Organ transplants are a brutal business

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Organ transplants are a brutal business

 

http://www.wired.com/wired/archive/11.03/parts.html Stripped for Parts Organ transplants are a brutal business. Just ask the donors. Our reporter spends a dark night with the living dead.

By Jennifer Kahn

 

The television in the dead man's room stays on all night. Right now the program is Shipmates, a reality-dating drama that's barely audible over the hiss of the ventilator. It's 4 am, and I've been here for six hours, sitting in the corner while three nurses fuss intermittently over a set of intravenous drips. They're worried about the dead man's health.

 

To me, he looks fine. His face is slack but flush, he breathes steadily, and his heart beats like a clock, despite the fact that his lungs have recently begun to leak fluid. The nurses roll the body from side to side periodically so that the liquid doesn't pool. At one point, a white plastic vest designed to clear the lungs inflates and begins to vibrate violently - as if some invisible person has seized the dead man by the shoulders and is trying to shake him awake. The rest of the time, the nurses consult monitors and watch for signs of cardiac arrest. When someone scratches the bottom of the dead man's foot, it twitches.

 

Mike Lorrig Organs stored in chemicals or on ice last only a matter of hours. The far more desirable container: a brain-dead body. None of this is what I expected from an organ transplant. When I arrived last night at this Northern California hospital I was prepared to see a fast-paced surgery culminating in renewal: the mortally ill patient restored to glorious health. In all my preliminary research on transplants, the dead man was rarely mentioned. Even doctors I spoke with avoided the subject, and popular accounts I came across ducked the matter of provenance altogether. In the movies, for instance, surgeons tended to say it would take time to "find" a heart - as though one had been hidden behind a tree or misplaced along with the car keys. Insofar as corpses came up, it was only in anxious reference to the would-be recipient whose time was running out.

 

In the dead man's room, a different calculus is unfolding. Here the organ is the patient, and the patient a mere container, the safest place to store body parts until surgeons are ready to use them. It can be more than a day from the time a donor dies until his organs are harvested - the surgery alone takes hours, not to mention the time needed to do blood tests, match tissue, and fly in special surgical teams for the evisceration. And yet, a heart lasts at most six hours outside the body, even after it has been kneaded, flushed with preservatives, and packed in a cooler. Organs left on ice too long tend to perform poorly in their new environment, and doctors are picky about which viscera they're willing to work with. Even an ailing cadaver is a better container than a cooler.

 

These conditions create a strange medical specialty. Rather than extracting this man's vitals right away, the hospital contacts the California Transplant Donor Network, which dispatches a procurement team to begin "donor maintenance": the process of artificially supporting a dead body until recipients are ready. When the parathyroid gland stops regulating calcium, key to keeping the heart pumping, the team sends the proper amount down an intravenous drip. When blood pressure drops, they add vasoconstrictors, which contract the blood vessels. Normally the brain would compensate for a decrease in blood pressure, but with it out of commission, the three-nurse procurement team must take over.

 

In this case, the eroding balance will have to be sustained for almost 24 hours. The goal is to fool the body into believing that it's alive and well, even as everything is falling apart. As one crew member concedes, "It's unbelievable that all this stuff is being done to a dead person."

 

Unbelievable and, to me, somehow barbaric. Sustaining a dead body until its organs can be harvested is a tricky process requiring the latest in medical technology. But it's also a distinct anachronism in an era when medicine is becoming less and less invasive. Fixing blocked coronary arteries, which not long ago required prying a patient's chest open with a saw and spreader, can now be accomplished with a tiny stent delivered to the heart on a slender wire threaded up the leg. Exploratory surgery has given way to robot cameras and high-resolution imaging. Already, we are eyeing the tantalizing summit of gene therapy, where diseases are cured even before they do damage. Compared with such microscale cures, transplants - which consist of salvaging entire organs from a heart-beating cadaver and sewing them into a different body - seem crudely mechanical, even medieval.

 

"To let an organ reach a state where the only solution is to cut it out is not progress; it's a failure of medicine," says pathologist Neil Theise of NYU. Theise, who was the first researcher to demonstrate that stem cells can become liver cells in humans, argues that the future of transplantation lies in regeneration. Within five years, he estimates, we'll be able to instruct the body to send stem cells to the liver from the store that exists in bone marrow, hopefully countering the effects of a disease like hepatitis A or B and letting the body heal itself. And numerous researchers are forging similar paths. One outspoken surgeon, Richard Satava from the University of Washington, says that medicine is only now catching on to the fundamental lesson of modern industry, which is that when our car alternator breaks, we get a brand new one. Transplantation, he argues, is a dying art.

