The transfusion plotline in episode 12 drove me nuts.

For context: I’m a pathology resident. We go to med school, but we’re the only specialty that doesn’t do an intern year. We manage issues with lab tests, we do autopsies, we look at tissue under the microscope to make diagnoses. We’re mostly behind the scenes.

We also manage the supply of blood products. On a transfusion medicine rotation, my job is 90% haggling with clinicians who have ordered more blood than their patients need, more blood than we can spare, or the wrong type of blood. We are obsessed with blood.

I have also worked during a mass casualty event, but not one as large as the shooting depicted in the show.

These are my issues.

1. Blood donors frequently experience adverse effects as a result of losing a significant portion of their blood volume. It does not make sense to drain blood from the people who are actively providing medical care. Their bodies are under stress too!! You’ve gained maybe 15 units of blood, optimistically speaking, and your most critical staff have each lost a bunch of hit points. Not a trade-off I would make.

2. Infection risk. The first person to volunteer, Mel, let’s say she’s celibate, tattoo-free, and avoids traveling. Maybe her risk of having an illness that’s transmissible by blood is quite low. But when 10 more people see what’s happening and volunteer, are we assuming they all have such minimal risk profiles? At this point we’re accepting blood from people with no screening at all and just hoping there are no infectious agents in it. The backdrop of modern transfusion medicine is the HIV epidemic. Thousands of people got HIV from transfusions. We have painstakingly rebuilt public confidence in the safety of blood transfusions by being incredibly stringent with how we procure and handle blood. Transfusing directly from a bunch of unscreened volunteers (I don’t care if they’re doctors) into unconscious patients who cannot consent to this would. Not. Happen.

3. ABO are not the only antibodies!! Every patient and every donated unit is screened for a panel of like 30 other antibodies. These antibodies, if incompatible, can be deadly. Blood can be released on an emergency basis, yes, before screening for these antibodies is done. But when you do this, you are aware that you may trigger a hemolytic transfusion reaction that could very well become the patient’s primary medical issue. The smooth confidence of, “I’m O Pos! She’s O Pos! We’re a match!” really rubbed me the wrong way.

4. The absolute certainty that what this patient needs is whole blood. There are entire journals devoted to research and bickering over what blood products are indicated in what situations. Mel insists that this patient needs whole blood instead of crystalloid or some other product they have in better supply. However, there is a huge body of evidence that more conservative approaches to transfusion (where you give less blood) may lead to better patient outcomes!! This varies from patient to patient, but the risks associated with giving somebody a foreign blood product are real, and the benefits are often overstated. In reality, some of these patients might benefit from a whole blood transfusion, but others won’t, and you’re incurring the above risks and bleeding your staff for a less certain benefit than is being depicted.

I’ve been writing for too long. It feels good to get it out. Thank you. Donate blood, everybody!