Lessons learned from the outcome of bloodless emergency laparotomies on Jehovah’s Witness women

by OrphanCrow 27 Replies latest watchtower medical

• 

  OrphanCrow

  The WT has promoted bloodless surgery as a viable (and better) alternative to surgery with blood transfusions.

  I have found a medical study that has been used to back up these "evidence based" claims.

  The title of the article is Lessons learned from the outcome of bloodless emergency

  laparotomies on Jehovah’s Witness women presenting in the extremis with ruptured uterus. Authors B. Chigbu · S. Onwere · C. Kamanu · C. Aluka ·

  O. Okoro · P. Feyi-Waboso · C. Onichakwe, published 2008 in the journal Archives of Gynecology and Obstetrics.

  http://www.ncbi.nlm.nih.gov/pubmed/18677500
  

  This study has been cited 11 times, most notably in Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology and in a publication authored by Shannon Farmer and Axel Hofmann (both Jehovah's Witnesses) and two others, Patient blood management–a new paradigm for transfusion medicine?

  In this study, the authors compare two groups of patients - a group of 20 JW women who did not receive blood with a group of 45 women who did receive blood transfusions as part of their treatment. Both groups of women had a similar condition - a ruptured uterus.

  The purpose of the study was to evaluate if women refusing blood transfusions had similar or different outcomes to those who relieved blood.

  In the non-transfused group, 3 women died (12%) and in the transfused group, 7 women died (15.6%). Hospital stay for the non-transfused group was 7 days and for the transfused group was 8 days.

  Those results were what were used to make this conclusion:

  This study has shown that patients who are in haemorrhagic
  shock from ruptured uterus and who still refuse blood transfusion
  can successfully be salvaged in a low resource setting.
  As physicians, we come into contact daily with people
  whose culture, religion, and beliefs forbid certain forms of
  treatment. Our ability to meet the needs of our diverse
  patient populations is one measure of our success or failure
  to provide optimal health care to our community. There is
  therefore the need to establish a BM&S program in
  resource restricted settings and elsewhere to educate and support physicians and staff who are committed to meeting the medical needs of Jehovah’s Witness patients and others
  who refuse blood transfusions.

  I think this study uses questionable methodology. I want to focus on the one most glaring flaw that I think this study has.

  That flaw has to do with the patients who died in the group that received blood transfusions.
  

  Here are the results that the researchers analyzed and compared:

  Table 1 shows that 17 (88%) of the patients not transfused
  survived. Three maternal deaths occurred in this
  group and the deaths were attributed to peritonitis. 38
  (84.4%) of the patients transfused survived. Six out of the
  seven maternal deaths in this group were due to peritonitis.
  These mostly indigent patients died of peritonitis because
  of delays in payment for antibiotics. Antibiotics were supplied
  only after payment. One patient died of disseminated
  intravascular coagulation. Infectious morbidity occurred in
  30% of those not transfused and 40% of the patients transfused.
  The need for ventilatory support was similar in both
  groups and was an average of 4 h. The length of post operative
  hospitalization was an average of 7 days for the
  patients not transfused and 8 days for those transfused.

  Let's take a closer look at the 6 women in the transfused group who died of peritonitis (infection):

  These mostly indigent patients died of peritonitis because
  of delays in payment for antibiotics. Antibiotics were supplied
  only after payment.

  Homeless women died from infection because they couldn't pay for their medicine. They didn't get proper medical treatment. Antibiotics were held back on them. Why? Because they were indigent - they were poor.

  And that is who the JW women who died are being compared to? A group of destitute women who had their medicine held back until they could find the money to pay for it? if at all? All six women who died from infection didn't receive treatment because they were poor.

  The cause of death for them was poverty. It was the lack of antibiotics that contributed to their deaths. Lack of money.

  Money. Pure and simple. Money is all it would have taken to change the outcome of this study. Either that or some compassion.

  Some antibiotics is all it would have taken to reduce the maternal death rate for the transfused group, possibly to as low as 0. And instead of this study being used to show how good bloodless surgery performs, it would have shown an increased risk to no blood patients of possibly up to 20%.
• 

  nugget

  So the differences between the 2 groups was more than whether they received a transfusion of not. The non transfused patients were not homeless, there is no record of prior medical conditions or general health which may also have affected the outcome.

  There is also no record whether the JW patients had all received antibiotics in a timely manner or whether those that died had done so after receiving antibiotics.

  If this was a study it would be hoped that both groups received the same medical care with the exception of the blood transfusion and that both groups were similar in other ways to ensure that the conclusions drawn were valid. It seems that the homeless women were treated differently and that failure to provide all the care they needed was what killed them.If you remove the women who did not receive antibiotics from the study then witness women did not do as well as the non witness women.
• 

  millie210

  It makes you wonder how they could receive surgery and ventilation while so poor (and in the case of some, receive blood also) and yet antibiotics were too over the top?

  Is this because of poor priorities? A distribution problem? Maybe they should have gotten the antibiotics before they arrived at the hospital and were unable to?
• 

  OrphanCrow

  Good questions and observations, Millie and nugget.

