilis. (2) Whole blood. (2) Growth ofserology and immu- (3) Plasma. nology. b. Use of anticoagulants. c. Parasitology : c. Blood for chemical analysis: (1) Difference between animalpara- (1) Containers. sites and bacteria. (2) Preparation of the patient. (2) Relationship of parasites andvec- (3) Time of collection. tors. (4) Type of specimen. d.Interrelationship of bacteriology,se- (5) Amount of bloodrequired ;use rology, and parasitology. chart. 2. Hematology : d. Blood for serologictests(including a. Function of blood in health and disease. blood banking) : givesame informa- b. Its relationship to clinical diagnosisand tion as in c (1) to (5). treatment. e. Blood for hematologic tests: give same 3. Chemistry : information as inc (1) to (5). a. Fundamental concepts. f. Blood for microbiologicexaminations : b. Introduction to and instructionin use give same informationas in c--(1) of instruments used in 'chemical to (5). analysis. 4. The Venipuncture : 4. Blood banking: a. Preparation of utensils needed. a. Responsibilities and limitations of lab- b. Preparation of skin. oratory assistant in this field. c. Selection of most suitable vein. b. Problems in blood banking: d. Technique of venipuncture. (1) Legal. e. Failure to obtain blood : (2) Technical. (1) Causes. c. Brief history of blood banking. (2) Remedies. d. Basic blood groups.

20 5. Routine analysis : Boyd, William, An Introduction a. Urinalysis : to the Study of Disease, 5thed.,Philadelphia, Lea and (1) Importance ofurinalysis as study Febiger, 1962. of end product of metabolism. Davidsohn, I., and Wells, B.B., Clinical Diag- (2) Kidney functionin health and dis- nosis by Laboratory Methods, ease. 13th ed., Phila- delphia, W. B. Saunders,1962. b. Gastric analysis: (1) Introduction. Goss, Charles Mayo, Gray'sAnatomy of the Human Body, 27th ed., Philadelphia,Lea and (2) Titration ofacidity. Febiger, 1959. c. Cerebrospinal fluidcell count. Kiely, L. J., and Langley,L. L., Wookbook and d. Occult blood andneutral fat in feces. 6. Basal metabolism Laboratory Manualon Human Anatomy and and electrocardiograph: Physiology, New York,McGraw Hill Co., a. BMRintroduction andpurpose. 1963. b. EKGintroduction and purpose. Lynch, M. J., Raphael, S. S.,and others. Medi- Bibliography and cal Laboratory Technology,Philadelphia, W. Audiovisual Aids B. Saunders, 1963. MacFate, R. P., Introductionto the Clinical A great part of thematerial to be included in the orientation Laboratory, Chicago, YearBook Medical lectures and discussionscan Publishers, Inc., 1961. be found in the textbooks,references, journals, Roe, J. H., Principles of booklets, and audiovisual Chemistry, 9th ed., St. aids listed below. Louis, Mo., C. V. Mosby.1963. Students should be requiredto read assign- ments pertaining to subjects covered during the References orientation period in thetextbooks.. An intro- duction to the Study ofDisease by Dr. William Board of Boyd, in particular, CertifiedLaboratoryAssistants, contains much useful basic Guide Book for an ApprovedSchool of Labo- information on these topics,and other assign- ratory Assistants, Secretary ments might be made from of the Board, this text to supple- 445 North Lake ShoreDrive, Chicago, 1963. ment material covered inother instructional Cook, E. B. M., "Safety in units. The booklets and the Public Health leaflets listed should be Laboratory," Public Health Reports,76:51, assigned to the studentsfor study,as should January 1961. the laboratory'sadministrative manual,the Dorland, W. A. American ward manual, and other Illustrated Medical materials related to the Dictionary, 23d ed.,Philadelphia, W. B. functions of the clinicallaboratory in which Saunders, 1958. the students willreceive their practicalin- struction. Ederer, Grace Mary, andTucker, Barbara, A wide variety "Accident Survey andSafety Programs in of films and filmstripsis Two Hospital ClinicalLaboratories," Ameri- available on the topicsincluded in the Orienta- tion program, can Journal of Medical Technology,26 :219- as well as on the various subject 227, JulyAugust 1960. units.Those listedare considered most useful at the laboratory Freney, Sister Mary AgnesClaire, Understand- assistant level.A suitable ing Medical Terminology,St. Louis, Mo., selection may be madefor showing to the students to supplement Catholic Hospital Association,1958. orientation classes and/ Montgomery, Lall,G., "The Work ofthe or during the specific subjectunit periods. Registry of Medical Some may be indicated Technologists," Ameri- again under unitout- can Journal of Medical Technology,25: 295- lines because of theirspecial relevancy tothat particular topic. 303, SeptemberOctober1959. Morrison, John, "TheMedicalLaboratory Basic textbooks Technologist asa Professional Member of the Patient's Team," Anthony, Catherine, American Journal of Textbook of Anatomyand Medical Technology, 26:252 -256; JulyAu- Physiology, 5th ed.,St. Louis, Mo., C.V. gust, 1960. Mosby Co., 1959. Rausch, Verna, Hovde, Ruth,and Ohlen, Mar- 21 r

garet, "A Training Program forMedical color, sound, 11 min., Coronet Films, Chicago, Laboratory Assistants," AmericanJournal of Ill. Medical Technology, 25:287 -328,Septem- ModernTechniquesofCollectingBlood berOctober 1959. Samples, color, sound, 44 min., Becton, Dic- Smith, Harry P., "Legal Responsibilitiesand kinson and Co., Rutherford, N.J. Liabilities of Pathologists and Medical Tech- No Margin for Error, B. & W., sound, 30 min., nologist," American Journalof Medical Motion Picture Library, American Medical Technology,26:11 -18JanuaryFebruary Association, Chicago, Ill. 1960.. Safety in the Chemistry Laboratory, B. & W., sound,15min.,Audio-VisualExtension, Booklets and leaflets for students University of Minnesota, Minneapolis, Minn. Sterilization Procedures in the Medical Office, Blood Groups, chart, ScientificProducts Co., color, sound, 29 min., Wyeth Film Library, Evanston, Ill. Box 8299, Philadelphia, Pa. Care and Handling of Glass VolumetricAp- The Compound Microscope, color, sound, 20 paratus, Kimble Co., Toledo, Ohio. min., Bausch and Lomb Optical Co., Ro- Common Medical Terminology,Abbott Labora- chester, N.Y. tories, North Chicago, Ill. The Nature of Glass, color, sound, 37 min., How to Care for HypodermicSyringes and Association Films, La Grange,. Ill. Allied Products, Becton, Dickinsonand Co., Vacutainer Technique, color, sound, 50 min., Rutherford, N.J. Becton, Dickinson and Co., Rutherford, N.J. Introduction to Biological Latin andGreek, by Venipuncture, color, sound, 15 min., Imperial Patrick H. Yancey, Spring HillCollege Press, Chemical Industries, New York, N.Y. Mobile, Ala.1959. Weighing with the Analytical Balance, B. & W., Manual of Laboratory Safety,Fischer Scientific sound, 20 min., University of Minnesota, Co., Pittsburgh, Pa. Minneapolis, Minn. Terms Used in Microscopy, AmericanOptical Why Johnny Bleeds, color, sound, 181/2 min., Co., Instrument Division., Buffalo,N.Y. Medical Illustration Service, Armed Forces The Theory of the Microscope,Bausch and Institute of Pathology, Washington, D.C. Lomb Optical Co., Rochester, N.Y. William Harvey and the Circulation of the The Use of Blood, AbbottLaboratories, North Blood, color, sound, 36 min., American Medi- Chicago, Ill. cal Association, Chicago, Ill. Films (all 16 mm.). Work of the Blood, color, sound, 13 min., En- A Control Program for CrossInfection in a cyclopaedia Britannica Films, Wilmette, Ill. Modern Hospital,color,sound, 22 min., Winthrop Laboratories, New York,N.Y. Filmstrips Analytical Balance and Its Use,B. & W., sound, 16 min., Fischer ScientificCo., Pittsburgh, Acid and Basic Solutions, B. & W., 10min., Pa. McGraw-Hill Film Dept., New York, N.Y. Chemical Lab Safety, color,sound, 25 min., Anatomy and Physiology, filmstrip serieson Communicable Disease Center, Atlanta,Ga. digestive, endocrine, urinary, and other body From One Cell, color, sound,15 min., American systems, 35 min., color, with record, U.S. Cancer Society local chapters. Army (available from Central Film Ex- HemoThe Magnificent, color,sound, 59 min., changes at most area Army Headquarters). Bell Telephone business offices. Handling and Use of Glassware, color,sound, Hospital .Care of Syringes andNeedles, Part 8 min., Communicable Disease Center, At- II, color, sound, 20 min., Becton,Dickinson lanta, Ga. and Co., Rutherford, N.J. Hospital Sepsis: A CommunicableDisease, (Note.Numerous other films and filmstripsare color,sound, 30 min., Hospital Division, available from pharmaceutical companies,health organ- Johnson and Johnson, NewBrunswick, N.J. izations, government agencies, educationalinstitutions, Infectious Diseases and Man-made etc.Film catalogs can be obtained bythe teaching Defenses, supervisor from these and othersources; a useful 22 guide is !Film Reference Guide for Medicine and Al- microbiology laboratory. lied Sciences," U.S. GovernmentPrinting Office, Wash- Basic principles of ington, D.C.Audiovisual Seminar filmstripsof the bacteriology, serology, andparasitology are Commission on ContinuingEducation, American So- covered in the Orientation Section.The student ciety of Clinical Pathologists,445 North Lake Shore should be allowed sufficient timeto practice the Drive, Chicago, Ill., 60611,may be too technical for this level, but skills described in thecourse so that he may can be stopped several times formore attain a satisfactory level of detailed explanations to simplifythe material.Bul- performance. letins issued three timesa year by the Audio-Visual It is suggested that thestudent use a note- Library of the ASMT Education& Research Fund, book for the laboratory exercisesas well as for Inc., Suite 25, HermannProfessional Building, Hous- class notes,All drawings, lists,descriptions ton, Tex., 77025, evaluate films,filmstrips, and other of test procedures, andoutlines kept in such educational materials; the Libraryalso has a number a of films and filmstrips available manner may be readily availableas reference on loan.) material.

Unit content

A.Preparation of Glassware,Pipettes, and Test Tubes for Sterilization. B.Sterilization of Glassware andMedia. C.Preparation and Storage ofMedia. D.Preparation of Smears ; Sensitivity Studies. E.PreparationofStainsandStaining Techniques.' F.Receiving, Handling, Processing,and Dis- posal of Infectious Materials. G.Preparation of Bacteriologicaland Sero- logical Specimens for Shipment.

'S

Unit IIBacteriology Suggested time: 8 weeks;320 hours (This isthe period suggestedfor the combined courses of Bacteriology, Serology, andParasit- ology covered in Units II,III, and IV.) Introduction The outline of thiscourse, and the succeed- ing two on Serology,Parasitology, includes instructional aids and guidancein only the ele- mentary and basic skillsencountered in the

23 Bibliography b. Glass containers used for the collection Bailey, W. R., and Scott, E. G., Diagnostic of specimens. Microbiology, St. Louis, Mo., C. V.Mosby c. Petridishes,Spray or Bray dish, Co., 1962. Brewer anaerobic dish. Burrows, William, Textbook of Microbiology, d. Glass slides. 17th ed., Philadelphia, W. B. Saunders, 1957. e. Glass rods. Dubos, Rene, ed., Bacterial and Mycotic In- f. Syringes. fections of Man, 4th ed., Philadelphia,J. B. 2. Types of pipettes used in the bacteriology Lippincott, 1964. laboratory : Hepler, 0. E., Manual of Clinical Laboratory a. Serologic, volumetric. Methods, 4th ed., 13th Printing Springfield, b. Automatic pipettors. Ill., Charles. C. Thomas, 1963. 3. Types of test tubes used in the bacteri- Levinson, S. A., and Mac Fate, R. P., Clinical ology laboratory : Laboratory Diagnosis, 6th ed., Philadelphia, a. Bacteriological. Lea and Febiger, 1961. b. Screw cap. Perkins, John J., Principles and Methods of c. Dunham (gas ). Sterilization,Springfield,Ill.,Charles C. d. Others. Thomas, 1960. 4. Cleaning,plugging,and wrapping of Schaub, I. G., Foley, T., and others, Diagnostic glassware : Bacteriology, 5th ed., St. Louis, Mo., C. V. a. Flasks, graduates, funnels. Mosby Co., 1958. b. Bottles. Simmons, J. S., and Gentzkow, C. J., Medical c. Petri dishes. and Public Health Laboratory Methods, d. Glass slides. Philadelphia, Lea and Febiger, 1956. e. Streaking rods. Smith, D. T., Conant, N. F., and Overman, J. f. Pipettes. R., Zinsser's Bacteriology, 13th ed., New g. Test tubes. York, Appleton-Century-Crofts, Inc., 1964. 5. Disposable plastic equipment : Stewart, F. S., Bigger's Handbook ofBacteri- a. Petri dishes. ology; 7th ed., Baltimore, Md., Williamsand b. Pipettes. Wilkins Co., 1959. c. Test tubes and applicators. Manuals d. Vials. B. B. L. Products Listing, B. B. L., Inc., 2201 6. Use of metal containers for sterilizing: Aisquith St., Baltimore 18, Md., 1956. a. Petri dishes. Catholic Hospital Association, Newer Concepts b. Pipettes. and Techniques in Clinical DiagnosticMicro- Suggested reading assignments biology, St. Louis, Mo., the Association,1959. for students Department of the Air Force, Laboratory Pro- cedures in Clinical Bacteriology, AirForce Air Force Manual, Chapter 1; pp. 17-23. Manual, U.S. Government Printing Office, Bailey and Scott, Chapters 6 and 7. Washington, 1962. Simmons and Gentzkow, pp. 617-618. Difco Laboratories, Difco Manual,9thed., Detroit, Michigan, The Laboratories, 1953. Audiovisual Aids Kim ler, Alexander, Manual of ClinicalBacteri- Chemical Techniques, series of 3-5 minute ology, Philadelphia, J. B. Lippincott, Co., color, sound films of Volumetric Flasks, 1961. Special Pipettes, and Pipettors, Naval Med- Unit outline ical School, Audiovisual Division, Building A. Preparation of Glassware, Pipettes,and 141, Room 11-B, Bethesda 14, Md. Test Tubes for Sterilization: 1. Types of glassware used in the bacteri- Laboratory Exercises ology laboratory: 1. In your notebook, draw, label, andname a. Flasks, graduates, funnels, bottles. the different types of flasks, graduates, 24 funnels, and bottles thatare used in B. Sterilization ofGlassware and Media: the bacteriologylaboratory. 2. In your notebook,draw the different 1. Methods of sterilizationdryheat : types of glass containersthat are used a. Temperature. for the collection ofspecimens. Label b. Exposure time. each and indicatethe purpose for c. Types of glassware thatcan be ster- which it is used. ilized by this method. 3. In your notebook,draw, label, andname 2. Methods ofsterilizationmoist heat: the different types ofpipettes and test a. and Arnold sterilizer. tubes that are used in thebacteriology b. Method of operation. laboratory. c. Temperature. 4. Practice makingcotton plugs for flasks, d. Pressure. test tubes, and pipettes. e. Exposure time. 5. Practice preparingsyringes, flasks, test f. Types of glasswareand media thatcan tubes, and pipettes forsterilization. be sterilized by thismethod. 6. Practice preparingglass slides for sterili- 3. Methods ofsterilizationboiling: zation. a. Temperature. b. Exposure time. Study Questions c. Types of glassware and mediathat can 1. What is the differencebetween a Florence be sterilized by thismethod. and an Erlenmeyerflask? 4. Methods ofsterilizationfiltration: 2. What type of containerwould be used to a. Types of filters. collect the followingspecimens : b. Media thatcan be sterilized by this a. 24 hr. urine culture. method. b. Sputum. 5. Methods of checkingthe effectiveness of c. Nose and . autoclave : d. Stool culture. a. Recording thermometers. e. . b. Sterilization indicators. 3. Why is itnecessary that the pipettes used in thebacteriologylaboratorybe Suggested readingassignments plugged ? for students 4. For what purpose are the following pieces Bailey and Scott, Chapter1 of glassware used: a. Petri dish. Audiovisual Aids b. Spray dish. Pressure Steam Sterilization,color sound, 30 c. Streaking rod. min., Dr. Harry E. d. Syringe. Morton, University of Pennsylvania School ofMedicine,Phila- e. Gas fermentation tube. delphia 4, Pa. 5. How is cottonprepared or folded for plugging flasks? Laboratory Exercises 6. For what kind of equipment may metal 1. In your notebook,make a containers be used for sterilization ?. that can be sterilized by: 7. What procedureis followed for cleaning a. Dry heat. the following: b. Moist heat. a. Petri dishes. c. Boiling. b. Pipettes. 2. In your notebook, c. Flasks. make a list of media that can be sterilizedby : d. Slides. a. Moist heat (autoclave). e. Test tubes. b. Moist heat (Arnoldsterilizer). f. Syringes. c. Boiling. 8. What effect wouldmoisture on cotton d. Filtration. plugs have on the sterility of media? 3. In your notebook,draw a picture ofan 25 autoclave andlabelthe following b. Agar slants. parts : c. Blood agar plates. a. Safety door. d. Chocolate agar plates. b. Condensation shield. 7. Storage of media : c. Pressure gauge. a. Refrigeration. d. Safety valve. b. Room temperature. e. Exhaust valve. f. Thermometer. Suggested reading assignments g. By-pass valve. for students h. Discharge valve. BBL Products Manual, General suggestions,pp. i. Condensation exhaust. 1-2. 4. Practice sterilization of glasswareand Bailey and Scott, Chapter 1; pp. 19, 20, and media using the autoclave. 24. Difco Manual, pp. 21-22. Study Questions Kimler, pp. 9, 11. 1. When would fractional sterilizationbe Simmons and Gentzkow, pp. 630-631. employed ? Stewart, pp. 35-43. 2. At what temperature, pressure, and length Laboratory Exercises of exposure time is routine media ster- ilized in the autoclave? 1. Practice weighing, heatIng, dispensing, 3. When would filtration be employedas a and sterilizing the following: means of sterilization? a. Broth. 4. At what temperature andexposure time b. Basic agar for : plates agar slants. should glassware be sterilized in the 2. Practice making the following: hot air oven? a. Blood agar plates. 5. Name three types of filters thatmay be b. Citrate agar slants. used in filtration sterilization. c. Urea agar slants. 6. What methodsmay be used to test the d. Bordet-Gengou agar plates. efficiency of the autoclave? S. Practice making the following: a. Chocolate agar plates. C. Preparation and Storage ofMedia : b. Gas fermentation (Dunham) tubes. c. Bismuth sulfite plates. 1. Physical states of media: d. Selenite broth. a. Solid (agars). e. Litmus milk. b. Semi-solid (gelatins). 4. In your notebook, makea list of the c. Liquid (broths). media used in your laboratory that 2. Weighing media: should not be autoclaved. a. Types of balances. 5. In your notebook, makea list of the b. Balancing of scale. media used in your laboratory that c. Measurement of media. should be slanted. 3. Dilution and heating: 6. In your notebook, makea list of the media a. Use of distilled water. used in your laboratory that should be b. Technique in heating media. put into Petri dishes. 4. Adjustment of pH by Colorimetricmethod. 5. Dispensing media prior to sterilization Study Questions for: 1. What type of media should be stored in a. Brothtubes and flasks. the refrigerator? b. Agartubes and flasks. 2. Describe the technique used for making c. Dunham fermentation tubes. blood plates. 6. After sterilization the technique ofmak- 3. What do thefollowingabbreviations ing: stand for : a. Agar plates. a. T.S.I. agar. 26 b. E.M.B.agar. c. B.C. agar. Hepler, pp. 163-164. d. S.S. agar. Kimler, Chapter 34. 4. What percent Levinson and MacFate,pp. 851-852. of blood iscontained in Schaub and Foley,pp. 26-27. blood agar? Stewart, pp. 191-195. 5. Can agar slants bemelted and reslanted? If so what wouldbe thepurpose of Audiovisual Aids doing this ? Antibiotics, color,sound, 15 min., 6. At what temperaturedoes agar melt? Encyclo- 7. At what temperature paedia BritannicaFilms, Wilmette, Ill. does agar solidify? BacterialAntibiotic 8. Define the followingterms : SusceptibilityTesting, a. pH. color, sound, 25 min.,Audio-Visual Library, b. Sterilization. ASMT Educational &Research Fund, Inc., c. Agar. Houston, Tex., 77025. d. Broth. Laboratory Exercises e. Gelatin. 1. Practice makingsmears according to the D. Preparationof Smears: Seniitivity Studies procedure outlined inlecture. : 2. Practicemaking smears fromthe follow- 1. Preparationof smears: ing specimensaccording to thepro- a. Technique of preparing: cedure used inyour laboratory : (1) Fixedsmears. a. Sputum. (2) Hangingdrop. b. Broth. (3) Wet mounts. c. Spinal fluid. b. Errors to beavoided. d. Urine. c. Technique of preparingsmears from : e. Exudate. (1) Sputum. 3. Practice makingwire loops and streaking (2) Body cavityfluids. equipment. (3) Exudates. 4. Outline inyour notebook the correctpro- d. Preparationof loops andstreaking cedure for makingsmears from the equipment. various laboratoryspecimensexam- 2. Sensitivitystudies : ined in your laboratory.Include a list a. Preparation of platesfor the addition of theerrors to be avoided. of antibiotic discs. 5. Draw andlabel the differentkinds of b. Type of mediato be used. loops and streakingapparatus used in c. Application of materialto plate. your laboratory. Indicatewhen each d. Description ofdisc method. would be used. e. Methods of dispensingdiscs : 6. List the typesof media usedin your lab- (1) Single application. oratory for antibioticsensitivity stud- (2) Machinedispenser. ies. f. Antibioticsused to test thesensitivity 7. Make a list ofthe antibioticused in your of : laboratory to test thesensitivity of the (1) Gram negativeorganisms. followinggroups of organisms: (2) Gram positiveorganisms. a. Gram positive. (3) Staphylococcus. b. Gram negative. (4) Others. c. Staphylococcus. g. Reading results of discsensitivity test. d. Mixed flora. 8. Outline theprocedure used inyour labo- Suggested readingassignments ratory for thedetermination of anti- for students biotic sensitivity. Air Force Manual, 9. Outline thetechnique used inyour labo- Sec. 3, p. 6. ratory for preparing Bailey and Scott,pp. 26-27 ; Chapter 34. a wet mount or hanging droppreparation. 27 Study Questions 6. Capsule outline 1. Why must and capsule stainprep- smears be fixed beforeapplying aration: stain? a. India ink. 2. What errors should beavoided inprepar- b. Hiss method. ing smears? c. Other methodsor modifications. 3. What 7. Capsule technique is usedin dispensinganti- technique: biotic sensitivitydiscs toan agar a. Principle. plate, by : b. Purpose ofreagents. a. Single discapplication. c. Technique. b. Machinedispenser. 8. Flagella stain(Leifson Method 4. What type Modified) of mediamay be used for the preparation: a. Basic fuchsin-tannic determination ofantibiotic sensitiv- acid stainingsolu- ity? tion. 5. How should material to beexposed to anti- b. Borax-methyleneblue counterstain. biotics beapplied to theagar plate? c. Other methodsor modifications. 6. What techniqua 9. Flagella would youuse for pre- staining technique: paring smears from thefollowingma- a. Principle. terial: b. Purpose ofreagents. a. Sputum. c. Technique. b. Exudate. 10. Spore stain 7. For what (Wirtz-Conklin)prepara- purpose woulda hanging drop tion : preparation bemade? Howwouldyou a. Malachitegreen. prepare such a slide? b. Safranin 8. For what couriterstain. purpose are fixedsmears made? c. Other methodsor modifications. 9. How should 11. Spore zones of sensitivityand re- staining technique: sistance be read? a. Principle. b. Purpose ofreagents. E. Preparationof Stainsand Staining c. Technique. nique : Tech- 12. C. diphtheriae stainpreparation: a. Neisser's stain. 1. Principlesandpurposes of stains. b. Albert'sstain. 2. Gram c. Other methods strainpreparation: or modifications. 13. C. diphtheriae a. Gentian violet. staining technique: b. Gram'siodine. a. Principle. c. Acetone-alcohol. b. Purposeof reagents. d. Safranin. c. Other methodsor modifications. e. Other methodsor modifications. 3. Gram Suggested readingassignments staining techniques: a. Principle. for students b. Purposeof reagents. Air ForceManual,pp. 3-2 ; 3-6. c. Technique. Bailey andSco,tt,pp. 32-36. 4. Acid-fast Levinson andMacFate, stain(Ziehl-Neelsen)prep- pp. 944-949. aration : Schaub andFoley,, pp.491-501. a. Carbol fuchsin. Simmons andGentzkow,pp. 619-623. b. Acidalcohol. Stewart,pp. 25-34. c. Loeffier's methylene blue. Laboratory Exercise d. Othermethods ormodifications. 5. Acid-faststaining technique dutline indetail inyour notebook the : nique used in tech- a. Principle. your laboratory fordoing the b. Purposeof reagents. following: c. Technique. 1. . 2. Acid-faststain. 28 3. Capsule stain. Laboratory Exercises 4. C. diphtheriae stain. 1. Make a list of the types of Study Questions used in your laboratory. 2. Outline the procedure followed in 1. For what purpose wouldthe following your stains be used? laboratory for disinfecting a contam- a. Hiss stain. inated area. b. Ziehl-Neelsen stain. 3. Outline the procedure used inyour labo- c. Gram stain. ratory for receiving, handling, proc- d. Albert's stain. essing, and disposing of infectious 2. What reagentsare used in the Gram material. stain? In what orderare they used? Study Questions 3. What reagents are used in the Ziehl- 1. What part of the bunsen burner flame Neelsen stain ? In what orderare they should be used for sterilizing inocula- used? ting needles and loops? 4. What is a mordant? Namesome reagents 2. Name three types of disinfectants. that can be used as mordants. 3. How would you protect cultures fromcon- 5. Name some stains thatcan be used as tamination ? counterstains. 4. How would you go about disinfectinga F. Receiving, Handling, Processing, andDis- contaminated area ? posal of Infectious Material: 5. How should containers be handled if they 1. The receiving and handling of infectious are contaminated on the outside? material : G. Preparation of Bacteriological and Sero- a. Handling containers contaminated on logical Specimens for Shipment: outside. 1. Shipment of bacteriological specimens: b. Types of disinfectants used in the bac- a. Types of specimens that may be shipped. teriology laboratory. b. Preparation of specimens: c. Necessity and technique of properly (1) Slants. sterilizingplatinumloopsand (2) Filter method. needles. c. Use of preservatives. d. Treatment of pipettes and capillary d. Packing. pipettes after exposure to contam- e. Choice of container. inated material. f. Outside markings. e. Handwashing technique. g. Postal regulations. 2. The processing and disposal of infectious 2. Shipment of specimens in frozen state: materials : a. Spinal fluid. a. Protection of cultures and contamina- b. Fecal specimens. tion. c. Throat swabs. b. Labeling, coding, and entering of speci- d. Tissue. mens in daily log book. 3. Preparation of serological specimens for c. Disposal of slides after smears have shipment : been read. a. Separation ofseijumusing sterile tech- d. Disposal of cultures after organisms nique. have been isolated. b. Preparation ofserum. e. Disposal of containers. c. Sealing, labeling, wrapping, and pack- f. Disinfection of a contaminatedarea. ing of specimen. Suggested reading assignments Suggested reading assignments for students for students Bailey and Scott, Chapter 7. Air Force Manual, Sec. 2, p. 13. Hepler, p. 163. Bailey and Scott, Chapter 6.

