Anatomy of a transplant: 13 lives, 17 days

Pediatric Transplant Center team
Some members of the transplant team, who performed a record number of transplants in January

It was “lucky 13” for the Boston Children’s Hospital Pediatric Transplant Center this January. Thirteen lives were saved by organ transplantation. Seven kidneys, three hearts, two livers and one pair of lungs were transplanted during the record-breaking month.

So what does it take to perform 13 transplants in 17 days?

“It takes a team,” says Dr. Heung Bae Kim, director of the Boston Children’s Pediatric Transplant Center. “We are very fortunate to have the talent and the resources necessary, so that when we call and say, ‘We have this many kids coming in for transplants,’ the team is ready, no matter what.”

Sixteen-year-old TJ Gregory is one of the lucky 13. He received a heart transplant in mid-January. He had been on the waiting list since October. Born with a serious heart defect called transposition of the great arteries, in which two main arteries leaving the heart are reversed, TJ has struggled with heart issues his entire life. At 40 days old, he had already undergone two open-heart surgeries.

“I was watching a playoff game on TV when Dr. [Elizabeth] Blume (medical director, Boston Children’s Heart Transplant Program) called and asked what I was doing,” says TJ’s dad Todd Gregory, “I told her I was watching the game and she said, ‘Do you think you could get it on the radio?’ As soon as she said that, I knew. I knew TJ had a heart.”

13 transplants in 17 days

Carefully choreographed

Organ procurement and transplant is a delicate process precisely orchestrated down to the last detail. It took more than 80 people to change the lives of these 13 patients and many more support staff, coordinators and technicians who mobilized at a moment’s notice.

“The team pulled together like champs,” says Eileen Migueles, RN, a clinical coordinator for kidney, liver and multivisceral transplants.

Migueles ensures that every surgery is seamless. She schedules the nurses, communicates with the operating rooms, the instrument room and the Central Processing Department to ensure there are minimal delays and enough sterile instruments and equipment for surgeons Kim and Dr. Khashayar Vakili to perform back-to-back cases.

“I keep things moving on the periphery to make sure the team has what it needs.”

Kathryn Franklin, RN, is Eileen’s counterpart for cardiovascular surgery.

“Our team performed three transplants within 24 hours, simultaneous lung and heart transplants followed by another heart,” Franklin says. “Everyone stepped in to help.”

Adds cardiovascular surgical technologist Matt Crosby, “As busy as we were, everyone stepped up — anesthesia, nursing, fellows, surgeons. The dedication this team has for their patients is amazing.”

The human resources component was one of the biggest challenges, explains Dr. Francis Fynn-Thompson, surgical director of the Boston Children’s Hospital Heart and Lung Transplant Programs, particularly at a time in which the hospital was at capacity.

“In this case, there were people that weren’t even on call who were offering to come in,” says Fynn-Thompson.

Difficult decisions

Coordinating the staff was just one component. The transplant team also had to contact the patients and coordinate their arrival at the hospital, ensuring they got there in a timely manner, and that they were ready for transplant.

Timing is everything,” Fynn-Thompson says. “Hearts and lungs can only be out of the body for approximately four to six hours before they need to be transplanted.

In addition, the team worked closely with the organ procurement team from the New England Organ Donor Bank (NEOB) to maximize the use of the organs.

“Timing is everything,” Fynn-Thompson says. “Hearts and lungs can only be out of the body for approximately four to six hours before they need to be transplanted.”

In order to accept the organs, the surgeon needs to confirm he had the people, resources and supplies in place to perform the surgeries. The timing of the transplant sometimes requires the donor be kept on the breathing machine for an additional period of time, until the organ can be procured. In which case, it could mean the organ procurement team has to go back and explain the situation to the family who has agreed to donate their loved one’s organs.

“These are tough conversations for organ procurement organizations, such as NEOB, to have,” says Fynn-Thompson. “I am constantly amazed by a family’s willingness to do this in the midst of their grief.”

Checks and balances

Once an organ is offered to a candidate, there is still no guarantee it will be suitable for transplantation. Viability is one of the many checks and balances performed prior to the recipient’s surgery. In this case, it is performed by the team procuring the organ.

“Once the organ arrives, the circulating nurse and surgeon verify it is the correct organ, the correct blood type, the correct donor ID number and if applicable — laterality — in the case of the kidney, left when it should be left,” says Migueles.

This “time out” is documented with an e-signature in the OR record. Then they document cold ischemia time (the time from when the blood supply to the organ is stopped to when it is taken off ice to be transplanted into the recipient) and warm ischemia time (the time from when the organ is taken off ice until the first recipient vessel is connected).

Another series of “time outs” occur when the patient is brought into the OR:

  • The OR nurse and the anesthesiologist verify the patient’s name, weight, allergies and the surgery scheduled to be performed.
  • Prior to the incision, the surgeon verifies it is the right patient having the correct surgery
  • Before the surgeon begins, he states, “If at any time during this surgery you see something that you don’t think is correct, please speak up.”

Upon completion of the surgery, instrument, sponge and needle counts are conducted and reported to the surgeon.

Postoperative care and recovery

Kierrah Leger, RN, is the nurse manager on 10 South. She is in charge of staffing and education for the nurses who cover lung, liver, kidney and multivisceral transplants.

“The word I would use to describe it is ‘challenging,’” says Leger.

Liver and lung transplant patients go to the ICU following surgery and are later transferred to the transplant floor, but most kidney transplant recipients go straight to the floor.

“Kidneys are usually the least complex in terms of surgery but most impactful from a floor-nursing standpoint,” says Laura O’Melia, RN, MSN, CPNP, director of Transplant Nursing. “The ICU nurses are used to a certain intensity, but the floor nursing isn’t. When we get a sudden influx of recently transplanted patients, we need more staff to come in to care for the other patients. For newly transplanted kidney recipients, there is one nurse to every two patients, and only one can be a transplant patient. ”

The sudden surge in transplant patients meant Leger had to perform a juggling act.

“I was living in the moment, switching nurses’ assignments, offering overtime.” says Leger. “It was a team effort, and it was so helpful to have the support of the hospital.”

I was always aware of the tragedy that had to happen. I thought about the family that was giving that heart, the decision they had to make. If I could, I would like to meet them. Maybe they would like to hear their loved one’s heart beating in my son.

In addition to nursing care, these patients and their families receive extensive education and guidance from transplant coordinators, nutritionists, pharmacists and social workers during their inpatient stay.

An increase in transplants not only creates a heavier workload during and following surgery, but also impacts the clinics in the ensuing weeks and months.

“They are seeing more patients,” says O’Melia. “Other families are waiting longer, there are more people in the outpatient lab waiting to get blood work, and there are more ultrasounds and echocardiograms getting done. Each transplant clinic visit involves time with multiple clinicians. It really speaks to the dedication of our staff.”

The impact of an organ donor

Tj, a heart transplant recipient, with his dad Todd
Tj with his dad Todd

It takes only one donor to save up to eight lives, yet the waitlist continues to grow. Despite a record number of organ transplants in the U.S. in 2015, there are still people who die waiting. Over 123,000 people – more than 1,900 of them children – are currently waiting for transplant in the U.S., of those approximately 77 of them are on the Boston Children’s waitlist.

On the day TJ received his transplant, his dad Todd couldn’t stop thinking about the other family’s sacrifice. “I was always aware of the tragedy that had to happen. I thought about the family that was giving that heart, the decision they had to make. If I could, I would like to meet them. Maybe they would like to hear their loved one’s heart beating in my son.”

Learn more about the Boston Children’s Pediatric Transplant Center.