 My name is Ann Nott, and I'm Senior Director of Loss Prevention and Risk Minigation with MMCIP. And the topic today for our presentation is religious considerations in the care of a Jehovah's Witness patient, bloodless medicine guidelines. I would like to introduce our speakers. First of all, we have Dr. Ken Tanaka. He is a professor and division head of cardiothoracic anesthesiology here at the Medical Center, Dr. Tanaka. And we have Mr. Guy Stafford and John Johnson from the Jehovah's Witness community who have been very gracious to come here and present the religious perspective, as well as several members of their community. So welcome to all of you. And thank you for letting us use this venue to provide this education. The purpose of this presentation is to fulfill a claim filed by this particular patient that we're going to review as mother. We agreed with our mediation of race consciousness and share knowledge with the medical staff and about the importance of honoring the prohibition against the use of blood products in the treatment of members of the Jehovah's Witness faith. So that said, our objectives today are to provide a brief overview of a surgical Jehovah's Witness patient, discuss components of bloodless medicine, and describe religious considerations related to bloodless medicine in the care of a Jehovah's Witness patient. So we'd like to just do a brief overview of the particular case that this particular claim arose from. This gentleman had a history of poorly controlled hypertension, congestive heart failure, chronic renal failure on renal dialysis. He presented for management of a chronic dissection of the ascending aorta, an aortic root, and had severe aortic insufficiency. As mentioned, he was of the Jehovah's Witness faith and did not accept blood products or blood derivatives, but would accept albumin, cell saver, cryo, salvage, and autologous blood, and that was documented in the record. In preparation for surgery and to respect the patient's wishes, several HNHs were monitored closely. Epigen was administered and he also received oral iron supplementation. He did the complex surgery was performed and intraoperatively the patient received autologous blood, albumin, cryo, DDAVP, factor 7, all in line with the patient's wishes. Initially the patient was hemodynamically stable at the completion of the surgery, but eventually he had increased needs for vasopressors and received plasma light, albumin, and prothrombin complex concentrates. Due to the patient's continued deterioration, though, after that there was a need for platelets. So a transfusion was given after the patient's proxy gave permission. Patient had a PEA arrest, required resuscitation, had severe right ventricular dysfunction, and was cannulated for ECMO. Following these events, the patient was treated for cardiogenic shock, anoxic brain injury, and findings compatible with embolic infarcts on the head CT. Unfortunately, the patient's condition continued to deteriorate, resulting in death, two months post-op. So the major issue that was identified in this case was failure to abide by the patient's wishes, not to receive blood or blood derivatives. So now I'd like to bring up Dr. Tanaka to talk about bloodless medicine. Thank you. Thank you, Anne. And my name is Ken Tanaka, and it's a great pleasure to be here and share my thoughts about bloodless medicine in cardiac surgery setting. So for me, bloodless medicine is a polaris. You know, that's something we always strive for. So this is not only for Jehovah's Witness patient, but all the cardiac patient, cardiac surgical patient, benefit from this effort. That's my belief. And transfusion obviously has some side effects, and we should be cognizant about that. And lastly, there are multiple transfusion alternatives available in the 21st century. So we should be always thinking about alternatives in transfusion medicine. So first of all, you know, we have to define anemia, you know, in those who come to surgery. So obviously, WHO defines it less than 13 hemoglobin for males and 12 less than 12 for females. But obviously, a lot of our patients do come below these numbers, and they are at risk for transfusion during and after surgery. And if you look at the cardiac surgery patient, about one-third of them have anemia, and then 20% of those have iron deficiency, which can be addressed before surgery. Now when a hematocrit goes down, that increased the risk of transfusion and associated mortality and morbidity, especially wound infection, you know, after cardiac surgery. So this is something we should be always considering when we take care of the patient. But one of my junior faculty, Mike Mazefi, and I have done a database study, this is a national database study, of a 20,000 patient undergoing colon surgery. And we found that any, you know, transfusion, even one or two units of transfusion are significantly associated with wound infection. So intra-abdominal infection as well as sepsis. So even in a relatively standardized colon surgery, the risk of transfusion exists. So you can imagine when it comes to cardiac surgery, one, two, three units of red cell can do to these patients. When we think about surgical patients, we always think that the lowest hemoglobin will happen during the surgery, and after the surgery everything should go well if, you know, intra-op management is good. But that's not the case. When you look at this data, the nadir of hematocrit actually occurs in the ICU. That means that patients continue to bleed in the ICU, receive fluids, and potentially receive red cell transfusion. So we should address not only intra-op, but post-op transfusion issues. That's one of the most important points that we should learn from the case that I'm presented. So fortunately, Maryland State has a very good database in cardiac surgery, and we can look at all the institutions in Maryland who performs