29 Laboratory Exercises c. Single-fit plunger. 1. Outlineindetailhow bacteriological 2. Needles : specimens are prepared for shipment a. Disposable. in your laboratory. b. Re-usable. 2. Outline the procedure used inyour labo- 3. Vacutainer method : ratory for the preparation and ship- a. Types and sizes of tubes. ment of specimens in the frozen state. b. Equipment. 3. Outline the procedure used inyour labo- c. Preparation of equipment. ratory for the preparation and ship- 4. Technique of venipuncture : ment of serological specimens. a. Preparation of patient. Study Questions b. Preparation of needle and syringe. c. Application of tourniquet. 1. What kind of specimen would be sent to d. Selection of vein. a reference laboratory in the frozen e. Application of . state? f. Insertion of needle. 2. What kinds of studies would be doneon g. Withdrawing the blood. specimens preserved in the frozen h. Release of tourniquet and withdraw- state? ing the needle. 3. What technique wouldyou use for separa- i. Application of pressure to prevent bleed- ting serum from clotted blood ? ing. 4. Why is whole bloodor serum not frozen 5. Patient approach in : for shipment? a. Isolation. 5. What kind of preservativemay be added b. Clinic and out-patients. to a fecal sample? c. Operating room. Unit HI Serology d. Delivery room. Suggested time: (See Bacteriology.) Suggested reading assignments Unit content for students A.Technique of Withdrawing Blood. Levinson and MacFate,pp. 242-243 and 559- B.Preparation of Tubes with and without 561. Anticoagulant. Simmons and Gentzkow,pp. 126-128. C.Preparation for and Performance ofthe VDRL Test. Audiovisual Aids Bibliography (See appropriate films listed in Orientation Unit.) Levinson, S. A., and MacFate, R.P., Clinical Laboratory Diagnosis, 6th ed., Philadelphia, Laboratory Exercises Lea and Febiger, 1961. Simmons, J. S., and Gentzkow, C. J.,Medical To become proficient in the performance ofa and Public Health Laboratory Methods, good venipuncture it is suggestedthat the Philadelphia, Lea and Febiger, 1956. students do the following: U.S. Dept. of Health, Education, andWelfare, 1. At first, make early morning roundswith Public Health Service, Serologic Tests for a technologist or I.V. nurse and ob- Syphilis, Washington, D.C., U.S. Government serve: Printing Office (Publication #411),1964: a. Approach to patients. b. Venipuncture technique. Unit outline c. Tubes used for the collection of blood A. Technique of Withdrawing Blood specimens. : 2. Practice performinga venipuncture on 1. Syringes : one another using the steps outlined in a. Disposable. lecture. b. Multi-fit plunger. 3. Practice performinga venipuncture on 30 new admissions and then clinicpa- b. Addition of mineral oil. tients. c. Sterile tubes. 4. When sufficient skill hasbeen obtained, 5. Types of examinations doneon untreated perform venipunctureson hospitalized blood : patients, at first under the supervision a. How serum is obtained. of a technologistor I.V. nurse and b. Centrifugation and composition. finally on their own. c. Serological procedures done on serum. d. Chemistry procedures done on Study Questions serum. e. Hematologicalproceduresdoneon 1. What antiseptic is usedfor cleansing the serum. site of a venipuncture ? 2. What approach and techniquewould be Suggested reading assignments used in obtaining blood froma patient for students in isolation? Levinson and MacFate,pp. 243.447. 3. Outline in detail thetechnique for per- Simmons and Gentzkow,p. 126. forming a venipuncture. 4. What errors should beavoided in perform- Laboratory Exercises ing a venipuncture ? 1. Draw in your notebook 5. In the vacutainer methodwhat piece of a picture of the equipment represents the different types of bottles and tubes barrel of a used in 'your laboratory for the collec- syringe ? What represents the plunger ? tion of blood. Indicate the type of anti- 6. What precautions shouldbe taken to avoid coagulant that is used for each. hemolyzing blood ? 2. Make a list of the type of proceduresthat can be done on the following: B. Preparation ofTubes with and without a. Plasma. Anticoagulants b. Serum. c. Whole blood. 1. Preparation of bottlesand tubes contain- 3. If vacutainersare used in your labora- ing anticoagulants: tory, make a list of the differenttypes a. Heparin. of tubes used. Color codethem, indi- b. Ammonium oxalate. cate the purpose for which theyare c. Potassium oxalate. used as well as the anticoagulants,if d. Sodium oxalate. any, that have been added. e. Sodium fluoride. f. E.D.T.A. Study Questions g. Combinations of above. 1. What is the differencebetween plasma 2. Types of examinationsdone on whole and serum ? blood : 2. What type of bloodspecimens (whole a. Amount of blood to be addedto tubes. blood, plasma, b. Hematological or serum) would be procedures (ESR, hema- used for the following: tocrit, CBC, etc.). a. Blood sugar. c. Chemistry procedures (protein-freefil- b. Protein. trate, etc.). c. Heterophil antibody. 3. Types of examinationsdone on plasma: d. Calcium. a. How plasma is obtained. e. Hematocrit. b. Centrifugation andseparation. f. Cholesterol. c. Hematology and chemistryprocedures g. Sedimentation rate. that are doneon plasma. h. Blood urea nitrogen. 4. Preparation of tubeswithout anticoagu- i. Prothrombin determination. lant : j. Carbon dioxide a. Size of tubes. determination. 3. Why is mineral oilsometimes added to 31 of control serum : test tubes in whichblood is to be col- g. Preparation (1) Reactive. lected? procedures require the use (2) Weakly reactive. 4. What type of (3) Nonreactive. of a sterile tube? of the anticoagulant is considered 5. Preparationfor the performance 5. What type of VDRL test : the best for the majorityof : a. Equipment: a.Hematological procedures. machine. procedures. (1) Rotating b. Chemistry (2) Hypodermicneedle of correctsize C. Preparation forand Performanceof the with and withoutpoint. VDRL Test: b. Glassware : storage of specimens : (1) Slides, 2x3inches. 1. The handling and bottles. a. Receiptof specimens. (2) Antigen emulsion of specimens. (3) 1-2ml syringe. b. Numbering or coding salinesolu- c. Labelingof transfer tubes inracks. c. Reagents(antigen and tions) : d. Types of racks. antigen 2. Separation of serumfrom clot : (1) Preparationand storage of a. Rimmingthe tube. emulsion. b. Technique ofcentrifugation. (2) Testing antigenemulsion. centrifugation. (3) Delivery needles. c. Speed of ofantigen d. Transfer of serum totransfer tube. (4) Preliminarytesting 3. Storage ofspecimen : emulsion. a. Pluggingof tubes before storage. (5) Preparationof saline solution. (temperature). d. Preparation of sera : b. Refrigeration clot. c. Lengthof refrigerated storagetime. (1) Separation from d. Deterioration of serumat room and re- (2) Centrifugation. frigerated temperatures. (3) Inactivation. qualitative test : 4. Introductoryinformation regardingthe 6. VDRL slide performanceofserologicalproce- a. Techniqueof test. dures : b. Serum controls. and repotting testresults. a. Necessityof adhering toprocedural c. Reading technique. d. Errors to beavoided. b. Checking equipment : assignments (1) Water bath. Suggested reading (2) Shaking androtating machines. for students (3) Centrifuges. Serologic Tests forSyphilis, pp. 1 -7;119-125. (4) Automaticpipetting machines. c. Techniqueof cleaning glassware : Audiovisual Aids (1) Tubes. VDRL Test forSyphilis, B & W, sound,23 min., (2) Slides. AudiovisualDiv.,CommunicableDisease (3) Pipettes. Center, Atlanta,Ga. d. Preparationof reagents : (1) Antigens. Laboratory Exercises (2) Saline solution. 1. Outline in yournotebook the procedure (3) Distilled water. used in yourlaboratory for checking Temperature control : e. the following: (1) Room temperature. of shaking machine. temperature. a. Rotation (2) Refrigerated b. Speed ofcentrifuge. f. Terminology usedin reporting results : c.Temperature of waterbath. (1) Reactive. d. Antigen emulsiondelivery needle. (2) Weakly reactive. 2. Outline in yournotebook the procedure (3) Nonreactive. 32 used in your laboratory for cleaning ogy, New York, Appleton-Century-Crofts, the following: 1952. a. Pipettes. Faust, C. C. and Russell, P. F., Craig and b. Slides. Faust's Clinical Parasitology, Philadelphia, c. Bottles. Lea and Febiger, 1964. 3. Outline in your notebook theprocedure Levinson, S. A., and MacFate, R. P., Clinical used in your laboratory for preparing Laboratory Diagnosis, 6th ed., Philadelphia, the following: Lea and Febiger, 1961. a. Antigen emulsion. Simmons, J. S., and Gentzkow, C. J., Medical b. Control serum. and Public Health Laboratory Methods, c. Sera to be tested. Philadelphia, Lea and Febiger, 1956. 4. Outline inyour notebook the procedure for doing a qualitative slideVDRL Manuals test. Department of the Army, Laboratory Pro- cedures in Parasitology, Technology Manual, Study Questions TM 8-227-2, Washington, D.C., U.S. Govern- 1. What is the size of the syringeused in ment Printing Office, 1961. the VDRL test? Catholic Hospital Association, Committeeon 2. What gauge and lengthneedle is used? Medical Technology, Parasitology, A Diag- Does it have a point? nostic Workshop for Medical Technologists, 3. How many oscillations shouldthe shaker The Association, St. Louis, Mo. make per minute ? 4. What kind of shaker is used? Unit outline 5. What terminology is used inreporting A. Collection, Handling, and Preparation of the results of the VDRL test? Fecal Specimens : 6. How long may antigen remainat room 1. Collection or receipt of fecal specimens: temperature before itis no longer a. Warm stool : usable ? (1) Purgation. 7. How should slides be cleanedprior to use (2) Proctoscopic material. for the VDRL test? b. Preserved stool: 8. How should the antigenemulsion be pre- (1) Polyvinyl alcohol fixative (PVA). pared? (2) Merthiolate-iodine-formalin 9. What is the pH of the salinethat is used ? (MIF). 10. Whet is thepurpose of inactivating sera c. Pinworm: before testing? (1) N.I.H. swab. 11. At what temperature andlength of time (2) Scotch tape mount. are sera inactivated? 2. Handling of fecal specimens: 12. How long maysera remain at room tem- a. Macroscopic examination for : perature before they must bere- (1) Blood. heated ? (2) Mucous. (3) Adult worms. Unit IV Parasitology (4) Barium or oil. 3. Preparation of fecal specimens: Suggested time:(See Bacteriology.) a. Wet preparation. (1) Saline. Unit content (2) Iodine. A.Collection, Handling, and Preparationof (3) Errors in preparation. Fecal Specimens. B.Performance of a Concentration Test. Suggested reading assignments for students Bibliography Levinson and MacFate,pp. 119-123. Belding, D. L., Textbook of Clinical Parasitol- Simmons and Gentzkow,pp. 888-889. 33 Laboratory Exercises 2. What percent formalin isused in the formalin-ether concentration method? Outline in your notebook the procedure used when doing in your laboratory for preparing the following: 3. What errors should be avoided this test ? 1. Saline slide. concentration test 2. Iodine slide. 4. For what reason is a 3. Scotch tape mount. employed ? 5. How much fecal sediment shouldbe pres- Study Questions ent after initial centrifugation? 1. What errors should be avoided inthe preparation of wet smears ? Unit V Hematology 2. What type of worms might be found on Suggested time: 10 weeks ; 400 hours. gross examination of astool specimen? Introduction 3. From what sources is material for para- student sitological examination obtained ? The material to be presented to the 4. For what purpose is a scotch tape mount has been outlined under 11 headings.It is or N.I.H. swab used? believed that a minimum of 20 class periods should be used to cover this basic background. B. Performance of a Concentration Test : Each section has accompanying practice ses- sions to allow the student to learn the tech- 1. Formalin-Ether sedimentation(Ritchie niques related to the theory which he studies. Technique) : In outlining the year's course, a maximum num- a. Equipment : ber of hours must be stated for each practice (1) Centrifuge. session, but the instructor will find that some (2) 15m1 centrifuge tubes. students should have additional practice time (3) Gauze. in order to become proficient in the techniques. b. Reagents : The outlined content for each section gives the (1) Saline. instructor guidelines to follow in materials and (2) 10-percent formalin. subject matter found in most books of labora- (3) Ether. tory techniques. c. Preparation of stool : (1) Emulsification. Unit content (2) Straining. A.Introduction to Hematology. (3) Centrifugation. B.The Blood Count. d. Technique of test : C.Hemoglobin. (1) Addition of reagents. D.Methods for Collection of Blood. (2) Centrifugation. E.Blood Smears. (3) Errors to be avoided. F.General Techniques and Discussion of Suggested reading assignments Blood Smears. for students G.Origin and Relationship of Blood Cells. H.Leukocytosis and Leukopenia. Simmons and Gentzkow, pp. 887-888. I. Coagulation. Laboratory Exercises J.Hematocrit, Cell Indices, and Sedimenta- 1. Practice the techniques described in lec- tion Rate. ture. K..Anemias. 2. Outline in your notebook the procedure Bibliography used in your laboratory for doing a concentration test for parasitological Bordewich, Patricia H., "Quality Control in examination. Methods in a Routine Hematology Labora- tory," Postgraduate Medicine, 33:5, May Study Questions 1963.(Also helpful for instructors is a paper 1. How many layers result after the addi- by Patricia H. Bordewich, "Statistical Eval- tion of ether and centrifugation? uation of Student Technical Performance," 34

Al information gained outweighs the difficulty encountered.) Watson, C. J., ed., Outlines of Internal Medicine, 9th or 10th ed., Parts IV and V, Dubuque, Iowa, Wm. C. Brown Co., 1958 or 1963. Wells, Benj. B., , 3d ed., Philadelphia, W. B. Saunders Co., 1962. Wintrobe, Maxwell M., Clinical Hematology, 5th ed., Philadelphia, Lea and Febiger, 1961. Unit outline A. Introduction to Hematology : 1. Formation and destruction of blood : a. Detailed discussion of the following schematic representation : b. The three major cell types of the blood simple description and explana- tion of : (1) Erythrocytered cell. (2) Leukocytewhite cell. (3) Thrombocyteplatelet. 2. Blood anticoagulants : I a. The function and use of anticoagulants. b. The kinds of anticoagulants and how mimeographed by and available from Hema- to use each. tology Laboratory, University of Minnesota 3. Blood cell diluents : Hospital, Minneapolis, Minn.) a. Principles of hemolysis, with discus- Bray, W. E., Clinical Laboratory Methods, 6th sion of osmosis and isotonic, hyper- ed., St. Louis, C. V. Mosby Co., 1962. (This tonic,hypotonic, and physiologic book is well-organized and should not be solutions. too difficult for student assignments. How- b. Qualities and use of diluents: ever, a few errors, such as in calculation (1) RBC diluents with discussion of of Hemoglobin standardson page 128, have Hayem's solution,0.85 percent been noted. The instructor should studyas- saline, Gower's solution, Poison's signments carefully so as to call sucherrors solution, and Rees-Ecker solu- to the attention of the student.) tion. Davidsohn, I., and Wells, B. B., Clinical Diag- (2) WBC diluents with discussion of 2 nosis by Laboratory Methods, 13th ed., Phila- percent acetic acid and 0.1 N hy- delphia, W. B. Saunders Co., 1962. drochloric acid. Manual for Teaching Blood Coagulation Tech- c. Red cell count. niques in the Routine Laboratory, General 4. Blood cell pipettes: Diagnostic Div., Warner-Chilcott Co., Morris a. General qualifications of manufacture. Plains, N.J. b. Units of measure ofa red cell and a Page, L. B., and Culver, P. J., A Syllabus of white cell. Laboratory Examinations in Clinical Diag- c. Calculation of dilution factors in the use nosis, Cambridge, Harvard University Press, of pipettes. 1961. (This is a preferred text for the students.It may seem too difficult for the Audiovisual aids and demonstration material laboratory assistant student at first, but with 1. Diagrams of the pipettes presentedon adequate classroom instruction andconcen- lantern slides or drawnon the black- tration on the student's part, the quality of board by the instructor.

35 Red blood cellsin the circulating blood

Bone marrow for Protein Reticulo-endothelial formation of new storage pool system"breakdown system" red cells

Iron storage pool "Waste products" in form of bile pigments excreted in the urine

2. Pictures of the three cell types. the technique and resultschecked by the in- structor before results arerecorded.The in- 3. Tubes (or a lantern slide oftubes) show- perfect pipettes for ing layers of blood elements. structor should allow only credit and should feel uponcompletion of the 4. Tubes containing anticoagulantwith the exercises that the .student hasmastered the identifying markings used in your technique of diluting red and whitecell pipettes. hospital. 5. One tube of blood withanticoagulant and one without, toillustrate the difference Study Questions in appearance. 1. What is the two-fold purposeof the white cell diluting fluid ? Laboratory Exercises 2. Name two fluids that can be usedto dilute red cells, other than Hayems. The objective of laboratory exercises accom- 3. Why and how (decrease orincrease) panying this lecture unit should include recog- would a bubble in the pipette affect nition by the student of the importanceof the count if the pipette were used? proper care in handlingblood specimens, using 4. What are the criteria for agood red cell the prescribed method for cleaning pipettesand diluent? understanding the common precautions and 5. Why is the white cellpipette shaken errors in pipetting.The student should learn vigorously after being diluted? to dilute both a red and a white pipette cor- this -6. Give the proper namefor the three rectly and not be allowed to proceed until formed elements of the blood. isaccomplished.Individualinstructionis essential at this time. 7. Platelets are produced in the bone marrow by what cell ? Eqz.iipmentNeeded :At least 5 red and 5 white pipettes for each student, dilutingfluid 8. Blood drawn by needle and syringe iskept bottles and filtering equipment,diluting fluids, from clotting by use of an necessary material forcleaning pipettes, gauze Name two used for preserving hema- or tissues, a sampleof anticoagulated blood. tology specimens. Which one is better, Exercises. The student should be given work and why? sheets with directions to filter dilutingfluids 9. What are the waste products of redcell and practice diluting pipettes until hehas com- breakdown which are excreted in the pleted 5 perfect pipettes of each type andhad urine and feces?

36 10. Which products of red cellbreakdown (3) Normal values. are stored and re-used by the body? (4) Sources of error. 11. Define osmosis. 12. When blood is mixed withdilute acetic Laboratory Exercises acid, the mixture turns brown. Why ? 13. Give the abbreviation and The objectives of this section should include the full chem- a review of the proper mixing and pipetting of ical name for sequestrene. (Found in blood, the proper care of the counting chamber, reading in Page and Culver.) the proper use of the microscope with the count- 14. Define, osmoticpressure. 15. What happens to the red cells ing chamber, developing and practicing the when the proper routine for mounting and counting, and solution in which theyare suspended is (a) hypotonic, (b) hypertonic? understanding the calculations fora count. The student should learn to meet exact standards in 16. Explain how to calculate dilutionfac- performance of counts. The following criteria tors for the white blood countas it is are suggest:4 : for white cell counts, the allow- done routinely. able difference between duplicate pipetteson a 17. What appearance of the plasmawould single sample should be 500 cellsper cu. mm indicate hemolysis of the red cells? for counts within normalrange, and 10 percent Why does the plasma have thisap- pearance? of the lowest count when the total is less than 500 or over 10,000.Duplicate red cell counts B. The Blood Count: must agree within 10 percent.

1. Counting chamber: Equipment Needed :Pipettes from the previ- a. Detailed explanation of all dimensions ous exercise, diluting fluids, samples of blood of the counting chamber. with known counts, counting chambers and b. Diagrammatic representation (seePage cover , and microscopes. and Culver, pp. 28, 29, 30): Exercises :The student should be required (1) Discussion of difference in Levy- to practice counting until the instructor has ob- Hausser chamber with Neubauer served technique and is satisfied with resultsto ruling, the Spencer Bright-Line, the extent that each individual student iscon- and the Fuchs-Rosenthal cham- sidered to possess adequate skill toallow him bers. to do patient work on preserved blood under (2) Proper cleaning of hemacytometer. strict supervision in the laboratory. 2. Performance of red and white cellcounts : a. Use of the hemacytometer : Study Questions (1) Necessity for proper shaking and 1. What kind of count wouldyou obtain if the proper method touse in the first three drops were not expelled mounting counts is generally dis- from the pipette before mounting? cussed, with more emphasis being 2. What happens to the white cells inthe placed on these functions during blood when you doa dilution for a red laboratory exercises. blood cell count? b. White cell count: 3. List three types of counting chambers. (1) Routine method of countingcells, 4. What is meant by the term "celldistribu- with diagrammatic illustration. tion"? (2) Calculation of the count, using dilu- 5. Why can you not do the following things: tion factors. (a) Remove theexcess liquid if you (3) Normal values. have too much on the counting cham- (4) Sources of error. berafterthepipettehasbeen c. Red cell count : mounted? (b) Add another drop if the (1) Routine method of countingcells, first one (1..!d not completely fill the with diagrammatic illustration. ruled area? (c) Keep using thesame (2) Calculation of the count, using dilu- pipette repeatedly if the mountwas tion factors. not igatisfactory the first two times? 37 the 11.0 or 101.0 in discussinganemia. (d) Adjust back to operation ofcolorimeter. mark if you over-dilutethe pipette? 4. Review of 6. Calculate thedilution factorsfor the fol- Blood Laboratory Exercises lowing (show work) :(a) laboratory exercises mark and dilutedto The objectiveof these drawn to the 0.2 introduce the studentto the tech- the proper markin a red bloodpipette. is mainly to after niques of doinghemoglobin concentration (b) Blood drawn tothe and has a good diluted in the usual man- he has beendoing cell counts 1.0 mark and of the use ofthe colorim- ner in a redpipette. (c) working knowledge di- eter.Stress is placed ontechnique; stand- Blood drawn tothe 0.1 mark and preparation ofcontrol luted in a white cellpipette. _____ ardization procedures, of red and solutions, andunderstanding correlation (d) Blood drawnto the 0.4 mark values are given nearthe diluted in a red cellpipette. cells and hemoglobin end of thetraining period.The exact method used to instructthe student willdepend upon C. Hemoglobin: which one is beingused routinely inthe in- stitution. He shouldbe allowed toperform at 1. Hemoglobin : and one colorimetricmethod. a. Simplifieddiscussion of structure. least one visual EquipmentNeeded :Severalhemoglobin b. Types of hemoglobin.Brief discussion instruments, bethemoglobin pipettes, dilutingfluid, reading of oxyhemoglobin, blood on whichthe hemoglobin and carboxyhemoglobin. and samples of c. Someterms related tohemoglobin and value is known. its alter- Exercises :The studentshould do aeveral conditions associated with until four replicates ation: hemoglobin determinations agree within0.5 gm/100 ml. oneach specimen, (1) Anemia. methods used in theexercise. (2) Erythrocytosis. for each of two Stress should alsobe placed on thecomparative 2. Determinationof hemoglobin : to point out thegreat varia- a. Visualmethods : values themselves (1) Discussion,mostly from historical tions possible. standpoint, of Sahli,Dare, and Study Questions Tallquist methods. 1. List the methodsin addition tooxyhemo- b. Calorimetricmethods : determination of hemo- (1)Oxyhemoglobintechnique and dis- globin for the globin concentration. cussion. disadvantages oradvantages (2)Cyanmethemoglobintechnique and 2. What are the discussion. of these methods? discussed briefly. 3. For what totalamount is the Sahlipipette (3) Van Slyke method What would the of hemoglobin andinterpre- calibrated in cu mm? c. Reporting dilution be if theblood measured in a tation of values : of 5 reporting hemoglobin Sahli pipette isplaced in a total (1) Discussion of ml of diluent? in gm/100 ml vs.percent. ml of diluent? In 10 hemoglobin and red 4. What are the100 percent andnormal (2) Correlatior of oxyhemoglobin method? count. values. for the 5. An oxyhemoglobindetermination was ml. Is this Visual aids anddemonstration material found to be 14.5 gm/100 value decreased,increased, or normal? 1. Demonstrationofvisualhemoglobin 6. Is the Sahlipipette calibrated tocontain method. or to deliver? to show reason for corre- 2. Lantern slides Collection of Blood : lation of red count andhemoglobin to D. Methods for be discussed only briefly. peripheral samples : 3. The same typeof material couldbe used 1. Collection of 38 a. Preparation of equipment. E. Blood Smears : b. Preparation of patient. 1. Purpose of the blood smear. c. Technique of obtaining sample. 2. Preparation for the smear : d. Delivery to the laboratory. a. Equipment. e. Storage in the laboratory. b. Collecting the blood. 2. Collection of venous samples : c. Making the smearslide and cover slip. a. Preparation of equipment. d. Criteria of a properly prepared smear. b. Preparation of patient. 3. Staining the smear : c. Technique of obtaining sample. a. The Wright's staining method, stress- d. Delivery to the laboratory. ing the importance of each step, the e. Storage in the laboratory. pH of the buffer, and timing. f. Importance of prompt and proper han- b. Recognitionofaproperlystained dling of venous sample and effects smear. on all hematologic determinations. 4. Examination of the stained smear : Audiovisual aids and a. The importance of examination of the demonstration materials gross appearance of smear. b. Overallscanningof smear on low 1. Lantern slides to illustrate the technique power : of finger-prick and venipuncture are (1) Proper distribution of all cells. good. (2) Correlation of cell distribution with 2. Observation of medical technologists col- total white cell count. lecting blood in the clinic and in the c. Examination. of smear under oil im- hospital. mersion lens : (1) Red cellssize, shape, color,in- Laboratory Exercises clusions. Some instruction in finger puncture may have (2) Plateletssize, number. been combined with the training technique, but (3) White cellsdifferentiation of age. stress on collection should be reserved for this (4) Nucleated red cellsidentification, unit. The counting techniques give the student correction of white count. a purpose for blood collection. d. Correlation of study with other deter- Equipment Needed :Usual collecting equip- mined values, such as total white ment.The student should make complete count, red count, hematocrit, and preparation for use. hemoglobin values. Emphasis is to Exercises :The students must makecom- be placed on correlation from a tech- plete preparations for doing finger pricks and nical standpoint, to imply accurate venipunctures. They can practiceon each other and inaccurate (reasonable and un- under careful observation and instruction of reasonable) as well as normal and the teacher, and if possibleon volunteers from abnormal. other sources. When a student has made several punctures, he should be able to do venipunctures Visual aids and on selected patients under supervision.In clo- demonstration materials ing finger pricks, several collections should be done and the counts checked foraccuracy. The 1. Lantern slides and microscopic slides supervisor should take duplicate counts from are invaluable from the time this exercise has the patient at the same timeas the student, begun until completion of the entire section. until these checks are withinrange. One source which may be helpful is the Hema- tology Correspondence Courses available from Study Questions the Department ofPost-graduateMedical Education, University of Kansas School of The instructor should prepare questions ad- Medicine, Kansas City 12, Kansas. For labora- justed to the manner in which the techniques tory students, Part I may be more useful than are taught. Part II. 39 2. For this section, slides should be shown Study Questions to illustrate RBC's which are normocytic, micro- 1. Definition :anisocytosis,poikilocytosis, cytic, macrocytic ;also, poikilocytosis, aniso- hypochromasia, polychromasia, throm- cytosis, Howell-Jolly bodies, polychromasia, and bocytosis, leukopenia. basophilic stippling.The diseases are not dis- 2. Some review problems : cussed at this time. a. On diluting a white cell pipettefrom the 3. Use miscellaneous smears showing the 0.4 mark to the 11.0 mark, you difference between well-prepared and stained counted the 4 corner squares and the smear as contrasted to poorly prepared and center square and found a total of poorly stained smears. 180 cells. This gives a total count of Laboratory Exercises b. Calculate the cell counts using the fol- The objective of this section is to make each lowing information : student aware of the need for properly pre- (1) Cells 42, 52, 46, 48. Areasame pared and stained slides as well as to make him as for routine WBC. Depth-0.1 proficientincollection and staining.The mm. Dilutionsame as for rou- tine WBC. Result _ erroneous impressions given by poorly prepared (2) Cells-102, 104, 104, 110. Area- and/or poorly stained smears should be stressed. 4 rows across in center square Equipment Needed :Slide carriers for the mm. Depth-0.1 mm. Dilution student, uncleaned slides, Wright's staining same as for routine WBC. Re- solution and buffer, staining racks, microscopes, sult and imme,:sion oil. 3. Name two situations in which a blood Exercises :This study should be divided into smear is done even if it is not re- at least three sessions, with the first session quested specifically by the physician. spent entirely on preparation of slides and mak- 4. How many smears are taken with each ing of the smear, the second session on stain- blood count, and why ? ing the smear and evaluating the stain, and the 5. Name three sources of blood for a blood third session on evaluation of the smear. The smear. sessions should include fingerprick slides as 6. What would you do if your blood smear well as slides from preserved blood.CBC's was too thin? must be done on the samples in order to corre- 7. Why would you find it hard to count a late results.For each assigned specimen, the blood smear which is too thick? student should complete a work sheet and hand 8. What general term indicates a decrease it in with the slide, so that the instructor can of hemoglobin concentration below the check his results and interpretations. A sug- normal value ? gested work sheet follows : 1. Hemoglobin gm/100 ml percent. F. General Techniques and Discussion of Blood Smears WBC .RBC 2. Observation of stained smear : Estimated 1. Review of low-power appraisal of smear. white cell count .Does this 2. Morphological separation of anemias : agree with the actualtotal white a. Hypochromic anemias. count? .Morphology and b. Normochromic anemias. estimated number of platelets c. Macrocytic anemias. Morphology of red cells .List 3. Platelets: the types of white cells you saw on a. Increasedsignificance. your slide. Considering b. Decreased----significance. the hemoglobin value and the appear- 4. Leukocytes : ance of the red blood cells (size and a. Leukopenia. hemoglobin content),what do you b. Leukocytosis. think the red cell count would be? c. Classification of leukemias.

