Bloodless medicine: A personal story

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Albumin: This major protein constituent of blood is often given to individuals who need to retain more fluid in their bloodstream, such as burn victims or patients with liver failure or extremely heavy bleeding (hemorrhage). Albumin (along with clotting factors, growth factors, and immunoglobulins) is sometimes referred to as a minor blood fraction. If you are a Jehovah's Witness, whether or not you can accept treatment with a minor blood fraction may be considered an individual "matter of conscience."

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Allogeneic blood: Blood donated from another individual, which is typically stored and then provided through a transfusion. Jehovah's Witnesses do not accept allogenic blood.

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Anemia: A condition in which an individual's blood can't supply an appropriate amount of oxygen to their organs and tissues, either due to a low volume of blood, too few red blood cells in the blood, or too little hemoglobin or iron in the red blood cells. Patients who are suffering from severe anemia are sometimes more difficult to manage, unless they are treated by a team that is very experienced in transfusion-free medicine.

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Apheresis: A process used to obtain blood components (such as platelets) from a donor. The blood is removed from the donor, the necessary cells are harvested and retained, and the donor's plasma is returned to the donor. Donated platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses. However, "therapeutic apheresis" may be acceptable to some Jehovah's Witnesses because it is a treatment performed on the patient's own blood.

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Blood banking: This is when blood is donated by a person for their own use or a specific individual's use at a later time. It is usually done because of fear that donor blood will not be available or might have contaminants, or because the person has a rare blood type. This procedure is not "bloodless medicine" because it involves blood storage and blood transfusions.

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Blood salvage: Blood salvage procedures collect blood lost during or after surgery. A variety of methods may be used to collect blood, including suction and drainage devices. The devices that are used are sometimes called "cell savers." Those who object to blood transfusions may feel comfortable with "closed loop" blood salvage, where the blood is never stored and retains a semblance of connection to the patient at all times.

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Cautery: Deliberate surgical destruction of tissue, either because the tissue is abnormal or to seal off a bleeding area. Cautery is a method of reducing bleeding during transfusion-free surgery. It may be achieved through heat, freezing, chemical scarring, electricity, light, and ultrasonic or microwave energy.

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Cell savers: Devices that capture and hold blood during or after surgery, so that the blood can be returned to the patient.

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Clotting: The complex chain of chemical events that produces a plug (clot) at the site of bleeding. It is important for a patient undergoing transfusion-free surgery to have good clotting ability, in order to reduce bleeding/blood loss. Certain medications may interfere with clotting, such as aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs; anticoagulants (such as Coumadin); vitamin E; and herbal preparations containing garlic or ginkgo biloba.

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Clotting factors: Chemicals that circulate in the blood and interact together to help cause blood clotting at the site of an injury.

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Coagulation: The conversion of liquid (blood) into a somewhat solid plug that can prevent further bleeding from a particular site.

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Colloidal solutions: Intravenous fluid solutions that contain water, salts, sugars, and protein. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Some colloidal solutions contain albumin -- a protein whose use is a matter of personal conscience for Jehovah's Witnesses.

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Cryosurgery: A surgical technique that uses extreme cold to destroy abnormal tissues in the body. It is sometimes used as a bloodless medicine technique -- by freezing tissue, bleeding is minimized.

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Crystalloid solutions: Intravenous fluid solutions that contain water, salts, and sugars. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Jehovah's Witnesses find cystalloid solutions such as Ringer's lactate and normal and hypertonic saline acceptable therapy.

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Donor: A person who gives blood. The donated blood may be stored and distributed to hospitals and medical centers to be given to a patient when needed (as a transfusion). When a patient receives whole blood in this way, this is considered traditional medicine -- NOT "bloodless medicine." However, donated blood may be used to harvest blood components that may be used during some bloodless procedures.

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Embolotherapy: Refers to various methods of blocking a bleeding blood vessel, preventing further blood loss. These include chemical agents that scar the inside of the blood vessel; mechanical agents that block a bleeding vessel, including metal coils and latex or silicone balloons; particles or microspheres, including gelatin foam; and injected liquid that quickly turns into a thicker gel-like or spongy mass to prevent bleeding from a vessel.