cardiac surgery and we can look at the data. So this is the transfusion data from these institutions. There's a significant variability in the red cell transfusion between 13% up to 60%. Now, intra-op transfusion goes from 4% to 59%, and it averages 1.7 units. Look at post-op, it goes from 13% up to 39%, and when you look at the mean number of transfusions, it's actually more than intra-op, almost three units of red cells given in post-op. So patients continue to bleed in the ICU, so we have to address that issue. Now, variability, as you can see, from an institution 1 to 10, the general trend that post-op transfusion is more than intra-op, but there are some institutions where intra-op transfusion is much more than post-op transfusion. But overall, when you have patients, those who come in with lower hematocytes get transfused, and for all the institutions, there's a good trend here that the lower hematocytes and then much higher transfusions that goes up to 90% in some institutions. So we really should address pre-op anemia for those coming to cardiac surgery. So I'll show you what we have done in our institution, and this is the data from 2011 through 2017. I joined 2014, so that's the data I'd like to focus. But if you look at the intra-blood usage, 2014 was about 36%. Now, 2017 is 25%. So there's a definite drop in there. So we have made a multidisciplinary effort to reduce intra-blood usage, so that has been shown in here. So all the product, including playlets, Red Cell, FFP, they are all down from 36% to 25%. Now, intra-op transfusion here is 17.5% in 2017. But if you look at the post-op transfusion, it's still higher than intra-op. It's almost 29%. So here you can also see the same trend that post-op transfusion is much more than intra-op transfusion. When it comes to the blood salvage, this is the most common thing that we do. Autologous Red Cell blood salvage, we often call this cell saver. Essentially, you collect the shed blood using anticoagulant, and then spin them down and then separate red cells from other debris, and then collect this in the back, so you get the concentrate of red blood cells. Now, this is acceptable for Jehovah's Witness patient, because this is considered as an extension of a patient's circulation. So this is a common procedure that we perform in every blood-less surgery cases. The issue is that you can concentrate hemoglobin by using a cell saver. But if you look at other components, playlets, fibrinogen, they all go down. So you basically spin them out. So you lose all the coagulation components and playlets by using a cell saver. So when I get one liter of a cell saver, actually, I'm not very happy because we are losing lots of playlets by spinning those blood. So that's not the best situation. Now, another technique is something called isobolumic hemodilution or acute normal bulimic hemodilution. In this technique, what we do is we take the patient's own blood, autologous blood into the bag, keep them connected to the patient for Jehovah's Witness patient. And after cardiopulmonary bypass is done, we return this blood to the patient so we can actually keep playlets, fibrinogen, and other coagulation factors in the bag and then we can return the blood after the heart-lung machine is done. So in the meta-analysis of this technique, there's about 0.8 units reduction in the red cell usage. These are not really Jehovah's Witness patients but general cardiac surgical patients and also there's a reduction in chest tube drainage after surgery. So in a large database of meta-analysis data, there is sort of a good signal that this technique works in most of the cardiac surgical patients. We actually have our own experience of using this technique and especially our patient tends to have large body size and good BMI so we could actually take a lot of autologous blood from these patients. So this is the recently published data in transfusion but we hypothesized that more than 900 cc of autologous blood will significantly reduce allogenic blood usage in cabbage and aortic valve surgery. So these are the data, this A&H is autologous group versus control, age, male percentage, about the same 90-minute bypass most of them work on aspirin but you can see that interrupt transfusion 10% versus 35% in the control and total transfusion 25% versus 45% so there is a significant impact on the transfusion by using high volume autologous technique. And the most important data I'd like to show you today is by using autologous blood you could actually reduce the blood product usage in a post-surgical period there's a significant difference in the post-surgical period so by having autologous blood you essentially reduce the post-op patients' blood loss and therefore patients are hemodynamically more stable and they do not receive any type of transfusion after surgery so it really increased the chance of blood less surgery in these patients So again, large database study by STS, American Society of Thoracic Surgery actually looked at the effects of autologous blood transfusion like we performed and this is a 13,000 case but in the nation only about 17% of this 13,000 patient received acute normal hemorrhemic hemodilution so this technique is still underutilized in most of the institutions but the effect is quite clear in most of the patients who receive autologous blood transfusion actually large body size but the transfusion rate is quite similar to what we have of that in my institution so sign language can drop in the red cell, playlets and plasma transfusions so these are very clear signals that autologous transfusion or acute normal bolimic hemodilution is a very good technique for blood less surgery Alright, so two techniques, cell salvage, it only recovers red cells, A and H, acute normal bolimic hemodilution you can keep all the components, red cell, playlets, fibring, all the blood coagulation factors so I'd like to show