40 Audiovisual Aids a normal differential.Only the classification Slides, both lantern and microscopic, to illus- of young cells as "young" is to be stressed.In trate various findings and changes in blood cells. other words, any change from the normal should be turned over to someone with more Laboratory Exercises training and experience. The objective of this section is to eliminate Exercises :On a preserved blood sample, the completely the textbook attitude of blood smear student should do a hemoglobin determination observation by the student.Differential count- and a red cell count in duplicate and make two ing should be postponed until the student smears, staining one of the smears and handing realizes that the actual classification of white both in with his work sheet. A complete white cells is only a part of utilizing a blood smear. cell differential is done on the stained smear and The laboratory assistant has a very important the student is to give a description of the ap- and critical role to play in screening patient pearance of the red blood cells, platelets, and slides.He must understand that the initial general appearance of the slide. A work sheet screening often means the difference between is prepared to record all information. adequate treatment for the patient or prolong- The same procedure is carried out on a smear ing recovery by not having the necessary in- obtained from a finger prick done on a fellow formation available for the physician to use. student. Equipment :Stained smears of all types. The results should agree with the results ob- Exercises :Continued practice on exercises tained by the instructor (who can do the red previously described, requiring the student to counts on an electronic counter). The finger correlate hemoglobin, white cell, platelet, and prick results can be checked by observing the red cell with each of the other pertinent pro- smear turned in by the student.Points should cedurEm and withWright'sstainedblood be taken away if the student does not complete smears. each result with the proper unit such as cells/ Study Questions cu mm gm/100 ml, or percent. The instructor can best prepare problem ques- Study Questions tions to fit study slides. 1. Review questions on any procedure com- G. Origin and Relationship of Blood Cells: pleted to date. 2. Questions in the area of differential count- 1. Formation of the blood cells : . a. Fetal blood formation and immediate post-birth. a. The largest blood cell of the normal b. First years of life to maturity. peripheral blood is the c. Aspiration of bone marrowpurpose b. In a poorly made blood smear, the dif- and technique. ferential count results would prob- 2. Identification of stained blood cells : ably show a falsely high percentage a. Classifications : of which cell type ? (1) Origin. c. Poikilocytosis refers to (2) Age: (a) Change in size. d. Smears stained with Wright's stain are (b) Change in intracellular structure. chemically fixed with (c) Change in staining properties. e. When Wright's stain is too acid, the (d) Evidence of cell function. erythrocytes will stain b. How to do a differential : f. A reticulocyte is (1) Number of cells to count. H. Leukocytosis and Leukopenia : (2) Recording of cell types. (3) Calculation of count. 1. Leukocytosis : a. Definitions neutrophilic;absolute, Laboratory Exercises relative leukocytosis, eosinophilia, The objective of this section is to train the lymphocytosis, monocytosis. laboratory assistant student in the counting of b. Physiological leukocytosis.

41 c. Neutrophilic leukocytosisdiscussion Study Questions of conditions in which this state oc- 1. What general factors are taken into con- curs :acuteinfections,intoxica- sideration in order to differentiate the tions, pregnancy, acute hemorrhage, various types of white cells on a post-,malignantgrowth, stained ? and myelogenous leukemia. 2. Name the leukocytes that are classified 2. The hemogram : as granulocytes. a. Arneth hemogramits development, 3. What are some other names for neutro- how it is used, meaning of "shift to phil ? left" and "shift to right." 4. What are the components of Wright's b. Schilling hemogramits development, stain? how it is used, meaning of "shift to 5. What should one do if a differential count left" and "shift to right." shows abnormal percentages in the 3. Infectious processes : following situations : a. Character of responses to : a. The neutrophils are increased. (1) Intensity of stimulus. b. The count shows a marked lymphocy- (2) Reacting power of individual. tosis. b. Schilling concept : 6. If there is any deviation on the blood (1) Neutrophilic battle phase. smear from the "normal," either in (2) Monocytic defense state. percentage or morphology, what is the (3) Lymphocytic cure stage. first responsibility of the laboratory 4. Significance of various blood changes oc- assistant? curring in : 7. What are the general criteria for de- a. Eosinophilia. termining whether a bloodcellis b. Basophilia. young? c. Leukopenia. d. Lymphocytosis. I. Coagulation : e. Monocytosis. 1. Introduction to coagulation :Simplified visual clotting not indicative of com- Demonstration material plex reactions involved ; clotting mech- The student will be carrying out exercises anism only as effective as influenc- listed below during this presentation, and dis- ing factors, just as a building is only cussions will point out findings on smears as strong as its foundation. which coincide with lecture material presented. a. Responsibility of the laboratory to de- tect which of the factors is weak. b. The more complicated testsusually Laboratory Exercises done by specially trained medical The objective of this section is to have the technologists ;duties of the labo- student become proficient in recognizing a de- ratory assistant involve more rou- viation from the normal in a blood smear. tine tests. Equipment Needed :Differentials and eval- 2. Factors influencing classification of hem- uation of same. orrhagic disorders : Exercises :During the time of presentation a. Vascular factor : of the preceding information, the studentcan (1) Contractionandretractionof complete a project which consists of evaluating injured vesselisfirstline of 25 differentials.Ea oh student is assigned a defense againsthemorrhage. box of prepared slides for which the differen- Muscle cells in all vessels except tials have been completed by the instructor. capillaries. Each result is checked for similarity of findings (2) Capillary permeability: and any gross difference is discussed with the (a) Injury and consequent forma- student. A work sheet is designed for use and tion of petechiae. is turned in with the slides. (b) RelationshipofVitamin C, 42 steroid hormones ; non-specific od,techniqueandinterpreta- relation to spleen. tion.) b. Platelet factorplatelets contribute to (2) Screening test to point out plasma hemostasis in following ways : factor deficiency or an antico- (1) alone, or with fibrin, form hemo- agulant presentinterpretation. static plug. (3)Prothrombin timeinterpretation. (2) participateinbloodcoagulation (4)Prothrombin consumption testin- process itself. terpretation. (3) may be essential to prevent pas- (5)Thromboplastin generation test sage of blood cells through capil- defined. lary walls. (6)Increased fibrinolysisinterpre- (4) may carry a local vasoconstrictor tation. identified as serotonin. (7)Fibrinogen concentrationdefined. c. Formation of clot. (1) First two factors stop or slow flow sgested reference for of blood, clot forms and stops student assignments flow and prevents renewed bleed- Page and Culver, p. 193, study Table 38; p. ing when vascular factor relaxes. 194, review tests in Table 39. (2) Brief discussion of three stages of fibrin formation and factors in- Laboratory Exercises volvedAHF, PTC, PTA, L.F., S.F. Class work is limited in this section since (3) Role of calcium. actual practice 'comes in department service. (4) Natural coagulation elements in The students should observe demonstrations of circulating blood. bleeding times, clotting times, and cuff tests. It should be the instructor's decision whether (5) Coagulation.elements presentin tissues. actual practice should be done in these tests. d. The removal of fibrin from the blood. 3. Tests to detect deficiencies in coagula- Study Questions tion factors : 1. How do the anticoagulants we use in a. Tests for vascular factor : hematology work to preserve blood (1) Cuff test (tourniquet test,capil- specimens and to prevent coagulation laryresistancetest,Rumpel- of blood? Leede)withprinciple,indica- 2. State the physiologic function tested in tions, technique, and limits of in- the following tests: terpretation. (a) Tourniquet test; (b) Bleeding time; (2) Bleeding time with principle and (c). Whole blood clotting;(d) explanation of tests : Prothrombin time. (a) Duke method. 3. A peripheral blood smear which you ex- (b) Ivy method. amined appeared normal but for the (c) Limitations and interpretations marked decrease in platelets. When of bleeding tests. this observation was reported and b. Tests for platelet factor : subsequently confirmed by a platelet (1) Platelet countsinterpretation and count, patient's physician requested limitations. the following procedures :a. Tourni- (2) Bleeding timesinterpretations. quet test ; b. Whole blood clotting time ; (3) Clot retractioninterpretation. c. Prothrombin time. What results (4) Prothrombinconsumption test would you anticipate in each instance? describe later. 4. Dicumarol and heparin (therapy) both c. Tests for coagulation mechanism : act on the blood clotting mechanism (1) Coagulation time of venous blood by limitations :(Lee-White meth- 5. Which test in the evaluation of coagula-

43 tion is used to follow a patient receiv- tion rate.He should calculate the values for ing dicumarol therapy, sand why? red cell indices and state whether or not 'these 6. A Vitamin K deficiency would be likely to results are reasonable according to the appear- cause ance on the smear. Slides may be demonstrated J. Hematocrit, Cell Indices, and Sedimentation for which they must estimate the MCV and Rate : MCH values from the appearance of the red cells on the smear. 1. Hematocrit : a. Definition and use. Study Questions b. Methods : 1. On eachofthefollowingcalculate : (1) Micro methodtechnique and (a) MCV; (b) MCH; (c) MCHC. sources of error. State whether or not the results you (2) Macro methodtechnique and obtained would be possible (techni- sources of error. cally), or should one of the results (3) Normal values and interpretations. used be repeated incorrectly. If the 2. Red cell indices : situation seems technically correct, de- a. Mean corpuscular volume (MCV) scribe the appearance of the red blood use, calculation, interpretation. cells, using correct terminology. (To b. Mean corpuscular hemoglobin (MCH) instructorGive several results for use, calculation, interpretation. calculation. Some of the problems c. Mean corpuscular hemoglobin concen- should be construed so that the MCHC, tration (MCHC)use, calculation, for example, will be too high, and the interpretation. student should recognize that there is d. Color indexuse, calculation, interpre- a technical error.) tation. 2. Erythrocytes with MCV and MCHC less 3. Erythrocyte sedimentation rate (ESR) : than normal would be described as a. Principles of the test : (1) Physiological factors. 3. If a patient has a marked anemia you (2) Curve of fall. would expect the ESR to be (3) Effect of anemia on curve. 4. When diluting a patient's blood in a white b. Use of the sedimentation rate : pipette, you noticed that a very dark (1) Increase in ratemeaning. brown color appeared. The corre- (2) Decrease in ratemeaning. sponding white cell count was 18,000 c. Methods : cu mm. The other laboratory data (1) Wintrobe and Westergren. were : (2) Sources of error. Hgb.:10.8 gm/ Audiovisual Aids 100 ml. Hct.: 49 percent. Lantern and microscopic slides for illustrat- RBC:4,800,000cu ing the relationship of indices values to the mm appearance of the red cells. Retic count :1.0 per- cent. Laboratory Exercises Give your impression of this situation and ex- .The objective of this section is to- broaden plain.(Do not try to diagnose the patient; is the student's view of the stained slide and its the situation probably correct technically?) relationship to known and calculated values. Equipment :Materials for performing com- K. Anemias : plete blood counts in combination' with a sedi- 1. General definition of anemia : mentation rate. a. Its role as a secondary symptom. Exercises :The student should do the de- b. The hemopoietic equilibrium. terminations necessary to calculate red blood 2. Physiological factors affecting hemato- cell indices in combination with a sedimenta- logical picture in anemia:

44 a. Reflection on health by composition of finding the value for the active disease and peripheral blood : after therapy, for example. (1) In health the balance between the formationand destructionof Laboratory Exercises erythrocytesand hemoglobin shown by constant level of these By this time in the trainingprogram, the ex- two substances in the peripheral ercises should include CBC's, red cellcon- blood. stants, platelet counts, and sedimentation rates. (2) Upset of balance results in anemia Vary the combination so that the student has physiological manifestations an opportunity to make decisions as to pro- indicatewhich phaseofthe cedure and adequacy of his own work. balanced mechanism is at fault: (a) Characterizationsofexcessive Study Questions red cell destruction. (b) Characterizations of decreasein 1. Differentiate between absolute and rela- formation of red cells. tive leukocytosis. (c) Qualitative changes in decreased 2. A patient has an anemia, and aftera hemoglobin and red cellcon- thorough work-up, the physicianpre- tentsappearance of immature scribes iron as the preferred treat- red cells in bloodreticulocytes ment. Give a probable range for the or nucleated red cells. values of the following tests before b. Clinical signs of anemia: treatment is started hemoglobin, red (1) Most physical signs due to general count, MCV, MCH, MCHC, hemato- decrease in oxygen-carryingca- crit, reticulocyte count. Whichone of pacity of the blood. the above factors would changeear- (2) Physicalsignsmore dependent liestafterthe treatment started? upon underlyingdisease proc- Why? This type of anemia is called esses and their complications. .What would be the most (3) General and progressive complaints. probable cause or causes for this type 3. Morphological classificationof anemias ; of anemia in the following situations? comparison of macrocytic andnor- a. Infant or young woman. mocytic and microcytic anemias by b. Woman 28 years of age. study of specific cases with slides. c. Man over 40 years of age. 3. In what type of anemia is the spherocyte Audiovisual aids and or spheroidocyte a characteristic find- demonstration material ing? What are the two main types of Select an anemia from the macrocytic,mi- this anemia (in regard to the cell de- crocytic, and normocyticgroups ;discuss and fect and way in which the disease is contrast it in detail with other membersof the acquired) ? What are the probable same group and with those in the other two values for the following in this situa- groups.For example, use pernicious anemia tion : MCV, MCH, MCHC ? Why would (macrocytic), iron deficiency (microcytic),and it be difficult to statea definite or hemolytic anemic (normocytic).Be sure to probable value for the WBC, Hgb, and contrast the etiology andappearance of cells RBC in regard to this disease? Acer- in thalassemia and iron deficiencyanemias. tain factor in the physical make-up Have the students makea chart to include the of the spherocyte is usedas the basis following categories for eachone of the three for the red blood cell osmotic fragility anemias : hemoglobin, red count, whitecount, test. What is this factor? platelets,reticulocytecount,MCV, MCH, 4. Continue this type of thorough studyques- MCHC, and description of slideappearance. tion to include all theareas covered in This can be done togetherso that every student this unit and in previous units to al- will have the assistance of the instructorwhen low the student a complete review. 45 Unit VI Clinical Chemistry Unit content Suggested Time: 10 weeks; 400 hours. A.Protein-Free Filtrates. B.Use of Standard Solutionsand Quality Introduction Control in the ClinicalLaboratory. The basic instruction C.Non-protein Nitrogen. in chemistry is divided D.Urea Nitrogen. into eleven sectionswhich should takea mini- mum of thirty discussion E.Protein(Total and AlbuminFractiona- periods tocover ade- tion). quately. Someinstructors may preferto dis- cuss glucose immediately after F.Glucose. protein-free fil- G.Amylase. trates and also keepall tests employinga protein-free filtrate H.Bilirubin. in one group, thenbranch I. out to otheranalyses. The order of CephalinCholesterol FlocculationTest. presenta- J.Uric Acid. tion is thus flexible.Suggested references for K.Creatinine. the instructorare given for each section,and special mention is made of suggestedrefer- Bibliography ences for the student whichmay be especially applicable. Annino, Joseph S.,Clinical Chemistry Prin- Suggestionsare given for student practice ciples and Procedures,3d ed., Boston, Little exercises to be followedduring the presenta- Brown and Co., 1964. tion of each section.These exercisesmay re- Davidsohn, I., and Wells,B. B., Clinical Diag- quire varyinglengths of time forindividual nosis by LaboratoryMethods, 13th ed., Phil- students, but theinstructor shouldsee that adelphia, W. B. SaundersCo., 1962. each student iscapable of performingeach ex- Freier, E. F., and Rausch,V. L., "Quality Con- ercise adequatelybefore allowing himto pro- trol in ClinicalChemistry," American ceed. Jour- nal of MedicalTechnology, 24 :195, 1c)58. Study questionsare presented at the endof Hawk, P. B., Oser,B. L., and Sumtherson, each section. to enablethe student to judgehis W. H., PracticalPhysiological Chemistry, own know edge of the materialwhich has been 13th ed., New York,Blakeston and Co., 1954. presentee;,.Instructors are urgedto supple- Henry, Richard J.,Clinical Chemistry, ment or change Princi- these questions to fittheir own plea and Technics,New York, HoeberMed. particular teachingsituation. Div., Harper andRow, 1964. Hepler, Opal E., Manualof Clinical Laboratory Methods, 4th ed.,Springfield, Ill., CharlesC. Thomas, 1958. Hoffman, W. S., TheBiochemistry of Clinical Medicine, 2nd ed.,Chicago, Yearbook Pub- lishers, 1959. Levinson, S. A., andMacFate, R. P., Clinical Laboratory Diagnosis,6th ed., Philadelphia, Lea and Febiger,1961. MacFate, Robert P.,Introduction to the Clini- cal Laboratory,Chicago, YearbookPublish- ers, 1961. Mollison, P. L., BloodTransfusion in Clinical Medicine, 3rd ed.,Philadelphia, F. A. Davis Co., 1961. Page, Lot B., andCulver, Perry J., ASyllabus of LaboratoryExamilations in ClinicalDi- agnosis, Cambridge,Mass., Harvard Uni- versity Press, 1961. Peters, John P., andVanSlyke, D. D., Quanti- 46 tative Clinical Chemistry,Vol. II, Baltimore, until the instructor feels that his resultsare Williams and Wilkins, 1956. reliable. Reiner, M., ed., Standard Methodsof Clinical Chemistry, Vol. I, II, III, NewYork, Aca- Study Questions demic Press, 1953, 1958, 1961. 1. Name the three agents for precipitating Simmons, J. S., and Gentzkow,C. J., Medical proteins and give an example of each. and Public Health LaboratoryMethods, 5th 2. In equation form, state the reaction which ed., Philadelphia, Lea and Febiger,1955. takes place when the Haden modifi- Unit outline cation of the Folin-Wu method is used to precipitate the protein. A. Protein-Free Filtrates: 3. Before most chemical proceduresare car- 1. Principle of the protein-freefiltrate. ried out, what initial step must beper- 2. Purpose of the protein-freefiltrate. formed to eliminate possible inter- 3. Methods of making protein-freefiltrates : ference? a. Folin-Wu filtrate. B. Use of Standard Solutions and Quality Con- b. Haden modification ofthe Folin-Wu filtrate. trol in the Clinical Laboratory: 1. Demonstrations Need for reliability of results in the lab- oratory : The actual procedures usedin the laboratory a. Accuracy and precision of determina- should be demonstratedas discussed.Stress tions parallel reliability : should be placedon the type and cleanliness of (1) One of the main difficulties lies in the glassware, care of thereagents, proper the fact that no method of analy- technique, and sources oferror.Improperly sis gives exactly the same result prepared filtrates will be helpfulto show the each time it is repeated. student the result of improperprocedure. (2) The second main difficulty lies in Laboratory Exercises the fact that we can use onlya Equipment needed: small amount and must consider All usual equipment and itrepresentative of the many reagents for preparation of theprotein-free filtrate.Tubes of sample unknowns thousands of milliliters of blood in the in the body. form of whole blood,serum, or plasma. Each student should set b. The laboratory itself,as well as the up duplicate fil- physician, must be assured that the trates, using each of the specimenssupplied. results are accurate. Stress must be placedupon good technique and sources of error. 2. Methods of control: A report sheet should be a. 'Standard solutions : kept. The following suggestedsampleis given : (1) Definition and purpose. (2) Preparation of the standard and Appearance ofAppearance reading of curve. Type of specimen of filtrate (3) Plotting of the standardcurve. Specimenspecimen (normal (clear, colorless, lipemic, etc.)colored, cloudy) (4) Value of the often checkedcurves over the permanently calibrated Whole curves. blood (5) Use of the reagent blank. Serum b. Control solutions : (1) Types of control solutions: Plasma (a) Pooled serum from the laboratory how it is used. The instructor should check the techniqueof (b) Commercially preparedhow it each student and should have filtrateschecked is used. carefully before theyare considered satisfac- c. The use of duplicate determinations. tory.The student should repeat this exercise d. The use of recovery solutions. 47 Suggested reading assignments (a) Ammonia freed,distilledinto for students acid and titrated. Frier and Rausch, p. 195. (b) Ammonia isdetermined color- Mac Fate, pp. 284-293. imetrically after Nessler's so- lution is added. Demonstrations (c)Ammonia nitrogen is set free as The student should practice construction of a gas which is then measured. standard graphs and the reading of concentra- c. Method of Folin-Wu, brief discussion. tions from them. d. Method of Koch-McMeekin, brief dis- cussion. Study Questions e. Method of Bock and Benedict. 1. What are standard solutions and why do Suggested reading assignments we use them? 2. What is the relationship between percent for students transmission and concentrations ? Annino, pp. 144-153,158-160. 3. Draw an example of the semi-logarithmic Hawk, Oser, and Summerson, pp. 545-548. graph paper and describe each of the Page and Culver, pp. 342-345. scales thoroughly. 4. Why is a blank tube included with each Demonstrations determination? It is wise here to demonstrate the actual pro- 5. What is meant by the "origin" on the cedure to be used in the laboratory exercise. graph paper? The step-wise procedure for the method of de- 6. Name four means by which a laboratory termining NPN used at your hospital should can control the reliability of the re- be described.As each step is described, the sults it turns out. proper apparatus,reagents, and techniques should be demonstrated.The same type of C. Non-protein Nitrogen* : demonstration applies to the Kjeldahl method. 1. Nitrogen-containing substances : a. Protein nitrogen. Laboratory Exercises b. Non-protein nitrogen : The students should set up protein-free fil- (1) Forms. trates and, utilizing a Kjeldahl method, esti- (2) Importance of use of protein-free mate NPN in a given sample. A report sheet filtrate. should be provided for each student where the (3) Composition of NPN. data accumulated during the procedure can be (4) Significance of estimation of NPN recorded. The entire procedure should be car- andimportanceinevaluating ried out under the supervision of the instructor. renal function. In recovery tests, a recovery of 90-110 percent (5) Normal NPN values. is necessary to be within range. A standard 2. Methods used in quantitative estimations solution should be used to check on the d4stilla- of NPN tion process and must be within an acceptable a. Micro Kjeldahl. range. The student should repeat this exercise b. Modification of classic Kjeldahl method : until the instructor feels that he is proficient (1) Principle. at it and his results are reliable. (2) importance of nitrogen -and am- monia free glassware and re- Study Questions agents. 1. Name three of the forms in which NPN (3) Basic change in all modifications is can be found in the body. a change in the digestion mixture. 2. Which of these forms is the chief de- This procedure has been considered outdated by many and terminant of the NPN value? has been replaced by the BUN test (see next section).If the 3. What is the name of the general method NPN is not used in your laboratory, it need not be taught to the student. used for determination of NPN value? 48 4. What is the normalrange for NPN in be prepared showing galvanometerreadings, whole blood? Inserum or plasma? concentration of standards, and calculationsto 5. What do high NPN values signify? reach answer in milligramspercent. Tiv:

