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School of Medicine
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Story and photos by Maryalice Yakutchik
SATURDAY, FEBRUARY 14, 2009
Betty Flowers, left, and Janet Hiller have a pre-dawn discussion
about transplant day logistics.
“Happy Valentine’s Day Miss Flowers!” Nikki Lawson, transplant nurse coordinator, greets Betty Flowers, a patient rep whose job here today requires the cool of an air traffic controller and savvy of a cat-herder. She’ll be directing donors and recipients and divvying up all their respective family members and significant others, getting all to go to the right places at the right times. No small feat, as patient confidentiality prohibits all these many players from fraternizing in advance of surgery.
“What does OK mean here?” Betty asks, pointing to a complex schematic of all the day’s comings and goings. Janet Hiller, paired donation coordinator, explains that it’s “OK as in Oklahoma”: one of the kidneys from Hopkins is bound for a hospital in that state; one from there, bound for Missouri; and one from Missouri, for Hopkins. This simultaneous 6-way interstate swap marks another first for Hopkins in terms of transplant.
The first patient is rounding a corner, approaching. Before she is in earshot, Betty confides in Janet and Nikki about this being a very special anniversary for her: On Valentine’s Day in 1970, her son was a deceased donor of a kidney here at Johns Hopkins.
“Today I can say that,” Betty whispers, “and not cry.”
Two donors sit propped in pre-op beds, shivering. Janet Hiller retrieves warm blankets from the recovery room stash next door, where both women soon will be bound, each minus a kidney. She tucks them in, chasing away last-minute jitters.
Nikki asks the nurses on the transplant unit how 31-year-old Shelby Fletcher – facing his third kidney transplant -- has fared overnight. Her brow furrows when she hears that he spiked a fever. She opens his door, peers into a dark room, and backs off: “I’ll let him sleep a bit longer.”
Nikki Lawson learns of Shelby Fletcher’s late-night
Dr. Robert Montgomery moves down the corridor washing down a chocolate bar with a cup of Dunkin Donuts coffee. His swagger,a consequence of the western boots he wears, is measured, methodical, even. He greets a buzzing swarm of nurses, surgeons, and support staff just outside of the OR: “So, we’re set to start all three donors at 7:30.” It’s not a question.
Brigitte Reeb, transplant administrator, announces: “One little change: the plane taking our kidney to Oklahoma is leaving from BWI instead of Martin’s.”
Dr. Dorry Segev greets Cindy Dabrowski, the altruistic donor whose unconditional offer of a kidney set this six-way chain into motion. Her husband sits protectively by her, book in hand, prepared to face three hours in the waiting room time while his wife’s kidney is removed. At 61, Cindy wants to give her organ to a stranger because she’s had good health and wants to share the wealth. “It doesn’t get more simple or profound than that,” remarks Nikki Lawson. “Or more beautiful.”
Janet Hiller kisses Cindy Dabrowski goodbye: “We’ll see you when you wake up!”
“Okay,” Janet pronounces as the last of the three donors is taken to an OR. “That’s 7:30 on the dot.”
7:58 a.m. OR No. 8
Dr. Mohamed Allaf makes a first incision in his donor patient.
8:15 a.m. OR No. 7
“Alright, let’s do a time-out,” Dr. Montgomery announces, surveying a patient who is anesthetized and strategically draped in blue papery cloths so that only her belly, painted brown with iodine, is exposed. Her name, blood type and allergies are reviewed; the destination of her kidney is confirmed.
8:29 a.m. OR No. 8
A quiet humming is punctuated by a periodic beeping: these are the calm, controlled sounds of laparoscopic surgery. Through two tiny incisions in his patient’s abdomen, Dr. Allaf manipulates instruments, suctioning here, grasping there, clipping here, cauterizing there, all the while monitoring his movements through wisps of digital smoke wafting across a video screen. He’s working right up against the liver; an anatomical fact that makes removing the right kidney a bit trickier than the left: “Hey, that’s a nice vein for a right side, huh?” he says to the urology resident at his left elbow who’s moving a camera inserted in a third incision.
