This is Lab Medicine Rounds, a curated podcast
for physicians, laboratory professionals and students.
I'm your guest host Anne Moyer, a pathologist
and laboratory genetics and genomics and associate professor
of laboratory medicine and pathology at Mayo Clinic.
Today we're rounding with Justin Kreer
a transfusion medicine pathologist and assistant professor
of laboratory medicine and pathology at Mayo Clinic to
discuss understanding the fundamentals of coagulation.
Welcome Justin.
I'm really excited to talk with you today about this topic.
Hey, thank you so much.
Me, me as well.
Well, let's go ahead and jump right into this exciting topic.
So the first question I've got
for you is, why is it important for physicians to
understand the fundamentals of coagulation?
I mean, those are some pretty complex pathways.
Well, you know, I guess first off
it makes my heart go pitter patter.
I, I love it.
But I guess more, more importantly
besides my own joy for it is I, I, I think it
it's generally complex like you're, you're saying it's a lot
of pathways and, and aspects to things and
and I think a lot of physicians have a lot
of things that are trying to juggle at the same time.
Same things for us in pathology lab medicine.
I think we have a lot
of things that we're trying to stay on top of.
And so if you have something complex, it
it's really tough to kind of keep things fresh.
Right. Because I, I guess I kind of joke sometimes
that I only remember what I read the night before.
So it, it's complex and then, you know, it
it really matters, right?
When we're looking at patients
if patients are bleeding and we need to figure out how
what's gonna be an effective way to help them stop bleeding
we need to understand some fundamentals to kind
of figure out that puzzle.
Likewise, if, if somebody is thrombosing
on the other side of the fence, right?
I mean this is, this is another, you know
leads to horrible outcomes, heart attacks, strokes.
At the end of the day, it's important
for all of us to have a couple of fundamentals
about how coagulation works so that we can deal
with this complexity when it matters for patients.
Well, that makes a lot of sense.
It definitely is a very important system
and in many of the contexts that you've already mentioned.
So since you end up talking with people
about coagulation a lot, in your experience, what are a few
of the common misunderstandings that people might have?
Yeah, I, I think the, the big thing and, and again
I'm not throwing shade on on somebody I can appreciate it
is just the, the simplifications that are drawn, right?
I mean, a number of years ago
very much there was a lot of focus on I N r.
Basically, I think coagulation sort of just got boiled
down to whatever that i n R value.
And, and that was, that was it.
You know, I used to consult on patients many times
bleeding out, and the only thing that's really been looked
at and trended is what their I n R value is.
Not that labs are the end all be all, but you know
also just an appreciation
for what is that clinical history for that patient.
The medications that they're
on really mattering potentially quite a lot.
And then in more recent years, right, viscoelastic testing
so tag rotem, you know, has really, I think taken over
especially for our surgical colleagues
has kind of taken center stage
and now I think they have maybe, you know
had those experiences to realize that I
and R is not the end all be all.
But now a lot
of times I think TAG has has become that for them.
And again, I can understand why that is.
You know, I think TAG is incredibly useful
in patients that are experiencing a major
and significant bleed.
And so I think
that our surgical colleagues have seen it help
in those situations and
and sort of have learned that that can be helpful.
And then the, the challenge that comes is then
they'll oftentimes extrapolate that
out into the non bleeding patient.
So for example, I one time was talking
with a colleague that like wanted to do a tag
on some outpatient in order to figure out how to
I'm using finger quotes here for the, for those listening
to the podcast, how to optimize the patient
for their surgery in a, in a couple of days.
And, and to me that's very much not the context.
If, you know, once you understand the principles
of how viscoelastic testing works, you know, if
if somebody is out grabbing lunch somewhere
and you have an abnormality, what does that mean?
And then on, on the inverse, a tag does not catch
everything that is a clinically significant bleeding risk.
And so even a normal tag could be misleading.
So, you know, good, good things.
You know, I, I like the I N R in certain situations.
I like that tag in, in certain situations.
Another example that comes across, I've
I've had people kind of bemoan the fact that, you know
we don't do bleeding times anymore.
And I think that's just a reflection
of the name of the test, right?
