| The Nasty Side of Organ Transplanting Second Edition Norm Barber Copyright Chapter 6 Aggressive Hospital Harvest Teams Most people have a cosy view of doctors and nurses warmly cooperating with each other to save lives. But reality is much different. Hospitals are stressful places for everyone and workers frequently end their shifts exhausted and disturbed. Doctors have higher than average levels of suicide and drug addiction. Many have worked and studied and been deprived of comforts to finish their education. They are dedicated and ambitious to gain new skills and invent new surgical and treatment procedures. Transplant technology has the mystical lure for doctors of becoming rich, famous and respected like Christiaan Barnard, Denton Cooley and Norman Shumway. There is also the unspoken aim of transplant technology which is eternal life. The transplant industry puts ferocious pressure on governments to increase organ supply so they can make more “heroic” attempts to do the impossible. When a brain-injured organ donor patient arrives it isn’t just a million dollars worth of surgical activity at stake it is the reputations and life dreams of men and women who seek victory for the sake of themselves and their patients. From this boiler room of adrenaline and hyperactivity the declaration of patient brain death is like the firing of the starter gun at the Olympic one hundred-metre race. The aggression temperature rises in this boiler room when two medical ideologies meet. Hindering the transplant faction’s goals are those tending the brain-injured patients who try every desperate attempt to maintain life, occasionally beyond the dignity of the patient and financial capacity of the hospital. They are motivated by similar drives as the transplanters, that of pride, ambition and compassion. They hold an allegiance to the Hippocratic oath of maintaining life and doing no harm to the patient even when this patient is in the process of dying. They wish to see apparently terminally injured patients walk out of the hospital. These professionals, often neurologists and neuro-surgeons, are the impediments to transplant surgeons desperately pushing for an early diagnosis of brain death and subsequent rush to the harvest table. Other enemies of those trying to maintain recuperative treatment for the potential donors are the transplant coordinators. They face similar pressures to obtain unquestioning consent from relatives and deliver what they call, “heart-beating cadavers” to the surgeons. They have the creepy task of looking through patient files to identify brain-injured patients, peeking through one-way mirrors at grieving families in the waiting room, and then meeting among themselves to decide who has the best chance of obtaining consent. One is chosen. It is crucial for that person’s career to obtain consent. The coordinator faces similar pressure to football players who need to score a goal in every game or are relegated to the minor league. Coordinators operate under similar motivations of pride, compassion, ambition and a basic desire to stay employed. The coordinator will push the relatives as hard as possible until there is outright anger and aggression or until other hospital staff discreetly intervene with coffee or by telling the coordinator to piss off. Doctors treating brain-injured patients face increasing pressure to declare their patients brain dead earlier and earlier. This is due to improving transplant technology, the rush of aging patients, little increase in donor numbers and financial reasons. Most transplants in Australia and other countries are corneal and kidney. Some governments openly float the view that kidney transplants are cheaper than dialysis this being an impetus for their performance. A year on dialysis costs nearly as much as a kidney transplant that should last seven years. Another more popular view is that a successful kidney transplant improves quality of life though it may shorten that life if surgery goes wrong or the patient dies early from immune-deficiency caused diseases. The cost of caring for sight-impaired or blind old people is another impetus for increased and earlier brain death diagnosis of potential donors. A cornea is cost effective when it improves the sight of a blind or partially blind senior citizen who might otherwise require continuous and expensive care. And accountants, and no one else, will see the financial benefit of the old person dying during or after cornea or kidney transplant surgery. Transplant coordinators are under pressure to pursue government objectives which are to reduce public medical costs by increasing harvest and transplant rates. Doctor Richard Nilges, Emeritus Attending Staff in Neurosurgery of the Swedish Covenant Hospital, Chicago, Illinois, USA recounts being pressured to declare patients dead for organ removal who later walked out of the hospital. "Committed as I was to the seriously injured or very sick patient under my care, whether he or she was brain dead or not, I had to literally fight off the transplant teams. One case I recall was when the transplant team was called to our community hospital without my knowledge and before I was ready to declare brain death on an unconscious patient who had a severe head injury in a motorbike accident. He had reflex extension of his arms and legs on painful stimulation. He was, therefore, not unresponsive even though his movements were no longer under the control of his will. His pupils reacted sluggishly to light. He had none of the criteria of brain death (except unresponsiveness). I rather too abruptly dismissed the transplant coordinator and his "team". I continued to treat this young man’s brain swelling. He walked out of the hospital and returned to college" 31 Same Day Harvesting and Aggressive Transplant Teams Treating doctors previously had a minimum of forty-eight hours to treat the patient prior to brain death tests. This gave relatives time to discuss the issue of consent with religious guides and extended family. It also gave time to perform repeated safe electroencephalograph tests for brain life and allow time for a possible positive change in the patient’s condition. Now in the era of Day Surgery when patients don’t even spend one night in hospital we have Same Day Harvesting. Half of all Australian donor patients are declared brain dead within 33 hours of entering hospital. 