D. Urea Nitrogen: standard graph should be turned in withthis chart. The student should repeat thisexercise 1. The place of urea in body function: until the instructor feels that he is proficient a. Relation to protein metabolism. at it and that his resultsare reliable.Accept- b. Concentration in bloodisindex of able recovery range should be90-110 percent. ability of kidney toremove waste material from blood. Study Questions c. Meaning of increased urea values in blood. 1. An increase in the level ofurea nitrogen 2. Methods to determine in the blood is indicative of disease urea vary in use or malfunction of what organ in the (suggests that the ideal method has body? not yet been found): 2. Inthedirect a. Anticoagulated blood, serum,or plasma Nesslerizationmethod can be used. is waverted to b. Most used and reliablemethods use by the enzyme. enzyme : 3. What are the normal values for bloodurea (1) Affected by time, temperature nitrogen? pH, 4. For what reason isa recovery solution concentration of substrate used in this BUN procedure? (urea), and by thepresence of 5. Why should sodium fluoride enzymatic poisons or inhibitors. never be used (2) Brief description as an anticoagulant in a BUN pro- of enzymes in cedure? general. c. Most frequently used methods require E. Protein(Total and Albumin Fractiona- urease added to whole blood. tion) d. Nesslerization ofa portion of protein- free filtrate commonly used. 1. Place of protein in the lifeprocesses : a. Protein substances. Suggested reading assignments b. Protein deficiency and how it affectsthe for students body. Annino, pp. 154-168. c. Plasma proteins : Page and Culver,pp. 342-345. (1) Albuminsignificanceofabnor- mal values. Demonstrations (2) Globulinsignificance of abnormal The actual procedure to beused in the labo- values ; fractions of globulins. ratory should be demonstrated.The proper d. Synthesis of protein. pipetting of whole blood using e. Significance of abnormal protein values an Ostwald pip- in general. ette, incubation procedure,preparation of pro- 2. Methods to determ;ne plasma proteins tein-free filtrates, color development,(Nessleri- : zation),and colorimetric analysisshould be in- a. Total protein content or the fraction- cluded. ation into component parts (suchas albumin and globulin)may be de- Laboratory Exercises termined. (1) Total protein methods used: The students should perform the examination (a) Kje!dahlmethodtheoryand under supervision, preparinga standard curve, running controls, procedure described. recovery tests, and deter- (b) Biuret methodtheoryand pro- mination of unknown in duplicate.The proper cedure described. use of recovery solutions and the reason for (2) Fractionation(Globulinispre- their use should be emphasized.A chart should cipitated and removedand al- 49 bumin content determined, glob- a. Mechanism controlling concentration. ulin content calculated by sub- b. Time to determine glucose: tractingalbuminvaluefrom (1) Fasting specimen. total protein value). (2) Post-prandial. (3) Albumin and globulin determina- c. Valueof wholeblood,serum,and tion : plasma. (a) Modification of Howe method, a d. Glycolysis. salting-out process. (1) Importance of speed in preparation (b) Theory and procedure described. of protein-free filtrate. (4) Electrophoresis. (2) Use of refr,geration and/or sodium (5) Use of standard protein solutions. fluoride. e. Normal ranges. Suggested reading assignments f. Maintenance of normal values by the for students body. Annii,o, pp. 184-194. (1) Physiology of increased values. Page and Culver, pp. 234-240. (2) Physiology of decreased values. g. Methods Most make use of fact that Demonstrations glucose contains an aldehyde group The actual procedure used in the laboratory with reducing abilities: should be demonstrated, stressing technique (1) Folin-Wu---classic method but and sources of error. measuresreducingsubstances other than glucose. Laboratory Exercises (2) Benedictmore specific but color The procedure for total protein and the pro- is not stable. cedure for albumin fractionation and analysis (3) Somogyimeasures true glucose. should be performed, with standards, controls (4) Nelson-Somogyimost reliable and unknowns. Charts should be prepared for method. the student to record all readings and deter- h. Importance of special tubes in per- minations.The instructor should check indi- forming glucose determinations. vidual technique and have the student repeat i. Demonstration and discussion of Nel- the exercise until the instructor feels that the son-Somogyi method. student is proficient at it and that the results are reliable. Suggested reading assignments for students Study Questions Annino, pp. 133-143. 1. Proteins are made up of combinations Davidsohn and Wells, pp. 415-422. of units called what? 2. Serum protein are divided into what two Demonstrations major groups? The actual procedures to be used in the labo- 3. What is the biuret reaction? ratory should be demonstrated.The proper 4. Proteins may be separated by what two pipetting of blood using an Ostwold pipette, major methods? the Folin-Wu tube, preparation of filtrates, 5. Name some pathologicalconditionsin color development, and colorimetric analysis which the protein concentration is of should be demonstrated. importance to the doctor. 6. What is the normal range for total pro- Laboratory Exercises teins, albumin, and globulin? The student should prepare test runs; using F. Glucose: the procedure demonstrated. A standard curve should run, control samples and unknownsall 1. Place of carbohydrates in body function. in duplicates.Charts should be prepared giv- 2. Glucose: ing all information and calculations.The in-

50 structor should observe individualtechnique H. Bilirubin: and should have thestudent repeat theexamin- ations until the instructorfeels that the student 1. Physiology offormation : is proficient at itand that the resultsare reli- a. Structure of bilirubin. able. b. Production ofbilirubin. 2. Methods ofdetermination : Study Questions a. Van den Bergh reactioncommon basis : (1) Indirect bilirubin. 1. Which anticoagulantis best for doing (2) Direct bilirubin. blood glucosedeterminations? b. Malloy and Evelynmethod ; modifica- 2. To precipitate theprotein in the Nelson- tions. Somogyi method,one uses 3. Abnormalbilirubinvaluesfoundin and jaundice : 3. Upon what doesthe ability ofglucose to a. Physical appearance of patient. reduce copper depend? b. Types of jaundice: 4. What is thepurpose of using the special (1) Retentive jaundice: Folin-Wu sugar tube? (a) Physiology. 5. What are twoconditionsnecessary for (b) Findings. the reduction byglucose to take place? (c) Conditions inwhich it exists. 6. Write the reactionwhich occurs during (2) Regurgitativejaundice : the reductionprocess. (a) Physiology. (b) Findings. G. Amylase: (c) Conditions in whichit occurs. Suggested readingassignments Understanding the determinationfor am- for students ylase and, indeed,all enzyme methodsrequires a background in organicand physiological Hoffman, pp. 326-339. chemistry.The laboratory Mollison, Chapters16 and 17. assistant student Page and Culver, does not have thisbackground. No doubthe pp. 396-411. will have themechanical ability toperform the Demonstrations test but will beso limited in understanding It is wise todemonstrate the actual whRit, he is doingthat the chances oferror are proce- greatly increased. dure used in thelaboratory. As each step is If the individualtraining described, the program requires that tilestudent learn to do proper apparatus, reagents, and amylase, the instructor techniques should bedemonstrated.Special will have toprepare emphasis should be lectures to fit theaverage ability to learn in given to use of freshun- each class. A lecture hemolyzedserum, technique for mixingcu- introducing anenzyme vettes, importance of procedure would haveto include material absence of bubbles when con- reading tubes, techniqueused in timing 1- cerning structure,classification, mode ofac- tion, factors affecting minute specimens, andpreparation of fresh activity, substrate, acti- Ehrlich's diazo colorreagent. vation, inhibition,specifidity, methodsof deter- mining activity, anda definition of the units in Laboratory Exercises which enzymeconcentrationis usuallyex- pressed, i.e., degrees The student shouldpractice the procedure of enzyme activity.If it demonstrated, including is felt that thisprocedure should be controls in duplicate included, and at leastone unknown in duplicate.He material to help inplanning the lectureand the laboratory exercises should be watched quitecarefully the first time may be found in clinical and will probably needhelp in timing the chemistry texts andreferences, suchas Clini- 1- cal Chemistry minute determinations.The student shouldre- Principles andProcedures by peat this exercise until J. S. Annino,op. cit., and A Syllabus of Labo- the instructor feelsthat ratory Examinations in he is proficient at itand that his resultsare Clinical Diagnosis by reliable. A chart shouldbe used to record all Page and Culver,op. cit. work.

51

ev, Study Questions resulting in precipitationof the proteins. 1. Why must the Ehrlich's reagent befresh d. Cephalincholesterolflocculationac- with each series of bilirubin deter- cepted as an accurate indexof the minations ? active disturbance of liver paren- 2. Describe the van den Bergh reaction. Also discuss the difference between chyma : (1)Most valuable in differentialdiag- the direct and indirect reactions. nosis of chronic and acute disease 3. Why must you use unhemolyzed serum or if combined with alkalinephos- plasma in this procedure? specimen phatase. 4. What should you do if your (2) Generally lacks specificityand will readsless than 10 percent trans- be altered in a number of clinical mission? Why? conditions not related toliver 5. Using Page and Culver, pp. 400-407, as a guide, discuss the five major types of parenchyma. jaundice, their cause, and laboratory Suggested reading assignments findings. Include a distinction between for students retentive and regurgitative types of jaundice and their respective labora- Annino, pp. 230-232. tory findings. Page and Culver, pp. 419-422. L Cephalin-Cholesterol Flocculation Test : Demonstrations It is wise to demonstrate theactual proce- 1. Principles of flocculation tests ingeneral : dure used in tho laboratory.As each step is a. Screening testsbased upon variations described, the proper apparatus,reagents, and in amount and type of protein pro- techniques should be demonstrated.If possi- duced. ble, have examples of 1+, 2+, 3+, and4+ re- b. Mechanism of flocculation andturbidity actions on hand for demonstration.Be certain tests. the students understand how tograde the re- (1) Relation of electrolytes to lyophilic sults since this is rather subjective. colloidal particles of protein. (2) Various tests were designed to Laboratory Exercises cause proteinsinpathological procedure as serums to become unstableand The student should practice the precipitate out of solution, while described.Stress to student potential sources normal proteins remain stable of error, such as exposure to light,increased reaction temperature, inadequatepreparation and, therefore, remain in solution. and contam- flocculation and of the reagent, age of the serum, c. Three general types of ination of glassware with traces ofacid.Stu- turbidity tests : dents should repeat this exercise untilconsid- (1) Cephalin-cholesterolflocculation reagent charged colloidal suspen- ered proficient and reliable. sion which is flocculated out of solution by a change of the dis- Study Questions tribution of proteins in the serum. 1. Why are the flocculation andturbidity (2) Thymol turbidityinvolves precip- tests termed empirical tests of liver itation of certain abnormal pro- damage or disease rather than liver teinfractionsbycompounds function tests ? which contain phenolic linkages 2. Most of the flocculation and turbiditytests or strongly polar compoundslike are measuring anincrease of what water and alcohol. portion of the serum ? (3) Zinc sulfate turbidityinvolves in- 3. Explain in your own words thegeneral teraction between abnormal pro- mechanism behind the flocculation and tein and a divalent ion (Zn++), turbidity tests. 52 4. Describe the principle behind thethree Laboratory Exercises main types of flocculation and tur- The student should practice theprocedure as bidity tests as described in Page and described, including controls andrecoveries in Culver. duplicate and at least one specimenin dupli- 5. Discuss the clinical application of the cate. He should be watchedcarefully the first cephalin-cholesterolflocculationtest time and will probably need help inreading the and flocculation tests in general. tubes in the colorimeter the firsttime, since they are timed.Reports of results should be J. Uric Acid: made on a chart form. As before,the student 1. General discussion of uric acid should become proficient in thisexercise be- a. In urine, result ofprotein catabolism; fore proceeding to the nextsection. in blood, result of protein metabo- Study Questions lism. 1. Upon what reaction are mosturic acid b. Normal values. reactions based? c. Significance ofelevated values. 2. What are the three basicmodifications of 2. Methods of analysis : this reaction used in uric acid pro- a. Several methods usecyanide in con- cedures, and what is the prime reason junctionwithphosphotungstate for these modifications? color reagent : 3. Which uric acid proceduredescribed is (1) Correct amount of lithium salts re- the most specific for uric acid and duces tendency of cyanide to pro- should be used as a reference method? duce turbidity. Why? (2) Urea will avoid turbidity as well as stabilize the cyanide so most pro- K. Creatinine : cedures based on the phospho- 1. Comparison of creatine andcreatinine : tungstate reaction are made more a. Structurally verysimilar. specific by sodium cyanide-urea b. Since creatinine is waste productof solution. creatine, concentration of former is (3)Blauch-Koch method makes it even proportional to latter present in body. more specific by use of enzyme 2. Creatinine : uricase : a. Amount ofcreatinine excreted daily is (a) Normal values. constant since it comes from the (b) Interfering substance,. amount of creatine in the skeletal b. Sodium silicate and sodium carbonate mass. have been substituted for cyanide in b. Creatinine level in serum is propor- some tests. tional to glomerular filtration rate : (1) Discussion of procedure for method (1) Main reason for changed creatinine using sodium silicate concentrationin bloodisim- (2) Discussion of procedure for method paired kidney function. using sodium carbonate. (2) Converse of (1) is not truenor- mal creatinine concentration does Suggested reading assignments notnecessarilyindicategood for students renal function. 3. Method a analysis most based onJaffe Annino,pp. 179-183. reaction :Interfering substances can Davidsohn and Wells,p. 23and pp. 451-452. make it non-specific for creatinine. a. In red blood cells,30-50 percent of Demonstrations due to creatinine. It is wise to demonstrate each step of the ac- b. In serum, plasma or protein-free fil- tual laboratory procedure as it is introduced trate,80-100percent of reaction to the student. due to creatinine. 53 Suggested reading assignments B.Blood Collection. for students C.ABO Blood Groups. Annino, pp. 173-178. D.Serum Grouping for ABO. Page and Culver, pp. 348-351. E.Rh Factors. F.Other Blood Groups. Demonstrations G.Anti-human Globin Test (Coombs Test) . Demonstrate the procedure used in the labora- H.Compatibility Testing 'or Crossmatching. tory,stressingstep-by-steptheapparatus, I.Processing, Storage, Issue of Donor Blood. technique, reagents, and sources of error. J.Blood Bank Records. Laboratory Exercises Bibliography The student should practice the creatinine American Association of Blood Banks, Tech- determinationincludingablack,standard nical Methods and Procedures, Chicago, The curve, control in duplicate, and unknowns in Association, 1962. duplicate.Reports should be made on a pre- DeGowin, Elmer L., Hardin, R. C., and Alsever, pared chart form ; the student should become J. B., Blood Transfusion, Philadelphia, W. B. proficient in the determination of this sub- Saunders Co., 1949. stance. Dunsford, Ivor, and Bowley, Christopher, Tech- niques in Blood Grouping, Springfield, Ill., Study Questions Charles C. Thomas, 1955. 1. Describe the Jaffe reaction. Mollison, P. L., Blood Transfusion in Clinical 2. Creatinine is a waste product derived Medicine, 2d ed., Springfield, Ill., Charles C. from what body substance? Of what Thomas, 1956. use is this substance in the body? Race, R. R. and Sanger, Ruth, Blood Groups in 3. Explain fully why the daily amount of cre- Man, Philadelphia, F. A. Davis Co., 1962. atinine excreted by any one individual Stratton, F., and Renton, P. H., Practical Blood is so remarkably constant from day to Grouping,Springfield,Ill.,Charles C. day. Thomas, 1958. 4. In what general condition or conditions U.S. Public Health Service, Biological Products, is the urine creatinine concentration Public Health Service Regulations, Title 42, increased and decreased? Part 73, Washington, D.C., 1962. 5. Increased serum creatinine is usually an Wiener, Alexander S., Blood Groups and Trans- indicationofdysfunction of what fusion, Springfield, Ill., Charles C. Thomas, organ? Why? 1943. Unit VII Blood Banking Available Booklets Hyland Laboratories, Hyland Reference Manual Suggested Time: 6 weeks; 240 hours. of Immunohematology, The Laboratories, 4501 Colorado Blvd., Los Angeles 39, Calif. Introduction Ortho Diagnostic Division, Blood Group Anti- Heavy and direct responsibility of blood bank gens and Antibodies as Applied to Blood work : Transfusion, Raritan, N.J., Ortho Pharma- 1. Need for exact technique and avoidance ceutical Corp., 1960. of short cuts. Public Health Service, Laboratory Pro- 2. Need for elaborate safeguards and seem- cedures for Modern Syphilis Serology, Com- ingly repetitive checks. municable Disease Center, Atlanta, Ga., 1961. 3. Need for legible, permanent, and accu- rate complete and identified records of Journals of interest all work in the blood bank. to Blood Bank personnel Blood. . Unit content Journal of LaboratoryTransfusion. A.Blood Donors. & Clinical Medicine.Vox Sanguinis.

54 Unit 'outline dice rejected as donors for whole A. Blood Donors: blood? 5. If a donor told you he hada heart condi- 1. Registration of donor: a. Name, address, etc. tion, what would you do? b. Medical history: B. Blood Collection: (1) Accuratemedicalhistorypro- A combined lecture and demonstrationis tection to both donor andrecip- recommended procedure. ient. 1. Preparation of donor's (2) Discussion of eachquestion and arm to give maxi- why itis asked ;emphasis on mum assurance of a sterile container hepatitis. of blood : (3) What disqualifiesa donor; what to a. Solutions to be used, such as green refer to M.D. for decision. soap, 70 percent alcohol, and 2 per- cent iodine (dried). 2. : a. Demonstration and discussion of meth- b. Technique of cleansing with sterilecot- od for determining hemoglobin ton gauze used, with forceps kept con- in antiseptic solution centration and the acceptablecon- or with sterile centration in a donor. cotton-tipped applicator sticks. 2. Identification of donor and b. Demonstration and discussionof blood confirmation pressure determination and accept- that donor numberon the history card, the pilot and laboratory tubes, able range of systolic anddiastolic pressures. and the 'blood container is thesame. 3. Preparation of blood container c. Acceptablepulserate,temperature and donor range, and body weight. set for (a) gravity bleedingor (b) vacuum bleeding. Suggested reading assignments 4. Phlebotomy. for students 5. Care of the donor. 6. Donor reactionsprocedure. AABB, Technical Methods,pp. 1-4, 80, 83-85. 7. Care of the unit of blood. Laboratory Exercises Suggested reading assignments for students Equipment needed: a. Sphygmomanometer and stethoscope. AABB, Technical Methods,pp. 6-8, 75-76, 85. b. Thermometers andcleaning solutions. DeGowin et al, pp. 236-245. c. Sterile disposable or sterilized lancets. PHS, Biological Products,pp. 51-52. d. Appropriate equipmentfor hemoglobin Laboratory Exercises determination. 1. Review techniques of donor 1. Practice taking medicalhistories that arm prep- are aration; observe, then performa prep- complete, permanent, andidentified. 2. Have demonstration and aration. practice in hemo- 2. Review checking of donor globin determination; intaking blood identification pressures; in placing, timing and read- on donor card, on pilot laboratory ing of thermometers. tubes, on blood container;assist by doing it. Study Questions 3. Observe a phlebotomy; performone under close supervision. 1. What diseasesare transmissible by blood 4. Place units of blood in transfusion? proper refrigera- 2. How often tor, laboratory tubes in theirproper may a donor give blood ? place, and filled-out donor cardin its 3. What is the minimum levelof hemoglobin place. a donor must have? 5. Observe and learn tocare for donor with 4. Why are donors witha history of jaun- a reaction. 55 Study Questions Introduction to Laboratory Method 1. What is the purpose of a thorough donor 1. Use of a known anti-Aand and-B serum arm preparation? on unknownblood samples of donors 2. When are pilot tubes attached to theblood and patients and on knowncontrols. container? When is the number at- 2. Equipment needed : tached? a. Clean glassslides and/or tubes 12 x 3. When are the pilot tubes filled? 75 or 13 x 75 mm. 4. If you are not able to get the needle into b. Applicator sticks or diSposablepipettes. the donor's vein on one arm, what do c. Centrifuge. you do? d. Interval timer. 5. If during the drawing a donor complains 3. Reagents :Commercial anti-A and anti- that he feels ill, what would you do? B serums. 4. Specimens used : C. ABO Blood Groups : a. Samplesof whole blood of unknown 1. Discovery of human blood groups A, B, group. and 0 by Landsteiner in 1900. b. Samples of whole blood ofknown group 2. Group AB discovered by vonDecastello A, B, AB, and 0 for examples and and Sturli in 1902. controls. 3. M, N, and P by Landsteiner and Levine 5. Method : 1927. a. Read andfollow carefully the direc- 4. Rh by Landsteiner and Wiener 1940. tions for use that come with the 5. Discussion of the four blood groups as antiserums. antigens and antibodies, agglutinogens b. If clotted blood used, showrimming and and agglutinins, iso-agglutinins. centrifuging of samples. 6. Brief discussion of inheritance of blood 6. Sources of error : groups. a. Too heavy acell suspension may lead to 7. Incidenceof blood groups in United absorption of antiserum without States. agglutination. b. Tests should be observed forspecified Suggested reading assignments time since a weak antigen may re- for students act slowly. c. Presence of clots maybe interpreted as DeGowin et al, pp. 52-63. false positive. Dunsford & Bowley, pp. 3-7. d. Heavybacterialcontaminationcan Mollison, pp. 176-182. cause error. Race and Sanger, pp. 9-49. e. Reactiontemperature higher than room Stratton & Renton, pp. 107-112. temperatures can cause error. Wiener, pp. 7-18. AABB, Technical Methods, pp. 11-12. Laboratory Exercises Hyland Reference Manual. 1. Review antigen-antibody reactionsand Ortho, Blood Group Antigens. demonstrate direct ABO grouping us- ing samples of known and unknown Audiovisual Aids ABO groups. Blood Grouping, color, sound, 21 min.,Film 2. Introduce student to the laboratorysheet Library, Imperial Chemical Industries, 488 for recording results ; results must be Madison Ave., New York 22, N.Y. permanent, dated, and signed. 3. Have students perform tests. Demonstrations Identification of slides or tubes and perform- Study Questions ance of directgrouping using known anti- 1. What blood groups did Landsteinerdis- serums by slide and/or tubetechnique. cover? When? 56 2. Describe an antigen and an antibody. 5. Procedure in the event the two methods do 3. Describe briefly how blood groups are in- not agree as to blood group. herited. 4. What is the incidence of the blood groups Introduction to Laboratory Method in the United States? 1. Equipment :clean glass tubes or slides, 5. Is heat used for ABO tests? test tube racks, disposable pipettes, 6. What is a hemolysin? centrifuge, glass marking pencils. 7. What are some possible sources of error 2. Reagents : known A, and B cells, normal in doing direct grouping tests? saline. D. Serum Grouping for ABO: 3. Specimens used : specimens of known and unknown blood groups. (Note :It is 1. Review Landsteiner discovery. possibletopreparea"rouleaux" 2. Review antigens and antibodies : serum by adding Dextran to a normal a. Naturally occurring anti-A and anti-B. serum for demonstration and student b. Hemolysins. practice purpose.) c. Immune antibodies. 4. Occurrence of rouleaux and auto or cold d. Rouleaux and cold agglutinins. agglutinins in serum; methods for solving these two problems. Suggested reading assignments 5. Sources of error : for students a. Dirty glassware or pipettes. AABB, Technical Methods, pp. 12-13. b. Placing cells in wrong tube. DeGowin et al., pp. 70-77. c. Hemolysis read as a negative result. Dunsford & Bowley, pp. 8-10, 13-18, 21-22. d. Lack of agglutinins in patient's serum. Mollison, pp. 175, 182-201. e. Presence ofirregularantibodiesin Ortho, pp. 10-11. serum which react at room temper- Race and Sanger, pp. 17-49. ature. Wiener, pp. 18-34. f. Bacteriogenic agglutination. Audiovisual Aids Study Questions Fundamentals of Human Blood Groups, film- 1. What general types of anti-A and anti-B strip, color, 35 mm., and disc, 16 inch, 331/3 are there? rpm., 15 min., Communicable Disease Center, 2. What may cause disagreement between Atlanta, Ga. the direct group and the serum group Technics in Blood Grouping, Part I-Slide of the same sample? Techniques, and Part II-Test Tube Tech- 3. How do you determine the serum group niques, filmstrips, color, accompanied by L. P. of a sample which contains cold ag- (331/3 rpm) record. Audio-Visual Library. glutinins? ASMT Education & Research Fund, Inc., 4. How do you determine a serum group on Hermann Prof, Bldg., Houston, Tex., 77025. a specimen which exhibits rouleaux formation? Demonstrations 5. Should both the cells and serum of an un- 1. Preparation of washed known A cells and known sample be tested for ABO B cells in an approximate 2 percent group? suspension of cells in saline. E. Rh Factors : 2. Identification of tubes and distribution of serum or plasma. 1. Landsteiner and Wiener's discovery of the 3. Addition of cells to proper tubes, incu- Rho (D) factor in 1940: bation and/or centrifugation, reading a. Percentage of Rho (D) positive and and recording results. negative persons in the U.S. popu.: 4. Comparison of direct and serum group- lation. ing results to determine blood group. b. Importance of this factor in blood trans-

