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Erythropoietin is usually the drug of choice for bloodless medicine because of its stimulative effect on red-blood-cell production. Hormones and vitamin B12 are also prescribed to encourage cell production. Doctors may employ a hyperbaric chamber to flood patients' blood with higher concentrations of oxygen so that they can better withstand surgical procedures and low blood levels, while oximetry devices and other noninvasive monitoring equipment keep close watch over oxygen levels.
During surgery, bloodless practitioners often do everything they can to stave off any blood loss that might require a transfusion. Among the techniques: cryosurgery to freeze tissue to be removed, or use of a harmonic scalpel, a vibrating laser that simultaneously cuts tissue and clots blood. Brain surgeons treating tumors and repairing blood-vessel malformations are also using a state-of-the-art gamma "knife" that delivers a high dose of radiation to precise points in the head through tiny holes in a helmet that resembles a salon hair dryer.
Still, except for such techniques as radiosurgery, virtually no surgery is completely bloodless. The blood that is shed during operations at places like Englewood may be suctioned out by cell-saving machinery, cleaned and then returned to the patient's body. Red blood cells can also be saved through hemodilution. In this procedure, hemoglobin-rich blood is pumped unit by unit from a vein and replaced by an equal number of units of a nonblood fluid to expand the volume to normal; the patient's own drawn blood is held for use after surgery. In another technique, doctors may use albumin, a protein found in plasma that is acceptable to many who refuse transfusions on religious grounds, to maintain or increase blood volume, or to manage an underlying medical condition. Says Shander: "They used to tell us, 'Give 'em a couple of bottles of blood--it won't hurt; it's good for what ails them.' Well, that might be easier, but I've learned to rely on less, with better results."
Since the Englewood program began in 1994, it has performed more than 1,500 bloodless procedures, twice that of any other institution. Most of them have been major operations that usually involve extensive blood loss and transfusions: liver resections, hip replacements, abdominal aortic aneurysms, hysterectomies and brain surgery. "From a medical point of view, there are no technical barriers to performing bloodless surgeries," says Dr. Sharo Raissi, a cardiac surgeon at Brotman Medical Center, one of a dozen hospitals in Los Angeles that offer such services. "There is no limit as to what can be done for patients, from open-heart surgery even to transplants."
In one especially difficult case that Shander oversaw at Englewood, 11-year-old Cristali Rodriguez came in with a rare pancreatic tumor, one of only 300 documented cases worldwide. Doctors in Philadelphia had declined to perform a Whipple procedure, a complex reconstruction of the digestive tract rarely performed on a child. Rodriguez's parents had refused a blood transfusion, and the girl's doctors felt that without it the operation was even more risky. Undeterred, Englewood surgeons did a 10-hour bloodless Whipple. There were no major complications, and a week later Cristali was eating pizza. Soon after her discharge, she was back in school.