The Secret Room in Your Hospital: Transfusion Medicine with Jennifer

Show Notes

In Episode 6 of No Referral Required, Mandy, Courtney, and Lara are joined by Dr. Jennifer, a pediatric hematologist-oncologist and transfusion medicine specialist, to pull back the curtain on one of the most important (and least understood) specialties in medicine. Dr. Jennifer explains what transfusion medicine actually is, walks listeners through the "vein to vein" journey of donated blood, and breaks down the four "flavors" of blood products hospitals keep on hand. She shares why plasma in the U.S. can only be made from male donors, what happens when a trauma patient needs blood before their type is known, and how her team programs the hospital's computer systems to keep patients safe without doctors having to memorize every nuance of blood banking.

The conversation dives into how donated blood is screened for infectious diseases — from HIV and hepatitis to Zika and Babesia — and why the U.S. blood supply is safer now than at any point in history. Dr. Jennifer explains the groundbreaking pathogen reduction technology that neutralizes viruses and bacteria in blood products, a new drug called nipocalamib that could prevent a rare fetal disease by blocking maternal antibodies from crossing the placenta, and why other countries require all doctors to train in transfusion medicine while the U.S. does not. She also discusses how her team supports patients who decline transfusions for religious reasons and the positive role social media is playing in patient education.

Transcript

Courtney [00:00:08] Hey everybody, welcome to episode number six of No Referral Required. We’re all here, everybody’s here. Hi, we’re all here and we have a great guest.

Lara [00:00:18] We are so excited to have Jennifer with us, who practices transfusion medicine, which is a fascinating area that I think a lot of our listeners might not be super familiar with. I think the general public is not super familiar with. Maybe even some people in medicine. We’re not trying to keep it a secret. But I think we’re going to have a great time kind of learning a little bit more about that today. So let’s start with, will you tell us a little bit about your background and what led you to this specialty?

Jennifer [00:00:57] Sure. Well, I am a pediatric hematologist oncologist by training. So in the US, that means you do a pediatric residency, excuse me, and then three years of fellowship, and then transfusion medicine, blood banking, it’s sort of a combo name fellowship. is a one-year fellowship in the US that you can do from any specialty. So traditionally, it’s like a pathologist who would do that in the States. In other countries, it’s usually a hematologist. So I then did that extra one-year fellowship after I finished. And so then that allows me to practice this, it is a weird, not secret, specialty that’s secretly in probably all of your hospitals. I hope so. It’s how you get blood.

Lara [00:01:47] Give us a big picture. If you’re explaining to somebody who doesn’t know anything about this, what is transfusion medicine?

Jennifer [00:01:54] Yeah, that’s a great question. So I’m a pediatrician right by training. So I’ll simplify the answer. You’re used to that. Yes, and kids have opened my eyes to the fact that it seems easily explainable, but not. My daughter, for example, thought that it meant that I transfused every patient at the hospital I work at, which would mean 70,000 times a year. No, it’s really just the oversight of all the blood transfusions that happen. There’s another related branch. So I could also practice at like a blood donor center. So like people have heard of probably the American Red Cross. And that’s where you go donate blood. So there’s a whole branch of my specialty where they have medical oversight over those procedures and make sure the donors are healthy and they do all the infectious disease testing like HIV. And then they ship it to our hospital as one example. And then my job is to make sure that all the patients are getting the safest transfusions possible. That’s it in a nutshell. I’m not physically doing all the transfusions, though. Our wonderful nurses and our colleagues in other specialties, like anesthesia, are really doing the brunt of the work.

Lara [00:03:08] That’s great. Tell us what drew you to this specialty.

Jennifer [00:03:12] Yeah, so it’s weird, and it’s kind of behind the scenes. Like, we’re kind of joking, but truthfully, even as a practicing pediatrician, which I was before I went into training, and then even as a fellow in hematology, which one would argue if you have a question about blood in a hospital, who do you call? You call your friend, the hematologist. I didn’t even know. Right, exactly. We all have them on speed dial. They’ve all helped me. What do I do with this or my patient’s bleeding, right? So even there, it was like, wow, what is all this secret insider information? So I happened to train at a really large place in the Southeast where we took care of a lot of patients with sickle cell anemia, which is a disease where children and adults need a lot of red blood cell transfusions. And I was just, I happened to be, I mean, this is just serendipity, all of us in medicine somehow get to where we are, but I happened to be matched up and had a daily clinic for three years with another pediatric hematologist who also did a transfusion medicine fellowship. And she like decoded the secret language for me. So we would be sitting in clinic and I’d be like, wow how do you know this patient needs like these special things matched for in their bloodstream or how do you know what to do and so she slowly kind of opened my eyes to this completely new specialty and she’s the reason I went into practice. and fellowship. And what’s great is I still get to work with her and another one of my mentors who are just sort of like mothers of the field. There’s another layer above them. So there’s a grandmother of our field in pediatric transfusion medicine specifically. And I’ve been also been able to work with her and see her at our yearly annual meetings where we talk about all the newest research and You know, now I’m actually running the little section of my field where we only focus on pediatrics. And that’s, I mean, it’s an honor to work with these kind of giants in my field.

Lara [00:05:24] That’s great. Tell us a little bit about what a typical day looks like for you. So you get up, you come into the hospital, what are you doing?