69% are harvested within 12 hours of brain death diagnosis and 98% within 24 hours. Queensland is the quickest to harvest incoming donors. It is possible to be harvested within 24 hours of being injured or suffering a stroke. Now that is fast service. 32 Treating doctors around the world are reporting increased pressure to declare brain death before adequate periods of observation, treatment and self-recovery. Harvesters demand doctors administer drugs and prepare organs for harvesting despite this accelerating brain damage. This changed priority from treatment to harvesting shows that the fear recuperative treatment may be reduced for prospective donors is not a suburban myth. Dr Richard G. Nilges, the retired Chicago neurosurgeon recounts more of his experiences. "With patients closer to brain death, the struggle was even more agonizing. The transplant team would be present in full panoply. The coordinator would object to my policy of two flat EEGs separated by 24 hours. I repeat his demand as I recorded it in a newspaper article: "Dr Nilges, you don’t need another electroencephalogram tomorrow. Today’s is flat. Declare death today". Of course, I did not declare death that day." 33 Dr Nilges reports pressure to preserve the organs for transplant at the expense of the patient, "I grew weary of being at loggerheads with the demands of the transplanters when their demands were contrary to the interests of my patients. To preserve a suitable kidney for transplantation, transplant technicians would demand that I order what I would judge to be an intravenous fluid overload. I would refuse patiently and sometimes impatiently, explaining that too much fluid would cause more swelling of the already injured brain and might cause my patient’s brain to die sooner. My commitment was to my patient, not to a faceless "society," to the next unknown (to me) patient on a waiting list. 34 The pressure to prematurely declare patients brain dead isn’t limited to United States and Australia. Dr Yoshio Watanabe, a cardiologist at the Chiba Tokushu-kai Hospital in Funabashi, Japan reports that, "…a 40-year old crime victim with a head injury was brought to the emergency room of Osaka University Hospital in August 1990, the team of physicians apparently looked at him as a potential kidney donor from the outset. Thus, as early as three days before the first diagnostic tests for brain death were made, they had started a set of new regimes (a combination of anti-diuretic hormone that reduces the urine volume, drugs that elevate blood pressure, and a drip infusion of a large amount of fluid) developed by this group, which is considered very effective in keeping transplantable organs fresh and viable. It would, however aggravate brain oedema, increase intracranial pressure, and accelerate the process of brain death. Without telling this fact to the victim’s wife and by using words of threat, they persuaded her (in a manner far from an informed consent) to donate his kidneys.35 The above example was in 1990 but things haven’t changed. Dr Watanabe reports on one of only four brain dead donors in Japan in a six-month period of 1999, "…a middle-aged female with a subarachnoid (and perhaps cerebral) haemorrhage. When she was brought to Kochi Red Cross Hospital, the physicians failed to give certain important life-saving measures, including administration of drugs to lower her extremely high blood pressure. Instead, they immediately told her family that she was in the state of ""impending brain death"" and did not explain the possibility of surgical removal of intracranial hematoma. A clinical diagnosis of brain death was made 60 hours after admission, disregarding the fact that repeated Phenobarbital administration could have made an accurate evaluation of brain function difficult. Preparations for organ transplantation were expedited…" 36 Dr Watanabe reports that a subsequent review of the incident showed that repeated apnoea tests were done even before the electroencephalogram became flat. This is illegal in Japan but legal in Australia. The problem with the apnoea testing, as stated elsewhere in this book, is that it deprives the brain of oxygen and speeds up brain death. When it is done repeatedly one can suggest, perhaps reasonably, that it is being done to create brain death rather than test for it. 37 Harvest Time The rush to prepare the ex-patient and now brain dead cadaver for harvesting is interspersed with moments of silence. Hospital staff allow relatives to bid farewell to the cadaver or patient with the confusing status. It or he or she will be maintained on life-support, despite being called dead, until the harvest and transplant teams are assembled and compatible recipients located and brought to the hospital. Doctors may have injected 20,000 units of heparin to prevent blood clotting. They may also have preserved the organs by putting the patient or corpse on a high fluid drip and inject drugs to increase blood pressure. They should wait until brain death is declared at which time two catheters will be inserted into the abdominal aorta and femoral vessels to flush out the blood from the organs with a cold solution. Theoretically no preparations for transplant organ maintenance should happen before the final brain death diagnosis is given and relatives have consented to harvesting. The anaesthetist paralyses