Unless you have been away on a remote island for the last few years, you know that the Canadian Red Cross is in a defensive mode following stinging attacks from the media and patient advocacy groups because HIV-tainted blood got into the Canadian blood supply in the 1980's.
Not mentioned anywhere in the criticisms are the doctors who make most decisions about administering blood during surgery: anesthetists.
Anesthetists are the physicians who look out for your well-being while the surgeons are concentrating on cutting, cauterizing and sewing. We make sure you are pain-free and that vital things like blood pressure or lung oxygen pressures are all OK. If general anaesthesia is used, we ensure that the patient is unconscious. Where the surgical bleeding is a concern, we replace blood losses, first with fluids like saline, but also later with blood-derived products as needed. As one of my colleagues sometimes puts it to his patients: "Anesthetists are your only friend in the operating room; everyone else is cutting you and making you bleed."
Anesthetists have, in my view, the dream job of hospital MDs. In general, their contact with patients is pleasant, their pay is good, and the effectiveness of their interventions is high. They are, in fact, completely indispensable to modern surgery. One disadvantage to the job is that anesthetists are responsible for giving lots of blood (usually in the form of "packed cells," a kind of blood concentrate), particularly during surgical procedures with severe blood loss. In fact, anesthetists give more than 50 per cent of the nation's blood supply to correct for blood loss during and after surgery. And, associated with every "unit" (about 250 mL) of blood given is a small, but definitely not trivial, chance of transmitting infection or getting some other complication.
Each unit of blood is tested for hepatitis B, and C; HIV; syphilis; and other pathogens. False negative test results, however, occur occasionally, particularly when the testing is based on detection of the antibody to the disease rather than on detection of the antigen, the actual virus that triggers the production of antibodies. In the case of a recent infection, the body may not have not had time to generate an antibody response, and a false negative test result sometimes occurs.
In my clinical anaesthesia practice, I worry about every unit of blood I give, convincing myself in each case that the benefits to the patient exceed the small but existent risk of infecting my patient with some dreadful virus.
Indeed, such increased concern over transmission of infection has changed what we teach young MD graduates about when to transfuse blood. In my training days, the conventional wisdom was to transfuse whenever blood hematocrit levels were under 0.3 (normal is about 0.45), especially in patients with heart disease or in those who have had a stroke. Now anesthetists and other physicians are far more reluctant to administer blood products to the patient and wait until we are assured that withholding them would actually put the patient's life in jeopardy.
In the case of patients who are confirmed orthodox Jehovah's Witnesses, the situation for the anesthetist is paradoxically far less complex. For me, there's really nothing to agonize over - I fully and completely respect their religious wishes to receive no blood products, even though by declining a needed blood transfusion some of these patients die postoperatively from oxygen deprivation.
(That the courts tend to sanction one's autonomy over one's life has had a significant bearing on my position in this matter. And the situation is different again for Reformed Witnesses who accept transfusions.)
I find the decision about giving or not giving blood more difficult when a patient asks me to promise not to transfuse during surgery, but has no reason for this request other than an exaggerated fear of becoming HIV infected. So far, I have always been able to convince such patients to allow me to give blood if it is absolutely necessary, usually by asking them about what they would want me to do in the very rare event of unexpected massive blood loss. Typically their response is, "Well, I would die unless I got blood, so of course..."
What should I do, however, if I can't convince a patient to permit me to give blood to save his or her life? One option is to respect the patient's decision. After all, how is this situation different from a patient's refusal to receive blood based on religious grounds? Yet I'm uncomfortable with this position.
My discomfort arises from the fact that such people are not making sound judgments about the current risks involved in blood transfusion. Frightened by reports of past blood-transfusion tragedies, people today are inflating the very small risk if HIV or other infection that actually exists. In such an atmosphere of fear, they are making ill-informed decisions about their own health care, decisions by which I must abide.
There are many situations in clinical medicine when a physician's decisions involve balancing risk to the patient. The cancer specialist must decide whether a proposed dose of chemotherapy or radiation will have the desired effect of eliminating the cancer instead of injuring the patient. The surgeon wonders if an elderly patient will benefit from a complex and risky operation.
So it is with blood transfusion decisions. From experiences with Jehovah's Witness patients, we know that, in the event of severe anaemia (excessively diluted blood), failure to transfuse blood vastly increases the chance of dying during and after surgery, especially among the elderly or those with weak or damaged hearts. These patients accept this possibility. Among other patients, the same risk involved with not transfusing in a life-threatening situation must be balanced against the minute risk of transmitting blood-borne pathogens. This balancing act will never be easy.
D. John Doyle M.D., Ph.D., FRCPC
Reproduced with permission granted 06/14/2001
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