 

Few researchers predict that human-harvested organs will become obsolete anytime soon, however; one cardiovascular pathologist, Charles Murry, says we'll still be using them a century from now. But it's reasonable to expect - and hope for - an alternative. "I don't think anybody enjoys recovering organs," Murry says frankly. "You tell yourself it's for a good cause, which it is, a very good cause, but you're still butchering a human."

 

Intensive care is not a good place to spend the evening. Tonight, the ward has perhaps 12 patients, including a woman who moans constantly and a deathly pale man who reportedly jumped out the window of a moving Greyhound bus. The absence of clocks and the always-on lights create a casino-like timelessness. In the staff lounge, which smells of stale pizza, a lone nurse corners me and describes watching a man bleed to death ("He was conscious. He knew what was happening"), and announces, sotto voce, that she knows of South American organ brokers who charge $60,000 for a heart, then swap it for a baboon's.

 

Although I don't admit it to the procurement team, I've grown attached to the dead man. There's something vulnerable about his rumpled hair and middle-aged body, naked save a waist-high sheet. Under the hospital lights, everything is exposed: the muscular arms gone flabby above the elbow; the legs, wiry and lean, foreshortened under a powerful torso. It's the body of a man in his fifties, simultaneously bullish and elfin. One foot, the right, peeps out from the sheet, and for a brief moment I want to hold it and rub the toes that must be cold - a hopeless gesture of consolation.

 

Organ support is about staving off entropy. In the moments after death, a cascade of changes sweeps over the body. Potassium diminishes and salt accumulates, drawing fluid into cells. Sugar builds up in the blood. With the pituitary system offline, the heart fills with lactic acid like the muscles of an exhausted runner. Free radicals circulate unchecked and disrupt other cells, in effect causing the body to rust. The process quickly becomes irreversible. As cell membranes grow porous, a "death gene" is activated and damaged cells begin to self-destruct. All this happens in minutes.

 

When transplant activists talk about an organ shortage, it's usually to lament how few people are willing to donate. This is a valid worry, but it eclipses an important point, which is that the window for retrieving a viable organ is staggeringly small. Because of how fast the body degrades once the heart stops, there's no way to recover an organ from someone who dies at home, in a car, in an ambulance, or even while on the operating table. In fact, the only situation that really lends itself to harvest is brain death, which means finding an otherwise healthy patient whose brain activity has ceased but whose heart continues to beat - right up until the moment it's taken out. In short, victims of stroke or severe head injury. These cases are so rare (approximately 0.5 percent of all deaths in the US) that even if everybody in America were to become a donor, they wouldn't clear the organ wait lists.

 

This is partly a scientific problem. Cell death remains poorly understood, and for years now, cadaveric transplants have lingered on a research plateau. While immunosuppressants have improved incrementally, transplants proceed much as they did 20 years ago. Compared with a field like psychopharmacology, the procedure has come to a near-standstill.

 

But there are cultural factors as well. Medicine has always reserved its glory for the living. Even among transplant surgeons, a hierarchy exists: Those who put organs into living patients have a higher status than those who extract them from the dead. One anesthesiologist confesses that his peers don't like to work on cadaveric organ recoveries. (Even brain-dead bodies require sedation, since spinal reflexes can make a corpse "buck" in surgery.) "You spend all this time monitoring the heartbeat, the blood pressure," the anesthesiologist explains. "To just turn everything off when you're done and walk out. It's bizarre."

 

Although the procurement team will stay up all night, I break at 4:30 am for a two-hour nap on an empty bed in the ICU. The nurse removes a wrinkled top sheet but leaves the bottom one. Doctors sleep like this all the time, I know, catnapping on gurneys, but I can't shake the feeling of climbing onto my deathbed. The room is identical to the one I've been sitting in for the past eight hours, and I'd prefer to sleep almost anywhere else - in the nurses lounge or even on the small outside balcony. Instead, I lie down in my clothes and pull the sheet up under my arms.

 

For a while I read a magazine, then finally close my eyes, hoping I won't dream.

 

By morning, little seems to have changed, except that the commotion of chest X rays and ultrasounds has left the dead man's hair more mussed. On both sides of his bed, vital stats scroll across screens: oxygen ratios, pulse, blood volumes.

