ASCLS Today Volume 34, Number 3

ASCLSToday Masthead 680

Volume 34, Number 3


Gerald D. Redwine, PhD, MT(ASCP)

The physical and chemical examination of urine samples plays an essential role in the diagnosis of patients’ pathological conditions. However, the sheer number of routine urinalysis can minimize their significance, especially considering that most analyses are automated, which can foster complacency for less than apparent problems. As a result of seemingly more critical concerns, one may defer the interpretation for the clinician to assess. Nevertheless, detecting abnormal results and possible causes is required, regardless of whether the analysis was manual or automated. Knowing the effects of pigmentation, drugs, pH, and ascorbic acid, for example, are samples that always need attention.

Manual analysis is further complicated, with several idiosyncrasies innate to manufacturers. For example, differences in popular brands, such as, Multistix, that requires reading each chemical pad at the specific time indicated. But the Chemstrip and vChem strips readings are stable between one and two minutes, except leukocytes read at two minutes, all necessitating the need for special attention to the manufacturers’ instructions. Concerning ascorbic acid, knowing that Chemstrip eliminates ascorbic acid interference with blood by overlaying the pad with iodate, and the vChem strips have a detection pad for the substance; in contrast, knowing that the Multistix has neither, is essential. Finally, knowing to ignore the different coloration on the perimeter of the pad on all strips and asking for a recollect on extremely high pH is also vital.

How are the critical thinking skills needed for a urinalysis assessment best developed? In academia, it seemed best, following initial training, to have students complete weeks of daily intensive practice of the entire urinalysis (physical, chemical, and microscopic) in an open lab setting on multiple patient samples. In combination with these analyses, they were given case studies like the ones administered later in a practical examination. The following is a composite of the answer stating what they thought was the most probable cause to three of the 17 cases given on their exam, using Multistix, with further comments in parenthesis. Assessments constrained the students to answer the question under the given condition, knowing they would ask for a recollect in some instances.

Case 1

Physical Examination Observed Result
Color Light yellow and cloudy
Chemical Examination Observed Result
Glucose Neg
Bilirubin Neg
Ketone Moderate
Specific Gravity 1.015
Blood Large
pH 5.0
Protein 30
Urobilinogen 0.2
Nitrite Neg
Leukocytes Moderate
Confirmatory Tests  
Protein (SSA) Trace
Ketones (Acetest®) Pos
Bilirubin (Ictotest®)  


  1. What would explain the apparent disagreement between the nitrite and leukocyte reaction?
  2. What accounts for the clarity of the sample in the chemical examination?
  3. What does the Acetest suggest about the chemical reactions, based on literature?


  1. Non-nitrate reducing organism. (i.e., bacteria, yeast, trichomonads, and chlamydia) Or Trauma. (Other less likely possibilities.)
  2. Large blood. (Also slightly enhanced the protein.)
  3. More sensitive because of the added glycine. (Glycine detects acetone. vChem strips have the same.)

Case 2

Physical Examination Observed Result
Color Yellow-brown and clear
Chemical Examination Observed Result
Glucose 2000
Bilirubin Small
Ketone Neg
Specific Gravity 1.030
Blood Moderate
pH 8.5
Protein 2000
Urobilinogen 0.2
Nitrite Positive
Leukocytes Negative
Confirmatory Tests  
Protein (SSA) 2+
Ketones (Acetest®)  
Bilirubin (Ictotest®) Small


  1. What could explain the single most unexpected finding within the chemical reactions?
  2. What could account for the protein and SSA discrepancy?
  3. What should the adjusted strip value read?
  4. What is the definitive source(s) for reporting the final specific gravity (SG) reading (manual/analyzer/and or name another source) on this specimen?
  5. With an SG = 1.040, what value is the final specific gravity?


