by nsrn 9 Replies latest watchtower medical
Hey, nurses: The March issue of Nursing 2007 has an article entitled "Can a Bloodless Surgery Program Work in the Trauma Setting?" pp.54-56. It's very pro-witness. I'm tempted to write a 'comment from readers' but not sure what to say. Anyone else read it? I'm not sure how to scan it on here or I'd post it.
Nancy
Darn.. I don't get that journal anymore. It would be a very interesting read. I'll have to see if it is available through the hospital's library.
nsrn, I don't know if this is the right article, but I just went to a hospital, that I had worked for site, and clicked education. You can find the nursing journals there. Bloodless Surgery Goes Mainstream Betty T. Sadaniantz, RN, MSN Monday January 1, 2007
“Providing emotional support for the patient’s spiritual convictions can be just as important and rewarding as addressing physical needs.”
What began as an alternative to blood transfusions for practicing Jehovah’s Witnesses has evolved into a new healthcare specialty — bloodless medicine and surgery.
Through a combination of state-of-the-art technology, careful patient preoperative preparation, intraoperative attention to minimize blood loss, and postoperative monitoring, care can be provided safely without the use of allogeneic blood products. Studies have shown this translates into a speedier recovery and significant savings in healthcare dollars. 1
Suzanne M. Russell, RN, is the coordinator for the Center for Bloodless Medicine and Surgery at Hartford Hospital, CT, a program begun in 1996 to meet the medical needs of patients with deeply held religious beliefs while respecting patients’ rights to autonomy and self-determination.
“It’s a rapidly growing field,” says Russell, although the initial interest was to serve the needs of the population of 25,000 Jehovah’s Witnesses in Connecticut. “Having a bloodless center involves reducing blood transfusions for all our patients by using the same type of techniques and avoiding situations that necessitate transfusions.”
Most surgical procedures can be performed with bloodless techniques, including those traditionally associated with a large blood loss, such as hip replacements and open heart surgery. Minimally-invasive laparoscopic techniques require tiny incisions and therefore reduce blood loss. With hand-assisted laparoscopic procedures, the incision is just large enough for one hand, avoiding big lateral incisions that are associated with increased blood loss.
“The blood loss is minimal, about 100 cc, and the patients are up and about quickly,” says Russell. “Since this technique works well for renal transplant donation, it may increase people’s willingness to participate as donors.”
Noninvasive procedures, such as ultrasonic destruction of kidney stones, can also sometimes be employed. Cryosurgery — another method to reduce bleeding — is done by freezing the tissue prior to resection. Neurosurgeons may use a gamma knife to perform stereotactic radiosurgery.
Mary Beth Legassey, RN, BSN, RNFA, manager of surgical services at North Shore Medical Center, Salem Hospital, Salem, MA, says her hospital uses cell salvage and the “Ortho Pat” system. “When using cell salvage, the operator needs to maintain an uninterrrupted continuous circuit to the patient. This is the only way the procedure will be accepted by a Jehovah’s Witness patient. Predonation is not an option because the blood is not connected to the patient and the blood is stored.”
Legassey adds that it is important to discuss alternatives that will be accepted by the individual. A Jehovah’s Witness healthcare proxy will greatly assist the healthcare provider by listing what is and what is not acceptable.
Opinions vary, however, regarding which conditions are inappropriate for bloodless surgery. According to Steven Gould, MD, of the University of Illinois at Chicago, “Some operations require four to six units; and when you get to that level, it’s hard to imagine not getting any blood.” 2
In contrast, Sharo Raissi, MD, of the Brotman Medical Center in Los Angeles, says, “There is no limit as to what can be done for patients, from open heart surgery even to transplants. 3
Preoperative patient preparation includes medication to stimulate red blood cell production, including iron and Vitamin B12. Erythropoietin, a hormone that stimulates the bone marrow to produce more red blood cells, is usually the drug of choice. It raises the hemoglobin before surgery to provide a margin of safety for the anticipated blood loss.
“For elective orthopedic procedures, erythropoietin is typically given 21, 14, and seven days preoperatively,” says Russell. “For more urgent needs, it may be given 8 to 10 days prior to surgery or at more frequent intervals.” Also, anticlotting medications, such as coumadin, heparin, or aspirin may be discontinued prior to surgery.
Legassey says the treatment must be proactive, not reactive. “This patient population needs a baseline hemoglobin and hematocrit drawn to determine if eyrthropoietin is warranted. Eyrthropoietin takes 7 to 10 days to increase blood levels. Moreover, eyrthropoietin should be given with iron to potentiate its effect.”
Throughout hospitalization at Hartford Hospital, efforts are taken to minimize iatrogenic blood loss from standard blood draws. With the use of microanalyzers, minute amounts of blood can be sampled. Pulse oximetry may be used in place of arterial blood gasses to monitor oxygen levels.
“We do smaller blood samples hospitalwide,” says Russell. “Patients can lose 61 to 70 cc of blood per day to the lab; so if you do the math, in a week or 10 days, they need a transfusion. In fact, most require an average of two to three units after a couple weeks in the ICU.”
