Dorothy McPhee has a life-threatening medical problem, an artery that could burst at any time.
The normal way of doing this operation is generally through the abdomen, a long vertical incision.
Leslie is a young girl with a serious spinal deformity.
The patient is a Jehovah's Witness and in a procedure of this magnitude it is unavoidable that some blood loss will occur.
Both patients need surgery, yet both patients have religious beliefs that preclude their accepting a blood transfusion.
Medical science is now providing doctors with alternative strategies to treat successfully patients who for various reasons avoid blood transfusions.
These new strategies may soon benefit all patients.
At the dawn of the 21st century, society is becoming increasingly diverse.
People everywhere are being exposed to different languages, customs, cultures and religious beliefs.
Adapting to these differences is a challenge to all strata of human society.
It is a singular challenge for the medical community.
We're living in a pluralistic society and the doctor has one set of values, but he or she will meet patients who have their own values and their own position about certain issues.
There's a lot of different cultures out there and they have entities specific to their own cultures that we as health care workers need to understand.
I think the duty of physician is not simply to preserve life, but the first and foremost duty of physician is to respect the patient.
In the past, the medical profession found it difficult at times to respect the health care needs of one religious group in particular, Jehovah's Witnesses.
This was because of their avoidance of blood transfusions.
That was the easiest decision because there was under no circumstances would I accept blood.
One thing I heard he says blood transfusion and immediately I said no, no.
I couldn't live with myself if I turned my back on my beliefs and my God and I wasn't going to accept the blood transfusion.
Their abstaining from blood transfusions was often misunderstood by the public.
There was certainly a time in years back where Jehovah's Witnesses were looked at by physicians and especially surgeons in a negative way.
I think before I had ever met a Jehovah's Witness I had a certain mindset that they were maybe a religious fanatic type person.
Part of it I'm sure is prejudice about a religious sect which the physician or the judge or the lawyer about which they may know next to nothing.
A lot of people nowadays have heard of dangers or diseases that might be contracted from blood and blood transfusions.
But frankly for Jehovah's Witnesses central to their avoiding blood transfusions is because the Bible highlights the preciousness of blood.
It's a very clear statement by the way.
It isn't something that takes a lot of theological study to determine a workout.
It says very plainly in the Christian scriptures abstain from blood.
From the point of view of someone who's not a believer this seems an irrational act.
For some people it seems to be anti-medicine. It seems to be somehow putting the patient in jeopardy.
I think some of us, myself included, was under the impression that maybe Jehovah's Witnesses didn't want the best medical treatment, that they were sort of against medical care.
There's no question it mattered to me whether she lived or died. I brought her to the hospital in the first place to help her recover.
I didn't want to just die and I don't think anybody wants that to happen.
It's not some sort of a suicide pact that they want to enter into with you. They want to live. They want to have good health care.
And I think that you can work with them.
I realized they wanted the best medical care, but they just wanted it without blood.
I think the effort has to be made to remove the perception that Jehovah's Witnesses are somehow in a category by themselves.
Clearly you can point to many religions. They all have one issue or another which you may or may not agree, but that's not the issue.
That this is a religious precept. This is not illogical stubbornness. This is a religious belief.
And just as I respect the religious beliefs of many other religions, I think I have to respect that.
All patients, as a general rule, have the right to receive treatment or to refuse to receive that treatment after they've had full, open and candid discussion with the treating physician.
I believe the basic element of patient's right is the right of self-determination. That is, the right of any patient to decide what shall be done with his or her own body.
Patient rights notwithstanding, some have claimed that declining what they consider life-saving medical treatment is irrational.
It's wrong to equate a refusal of a treatment with suicide, which is a conscious choice to end one's life.
There is always a legitimate question about a patient's competence, but just the mere refusal of blood in itself is not any kind of such indication.
I don't believe that refusal of treatment is irresponsible or irrational. I think that just because one person chooses to not take this pill or that fluid or this kind of solution is their own personal choice.
We have patients who say they don't want to be on a mechanical ventilator. They don't want a breathing tube.
