A
surgeons account of what happens when he gets The Call.
Once
I get that call, everything changes. I might be out with my children,
at the movies with my wife, or perhaps sleeping when the call comes:
There is a donor for one of our patients on the pediatric cardiac
transplant waiting list.
After
that, it is hard to think about anything else. Once we accept a heart
for transplant, a cascade of events unfolds that will change the
lives of many people. Even if I don’t need to be at the hospital
for a few hours, mentally I am already there. In my head I am working
over the details of the operation, reviewing what our cardiologists
think of the donor and evaluating the stability of the recipient.
Heart
transplants almost always occur at night to prevent disruption of
hospital’s elective operative schedules, minimizing inconvenience
to their own patients and staff. The donated organ, which may be
hundreds of miles away, must be brought to our medical center. We
usually don’t get to start the implant of the donor heart till
sometime after midnight.
Coordination
and timing of a heart transplant could become an Olympic event,
involving at least two teams at two hospitals – a harvest team and
a donor team — each with a different set of objectives. I will make
at least 10 calls before I get to the hospital. Dozens of people on
our transplant team will be alerted: cardiologists, nurses,
anesthesiologists, surgeons, intensivists, perfusionists. As is
customary, we send our own team of surgeons to pick up the heart.
Other transplant teams may also be involved, sending their own
sleep-deprived surgeons in to harvest the lungs, liver or kidney.
The
donor story is always horrible. The children frequently succumb to
trauma, terminal illness or, perhaps most tragic of all, child abuse.
The donor stories stay with me, and lately I have stopped asking how
the child died. I cannot forget the father who, backing out of his
driveway, accidentally ran over his child. My children still don’t
understand why, whenever they are playing basketball in our driveway,
I make them stop and line up where I can see them before I pull my
car out.
Every
harvest surgeon arrives at the donor hospital with an ice-filled
cooler, often having traveled late into the night via some
combination of plane or helicopter or ambulance. The organ harvest is
as critical as the transplant itself. If an organ is not protected
and preserved well, the transplant won’t work, no matter how
technically perfect the transplant operation might be. Travel time
needs to be as short as possible; every hour between harvest and
transplant can have deleterious effects on organ function.
The
schedule for the transplant operation itself is made, adjusted, then
readjusted. We all know that it’s only a guideline and that delays
are the rule. Eventually it all starts to come together.
The
heart is placed in a cooler. The donor surgeon rolls it through the
hall, with one hand on the cooler and one hand holding his phone to
his ear, walking to the ambulance that will take him to the airport.
He tells me that they are on their way and that the retrieval went
fine. “No issues,” he says. I always reply the same way, though
I’m not sure why: “Safe travels,” and “Bring me back a
winner.”
Back
at our operating room, the pediatric cardiac anesthesiologists have
been kept apprised of how things are progressing. We need to have our
patient completely ready to implant the heart as soon as it arrives.
The family hugs the child on his way to surgery, with kisses and
tears all around. The patient has been partly sedated already and
remains the calmest of everyone. The parents ask for “some of what
he is having.” We smile and say that we are not allowed.
We
will make the first incision just before midnight so that we are
ready to implant the heart when the donor team arrives. The donor
team people arrive five minutes later than expected, at 1 a.m.; in
New York City there is traffic even at this hour. They join us just
as we are removing the recipient’s own heart.
As
the donor surgeon scrubs in to join me for the implant, he tells me
they used the ambulance sirens to get through the traffic. Once the
diseased heart is out, we can see that it is three times the size of
the new heart. For technical reasons, this is good. The new heart
will fit easily in the chest.
The
implantation proceeds without incident. There are certainly more
difficult procedures in congenital cardiac surgery to perform than a
heart transplant, but few freighted with more anticipation. After
all, the heart that we are asking to sustain our patient started off
this morning in another child. The transplant cardiologist who has
been taking care of this child for the last year meets us in the O.R.
at 4:15 a.m. “How is it going?” she asks.
After
the heart is sewn in and we allow it to be perfused with blood, it
starts to beat. Within 30 minutes, it is beating strongly enough that
the patient can come off the heart-lung machine. The boy is on his
own.
Another
cardiologist, an expert in echocardiography, has joined us and tells
us that the new heart is working well. The patient’s cardiac
function is the best it has been in over a year. We can begin to
close.
The
next conversation I have will be with the family. The sun is starting
to come up, and it is a new day.
Dr.
Samuel Weinstein is director of pediatric cardiothoracic surgery and
adult congenital heart surgery at the Montefiore Einstein Center for
Heart and Vascular Care in New York.