Every Med Tech has made errors in his or her lifetime. We are all human and good people make errors. It’s the lessons we learn from those errors and the paths we follow after we realize those errors that help us to grow and improve not only ourselves, but the world around us.
When I was 22 years old, straight out of college, I got a job working in the laboratory of a small rural hospital. I focused in Chemistry, Hematology and Blood Banking. This hospital was so small there wasn’t even a night shift so often we had to take turns being on-call through the night, running the laboratory completely on our own, if we got called in.
One night while I was on-call, a small child, maybe 2 or 3 months old, came into the hospital running a high fever; she was listless and lethargic. A spinal tap on the baby indicated that she had a form of Meningitis. I knew we had to act quickly and that it was up to me, a 22 year old Med Tech straight out of school, to determine what was causing that Meningitis so that she could be properly treated.
After running some glucose and protein tests on the spinal fluid, everything was pointing towards bacterial Meningitis. I quickly began the Gram stain. I had done numerous Gram stains in school—but I wasn’t a microbiologist, I was a generalist, and I certainly wasn’t very versed in all the common mistakes and potential errors in Gram staining. The pediatrician came down to the lab and is looking over my shoulder eagerly waiting for the results. I look at the slide and see bacteria that were stained red. “It’s Gram negative,” I said. The doctor took off in a hurry to treat the patient accordingly.
A really competent microbiologist would have quickly realized that shape of the bacteria was cocci in pairs, indicating the most common cause of Meningitis in young babies, Strep Pneumo, which is Gram positive. They would have also known that Strep Pneumo is extremely susceptible to over-decolorization causing the stain to lose purple coloring and counterstaining red, indicating Gram negative. But I was not competent in performing Gram stains and this small hospital did not have a system in place for me to call someone more versed in microbiology to verify the results, nor did it even have a meaningful competency assessment in place. I simply did not have enough experience to become competent to perform and report a gram stain on a spinal fluid in the middle of the night.
In the morning, before I went home, something urged me to go to the incubator and look at the culture plate from the spinal fluid culture. I quickly noticed the characteristic green look and the amount of growth in such a short period of time. I knew at that moment I had made a serious error. I called the doctor immediately and told him the bacteria was presumably Strep Pneumo, a Gram positive organism and not a Gram negative organism like I had thought only hours before.
That young baby could have died because I called the Gram stain incorrectly. The life of someone’s 3 month old child was in my hands that night—and I made an error. When I learned that the doctor was able to adjust treatment in time and that infant was going to be okay—I dropped to my knees and thanked God.
I had an epiphany at that moment, I said to myself “Look at this career I have chosen, look at the impact I am making.” It was in that moment that I fully understood the incredible responsibility that came with this profession. It was no longer just the job that brought in a paycheck. It was much more than that. It was helping to save lives. I quickly learned never to be flippant about that responsibility and never to be too proud to say “I will need to do further testing and consult with my colleagues to verify this result.”
I also learned the importance of real and meaningful competency assessments. Too many labs see it as a paperwork exercise; check off boxes and shove the files it in a filing cabinet for when it’s time for inspection. Competency and training needs to be so much more than that. Everyone who works in a lab needs to be experts in running the tests they may be required to run. They need to know what the common mistakes are and what can go wrong with the test. When you should call out for a second opinion. In a hospital setting especially, lives hinge on the results obtained from those tests.
To this day I think back on my experience 30 years ago in that rural hospital and that little girl whose life was almost cut short because of an error I made. Looking back, I know that it was a changing point in my life. It was the moment I truly understood the great purpose and responsibility of being a laboratory professional.
*child pictured above is not the same child from the story