Three Rivers

Expert Blog

11/16/09

The Luckiest Man
By: Jim Trisch, Director of Donation Services
In “The Luckiest Man,” a patient with ALS decides to terminate his life and become an organ donor. Is this possible? What is the difference between this type of donation after cardiac death and the other donors on Three Rivers who have been brain dead?

At OneLegacy we had the opportunity to work with a truly inspiring family of an ALS patient who self-designated as a donor. In our case a young lady at the last stages of her disease asked to be removed from her ventilator and give the gift of life, turning tragedy into triumph and saving three lives

WHAT IS ALS?
Amyotrophic lateral sclerosis (ALS), sometimes called Lou Gehrig's disease, is a rapidly progressive, invariably fatal neurological disease that attacks the nerve cells (neurons) responsible for controlling voluntary muscles. Eventually, all muscles under voluntary control are affected, and patients lose their strength and the ability to move their arms, legs, and body. Patients lose the ability to breathe on their own and must depend on ventilatory support for survival.

Because the disease usually does not affect cognitive abilities, patients are aware of their progressive loss of function and may become anxious and depressed. This information is provided by: http://www.ninds.nih.gov/disorders/amyotrophiclateralsclerosis/detail_amyotrophiclateralsclerosis.html

THE REAL-LIFE STORY

There are three major differences between the Three Rivers episode and the real-life story:

1. Victor, the ALS patient in the episode, removes the ventilator himself and was driving, speaking and moving. This would indicate that he was not in the last stages of his disease. To be considered for donation after cardiac death a patient would be unable to speak or move. OneLegacy would not consider a patient such as Victor as a potential donor.

2. Victor becomes a heart and lung donor but presently patients that are donors as a result of donation after cardiac death, or DCD, are primarily liver, kidney and tissue donors. Hearts, lungs, and pancreas are rarely recovered in donation after cardiac death; it is usually based on the circumstances of the patient’s death that make it difficult to transplant those organs. The story line also implies that while Victor was in surgery his heart was damaged and his lungs were failing, which was the primary reason he was placed on the ventilator. Since neither of these organs were functioning well, they are not medically suitable for transplantation.

3. Victor chooses who will receive his organs, giving them to transplant candidates he meets while he is at the Three Rivers hospital. There is a UNOS provision for directed donation which allows family members of a deceased donor to specify an individual to receive their loved ones organs. This provision is intended to allow donor families to give organs to friends and other family members. The recipient of directed organs must be listed for a transplant with UNOS and be a match in size and blood type to the donor.

In reality, Victor would have been overseen by the organ procurement organization, not the hospital or transplant center. That means his decision to donate would have been confidential and other patients or transplant surgeons at the hospital would not have known of his wishes. Patient confidentiality and equitable distribution of organs is vital to avoid the ethical and legal issues created by Victor’s decision to meet potential recipients before his donation.

WHAT IS DONATION AFTER CARDIAC DEATH?

As Three Rivers has shown consistently, the vast majority of organ donors come from patients who are brain dead. There is an excellent expert page about brain death listed below. In this episode we see another depiction of how a patient can become a donor.

In a return to where organ donation began 40 years ago, before the acceptance of brain death, some patients are becoming organ donors after cardiac death.

Typically when a person suffers a cardiac death, the heart stops beating. The vital organs quickly become unusable for transplantation. But their tissues – such as bone, skin, heart valves and corneas – can be donated within the first 24 hours of death.

Some people with non-survivable injuries to the brain never become brain dead because they retain some minor brain stem function. The option of donating organs after cardiac death may be presented to these families after the family decided to discontinue life support.

Donation in such cases entails taking the patient off the ventilator, typically in the operating room. Once the patient's heart stops beating, the physician declares the patient dead and organs can be removed. The physician that declares death is not involved in transplantation. The transplant team is not present during the death but come into the operating room for the recovery of organs after the patient has been declared dead.

Today, organ donation after cardiac death has increased the donation of life-saving organs – mostly kidneys and livers – by as much as 25 percent in areas of the country. Some experts estimate that it could increase the number of deceased-donor organs in the U.S. by thirty percent saving many lives for those awaiting a life saving organ transplant.