It's an everyday event for a patient who has malignancy, a cancer, to refuse some treatment or other. They don't want to have chemotherapy. They don't want to have radical surgery.
So the idea that patients refuse treatment is something that I work with, not to, don't take as a personal insult.
These facts are often obscured by news stories claiming that someone died because he refused a blood transfusion.
To say that one has died because of refusal of blood I think is a very general misleading statement.
That's an oversimplification of the tragic event.
It's rarely, if ever, the case that a patient refused a blood transfusion and therefore died.
People die because of either a medical disease or a consequence of trauma or surgery where there's been complications.
I can tell you I have done over 200 your witness patients. I have never lost a patient because I could not give the patient blood.
Why then does blood transfusion remain the standard treatment for serious blood loss?
I think that physicians have been brought up with the idea that blood is the gift of life and that inherently blood is good for you.
The refusal to accept a blood transfusion bothers and concerns many physicians because they're worried that without the transfusion the well-being of the patient is jeopardized.
To appreciate fully why physicians feel this way one needs to understand a little about blood and why transfusions are given.
Blood circulates through the body by means of an amazingly intricate system of conduits called veins and arteries.
Arteries carry oxygenated blood away from the heart eventually branching into tiny vessels called capillaries.
These deliver the oxygen-rich red blood cells to every part of the body.
Nutrients and oxygen are exchanged for carbon dioxide and other wastes at the cellular level.
Veins then transport the oxygen-depleted blood back to the heart which pumps it to the lungs.
There the carbon dioxide is exchanged for oxygen and the cycle begins anew.
This cycle is absolutely essential to life.
If there's no blood to bring the oxygen to the cells, the cells die, the body dies.
When someone suffers severe blood loss doctors have two urgent priorities.
The most critical immediately is to stop the bleeding.
Everything takes backseat to stop the bleeding.
And number two is to restore the volume within your system.
What can happen when a patient loses too much blood volume?
Then you don't deliver blood to the brain or the other organs and a person can die.
And what you need to do is restore volume, restore perfusion, and restore oxygenation.
A way of correcting that decrease in blood volume is by giving other fluids intravenously.
This can be done using any one of a number of fluid types and doesn't necessarily require blood.
Increasing numbers of patients are opting to avoid blood transfusions for personal reasons.
If you've ever had a conversation with a patient the night before surgery
and you were to ask them if they had a preference, would they prefer to avoid a blood transfusion?
The answer is always yes.
I would say that today at least 80% of the patients would strongly favor not to have blood transfusions.
Blood transfusion traditionally considered a normal adjunct to surgery
presently is considered something that has to be avoided.
I mean there are real risks as far as transfusions are concerned.
There are concerns about blood borne pathogens and certainly the concern about AIDS.
It's a biological product. It can have diseases, etc.
We screen for most of them but there are some there that we just don't know about.
We've certainly seen some horrendous new diseases in the form of HIV come along that probably didn't exist in the past.
Whether the next disease will come along in 10 weeks, in 10 years or 100 years, nobody can say.
We have hepatitis C, hepatitis B that are transmitted and the social costs of that are very high.
There are transfusion reactions that occur.
They're very rare but they can be potentially dangerous or even life threatening.
We can mix the blood up and cause catastrophe.
Patients have died and do die from getting the wrong blood.
It is interesting to realize now in the late 90s or early 2000s that the blood transfusion
to a certain extent does not do what we always use blood transfusion for.
We have become persuaded over the years that many of the bad things that happen to patients after surgery
are in fact not bad luck, are not lack of surgical skill, but are in fact the complications of transfusion.
These concerns have spurred the development of a wide range of alternative strategies,
treatments that are acceptable to many of Jehovah's Witnesses and others who also choose to avoid blood transfusions.
Alternative strategies can be grouped around four organizing principles.
That involves anesthetic factors, it involves the use of certain substances and it certainly involves also the surgical technique.
The most important technique to control bleeding is to avoid bleeding.
But with less bleeding during surgery the result at the end is better and the outcome is more likely to be smooth.