Jennifer [00:05:35] Okay, so I have so many hats and so I have multiple jobs. So it’s also very weird and I think a lot of the listeners will be probably like practicing medicine or in a health field and so they’ll sort of, hopefully understand, but I still, I do all kinds of things, right? So I still am a practicing hematologist. So half a day of clinic per week where I see my own patients or I have fellows, which are trainees in medicine or residents, which are trainees or medical students, where I’m seeing patients with them and I’m teaching them the basics of hematology. So that could be, that’s my Thursday morning, for example. And then there’s other days where I’m just coming into the blood bank, which is like a secret room in our hospital, right? Nobody knows where it is. I can tell you after the podcast where we are. I promise your nurses know because they come and pick up blood. So I come into the lab and I, for example, need to just kind of see what happened overnight. Did any patients in my hospital have a possible reaction to a blood product? I would need to look through the details of that. And we actually quote, unquote, round in the blood bank. So just like clinically, I do also attend on our inpatient hematology service where I see patients who are admitted to the hospital, who the general pediatricians or the surgeons have consulted or phoned their friendly hematologist. They have questions. So I still do that, but then we also round in the blood bank, right? So I have residents in the U.S., they’re pathology residents, but we also have other kind of learners with us because we don’t want this field to be a secret. It’s really important, for example, that hematologists know a lot more depth about our field. So we often have adult and pediatric hemlock fellows rounding with us. We have the anesthesiology interns at our hospital are required to round with us. I didn’t know that. That’s a good idea. Awesome. Yeah, they transfuse a lot of blood. So we’re teaching during our rounds, right? And we’re looking at all the patients that had reactions. We’re looking at patients who made antibodies or proteins in their bloodstream against certain proteins, for example, against red blood cells, which is common in certain groups of patients. Those patients with sickle cell anemia that I talked about earlier, they commonly will make antibodies. And so we have to do special matching of their blood. We help our obstetricians a lot at my hospital. Which is super interesting. So moms can actually make antibodies or proteins against their baby’s red blood cells. And then those proteins can cross the placenta and cause the baby to have anemia. And that is a very niche and rare disease. For the listeners, it’s called hemolytic disease of the fetus and newborn or HDFN for short in doctor land. But I’m an expert in that disease, which is very strange. I get calls and consults from all over the country. So my day, and then I of course do teaching, right? So I teach the medical students and all the learners that I just talked about. So I’m giving lectures all over the place. and grand rounds and noon conference and all these learning things. And then I do a little research. So I dabble in little projects that I think are interesting, like, oh, of the thousands of patients who got this new blood product in my hospital. How did they do? Did it work? Did they have any reactions that I wasn’t expecting? And then I also obviously write a lot of things with my friends who are also experts in pediatric transfusion medicine. So we write review articles and journal articles and we do podcasts. And we just try to get the word out there. I do some advocacy work around that really rare disease in the US anyway, called HDFN. So I work with a wonderful group called the Aloe Hope Foundation, who really advocate for getting women who are sensitized, they have those antibodies, into doctors who know more about that because it’s so strange. A lot of just sort of general practicing doctors wouldn’t even know about that. So we do a ton of work around that. And then I’m involved in all my societies. So all the medical meetings. I lead a lot of work and I’m on the board of directors for one of our niche groups. And so we’re planning our meetings all the time. Which experts do we want to come? So really my day is a mishmash of all those activities. And for my friends who know me and my family, it’s totally me, right? Like I have a little bit of ADHD. I’m always doing something and It just keeps my day pretty exciting and different. There’s never like a standard day of what I’m what I’m walking into, which I think is kind of fun. Yeah.

Mandy [00:11:05] Do you have to take call at night?

Jennifer [00:11:07] Oh, yes. I do take call just like all the other doctors. What’s weird about transfusion medicine is I’m taking call for a lab. But actually, a lot of doctors don’t know there are doctors on call for every section of the lab. So 24-7, 365 days a year, there’s a doctor on call that, like, you can call me, for example, if we can’t figure out what the antibody is that your patient made, or let’s say a surgeon is taking care of a patient operating in the operating room, and they need blood, like, yesterday, always, right? What’s taking so long? And they’ll call me and I’ll say, oh, well, your patient had this really unexpected reaction. We have to do this special thing, like wash all their blood products. And that takes time. So there are issues that come up in the middle of the night, for sure. And on holiday weekends, where we, yeah, always trauma patients come, they tend to be on holidays. Right. We’re also kind of managing our inventory. So we’re making sure, just like a grocery store, we can’t run out of blood. Like right at my house, we can’t run out of milk. So I’m, you know, always making sure that we have enough kind of planning for what is coming, which is sometimes tricky, but yeah, we do take call just like all doctors.

Courtney [00:12:25] Okay. You said, I’m asking a, I’m the lay person. I’m the one who does not know. So you’re saying a few words, but the one that you keep saying is blood product. Oh, yes. Does that mean just a bag of blood that you hang on a pole? Or what are we talking about?

Jennifer [00:12:41] So there’s different flavors of blood, which is not really known to the general public.

Courtney [00:12:45] So you’re not talking types, or you are talking types?

Jennifer [00:12:48] Some. So there’s different kinds of blood that you might transfuse for different reasons. So probably your audience has heard of anemia. So when your blood count is low, there’s tons of different reasons for that. But sometimes doctors need to transfuse patients with red blood cells for that. And then there’s three other flavors. For example, I used to practice oncology. I don’t anymore. I’m just in too many things. But when I treated patients with leukemia, for example, I would give them chemotherapy drugs. And that would drop not only their red blood cell count, but also their platelet count. And so platelets are in charge of clotting your bloodstream. So the count would be so low that they’d be at risk for just having bleeding. And so I would prescribe them platelet transfusions. And then the other two products are plasma, or in Dr. Land, we might call it FFP, fresh frozen plasma. And that’s the, if you think about the liquid part of your bloodstream, you have all these proteins in there that you need to clot your blood in addition to platelets. And you have other proteins that are important, like that a medical audience would understand, like albumin. So anyway, there are different reasons that doctors might want to give plasma. A common one would be a trauma patient. So someone just got in a car accident and they’re bleeding, they’re hemorrhaging, massive amounts of blood. Well, we need to replace everything in their bloodstream. So we’re going to give them red blood cells and plasma and platelets. And then the fourth product is not commonly used in a hospital. It’s called cryoprecipitate AHF. That’s the official medical name of it. Nobody calls it that. We all in a hospital call it cryo. We love to like- Shorten everything. Yeah. And every specialty has their own acronym. Everybody’s in a hurry.

Mandy [00:14:44] We can’t be talking. Yeah, that’s right.

Jennifer [00:14:45] I need cryo, right? So really the only modern reason that a doctor would need that product for a patient is if they have low fibrinogen, which is another one of those proteins that’s in the liquid part of your blood that’s really important for keeping clots stable. So we commonly will see it used, again, after a patient has surgery, like in the operating room. Or there are certain conditions, like babies can be born and not have functional fibrinogen. I’ve seen patients with that. So they need that specialty product. I’ve been saying my whole career that that’s the one blood product that’s hopefully going to go away, knock on wood. But for 20 years, I’ve been saying that I’ve been wrong.

