It’s a huge adrenaline rush when an organ transplant is imminent—starting when that first call comes and a highly orchestrated process begins. But few hospitals can do everything right seven times—all at the same time.
Northwestern Memorial Hospital (NMH) answered this call last summer when Gift of Hope, the organ procurement organization for Illinois and northwest Indiana, notified them that seven organs from one donor were available if recipients matched. NMH and Ann & Robert H. Lurie Children’s Hospital of Chicago had five very sick people who desperately needed them. Without hesitation, 120 clinicians and staff quickly responded to make sure every one of these transplants happened.
“Let’s do it!” exclaimed Juan Caicedo, MD, associate professor of Surgery, when he learned two kidneys and a pancreas were available. Ability to accelerate on a dime characterizes all the transplant teams, but their ability to conquer logistical and treatment challenges was also the reason why the lives of these five recipients changed dramatically over two days.
To respect patient privacy, many names, dates, and other identifying details are omitted from this story. It is important to note that everyone involved honors the donor and family who gave a heart, lungs, liver, kidneys and pancreas so that others might live.
Gift of Hope made its first call to the liver team at 6:53 a.m., followed up with calls to the other transplant teams. Those notifications set many moving parts of the process in motion and raised questions requiring immediate answers. Can the organ be brought to the recipient’s hospital fast enough? Is the patient ready for transplant right now? Can the patient get to the hospital in time?
When organs become available, many hospitals are notified but ultimately decline or are not selected for various reasons. The United Network for Organ Sharing (UNOS) authorizes a hospital as the primary acceptor of an organ when that facility has an available patient who is ranked at the top of the priority list, and the capability to perform transplants under tight constraints. Undaunted by the mass mobilization effort ahead, Northwestern accepted all the organs.
“Logistical details can make or break a transplant. All the health providers here had a tremendous commitment to make sure logistics did not prevent us from offering healthy organs to our patients,” says Malcolm DeCamp Jr., MD, chief of the Division of Thoracic Surgery and Fowler McCormick Professor of Surgery, who performed the bilateral lung transplant.
Shift to High Gear
Three procurement teams were the first to hit the ground running to the local hospital where Gift of Hope staffs were caring for the donor. Teams of fellows, surgeons and nurses assessed the organs’ functions and appearances to judge if they were viable for transplant. Then, they procured and specially packed the organs in coolers and started the tense trip back to downtown Chicago.
Meanwhile, clinicians left their homes and assembled at NMH into five operating room teams, five anesthesia teams, three perfusion teams, three ICU teams, along with staff from three labs, pharmacy, housekeeping, pathology, radiology, social services, patient transfer and the blood bank. They waited, fixated on the moment when the organs would reach the ORs.
Surgeons for each procedure served as point persons during the entire process for each organ, but absolute trust between team members kept events moving along smoothly. Numerous phone calls between all the teams at different locations monitored progress and enabled decisions about when to set the next step in motion, including when to put patients to sleep so anesthesia time was minimized
First stop for all transplant organs was NMH’s blood bank, where identifiers were electronically and manually cross checked to ensure blood type and immune compatibilities. Blood supply was also issued for each procedure, and the organs were sent to the ORs.
“We keep our eyes on things very stringently, and this case got tricky because we got all the organs within about 45 minutes, which is a lot in a short time. We had one UNOS number for the same donor, and we had to make sure the right organ got to the right patient,” explains Pam Lehner, MT (ASCP) SBB, Blood Bank resource coordinator.
After the organs were released to the ORs, surgical teams inspected them again and began “benching” the organs. A process lasting up to several hours, benching means organs are prepared by trimming or extending vasculature to fit into the recipient’s anatomy.
For each team, the real euphoria began at milestones during each procedure when the kidney started to make urine, the heart beat, the smooth red liver produced bile and the lungs took a breath.
“You start with this limp, white lung. Then when you start to pass blood through it, it pinks up right away and it is one of the most beautiful things in medicine,” Dr. DeCamp says.
In multi-organ transplant, the heart is always harvested first, and the team with Chris Malaisrie, MD, associate professor of Surgery in the Division of Cardiac Surgery, was the first to save a life. “It was 3 in the morning, but we were all standing there feeling really ecstatic when the heart rate monitor sounded a regular rhythm. We’ve done this so many times, and every time is so exhilarating.”
Leveraging close proximity and expertise, pediatric patients at Lurie Children’s Hospital and adults at NMH benefit from the Northwestern University Affiliated Transplant Centers (NUATC) program. The program enables Northwestern physicians to provide transplant care for pediatric patients, life-long follow-up and cooperative research between the institutions.
Unlike the heart and lungs, abdominal organs have a longer “shelf life” with preservation before transplant. To take advantage of both available kidneys, Dr. Caicedo did back-to-back procedures. He transplanted one kidney in a patient at Lurie Children’s Hospital, crossed the second-floor bridge linking to NMH and immediately prepped to transplant the pancreas and second kidney.
Kim Ostrander, an RN on the abdominal transplant team, was one of several nurses who circulated between NMH’s OR and families in the waiting room to update them every two hours.
“It was a great feeling to help a patient who was dying from organ failure. I feel like this every time I help with a transplant,” Ostrander says.
When all the transplants were completed, nearly everyone had been working for 20-plus hours straight. Tired, yet elated that five patients had a new lease on life, the teams called it a day. For the morning shift just arriving, the day was beginning and the ORs were ready.
Most transplants take place at night into early morning during unpredictable times. Transplant experts accept this lifestyle because this mission is so important to them and they want to perform innovative treatments.
“Other medical professionals may not exactly envy our schedules, but there is nothing cooler in medicine than unclamping an organ and restoring blood flow and watching it come back to life, and knowing what this means for your patient,” says Anton Skaro, MD, PhD, associate professor of Surgery, who gave software developer Willy Jin a new liver.
Jin, 42, remembers when transplant coordinator Aly Yoder, RN, called him the night of his wedding anniversary to tell him a healthy liver was available. “Then it all came together at once, so quickly. I was very emotional at the time. I know that there were a lot of people involved, even if I did not meet all of them.”
Well into post-op, Jin feels his energy coming back and he is healing very well. “Everybody says, ‘I hope you are feeling better,’ and that is very encouraging.” Immediately after the procedure, he met another organ recipient recovering post-op, and they remain in touch.
By UNOS standards, pulling off five simultaneous transplants is extraordinary. Last year, there were only 11 times when seven organs from the same donor were transplanted at one medical center.
Northwestern enhanced its capability to save lives when it started its Lung Transplantation Program on Independence Day 2014. Adding this program meant that multiple organs from the same donor would likely become available. Northwestern prepared by creating additional transplant teams.
Performing seven organ transplants on five people simultaneously is an example of why Northwestern ranks among the nation’s top transplant programs, as measured by volumes and patient outcomes. In 2014, NUATC led the country in the number of living donor liver transplants. The same year, NUATC teams performed the most pancreas and living donor kidney transplants in Illinois. One-year patient and graft (organ) survival rates compare very favorably with national statistics.
“I think it says a lot about all of us that we do this on a regular basis,” says Dr. Skaro, “and we love it.”