“Doctor, can you play some music?” a female patient requested. “I’m nervous. I need music to calm me down.”
“What music do you like?” the doctor said, reaching out for his iPad. “Can you play me Celine Dion?” she asked.
As Dion’s mellifluous voice wafted through the air, serenading the expectant nervous mother so did silence fall on the theatre except for some intermittent muffling of instructions by Dr. T. Igbokwe (not real name) to his assistant and the theatre nurse.
Punch correspondent had arrived at the three-storey hospital, located in one of Lagos’ busiest and densely populated area at 6.00am, two hours ahead of the appointment time. It took another two hours before the first operation, a caesarean section, kicked off.
The young mother-to-be, with a protruding stomach, lay on one of the beds in an enclosed spick and span wide space, located directly opposite the theatre on the last floor. She was roused up and gently led into the theatre by a nurse.
She was then aided to climb unto the operating table and asked to sit on a black rubber-like object. A tray with an array of surgical tools – scalpels, forceps, and retractors – was on a detachable platform on the table.
“She has opted for an elective caesarean section that would require no blood transfusion,” Dr. Igbokwe said as he made the patient bend with her chin touching a pillow placed between her raised knees and face in preparation for anaesthesia.
Commonly referred to as bloodless surgery, the Centre for Bloodless Medicine and Surgery, Johns Hopkins, United States, describes it as any surgical procedure that is performed without a foreign blood transfusion.
In Africa and other parts of the world, bloodless surgery is synonymous with Jehovah’s Witnesses. They are known for their refusal to accept blood transfusions as part of medical treatment – primarily on religious grounds.
With the patient’s arms secured and placed on extendable parts of the table, Igbokwe, who is a family physician and an anaesthetist, then gave the patient epidural and spinal anaesthesia.
The pregnant woman groaned as the injections were given. It was a regional anaesthesia.
“I gave her both epidural and spinal anaesthesia to reduce any possible pain she may feel after surgery. Epidural anaesthesia usually does not last long; and often times, the anaesthetist is not always there till the end of a surgery,” he said in response to Punch's inquiry.
The woman was about to have her second child; she was delivered of her first baby also through a C-section.
Dressed in theatre gowns, face masks and caps on, Igbokwe along with his assistant and a nurse were ready to deliver the woman of her baby. There was some cleaning of her abdominal region.
Dr. Igbokwe explained that a C-section is a major surgery that can lead to loss of more blood by a woman than in vaginal birth.
Bloodless surgeryThe doctor picked up a surgical knife and made a straight incision in the abdominal area (horizontally across the lower end of the uterus, called a low transverse incision, which aids reduced blood loss and a decreased chance of rupture).
He began to cut open layers of the abdominal skin, the muscle, fascia, peritoneum, uterus and eventually the amniotic sac. As the cutting went on, the doctor would momentarily use a tool connected to electricity to cauterise the patient’s blood vessels.
He called it “cut and burn”; a process meant to ensure that little or no blood is lost during surgery.
A further incision was made in the uterus with a horizontal cut to rupture the amniotic sac (a bag of fluid inside a woman’s womb where the unborn baby develops and grows).
As the cut was made, some fluid spewed out...
With the sac opened, the baby was removed from the womb. The umbilical cord was cut and the placenta was removed.
The sober faces of the medical team lit up as one of them brought out the baby. The baby was quickly taken away by the nurse into an adjacent room in the theatre to be cleaned up.
“Where’s my baby? Why is it not crying?” the new mum asked. In answer, the newborn’s innocent cry reached its mother.
Then the process of stitching up the womb began. It seemed more complicated and took a longer time than opening up the uterus; as the doctor dexterously used a scissors-like instrument to pick up a small, curved silver piece of metal to stitch up the opening, layer after layer.
Dr. Igbokwe has lost count of the number of bloodless surgical procedures he has conducted.
“Did you see any blood on the floor?” he asked as he completed the stitching. There was none.
“Like in all surgeries of this kind, the focus is always on minimising the loss of blood. Nobody wants to be exposed to blood. If all patients know that a surgical procedure can be done without the risks associated with blood transfusion, they will opt for bloodless surgery,” he said.
