Bloodless Orthopaedic Surgery: A Doctor's Perspective
Dr. Jeffrey Sewecke is an orthopaedic surgeon at Allegheny General Hospital with special interests in fracture care and joint replacements. For the past seven years, Dr. Sewecke has worked closely with the Center for Bloodless Medicine and Surgery in assisting with the care of patients who cannot accept blood transfusions such as patients who are Jehovah's Witnesses.
CBMS: What are some of the challenging situations that you have been involved with in caring for patients who refuse transfusions?
Dr. Sewecke: I have had patients who were in need of emergency surgery due to complex fractures that resulted from various traumas including falls and automobile accidents. I've also cared for patients who have needed previously replaced joints replaced again. Additionally, I've cared for a number of patient who required knee or hip replacement due to more routine circumstances including arthritis.
CBMS: Why can surgery following trauma be such a challenge when dealing with a patient who refuses transfusions?
Dr. Sewecke: Surgery in a patient who refuses transfusions provides a challenge under any circumstances. Trauma surgery adds a number of extra variables including injuries to other parts of the body and blood loss that is associated with the fracture.
CBMS: Do you know of any special techniques that have been employed to meet these challenges?
Dr. Sewecke: From an orthopaedic standpoint, we have been able to at times alter our planned procedure in order to minimize further blood loss. For instance with some fractures, in order to stabilize the patient we have placed a device on the outside of body to stabilize a fracture rather than the internal placement of a rod. This is called an external fixator. This external fixator has been sufficient to address certain fractures altogether. In other patients, an external fixator can be placed more as a bridge procedure until the patient can safely tolerate a more extensive surgery. While these approaches are not appropriate for every patient, they have been useful for a number of persons.
In a more general sense, the arrangement of the Center for Bloodless Medicine and Surgery is an aid to the physicians in that we have a resource for understanding clearly the patient's concerns and which options are available for these patients. This has also resulted in a culture of greater acceptance among physicians regarding the needs of these patients so that we can work together to provide the best possible outcome within the limitations expressed by the patient.
CBMS: Are there other physicians or departments that you collaborate with in order to provide for the needs of a patient who refuses transfusions?
Dr. Sewecke: Working with the Bloodless Medicine Department we are able to get the assistance of hematology in pre-operatively addressing anemia in elective cases. Within the operating room, we are also assisted to ensure that we are abiding by particular patient wishes for the set up of cell salvaging equipment by working with our Perfusion and Anesthesia Departments. Finally, we also work with our Critical Care Medicine Physicians to address the needs of patients when post-operative anemia is a concern.
CBMS: What can patients who refuse transfusions do to assist you to provide them with the best care?
Dr. Sewecke: There are a number of things.
I fully respect the rights of patients to make decisions in keeping with their values, wishes and traditions. I have found many of these patients to be especially pleasant and agreeable to work with and I welcome the opportunity to care for others who share their concerns.
That said, they do need to understand that even with the advances in medicine and surgery which now make it possible for us to safely care for a majority of patients without transfusing them that there remains a measure of risk which the patient is accepting when he rules out the use of transfusions. It is incumbent upon me as a physician to explain both the risks and benefits of a procedure to a patient. So it is most helpful and appreciated by physicians when patients do not hurry to become offended by our counseling them regarding risks and benefits whether they relate to bleeding, anesthesia, joint function, allergies or other risk factors.
Secondly, we ask our patients to cooperate in our efforts to assist them safely. For many this may involve pre-operative evaluation by a cardiologist. For some it may involve evaluation by hematology or gastroenterology regarding potential bleeding concerns or concerns about blood count. All of our patients are given instructions regarding discontinuation of certain medications and supplements. This is done because of the extra bleeding risk that they pose. While abiding by this is important for any patient, especially is this the case for our patients who refuse transfusions.
CBMS: How can a patient be evaluated by you for potential knee or hip replacement surgery?
Dr. Sewecke: The office number of Allegheny Orthopaedic Associates is 1-877-660-6777. A patient requesting care without transfusions should mention this at the outset of their appointment so that we can make special plans according to the need.