the donor body to prevent pain or panic reaction to being cut apart. While not routinely done anaesthetic may be administered to stop possible pain and to soothe medical staff fears that they are hurting the donor. Heart and pulse rate monitors may be turned off so staff don’t see and hear the body’s reaction to being sliced open. Tubes and drips are inserted and pumps started. The surgeon slits open the donor’s chest then saws up the middle of the breastbone with an electric circular saw. The surgeon pulls apart each half of the ribcage to expose the viscera and inserts separators to keep the ribs apart. A nurse or assisting surgeon pours ice slush over the surface of the organs. Chilled organs last longer just like chilled meat. The heart is generally removed first with the lungs if both are going into the same recipient. Extracting just the heart requires two thoracic surgeons, an anaesthetist, two experienced nurses, one perfusionist and various stand-by staff and students. The donor’s real death is frequently determined when the aortic clamp is applied and the heart paralysed. After being cut out the heart is rinsed of blood, perfused in a cold preservative and put in a picnic cooler filled with ice and coolant and rushed to the recipient’s hospital. Heart and lungs go first since they last just six hours which can be difficult if there is a three-hour flight. Another process is by removing the heart in a block of crudely dissected and cooled tissue from which the wanted organs are carefully dissected outside of the body by the specialised teams of harvesters. Harvesting the donor’s liver is particularly difficult and often involves massive bleeding where the corpse requires blood transfusions to keep it alive, or viable, or whatever. The liver and pancreas may be removed together and taken to a table just behind the main donor table where they are separated for two different recipients or, if not donated or needed, either put back into the body, thrown away or used for research. Kidneys are removed last due to the anatomy of the body and because their Use-By date is anywhere from 24 to 72 hours. Transplanting surgeons may remove their particular organ and leave with the picnic cooler on a fast private jet, but usually there are separate harvesters and transplanters. The transplanters prefer to stay with the recipient and wait for delivery by road or aircraft. They may have lunch or sleep while awaiting the organ as transplanting can be a long, gruelling job requiring a high level of fitness while maintaining a subtle touch even whilst exhausted. The Less Than Desperate Organ Courier Most people have seen promotional images of harvest surgeons or nurses desperately rushing to an ambulance or aircraft to deliver the organ to a patient flickering on the edge of life and death. One can imagine the nurse sitting in a double seat of an aircraft carefully watching the temperature on an incredibly complex and expensive portable fridge. Actually, the organ, usually a kidney, is packed with ice and cooling liquid into what is called a picnic cooler or Esky. It resembles those six-dollar Styrofoam boxes used to transport broccoli sprinkled with ice to the morning markets. The organ is often sent by ordinary courier to the airport where another courier at the destination picks it up. Harvesters regularly send kidneys across the Nullabor Plain between the Royal Perth Hospital in Western Australia and the eastern states. On one occasion a World Courier (Australia) Pty Ltd courier put a Styrofoam box on the plane to Adelaide thinking it contained a kidney. It didn’t. He discovered the warm kidney in his van the next day after receiving an unpleasant phone call from the waiting hospital staff. The kidney was ruined. Peter Hornsey, the expectant recipient, was waiting in the Queen Elizabeth Hospital in Adelaide. Doctors had already inserted a catheter in his neck and doused him with anti-rejection drugs. Peter was somewhat disappointed to say the least. Doctors pulled the catheter from his neck vein, sewed up the wound, sent him back home and back onto the waiting list.38 Reasons for Not Using an Organ Organs are initially rejected if the donor is considered an infectious disease risk. This takes the form of infection discovered in the body or the hospital may have fears over the donor’s disease history including social history problems such as homosexuality, pituitary growth hormone injections, being a transplant recipient or from recently being a “working girl”. Further rejections may occur from receiving hospitals because of unusual physical characteristics of the organs, tumour presence, unforeseen damage during the event leading to brain death or by surgical error during harvest. Despite all the above organs are now being used in the United States from donors with a history of cancer. Acceptance of organs varies depending on the country. Australia prides itself with the world’s highest standards of infection control and won’t accept a range of body products from other places including Europe and the United Sates. Australia’s standards are uniform between states so an organ rejected in one hospital is likely to be rejected in another so after one rejection it is no longer considered. In the United States standards vary so greatly between states and hospitals that a rejection in one place may be acceptable to another. When an organ is rejected transplant coordinators phone the next waiting hospital, giving them one hour to accept or refuse. This continues until the organ is either accepted or passes the use-by date and is discarded or, theoretically, inserted back into the corpse for burial or cremation. Business is business in the United States and every organ is flogged until even the most desperate hospitals reject it. Use-By Times The Use-By time for hearts or heart/lung combinations is five or six hours. Lungs