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Endoscopy: A scope that can be used to visualize the inside of the body, either through insertion into a tiny incision or by passing the scope through a body opening (such as the mouth or anus). Endoscopy is used to examine, biopsy, or surgically treat a variety of conditions. Types of endoscopy include arthroscopy (joints); bronchoscopy (bronchial tubes, lungs); colonoscopy/sigmoidoscopy (large intestine); colposcopy (vagina, cervix); gastroscopy (stomach, small intestine); laparoscopy (abdomen); and others. Endoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding. It is therefore a valuable bloodless medicine technique.

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Erythropoietin: Erythropoietin is the name of a chemical normally produced by your body, primarily by your kidneys. Erythropoietin stimulates the bone marrow to produce red blood cells. Laboratory-made synthetic erythropoietin (e.g., Procrit, Epoetin alfa, Epogen, or Aranesp) may be administered prior to a bloodless surgery procedure in order to maximize your bone marrow's production of red blood cells. Other synthetic chemicals that mimic the activity of erythropoietin are in development.

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Fibrin glue: A substance made from human clotting factors. These clotting factors can be harvested from donor blood plasma or from a patient's own blood plasma. Fibrin glue can be applied to a bleeding vessel. It both blocks the vessel from bleeding and activates normal clotting/coagulation activity. Because fibrin glue is made from blood products, each individual will need to examine their own conscience to decide if its use is personally acceptable.

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Fluid expanders: Intravenous fluid solutions that are used to increase the volume of fluid in the circulating blood. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Gamma knife: A high-tech surgical tool that can be used for brain surgery. This technique utilizes a powerful and precise form of radiation to destroy tumors or abnormal blood vessels with less blood loss than a traditional scalpel.

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Harmonic scalpel: A surgical tool that uses ultrasound waves to cut tissue and seal bleeding vessels at the same time -- a helpful characteristic in transfusion-free surgery, because it helps keep blood loss to a minimum.

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Hemodilution: The process of making blood more dilute than normal. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Hemoglobin: A chemical within red blood cells that allows oxygen to be carried throughout the body.

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Hemophilia: A disease in which the blood clotting system is defective, resulting in an increased likelihood of serious bleeding after even minor injury.

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Hemorrhage: Heavy bleeding.

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Hemostasis: To stop bleeding.

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Hyperbaric: To be at higher-than-normal atmospheric pressure. Hyperbaric oxygen therapy is used in some facilities to assist bloodless medicine in certain situations. You enter a chamber and breathe pressurized oxygen, which concentrates oxygen in your blood.

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Hyperoxic: Having higher-than-normal oxygen saturation.

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Hypotensive: Having low blood pressure. Hypotensive anesthesia is a technique that lowers a patient's blood pressure below normal during surgery. Blood loss tends to be slower when your blood pressure is low. However, blood pressure must be maintained at a particular threshold to ensure that all of your body's organs and tissues are receiving blood, so the practice of hypotensive anesthesia requires great skill and extraordinarily careful monitoring.

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Intraoperative: During the course of an operation.

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Iron: A nutrient that is required by your red blood cells for good oxygen-carrying capacity. Iron is important for bloodless surgery and can be obtained from dietary sources like red meat or through supplements, such as ferrous sulfate or ferrous gluconate.

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Kidney dialysis: A procedure in which the blood is cleansed of toxins through an outside machine, replacing work that the kidneys normally do.

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Laparoscopy: A surgical technique in which a lighted scope is inserted into a tiny incision in the abdomen. Laparoscopy can be used to visualize the inside of the abdomen for diagnosis, to retrieve tissue samples for biopsy, and to perform surgery using tiny instruments that are also passed into the abdomen through tiny "keyhole" incisions. Laparoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding and may therefore be valuable for bloodless treatment of some conditions.

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Laser surgery: A surgical technique that uses the energy from light to cut through tissues. It can reduce bleeding compared to traditional scalpels and may therefore be valuable for bloodless treatment of some conditions.

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Major fractions: Blood products containing plasma, red blood cells, white blood cells, and platelets. Jehovah's Witnesses do not accept major blood fractions as part of any treatment.

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Mediastinal autotransfusion: A procedure performed most commonly after heart surgery, in which the fluids (including blood) that collect in the chest during and after surgery are collected and then given back to the patient through an IV.

