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What a waste of money!

Needless blood transfusions.

What a waste of money!

Although today is world blood donors day let me be controversial. One huge wastage of money is needless blood transfusions.

World blood donors day 14 June 2020. Are you making the ultimate gift of life?

Safe blood saves lives, but many people across the world have little or no access to blood transfusion. That is why blood donors are a precious resource and why we are celebrating them on 14 June, World Blood Donor Day.(1)

Please watch this video

Please watch this video to show the desperate need for people to donate blood

On world blood donor day we highlight the urgent need to increase blood donations at the global level. Our video walks you through the growing need to donate blood and save lives. Swiss Learning Exchange (SLX) and SDGPlus are committed to building communities focused on sustainable development and growth (2)

How do they choose which blood group to use?

It’s called the ABO system and this video explains this beautifully (3.)

What they don’t talk about a major reason for the huge wastage of blood. Needless blood transfusions.

The commonest reason for blood transfusion

The commonest reason for blood transfusion worldwide is due to a lack of iron in the blood- commonly called iron deficiency anaemia.

The clinical definition is a level of iron that is sufficiently low enough to impair the quality of life for that person.

It is a laboratory diagnosis of haemoglobin (an iron-containing compound in the blood that carries oxygen) level of less than 13.5 in a man and less than 11.5 in a woman.

However, there are hundreds of millions of people throughout the world whose haemoglobin levels are below that level who have no symptoms of anaemia and have learned to live with it.

From personal experience of the 35 patients who were admitted during my general medicine internship for a blood transfusion in no case was it necessary.

Risks of inappropriate transfusion for the junior doctor.

If you have a case of a patient who doesn’t need a transfusion but has been sent in for one then you are between a rock and a hard place. If you don’t transfuse you risk the wrath of your middle-grade doctors or your consultant (who writes your reference.) If you do transfuse and the patient doesn’t need it then you risk the wrath of the haematologist (blood doctor) who gets very angry because you have ruined the blood picture. My own view is that a transfusion should only be done after reviewing by a haematologist or in an emergency on the authority of the consultant on call.

This happened to me a lot!

Medical Emergencies

Nobody is going to deny a patient blood in a medical emergency if they desperately need blood.

However, in an emergency it’s not blood that you need-its blood volume and in such circumstances, you need a plasma expander to fill up the gap.

However, my argument is that if someone has a medical condition that could develop into a life-threatening emergency. Then as soon as it is diagnosed it should be treated as a routine before it reaches an emergency status. For example, consider an aortic aneurysm – where the main artery coming out of the heart expands. If it ruptures as an emergency you’ll be lucky to make it to hospital. Medical teaching says that it should only be operated on when the diameter of the aneurysm reaches 4 inches. However, if it’s at 2.5 inches and expands to 3 then at some stage it will go to four inches. Rather than wait for that time isn’t it safer to treat as a routine and use a plasma expander as far as blood transfusion is required.

Listed for routine surgery

Once a patient has been listed the surgery it is a good clinical practice to put them all on iron, vitamin B12 and folic acid supplements for at least 6 weeks prior to surgery. The reason is that will raise the blood iron levels. If they lose any blood during surgery then theoretically they will still be in the normal range and so pre and post-operative transfusion would be unnecessary. However, it’s very rarely done.

Post-surgery loss of blood

When I was a medical student I was trained by a very prominent surgeon and a lecturer in obstetrics (doctors who look after pregnant women). In both cases, if the patient how had lost blood during surgery or childbirth they would be assessed and asked if they were planning anything strenuous during recuperation. They never would! If they were not too bad they will be put on iron vitamin B12 and folic acid. In near enough every single case that patient’s blood iron levels would be normal in about 6 weeks. This would negate the need for transfusion.

Jehovah’s witnesses

Can you see now why there is considerable overlap between good quality clinical medicine and the Jehovah’s witness stance on transfusion? They forbid transfusion. Whilst I can not go that far I would say that the majority of transfusions are not needed.

However, it’s not all plain sailing as this video shows

Sometime ago BBC news reported Contaminated blood scandal: What have we learned so far? (4)

If you see the article you can see the judge giving a witness a hug.

I remember one case from my junior doctor days.

A patient came in.

By chance they found a low iron level in the patient’s blood.

My seniors said that they were going to give him a blood transfusion.

I pleaded with them not to.

I said he’d learn to live with it and there safer alternatives.

I was overruled.

Why? I am a foreigner.

It is the most dangerous product a doctor can prescribe.

It’s expensive.

It can cause incurable infections.

It can cause allergic reactions.

In most cases good clinical practice can negate its use.

Yet it’s prescribed every day.

It’s blood.