57 fusion and in pregnancy. Formation e.Excessive amount of anticoagulant in of anti-Rho (D) in Rh negatives sample. and percent of irregular antibodies f. Rouleaux formation. that are anti-Rho (D). g. Antibody coated cells. c. Other Rh-hr factors. h. Plasma clots. d. Weak or intermediate Rh factors. i.Dirty glassware. e. Complete and incomplete Rh antisera. j. Heavy bacterial contamination of spec- 2. Fisher-Race nomenclature. imen or antiserum. Suggested reading assignments Laboratory Exercises for students 1. Review Rh factors and formation of anti- bodies to them. AABB, Technical Methods, pp. 14-20. 2. Demonstrate Rh testing and havestudent DeGowin et al., pp. 79-88. perform tests, using controls. Dunsford & Bow ley, pp. 19-61. 3. Have student learn how and whereto Hyland, pp. 36-45. record the results. Mollison, pp. 202-219. Ortho, pp. 18-25. Study Questions PHS, Biological Products, p. 52. 1. What is the most clinically important Rh Race & Sanger, Blood Groups in Man, pp. factor? Why is it clinically impor- 115-173. tant? Stratton & Renton, pp. 154-189. 2. Why do we use controls? Wiener, pp. 245-254. 3. What two types of serum are used in Rh testing? Demonstrations 4. For what Rh factors can we test? Performance of anti-Rh tests using complete 5. Name at least five possible sources of and incomplete serums and the methods called error in Rh testing. for in the directions for use of each serum. F. Other Blood Groups : Introduction to Laboratory Method 1. M, N, and P discovered in 1927 by Land- steiner and Levine, following injec- 1. Review of formation of anti-Rh anti- tion of rabbits with human blood cells. bodies and their thermal optiMum ; 2. Antibodies to blood groups usually found also potentiation by macromolecules asresultofincompatiblecross- in some instances. matches, transfusion reactions, and 2. Equipment : glass slides, warm view box, hemolytic disease of the newborn. tubes and racks, waterbath, centri- 3. List of blood groups in order of their fuge, applicator sticks and/or Pasteur discovery (Race & 'Sanger). pipettes, interval timer. 4. List of most clinically significant antigens 3. Reagents : antiserums, saline, albumin. other than ABO and Rh. 4. AnticoaguLted orclottedblood from donors and patients. Suggested reading assignments 5. Directions for use that come with anti- for students serums most important. AABB, Technical Methods, pp. 20-22, 24-27. 6. Controls : Hyland Reference Manual, pp. 29-32, 34-35, a. Test cells with addedalbumin. 47-55. b. Known positive and known negative Mollison, pp. 224-249. cells. Ortho, pp. 27-36. 7. Technical factors and sources of error : Race and Sanger, pp. e6-112, 183-232. a. Omission of antiserum from test. b. Insufficient time for reaction to occur. Demonstrations c. Use of too concentrated cellsuspension. Demonstrations of testing for blood group d. Use of outdated antiserum. antibodies may be given with emphasis on fol- 58 lowing directionsfor use ofserum and the use of positive and 2. Direct Coombs test: negative controls. a. Principal uses: Introductionto Laboratory Method (1) Testing infant's cells insuspected 1. Equipment and cases of hemolytic disease of new- specimensthose used in born. ABO and Rh testing. (2) Testing cells of patientssuspected 2. Reagentsmay belicensed antiserums or of having auto-immunehemolytic serums found in laboratory testingor anemia. crossmatching. (3) Testing of patient cellsfollowing a 3. Methodmay be thedirections for use of transfusion reaction. the licensedserums or the tempera- b. Method for doing ture, medium, and time test. of reaction 3. Indirect Coombs test: found best for the laboratoryserum. a. Principal uses: 4. Known positive and negative control cells (1) Testingserum of pregnant women tested in parallel with theunknown for antibodies, using previously sample assure reactivityof the anti- characterized red cells. serum. (2) Testingserum of 5. Sources oferror as in Rh and ABO. patients and donors for antibodies, usingcells 6. Clinical application: If patient hasan as above. unusual antibody, donorbloods may (3) Crossmatching. be screened for theantigen before (4) Antigen testing for Du, crossmatch. Kell, and other rare bloodgroups. Laboratory Exercises b. Method for doing test. 1. Review lecturenotes and reading. Suggested reading assignments 2. Demonstrate settingup and reading tests for students and recording results. AABB, Technical Methods,pp. 22-24,65. 3. Have students doperformance andre- cording of tests. Dunsford & Bowley,pp. 63-69. Hyland Reference Manual,pp. 58-66. Study Questions Mollison, pp. 299-309. 1. What are the clinically Ortho, pp. 37-42. important blood Stratton & Renton,pp. 60-78. factors in thisgroup ? Why are they clinically important? Demonstrations 2. Why is it important to follow directions Demonstrations of both directand indirect for use thatcome with an antiserum? antiglobulin testsmay be done. 3. Why is it importantto use positive and negative controls in testingfor anti- Introduction to LaboratoryMethod gens such as Kell and Duffy? 1. Equipment: tubes,racks, waterbath,cen- 4. Which bloodgroup system is different trifuge, and squeeze bottle foradding from all other systemsso far dis- of saline. covered? 2. Reagents: anti-humanglobulin serum, 5. What is a "public"antigen and what isa serum containing an antibody suchas "private" antigen? anti-Rho (D). G. Anti-human GlobulinTest (Coombs Test) 3. Specimens of blood withRho (D) and : Rho (D) negative. 1. Explanation of antibodies as globulins : 4. Controls of antibody-coatedcells may be a. Not all antibody-coated cells agglutinate purchased or prepared in laboratory. in test tube. 5. Technical factors: each lot of anti-human b. Anti-human serum produced in animals serum varies; read directions foruse. usually rabbitor goatagglu- Anti-human serum beingused may tinate antibody-coatedcells. not demonstrate all antibodies. 59 6. Sources of error : Dunsford & Bowley, pp. 70-71. 71-75. a. Evenexceedingly small trace of serum Hyland Reference Manual, pp. can inactivate theCoombs reagent. Mollison, pp. 310-318. Thorough washing of cells before Ortho, pp. 48-53. adding Coombs serum is essential. Stratton & Renton, pp. 208-237. b. Contaminatingbloodsampleswith Audiovisual Aids Wharton's jelly may cause agglutin- The Point of No Return,color, sound film, ation of cells. 20 min., Ortho Diag. Div.,Raritan, N.J. c. Detergents orchemicals on glassware or in saline may causeagglutination. Introduction to Laboratory Method d. Incubation time of cells and serum may 1. Equipment : same as forother procedures, be too brief to allow coating. plus microscope for reading cross - matches.. Laboratory Exercises 2. Reagents :Anti-A, B, and Rho (D), al- 1. Review of lecture notes andreading. bumin, anti-human globulin serum, 1 2. Supervised performance of tests. enzyme, saline. 3. Procedure of recording test results. 8. Specimen used : a. Patient specimenmust be identified Study Questions clearly and accurately, with name, 1. What is the principle of theanti-human hospital number, ward or room, sex, globulin test? service, date. 2. Why must the cells be washedthoroughly b. Donor blood must be from apilot tube before the anti-human globulinis which was att ched to theblood added? container and filledat time of 3. When is the direct Coombs used? donation. 4. What is the difference between thein- 4e Control measures may include : direct Coombs test and direct test? a. Group and typeof each patient. 5. Are all Coombs serums just alike? b. Use of coated cells in Coombs cross- 6. What are the sources of error which JIUSt match tubes. be avoided in performing the anti- 5. Ter.11):cal factors : human globulin test? a. *,01.1eaux formation. H. Compatibility Testing or Crossmatching : b. Cold agglutinins. c. Patient cellspositive to direct Coombs 1. Purpose of crossmatching : test. a. Testing compatibilityof donor's blood 6. Source of error: with recipient's blood for trans- a. Not adding serum tocells. fusion. b. Inadequate identification of crossmatch b. Need for accuracy and care, avoidance tubes. of all shortcuts. c. Use of patientsample which is too old 2. Typei of crossmatch (especiallyto be avoided when a. Major. patient is having many transfus- b. Minor. ions). 3. Crossmatching procedures and indications d. Too violent agitation of crossmatch for use of each : tube when suspending cells after a. Saline. centrifugation. b. Albumin. c, Cdombs. Study Questions I. Why does the blood bank insist on having Suggested reading assignments full identification in a patient sample for students of blood? AABB, Technical Methods, pp. 29-33,88-89. 2. When is the proper time to label the DeGowin et al, pp. 182-190. sample of the recipient's blood? 60 3. Why is it important to have fresh samples a. Blood issued by a blood bank to another of blood forcrossmatch when the patient is having blood bank or hospital. many transfusions? (1) Distribution records should 4. List the test whichshould be performed include what, when, where, andwho. in crossmatchingblood for trans- (2) Shipping container fusion when there is should be ca- no emergency. pable of maintainingtemperature Give the reason forperforming each test. below 10° C. during periodof shipment. b. Crossmatched bloodissued by a blood I. Processing, Storage,and Issue of Donor bank for a patient. Blood : (1) Request for theblood must be 1. Processing techniqueshave been learned signed by a responsibleperson, except for a serologicaltest for syph- must include thename, hospital ilis, whichmay or may not berou- number, room or ward,sex, age, tinely performed in theblood bank; etc., of patient, and must becare- instruction in performanceof such a fully checked againstthein- test, if necessary. formation on the crossmatched blood. 2. Organization ofprocessing techniquesand proper recording of results. (2) Release ofa unit for transfusion 3. Labeling of blood: must have safeguard checks. a. Information on printedlabel. b. Donor number Suggested reading assignments ; group and type. for students c. Expiration date: how it is determined and why. AABB, Technical Methods,pp. 59-62, 87. d. Checks and rechecksused in blood bank CDC, LaboratoryProceduresfor Modern to assure that each unitof blood is Syphilis Serology. correctly labeledas to group and PHS, Biological Products,pp. 52-56. type. 4. Blood storageconditions : Demonstrations a. Optimum storagetemperatures within May include STS,labeling, blood inspection, a 2° C. range between1°-6° C. culturing, and issuing. b. Cleanliness ofblood storage refrig- erator and freedomfrom extra- Laboratory Exercise neous materials for safety ofblood The techniques underthissection can be stored there. learned by observationand then performance. c. Frequently tested alarmsystem asa Special emphasiscan be given to labeling and precaution. to release of crossmatchedblood. d. Records ofstorage temperaturesby a recorder chartor by twice daily Study Questions reading and recordingfrom accu- 1. Why does citrated rate thermometerin the refriger- whole blood (human) ator. have an expirationdate of 21 days? 2. Why is a serologicaltest for syphilis done 5. Daily inspectionand inventory ofblood on shelf ready for issue; on blood for transfusion? units of 3. Why is blood storedat temperatures be- blood inspected foroutdating, clots, low 10° C.? hemolysis, unusualcolor or cloudi- 4. Why shoulda request for blood fortrans- ness ; inspection record kept. fusion to a patient' 6. Culturinga unit of blooda month after include more than it has "expired" the name of the patientfor whom it is to check on tech- intended? nique used in drawingblood. 5. Why should blood 7. Issuing blood: stored for issue bein- spected? 61 3. Why are recordsof blood storage temper- J. Blood Bank Records : atures kept? 1. Blood bank legally liablefor negligence in 4. How long must wekeep our blood bank its operation ; inadequateand poorly records? kept records do not helpin a court of law : Unit VIII RoutineAnalysis trans- a. Some 85percent of errors in Suggested Time: 6 weeks;240 hours. fusionpracticeareclericalin nature rather thantechnical.For Unit content patient's safety, keep allrecords A.Introduction to Urinalysis. fully so that planned checksagainst B.Specific Gravity and pHof Urine. Copying of in- error can operate. C.Urinary Sugars. formation should be kept to amini- D.Urinary Proteins. mum. E.Ketone Bodies. b. Record forms vary, butrecords should F.Bilirubin, and Urobilinogen. be made concurrentlywith the per- G.Microscopic Exam ofUrinary Sediment : formance of each procedure.They PartI,Introduction and 'Organized should be legible, indelible,initialed, Sediment. and dated. H.Microscopic Exam ofUrinary Sediment: 2. Technical Methodsand Procedures of the Part II, Unorganized'Sediment, Miscel- AABB lists the kinds ofrecords to be laneous Structures, AddisCount, and kept: Review. a. Donorrecords,including donorre- I.Suikowitch Test forQualitative Urine actions. Calcium. b. Transfusion requestrecords. J.PhenosulphonphthaleinExcretionTest c. Transfusionrelease records. (PSP). d. Record of transfusion. K.Gastric Analysis. e. Transfusionreactions records. L.Examination of Feces for NeutralFat and f. Record of bacteriologicalstudies. Occult Blood. g. Record ofrefrigeration temperatures. Note: Samples of studentwork sheets for h. Record of blood inspection. routine urinalysis, urinemicroscopies, Sulko- i. Record of blood receivedfrom outside witch test, PSP test, gastricanalysis, and oc- source. cult blood are given atthe end of this unit. j. Laboratory work records. To this should be addeddistribution records, in Bibliography the event that the blood bankships blood. Davidsohn, I., and Wells, B. B.,Clinical Diag- 3. The length of time recordsshould be kept nosis by Laboratory Methods,13th ed., Phila- varies in each State. delphia, W. B. Saunders,1962. Dorland, W. A., The AmericanIllustrated Med- Suggested reading assignments ical Dictionary, 23d ed.,Philadelphia, W. B. for students Saunders, 1958. Dukes, C. E., Urine Examinationand Clinical AABB, Technical Methods, pp.57-58, 92. Interpretation, London, OxfordUniversity PHS, Biological Products, pp.19. 'Press, 1939. Hepler, Opal E., Manual ofClinical Laboratory Study Questions Methods, 4th ed., Springfield,Ill., Chas. C. 1. Is it a good idea to writetest results on a Thomas, 1958. slip of paper, then copy themneatly in Kolmer, John A., ClinicalDiagnosis by Labo- the laboratory record ?If not, why ratory Examinations, 3ded., New York, Ap- not? pleton-Century-Crofts, Inc., 1961. 2. What is the way to correct an errorin Lippman, R. W., Urine andUrinary Sediment, the records when they areindelible? Springfield, Ill., Chas. C. Thomas,1952. 62 Page, Lot B., and Culver,Perry J., Syllabus of f. Specific gravity1.015 to 1.025 in a Laboratory Examinations inClinical Diag- normal individual. nosis, Cambridge, Mass., Harvard University 4. Composition of urine: Press, 1960. a. Made up of 960 parts water and 40 Simmons, J. S., and Gentzkow,C. J., Medical parts solids. and Public Health LaboratoryMethods, Phil- b. Composition of solid matter in normal adelphia, Lea and Febiger, 1955. urine. Watson, C. J., Outlines of InternalMedicine, (1) Organicurea (40-50% of solids 9th ed., Part V, Dubuque,Iowa, Wm. C. Brown Co., 1958. excreted), uric acid, creatinine. (2) Inorganicchlorides,phosphates, Booklets sulfates, ammonia. c. Medical Laboratory AssistantCourse, L.A. 7 Abnormal substances found in urine in various conditions: Urinalysis Manual, Minneapolis,Minn., Uni- versity of Minnesota, 1960. Acetone, albumin, bile, blood,pus, Medical Laboratory Assistant hemoglobin, glucose, fat. Course, L.A. Cystine, UrinalysisLaboratoryExercise spermatozoa,epithelial Manual, cells, sulfonilamides, casts, bac- Minneapolis, rinn., University ofMinnesota, 1961. teria, parasites. Medical Laboratory AssistantCourse, L.A. 8 5. Routine urinalysis--usuallyconsists of Urinalysis Manual, Minneapolis,Minn., Uni- color, transparency, specificgravity, versity of Minnesota, 1959. pH, protein,sugar (acetone and dia- Urine as the Index of Healthand Disease, Aries cetic acid when indicated), andmicro- Pictoclinic, Vol. 5, Number 4,The Ames Co., scopic examination. Inc., Elkhart, Ind. 6. Collection of urine specimens: The Neglected Art ofUrine Testing, Ames a. Types of containers for collecting urine. Pictoclinic, Vol. 6, Number9, The Ames Co., b. Preservation of urinespecimens : Inc., Elkhart, Ind. (1) Changes thatoccur in urine stand- The Significance of Proteinuria,Ames Picto- ing at room temperature for clinic, Vol. 5, Number 9,The Ames Co., Inc., several hours. Elkhart, Ind. (2) Methods of preservationrefrig- eration, toluol or thymol. Unit outline c. Voided urine specimens. A. Introduction to Urinalysis: d. Catheterized urine specimens. 1. Brief review of thekidney : e. Collection of urine for : a. Diagram of the gross anatomyof the (1) Routine urinalysis. kidney. (2) Qualitative urinetests. b. Function of thekidney. (3) Quantitative urinetests. 2. Purpose and definition of urinalysis. 7. Physical properties ofurine: 3. Properties of urinein a normal indi- a. Urine volume : vidual : (1) Measurement andusage. a. Coloramber or straw colorin health. (2) Terminology: b. Reactionnormally polyuria,oliguria, has a slight acid anuria, nocturia, diuresis. reactionpH 6 (range 4.8-7.5). b. Color : c. Odornormally has a peculiardis- (1) Normalyellow (dueprimarily to tinctive odor. urochrome) ;varies from pale d. Tastenormally hasa bittersaline straw to a deep amber color. (salty) taste. (2) Abnormal colorspale, e. Urine volumeaverage quantity dark yel- ex- low,brown-red,yellow-brown, creted in 24 hours ina man in good or beer brown, orange-red health is 1200-1600 ml. or (approx. 3 orange-brown, red, darkbrown pints). or black. 63 c. Transparency : specimens to be tested for color, (1) Normalclear when voided. transparency, odor, and foam. (2) Abnormalcloudinessmay be due Laboratory Exercises to . mucin or mucousthreads, 1. Review of urinalysis equipment : amorphous phosphatecrystals, bacteria, amorphous urate crys- a. Become familiar with the names, usage, tals, pus, blood, or fat. and care of the equipment. d. Odor (due' to volatile acids) and their b. Wash all urinalysis glassware by the proper cleaning procedure. causes: 2. Physical properties of urine : (1) Ammoniacal odor,(2)"Urinod," (3) a. Brief review of the physical properties Fruity odor,(4) Odor of of urine. mercaptans, (5) Odor in urinary tract infections. b. Demonstration of the proper technique (1) Normalwhite foam. for doing color, transparency, odor, (2) Abnormalyellow and foam on urine specimens (indicativeof what to look for. presence of bile pigments). c. Student exercise. 8. Urinalysis equipment : a. Usage and types. (1) Examine the demonstration urine specimens for physical properties b. Care of equipment: (1) Cleanliness, (8 for color, 6 for transparency, (2)Proper cleaning 3 for odor and 3 for foam). procedure. 9. Personal (a) Record observations by sight, cleanlinessintheurinalysis smell, or shaking. laboratory. (b) List the probable cause or causes Audiovisual Aids for each. (2) Unknown urine specimensRecord The Role of Urine in Diagnosis, filmstrip, theresultson four unknown Parts 1 and 2, Audiovisual Seminars 100and urine specimens for color, trans- 101, Commission on Continuing Education, parency, order, and foam. American Society of Clinical Pathologists, Study Questions Chicago, Ill. Work of the Kidneys, B. & W., sound, 11 min., 1. Draw the kidney, ureter, bladder, and Encyclopaedia Britannica Films, Wilmette, urethra. Ill. 2. Briefly list the steps used in washing urinalysis equipment. Introduction to Laboratory Method 3. Give the procedure for the collection of a 24 hour specimen. 1. Equipment : 4. Name three ways to preserve urine. a. Issued to each student : urinometer and 5. What care must be exercised in theuse cylinder, universal pH paper and of preservatives? color scale, eye droppers and bottle, 6. Name five reasons why it is important to test tubes (25 x 150 mm. and 16x examine a urine specimen immedi- 150 mm.), centrifuge tubes, test ately after voiding. tube rack, glass marking pencil. 7. Why is it important to record the physical b: To use for exerciseon physical prop- properties on a urine specimen? erties of urine : test tubes and rub- 8. What color, transparency, odor, and foam ber stoppers. would you expect in a normal urine? 2. Specimens used : 9. Briefly describe howyou would collect the a. Demonstrationurinespecimensfor urine for the following tests: color (8 urines), transparency (6 a. Routine urinalysis. urines), odor (3 urines), and foam b. Qualitative urine tests. (3 urines). c. Quantitative urine tests. b. Unknown urine specimensfour urine 10. Name the normal constituents of urine. 64 11. Name five colors seen in urine and their curacy with standardsolution probable causes. and make correction if necessary. 12. Name four substances which affect the (3) Using well-mixed urine specimen, odor of the urine and their probable read the urinometer. causes. (4) Requirementsforreadingthe B. Specific Gravity and pH of Urine : urinometer : clean urinometer, no bubbles around urinometer, uri- 1. Specify gravity : nometer should be floating freely, a. Definition of specific gravity. read on flat surface, read at bot- b. Purpose of doing specific gravity on tom of meniscus, make urinom- urine. eter correction if necessary. c. Determination of specific gravity by use 2. pH: of a urinometer. a. Definition of pH. (1) Means of testing a new urinometer. b. pH values in normal urine. (2) Calibration of urinometer with dis- (1) Normal urine pH is 6.0 (range of tilled water and potassium sul- 4.8-7.5). fate solutions. (2) Freshly voided urine is almost al- d. Specific gravity corrections. ways acid in reaction. (1) Temperature correction for pre- c. Determination of urinary pH. cise work-0.001 should be added (1) Litmus paper. to the reading for each 3°C. (2) Nitrazinepaper(universal pH above standard temperature and paper) pH range of acid, pH 4 to 0.001 should be subtracted for pH 7, alkaline. each 3°C. below standard tem- (3) Combistix (Ames) pH range 4.5- perature. 9.0. (2) Correction for protein and sugar d. Significance of an alkaline reaction in in the urine : urine. (a) When urine contains 1 percent (1) Freshly voided urine. (1 gm. protein or sugar per 100 (2) Decomposition upon standing at ml. of urine) protein or sugar, room temperatureforseveral 0.003 must be subtracted from hours due to the breakdown of the specific gravity. urea by bacteria to form am- (b) Quantitative tests for urinary monia. sugar and protein are run to e. Significance of increase in acidity. determine the exact amount (1) Drugs (3) Fever present. (2) Acidosis (4) Excess protein e. Specific gravity of urine : f. Precautions. (1) Normal valueisfrom 1.015 to (1) Freshly voided urine specimen. 1.025. (2) Caution in using preservatives. (2) Pathological range is from 1.001- 1.060. Introduction to Laboratory Method (3) Generally, in disease and in health, 1. Equipment. thespecificgravityofurine a. Urinometer and cylinder. varies inversely with the volume b. pH paper and color scale. of the urine with the following c. Stirring rod. exceptions : diabetes mellitus and d. Marking pencil. terminal nephritis. 2. Specimens used. f. Procedure for determining the specific a. Urine specimens with known specific gravity of urine : gravity and pH.. (1) Check cleanlinessof urinometer b. Unknown urine specimens 4 urine cylinder. specimens to be tested for specific (2) Check urinometer daily forac- gravity and pH.

65 Laboratory Exercises b. Storage of carbohydrates. 1. Review of technique for doing specific c. Excretion of carbohydrates. gravity and pH on urine. 2. Glucose (glucosuria or glycosuria). 2. Demonstrations. a. Definition. a. Clean anddirtyurinometers(note b. Causes. meniscus). c. Tests for detecting glucose in urine b. Urine specimens with known specific depend largely upon ability to re- gravities and pH. duce certain substances (reducing 3. Student exercise. ability due to aldehyde nature). a. Check urinometer for accuracy. (1)Other reducing substances found in b. Observe demonstration specimens for urineuric acid, creatine, fruc- specific gravity and pH. tose, lactose, pentose, homogen- c. Perform the following tests on four tisic acid, glucuronic acid, chloro- urine specimens :color, transpar- form, formaldehyde. ency, odor, foam, specific gravity, (2) When substancewithreducing and pH. ability is detected in the urine d. Record the results on a chart. and there is any doubt on clinical 4. Acceptable student performance. grounds that substance is glucose, a. Specific gravity of + 0.002 from cor- a fermentation test with yeast rect result. should be carried out. b. pH should be ± 0.5. 3. Screening tests for glucose (to tell whether reducing substance is present or not) : Study Questions a. "Galatest" (commercial testDenver 1. Define:a. specific gravity.b. pH. Chemical Manufacturing Co.) 2. How would you obtain the specific gravity (1)Principle: bismuth oxide is reduced with a small amount of urine? by urine sugar to a finely divided 3. Give the technique for determining spe- black metallic bismuth (grey or cific gravity. black) color, indicates a positive 4. What is the specific gravity of normal test. urine? (2) Contents of powder. 5. What is the pH of normal urine? (3) Precautions. a. Range: (4) Procedure. b. Average : (5) Interpretation of results. 6. What changes occur in the pH after urine b. "Tes-tape"and"Clinistix"enzyme has been standing at room tempera- tests using glucose oxidase and are ture for several hours? Why? specificforglucose(Tes-tape 7. Give the technique for determining pH. Lilly Co.; ClinistixAmes Co.) 8. Name two substances in urine which will (1) Principle. increase the specific gravity. (2) Contents of paper strip. 9. Of what significance is a high specific (3) Nature of chemical reaction. gravity? (4) Procedure. 10. Of what significance is a low specific (5) Interpretation of results. gravity? 4. Qualitative tests for urine sugar (to give 11. How would you make a temperature cor- rough estimate of amount present). rection on the specificgravity of a. Benedict'squalitative testreduction urine? of copper sulfate. C. Urinary Sugars. (1) Principle: ability of glucose to re- duce cupric hydroxide to cuprous 1. General considerations. oxide. a. Utilizationof carbohydrates by the (2) Reagent used. body. (3) Procedure for doing test. 66 (4) Interpretation of the testgrad- b. Clinitest tablets and color charts. ing, amount of precipitate, color c. Tes-tape paper and color chart. changes in supernatant and in d. Clinistix strips. mixed solution, approximateper- e. Galatest powder. cent glucose present. 4. Specimens used. b. "Clinitest" (commercial tablesAmes a. Normal and abnormal urine specimens. Company). (1) Principle. b. Four unknown urine specimens for urine sugars. (2) Contents of tablet. 5. Methods used : Benedict's, Clinitest, Gala- (3) Precautionson using tablets. (4) Procedure. test, Clinistix, and Tes-tape. (5) Interpretation of results. c. Fermentation test. Laboratory Exercises (1) Principle. (2) Reagents. 1. Explain and review principle and tech- (3) Procedure. nique for doing tests for urinesugars. (4) Results of test. 2. Demonstrate Benedict's urinesugars and 5. Quantitative tests for urinesugar. normal and abnormal urine specimens a. General considerations. with Clinitest, Galatest, Clinistix, and (1) Use and procedure fordilution. Tes-tape. (2) Use and procedure for removalof 3. Student exercise. protein. a. Look at demonstration specimens of b. Benedict's quantitativemethod. Benedict's urine sugars and record c. Somogyi method. results asto supernatant color, d. Fermentation test. amount of precipitate,colorof mixed solution, and final result. Introduction to LaboratoryMethod b. Look at demonstration of commercial tests using normal and abnormal 1. Introduction to urinesugars using pri- urine. marily screening and qualitativetests. c. Using Benedict's qualitative test, de- 2. Equipment. termine urine sugars on fourun- a. 16 x 150 mm. test tubes. known specimens. b. Eye droppers and bottic.t. (1) Follow directions given in lecture. c. 'Stirring rod. (2) Record resultsas to supernatant d. Marking pencil. color, amount of precipitate, color e. Boiling water bath) or mixed solution, and final result. Cold water bath with racks. d. Do commercial tests(Clinitest, Clin- istix, Tes-tape, and Galatest) for 3. Reagents. urine sugars on two of the four a. Benedict's qualitative reagent. specimens provided.

Name of Major component Negative commercial Detects Positive UNKNOWN test of reagent, strip result result SPECIMENS tablet, or powder (color) (color) 1 Clinitest

Clinistix

Galatest Tes-tape I

67 (1) Follow directions given in lecture. b. Constituentsofurinaryprotein (2) Record results : serumalbumin,serumglobulin, 4. Acceptable student performance is ability mucin, proteoses. to grade the results accurately. c. Causes of proteinuria. 2. Testing the urine for protein. Study Questions a. Requirements of the specimen. 1. Draw in chart from the tests for reduc- (1) Clear urine by filtration or by cen- ing sugars in urine and include the trifugation. following: (2)Removal of mucin by acidifying a. Name of test. with acetic acid and filtering. b. Major components of reagent used in (3)Urine voided early in evening or a the test. few hours after a mealmost c. Brief description of the test method. likely to contain protein. d. Description of the interpretation of the (4) Dilution of extremely concentrated results of the test. urine. 2. What is the most common sugar present b. Causesoffalsepositivetestsfor in the urine? List other sugars that protein. may be present. 3. Qualitative tests for determining protein 3. What is each of the following: in the urine: a. A screening test? a. Principle: b. A qualitative test? (1) Means of precipitation of protein. c. A quantitative test? (2) Sources of error. 4. Name the following : b. Ring or contact tests : a. 3 screening tests for urine sugars. (1) Robert's test. b. 2 qualitative tests for urine sugars. (2) Heller's test. 5. How are the results for the following c. Precipitation tests (heat tests) : recorded : (1) Principle. a. Screening tests for urine sugars. (2) Exton's sulfosalicylic acid. b. Qualitative tests for urine sugars. (3) Heat and nitric acid test. c. Quantitative tests for urine sugars. (4) Salt-acetic test (Purdy's) : 6. Name 2 tests which are specific for glu- (a) Principle of test. cose. What do the other tests detect? (b) Reagent. 7. Name 3 conditions in which you would (c) Procedure. expect to find sugar in the urine. (d) Interpretation of results. 8. How would you differentiate whether a (5) "Bumintest" (tabletAmes Com- pany): redaction of Benedict's solution is due (a) Principle of test. fc glucose or lactose? (b) Contents of the tablet. 9. Name two tests for urine sugars which (c) Precautions stability of tablet, you prefer and for which you would urine turbidity, and interfer- have the most confidencein your ing substances. results. (d) Procedure. 10. Name 6 reducing substances found in (e) Interpretation of results. the urine. d. Colorimetric tests : 11. Define: (1) "Albutest"(tabletAmesCom- a. renal glucosuria.b. renal threshold. pang) D. Urinary Proteins. (a) Principle of the test. (b) Contents of the tablet. 1. Introduction. (c) Procedure. a. Derivation of urinary proteins. (d) Interpretation of results. 68 (2) "Albustix" (reagent stripsAmes c. Reagents. Company) : d. Procedure. (a) Principle of test. e. Interpretation of results. (b) Contents of the strip. f. Paper electrophoresisall urines pos- (c)'recautions. itive for Bence-Jones protein should (d) Procedure. be checked using electrophoresis (e) Interpretation of results. pattern. (3) "Uristix"(reagentAmes Com- 6. Mucin : pany) : a. Introduction. (a) Colorimetriccombinationtest b. Method for detection. forproteinandglucosein c. Causes for mucin in the urine. urine. (b) Principle of test. Introduction to Laboratory Method (c) Contents of stripprotein test- 1. Introduction to urine proteins using quali- ing area and glucose testing tative tests (both precipitation and area. colorimetric tests). (d) Precautions. 2. Equipment : (e) Procedure. a. Graduated centrifuge tubes-16 x 150 (f) Interpretation of results. mm. (4) "Combistix" (reagent stripAmes b. Graduated cylinder for making Company) : Erlenmeyer flash Bumintest (a) A "dip and read" test for the reagent. determination of proteinuria, c. Centrifuges. glycosuria, and urine pH. d. Boiling water bath with racks. (b) Principle of test. Cold water bath (c) Contents of strip. e. Esbach tubes for demonstration. (d) Precautions. f. Stirring rod. (e) Procedure. g. Glass marking pencil. (f) Interpretation of results. h. Small squares of paper. 4. Quantitative tests for determining pro- 3. Reagents : tein in the urine : a. Salt-acetic acid reagent. a. Principle : b. Esbach reagent. (1) Types of specimens required. c. Bumintest tablets. (2) Value of quantitative determinations d. Albutest tablets. in nephrosis and nephritis. e. Albustix strips. b. Esbach method : f. Combistix strips. (1) Principle. g. Uristix strips. (2) Reagent. 4. Specimens used. (3) Procedure. a. Normal and abnormal urine specimens. (4) Esbach tube. b. Four unknown urine specimens. (5) Method of reporting. 5. Methods used :Salt-acetic acid, Bumin- c. Biuret method : test,Albutest, Albustix, Combistix, (1) Principle. and Uristix. (2) Reagents. (3) Procedure. Laboratory Exercises (4) Method of reporting. 1. Explain and review principle and tech- 5. Bence-Jones protein : niques. a. Introduction : 2. Demonstrate urine proteins using the salt- (1) Type of protein. acetic acid method, Bumintest, Albu- (2) Detection of protein. test, Albustix, Combistix, and Uristix. (3) Characteristics of protein. Demonstrate Esbach method. b. Principle of test. 3. Student exercise :

