The most dangerous product a doctor can prescribe

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.

Well organised 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.

Bloody dangerous!

It is the most dangerous product a doctor can prescribe.

It’s expensive.

It can kill.

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
Its blood

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.

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 a 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.

The accepted form of treatment

The principle of treatment is find the cause, treat the cause, correct the anaemia.

To correct the anaemia the principle of treatment is give iron supplements, give vitamin B12 supplements and folic acid supplements. If need be remove the spleen (very uncommonly needed) and then transfusion.

However every junior doctor will tell you that whilst doing days on call they get a few admissions from family doctors a week with a letter saying “Low haemoglobin transfuse urgently.” In very few cases is a transfusion justified or necessary.

Risks of receiving blood for the patient

The most important are blood incompatibility- which can kill. — allergic reactions and infection.

Blood is grouped depending on your blood grouping, A, B, AB or O and your rhesus level. If you give the wrong group of blood to a patient you can kill them.

Allergic reactions, these are easily treated.

Infection there is always the risk of blood borne infection passing from donor to recipient. In fact I never forget one of my patients (who has now died) who was transfused before he came to our hospital but he developed HIV infection due to the transfusion. Sometime later I was asked to take a blood sample from this patient. I used universal precautions and put a yellow danger of infection label on the form and bottle.

Within minutes this jobsworth technician came on the ward and shouted out “This man is HIV positive and I am not risking MY staff by doing this sample.” If he had shouted any louder they may have heard him in Australia! This is the same hospital that accused me of a breach of confidence for passing on the email address of a patient to a friend. I had his permission, he’d put it on the stroke association website, he never complained. When they said he’d made a complaint he sent in a lawyer’s letter saying he hadn’t.

Risks of innappropriate 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 review 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 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 cannnot go that far I would say that the majority of transfusions are not needed.

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 were bed blockers.

Conversely if this didn’t happen then 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 grade 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 for?”

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

Doctor “How often are you seen in a warfarin clinic?”

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.