I never cease to find this remarkable.
Once the liver was ready, I brought it into the recipient room, where the team was waiting. When they saw me, Dr. D’Alessandro took the Klintmalm clamp and placed it on the last remaining attachment to the liver, the hepatic veins going into the vena cava. He cut the recipient’s liver out. I watched over his shoulder.
There is no more amazing sight in surgery than the abdomen once the liver has been removed. The vena cava—the large vein that brings blood from the legs back to the heart, which is normally enveloped by the liver—is fully exposed, coursing from bottom to top, and there is a huge, empty space around it. It is an unnatural but weirdly beautiful sight.
Dr. D’Alessandro took the new liver and started sewing it in—in steps. Upper cuff first. Then portal vein. Then flush. Then re perfuse. The liver pinked up and looked beautiful. Everyone looked happy.
Then Dr. D’Alessandro mentioned that I needed to go. There was another procurement, up in Green Bay.
2
Puzzle People
If you think of physical genius as a pyramid, with, at the bottom, the raw components of coordination, and, above that, the practice that perfects those particular movements, then this faculty of imagination is the top layer. This is what separates the physical genius from those who are merely very good.
— MALCOLM GLADWELL, “THE PHYSICAL GENIUS,” THE NEW YORKER
Madison, Wisconsin
My kids love to do art projects. They sit at the kitchen table and draw, cut, and glue princesses and animals and houses. The projects go on for weeks, cluttering up multiple rooms in our house, but in the end, the kids get a real sense of satisfaction as they play with their creations—until they are ready to move on to the next project.
My projects are my patients. Each one requires something cut out, glued in, or fixed up until it’s time for me to move on to another. Cindy was a particularly memorable “project.” When I first did a liver transplant on her, she was gravely ill, probably within a day or two of dying. I had gone to bed early the night before. At around two o’clock in the morning I got the phone call. I answered it on the first ring because, when I’m on call, as I was that night, I sleep with one eye open.
It was one of our coordinators for organ offers, Pamela. “We have a liver offer. It looks like a good one. He is a forty-four-year-old male, died of a drug overdose. Twenty minutes of CPR. Perfect liver numbers.” Pamela spent the next five minutes giving various details about the donor’s stability, previous medical history, and other lab values. I half-listened, partly because as long as the liver looked good, we were going to use it.
I asked Pamela who’d come up first for the liver.
“Cynthia R. MELD forty. Should I have the coordinator call you?” The MELD (or “Model for End-Stage Liver Disease”) score predicts how sick a patient’s liver is, and how likely she is to die without a transplant. A scoring system based entirely on lab values, the MELD score determines where a particular patient’s name will fall on the transplant list. The scores range from 6 to 40. When your score is below 15, it typically means your risk of having a bad outcome during a liver transplant outweighs your risk of dying without a transplant, and we typically will not proceed. As the score gets higher, it means your liver is becoming more dysfunctional and you are at greater risk for dying without a transplant. Allocation of livers is based entirely on risk of wait list death, with no consideration of quality of life, ability to work, or some prediction of your likelihood of returning home or to a “valuable” life afterward.
So begins the round of endless phone calls involved in coordinating every transplant, from identifying the potential recipients, who can be at multiple programs around the country; to bringing them into the hospital and making sure they are healthy enough to receive the organs; to running numerous tests on the donor to rule out infection risks; to running tissue typing to identify blood type and genetically match the donor and recipient; to setting up OR times at both the donor and recipient hospitals; to getting planes ready to fly all the donor surgeons and teams to the donor hospital; to, of course, making sure the donor family is comfortable with the timing so they can say good-bye to their loved one and talk to the transplant team. Each time there is a hiccup, and the timing has to change, all this has to be reset.
