Normal marrow Section WebPath Photo

Normal marrow Higher power, section WebPath Photo

Normal marrow Smear WebPath Photo

Normal marrow WebPath Photo

Normal marrow WebPath Photo

Rouleaux formation WebPath Photo

FINISHING UP: Thankfully, hemoglobins with excessively high oxygen affinity ("Chesapeake" and many others) are uncommon. As you'd expect, these render the patient polycythemic.

* Red-cell substitutes have been a disappointment. A bovine hemoglobin preparation delivers the goods but only lasts for a day in the bloodstream; it is now in widespread use in some nations and helps JW's in the USA. The older perfluorocarbon emulsions ("Fluosol", others) required patients to breathe 100% oxygen which was deadly to the lungs. Review Am. J. Clin. Path. 118 S: S-71, 2002. Update from the Hop: Arch. Path. Lab. Med. 131: 734, 2007.

We'll do polycythemia vera, other secondary polycythemias, acquired (autoimmune) aplastic anemia, and the myelodysplastic syndrome under "White Cells". Enjoy these pictures:

{13856} red cell, normal blood. (If platelets stick to polys, it's EDTA anticoagulant effect ("satellitism"). Some folks have a gene to make this happen.)

JEHOVAH'S WITNESSES AND BLOOD TRANSFUSION

Sooner or later, you will run into the issue of blood for Jehovah's Witnesses. The group is authoritarian, tightly-controlled, and forbids blood transfusions for its members.

Ask a spokesperson for the details. "Many Jehovah's Witnesses feel that accepting a blood transfusion will lead them to eternal damnation" (Ob. Gyn. 102: 173, 2003). Here are some references that will help you in your thinking.

On the one hand...

• It is hard not to admire people who give up their lives for moral principles -- even if the rest of us think they are misguided (even deceived). This is very clear in the case of a Jehovah's Witness freely refusing blood and dying as a result. US law is unequivocal in supporting the rights of adults to do this. Likewise, Jehovah's Witnesses around the world go to prison rather than serve in the armed forces. As a beginning Christian, I belonged to a pacifist denomination, and although I decided this position was wrong (at least for me), I retain a special admiration for anybody who takes the hard road because something else is of ultimate importance.
• For some reason that nobody has explained in the refereed medical literature, Jehovah's Witnesses are free to accept fractions made from red cells, from white cells, from platelets, or from plasma. However, they may not take any of the fractions themselves, or whole blood. They appear quite willing to accept stem cells from other people (Bone Marrow Transplantation 32: 437, 2003).
• The leadership seems to have reversed itself (June 2000) and now permits use of the cell recycler and polymerized cow's hemoglobin. Ask first.
• Members believe that if a child is transfused, he/she can be "cut off" from the possibility of obtaining eternal life (J. Emerg. Med. 14: 251, 1996). In the 1980's, one spokesman told me that the child would be stigmatized, regarded as satanic, and that this was something to take into account before transfusing a child against the parents' wishes. More recently I have been reassured that this will not happen.
• There is a saying among blood bankers that we are the only business people in the community who work hard to reduce demand for our product. I never saw the point to most "routine" transfusions. So I was not at all surprised when a Portland bloodless surgery group found that Jehovah's Witnesses who had total abdominal hysterectomies without blood transfusions did as well as or better than controls who had transfusions (Am. J. Ob. Gyn. 180: 1491, 1999; plus, remember these folks don't smoke or drink). Obviously it would be stupid (at best) to generalize this to more serious surgery, or to hematologic disease.
• Very extensive surgeries can be performed without blood, especially when erythropoietin, hemodilution, and special coagulators are used (J. Ped. Surg. 32: 1759, 1997; Ann. Thoracic Surg. 69: 935, 2000). Recombinant factor VII is a great asset (Am. Surg. 73: 818, 2007). These also cost third-party payers (i.e., ultimately you and me) lots of money (Br. Med. J. 318: 873, 1999). (Smokers and reckless skydivers also cost society extra.)
• Several sensitive articles have appeared that physicians may find helpful in understanding those whose values differ (a good one: Am. J. Psych. 156: 304, 1999).
• Be sure you do not confuse the JW position against blood transfusion with the beliefs of other sects against all medical interventions.
• Despite the fact that members insist they are "neutral" and have no loyalty to any secular government, they do point out that their legal battles have enlarged the freedoms of their neighbors (i.e., the government can't make your kids say the pledge of allegiance, and you can also keep your kids out of sports and the other extracurricular activities that are so important to most teenagers even if your kids very much want to participate.) However, in the landmark, unanimous Supreme Court decision "Chaplinsky vs. New Hampshire", the court ruled that a Jehovah's Witness cannot scream hateful things about other people's religions on a streetcorner (the "fighting words" doctrine).
• Unlike other militants (the anti-biotechnology people, the anti-animal-research people, the anti-stem-cell people), the Jehovah's Witnesses are not trying to force ideology and a disinformation campagin on everybody else, or interfere with medical progress. Especially for this reason, I urge you to respect them.

