Other references to Joel Engardio. This article is favorable to JWs about blood. But scroll down to next post to see his comments in "Apocalypse Later"
Source: http://www.sfweekly.com/issues/1999-02-17/news/news2.html
Surgery Sans Blood
Jehovah's Witnesses refused transfusions -- and led the way to bloodless surgery
By Joel P. Engardio
Published: Wednesday, February 17, 1999
Every so often, Cathy Montoya is awakened on a Saturday morning, like the rest of us, by a pair of smiling proselytizers who have knocked on the door. They read her a Bible verse about God's kingdom, and hand over the latest copy of the Watchtower magazine. She thanks them, and then heads back to bed.
Besides those occasional visitors, and the two cashiers she works with at Safeway who happen to be of the same religion, Montoya never gave Jehovah's Witnesses much thought.
Until now.
Montoya has a congenital heart defect, and is lying in the preop room of Seton Medical Center about to undergo an aortic valve replacement. Her husband and parents stand around her, silently praying as a nurse prepares Montoya for the open heart surgery that is an hour away. The Montoyas are Catholic, but when the doctor cracks open Cathy's chest, he will operate using surgical advancements developed for and perfected on Jehovah's Witnesses.
Montoya's heart surgery will be bloodless.
She didn't ask for a transfusion-free operation, but for decades, Jehovah's Witnesses have made that request. While the religion claims blood is sacred and the Bible forbids using it in any form, doctors -- propelled by the AIDS scare -- are finding ways to rely on blood less, and still save lives with surgery. "Blood transfusions are basically no good, and we are very aggressive in avoiding them for everybody," says Dr. Alex Zapolanski, director of cardiac surgery at the San Francisco Heart Institute and the surgeon doing Montoya's operation.
More than half of the nearly 900 heart surgeries at the institute last year did not involve blood transfusions, and only a fraction of the patients in those bloodless operations were Jehovah's Witnesses. The medical benefits going bloodless are clear: If the chances of HIV infection through transfusion are now remote, acquiring hepatitis through donated blood is not. And even the cleanest donor blood is still foreign, and can weaken a patient's immune system.
Zapolanski is not alone in his views on limiting blood transfusions. A study released in this week's New England Journal of Medicine shows that some critically ill patients actually have a better chance of survival when blood transfusions are limited, while younger and less ill patients are more likely to die when given more blood. As a new generation of doctors challenges blood's status as an all-purpose healer, fewer people are receiving blood than ever before: Ten percent fewer patients received transfusions in 1994 than in 1992, according to the latest statistics compiled by the Center for Blood Research in Boston.
"Indirectly, medical science is starting to see the wisdom of God's law," says James Pellechia, a spokesperson for the Jehovah's Witness church in New York. "While the Bible is not meant to be a book of science or medicine, we believe that when people follow its guidelines, it results in the best and healthiest way of life."
Zapolanski says the bloodless trend has nothing to do with what Jehovah's Witnesses read in the Bible, that it's only about the realization of good medicine. Still, the rise of bloodless surgery has created a rare happy circumstance: For a change, religious belief and medical science stand on common ground.
Cathy Montoya nervously runs her fingers through her dark, bobbed hair as she lies in the preop room. It is just past dawn and a trashy Jackie Collins novel sits open on the bedside table. The young mother of two toddlers laughs and jokes with her husband and elderly parents who have gathered by her. They all saw the movie Patch Adams days before her surgery.
"This family laughs a lot -- it's a coping mechanism," Montoya says. "It's my personality, but believe me, I'm stressed-out on the inside."
It's the first week of January; Montoya postponed the operation until after the holidays, even though her doctor suggested it be done sooner. Her faulty valve, which up until now produced nothing more ominous than a slight murmur, has begun to cause a back-flow of blood into the heart. This reverse flow is enlarging her heart toward the point where it could lose elasticity and fail.
"I started crying when they told me. I couldn't believe it," says Montoya, who is just 34 years old. "I thought, 'I'm too young to have heart surgery.' But I knew this is serious."
When the nurse ushers everyone out of the room for a few minutes, Montoya's husband, Rick, lets his joking smile fade. "I'm very nervous. They're going to operate on the organ that keeps her alive," he says, matter-of-factly. "One slip and she's gone."
Rick pauses, thinking about what he's said. His eyes begin to well. "I can't imagine life without her."
Though anxious about her chest being opened, Montoya is not worried about the bloodless approach. Because Montoya is not a Jehovah's Witness, Zapolanski had her donate a pint of her own B-positive blood prior to the surgery -- just in case. "I don't feel like a guinea pig in any way," she says. "Medicine has progressed and my surgeon is progressive, which is a good thing."
