A reader wrote to me and asked about the horrors of organ procurement. Ross asks me to share with you what I know.
First of all, when I started my career, it used to be called a 'harvesting the organs'.
There's been a name change and I'm not sure why.
My first death I witnessed as a clinician was during my internal medicine clerkship, my very first rotation in the summer of my third year. A woman had gone to Mexico for experimental treatments for her breast cancer. It was very advanced due to the lack of standard medical treatment. There were fungating lesions coming up through the skin, and they stank and oozed infection. This is the natural course of breast cancer when it is left untreated.
Her family had dropped her off at the hospital to let her die.
I would like to say she had no visitors but it was even more sad. There was a massage therapist she hired to play music and massage her as she died.
There was no family.
As we rounded through the day you could hear the music and smell the oils and see the massage therapist working, while the patient was totally unresponsive and working her way through the dying process, which I didn't know how long it would take. Let me tell you real life is a lot slower than in the movies where the monitor in an otherwise unmonitored room goes beep beep beeeeep beeeeeeeep silence/alarm.
The nurses called my intern to tell us she had passed. He paged me and we went to the bedside. He showed me the three things you verify--absence of reactivity to light with the pupils of the eye, absence of breathing, absence of heartbeat. You double check to make sure.
I found it hard to pay attention because at the time I didn't know I was a medium, but I could see the spirit of the deceased in a cheerleading costume across the room trying to get my attention. She was jumping up and down and mouthing the words, 'I AM OKAY! I FEEL TERRIFIC! I AM NOT DEAD!'
A look of surprise and dismay flashed across my face and I tried my best to hide it. I said back to her with my mind--'I'm just learning this and I have to do what I am here to do!'
Then she stopped jumping and watched as I learned what my intern was teaching me to do. She was a kind soul, not a medically educated one, and most certainly she wanted things done 'her way'. I didn't see her again and I'm sure she had been taken up by that time. She couldn't wait to leave that body.
One of the first things I have learned is that almost every soul I encounter in a peri-mortem setting is surprised that their family can't see and hear them like they used to. They are frustrated and surprised. They also somehow know through some instant network I can't understand--who is a good person who CAN see them and give messages on their behalf. And they wait and take turns to go to that person, lots of them, when there is need.
The second thing I know is that closed head injury can be a little tricky. Yes, there is damage you can see on the films. I've seen one baby who didn't have a seatbelt who looked normal on the outside but her brain was completely fractured into two pieces with a huge line separating the parts. There is usually lots of other damage with it, broken bones, internal bleeding, but sometimes it's an isolated thing.
When I was at the VA as a student, on my neurology rotation, there was a 'brain dead' or 'comatose' patient who had slammed his motorcycle straight into the side of a truck. The pelvis had what we call an 'open book fracture'. There was bladder damage and a lot of surgery had taken place to heal the injuries to the organs and the bones. He never woke up at the hospital where the accident happened, and he had been transferred from that other state to San Diego VA for continuation of care.
We did all the tests on him, the squirting cold water in his ear, the doll's eyes (you turn the head from side to side and the eyes don't stay front, they move with the head just like a doll). There's a book about this we all study, the Diagnosis of Stupor and Coma.
It was his family that showed me something, his first reaction, and it was really slow but obvious. I might have been wiggling a finger or thumb. But it was real. I showed my resident and she dismissed it as a reflex. But this was a young, healthy, once soldier. He was determined. And as the days progressed, with my listening to the family and being the patient advocate, the team began to realize he really was 'inside' and 'waking up'.
There are two kinds of places for a patient like this to go. If they are asleep, they go to someplace that specializes in patients who need a ventilator, dialysis, long term ICU type of care. I wouldn't call these individuals 'vegetables' because it's not nice, although perhaps for layman's terms it's descriptive for someone who is very sick but isn't going to die anytime soon, and is never going to get better. The other place, is a specialty hospital for those who have had serious brain injury and are expected to recover. The place we send people here is Rancho Los Amigos. It's intensive therapy round the clock for a minimum of six months. It's very expensive, but it works. People have to re-learn the daily basics of self-care and how to walk. And they do.
So what we achieved for this patient is he was given the resources to make a 'full recovery'.
I will be the first to tell you that the personality changes, it's not the same, after an injury like this. The patients have headaches, memory problems, and frustration with their limitations because they know it and remember what life was like before their accident. Sometimes they have seizures off and on. Recovery from major closed head injury is not like the movies in this either. But this patient was able to tell me thank you, that he was glad to be awake, and he wanted to work hard on his recovery. I don't recall if he came back or he woke up that much with us on our service. I took care of him a long time.
At the beginning I thought what my resident and attending had told me about this patient was true. It was only through time--three months after the accident was when I met him--and listening to his loved ones that I was able to intervene on his behalf and change the course of his recovery.