On the other hand...

• No reasonable person questions that blood transfusions save lives, and sometimes are necessary to save lives. Members do die because they refuse transfusions, and not because of lack of surgical skill. I cannot address the spiritual issues. But literature that I've seen from the Jehovah's Witnesses on the risk-benefit ratio for transfusions in very-sick people seem to me to be one-sided at best.
• A Jehovah's Witness woman is 44x more likely to die in childbirth than a woman who will accept a blood transfusion (Am. J. Ob. Gyn. 185: 893, 2001 -- as you'd expect, a plan to "optimize hemoglobin using erythropoietin prior to delivery" in these women was a dismal and expensive failure)
• In Italy (and probably elsewhere in Europe), most physicians will not even undertake the workup of an adult JW with likely leukemia, because of all the problems that blood refusal will create. (In the US, this probably shocks us, but think about it. Problems range from additional public expense to increased likelihood of a bad outcome to dealing with militants and snoops to watching somebody actually die of anemia or thrombocytopenia as a result of your chemotherapy and being forbidden to save them.) A team in Milan has actually developed a protocol for JW's with adult leukemia: Eur. J. Haem. 72: 264, 2004, and has gotten some complete remissions; they argue that hematologists should reconsider the boycott and I'm inclined to agree.
• In Bulgaria, the Jehovah's Witnesses accepted a government condition, allowing them to collect money and proselytize only if they promised not to punish members who received blood transfusions. This may now be official policy worldwide (Lancet 356: 1114, 2000). The denomination used to forbid immunizations and organ transplantations, but has reversed itself. In the 1930's, the denomination conducted an inflammatory disinformation campaign against aluminum cookware. With no basis in fact, the JW's viciously smeared the medical profession as evil conspirators against the health of the public. This is now factual history. Perhaps the position on transfusion will change too. So far as I know, all sects have made ghastly mistakes at one time or another. Some acknowledge their past errors. Others don't.
• Since 1961, any adult member who accepts a blood transfusion knows he or she will be disfellowshipped and shunned (i.e., you are allowed no contact with anyone who still belongs to the cult.) For example, the member will not get to go to his/her children's weddings or his/her parents' funerals. The marriage will probably break up, the rest of the family will try to keep the children away from the disfellowshipped parent, and friendships will end. When a Jehovah's Witness is in the hospital, the "visitation committee" comes around to remind doctors not to transfuse their fellow-believer, and of course to snoop and be sure there's no transfusion. Blogs (you can find them yourself) talk about grown children of disfellowshipped members trying to see their dying parent at the hospital. The "visitation committee" may well be keeping watch outside the dying parent's room -- and if the child even speaks a parent who accepted a blood transfusion thirty years ago, the child, too, will be "disfellowshipped." WITH PRESSURES LIKE THIS, I THINK REASONABLE PEOPLE CAN ASK WHETHER REFUSING A NEEDED TRANSFUSION IS REALLY A FREE CHOICE.
• When I was doing blood banking as a pathologist, I got tired of the "hospital visitation committee" people marching into the lab and saying, "Thus-and-so is a patient in this hospital and is a Jehovah's Witness, be very sure you don't transfuse him/her." I found it hard to be polite to these people, and of course got told I was "damned eternally." With HIPPA, of course, you need to tell these people nothing beyond to get out and stay out.