 

All of this vigilance is good, of course: After all, transplants save lives. Every year, thousands of people who would otherwise die survive with organs from brain-dead donors; sometimes, doctors say, a patient's color will visibly change on the operating table once a newly attached liver begins to work. Still - and with the possible exception of kidneys - transplants have never quite lived up to their initial promise. In the early 1970s, few who received new organs lasted even a year, and most died within weeks. Even today, 22 percent of heart recipients die in less than four years, and 12 percent reject a new heart within the first few months. Those who survive are usually consigned to a lifetime regime of costly immunosuppressive drugs, some with debilitating side effects (see "Another Man's Poison"). Recipients of artificial hearts traditionally fare the worst, alongside those who receive transplants from animals. Under the circumstances, it took a weird kind of perseverance for doctors operating in 1984 to suggest sewing a walnut-sized baboon heart into a human baby. And there was grief, if not surprise, when the patient died of a morbid immune reaction just 21 days later.

 

By the time we head into surgery, the patient has been dead for more than 24 hours, but he still looks pink and healthy. In the operating room, all the intravenous drips are still flowing, convincing the body that everything's fine even as it's cleaved in half.

 

Although multiorgan transfer can involve as many as five teams in the OR at once, this time there is only one: a four-man surgical unit from Southern California. They've flown in to retrieve the liver, but because teams sometimes swap favors, they'll also remove the kidneys for a group of doctors elsewhere - saving them a last-minute, late-night flight. One of the doctors has brought a footstool for me to stand on at the head of the operating table, so that I can see over the sheet that hangs between the patient's head and body. I've been warned that the room will smell bad during the "opening," like flesh and burning bone - an odor that has something in common with a dentist's drill. Behind me, the anesthesiologist checks the dead man's mask and confirms that he's sedated. The surgery will take four hours, and the doctors have arranged for the score of Game Five of the World Series to be phoned in at intervals.

 

I've heard that transplant doctors are the endurance athletes of medicine, and the longer I stand on the stool, the better I understand the comparison. Below me, the rib cage has been split, and I can see the heart, strangely yellow, beating inside a cave of red muscle. It doesn't beat forward, as I expect, but knocks anxiously back and forth like a small animal trapped in a cage. Farther down, the doctors rummage under the slough of intestines as though through a poorly organized toolbox. When I tell the anesthesiologist that the heart is beautiful, he says that livers are the transplants to watch. "Hearts are slash and burn," he shrugs, adjusting a dial. "No finesse."

 

Two hours pass, and the surgeons make progress. Despite the procurement team's best efforts, however, most of the organs have already been lost. The pancreas was deemed too old before surgery. One lung was bad at the outset, and the other turned out to be too big for the only matching recipients - a short list given the donor's rare blood type. At 7 this morning, the heart went bust after someone at the receiving hospital suggested a shot of thyroid hormone, shown in some studies to stimulate contractions - but even before then, the surgeon had had second thoughts. A 54-year-old heart can't travel far - and this one was already questionable - but the hospital may have thought this would improve its chances. Instead, the dead man's pulse shot to 140, and his blood began circulating so fast it nearly ruptured his arteries. Now the heart will go to Cryolife, a biosupply company that irradiates and freeze-dries the valves, then packages them for sale to hospitals in screw-top jars. The kidneys have remained healthy enough to be passed on - one to a man who will soon be in line for a pancreas, the other to a 42-year-old woman.

 

Both kidneys have been packed off in quart-sized plastic jars. Originally, the liver was going to a nearby hospital, but an ultrasound suggested it was hyperechoic, or fatty. On the second pass, it was accepted by a doctor in Southern California and ensconced in a bag of icy slurry.

 

The liver is enormous - it looks like a polished stone, flat and purplish - and with it gone, the body seems eerily empty, although the heart continues to beat. Watching this pumping vessel makes me oddly anxious. It's sped up slightly, as though sensing what will happen next. Below me, the man's face is still flushed. He's the one I wish would survive, I realize, even though there was never any chance of that. Meanwhile, the head surgeon has walked away. He's busy examining the liver and relaying a description over the phone to the doctor who will perform the attachment. Almost unnoticed, an aide clamps the arteries above and below the heart, and cuts. The patient's face doesn't move, but its pinkness drains to a waxy yellow. After 24 hours, the dead man finally looks dead.

 

Once all the organs are out, the tempo picks up in the operating room. The heart is packed in a cardboard box also loaded with the kidneys, which are traveling by Learjet to a city a few hundred miles away. Someday, I'm convinced, transporting organs in coolers will seem as strange and outdated as putting a patient in an iron lung. In the meantime, transplants will survive: a vehicle, like the dead man, to get us to a better place. As an assistant closes, sewing up the body so that it will be ready for its funeral, I get on the plane with the heart and the kidneys. They've become a strange, unhealthy orange in their little jars. But no one else seems worried. "A kidney almost always perks up," someone tells me, "once we get it in a happier environment.