The Best Australian Science Writing 2013 (22 page)

Ian Gibbins

1. Preparator

Surrounded by rows of knuckles

boiled and bleached free of their marrow

I focus through my lenses

to place facet on articulated facet

and with a skeleton of surprise, I reconstruct

this intimation of a beating heart.

In preparation for display

my texts and numbered charts are closed

the cabinet door locked shut;

under the magnifying beams of spotlights,

I polish my glass eyes

and stitch my skin tight around me.

2. Students

Once the paperwork is done

the rest is just formality

an irredeemable end

to caged silences of a lifetime

precisely at the tip of a scalpel

this he, this she

when cool with missing breath

we look on and look away.

3. Donors

No-one is likely to argue

that, any time soon,

we will be moving far from here.

Not because our bones

have become soft and yellow,

carefully exposed

below these anonymous cotton sheets.

Nor because our nerves,

now slack, without tension or tone,

no longer sing like piano strings.

Nor even because our

rich red blood and

dark shining muscles

have ceased to pump, to pulse.

As you can see, we are done with action:

all we have left is intent and desire;

all we wish is for

you to feel our warmth.

Death

Teachers

How a donor is done

Kellee Slater

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.

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 show-stopping 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.

When everything is in place and both teams are ready, someone cries out ‘Cross-clamp!' Then it is on for young and old as the clock is ticking. Up to this point, it has been a careful and considered surgery. Now it is all about speed. We move like Edward Scissorhands, chop, chop, chop. This is the trickiest part – to move fast without cutting something you shouldn't. Our success is measured by the time it takes to get the organs into their new owners, because from this moment everything is dying. It all happens at once: the aorta, a hosepipe-sized artery carrying blood from the heart to the legs via the abdomen, is clamped; the inferior vena cava, the massive vein carrying blood from the legs to the heart, is severed and the donor is exsanguinated. Five litres of blood floods into the body cavities. At the same time, the hanging bags of preservation solution are run through, full speed. The blood in the veins is replaced by the ice cold fluid and almost instantly the deep red colour of the liver fades to beige, the heart stops beating and the only noise in the room is the sound of blood being removed by the suckers.

The heart and lungs are lifted out of the body first. The heart surgeons cut the blood vessels that suspend them in the chest. Just before the windpipe is divided, the anaesthetist delivers several final puffs of air via the breathing bag in order to blow the lungs up to their full capacity. This stops the delicate air sacs from getting glued together during transport. The two lungs and heart are then lifted out of the chest, like fully inflated balloons. This is a clumsy block of tissue. Imagine trying to manipulate two wet pillows tenuously connected in the middle by a wobbly heart. It requires two hands to clutch the jiggly parcel and carry the organs to a waiting sterile table, wrap them carefully in three layers of plastic bags and bury them in ice. It is then my turn to free the liver from its last few attachments as fast as I can and place it into its own bags. Like the lungs, the kidneys are also delivered as a pair, but are separated into right and left once they
are out of the body. They are bagged separately, the left one being the more favoured by transplant surgeons as its naturally longer blood vessels make it a little easier to transplant. Then we are done and I stitch the skin wound closed, gather the labelled and bagged organs, and hit the road.