Describing the precautions he took since there was no blood transfusion involved, Igbokwe explained, “We ensured that before she underwent the C-section, her blood level was at optimum level – 10ml and above is standard for a lot of people. Another thing worth mentioning is that in bloodless medicine and surgery, there is what we call permissible anaemia. You can treat a patient even if his blood count is 20. We can over time build up his blood level before surgery (if there is time to do so).
“In some cases, if the patient’s blood count is 48 before surgery, it can drop to 20; that means the patient has lost a lot of blood during surgery. When at 20, there are ways to build up the patient’s blood count. It can be through intravenous iron, erythropoietin (hormone stimulating production and maintenance of red blood cells), among other means.”
In about an hour, the new mum was back in her bed with the newborn placed in a cot beside her.
Her preoperative blood level was 39 per cent while her post-operative blood count was 35 per cent, our correspondent gathered.
The sober faces of the medical team lit up as one of them brought out the baby. The baby was quickly taken away by the nurse into an adjacent room in the theatre to be cleaned up.
“Where’s my baby? Why is it not crying?” the new mum asked. In answer, the newborn’s innocent cry reached its mother.
Then the process of stitching up the womb began. It seemed more complicated and took a longer time than opening up the uterus; as the doctor dexterously used a scissors-like instrument to pick up a small, curved silver piece of metal to stitch up the opening, layer after layer.
Dr. Igbokwe has lost count of the number of bloodless surgical procedures he has conducted.
“Did you see any blood on the floor?” he asked as he completed the stitching. There was none.
“Like in all surgeries of this kind, the focus is always on minimising the loss of blood. Nobody wants to be exposed to blood. If all patients know that a surgical procedure can be done without the risks associated with blood transfusion, they will opt for bloodless surgery,” he said.
Describing the precautions he took since there was no blood transfusion involved, Igbokwe explained, “We ensured that before she underwent the C-section, her blood level was at optimum level – 10ml and above is standard for a lot of people. Another thing worth mentioning is that in bloodless medicine and surgery, there is what we call permissible anaemia. You can treat a patient even if his blood count is 20. We can over time build up his blood level before surgery (if there is time to do so).
“In some cases, if the patient’s blood count is 48 before surgery, it can drop to 20; that means the patient has lost a lot of blood during surgery. When at 20, there are ways to build up the patient’s blood count. It can be through intravenous iron, erythropoietin (hormone stimulating production and maintenance of red blood cells), among other means.”
In about an hour, the new mum was back in her bed with the newborn placed in a cot beside her.
Her preoperative blood level was 39 per cent while her post-operative blood count was 35 per cent, our correspondent gathered.
Second bloodless surgery
Just after the caesarean section, another patient was wheeled in for a bilateral mastectomy.
Before the second surgery, Igbokwe explained that the bilateral mastectomy (surgery to remove all breast tissue from both breasts as a way to treat or prevent cancer) comes with a higher risk of complication than a unilateral mastectomy.
“The second patient has cancer. She has had a lump removed from one of her breasts which after investigations was said to be benign. But afterwards, she was diagnosed with cancer in one of her breasts. She had undergone chemotherapy (treatment of disease by the use of chemical substances, especially the treatment of cancer). Unfortunately for her, there are lumps in the other breast. Her dilemma is: whether she should investigate whether the lumps are malignant – cancerous – or not.
“What if the investigations say the lump is benign, then she later develops cancer also in the other breast? That is her worry. Initially, she had agreed that the first breast with cancer should be removed. But right now, she and her husband have agreed that both breasts should be removed. So, we are looking at a bilateral mastectomy. This is a complicated surgery, especially with someone who had undergone chemotherapy,” the doctor said.
The woman undergoing the mastectomy was in the theatre when Punch man was invited in.
“She is under general anaesthesia. Her blood count is 35 per cent. The general anaesthesia was augmented with tumescent anaesthesia. Tumescence means deadening the area you want to operate on so that blood loss will be reduced because of suture,” Dr. Igbokwe pointed out as he began to remove the first breast.
