How Death Becomes Life

by Joshua Mezrich

  Dr Joshua D. Mezrich is an associate professor of surgery in the division of multi-organ transplantation at the University of Wisconsin School of Medicine and Public Health.

  First published in the United States in 2019 by HarperCollins Publishers, 195 Broadway, New York, NY 10007.

  Published in hardback and trade paperback in Great Britain in 2019

  by Atlantic Books, an imprint of Atlantic Books Ltd.

  Copyright © Joshua D. Mezrich, 2019

  The moral right of Joshua D. Mezrich to be identified as the author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act of 1988.

  All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of both the copyright owner and the above publisher of this book.

  ‘Sympathy for the Devil,’ words and music by Mick Jagger and Keith Richards ©1968 (Renewed) ABKCO Music, Inc., 85 Fifth Avenue, New York, NY 10003.

  All rights reserved, used by permission of Alfred Mus.

  10 9 8 7 6 5 4 3 2 1

  A CIP catalogue record for this book is available from the British Library.

  Hardback ISBN: 978 1 78649 886 1

  Trade paperback ISBN: 978 1 78649 887 8

  E-book ISBN: 978 1 78649 888 5

  Printed in Great Britain

  Atlantic Books

  An imprint of Atlantic Books Ltd

  Ormond House

  26–27 Boswell Street

  London

  WC1N 3JZ

  www.atlantic-books.co.uk

  For G, S, K, and P.

  And for the donors, living and dead.

  You are true heroes.

  Contents

  Note from the Author

  Milestones in Transplantation

  Part I: Out of Body

  1 A Perfect Organ

  2 Puzzle People

  Part II: The Making of a Transplant Surgeon

  3 The Simple Beauty of the Kidney

  4 Skin Harvest

  5 Kidney Beans: Making Kidney Transplant a Reality

  Part III: Expanding the Horizon Beyond the Simplicity of the Kidney

  6 Open Heart: The Invention of Cardiopulmonary Bypass

  7 Hearts on Fire: Making Heart Transplant a Reality

  8 Sympathy for the Pancreas: Curing Diabetes

  9 Prometheus Revisited: Liver Transplants and Thomas Starzl

  Part IV: The Patients

  10 Jason: The Secret Is to Live in the Present

  11 Lisa and Herb: Should We Do Liver Transplants for Alcoholics?

  12 Nate: The Selection Meeting, or Who Gets an Organ and Why?

  13 Michaela: We Are All the Same on the Inside

  Part V: The Donors

  14 As They Lay Dying

  15 Healthy Donors: Do No Harm

  Part VI: Today and Beyond

  16 Complications

  17 Xenotransplantation: From One Species to Another

  18 So, You Want to Be a Transplant Surgeon?

  Acknowledgments

  Notes

  Selected Bibliography

  Index

  Note from the Author

  The following book is neither a memoir nor a complete history of transplantation. I am not old enough to write a memoir, and a few excellent complete histories of transplantation exist already (and are listed in the bibliography). My goal is not to provide a chronological depiction of my coming-of-age as a surgeon, but rather, to use my experiences and those of my patients to give context for the story of the modern pioneers who made transplantation a reality.

  The remarkable events that allowed mankind to successfully transplant organs between two individuals that are not genetically identical occurred relatively recently. In the early 1950s, the idea of transplantation remained in the realm of science fiction. By the late ’60s, multiple organs were being transplanted, with a few poignant successes and many failures. True success with organ transplantation was realized in 1983, with the approval of cyclosporine. These accomplishments were achieved on the backs of a relatively small number of truly incredible people.

  My own training began with four years of medical school at Cornell University Medical College in New York City. I then did my surgical internship and first year of residency at the University of Chicago Hospital and Clinics. After that, I spent the next three years performing transplantation research at Massachusetts General Hospital. I then returned to the University of Chicago for three more years of surgical residency. Thereafter, I came to Madison, Wisconsin, where I completed a two-year fellowship in organ transplantation. I have been in Madison ever since, performing organ transplants and running a basic science lab studying the immune system.

  By illustrating what it took for me to practice transplantation, and by painting a picture, with the stories of my patients, of how the discipline has touched so many, I hope to highlight the incredible gift transplantation is to all involved, from the donors to the recipients to those of us lucky enough to be the stewards of the organs. I also will show the true courage of the pioneers in transplant, those who had the courage to fail but also the courage to succeed.

  All the details in this book are historically accurate and factual to the best of my knowledge, with some minor patient details changed in a few cases to protect the identity of an individual, if requested.

  Milestones in Transplantation

  Part I

  Out of Body

  I have great respect for the past. If you don’t know where you’ve come from, you don’t know where you’re going. I have respect for the past, but I’m a person of the moment. I’m here, and I do my best to be completely centered at the place I’m at, then I go forward to the next place.

  — MAYA ANGELOU

  We are not makers of history. We are made by history.

  — MARTIN LUTHER KING JR.

  1

  A Perfect Organ

  In a Small Plane over the Hills of La Crosse, Wisconsin, September, 2:00 a.m.