Courtney [00:15:29] Why do you want it to go away?

Jennifer [00:15:30] Is it hard to keep or hard to… Well, no, and we have plenty of it. We can freeze it. It’s just a blood product and there’s a drug. There’s a pharmaceutical that’s been made since the 1950s, actually. So a really long time. That hasn’t really caught on in the U.S., but other countries use something called fibrinogen concentrate, which is manufactured and it’s safer from an infectious disease standpoint. Yeah, it doesn’t come from a person, right? I mean, in some ways it does. Sure, sure. Further upstream. Yeah, we think of it as much safer.

Mandy [00:16:08] Exactly, yeah. So that is an excellent segue to, I want to know, talk us through the path of a donated unit of blood. Because that’s probably what people know. Oh, yeah.

Courtney [00:16:20] That’s all they know, is I go to the Red Cross, or roll up my sleeve, and I get a brownie when I leave. or whatever. Cosmic brownie and a Coke. Yeah, and they’re really nice.

Mandy [00:16:32] Talk us through that and then to the recipient.

Jennifer [00:16:35] Sure.

Mandy [00:16:35] What’s happening in that whole path?

Jennifer [00:16:37] Vein to vein we call it. Vein to vein! And so I don’t work at a donor center, but it’s certainly like as part of my training I did, right? And so a healthy person, usually over the age of 18, it depends on your state, but your listeners, if you’re not a blood donor and you’re healthy, it’s an easy way to help a lot of patients. And actually we’re always sort of in a deficit. We’re always, needing more blood, especially in the summertime. We’re recording this podcast in July, and this is a really tough time for us. So if you can donate, if you’re healthy and adult, it’s a really nice volunteer way to help your community. And it only takes 15 minutes. So you walk in to your neighborhood blood donor center, and basically they ask you questions, making sure you’re healthy and that you don’t have risky behaviors. so that you’re not going to give a patient an infectious disease. And if you pass the questionnaire, they measure your vital signs, make sure you have a good healthy heart rate and blood pressure. And then a phlebotomist draws a whole unit of your blood. So just everything all at once, the red blood cells and the water part and the platelets. And then our blood supplier is called Blood Assurance here. And what they do is they process that unit by testing the type. I know you asked about that earlier. So people might know or your moms know, I promise you. what your blood type is, O or A or B or AB. And they double and triple check it, right, before they smack that label on it. They want to make sure that’s labeled correctly. And then they do all those infectious disease testing that we want to make sure we’re not giving patients when we’re transfusing them, right? So HIV and hepatitis B and C, et cetera. And after all that processing, then they ship it to our hospital here, and then we double check the type again. We don’t even trust their label. We double and triple check that, right? We want to make sure, yep, that’s really an A unit. And then we put it in the fridge and wait for someone to order it and it’s ready to go.

Courtney [00:19:00] Do you freeze it or is it refrigerated?

Jennifer [00:19:03] So that depends on the product. So most people when you talk about blood are thinking about red blood cells, so that’s refrigerated. And the vast majority of whole blood units that a person would go to their community donor center or maybe like a van would come to their workplace they’re gonna process those whole blood units into red blood cells. About half of the products that are transfused at my hospital yearly are those. So those are red blood cells. And then they can make the water part, the liquid part of the blood from that same unit, but there are safety steps. And so because of some kinds of reactions patients can have, The whole United States actually can’t make the liquid part, the plasma, from any woman who has donated a whole blood unit. They can only make it from men. Oh, I didn’t know that. Yeah, and it’s just because of the risk of one of the reaction types actually called, the doctors will know this, TRALI, transfusion-related acute lung injury, which used to be the number one cause of a patient unfortunately passing away because of a transfusion reaction. So we figured that out, well, 15, maybe almost 20 years ago now, that it wasn’t a good idea because women make HLA antibodies, which ultimately can contribute to that kind of reaction type. And you make HLA antibodies from pregnancy. And I think almost 100% of women by the time they’re 40, I think in the U.S., have been pregnant. So they make those antibodies. So that’s why there’s that rule.

Courtney [00:20:45] So women can’t donate plasma? Is that what?

Jennifer [00:20:48] Yeah, but they can donate everything else. Donate blood, yes. Donate whole units, right? And then the manufacturers just don’t make plasma out of those whole units. But they can make real blood cells. So I’m not discouraging the audience. I’m going to donate blood. Please do that. I just wanted to make that clear. Yes, yes. And then the other blood products, there’s some nuance to how they make them. So they can spin it down, make the water part or the plasma part, and freeze it. That’s called fresh frozen plasma. Cryo is made from a similar process. And then platelets are special. So for a really long time, well, maybe I don’t know, 20 years or so, we’ve been actually not taking the platelets out of a whole blood unit. It used to be that they would pool those together to make an adult dose of platelets. So some doctors may remember what we called a quote unquote six pack of platelets. Those were whole blood derived platelets, right? So now basically across the US, all the blood centers are making what we call apheresis platelets. So if you have time in the audience, So you actually have to go and you get hooked up to this special apheresis machine. And it’s really smart. There’s a computer in there. And you can program it to take just the platelets out. And then the blood donor gets all those other pieces, all those other flavors back of their blood. It takes an hour. That’s the issue. It’s like a real big deal. And then platelets are kind of finicky. I call them the divas of the blood bank. They need to be shaken all the time and they can only be at room temperature. Like all the other blood products we talked about are refrigerated or frozen, which is easy to transport, right? And they have a longer life, like a shelf life, right? Like milk, you can imagine, you can keep that a while in your fridge, right? If it was at room temperature, it wouldn’t be so good. Platelets are kind of like that. So they’re only good for five days. So we need like a constant replenishment of that. platelet product to have enough on our hospital shelves to give to patients. Yeah, they’re kind of special. Yeah, they are. Sounds like it.

Lara [00:23:00] How much at one time, how much supply does a blood bank keep on hand for a large academic medical center?

