August 15, 2014 at 8:55 PM

Pat, your question plunges us into the controversial, emotional, logistical, and religious quagmire of blood transfusion therapy. In your story, you’ll need to first understand and forensically eliminate transfusion related causes of death. To paraphrase Sherlock Holmes, whatever remains after you eliminate known transfusion complications, however unlikely, must be the cause of death. So lets review some potentially deadly transfusion complications:
1. Transfusion reactions: A type of system wide allergic reaction, possibly caused by mismatched blood, leading to circulatory shock. Your character might experience chest and back pain, anxiety, fever or low temperature, low blood pressure, and nausea. This would come on rapidly during or immediately after the transfusion. Blood tests are used to confirm this problem.
2. Hemolytic reactions: In which the body’s defenses attack the transfused blood cells and destroy them. This can be immediate like a wildfire, or slow over days. Toxic byproducts from the broken blood cells poison the body, leading to multiple organ failures, especially of the kidney and liver. Blood tests can help to determine if this is happening.
3. Graft vs. Host reaction: The transfused blood attacks the patient. This is the reverse of number two above, but similar in presentation and can be just as deadly. Again, blood tests help to diagnose this complication.
4. Infections: Although blood is carefully tested before transfusion, some infections still occur rarely. This includes bacteria, viruses (such as hepatitis B and C, HIV, West Nile), parasites, and Creutzfeld-Jakob disease (the human version of Mad Cow.) Cultures of the blood and antibody tests can determine which organism has infected your character.
5. Fluid overload and congestive heart failure. This usually occurs immediately or within a few hours of the transfusion. Bloody, foam-like froth may leak from the patient’s mouth, and they complain of difficulty breathing. Oxygen levels in the blood will be low (measured via a finger pulse oximetry monitor or blood tests). Using a stethoscope, wet, crackly sounds are heard in the chest. Chest X-rays will show a streaky, white, ground-glass pattern. This is often correctable, but can be rapid and deadly.
6. Heart attack or stroke due to thickening of the blood from the added blood cells. Thickened blood is dense, sticky and harder to circulate Think of your heart trying to pump syrup instead of water. Diagnosed with blood tests.
7. Iron overload with liver and heart damage. This can be mild or severe enough to kill. Diagnosed with blood tests and liver biopsy.
8. Rapid spread of cancer. Probably due to immune system impairment caused by the transfusion. This is a delayed cause of death from blood transfusion, over weeks to months. There is no specific diagnostic test and therefore no way to prove that the transfusion was responsible for the spread of the cancer.
9. Massive system wide inflammatory response that can lead to many problems, including DIC, an inability to form blood clots. Ironically, DIC causes the patient who got a blood transfusion to bleed to death. Blood coagulation tests are used to diagnose this. Patients may bleed continuously from puncture sites, the mouth, rectum, and eyes.
10. Metaphysical death: Eternal damnation due to the intake of another person’s blood. This is a religious or spiritual belief that is held by fair number of people and groups. To the devout believer, this is a fate worse than bleeding to death.

Many of the above causes presuppose that all the proper procedures for blood transfusion have been followed. You’ll also have to rule out a distracted, incompetent, or malicious healthcare worker who used the wrong blood, stored, handled, or transfused the blood incorrectly, or introduced a large amount of air during the transfusion. If you are looking for a “non-transfusion” related way to kill your character, tampering with the computer codes, ID bands, or blood labels could work. Foul play could eventually be discovered by retesting all the blood, but by then it might be too late, and the killer long gone.

If none of the above complications explains the death of your character, then you have a coincidental death from another totally unrelated cause, or a very clever assassin.

H.S. Clark, MD

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