Chapter 05: The Boutique Blood Bank and the Details of Transfusion Medicine
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Description
Here Dr. Lichtiger details many facets of the Blood Bank’s operations. He first talks about the challenges of running blood drives to acquire necessary blood, noting plans to expand the laboratory and increase the number of community recruiters. He notes that the MD Anderson name inspires many individuals and organizations to respond to blood drives. (He describes conducting drives at the Houston Chronicle at 2 am or 4 am, when the night staff is there to donate.) Dr. Lichtiger next talks briefly about the history of blood banking and describes how the field of Transfusion Medicine transformed it into a clinical practice (in the late 80s). He notes that working with patients over the years has taught him “tricks” for treating patient and offers the example of treating RH disease in pregnant women. He then talks about cases in which the field’s wisdom about blood transfusion either cannot work well at MD Anderson or does not apply because of patients’ special conditions. For example, research shows that patients do well with the freshest blood possible, and Dr. Lichtiger describes how quickly blood breaks down and loses its therapeutic power. In addition, though patients are encouraged to bank their own (autologous) blood for procedures whenever possible, cancer patients are often too ill to do so. Autologous blood is recommended to protect the patient from receiving (allogeneic) transfusions from other people whose blood may carry infection. Dr. Lichtiger explains how the Blood Bank guarantees the safety of the blood products made available, going beyond the standard guidelines for safety. They also carefully screen donors and do not accept blood from anyone with a history of cancer.
Next Dr. Lichtiger describes the technological advances that the Blood Bank has adopted to speed up collection of blood from donors (using a device based on an invention by Dr. Emil J. Freireich [Oral History Interview], the continuous flow blood separator). He also explains the ways that MD Anderson surgeons succeed in reducing transfusions during surgery (including using surgical instruments that coagulate blood as they cut). Outpatient services consume 30% of the Blood Banks stores. At the end of this Chapter, Dr. Lichtiger describes how Transfusion Medicine designed a special transfusion process for a Jehovah’s Witness, whose religion dictated that an individual can never be separated from his/her blood.
Identifier
LichtigerB_01_20120611_C05
Publication Date
6-11-2012
City
Houston, Texas
Interview Session
Benjamin Lichtiger, MD , Oral History Interview, June 11, 2012
Topics Covered
The University of Texas MD Anderson Cancer Center - An Institutional Unit Overview Overview Definitions, Explanations, Translations The Researcher The Clinician The Administrator This is MD Anderson Discovery and Success Building/Transforming the Institution Multi-disciplinary Approaches Professional Practice The Professional at Work Collaborations Growth and/or Change Beyond the Institution Patients Offering Care, Compassion, Help
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD :
You were talking about the fact that the service really commanded a lot of respect.
Benjamin Lichtiger, MD :
Yeah, that’s my perception. Did other people have to say that? But what I pick up—and people do respect us because we are there. We’re interventionists. We try to work with them and work each case individually. There’s no generalization. Everybody gets this, everybody gets that. That’s where we are today, and we are now trying to expand further our blood bank and our donor operation because we are very excited with Dr. [Ronald A.] DePinho’s idea of the Moon Shot that he mentioned, and so we feel that we will have to be part of it, although nobody mentioned that. But many times I told my colleagues that they treat me, the blood bank, as a mistress. They keep us in the dark. But whenever they feel lonely they—(laughing) That’s okay. I don’t mind, not at all. I know perfectly what our role is and how we have to operate.
Tacey Ann Rosolowski, PhD :
What are your plans to expand alongside the Moon Shots?
Benjamin Lichtiger, MD :
We are preparing a plan to present to Dr. DePinho and the authorities in the department about expanding our capabilities. We are building an expansion of the laboratory. We are going to get additional recruiters, community recruiters, additional buses and people to go out and drive because we are “fortunate” that most of the people in Houston have heard of MD Anderson and one way or another had a family member that was treated here or had cancer, one way either directly or indirectly. When we go in and we say, “We are MD Anderson,” people know exactly what we are talking about. Other community blood centers have to go in and say, “We give blood to Bacliff and to Clear Lake and here and this and Jacinto.” People have no allegiance to that, but there are people we go and visit and they say, “My grandmother had leukemia. She died, but she received such care. We will never forget, and we are very grateful.” And we capitalize on that, very frankly. It’s a tremendous marketing tool.
