'Bloodless' lung transplants offer hint at surgery's future

Hospitals are working to further innovate such operations, both to treat those who shun transfusions for religious reasons and, more broadly, to limit surgical transfusions for all patients, citing related adverse effects and what they say is unnecessary

Kevin Sack / New York Times News Service /

Published Feb 27, 2013 at 04:00AM

HOUSTON — In April, after being told that only a transplant could save her from a fatal lung condition, Rebecca Tomczak began calling some of the top-ranked hospitals in the country.

She started with Emory University Hospital in Atlanta, just hours from her home near Augusta, Ga. Then she tried Duke and the University of Arkansas and Johns Hopkins. Each advised Tomczak, then 69, to look somewhere else.

The reason: Tomczak, who was baptized at age 12 as a Jehovah’s Witness, insisted for religious reasons that her transplant be performed without a blood transfusion. The Witnesses believe that Scripture prohibits the transfusion of blood, even one’s own, at the risk of forfeiting eternal life.

Given the complexities of lung transplantation, in which transfusions are routine, some doctors felt the procedure posed unacceptable dangers. Others could not get past the ethics of it all. With more than 1,600 desperately ill people waiting for a donated lung, was it appropriate to give one to a woman who might needlessly sacrifice her life and the organ along with it?

By the time Tomczak found Dr. Scott Scheinin at The Methodist Hospital in Houston last spring, he had long since made peace with such quandaries. Like a number of physicians, he had become persuaded by a growing body of research that transfusions often pose unnecessary risks and should be avoided when possible, even in complicated cases.

By cherry-picking patients with low odds of complications, Scheinin felt he could operate almost as safely without blood as with it. The way he saw it, patients declined lifesaving therapies all the time, for all manner of reasons, and it was not his place to deny care just because those reasons were sometimes religious or unconventional.

“At the end of the day,” he had resolved, “if you agree to take care of these patients, you agree to do it on their terms.”

Tomczak’s case — the 11th bloodless lung transplant attempted at Methodist over three years — would become the latest test of an innovative approach that was developed to accommodate the unique beliefs of the world’s 8 million Jehovah’s Witnesses but may soon become standard practice for all surgical patients.

No safety net

Unlike other patients, Tomczak would have no backstop. Explicit in her understanding with Scheinin was that if something went terribly wrong, he would allow her to bleed to death. He had watched Witness patients die before, with a lifesaving elixir at hand.

Tomczak had dismissed the prospect of a transplant for most of the two years she had struggled with sarcoidosis, a progressive condition of unknown cause that leads to scarring in the lungs. The illness forced her to quit a part-time job with Nielsen, the market research firm.

Then in April, on a trip to the South Carolina coast, she found she was too breathless to join her frolicking grandchildren on the beach. Tethered to an oxygen tank, she watched from the boardwalk, growing sad and angry and then determined to reclaim her health.

“I wanted to be around and be a part of their lives,” Tomczak recalled, dabbing at tears.

She knew there was danger in refusing to take blood. But she thought the greater peril would come from offending God.

“I know,” she said, “that if I did anything that violates Jehovah’s law, I would not make it into the new system, where he’s going to make Earth into a paradise. I know there are risks. But I think I am covered.”

The approach Scheinin would use — originally called “bloodless medicine” but later re-branded as “patient blood management” — has been around for decades. His mentor at Methodist, Dr. Denton Cooley, the renowned cardiac pioneer, performed heart surgery on hundreds of Witnesses starting in the late 1950s. The first bloodless lung transplant, at Johns Hopkins, was in 1996.

But nearly 17 years later, the degree of difficulty for such procedures remains so high that Scheinin and his team are among the very few willing to attempt them.

In 2009, after analyzing Methodist’s own data, Scheinin became convinced that if he selected patients carefully, he could perform lung transplants without transfusions. Hospital administrators resisted at first, knowing that even small numbers of deaths could bring scrutiny from federal regulators.

“My job is to push risk away,” said Dr. A. Osama Gaber, the hospital’s director of transplantation, “so I wasn’t really excited about it. But the numbers were very convincing.”

None of the 10 patients who preceded Tomczak, including two who had double-lung transplants, had problems related to surgical blood loss or postoperative anemia, Scheinin said. The first, a North Carolina man who received a lung in 2009, died in November after developing internal bleeding and an infection. Several others had various postoperative complications, but all were doing fine, Scheinin said.

Scheinin, 52, a native New Yorker, said he liked the tightrope walker’s rush of operating without a net. He said his focus was intensified by the knowledge that if a patient died for lack of blood, a second life might hang in the balance — the wait-listed patient who would otherwise have received the organ.

“If I agree to do an aortic bypass on a patient who refuses blood, and it’s a risk we’re both willing to take, that’s between me and him,” Scheinin said. “With a transplant, if the patient dies, you risk having people say you wasted a precious organ.”

Other benefits

But Scheinin and his team are also motivated by the broader agenda — of limiting transfusions for all surgical patients, not just those with religious objections.

The latest government data show that one of every 400 units transfused is associated with an adverse event like an allergic reaction, circulatory overload or sepsis. Even so, the share of hospital procedures that include a transfusion, usually of two or three units, has doubled in 12 years, to one in 10.

Yet at dozens of hospitals with programs that cater to Jehovah’s Witnesses, a million-patient market in the United States, researchers have found that surgical patients typically do just fine without transfusions.

“They are surviving things that on paper were not expected to go well at all,” said Sherri Ozawa, a nurse who directs the long-established bloodless medicine program at Englewood Hospital in New Jersey.

The economy is also helping the blood management movement. Processing and transfusing a single unit of blood can cost as much as $1,200, and many hospitals are trying to cut back.

Experts say they are beginning to see a measurable impact on blood usage, although the data to support it are not yet available. Dr. Richard Benjamin, the chief medical officer of the American Red Cross, predicted that the numbers would show the first decline in use since the AIDS scare began in the 1980s, perhaps by 1 million units.

“We’re changing this culture, this knee-jerk transfusion reaction,” Scheinin said. “And I think that’s been a good thing for all our patients.”