At 3:15 a.m., the phone rang again. (This second call is when I focus on the recipient.) Jaime, the transplant coordinator who focuses on our patients before and after transplant, gave me some more information on Cynthia, who goes by “Cindy.” She had been admitted multiple times over the last few months. She had recently been treated for pneumonia and had spiked a fever the day before. She had gone into renal failure during this hospitalization and was now on dialysis. She was obtunded (i.e., confused from her liver failure to the point of almost being in a coma) and yellow as a banana. Her blood wasn’t clotting at all, and she was oozing from her gastrointestinal tract (in her bowel movements), her nose, and around her IV lines. She was getting blood transfusions every day.
I trust Jaime, but given the severity of Cindy’s illness, I decided to do my own chart biopsy. I turned on my computer and maneuvered through all the firewalls to log into the hospital system. I kept Jaime on the phone through this, since I might have to decide to call in a backup patient in case Cindy seemed too sick.
This crazy concept of calling a backup in case I deem Cindy too sick and skip her highlights the emotional challenge of being on the liver transplant list. When you are waiting for a liver, you want to be as healthy as possible going into this massive operation, but at the same time, you need to get sicker to get the liver, but not too sick that you get passed over when the time comes. When I evaluate an offer, I need to decide if I can get the patient through without killing her in the OR, fully aware that if I skip someone because she seems too sick, I am likely signing her death warrant.
Nowadays, we are willing to push things pretty far. I will take patients with breathing tubes, renal failure, fevers, and on medication to support their blood pressure. I will take patients who are having active GI bleeds, who have tumors growing in their liver, who have blood vessels that are clotted, and who may need bypasses of these blood vessels or some other heroic measure. But if I think someone is too sick, I’ll have the backup recipient brought to the hospital, where the coordinator will tell this person that he will get the liver only if something happens to the person it is intended for. What must that be like for a patient—driving to the hospital in the middle of the night, getting prepped for surgery, even being wheeled down to the pre-op area, knowing he will receive this gift of life only if the intended recipient dies? It’s horrific to contemplate, but from my point of view, I don’t want to waste a healthy liver.
I looked over Cindy’s data. I felt as if I knew her at this point, having gone through her history, labs, films. I have seen her digital insides, have examined her lungs and her liver and her spleen and her bowel and her blood vessels. If I saw her on the street, I wouldn’t recognize her, but if I looked into her open abdomen, I would know her immediately, from her shrunken liver to her large spleen to her massive varices (big, swollen veins), which are carrying blood in the wrong direction (because of so much resistance to flow caused by that shrunken liver) and led to her GI bleeding, confusion, kidney failure, and now her imminent death.
I told Jaime it’s a go. Let’s not bring in a backup.
I finally met Cindy and her family at 4:30 p.m. I would come to know them quite well, particularly her daughter, Ally, and husband, Michael. I could see how much they loved Cindy, and how worried they were. I talked to them about the surgery and told them how sick she was. I told them the donor organ looked like a good liver. I went through some data—x percent chance of this, y percent chance of that, the possibility of bleeding, a bile leak, the clotting of blood vessels, organs being injured, the liver not working. But the questions they cared about most I couldn’t answer.
First, I couldn’t tell them
much about the donor. We avoid giving too much information about donors, since it would be too easy to figure out their identities on the internet. And of course, Cindy’s family wanted to know when the operation might take place. I had no idea. The various coordinators were busy trying to place all the organs. We had a good brain-dead donor (but with a heartbeat), so that meant being able to place the heart, lungs, liver, kidneys, pancreas, and maybe even the small bowel and skin, bones, and eyes. Some of the recipient surgeons involved probably wanted more tests done on this donor—a cardiac catheterization, an echocardiogram, a liver biopsy (which we’d requested), a bronchoscopy. That meant the donor would be wheeled down to the cath lab, where a cardiologist would stick a needle in his groin and snake a catheter in his heart to shoot pictures of his coronary arteries; another doctor would stick a needle into his liver for a biopsy; and a third would send a scope down into his lungs to look at his airways.