  1. Negative leukocytes could result from any or all three of the following. 1) Alkalinity 2) >3g/dL glucose 3) High specific gravity.
  2. Alkaline pH can cause a false positive protein; also, the blood that is missing in the supernatant for the SSA could account for the 2+ SSA.
  3. Because pH is ≥ 6.5, then add .005 to the dip strip value. Strip SG = 1.035. (Multistix only)
  4. Because of the ≥ 100 protein, then run on the refractometer. (Total Solid (TS) meter/Refractometer.)
  5. Subtract 0.003 for every 1 g/dl protein; subtract 0.004 for every 1 g/dl glucose. Report SG: 1.026.

Case 3

Physical Examination Observed Result
Color Yellow-green
Chemical Examination Observed Result
Glucose Neg
Bilirubin Neg
Ketone Neg
Specific Gravity 1.010
Blood Trace
pH 8.5
Protein 300
Urobilinogen 0.2
Nitrite Neg
Leukocytes Large
Confirmatory Tests  
Protein (SSA) 1+
Ketones (Acetest®)  
Bilirubin (Ictotest®)  


  1. What could explain the disagreement that exists within the chemical reactions?
  2. Explain the correlation between chemical reactions and the SSA?
  3. What are the two specific adjustments needed for the specific gravity?
  4. What is the final strip specific gravity?


  1. A non-nitrite reducing microbe such as Trichomonas or Chlamydia. Or postrenal trauma. (Other nitrite negative possibilities. Also, if not for the trace protein, ascorbic acid is suspect.)
    Best observation: Yellow-Green ~ Biliverdin. False-negative bilirubin. Hence, the need for a recollection and run on a fresh sample to ascertain the true values.
  2. Expected the SSA to be greater. Alkaline pH can cause a false positive protein, or in this case, falsely increase the value.
  3. Because pH is ≥ 6.5, then add .005 to the dip strip value. Because of the ≥ 100 protein, then run on the refractometer. TS (Total Solid) meter/Refractometer. (Multistix only)
  4. Strip SG = 1.015.

Responses to the open lab concept, despite significantly more than usual time commitment on behalf of all involved, and reagents, the sacrifices were met with positive feedback from the students on superseding their learning outcomes. The learning outcomes summarized is critical thinking applied to urinalysis case studies.

Brunzel, N. A., MS, MLS(ASCP)CM. Fundamentals of Urine and Body Fluid Analysis, 4th Edition

Gerald D. Redwine is an associate professor at Texas State University Clinical Laboratory Science Program in San Marcos, Texas.


Carolyn Sabady, PBT(ASCP)

It is no secret that phlebotomists and laboratory personnel carry a significant amount of weight on their shoulders. Whether they are assisting in a stat situation, processing a sample, or acting as a liaison between the patient care team members and the medical laboratory technologist, laboratory personnel need to be resilient. Building resiliency in our laboratory personnel will not only keep team members engaged, but will also increase productivity, and most importantly, increase patient satisfaction.

What is resiliency? Whether faced with a disaster, tragedy, or a difficult work situation, resiliency is how well a person can adapt to the events in their life. According to Psychology Today, “Resiliency is not some magical quality; it takes real mental work to transcend hardship.” The question then becomes, how can we build this quality?

“Building resiliency in our laboratory personnel will not only keep team members engaged, but will also increase productivity, and most importantly, increase patient satisfaction.”

Compartmentalize your Cognitive Workload

Knowing that laboratory personnel across the nation are overloaded with information from a variety of sources, one way to build resiliency is to compartmentalize your cognitive workload. For instance, you receive a phone call to add on testing, you are asked to do a stat collection in the operating room, and you have that timed troponin that is close to becoming overdue. What do you do?

It is a natural reaction to figure out how one must manage all the tasks at once, however, simply asking yourself, “What is the priority?” is a simple way of avoiding a catastrophe. The add-on testing may not need to be completed immediately, but the stat collection in the operating room would. Reaching out to the patient care team member to communicate you have stat collection in the operating room would alleviate the pressure of missing the timed troponin.