Jennifer [00:23:07] That’s a great question. We shoot for having five days of our normal usage in the hospital. So if you walk into our blood bank, you’ll see this massive row of refrigerators. It’s kind of like walking into a restaurant, like if they have an open kitchen, you can see they have all the ingredients there in the fridge right next to where they’re cooking, right? So we have almost 500 or sometimes 600 red blood cell units just immediately available to give to patients. And so to kind of finish the journey vein to vein, like let’s say, If a doctor orders a red blood cell unit, well, we need to make sure that it’s compatible for the patient’s blood type. So we’re doing testing that the doctor orders what is that patient’s blood type, that’s called a type, and then a screen, which we often pair together. So doctors and nurses will say type in screen. The screen is looking, do they have any antibodies that we need to match for specially? Because that can make it a little difficult. We want to always be compatible, right? So that testing takes up a lot of time in our blood bank. We, at my big academic center, test almost 12,000 patient samples a month. for just a type and screen. And then we have to make sure they match before we ship that blood product off to the floor to be given, usually by a nurse, depending on the clinical situation. There are some doctors, mainly anesthesiologists and surgeons, for example, who need to transfuse a lot of blood product really, really quickly. So sometimes we’re actually not just handing out one unit at a time, but we’re handing out to take this kitchen analogy kind of far, we hand out big coolers, just like the kind that you take to the beach. You know, for the 4th of July weekend, you might have sodas and sandwiches. We hand out those same kind of coolers, obviously not the exact same kind. They’re medical grade, right? But we’ll hand out lots of blood products at once for our patient who’s hemorrhaging.

Courtney [00:25:16] Yeah. Do you do that before somebody has a problem? Like I’m thinking like, you know, they’ve had a surgery, they’re in recovery, then they get admitted, because maybe they need to stay for a minute or whatever. Do you go ahead and type and screen them, or you wait until it’s determined that they need a blood transfusion, maybe after the fact?

Jennifer [00:25:35] That’s a good question. We encourage all the people who care for patients, so all our, especially proceduralists, like our surgeons, to get and type and screen if they think the patient’s going to need blood, because that testing takes at least an hour. And so you don’t want to be waiting on that test result if your patient needs blood. So doctors at my hospital are pretty good at making sure they have that test on hand. And then, you know, sometimes doctors, we’re humans, doctors are humans, and maybe somebody forgot along the way. It’s okay. We can always hand out a safe blood product for an urgent or emergent patient, right? Well, that’s what I was going to ask.

Courtney [00:26:17] Somebody comes to the emergency room, they’re bleeding out, they need blood. We don’t know their blood type, right? Exactly.

Jennifer [00:26:22] We can’t do that test quickly. And so there’s universally compatible blood products. So each of those flavors, like your audience might know that O is the universally compatible red blood cell type. So we always want to have plenty of stock of O red blood cells at my hospital in particular, because we take a ton of those trauma patients where we don’t know their blood type. So we just hand out O. We even make it easy and have it already in a refrigerator in our emergency rooms, both our adult and our pediatric, so that it’s just available for the nurses and doctors right there when they need it.

Mandy [00:27:01] Okay, so you mentioned that as the blood is getting processed that it gets tested for a couple of things. You mentioned hepatitis and HIV. Are there other things that are commonly tested for or are there pathogens that sort of emerge over time and have gotten rolled into the testing as blood donations have been processed through the years?

Jennifer [00:27:22] Yeah, excellent question. So in the U.S., the FDA, the Food and Drug Administration actually mandates certain testing. And it’s based on research, right, and what we obviously don’t want our patients to get when we’re prescribing blood products. So in addition to HIV, hepatitis B, and hepatitis C, which I already mentioned, All the blood that’s donated in the U.S. is tested for HTLV, which is human T lymphotrophic virus. Probably the doctors will know a little bit about it, but it’s an uncommon infection that can cause disease in patients. We don’t test specifically for malaria, but when a healthy person walks in to donate blood, they ask them questions about where they’ve traveled, and that’s to get at the malaria risk. We also test for a really uncommon, at least in the U.S., little bug called Babesia, which is common in other parts of the world. That’s been added over the years as people have sort of brought that into the U.S. T. cruzi is another one of those bugs, little critters we don’t think about a lot in the U.S. that we now test for. Depending on the season, we also test for the West Nile virus in certain parts of the U.S. And then one test that I remember, let’s see, I think it was like 2015, so about 10 years ago, that the FDA mandated we started testing for, and maybe the lay public remembers this. Remember Zika virus? Yeah. And so the FDA, you know, with our research in the community of transfusion medicine, not me individually, but like the research showed that could be transmitted through transfusion. And so they mandated that everybody test for Zika, but now that testing requirement is gone. So things do come and go, but that’s the current list as of 2026.

Mandy [00:29:18] So patients will occasionally ask us that, or tell us that they don’t want blood from persons who have been vaccinated against COVID. Yes. And so how would we answer that from?

Jennifer [00:29:32] Yeah, and I get that question too, actually, from parents. And, you know, I think they’re coming from a really good place, which is they’re worried about the health of their child, or your patients are just worried about their overall health, right? So, it’s an easy answer because I just gave you guys the list of what is required to be tested. And so, we don’t test for that, really. So, when we buy blood, obviously, they’re never going to ship us blood that has any positive test for those diseases I just listed. But the blood donor centers don’t even test for that. There also is not a way for us to test for that in the hospital. So, for example, sometimes parents will ask me as a hematologist, oh, can’t you test the blood to see if it comes from a person who has been vaccinated against COVID? Well, if you’ve had a COVID infection or you’ve had a COVID vaccine, your body makes proteins or what we call antibodies against a certain part of that virus. And from a lab testing standpoint, we can’t tell the difference. So it’s a pretty easy question to answer. Sometimes I like to dig a little deeper. deeper about maybe why a parent or patient is asking that question. And I find oftentimes it just comes out of a concern for their child or themselves and not really understanding how safe the blood supply right now really is in the US. We’ve, I mean, I know we’ll talk about it in a little bit, but this is like the safest time in history to get a transfusion, which is awesome. It’s great. Yeah. It’s great news.

Lara [00:31:21] That sort of asked her, what is something you think the public doesn’t understand about blood banks? I think that’s a good one. How safe it is.

