They sent me on a donor run today. A donor run is when a transplant surgeon travels to an outlying hospital to harvest organs. As far as I can tell, there’s a call schedule shared between the transplant surgeons in a large area, but going out usually implies that you plan on using at least one of the organs at your own institution. Usually this is the liver, since this is the trickiest to harvest correctly, and the surgeon likes to know that no useful pieces were accidentally left behind, and no unrecognized variant arteries were damaged.
“They” sent me, as in the senior residents universally declined to go (bad time of day, weekend, weather, etc), and were secure in the knowledge that I would jump all over the opportunity if they let me. When I told the attending I was being sent, his response was: “You? !! Oh, really. I guess so.” Later on: “Why on earth did they send you? Where are the other guys? They’re a bunch of lazy slackers . . . I’m going to be grouchy about this for an hour. Go to sleep.” Five minutes later: “Do you tie well?” Me (afraid to claim something I won’t be able to live up to): “I wouldn’t want to say that.” Surgeon: “You should be able to tie well. If not, you should be practicing. If you can’t tie well, no attending will let you do anything. . . So, Alice, can you tie?” Me: “Oh yes, very well!”
This surgeon is young, dedicated, ambitious – aggressive, even. He makes himself available at all hours, ready to go on donor runs at any time, and then come back and spend the next eight to twelve hours transplanting what he harvested. I called him once at night to say I felt uncertain about a patient. He reassured me over the phone, and then fifteen minutes later turned up in the patient’s room, sitting down to chat with him, and then to explain the lab results to me in detail.
He holds himself to very high standards, and he demands the same from the residents. When he called to tell me to go on this run, one of the senior residents remarked, “He’s an old school surgeon. If things aren’t exactly right, he’ll get upset. Don’t take it personally.” I’m still not sure what he was talking about. I take this attending’s remarks personally to the extent that I’m pleased he recognizes me now, even if he’s not exactly thrilled to have me with him. I’ve made mistakes around him, and he knows that. On the other hand, after a few hours of sleep, he was much more cheerful, and by the end of the trip kept repeating how much I’d learned today, and how I would learn even more, and get to do more of the procedure, on future runs. I know that I don’t know enough – anatomy, surgical technique, transplant lore – and the best way for me to learn more is to have him firmly unhappy when I don’t work hard enough.
As for the procedure itself, what can I say? Regard for current news prevents me from going into much detail, except to say that the patient had sustained clearly unsurvivable injuries, and was pronounced brain dead before we were even called. The entire proceeding was marked by respect for the family’s wishes (allowed to take this, not allowed to take that, make things look good for the family), and some (limited) sorrow over a young person’s tragic death. Not too much of that, however, because frankly this is a brutal procedure, and the only way to do it is to completely block consideration of the donor as once-living (he’s dead now, completely dead now) and to concentrate on the patients whose lives will be saved by what we did. I did my best to do exactly what the attending wanted, and although my skills still leave a great deal to be desired, I did tie well enough not to tear blood vessels or leave them leaking, and at least I answered all the anatomy questions correctly.
Some people question the ethics of transplantation, denying the existence of “brain death.” I’ve thought about this a fair amount, since this would be absolutely impossible to do if there were any question of the donor being in any sense alive. (Remember that one of my reasons for staying out of ob/gyn, in the end, was concern about the abortifacient nature of contraceptives, since almost every single one acts in some aspect by preventing implantation of a conceived child.) I concluded in the end that brain death, when rigidly defined (absence of every single brainstem reflex, no confounding circumstances, after extensive testing) and properly diagnosed (by two doctors from separate services, apart from the transplant surgeons) is a real entity. This patient, for example, still had oxygenated blood flowing to his organs, but only because of aggressive ventilatory support and several iv pressors. In fact, our work was made more difficult by the fact that he was becoming very difficult to oxygenate, or to maintain a pressure on. He was indeed dead, and his body was on the edge of shutting down despite all our technology. We hastened nothing. I think some of the lay objections stem from a confusion between brain death (the concept that the brain is as vital an organ as the heart or lungs, and once it stops working, the rest of the body will follow shortly) and “permanent vegetative state” (which is a vague and difficult to diagnose condition in which the person breathes on their own, but doesn’t seem to respond to stimuli; this is what people recover from on very rare occasions). People cannot recover from brain death.