MUSKAAN SHAH – INTERNSHIP REPORT

Location: Qure Hematology Clinic, Ahmedabad

Duration: Four weeks

ABOUT QURE:
Qure is a hematology clinic situated in Ahmedabad, which aims to cure patients affected by
blood disorders in an approachable and affordable manner.

INTERNSHIP SUMMARY:
I interned at Qure for four weeks to be precise. During my time there I saw plenty of patients,
learned how to work in a laboratory, read books about various disorders like Hemophilia and
factor deficiency disorders and picked up some key communication skills due to my
interaction with the patients. I also observed procedures like Bone Marrow Biopsies and
Aspirations and ITs. I was also given the opportunity to visit a blood bank and Sterling
Hospital for one day with one of the doctors.

KEY RESPONSIBILITIES:

Seeing patients

1. During my internship I saw patients with different doctors, but majority of them were
with pediatricians. The first patient I met was a six-year old boy, who had excessive
bleeding from his teeth. The doctor studied the file and made me aware of the case.
She first tried to see the severity of the bleeding, and then asked as to when did he last
have any issue of bleeding, what unusual symptoms were his parents observing in
him, and whether he was taking his medications on time. That was when the parents
said that after a few doses, he was feeling fine and they didn’t have enough money to
get the medicines so he hadn’t been taking them since a month or two. The doctor
prescribed more affordable medications and asked the nurse to provide the medicine
to stop the child’s bleeding. They were asked to come back after fifteen days for a
follow up.
2. I observed many patients suffering from ALL (Acute Lymphocytic Leukemia), and
read about the chronic lymphocytic and myeloid leukemia.
3. I also met patients with deficiencies in the factors of the Coagulation Cascade. Most
common ones were Factors VIII and IX which is also known as Hemophilia A and
Hemophilia B. Another factor was fibrin stabilizer, Factor XIII. Treatment for
deficiency in Factor XIII is usually Plasma and Cryoprecipitate, or simply ‘cryo’.
Cryo is usually more preferable for treating the patient, but Plasma can be used.
4. Moreover, I saw numerous patients with different disorders like Immune
Thrombocytopenia, Thalassemia, Sickle Cell Anemia and the ones mentioned above.

Laboratory Work:

1. I was taught how to make peripheral blood slides, and how to stain them using a
Leishman stain. Wearing gloves during this process is very important. A capillary is
taken and a generous drop of peripheral drop is put on the slide. Another slide, known
 as the spreader is taken and a tongue-shaped smear us made. It is extremely crucial to
label each and every slide properly before staining it. The smear is allowed to be dried
and is then taken for staining. The slide is completely covered with the stain and left
for about 2-3 minutes. The buffer is added and mixed properly using a dropper. It is
left for 8-9 minutes and then
washed. Once dried, it can be
observed under an electron
microscope.
2. I learnt to draw the cells,
observe them under a
microscope and differentiate
and identify each one of them.
The blood cells include
erythrocytes, leukocytes and
platelets where I learn about
the types of leukocytes and
morphologies of erythrocytes
in detail. There are two
categories of leukocytes or
white blood cells: granulocytes and agranulocytes. Cells with grain like structures are
neutrophils, eosinophils and basophils. The agranulocytes include monocytes and
lymphocytes.

Observing Procedures:

1. I observed a bone marrow

aspiration and biopsy. It is
usually carried out to study
the morphology of immature
blood cells. The slides were
kept ready to prepare the
smears because I learnt that
marrow can clot faster than
blood can. The doctor is
supposed to wear sterile
gloves and then cannot touch
anything which isn’t sterile.
The area to be operated is
cleaned first, from the center,
moving outwards. A local
anesthetic is given and the BM sterile needle is inserted at the hip. The needle is
inserted through the bone, and the aspiration is taken. The slides are made as fast as
possible and some of the aspiration is collected in vacutainers if in case required for
future. The next step is to do the biopsy. I was taught at the clinic that the BM Biopsy
is a sort of a fracture as a tiny, cylindrical piece of the hip bone is taken out. Imprints
of the bone are also taken, and then it is placed into a preservation chemical. It is very
important to make sure that all the vacutainers and everything else is labeled with the
patient’s name and all the used syringes, cloths and everything is properly disposed
of. I also learnt that the gloves must be torn and then thrown away to reduce risk of
reuse.
 2. An intrathecal is a procedure carried out to prevent the spreading of any blood cancer
from spreading to and in the nervous system. Therefore, a variety of medicinal
chemicals need to be very carefully and in the correct order injected. I saw this
procedure while the doctor carried it out and she explained me how and why it is very
important to make sure that which medicine should be injected first and which ones
must follow.

Visit to the Blood Bank:

I first saw a donor donating blood, and the other donor donating platelets. The donors are
usually given a calcium pill or glucose water to make sure that they are comfortable. They are
made to sign a consent form before they donate the blood.

The blood is collected in a 450ml bag and so are platelets. In case of platelet donation, an
anticoagulant is also suspended. Once the blood is collected, two vacutainers(plain and
EDTA) are filled.

These vacutainers are sent to the grouping and testing section where the blood is first checked
to be infected from HIV, malaria or hepatitis, Then, in another machine the blood group is
checked. The blood bags are directly sent to the component separation room where the cells
are separated.

Red blood cells are stored at 4 degrees Celsius and have a shelf life of 42 days; plasma is
stored at -30 degrees Celsius and can be stored for upto a year. Platelets are kept at 22
degrees Celsius, in a rocking motion and have a shelf life of only 5 days. Cryoprecipitate is
stored at -80 degrees Celsius.

I then went to the room where the blood bags were being provided to the patients’ relatives.
The request letter sent by the doctor would be read and the entire entry system worked with
barcodes. The blood groups were tested again manually once again using reagents and it was
made sure that the patient’s blood and donor’s blood match. Then, with the bar code, doctor’s
name, patient’s name and all other details, the donor’s blood bag is provided.

KEY LEARNINGS:

I learnt many things throughout the period of one month, like my perspectives of
seeing patients on the first day and then seeing patients on the last day was so different that it
left me thinking as to how much I had learnt by then. I can go to a pathology laboratory and
no more get confused as to why the vacutainers all have different colors on them. I also saw
the world in a doctor’s perspective and so realized that there is no good in hiding anything
from your doctor. These many disorders and observations above and changed my perspective
of blood, procedures, doctors and much more…and also made a difference in my daily,
applied lifestyle.

Taking the history was more like a training as to how to communicate with the
patient. Communication must be done through your eyes when talking to a patient, so that the
patient would feel comfortable to talk to you and see the compassion in a doctor. A
conversation with the patient must be done in such a way that the person would trust the
doctor to tell them everything. The history usually involves why the patient has come there,
what the patient had done before, about the symptoms, about any other problems like blood
pressure or diabetes, whether the patient has taken any transfusions in the past or may have
been admitted in a hospital before. These are very common aspects while taking any history,
for example, a flow chart is made of the whole family: the parents, the spouse, the children
and what they are suffering from or what they have been through before…so that any
disorders that can be inherited can be tracked down and planned easily for the future to be
safe for the entire family and the generations to come.

Patients’ concerns and worries are something a doctor must be able to understand
while conversing with the patient. A few of the patients I saw with the doctors were not
uncomfortable in having me around, but were very nervous about seeing the doctor itself, or
were worried as to what had happened to them. In one of the cases when I saw one of the
doctors assuring the patient that it was going to be alright and she didn’t think that it was
anything serious, after a while I saw a sort of relief on the patient and his wife’s face as they
thanked her, saying “You are the most understanding and patient doctor we have seen, thank
you.”