separately are six hours. Livers up to 34 hours. Pancreas up to 20 and kidneys up to 72 hours. Corneas last ten days and can be harvested twelve hours after cardiac death. The above figures are from the monograph, Using the Bodies of the Dead, by Swedish writer Nora Machado. In What Every Patient Needs To Know, published by the United Network for Organ Sharing (UNOS), the American organ allocation outfit, it is written that livers last up to12-24 hours, kidneys 48-72, pancreas 12-24 and hearts and lungs 4-6 depending on the quality of harvesting, state of organs and care of preserving and transport. The donors and recipients usually reside in the same city but organs and parts are flown to other cities and states. For example, South Australia doesn’t have a heart transplant unit so their hearts go to the larger states. When there is a particularly good tissue match or an acute patient is quickly dying an organ may go interstate despite qualifying recipient hopefuls waiting in the same hospital as the dying donor. Patients awaiting organs may also be left in the lurch if their state is an organ debtor to another and that state wants payment immediately. Skin and Bone Harvesting Following vital organ removal there is no longer any doubt the patient is really dead. A new group of dismantling surgeons then continue a bloodier and less delicate harvest. They come from the Skin and Bone Banks that rent hospital facilities but get the remains for free. The following is representative of United States harvesting which is the most extensive in the world. Some countries don’t allow commercial harvesting. The dismantler using a knife cuts the scalp at the back of the head from ear to ear then, in an effort which requires some strength, pulls it over the face so it fits inside out with the hair on the inside. He, and it is usually a man, saws off the top half of the skull with an electric saw making a notch at the back so when it is replaced for the funeral it won’t slip off and distress relatives. The skull top makes a slurping sound as the dismantler lifts it off. The harvester then removes the valuable Dura matter, the protective lining between the brain and skull. Depending on the wishes of the donor or relatives the top half of the skull may be replaced and the scalp and hair pulled back over to reveal the face. Otherwise jaw bones, inner ears and cartilage are removed making it impossible to display the face at the funeral unless covered with a mask resembling the face of the deceased. Harvesters dressed in rubber gloves, hats and aprons strip, peel and cut skin from arms, legs, front and back of the torso or anywhere. They pull out and wash the valuable major leg veins and the muscle covering called Fascia. Dismantlers and autopsy crews slice out soft, silky urological tissue and report that human muscle smells like lamb meat. They remove trachea cartilage, ligaments and tendons. A prized sack called the pericardium, similar to Dura Matter and surrounding the heart, is taken and sold for repair patches that are placed over the brain after surgery. Both fetch high prices though dura matter has been subject to prion disease scares. Pituitary glands are left untouched due to their somewhat mysterious and nasty history of transmitting the terminal Creutzfeldt-Jakob disease. Dozens of valuable bones including the femur, acetabulum (hip socket), hemi-pelvis, humerus, radius, ground humeral, tibia, ulna, osteochondral bone, and cranial plate are taken for what is euphemistically called recycling. Intestines are occasionally removed in the United States and other countries and transplanted, sometimes in combination with livers, but without great success. Intestines aren’t transplanted in Australia and rectums are not transplanted here or in the United States. Rectum cancer is a major killer in affluent societies but one can imagine the public relations disaster for the industry if a recipient experienced a Graft-Versus-Host reaction. It is the junior medical staff who clean the harvested intestines that smell like a combination of vomitus and faeces. They say the smell of gastric acid is unforgettable. You remember it to the day you die. Funerals More Expensive Open casket funerals can be a problem with so much of the donor corpse removed or damaged. Some bodies could more appropriately fit into a large bucket with a lid than a coffin. To create the image of a gently sleeping, fully intact donor morticians shove plastic piping up the cadaver’s spinal cavity, legs and arms to provide bulk where the bones previously resided. In Australia they do it cheaper. Simon McLeod, formerly of the Glebe Institute of Forensic Medicine, also known as the Sydney City Morgue, said they used a broom handle on an elderly lady after removing her whole spinal column. They also belted one murder victim with a hammer. He had a round fracture and staff suspected that he had been killed with a hammer. They wanted to see if the hammer wounds they inflicted were identical to those that killed him a few hours earlier. One can understand their rational. The Sydney City Morgue also allowed a plastic surgeon to sneak in, without the permission of relatives, and practice doing nose jobs on the corpses. Imagine what relatives at a funeral would think seeing the newly deceased with a different nose. Morticians plug the holes, fill the bodies with gel filler, tape and wrap the bodies and put them in a liquid and odour proof bag with just their faces and hands sticking out. Plenty of scarves, a favourite suit and, perhaps, sunglasses, will disguise the fact that the deceased has been partly skinned, de-gutted and deboned. Morticians are artists and the immense challenge of fixing up harvested bodies is matched by their prices. Neither the transplant industry nor governments recognise the extra costs of funerals for relatives of organ donors. |