My first experience with turning off the ventilator was as an intern. I was in ICU and my chief resident called me over and said, 'shhhh!' and pulled open the curtain of a room, let me in, and closed the door behind us. I didn't know what to expect. There was a patient connected to the ventilator with full drips and tubes like any other ICU patient.
The only thing I could remember for sure was that the nurse looked very sad, and my resident was excited to teach me something new.
We were turning off the ventilator. This too was a motorcycle injury patient with massive head trauma who didn't have any family to claim him. He'd been in the ICU too long. So two attendings, after the ethics consult came through as it was okay, signed off on the orders to discontinue the ventilator. We 'pulled the plug' which isn't actually pulling a plug at all, it's turning off the ventilator. You still leave it connected.
There is a series of arrthymias the heart goes through as it dies. The resident wanted me to watch it on the monitor, and learn it.
I have taught residents this many times during the phase of organ procurement when the ventilator is turned off. You get ischemic changes, then it slows down as the parts of the heart die in sequence, atrium first, then the ventricles, then an isoelectric EKG (flatline). The whole thing takes about five minutes, it's longer than you'd think.
The nurse was sad because he was young. And I didn't know any better, nor did the resident, how sad it was. He had been on a pentobarbital coma to rest his brain as a last chance for it to recover, and it didn't. I wish I had realized he had family somewhere who never knew what happened to him, and how sad it was.
In the hospital, I grew to learn that the organ procurement/donation coordination organization--One Leg Ah See--finds patients like the motorcycle one here of interest. When there is brain death, they come on the scene and no one gets to write any more orders for the patients. It's not your patient any more. However, if you are a surgery resident, and it was your patient, this organization will pay you money to insert the arterial line and central line if there were none already in place. It was a couple hundred dollars back in the day twenty years ago. The surgery residents loved this!
As an anesthesiologist--resident, attending, it's all the same--you are given a protocol to follow. There are medicines you have to give at certain times. There's a xeroxed sheet in huge font they hand you to remind you of the steps. There's also things you can't give. To keep the organs healthy, they want the blood pressure and pulse to be a certain range. So it's a little hard to keep them there in a body that is between life and death. Usually the blood pressure runs on the high side. They watch you but not that close, and as you gain experience, it becomes a 'yeah, yeah, yeah I did it' kind of thing instead of scrutiny. You never really see the same teams ever, except sometimes for the coordinator nurse who used to work with you at the hospital but left to get that cushy/'better' job where there's no heavy lifting. Sometimes there's a person who was a surgical resident but didn't make it through the training who works with the team too. And sometimes there's a perfusionist for the organ from the receiving end of the transplant there. I know at UCSD, they would send their private plane to the hospital, be there at the procurement, and carry it back as long as the whole time the lungs were out was less than five hours. Longer than that it would go bad.
I remember one time when the plane couldn't land due to fog, and the person who was ready to receive the lung had to go home and wait for another day. The lung itself was past the five hours.
That was very sad.
But back in the O.R. with the teams of famous surgeons who are from big academic transplant centers, who act like they own the place in the lounge, I'm usually very quiet and do my thing.
Sometimes I have the spirit of the person with me and talking. I've seen a spirit of a girl/young woman standing three feet up off the ground with Jesus as we had our minute of silence while we played her favorite song at the family's request before the procurement began. He was talking with her and I couldn't hear their conversation it was across the room, but He waved to me and smiled. I knew everything was okay.
Other times people ask me what I am doing? I explain it with my mental conversation to the souls what my job is, how I keep the organs healthy until they can get to the recipients.
Many are a little embarrassed at how they died. They don't want others to know. They like it that something useful is coming from their death. Uniformly they think all the medical stuff is cool and they like to watch. Many of them promise that if they get another life they won't make the same mistakes again. I've heard this one often, and I always am encouraging to the soul and kind, although I know souls, and sometimes it takes lots more than one crash and burn for them to learn their soul lessons.
Do I ever tell anyone in the room of my experiences? No. They are working and I want them to do their best.
What I give is no anesthesia (I actually cheat and run it at 0.2 percent, just barely anything, 'just in case'), paralysis, lots of steroids, and blood pressure medicines to keep it in range. I give diuretics too.
I am present until they are ready to cross clamp the aorta. Everything is ready to be removed, but the blood vessels are still connected. When they give me the signal, I turn off the ventilator (I always double check to make sure), and I leave the room. If I have a student with me I point out the cardiac EKG sequence as the heart dies, and I tell them with a little theatrical drama for emphasis that if they see this happening in the O.R. and it's not a procurement, you better pull out all the stops and do everything you can to save your patient!