8:40 a.m. OR No. 8
“This is the ureter they’re getting,” Dr. Allaf determines, having briefly debated with himself about how much of the duct to leave attached to the kidney. “You don’t try to impress,” he says, cognizant that his surgical handiwork stands to be critiqued by a transplant team halfway across the country. “You do what you can.” He clips it.
9:05 a.m. OR No. 8
An empty cooler – soon to contain a donated kidney
-- sits in the office of the Incompatible Kidney
The OR becomes crowded. An organ procurement specialist arrives, carrying a box in which he’ll pack this organ that’s destined for Oklahoma. “Do we want a gift card with that?” Dr. Allaf quips. Dr. Andy Singer positions himself at the foot of the table, ready to flush the kidney of blood with a preservative solution in those first few critical moments when it’s out of the donor’s body: “He’s relaxed and done early,” Singer says of his surgical colleague, Mo Alaff. “That’s usually a recipe for success.”
9:20 a.m. OR No. 8
“You think you’re done, and you’re not,” Dr. Allaf observes, cutting and cauterizing some more. “I feel like I’ve gone through this tissue 10 times.”
9:24 a.m. OR No. 8
Dr. Allaf clamps the artery that feeds blood to the kidney: “That starts cell dying time,” he announces, referring to so-called “warm” time which will last from now until when the kidney is plunged in an icy bath and flushed of blood.
9:25 a.m. OR No. 8
An aptly named “endocatch” bag attached to the tail of one of the laparoscopes catches the kidney while it is still inside of the donor’s body and trailing varying lengths of artery, vein and ureter. Moving with urgency now, Dr. Allaf cinches the bag. There’s a collective holding of breath in anticipation as he pulls the tidy package up and out through an incision made for this purpose; one nurse comments that it’s like “birthing a baby.”
9:27 a.m. OR No. 8
Dr. Singer empties the bag o’ kidney into an ice bath, isolates the artery and begins flushing the organ which turns paler and colder with each passing second. “Cold time” for this kidney, bound for Oklahoma, will likely last five hours.
9:29 a.m. OR No. 8
A procurement specialist boxes the organ in a big cardboard package marked “DONATED HUMAN ORGAN/TISSUE FOR TRANSPLANT.” Two tubes of the donor’s blood, O-positive, are being shipped along with the fist-sized kidney, as are the donor’s consent forms.
Hugging the package close to her body, Brigitte Reeb jogs down the halls through the emergency department and out to a waiting ambulance. She’ll spend this, her 39th birthday, escorting the kidney to a charter flight bound for Oklahoma and waiting at BWI on a kidney bound for Hopkins from Missouri.
Nikki Lawon, left, and Janet Hiller make last-minute
tweaks to a schematic plan that outlines the comings
and goings of patients and kidneys.
Brigitte straps the precious box to a gurney in the back of the ambulance and hops in front with the driver, Rocco, for a 20-minute siren-wailing trip to the airport.
9:58 a.m. OR No. 7
Bruce Springsteen blares in the OR where Dr. Montgomery is stapling a ureter before cutting it and, finally, clamping the artery of the donor kidney he’s removing.
During a subsequent Fleetwood Mac song, Montgomery receives word confirming the delivery of dozens of roses that he ordered – one each for all of the many Hopkins nurses and physicians spending their Valentine’s Day working together.
10:15 OR No. 7
Dr. Montgomery clamps the artery of the donor kidney. Warm time starts.
10:19 a.m. OR No. 7
Dr. Montgomery widens the incision through which he’s attempting to wriggle a kidney-stuffed endocatch bag.
“Hey Janet,” Dr. Montgomery says: “Have we heard from the other centers?
“About 45 minutes ago, the St. Louis surgeon started on their donor.”
The St. Louis donor kidney is scheduled to fly charter jet to BWI, ETA 1:30 p.m.
