Transplant surgeons are using a new, controversial procedure to retrieve organs

MARY LOUISE KELLY, HOST:

Transplant surgeons are using a controversial new method to retrieve organs from donors. The procedure is stirring excitement. It is also raising tough questions. NPR health correspondent Rob Stein is the first journalist to witness this procedure in the U.S. And before we start, a warning - we are going inside an operating room while doctors remove organs from a donor who has been declared dead.

ROB STEIN, BYLINE: Dr. Marty Sellers is walking a nurse through his checklist of surgical tools in an operating room in eastern Tennessee.

MARTY SELLERS: So as I'm cranking open the sternal retractor, you get ready to hand me the cermeyos (ph).

STEIN: Sellers and his organ recovery team from Tennessee Donor Services flew in from Nashville this morning to try to retrieve a liver and two kidneys from an organ donor.

SELLERS: As I'm cranking it open, I should tell you, but in the chaos of it, I might not be very verbal.

STEIN: This isn't just any organ retrieval. Sellers is one of a growing number of transplant surgeons using a new technique for obtaining livers, kidneys and hearts - NRP, normothermic regional perfusion.

SELLERS: It's not hyperbolic to say it's a big deal. We're saving a lot of lives that otherwise wouldn't have a chance. And the data indicate that if NRP was used nationally to the extent that we're able to do it here in Tennessee, we could essentially eliminate liver waiting list deaths. So anytime you can say that, yeah, that's a big deal.

STEIN: But NRP is hugely controversial. Here's why. There are two ways someone can be declared dead and become an organ donor. Either someone is brain dead because they have suffered a total irreversible brain injury, like from a stroke or motorcycle accident, or they're dead because their heartbeat and circulation have ceased permanently, like when a family decides to withdraw life support because all hope of recovery is gone.

That's where NRP comes in. After the patient has been declared dead because their heart and circulation has stopped, doctors quickly hook up a specialized external pump. That restores blood flow and sometimes a heartbeat to try to minimize damage from the organs being deprived of oxygen-rich blood.

SELLERS: So when we put them on ice to be transported to the recipient center, the organs are in a healthier state, and therefore, when they get into the recipient, they perform better immediately and long term.

STEIN: But critics say restarting circulation is reversing the condition upon which the donor has just been declared dead, raising thorny ethical questions. The surgeon also clamps off blood flow to the brain to make sure any brain activity doesn't resume. But that raises questions too, including whether some blood might be getting through. Dr. Matthew DeCamp is a bioethicist at the University of Colorado.

MATTHEW DECAMP: I think the bottom line is that NRP violates foundational ethical norms around the determination of death and should not be pursued.

STEIN: Sellers and others argue NRP is saving lives.

SELLERS: It's irrefutable that we are not causing any increased deaths with NRP, and we're saving more lives with NRP. And if you can argue with that, I don't have much to say to you. I don't want to oversimplify it, but it's life or death. And while people are discussing the pros and cons of it, people are dying.

(SOUNDBITE OF WRAPPER TEARING)

STEIN: Sellers gets back to preparing for today's procedure, but soon discovers that the hospital doesn't have the saw he needs to open the donor's chest. So everything's suddenly on hold.

SELLERS: The family is on hold, and obviously, an emotional time for them. The recipients are on hold. You know, they were expecting to take the liver recipient to the OR at a certain time today, and now it's going to be significantly later.

STEIN: Throughout all this, the team has been searching for recipients for the organs. That's also often fraught with complications. Some hospitals won't accept NRP organs.

Finally, the right saw arrives. The donor's bed is wheeled from intensive care to a room near the OR. That's where her life support will be withdrawn and the family says their last goodbyes. She's in her 40s, suffered a stroke three days ago. The hospital does not want to be named to protect the donor's identity.

SELLERS: The family has the desire for her to be an organ donor and really couldn't think of a better way to end the chapter in her life than to extend her legacy and save the lives of others. So to honor her gift of life and her family's decision to share the gift of life through donation, can we take a moment of silence, please? Thank you.

STEIN: Everyone then waits for another member of the team, Preston Lambert, to give the word that the breathing tube has been withdrawn.

PRESTON LAMBERT: The patient has been extubated at 11:50, heart rate...

STEIN: The donor must stop breathing on her own within 90 minutes or the procedure will be canceled. That happened in the middle of a long, late night last week.

LAMBERT: Twenty-five minute vitals - heart rate 124, blood pressure...

STEIN: How's it going so far?

SELLERS: Slow, but hitting in the right direction, at least.

STEIN: I pull another member of the team aside. Deana Clapper helps from the Tennessee Donor Services.

DEANA CLAPPER: You know, it's a flood of emotions when this happens. You never want somebody to die. Yet, when situations occur that someone is not going to be able to survive, we definitely want to be able to help somebody else.

STEIN: Finally, there's news.

LAMBERT: I have a text message from the ORC. We are rolling.

STEIN: The donor has stopped breathing in time. The nurses are rolling her bed into the OR.

(CROSSTALK)

STEIN: The OR doors swing open to rush in the donor's bed and move her to the operating table. The organ retrieval team gathers around the operating table. That includes a surgeon from another state learning how to do NRP so he can start soon. Everyone waits another minute or so to make sure the donor's breathing doesn't spontaneously resume within 5 minutes.

SELLERS: We good?

CLAPPER: Yeah.

SELLERS: Make incision.

CLAPPER: So declared a 12:58.

(SOUNDBITE OF SAW)

STEIN: Sellers uses the saw to open the donor's chest and quickly does the first key step. Clamps close the major blood vessels from the heart to the brain.

SELLERS: (Inaudible) vessels are clamped. (Inaudible). See what happens. Drain.

STEIN: Then Sellers gets to work attaching the pump to the heart.

SELLERS: Get ready to bump.

STEIN: That's trickier than usual because the donor's obese.

SELLERS: Can someone come get the saw off the mayo stand please?

STEIN: So Sellers ends up doing a modified version of NRP, and the pump restores circulation to the organs.

SELLERS: So what time were we on?

LAMBERT: 13:03.

STEIN: Sellers starts removing the organs and quickly discovers...

SELLERS: Liver's no good.

STEIN: The liver is full of fat and diseased, a huge disappointment. Sellers starts working on the kidneys.

SELLERS: Scissors, please. Scissors?

STEIN: Sellers suddenly steps away from the operating table.

Tell us what happened.

SELLERS: Contamination break. Skin break.

STEIN: He nicked his left index finger with a scalpel. He stops the bleeding and changes into a new gown and gloves and gets back to the operating table.

SELLERS: Are we pumping these kidneys or not? Have the ice ready?

LAMBERT: Ice on the back table. Kidneys are out at 14:26.

STEIN: Once the kidneys are out, Sellers assesses them in a bowl of ice.

SELLERS: Right kidney.

CLAPPER: Right kidney. I got it.

SELLERS: Thirteen by 5 1/2.

STEIN: Finally, the kidneys are placed in special containers that monitor and preserve them. I ask Sellers how things went.

SELLERS: Disappointing when the liver is not usable, but that's not anything related to us other than it's just disappointing when you have a home for the liver and it winds up not being transplanted. But no, I mean, we got two kidneys out of a donor that only had two kidneys to transplant, so by that standard, you'd call it success.

STEIN: Turns out, only one of the kidneys was able to be transplanted, but that kidney saved a life. Sellers turns to a colleague to ask about his next case as the debate continues over the ethics of using this controversial new way to retrieve organs for transplants.

Rob Stein, NPR News, eastern Tennessee. Transcript provided by NPR, Copyright NPR.

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