Develop Mental Agility

Another tactic that is useful is to develop mental agility. When stressors hit, you want to respond to the situation rather than react. The doctor or patient care team member that is upset because they did not receive his or her results in a timely fashion calls angry and upset. Instead of responding with an emotion such as, “I just have too much going on,” pause. And take a moment to reflect on the situation from a neutral standpoint—“I understand the concern that you did not receive your results in a timely fashion, but I would be happy to assist in figuring out what the delay was.”

According to Rich Fernandez in Harvard Business Review, “Being mentally agile, and decentering stress when it occurs, enables the core resilience skill of ‘response flexibility.’” Fernandez also states that Linda Graham, renowned psychologist, describes this as “the ability to pause, step back, reflect, shift perspectives, create options, and choose wisely.”

Knowing that the laboratory is multifaceted and that we have interactions with all areas of healthcare, we need to promote resiliency within our teams. Stress is bound to occur, but it is how we compartmentalize it and reflect from a neutral standpoint that will assist us in being productive, engaged, and provide the best care for our patients.

Carolyn Sabady is phlebotomy supervisor at ACL Laboratories in Milwaukee, Wisconsin.


Kim Alexis Espejo, ASCLS-IL and Region VI Developing Professional Chair

The MLS Club at the University of Illinois Springfield participates in campus events to promote the club and advocate for the medical laboratory science profession.

Medical laboratory science (MLS), the profession, program, and in my case, club, was never a well-known entity at the University of Illinois Springfield (UIS). As co-president of the MLS Club at UIS, we do plenty to promote our club, program, and profession. Our goal is to broaden the scientific understanding of the diagnostic processes of medical laboratories. The MLS Club hosts many events throughout the year to promote our love of science, which are open to all students and faculty on campus.

Last spring, we did a microbiology E. coli demonstration at our campus’ Health and Wellness Fair. We subcultured the organism on MacConkey agar to show the green sheen it produces. Additionally, we showed the organisms are Gram negative rods under the microscope and had educational information about E. coli. This year we plan to do a Hematology Sickle Cell demonstration and show what sickled RBCs look like under the microscope. Additionally, we will have an educational board about the disease and explain why it is important to get screened, especially for athletes to avoid possible oxygen crises.

We also participate at the UIS campus involvement expo every semester for student involvement. But the biggest event we hold is a lab-inspired carnival. We’ve done it for three years, and all the games have a lab twist, like beaker pong, biohazard bucket toss, anti-booty bounce, etc. At this event we give out free cotton candy and popcorn and do face painting. It is a big hit because students are drawn in with the games and free food, and they end up learning more about MLS.

Another popular event we hold is blood typing events. Not many people know their blood type, so it’s always fun for them to find out. Our program also sponsors blood drives on campus, which are a big success. For Lab Week we plan events such as blood typing, urine drug screen demonstration, cookie blood cell decorating, etc.

Besides events, we also hold fundraisers. Our most popular fundraiser is the annual Poinsettia and Christmas cacti sale. This brings in funds so that our students don’t have to pay to go to the state meeting in the spring.

Furthermore, we participate in service projects. We volunteer as a group for Dance Marathon and the UIS’ trick-or-treat for canned goods. For this we are assigned a neighborhood in town, and the week before Halloween we knock on doors to tell them about the event. Halloween night, we come back to trick or treat, but instead of candy we ask for nonperishable food to donate to the local food bank.

Lastly, we are working with ASCLS-IL to create a parody music video to promote the profession. I think holding fun and interactive events is an excellent way to advocate for the medical laboratory science profession.

Kim Alexis Espejo is a student in the Medical Laboratory Science Program at the University of Illinois Springfield.

Editorial Note: The MLS Club at UIS has been very active throughout the social distancing and shelter-in-place recommedations to keep their members connected and visible. Check out their recent activities on the MLS Club at UIS Facebook page.


James Hollowell, ASCLS Developing Professionals Forum Vice Chair

University of Louisiana-Monroe MLS graduate Jennifer Nguyen at the Spring Into Health event in Monroe, LA. Students used “glitter bug” solution and UV lights to show kids how dirty their hands can get and taught proper hand washing technique.