you one case here, this is actual Jehovah's Witness patient this is a new case, 43-year-old with a congenital cardiac surgical history, tetralogy of fallow correction at a young age, now she needs a redo pulmonary valve replacement so numbers are great, you know, playlet is 200,000, hemoglobin is 13, she was on the but if you look at predicted risk of transfusion, she would get 80-100% chance of red cell transfusion so this is a very high risk case, so even with a standard technique, I think this case would be very difficult so what do we have to think about, so in the normal patient, we always have a red cell as an alternative or treatment for low hematocrit, profile on latex state, and in 5-inrogen deficiency, reduced thrombin generation, low playlets, we have all these agents to support but in Jehovah's Witness patient, we have very limited support, especially for the red cell mass so I looked at the literature and this case is a very interesting, very successful kidney pancreas transplant and everything went well, but after surgery, patient has splenic vein thrombosis and bleeding and other complications, so hemoglobin goes down below 6 grand per liter after, you know, second day of surgery, so what they did was hemoglobin-based oxygen carrier this is available for compassionate usage, approved by FDA for that purpose it essentially gives a hemoglobin mass, since hemoglobin is in a bag 12 to 14 grand per liter it's a 250 cc bag and half life is about one day so it looks like this, this is the bag, so what they did was when hemoglobin went down they gave three shots of two units or six units of this bag and then when the hemoglobin was recovered to about 6 to 7 range and they continued to maintain patient this way now this patient had metahemoglobinemia but that was treated with methylene blue and a hypertension was also managed, of course the hemoglobin scavenges nitric oxide so that has to be treated with anti-hypertensives and overall patient did quite well and survived this complication so in this particular patient I also contacted FDA for emergency IND investigational drug approval and we obtained that and we were able to obtain 10 bags of hemoglobin-based oxygen carrier that was sent to our investigational pharmacy and we kept them prior to surgery and we actually obtained a consent from patient proxy and then we got ready for the surgery so these are potential alternatives that are available to replace some of the components in surgery so I don't have to go into details but I just want to show you that the pro-thermin complex that actually is a very reasonable source for some of the factors, vitamin K-dependent factors and also we have fibrinogen available so instead of cryoprecipitate we could use fibrinogen concentrate to replace low fibrinogen state so here we have alternatives and then for low hematocrit we have an option to use hemoglobin-based oxygen carrier so fortunately Medical Center supports thromboelastometry at a point of care in the operating room so we have a protocol, we have technicians available 24-7 for cardiac surgery so we can quickly get the coagulation test done at the bedside so we have all these numbers here but I just want to show you depending on different numbers we do different things so when this is a fibrin-specific clot formation so when this goes down we can actually use fibrinogen now when this big one goes down this usually indicates low platelet and we actually use platelet transfusion for normal patient but for the J4-admittance patient we use alternatives and lastly we have a clotting time that will give us indication for the need for the growth of fibrinogen concentrate for normal patient plasma transfusion we also use in this patient cerebral oxygenation monitoring cerebral oximeter that will give the information about oxygen state inside the frontal lobe of the brain so we actually look at this number and we titrated hemoglobin-based oxygen carrier so for here this patient hemoglobin the oxygenation went down and when we gave hemoglobin-based oxygen carrier they actually went up and then again when we gave this agent the cerebral oximeter numbers went up so not only based on the hemoglobin value we can also use other objective parameters to guide hemoglobin-based oxygen carrier so I think this is a very important information that we could use multiple data to think about the indication for hemoglobin-based oxygen carrier or even red cell transfusion for some of the other patients so thromboelastometry was used effectively in this case and as you can see, re-warming time it was these numbers were abnormal actually indicating the coagulopathy so in this case we preemptively acted on these coagulopathy we use a prothermic complex concentrate as well as fibrinogen concentrate as you can see when you give fibrinogen this band goes up indicating fibrinogen is being replaced and also clotting time went from 95 to 68 seconds so that means that clotting has been improved by prothermic complex concentrate so by using multimodal techniques to monitor the high-risk patients I think we can really improve the outcome of these patients so I'll skip those but essentially showing how fast we can treat these patients so most of the coagulation treatment was done within 30 minutes after the completion of cardiopulmonary bypass and patients did not bleed much after surgery so my proposal as an overall structure for the blood-less surgery is something like this so we have blood-less surgery and also we need to have a pre-op a pre-op, anemia management portion and also we have to think about inpatient blood management that might span into ICU management so that will also work closely with the investigation of pharmacy with regard to hemoglobin-based oxygen carrier and of course we have a coordinator from Jehovah's Witness Society and we have a very good communication here as a center for blood-less surgery