Tacey Ann Rosolowski, PhD :
This service—you manage everything that happens inside and then everything that happens outside in terms of the volunteers who go out.
Benjamin Lichtiger, MD :
Exactly—go out to companies, schools, army bases, airline companies, churches. Anybody that will show us a vein, we’ll be there any time of the day or night. We go to the Houston Chronicle at four o’clock in the morning, and we go there at seven o’clock at night because they’re producing the paper, and we come back at two o’clock in the morning. We have to catch the donor whenever the donor is available.
Tacey Ann Rosolowski, PhD :
That’s right. Now do you make a special appointment with them? Or you just go out—
Benjamin Lichtiger, MD :
No, no. We just go out and have a blood drive, and we set it up with them. We arrange it. I call them. We set it up, and either they give us space to put the beds or we drive up with our buses, self-contained and everything, and we do it over there. The community has been very gracious, very supportive, so there’s nothing negative I can say about that.
Tacey Ann Rosolowski, PhD :
That’s great.
Benjamin Lichtiger, MD :
And the companies, we are aware of companies that give to the other blood bank, but they make it a point to once a year or twice a year give to MD Anderson. It’s a shared resource.
Tacey Ann Rosolowski, PhD :
It also seems like a constant stream.
Benjamin Lichtiger, MD :
Absolutely, yeah. We won’t feel offended.
Tacey Ann Rosolowski, PhD :
I wanted to ask you because I had never—before I began preparing for this interview I had never read the term transfusion medicine before, and I was curious about that, if that was a relatively new field when you entered?
Benjamin Lichtiger, MD :
It’s a field that really—before it was blood banking and people didn’t like the term blood banking, and more and more as we were trained in blood banking and we interacted with patients and we had meetings and consulted with doctors and patients, it became like we were practicing medicine, practicing transfusion medicine, so nationwide it changed, the term.
Tacey Ann Rosolowski, PhD :
And when did that change accordingly?
Benjamin Lichtiger, MD :
I would say in the mid to late ‘80s.
Tacey Ann Rosolowski, PhD :
Now was that transformation of the practice something that was happening all over the country? Was MD Anderson sort of unusual in how quickly they—?
Benjamin Lichtiger, MD :
No, it was happening in other places—Mass General. There were people that were very involved. There were surgeons and—(beeping)
Tacey Ann Rosolowski, PhD :
I’ll just pause this. (audio pauses )
Benjamin Lichtiger, MD :
Surgeons and clinicians, people that established the blood bank, and they were actually—the first blood bankers, most of them were hematologists. They were seeing patients, and they were directing blood banks. They are the ones that brought the nexus of the two practices—the medical—the frontline, bedside experience to the blood bank and the blood bank to the bedside. After we finish this I have to go and see a patient because she has some reservation about what we are doing to her, so I have to go and sit down and talk with them.
Tacey Ann Rosolowski, PhD :
I can see how that—you called it interventionist or collaborative—structure was there from really the beginning.
Benjamin Lichtiger, MD :
Yeah, from the very beginning. I felt very strongly because—I don’t want to sound— make it like a pejorative term or something that is dismissive. But I don’t know neurosurgery. I rotated. I helped, but I don’t know neurosurgery. I’ve never done it. I don’t remember any more how to do an appendectomy. The surgeons don’t know blood banking. You understand? The clinicians do not know blood banking when I tell them—they rely on me to tell them this is the unit, this is what you have to take. I realized in my rotations, in my rounds, that they really didn’t know what to order, when to order, how to order, so we practically co-opted that. Today the orders for transfusions—say I need red cells, I need platelets, or I need plasma. In other institutions I see the clinician orders, “I want all negative, I want this, I want this.” No, he doesn’t. The only thing—you physician that has seen the patient, you need red cells, you order red cells. We’ll take care of the rest because I have a lot of information. They’re telling me what to give the patient and when to give it, how to give it. I’ll talk to the nurse and tell them do this or this or this. The doctor, the only thing he has to worry about is the medication. I’m going to give an antibiotic, and the pharmacy prepares it. We prepare it in the way that’s tailored for that particular patient.
