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Published July 7, 2005

The bloodless revolution


Rahul Chandran, Staff Writer

When Dr. Tuan Nguyenduy made a 15-centimeter incision in the sagging flesh of Arnold Styles' chest, sawed through his ribs and retracted the pericardium to expose the diseased heart, he knew that his hunch had played out right. The 48-year-old cardiothoracic surgeon at Spartanburg Regional Medical Center saw that the walls of Styles' heart were thickened from disease.

Just earlier, he had cut a small incision in Styles' leg about 30 centimeters of a superficial vein. The vein would be fashioned into smaller segments, which would then replace the diseased arteries in Styles' heart.

"I knew I was in for a long one. What I didn't know was whether I would go for an off-pump surgery or put Mr. Styles on a heart-lung machine." Nguyenduy usually delays his decision on what method to use until "I am in there and take a look." What he saw did not excite him.

Styles, body ravaged by decades of assorted illnesses and at least seven major surgeries, lay on the operating table, surrounded by scrub nurses, an anesthesiologist, hematologists and circulating nurses.

Unsure whether Styles' 68-year-old heart would bear the strain, Nguyenduy put two sutures in the heart's wall to see whether it would hold up or whether it would start bleeding. If bleeding started, Nguyenduy would have to take his hands off and wait while others would mop up.

Ordinarily, with a supply of four or five units of blood at hand, and even more available if required, Nguyenduy would not have worried about bleeding this early in the surgery. After all, despite the importance of the organ involved, heart surgery was no longer the esoteric frontier of medicine it once was. But the Arnold Styles case had one difference.

Styles is a Jehovah's Witness and literally interprets the biblical pronouncement that man should abstain from blood. Styles had made it clear that he did not want a transfusion, even if that was the only way to save his life. "Everything has a price, and I am willing to die for my faith. I take it very seriously," he said.

Moments before being rolled into surgery, Styles had told Susan, his wife of 17 years, "If I open my eyes today, it would be a great day."

A living example

A short stocky man with blue eyes, an unfailingly happy persona and an infectious chuckle, Styles likes to describe himself as a "walking medical practice."

Doctors at Spartanburg Regional and other hospitals in the area have opened him up seven times over the last 35 years for a mind-numbing assortment of surgical procedures.

Now, sitting in the living room of his house off Vanderbilt Road, more that six months after bypass surgery, Styles ticks of his medical conditions:

• In 1977, surgery for a bladder infection; in 1977 and 1978, successive "repairs" on the previous surgery.

• In 1998, surgery to correct an abnormality in the carotid artery, which took doctors seven-and-a-half hours on the operating table to fix. And then, almost inevitably, something went wrong, and he had to be opened up again.

• The latest was a carcinoma that they discovered on Styles' shoulder. "They took part of my thyroid out for that one," Styles said.

To top it all off, Styles is diabetic, which makes all surgeries riskier because the high sugar content in his blood does not allow it to clot quickly.

The bypass came after a fainting spell in October 2005. Doctors found that Styles had been suffering from silent heart attacks for almost two years. Whole sections of the arteries in Styles heart were completely clogged.

But his medical history and previous surgeries seemed to preclude a heart operation.

"At first, Spartanburg Regional did not think me a viable candidate for a bypass," Styles said. Not many doctors were willing to operate on a 68-year-old man with a diabetic condition, blockages in multiple arteries and an aversion to blood transfusion.

"They gave me five or six months to live, and I could still die tomorrow," Styles said. "I could not accept that." And so, with his wife, Susan, Styles began looking for other hospitals that might do the surgery.

However, administrators and doctors who first reviewed Styles' case decided to get Dr. Nguyenduy's opinion. And Nguyenduy decided he would operate.

Because Styles did not want a blood transfusion, the hospital would have to increase his blood count before wheeling him into surgery. They accomplish this by giving him extra iron, building up the red blood cells, so if Styles started bleeding during surgery, his blood count would still be high enough not to cause problems.

Taking greater care with blood

"Earlier, most doctors used to operate on anemic patients," said Dr. Robert Rainer, director of pathology at Spartanburg Regional and the father of the hospital's bloodless medicine program. "One of the things that makes an institutionalized bloodless medicine program different is the preoperative care. We make sure the patient's blood count is sufficiently high so that blood transfusion is not required."

Hospitals in the United States have been doing bloodless surgery for patients who objected to blood transfusions even as far back as 1970. Now, hospitals have understood the need for system-wide bloodless medicine programs where the de-facto rule is "conserve blood."

"Doctors can be very cavalier about blood. For a long time, the U.S. had one of the safest and largest supplies of blood, so doctors did not feel the need to watch the amount they use in surgery," said Yvette Bunch, administrator of Spartanburg Regional's Bloodless Medicine program. "So, at the slightest hint of blood loss, the doctor would transfuse."

The need for a bloodless program at Spartanburg Regional was kick-started by growing blood shortages at the Piedmont Blood Bank, which met most of the hospital's needs. With the donor base declining, the hospital was forced to cancel many elective surgeries. Another concern was the possibility of diseases borne by donor blood.

So Rainer and Bunch decided to set up the bloodless medicine program. Around 2001, after department-wide consultations, they came up with a list of imperatives that Spartanburg Regional would adhere to.

"Part of the problem," said Dr. Lawrence Goodnough, professor of Pathology and Medicine at Stanford University and president of the Society for Advancement of Blood Medicine, "is that there are no clinical care pathways in blood transfusion. So there could be tremendous variability in transfusion outcomes."

Spartanburg Regional now routinely advises patients of its bloodless program. "Not only does bloodless medicine make good economic sense, it makes sure people with aversions to blood transfusions don't fall between the cracks," Rainer said. Over the years, the hospital has also acquired a number of devices routinely used in the 100 or so bloodless medicine programs in the country.

Spartanburg Regional currently uses about 600 units of blood every month. Rainer said that number has remained steady, though the number of patients has increased dramatically.

It helps to have a beating heart

When the first two sutures held, and Styles' heart didn't bleed, Nguyenduy knew he would do an off-pump surgery -- medical parlance for surgery that would be performed on a beating heart.

Most doctors prefer bypassing the heart and lungs and hooking up patients to a heart-lung machine while the surgeon fashioned new components for the diseased heart.

But Dr. Nguyenduy prefers operating on a beating heart. His preference is backed by some research that shows that recipients of off-pump surgeries fare better after surgery. On average, they handle the surgery better and walk sooner, he says.

Having immigrated to the United States from Vietnam in 1974 to go to graduate school in chemical engineering, Nguyenduy changed his mind midway and decided to become a doctor. Graduating from the Albert Einstein College of Medicine in New York, Nguyenduy finished his general surgery training at the State University of New York and accepted a cardiothoracic fellowship at George Washington University in 1991. He has been a network physician at Spartanburg Regional since graduation in 1994.

Dr. Nguyenduy thinks of heart surgery as buying the patient time. "It is not a cure. The only cure is a healthy lifestyle.

"The procedure itself is simple," Nguyenduy says with characteristic humility. The only thing that could complicate the procedure is bleeding.

He remembers Styles impressing on him, again and again, that he did not want a transfusion. "He was very clear on that. But we'd done it before, and with the bloodless medicine program in place, we now have some fancy gadgets that tell us before anything can go wrong."

Four and a half hours after the first incision to harvest a vein from Styles' leg was made, Dr. Nguyenduy fashioned a splint with steel wire that would hold Styles' ribs together till they healed. Styles would walk in less than six hours after the surgery.

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Mr. Jan B. Wade
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Enhance Outcomes - Control Cost
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