69 a. Observe demonstration specimens of 7. In what condition is Bence-Jones protein urineproteins(salt-aceticacid present in urine? method), and record results as to 8. What is the significance of the presence amount of precipitate and result. of protein in the urine? b. Observe demonstration of commercial 9. When are quantitative determinations of tests using normal and abnormal the daily excretion of protein neces- urine. sary? c. Observe demonstrations of quantitative 10. Name two diseases in which the urine urine proteins (Esbach method). protein is elevated. d. Using thesalt-aceticacidtest and Bumintest, determine proteins on E. Ketone Bodies : the four unknown urine.specimens. Record the results as to amount of 1. Introduction : precipitate and grade. a. The three ketone bodies : Acetone, dia- e. Using Albutest, Albustix, Combistix, cetic acid, and beta hydroxybutyric and Uristix, for urine proteins on acid. two of the four specimens provided. b. Clinical significance of ketone bodies in Recor 4 the results in chart form urine. similar to the one used forre- c. Origin of the ketone bodies. sultswith commercialtestsfor d. Chemical hature of the ketone bodies. urine sugars and give the name of e. Definitions : ketonuria, acidosis, ketosis. the commercialtest(Bumintest, 2. Acetone : Albutest, Albustix, Combistix, Uris- a. Definition. tix), major component or reagent, b. Occurrence : tablet, or strip, negative andpos- (1) Mild acidosis. itive results(turbidity or color), (2) Severe acidosis. and unknown specimen results. (3) In children. c. Methods for determining acetone : Study Questions (1) Rothera'stest (sodiumnitro- prusside) 1. Draw in chart form the tests for protein (a) Sensitivity of test. in the urine and include the following: (b) Principle of test. a. Name oftest(salt-aceticacid, Ex- (c) Reagents used. Ton's, Purdy's, Robert's, Bumin- (d) Procedure. test, Albustix, Albutest, Combistix, (e) Interpretation of results. Uristix). (2) Acetest (commercial tabletAmes b.. Major components or reagent used in Company) : the test. (a) Principle of test. c. Brief description of the test method. (b) Contents of the tablet. d. Description of the interpretation of the (c) Precautions. results of the test. (d) Procedure. 2. Why should the urine for protein tests be (e) Interpretation of results. clear and acid? 3. Diacetic acid (aceto-acetic acid) : 3. List four possiblecauses for a turbid or a. Definition. cloudy urine. b. Occurrence. 4. What are the chief constituents of urinary c. Methods for determining diaceticacid: protein? (1) Gerhardt's FeCI3 test: 5. Give the procedure for Esbach's quanti- (a) Principle of test. tative test for protein and draw an (b) Reagent used. Esbaci: tube. (c) Procedure. 6. Give the procedure for identification of (d) Interpretation of results; how to Bence -Jones protein. check for false positive results 70 and compounds giving false acid on the four unknown urine positive results. specimens. (2) "Ketostix"(commercialdipstick d. Perform the commercial test "Acetest" testAmes Company): on two of the four specimens pro- (a) Principle of test. vided. (b) Sensitivity of test. e. Record the results in chart form for all (c) Specificity of test. specimens and test. (d) Interpretation of results. 4. Beta-hydroxybutyric acid: Study Questions a. Definition. b. Occurrence. 1. Under what conditionsare tests for ketone c. Hart's test described (clinical signifi- bodies performed? cance; why not done routinely) : 2. Name three ketone bodies whichare (1) Principle. found in the urine. (2) Reagent used. 3. Which of the three ketone bodies exists (3) Sensitivity of test. in the smallest quantities in the urine? (4) Specificity of test. Which is said to be most toxic? (5) Interpretation of results. 4. Of what clinical significance is thebeta- hydroxybutyric acid test, and why is Introduction to Laboratory Method it not done routinely? 5. Name four pathologicalconditionsin 1. Equipment : which acetone is present in the urine. a. 15 x 150 mm. test tubes. b.Boiling water bath. F. Bilirubin and Urobilinogen. 2. Reagents used : a.Rothera's reagent. 1. Bilirubin : b.Concentrated ammonium hydroxide. a. Introduction: c.10 percent ferric chloride. (1) Origin in body. d. "Acetest" tablets. (2) Mechanism ofpresence of bilirubin e. "Ketostix" strips. in urine. 3.Specimens used : (3) Significance of bilirubin in urine. a. Four unknown urine specimens forace- (4) Constituentsandderivativesof tone and diacetic acid. bile which appear in the urine: b. Demonstration specimens ofnegative (a) Bilepigmentsbilirubin,bili- a-,d positive results. verdin. 4. MethGds used: (b) Bile acids. a. AcetoneRothera's test and "Acetest." (c) Urobilin. b. Diacetic acidGerhardt'stest. (d) Urobilinogen. (5) Physical properties of bilirubin. Laboratory Exercises (6) Stability of bilirubin in urine. b. Methods for determining bilirubinin 1. Review principle and demonstratetech- the urine: nique for performing thetests for (1) Foam test : acetone r diacetic acid. (a) Procedure. 2. Demonstrate specimens of negativeand (b) Interpretation of results. positive results for acetone anddia- (2) Gmelin's test: cetic acid. (a) Procedure. 3. Student exercises : (b) Sensitivity. a. Observe the demonstration specimens (c) Interpretation of results. for acetone and diacetic acid. (3) Harrison's spot test: b. Perform the Rothera's test foracetone (a) Principle. on the four unknown urine specimens. (b) Reagents used. c. Perform the Gerhardt's test for diacetic (c) Procedure. 71 (d) Interpretation of results. b. Demonstration specimens of negative (4) "Ictotest" (commercialtablet and positive results for bilirubin Ames Company) : and urobilinogen. (a) Principle. 4. Methods used : (b) Contents of tablet. a. BilirubinHarrison'stest and "Icto- (c) Precautions. test." (d) Procedure. b. UrobilinogenEhrlich's test. (e) Interpretation of test. 2. Urobilinogen: Laboratory Exercises a. Introduction : 1. Review principle and demonstrate tech- (1) Origin in body. nique for tests for bilirubin and uro- (2) Mechanism of presence of urobilin- bilinogen in urine. ogen in urine. 2. Demonstrate specimens of negative, pos- (3) Significanceofurobilinogenin itive, and false positive results for bili- urine. rubin and urobilinogen. (4) Physicalpropertiesofurobilin- 3. Student exercises : ogen. a. Observe thedemonstration specimens (5) Stability of urobilinogen in urine. for bilirubin and urobilinogen. b. Methods for determining urobilinogen b. Perform the Harrison's test for bili- in the urine : rubin on the four unknown urine (1) Ehrlich's aldehyde test : specimens. (a) Principle. c. Perform the Ehrlich'stest for urobilin- (b) Reagents. ogen on the four unknownurine (c) Procedure. specimens. (d) Interpretation of results : d. Perform the commercial test"Icto- Differentiation between uro- test" on two of the four specimens bilinogen and porphobilinogen provided. and indol. e. Record the results in chartform for all Compounds which may give specimens and tests. false positive reactions with Ehrlich's aldehyde reagent. Study Questions c. Determination of urobilin in urine : (1) ,Schlesinger's test. 1. In what pathological conditions is the (2) Interpretation of results. urine examined for bilirubin? For (3) Significance of abnormal results. urobilinogen? 2. Bilirubin gives a (n) color to the urine and is detetced in the Introduction to Laboratory Method laboratory by means of (name) test. 1. Equipment : A positive test is indicated by a (n) a. 16 x 150 mm. test tubes. color which is due to b. Eye dropper and bottle. , a(n) product of bilirubin. c. Rubber stoppers or #4 corks. The reagent used to detect bilirubin in 2. Reagents used : urine is and is composed a. Saturated barium chloride strips. of and b. Fouchet's reagent. 3. Upon what basic principle do tests for bile c. Ehrlich's reagent. depeild? d. Saturated sodium acetate. 4. and give a posi- e. Chloroform. tive reaction with Ehrlich's reagent. f. "Ictotest" tablets and filter . Explain how you can distinguish be- 3. Specimens used : tween the two. a. Four unknown urine specimens forbill- 5. Give two reasons for an increase in the rubin and urobilinogen. amount of urobilinogen in the urine. 72 sediment: F. Microscopic Examinationof Urinary Sedi- 2. Organized mentPart I: Introduction andOrgan- a. Redblood cells (rbc) ized Sediment: (1) Significance and source. (2) Description: 1. Introduction: (a) Normal. resulting a. Definitionof urinary sediment. (b) Changes in appearance b. Requirements of specimensfor micro- from varying osmolarity. scopic examination of urinarysedi- (3) Substances mosteasily confused ment: with red blood cells andhow to (1) Clean specimen. differentiate them from redblood (2) Fresh first morningspecimen. cells. (3) Well-concentratedspecimen. (4) Reasons for occurrencein urine. (4) Well-mixed specimen. (5) Manner of reportingresults. c. Preparationof specimen for micro- b. White blood cells(wbc) : scopic examination: (1) Significance and source. (1) Centrifuge 10 MLof well-mixed (2) Description. specimen at 3000 R.P.M. forfive (3) Substances mosteasily confused minutes. with white blood cellsand how to (2) Decant quickly. differentiate them fromwhite (3) Mix remainingliquid with sedi- blood cells. ment. (4) Reasons for occurk.mecin urine. (4) Place drops onslide, cover with (5) Manner of reportingresults. coverslip. c. Casts: d. Direct examinationof the sediment: (1) Definition. (1) Scanning. (2) Sites of formation. (2) Enumeration of thesediment: (3) Significance ofcasts in the urine. (a) Average numberofrbc/high (4) Description. power field. (5) Substances mosteasily confused (b) Average numberof wbc/high with casts and how todifferen- power field(note presence and tiate them from casts. size of clumps). (6) Manner of reportingresults. (c) Average and typesof casts per (7) Watson'sclassification of casts as low power field. found in Watson's Outlinesof In- (d) Unorganized sediment(list kind ternal Medicine, Part V. and whether few, moderate, or (8) Classificationandformationof many/high power field). castsas foundinLippman's (e) Note presence ofbacteria, yeast, Urine and UrinarySediment: epithelial cells, etc. (a) Hyaline casts. e. Types ofurinary sediment: (b) Granular casts: (1) Organized sediment(greatest im- Finely granular casts. portance). Coarsely granular casts. (a) Definition. Cellular casts. (b) Contents of organizedsediment: (c) Waxy casts. red bloodcells, white blood (d) Fatty casts. cells,epithelialcells,casts, (e) Broad casts. bacteria, parasites, yeast, and fungi. Introduction to LaboratoryMethod (2) Unorganized sediment: 1. Review of techniquein using microscope (a) Definition. looking for (b) Contents of unorganizedsedi- and in enumerating and ment: crystals and amorphous red blood cells, whiteblood cells, and material. casts. 73 2. Equipment : d. When thoroughly familiarwith ap- a. Microscope and lamp. pearance and examinationof known b. Applicator sticks. specimens, examine the four un- c. Glass slides. known urine specimens for red d. Cover glasses. blood cells, and white bloodcells ; 3. Reagents usedglacial acetic acid. grade and report. 4. Specimens used : e. Examine thefour unknown urine speci- a. Demonstration specimens of redblood mens for casts; gradeand report. cells, white blood cells, and different 5. Acceptable student performance : types of casts. a. Ability to find redblood cells, white b. Four known specimens with red blood blood cells, and casts in urine. cells and white blood cells. b. Ability to grade red blood cells,white c. Four known specimens withdifferent blood cells, and casts in urine. kinds of casts. c. Ability to identifythe various kinds of d. Four unknown specimens withred casts found in urine sediment. blood cells and white blood cells. e. Four unknown specimens withdiffer- Study Questions ent kinds of casts. 1.What is included in (a) organized sedi- Laboratory Exercises ment and (b) unorganized sediment? 2.Which structures are (a) graded under 1. Review the procedure for obtaining sedi- low power,(b) graded under high ment to be examined : power ? a. Type of specimen. 3. What is the most satisfactory methodof b. Centrifuging. urine collection when a microscopic c. Transfer of sediment to slidefor ex- examination is requested? amination. 4. Name four changes which might occurin d. Examination of sediment with the mi- the results of a microscopic examin- croscope. ation if the urine has been sitting at e. Proper grading of results found. room temperature forseveral hours 2. Demonstrations : before examined. a. Red blood cells (intact, crenated, and fre- shadow). 5. Name three conditions which are b. White blood cells (clumps and single) . quently associated with hematuria. c. Various kinds of casts(show both 6. Name the following : under low and high power objec- (a) Microscopicstructureswhich tives of microscope). might be mistaken for white 3. Student work sheet for microscopic ex- blood cells under the micro- amination of the urine. scope; state briefly how todif- 4. Student exercise : ferentiate from white blood a. Observe the demonstration specimens cells. of red blood cells, white blood cells, (b)Three structures which might be and casts before beginning on your confused with red blood cells ; own. tell how you would differen- b. Examine the four known urine speci- tiate them from red blood cells. mens for red blood cells and white Threemicroscopicstructures blood cells; grade and report them which might be mistaken for on the Student Work Sheet for casts; state how to differentiate Urine Microscopics. them from casts. c. Examine the four knownurine speci- 7. Give four precautions necessary in mount- mens for casts; grade and report on ing a drop of the urinary sediment on Work Sheet. the glass slide. 74 8. The size of (a) a red blood cell is (3) Ammonium biurate crystals. microns; (b) a white blood (4) Calcium phosphate. cell is micra. (5) Magnesium phosphate (rare). 9. What three forms of red blood cellsmay (6) Calcium carbonate. be found in the urine? d. Abnormal crystals: 10. Name three of the most commonerrors (1) Description, significance, and dia- which result in failure to find impor- gram of each type of crystal. tant structures in the urine by micro- (2) Comparison with normal crystal scopic examination. with which it might be easily con- fused. 11. Briefly describe the following:(a) The appearance of a red blood cell in the (3) Abnormal crystals are not reported urine; (b) The appearance ofa white on microscopic evidence alone, blood cell in the urine. but must have confirmatory chem- ical tests : 12. Complete the following: (a) Thepres- (a) Cystine crystals. ence of red blood cells in the urine is (b) Leucine and tyrosine crystals. called .(b) The presence of white blood cells in the (c) Cholesterol crystals. urine is called (d) Hippuric acid. (e) Sulfonamide crystals: 13. How can you distinguish between hemo- Sulfadiazinfree and acety- globinuria and hematuria:(a) Micro- lated forms. scopically ;(b) Macroscopically. Sulfapyridine. 14. (a) How are casts formed? Sulfathiazole. (b) What are casts? (c) Which is the most common type 2. Miscellaneous structures occurring in the of cast? urine: (d) Name 4 kinds of casts and give a. Epithelial cells: their distinguishing character- (1) Appearance. istics. (2) Relation of site of origin to the H. Microscopic Exam of Urinary Sediment size and shape. Part II: Unorganized Sediment, Miscel- (3) Types of epithelial cellsseen in laneous Structures, Addis Counts. urinary sediment. b. Urinary calculi. 1. Unorganized sediment: c. Bacteria and parasites: a. Introduction: (1) Appearance andmeans of identi- (1) Significance. fication. (2) How to report results. (2) Significance of bacteria in urine. b. Normal crystals of acid urinedescrip- d. ParasitesTrichomonas vaginalis(or tion, significance, and diagram of hominis). each type of crystal : e. Yeast cells. (1) Amorphous urates(sodium and f. Spermatozoa. potassium acid urate). g. Mold-fungi. (2) Uric acid crystals. h. Fibrin threads: (3) Calcium oxalate. (1) Appearance. c. Normal crystals of alkaline urinede- (2) Occurrence with blood casts. scription, significance, and diagram i.Starch granules. of each type of crystal: j.Fat globules. (1) Amorphous phosphates (tricalcium k. Artifacts in the urinary sediment: phosphate, magnesium phosphate, (1) Fibers of cottonor wool. and calcium carbonate). (2) Bubbles or air. (2) Triple phosphate (ammoniummag- (3) Dirt and scratcheson slide. nesium phosphate). (4) Talcum powder.

75 3. The Addis sediment count: (b) Look for casts and crystals : a. Introduction : Grade the number present per (1) Importantconsiderationincol- low power field after looking at a lection: and examination ofspeci- minimum of 10 1pf. men. Identify the kind under high (2) Procedure. power. (3) Calculations. (2) High power: (4) Results. (a) Grade red blood cells and white (5) Normal values for adults: blood cells according to the (a) Erythrocytes: 0-500,000/12 number present per high power hours. field after looking at a mini- (b) Leukocytes: 0-1,000,000/12 mum of 10 hpf. hours. (b: Identify the casts and crystals. (c) Epithelial cells: may increase to c. Grading of structures in urinary sedi- 2,000,000- 5,000,000. ment. (d) Hyalinecasts :0-5,000/12 Importance of quantitative relation- hours. ship of the sediment to the urine (6) Children normallymay have more sample. albumin and casts thanadults; Examine the sediment microscop- erythrocytes and leukocytesmay ically under reduced light and use be less than for adults. the low-power objective first to 4. Review of microscopic gain crudeestimationof the examination of variety and quantity of elements urinary sediment: present and to look for casts. The a. Procedure for urine for urinarymicro- high-power objective is used for scopic sediment examination: making finer distinctions and for (1) Centrifuge 10 ml. ofwell-mixed enumerating the red blood cells urine for 5 minutes at3000 rpm. and white blood cells. (2) Decant 9 ml. of the supernatantand (3) A minimum of 10 fields must be use for qualitative protein test. counted for an accurate determin- (3) The remaining1ml.ismixed ation of the number present. thoroughly withan applicator stick to insure equal distribution Introduction to Laboratory Method of the sediment. (4) One or two drops ofwell-mixed sed- 1. Reviewoftechniqueforperforming iment are transferred toa num- urinary sediment for microscopicex- bered glass slide withan appli- amination for red blood cells, white cator stick. blood cells,casts,normal and ab- (5) A coverslip is placedcarefully over normal crystals, and miscellaneous the wet .film. structures. (6) Precautions: 2. Equipment : (a) Drop should beproper size so a. Microscope and lamp. there will beno bubbles (not b. Applicator sticks. enough). c. Glass slides. (b) Drop should beproper size so d. Cover glasses. the coverslip will not float(too 3. Reagents used : glacial acetic acid. much). 4. Specimens used: b. Examination of wetfilm of urinary a. Demonstration of specimens of various sediment under the microscope: kinds of normal crystals, abnormal (1) Low power: crystals, and miscellaneous struc- (a) Examine systematically. tures.

76 b. Four known specimens withnormal (a) Grade red blood cells, white blood crystals. cells. c. Four known specimens with abnormal (b) Identify casts, normal and ab- crystals. normal crystals, and miscel- d. Four known specimens withmiscel- laneous structures. laneous structures. (3) Record the results. e. Four unknown specimens with normal c. Acceptable student performance : ability crystals. to find, grade, and identify correctly f. Four unknown specimens withabnormal all microscopic structures found in crystals. the urinary sediment. g. Four unknown specimens with miscel- laneous structures. Study Questions Laboratory Exercises 1. Give the type of illumination, objective size, and total magnification used to 1. Microscopic examination of the urinefor grade the following microscopic struc- normal and abnormal crystals and tures : miscellaneous structures: a. White blood cells. a. Review of procedure for examination b. Hyaline casts.. and grading of normal and abnor- c. Red blood cells. malcrystalsandmiscellaneous d. Triple phosphates. structures. e. Sulfonamides. b. Demonstrations of variouskinds of f. Calcium oxalate. normal and abnormal crystals and g. Tyrosine and leucine. miscellaneous structures. 2. What would you expect to findmicro- c. Student exercises : scopically in a specimen that visually (1) Examine the four known urine appears (a) like "brick dust "? (b) specimens for normal and ab- cloudy red in appearance? normal crystals, and miscellan- 3. Name three structures whichyou might eous structures ; grade and report. find microscopically if the urine speci- (2) When thoroughlyfamiliar with men is turbid. the appearance and examination 4. If the urine specimen contains protein, of the normal and abnormalcrys- what microscopic structure shouldyou tals, and for miscellaneous struc- particularly look for? tures grade, and report. 5. How are the following graded:(a) aor- d. Acceptable student performance:abil- mal crystals (b) abnormal crystals ? ity to find, grade, and identifynor- 6. Sulfonamide crystalsare found in urhx. mal and abnormal crystals andmis- of what pH? cellaneous structures. 7. What is the clinical significance offind- 2. Urine MicroscopicsReview: ing sulfa crystals in the urine? a. Specimen usedFour unknown urine 8. Draw thefollowingstructuresfrom sediments. urinary sediments as they wouldap- b. Student exercises: pear magnified 430 diameters : (1) On the four unknown urinesedi- a. Red blood cells (crenated, swollen,nor- ments, thoroughly examine the mal). entire illumination: b. Triple phosphate crystals. (a) Grade the casts, normaland ab- c. Ammonium biurate crystals. normal crystals, and miscel- 9. Draw thefollowingstructuresfrom laneous structures under low urinary sediments as they wouldap- power. pear magnified 100 diameters : (b) Identify under highpower. a. Squamous epithelial cells. (2) Examine under high power: b. Calcium oxalate crystals(2 forms). 77 c. Uric acid crystals (3 forms). (5) Bet up a normal urine to be used d. Granular casts. as a control. e. Cylindroid. (6) If urine remains turbid after cen- 10. a. Name three normal crystals found in trifuging, a blank must be set up acid urine. to compensate for turbidity not b. Name three normal crystals found in due to calcium. alkaline urine. (7) Interpretation of results: c. Name four abnormal crystals found in (a) The turbidity in the blank tube urine. must be subtracted from the 11. What additional information is neces- unknown tube before compar- sary in order to report the presence ing to the control tube. of abnormal crystals? (b) The turbidity in the unknown tube is compared to that of the I. Sulkowitch Test for Qualitative Urine Cal- control urine. cium. (8) Resultsgraded according to tur- bidity present in unknowns when 1. Introduction: compared with control : a. Excretion of calcium in the urine. (a) Negativeno turbidity or pre- b. Important in study of bone disease. cipitate. c. Increase and decrease in urine calcium. (b) Less-than the control. d. Normal values. (c) Same as the control. 2. Introduction to laboratory method : (d) Greater than the control. a. Principle of Sulkowitch test : f. Quality control : (1) Qualitative test for detecting the (1) Normal urine serves as compari- presence or absence of calcium in son control. the urine. (2) Abnormal urine to check on the re- (2) Ca+++ ammonium oxalate at pH action. 5-4 Calcium oxalate (insoluble). g. Clinical application : (3) Patient should be on a diet that is (1) Results of "greater than the con- low in calcium and has a neutral trol" are obtained when there are ash for at least three days. abnormally large amounts of cal- b. Equipment : cium present : (1) Graduated centrifuge tubes. (a) Hyperparathyroidism. (2) Rubber stoppers. (b) Tuberculosis. c. Reagents : (c) Diabetes. (1) Glacial acetic acid. (d) Febrile disease. (2) Sulkowitch reagent(oxalic acid, (2) Results of "less than the control" ammonium oxalate, and glacial or "negative" are obtained when acetic acid). smaller than normal amounts of d. Specimens used : calcium are present : (1) Normal urine specimen to be used (a) Hypoparathyroidism. as a control. (b) Tetany. (2) Four unknown urine specimens to (c) Rickets. be tested for urinary calcium. (d) Sprue, celiac disease. e. Method: h. Normal values : urine from normal sub- (1) Collect urine for 24 hours, mix, jects usually show faint turbidity. measure, and record total volume. (2) Centrifuge aliquot of urine if it is Laboratory Exercises turbid or make a blank for it. 1. Review and demonstration technique of (3) Adjust aliquot to pH 5. Sulkowitch test : (4) Add Sulkowitch reagent, mix, allow a. Normal and abnormal controls. to stand for 2 minutes. b. Blank and unknown urines.