Tacey Ann Rosolowski, PhD :
Yeah, I’m really struck that in this instance probably more than almost anyone else I’ve spoken with that this fit really early with Dr. Clark’s vision of the team, everybody collaborating.
Benjamin Lichtiger, MD :
Yes, everybody. I get up at four o’clock in the morning; 4:30 in the morning [I get] a page, and it’s Neurosurgery because the neurosurgeons know that I will be looking at the case, and they say, “I need to do this case, and the patient has these parameters. What do you suggest we do? How do we do it?” We just discuss the case and prepare a plan of action because I know that if you allow me to use—we have tricks that can make things easier.
Tacey Ann Rosolowski, PhD :
Can you give me an example?
Benjamin Lichtiger, MD :
Well, for example, you must have heard that there are women that form antibodies when they’re pregnant. It is the Rh disease, it’s called.
Tacey Ann Rosolowski, PhD :
I’m sorry, what was that?
Benjamin Lichtiger, MD :
Rh. It’s Rh incompatibility with the fetus, and they need special treatment. Some of them lose their child, lose the pregnancy. Our patients receive such intensive chemotherapy that their immune system drops. Temporarily, but it drops. At that time they cannot form antibodies. All negative blood or any Rh-negative blood is in very, very low supply, sometimes nonexistent. We give them Rh-positive. We have learned the trick because we know they’re getting—we can fly under the radar, so to say. Now the patient I’m going to see has an objection. She’s an Rh-negative, and she doesn’t want Rh-positive blood. I have to go and sit down and explain to her. She’s a bone marrow transplant. Her immune system is down.
Tacey Ann Rosolowski, PhD :
So there won’t be a problem.
Benjamin Lichtiger, MD :
There won’t be a problem, so these are what I call tricks that we go ahead and take advantage. But in a couple of months when her bone marrow recovers I have to be careful what I give her. That’s why we test for everything.
Tacey Ann Rosolowski, PhD :
When did you discover this particular trick?
Benjamin Lichtiger, MD :
Oh, back in the late ‘70s. I have known that for years. That’s another thing. And the others I discovered by accident because patients have gotten some units of blood that were not supposed to go to them, and they never had the reaction. Nothing happened to them. On the contrary, they incremented. I realized this all depends on the immune status of the patient. It depends on the category of the patient, what disease they have, but we have a very rich information system that allows us to handle that. Before every patient, we analyze every case individually.
Tacey Ann Rosolowski, PhD :
And how does that work? You have all this—who gathers that information and then who—?
Benjamin Lichtiger, MD :
It’s collected as the patient evolves. We collect it constantly, and we have access to ClinicStation, which is the information system for patients, and we write notes there. We say this patient we did this, we did this, we did this. We are constantly—we also have the blood bank information system that stores all the data on the patients, so we know.
Tacey Ann Rosolowski, PhD :
That’s amazing. That is amazing. I thought it was interesting that you used that phrase of boutique blood bank.
Benjamin Lichtiger, MD :
Yes, it’s a boutique really. I cannot depend on a blood bank that operates like it’s just an assembly line, a widget factory. All the widgets have to be the same. If it can’t, it’s not for us. For example, data is coming out showing we need to give—the patients do much better when they get fresh blood, fresh as possible. Now we can do that because our units of blood collected yesterday are already on the shelf, are being transfused. But I need at least 4,000 units a month. I can’t. I barely collect 3,000. Platelets—the platelets that we collect and we produce are one day old, maximum two days. When I buy platelets from outside they are three days old. It’s a different product. They are already thirty percent, forty percent are dead—are gone because when we collect a unit of blood— A red cell has a span of 100 days. When I collect a unit of blood—if you give me a unit of blood today you have one percent of cells are one day old. One percent are two days old, three, four, five. I have cells that are 100 days old. Every day you’re losing one percent. I try to give the patient the freshest blood possible because it has a different—but I can’t because I don’t have enough blood. I have to buy, and when I go out to different blood centers they send me whatever they have. They have me over a barrel.
Tacey Ann Rosolowski, PhD :
And it may not be the freshest blood.
Benjamin Lichtiger, MD :
But I hope to correct it in time.