Jennifer [00:31:29] Yeah. And I, you know, I think the safest transfusion is the one not given, which is a little bit weird to think about considering my whole job is handing out safe transfusions. Right? So wait a minute. Like the best job would be if I went away, right? And the other thing that I like, you know, the lay audience may not know is like, this is what we’re thinking about day in and day out. We’re literally my job is to make sure that blood is safe, right? So and it’s not just me personally, it takes a village, right? There’s a whole industry kind of and a whole specialty that’s behind the scenes to a lot of doctors. Our whole job is making sure that blood products are safe for patients. And so I highly encourage my colleagues, and this is kind of me wearing my hematology hat. For example, if I’m seeing a child and they have low blood counts, I want to know why. And I wanna get to the bottom of that. So like a really common reason in children is to have iron deficiency. That’s one of the nutrients that you get from eating red meats and other foods. And it’s really common in little toddlers, for example, who are just picky, right? For those moms in our audience. Sometimes I wondered about my child, how did she live through this? What is she eating? Yeah, like nothing, like bites, right? Yeah. Chicken nuggets, I don’t know, French fries. But anyway, that’s a super common reason. And we can fix iron deficiency, but with just a vitamin supplement, right? So you get to the root of that before, for example, that child needs a surgery, then maybe they don’t need a red blood cell transfusion because they’re not anemic, right? So I encourage my physician colleagues to kind of get to the root of the problem before they refer a patient to have, for example, an elective surgery. You really don’t want them to need a transfusion if they don’t need it.

Courtney [00:33:21] What’s the biggest logistical challenge in managing all those? I’m like, are you freezing down there in the blood bank? Like, is it cold to you? Like, you know what I mean? You’re like, ugh. Like, count my blood. Little packages or whatever they are. Units, you said? Yeah. I mean, what’s logistically hard about that?

Jennifer [00:33:38] Oh, gosh. Like, surprisingly, Many things come from even physicians and just medical professionals in general not knowing any of the logistics or nuances of what we do. I mean, I admit it too. I used to, as a hematologist, and then I actually feel really terrible now looking back. I just didn’t understand the specialty at all. So I used to moonlight, which in Dr. Land, and especially for pediatricians, we don’t make a lot of money, right? So I used to try to make extra money on the weekends. I would go moonlight at a general hospital taking care of the children in that hospital. And sometimes they would need transfusions. This was in another state. And I would call the blood bank, not knowing anything, and just complain, why is this taking so long? Why do you need this other test? What are you doing down there? Like, I used to think they’re just sitting there twiddling their thumbs or reading People magazine or just trying to make my life difficult, right? They weren’t, they truly were just trying to make sure that my patient’s blood type was compatible with the red cell unit they wanted to hand out, and all these other details that we’ve kind of discussed and talked through, right? And so I think it’s been frustrating, like from my mentors and from my training, My viewpoint on this has completely flipped. And so when I was a brand new doctor doing this specialty, I used to sort of grump and gripe, why doesn’t anyone know anything about this? Like, why don’t people know it takes an hour to do a type in screener? Or why don’t people know that we only have, you know, five days shelf life of a platelet? I’m not going to hand out, like sometimes the operating room teams will say like, wow, this patient’s really bleeding. Can we have 10 units of platelets? Whoa, I mean, I wish I could give you 10, but I always have exactly what we need. And like the dose is just one unit per patient, right? So there’s so many little things that I think doctors don’t know. And I used to blame them for not knowing, but now I don’t blame them. There’s so many different things. There’s so many different, all the stuff we need to know. And I mean, it comes truly because I didn’t know these things either as a practicing doctor. I didn’t know these things. Right. So what I think is awesome is like, we’ve built all these tools. So we make it as easy as possible for our staff at my hospital to just do the right thing and know what to do, right? So like the computer order sets are super smart at my hospital. We built them. Oh, I didn’t say this at the beginning. So I also am a clinical informaticist because I like to do five things at once, right? So I’m board certified in this new specialty in medicine called clinical informatics. And it’s like, It’s really important, obviously, for what I do, but it’s just kind of keeping me also up to date on the coolest new things. And so what it allows me to do is program our computer. So we all use a system at our hospital. It’s pretty commonly used across the world. Actually, it’s called Epic. So I can program in Epic. And make sure, for example, if a patient’s blood type has only ever been drawn once at my hospital, we really want to know that that’s right. And so we require all the patients to have two blood types before we hand out type-specific red blood cells, right? So the computer, we programmed it to be super smart. It’ll automatically order that second blood type for the doctor. They don’t have to think about it, right? They don’t have to know that nuance. In fact, probably none of the doctors at my hospital know because they’re never ordering it. It’s just automatically happening, right? And it used to be like, wow, why doesn’t every pediatrician know the dose of, for example, a platelet unit for a baby? Like, we don’t want to give a big adult unit to a little tiny baby. Why don’t they know that it’s just, you know, this amount per weight? Well, now I just programmed the computer so it does the calculation. So the doctor doesn’t have to think about it. So I stopped blaming the doctor and I’m more of like, let’s get the safest thing at the right dose for the patient. So we put in all these tools in place just to make it easier.

Mandy [00:38:03] That’s great. That probably leads into the next question and may answer it for you. But what advances do you think are going to have the biggest impact on blood banking or transfusion over the next decade?