• "The tort of misrepresentation": Legal scholars are now arguing about whether there exists "THE PRIVATE RIGHT TO SUE WHEN A RELIGION MISREPRESENTS SECULAR FACTS", i.e., for lying to the faithful about the scientific facts relating to blood transfusion. The deceit in the 2006 edition of "How can blood save your life?" is there for anyone to see. "Still, for years claims have been made the blood saves lives." "One death for every 13,000 bottles of blood transfused", data from 1960. A barrage of half-truths and outright lies follows, including the suggestion that the blood you get in an American hospital may come from a third-world nation and not be screened for disease, or that "we cannot assume that all blood is yet being tested [for AIDS]", or the shameless, blatant lie that the US blood supply is not screened for HTLV-1. If the JW's weren't a religion, they'd be in serious trouble already over the deaths they've caused. See the landmark article, "Jehovah's Witnesses, Blood Transfusions and the Tort of Misrepresentation", by K. Louderback-Wood, Journal of Church and State, Vol 47, Number 4, pages 783-822, 2005. It's a review of the quotations from their indoctrination tract compared with the actual sources -- the pattern of deliberate, consistent deception seems obvious to me despite the tract being written in lawyer-ese. If this does come to trial, the author of "How can blood save your life?" will be torn to shreds on cross-examination in front of the jury. I am wondering about both civil and even criminal charges against physicians involved in the sect who fail to tell others, "Now, that one and that one and that one are all lies."
• A portion of the indoctrination tract "Blood Transfusion -- How Safe?" downloaded by me on November 12, 2009 from the Jehovah's Witness official site and seen to be copyrighted 2006, reveals a pattern of deception through the use of material that the authors must realize is way out of date.
  • A 1960 article, from the era before hepatitis B testing, quotes a risk of one death in 1000 to 3000 or possibly 5000 transfusions." There is no more current data cited.
  • The JW's cite US News and World Report from May 1, 1989, claiming that "about 5% of those given blood in the United States get hepatitis -- 175,000 people a year. About half become chronic carriers, and at least 1 in 5 develop cirrhosis or cancer of the liver. It is estimated that 4000 die." What the JW's do not mention is that this was BEFORE we tested all units for hepatiits C, which is now vanishingly rare after transfusion.
  • The JW's quote someone at the American Red Cross from 1989, saying "We can't just keep adding test after test for each infectious agent that might be spread." In fact, we have been doing just that whenever possible. Consider the case of West Nile. And as soon as transfusion-related prion disease became recognized on the basis of one case, we began screening all units.
  • The JW's claim "Even the test for hepatitis B is fallible; many still contract it from blood." Many? The JW's are being deliberately vague. Nowadays the risk from a screened unit is about 1 in 150,000.
  • Initially, we screened for hepatitis C using the antibodies that patients generate themselves. The JW's write, "Moreover, will people be satisfied with the announced test for hepatitis C? The Journal of the American Medical Association (January 5, 1990) showed that a year can pass before antibodies of the disease are detectable by the test." What the JW's don't tell their readers is that NAT testing was added in 1999, detecting the virus itself. Today no one knows the risk, but it is apparently less than 1 in one million screened units.
  • The JW's cite the "window period" during which a donor's blood may contain HIV without an antibody. They cite examples from the past, in which people were infected in this way. What they fail to tell their readers is that in 1999, nucleic acid amplification testing was introduced to detect the virus itself, and the risk is presently estimated at less than 1 in 1,900,000 units transfused.
  • The JW's write about a virus that "is believed to be the cause of adult T-cell leukemia / lymphoma and a severe neurological disease." They are referring to HTLV-I. They claim, "This virus is already in the blood donor population and can be spread in blood." What they do not tell their readers is that since HTLV-I and HTLV-II were discovered in the 1980's, all units are now screened for both viruses and the risk of getting sick is so low that it's not known.
  • Finally, the JW's use sleight-of-mouth to make readers believe their blood may not be screened for disease at all. "We cannot assume that all blood is yet being tested. For example, it is reported that by the start of 1989, about 80% percent of Brazil's blood banks were not under government control, nor were they testing for AIDS." But in the developed world, in 2009? Get real.
  • Elsewhere in the indoctrination tract ("The Blood That Really Saves Lives"), the JW's cite a classic study "Effects of Early Transfusion on Gastronintestinal Haemorrhage", Br. J. Surg. 73: 783-5, 1980. Here is how the JW's represent the article:

