DANVILLE, Ind. (AP) - The woman lay draped and still on the operating table, while nurses and surgical techs bustled around the room, placing surgical equipment on the tables surrounding her. As the surgeon moved closer to the patient, a tall man in scrubs stepped forward and cleared his throat.
“Time out,” Steven Ashley said, and the room fell silent.
He read a few words about the woman no one in the room knew, but who was the reason they were there that night. He shared personal messages from her family, including a few inside jokes, and then pulled a laminated card from his pocket.
“Remember,” he read, “this room becomes sacred when a family entrusts us with one of their most precious possessions.”
The middle-aged woman on the operating table, he reminded everyone, was both dear to her husband, children and other family members, and a hero. To honor her, he said, everyone in the room should conduct themselves as “though the family were present.”
Then, there was a moment of silence, heads bowed, eyes down.
Most surgeries do not begin with such a preface. But this was no routine surgery.
Although the woman on the operating table continued to breathe with the help of a ventilator, she had been declared dead a day earlier.
This procedure was not to save her life, but to allow her in death to save the life of others.
Much has been written about the dramatic world of transplant surgery - the journey that donated organs take to their new homes, the painstaking work the transplant surgeon does to stitch in a second chance at life for the recipient.
Hours, often days, before that surgery, a team of organ recovery coordinators lays the groundwork. This delicate process, which lasts 24 to 48 hours and in some cases longer, moves slower, with less action.
This is the story of that prequel.
On a recent spring evening, a team of organ recovery coordinators headed west from their offices at the Indiana Donor Network to the intensive care unit at Hendricks Regional Health’s Danville hospital, where the woman had been treated.
Earlier in the day, a doctor had had the most difficult of conversations with her family, saying her prognosis was poor. In the morning, the family met with another Indiana Donor Network team, who talked to them about organ donation. Over the course of the day, they had decided to donate the woman’s organs.
The woman’s family consented to have an IndyStar photographer and reporter follow the organ-recovery journey. They asked that her name, cause of death and other identifying details not be shared.
While many people are registered to be organ donors, circumstances have to be just right for their organs to be suitable for donation. Each year the Indiana Donor Network receives about 30,000 calls from hospitals about patients who might become candidates for donation.
Of those, about 5,500 lead to referrals. Last year, 165 people in Indiana became organ donors.
The need for organs is great. About 114,800 people across the country are waiting for organs. Last year 34,768 received organs, according to the United Network for Organ Sharing, or UNOS.
The Indiana Donor Network recovers on average 3.76 organs by donor, more than any other organ procurement organization in the country, the staff said.
“We maximize donations from the donor and save as many recipients’ lives as we can,” said Luke Jones, supervisor of organ services at the Indiana Donor Network.
Earlier that afternoon, the doctor had administered a final, painstaking round of tests on the woman. He had checked for a cough or gag reflex, noted her pupils did not react to light, and that she had no pain reflex. Speaking clinically, he declared her brain dead, meaning she had no blood flow to her brain. The ventilator ensured her body continued to receive oxygen, in turn allowing her heart to beat and circulate blood to her organs.
At this point, her care transferred from the hands of the Hendricks ICU staff to those of the Indiana Donor Network.
The woman’s family had decorated her sterile room with personal touches, affixing photos and multi-colored messages of love on a large poster. Three copies of a photo of a mother elephant and her calf nuzzling also adorned the walls.
With members of her family clustered nearby, the team from the Indiana Donor Network eased in and out of the woman’s room, delicately navigating around the family’s emotional needs. While their primary task remained the organs, they also recognized they had a role to play in helping the family grieve.
“Generally we introduce ourselves because we are in and out of there, testing,” said Anne Kasey, one of the organ recovery coordinators on duty that night. “This is a process not a lot of people know about. We want to let them know as much as possible. . We try to spend as much time as we can. It’s a way to educate them about something their loved one is going through.”
First, the organ recovery coordinators drew about 30 vials of blood from the patient. They took urine and sputum samples as well as a blood culture. Then, they ordered tests such as a chest X-ray and EKG to assess the quality of the heart. In some cases, they will request additional abdominal scans to measure the size of organs such as the kidneys or liver.