Jennifer [00:38:15] Well, so some things that I think we’ve done over the past 10-ish years, or maybe 20, are gonna help us for the next decade. So one massive thing that’s happened in my field is called pathogen reduction. So we spent a lot of time talking about all those infections. Why not just wham all the bugs growing potentially in a blood product, right? Like why not just take out all the pathogens? Well, we figured that out. So there’s a technology that uses a chemical and a light, and I’m not gonna get into all the details, but we’ve had pathogen-reduced platelets and plasma for decades, actually. They’ve not been approved by the FDA until about 10 years ago, and my hospital uses them. And so all the platelets, they’re not an infection risk anymore. That’s a huge deal. When I’m transfusing, for example, a child who we’re curing of leukemia, right? Like 95% of childhood cancer leukemia, childhood leukemia is cured, right? So they’re gonna get a lot of transfusions maybe early in their childhood, but then they’re gonna have a normal lifespan. So them getting one of these infections has a major consequence on their health forever. So we have pathogen reduction technology available plasma and cryo, that other special blood product. We’re working on it for red cells. It’s a little bit persnickety. So that’s one big thing that I hope is coming soon. But pathogen reduction also, if you think about it, like COVID is a great example. We never saw that coming. Well, what’s the next thing we don’t know about? We have a list in my field. I’m not going to scare your audience with a list, okay? It’s good someone’s thinking of a list. That’s a reassuring thing. Yeah, but like Ebola, right? This is not our first time with Ebola in the U.S. We had plans before. This happened 10, maybe almost 15 years ago. We already had a plan for that, right? Because that is obviously transfusion transmitted, right? It’s a bloodstream infection, right? So instead of being reactive to what is happening, pathogen reduction is proactive. It whams all kinds of viruses and bacteria. So that, I think, is coming anew. There’s a lot of stuff in patient blood management, which I sort of hinted at. So like, figuring out the reason why your patient is anemic before they need a transfusion. So there’s a lot of work happening in that field. And also, there’s a lot of realizations I would say over the past 50 years that not every transfusion is safe, right? There are some side effects that we cannot mitigate. Some people will have allergic reactions to blood products. We can’t sort of clean blood, quote unquote. to be free of allergens, right? So there’s all kinds of things for us to do to try to prevent transfusions, right? So a big one that maybe your audience will know about if they have kids. So it used to be that As soon as your baby was born, if your partner’s in the room, they immediately clamp the cord and then the OB lets them cut the cord, right? You might have had that special moment in your house. Well, the pediatricians and all the smart people doing research actually figured out that’s not the best idea. It actually is better to wait, so we call it delayed cord clamping. What’s the point of that? Well, the baby gets a little more blood flow from mama and the placenta, so they’re not anemic, so they don’t have a low blood count. So that actually saves transfusions after the baby’s born. Huge advance in I would say transfusion medicine because I think it’s preventing transfusions is part of my work, right? So that’s a huge deal. And then we’ve done all these landmark trials, some of which were led by some of my mentors in pediatric transfusion. And the physicians and medical professionals in the audience will recognize them. These are the transfusion trigger clinical trials. So doctors used to transfuse a lot more than we do now. So patients would just be mildly anemic and the old anesthesia textbooks would write, oh, when a patient’s hemoglobin is just one point below normal, they need a transfusion, right? I know, that’s scary. We don’t do that now. So the whole field has moved toward, yes, you definitely really need it. We’ve all moved toward restrictive transfusion, which is lower and lower numbers before a doctor prescribes a transfusion. There’s a ton of nuance in that when you’re talking about babies. How much oxygen are they on? How premature are they? So there’s a couple of landmark trials that were published during the COVID pandemic that really has changed when pediatricians and neonatologists transfuse babies, which is saving transfusions, right? So I think that will continue to move down that way towards more restrictive triggers of transfusions. And then one really cool thing that I think is gonna completely change the field And I’m just going to go to that one little disease that I’m an expert in, that HDFN, which is so cool. There is technology available. And actually, when I was pregnant with my daughter, who’s 13 years old now, it was available, and I got it specially because I worked where it was invented. So it’s called cell-free fetal DNA. And so your obstetricians in the audience will know a little bit about this, but the lay public will understand too. When you’re pregnant, you’re used to get something called a triple screen. So they’re looking for various diseases, including trisomy 21 and 18, et cetera. So instead of drawing a triple screen, from a fluid where the baby’s DNA is, like the amniotic fluid, right? Now we can draw a blood sample from mom. So I’m going to use myself as an example. So when I was pregnant with my daughter, they drew a blood sample from my arm and they amplified my daughter’s DNA. So they could do testing on her genetic makeup and tell me, for example, before they could tell her gender on the ultrasound, I knew she was a girl. That’s so cool. So cell-free DNA is now available for all those little extra blood proteins that I was alluding to. So a common antibody that moms will make against the baby is called a big D or anti-D antibody. And the issue is you don’t know when you’re pregnant with a baby. Does my baby have that antigen where my antibody against it can bind and cause a problem like anemia? Well, now we can do cell-free DNA testing and tell that mom. very early in her pregnancy, so less than the first trimester for sure, so less than 12 weeks. Oh, your baby doesn’t even have this antigen, so you don’t have to worry your baby’s gonna be fine and not be anemic from your anti-D antibody. So I think we’re going to see more and more of those tests developed. And even in the last five years, I’ve seen it explode in the number of antigens we can test for using mom’s blood. So not getting an amniocentesis or other risky procedures during pregnancy, but just having the moms get a blood draw. And then one other really cool thing is, okay, this, I hope I can explain it in a simple way, but there are new drugs coming online, and one is really exciting. It’s called nipocalamib, and we give it to the moms, and it blocks the antibody from crossing the placenta, causing that disease in a baby. How cool is that? So we have a clinical trial open at my hospital for babies who have a related disease, but it’s against platelets instead. So it’s just stopping that mom’s antibody from going through the placenta and causing that disease in their baby. This is gonna be a game changer, not just for HDFN, that little tiny disease, but all kinds of other diseases where patients make antibodies against themselves and cause problems, right? So that’s all coming online. I think in 10 years, for sure, the field of medicine is gonna be forever changed. And I foresee we’re gonna be giving that drug a lot more to moms. and then we’re gonna see a lot more healthy babies because we’re preventing diseases, which is really cool.

Mandy [00:47:23] Do other countries do blood donation and transfusion different? Yes. In the U.S.

Courtney [00:47:30] I was like, okay, then you’re alluding to the fact.

Jennifer [00:47:34] Yeah, we do a lot of things differently. Yeah. So, , One example, and I’ll try to relate it back to things that we’ve already talked about, but I sort of am never mad at the physicians in America for not knowing things. Other countries actually require doctors to know a lot more about transfusion medicine. Our friends to the north in Canada require all the residents, so all the new doctors, no matter what specialty they’re going into, to spend two weeks learning about transfusion medicine. So they have a boot camp, they get all kinds of lectures, they have case studies, they need to make sure they know what are the risks of transfusions, what are the benefits, what could I do instead, what can I tell my patients about reactions, How can I consent a patient for a transfusion? How would I answer, you know, they would know that COVID question when a patient answers, because they’ve already had that education. Very similarly in much of Western Europe, Australia, New Zealand, it’s just required. It’s part of their medical education. It’s not in the US. I know.

