I like the way the say some would just "bleed out."
http://www.portlandtribune.com/archview.cgi?id=32615
In hundreds of surgeries a year, doctors take ‘bloodless’ route
By PETER KORN Issue date: Fri, Nov 11, 2005 The Tribune
John Hanna remembers what it was like for Jehovah’s Witnesses in Portland before 1991. Good medical care was hard to find.
Understand, Hanna knows there are plenty of fine physicians in Portland. But Witnesses have a long history of conflict with the medical community because their religion forbids the transfusion of blood.
A few local doctors treated Witnesses, Hanna says, but major surgery was almost impossible to get. Unable to find local doctors willing to perform surgery within its guidelines, the Witness community would send members out of state for surgery. Even worse, Hanna says, were trauma patients, victims of accidents. “There were cases where people would just bleed out,” he says.
Hanna and other leaders of the Witness community started talking to local physicians. Which led them to David Rosencrantz, a sympathetic urologist at what is now Legacy Good Samaritan Hospital & Medical Center. What Witnesses wanted was surgery aimed at minimizing blood loss, and surgeons willing to respect their beliefs, even if it meant letting them die by not giving them transfusions.
What they got, thanks to co-director Rosencrantz, was Legacy Health System’s Bloodless Surgery and Medicine Program, the only one in Oregon and among the first in the country. And Rosencrantz? Well, he’s a bit of a hero to some in the Witness community. As a result, he’s pushed for changes in surgery that affect everyone.
“We found a doctor willing to carry the banner and help people better understand our needs,” Hanna says. “He’s been a champion of our position.”
Bloodless surgery — on the face of it, the phrase doesn’t make sense. Surgery almost always involves blood, often lots of it. But what Rosencrantz and colleagues try to do is limit bleeding as much as possible so that Witness patients do not need transfusions.
Consider the program’s first case, back in 1991. A Witness at a hospital outside Portland had suffered a miscarriage and was bleeding profusely. Emergency doctors said she needed a transfusion, but she refused. Her sister-in-law, who had heard about the new program at Good Samaritan, phoned Rosencrantz from the hospital emergency department.
“She was bleeding to death,” Rosencrantz says. “They didn’t know what to do.”
What they did was transport the woman to Good Samaritan, where Rosencrantz called in a gynecologist and an anesthesiologist to try to stop the bleeding. The surgeons, using a piece of equipment called an argon beam coagulator — which uses gas and electrical current to help stem bleeding — succeeded. So why was the originating hospital, which had its own coagulator, unable to care for the woman? Rosencrantz thinks the answer lies in attitude.
“They were stymied by the fact that she bled and bled, and they couldn’t give her blood,” he says.
Saying no to the safety net
Bloodless surgery actually begins well before a patient has seen an operating room. Medications are used to boost the blood’s red cell count weeks before surgery, and to improve the blood’s ability to clot. Surgeons can use high-tech scalpels to limit the cuts that cause bleeding, and cauterize vessels so they stop bleeding. Blood salvaging also is part of the program. Using machines called cell savers, surgeons can capture lost blood and return it to the patient.
But often the answer to Witnesses’ prayers is not so much technique as patience — surgeons taking extra time to make sure they don’t nick or scratch with their instruments, because the safety net — transfusing to replace lost blood — is unavailable.
“If you’re going to truly do bloodless surgery you’re pushing the envelope,” Rosencrantz says, “using all the techniques you can to not lose blood.”
Blood is complicated stuff. It can carry disease, it can sustain life, and it deteriorates. Blood is expensive, about $500 a pint. Before World War I, when blood typing and transfusion techniques were refined, losing blood was a death sentence.
But transfusions are not an exact science. For instance, there is disagreement among physicians as to when they are necessary.
