A pioneer of bloodless surgery

Jock Davis smiled and sat up on his bed at Pennsylvania Hospital last week, looking more like a guy on vacation than on high-dose chemotherapy for a blood cancer called multiple myeloma.

He had come all the way from Rochester, N.Y., for a stem cell transplant because Patricia Ford, the doctor directing his care, was willing to withhold a standard part of the multi-week treatment: a blood transfusion.

As a Jehovah's Witness, Davis, 48, has religious objections to receiving blood, including his own. Ford, director of the hospital's Center for Bloodless Medicine and Surgery, performed the world's first no-transfusion stem cell transplant more than 15 years ago.

While most centers still consider it too risky to attempt, Ford keeps making history. Davis was her 100th "bloodless" transplant patient, an unprecedented milestone.

"People think I'm doing something mystical or magical," said Ford, a blood and cancer specialist. "It's not."

And bloodless therapy is not just for Jehovah's Witnesses.

Although Ford's strategies - many surprisingly low-tech and commonsense - were developed to enable Witnesses to undergo major elective surgeries, they have become standard throughout Pennsylvania Hospital. The bloody truth is that avoiding transfusions reduces complications, costs, and recovery time for patients in general."It's amazing," said Ford, "how much blood is collected and wasted and given unnecessarily in this country."

The primary components of blood seem a bit magical, even if Ford's methods aren't. If red blood cells stop ferrying oxygen throughout the body, vital organs die within minutes. White blood cells are the immune system's army, fighting invaders. Platelets regulate clotting, instantly sensing when blood is leaking. These cells all float in the watery plasma.

The blood also contains more than a thousand minor components, including the stem cells that give rise to all of it.

Jehovah's Witnesses - with more than a million members in the United States - reject transfusions because they broadly interpret a Bible passage that bans the "eating" of blood. However, as science has revealed the fluid's complexity, that interpretation has evolved to apply only to the four primary blood components, not to stem cells.

"I don't need a doctor who shares my beliefs," Davis said. "I just need one who respects them."

In the 1990s, Ford developed a reputation among Witnesses for doing exactly that.

She discovered that massive intravenous doses of blood-building agents such as iron, vitamins K and B12, and cell growth factors could rapidly boost the supply of red blood cells and platelets.

She became adept at bulking up patients' blood so surgical losses were less dangerous. To compensate for low platelet counts, she used a drug called aminocaproic acid that slows the breakdown of blood clots.

She also stressed low-tech strategies. Saline nasal sprays, stool softeners, and drugs for gastric reflux prevented irritation that could trigger bleeding. Fever, which shortens the survival of red blood cells, was aggressively treated with acetaminophen (Tylenol). Painkillers that reduce clotting, such as aspirin, were forbidden. The number of blood samples taken for testing was restricted.

Even needle punctures became an opportunity for better blood management after Ford noticed that patients developed painful bruises at the spot where blood was drawn.

"Now, we tell patients, 'Make sure you put pressure on the spot for three minutes after the blood sample is taken,' " Ford said.

With such strategies, major elective surgeries, pregnancy-related blood loss, even internal bleeding from a gastric ulcer could be managed without blood transfusions.

Now, about 700 Jehovah's Witnesses a year are treated through the hospital's center for bloodless medicine, which coordinates not only medical care but also financial, nutritional, and social services.

It's one thing to forgo a transfusion in a patient who has too little blood; it's quite another when the patient basically has no blood.

So Ford was not optimistic in 1995 when she agreed to do a stem cell transplant on a young Witness who was terminally ill with a blood cancer called lymphoma.

The transplant involves destroying the blood system with near-lethal doses of chemotherapy, then regenerating it with stem cells.

These stem cells are extracted from the patient's blood before chemotherapy and put back afterward. But like evacuees returning to a ruined village, the cells must work in a devastated environment - and they can work only so fast.

That's why patients are normally given transfusions during the week or two that it takes stem cells to do their job.

"The presumption was that you wouldn't be able to survive a transplant without getting red blood cells and platelets," Ford said. "Every doctor said patients would die of profound anemia or bleeding."

Privately, she put the patient's chance of survival at less than even.

Fortunately, she was wrong.

"He did phenomenally well," she recalled. "He was in and out of the hospital in two weeks. He's now married and has children."

Since then, Ford's program has shown that bloodless transplants have acceptable risks (a mortality rate of about 5 percent) and unexpected benefits (one day less in the hospital, which reduces costs).

For Davis - who was diagnosed in late 2009 with myeloma, a malignancy of plasma cells - a transplant will not be curative. But it could put him into a prolonged remission.

"I have patients who have been in remission five, seven, even 10 years," Ford said.

On Monday, four days after two infusions of chemotherapy, Davis sounded in good spirits, albeit hoarse and exhausted.

"I've had some vomiting and diarrhea, but no bleeding, no dizziness," he said. "There's some discomfort, but that was to be expected."

Ford's judicious approach has enabled about a third of her regular transplant patients to forgo transfusions.

Contrary to conventional wisdom, transfusions are not benign. Though donor screening and blood testing have reduced the danger of viral infection, transfusions pose risks of bacterial contamination, lung injury, circulatory-system overload, transfusion errors, and more.

That's why she is dedicated to reducing America's vampire-like ways (blood use per patient in the United States is far higher than in Europe and Canada). In 2001, she helped found the Society for the Advancement of Blood Management.

Better blood management, she said, "can be used to improve outcomes for all patients."

Source: Philly.com Health News , By Marie McCullough "Inquirer Staff Writer"