It seems so perfect that, you know, hey, let's
let's lance you and then we'll measure how long you bleed.
That seems like the perfect, like correlate
for how we should be measuring
or what we should look be looking
at with the lab test until you figure out that, oh
that test was really only a good test for kind of the
what we call the primary hemostasis.
So the, the von Willebrand factor and, and platelets.
But you know, none
of these anticoagulants aren't really gonna be reflected
in that bleeding time.
So yeah, this over-relying and, and I guess one more example
since I'm a transfusion medicine physician, right?
Is this idea of, oh, well, you know, if somebody's bleeding
like we can just get them to stop bleeding
with fresh frozen plasma, you know, and
of course that is sometimes what people will reach for
but depending on what the clinical situation is
if there's an an inhibitor on board
those couple percent of coagulation factors
aren't really gonna make a a difference.
So I think the common misunderstandings kind of for me
all file under this kind of simplifications
which I think is just a reflection of it's a complex system
and many of us, you know, haven't been taught it.
And, and in a way that we can kind of get our arms around it.
And, and that probably includes
or I know that includes me as a teacher.
I think one of my, you know, genesis
in this area was the fact that I tried to teach coagulation
to a resident once, kind of in a one-stop shop.
And, and just then realizing the next day when
there was a clinical situation that came
up and I was like, oh, you got this, you know, I taught you
I gave you the keys
to the kingdom and you understand it all.
And they looked at me like, you know, Dr.
Gr, I, I do not remember a single thing you said.
Right? So they, they complex
and the way we convey it, you know
people are trying to adapt and overcome as best they can.
So, but simplifications are
are really the, the big misunderstanding.
I see.
And, and unfortunately I think that gets
to the patient's bedside.
I think that makes a lot of sense.
I think human nature is such
that when we've got something that's very complicated
that despite our best efforts, we've tried to understand it
but it's still complicated and confusing.
If we don't have a really solid foundation
it's easy to fall into oversimplifications.
So I guess with that in mind
it's probably important to make sure
that medical students come out
with a really strong foundation in coagulation
so that they can avoid some of these pitfalls.
And since I know you have a passion for education
do you have any thoughts on what we could do
better to teach a complicated topic like coagulation?
Yeah, well, pinging on your question for a second.
You know, that's one of the challenges that I still struggle
and reflect on is trying to teach somebody about coagulation
before they really have experience seeing patients bleed.
So I know that I am a lot more effective when
I teach the anesthesia residents who rotate
through transfusion medicine, right?
'cause 'cause for them, it's not such an, an abstract topic
but for somebody who's a, a first year
or second year medical student, you know, this concept is
is really kind of nebulous.
They don't have the clinical experience yet to
kind of hang their, their hat on the
on the coat rack kind of thing, so to speak.
But a few, a few things that I think are really
helpful are just kind of some of the fundamentals
of how do we learn and teach, you know, so for example
the idea of spaced retrieval practice, right?
So my time of do, of teaching the, the resident
all of coagulation, like in one, like sit
down like session in the break room over the course
of a about an hour is, is just too much too fast, right?
So nowadays what I do a lot
of times is I break those up into sessions.
So, you know, the first session I'll talk about, you know
how do we initially form the platelet plug and
and plasmatic coagulation those factors.
And then I'll come back another time
and they'll have to tell me how that initial thing worked.
And then we'll start talking
about the endogenous anticoagulants and how that works.
So then we'll come back a third time
and they will again take me
through everything we've learned so far.
And then we'll start talking
about the fi lytic aspects of coagulation.
And so by kind of spacing it
out and revisiting it, the educationalists
in the world would say we're interrupting, forgetting, and
and building stronger memories.
Another way I try to do it is I try to make it explicit
and concrete.
'cause like, if we just sort of say these things
and they're just sort of out there as this amorphous these
these words, you know, it, it's really hard for I think
learners to really understand what this means.
And so I use very concrete examples
in that I actually will put either, you know, playing cards
and poker chips to help people understand the physicality
of what's going on.
And I think
that really makes a big difference when we put things down
and people can then visualize what is actually
happening when somebody, somebody is bleeding out
and what needs to happen for them to stop bleeding.
