Moore truly was a man ahead of his time, one who believed in surgery as much as anyone ever has. But he also understood the limitations of aggressive surgery, beyond which only suffering and prolongation of misery can ensue.
I’m with Starzl and Moore on the prospects of progress in our current era. Backed by careful laboratory study and sharing of data at national meetings, our modern pioneers, filled with courage, will keep our field marching forward. It is likely that, in the next few years, we will see trials in xenotransplantation using genetically modified pig kidneys in humans. We have numerous tolerance protocols, where patients receive a short course of immunosuppression and then are taken off immunosuppression completely, that work on a small scale, and more and more ideas are entering the clinical arena every year. In addition, novel immunosuppressants we’ve introduced into the clinic in the last decade are showing promise for our efforts to develop less toxic strategies to keep organs going.
There are so many things I love about being a surgeon. There is nothing quite like spending countless years mastering a trade, finally reaching a point where you alone can open people up and save them when they are at risk of dying. And of all fields, transplant is the best. Every time I put an organ in and it works, I can hardly believe it. I love the fact that we take something from death and give something of great value to the donors and their families. I am truly honored to be a part of this wonderful gift between two people who will forever be connected. On top of all that, I love immunology, the true science of transplant.
The only downside is the never-ending sense of responsibility, the knowledge that despite all the victories, there are also many failures, some of which happened because of decisions you, the surgeon, made. As Starzl said, it does prevent you from living a “normal” life. I often have the feeling that my job is to fix people with illness so they can go back out and live their lives, do things that I would love to do but don’t have time to. I have trouble turning my brain off when I get home, trouble living in the moment. My head is always spinning with thoughts of a patient who is having a problem, of some test or procedure I’m waiting on, of a call from a resident about a blood pressure that is too low or a temperature that is too high. I have read so many quotes by surgeons who say that when they look at a patient with an illness, someone whose life is on hold, they feel racked by uncertainty about the diagnosis, and envious—envious of this patient lying in bed resting. He has no responsibility other than his own illness. He has been freed from his worldly responsibilities. No doubt the experience of a major illness is miserable. It separates you from your friends and family, not to mention causing you pain and other physical suffering. At the same time, it releases you from the demands of your life, all the things you have to do every day that you wish you could blow off.
I don’t regret my training, my practice, my choices—in fact, I am grateful for the responsibility and the privilege that come with being a surgeon. I am grateful also to play a small role in carrying the baton that the transplant pioneers have passed on to us. At some point, we will hand that baton off to another generation of driven, courageous transplant surgeons, who will move the field to dimensions we can’t even dream of.
At the same time, I feel a sense of relief when my kids say they will plan on doing anything with their lives but what I do. Still, they are young. In the end, they will probably both become transplant surgeons. And I will be very proud.
AS THE PLANE levels out at twenty thousand feet, I look over at Felix, our German-trained procurement surgeon, stretched out comfortably in his seat, headphones on, fast asleep. Wide awake myself, I look out at the night sky, now lit up by the moon. For a second, I wonder what I’m doing here, flying in this little plane over the farmlands of Oshkosh, separated from my family. My two little girls, now sleeping peacefully at home, will wake up in the morning and discover me gone, an experience they’re quite familiar with.
I shift my gaze back to Felix, along his extended legs, and down to the cooler he is so unceremoniously using as a footrest. Inside sit a liver, two kidneys, and a pancreas. Somewhere else in this same night sky, under this same moon, two other planes are flying in different directions from ours. Each one has a cooler: one contains a heart; the other, two lungs.
Just two days ago, these organs were working in concert, allowing a forty-two-year-old father to eat, drink, go to work, hold his kids. These organs helped him climb up on his roof to clean out the gutters—but they couldn’t stop him from falling off. Now they sit in ice, until they will be filled with blood and returned to the living, ready to sustain a new body, allowing five other people to live, love, be happy, be sad, enjoy their families. These five people don’t know one another, don’t even live in the same city, but they will forever be joined by the web of transplantation. They will be saved by some guy who will never get to see his gift of life. But maybe, down the road, his wife and children will. And maybe they’ll think, Yes, he was some guy. I know that’s what I think.