Unlike regional anaesthesia, where a patient can be aware of what is going on, general anaesthesia puts a patient to sleep.
After putting the patient under anaesthesia, the doctor began to make an incision around her breast. With care and precision, he removed the breast tissue and other parts of the breast were removed.
The tissue beneath the skin down to the chest wall and around the borders of the chest was also removed.
During the operation, a process called diathermy (a surgical procedure involving the production of heat in the removed breasts by high-frequency electric currents, to cauterise blood vessels so as to prevent excessive bleeding) was used.
According to the doctor, other techniques used in bloodless surgery have to do with carefully cutting through tissues to avoid blood loss and optimisation of haemoglobin to ensure that general blood count is sufficient to carry out an operation.
“The second step is meticulous haemostasis. During the operation itself, there is what is called haemodilution; one has to put a lot of liquid into the body system to dilute the blood of the patient. Sometimes, we can deliberately create a low blood pressure in the patient.
Blood vs bloodless“I am not sure anyone will gladly accept a blood transfusion if he gets to know what it involves. Scientifically speaking, using blood transfusion is bad medicine. People think they do not have alternatives to blood transfusion. There is what is called plasma expander (agent that boosts plasma volume and used to treat patients who have suffered haemorrhage or shock); erythropoietin. What kills people is not anaemia in cases of acute malaria or typhoid, but circulatory collapse. Blood expires after 35 days. You cannot keep blood forever,” Okoawo explained.
A Spanish anaesthesiologist, Lara Oller, at a bloodless scientific conference in UCTH, had said the older the blood, the more likelihood of transfused patients dying.
Similarly, the Head, Bloodless Surgery Unit of the institution, Dr. Nathaniel Usoro, said medical scientists had yet to prove the efficacy of blood transfusion.
“Blood transfusion leads to delayed recovery evidenced by longer hospital stay, delayed wound healing, wound infection, etc. When complications of blood transfusion occur, recovery is further delayed. Bloodless care leads to quick recovery, certainly far better than transfused patients of the same category of illness in virtually all studies done,” Usoro said.
The UCTH surgeon pointed out that blood transfusion causes up to 400 per cent hypoxia (reduced oxygen in tissue) rather than improving tissue oxygenation.
“Thus, the more critical the patient’s condition, the more harmful blood transfusion can be,” he said.
A former director at Hospital Services in Lagos State Ministry of Health, who spoke on condition of anonymity, however disagreed.
“A medical doctor should not say blood transfusion is harmful without that statement being qualified. A lot of people rely on the expertise opinion of a medical practitioner. I don’t see anything wrong with blood transfusion as long as the blood is properly screened,” he pointed out.
Corroborating the medical practitioner’s view, another expert, Dr. Olabanji Ajiboye noted that in “cold cases” surgeries can be performed without blood transfusion.
“But in situations whereby there is excessive blood loss due to an accident or a woman in C-section is bleeding for days, there is nothing else to do than to give blood transfusion. Or, how do you handle that? You will lose the patient. People in dire need of blood transfusion cannot be denied of it.
“There is nothing wrong with blood transfusion as long as the blood is properly screened. It is not true in most cases that blood transfusion is dangerous and unhealthy,” Dr. Ajiboye stated.
It was the same verdict a medical doctor of 25 years experience, Dr. Olukayode Adegboyega, gave concerning the value of blood transfusion. Adegboyega said acute blood loss requires blood transfusion. “In cases of acute blood loss, like industrial mishap or automobile accident where a patient has lost so much blood, transfusion will become inevitable. There is no time to waste in that situation. Blood carries oxygen and you do not want to deprive vital organs of that,” he said.
In 2015, the NBTS said it had 17 blood transfusion centres across the country. Private blood banks also exist, apart from those in tertiary and secondary health facilities.
Maintaining those facilities however does not come cheap, said Dr. Smith.
According to her, it cost N2,000 (handling fee) to access one unit of screened blood in Nigeria.
She explained that screening is carried out for four blood-borne infections: HIV 1 and 2, hepatitis B, hepatitis C and syphilis.
