How to Do a Liver Transplant (13 page)

We would fly in all types of weather conditions. Because of the urgency in getting the organs back to base, we could not wait for inclement weather to pass. There were many nights when we took off in blizzards or ascended turbulently through violent thunderstorms, only to emerge above the clouds and be treated to a spectacular lightning show from above. Occasionally, when we returned our plane would have to land at an alternative airport due to
bad weather and we would have to get our car with its sirens to meet us and take us back to the hospital in a heartstopping ride through Denver's snowy streets. I developed quite a fear of dying in that small plane. There have been a few tragedies where entire transplant teams have been lost when their aircraft have crashed. As the donor surgeon in charge, it was my call if, after consulting with the pilots, I felt the weather was too dangerous to head out. I would much rather let the organs go than risk the lives of my team. Because we were constantly flying over the mountains, I would always take a ski jacket, food and water on the trip. Somehow I thought it would be a terrible shame to survive a crash in the mountains only to die from hypothermia or starvation. I think I had watched the movie
Alive
(about the Uruguayan rugby team who crashed in the Andes and ate the dead bodies of their friends) one too many times.

We would fly to some extraordinary places on those trips, including the town of Leadville. This tiny dot of a town boasted the highest altitude airport in north America, at 9927 feet. Deep in the heart of the Rockies, it was wedged in a valley between two towering mountains, and our little plane would have to descend rapidly between the peaks. Because of the altitude, getting out of the plane was literally breathtaking. This place was so remote that there were no taxis in the middle of the night to ferry us into town. We laughed when we got our instructions to jump
in an old school bus parked by the side of the landing strip and drive ourselves to the hospital.

Once we had the organs in our possession, I would haul the heavy coolers back to the operating theatre where the transplant team would be waiting for me. We would then prepare the liver for transplant and I would assist one of the bosses to sew it in. I would then often switch theatres and help sew in at least one of the kidneys into another recipient. I would have been awake, more or less, for 36 hours.

Even worse than the sleep deprivation and travel, the most awful part of donor surgery was undoubtedly the delays. From when I first heard that there was going to be a donor, it could sometimes be 24 hours before the surgery would actually commence. The donor would be kept breathing on the ventilator in the ICU while all the tests were run, family permissions sought and all the recipients called in. Donor surgery was also frequently delayed whilst waiting for relatives to fly in from around the country to say their goodbyes. The problem, albeit selfish, was that as soon as I heard about a donor, I'd rearrange the following day knowing I would have to fit in a sleep somewhere. With every small delay, I would have to change my plans again and again. So many times I would be getting in the car at two in the morning only to get a call telling me that there would be a delay of an hour or more. Not enough time to have a bit more sleep or do anything else other than just wait and watch late-night infomercials. I have bought
more than my share of wondrous cleaning products over the years from watching these shows.

Then there were the delays that would break your spirit. We would arrive at a remote hospital in the middle of the night and be told that a more urgent case had just come in. Because our patient was dead, the emergency would take priority and we would be bumped for several hours. We would have to hunker down in a darkened tea room on the same 20-year-old cracked vinyl chairs that are in every hospital and listlessly drift in and out of sleep. We would then be shaken awake a few hours later and, with our eyes bleary and our tongues furry, spring into action to do a three-hour surgery. The poor old pilots would also have a long night sitting around waiting for our return. They would sit huddled in the plane or in some late-night coffee shop, trying to stay warm and awake. We were always so happy to see them when we came back to the plane because they would greet us with styrofoam boxes full of fried eggs, bacon and hash browns sourced from Denny's restaurant – the only place open 24 hours in many American towns. Doing donors took a lot of energy and, after being awake all night, the greasier the food, the better it tasted, and we would feast like we hadn't eaten for days.