I don't like to watch what happens next. It reminds me of sharks in those nature shows where they eat and you can't see much except sharks going crazy for food. I know these are professionals, they have to work fast to help others, and they are very good at what they do. My mother has a cadaveric kidney graft and it's blessed our lives, and we are thankful. I've never been a hunter but I have cleaned fish with my dad back when we used to go fishing. Some things aren't pretty but they need to be done so that you can eat the fish, or the meat, or in this case, donate life.
The last thing I have to share is the liver transplant. I was a surgery resident, or perhaps an anesthesia one, at the time. I did my second year once as a surgeon and then I had to repeat it when I switched to anesthesia.
A woman who had just received a liver transplant had been presumed to be brain dead because she wasn't reacting to anything.
She was an Asian mom, in her fifties. I think the transplant was for, oh, I can't recall.
But because they thought she was brain dead--neurology, everyone--although they didn't do the brain flow or brainwaves scan--they turned off all the drips that help to make the blood pressure compatible with life for the new liver.
There was a miscommunication.
The attending anesthesiologist had given a little muscle relaxant (paralytic) on the way up in the elevator just so the patient wouldn't move around when they admitted her to ICU and gave report. He didn't tell anyone. This was his custom. It was to 'help'.
Well with the liver just coming online, there wasn't anything to metabolize that muscle relaxant that is powerful and used for surgery.
When word came around to him, he said, 'let me try to reverse it' and he gave the reversal medicines, and she wasn't brain dead at all!
But the liver was.
She ended up needing a second transplant that same week.
And she never made it out of the hospital.
It was a lawsuit I'm sure. We had a team of them at the University and they knew how to win cases. University law is a little different from regular one, and most lawyers who go up against the University don't understand it enough to win a case against the lawyers defending the University who do. If you ever need to sue a University of California anything, make sure from the beginning your lawyer you are retaining has a proven track record in this situation.
So that's the truth, my truth, on organ transplantation.
Would someone in the operating room, or like the ICU liver transplant patient, feel everything and know what is going on when there is muscle relaxant on board and no other pain medicine or anesthesia?
Yes.
As a matter of fact, early in my training, I'm not sure it's done any more to be honest, there was something called a 'punitive intubation' in the ER. I've never done it, but I've heard of it. When someone has done something awful (murdered a bunch of people or something really bad like that), sometimes the care team leader will reverse the order of the drugs used to intubate a patient. The normal order is sleeping drug first, then paralyzing drug. To be honest, many of the trauma patients are so intoxicated with alcohol and drugs I think they have the equivalent of the sleeping drug on board to begin with. But for the ones who were not so lucky, and were designated to receive the punitive intubation, they would be fully aware of the intubation while it is taking place and powerless to move or stop it, and THEN knocked out once the sleeping drug was given.
To be honest, with a rapid sequence, it's given in such quick succession in the same i.v. that I doubt there's much time when someone would be aware during a 'punitive intubation'. I know because paralysis reversals are also given in such quick succession. And some anesthesiologists even mix the two drugs in the same syringe, and it works just the same as if it was two syringes.
It's troubling to think someone would ever authorize a punitive intubation. I've only heard of it. And perhaps it's just folklore from the training hospitals.
I wouldn't worry about it.
So there you go, I hope this answers your question Leonie <3
With all our love,
clap! clap!
OH--Ross wants me to share about his birthday.
Last night he wanted us to go out to eat at our favorite seaside restaurant. It's open air. In winter we bring blankets for our laps. The restaurant used to provide them but now they don't.
He told me to order something 'about the middle on the left side' of the menu, and also, 'a glass of wine'. I ordered the mahi mahi fish tacos, and a glass of Angeline rosé.
He wanted 'crème brûleé' but they didn't have any, so he let Anthony choose, and he chose the carrot cake. Anthony was all about the cake and I had to make him wait so I could take a picture and we could sing for Ross, which we did.
Just before dessert, I had four orchids from our dishes' and Ross had me toss them over the rail and make a wish.
Anthony asked me what I wished for? I wished for Ross to hold my hand.
I thought nothing of it.
But after the bill was paid and I was about to stand up, Ross came before me, and held BOTH of my hands, and looked at me.
He said, quickly, 'You are beautiful and I will always remember you' and let go of my hands and disappeared.
I was deeply touched. I hadn't thought anything of my wish (I thought perhaps, next year, next incarnation...you know?)...and his words were both kind and loving. His actions were even louder than words.
We are spending time with friends this weekend, so that is why we celebrated Ross a little early. I am content for his birthday to be here, and also, we are delighted with the joy his bracelets are bringing souls! We have a new batch to send out, hopefully this morning, and if not, then another time this weekend.
Aloha and Mahalos,
Namaste,
Peace,
Ross and Carla
The Family
P.S. if you enjoyed reading about my experiences communicating with my patients who have transitioned, here is the complete e-book taken from my notes I wrote after every time it happened in my training. https://reikidoc.blogspot.com/2014/09/messages-from-my-patients-entire-set.html