78 2.Student exercise: a. Principle of laboratory test a. Do Sulkowitch tests on four unknown (1) The patient is injected with 6mg. urine specimens usinga normal of PSP and the urine is collected urine as a control. at timed intervals. b. Record resultson Sulkowitch Test (2) Normally the amount of dyeex- Student Report Sheet. creted is independent of urine volume. Study Questions b. Equipment : 1. What urinary constituent does theSulk- (1) Stainless steel graduates. owitch test detect? (2) 1000 ml. graduates (for measuring 2. Briefly give the reaction whichoccurs in urine volume). the Sulkowitch test.What could be (3) Stirring rod. the clinical significance ofa high re- (4) Hellige colorimeters. sult? What could be the clinical sig- (5)Bausch & Lomb colorimeters. nificance of a low result? c. Reagents : 3. Why is it important to adjust pH of urine (1) 20 percent sodium hydroxide. before adding Sulkowitch reagent? (2) Glacial acetic acid. 4. Why is it necessary torun a blank with d. Specimens used : cloudy urines? (1) One set of four PSP urine speci- 5. For best results, the patient is puton a mens per student. diet for days (2) Standard PSP curve for the Bausch before doing the Sulkowitch test. & Lomb colorimeter. 6. Calcium in the urine is detected by e. Methods : reagent which is made up of (1) PSP test using Hellige colorimeter. and chemicals.It (2) PSP test using Bausch & Lomb is used in the detection ofdisease. colorimeter(or other colorim- The principle of the method depends eters). f. Sources of error : upon the precipitation of _ by at pH (1) Exact timing of specimens isnec- essary. . The precipitate in the unknown urine is comparedto (2) The test is unreliable unless the a and graded as volume of each specimen is 50 ml. or more. 9 or g. Clinical applicationIn patients with decreased renal function, the dimin- J. PhenosulphonphthaleinExcretion Test : ution of excretion of dye isa rough indexofthedegreeofrenal 1. Introduction : damage. 2. Kidney function test. h. Normal values: a. PSPdye chiefly excreted by the kid- (1) The maximum, minimum, andaver- ney tubules. age normal values in percent of b. Excretion of dye dependentupon two dye injected : factors : (2) Recovery of 25 percent ofdye in- (1) The rate of renal blood flow jected is the lowest limit ofnor- (2) Tubular ability to excretethe dye mal for the 15 minute specimen. 3. Introduction to laboratorymethod : (3) Abnormal elimination of dye isre-

15 min. 30 min. 60 min. 120 min. Maximum 50 percent 24 percent 17 percent 10 percent Minimum 28 percent 13 percent 9 percent 3 percent Average 36 percent 18 percent 12 percent 7 percent 79 flected chiefly in the first 15 min found in the analysis of the gas- ute specimen, and so . this is the tric contents. most important specimen. (2) It represents the number of mil- liliters of 0.1 N NaOH required Laboratory Exercises to neutralize 100 ml. of gasti IL; 1. Review and demonstration of the tech- juice. nique of performing the PSP test, (3) Calculation of degrees of acidity. Hellige colorimeter, and Bausch and e. Normal valuesfor a fasting specimen : Lomb colorimeter. Volume of gastric 2. Student exercise : juice 10-50 ml. a. Do PSP test on the foururine speci- Free acid 5-20 degrees of mens from one patient, doing both acidity methods using the Hellige colorim- Total acid 15-45 degrees of eter and the Bausch and Lomb acidity colorimeter. f. Define b. Record results on Phenosulphonphtha- (1) achlorhydria. lein Excretion Test-Student Work (2) hyperchlorhydria. Sheet. (3) hypochlorhydria. Study Questions 2. Topfer's test : a. Principle oftestmeasurement of free 1. The PSP test is a test to determine acid. One milliliter con- b. Reagent used. taining milligrams c. Procedure. of dye is injected intravenously. d. False positive results. 2. Urine specimens are collected at e. Normal values forfree HCL : 5-20 de- grees of acidity in fasting specimen. and minute intervals 3. Phenolphthalein test : after of the dye. a. Principleoftestmeasurementof 3. PSP dye is color in acid "combined acid." solution and color in b. Reagent used. alkaline solution; therefore c. Procedure. is added to the urine after the d. Normal values :total acid :15-45 de- has been measured and recorded. grees acidity for fasting specimen. 4. The most important urine specimen is the Combined acid = total acid free specimen and the normal acid = 10-15 degrees acidity for percent PSP dye excreted for this fasting specimen. specimen is (give range 4. Boas test : of normals). a. Principle of testspecific for freeHCL. 5. What was the difference between the re- b. When to use the test. sults on the two colorimeters? Which c. Procedure. colorimeter did you feel gave the-most 5. Kelling's test for lactic acid : accurate reading and why? a. Principle. b. When to use test. K. Gastric Analysis : c. Procedure. 1. Introduction to gastric analysis: d. Reporting the presence or absence of a. Principle of gastric analysis. lactic acid as : positive or negative. b. Method of performing the test on the 6. Tubeless gastric analysis by use of the patient. "Diagnex Blue" test : c. Stimulation of the gastric mucosa. a. Principle of testdetermine presence d. Definition of degrees of acidity. or absence of free HCL in the stom- (1) Term used to express the acidity ach by a tubeless technique. 80 b. Procedure. c. Total acid (fasting specimen) = 15-45 c. Results of test. degrees of acidity. Demonstrations Laboratory Exercise 1. A short lecture by a physician on gastric 1. Review the techniques of performing the analysis and demonstrate the tech- Topfer's test, phenolphthalein test, nique of using the Levin duodenal tube Boas test, and Kelling's test for on a patient or student. lactic acid. 2. Techniques for doing Topfer's test, phenol- 2. Demonstrations : phthalein test, Boas test, and Kelling's a. Demonstrate technique and results of test for lactic acid. gastric specimens using Topfer's 3. Specimens of various results obtained test, phenolphthalein test, Boas test, with Topfer's test,phenolphthalein and Kelling's test for lactic acid. test, Boas test, and Kelling's test for b. Demonstrate the "Diagnex Blue" test. lactic acid. 3. Student exercise : 4. "Diagnex Blue" test. a. After watching the demonstrations, do gastric titrations on the four gas- Introduction to Laboratory Method tric specimens (fasting, 20 minute, 1. Briefly review the principles of Topfer's 40 minute, and 60 minute) from test, the phenolphthalein test, Boas patient, Mrs. X, who has a diagnosis test, and Kelling's test for lactic acid. of gastric ulcer. 2. Equipment : b. Record results on Gastric Analysis a. Graduatedcylindersformeasuring Student Work Sheet. the total volume of the specimen and the aliquot of specimen used in Study Questions the titration. 1. (a) What does the Boas test determine? b. 50 ml. Erlenmeyer flasks. (b) When do we do a Boas test? c. Burette stand, rod, and base. 2. Give the normal values for the following d. Stopcock grease and pipe cleaners. in a fasting specimen: e. Evaporating dishes. a. Free HCL. f. Test tubes. b. Combined acid. 3. Reagents : c. Total acid. a. 0.1 N NaOH. 3. Do the results of the gastric specimens b. 0.5 percent Topfer's indicator. in the laboratory exercise(above) c. 1 percent phenolphthalein. correlate with the diagnosis ? Explain. d. Boas reagent. 4. Name two of the most common gastric e. 10 percent ferric- chloride. stimulants. 4. Specimens used :four gastric specimens 5. What is the purpose of doing an analysis (fasting, 20 minute, 40 minute, 60 on gastric contents ? minute). 6. If 4.1 ml. of 0.1 N NaOH were used to 5. Method : neutralize 10 ml. of gastric juice, a. Topfer's testfor free acid, phenol- what would the degrees of acidity be? phthalein test for combined acid. 7. Examine the results below for four patient b. Boas test for free acid incases of low results : or no acidity, and Kelling's test for a. Which results are satisfactory? lactic acid. b. Which results would you question? 6. Normal values : 8. Define : a. Free acid (fasting specimen) = 5 20 a. Degrees of acidity. degrees of acidity. b. Achlorhydria. b. Combined acid(fasting specimen) = c. Hyperchlorhydria. 10-15 degrees of acidity. d. Hypochlorhydria.

81 Patient X Patient Y I Patient Z Patient A Free acid (fastingspec.). 0 15° 20° 40° Total acid (fastingspec.). 10° 45° 18° 60° Lactic acid neg neg neg pos Boas test neg neg pos neg

9. What is theadvantage of doinga "Diag- nex Blue" test? (2) The tests employoxidizing reac- tions occurring with theion in 10. Give the principleand procedure of the "Diagnex Blue" test. the hemoglobin molecule. (3) Steps in the oxidizingreaction : L. Examinationof the Feces forNeutral Fat d. Sensitivity andreliability of thevar- and Occult Blood: ious procedures. e. Collection of the stool specimens. 1. Neutral fat: f. Color of the stoolspecimens : a. Introduction: (1) Influence of variousfoods and med- (1) Occurrence offats :neutral fats, ications on the color ofstools. fatty acids, andsoaps. Milk diet. High fat diet. (2) Appearance ofneutral fats. Meat protein. Blood. (3) Diseases inwhich fatsoccur in the Spinach. Calomel. feces. Carrots, beets. Bismuth, iron b. Procedure: Chocolate and charcoal. (1) Neutral fat isstrained by mixing cocoa. Barium. a small amount of feceswith a saturated solution ofSudan III (2) Importance ofa meat free diet. in 70 percent alcohol. g. Increase and decreasein amount of (2) The dye is stool. dissolved by the fat h. Properties of globules, staining theman orange stool specimens: red. (1) Shape andconsistency. (3) Fats are always (2) Gas formation. present in feces in (3) Mucous small amounts;therefore, their or pus. demonstration by staining i. "Hematest"(commercial tabletAmes meth- Company). ods must beinterpretedcau- tiously. Introduction to LaboratoryMethod (4) Chemicalquantitation of totalfat 1. Principles oflaboratory tests: and expression interms of dry a. Benzidine. weight of feces withthe patient b. Gum guaiac. on a standard diet isa better in- c. "Hematest" (commercial dicator of the state offat absorp- tabletAmes tion but requires Company). more elaborate 2. Equipment: laboratory facilities. a. Filter paper tests(benzidine and 2. Occult blood inthe feces: gum a. Definition of occult blood. guaiac) : (1) Filterpaper. b. Conditionswhere occult bloodmay be present. (2) Tongue depressorsticks and appli- cator sticks. c. Principles of tests todetect occult blood: (1) Tests : b. Test tube methods(benzidine andgum gum guaiac, benzidine, and guaiac) : orthotoluidine. (1) Tongue depressorsticks. 82 (2) Evaporating dishes. (3) Place "Hematest" tablet in center (3) 10 ml. graduated cylinders. of specimen. c. "Hematest" : filter paper. (4) Place one drop of water on the 3. Reagents : tablet, wait 5-10 seconds, and a. Filter paper tests (benzidine and gum flow a second drop on the tablet guaiac) : so it runs down the sides onto the (1) 3 percent hydrogen peroxide. filter paper. (2) Glacial acetic acid. (5) A positive reaction is read on the (3) Benzidinedihydrochloride (pow- filter paper within two minutes. dered). (6) Check all positive "Hematest" spec- (4) Benzidine solutionunstable and imensbyrunningaguaiac made just before use. and/or benzidine test. (5) 2 percent alcoholic solution of gum (7) Results : guaiac. (a) Negativeno color appearing on (6) Working gum guaiac solutionun- filter paper around the tablet. stable and made just before use. (b) Positivearea on the filter paper b. Test tube methods (benzidine and gum around the tablet turns blue : guaiac) : same as for filter paper The zmount of blood is pro- tests, plus ether. portional to the time of appear- c. "Hematest" :commercial"Hematest" ance and to the intensity of color. tablet. The color on the tablet is of 4. Specimens usedstool specimens obtained no significance. from patients. d. Benzidine and gum guaiactest tube 5. Methods : method : a. Benzidinefilter paper method : (1) Soften 1-2 grams of feces in small (1) Small amount of feces is smeared evaporating dish. on filter paper. (2) Add 8-10 ml. of ether and mix (2) Add small amount of freshly pre- thoroughly. pared benzidine solution to fecal (3) Discard the ether layer. smear on filter paper. (4) Add 1/3 volume of glacial acetic acid (3) Results: to the remainder of the feces and (a) Negativeno color. mix well. (b) Tracefaint blue forming (5) Extract the fecal-acetic acid solu- slowly. tion with 10 ml. of ether. (c) Positiveblue appearing almost (6) Into a test tube, mix 1 volume acetic immediately, never intense. acid-ether-fecal mixture-1 vol- (d) 4 + immediate intense color. ume benzidine solutionLor 1 vol- b. Gum guaiacfilter paper method : ume working gum guaiac solution. (1) Small amount of feces is smeared (7) Results are graded in the same on filter paper with stick. manner as for the filter paper (2) Add 2 drops of glacial acetic acid methods. to feces on filter paper. 6. Control : (3) Add 4 drops of freshly prepared a. Test the reagents by running controls. working gum guaiac solution. b. Negative controlfilter paper plus re- (4) Results are graded the same as for agents. benzidine. c. Positive controlblood on filter paper c. "Hematest" : plus reagents. (1) Hands, dropper, and working area must be clean and free from, Laboratory Exercise traces of blood. 1. Review and demonstrate filter paper and (2) Smear a solid specimen of feces on test tube tests for benzidine gum filter paper. guaiac, and use of "Hematest" tablets.

83 2. Student exercises : 3. What is the purpose of running negative a. 'On the four unknown stool specimens, and positive controls with each batch do: of occult blood determinations? (1) Filter paper testsbenzidine and 4. The recognition of occult blood in the feces gum guaiac. is very important in the diagnosis in (2) Test tube testsbenzidine and gum what two diseases? guaiac. 5. In the test tube methods for occult blood, (3) "Hematest" tablet test. what is the purpose of extracting the b. Prepare fresh working solutions for feces with ether? the tests. 6. What is the function of the glacial acetic c. Record your results on Occult Blood acid in the second ether extractions? Student Work Sheet. 7. Which of the following results should be d. Include negative and positive controls rechecked before giving results to the with your specimens. doctor? Why? SpecimenBenzidine GuaiacResults OK Why? or to be Study Questions rechecked 1. What is the purpose of doing an occult 1 4+ neg. on a stool specimen? 2 4+ 4+ 3 neg. 4+ 2. Why is the guaiac test usually used in- 4 neg. trace stead of the benzidine test? 5 trace trace

84

ROUTINE URINALYSIS STUDENTWORK SHEET [Sample Student Work Sheets]

Specimen #

Color Physicalproperties Transparency

Reading

Specific Gravity Urinometer correction

Corrected specific gray. pH (pH Universal paper)

Urine sugars (Benedicts qual. test)

Acetone (Rothera's test)

Diacetic acid (Gerhardt's test)

Urine proteins (salt-acetic acid test)

Urine microscopics:

Red blood cells (hpf)

White blood cells (hpf)

Grade (lpf) Casts: Identify (hpf)

Normal crystals (lpf)

Abnormal crystals (hpf)

Miscellaneous structures

Bilirubin (Harrison's test)

Urobilinogen (Ehrlich's test)

86 Student's Name ...... - Date GASTRIC ANALYSIS STUDENT WORK SHEET

Free HCL Total acid

Time Amount ml. of Degrees of ml. of Degrees of Boas Lactic 0.1 N NaOH acidity 0.1 N NaOH acidity test test Fasting

20 minute

40 minute

. 60 minute

1

OCCULT BLOOD STUDENT WORK SHEET

Specimen # Color of Benzidine Gum Guaiac specimen "Hematest" Filter paper Test tube Filter Test tube

Negative control (filter paper + reagents).

Positive control (blood + filter paper + reag.).

87 Student's name: Date URINE MICROSCOPICSSTUDENT WORK SHEET

Specimen #

Red blood cells / hpf. Grade 0, occ, 1, 2, 3, 4.

White blood cells / hpf. Grade 0, occ, 1, 2, 3, 4.

Grade / 1pf0, occ, 1, 2,3,4. Casts Identify (hpf).

Normal crystals / 1pf. Grade: 0, occ, 1, 2, 3, 4. List the kindsseen.

Miscellaneous.

Student's name: Date: SULKOWITCH TESTSTUDENT WORK SHEET Unadjusted Date Spec. # Adjusted I Blank urine pH urine pH (if needed) Result

88 SHEET PHENOSULPHONPHTHALEIN EXCRETIONTESTSTUDENT WORK (PSP) Hellige color B. & L. color Minutes Urine Dilution Date Spec. * used Rdg. Per centPer contI Reading volume PSP dyePSP dy. (ml.) excreted

Peters, J. P., and VanSlyke, D. D., Quantita- Unit IX Basal Metabolism tive Clinical Chemistry,Vol. I & II, Balti- Electrocardiography more, Md.,Williams and WilkinsCo., 1956. Suggested Time: 2 weeks;80 hours. Roe, Joseph H.,Principles of Chemistry,9th ed., St. Louis, Mo., C.V. Mosby Co., 1963, Unit content Chapter 32. A.Introduction to BasalMetabolic Rates. Techniques in BasalMetabolic Tests, Medical B.Calculation of BasalMetabolic Rate Tests. Laboratory Assistant Course,University of C.Introduction toElectrocardiography. Minnesota, Minneapolis,Minn. D.Performance of EKG Test. Watson, C. J., Outlinesof Internal Medicine, E.Mounting Techniques andIsolation Tech- Part II, 9th ed.,Dubuque, Iowa, Wm. C. niques. Brown Co., 1958. Bibliography Unit outline American Heart Association,Recommendations Basal Metabolic Rates : Pressure, The Association, A. Introduction to for Human Blood 1. Definition of basalmetabolic rate. New York, N.Y. the BMR : Anthony, 'Catherine P.,Textbook of Anatomy 2. Factors influencing and Physiology, 5th ed.,St. Louis, Mo., C. V. a. Age. b. Sex. Mosby Co., 1959. Winsor, Travis, A Height and weight (usingthe DuBois Burch, George E. and Surface Area Formula). Primer of Electrocardiography,4th ed., Phil- 1960.. d. Temperature. adelphia, Lea & Febiger, state : EKG Techniques inElectrocardiography Tests, e. Post-absorptive Assistant Course, Uni- (1) Definition. Medical Laboratory (2) Respiratory quotient. versity of Minnesota,Minneapolis, Minn. Exercise Manual, MedicalLaboratory Assistant f. Physical repose. Course, University ofMinnesota, Minne- g. Mental repose. h. Medication. apolis, Minn. 3. Methods for measuringbasal metabolism : Manuals accompanyingEKG instruments (i.e. with instructions a. Directmethod (colorimeter). Sanborn, Cambridge, etc.) (Tissot apparatus). for operation andmaintenance of machines. b. Indirect method 89 c. Modified indirect methods: dilution of zephirin chloride(or (1) Benedict-Roth machine. alcohol). (2) Sanborn Waterless machine. d. Height and weightscale measuringin (3) McKesson Metabolator. kilogramsandcentimetersfor 4. Description of BMR machine: height and weight. a. Parts of BMR machine. e. Barometric pressurebarometet. b. Uses for each part. f. BMR machine. c. Advantages and disadvantages of the g. Sterilizedmouthpieces and noseclips. BMR machine. h. Pencils and rulers. d. Precautions in using BMR machine. 3. Method: 5. Preparation of the patient : a. Preparation of patient(personal data, a. Patient date (name, address, age, pre- height, weight, post-absorptive vious BMR's, post-absorptive state, state, physical repose, mental re- and physical repose). pose, temperature). b. Height and weight of patient. b. Setting up the BMR machine and test- c. Blood pressure. ing for accuracy. d. Mental repose. c. Connecting the patientto the BMR e. Temperature and pulse : machine. (1) Procedure for taking temperature d. Actual performance of running the and pulse. BMR test. (2) Temperature correction factor for e. Care of the BMRmachine after per- calculation of accurate BMR. formance of the test. 6. Procedure for performance of BMR test : a. Barometricpressure(using barom- Demonstration and Laboratory Exercises eter). 1. Observation of the BMR machine: b. Setting up the BMR machine. a. Demonstrate the variousparts of the c. Testing BMR machine for accuracy. BMR machine and explain the uses d. Connecting the patient to the BM11, of each part. machine: b. Student exerciseDraw a simple di- (1) Explanation and instructions to the agram of the BMR machineand patient. label all parts. (2) Precautions and things to check. 2. Preparation of patient : 7. Care of the BMR machines (after each a. Demonstrations : test, daily, weekly). (1) Use of the barometer for taking 8. Diseases affecting the BMR : barometric pressure. a. Diseases characterized by a high meta- (2) Use of sphygmomanometer and bolic rate. stethoscope for blood pressures. b. Diseases characterized by a low meta- (3) Correct use and care of thermom- bolic rate. eters. (4) Taking pulse rate with watch with Introduction to Laboratory Method second hand. b. Student exercises : 1. Principle of procedures for taking blood (1) Take barometric pressure for the pressures, pulse rates, temperatures, day. height, weight, barometric pressure, (2) Work in partners and do the fol- and for use of BMR machine. lowing on each other : 2. Equipment and supplies : .(a) temperature (b) blood pressure a. Blood pressuresphygmomanometer (c) pulse rate. and stethoscope. b. Pulse ratewatch with a second hand. Study Questions c. Temperature thermometers, tissue 1. What is meant by basal metabolic rate? wipes, soapy water, and 1:1000 2. What is the usage of the following parts 90 of the BMR machine?(List 6-10 terviewing and obtaining personal parts found on your own particular data from the patient (name, age, BMR machine.) post-absorptive state, mental and 3. Define : blood pressure, body temperature, physical repose, temperature, blood pulse rate, systolic pressure, diastolic pressure, pulse rate, height, pressure, respirations. weight) and obtaining barometric 4. What is the percent error in BMR due to pressure. rise in temperature ? b. Student exercises : 5. What are some defects in the instruments (1) Work as partners and do the follow- used for taking blood pressures which ing on each other : would result in an inaccurate blood (a) personal data(b) temperature pressure ? (c) blood pressure (d) pulse rate. 6. What are the normal values for the fol- (2) Take blood pressure of two other lowing: people. a. Temperature, pulse rate, blood pressure. (3) Obtain barometric pressure from b. BMR. barometer. 2. Performanceof BMR test (students B. Calculation of Basal Metabolic Rate Tests : work as partners) : 1. Formulas for calculating BMR : a. Set up the BMR machine, check for a. Gas factor. accuracy, connect patient to ma- b. Respiratory quotient. chine and run a timed BMR test. c. Dubois 'Surface Area Formula. b. Save recording and tape on Student 2. Calculations : Work Sheet (for calculation at a a. Using the liters of oxygen the patient later time). used in a specific time interval as c. Record all data on Student Work Sheet. obtained by running the test and 3. Calculation of BMR test : converting to cal./sq. m./hr. a. Review of the calculations for the BMR b. Comparison of calories/sq. meter/hour test. with the average normal for age, b. Student exercise : sex, and living environment giving (1) Using the data from Exercise 2, the answer in terms of percent. calculatethe BMR ofyour c. Correction for patient's temperature if patient. necessary. (2)Record all data on Student Work 3. Determination of a satisfactory BMR : Sheet. a. Evaluation of patient data (tempera- (3) Also calculate the tidalair and ture, physical and mental repose, minute volume for the exercise. post-absorptive state). 4. Calculation exercises.Complete calcu- b. Evaluation of BMR test with duplicate lations of assumed patients with given runs. date (age, height, weight, tempera- 4. Cutting and mounting of BMR tracing ture, barometric pressure, spirometer with proper recording of data. temperature, and liters of oxygen/- 5. Review of BMR terminology : timed interval),record on Student a. Basal metabolic rate. Work Sheets. b. Blood pressure (systolic and diastolic). c. Barometric pressure. Study Questions d. Vital capacities. e. Tidal air. 1. During the actual running of the BMR f. Minute volume. test, what are the 3 factors noted? 2. Briefly describe the following diseases, Demonstration and Laboratory Exercises giving their clinical findings, symp- 1. Interview and preparation of the patient : toms, and manifestations : a. Demonstrate proper technique for in- a. myxedema.

91 b. hyperthyroidism. prime duty toward the patient in run- 3. Name 3 diseases in which the BMRmay be ning a BMR test?(It is also an im- elevated. portant factor influencing the BMR.) 4. Name 3 diseases in which the BMRmay 9. Define : be low. a. exophthalmus.e. mental repose. 5. List 8 factors which would affect the b. post-absorp- f. tidal air. BMR. tive state.g. minute volume. 6. What kind of a result (highor low) would c. respiratory h. barometric you expect in the BMR if there was a quotient. pressure. leak in the machine? d. physical i. vital capacity. 7. What is the criterion for drawing the repose. oxygen slope line? 10. If your patient had a temperature of 8. As a laboratory assistant, what isyour 99.9°F., calculate the change in the BMR.

Student's name STUDENT WORK SHEET FOR BMR EXERCISES Patient's name: Date: Time: Address: Previous tests: Where: 8-10 hr. rest: No food or since 7 p.m. evening before Age: Sex: Height: Weight: Blood pressure: Barometric pressure: Temperature: Pulse rate:

Pulse Respirations I Spirometer temp. Liters 02 consumed time Test # 1 Tes; # 2

Calculations Test # 1 Test # 2 Surface area (sp. m.) Liters of 02 / hour Cal./sq. m./hr Normal value (cal/sq.m./hr.) % BMR (minus or plus) Temperature correction % BMR (corrected for temp) Tidal air Minute volume Results of test (repeat, satisfactory, unsatisfactory) Cut and tape BMR test in this space- 92 Student name:

BMR CALCULATIONSSTUDENTWORK SHEET Patient Patient Patient # 1 # 2 Patient Patient Patient Patient Patient # 3 # 4 # 5 # 6 # 7 # 8 - Name Mrs. Jane Mr. Miss Mr. Bob Mary Brown Smith Large Miss Small Grey ;fones Doe Roe Age 32 years 5 years 42 years 59 years 61 yrs. 12 years 18 years 23 years Weight 69 kg. 26 kg. 97 kg. 44.3 kg. 63.1 kg. 40 kg. 55.4 kg. 58 kg. Height 159 cm. 100 cm. 182 cm. 162.5 cm. 147 cm. 142 cm. 164 cm. 168 cm. Temperature 98.8°F. 99.6°F. 98°F. 98.6° F. 100°F. 98°F. 98.6°F. 98.8°F. Barometric 751 750 745 745 740 749 750 Pressure mmHg mmHg mmHg 755 mmHg mmHg mmHg mmHg mmHg Spirometric 22°C 23°C. 21°C. Temperature 21.5°C. 23°C. 21°C. 20°C. 22°C.

Liters 02/6 1.12 0.65 2.20 1.50 minutes 1.33 1.20 1.30 1.41

Surface Area (sq.m.)

Liters 02/hour

Cal./sq.m./ hour

Cal./hour patient used

Normal Valve (cal/sq.m./ hr) . %BMR (minus or plus)

Temperature Correction

%BMR (corrected for temp.)

93 C. Introduction to Electrocardiography : a. Parts. b. Usage of the different parts. 1. Definitionof electrocardiography,elec- c. Diagram of the mechanismof the ma- trocardiogram, electrocardiograph. 2. General principle of the EKG machine chine. (Cambridge, Sanborn, etc.) : Example :

Stylus C-

d ...A ...Iv11111 naci Ingism=numilulb 111111111ffigUMEI YAM .1"""

Heart Radio tubes Galvanometer Heat sensitive paper

3. Heart : a. Definition. b. Diagram of chambers of heart and main vessels. c. Functions of eachchamber of the heart (RA, RV, LA, LV) d. Diagram of circulation of blood. e. Contraction of thechambers of the heart. f. Explanation of cardiac waves : (1) "P" wave. (2) "QRS" complex. (3) "T" wave.

Lead I right arm to left leg. Lead II right arm to left leg. Lead IIIleft arm to left leg. Right leg acts as a ground. (2) Unipolar limb leads or augmented vector (AV) leads. (a) Lead AVRright arm potential. g. Interpretation of anelectrocardiogram : (b) Lead AVLleft arm potential. (1) Normal electrocardiogram pattern. (c) Lead AVFleft leg potential. (2) Abnormalities in the electrocardio- b. Chest leads (V) : gram pattern. (1) Adult (show diagram) : 4. Leads (limb and chest) : (a) Lead V1fourth intercostal space a. Limb leads : at right border of sternum. (b) Lead V2fourth intercostal c. Wandering baseline. space at left sternal border. d. Jittery baseline. (c) Lead V3 midway between V1 e. Poorly defined baseline. and V2. 6. Variations in technique for taking EKG: (d) Lead V4at outer borderof a. Infants. apex beat area or in midclavic- b. Infectious diseases. ular line at the fifth intercostal c. Master's "2 step" test (exercise EKG). space. (e) Lead V5same level as V4,in Introduction to Laboratory Method anterior axillary line. 1. Review of parts and usage of the EKG (1) Lead V6same level as V4 and machine. V5 in mid-axillary line. 2. Equipment and supplies : (2) Variation in children. a. EKG machines. (3) Lead marking system (code). b. EKG electrodes and patient cable cord. c. EKG electrode jelly. D. Performance of EKG Test: Laboratory Exercises 1. Standardization of EKG machine : 1. Operation of the EKG machine (stand- a. Time standardization (horizontal trac-, ardization and limb leads) : ing). a. Demonstrations: b. Voltage standardization (vertical trac- (1) Demonstrate the various parts of ing). the EKG machine and explain the c. Voltage standardization at 0.5 centi- uses of each part. meters. (2) Demonstrate proper application of 2. Preparation of patiert : limb lead electrodes to patient. a. Explanation of EKG test to patient. b. Student exerciseWork inpartners b. EKG electrodes : and do the following: (1) Usage and purpose of electrodes. (1) Standardize the EKG machine. (2) Application of electrodes to patient: (2) Dr the six limb leads on partner (a) Limb electrodes. and save tracing.(Tracings are (b) Chest electrodes. mounted at a later laboratory (c) Precautions to take in applying period.) electrodes. 2. Performance of EKG Test: c. Attaching the EKG patient cable con- a. Chest leadsDemonstrate the positions nections. and placement of electrodes on chest 3. Operation of EKG machine (see manual of patient. accompanying the machine) : b. StudentsWork in partners and do the a. Connecting EKG machine. following : b. Proper grounding. (1) Standardize the EKG machine. c. Parts and usage of machine. (2) Do the six limb leads and the six d. Standardization of machine. chest leads on partner and save e. Taking the limb leads (1, 2, 3, AVR, tracing to be mounted at a later AVL, and AVF). laboratory period. f. Taking the chest leads (V1, V2, V3, V4, c. Standardization at 0.5 cm.. V and V6). (1) Demonstrate technique of stand- g. Completing the EKG test. ardization at 0.5 centimeter. 4. Care of the EKG machines : (2) Student exerciseWork in part- a. Care after each EKG test. ners and do the following: b. Daily EKG duties. (a) Standardize the EKG machine 5. Difficulties and remedies in taking EKG : in the usual manner. a. Somatic tremor. (b) Do the six limb leads and the six b. Alternating current (AC) interference. chest leads on partner.

