However, doctors’ love affair with transfusions was all going to change in 1980.
For some time it had been known that some virus particles could be transmitted by the blood-borne route. Such were hepatitis viruses. A more lethal virus, HIV, came to us in epidemic form in the early 1980s. At the time, however, many donors who were HIV positive were unaware of the dormant virus in their bloodstream and continued to donate blood. There was not yet any reliable test to detect HIV, and methods to render blood safe and free of AIDS virus had not been discovered.
The situation resulted in a particular tragedy for hemophilia patients. These unfortunate patients, who have a deficiency of clotting factor, were treated with a blood product called factor 8. This protein, which helped form clots, was derived from the blood of multiple donors and so massively increased the risk of acquiring a blood-borne infection. In Montreal Children’s Hospital, by the end of the 1980s, all 22 of the children in the hemophilia clinic had succumbed to HIV AIDS — never having engaged in drug use or sexual activity.
Thus came a great fear of any blood transfusion, and rightly so.
All blood is now tested for Hepatitis B, C, and HIV. The risk for each unit of blood transfused is, for Hepatitis B, 1 in 80,000, for Hepatitis C, 1 in 3 million, and for HIV AIDS, 1 in 4 million.
There are now stricter thresholds for blood transfusions. Persons are not transfused routinely, and the level of hemoglobin need to justify a transfusion is more carefully scrutinized. Surgeons now perform “keyhole surgery” to minimize blood loss.
In newborns, some of the transfusions were occurring because of blood testing for basic levels and for body chemistry. Technology has helped to perform tests on lower volumes of blood. This advance has been developed with the help of the Jehovah’s Witness community, which correctly pointed out that doctors were partly to blame for their child’s blood loss. Jehovah’s Witness beliefs preclude the donation of blood.
Throughout the transfusion phobia of the 1980s and 1990s, we were continually asked if there were alternatives to blood donation. Erythropoietin, better known for its use in stimulating hemoglobin increases in athletes, can be used to increase hemoglobin in patients with low hemoglobin. However, it takes one to three weeks to achieve a rise in hemoglobin and so is not suitable for emergency situations.
In some cases, parents and other family members offer to give their blood to reduce the risk to the child. This is very conscientious on the part of the relatives, but there are risks:
The relative needs to be of the same blood group as the child.
The relative may not have divulged his or her high-risk status.
Banking of a relative’s blood can only be done in major centres.
Banked blood takes a couple of days to process and expires in three weeks, often being unavailable for the next blood crisis of the child.
It should be reassuring that today blood transfusions are safer than ever. But what if we had a product that could act like blood (carry oxygen to tissues) but was made of synthetic materials? The theoretical benefit would be longer shelf life, sterility (no disease risk), and compatibility with any blood type. (After all, blood transfusions are liquid organ transplants, and rejection is always possible, despite cross-matching.)
Two materials exist that can act as synthetic blood substitutes. These are liquids that allow dissolved gases to be carried to the tissues. Both are experimental, and one of them is entirely synthetic. The NHS in Britain plans to commence trials with blood substitutes in 2017. Cost will be a factor, and for the foreseeable future, blood loss will be continue to be replaced by safe donor blood.
REFERENCES
Blood transfusion information for patients, and their family. The Kingston Hospitals. 2016.
Clevenger, B., and A. Kelleher. Hazards of blood transfusion in adults and children. Continuing Education in Anaesthesia, Critical Care, and Pain, vol. 14, no. 3, 2014, pp. 112–118.
HANDING IN THE PAGER
LAST YEAR IT DAWNED on me that my pager had only gone off twice in the previous two months. One of these calls came through at two in the morning, and was meant for another doctor with a name similar to mine!
At $14.50 a month rental, it was time to unload this 1975 technology, as most calls were now coming in on my cellphone. This caused me to reflect on the many ways that people used to locate their doctor over the past four decades.
In the course of a typical day, I often hear people say “I wasn’t able to get hold of my doctor.” This surprises me, especially in an age in which communication is so easy. Not so in the old days, when notes would appear under doors, or doctors would sit by the phone all night to receive emergency calls. And then “paging” was introduced.
When you started as an intern, the switchboard would call your name over the hospital loudspeaker system. “Dr. Smith, wanted in casualty” (E.R.), or “Dr. Smith, call Ward 13.” There was no place to hide! Everyone knew if you were on call, and also how busy you were.
In the late 1970s we were introduced to “beepers.” (In the UK, they were called “bleeps.”) These clipped onto the pocket of your white coat and made a high-pitched beeping noise. The trouble was, you never knew who or what was calling you. At the nearest wall phone, you dialled zero for the switchboard, and the operator relayed the message as to what extension was looking for you. This new locating system also allowed you to wear more than one pager, providing respite for another physician who might have gone for lunch or a shower.
Voice pagers came along in the 1980s. These were revolutionary, as they allowed a message such as “Appendix surgery in 20 minutes, OR2!” to be relayed immediately, without a three-way call. It made a lot of sense to have one pediatrician on call for a group of six or eight, and complications over the weekend were attended to by the on-call doctor. With the advent of voice pagers, doctors on call could venture downtown with the same degree of responsiveness as they would have at home. The only problem was that the message could be heard by everyone in the vicinity.
In 1989 we decided for the first time that it was okay to go to a movie while on call. The blockbuster of that year was a horror movie called Nightmare on Elm Street. We met our friends, and I sat on the outside seat, two rows from the back. Thirty minutes later, a voice page blasted out details of the concerns of a parent whose baby had been operated on that week. As I rushed to the lobby to silence the pager, the audience seemed much more startled by its vocal blast than by any scene in the movie. Needless to say, I was glad it was dark in the cinema.
Thereafter came pagers with digital screens relaying messages that were confidential and were deleted afterward by the attending doctor. But it is the proliferation of cellphones that has been the greatest boon to the medical profession. Doctors' mobility has been enhanced and our availability has been improved at the same time. Not only that, but patients, nurses, and students too have their own cellphones to facilitate direct contact.
When a child is newly diagnosed with a difficult diagnosis such as Type 1 diabetes, it is my practice to give the parents my cell number, to allow discussion on unforeseen problems. Never have I regretted the sharing of my personal number, and never has it been abused.
Time to turn in the pager.
ABOUT THE AUTHOR
Dr. Michael Hefferon practices as a pediatrician in Kingston, Ontario, where he is assistant professor in Pediatrics and Oncology at Queen’s University.
Born in Dublin, Ireland, and raised in a bilingual Gaelic household, he secured a scholarship to study medicine at University College, Dublin. Choosing to specialize in children’s medicine, he trained in Dublin, in Liverpool, and then in Kingston, Canada.
Dr. Hefferon became a fellow of the Royal College of Physicians of Canada in 1986.
His training, teaching, and pediatric practice have aroused his interest in medical beliefs — some based more on myth than fact — which he has drawn to the attention of colleagues through continuing medical education programs and his membership
in medical organizations.
He lives in Kingston, Ontario, with his spouse, Catherine, while maintaining strong links with the British Isles.
Of Plagues and Vampires: Believable Myths and Unbelievable Facts from Medical Practice Page 9