10:22 a.m. OR No. 7
The flushing of the kidney begins. Cold time will last from now until the moment the artery is unclamped in the recipient and reperfusion begins. This kidney is staying in- house, being carried, via Janet’s personal cooler, to an OR next door for transplant into 70-year-old Alfred Finke.
Janet Hiller hugs Alfred Finke’s wife, and scoops up his toddling grandbaby, flushed from having run up and down the hospital hallway. “Your new kidney’s out,” Janet announces to Mr. Finke, slouched on the edge of his bed. “It’s waiting for you!”
“So it looks good, does it?” Mr. Finke wants to know.
“All the swapping’s going like clock work,” Janet assures. “They’ll be coming for you in about an hour. “And to think we didn’t even know for sure that you were going to be a part of this ‘til last night at 5’o clock,” she adds, referring to when Finke passed a stress test and was cleared for surgery.
“How long is my transplant scheduled to take?”
“About 3 hours total,” Janet says.
The first hour is taken up with surgical prep and administration of anesthesia. The transplant itself is a deceptively simple operation involving only three hook-ups: vein is sewn to vein; artery to artery; and ureter to bladder. It usually takes about an hour and a half. Then there’s a half hour or so of stitching and closing until the patient moves to a bed in the recovery room.
“Once blood flows into the new kidney, it produces urine right away,” Janet adds, describing that climactic moment in the OR of which kidney transplant teams never tire.
Janet Hiller carries ice-filled coolers to two operating
rooms where donors are undergoing surgery.
Nikki Lawson finally catches up with her patient Shelby Fletcher, who seems more concerned about his surgeon than he does himself: “Does Dr. Montgomery have his A-game on today? Has he had lunch yet? I don’t want him in the OR, shaking. Maybe I’ll tape a Snickers bar to my stomach for him.”
Shelby’s mother, Sharon, who was his first donor, two transplants ago, hugs Janet Hiller, saying: “I’m just sorry it took us this long to get to Hopkins.”
While escorting the extended Fletcher clan to their waiting room, Janet Hiller spies the Finke family rounding a corner. They’re far from their appointed waiting area, out walking the baby in hopes of tiring him before naptime. The Fletchers make a fuss over the child and share hospital small talk with the Finkes. None of them realize they’re all involved in the transplants taking place here today. Janet slides away: “They’ll figure it out in less than three minutes, I bet, despite all our efforts to keep the donors and recipients and their families separated and anonymous.”
Three donors are resting in the recovery room, each minus a kidney that will soon be sewn into one of the three recipients being prepped for surgery. Two kidneys sit on ice in coolers in their respective ORs. One is winging its way from St. Louis, Missouri, scheduled to arrive at Hopkins in about half an hour. Wave two of the 6-way transplant is set to start.
Oklahoma calls to report that it received the kidney from Hopkins: “Everything looks good at all three centers,” Brigitte Reeb reports.
Brigitte Reeb, left, and Janet Hiller, are elated as the 14-hour
transplant day, three-months in the planning, comes to a
The last of the recipients – a Baltimore man receiving a big, hearty kidney that arrived at Hopkins from St. Louis – heads out of pre-op and into an OR. He had been told that his surgery probably wouldn’t start until about 5 p.m. No one – especially those who spent the past months planning the first-ever six-way exchange involving three hospitals in three states all on one day – anticipated the event would have gone this smoothly.
2:23 p.m. OR No. 7
Shelby Fletcher’s new kidney is in. Dr. Montgomery unclamps the artery: “See it go pink?” A gorgeous kidney. Absolutely gorgeous.”
2:25 p.m. OR No. 7
Dr. Montgomery: “Alright. Let’s see now what we’ve got here.”
2:26 p.m. OR No. 7
Dr. Montgomery: “Shelby’s new kidney is making urine already. Isn’t that beautiful? You take a kidney out of a person, put it on ice, keep it in suspended animation, sew it up into another person and it starts making urine right away. I never get tired of that!”