It seems car accidents must be an integral part of any holiday season. As road death is a key source of organ donors, I want to share the relationships I have had with organ donors, after their deaths.
This post is longer and more serious than my usual stuff. Less tirade, less jokes. But this is serious stuff, and if you are lucky, you may get to participate in this procedure one day (Of course, another version of lucky would be to die a peaceful death).
Where they found me
As a surgical registrar attached to a liver transplant unit, I was offered the unique chance to be on call for liver retrievals. Basically, this means if the unit is offered a liver, I am called to travel to where the donor is, and help the transplant surgeon remove it at an operation. For a surgical trainee this is a win-win situation. The operation is complicated, intense and not often witnessed by trainees. Transplant surgeons like to have research bunnies to get out of bed to assist in a semi-aware manner, allowing another member of the team to stay in bed, so they can help with the implantation later.
A call for transplant always occurs late. Patients are usually pronounced brain dead in the light of day, after a ward round. Over that day, the family has to come to terms in “death” in a loved one who has not outwardly changed, and whose ICU machines are still beeping. In the midst of that, they try to get their head around organ transplantation, with the help of doctors and transplant nurses. So when the call comes, they ask if you are free at 11pm, or 1am, or 2am. Very tempting to turn it down. But the times I took up the challenge, I was tiredly happy with my decision.
Even if the decision is made quickly, it takes time to perform blood-typing, and then the waiting lists are reviewed and decisions are made to offer each organ to a particular centre. Donors can share their tissue (ranging from corneas to kidneys, hearts and intestines) to recipients across a state, and often across the country. Some units, particularly heart units like to retrieve themselves, so they might fly to the operating theatre. I was once involved in a retrieval in Darwin, which involved us (the abdominal team) flying in a private jet from Melbourne, and the heart team traveling from Queensland.
Getting organised
Usually, an organ retrieval is booked as the last case of the day. It is important that the donor, who has died and is stable, does not delay emergency surgery on people who are alive and sick. However, if they start to decompensate, they may be bumped ahead in the queue – their organs “belong” to usually at least three or four sick people, and that hangs over everyone’s head. As the least experienced person in the team, I am generally focussed on not being the person to ruin everything.
Without thinking, I guess I imagined organ retrieval to be a bit shady, done in a dimly lit theatre, with cheap intruments. Maybe there are too many urban myths about guys in icy bathtubs with scars on their backs. But the procedure is top drawer. Although it doesn’t occur until most others have gone home, it looks like any other big operation – the drapes, the gloves, the scrubbing, the anaesthetist, the works. The operating surgeons don’t accept sub-standard equipment, and throw tantrums in much the same way they do for any other critical case.
In the down times waiting for operating time, I liked to ask the surgeon about the liver recipient. Usually, they wouldn’t share much, but I’d find out their age, or sex or disease. The surgeons seem to care a lot about the waiting list – how long the patient had been waiting; why they chose this one above that other one. During the procedure we talk about which organs we are taking and where they are going. It is amazing to see a broken body, and know that they were sending their organs across the country.
The last operation
The operation is one of those nerve bending, high concentration affairs. The task initially is to make sure there is no unknown medical or anatomical contraindication to transplantation. If the vessels are too short, or in the wrong place, it is sometimes not possible to implant the organ. Sometimes the liver will be of poor quality, so will be rejected as unsuitable, or is resected with a biopsy to be reviewed prior to decision to implant. At the home hospital, the recipient doesn’t start their long operation until they know they will have a liver.
Isolating the organ, and identifying the relevant vessels is an intricate procedure. Dealing with big blood vessels is always nerve-wracking for surgeons, as a slip means blood loss, and stress. In an organ retrieval it can mean damage to the organ, and a difficult or impossible transplant. If the surgeon is under stress, it normally means the assistant is taking the brunt. Cannulation of the IVC (big, fat blood vessel) is stressful with a surgeon you know well, but you don’t always get to operate with surgeons you like. Nuff said.
Amidst all this stress, it gets a bit busy. The chest team (who are responsible for the heart and lungs) and the abdominal team (responsible for the pancreas, liver, kidneys, intestines and vessel patches) take turns around the table, or work in tandem. At times, this means four or more surgeons and at least two scrubbed nurses and their equipment sharing elbow room. Meanwhile, a corneal bank representative works at the head end to harvest the corneas. Busy can’t mean frantic, though. The organs are important, and the only urgency is external. So the surgery proceeds without hurry. These surgeons are some of the best technicians around, and they don’t rush.