How a donor is done

A
doctor I passed in the hall at a donor hospital once asked me, ‘Is that my patient you have there in your cooler?' I chuckled because my strange job reminded me of the grisly scene in the movie
Fargo
where heavily pregnant police officer Marge Gunderson matter-of-factly says, ‘I guess that was your accomplice in the wood chipper … and it's a beautiful day …' It was usually late at night when we slipped into the donor hospital as discreetly as we could. We came and went via back entrances and dark alleyways just in case the family of a donor might catch us leaving with a cooler filled
with organs from their relative. It was important too not to discuss a donor whilst we were taking a taxi to and from the airport in small towns because there was a fair chance that the driver might know the donor, their family or the details of the death.

Once I was up to speed with donors, Dr Kam left me to it and every case was mine to refuse. My constant companion on these frequent trips was a delightful fellow named Steve Kelly. He was not a doctor but came from a scientific background, and had become a professional surgical assistant. He was lovingly known wherever we went as ‘Dr Steve'. He had been doing donors for so long that it was impossible to tell that he wasn't a surgeon. I was always happy he was there and he was the one who taught me how to become proficient at this very technical operation. Because he was in his late 50s and looked far more experienced than me, the nurses at the donor hospitals always spoke to him as though he was the person in charge. He was the nicest man and such a great teacher that I found it hard to correct them and rarely let on that I was actually supposed to be in charge. I would just smile, let it go and hope my actions would provide some evidence of my ability.

Organ donation is a much misunderstood procedure. People have told me that they think we do a ‘slash and grab' to retrieve organs and that we ‘hack' people open to plunder them of their bits and pieces. This isn't helped of
course by the wildly untrue tales of hapless tourists waking up in ice-filled baths in South American hotel rooms to find they are missing their kidneys. The reality of donor surgery could not be more different. Removing organs for transplant is a careful operation, performed in an operating theatre with an anaesthetist, surgeon, assistants and an army of nurses. It takes hours of hard slog and if it wasn't for the dead body on the operating table at the end, the casual observer would be forgiven for thinking that we were performing any other routine surgery. The utmost reverence is paid to the deceased and even the most minor details are thoughtfully considered. Our aim is to leave the donor looking like we have not been there. I wait patiently in the tea room at the end of the case while the nurses wash the body and comb the hair. The long incision I have made is covered with a neat dressing. We cover the body completely with a clean white sheet and when we have gone, the family is able to come in and say their final goodbyes.

Despite all the respect that is paid, I still find donation a really gruesome task. I have done it hundreds of times and I think I will always feel this way. The donor team always uses the local anaesthetist and nursing staff, so in addition to your own emotions, you also have to deal with the reactions of the locals who are usually seeing this side of donation for the first time. At the smaller hospitals, many of the staff will have been involved in the patient's care and may have formed a connection to them. It is impossible to
prepare someone for the sight of a human heart removed from the chest when moments before it was still beating. Then at the end, before the wound is closed, there is the shocking appearance of a hollowed-out body devoid of its organs, when only a short time before they seemed to be a living breathing person. It can be so traumatic that I have seen theatre staff burst into tears during the procedure. I too still find it very sobering and try not to look back at the body once I have left the table. If you take the time to notice, often everyone in the theatre goes about cleaning up the room with their backs turned to the donor, trying not to think about the sad scene.

Anaesthetists can also have a really hard time because donors are the only cases where they are not there to perform their usual task of keeping the patient asleep, alive and pain-free. In donation surgery their job changes and they are there to make sure the lungs are receiving oxygen and to keep the blood pumping around the body using powerful stimulant drugs. During routine surgery, the anaesthetist is the first person to see the patient and the last one to bid them farewell when they deliver them to recovery. For donors, however, there is no recovery and the moment the heart and lungs are removed, the anaesthetist's job is finished. The regular beat of the heart monitor that sets the tempo of the operating theatre abruptly ceases as the heart is stopped from beating by the preservation liquid running through it. There is silence in the room
and instead of an operating theatre the atmosphere is more like that of a mortuary. It is completely unnatural for an anaesthetist to leave the theatre without their patient and I can tell that some have a hard time deviating from the routine. Many times they will stand firm at the head of the bed, looking a little unsure what to do next, mesmerised by the stunning sight of the organs being lifted out one by one. We thank them for being there and gently tell them they can go home if they wish.