Anesthesiologist David Farris, the bloodless surgery program’s co-director, says if a surgical patient’s hemoglobin count, a measure of red blood cells, falls below 10, most anesthesiologists will call for a transfusion. But it’s better to set the limit at a blood count of seven, Farris says. According to Farris, transfusions lead to higher fatality rates among surgical patients. Doctors haven’t yet figured out why, but blood-borne infections are suspected as at least one cause, Farris says. Whatever the reason, transfusions increasingly are being avoided in all patients unless necessary.
Some patients lost
Farris has watched patients die with bloodless surgery that he knew he could have saved. That’s the other side of the bloodless surgery program. Witnesses sign all the appropriate paperwork, and every effort is made to ensure they are sincere and firm in their beliefs, but sometimes even bloodless surgery can go wrong — bleeding won’t stop, clotting techniques don’t work, and a surgical team is left with a patient who needs a transfusion to live, but won’t allow it.
When that has happened, Farris has discovered he could deal with patients dying on their own terms. “I’ve had other patients die as well,” he says. “I wasn’t going to stop them all. Death is a natural part of being here. This program is about self-determination.”
Rosencrantz and Farris direct the medical end of the bloodless surgery program, but what makes the program so successful, according to a number of area physicians, is coordinator Mary Anne Knauss.
Knauss, who serves as liaison between the hospital staff and patients, is a Witness herself. She has dealt with doctors who refused to treat her son for a ruptured spleen when she refused to allow transfusion, and now she deals with both Witness patients and doctors, building trust on both sides.
For years, a poorly kept secret in the medical community was physicians respecting the “no transfusion” orders of Witness patients until the patients became unconscious and near death. At that point, doctors would resort to transfusion, with the patient unable to prevent it. That doesn’t happen anymore, at least not at Legacy, Knauss says. Knauss makes sure both patients and doctors know what is expected of them, and she makes sure everyone follows through.
“What she did was make these people understand before they started, what they were in for,” says Larry Eidemiller, a surgeon who worked with the bloodless program until his retirement in 2000. “She was trusted and made sure they did understand beforehand and followed up.”
‘We feel blood is sacred’
Jonathan McEwen’s understanding came in a hurry. Three years ago McEwen, a Witness, slammed his moped into a Dodge Dakota in Tualatin. His face was crushed, his skull cracked, one eye fell to the ground and one leg broke in two places. And he lost a lot of blood.
Paramedics were ready to give McEwen blood, until they found his wallet medical ID that stated “No Blood” in bold letters.
A Life Flight helicopter rushed McEwen to Legacy Emanuel Hospital & Health Center for two months of surgery and care he says he hardly remembers. But he does recall his arrival.
“Of course the doctors recommended stuff like crazy,” McEwen says. “But because of my strong faith I refused. We feel blood is sacred and the Bible says directly it should not be eaten, and putting it into me is the same thing.”
McEwen entered Emanuel weighing 185 pounds and left at 130. He knows he came very close to dying. And he’s thankful. “I’m thankful that they respected my wishes. But I would expect nothing less,” he says.
At first glance, Legacy’s bloodless surgery program, which performs close to 800 surgeries a year, is about a small minority of patients — Jehovah’s Witnesses like McEwen. But the blood-saving protocols used by the program’s doctors have applications for all surgical patients.
Patients hold more power
Cell savers and coagulants and pre-surgical blood building medicines are becoming commonplace as more physicians recognize the dangers of transfusions for everybody. Also, blood is in short supply.
“Blood conservation is the wave of the future,” Rosencrantz says. Good Sam’s initial bloodless surgery program began with 40 surgeons participating, and today more than 300 have committed to working under the program’s guidelines.
In fact, 5 percent of the people who sign up for elective surgery under the bloodless surgery program are not Jehovah’s Witnesses. “They’re afraid of disease,” Knauss says. Knauss says most tell her they have family members who have suffered or died from AIDS or hepatitis C.
The very existence of the bloodless surgery program demonstrates how much medicine had changed in the last 15 years. When he began practicing medicine, Rosencrantz says, the idea of patients being in charge and overruling physicians’ advice was far-fetched.