Operating underwater
All organs for transplant require transporting, even if it is around the corner to an adjacent operating theatre. In order to reduce the damage to the organs, the transport time is minimised, and they travel in ice water (“cold ischaemia”). Therefore, before the organs are removed from the body, they are cooled. This means buckets of ice cold fluid, with big chunks of ice and slurry is poured into the abdominal cavity. Then the organs are further flushed with cold solutions through their blood vessels. And the surgeons operate on with icy numb hands, and wet feet.
The attitude and the aftermath
Logically, I shouldn’t have been surprised. But it was really cool when I saw how much all those staff care about the donor. Only the transplant organs are removed and the incisions are sewn up carefully. The sutures and dressings are almost the same as those done on living patients, and provide minimal deformity. The patient is cleaned up and covered with a sheet, and then treated as respectfully as any other patient who dies in hospital.
The theatre staff and the assistant (me) return home after a long night, usually meeting early morning traffic on the way. I got a speeding ticket in the middle of the night more than once. The surgeons take the organs to their new homes, and often can’t resist hanging around to watch the marathon implantation.
Why I am a registered organ donor
Transplant surgeons care about donors. Staff respect them, and the decision they have made. Their job in this case is to implement the wishes of the donor and not waste their sacrifice. I have dissected a human cadaver in medical school and that is why I don’t want to donate my body for dissection. I have assisted at an organ retrieval for transplant, and that is why I am on the Organ Donor Register.
Photo credit: madaise via Flicker
Very nicely written, Dr Cris. I still remember the ones I helped with as a general surgery resident. I too have signed my driver’s license to be an organ donor.
Excellent review of the complications and implications of dealing with the difficult to broach subject of organ donation. Hopefully more poignant writing like this will encourage empathy and sympathy to overtake apathy when physicians are providing information on organ donation to distressed relatives.
Thank you DrCris
@sandnsurf
Excellent post! My father is a liver transplant recipient, so all of this is somewhat personal for me. I knew beforehand that harvesting was done in similar conditions, because after all, the organs are going to their recipients–can’t have slip-shod work–but this is the second time I’ve read (having never seen one) that the closure was done in similar fashion as well. However, when one really thinks about it, I don’t know of any surgeon who would just “turn it off” and say “screw it” and allow for less-than-professional diligence on whatever they were working on, regardless; if it’s worth scrubbing up, it’s worth doing your best.
I did not know that harvesting was done on ice, though. That’s a new one–wow. Great job again!
@enrico, @sandnsurf, @rlbates: Thanks for your comments. I know this is a really special thing to have been involved in (and probably the only opportunity I will ever have to fly on a private jet to Darwin and back). It is too easy to think of it as mutilation, especially when you are distressed. When unsure, then say no, right? In this case, I reckon that is pretty dangerous.
@enrico: I never realised you have such a close association with transplantation. I know a few recipients (including one double recipient), as we have had some do research here. It is certainly a long road for recipients, but they get so much value. I think the families of donors get neglected a bit – they are expected to stand by this tough decision, and cope with an often traumatic death at the same time. I’m glad I could be involved.
Great post!
As an Anaesthetic Registrar up in Darwin I took part in two organ retrievals. I was very impressed with the care and dedication of the surgeons – not just regarding technical aspects or organ retrieval, but also to the concerns of the donor and recipients. The main hitch was usually providing enough ice!
I remember a chap who tragically committed suicide by shooting himself in the head. The first thing his family said when they were told he was brain dead was, “he’d want to be a donor”. It really was the only good thing that could come out of such a horrendous waste of a man’s life – the silver lining on a dark, dark cloud. To later hear how the lives of five other people were transformed was deeply moving. I could only think of the donor’s family and the small comfort it must give them.
Please, everyone, support organ donation.
@precordialthump: Thanks for sharing. I don’t get to meet the families so much, as the surgeon for the donor, and it is really nice to hear those sort of stories. I guess the only things we get to hear about donor families is when there is a problem or conflict. Or on the news, I suppose. It is great to hear people are wanting to participate in transplantation.
Very nice post! I’m an organ donor myself and try to encourage others to become donors as well.
I’m actually filming a liver transplant in Jan/Feb. Really looking forward to it!
Really well written and interesting! I have my final placement in a multi-organ transplant unit and its really interesting to hear where they really come from. Transplant can be a very challenging, both ethically and complexity of practice, area to work in, but it is also extremely rewarding.
Thanks for sharing your experience and promoting organ donation.
@rdjfraser
@Robert Fraser RN(c), @SterileEye: Glad you like the post.
[…] Organ Donation from the Inside […]
[…] I need to find a way to reassure my sister that we don’t “butcher” the body when donor organs are harvested. I need to get her to read Dr Cris’ blog post “Organ Donation from the Inside” […]