A few hours after drawing the blood, they returned to the patient’s side to biopsy a few lymph nodes near her groin. These would be tested to ensure a good match between donor and recipient. Kasey’s teammate, John Heflin, noticed that the patient’s urine was as clear as water, suggesting she might have had diabetes insipidus, a common condition in organ donors due to insufficient levels of a hormone made in the brain. In keeping with Network protocol, the woman received a medicine to reverse the condition.
About 9:30 p.m., a few hours after the organ recovery team arrived, they chatted with the woman’s family. They recommended the family head home to rest and come back the next day to continue their vigil.
The organ recovery coordinators, however, worked through the night. Recovery coordinators work 24 hours on, 48 hours off. The team here had started at 8 a.m. and wanted to have everything in order by 8 a.m. the next morning, when another team would replace them.
At any given time, six organ recovery coordinators - typically in three teams of two - are on call throughout the state. One team is based in Fort Wayne, but the Indiana Donor Network’s 24 organ recovery coordinators can expect to be called to cases all over the state.
“We do this job with the understanding that you may be out to dinner with your family or friends but you always have scrubs in your backpack and you have to go out when you’re called,” said Kasey, who first learned about the career while working as a nurse in an intensive care unit.
As the ICU quieted down for the night, Kasey and her team settled into an empty room that they used as their base. Most hospitals provide a designated space for the Indiana Donor Network staff to use while they are in house.
If the organ recovery team has any medical concerns that go beyond their expertise, they can contact one of the Network’s medical officers, both of whom are always on call. The chief medical officer, Dr. Tim Taber, has even fielded calls while on vacation in France.
One organ recovery coordinator drove the woman’s blood samples to an Indianapolis lab for testing. The blood is screened for infectious diseases, such as hepatitis B and C, HIV, West Nile virus, CMV, and Epstein-Barr virus. Other vials go for A-B-O blood type and more exacting tests to determine specific proteins, known as human leukocyte antigen, or HLA, typing that helps determine compatability between organ donor and recipient.
“Every case is sad but there’s a positive outcome in it for the family and the patient and the recipient,” Kasey said. “When we place organs, because we are allocating organs, we are able to know who that organ is going to. That’s the positive part to it, you know these organs are going to recipients that are going to save their lives.”
In this case, Kasey and her team did not know where the woman’s organs were headed because their shift ended just as the blood results came back, around 7:30 the next morning. By this time, a new team was heading out to Hendricks Regional to take their place.
Two hours later, Steve Ashley, the organ recovery coordinator who read the family’s personal messages in the operating room, started the matching process. He entered the patient’s metrics into the DonorNet database, operated by UNOS, and hit “match run.”
DonorNet relies on a complicated algorithm to decide who should receive the organs. The formula takes into account a variety of factors, including the distance the organ would have to travel and the health of the potential recipient.
In some cases, Kasey said, this is the longest part of the process. If the medical center of the first recipient on the list declines, the next center on the list is contacted.
Once the team knows which organs will be going where, they begin to coordinate the organ recovery time. This requires balancing when the hospital has a free open operating room with the complicated schedules of the surgeons coming to take out the organs. Surgeons can travel from anywhere in the country for the organs.
For some cases, as many as six surgeons can crowd into an operating room. The doctors work simultaneously but biology dictates the order in which the organs are removed. Thoracic organs, like the heart and lungs, have a shorter window of time in which they can be out of body so they come first, followed by abdominal organs.
Often organ recovery procedures take place in the middle of the night - when operating rooms and surgeons are most likely to be free. The family of the donor always receives at least four hours’ notice so they can say their final goodbyes.
On this night, shortly before midnight, the organ recovery coordinators gathered in the donor’s room. Hendricks Regional Health staff and the surgeons started the procedure at midnight, about 36 hours after the woman’s family first learned doctors could do nothing more to save her.
The family braced themselves for this moment. At some point in the past 24 hours, one member of the Indiana Donor Network had made a recording of the woman’s heartbeat. This goes inside a teddy bear that is a keepsake for the family.