Careful surgery means preventing blood loss.
Age is no factor. We have operated on newborns, we have operated on people in their 90s.
A surgeon who operates without losing large amount of blood is almost invariably a good and careful surgeon.
One who loses large amounts of blood is most often the reverse.
A variety of instruments are now available to help surgeons minimize bleeding.
There are strategies for intraoperatively using electrocortery instead of scalpels.
If there is some bleeding persisting there are calculation techniques, best of which is at the moment argon beam calculation.
There are non-invasive tools that enable the surgeon to see inside the body, minimizing surgical incisions.
You can use drugs, topical application of different products that will help prevent blood loss.
We have now several methods available like the fibrin glue.
Fibrin glue made from blood fractions stimulates coagulation upon contact.
The fibrin tissue adhesive is certainly very, very useful because it does not harm the tissue.
In a Jehovah's Witness where blood loss is so, so, so critical I think that you have to be very extremely meticulous not to lose even a drop of blood.
There are new technologies of hemodilution and reinfusion that make the operation easier
and which are acceptable to people who have a religious precept against blood transfusions.
The principles of hemodilution in terms of reduction of blood loss are really quite simple.
Basically we do a closed circuit on the patient.
We draw off blood from the patient, keep it in contact with the patient and substitute it with fluids.
That results in a diluted blood and therefore the patient loses only diluted blood rather than native or concentrated blood.
When the patient bleeds intraoperatively the red cell loss is less.
It would be like taking a quart of milk and adding water so you have three gallons of it now but the original quart is still in there
but if you were to spill it into something it would be a lot of water and a fraction of the milk
and then at the end you get rid of the water and then you're back to where you started.
And we use that routinely in this institution especially for those patients who have anticipated a significant blood loss.
I think that's probably nowadays besides not just for Jehovah's Witness a pretty good standard of care for large volume loss surgery.
If we do lose blood this is the kind of case where we use a cell saver.
It will suction up any blood that's lost, we wash it, we clean it, we process it, we filter it and then we'll give it back to you.
Cell salvage is a very important technique because when you use cell salvage the blood lost by the surgeon is not lost for the patient.
In any trauma patient with a significant blood loss I would always prepare the cell saver system.
A key element in stimulating the body's ability to replenish its own blood supply is a hormone called erythropoietin.
Erythropoietin is a natural substance.
It is formed in the kidneys, other organs as well but primarily the kidney to help our bone marrows form the red blood cells that are going to carry our oxygen.
Blood cell production takes place primarily in the sternum, the ribs, the vertebrae and the pelvis.
Recombinant erythropoietin boosts the body's natural production of red blood cells.
If I know the patient is going to be in the hospital a long time I may start them on some recombinant erythropoietin so that they can start building up their own blood stores.
This can be a very cost effective strategy to reduce the utilization of allogenic blood transfusion.
One of the most exciting things about this whole field and transfusion alternatives is that the majority of things that we talk about are within the reach of physicians and hospitals around the world.
There are now available techniques in almost every subspecialty of surgery and medicine that allow bloodless treatment.
Alternatives like any other therapy are not necessarily free from risk so a patient, a witness patient in particular, may want to become informed about the benefits and the risks that are associated with any particular treatment.
They should be a prudent consumer.
How effective are these alternative strategies in helping doctors treat patients who do not want blood transfusions?
Leslie Lacks had just begun elementary school when it became apparent that she had a degenerating spinal deformity.
Doctors diagnosed Leslie's condition as a severe form of scoliosis.
Scoliosis is a curvature of the spine so we have to correct it as much as the spine flexibility allows us.
After a brace failed to correct her condition, doctors recommended an extensive surgical procedure.
We use essentially a series of hooks and metal rods made out of stainless steel that are implanted in the patient's back and used to essentially distract the spine and achieve alignment.
The Lacks wanted the surgery performed without a blood transfusion so they found a surgical team that had experience using bloodless techniques.
Before the surgery, Leslie's doctors boosted her blood through the use of iron and recombinant erythropoietin.
