CLINICAL ISSUES

HeMYTHology:
10 myths of hematology
Are you a believer?
By Roy Midyett, MT(ASCP)

ere arc 10 generally accepted concepts from the hematology lab, and the reality checks for each. What is your
own "myth factor"?

M Y T H # 1 : Band counts are important.

REALITY: It is hard to make a case for the importance of a

parameter that has no clear-cut definition. Various attempts
at defining bands exist in literature and textbooks but, in
actual practice, there is a very wide range of opinions. Like
the definition of art, it is one of those "I-kjiow-it-wheii-I-seeit" type of things. So problematic are bands that the College
of American Pathologists (CAP) could not reach a consensus
with its participants using Kodachrome examples. That's why
y(Uir master list says "grans/bands." .-Xnd some institutions have
done tlie same thing, combining neutrophils and bands into
one category. Do not be surprised if your emergency room
doctors and pediatricians are reluctant to abandon bands.
M Y T H # 2 : Moving averages are averages.

REALITY: This is a "partly true" statement, which in

classic True/False rules makes it false. "Moving averages,"
Xb ot Bull's algorithm is actually a complex equation that
shaves off outliers, uses information from the last batch to
figure the current one and cannot be done without a calculator. Since it uses data from the previous batch tofigurethe
current batch, it may take a while for the graph to rebound
back to normal if it has been out.
M Y T H # 3 : Linearity verification must be performed
periodiaaUy on hematology analyzers.

REALITY: The current CAP checklist does not address the

issue of linearity ;tt all, just calibration so, as flir as CAI^ is
concerned, the linearity perfonned when the instrument is installed shoukl suffice. The Clinical Laboratory- Improvement
Act (CLIA) refers to "reportable range," but tloes not specify
frequency. Other than state and federal regs, should you be concerned? Tf an instrument is kept in good repair and calibration
according to nianutacturer specs, virtually nothing will significantly aftect the linearity. Lmeariti," is tbe "personality," while
calibration is tbe "attitude," which we know can change.
IVtYTH # 3 : On a stained blood smear, one platelet equals
W.OOOxW/L

REALITY: This is another "partly true" statement. On a wellmade wedge smear from a imnntil specimen where the red
blood cells (RBC^s) are just touching, the nile holds true: In a
lOOxfield,one platelet equals about I5,(K)()xl()''/L in the specimen. But on a smear from a very anemic blood, going far back
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November 2003

MLO

the smear where the RBCs' touch, will give an inflated

estimate of platelets, hi other words, your "view" must reflect
tlic RBC] count to get a valid 15,000 rule. The opposite holds
true for a polycjthemic blood: The observed field will have to
appear iiiore "crowded" to get an accurate estimate.
M Y T H # 5 : Hematology analyzers must be recalibrated at
regular intervals.

REALITY: 'I his is really a trick statement, and the key word
is "recalibrated." Analyzers do not have to be recalibrated per
se, but the calibration does have to be verified at regular intervals. In other words, if your calibration procedure shows your
"Acme" analyzer within tolerances when you run the cali!)rators, you do not have to hit the "recal" button. Most of us hit
the button anyway, even it the adjustment is insignificant. It
makes us feel as if we are getting our moneys worth.
M Y T H # 6 : H your instrument flags the diff, you must check
the slide.

REALITY: This is prolv,ibly the most widely practiced misuse

of lab resources, and my personal least-favorite mjth. Many
man-hours are wasted in labs by checking slides that do not
necessarily have to be checked. The solution? Do your ovvii study
ot your instrument, and see if the flags work for your needs and
your own definition of ahnonnal. Quick example: If your lowest level diff fiag (lefi shift -i-, Imm grans/bands +, etc.) almost
always flags normal patients, and does not catch any ahnonnals
by itself, it is a useless flag for your lab and \'our ilefinition of
abnonnal. 'Lhere are too many laboratories diat are n(jt using
the sophisticated technology of modern analyzers intelligendy
or efficiently. My experience is that technologists and analyzers
have an error rate (both may miss a small percentage of "abnormal" cells) and they are about even, if you fine-tune tbings.
M Y T H # 7 : Hematology commercial controls must be
parallel tested before being put in use.

REALITY: I cannot think of a real-life scenario where parallel testing of assayed controls would be of inucb value. The
main reason? Henie controls come with "insert values," a
list of expected ranges for your instrument, which make parallel testing moot. Let us say you receive a new lot of controls, and parallel test them that is. test them on the analyzer after running the current lot, so you know the
instrument is performing properly, and thus know the new
lot is also all right. Then you put the new lot away for two
weeks. When you later put the controls into use, you find
that the RBC^ values are all out of the 2sd range on the low
side, as the insert sheet tells you. What do yt)U do now?
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HEMYTHOLOGY

WJn'tberytm hiive parallel tested or not, you still have to decide

whether you have n control material prohlem or an instrument prohlcm. Parallel testing makes sense and is necessary' when you receive unassayed control, as in coagulation
fontrnls. Many labs still do some fine-Uining on their commercial controls anyway, such as readjusting the mean and
SD, hut for the most part, it is just that: fine-tuning.
M Y T H # 8 : If you never have outliers, the system is working.

REALITY: Acrually, the opposite is true. If you never have

outliers for a particular system, chances are one of two things
is happening. l''irst, your quality control (QC) limits are set
so hroadly that they would virtually never he out of range.
Secondly, the (JC^ just is not measuring irhat you thought it
was or measuring in the n'ny you think it was. Either one
means the QC is not detecting errors or problems. If a QC
tool is never out, it is not doing you any good.
M Y T H # 9 : Very low white hlood cells (WBCs) must have
manual diffs.

REALITY: When the V\'BC:s are in the ultra-low range below say, ().6xlO"/L this is the time when automated instruments really can he usefiil. I'he number of WBCs on a wedge
smear with an 0.6 WTiC is statistically too small, and ittakes too
long to count; the results usually are not wortli the ef(-brt. Since
a good automated instrument (with good low-end sensitivity)
will still he counting hundreds of cells, even on a low count, tlie
automated diff will give you better infonnation than a manual

diff. Of course, you can make huffy coat smears, but again, the
effort involved vs. useRil info must he considered. Many labs
make use of "TFT'C" t(K) few to count and reserve huffycoats or manual diffe for the insistent physician.
M Y T H # 1 0 : Microhematocrhs must he QCd.

REALITY: We are now tlrmly in the area of controversy. My

position on this issue is this: The microhematocrit is a "primary" method that is, a method against which other methods, controls, reagents, instruments and calihrators are standardized and, as such, cannot be QCW in the traditional sense.
In the case of microhematocrit, if the RPM is checked and the
packing time is standardized, that is it. If you are comparing
instrument HCHs to the microhematocrit every day, then you
are not QC^ing the manual crits; you are doing the opposite.
Depending on your own "myth factor," you may decide
to re-examine your procedures and policies. You might even
discover some myths of your own. D
Roy MJdyett. MTIASCP) is hematology supervisor at Presbyterian Hospital,
Whittier, CA
Additional reading:
1
2.
3.
4.
5.
6.

CAP Hematology Glossarv. 2003.

Brown B. Hemalology Principles and Procedures. 1993,
Coulter STKS Reference Manjal. 1991.
CAP TODAY. Summer 1994.
CAP Hematology and Coagulation Checklist. 2001.
Code of Federal Regulations [CLIA 88) 67.

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