Within the operating suite, the surgical team remains attentive to minimizing blood loss. Hypotensive anesthesia may be given to reduce bleeding. Electrosurgical and argon beam coagulators and electrocautery may be used to limit bleeding. With certain procedures, such as a liver lobe resection, the harmonic scalpel can be used to coagulate blood while cutting, via sound waves.
Various pharmaceutical agents, including aprotinin, vasopressin, and prostacyclin can be administered to reduce blood loss. Finally, in a process called hemo-dilution, a specified volume of the patient’s blood may be diverted into a closed circuit during surgery, volume expanders administered for the duration of the procedure, and then the patient’s blood readministered. Any blood that is lost despite these measures may be recovered, filtered, washed, and recirculated via an advanced cell saver system.
Postoperatively, patients may be treated with a hyperbaric chamber, which allows greater oxygen absorption by the tissues, thus speeding recovery. Control of hypertension and adequate rewarming are important aspects of care.
According to Russell, for a successful bloodless program, you need teamwork and cooperation. “You have to have everyone on board, from admitting to radiology to nursing.” An ad hoc committee with members of the nursing, laboratory, and pharmacy departments provides an appropriate forum to monitor issues. “A strong nursing coordinator will bring the disciplines together and set policies and procedures.”
In a bloodless medicine and surgery program, the nursing staff discusses alternatives to transfusions with the patients and assists them in identifying which blood products, if any, and which techniques are acceptable to them. If there are no religious objections, the patient may be concerned about the risk of disease with transfusions but still want blood products in a life-threatening situation.
Advance directives are completed to spell out what is acceptable, and patients are asked to sign a release of liability for no blood. A patient who is absolutely “bloodless” will be identified by a wristband, a sticker on the chart, a sign at the head of the bed, and a notation on the surgical schedule.
Legassey points to potential problems to consider. “State law in Massachusetts states the healthcare provider must do everything possible to save the life or limb of a child. Hence, when caring for children of parents with religious beliefs, it is important for us to explain we understand their religious beliefs but are mandated by law to use alternatives and if necessary to give blood.”
“The harsh reality of a patient’s decision to refuse treatment can become a moral dilemma for the healthcare provider,” says Legassey. “However, providing emotional support for the patient’s spiritual convictions can be just as important and rewarding as addressing physical needs. A Jehovah’s Witness patient whom I cared for told me, ‘It would be worse for me to receive blood than to die.’ As nurses, we have an obligation to care for our patients without being judgmental. These patients are extremely grateful for our respectful treatment.”
At Hartford Hospital the nursing staff is taught to be extra attentive to signs and symptoms of blood loss so it can be promptly stopped. “We don’t have the option of hanging a couple units of blood to buy time before finding the bleeding source,” says Russell.
What does the future hold? With 14 million units of blood used in the US alone last year, 4 periodic shortages, and a conservative cost of $200 to $500 per transfusion, 3,4 hospitals are investigating ways to reduce blood usage. Patients are increasingly aware of the hazards of transfusions, including hepatitis and AIDS, transfusion reactions, and mishandled blood.
At Hartford Hospital, mortality and length of stay have been found to be lower for the bloodless surgical patients, as compared to those of the traditional patients. “It is an interesting and rapidly expanding field,” says Russell. “It is cost-effective, it doesn’t require a lot of high-tech equipment, and the patients are happier and go home earlier. It’s a win-win situation that makes a whole lot of common sense, and I’m sure it will be standard care someday.”
I have a copy of the march issue with me now, however my scanner is down. I'll try and post a copy tomorrow.
I heard a representative from the Red Cross report that blood donations are at an all time low.
If the trend continues perhaps alternative to blood transfusion will have to be pursued for a percentage of surgeries. All the attention to bloodless surgery and alternatives may benefit everyone in the future.
Wouldn't it be cool if JWD nurses collaborated on an article that exposes unethical aspects of the WTS's blood policy?
I'll read the article tomorrow when I get up... thanks for posting it!
The term "bloodless" is a a misnomer since this involves hemodilution and other machines that take one's blood out of the body and then transfuse it back into the body.
In some cases the blood can be disconnected from the body for blood tests and in some surgeries. These machines were banned up until the 1980s by the leadership. Bloodless also involves storing one's own blood too - which is banned by the leadership.
So where's all this stated in the Bible?
HLC members are not at the hospital to represent the JW who needs help. The HLC member is there to represent the views of the WTS leadership and to enforce the leadership's doctrine.
I resent the Nurses Association talking to these HLC individuals. These are individuals who enforce shunning on JWs who wish to disagree with the leadership. In effect the Nurses Association is supporting creed bigotry practiced by the JW leadership by collaborating with the HLC members.
I've noticed that most nurses view the patients who refuse blood as crazy or brainwashed. They don't say this to the patient, but they make plenty of comments behind their backs. I have never heard a nurse who really accepted the refusal of blood as a good or wise thing.
There is so much emphasis on culteral and political correctness these days. I am sure that is behind this article.
