How to Do a Liver Transplant (12 page)

It is a misconception that anyone who dies can donate their organs. You actually have to expire in a very special way. The brain has to die before the body in a process called, funnily enough, ‘brain death'. The patient must also die either in the hospital whilst on a breathing machine or on the way to the hospital whilst oxygen is being given and the heart is still beating. It is not possible to use the organs of someone who is found stone cold dead on the floor at home. Brain death means that the part of the brain that controls breathing must be so severely injured that there is no hope of recovery. This can occur after a stroke or a head injury caused by an accident, murder or suicide. Amazingly, as long as it has oxygen, the heart will continue pumping independent of the brain, beating under the steam of its own primitive electrical impulses. The problem is, however, that the brain controls breathing. If the damage is bad enough, the brain will halt the drive to breathe and brain dead people become completely
dependent on a ventilating machine to take over this function. Within a few moments of turning the machine off, the breathing stops, the heart will become deprived of oxygen and a few minutes later it will stop beating. Almost straight away, every organ in the body begins to die; blood clots form in the tiny veins, cells burst and spew out their toxic contents. Bacteria move in and within a few minutes the body starts to rot. When you are doing a donor, the smell of decay appears pretty quickly.

Many people have told me that, ‘I'm not going to donate my organs because I'm worried that I might not really be dead.' Trust me, testing for brain death is taken very seriously and there are multiple checks and balances to ensure you really are dead. If a patient does not pass any one of these tests, they are not brain dead and donation cannot occur. This is rock solid and is the cornerstone of donation.

Aside from the requirement to be brain dead, the number of dead people suitable to donate dwindles again because there are lots of characteristics that make people's organs instantly unsuitable for transplanting. Donors over 65 years of age are often not optimal because – well, they are just too old. Old organs have endured the rigours of a long life and definitely have a ‘best before' date. They don't work as well, especially when transplanted into a very sick patient. Recently, I was standing in the queue at the driver's licence office. The couple ahead of me
were well into their 80s and both in wheelchairs. They were having a spirited argument over whether or not they should check the organ donation box on their licence application. It took all my willpower not to lean over and whisper that it would be OK if they gave it a miss. Some other donors have HIV or hepatitis B or C and are usually not suitable unless the recipient has the same virus. Just like a blood transfusion, these viruses are transplanted right along with the liver.

The organs of alcoholics, smokers or the obese can be unsuitable too because of the ravages of these abuses. Some people are too overweight to donate because fat in the liver means that it won't work very well. People who have died of undiagnosed infections cannot be donors and, finally, any patient who has had cancer is usually unsuitable for transplant. There have been cases of recipients inadvertently receiving organs with cancer cells in them and quickly meeting the same fate as the donor after the transplant. All of these factors can make the total number of dead people who can donate very small indeed, because it is quite unlikely that young, healthy, non-drug-taking thin people will die.

For the relatives keeping vigil at a beloved family member's bedside, making the decision to donate must be agonising. Aside from a breathing tube in the mouth, brain dead people appear to be simply asleep. They are warm, their heart is beating and their chest will rise and fall. They
look peaceful and I trust they are. I'm sure that the families who are lovingly holding their hands and stroking their hair must hope that the doctors are wrong and that their eyes might suddenly flutter open. It is not possible for me to comprehend how a family makes a decision to donate at such a time. I'm sure that there is some comfort if the family knows that organ donation was something that the patient wanted to do if the unthinkable happened. Maybe the idea that a little part of their relative will live on in someone else is a big motivation. Their grief is difficult to watch and I think these families are very brave.

Once a family gives the go-ahead to donate their loved one's organs, the Intensive Care doctor calls the organ donation agency. In the United States this is the United Network for Organ Sharing (UNOS) and in Australia it is Donate Life. In the US, this organisation is run by a board alongside the federal government and is completely separate from the transplant hospital. This is of key importance as it means that no transplant surgeon can ever be involved in decisions about which patients should be donors. Within UNOS there are ten Organ Procurement Organisations (OPOs) covering the 50 States whose job it is to distribute organs via a central computer system. When an Intensive Care Unit notifies the OPO there is a brain dead patient, a nurse from the OPO is immediately dispatched to that hospital. These specially trained nurses talk to the family and check the entire medical history of the donor. If it all
looks good, the OPO nurse offers the heart, lungs, liver, kidneys, bones, pancreas, eyes and small bowel, frequently to many different transplant units. In the US, all patients listed for transplant are entered into a central database. When a donor becomes available, their vital numbers are also entered and a list of suitable recipients in the local area is produced. The transplant surgeon representing that patient is called and informed about the offer. That surgeon may accept or refuse that organ for that patient based on many medical factors – for example, the top listed patient may have an infection and not be well enough to have a transplant. If the local unit does not want to use the organ for that patient, then it is offered on to the next hospital in the area with a suitable patient and so on. Literally dozens of telephone calls are made and each donor offer can result in 12 to 24 hours of work even before the donation operation commences.

Each organ has a slightly different procedure for matching to a recipient. For livers, it is surprisingly easy. All you need is the same blood type and a reasonable size match and that's it. It is difficult to put a big liver into a small person because it simply will not fit. Conversely, you cannot transplant the liver of a 55-kilogram woman into a 105-kilogram man – there may not be enough liver for him to survive. The only time we go outside of size criteria is for children. In order to fit, a smaller piece must be cut from a whole adult liver. The other neat thing we
can do to make a rare resource stretch further is slice a liver in half in a type of two-for-one deal. This way, both an adult and child can be transplanted from one liver. This can't be done with all donated livers, though, and for this technique to work well, only perfect livers from fit young donors will do.