    The British Journal of Surgery (October 1986) reported that prior to the advent of transfusions, gastroinestinal hemorrhage had "a mortality rate of only 2.5 per cent." Since transfusions became customary, "most large studies report a 10-percent mortality." Why a death rate four times as high? The researchers suggested: "Early blood transfusion appears to reverse the hypercoagulable response to haemorrhage thereby encouraging rebleeding."

    The researchers were actually examining the old-fashioned, unscientific practice of early blood transfusions for GI bleeders. Since the figure of 2.5% is astonishingly low and comes from a paper from 1924, it may reasonably be questioned, and the authors also note that the 1924 population was a selected group of young, physically-fit individuals who may have gone straight to surgery. The underlying causes of the bleeding aren't stated, but we may think that the 1986 study included many inoperable cirrhotics, who typically bleed to death sooner or later regardless of what we have to offer. The JW's are apparently trying to trick the reader into believing that the 1986 study was a comparison between GI bleeders who were transfused and those who were not transfused. The researchers actually compared patients who were transfused when they came in versus patients who were transfused only if their hemoglobin dropped below 8 g/dL. The authors explain:

    Of the 26 patients randomized to receive no blood transfusion within 24 h of admission, five did require transfusion on their first day for anaemia worse than 8 g/dl.

    No scientific physician will be surprised that patients who were transfused for no real reason ended up doing worse and requiring more blood in the long run than patients for whom transfusion was delayed. You're just supplying more pressure to keep the pumper open. The authors finish up:

    The role of blood transfusion in the treatment of gastrointestinal haemorrhage has never been questioned seriously although it is accepted that patients who are transfused more than 4 units of blood fare worse than those who require less than 4 units.

    Go figure -- they must have also been sicker to begin with. The authors conclude from their study,

    Therefore, where possible, blood transfusion should be delayed. If it does need to be given for severe haemorrhage, early surgery should be considered.

    I think a reasonable person would agree that the purpose and findings of the study should not be presented as part of an overall indictment of blood transfusion.

  • The JW's have the integrity to admit that their members' refusal of blood does indeed cost some of them their lives. They might cite a large study from the Netherlands (BJOG 116: 1103, 2009) showing figures for women giving birth:

    Women who are Jehovah's witnesses are at a six times increased risk for maternal death, at a 130 times increased risk for maternal death because of major obstetric haemorrhage and a 3.1 times increased risk for serious maternal morbidity because of obstetric haemorrhage, compared to the general Dutch population.

  A group in Scotland extrapolated a 65x risk of fatal postpartum hemorrhage (Arch. Gyn. Ob. 276: 339, 2007).

  • Better surgical techniques today have greatly reduced the need for blood transfusion during most (not all) major surgeries (Ann. Royal College Surg. 87: 3, 2005). This is where the JW recently got their host of "facts and figures" to "show" that the no-transfusion major surgeries that they demand are actually LESS expensive overall. If this were true, the hospital administrators (driven by the profit motive) and the resesarch piranhas would have sat up and taken note. They haven't. Anesth. Clin. N.A. 23: 327, 2005 didn't look at JW-style "bloodless surgery" at all, only at heart surgeons' perhaps overusing blood transfusions. Am. J. Ob. Gyn. 180: 1491, 1999 ("no increased hospital charges") was simply for routine hysterectomies for JW's. A celebrated "bloodless surgery" triumph of spinal surgery (Minerva Anesth. 73: 323, 2007) used autologous donations beforehand. Anyone who is scientifically literate will recognize the common fallacies (cherry-picking, failure to control for other variables, i.e., the sicker people are the ones who get transfused; a dead patient costs nothing; srgeons will not operate a JW who is likely to die without a transfusion). Anyone believing that the "bloodless surgery" that saved the life (barely) of a JW with a 30 pound sarcoma was cheap or should be the norm (J. Surg. Ed. 64: 212, 2007) isn't thinking. Will the rest of us willingly continue to pay for this?
  • It's my hope that this will be helpful to physicians counselling folks who have read the indoctrination tract. The public cannot keep itself up-to-date on all scientific issues. However, most people DO eventually catch on when they are being lied to, and they do NOT like it. My livelihood depends on my being known as an honest man of science. I have risked personal harrassment by placing these notes on line, simply in the hope that someone, somewhere will use them to de-hoax a victim and save ultimately save a life. One member of the anonymous group says a physician has a duty, in informed consent, to tell JW's that the booklet is deceptive. You decide.
  • Because it seems to me that it is only a matter of time before the JW leadership pays the price for "the tort of misrepresentation", I do not intend to discuss this further. Call my unspiritual if you want.