To answer any of your questions about organ and tissue donation, contact Donate Life America at 800-355-7427. To save lives as an organ and tissue donor, sign up today at www.donatelife.net

11/09/09

Where We Lie
Acetaminophen overdose -- anything more than the package-recommended 4 g/day -- has been associated with severe hepatic necrosis leading to acute liver failure. In fact, liver toxicity from acetaminophen poisoning is by far the most common cause of acute liver failure in the United States, researchers reported in a 2005 December issue of Hepatology.

Acetaminophen is the generic name of a drug found in many common brand name over the counter products such as Tylenol, as well as prescription products such as Vicodin and Percocet.

Acetaminophen is an important drug, and its effectiveness in relieving pain and fever is widely known. This drug is generally considered safe when used according to the directions on its labeling. But taking more than the recommended amount can cause liver damage, ranging from abnormalities in liver function blood tests, to acute liver failure, and even death.

In the Three Rivers episode Megan O’Hara had an injury and took several acetaminophen to deal with her injury. By taking too many she damaged her liver. Here’s why.

The liver is the primary site in the body where acetaminophen is metabolized. Liver damage from acetaminophen occurs when the glutathione pathway is overwhelmed by too much of acetaminophen's metabolite, NAPQI. Then, this toxic compound accumulates in the liver and causes the damage.

Here’s what you can do:
-Read the labels of the medication bottles carefully and determine the amount or strength of acetaminophen in each pill or spoonful.
-Become familiar with all of the other medications that you are taking. Remember that over 200 drugs contain acetaminophen as one of the ingredients and that certain drugs, such as phenobarbital, can significantly increase liver damage.
-Before you take the medication, write down (record) the maximum safe number of pills or spoonfuls that you can ingest over 24 hours. Stick to that quantity and do not deviate. If, however, you are unsure of the safe number of doses or think that you need to take more than you should, call your doctor or pharmacist.
-When you receive a prescription for a new medication, ask your doctor or pharmacist whether it affects the body's metabolism (processing) of the other medications that you are taking, including acetaminophen.
-If you have been drinking alcohol regularly, do not exceed taking 2 grams of acetaminophen over 24 hours. Be honest with yourself about the ingestion of alcohol.
-Record the number of pills or spoonfuls of acetaminophen and the time that you take them.

11/02/09

Alone Together
By: Dr. Linda Sher, Associate Professor, Clinical Surgery
USC Abdominal Organ Transplant Program
In the Three Rivers episode “Alone Together,” Rudy Boyle needs a liver transplant. Dr. Linda Sher discusses why patients may need a liver transplant, how candidates for transplant are prioritized on the national waiting list and what happens when an organ becomes available.

Liver transplantation is the surgical replacement of a diseased liver with a healthy liver. The indication for this operation is end-stage liver disease, characterized by patients suffering from reduced liver function, muscle loss, fatigue, encephalopathy, signs of portal hypertension, poor blood clotting, jaundice and primary liver cancer.
A variety of liver diseases can lead to end-stage liver disease. There are generally two main categories:
1. Liver disease that result from damage to the liver cells from various causes including viruses (Hepatitis B and C) and/or alcohol
2. Liver disease caused by problems concerning the bile ducts
There are other causes of end-stage liver disease, but they are less frequent. These include metabolic disorders, benign and malignant diseases and fulminant hepatic failure. Prior to transplantation, a multidisciplinary liver transplant team evaluates potential liver recipients.

After an evaluation is completed, if the patient qualifies for a liver transplant, the patient is placed on the liver transplant waiting list with UNOS (United Network for Organ Sharing).

The waiting time depends on the patient blood type, size and general medical condition. Patients on the waiting list receive a MELD score. The Model for End-Stage Liver Disease (MELD) system was implemented February 27, 2002 to prioritize patients waiting for a liver transplant.

MELD is a numerical scale used for adult liver transplant candidates. This is a score which is calculated using blood tests that reflect various complications of the liver disease. The range is from 6 (less ill) to 40 (gravely ill). The individual score determines how urgently a patient needs a liver transplant within the next three months. In some situations, there may be factors that increase the urgency of the transplant and the MELD score can be upgraded for certain circumstances.

There are different sources of donor livers. Usually the liver is obtained from a deceased donor. Due to a continuous shortage of donor livers and the high incidence of liver disease, the waiting time is increasing every year. Hundreds of people die each year while waiting for a deceased liver to be offered. Donor livers also can be obtained from a family member or a friend who donates a portion of his/her liver to the patient.