And then also it's, it's a lot
of times connections to what they already know.
And that's probably where the more advanced learner
the anesthesiologist, right?
They understand certain medications
they understand certain reversal agents
but when we go through this
they can understand why that is what they're going to.
And you see these, you know
light bulbs go off as they can make connections
and the people that can make connections
to what's already learned.
That's another way that educators are making it
a more robust memory.
And I think that's one of the challenges of
teaching it initially is what can we kind of relate it to.
And so that's why I do things like
one example is when we talk
about platelets getting activated, I
I sometimes give the analogy
of it's like going clubbing with your friends, right?
How do you know you're approaching the nightclub, right?
Like you, you hear, you hear that techno music going
you can see the glow sticks going
and you can smell the, the cheap cologne or perfume.
And, and so I kind of use those three
and then I talk about how, you know
if you have somebody that is on Plavix and aspirin
two medications that inhibit platelet function
we've talked about what that mechanism is.
We can say, Hey, you could have earmuffs on
and have your, you know, your nose plugged up, but you know
you can still see the glow sticks going
on to kind of explain, you know, the
the redundancy that mother nature has given us
to platelet activation.
So that's where I try to, even
if the students don't have a specific clinical situation
they can kind of pair it to, I try to make it relatable.
Not saying that everybody's going clubbing every weekend
but try, try to figure out a story, right?
'cause I think those stories make it memorable.
And then also I avoid all the things that are kind
of that nuanced stuff that some
of us need to study for our boards.
You know, which glycoprotein is grabbing
onto Von Willand factor
which glycoprotein is binding onto fibrinogen.
But you know, for your average learner that's, you know
additional details that kind of, I think get in the way of
you know, when I have somebody bleeding in front of me
what do I need to be doing and thinking about?
I think those are all fantastic strategies
and I have to admit
that even though I'm not much of a partier
I definitely think that that platelet party sounds
like a lot of fun to hear more about someday.
So I may have to, to find
out a little more about that analogy
for the people though that don't necessarily have the luxury
of having one-on-one education sessions
because maybe they're already in practice.
I think another good opportunity can be attending
conferences. And as such
I heard that we've gotten upcoming breeding, bleeding
and Thrombosing diseases conference that'll be here
in Rochester soon.
And are there any sessions that you are looking forward
to in particular at that conference?
Yeah
Yeah. Well, I'll be presenting
and talking about, you know, coagulation fundamentals.
So I think
but I think the favorite one that I'm really looking forward
to is Dr.
She Harden is gonna be talking
about factor 13 deficiency in inhibitors.
And for me that's, that's something that deepened my soul
I think is a lot more prevalent
a challenge in our hospitalized patients.
And we're recognizing, I think that a lot of the reason
that it has been under-recognized is because there's a lot
of limitations for testing and how do we assess it.
So I'm really kind of excited to, to get that update
from her and understand if we, how we have new tools
and how do we go about kind
of assessing factor 13 deficiency and addressing it.
That sounds really exciting.
I think going to conferences is a good way to touch base
with a subject maybe you've learned about in the past
but especially when there's new cutting edge
things that are there too, that makes it even more exciting
for people of all skill levels to be attending.
So thanks for telling us about that.
Yeah, thank you.
I'll see you there.
Great. I think I'll be signing up for that one.
Well, for everybody else, join us for the 18th bleeding
and Thrombosing Diseases conference to be held in Rochester
Minnesota and live streamed October 4th through sixth 2023.
Visit Mayo clinic labs.com/bt 2 0 2 3 for more information.
So we've been rounding today with Dr.
Kreer about understanding the fundamentals of coagulation.
Thank you so much again
for taking the time to discuss this exciting topic with us.
If you'd like to hear more on this topic, Dr.
Kreider will be presenting at the 18th Bleeding
and Thrombosis Diseases conference in October.
Again, please visit mayo clinic labs.com/bt 2023.
For more information to all our listeners
thank you for joining us today.
We invite you to share your thoughts
and suggestions via email to MCL education@mayo.edu.
If you have enjoyed this podcast
please subscribe until our next rounds together.
We encourage you to continue to connect lab medicine
and the clinical practice through educational conversations.
Thanks again.