• A group within the Jehovah's Witnesses sect that accepts blood transfusions remains entirely anonymous -- if any member of this group were to use his/her name in public, he/she would be disfellowshipped and lose his/her family as a punishment (J. Med. Ethics 26: 375, 2000). One member was disfellowshipped simply for writing a supportive e-mail to the group -- his wife turned him in. Click here for the physicians' page of the Associated Jehovah's Witnesses for Reform on Blood. One ethicist suggests that physicians need to tell Jehovah's Witnesses that the group exists (J. Med. Ethics 26: 299, 2000) -- I agree but doubt this would have any effect. Much more likely is showing them that they've been lied to about the secular facts -- in my own experience, people leave "movements" when, and only when, they discovered they have been maliciously deceived.
• Please remember that for any denomination, the leadership is not the members. Where dissent is not tolerated, you cannot know the hearts of the faithful. I have found individual members to be motivated by an uncommon concern for my own spiritual well-being, which I appreciate despite my disagreements. However... the denominational leadership often finds itself under sharp public criticism. In 1987, it expressly instructed members who work in the health-care setting to breach medical confidentiality. In the cited example, a member who learned that another member had an abortion was expected to announce this to the congregation. Of course this is a crime in many jurisdictions (J. Med. Ethics 26: 381, 2000), and as a physician, simply having people like this around me makes me extremely uncomfortable. When one ethicist suggested a don't ask, don't tell approach for Jehovah's Witnesses needing blood (J. Med. Ethics 25: 469, 1999), the denomination's lawyers responded with a piece (J. Med. Ethics 25: 463, 1999) full of more venom and obvious distortion than I had ever seen in a journal article. Letting children know that they are set apart from an evil world includes requiring them to leave the classroom during other children's birthday parties. Most are not allowed to participate in sports or extracurricular activities, i.e., the situations in which they would probably develop friendships with non-JW's. There are over 1000 divorce actions in the US each year because one partner embraces the sect and the other does not, and these tend to be extremely bitter. Beginning in 2001, the media gave a lot of attention to the supposed massive protection of pedophiles and punishments meted out to the children who bring accusations even if they're probably true. As we've seen before, this is a politicized subject where it's often hard to get at the truth. But throughout the crisis, despite the resignation of church leader William H. Bowen over the issue (he called the sect a "pedophile's paradise"), the main JW internet site continued silent. And right or wrong, people seem to judge the denomination by its focus on direct put-you-on-the-spot, proselytization and staying uninvolved with our tolerant, pluralistic mainstream society rather than community service and philanthropy. The notions of altruism, kindness to strangers, and universal love -- ideas that are absolutely central to all the major world-faiths as I know them -- are conspicuously absent from what I've read of the JW literature. However, I have known several individual members who have been among the nicest people I've known, and during the years when I considered a pacifist commitment, I came to admire them very much. One commentator on these notes in 2004 wrote to me that there cannot possibly be general peace and goodwill among human beings until "there is only one religion left standing." There's literature with pictures depicting the supernatural mass-slaughter of all non-JW's. It's obviously directed toward simple folks and children. I don't appreciate this. The denomination also teaches that family members who accept transfusion or drop membership should be killed by stoning, and the fact that they do not do so is merely because national law forbids it. In France and Italy, most physicians simply transfuse Jehovah's witnesses while they're asleep in surgery, without telling them or simply lying (Eur. J. Anaesth. 8: 297, 1991; Med. Educ. 36: 479, 2002). I find this unacceptable; others may disagree, feeling that these people's choice -- in contrast to the choices your physician must offer you -- is neither honestly-informed nor free.
• For the clinical strategies in managing Jehovah's Witnesses, see Am. J. Med. 119: 1013, 2006. The most helpful article on the personal issues that I've found is J. Med. Eth. 24: 295, 1998. The author urges physicians to help patients make a genuinely free, informed decision by conferencing with them, giving accurate information, and asking them why they believe as they do and what pressures are on them. Whatever decision the adult patient reaches must be honored.