In the case of a deceased donor organ, the transplant center receives a liver offer from UNOS for a specified patient. The patient is then notified and admitted to the hospital. While the donor team is procuring the donor liver, the recipient team begins to prepare the patient. The diseased liver is removed and the healthy liver is put in its place. The operation usually takes 6-8 hours.

After the operation the patient is watched closely to assure that there are no complications and that the liver is functioning properly. In the early post-operative period, the patient begins taking medications to prevent the new liver from being rejected by the body. The patient is discharged home when the patient recovers, the liver is functioning well and the level of the anti-rejection medications is stable.

The patient continues to be seen in the clinic to be evaluated for the liver function and to look for and manage potential side effects of the anti-rejection medications. Depending upon the pre-transplant condition, the patient may reach full recovery in a few weeks or in a few months.

Despite the complexity of the early post-transplant period, patients gradually return to their lives and have an excellent quality of life. They are able to return to school and work, they get married, have families, travel and enjoy an excellent quality of life.

10/26/09

Code Green
By: Dr. Gonzalo V. Gonzalez-Stawinski, M.D.
Thoracic and Cardiovascular Surgery
Cleveland Clinic

In the episode “Code Green”, Dr. Andy Yablonski calls his transplant colleague Dr. Gonzalo Gonzalez to ask if Dr. Gonzalez could recover a donor heart for one of his patients and bring it to Three Rivers transplant center. But Dr. Gonzalez is more than a character, he is a real-life transplant surgeon at the Cleveland Clinic and is the inspiration for the character of Andy Yablonski, played by Alex O’Loughlin. Here is a conversation between Donate Life (DL) and Dr. Gonzalo Gonzalez (GG).

DL: When did you first meet Alex O’Loughlin?
GG: Our first conversation was over the phone. I was coming back from a meeting in Orlando and was stuck at the airport. Carol Barbee (“Three Rivers” executive producer) called me and said Alex wants to talk to you. I called Alex and found we had a lot in common. That first call lasted about an hour. It was like talking to one of my best buddies, we just got along.

DL: Did Alex come to see you at work at the Cleveland Clinic?
GG: He did and even followed me in the operating room. I think he was impressed with who I am as well as with what I do. I tend to be pretty level-headed and keep the whole surgeon thing on the down low. But when I am operating there is a whole different persona. I am very focused. I am also very passionate about the work I do and about my patients.

DL: Do you see yourself in the character Andy Yablonski?
GG: People tell me, dude, that’s exactly you! How I deal with patients, certain mannerisms, I do see myself in the character. There was a scene where Andy flicks off his gloves and slingshots them into the trash can. I taught him that!

DL: How does it feel to know that Andy is based on you?
GG: It’s surreal. Not a lot of people will ever have the experience of having a television character loosely based on them. It’s flattering but it’s also cool to just have people recognize what we do in your work and how we help save lives.

DL: In an interview Carol Barbee described transplant surgeons as “adrenaline junkies,” is that how you see yourself?
GG: When I heard her coin that phrase I thought, wow, are we that transparent? But it’s true. The stakes are so high and we thrive on being on the edge, being the best, and saving lives. We live for helping and being great at what we do. There is no better sensation than when the whole process goes right.

DL: Do you think “Three Rivers” is pretty realistic?
GG: I would say 90% of the time it is very much like a typical day for us. I enjoyed the process of helping to create the show. I had the opportunity to sit with the writers and they are really trying to stick to the medical aspect of what we do.

DL: Is there a specific scenario you helped with?
GG: In the first episode there was a pregnant woman who needed a heart transplant. I suggested that she have a neurological injury so that there was a dramatic element about whether they would be putting a good heart into a brain damaged patient.

DL: What’s it like to be an expert consultant on a TV show?
GG: It’s been amazing to go through the process of creating a scene and then seeing it come to life on the screen. It’s incredible to see all the elements come together and I’m always impressed by what the final product looks like. It’s fulfilling to know you had a hand in it.

DL: You play yourself on this week’s episode of “Three Rivers,” how did you like acting?
GG: It was scary as hell. It is easier to do open heart surgery than to act. Honestly, the outtakes from that scene are painful to watch. There is definitely a mutual respect between what actors do and what I do. I’d rather do open heart surgery any day.

