Patient Blood Management: Some Comments from Others and Some From Us
"The Ethics of Bloodless Medicine," published Aug. 14, was the last in a trilogy of articles in The New Yorkerdiscussing lessons learned from transfusing, and not transfusing Jehovah's Witnesses. The reports are in keeping with the magazine's habit of regularly addressing medical topics (see also "The Excrement Experiment, How a stranger's feces might save your life," Nov. 24, 2014 and "Can AIDS be Cured? Researchers get close to outwitting a killer," Dec. 15, 2014).
These "Medical Dispatches" are a reminder that the lay press does not perform under the strictures of peer review that the academic press endures. If it did, it is unlikely that any journal editor would have endorsed the comment by a Pennsylvania hematologist oncologist that "a bag of blood that has been sitting in storage is like a dirty fish tank you haven't cleaned in months," as an appropriate description of the red cell storage lesion. This is erroneous on its face, based on multiple controlled trials. Nonetheless, more flamboyant discourse is an understandable prerogative in conventional journalism that is denied in academic literature. There are other examples. "Flesh eating bacteria" are more likely to draw attention than reference to vibrio vulnifcus and, similarly, "brain rotting disease" is more likely to pique curiosity than variant Creutzfeldt-Jakob disease.
This editorialist's carping about potential for disappointment with medical journalism's exaggerations aside,The New Yorkerarticles are a valuable reminder of some of the justifications for patient blood management. Experience with restricting transfusions for Jehovah's Witness patients, without apparent harm to them, certainly prompted suspicion that transfusion triggers were too generous. Suspicion has become all but conviction with publications showing that appropriately chosen patients tolerate what was previously regarded as unacceptable anemia.
The New Yorkerarticles did, however, also remind readers that some profoundly anemic patients die if not transfused. There are limits to how low the transfusion trigger can be set. Others recognize this. The category "Avoidable, delayed, or under-transfusion" is now included in the Serious Hazards of Transfusion reports of the UK's hemovigilance experience.
While the treatment of Jehovah's Witnesses has confirmed the value of selectively lowering transfusion triggers, tensions are emerging among those who regard this reduction as a general business opportunity and those who see it as a broad medical imperative. The business opportunity has emerged because administrators controlling hospital purse strings, confronted with dwindling reimbursements, recognize that costs can be contained if less blood is transfused. The medical imperative, on the other hand, recognizes that complications are avoided when unnecessary transfusions are eliminated.
Certainly, in light of current understanding, not all patients who were previously regarded as candidates deserved transfusion, however, every patient's candidacy now must be a medical decision, not a cost decision.
Merlyn Sayers, MBBCh, PhD, President & CEO, Carter BloodCare; MSayers@carterbloodcare.org