In the silent ICU, a family services coordinator stood close to the woman’s husband. The two walked beside the gurney as hospital staff wheeled it out of the ICU room and to the hospital’s operating room through an empty corridor. Only a hospital security guard witnessed the desolate parade. No one spoke. Every now and then, the husband choked back a sob.
The doors to the operating room opened, and the gurney continued. The woman’s husband could go no further. He exited the darkened surgical wing, then left the hospital.
Inside the operating room, lights shone brightly. An anesthesiologist was already hard at work. He monitored the woman to make sure her organs were well-oxygenated and as healthy as possible.
DonorNet and the test results determined that three of the woman’s organs, her kidneys and her liver, would go to recipients. All went to patients in Indianapolis. Only one surgeon, IU Health’s Dr. Burcin Ekser, with the assistance of a surgical fellow, performed organ procurement surgery on this night. Just around midnight, the two doctors arrived, in a car with a driver from the Indiana Donor Network.
The Indiana Donor Network organ recovery coordinators, the anesthesiologist, a few hospital staffers and the IU Health gathered under the bright lights of the operating room.
After the moment of reflection, led by Ashley, everyone started to move rapidly and efficiently.
At 1:14 a.m. the critical “cross clamp” moment occurred, halting the flow of blood to the heart. This is the time when the heart would be removed if it were headed to another chest or to research.
The pressure would have been even greater if the procedure included the removal of heart or lungs. Hearts must be transplanted within four to six hours after they leave a body and are packed into a cooler filled with ice. Ideally, they should sit on ice for no longer than three hours. Lungs can last six to eight hours.
In long-distance cases, an Indiana Donor Network jet will wait at the nearest airport for the organ to be removed. Once the blood flow to the heart is stopped, someone in the operating room will text the pilot, who will start one engine in preparation for takeoff as soon as an ambulance arrives at the airport with the organ.
Abdominal organs have larger windows of time. Livers, for instance, have about eight hours. Because kidneys can go on a pump that will send fluid regularly through the organ, minimizing tissue damage, they can last up to 72 hours outside the body. This means that if necessary they can travel via commercial air to their new home, said Sherry Quire, director of organ services for the Indiana Donor Network.
But this donor’s kidneys and liver did not have far to go - only about 20 miles back to Indianapolis, where Indiana University Health doctors would transplant them later in the day. The team in the operating room prepared to remove the organs, triple-bagging large metal bowls with clear sterile bags filled with “slush,” partially frozen saline solution.
Shortly before cross-clamp, Ashley made and received a volley of phone calls. Researchers on the West Coast were curious about the donor’s pancreas, but wanted to know the condition and the size of the organ before accepting it.
Then the researchers called back and say they would, in fact, like the pancreas for their study. So another receptacle was prepared for that organ, which would go back to the Indiana Donor Network offices, then be packed and shipped.
At 1:28 a.m., the large purple liver was removed from the woman’s body and put in one of the large metal bowls. Five minutes later, the right kidney came out and three minutes after that the left followed. An IU Health staff member, who accompanied the doctors to the procedure, trimmed fat off the kidneys.
Ekser and his colleague began to sew the patient back up. Just before 2 a.m., they finished their procedure. Ekser walked over to closely examine the liver.
In this case, he was pleased with what he saw, but it’s not uncommon for a surgeon at this stage to decline the organ, fearing it might be the wrong quality or size for transplantation. If the Indiana Donor Network staff has a sense this may happen, they may try to line up a local backup to take the organ.
The IU Health doctors left the Hendricks County hospital almost immediately, ducking into a car that was waiting to take them and their precious cargo of two kidneys and a liver back to Indianapolis.
The organ recovery team moved at a more leisurely pace. They packed up their equipment, and the woman’s pancreas, and wheeled their belongings through the hushed hospital.
Meanwhile, in an Indianapolis hospital, surgical teams awaited the organs that would help them save three people’s lives.
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Source: The Indianapolis Star
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Information from: The Indianapolis Star, http://www.indystar.com
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