I lean back and close my eyes. But I can’t sleep.
Acknowledgments
It is hard for me to remember a time when books were not a part of my life. I credit this to a rule my parents instituted when I was a child: we had to read two books a week. As I remember it, my parents would also read the books my two brothers and I had selected, and we’d then have lengthy discussions about them at the dinner table. My parents limited the TV we watched, but for some reason they always allowed us to watch M*A*S*H (as long as we had read our weekly two books). To this day, I tell people I’m a “meatball surgeon,” and I’ve always wanted to visit Crabapple Cove, Maine, home to my hero Hawkeye Pierce.
I can still remember the moment the spark that would become this book was ignited in my brain. I was sitting on a boat in Miami, late at night, reading The Emperor of All Maladies, by Siddhartha Mukherjee. Everyone else had gone to bed, and I knew I had to get up early in the morning for some family activities, but I was enthralled. As I read through the night, fascinated by Mukherjee’s ability to use his patients’ stories to recount the history of cancer, to make the story accessible to those of us who know little about the topic, I thought about my own field of transplantation, with its incredible history and its ingenious founding fathers. I thought about how new the field of transplant really is, how in the 1940s and ’50s, transplantation was truly a pipe dream; in the ’60s, it started to happen; and by the ’80s, it had become commonplace. I also realized at that moment that some of those pioneers who’d given up so much to make transplantation a reality were still alive to tell their stories.
As I started to put together my thoughts on how I would tackle this project, another book gave me some clues: My Age of Anxiety, by Scott Stossel. While Mukherjee uses his patients’ stories to tell the history of cancer, Stossel uses his own experiences and struggles to recount the history of anxiety. It was at this point that I decided I would use my coming-of-age as a surgeon and my patients’ stories to illustrate the drive and commitment of transplant’s pioneers. My hope is to make the story of transplantation accessible to those outside the field of medicine, in a way Mukherjee and Stossel did before me with their own topics.
There are many people to thank for supporting me in this project. I will start with my brother Ben. I have watched Ben with fascination in his career as a writer, which started when he was in high school. I remain amazed that he has been able to keep going for so many years, in such a competitive field, without developing an ounce of negativity. Ever since I voiced my desire to write this book, Ben has been the most supportive person I can imagine, and without him, I would not have followed through on this project. He helped me obtain an agent and gave me extensive advice on actually writing the manuscript. Now that it is a reality, and I have become a published author, I guess he has to perform an organ transplant. Any organ will do. I’ll give him the same advice I give my fellows: Don’t screw it up.
Next, my agent, Eric Lupfer. I can only imagine what he was thinking w
hen we first spoke some years ago and he agreed to sign on to this project. I’m almost embarrassed to look back at the first outline I sent him after that phone call. (Just as a taste of what it was like, it was titled “The Legend of Big Daddy”—that’s me, by the way.) In many ways, he saw what I was trying to do through this process better than I did. I am absolutely blown away by the role he played in molding this book; his positive, relaxed attitude throughout the process; and his gentle (yet firm) guiding hand. None of this would have happened without him. I will be forever grateful.
To my editor, Gail Winston. I remember so vividly the day we met. She immediately understood what I wanted to do with this project, and she was honest about how complex and challenging it might be. She has taught me so much about writing, but a few lessons in particular come to mind: stay disciplined, give the reader credit that they will remember and understand what I have said before, and establish credibility about who I am and why I can tell this story. Gail has so much respect for the readers she works for! I recently read an article on being an author by Thomas Ricks (“The Secret Life of a Book Manuscript,” The Atlantic, August 22, 2017). In it, his editor tells him, “The first draft is for the writer. The second draft is for the editor. The last draft is for the reader.” I’m sorry I sent Gail that massive first draft! I remember telling her to skim it quickly, to make sure it was going in the right direction. After a few agonizing weeks (during which I was picturing her writing to tell me we should just forget the whole thing), she told me that editors don’t just skim manuscripts, no matter how rough they may be! I guess I should have warned her I was a Russian language and literature major in college. Even Dostoyevsky would have been impressed with the length and rambling of that one! Thank you so much, Gail, for not giving up on me. And I do plan to pitch a book called The Cutting Room Floor. I’m guessing she will pass on that.