Tacey Ann Rosolowski, PhD :
How could you address that problem? Benjamin Lichtiger, MD Well, that’s why we need to expand our collections, to go out and collect the blood because on one side I have the ICU guys, the intensivists—they’re really pushing for that and they want this, and we don’t disagree with them. We know that the need exists. The customer wants this product. It makes sense. We’ll give it to them somehow.
Tacey Ann Rosolowski, PhD :
I wanted to ask you about several issues that seem to be in discussion in the background materials I got, and one of them was that there was an article about the shift between using allogeneic blood transfused from—this is for the recorder obviously—blood transfused from another patient to autologous blood—blood taken from the patient and then given back to the patient. What is the status of that discussion now?
Benjamin Lichtiger, MD :
Well, if a patient goes in for a valve replacement or goes in for some operation, knee replacement, hip replacement, it’s okay. I believe in that. I really do.
Tacey Ann Rosolowski, PhD :
The autologous blood?
Benjamin Lichtiger, MD :
Yes, I do. Our patients come in at seven grams, low. They’re very low. They have no chance of doing that, and besides there are some patients I have that walk out from the hospital—they walk out in remission, but they consume 450 units of blood component. They can never make it. Our institution is not—our patient population unfortunately cannot avail themselves to that because their needs are so immense for the particular patients they cannot, so we make it available to those cases. For example, some surgeons, they bring in patients for certain protocols, and they have good hemoglobin, and we take two units of blood and give it to them autologous. But some don’t.
Tacey Ann Rosolowski, PhD :
When this conversation came up in the profession, the positives and the negatives—because obviously the article I read said yes, whenever possible use autologous blood.
Benjamin Lichtiger, MD :
Whenever possible, yes, autologous blood.
Tacey Ann Rosolowski, PhD :
What were the issues? Why was that becoming such an important conversation to have?
Benjamin Lichtiger, MD :
Well it all came in the early ‘80s when they came out with the issue of—HIV started to come up and then hepatitis C and hepatitis B, so people realized that we can draw blood and give it back to the patient, so much so that we used to draw two units from the patient before he went into the OR. Even in the OR when they put in a line, an arterial line, they’ll draw two pints of blood and give it back to the patient during the operation just to avoid transfusion, and many hospitals do it, but here our patients are not in the situation to go through it.
Tacey Ann Rosolowski, PhD :
How do you—? (beeping)
Benjamin Lichtiger, MD :
—high blood usage and letting us know.
Tacey Ann Rosolowski, PhD :
At some point I’ll ask you how that has improved your life or whether it’s made it—
Benjamin Lichtiger, MD :
Just a—I have no complaints. If they don’t reach me on this, they’ll reach me somewhere else, some other phone line. I’m okay, and that’s life. It comes with the territory.
Tacey Ann Rosolowski, PhD :
Do you need to take that one?
Benjamin Lichtiger, MD :
Yes.
Tacey Ann Rosolowski, PhD :
Okay, I’ll pause. (audio pauses ) I wanted to ask you—following up on that, what are the measures that you take to guarantee the safety of the products—the blood products that you do transfuse?
Benjamin Lichtiger, MD :
Well we follow very strictly the requirements of the FDA. You do or you do. There’s no alternative. They come in and inspect us every year and spend a month here checking out everything. We’re also inspected by the American Association of Blood Banks, AABB, and the CAP, the College of American Pathologists. We train our people very well, and we do things according to what has to be done and more so. Our standards and procedures are very, very strict and demanding just because when in doubt, when we have a doubt of a blood product, we throw it out.
Tacey Ann Rosolowski, PhD :
You said that you go beyond what’s required. What are some of the additional measures that you take?
Benjamin Lichtiger, MD :
For example, the guidelines—they usually indicate that you can keep platelets for five days. We do not have that. They have to be two, maximum three days old because they are not therapeutically effective in our experience. We go beyond what’s really required. We will delete deferred donors that—because physicians are involved then we will look at the pathological entity that somewhere else has not paid attention. We pay attention, and we’ll defer the donors and eliminate the donor for giving. On the other hand, the rest of the blood banks will draw blood from patients that had carcinoma of the brains, carcinoma of the prostate, renal cell carcinoma. We don’t. We do not accept donors that have had any type of cancer.
