With less blood shed
Steve and Jane Hewitt searched far and wide for a surgeon who could straighten their teenage daughter’s severely curving spine which had hunched her over at a 105-degree angle. The extremely long and difficult surgery involves exposing and separating the muscles from the entire spinal column and installing cadaver bones attached with screws and metal rods for support.
The Hewitts had an additional requirement that made their search even more difficult: The surgery had to be done without blood transfusions. As Jehovah’s Witnesses, they adhere to a biblical admonition against receiving blood.
Surgeons in Kansas City, Kansas, near their hometown, refused to take the case, warning that Sarah, 17, would die during the operation without blood. A Dallas surgeon concurred. But without the procedure, they warned, the condition known as Scheuermann’s kyphosis would likely paralyze and kill her within a decade.
“When they said ‘transfusion,’ our hearts were in our stomachs,” recalled Steve Hewitt. “We cried every night.”
Their church came to the rescue. The Jehovah’s Witnesses’ hospital liaison committee directed the Hewitts to Dr. Ram Mudiyam at the 600-bed Fountain Valley Regional Hospital and Medical Center in Orange County, which has one of the nation’s oldest “bloodless medicine” programs.
Wearing the hospital’s special purple “no blood” tag around her wrist, Sarah emerged from the surgery 11 1/2 hours later in good shape -- with no transfusions -- and was walking a few days later. Her spine is now close to normal.
What makes sense religiously for the Jehovah’s Witnesses, a growing number of physicians and researchers are finding, is in fact good medicine for the rest of the population, for health as well as economic reasons.
Building on knowledge gained from performing thousands of complex surgeries on patients who refuse transfusions for religious reasons, doctors now are using the technique on other patients, performing open-heart and lung surgeries, replacing knees and hips, removing prostates and treating cancer patients -- often with little or no transfused blood. Their experience and studies documenting results are encouraging growing numbers of physicians -- and now large academic centers -- to implement their techniques.
About 100 hospitals across the country, including about a dozen in Southern California, have created bloodless programs.
The Witnesses’ aggressive push, which began in the 1980s to encourage surgeons and hospitals to attempt bloodless procedures, dovetailed with the concern over HIV and hepatitis C viruses tainting the blood supply, which highlighted the risks of using donated blood.
“Once we saw that we could do it, we started seeing it as an opportunity because there is a benefit to everybody,” said Dr. Nicolas Jabbour, a USC Medical Center surgeon who performed his first bloodless liver transplant in 1999. In a small study published last summer in the Annals of Surgery, Jabbour and his USC liver-transplant team compared results for 38 patients -- eight Jehovah’s Witnesses who did not receive transfusions, and 30 other patients who did receive blood -- in surgeries performed from 1998 to 2001. All eight Witnesses survived, contrasted with 27 survivors among the 30 other patients, who received about 4.5 pints of blood on average.
Englewood Hospital and Medical Center in Englewood, N.J., which operates one of the most extensive bloodless management programs for all patients, not just Witnesses, has the lowest cardiac-surgery mortality rate in New Jersey, according to state statistics. Dr. Aryeh Shander, chief of anesthesiology and critical care, says the cardiac unit probably uses “the lowest amount of blood in the world” after the hospital implemented an aggressive campaign to teach all of its physicians how to avoid transfusions.
Blood conservation is among the primary goals of a group of doctors who forged the Society for the Advancement of Blood Management a few years ago. Already, periodic blood shortages have forced hospitals to cancel elective surgeries, and more critical shortages are forecast. Fewer people are eligible to donate blood because of potential exposure to ailments such as mad cow disease. Blood banks, meanwhile, have hiked prices to as much as $500 a pint, giving hospitals an incentive to use blood more judiciously.
Yet, hospitals are vampires, draining at least a pint from each intensive-care patient per week just for testing, substantially raising the odds of a future transfusion. There is even a medical term for this: “iatrogenic” -- that is, doctor-induced anemia. Many bloodless programs have reduced routine daily testing and now take samples in pediatric vials one-fifth the adult size.