Patricia Newton, medical director of Legacy’s Clinical Ethics program, says two decades of court cases have tipped the balance away from the idea of the all-powerful physician. “It’s very clear now that patients can have the right to refuse any therapy, including life-sustaining therapy, if they understand the ramifications of their decisions.”
Newton says that every day cancer patients have to decide whether to submit to chemotherapy, which may extend their lives, but at a cost. Every day thousands of Americans quit dialysis, knowing they are signing their own death warrants.
“If they say it’s more important to me to not receive blood than to live, then people have the right to determine that for themselves,” Newton says.
| Children benefit from technique One of the most successful Legacy Health System programs is the pediatric cardiac surgery program headed by Dr. Albert Starr. Starr and his colleagues have garnered national attention for their successful heart surgeries on even the smallest of newborns. And the success of the Children’s Cardiac Center surgeries can be traced to a strong connection with the bloodless surgery and medicine program. Dr. John Iguidbashian, a cardiothoracic surgeon at Legacy Emanuel Hospital & Health Center for 10 years, says bloodless surgery techniques are incorporated in all of the cardiac program’s pediatric surgeries. In fact, Iguidbashian says, many of the program’s lifesaving surgeries would not be possible without bloodless surgery protocols. About 10 times a year, for instance, the surgeons operate on a child with hypoplastic left heart syndrome, a congenital condition in which only the child’s right ventricle is working. The condition requires three operations, and long-term survival, even with successful surgery, is only about 20 years. But without the operations an infant would have no life to look forward to. And without medicine that builds red blood cells, the surgeries would not even be thinkable. Before blood-building protocols developed at the bloodless program became available, virtually nobody operated on these children. The bloodless program has helped the pediatric surgery program in other ways, as well. Infants and young children have much less blood than adults, which means less to spare. If a transfusion is going to be avoided, every drop counts. “We’ve developed techniques to conserve blood through our experience with the bloodless program, and we do our more routine surgeries with less blood transfusion than other programs,” Iguidbashian says. “We conserve all blood during the surgery,” Iguidbashian says. Cell-saver suctioning and recycling are common in Legacy’s pediatric heart surgeries. Children of Jehovah’s Witness families have long been the focus of one of the most difficult ethical dilemmas facing physicians and hospitals. Over time, the medical profession has come to accept the right of adult patients to determine their own treatment and to deny treatment such as transfusion. But when children are involved, parental authority usually does not carry the day. Traditionally, hospitals have had to gain court orders to treat children over the objections of parents. That’s a situation nobody likes, according to Patricia Newton, medical director of the Legacy clinical ethics program. Just when a child most needs parental support, as he or she is entering surgery, the child is effectively removed from the guardianship of the parent. In an attempt to avoid these battles, the bloodless surgery program has developed a consent form that allows parents as much leeway as possible, basically stating that the hospital will do all it can to avoid transfusion, but acknowledging that transfusion can occur as a last resort. By signing this form, parents and guardians are allowed to stay involved with the child. According to bloodless surgery program coordinator Mary Anne Knauss, since the pediatric bloodless surgical program opened at Legacy, no court orders have been necessary, and some Jehovah’s Witness children have received transfusions as a last resort. Legacy’s staff performs about 250 pediatric surgeries a year with bloodless techniques, and most of them are not the children of Jehovah’s Witness families. “The tougher cases come here,” Iguidbashian says. Tougher usually means smaller. “It’s the really small ones you have to be careful with, and it takes another level of meticulous surgery and blood conservation.” Iguidbashian insists the children recover more quickly and completely if transfusions are avoided. Infection rates are lower and children suffer less inflammation, too. Iguidbashian says the center has a mortality rate from all heart surgeries of about 1 percent, compared to a national average of around 4 percent. “We’re very meticulous with our surgery,” he says. “We don’t have a lot of bleeding and sloppy work. We rarely have to take a patient back to the operating room for bleeding. |