One chap, obviously feeling odd that he had not run through his usual post-surgery checklist, asked me, ‘What was your estimated blood loss?'

I looked up quizzically, not sure that I had heard him correctly, and finally replied, ‘All of it, actually.'

He flushed with embarrassment when he realised what he'd asked. Another thing that anaesthetists do is give medication to paralyse the donor to stop them from moving. Yes, despite being dead, donors frequently move. It can really freak everyone out, me included. Donors have primitive spinal reflexes that cause them to twitch, move their hands and have erections. I just about passed out the day the anaesthetist omitted the paralysis medication and a donor's hand twitched violently, slapping me hard on the backside.

There are usually two pairs of surgeons operating during donation surgery, one team for the heart and lungs and the other to take the liver, kidneys and pancreas.
Other groups from the eye and bone bank come for the corneas and bones after the deceased has been taken to the morgue. When the donor is brought into the operating room, all activity stops while we check that the paperwork is all done and, most importantly, that the donor's identity is correct. I don't think that there has ever been a case of mistaken identity and it is my mission to ensure that there never will be. That would be difficult to live with.

The donor is positioned on the table in a rather unseemly pose, with their arms taped high above the head. This gives us lots of room to work. It can get pretty tight for space with the heart and liver teams working alongside each other and sometimes a sleep-deprived unfriendly rivalry results in toes being stepped on and elbows to the ribs. The body is opened via a long cut from the neck to the pubic bone and a noisy power saw is used to slice the breast bone up the centre. A metal frame is inserted into the gap and the chest is slowly cranked open. The heart is then fully on display, beating steadily in its sac. This is a showstopping sight and, exposed like this, the heart makes a soft slapping sound as it pounds away. At the same time, one of the chest surgeons passes a telescope through the nose and into the lungs to ensure the windpipe is clear and that the lungs are healthy. They are looking for cancer and infections that might render the lungs unsuitable to use. From time to time they even find some surprising things down there. One donor I went to met his end by crashing
his Harley Davidson into a tree whilst riding to the Sturgis Motor Cycle Rally in Wyoming. Down his windpipe we found the piece of gum that he had been chewing at the moment of impact. He had inhaled it and it was wedged hard and fast. It was probably what killed him. Life can hinge on the smallest things.

Once the chest is cracked, it is my turn to spring into action. The abdomen is also propped open with a metal frame that fully displays the liver and bowels. A careful inspection is made of all the organs to determine if they are usable. Hopefully, there will be a smooth, rich red liver with sharply angled edges. A bad liver is one that contains too much fat that accumulates in little bubbles throughout the cells. These livers have rounded edges and are so fragile that they can bruise and split like a piece of overripe fruit if they are not handled gently. We call them pumpkins because of their golden colour when the blood is drained out of them. Sadly, fatty livers are all too frequently found as the waistlines of the western world expand, fuelled by our fast food diets. The fat damages the inner workings of the liver cells and causes liver disease. If a liver contains more than 40 per cent fat, it may not work very well and a very sick liver transplant recipient can have a slow and painful death if they receive one. A skilled donor surgeon must eyeball the liver and take all of this into account, literally deciding right there at two o'clock in the morning whether a recipient will live or die that day.

Once the two teams of surgeons decide that all the organs are good, we get down to the business of carefully dissecting their blood supplies out of the surrounding fat and breaking down all their connections to the body. The liver has a very complex blood supply and is different in every patient. The blood vessels to the liver have to be taken with as much length as possible so there are lots of options when it comes time to sew them into the recipient. Everything is detached as much as possible while the donor's blood is still circulating. When both the chest and abdominal surgeons are ready, the anaesthetist gives a massive dose of a blood thinning medication called heparin that renders the blood as thin as water. This allows us to wash all the blood out of the body and replace it with the preservative fluid that makes transplant possible. This fluid is pumped in via tubes inserted into the major blood vessels in the donor's abdomen and chest. This liquid is ice-cold and surprisingly sticky. It is called UW (University of Wisconsin) solution and contains a complex combination of salts and preservatives that prevent the cells in the organs from bursting when they are stored at a low temperature.