God Panels and Hep B by Gary Grist BS RN CCP Emeritus
In cataloging documents for the AmSECT History Committee, I reviewed a fun and entertaining publication saved from oblivion by Mark Kurusz. It is the program from the 6th annual meeting of the American Society of Extracorporeal Circulation Technicians in 1968. It was sponsored by the Southern Pacific Regional Organization. The registration fee was $5. There were 10 exhibitors, of which only one or two still exist. Nineteen sixty-eight was the year I started working in perfusion, but I was not in attendance at this meeting.
Blood Gas Interface
There were 12 scientific sessions, ten of which were presented by MDs or PhDs. Although the pamphlet does refer to “Extracorporeal Perfusionists” in its invitation, Walter Simpson with James Dearing and Colin Green with Maurice Robertson were the only “circulation technicians” to present. They gave two talks. One on protein denaturation in the bubble oxygenator at the blood gas interface and one on the Rygg-Kyvsgaard bubble oxygenator.
Some of the session listings have short, abstract-like summaries in the pamphlet. It is interesting to see what people were concerned about in 1968. In the pamphlet introduction, achieving unity among AmSECT members was paramount. In the scientific sessions, one discussion addressed all these problems: emboli, hemodilution, filtering, and heparinization. Another session described computer-based post-op monitoring (way ahead of its time). The was no discussion about coronary artery bypass grafts or cardioplegia in any of the presentations. Rather there was a presentation on coronary artery thromboendarterectomy while on cardiopulmonary bypass.
Another speaker talked about his experience in selecting patients for chronic hemodialysis. In 1968, I was working in hemodialysis as well as cardiac perfusion. I remember that time well. Health insurance companies did not cover chronic hemodialysis then. A routine bypass run at the time was typically 2-4 physiologically stressful hours which could damage patients’ kidneys. Some heart patients who survived their surgery but who developed irreversible post-op renal failure were just sent home to slowly die of their uremia. Peritoneal dialysis had not yet been adapted for chronic application. And patients could not afford the cost of chronic hemodialysis treatments nor did they qualify for the limited resources available at the time to treat chronic renal disease. Local hospital committees decided on how the small number of treatment slots available should be allocated. “Social worth,” an assessment of the patient’s potential contribution to society, was the primary criterion for determining who would receive the life-sustaining treatment. This presenter described his hospital’s committee for choosing which patients were to receive life-saving chronic hemodialysis and which patients were to die of uremia. The committee consisted of a physician, a social worker, and a vocational rehabilitation expert. Often there was a patient age limit as well, usually 54 years or younger. Committees like these would become known as “God panels” because they would select who would survive and who would not survive . Every hospital performing hemodialysis had a panel of this type. It was a sad time. There was no hospice care then either for dying renal patients. It was not until 1974 that the first hospice was founded in America . In 1972, federal legislation was enacted to cover catastrophic health diseases like chronic renal disease, making chronic hemodialysis available to all patients who needed it. Clinical triage is a medical matter of fact even today when a pandemic can overwhelm limited medical resources like ECMO.
Hep B, Yellow Eyes And Prison Donors
Another discussion talks about the post-op complication of serum hepatitis (hepatitis B, Hep B) from all the blood transfusions heart surgery and hemodialysis patients received. In 1968 heart patients were exposed to multiple units of blood, perhaps dozens of units on a routine basis, both for priming and operative blood loss. The hematocrit values of many renal patients often fell into the low teens or even into the single digits because their kidneys no longer produced erythropoietin (EPO), the hormone that stimulates red blood cell production. As a result, they received frequent blood transfusions during treatment. EPO medication to reverse anemia in renal patients was not developed until the 1980s. Transfusions were not just dangerous to patients. Perfusionists and hemodialysis technicians who administered the transfusions were also at risk. I can readily identify with this because I got serum hepatitis from a needle stick in the 70s. My eyes were yellow and my stools were white for nine months. Hep B almost ended my career and my life. In 1968 there was no test for Hep B in donor blood. Sole reliance in detecting serum hepatitis was placed on the reliability of the donor’s history . Screening blood donors for Hep B did not begin until 1969 and only became mandatory in 1972 . The best blood was from volunteer donors whose history was thought to be more reliable than donors who sold their blood. But, the need for blood was acute. One of the scandals from the 1960s-80s in blood procurement was that many hospitals harvested blood from prisons . One hospital well-known to perfusionists sent a bus to the local correctional facility monthly to buy blood from prisoners. Is there a riskier group to collect blood from than prisoners? IV drug abuse, risky sexual practices, hepatitis, you name it. A convict is not going to give an accurate medical history and jeopardize the $8 he receives for his blood. Not until 1982 did the FDA unofficially request blood suppliers to stop purchasing blood from prisoners because it was considered too risky. It was thought that as many as one-in-five units in the total blood pool were contaminated. Since no screening test was available and not everyone exposed to blood transfusions developed Hep B, no one really knew what the risk was. Later retrospective testing of Hep B positive blood donors found that 52%-69% of the recipients of their blood developed the disease.
This is the kind of historical document that makes perfusion history fun to read and discuss. And for old timers, brings back many memories, both good and bad!