A Surgeon Reflects On Death, Life And The ‘Incredible Gift’ Of Organ Transplant
Monday, January 14, 2019
When Joshua Mezrich was a medical student on the first day of surgical rotation, he was called into the operating room to witness a kidney transplant.
What he saw that day changed him.
After the donor kidney came out of ice and the clamps on it were released, he says, "it turned pink and literally, in front of my eyes, this urine just started squirting out onto the field."
Mezrich was blown away: "I just had this sense like, 'This is so amazing, what we're doing, and what an incredible gift. And could I ever do this? Could I ever be part of this exchange, this beautiful thing?' "
He went on to become a transplant surgeon and has since performed hundreds of kidney, liver and pancreas transplants. He also has assisted in operations involving other organs.
Each organ responds to transplant in a different way.
"The liver will start pouring bile. The lungs start essentially breathing," Mezrich says. "Maybe the most dramatic organ, of course, is the heart, because you put it in and you kind of hit it like you hit a computer, maybe you give a little shock and it just starts beating, and that's pretty darn dramatic."
Mezrich is an associate professor in the division of multiorgan transplantation at the University of Wisconsin School of Medicine and Public Health in Madison. He reflects on his experiences as a transplant surgeon and shares stories from the operating room in his book, When Death Becomes Life.
On the different types of organ donors
There are a few different scenarios [where] we take organs from deceased donors, the most common being those that are brain-dead. Those patients have no blood flow to their brain, so they're considered legally dead, but their heart is still beating, their organs are getting blood flow, and they're often in a fairly stable situation, so we can take our time.
There's a second type of donor, which we call "DCD," or donation after circulatory death. These patients are actually still officially alive, but they've reached the point where the decision has been made to withdraw support. And in those patients, we wait to withdraw support until everything has been discussed, and often the family is in the room when that support is withdrawn by their primary doctor, not by us. ...
You know, it's an interesting thing, because you really think about what really is death? How is it defined? Do patients feel the same way as we do? These are kind of some of the really interesting challenging parts of being in this field.
On how transplant takes a long time and requires stamina from doctors
I train a lot of people in transplantation, we call them fellows. ... These are people who've finished their general surgery residency and now they're getting additional training [in] transplant, and they're excellent. ... Being a surgeon, particularly liver transplant, is all about kind of intestinal fortitude or inner strength. You've just gotta keep your wits and stay strong through all the different things that maybe can go wrong and fight through it. That's certainly what a liver transplant is like.
On having to make the judgment call about giving livers to patients with alcoholic liver disease
Transplant is one of those things that it's an amazing science and the surgery is very heroic, but if there isn't the social support and the ability to take care of the organ, it'll surely fail. You have to take all these medications to prevent rejection. You have to follow up a lot. Sometimes you have to battle through different complications, and so it really requires a village, if you will, to support any type of transplant.
This is a really important topic when we think about liver transplantation. So in the early days of liver transplant — '60s, '70s — initially people decided not to transplant patients with alcoholic liver disease because of the thought that they did this to themselves and maybe they didn't deserve it. I think now most people would agree that alcoholism is a disease, and it's a disease that is hard to treat and it can come back.
So rather than maybe think about it as, "These people are being stupid," or they're like your silly friends who drink too much, they truly have this addiction and it's a disease like other diseases, like hepatitis C, like the other things we transplant with more complex names. And it's been shown that we can get good outcomes in patients with alcoholic liver disease, as long as they have insight into their disease, and kind of have a support system to try and deal with the transplant afterwards.
But it is controversial, because patients with alcoholic liver disease often have a lot of failed relationships, have a lot of challenges in their life, don't have great family support. It's challenging to talk about some of these patients and wonder if we are going to get the best outcome, if this transplant is actually going to fix their problem or not. I think our health care system likes these heroic treatments like a liver transplant, but we don't put enough into prevention, into really understanding and managing the disease, and that can be sometimes a challenge. We've had many incredible victories with transplanting livers into [patients with] alcoholic liver disease but we've also had some dramatic failures.
On what it's like talking to the families of donors
This is really one of, in my opinion, the most special parts of being in my field of being a transplant surgeon. I was really nervous the first time I met a donor family because I thought they were gonna look at me and think I'm this vulture who is taking the organs out of their loved one, and I could only imagine the images they might have had.
But I'll never forget that interaction and most that I've had with the donors: They hung on every word. ... They wanted to know about the recipients. It truly was this beautiful legacy of their loved one, often who has died unexpectedly, sometimes a young person, and it gives them this positive thing to hold onto in this otherwise terrible time.
It is so incredibly special, and I truly believe the donors, even the deceased donors, are our patients just as much as the recipients. It's so important that we connect with the family, that we let them understand the process, that we are able to do a great job to make this incredible gift work. It's quite emotional. It really is an incredible bond when we interact with these families.
On saying a few words about the donor before the operation begins
I want to reiterate as many times as possible how important the donors are, how much they're heroes to us, and we always want to remember their stories and this gift that they're giving. It's very emotional when we go on these procurements, and in our group when we go on a procurement, when we're in the operating room, we always take a pause and our people from our organ procurement team will, after a moment of silence, will read something. Often it's a poem or something that one of the loved ones asked us to say about the person, maybe a little bit about who they were, what was important to them. Sometimes it has a religious base, sometimes it doesn't.
And we all kind of sit and think about it, and it is very special. It's emotional. And then the second that's over, we move on and really go after the task at hand. So it's interesting. You have this emotional experience, and then you have to very quickly kind of push it out of the way and and move on to the operation, but it's always very special.
Sam Briger and Mooj Zadie produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Scott Hensley adapted it for the Web.
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