so I think Epic needs to have blood-less surgery consultation and that should list all the available components or alternative techniques so this is just a suggestion and also data collection is important but that's a separate issue so anemia clinic is probably something we should also strive for which is not currently done on a routine basis for all the cardiac surgical patients so to summarize I think blood-less surgery is feasible it's a very important way to conserve red cell, non-red cell components and I think it benefits all the patients including Jehovah's Witness patients so preparing for post-op bleeding is important I think hemoglobin-based oxygen carrier was very useful in this particular case and then we as an anesthesiology department we have multimodal way to monitor these patients from coagulation to oxygenation so we have some expertise and I think in the future we really need a care coordinator who will help us communicate effectively with the patient and also with the interdisciplinary team thank you for your attention Thank you Dr. Tanaka and now Mr. Stafford and Mr. Johnson so good afternoon so my topic today is Jehovah's Witnesses, the medical and ethical challenge and I'd like to extend a warm welcome for all who took time out of their busy schedules to be present with us this afternoon my name is Gastaford and I'm a local minister here in the Baltimore area and I also volunteer on the Baltimore Hospital Liaison Committee for Jehovah's Witnesses which I will refer to throughout this presentation as the HLC so our committee graciously appreciates the invitation extended to us by Ann Norton and Dr. Galati and I'm sure there were others involved and we appreciate that and making this presentation possible we cherish these opportunities so thank you so just want to sort of get it started you know it's not uncommon to have several of our members admitted at any given time to this facility so we very much value and appreciate the excellent care that we've received over the years through this hospital doctors in hospitals we understand that you face the challenge of improving healthcare quality patient safety keeping abreast of all the technical advances also keeping abreast of all the legal requirements and changes therein while at the same time trying to control and reduce costs so additionally we see that we're living in a time where there's an extremely cultural diverse society and it's no different here and because of age upbringing and gender values and beliefs they differ even among people the same background so we know that this puts doctors they face a challenge on trying to understand individual views they try to understand individuals backgrounds and the convictions of the patients and so this also includes understanding Jehovah's Witnesses as well now at times clinicians may find the choices of their patients somewhat hard to understand however when a person's actions clearly spring from their religious and moral convictions they merit the attention of the doctor in a general sense Spinoza's philosophical approach on life also applies to healthcare and that is understanding the religious belief of another does not require a doctor to accept or follow them the intent of this presentation is to inform healthcare providers about the values and beliefs of patients for Jehovah's Witnesses as they relate to their medical care so these are the presentations objectives so through this discussion we'll highlight our position on medical treatment the hospital liaison committee network the resources for the medical community and protocol for treating Jehovah's Witness patients now regarding this first point what is our position on medical treatment so first of all we seek quality medical care which is the very reason that we come to find facilities such as this one secondly we request the use of transfusion alternative strategies additionally we've thought this through and these decisions that Jehovah's Witnesses may make they are informed choices we do however refuse allogeneic blood transfusions so Jehovah's Witnesses contrary to maybe some beliefs out there we cherish health and we definitely cherish life and some may have felt maybe in the past that Jehovah's Witnesses were anti-medicine and nothing can be further from the truth we come to find institutions like this because we want the best medical treatment that's available and so that's why we come to these facilities such as the one just mentioned here University of Maryland and we want to receive quality medical care for ourselves and for our families to support Jehovah's Witness patients the HLCs or the hospital liaison committees we provide personal assistance because you can imagine for a person who's under matter of the rest sometimes they may need a little assistance and kind of organizing their thoughts and it should be noteworthy to mention that we don't arbitrarily put ourselves into their medical treatment they seek us out and that's how we come to be involved in this situation so what do we do for them? we support the witness patient HLC provides personal assistance such as emergencies the need for a doctor referral or to help resolve spiritual or moral questions related to their medical care now to understand Jehovah's Witnesses refusal rather blood transfusion one must understand their Bible based reason for doing so so the view is simple it's uncomplicated and it's based upon this text Acts 1520 Epstein from Blood and we view this very seriously and we view this as a command from our God and our Creator so shown here's a variety of translations if you look at the bottom of the screen a variety of translations some use for centuries that all read the same but the question is how do we understand this today? Epstein from Blood while this chart breaks down Jehovah's Witnesses position on allergen egg blood we refuse whole blood including the naturally