To my partners in transplantation, thank you for teaching me how to perform these challenging operations and take care of our patients. Transplantation is a team sport, and we have the best team in the world! Thanks, too, for supporting me through this project—I know it took some extra work from all of you, and I hope you don’t make me pay for it.
To all the people I was able to interview, complain to, and argue with through this process—there are too many to name, but nevertheless, I will name some: Sir Roy Calne, Paul Russell, Leslie Brent, David Hamilton, David Cooper, John Daly, Hans Sollinger, Münci Kalayoğlu, David Sutherland, Nancy Ascher, Allan Kirk, Charlie Miller, Arash Salemi, and of course Thomas Starzl; my friend and mentor Joren Madsen, for critically reading the text; the pioneers in our field who gave up so much to make transplantation a reality; our fellows, whom I am so proud of—every year, I am blown away by how well trained you are and how hard you work to become transplant surgeons; it is because of you that I can do my job every day—and Janet Fox, Elaine Snyder, and Mike Armbrust, who helped me track down patients and make our transplant program work.
To my family. To my incredible parents, Molli and Reuben, who have been my greatest supporters throughout my life. Thank you for always teaching me I can do whatever I want as long as I work hard and learn along the way. To my brothers, Jon and Ben, and their families, for their undying love and humor. And to the four people who make my life worth living every day: Gretch, Sam, Kate, and Phoebe (yes, one of them walks on four legs). Gretch, I’ll never forget that day I walked into the lab and saw you standing over that pig, doing a lung transplant. (I know you looked at me and thought my shirtsleeves too long.) Transplantation has brought me so many amazing things, but they all pale in comparison to the life we have been able to build together. I owe all my successes to you; your drive, integrity, and quality inspire me daily. You are the most amazing person I have ever met. I am not worthy. Sam and Kate, you are the two best things in my life. When considering all of my accomplishments, being your father is what I am most proud of. I love that you are both obsessed with reading. I never had to institute the two-books-a-week rule with you two—that would actually have decreased your volume! (I hope this acknowledgment embarrasses you; little else gives me so much joy!) And Phoebe: sadly, you are my best friend! You have played a large role in this project. Our long, aimless walks around the neighborhood as I worked through story after story were invaluable to this book. It’s sad to think you can’t actually read this.
To my lower back—you are perhaps the one thing that did not support me in this endeavor. I had always thought surgery was hard on the body. Little did I know that spending hour upon hour hunched over a computer would be even more physically demanding. It may be time for a standing desk . . . or perhaps a back transplant.
To my patients: You are my inspiration. I learn so much from you every day. Thank you for allowing me to be with you while you struggle with illness. Thank you for opening up to me (and for letting me open you up), sharing your most vulnerable fears and secrets. It is truly an honor to take part in your care every day, a privilege that all of us in medicine share. We learn more about strength, grace, honesty, and love from you than we could ever give back.
And most of all, to the donors, living and deceased. You are the reason transplantation exists. You are true heroes. I like to believe the donor gets as much out of the act of transplantation as the recipient. As the saying goes, it is better to give than to receive! Thank you for running into that burning building to save someone. Thank you for taking that leap of faith. Your courage gives hope to us all.
Notes
CHAPTER 2: PUZZLE PEOPLE
21 Lyon, France, June 24, 1894: The primary source for this section on Alexis Carrel is the recent book by David Hamilton, The First Transplant Surgeon: The Flawed Genius of Nobel Prize Winner Alexis Carrel (Singapore: World Scientific Publishing Co., 2017).