Lara [00:48:41] It’s a leading question, but I assume you think we probably should do that here? I do.

Jennifer [00:48:46] But honestly, as time has gone on and I’ve realized how much our poor medical students are learning already, there’s too much. There’s too much for them to need to know. So we build all these fancy tools so they don’t have to know as much, at least at my hospital. Pathogen reduction has been available in much of the Western Europe and other countries like Australia, et cetera, for decades. Fibrinogen concentrate, for example, our colleagues in Brazil have been using that drug instead of cryoprecipitate for a really long time. And in fact, the whole country of Canada doesn’t even make cryo anymore. That’s why I keep saying, hopefully it will go away. They only use fibrinogen concentrate. Yeah, so it’s really different here. But we’re a really big country, so to be fair, you know, it’s easier for smaller places to roll out and do sort of things on a systemic or sort of everyone has to do it the same way basis. Yeah, each hospital kind of sets their own policies in the U.S. and so hopefully we’re setting good policies at my hospital. We’re always trying to do the right thing, but every hospital makes their own decisions.

Lara [00:50:04] You know social media has had a huge impact on medicine in general. Do you see that for your field? Do you see as much of an impact?

Jennifer [00:50:11] Yeah, interestingly, I do. And I see a positive impact. So I think it’s great that our patients have all this information available to them. And I think AI is coming at us quite quickly, too. I love it when, for example, a patient walks into my clinic and the parents have already researched what they think might be going on, because then we can have a really thoughtful discussion about why maybe I think, well, that’s not quite right. Maybe let’s do a little more testing and sort of, you know, hone in on what’s really going on. Or yeah, I totally agree. This may be what’s going on with your child. So I love that our patients come more informed to us than they ever have been in the past. I would say, like over the past 20 years, it was a rare patient, but I remember one in particular. He was the first patient I ever treated for leukemia. So it was a brand new fellow. He’s graduating high school this year, which is so crazy. His parents sent me the graduation announcement, which was adorable. But, for example, his father is in a healthcare-related field, right? So he really knew the right questions to ask. And I remember our first visit, when I was making the diagnosis, he printed, I mean, this is how old I am, right? He printed a 300-page protocol for how to treat this specific childhood leukemia, and we went through it page by page, right? Now, in this day and age of AI, someone could have that summarized, right? Into a one-page summary, right? That’s great, because they’re asking me like, oh, look at all these side effects. Let’s talk about that. What do you think is really going to happen with my child, right? So now patients might ask doctors or nurses. So for the audience who’s coming into your office, if you’re talking to them about a blood transfusion, they might have watched a social media video about some of the risks of transfusions. Maybe that’s why they’re asking you questions, right? Or maybe they watched, so, one of the societies I belong to, the Society for the Advancement of Patient Blood Management, they put out all kind of videos, TikToks and other things about, hey, ask your doctor about iron deficiency and maybe I could be treated before I have my surgery so I don’t need a transfusion. So I actually think social media is having a positive impact on my field because it’s getting the information to the patients. And especially like we were just talking about how doctors in the US don’t really know a lot about blood banking and transfusion medicine. That’s okay. If your patients are coming to you with information, I love to have an open mind about things. That’s just my personality. So like try to have an open mind about it and like maybe it’ll improve your clinical practice. Interesting.

Mandy [00:52:59] I’ve seen this play out in patients who have very strict beliefs about blood transfusion and looking up alternatives and options. Can you speak to that a little bit for those groups who have refusal of blood products or how you might talk to someone about that or their options so that we can still keep them safe?

Jennifer [00:53:20] Yeah, that’s a great question. And so actually, the classic example, which probably the audience has heard of our patients who are Jehovah Witness, that is a religion that precludes them from accepting blood products. The first thing to know is that we can still treat those patients and keep them safe, right through surgeries and other things where they might need help. with their blood counts. So I would say go to your hospital’s expert in the alternative to blood products. So I am my hospital’s expert.

Lara [00:53:56] Makes perfect sense, right?

Jennifer [00:53:58] So I am officially the, what do they call me? The hospital liaison to the JW community. And so what does that mean? It means

Lara [00:54:08] I’ve had a number of patients that have needed big surgery and it’s a little stress-inducing as a surgeon.

Jennifer [00:54:19] What we do is I work with a group of really smart people who optimize these patients. So we might give them vitamins like iron or other supplements to make sure their blood counts are nice and high before surgery. The Jehovah Witness community recently put out a statement that their members can donate blood for themselves. We call that autologous donations. So we can optimize a patient so they can go donate blood for themselves. We’ll have it in our hospital blood bank just in time for their surgery, for example. And then there’s all kinds of other things that are alternatives to blood products. There’s nothing perfect though, right? So we are working on it. I once had a medical student ask me if, why can’t we just give manufactured blood? And I said, oh my gosh, I mean, if you could do that during your career, you would make billions of dollars, right? Like a universally compatible non-human blood product. We’re working on it, but we’re not there. So, but there are other adjuncts that can stop bleeding. For example, there’s factor products and other like very nuanced alternatives that your friendly, likely hematologist can inform your patient about. The other thing to know for, there’s other groups of patients that just want to avoid transfusions. that’s completely reasonable considering all the risks of a transfusion, right? And so other hospitals do things like only draw blood in little tiny sample tubes so that we don’t make patients anemic or children’s hospitals do this really well. They only draw labs that are necessary, right? They are not drawing labs every single morning just to make sure everything is still stable, right? Like we are really thoughtful about only getting blood samples from babies when we know it’s going to change what we’re doing for that patient, right? So there’s different things that you can do to sort of conserve your own blood that can help patients like that. But likely your hometown hospital has a liaison to the JW community. If you don’t, their website actually is awesome because there are doctors who are practicing JWs, right? And so our local sect here in my town is led by a cardiovascular surgeon. So when I call him with certain questions, we can go through the medical literature together, we can come up with a really individualized plan for a patient that’s at my hospital who might need surgery, for example, and sometimes we’re gonna talk to that surgeon and anesthesiologist and have them set up what we call a cell saver so we can actually collect the blood that a patient’s bleeding during the surgery from whatever incision or work is happening. We can collect that blood and we can process it and give it back to the patient. So there’s all kinds of really cool stuff we can do for patients, yeah. Definitely has to be planned for in advance of the surgery.