10/20/09

Good Intentions
By: Howard J. Eisen, MD
Thomas J. Vischer Professor of Medicine
Chief, Division of Cardiology, Drexel University College of Medicine and Hahnemann University Hospital
Director, Drexel Center for Cardiovascular Disorders
Director, Center For Advanced Heart Failure Care at Hahnemann

In the Three Rivers episode “Good Intentions,” Dr. Yablonsky tells Scott that today he got lucky. Scott had just been listed for a transplant and Brenda had been waiting for 6 years, why wouldn’t Brenda be first in line for the next available heart?

To most people, the term transplant “waiting list” implies that candidates in need of a transplant are ranked in a static order. People think that when number “one” on the list gets their organ then the next in line is number “two.” But that is not really how it works.

In many ways, who is “next” on the list depends on the donor, not the recipient. This is because it is the donor’s blood type, height and weight, size of the organ, and location of the donor’s hospital that are key factors in who will be getting the call to receive the gift of life.

When the family of a donor gives consent to donation or a patient is registered as an organ donor, the specifics about the donor are provided to UNOS by the Organ Procurement Organization working with the donor and their family. UNOS prints a unique “list” called a match run that ranks the recipients who meet that donor’s medical criteria and location.

There are, of course, factors on the recipient side. For hearts, the sickest patient will receive priority. Pediatric patients, people under 18 years old, are also given priority.

In “Good Intentions” the organ donor was a male, about the size of Scott, the same blood type, and in the same region. It is believable that Scott would be able to receive that organ before anyone else because it matched his medical criteria. This happens not uncommonly.

In my own work as a transplant physician, I have had many patients who are transplanted while on the waiting list for a shorter time than other patients. The important factors, besides time on the waiting list, which determine how long people wait for a donor heart include:

1.severity of disease: the sicker patients are usually the highest priority patients. Patients who are highest priority or Status 1A will often wait for shorter times than patients who are less sick and therefore lower priority or Status 1B or Status 2. This allows donor hearts to go to those patients who need it the most and are least able to wait;
2. blood type: this is a crucial factor. Transplant recipients can only accept hearts from compatible donors. Blood type AB patients are the universal recipients and can receive organs from any donor. They wait the shortest time. Blood type O patients are the universal donors but can only receive hearts from O donors (45% of donors) so they wait the longest. Blood types A and B are in between AB and O in waiting time.
3. size: bigger patients have a longer wait because there are fewer big donors and donor size is roughly matched to that of the recipient.
4. antibodies; other than blood type, there is no cross-matching in heart transplantation (as opposed to kidney transplantation) with one exception. Every recipient is screened for certain kinds of antibodies. Antibodies are proteins which attach to other proteins. The antibodies that we screen for attach to proteins on the surface of donor heart cells and will destroy the donor heart. Patients may develop these antibodies if they have received blood transfusions before transplant, if they are women who have given birth to several children or if they have certain mechanical heart assist devices implanted to keep them alive. We call all of these patients “sensitized” and these patients have to undergo a crossmatch when an otherwise acceptable heart is identified. If the recipient has a positive crossmatch with the potential donor, that recipient generally will not be given this heart because of the risk of damage to the donor heart in this recipient.
One final thing: the shortest that one of my patients has waited on the transplant list is 15 minutes (blood type AB) and the longest is over 18 months (blood type O).

10/12/09

Ryan's First Day
By: LuCyndi M Ramirez, RN BS MA CPTC
Manager, Organ Procurement
OneLegacy, the Organ Procurement Organization greater Los Angeles

In the "Three Rivers" episode Ryan's First Day, an Organ Procurement Organization helped Daniel's mother face the tragic loss of her son by helping her better understand what was happening and by giving her an opportunity through donation to help others.

Daniel's mother didn't understand how her son could be dead when it looked like he was just sleeping. Many families have this concern and confusion and Organ Procurement Organizations work with families to help them understand brain death.

What is brain death?
When someone is brain dead, it means that there is no blood or oxygen flow to his or her brain or brain stem. Thus, the brain is no longer functioning in any capacity and never will again.

If my loved one is brain dead, why does the heart continue to beat?
The heart has its own pacemaker independent of the brain. If it has oxygen and glucose, it continues to beat.

Would removing the respiratory support equipment be the same as causing the death of my family member or "taking them off life support"?
No. Once the patient is brain dead, he or she is legally dead. The brain will never recover. The respiratory support equipment keeps oxygen flowing to the organs which will keep the heart beating. When the ventilator is discontinued, the heart will stop beating after several minutes without oxygen.