My phone rang just before midnight. Pamela again, back on her shift. An OR for the donor had been booked for 1:00 p.m. tomorrow. At 3:00 a.m. Pamela called again. The OR time had been moved to 3:00 p.m.
At 7:00 p.m. we were finally in the OR. The anesthesia team put Cindy to sleep. I sat in the room watching them put gigantic IV lines into her neck, to pour blood in when I began exsanguinating her. I noticed that her systolic blood pressure was starting at 60 mmHg, dangerously low considering I hadn’t even started the bloodletting. I watched them dial up the blood pressure meds. I considered whether I should call in a backup recipient now, as the likelihood of Cindy not making it had risen a little bit. Nah, forget it. Our team was packing up at the outside hospital, a thirty-minute flight away. Our fellow had sent a picture of the donor liver to my phone; it looked perfect. I’m putting this thing into Cindy. It’s hers now. If she gets buried, it will be buried with her.
At 8:15 p.m. we finally made the incision. My second-year fellow Emily sliced through Cindy’s skin. Everything was bleeding. This was not surprising, given that she had absolutely no clotting factors in her body and was already bleeding from every IV site and orifice. But she was not Cindy to me anymore. I no longer thought of her life, her family, whether she was male or female, young or old. I don’t think I would have been able to do to her what I was about to do if I thought about that. I had seen her films, had a mental image of what everything in there should look like, but now I needed to put together the puzzle.
A liver transplant can involve anywhere from a thousand to a million pieces. Despite the exquisite quality of CT scans and MRIs these days, you never quite know what a liver transplant, or any operation, is going to be like until you start. But shortly after opening, you have a pretty good idea. If the diseased liver is shrunken and mobile, and you can reach in and pull it up right away, you know it won’t be that difficult to get it out. If it is stuck to the tissue around it from years of inflammation and damage, however, you know you’re in for a battle. If you lose 2 liters of blood just cutting through the skin, you know you’re screwed.
We got into Cindy’s belly and sucked out 8 liters of beer-colored fluid—we call this fluid ascites; it bathes the organs in most patients with advanced liver failure. (I congratulated Steph, our scrub nurse, for guessing 7.5 liters—the closest to the actual number without going over. Good, clean OR humor.) We put our retractors in and looked at the liver. I could tell right away this was going to be bloody but not that bad. We got two suctions ready to suction the ascites and blood we were going to be swimming in throughout the operation. Emily and I had both put knee-high waterproof “booties” over our OR clogs, so we wouldn’t be standing in soggy socks by the end of the operation (something we have all learned the hard way).
The surgery itself went quite well. Cindy’s beautiful new liver worked right away, and we were able to stop the bleeding without too much trouble. We finished at around 3:30 a.m.—a little long for some surgeons, but I believe in taking my time and making sure everything is perfect before I leave. I went downstairs to talk to the family, leaving Emily and “anesthesia,” as we refer to the anesthesia team in the OR, to move the patient to the ICU and to complete all the never-ending paperwork. I told the family the case had gone well. I mentioned that Cindy’s pressure was pretty saggy throughout, but I was hopeful that would correct itself over the next day or so. She would go to the ICU with a breathing tube in. She was critically ill, but I thought she would be okay. They asked me if her kidneys would recover, and I said I hoped so.
EMILY CALLED ME at around 8:00 a.m. on post-op day five. “Hey, Josh, it looks like there is bile in Cindy’s drain.” Damn. My stomach immediately jumped into my mouth. Every time something goes wrong with one of my patients, I get this incredibly awful feeling, something like guilt mixed with nervousness mixed with depression. Bile can’t be good. It had to be leaking from where we’d sewn her bile duct together. The two ends of the duct had seemed fine in the OR, but she had been so unstable over the last couple of days that perhaps her low blood pressure had caused the ducts to fall apart. Bad blood flow can lead to bad healing.