  If you download the study and go over it, there are a lot of other questions that arise about sample group selection and comparisons.

  The authors claim that demographics were analyzed between the groups, but if so, why this discrepancy with socio-economic status?

  There is very little data included in the study and several statements that the authors make are unsubstantiated.

  It is clearly biased and contains questionable conclusions

  millie: Is this because of poor priorities?

  That is a moral question and not valid to be brought into the equation when analyzing results. Indigent is not a moral position even though some authors would like to subtly use it as one - it is a position defined by economic situation.

  Millie, your query, I think, is exactly the one that the authors want you to make

  
  
• 

  dubstepped

  I'm no scientist, but isn't that sample size way too small to be conclusive in any manner? Not to mention the astute observation as to the real cause of death.
• 

  nonjwspouse

  Once again, Birdie, you provide so much food for thought, encouragement to look deeper into the extremely important details.
  

  I look Forward to each of your well researched, and well presented observations and findings.

  Keep it up, my far away friend, for as long as you can stand it!
  
• 

  OrphanCrow

  dubstepped: I'm no scientist, but isn't that sample size way too small to be conclusive in any manner? Not to mention the astute observation as to the real cause of death.

  I'm not a scientist either. But I did really like the research methodology class I took when I was in university. My professor, ol' Bernie, would have had a heyday with this study. He would have got a full, entertaining, 3 hours of critique out of this one study alone, I am sure.

  20 is a small sample size. I don't know if it is sufficient. I would be more concerned with the differing sample sizes and the inherent statistical problems that arise when comparing such groups.

  As well as the inability to control for external factors. Far too many variables between groups with the most obvious one of all - economic status that affects the level of care.

  After approval of the protocol by the Ethics and Investigation
  Committee, we examined the ward records, operating
  room records and case files of all patients who underwent
  emergency laparotomies for ruptured uterus at the Abia
  State University Teaching Hospital between 1 January
  2000 and 31 December 2006. Patients who were haemodynamically
  stable at presentation were excluded from the
  study. The inclusion criteria were a diagnosis of ruptured
  uterus with clinical features of hypovolaemic shock or
  blood pressure of less than 90/60 mmHg, and a preoperative
  haemoglobin concentration of 8 g/dl or less. Twenty
  such patients who were of the Jehovah’s Witness sect and
  who refused blood transfusion were identified. Another 45
  patients (made up of 2 JW and 43 non JW) who accepted
  blood transfusions were identiWed. Both groups were evaluated
  for various obstetric and demographic variables: age,
  parity, gestational age at delivery, placental location, and
  number of previous cesarean deliveries.

  The authors make that last statement but they don't provide the data to support any comparative conclusions about those variables. They just simply say the groups were evaluated. And....??? Why can't I see that data?
• 

  steve2

  So, if you assume the small sample size IS sufficient to draw reliable conclusions (a big if), the better survival group in terms of transfusions versus nontransfusions was the transfused group - because 6 of 7 deaths were due to delayed start of post-surgery antibiotic treatment, not any surgical or transfusion failures.

  This points to the study being deeply flawed. The 2 groups are simply not comparable across all important variables (socio-economic status, health status, etc) except treatment (transfusion versus no transfusion). In research parlance, important variables were not "held constant".

  I'm surprised it was published in the first place - or that the authors didn't acknowledge its limitations regarding viability of nontransfusion outcomes. Given the consequences, that is an extraordinary failure on the authors' part.
• 

  OrphanCrow

  Thanks, Nonnie.

  I usually find it easier to deal with the casualties of the JW blood ban from the distance of medical studies and legal cases. Personal stories can sometimes rock my world too much...hard to handle too much real pain.

  It is unbelievable as to how many of the JW deaths are recorded as statistics in the scientific literature. And my mind boggles at the numbers of those not published.

  This particular study unsettled me, though, Usually it is the JW women (or children or men) who died from refusing blood that are on my mind when I close my eyes at night. This time, all I could think about were the 6 women who couldn't afford antibiotics, and instead, ended up as statistics to be included in a study to promote the JW elite brand of medicine: their technologically rich, bloodless world
• 

  OrphanCrow

  steve2: This points to the study being deeply flawed.

  Deeply.

  I'm surprised it was published in the first place - or that the authors didn't acknowledge its limitations regarding viability of nontransfusion outcomes. Given the consequences, that is an extraordinary failure on the authors' part.

  Unfortunately, the scientific/medical world is not a clean world. Remember the fraudulent hetastarch researcher? Joachim Boldt? The WT "expert" who is blacklisted all over the place?

  Lots of studies get past ethic boards and peer review. It is an ongoing problem for scientists right now, especially with the surge that digital transmission has allowed. The studies being released have created an explosion in material that is difficult to police and evaluate.

  This is a website that attempts to monitor bad science:

  http://retractionwatch.com/
  

  I am not surprised - this is typical for what I would expect the bloodless world to use as their "evidence based research".

  Quack science. A hundred years ago, it was a radio active belt and a wooden box with wires coming out of it that the WTS promoted. Today...it is bloodless surgery