Lara [00:57:20] A lot of people need to come together to do that. Okay, so now we’ve come to the part I always enjoy, speed rounds. So we’re gonna go through some quick questions, they’re supposed to be kind of fun. So just quick answer, I mean, you can take whatever time you need, but that’s the idea here. So first one, Are you superstitious?

Jennifer [00:57:45] No, not really.

Mandy [00:57:46] Okay.

Jennifer [00:57:47] No, I used to believe in Dr. Lin and like black cloud, white cloud. Yeah, no, it all comes around for everyone eventually.

Mandy [00:57:56] One day.

Lara [00:57:58] It’s been 10 years. Maybe eventually. Which other specialty do you have to ask for help from the most?

Jennifer [00:58:06] Oh, that is so interesting. Anesthesia, hands down. Yeah, they transfuse a lot of blood products at my hospital. Yeah, they do.

Lara [00:58:14] You’re running to get it. What’s a word or phrase you end up saying multiple times per day?

Jennifer [00:58:21] Don’t worry, your body will heal itself. Because I’m a pediatrician, that’s generally true. For our audience who treats adults, that’s probably not true. But it’s a nice thing you can use as a parent too, right? With skinned knees, don’t worry, your body will heal itself. We don’t need to treat that.

Lara [00:58:41] Who in your inner work circle could you not live without?

Jennifer [00:58:45] Oh, I have an MFM that I just can’t live without.

Courtney [00:58:48] Say that, what does that mean?

Jennifer [00:58:49] His name is Matt Grace, maternal fetal medicine. Okay, okay. Can’t practice without him.

Mandy [00:58:55] That’s great.

Jennifer [00:58:56] Wonderful, yeah.

Lara [00:58:58] If you could ask your boss or chair for one thing, what would it be? Be it small, be it large. A parka.

Jennifer [00:59:06] One hour extra per day. I don’t know if they could make more time, but I could get so much more done if I can get another hour.

Lara [00:59:16] What other medical specialties gross you out? What could you not do?

Jennifer [00:59:20] Oh, ophthalmology for sure. Anything with the eyeballs grosses me out.

Courtney [00:59:25] Everyone’s got their thing. And as someone who wears glasses, that’s interesting. I know.

Jennifer [00:59:28] You could be like, oh yeah, I’m numb to it. It’s part of the reason I wear glasses. I will never have LASIK or wear contacts, no way.

Courtney [00:59:37] That grosses me out too.

Lara [00:59:39] Would you encourage your children to pursue a career in medicine?

Jennifer [00:59:43] I would. I’m an optimist. I think you guys can tell. Yes. I don’t know that a lot of doctors would say that, but it is so rewarding. I can’t imagine what else I would do. There’s definitely been times in my career where I’ve had little periods where I’m not as in love with the daily tasks, but it’s so rewarding. I love being involved and really help healing everyone. That’s great.

Lara [01:00:09] Do you have a joke about your area of medicine? Oh, yes, I do. We all have our jokes. Yes, I do.

Jennifer [01:00:14] Because mostly in the US, my colleagues are pathologists by training. Sort of the stereotype about pathologists is they’re living down in a lab basement in a dark room. They don’t like to come out and talk to other doctors. They’re looking under the microscope to see if someone has cancer. So how can you tell a pathologist is outgoing, like really social? They’re looking at your shoes, not their own shoes. I’m an honorary pathologist, not really. We all think I’m like way too outgoing.

Courtney [01:00:54] Okay, well, our final question, and you kind of alluded to it, but I hope you can come up with something, is if you could do any job in the world outside of medicine, you don’t have to start over from scratch, like you just wake up and you’re doing it, you have all the knowledge, you have the business established, whatever that is, the credentials you need, whatever, and it still supports yourself, so you don’t have to make any lifestyle changes, you know, whatever, we’re trying to make it as easy, what would that be?

Jennifer [01:01:23] OK, I do have an answer for that. OK, good. It would be an organizer, a professional organizer. Oh, that’s a good one. Yeah. And it kind of has to do with my current job, right? So I kind of joke that being meticulous is really, like, it’s super important, right? I can see that. Yeah. This space for the A, this space for the B. Yeah, we’re super organized. We can’t get any detail wrong, right? Like, my lab is inspected by the FDA. They can come at any time. Sure. They’ll even yell at you if you use the wrong color pen. I’m not joking, right? So it’s a feature, not a bug, that will be like, this is incorrect. We had to redo it. So I feel like that my job has made me so ridiculously organized, even to the point where when my daughter crosses out, you scribble out your wrong math answer in the hospital. The FDA requires that you only write one single cross out and you write the date and your initials and then you write the correction above the cross out. I’m like, why did you just scribble that out? And she’s like, mom, this isn’t my job. So I would love, I could do organizing all day long. Maybe I’ll do that when I retire, actually. Yeah, there you go. That’d be so fun. I would hire you.

Courtney [01:02:41] You can start at my house. I know. Faithful personality. Come on. Come on. OK. Well, we are so thankful that you spent your time with us. Thank you all. This was fun. Yeah, it was great.

Mandy [01:02:50] Very informative.

Courtney [01:02:51] Yes, extremely. I had no idea what I was going to hear, so this is always good. Good. Awesome. And thank you listeners for listening, for being with us. Make sure you’re following us on Instagram, going to our website, noreferralrequired.com and listening on all the platforms. And we will be back soon. Bye. Bye-bye. Thanks.

Lara [01:03:10] Post-interview addendum, donated blood is also routinely tested for syphilis prior to administration. This podcast is intended for informational and educational purposes only and is not a substitute for professional medical advice, diagnosis or treatment. The views and opinions expressed by the hosts and guests are their own and do not constitute medical guidance for any individual case. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or health concern. Never disregard professional medical advice or delay seeking it because of something you have heard on this podcast. By listening to this podcast, you acknowledge that the host, guests, and producers are not responsible for any decisions or actions you take based on the information discussed.