  While I’d been on planes many times, I’d never experienced the full power of a thunderstorm at ten thousand feet. The small King Air, a six-passenger dual prop, was bouncing around uncontrollably. Every few seconds, it would go into free fall and then hurl itself back up violently. The two pilots in the cockpit were hitting knobs and dials, trying to silence the various alarms that sounded as we rocked violently back and forth. It didn’t help that our physician’s assistant Mike, who had been on hundreds of flights in small planes before, was screaming uncontrollably, “We’re gonna die! We’re gonna die!”

  Given that Mike was such a seasoned member of our team, I could only assume that this particular flight was going badly. When the pilots glanced back to see the source of the screaming and cursing, I could make out the fear in their eyes. I looked at the spinning altimeter and noted that our plane was popping up and down as much as a thousand feet at a time. Outside the window, the lightning was shooting horizontally. The rain was constant and loud, and I was sure I heard pieces of hail hitting the windshield.

  IT WAS THE third month of my transplant fellowship at the University of Wisconsin. I hadn’t chosen transplant surgery so I could fly through thunderstorms in the middle of the night over the fields of central Wisconsin. Hell, I’d grown up in New Jersey, spent most of my life in the Northeast, and had never known anything about the Midwest. I had been drawn to Madison because it is one of the best places to be a transplant fellow. I was learning how to perform kidney, liver, and pancreas transplants, and how to take care of these complicated patients while they waited for organs and then recovered from thei
r surgeries.

  One unique part of the discipline of transplantation is the procurement of organs from donors. While we do perform transplants, particularly kidneys, with organs from living donors, the majority comes from people who have just died. Rather than transporting donors, who typically remain on a ventilator, brain dead but with a beating heart, we send a team out first, to meet with their families to thank them for their gift and then to perform the surgery to remove their organs. We then take those organs back for transplant into waiting patients.

  On this particular day, I’d received a phone call at around 5:00 p.m. telling me to come to the OPO (organ procurement organization) at 9:00 p.m., for wheels up at 9:30. The thirty-minute flight from Madison to La Crosse had been without incident. We arrived at the donor hospital at around 10:30. The donor was a young man (almost a boy) who had died in a motorcycle accident. That detail is easy to remember, as Wisconsin, being the land of Harley (not to mention a state where wearing a helmet is frowned upon), produces a never-ending supply of donors who’ve died in motorcycle accidents. In the winter, it’s snowmobile accidents, the snowmobile being the vehicle of choice for bar hopping in the evenings—which sounds like fun but is also incredibly dangerous, given the power of those machines.

  After we examined the donor at the hospital in La Crosse, confirming his identity and blood type, and went over the paperwork, including the declaration of brain death, we met with his family.

  This continues to be one of the most difficult and, at the same time, most rewarding aspects of my job. No matter how tired I am, the interaction with the donor family always reminds me how wonderful and cathartic the donation process is. These people are going through the worst experience of their lives, as most donors die far too young and unexpectedly. Often, the family members have not even had the opportunity to say good-bye. Perhaps the one positive notion that family members can hold on to is this: with this ultimate gift, their loved one will save the lives of, and live on in, as many as seven other people. Their gift of life will be a legacy their families can cherish amid the brutal pangs of loss they have to endure.

  We have a picture in our transplant unit of a mother whose teenage daughter died in a tragic car accident. This young girl saved at least seven lives. Some years later, the mother met the heart recipient at a transplant picnic we sponsored, and a picture was taken of her using a stethoscope to listen to her daughter’s heart beating in the chest of the man she had saved.

  This family tonight in La Crosse was no different. They asked how and when they could possibly make contact with the recipients, a process that we can help facilitate down the road if all parties agree. Then, once all their questions were answered, they said their final good-byes.

  Once the donor was transferred to the operating table and prepped, we scrubbed in and placed the sterile drapes. At this point, all emotions from the encounter with the donor’s family were pushed out of our minds. We had a job to do: to get all the transplantable organs out and flushed so that they would spring to life when placed in their new “owners.” Our team, which had come for the abdominal organs, was not the only one in the operating room that night; there were two others: heart and lung teams, waiting to take their respective organs. We stood around the operating table, separated by the patient’s diaphragm. They focused on the chest, and we focused on the belly.

  I took a scalpel and made a long incision from “stem to stern,” or from the notch at the bottom of the neck down to the pubis. As I dissected through the tissues and entered the belly, the cardiac team took a saw and began opening the chest. I quickly grabbed a malleable (a long, bendable steel retractor) and held it in front of the liver, to make sure they didn’t get a little careless with the saw and injure this beautiful organ.

  There is a natural conflict between a cardiothoracic team and an abdominal team. We all realize the importance of the incredible gifts the donor is giving, and we are all the stewards of these organs. At the same time, the procurement team always gets blamed for anything that goes wrong with the recipient operations that follow.

  “Why is the upper cuff of the liver so short?”

  “Why didn’t I get more vena cava below my heart?”

  We’re all trying to bring back the best organs we can. So, everyone protects his turf.