Recruitment events bring visibility to our field and are a vital part of ensuring a strong future for laboratory professionals. Now that the nation faces a widespread shortage of laboratory staff, it is critical we attract new students to fortify our numbers. Many people are unaware of the work that goes on in the laboratory or how they could become a member of the healthcare team behind the scenes.

Our MLS program here at the University of Louisiana-Monroe views recruitment events as a top priority and sends students and staff to various schools and public health fairs across the state as frequently as possible. The students alone participate in an average of 20 recruitment events per year as a part of professional development activities during their second year of the program. We love to speak to local high school science classes, community college classes, and, frequently, give presentations at our university.

A method of recruitment that we’ve found to be particularly effective is non-biohazardous case studies. It’s something interactive that shows students the kind of work we do in the laboratory and is a fun way to get new people interested in the profession. Even something as simple as a short PowerPoint presentation can be enough to introduce new people to our field and drum up interest in the laboratory. We have seen a massive increase in the number of students applying to our program. It is so easy to reach out to local schools, and they are usually very accommodating and excited to hear from us.

I believe there are so many people out there who would love the laboratory if they just knew all the things we do. Members of this Society should strive to find students interested in the health field or that love science and show them how they can make a career out of the combination of the two!

James Hollowell is a student in the Medical Laboratory Science Program at the University of Louisiana-Monroe.


Patient Safety Corner

Stacy E. Walz, PhD, MS, MT(ASCP), ASCLS Patient Safety Committee Chair

One of the many wonderful resources easily accessible by laboratory professionals, other healthcare professionals, and the general public, is the blog, Lab Testing Matters, sponsored and managed by COLA. For several years now, the ASCLS Patient Safety Committee has proudly been supplying articles for posting to this site.

The 2019-20 theme for articles supplied by the Patient Safety Committee is “Improving Diagnosis in Health Care,” based on the report published in 2015 by the National Academies of Sciences, Engineering and Medicine. In this report, clinical laboratory professionals were specifically identified as critical partners in addressing a specific type of medical error: diagnostic error. The working definition of diagnostic error is, “the failure to (a) establish an accurate and timely explanation for the patient’s health problem(s) or (b) communicate that explanation to the patient.”

The report acknowledges the complexity of the diagnostic process and that it occurs within the context of a work system, workplace culture, and physical environment. Multiple team members are involved, performing specific tasks within their scope of practice, using tools and technologies, all of which can impact the accuracy, timeliness, and communication of a diagnosis.

The authors of the 2015 report suggest eight goals to improve diagnosis in medicine:

  1. Facilitate more effective teamwork in the diagnostic process among healthcare professionals, patients, and their families;
  2. Enhance healthcare professionals’ education and training in the diagnostic process;
  3. Ensure health information technologies support patients and healthcare professionals in the diagnostic process;
  4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice;
  5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance;
  6. Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses;
  7. Design a payment and care delivery environment that supports the diagnostic process, and
  8. Provide dedicated funding for research on the diagnostic process and diagnostic errors.

The Patient Safety Committee decided to devote an article to each of these goals, paying specific attention to how clinical laboratory professionals can play a role. We felt it was important to go beyond just educating our colleagues about these goals, because it can be challenging to see how best we “fit in” to some of these initiatives.

In my personal experiences presenting on the topic of patient safety, my laboratory colleagues are usually in agreement with the need to get involved in improving patient safety, but often ask, “What can I do?” We are lucky to have some very engaged members on the Patient Safety Committee who are involved in their workplaces or in the education of MLT/MLS students in some ground-breaking quality improvement activities that directly relate to improving diagnosis in healthcare. We invite you to access the Lab Testing Matters website frequently and learn from your ASCLS colleagues.

National Academies of Sciences, Engineering, and Medicine. (2015). Improving Diagnosis in Health Care. Washington, DC: The National Academies Press.

Stacy Walz is chair of the Clinical Laboratory Science Program and associate professor of clinical laboratory science at Arkansas State University in Jonesboro, Arkansas.