Because blood consists of living cells, it cannot be pasteurized. Eliminating transfusions essentially eliminates the risk of blood-borne viruses, bacteria and infections that blood donors may unknowingly carry. (Blood banks now test for only a half-dozen such risks.) The fewer transfusions patients get, doctors have found, the less likely they are to suffer infections, strokes and allergic reactions. A 1997 study found that 27% of those transfused after hip fractures suffered infections, compared with 15% of those who didn’t receive blood. Pope John Paul II was ill for two months with cytomegalovirus -- a viral infection with some symptoms similar to mononucleosis or hepatitis -- contracted from transfusions he received after a 1981 assassination attempt.
Even donating one’s own blood ahead of an elective surgery, which is generally seen as a safer alternative to taking donated blood, isn’t without risk. On rare occasions, hospital clerical errors have led to patients receiving someone else’s donated blood. Cold-storing the blood seems to diminish the critical red blood cells’ oxygen potency. And just like milk, the older the blood is, the less effective -- and possibly deleterious -- it may be, studies have indicated. The FDA limits shelf life to 42 days, with trauma hospitals typically getting the oldest blood because they use it fastest, some reports have shown.
There are times -- such as in accidents that cause heavy blood loss -- when nothing else will do. Some Jehovah’s Witnesses have died when a simple transfusion would have saved them.
Dr. Sarada Mylavarapu recalls watching helplessly as a 48-year-old mother of two died during open-heart surgery several years ago. “It was gut-wrenching to watch -- she was bleeding to death,” the Fountain Valley anesthesiologist said of the woman, a Witness. “Just blood -- that was all she needed.” But it is a crime for doctors to give blood to an adult patient who refuses it.
Robert Avila, a retired industrial designer who spearheads the Witnesses’ Southern California hospital liaison committee, says Witnesses would generally prefer to die rather than consent to a transfusion as long as they know their physicians did their best. “We don’t have an answer for everything,” he says, “and there are some times when we know the outcomes are not what we would want.”
In non-Witnesses, surgeons skilled in bloodless techniques often are aware that they may need to use blood, depending on the patient’s condition and the surgical procedure. “Applying the same principle to all major surgeries, in no way will you expect zero transfusions,” says USC’s Jabbour. “But the aim is to decrease or eliminate transfusions in major surgery.”
There is no single silver bullet involved in performing surgery without blood, but rather a combination of preparation, technique, equipment and attitude.
It starts with optimizing a patient’s red blood cell counts, if low, beginning about a month before elective surgery, using the protein erythropoietin (Epogen and Procrit) and intravenous iron. Yet most hospitals do pre-admission testing only a few days before surgery, too late to correct an anemia problem.
Surgeons and anesthesiologists use special techniques and equipment that minimize blood loss. They include the Cell Saver, a machine that cleanses and recycles blood lost during an operation and pumps the red cells back into the body. A procedure known as acute normovolemic hemodilution can be used to draw blood from the patient just before critical bleeding is anticipated in surgery and replace it with stabilizers, pumping the blood back into the patient later.
Less-invasive surgical tools in the bloodless arsenal include harmonic scalpels, which use ultrasound to cut and coagulate tissue; electrocauterizing devices that can sear blood vessels closed; argon-beam lasers; and blood stoppers such as FloSeal, granules of specially engineered “clotting factors” that the surgeon dabs on bleeding tissue to aid coagulation. Where possible, rather than making large cuts in the flesh that cause more bleeding, they do laparoscopy, endoscopy and interventional radiologic procedures that kill tumors with radio-frequency energy and heat, for instance, making removal of a tumor on the lung far less traumatic.
They also employ a variety of drugs that can stop hemorrhaging by improving clotting, such as NovoSeven, approved for hemophiliacs.
And surgeons -- aware that transfusions are not an option for Witness patients -- have learned to refine their technique by making more precise and gentle incisions. “It definitely ups your game,” says Dr. Reginald Abraham, a cardiologist at Fountain Valley. “You’re just that much more careful about even a minute amount of blood loss.”
