Dr. Daniel DiBardino didn’t have much time for niceties on Sept. 8 as he consulted patient Michael Anderson about the emergency cardiac bypass he needed. Anderson is a Jehovah’s Witness — opposed to donor blood transfusions — and DiBardino needed to know if he could breach that religious conviction during the procedure.
“What if he’s bleeding to death, which occasionally can happen in cardiac surgery?” he recalled asking Anderson and his wife. “A lot of things can go wrong.”
“Absolutely not,” was the reply.
A decade ago, that answer might have touched off a doctor-patient argument or the kind of ethics crisis featured in medical TV shows.
But as doctors have come to understand the risks of blood transfusions and the ways to avoid them — helped in part by studies of Jehovah’s Witnesses — much has changed.
Hospitals such as Hennepin County Medical Center (HCMC), where DiBardino practices, have become more accommodating — and more adept at conserving patients’ own blood during surgeries.
“When I was in medical school, honestly, that was never a thing; people didn’t talk about blood conservation,” DiBardino said. “You just used blood because that’s what you did. And that has changed.”
Today, for example, surgeons understand that one unit of blood often works as well as two and that excessive blood from donors can result in transfusion-related complications and even deaths. As a result, HCMC has reduced the use of donated red blood cells by 32 percent since 2009. Other Twin Cities hospitals have reduced their use of blood products as well.
HCMC has taken the approach a step further through its Bloodless Surgery and Medicine Program, including a firewall in its computerized medical records system that prevents doctors from ordering donor blood products once patients have refused them.
The computer system gives doctors alternatives, such as medications that stimulate more blood production in the body, which they can consider even when preparing for emergency surgeries, said Dr. Jed Gorlin, who directs transfusion medicine at HCMC and is the medical director for Memorial Blood Centers, a regional donor agency.
“In the heat of battle, you won’t remember all of those,” Gorlin said, “so it’s a checklist to go through all of that stuff.”
The Jehovah’s Witnesses’ objection to receiving donor blood comes in part from interpretations of the Bible, including a passage in Acts that calls on people to “abstain from pollutions of idols, and from fornication, and from things strangled, and from blood.”
Practical interpretations vary somewhat, Gorlin said. Some members of the religion accept the experimental use of a substitute made from cow’s blood, while others refuse it. A few object to the use of a machine that recycles a patient’s own blood once it has exited the body. But almost all reject transfusions of red blood cells from donors.
Anderson, 66, has walked hundreds of miles visiting homes in southwest Minneapolis to teach his religion. He carried a medical directive with him for just such emergencies.
Then, driving from his home in Robbinsdale to his Kingdom Hall on Sept. 8, the minister knew something was wrong.
“All the way there, I had pain and it wouldn’t go away, and it wouldn’t go away and it wouldn’t go away,” he recalled.
Medics determined that he was having a heart attack and gave him aspirin and nitroglycerin pills, which had eased his pain by the time DiBardino sat with him to discuss his surgery: a triple bypass to reroute blood flow around blockages to the heart.
“There was no question ... transfusion would not be an option,” Anderson said in an interview from his hospital bed last week.
HCMC’s policy is to accommodate such objections for adult patients, when they are conscious and able to communicate their wishes, but not necessarily for parents acting on behalf of pediatric patients.
A 1944 child labor decision in Massachusetts still governs such cases, stating that “parents are free to become martyrs themselves. But it does not follow that they are free ... to make martyrs of their children.”
Once viewed harshly by the medical establishment, Jehovah’s Witnesses have taught doctors much about the body’s ability to survive surgeries without transfusions, Gorlin said. He gave a lecture in South Dakota this month titled “Management of blood: What we can learn from Jehovah’s Witnesses.”
A key measure is the patient’s hemoglobin, the protein in red blood cells that carries oxygen from the lungs. Doctors once thought a hemoglobin measure of 10 grams per deciliter was the key threshold at which patients needed a transfusion. Now, they have found that patients are just as likely to survive if their levels drop to seven.
In one local case, a woman who hemorrhaged after childbirth survived despite her hemoglobin dropping to 2.3.
“Nobody really knows for any given person how much blood loss they’ll tolerate,” DiBardino said. “You just have to kind of put your faith into it.”
‘Every red blood cell matters’
Still, the odds of surviving the triple bypass that Anderson underwent are substantially lower without transfusions, DiBardino said.
As a result, surgeons make it a priority to conserve blood, from the initial step — severing a leg vein to serve as a bypass line around a clogged artery — to connecting that bypass line to the heart.
“It’s on your mind that every red blood cell matters for this guy,” DiBardino said. “You’re operating on the biggest structures filled with the most blood in the human body.”
At the end of the four-hour operation, Anderson’s hemoglobin level stood at seven. But with rest, iron pills and other medications, it rose to 12.
One week later, Anderson had fewer IV tubes and was standing and eating solid food. Two weeks later, he was back home.
He believes his clean living helped him survive the surgery and said he is eager to ease back into walking and his door-to-door ministry.
“It’s just a matter of pacing myself,” he said, “as I go.”