Our treatment options were limited, but there were options. The first, surprisingly, was formaldehyde. As an embalming agent, the chemical cauterizes tissue by cross-linking proteins; that is what gives embalmed tissue its feeling of firmness. In medical treatment, formaldehyde can occlude the spiderweb of tiny blood vessels crisscrossing the surface of prostate tumors. Instilling a dilute solution of the chemical directly into Jake’s bladder and bathing the tumor surface with it might halt the steady seepage of blood. Since virtually none of the instilled chemical is able to escape into the rest of the body, there is no toxicity.
Another option hinged on the fact that while the bloodstream stands ready to form clots wherever needed to limit bleeding, it is also constantly breaking down existing clots as wounds heal. Within the circulating blood, therefore, there is a dynamic balance between the formation and dissolution of clots. Substances released by some tumors, including prostate cancer, enhance clot-busting and thus promote bleeding. A medication known as aminocaproic acid, or Amicar, inhibits the activation of the clot-dissolving system, tipping the balance back toward clot formation. Giving Jake Amicar might be another way to stop his life-threatening ooze.
By the time Jake arrived in the intensive care unit, the nurses were ready to start administering formaldehyde and an intravenous drip of Amicar, both ordered by the consulting urologist. The following morning I was pleased to note that the bladder tube drainage was only faintly blood-tinged—a good sign. Jake’s hemoglobin count, however, had dropped to 5.6. I knew he was tough, but this was like asking him to climb Everest without oxygen. We were giving him oxygen, of course, but without red blood cells to carry it to where it was needed, the benefits were limited.
How could we boost red cell production? Normally, in response to anemia, the body manufactures erythropoietin, a hormone that stimulates bone marrow, the body’s blood-cell factory. Though banned by sporting authorities as a performance-enhancing drug, synthetic erythropoietin would provide just the sort of assist Jake needed. High-dose injections could speed the recovery of his hemoglobin count. But there was a catch: Some Jehovah’s Witnesses consider erythropoietin to be a blood product and therefore prohibited by their faith just as transfusions are. Through Jake’s wife I was put in touch with an elder of their church, who was more than happy to come and talk with my patient about the use of erythropoietin. “It’s a personal choice,” he explained as we sat at Jake’s bedside, “because it’s made in a test tube and isn’t derived from blood. Each Jehovah’s Witness must decide for himself.” Jake and his wife decided they were comfortable with the idea of using erythropoietin, and we started daily injections.
At that point there was nothing else to do but wait. As the week wore on, there was no further bleeding and Jake remained stable. I wanted to check the blood count every day, but the hematologist stayed my hand. “He needs every drop he has,” he reminded me. “No unnecessary blood draws.” We used a pediatric-size tube to minimize blood loss when we finally did draw blood at the end of the week. The lab reported back that Jake’s hemoglobin count had improved to 6.3. We were all relieved. Although far from normal, things were finally moving in the right direction.
“So, Doc, was it the prayers or the shots?” a smiling Jake wanted to know.
“I couldn’t really say,” I answered, “but just to cover our bases, maybe you could pray for the shots to keep working.”
There was no further bleeding. Over the next 10 days, Jake’s hemoglobin rose to 8.0, and he gradually gained strength. When we sent him home he still had to contend with his prostate tumor, but the urgent battle against bleeding had been won. We had bought Jake more time, and we had been able to do it without transfusions.
H. Lee Kagan is an internist in Los Angeles. The cases described in Vital Signs are real, but patients’ names and other details have been changed.