95 (c) Assume that lead V3 has to be a. Precautions involved in doingEKG on cut down to a standardization patients in isolation. of 0.5 centimeter because its b. Technique involved in doing EKG in peaks go beyond the edge of the isolation. ruled area.Cut down lead V3 Personal technique to avoid con- accordingtodirectionsand tamination. return lead V4 to full stand- Technique for operation of EKG ardization. machine. (d) Save tracing to be mounted at (3) Special equipment needed. a later laboratory period. c. Clean-up of operator and EKG machine Study Questions after doing EKG in isolation. 1. Define the following : Laboratory Exereb.s.i, a. electrocardiograph. b. electrocardiogram. 1. Work in partners and do the following : 2. Draw a diagram of the heart and show a. Do an EKG as would be done normally how the blood circulates through the on a patient. heart. b. Cut and mount tracing on the EKG 3. Name the 4 chambers of the heart and the student work sheets. functions of each chamber. c. Be sure, that tracings are correctly 4. Trace the route of the heart voltages, from labeled. the patient to the recording tape. d. Hand in all EKG mountings. 5. What is the difference between unipolar 2. Change the chart paper in EKG machine. and bipolar leads? 3. Change the dessicant in EKG machine. 6. To what phr.:Je of cardiac circulation does 4. Have an instructor check EKG machine. each wave of the electrocardiogram 5. Students should be graded on operation correspond? and knowledge of the machine. 7. What particular potential does each of the limb leads represent? Study Questions 8. What is the purpose of grounding the 1. What is the universal standard for voltage machine? standardization? 9. Why is every tracing standardized? 2. What would you do if a patient had one 10. What facts must be recorded on every leg amputated ? electrocardiogram? 3. Draw an example of the following : 11. How fast does the paper in an electro- a. Somatic tremor. cardiograph machine move? b. "AC" interference. 12. a. How do you regulate the width of c. Wandering baseline. the baseline of the electrocardiogram? 4. What does the electrode jelly consist of ? b. How wide should the baseline be? What is the purpose of each ingre- 13. a. When would you find the need to dient? standardize at 0.5 centimeter ? 5. What is the location of : b. Brieflydescribethetechniqueyou a. Lead V, would use to standardile at 0.5 cm. b. Lead V4 c. Lead V6 E. Mounting Techniques and Isolation Tech- 6. How would you remedy the following : niques. a. "AC" interference. 1. Mounting techniques. b. Wandering bas cline. a. Technique involved in mounting EKG c. Somatic tremor. tracings. d. Poorly defined baseline. b. Proper labeling and identification of e. Jittery baseline. EKC tracings. 7. What is Lead V4R? When is it taken? 2. Isolation techniques. What does it detect?

96 8. What is the purpose of theMaster's test? 9. Briefly describe theisolation technique. b. Why must a physician bepresent dur- 10. Briefly describe thetechnique you would ing the Master's test? use in doing anEKG on infants.

EKG STUDENT WORKSHEET

Properly Patient: labeled Date: standardization Time:

Lead AVR Lead I Lead H Lead HI

Lead V1 Lead V2 Lead AVL Lead AVF

Lead V5 Lead Vo Lead V3 Lead V4

Student nari.: 97

APPENDIXES APPENDIX A should be insured through regular budgets, gifts, or endowment, but not entirely through Requirements of the Board of Certified Labora- student fees. tory Assistants of the American Society of Clinical Pathologists and the American So- ciety of Medical Technologists B. Organization : (Extracted from Guidebook and Essentials for 1. Adequate space, light and modern equip- an Approved School of Laboratory ment should be provided in the laboratory. A Assistants, May 1964) * library containing up-to-date references, texts and scientific periodicals pertaining to clinical The program for training of laboratory as- laboratory work should be maintained or be sistants is not to be construed as being a pro- readily accessible. gram to train replacements or substitutes for 2. Satisfactory record systems should be medical technologists, nor is it intended at any provided for all work carried on in the labora- time to duplicate the training program for tory, with monthly and annual compilations. medical technologists.The sponsoring organ- 3. Transcripts of high school credits and izations recognize the registered ASCP medical other credentials must be available. An accept- technologist as the primary and pivotal labora- able school keeps records of each student's tory worker through whom the laboratory attendance and grades, and it is also recom- director sets standards for quality performance. mended that the type of tests performed be The scope of the training program in schools recorded.The school should have a synopsis approved for training laboratory assistants of the complete curriculum on file, including must be adjusted to the limits imposed by the the rotation of assignments, outlining of in- required academic background of the trainee. struction supplied by the laboratory, and a list Laboratory assistants trained in these schools of the prepared specimens used to augment the are to work at all times under the supervision student's experience. of qualified registered ASCP medical tech- 4. At least two students should be enrolled nologists and pathologists or other qualified in each class.Classes should not be started physicians and never as independent practi- more frequently than semi-annually except tioners. under especially approved circumstances. The CLA Board has established the following standards for this training : C. Faculty : 1. The school should have a competent A. Administration : teaching staff. The director must be a graduate 1. Acceptable schools for training certified in medicine who is certified by the American laboratory assistants may be conducted by ap- Board of Pathology or who has had training proved medical schools,hospitals, or other and experience in clinical pathology acceptable acceptable laboratories, suitably organized in to the CLA Board. He shall take part in and accordance with present educational standards. be responsible for the actual conduct of the Acceptable schools must be separate from training course.He shall be in daily attend- A.M.A.-Approved Schools of Medical Technol- ance for sufficient time to supervise properly ogy, and although both types of schools may be the laboratory work and teaching. operated in selected large institutions, there 2. In laboratory practice, enrollment may must be complete physical separation of instruc- not exceed two students to each member of the tion of the two types of students. teaching staff.The staff must include not less 2. All training shall be under competent than one instructor whose duties include super- medical control. vising and teaching program and who possesses 3. Resourcesforcontinuedoperation a bachelor's degree, is a registered medical technologist (ASCP) and who has had three * Further information is available from the Secretary, Board of Certified Laboratory Assistants, 9500 South California Avenue, Ever- years of experience or its equivalent. A tech- green Park, Ill. 60642. nologist instructor should be a registered medi-

100

, cal technologist (ASCP) or equivalently quali- clinical chemistry-10 weeks; blood banking fied, and preferably have had at least oneyear 6 weeks ; routine analysis-6 weeks; and BMR- of experience. EKG-2 weeks. 5. The instruction should followa planned D. Prerequisites for admission: outline and include text assignments,lectures, discussions, demonstrations, supervised 1. Primary educational prac- requirement for tice, practical examinations, andquizzes, both admission is graduation froma high school ac- oral and written.Deviations from the plan credited by the appropriateregional accredit- may be authorized by the Board. ing agency.It is recommended that applicants have demonstrated ability andinterestin science and mathematics. F. Clinical material: 2. Certification of equivalenttraining may, 1. Each student should receivepractice at the discretion of the Board,be accepted in training, adequate in kind and lieu of this requirement. amount, under competent supervision.Participating hospitals and laboratories should be accreditedor be E. Curriculum : otherwise acceptable to the Councilon Medical Education of the American Medical 1. The course of training Association must be at least and/or the Board of CertifiedLaboratory As- 12 months in duration andshould be uninter- sistants. rupted. A student shall be required to com- 2. Approved schools shouldhave available plete 40-44 hours oflaboratory trainingper laboratory material equivalent to that week. provided by a hospital of 100 beds and3,000 yearly ad- 2. A minimum of 100 didacticinstruction missions and a minimum of 50,000 hours is required either in tests a year the form of tutorial with a distribution of clinical materialsufficient type organized instruction ifclass enrollment to provide adequate technical trainingin the is less than five students,or as formal lectures various laboratory divisions. if enrollment is fiveor more.Stress is to be placed ontechnicalperformance andthe sources and detection oferrors rather than G. Ethics : pure theory. 1. Excessive fees and commercialadver- 3. Ten (10) weeks of trainingmust be de- tising should be considered unethical. voted to "Orientation tothe Clinical Labora- tory" and include basic 2. Approved schools shall not beoperated orientation in :pro- for profit and student fees shall notexceed the fessional adjustments, relationsand organiza- cost of books, supplies, tions ; a nominal allowance medical ethics and conduct; medical for breakage, or whennecessary, other opera- terminology ; laboratory records; basic anatomy tional costs. and physiology; handling,identifying, and care 3. Schools must clearly indicatetype and of laboratory equipment; aseptic technique and level of training. methodsof sterilization ;basiclaboratory 4. Schools conducted primarily forthe pur- mathematics ; preparation ofbasic _laboratory pose of substituting students for paid medical solutions and media; basic elements of quality technologists will not be consideredfor ap- control ; handling of histologicand cytologic proval : specimens ; instruction in bloodcollecting tech- a. Student should not assume there- niques ; introduction to basichematology, serol- sponsibility or take the place ofa qualified ogy, blood banking, urinalysis, basal metabo- medical technologistor certified laboratory lism, and electrocardiography. assistant. 4. The sequence of instructionduring the b. The provision ofroom, board and remainder of thecourse may be at the discretion maintenance, or a minimal monetary of the director. allowance It shall include basic technical inlieuthereof,areacceptable.Monetary instruction in bacteriology,serology and para- stipends in excess of this allowanceare dis- sitology-8 weeks ;hematology-10 weeks; couraged.

101 c. The staff of medical technologists and school may be sentto Secretary, Board of certified laboratoryassistants should beade- quate to accomplish Certified LaboratoryAssistants, 445 North the work of thedepartment Lake Shore Drive, Chicago, independent of thepresence of students. Ill. 60611. Forms d. Any indication will be supplied forthis purpose on request and of exploitation ofstu- should be completed by thedirector of the lab- dents will result inwithholdingor retraction of approval ofa school. oratoryrequestingapproval.Inquiriesre- garding certification of 5. The certifiedlaboratory assistant qualified laboratoryas- shall sistants should be similarlyaddressed. be required toadhere to the followingCode of Ethics : 2. Schools applying forapproval shall be "Fully cognizant ofmy responsibilities subject to an initialinspection, and approved as a certified laboratoryassistant, I affirm schools shall be subjectto periodic reinspection my by teams composed willingness to dischargemy duties withaccu- of representatives ofthe racy, thoughtfulness, andcare. American Society ofClinical Pathologists' and "Realizing that theknowledge obtained the American Societyof Medical Technologists. concerning patients inthe course ofmy work An annual reporton a form approved by the must be treatedas confidential, I holdinviolate Board will be requiredof all approved schools. the confidence(trust) placed inme by the Continued approval shallbe based on the ful- patient and bymy supervisor and physician. fillment of the standardsfor the training of "Recognizing thelimitationsof my Certified LaboratoryAssistants. duties, I shallwork at all timesunder the a. If on inspectionan approved school supervision ofa qualified doctor ofmedicine is found to be deficientin its educationalpro- and/or a medicaltechnologist, who isregistered gram, it shall be so notified and ifthe deficiency by the AmericanSociety of ClinicalPatholo- is not corrected withinone year, approval shall gists and whoabides by the Codeof Ethics of be withdrawn. that profession. b. If a school hasnot functioned for two "The Code ofEthics shall be years, it shall be notified that if with the Code consistent it is notre- of Ethics ofthe American activated within thenext year, it shallbe Medical Association." dropped from the listof approved schools.

H. Health: 3. Approval ofa school may be revoked by the Board forcause at any time. 1. Applicantsshall be required to submit 4. Approved schools evidence of goodhealth, anda report of a med- shall notify the CLA ical examination Board whenevera change occurs in the director- including a roentgenexami- ship of the school. nation of thechest shall bea part of the student's record. a. If there is a change,information on 2. Provisionshould be made qualifications of thenew pathologist-director for medical must be submitted care and hospitalization,when necessary,for a in duplicate to theBoard as reasonable lengthof time. soon as possible.If the new director'screden- tials are in order, 3. Every precautionshould be taken the school's approvalwill be to pre- continued. vent any healthhazard in thelaboratory. Any injurieson duty should be takencare of at once b. If there isan extended interval dur- as an emergency. ing which there isno director, the studentsal- ready enrolled willbe permitted to I. Admission complete to the ApprovedList : the course butno new studentsmay be enrolled 1. At present, until a pathologist-directoris appointed and application forapproval of a approved.

102 APPENDIX B

Training Laboratory in Hospital Program

Corridor SCALE: 3/16".1' 103 APPENDIX C

Training Laboratory in Vocational School

Blackboard

Instructor's desk

Sink

Student benches (with center cabinet)

Student benches

Central work bench with raised center section; drawer units

Fume hood

Work area (with storage cabinets) Refrigerator

SCALE: 1/4".1'

104 APPENDIX D B. Suggested Expendable Equipment Items (average number per student, except as other- wise noted) Equipment for Training Program Beakers : 50 ml. 3 A. Suggested Non-Expendable Items 100. ml. 2 of Equipment 150 ml. 1 250 ml. 1 Analytical balance. 400 ml. 1 Artificial arm (for venipuncture). 600 ml. 1 Autoclave. FlasksVolumetric with stopper : Automatic pipette washer. 50 ml. 3 Balancetriple beam. 100 ml. 4 Barometer. 200 ml. 1 BMR machine of standard make and quality. 500 ml. 1 Bunsen burnerone for every 2 students. 1000 ml. (per 2 students) 1 Burette stand, rod and clampone for every 2 Erlenmeyer : students. 25 ml. 10 Centrifuge : 50 ml. 2 Floor modelone for every 12-15 students. 125 ml. 3 Table modelone for every 6 students. 250 ml. (per 2 students) 1 Micro-hemotocrit and reader. 500 ml. (per 2 students) 1 Chemistry hood. 1000 ml. (per 2 students) 1 Differential counterone for each student. Test tubes Distilling apparatus. 13 x 100 mm. 12 EKG machine on standard make and quality. 15 x 125 mm. 18 Hematology pipette washerone for every 6 16 x 150 mm. 6 students. 10 x 75 mm. 24 , standard laboratory model. Centrifuge tubes: Interval timer. graduated 6 Microscopeand lampone binocularper plain 12 student. Cuvettes for colorimeter 12 NPN heater (6 unit) one for every 3 students. Cylinders, graduated : Pipette shakerone per student. 10 ml. 2 Polyethylene pipette jars. 25 ml. 2 Racks : 100 ml. 1 Filtering rackone for every 3 students. 500 ml. (per 2 students) 1 Sedimentation rack(6 place)one for 1000 ml. (per 2 students) 1 every 6 students. Sedimentation Rate tubes 2 Staining rackone for every 6 students. Curvettes for colorimeter 12 Test tube racktwo per student. BottlesReagent with ground glass stoppers : .Refrigerator. 125 ml. Rotatorfor VDRL'sone for 10 students. 250 ml. Spectrophotometer :One for every 6 students. 500 ml. One each of the mostcommon types used 1000 ml. in the area if possible. brown (500 ml.) Stop watchone for each student. dropping Thermometerone for every 2 students. (Bottles should be available insufficient Utility oven. quantities for each student to use in preparation View boxone for every 2 students. and storage of reagents, stains, solutions, etc. Water bathone medium size for every 6 stu- Quantities are not listed but suggested kinds dents. and sizes are listed.)

105 VDRL Antigen 2 Blood Counting: Pipettes(per 2 students): RBC 20 Volumetric : WBC 1 ml. 20 18 Hemaglobin 20 2 ml. 12 Burettes : 3 ml. 24 4 ml. Automatic burette One per class 10 Burette with stopcock One per student 5 ml. 12 Miscellaneous : 10 ml. 6 Foline--Wu Sugar tubes 5 Measuring (Mohr) NPN tubes 2 ml. 4 4 Urinometers with cylinder 2 1 ml. 6 Esbach Albuminometer(per 2 students)__ 1 5 ml. 4 Funnels-65 10 ml. mm. dia. 10 12 Counting chambers (withseveral extra Ostwald-1 ml. 12 in case of breakage) 1

106 APPENDIX E Suggested Supplies Miscellaneous: Tongs Filter paper Spatulas Lens paper Urinalysic: Glass tubing pH paper Rubber tubing Urine cartons or bottles Glass slides Blood Bank: Cover slips Polyethylene bottles (wash bottles) Glass stirring rods Dishwashing: Wooden applicator sticks Brushes Syringes Acid cleaning solution Needles Detergent Tourniquets Rubber gloves Stop-cock grease Wire baskets First Aid kit Paper Supplies: Towels Scratch pads Hematology: Semi-log graph paper Capillary tubes Report sheets Blotting paper Rulers, scissors, stapler, etc. Blades for finger pricks China marking pencils Mouth pieces and tubing Glass marking pencils (diamond point) Chemistry: Labeling tape Weighing paper Mailing cartons from State Health Forceps Department Laboratory List of reagents and chemicals should be preparedfrom procedures to be used in the teaching program.

107 1111111111111I1I1IMMIMMINNIMMEIMMIMMIN1 IIIIIIIIIIIIIIMMINSIMIllNEEMEMENMEIMMISIMMEN111 IIIIIIMMINNIMMNIM1111111111 111111MNIMMEINIMMIBMINIM IM 111211111111111111111111111 NI :1.. 11111111111 11111111111111: .: U IIIIMEININN MIN MUM IIIIIIMINE : s . . INIIIIIIIIIMIIMMIIIMIIIIIIIIMMINNMINI' . . ISIMININININIIIMINIINIMIIIIIIIIIIIIIII.: N EEMENNINN IIIIIIIINIEMIMIMMIIIIMIN- IIIIIIIIIIMM ENEM 11111111111111111 IIIIIIIIIIIIIIIIEMMINIIIIIIIIIIIIIN' . 11.1111.1111111MIIMINIMMEMENMEM : 1111.11111111111111111111 IIINIMME MEMEMINI MI INIIIIIIIIIIIIIN11110 MEININEINNI NUM IIIIIIMMINEMIN IIIIIINIMIN 11111 MIMI NIMBI. -= IMENIIIIIIIIIMINIMMI111111 - 1ENEMININIMMININIIIII IIIIIIIIIIIIIIIIIIIIIMMM11MMINEMENINNIINIIIMMIIIIIIIIIII MINI I... IMMEMENINININNIIIIIIMMENIMNIIMININI 1111111MIIMMIIIIIIIIIIIIMI1111 1 111.11.111111.111111110.11B11.11111111111111111*.V""W""k" IMMIMMEIMIll 11.111.111.1111111111.111 111111111111MINNIIIIIMIIII MIINNIMI E MINNENIIINIIIIIMIMMI11 1 m " IIIIIIIII _ .1 .. IIIIIIIIIN1111IIIIMMIMIIIIIIMIIIMMMININIKEN 111111 1111111111 '- IMMEINNININMMIEMMIEMMIIIIMININIIIIMENNEll 111 :... IN 1111 11111111111111MIN I .. . 1 In EMNO 111111111 . . MININEININNIMEMMIIIME 1111111 N UM IMINIEMMIMEMIEMEEIMI MN NINIMMINININOMME INEINIENIIIIIIIIMMIERIMIN 111111111ININ I a IEMEININIMMINIMEMMIMIMEIIIIIENIIMI11.11MaliallINIMINIMIIMM " t. IMMEIMMEIMMININIIMININIMMINIMMI 111111111111111.11111111111.1111111111111111111111 11111111MEMIIIIIMIIIIIIIIMEMEM ME : IIIIMMINMENIIIIIIMMIIIIIII11111111.1.1111111.11M1 MM MIE . NEMEINENNININIIIII IM 111111111111av 1. 111101111111111111 IIIIIIEININIkm--*DD APPENDIX G

TALLY OF TESTRESULTS Name of test ResultUnknown Standard result Date

I

109 APPENDIX H WEEKLY REPORT OF LABORATORY PROCEDURESAND ASSIGNMENTS COMPLETED Student: Number Name Week number:

Lab assignment

Lecture attendance: Present: Absent: Demonstration attendance: Present: Absent: Practice sessions missed:

Sunday Procedures Monday Tuesday Wednesday Thursday Friday Saturday completed in laboratory No.Init.* No. Init.No. Init.No. Init.No. Init.No. Init.No. Init.

Reading assignments completed:

Miscellaneous: Complete * This form is to be completed by the stu- Student. dent,initialled by the responsiblein structor, and turned in before starting Approved the next week's classes.

110 Name______(Last) (First) (Middle initial) Month of 19 ______forwardbroughtHours Unit No. Unit Time I Monthly HoursTotal Hoursdate to Grade ...3..,1 OrientationBacteriology 54 HematologyParasitologySerology 67 BloodClinical banking chemistry . 98 BMREKGRoutine analysis AbsenceKEYTardiness TO RATING ______Conduct Attitude Training situation 1 Adjustment to H _Progress.ProgressQuantity of 'work Quality of work other______UUnsatisfactory.SSatisfactory.0Outstanding. Student's signature Instructor's signature Date 19 APPENDIX J STUDENT RECORD (By Departments) Student Department Dates: From To

Very Test grade Evaluation good Good Fair Poor grade Intelligence A-90-100 Very good-4 B-80-90 Good-3 Perseverance C-70-80 Fair-2 Initiative FBelow70 Poor-1 Ability to follow directions Tests and quizzes Organizing ability Date Grade Willingness to accept responsibility

Judgment

Accuracy

Speed

Spirit of cooperation I Manner with patients Evaluation grade: Comprehensive: Personal appearance Final grade on course:

Remarks and impressions

Signature of instructor

112 APPENDIX K 12. Mental alertness (acceptsresults blindly and without question orrealizes and STUDENT PROGRESS REPORT corrects errors) Instructors please grade as follows : 1. Whenever possible use lettersindicating : GROUP III :PERSONALITY RATING : A-Very Good ;B-Good ;C-Satisfactory ; 1. Cooperativeness (ability to getalong with D.--Unsatisfactory or Poor. fellow-workers) 2. Where a letter grade seemsunsufficient, 2. Attitude toward fellow-workers supplement with remarks. 3. Attitude toward staff Name of Student 4. Attitude toward profession Instructor u.Professional conduct (ethics, mannerisms, etc.) GROUP I. WORK RATING : 6. Work habits (neatness,planning ahead, etc.) 1. Accuracy (quality of work) 7. Personal appearance 2. Speed (without sacrifice to accuracy) 8. Willingness to acceptsuggestions and 3. Dependability criticism learning, 4. Sense of responsibility (toward 9. Punctuality performing tests assigned, and conduct) 10. Courteousness 5. Organizing ability 11. Tact 6. Economy in use of materials, time, energy, 12. Adjustment to situations etc. 13. Tolerance of mistakes of others 7. Technique in general 14. Integrity (would he check a resultwith- 8. Consistency and uniformity(consider out being told to ?, etc.) replicates repeated standards and un- 15. Check any of the followingwhich might knowns) apply to this student : 9. Initiative and judgment Complainer Moody Poor health 10. Attention to details Ambitious Good sense ofExcitable 11. Completes work on time Overconfident humor Suspicious 12. Dexterity (ability to work with hands and Lazy Seclusive Unappreci- to handle equipment) ClockwatcherDeceptive ative of the 13. Technical competence(resourceful,or- Poor rights of derly, systematic, knows principles un- attendance others derlying technique, etc.) List any outstanding or unusual qualitiesnot covered : GROUP II:MISCELLANEOUS List any special difficulties encounteredby this student (handling the equipment,learning 1. Intelligence (uses his head) subject matter, following instructions, etc.) : 2. Industry (makes use of spare time to good Recommendations for improving perform- advantage) ance : 3. Application to study Please give a brief, general evaluation of this 4. Background in basic sciences student : 5. Ability to learn Would you hire this person to workwith or 6. Desire to learn 7. Scientific curiosity(extra reading-in- under you ? terest in new procedures) With or without reservation? 8. Willingness to seek advice and help If with, explain : 9. Improvement Date Tardiness 10. Interest in the subject (above average, average, or indifferent) Attendance 11. Inspiration of confidence(poise,self- control, sincerity, etc.) Instructor 113 APPENDIX L FINAL EVALUATION RECORD

Date : Basal MetabolismElectrocardiography GRADE RECORD OF Final Grade Passing Grade Grade Code : at the completion of months course in A 90-100% Grade B 80 90% Orientation C 70 80% Bacteriology F Below 70% Serology Recommendations and Remarks : ____ Parasitology Hematology Clinical Chemistry Director of School Blood Banking Routine Analysis

APPENDIX M STUDENT FILE CARD ON GRADUATES

MEDICAL LABORATORY ASSISTANTS Name Date entered: Address Date completed:

Final average Out of Class standing Remarks and/or impressions: Instructor

114 APPENDIX N

Laboratory RecordForma The laboratorycensus or work tally is of prime importance are listed with the specific testsperformed, and to laboratorymanagement seven sources of material and to hospitaladministration in estimating are listed across the staff needs and top of the sheets:blood, urine, feces,CSF, predicting incomepotential re- gasp ic, sputum, and others. spectively.It is also of strategicimportance to The daily count oflaboratory proceduresis persons concerned with planningmedical labo- the responsibility of ratory assistant training.It can be used to each laboratorysection. The monthly reportshould be under thedirec- evaluate learningexperience potential,ade- quacy of teaching-service tion of the chieftechnologist.The monthly staff, and income summary of the laboratory potential related to census, representing requested investment innew total tests per laboratoryand the grand total equipment to improveservice. for all laboratories, In order for the can be brief and still in- census to be effective for all formative.An' example ofa total report these purposes, therules for countinglabo- follows : ratory procedures shouldbe consistent through- out the country. In1954, the AmericanSociety GENERAL HOSPITAL of Clinical Pathologistsproposed a set of rules LABORATORY CENSUS for countinglaboratory procedures.These April 1964 rules were revisedin 1957 andare in use in Laboratory: Number of this revised form Teats today. A completeset of Hematology-Urinalysis 2,500 ASCP Forms forReporting Clinical Chemistry 2,020 Pathology Blood Bank Tests, SurgicalSpecimens and Autopsies(2nd 950 Bacteriology 1,822 Rev., 1957)can be obtained fromWhiting ECG Press, Rochester, Minn., 600 for $4 per set of25. Tissue-Pathology 1,270 For simplification,the instructions andthe Total 9,162 form are orientedaround six categoriesunder clinical pathology The yearlycensus, the total of all monthly :bacteriological, chemical, census data, per test and immunological,microscopical, per laboratory, should physical,and be completed at theclose of the fiscal others, plus theadditional sections ofsurgical year. The pathology and autopsies. format of this reportcan be the same as the The six categories monthly report form.

* U.E. GOVERNMENT PRINTING OFFICES 1566-0217-734 115