Three nurses dressed in blue scrubs arrive; one injects some Valium into the intravenous line protruding from Montoya's arm. "Better kiss her now before she falls asleep," the nurse says.
"I love you," Rick says, as Montoya struggles to keep her eyes open. "You'll be OK."
In the operating room, Montoya is surrounded by the heart/lung and anesthesia machines, various monitors, and a half-dozen stainless steel carts draped in blue coverings, which hold an array of sterile scalpels, scissors, and clamps.
The cell-saver machine also sits close by. Integral to bloodless surgery, the dishwasher-sized box is equipped with cylinders that spin collected blood, cleaning it before returning it to the body. A nurse follows each stroke of the surgeon's knife with the cell saver's hand-held suction gun. It is attached to a long, plastic tube, through which every stray drop of blood travels back to the machine for recycling.
Montoya's entire naked body is painted with an iodine prep solution that kills bacteria and gives her skin a yellowish, jaundiced glow. Everything except a rectangle from her belly button to her breasts is draped in blue gowns. The exposed skin is covered with a clear, Saran Wrap-like sheath.
The first incision is done with a scalpel, about four inches long down the center of the chest. Zapolanski likes to work with openings shorter than the traditional eight inches; less room to bleed.
With the first cut done, the scalpel is quickly tossed aside. In bloodless surgery, the doctor relies on a laserlike device that, as it cuts, uses heat to seal vessels and stop bleeding. This instrument, known as an electro cautery, sparks as it burns through the fat and the surgeon clears a path to Montoya's sternum. Smoke rises from her chest.
There are a few inches of fat covering the sternum, and Zapolanski keeps poking his finger in the opening he has cut, trying to feel down to the breastbone. He uses a metal spatula to push the flesh aside so he has room to cut across the sternum when he reaches it.
Revving up the saw, which makes a high-pitched sound, like a dentist's drill, Zapolanski begins to cut. His assisting surgeon and a nurse must help as they lean in and almost wrestle over Montoya's body in an effort to pry open the rib cage. The nurse inserts a retractor, and Zapolanski cranks it as the sternum separates to reveal the heart beating under its pericardial sac.
The surgeon burns through the sac, exposing the heart, which rolls in a sideways motion, rather than beating up and down.
"That was the most difficult part of the operation," Zapolanski says. "Once we get it open and get access, the rest is easy."
To replace Montoya's valve, the surgeon will have to stop her heart. He calls for the anesthesiologist to inject a massive dose of the drug heparin, which primes the patient's blood to move through the heart/lung machine that will oxygenate and circulate her blood -- and, everyone hopes, keep her alive -- during the remainder of the operation.
For 64 minutes, Montoya's heart does not beat. During that time, Zapolanski cuts out the defective aortic valve that was causing the dangerous back-flow of blood. Then he sews in her new valve, taken from a cow's heart.
During the operation, Montoya's hematocrit level -- the percentage of essential red cells in her blood -- plummets to 23. The normal percentage is almost double that, between 40 and 45. Years ago, the old medical school rule was to transfuse if the hematocrit reached 30. Now, Zapolanski doesn't like to consider transfusing until it gets to 18.
"Most physicians have knee-jerk reactions with transfusions and just give them out liberally and indiscriminately. I don't," Zapolanski says. "We take it to the other extreme."
But he is not dogmatic. Nearly half of the institute's heart surgeries last year did require some use of blood. And Zapolanski doesn't use the same criteria for an elderly lady who weighs 90 pounds and a man in his 40s.
As he operates, the handsome, 47-year-old, Argentine-born surgeon tells his favorite Fidel Castro jokes and makes dinner plans while looking into an open heart with his fiber-optic headlight. Yet he works with a cautious intensity, obsessed with closing his operations perfectly.
Montoya's heart is shocked back into running. All that's left is wiring the sternum shut and sewing up her chest. "I could close, but I'm dragging my feet," he says, blotting the sternum with gauze and suctioning with the cell saver. "I'm making sure she's dry and doesn't bleed."
The last group you'd expect to agree with Dr. Zapolanski's disdain for donor blood is the Red Cross. But by the group's own numbers, the chances of contracting AIDS from a pint of blood is about 1 in 700,000. For the currently incurable hepatitis C, the risk is as high as 1 in 30,000. The danger increases with each bag of blood a patient receives, and a lot of blood is given: In the U.S., nearly 3.5 million people receive some 11 million units of blood each year.
For hospitals, going bloodless may be good business. With blood costing $400 to $500 per bag, there's good fiscal reason to cut back on the amount of blood transfused each year. And, of course, the fewer patients who contract blood-borne diseases from transfusion, the fewer lawsuits there are to settle.