Tacey Ann Rosolowski, PhD :
What’s the reasoning for that?
Benjamin Lichtiger, MD :
Because we know from our experience here that the people are walking around with circulating tumor cells, and I cannot bring in those units to give to our patients. However, I have no control over the blood I’m buying from outside, but I’m trying to limit as much as I can. We are very, very sensitized of that issue. We are very concerned, and we’re trying to do the best we can.
Tacey Ann Rosolowski, PhD :
What’s the—I remember reading in the—there was a report about the 2002 drop in the blood supply, and I’m wondering are you still here facing challenges with shrinkage of the blood supply and the expansion of it again?
Benjamin Lichtiger, MD :
The shrinkage of the blood supply.
Tacey Ann Rosolowski, PhD :
In 2002, yeah. Apparently there was an article that there was just this enormous drop in the repositories of blood, and I’m just wondering if—
Benjamin Lichtiger, MD :
Well, this is—that’s usually—when it comes out I think it was with the West Nile.
Tacey Ann Rosolowski, PhD :
With the—?
Benjamin Lichtiger, MD :
West Nile virus, I think it was, and new testing comes out. The mad cow disease because so many people live in Europe—lived in Europe—and how many of our servicemen have served in Europe with their families. That really dropped our pool of blood donors by a couple of million. It was a major, major setback, but now we are back to normal levels.
Tacey Ann Rosolowski, PhD :
Pretty stable.
Benjamin Lichtiger, MD :
Yes, we’re okay.
Tacey Ann Rosolowski, PhD :
What are the new technological advances that have helped the functioning of the blood bank?
Benjamin Lichtiger, MD :
Well, now we have automation. For example, just to do the routing ABO, the rates determination and the screening for evidence of previous antibodies from previous transfusions or pregnancy are now put in the machine. The machine takes care of that—accelerates. We do about 500 to 600 total a day, so they are stamped, and the ones that are positive, then somebody takes over and manually works it up. That has accelerated very much, the fact that now we have—the fact that we can collect from some donors—quite a few donors—double red cells, two units of blood at the same time in one sitting.
Tacey Ann Rosolowski, PhD :
How does that work?
Benjamin Lichtiger, MD :
It performs very well because if a donor that is tiny as myself with a blood level, we can give two pints of blood and still function perfectly well. It has been shown, and we do that quite often so that really expands—
Tacey Ann Rosolowski, PhD :
What’s the mechanism? Is it a special—?
Benjamin Lichtiger, MD :
It’s a machine.
Tacey Ann Rosolowski, PhD :
It’s a machine.
Benjamin Lichtiger, MD :
Yeah, we put one on, and in twenty minutes we get two pints of blood, so that has expanded our capabilities of generating inventory, so there’s a technology. Technology gets involved also that we can go out on drives and the device to collect platelets or red cells is big as probably—a little bit bigger than your case. And we connect the donor to one needle—connect and get the bag of product in twenty minutes to half an hour. It made it easier for the population to really—
Tacey Ann Rosolowski, PhD :
The portability. Now the way you’re describing this, are you only collecting platelets, or you’re collecting the entire blood product?
Benjamin Lichtiger, MD :
No, there are donors that will just give platelets, and there are donors that give red cells, and donors that will give plasma. It depends, and it depends on the blood of the donor.
Tacey Ann Rosolowski, PhD :
Okay, because I was going to ask you about— I’ve interviewed Dr. [Emil J] Freireich, and he talked, of course, about the blood separator, so I’m wondering is this—
Benjamin Lichtiger, MD :
Yeah, we use it. Different versions, derivatives of the blood separator, and we use precisely the blood separator he invented. There’s a more modern version, but it’s a J Freireich invention there.
Tacey Ann Rosolowski, PhD :
And that’s pretty amazing. When he described when he was first developing it, all the tubes going all around this, and now it’s in a little tiny case. You can carry it with you.
Benjamin Lichtiger, MD :
Absolutely, it has minimized. Yeah, absolutely.
Tacey Ann Rosolowski, PhD :
I was also reading a bit about certain measures that are being taken to reduce the need for transfusions. Has that affected MD Anderson patients at all?