The matching process for hearts and lungs is also pretty simple. Again they are allocated according to blood type and size. Only a certain sized organ can fit inside the fixed cavity of a person's chest. Kidney matching is slightly different and more complex. Because there are two kidneys in each donor, two patients can be given the opportunity to get off dialysis. Every person who is waiting for a kidney transplant in the United States has their blood tested for a variety of special characteristics. This information is stored in the computer. When a donor kidney becomes available, it is tested for the same characteristics. This individual combination is then matched against the recipient database and occasionally a perfect match comes up. This is a little like winning the lottery for the recipient because the match makes the risk of rejection lower. The matching kidney is packed up and flown to wherever that recipient is in the country. To keep things fair, the next time there is a kidney in the state receiving a perfectly matched one, that organ is ‘paid back' to the state that lost the kidney. A bit like, ‘I'll give you one of mine, if you give me one of yours.' If there is no perfect match for a kidney in the whole of the
country, the kidneys go to the next closest match in the donor's home region.

In Denver, it was my job to retrieve organs from hospitals throughout the States of Colorado and Wyoming to the north. Ideally, a liver needs to be transplanted within eight to 12 hours of it coming out of the donor and a kidney is best put in within 24 hours. Any longer than this and the organs do not work very well, so it is very important to have a reliable means of transport to get back as quickly as possible with our precious cargo. For donors in town, we circumvented Denver's often horrendous traffic by travelling in a forbidding black Lincoln town car resplendent with sirens, lights, tinted windows and the words organ transplant team emblazoned down the side. Our driver would give us a white-knuckled ride with sirens blaring as he flew across intersections and weaved through traffic. I would remind him that we didn't have to go so fast – the patient we were going to be operating on was already dead and we didn't want to join them.

But the enduring image of organ donation seems to be of teams of surgeons flying all over the countryside toting their organs in beer coolers. I frequently had to climb aboard a plane and fly to all manner of tiny hospitals deep in the heart of the Rocky Mountains. Medical students always get very excited when they get the opportunity to go on one of these flying retrievals. They tell me how glamorous it all is. I suppose it is for about a minute (take-off
is pretty cool) until reality soon sets in and you realise you will be awake all night, be absolutely starving, dirty with sweat and blood, with the smell of a dead person lingering in your nostrils. Doing donors in Colorado meant that I would miss a night of sleep every three days. It was gruelling work. Because most donors happened after midnight, I would try and get a few hours' sleep before heading off to the airport. While this ‘power nap' always sounded good in theory, it was incredibly difficult to nod off because of the anticipation of being up and working all night. My mind would race, thinking about how on earth I would pay back my sleep deficit and still fit in everything else I had to do the following day.

My initial encounter with donor surgery in Denver was of course on my first night on the job. I was attending the annual transplant ‘Cook Out', a team-building event held for the staff in the transplant unit. Vast quantities of seafood, steak and corn on the cob were roasted on an open fire and consumed with lashings of melted butter. As often happens at these events when everyone is enjoying themselves, a telephone call came in saying that there was a donor. Someone had died of a brain haemorrhage in a hospital on the other side of the Rocky Mountains, so a trip in the Learjet was required. Because it would be my
first donor in America and the first time the bosses would have an opportunity to see my work, one of them had to accompany me. They drew straws and the lucky recipient of the short one and I reluctantly left the party early to get a few hours' sleep before we had to fly.

Unfortunately for my boss, as well as having the task of taking a donor novice through what is a complex operation, he also developed a dose of gastroenteritis that night. He spent those few hours before we left suffering violent vomiting and diarrhoea and, by the time we boarded the jet, he was not in top form. He sat slumped in the back of the plane wearing dark glasses and looking as though he might throw up at any moment. One of the donor nurses suggested that we should give him a litre of intravenous fluid to freshen him up. This is a pretty common remedy for gastro amongst doctors and considering I was eager for him to feel well enough to help me get through my first donor, I was right on board with the idea. It was decided by everyone that a great preliminary test of my abilities would be to see whether or not I could put an intravenous (IV) line in my new boss during take-off. As the plane lifted off, I plunged the needle into his arm. The blood flashed back and I slid the slender plastic tubing into his vein. Thankfully I didn't miss or I may have been out of a job in the first week. I set up the IV and ran the restorative fluid through. It was just the ticket to revive him for a few hours and we
had a very successful trip. I was a little worried about the possible implications of operating with a supervisor who looked to be in worse shape than some of the patients, but it then occurred to me that the patient we were going to operate on was already dead, so it probably didn't matter all that much.

Our jet flew out of a small commercial airfield called Centenary. Contrary to what most people think, our aircraft was not like a ‘rock star' jet with cute flight attendants, delicious food and in-flight movies. It was a tiny speck of a thing with five passenger seats and two pilots sitting elbow to elbow up front. There was no standing room and no toilet. Our identification was always checked by the pilots prior to boarding. This was post-9/11 America and security was tight, even on small private planes. The year before I arrived, the Denver donor team was the first plane allowed back in the sky after the total flight ban of September 11. They had a fighter jet escort so they weren't inadvertently shot down by a twitchy US military.