Thursday, July 7, 2016

Blood Medicine, part three

 An operating room nurse responded to Part Two of this series:
“So you’re saying, if a woman in our birthing center is bleeding out, we should just let her die rather than give her blood?”
Are those really the only two options – blood transfusion or death?
Medical treatment can involve life-or-death decisions, so of course it can get emotional. Not just for the patient, but for the care-givers as well. Competent doctors and nurses believe – in many cases correctly – that their decisions are life-saving; therefore any patient who disagrees with them is at best misguided or at worst, suicidal.

However: There is also this mindset among medical people - particularly in an emergency -  that,
‘If we don’t do THIS instantly, even though it has risks, we’ll lose the patient. We’ll have time to deal with the consequences LATER.'
‘So let’s save the life of the woman who’s bleeding out after childbirth by pumping blood into her. And if the blood causes Hemorrhagic shock, we’ll deal with that LATER. And if she catches AIDS from the transfusion, we’ll deal with that LATER. And if we increase her risk of cardiovascular disease or cancer, we’ll treat that LATER. But RIGHT NOW we’ll lose her if we don’t give her blood.’

Stop! In Part One of this series we used the illustration of a car losing oil. If your mechanic simply added oil, you’d find another mechanic who would look for why your car is losing oil. And the best mechanic would tell you how to avoid damaging your engine in the first place.
Scenarios in which doctors are inclined to order blood transfusion can be placed in three general categories:
  1. Elective surgery.
  2. Emergencies, such as traumatic blood loss.
  3. “Anemia.”
I put anemia in quotes because it seems to mean different things to different medical people. Until recently, doctors would call a patient dangerously anemic if their hemoglobin level fell to 9 or 10. Newer recommendations from the American Association of Blood Banks in March of 2012, however, lowered the bar, stating that a level of 8 or even 7 in an otherwise stable patient was acceptable.

Some Jehovah’s Witness patients – who refuse blood for reasons of conscience – have had hemoglobin drop as low as 1.4 and survive.

It bears pointing out, too, that hemoglobin measurement has been shown to vary by as much as 1.3 based on the type of device used, and where and how the measurement was taken.

Hemoglobin is only one parameter of a decision that you are dangerously anemic. Anemia, then, is a diagnosis based on a doctor’s judgment. He makes that call based partly on what is called the Standard of Care. It should be noted, however, that the “Standard of Care” set up by hospitals and followed by doctors is not a medical term, but a legal one, designed to help avoid lawsuits for malpractice. Many American hospitals, recognizing that the AMA is correct in saying that blood does more harm than good (and more importantly, recognizing that blood transfusions are costing them MONEY) are revising their Standard of Care to significantly reduce diagnoses of “anemia.”

If your doctor says you need a transfusion because you are anemic, get more tests; get another opinion and, if necessary, get another doctor. There are other, better ways to correct your blood numbers, assuming they even need correcting.

Your blood system, like so many other systems in your body, is over-built. Normal healthy blood is able to deliver about five times as much oxygen as you actually use at rest. This is why a blood donor is able to give away about 10% of their blood and, in most cases, get up and walk away with no side effects. It’s why you can travel from sea level to Leadville, Colorado (elevation 10,000 feet) without passing out even though this, too, will lower your blood's oxygen-carrying ability by about 10%. You could even move to Leadville and then immediately donate blood, lowering your oxygen-carrying ability by 20%. And while you would probably have some temporary side effects, you won't die from it.

So, if moving to Leadville and then donating a unit of blood won’t kill you, neither will a 20% drop in your blood oxygen level for some other reason.

Elective surgery
Elective surgery should never be a blood transfusion situation. “Elective” in this case means any procedure that is planned for, rather than unexpected. And that planning means there’s time to build up your blood in advance. It also means the procedure can be planned in such a way that it minimizes blood loss. Every type of surgery, from hip replacement to heart transplant can be and has been done without blood. If you surgeon says your particular elective surgery cannot be done without blood, again, consult another surgeon.


So that leaves trauma. Trauma as we are using it refers to emergency, unplanned blood loss. Would that include the woman bleeding out in the birthing center that Nurse Ratchett wrote me about? Not really.

Hospitals, as we stated earlier, are getting serious about reducing blood transfusions. One of the ways they are doing that is by considering in advance of every birth the possibility of postpartum hemorrhage. According to the Journal "American Family Physician":
“The best preventive strategy is active management of the third stage of labor…Active management, which involves administering a uterotonic drug with or soon after the delivery of the anterior shoulder, controlled cord traction, and, usually, early cord clamping and cutting, decreases the risk of postpartum hemorrhage and shortens the third stage of labor with no significant increase in the risk of retained placenta…Active management decreases the incidence of postpartum hemorrhage by 68 percent.”
Another study showed that infusion of tranexamic acid (TXA) significantly reduced blood loss in postpartum hemorrhage.

So no, Nurse Ratchett, your choices are not simply ‘blood transfusion or death.’ And the same is true in other instances that used to be considered emergencies.

But what about unexpected trauma: car or work accidents for example? We’ll look at those in Part Four. 

Please leave a comment. 
 Bill K. Underwood is a columnist and author of several books. You can support this page by following this link to his books at

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