In this case the patient ended up with HIV infection (Human Immunodeficiency virus) and died.

They covered it up big style.

Blood transfusions are a huge waste of money and good clinical practice can avoid the need for the majority of them.

The lab technician

I went to see this patient afterwards to give my condolences. He didn’t blame me. However I had to take some blood from him. I put yellow Danger of Infection stickers on each blood bottle and the form.

Within minutes this lab technician came on the ward and said

“This man is HIV positive and I am not risking my staff by doing this blood sample.”

My response.

“Great, if you said it any louder they may have heard you in Australia.” I had to ask the nurses to transfer this man to another hospital.

Bloody dangerous!

It is the most dangerous product a doctor can prescribe.

Risks of giving blood

Firstly let me assure you that there is no risk in giving blood. The equipment is only used once.

Why do we not pay people to donate blood?

In the USA they pay people to donate blood. In the UK we don’t. The reason being we only want healthy motivated people to donate. In America it is very often homeless people on lower incomes who frequently have diseases who donate blood- poor health is inextricably linked to poverty. No matter how safe your screening is it is not 100% safe. Therefore you minimise the risk by bit and only having healthy motivated people donate.

Well organised good quality clinical medicine is value for money medicine.

Government pressure to cut costs

There has been considerable discussion in the UK Media of budget cuts it to the National Health Service. For those of you who do not know this in the UK all Health Care is given free to the patient paid for out of taxation. Hospital managers are now under great pressure from ministers to cut the NHS bill. The public fear that this will be at the expense of patient care. It doesn’t have to be.

Good quality clinical medicine is value for money medicine

When I was a third-year medical student I attended a wonderful lecture at Rotherham Hospital. The clinical director said that’s when he was a final year medical student he could not understand why there was such a conflict between managers and clinical staff. Some 25 years later he still couldn’t understand why there was such a conflict.

The reason being good quality clinical medicine is value for money medicine.

Let us take a classical case- blood transfusion. To give a patient a blood transfusion costs about £200 to keep a patient in hospital and at least £50 per unit of blood. In most cases it’s unnecessary and blood is the most deadly thing a doctor can prescribe. However it’s a huge waste of money.

Other examples of good quality clinical medicine saving money.

Bed blocking

In the UK there have been scandals of patients being left in hospital full weeks if not months on end while social care is waiting for them. They are called bed blockers. One of the consultants I was with taught us if you admit a patient and you suspect they will not be able to cope at home. Then the first line of your history should say “this patient needs social assessment.” If you start social assessment on a patient on the day they are admitted to hospital you could save them at least one month in hospital. Yet it is rarely done. I did this on all my patients who I suspected could not cope at home using a little common sense. None of them became bed blockers.

Conversely, if this didn’t happen then the social assessment would start on the day they before were due to be discharged. They’d go home and not cope and hence re-admitted and kept in for months.

However, I can tell you from my own personal experience that a lot of middle grades and senior doctors do not like it when a smart junior does this- it makes them look bad. Trust me I am speaking from experience!

Warfarin

It is very common for people in hospital to be on Warfarin. It’s a drug that is given to thin the blood most commonly given in people who have atrial fibrillation (irregular heart beating) blood clot formation and those with artificial heart valves. The thing is the dose that is given depends on the result of a blood test called the International Normalised Ratio (INR). Warfarin has a half-life of 3 days so it takes 3 days to work. That means that even in the acute phase you only really need to take an INR every 3 days. However, all too often they do INRs every day and it is only prescribed for one day

It never ceases to amaze me when the following situation arises:

Doctor doing night shifts: “How long have you been taking warfarin

Patient: whose warfarin has not been prescribed “Ten years.”

Doctor “How often are you seen in a warfarin

Patient “Every six months.”

You will then be amazed that an INR has been done and the warfarin has only been prescribed for one day!

Hence millions of needless INRs are done every year at inordinate cost to the taxpayer.

The solution

I’d make sure that in-hospital doctors in training are given half a day of protected teaching and case by case teaching on ward rounds.

For family physicians, I’d ensure that they got half a day’s training by webinar once a week.

In the long run, this would greatly reduce the NHS cost to the taxpayer.

However, the politicians need to remember that good clinical medicine is value for money medicine.

Bibliography

(1) World blood donor day 2020 https://www.youtube.com/watch?v=T0R7g9oFhlk

(2) Donate Blood | World Blood Donor Day | SDG Plus https://www.youtube.com/watch?v=XPL_NjPfLBU

(3) Compatible blood transfusions https://www.youtube.com/watch?v=Cqq_7Gaae7E

This presentation contains images that were used under a Creative Commons License. Click here to see the full list of images and attributions: https://link.attribute.to/cc/191829

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