separated primary components of red cells white cells, platelets and plasma but potentially acceptable are what we refer to as blood fractions that are derived from a component of blood so potentially acceptable means this that each individual must decide on these matters some of these decisions have been made in advance others may be made when a procedure is discussed with a physician therefore it's extremely important and we encourage good communication between the doctor and the patient so this sometimes can be confusing to the medical field we do understand that you treated one Jehovah's Witness patient he decided this you treated another Jehovah's Witnesses a Witness he decided that one witness he accepted this the other one accepted that well the reality is beyond whole blood red cells, white cells, platelets and plasma the decision primarily and the derivative of those primary components rests with the conscience of that patient so we just wanted to point that out so one common natural question is what about the use of a patient's own blood? well we take the position that pre-operative otoglous blood collection in storage is something that's unacceptable to Jehovah's Witnesses but now what is potentially acceptable? well that means once again each we back up a little bit that we refuse the use of our pre-operative blood or pre-operative otoglous blood better known as BAD but once again potentially acceptable procedures named here such as hemodialysis cardiopulmonary bypass or the use of a heart lung machine blood salvage these are something that's up to the individual witness patient and once again you may run into one witness that will accept and another witness that won't accept but that's up to their individual conscience so again good communication between the doctor and the patient is vital yet we've noticed that here this facility they do an excellent job by engaging in discussions with the witness patients prior to procedures and of course this reduces problems so the course of treatment for witness patients may be different however with good planning we can produce excellent results so to help those who care for Jehovah's Witnesses and to legally protect themselves against unwanted blood transfusions witnesses make their informed choices by carrying the document that's illustrated on this slide and it's entitled the adorable power of attorney for healthcare now this is a state specific signed legal document which clearly states the refusal of blood and the four primary components it may also include other healthcare wishes that the patient may have such as those discussed earlier and it designates a healthcare agent in the event that the individual or the witness patient cannot speak for himself now particularly challenging our situations involving children and we certainly understand that so when faced with ethical and social issues involving children there are several points to keep in mind when witness parents refuse to give consent to transfuse their children but here's a few points we truly want to highlight and that is first and foremost we love our children we love our children as much as anyone else loves their children and we seek good prenatal care and we work extremely hard even outside of the medical realm to raise our children to educate them to protect them from unsafe and risky behaviors such as smoking and recreational drug abuse and things like these however we refuse blood transfusions not to be confused with we refuse medical care we want medical care for our children just without blood so the medical literature supports the safety and the efficacy of non-blood medical management and next slide here and parents would certainly request that they have skilled and willing physicians and we also know that when it comes to children that this is difficult for everyone so we do recognize that you may not we may not get 100% assurance that blood will not be used we simply ask this please do the very best you can to avoid it so parents they desire mutual respect and good communication with the physicians so there are times when we help witness parents to understand the legal realities faced in these situations and even if a hospital seeks legal intervention parents would like to be notified so that at the very least they can have an opportunity to express their wishes on this subject so many doctors have avoided blood transfusions before these issues occur by considering the following clinical aspects the hazards of transfusions we just talked about earlier in one of the discussions there's much published medical information on this subject even dealing with children judicious clinical management protocols and we certainly highly recommend to consult experienced physicians who may have dealt with some of our younger witness patients and then where it becomes necessary the patient may need to be transferred to another physician or even perhaps another facility and so we find that by following these strategies as possible for law for ethics and for medicine to be practiced together now because of the occasional challenges in providing healthcare for Jehovah's Witnesses a well-organization done to minimize conflict and to develop a cooperative relationship with the medical community well we've established a network a worldwide network in fact of hospital liaison committees or as we affectionately call them HLCs our national office in Wal-Kill New York they direct the work of over 140 HLCs in parts of the Caribbean each committee is made up of community-based ministers who knowledgably interact with physicians and hospital personnel, social workers and members of the judiciary and a few of our members present here with us today so how can we be a resource to you in helping with the needs of Jehovah's Witness patients well here are a few ways we can provide medical articles and other information we can arrange for a