In the shower, I pictured the operation we would need to do—most likely a Roux-en-Y hepaticojejunostomy. In other words, we would divide her small bowel, pull one end up to the bile duct, sew that onto the bowel, and then plug the other end back into the bowel so it looked like a Y.
Now the guilt was seeping in. You really have one shot at getting surgery right on a sick patient, particularly one who is on immunosuppression (i.e., drugs to prevent the immune system from attacking the new organ). Once you have a complication, you’re backpedaling.
I could already see that Cindy would now be hospitalized for months, would likely get numerous infections, have prolonged intubation, have an open wound, need various antibiotics, probably grow fungus out of her belly, get line infections and deep vein thromboses (DVTs), and probably never come out of renal failure. Nice thoughts.
I drove to the hospital and headed directly to the ICU. Cindy’s drain looked like shit. I don’t mean it looked bad. I mean it actually looked, and smelled, like shit. I wasn’t sure what I’d screwed up, but I couldn’t help wondering if another surgeon could have avoided this. Emily got the OR ready, and we rushed Cindy off for surgery. I was super anxious until we got her into the operating room. As a surgeon, when you have a complication, you’re dying to fix it. Waiting to go to the OR is agonizing, and sometimes it seems like everyone is putting up barriers to your doing so—missing paperwork, delayed lab results, absent staff.
We opened Cindy up and scooped out what seemed like a liter of poop. We saw that the liver looked great (other than being poop-stained) and the blood vessels were fine, as was the bile duct. As we looked around, we found a large hole in her right colon. I had no idea how that got there. Maybe it was from a retractor; maybe it was from her low blood pressure and high-dose steroids. It wasn’t directly my fault—but did that make any difference?
Emily and I removed Cindy’s right colon and gave her an end ileostomy and long mucous fistula that she would keep for the next year. In other words, we pulled the end of her ileum (small bowel) right through her abdominal wall so that her stool would come directly out into a bag; we also pulled the disconnected colon out as well as a double-barreled ostomy, so it couldn’t leak into her belly. After that repair, Cindy had a pretty tough course—a three-month stay in the hospital; an open, gaping wound; several readmissions; rounds of nursing home care. But she finally got better and made it home. And we were able to reconnect her bowels so she could poop like the rest of us again.
Her family was with her every step of the way, and it was definitely tough on them, but they weren’t done giving. Cindy’s kidneys never recovered. She was going to dialysis three days a week, four hours at a time. It is a miserable existence, but it was keeping her alive. The good news was this was something we could fix. We just needed a kidney. And immediately, her daughter, Ally, stepped forward to give it. Once that kidney was in there, she would be as good as new, ready to get on wit
h her life.
This is why I love the field of transplant. Since I began taking care of sick people, I have noticed that one of the hardest things about getting sick, really sick, is that you are separated from the people you love. Even when families are dedicated to the patient, illness separates the well from the sick. The sick suffer alone, they undergo procedures and surgeries alone, and in the end, they die alone. Transplant is different. Transplant is all about having someone else join you in your illness. It may be in the form of an organ from a recently deceased donor, a selfless gift given by someone who has never met you, or a kidney or liver from a relative, friend, or acquaintance. In every case, someone is saying, in effect, “Let me join you in your recovery, your suffering, your fear of the unknown, your desire to become healthy, to get your life back. Let me bear some of your risk with you.”
I saw Cindy in my office on a Tuesday in October, about a year and a half after her liver transplant, the day before I was planning to perform her kidney transplant. She was with Ally. Cindy tearfully asked me what the chances were that the operation would be successful.
“Of course it’s going to work,” I told her. I didn’t say this out of a surgeon’s narcissism. The reality is that she was getting a young, living-donor kidney from a healthy donor, all the immunologic tests we had performed indicated no evidence for risk of early rejection, and the procedure has become quite commonplace. I just needed to put the last piece of the puzzle in place, and she would be on her way.
How Death Becomes Life Page 2