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Minimally invasive surgery: Procedures that use small surgical cuts and holes, or no cuts at all. These methods can greatly reduce the amount of bleeding and are therefore of great importance to bloodless medicine. An example is endoscopy, which uses scopes inserted into small cuts or body openings. Another example is lithotripsy, which uses sound waves to break up a kidney or other stone into smaller bits, allowing it to pass out of the urinary system without having created any incision at all.

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Minor fractions: Blood products containing clotting factors, albumin, growth factors, and immunoglobulins. Some Jehovah's Witnesses accept minor blood fractions as an individual "matter of conscience."

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Normothermia: Normal body temperature.

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Normovolemia: All people maintain a particular volume of fluid circulating throughout their bodies; this is referred to as "normovolemia." During surgery, you will be given balanced intravenous solutions (volume expanders) to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery.

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Oximeter: A device that monitors the amount of oxygen carried by the hemoglobin in red blood cells. In bloodless medicine, any blood a patient loses is not replaced by transfusion, so it is extremely important to monitor how much oxygen the patient's body is receiving from the remaining blood.

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Plasma: The fluid component of blood, in which the various types of blood cells are suspended. Jehovah's Witnesses consider plasma to be a major blood fraction and do not consider it to be an acceptable part of treatment.

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Plasmapheresis: A type of apheresis that is used to separate plasma from blood. Blood is removed from a donor, the plasma is harvested and retained, and the donor's blood cells are returned to him or her. Plasmapheresis may also be performed on a patient's own blood as a treatment for certain conditions.

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Platelet: A component of blood responsible for blood clotting at the point of an injury to a blood vessel. Without platelets, our blood would not be able to clot and hemorrhaging or uncontrolled bleeding would result. Platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses as part of any treatment.

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Platelet gel: A concentrate made from a patient's own blood plasma, mixed with calcium and clotting compounds produced in cows. Platelet gel concentrates can be applied during the course of surgery to control bleeding. As with fibrin glue, platelet gel concentrates are produced from plasma, so their use by some individuals is a matter of conscience.

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Primary blood components: Red cells, white cells, plasma, and platelets (also called major fractions). Jehovah's Witnesses do not accept primary blood components (major fractions) as part of any treatment.

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Procuren solution: A solution made from an individual's own blood. The growth factors in the patient's own platelets are harvested, and reproduced in a laboratory to create the procuren solution. This solution is then applied to a wound to improve healing capacity and shorten duration of healing.

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RBC nuclear scan: A test in which the individual's own red blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of bleeding, because the tagged red blood cells will be seen leaking from these areas.

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Scalpel: Originally, a scalpel was a very sharp, small knife used to perform surgery. Now a scalpel can use a variety of energy sources to cut through tissue, including light (laser scalpel), microwaves (microwave-coagulating scalpel), ultrasonic energy (ultrasonic and harmonic scalpels), and radiation (gamma knife).

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Stereotactic/Stereotaxic: A technique for locating the exact area needing treatment by using advanced imaging techniques that verify the three-dimensional coordinates of the abnormal area. By pinpointing the exact area, the surgeon can minimize the amount of cutting (and hence bleeding) that occurs during surgery.

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Transfusion: The delivery of blood products to an individual to replace blood that is lost during surgery or from injury. The blood or blood products are usually donated anonymously or through blood banking, then stored until the time they are needed. At that point, the blood products are administered through an intravenous (IV) line into a patient's vein. A blood transfusion is what bloodless medicine seeks to avoid.

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Ventilation: To provide a patient with oxygen.

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WBC nuclear scan: A test in which an individual's own white blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of infection, because the tagged white blood cells will migrate to these areas.

Suzanne K. is a 46 year-old woman with three children who had to undergo surgery to have her gallbladder removed. Because she is a Jehovah's Witness, she opted for using bloodless surgical methods. She answered questions about what was involved in taking that approach.

Suzanne, what was the reason you had gallbladder surgery?

Well, I'd had ultrasounds and tests that showed that my gallbladder was full of stones. I was having these periods of pain, and my doctor was pressuring me to get the gallbladder taken out so that I wouldn't risk other problems. I put it off because I really didn't want to have surgery. As a Jehovah's Witness, I wouldn't allow it to be done with any blood being given. And it was hard to find a good time to do it -- a time when I wouldn't be needed by my family during my recovery!