doctor-to-doctor consultation or referral we can assist in the transfer of a patient if necessary we are available 24-7 for patients and clinicians clinicians as well and we cherish the opportunity to stand before you today and make presentations to medical staff bioethics and legal personnel also you can contact any of our local members home phone, cell phone, whatever phone number they have available and if you would like to have some of our materials I'll show you a few minutes where you can find them and some of the resources we make available to you so much of it is web-based these days so websites with links to PubMed journals, clinical papers peer-reviewed resources evidence-based summaries and it's good to know that although they're contained on our website the information is from people like yourself and so we really encourage you if you haven't had an opportunity to look at our website and it certainly has many subject matters I'm just going to breeze through a few that are available management and optimization of hemostasis and additional information medicine and surgery cardiothoracic and vascular surgery and it's just a plethora of information available on the website that we feel will be valuable to you and so we encourage you to explore the site and you'll be amazed and delighted at what information is available to you printed as well as electronically so we also produce high quality medical articles that are featured on our website and in citations provided by doctors this clinical evidence detail strategies to avoid blood transfusion and we also distribute the following clinical strategies and these documents are designed to manage hemorrhage and anemia with our blood transfusion in several key settings they are as you can see noted surgery critical care obstetrics and gynecology and GI bleeding and if you had an opportunity or you will have an opportunity to view these because we left in the back today there are hundreds of medical articles referencing details within each document and many doctors and departments even here at the University of Maryland have used these references in treating Jehovah's Witness patients so the HLC can make these available to you upon request but as we mentioned today they supply this outside in the lobby and we encourage you to pick up a copy if you have not already do so upon leaving so this is the packet that we've brought with us today so it's illustrated here for medical professions and it professionals and it contains information about our HLCs and a religious and ethical document detail on our position on medical therapy and other topics we'll also insert other clinical based articles and summaries based on the doctor's specialty so finally here's a recommended protocol for treating Jehovah's Witnesses review relevant blood conservation and transfusion alternative strategies and treat the patient without using donor blood consult with other doctors experienced in managing patients without blood transfusion there are many here at this hospital that have skillfully worked and treated Witness patients and others who desire bloodless medicine contact the local HLC to locate cooperative doctors at other facilities for consultation on alternative blood transfusions alternatives to blood transfusion our national office maintains a list of doctors in many specialties who have been Witness patients for decades some of whom have published some of the medical articles that you have access to on this subject and on occasion doctors here have successfully consulted with some of these doctors as well and then lastly transfer the patient if necessary to a cooperative doctor or facility before the patient's condition deteriorates in your case many patients are actually being transferred here to your facility however there may be situations where you cannot accept the case for one reason or another we understand that and if that does happen in the case is critical time is of the essence in making this decision so we trust that this presentation has been informative we certainly hope it was and Wilder Hope as Witnesses may have presented the medical community as a medical and ethical challenge we find that many have met that challenge and so we remain confident that you will continue to offer a high standard of care which includes the use of your skills to treat patients without blood transfusion and so we encourage you to please contact us if you have any further questions or obtain it by calling the number of our national office located on our website so once again I'd like to thank you for the opportunity to stand before you and make this presentation and have the privilege of presenting this subject to you today so we're going to turn it back over to Ann and after which I believe we'll have a little question and answer session we do have time a few minutes for questions and answers for the audience Dr. Tanaka would you mind coming Mr. Stafford I'm sorry and Mr. Johnson do we have questions yes so autologous blood refers to the pre-op donation so you completely separate you separate the autologous blood from the patient and keep them say in the blood bank so interrupt essentially we can take the blood but we can still keep them connected to the patient through IV tubing so that doesn't separate from the patient now if it's non-Jehovah's Witness patient we can always separate that's an option as well so I mean the difference will be less if it's non-Jehovah's Witness patient other questions okay well thank you all for attending and I'd really like to thank Dr. Tanaka for his time today and presenting this information to Mr. Stafford and Mr. Johnson and the members of the Jehovah's Witness community that we're here today to support this I think it's very valuable I'm glad we have recorded this so that we can put it out for others that we're not here today to enjoy the presentation thank you all very much