So it was essential that we do the surgery without excessive blood loss.
The way that we were able to achieve this is using two techniques, basically one of them is what's called the cell saver.
The other technique we used is called hemodilution.
It is safer in that it is the patient's own blood and it has remained in continuous circulation with the patient so there's no chance for contamination or blood transmitted diseases.
The surgery was a success and no blood transfusion was administered.
Within days, Leslie was up and walking.
She's so happy. She can be able to stand now and say mommy I'm as tall as you now.
Although Leslie will have to wear a brace for a while, doctors are confident she will lead a normal life.
I would like to skate and skateboard, maybe learn how to snowboard and stuff like that.
Sometimes alternative strategies involve new surgical techniques to reduce blood loss in patients that don't want a transfusion.
75-year-old Dorothy McPhee suffered an abdominal aortic aneurysm, a life-threatening condition that traditionally requires extensive surgery.
The normal way of doing this operation is generally through the abdomen, a long vertical incision from the lower chest down to the pubic area,
having to work around and behind the entire intestinal tract, hospitalization ranging at best four or five days to an average of a week or even more, presuming there are no operative complications.
Since Dorothy is one of Jehovah's Witnesses, her physicians used a surgical technique that minimizes bleeding.
What we did today is called endovascular aortic surgery, specifically endovascular meaning we're working within the artery.
Through that artery we place our catheters, our wires, all the instruments that we steer right up into where the aneurysm is,
and then we can visualize the aneurysm by doing fluoroscopy, x-ray technology.
Dorothy's surgeons inserted a wire mesh called a stent and were thus able to repair her aorta without a large surgical incision that would have caused a lot of bleeding.
Small incision in the groin, all the manipulations through that, a virtually pain-free, complication-free post-operative course, home generally 24 hours. So everybody's a winner.
I feel fine. I never would have believed it, but I do.
Two days after her surgery, Dorothy was sent home. She recovered nicely.
A growing number of health care providers are willing to meet the challenge of treating patients who avoid blood transfusions.
With the development of all those techniques, there's nothing really specific about Jehovah's Witnesses anymore.
We know that they don't want blood transfusion, and we have the technology to follow their wish.
The belief that you don't want a blood transfusion should not in any way, that should be a tiny part of the whole medical care environment.
That should be acknowledged, be put over to the side, fine. Now is the other 99% of your care.
I guess it could be likened to a patient who is allergic to penicillin. You wouldn't expect the physician to say, well, I'm sorry, I can't treat you because I can't administer penicillin. No.
He simply says, we'll give you a medical alternative. We'll give you another antibiotic. And he gets on with treating the patient.
This enlightened approach to patient care has exciting implications for the public at large.
The fact that we couldn't use blood in Jehovah's Witness, we learned how we didn't have to use blood in many, many other situations.
So it has actually propelled us in the right direction.
Transfusion alternatives, clearly, are good medical practice, sound medical practice, safe practice for our patients.
Indeed, it is a standard that should be available to all patients.
What we're talking about here is going to be a moot point because bloodless medicine and surgery will become, in the next five to ten years, so widespread that it won't be novel anymore.
Jehovah's Witnesses have had the unique privilege, because of their religious position in the matter, of helping doctors to learn better ways to treat patients without subjecting them to the risks of blood transfusions.
What I have seen in my own experience is that they have turned the medical profession around to the point where the gold standard of treatment, frequently now, is to treat people without blood.
Already, some 100,000 physicians worldwide are making bloodless medicine and surgery available to any patient who does not want a blood transfusion.
Many experts agree that in the near future, medicine and surgery without the use of blood transfusions will be the standard of care for all patients.
There are now available techniques in almost every subspecialty of surgery and medicine that allow bloodless treatment that we are getting away from blood transfusions in general.
As a heart surgeon, it's unusual for the guy not to like blood. He should love blood, but I don't.
I'm very proud when my patient comes out of the operating room and has not received any transfusion.
I can see within the next few years us getting to a point where we do not have to even think about giving blood.
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