Anyway, I finally realized that I needed to get on with it. So my husband and I started reading up on the kind of surgery I'd need.

What information did you find?

I thought it was exciting that they can take out your gallbladder through such a tiny opening now, using scopes and special tools. This obviously seemed less likely to cause bleeding. We're lucky because we live in a big city, so we could look around at all the hospitals in the area and find out which ones have done a lot of operations without giving blood, and which ones have doctors, nurses, and anesthetists committed to bloodless medicine. We also talked to friends in our church to find out who they had gone to.

It used to be that some doctors would refuse to take care of Witnesses because they thought they'd get sued if something went wrong and the doctor couldn't use blood. My husband did a lot of the reading, and he was pretty convinced that we had to go somewhere with more experience operating on patients without using blood, so they would know what to do if I did have any complications.

So, you chose your surgeon by virtue of his experience with bloodless techniques?

Yes, but not just the surgeon, the whole program. I went to him with all the information about how I wanted to have the gallbladder taken out though the scope. And he was fine with that, because he'd already done so many and didn't feel at all nervous about whether it would be too dangerous for me or risky for him malpractice-wise. He said if I hadn't brought it up, he would have, because he pretty much prefers to do the scope surgeries for gallbladders, unless you have some other problem. That made me trust him more.

What kinds of things did you do to prepare for your surgery?

I had iron-poor blood -- I always have, on and off. So right away he had me start to take iron tablets, and I paid more attention to my diet to eat more foods with lots of iron in them. He gave me pamphlets about nutritious eating, and that was really helpful. And I took some other vitamins -- folic acid, I think, and some B vitamins and E. I think to make my blood better and help me heal faster. We set up the surgery date a couple of months in advance, so I had time to make a difference with my diet and the vitamins, and so I could get everything organized at home.

How did you make your need for bloodless medicine clear to the surgical team?

My husband and I had taken care of that a long time ago. We had written down and notarized our medical directives, and we have key chains and medical alert bracelets that we and the kids wear. These are sort of like what a diabetic patient would wear, to make sure that if we are in an accident, we wouldn't be given blood.

You can even get forms on the internet that are very professionally written to fill in with your preferences about not receiving blood products or whatever. So we already had all that, and we just made sure that my doctor and the admissions office at the hospital had copies. Also, my husband had them in his wallet when he brought me to the hospital for my operation, so if there was any kind of confusion he could pull out the papers.

But the place we went was very professional, and they had a special bracelet for me, along with the regular hospital ID bracelet. The special bracelet said "No Major Blood Products Under Any Circumstances," which was also written real big on the front of my chart. And just like they always ask you about your allergies, the nurses kept checking with me that the bloodless request was right.

What kinds of things were done for you during the procedure?

Well, of course I was asleep for most of it, but I know that my doctor told me in the office beforehand that they would be using special tools to immediately stop any bleeding. And the openings they made were as small as possible, just enough to be able to put the scope and tools inside. I had an IV to keep my fluids up, and the anesthetist did a lot of work with my doctor, so he knew what to watch for. I know they used a lot of monitors to see how I was doing and watch for any complications.

What happened after the procedure?

I was lucky because I'm pretty good at healing. I think all the vitamins I took must have helped too, because the wounds stayed clean with no complications. I have to say, the wounds were tiny but they hurt more than I thought they would. And I really felt sick for the first couple of days -- maybe the medicines that put you to sleep made my stomach upset.

One good thing is that my iron didn't drop back down, so when I left the hospital, they said my blood was still good.

What would be helpful for other people to know when they are about to have a bloodless procedure?

I'm glad my husband found the names of people who were good at these kinds of operations. That's probably the main thing. The nurses and everyone knew what we were talking about when we said we wanted bloodless methods. They didn't act all surprised or disapproving or anything, which used to happen a lot. They understood our position, and they knew what to do to make sure that's what happened. So read about the people you're going to see, and read about the kinds of operations so you can ask for the best options.

 

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Review Date: 5/10/2007

Reviewed By: Corey Cutler, M.D., M.P.H., F.R.C.P.C, Department of Medical Oncology, Dana-Farber Cancer Institute; Instructor in Medicine, Harvard Medical School, Boston, MA. Review provided by VeriMed Healthcare Network.


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