"We support the concept that you should not give blood, or any other medicine, unless the benefits outweigh the risks," says Dr. J. Lawrence Naiman, chief medical officer for the American Red Cross Blood Services of Northern California. But Naiman does wonder whether the "transfusion trigger point" has been allowed to drop too low.
"One concern I have is getting carried away trying to avoid blood totally," Naiman says. "That's a delicate, thin red line you're drawing, and if you draw it too low, you can risk jeopardizing the patient."
Still, Naiman admits, today's more conservative approach to blood is a welcome medical advance.
"Jehovah's Witnesses forced physicians to stretch their imaginations to think about what they could do without blood," Naiman says. "Physicians successfully bent the rules in treating Witnesses, which has given them confidence that they don't need to transfuse as often as they once thought."
Cecil Swindall is sitting up in his hospital bed, groggy, looking at his wife, Ruth, when Dr. Zapolanski walks into the room. The patient is doing well, considering that just days ago, a 12-centimeter aneurysm -- a thinning and ballooning outward of an arterial wall -- had been sitting on his heart.
The 73-year-old elder of the Clearlake Jehovah's Witness congregation survived the riskier side to bloodless surgery. His blood count was too low for doctors to safely remove his aneurysm without transfusing. Since transfusion was not an option, Zapolanski had to try to build Swindall's blood count artificially with a drug that stimulates the bone marrow to make more red blood cells. The treatment takes time -- up to several weeks -- and Swindall's aneurysm could have blown any day, with disastrous, probably fatal, results.
Despite his strides in bloodless surgery, Zapolanski says he doesn't particularly enjoy treating Jehovah's Witnesses because of the enormous demands they place on his ability.
"The Jehovah's Witness patient puts more pressure on me to be perfect, because nothing can go wrong. If it does, I have to let them die on the table," Zapolanski says. "And that goes against everything I stand for."
At Los Gatos Medical Center, the latest Bay Area hospital to open a transfusion-free medicine program, Dr. John Kelley oversees many of the bloodless surgeries. Techniques that deliberately lower blood pressure and add fluid to the body, so the patient ends up bleeding saline solution instead of red blood cells, can help make worst-case scenarios rare, Kelley says.
"It's like going in with your seat belts and air bags on already," Kelley says.
The risks Jehovah's Witness patients are willing to take have undeniably helped doctors discover new thresholds in the body's ability to recover from low blood counts. But relations between the Jehovah's Witness church -- which now boasts some 1 million American members -- and the medical establishment have not always been amicable. There was such animosity, in fact, that doctors and hospitals at times sought court orders to force blood transfusions on Jehovah's Witness patients.
The mood slowly began to shift about 10 years ago, when the church started a lobbying effort to get hospitals to consider bloodless medicine. One of the initial hurdles involved simple misunderstanding: The Witnesses often were confused with Christian Scientists, who rely on prayer instead of medical treatment when they are sick. The Witnesses, however, accept all medical care, except blood.
"We had to insist that our saying no to blood did not mean we were fighting medicine," says Eugene Rosam, who helped direct the church's outreach program. "We were, in fact, encouraging medicine to make new advances to treat us and benefit everyone else."
Dr. Randall A. Oyer, director of the bloodless surgery program at Walnut Creek's John Muir Medical Center, says his hospital was approached by the church, and in 1994 John Muir became the first bloodless center in Northern California. Now there are almost 80 such programs at hospitals across the country.
"The Jehovah's Witnesses are a very organized and informed group who did lobby physicians to take care of them," Oyer says. "They were perhaps the prime motivators of bloodless medicine initially, and equal contributors once the AIDS scare hit."
In his five years directing the bloodless program at John Muir, Dr. Oyer has lost one Jehovah's Witness patient as a result of blood refusal.
"She could have desperately benefited from a blood transfusion," Oyer recalls. "It was a painful situation, but I respected the patient's rights and took comfort that the patient and her family were peaceful with their decision."
Two days after Cathy Montoya's aortic valve replacement, she is out of intensive care and resting in a regular hospital room. Her kids, ages 2 and 4, see Mom for the first time since the surgery. The youngsters try to crawl around her, offering hugs, while being careful not to touch her belly.
"My chest still hurts, but nothing like when I first woke up," Montoya says.
Lingering pain and a 4-inch scar are her only reminders of the heart surgery she dreaded for so long. She is amazed; under the anesthesia, it all seemed to happen in the blink of an eye. And she wonders about that pint of blood she donated, the one that was never used. "It's incredible," Montoya says. "I thought for sure they'd have to use some of it."
Although still in the hospital, Montoya sees her life already returning to normal. She can't wait to go home. The prospect of a return to work is less exciting, but when she does go back to Safeway, she plans to talk to those two Jehovah's Witness cashiers.
"When I see them, I'll have to ask about what they believe," Montoya says, "and let them know how it helped me.