Are there any documented cases where a patient was declared brain dead and later restored to a normal life?
No. If you have heard about a person who was supposedly brain dead and recovered, they were actually in a deep coma or vegetative state with slight brain activity-not brain dead. The Organ Procurement Organization ensures the brain death tests are done correctly as a check and balance to the system.

Daniel's name was put on a wall of donors at Three Rivers to honor his gift. Are there ways that organizations really honor donors?
In the episode, as in reality, organ donation is a step which can start families on the road to grieving and recovery. There are many ways we honor and celebrate the life and legacy of organ and tissue donors, from local donor remembrance ceremonies and run/walks to the National Donor Memorial where families can create a tribute: http://www.donormemorial.org/

This season you can dedicate a rose in the Family Circle Garden which rides on the Donate Life Rose Parade Float on New Year's Day. You can create a special dedication for a donor, recipient, someone who is waiting for a transplant or someone who has died waiting. http://www.donatelifefloat.org/prod/components/family_circle/join.html

10/5/09

Place of Life
By: Dr. David Jacobs
Trauma Surgeon
Carolinas Medical Center, Charlotte, NC

The Three Rivers’ episode Place of Life gives me an opportunity to talk about the very prevalent myth that “if I’m an organ donor, they won’t work as hard to save me.”

As a trauma surgeon at Carolinas Medical Center in Charlotte, North Carolina, I take care of severely injured patients every day. Most will survive, and ultimately return to their previous state of good health, but unfortunately, some will not survive their serious injuries. However, regardless of how serious the injuries seem to be when the patient arrives, even if we think that these are non-survivable injuries, we give every patient the benefit of the doubt, and do absolutely everything we can to save that patient’s life. The possibility of organ donation does not even enter our minds until we’ve tried everything we know how to do, and everything points to the fact that the patient will not survive. Only then do we even begin to consider the possibility of donation, not only because it will ultimately benefit so many people who are currently on the waiting list for an organ transplant, but also because we have seen how much it can mean to a grieving family to know that their loved one did not die in vain.

But I know that a lot of people are concerned that if they indicate on their driver’s licenses that they’d like to be organ donors, that if they get in a bad accident, doctors like me will not do everything possible to save their lives in order to allow them to become organ donors.

Here’s why that can’t be true:
1) First of all, all doctors take the Hippocratic Oath when they graduate from medical school. That oath says that, above all else, we will do everything we can to preserve the lives of our patients. Doing anything less would violate that sacred oath.

2) Secondly, in order to be an organ donor, you have to be dead, but you also have to have a good blood pressure, and good heart, lung, liver and kidney function. You can’t have any of those things unless the medical team is doing absolutely everything they can to stabilize you and save your life. That brings up the question as to how you can be dead with a good blood pressure, and good organ function. We’ll discuss that more next week.

3) Thirdly, the medical team in charge of your care is completely separate from the transplantation team. That includes paramedics, doctors, nurses, and anyone else connected with your care before you get to the hospital and during your hospitalization. No one on your medical team knows who is on the transplant list, and none of us have anything to do with deciding who gets an organ transplant. Like I said before, we only call the organ donation team when we’ve done everything we can, and it is clear that your injuries are too severe for you to survive. The organ donation team can then decide whether it’s possible for you to become an organ donor, and will then talk with your family about that possibility. I have nothing to do with that discussion or that decision.

4) Finally, when you come into the hospital after a bad accident, we do not know whether or not you have made the decision to be an organ donor. Many patients show up without any identification, so we don’t even know who they are, much less whether they want to be an organ donor. And even if your driver’s license says that you want to be a donor, people do change their minds. We also see a lot of patients who do not have an organ donor card, but who end up becoming organ donors anyway. So we treat everyone the same from the outset and do everything we can to save their lives.

Here’s the bottom line: Your commitment to donation will not interfere with your medical care. Organ, eye and tissue donation becomes an option only after lifesaving efforts have been made, and you have been declared dead. Only then will the organ donation team speak with your family about your possibly becoming an organ donor.

So go ahead and sign up today to be a registered organ, eye and tissue donor, and be sure to discuss your decision with your family.

If you don’t make the decision now, then it will be up to your family to decide because, if you’re that badly injured, you won’t be able to make your wishes known. Don’t put your family in that position. Go to www.donatelife.net to find out how to sign up to be a donor in your state. And trust me when I say, if you’re ever in a bad accident, and I’m your doctor, I won’t be checking for your organ donor card before deciding how I’m going to treat you.