To keep blood running at any NBTSC, Smith gave an estimate of what is needed, “When the building and infrastructure are in place, the estimated number of units of blood should be multiplied by about N70,000 per unit for a minimum of 10,000 units per centre. The total number of units of blood per population is put at 10 donors per 1,000 people,” she disclosed.
To purchase screening reagents and other consumables, Smith said it would cost at least N100m per quarter.
The NBTS boss added that a blood collection centre would require N6m to maintain yearly, while a screening centre could cost as much as N15m to remain in business.
“These are operational costs which exclude salaries for staff,” she stated.
Speaking on claims that blood transfusion is more expensive, Prof. Ashiru, said:
A Spanish anaesthesiologist, Lara Oller, at a bloodless scientific conference in UCTH, had said the older the blood, the more likelihood of transfused patients dying.
Similarly, the Head, Bloodless Surgery Unit of the institution, Dr. Nathaniel Usoro, said medical scientists had yet to prove the efficacy of blood transfusion.
“Blood transfusion leads to delayed recovery evidenced by longer hospital stay, delayed wound healing, wound infection, etc. When complications of blood transfusion occur, recovery is further delayed. Bloodless care leads to quick recovery, certainly far better than transfused patients of the same category of illness in virtually all studies done,” Usoro said.
The UCTH surgeon pointed out that blood transfusion causes up to 400 per cent hypoxia (reduced oxygen in tissue) rather than improving tissue oxygenation.
“Thus, the more critical the patient’s condition, the more harmful blood transfusion can be,” he said.
A former director at Hospital Services in Lagos State Ministry of Health, who spoke on condition of anonymity, however disagreed.
“A medical doctor should not say blood transfusion is harmful without that statement being qualified. A lot of people rely on the expertise opinion of a medical practitioner. I don’t see anything wrong with blood transfusion as long as the blood is properly screened,” he pointed out.
Corroborating the medical practitioner’s view, another expert, Dr. Olabanji Ajiboye noted that in “cold cases” surgeries can be performed without blood transfusion.
“But in situations whereby there is excessive blood loss due to an accident or a woman in C-section is bleeding for days, there is nothing else to do than to give blood transfusion. Or, how do you handle that? You will lose the patient. People in dire need of blood transfusion cannot be denied of it.
“There is nothing wrong with blood transfusion as long as the blood is properly screened. It is not true in most cases that blood transfusion is dangerous and unhealthy,” Dr. Ajiboye stated.
It was the same verdict a medical doctor of 25 years experience, Dr. Olukayode Adegboyega, gave concerning the value of blood transfusion. Adegboyega said acute blood loss requires blood transfusion. “In cases of acute blood loss, like industrial mishap or automobile accident where a patient has lost so much blood, transfusion will become inevitable. There is no time to waste in that situation. Blood carries oxygen and you do not want to deprive vital organs of that,” he said.
In 2015, the NBTS said it had 17 blood transfusion centres across the country. Private blood banks also exist, apart from those in tertiary and secondary health facilities.
Maintaining those facilities however does not come cheap, said Dr. Smith.
According to her, it cost N2,000 (handling fee) to access one unit of screened blood in Nigeria.
She explained that screening is carried out for four blood-borne infections: HIV 1 and 2, hepatitis B, hepatitis C and syphilis.
To keep blood running at any NBTSC, Smith gave an estimate of what is needed, “When the building and infrastructure are in place, the estimated number of units of blood should be multiplied by about N70,000 per unit for a minimum of 10,000 units per centre. The total number of units of blood per population is put at 10 donors per 1,000 people,” she disclosed.
To purchase screening reagents and other consumables, Smith said it would cost at least N100m per quarter.
The NBTS boss added that a blood collection centre would require N6m to maintain yearly, while a screening centre could cost as much as N15m to remain in business.
“These are operational costs which exclude salaries for staff,” she stated.
Speaking on claims that blood transfusion is more expensive, Prof. Ashiru, said:
“When a patient in a surgical procedure is losing blood, the next thing is to give blood (transfusion). As to whether bloodless surgery is more cost-effective than blood transfusion-surgery, for me, what matters is the patient’s life.”
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