Most physicians and hospitals will say that transfusions should be done only when necessary, but their definitions of “necessary” vary widely. “Tradition and conviction,” rather than scientific study or even art, dictate the common trigger points, says Englewood Hospital’s Shander. Some physicians at Englewood have expressed the view that transfusions can’t hurt patients but Shander disagrees. “We aren’t giving any benefit and we may be adding risk,” he says. “Sometimes the risk is appropriate because the benefit is great. But when the risk is there and there’s no defined benefit, then how can you justify giving one?”
Many physicians automatically transfuse when a patient’s hemoglobin -- a measure of the oxygen-rich red blood cells in the body -- drops below normal levels of 13 to 15 grams per deciliter of blood. Some opt to do it when the count dips to 10 grams, and others when it hits 7. A cardiac patient was transferred to Fountain Valley last week after a surgeon at another hospital refused to operate because her hemoglobin was 14.
Few large, prospective clinical trials have compared outcomes. The largest, reported in the New England Journal of Medicine in 1999 and conducted on 838 critically ill patients, found a slightly lower mortality rate in those given blood when hemoglobin levels dipped to 7 grams compared with those transfused at 10 grams or above.
“When hemoglobin was allowed to go down, it made no difference and there was a suggestion that there was some harm done when you gave more blood,” said lead investigator Dr. Paul Hebert, a critical care physician and epidemiologist at the Ottawa Hospital in Ontario, Canada.
Witnesses have many examples of medical personnel warning that they will die without blood -- only to be proven wrong. Avila’s committee fields about 200 such calls a year.
Pregnant with twins, Cristina Cortez went to a large Los Angeles hospital with premature contractions and a hemoglobin level of 7.8. Without blood, the doctors said she and the babies would die. They put her on iron supplements, which barely raised her hemoglobin in a week. The medical staff tried to talk her out of transferring to another hospital, warning that her treatment would be no different. But she went to Fountain Valley, where Dr. Vinod Malhotra, director of the hospital’s bloodless program, put her on intravenous iron, Epogen and prenatal vitamins, aware that the babies were absorbing the iron first. She delivered two healthy baby girls -- one vaginally, the other by caesarean (the cord was wrapped around her neck) -- without any transfusions. At delivery Cortez’s hemoglobin level went as low as 6, but doctors maintained the iron supplementation, and she left the hospital in four days.
Staffers at Fountain Valley Regional Hospital jokingly refer to suit-clad members of the liaison and patient visitation committees as the “Witness Protection” program. They roam the halls, meet with doctors and sometimes observe surgeries. Though few have formal medical training, they are well informed on medical issues, some doctors say. “They know every argument we’re going to make and always have an alternative,” says anesthesiologist Dr. Andy Plisko.
The Fountain Valley hospital program attracts about 120 Witness patients a month from across the country, largely because of the reputation of Malhotra, who began working with the Witnesses about 25 years ago.
He attended medical school in India, where blood was often scarce, so the idea of doing surgery with little or no blood made sense to Malhotra, who, like the other Fountain Valley doctors, is not a Witness.
One of his regulars is Geraldine Smith of Santa Ana. Recuperating from a bloodless hip replacement earlier this month, she’s been seeing Malhotra for years. Has she been in the hospital before, a visitor asks? “Girl, how many times,” she answers, all for procedures for which surgeons not cognizant of bloodless techniques would typically have transfused several units.
Says Smith’s daughter, Rachele Flemings, “Distance doesn’t mean anything when you have someone who is going to respect your wishes.”
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Learn more
More information about transfusion-free medicine,
and the hospitals that offer bloodless services, is available
at the following websites:
The Society for the Advancement of Blood Management, a U.S. physician-led group, www.sabm.org.
Network for Advancement of Transfusion Alternatives, a European-based international organization, www.nataonline.org.
Jehovah’s Witnesses health website, www.noblood.org.