21 Sante Geronimo Caserio: “Caserio Struggled for Life; the Assassin’s Courage Failed Him in the End,” New York Times, August 16, 1894.
21 “How you are hurting me”: “Assassination of President Sadi Carnot,” Otago Witness, Issue 2105, June 28, 1894.
21 An injury to the portal vein: Georg Heberer and R. J. A. M. Van Dongen, eds., Vascular Surgery (Berlin: Springer-Verlag, 2012), 4.
23 embroidery lessons at the home of Madame Leroudier: Described in R. Cusimano, M. Cusimano, and S. Cusimano, “The Genius of Alexis Carrel,” Canadian Medical Association Journal 131, no. 9 (November 1, 1984): 1142.
23 1902 published a paper: A. Carrel, La technique opératoire des anastomoses vasculaires et de la transplantation des viscères (Lyon: Medical, 1902), 99859–62.
24 “the crowd of imbeciles and villains”: Joseph T. Durkin, Hope for Our Time: Alexis Carrel on Man and Society (New York: Harper and Row, 1965).
25 “Carrel patch”: Published in A. Carrel and C. C. Guthrie, “Anastomosis of Blood-vessels by the Patching Method and Transplantation of the Kidney,” JAMA 47 (1906): 1648–50.
26 “Successful Transplantation”: A. Carrel and C. C. Guthrie, “Successful Transplantation of Both Kidneys from a Dog into a Bitch with Removal of Both Normal Kidneys from the Latter,” Science 23, no. 584 (March 9, 1906): 394–5.
27 “perform a series of similar operations”: A. Carrel, “The Surgery of Blood Vessels, etc.,” Johns Hopkins Hospital Bulletin 190 (January 1907): 18–28.
29 Murphy showed in mice: J. B. Murphy and A. W. M. Ellis, “Experiments in the Role of Lymphoid Tissue in the Resistance to Experimental Tuberculosis in Mice,” Journal of Experimental Medicine 20 (1914): 397–403.
32 “Alexis Carrel”: Sir Roy Calne, email to author, November 21, 2016.
CHAPTER 3: THE SIMPLE BEAUTY OF THE KIDNEY
44 At the time, Willem Kolff: The primary source for this section on Kolff is the book by Paul Heiney, The Nuts and Bolts of Life (Gloucestershire, UK: Sutton Publishing Ltd., 2002).
CHAPTER 4: SKIN HARVEST
53 “I cannot give any scientist”: P. B. Medawar, Advice to a Young Scientist (New York: Harper and Row, 1979).
58 North O
xford, England, The Blitz, 1940: The primary source for this section on Peter Medawar is the autobiography by Peter Medawar, Memoir of a Thinking Radish (Oxford: Oxford University Press, 1986).
60 published a more complete report: Publication is R. E. Billingham, L. Brent, and P. B. Medawar, “Actively Acquired Tolerance of Foreign Cells,” Nature 172 (October 3, 1953): 603–6.
60 “biological force”: Alexis Carrel, Nobel Lecture, December 11, 1912.
62 “The Fate of Skin Homografts in Man”: Publication is T. Gibson and P. B. Medawar, “The Fate of Skin Homografts in Man,” Journal of Anatomy 77 (1943): 299–310.
63 “ ‘My dear fellow’ ”: Medawar, Memoir of a Thinking Radish, 111.
63 Immunogenetics Laboratory, University of Wisconsin, 1944: The primary source for this section on Ray Owen is the article by James F. Crow, “A Golden Anniversary: Cattle Twins and Immune Tolerance,” Genetics 144 (November 1996): 855–59.
64 Owen published: Publication is R. D. Owen, “Immunogenetic Consequences of Vascular Anastomoses Between Bovine Twins,” Science 102 (1945): 400–401.
65 published their findings: Publication is R. E. Billingham, G. H. Lampkin, P. B. Medawar, and H. L. Williams, “Tolerance to Homografts, Twin Diagnosis, and the Freemartin Condition in the Cattle,” Heredity 6 (1952): 201–12.
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