  I think about operations in steps. Step one: open the belly. Step two: mobilize the right colon and duodenum, and expose the aorta and vena cava. Step three: loop the aorta to prepare for cannulation (i.e., the insertion of a plastic tube into an artery that will allow us to flush the blood out).

  That night, we got through our steps, which included freeing up attachments to the liver and separating the liver from the diaphragm and retroperitoneum. We dissected out the porta hepatis, identifying the hepatic artery and the bile duct. We divided the bile duct, letting the golden bile pour out into the abdomen. Then we cleared off the portal vein. Next, we mobilized the spleen and exposed the pancreas. As we neared the end, we identified the renal veins and arteries, which lead to the kidneys.

  By now the cardiac team had scrubbed out and was standing behind us anxiously. Our portion of the operation is always much more involved than theirs, and as usual, they were constantly asking us when we would be ready. In their defense, their recipient surgeons (often hundreds of miles away) typically have already taken their patients to the operating room and begun opening their chests and getting them ready to be placed on bypass for removal of their sick hearts or lungs.

  Finally, we were ready. We placed our cannula in the aorta. The cardiac team then placed a cross-clamp on the aorta and started infusing cardioplegia solution (which causes the heart to stop beating). Then they got ready to cut into the vena cava right before it entered the heart. (We made sure to protect as much vena cava as we could from those bastards. They didn’t need it for their transplant, but we did for ours.) Once they cut it, the blood started to well up and out of the chest cavity. We started our flush through the aorta and then placed a second cannula in the portal vein. In poured the cold “University of Wisconsin solution,” the wonderful solution, invented at our own institution, that preserves the organs and helps make all this possible.

  The blood turned clear as it flushed out into our suction devices. We then poured buckets of ice into the abdominal cavity. Our hands began to cramp and ache from the ice as we held our cannulas in place. The good news was that, after a couple of minutes, the pain dissipated (as did all other feeling in our hands). The organs were cut out, flushed some more, and placed in bags.

  Then we all went our separate ways.

  That evening, I called Dr. D’Alessandro on the way out and told him we had a perfect liver. Of course, he was sleeping soundly in his bed. He would direct the OR team back in Madison to take the recipient patient to the operating room and start removing the old liver.

  We took a cab back to the airport. It was about 1:45 a.m. at this point. We were all exhausted, but also filled with the satisfying feeling that always accompanies an operation gone well. The added bonus was that our cooler was filled with four organs that would go into three separate patients—a liver, a kidney, and a combined kidney and pancreas (called “simultaneous pancreas and kidney,” or SPK). At the airport, we walked out onto the tarmac, where the pilots were waiting.

  FOR SOME REASON I remember this vividly, even though it was more than ten years ago. It felt windy and cool that morning, quite different from the stifling summer weather we’d experienced when we landed a few hours before. There was the unmistakable feeling that a storm was coming.

  The pilot turned to me and asked if I thought we should go. We both looked over at the cooler with the sticker reading “Organs for Transplant.” I mentioned to him that he shouldn’t worry about the organs; thanks to UW solution, the carefully designed preservation solution that would allow the organs to be metabolically inactive, they could wait awhile. I could always call Dr. D’Alessandro and tell him to delay the recipient.

  Instea
d, I asked the junior pilot if he thought it was safe. I say “junior” because he looked all of about ten years old.

  “It should be,” he said. I detected a slight tremor in his voice.

  Not that convincing, but I agreed to go.

  We took off, and everything seemed pretty smooth. But about ten minutes in, things started to get crazy.

  As the plane bucked and the alarms sounded, I really did think this was it. I thought about my family, particularly my little girl, born two weeks before we moved to Madison for my fellowship. I was bothered by the idea that someone at my funeral would say I’d died doing what I really loved. That’s bullshit. There is really no great way to die, certainly not in a stupid little plane in the middle of the night.

  We finally got through the storm, and as quickly as it started, it stopped. The pounding rain and the turbulence subsided, the plane settled, and we sat in silence for the last five minutes of the flight.

  After we landed, I asked one of the pilots how commercial planes could possibly be landing in this weather. He said, “Oh no. The airport is totally closed, only open for emergencies.” I remember feeling somewhat pissed about this, but in a way, what we had just done qualified as an emergency.

  I OPENED THE bag with the liver and dropped it into the sterile bowl filled with ice. I was in the operating room back in Madison, and Dr. D’Alessandro and my co-fellow Eric were almost done with the hepatectomy, or removal of the diseased liver.

  The donor liver was truly a perfect organ. I cleaned the extra tissue off it and meticulously tied off all the small vessels that came off the cava (though, of course I would still be blamed for any bleeding they got into after reperfusion). I then separated the pancreas (which we’d also use) from the liver, making sure not to injure either and to leave enough portal vein and artery for both transplants. I placed the pancreas in its own bag, which I would bring back down to the “lab.” This organ would be prepared and transplanted in the morning into a type 1 diabetic, along with one of the donor kidneys we’d just procured. The other kidney would go into a different recipient. In two other states, two different patients were receiving the heart and the lungs from our donor in La Crosse.