{13858} red cell, normal marrow, unusual stain
{13976} red cell, normal blood (two orthochromatic normoblasts)
{20780} red cell, normal blood
{46538} red cell, normal blood
{26161} basophilic normoblast (prorubricyte)
{26162} basophilic normoblast (prorubricyte)
{26197} basophilic normoblast (prorubricyte)
{26198} basophilic normoblast (prorubricyte)
{26223} polychromatophilic normoblast (rubricyte)
{26224} polychromatophilic normoblast (rubricyte)
{18690} orthochromatophilic normoblast (metarubricyte)
{10127}red cell, even staining for hemoglobin

{10130} Heinz bodies
{10418} nucleated red cells in hemolytic disease of the newborn
{21113} hemolytic disease of the newborn
{13898} polychromasia (the purple, large red cells are "reticulocytes")
{14722} reticulocytes, normal
{14723} reticulocytes, too many
{39616} erythroid hyperplasia
{39617} erythroid hyperplasia

{27434} plasmodium vivax
{13880} cold agglutinins in the blood
{12299} hereditary spherocytosis
{16172} spherocytes
{11547} hereditary elliptocytosis (spherocytosis variant)
{13892} hereditary elliptocytosis (spherocytosis variant)
{12305} spur cells ("acanthocytes"' E.T.-finger cells); abetalipoproteinemia case; there are other odd genetic syndromes featuring this anomaly
{13871} abetalipoproteinemia smear (lymphocyte in upper right)
{20128} abetalipoproteinemia smear

{17419} sickle cell disease
{13907} target cells
{16167} target cells
{16177} target cells
{16169} stomatocytes (flattened uniconcave RBC's typical of acute drunkenness, liver disease and various rarities, everyone's allowed a few)
{12308} schistocytes
{13895} schistocyte
{16178} schistocytes
{17137} DIC
{20149} thalassemia
{13877} basophilic stippling
{10430} "megaloblasts" (i.e., the red cell precursors in pernicious anemia)

{13751} megaloblastic blood smear
{13754} megaloblastic marrow
{13757} megaloblastic marrow
{13889} macro-ovalocytes (i.e., megaloblastic anemia)
{12302} teardrops

{14013} sideroblastic blood (dimorphic RBC population)
{27342} ringed sideroblasts, iron stain (not the greatest photo)
{09054} iron in mitochondria
{14025} Pappenheimer body (retained iron-loaded mitochondrion, i.e., you have sideroblastic anemia and/or have had a splenectomy; you need a Prussian blue stain to see them well)
{16168} Pappenheimer bodies
{13854} polycythemia vera blood
{13976} rouleaux
{14028} multinucleated red cell (DiGuglielmo's?)
{23920} myelodysplastic syndrome
{13883} Howell-Jolly bodies (stray chromosomes not extruded; usually mean the patient has had a splenectomy and they were not removed)

{16170} Howell-Jolly bodies
{13904} post-splenectomy
{29011} blood bank

Howell-Jolly bodies and nucleated red

WebPath Photo

Let the young sing songs of death. They are stupid. The finest thing under the sun and the moon is the human soul. I marvel at the small miracles of kindness that pass between humans. I marvel at the growth of conscience, at the persistence of reason in the face of all superstition and despair. I marvel at human endurance.

-- Anne Rice, "Pandora" ("The Vampire Chronicles")