Benjamin Lichtiger, MD :
In general, I’ll tell you that our surgeons, or some of the surgeons, are very conservative. I imagine we do about fifty to sixty operations a day. Then they use ten units of blood the whole day. I mean, those guys—I tell them—and I tell them don’t be offended, but I tell them surgery presents no strategic challenge to us. I had a problem with the outpatient transfusion. They consume thirty percent of our blood supply in outpatient transfusion with patients coming continuously to get a transfusion and go home. That’s very, very active. But in general, I think—I will call physicians and tell them, “Hey, your patient has 5,000 platelet count, which is terminally low.” And they’ll tell me, “Leave them alone. She’s doing fine. I’ll call you when I need platelets for the patient.” They’re very conservative. In other places they may recommend using certain mechanisms to avoid a loss of blood, and here those guys operate with certain devices that coagulate as they cut.
Tacey Ann Rosolowski, PhD :
What is the device?
Benjamin Lichtiger, MD :
It’s a Bovie or a laser. They will cut through a liver with the laser, and it doesn’t bleed, and you smell cooked liver, grilled liver in the OR. But this guy here would remove half a liver without using a drop of blood. Here I must say my colleagues in the different disciplines are very, very conservative. I cannot say anything about what they do, how they do.
Tacey Ann Rosolowski, PhD :
What are some—I was reading about a case where at MD Anderson they had to develop a special procedure to give a transfusion to a patient who is a Jehovah’s Witness. I was wondering if you could talk about that and if there are any other special challenges that patients present because of the diversity of the patient community.
Benjamin Lichtiger, MD :
Yeah, I was involved with that. We were involved with that, and that was a number of years ago. There was a patient who had to undergo I think a hemipelvectomy, but he was a Jehovah’s Witness, so myself and the anesthesiologist Dr. Jacques DuPuis—he’s gone from here. He retired. And so we talked to him, and we developed a contraption where we connected—where we drew blood from his vein or from his neck, and we connected it to another vein, so we were giving him blood. We drew into bags and maintained a reservoir because he had good hemoglobin, and we were infusing it during the procedure as he was needing it, and they did the operation very well.
Tacey Ann Rosolowski, PhD :
The challenge is that the Jehovah’s Witness cannot be physically separated from his own—
Benjamin Lichtiger, MD :
Yes, the blood cannot break the physical separation with the body, so we maintained throughout the circuit. The blood was never disconnected from his body, and it was several bags because we really broke down—we—my colleague there at the institute put him to sleep and broke down his hemoglobin to almost five grams, and he diluted him. He put in a lot of saline, so he was bleeding his blood, diluted blood, and as the operation was going on to maintain a cardiovascular perfusion, we were infusing the blood. Do you understand? And then we gave him all the blood back.
Tacey Ann Rosolowski, PhD :
Was there anything that you learned from that particular situation that you could take to other cases?
Benjamin Lichtiger, MD :
That we need to talk to the patient. No matter what religion or whatever, sit down and talk with them and see what we can do—and to be flexible. There are many ways of doing things that will satisfy the patient’s needs.
Tacey Ann Rosolowski, PhD :
Are there other religions or ethnic groups of patients that have special needs that influence what you do?
Benjamin Lichtiger, MD :
No. No, I don’t think so. I have not encountered any because most of the patients that come here, they know they’ll need blood. They all know. If it’s a Jehovah’s Witness and it’s a child, the court takes over the case, and so we have no issues there. Yeah, the court and Child Protective Services, they name a guardian, and no matter what the parents say if you have to transfuse, we transfuse. There’s no arguing there.
Tacey Ann Rosolowski, PhD :
Wow, I hadn’t even thought of that.
Benjamin Lichtiger, MD :
Yes, yes. Even before they come they know the child will be taken—we place a phone call. Do you understand? I don’t know the mechanics, but I was told to place a phone call. There’s a judge, and it’s just, that’s it. We do it.
Recommended Citation
Lichtiger, Benjamin MD, PhD and Rosolowski, Tacey A. PhD, "Chapter 05: The Boutique Blood Bank and the Details of Transfusion Medicine" (2012). Interview Chapters. 1460.
https://openworks.mdanderson.org/mchv_interviewchapters/1460
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