Thoughts from the Transition Zone
The harvest itself was routine. But what is routine is quite extraordinary. An army of coordinators had been on the phone for countless hours to bring together this group of people who could maximize the potential of these, now orphan, organs in a body about to die. Working side by side with a harvest team from another city taking the liver and kidneys, we divided shared vessels in the middle so we could each have enough tissue for our respective organs. When we were all ready, I put the cold potassium solution into the heart, which immediately stopped its beating and turned it into a flaccid, pale, cold, apparently lifeless organ. I removed the organ from the body, realizing that this completed the process of death, and marked the beginning of a difficult time in the Donor Zone. The people here will be going home saddened, the family grieving. But I had many details to think about- no time to reflect. I thanked everyone in the operating room, and we jumped into the waiting ambulance. In any other setting, this would have been a funeral procession; and indeed that was yet to come for the Donor. But this was a different journey as the orphan organ was heading toward a new home.
It will be an entirely different feeling as we enter the Recipient Zone. It will be permeated by anticipation, excitement, and hope. As I walk through this Emergency Room, eyes will also be on me, but not in the same way as the Donor zone I left just over an hour and a half ago. “Good news!” “They’re waiting for you!” People here have a sense of pride, and hope for our patient, the Recipient. It will be very upbeat as I enter the operating room where the transplant surgeon will have placed the patient on the heart lung machine. The life support equipment which had kept the patient alive for the past week will be in the hallway outside the OR, no longer needed, being cleaned up by technicians. Everyone in the Recipient Zone will be focused on installing the new heart into a person who will now have a future. I will assist the transplant surgeon in sewing in this one pound organ into its new home. He will take the clamp off of the aorta, fresh blood will run into the coronary arteries, and the gray tissue will turn pink. Will it start? Will it work? Within a minute or two, the muscle will jump to life and start beating. With the installation finished and after some time for recovery, the job of the heart-lung machine (which weighs 1250 pounds and contains 40 feet of tubing) will be taken over by this little one pound piece of beating muscle. The machine will be disconnected and, no longer needed, it too will be cleaned and put to rest. The surgeon will give the news to the anxious family that all is well so far, and it will have been a good day in the Recipient Zone. 20 professionals will have spent 18 hours to make this happen and they will go home with a feeling of accomplishment, albeit somewhat tired. But it won’t be over at that point. In the ICU there will also be some anxiety, because the outcome is not guaranteed. While the recovery of the heart is highly likely, the other organs have been damaged by the near death of the patient. Hopefully damage is temporary, but how the liver, kidneys and brain will do is yet to be seen. Ultimate success will require meticulous attention to hundreds of details over the next weeks and months. And how will she, the patient, do in herself? Her spirit? Her soul? There will be much to think about and little time to reflect.
But at the moment, I am in a very different zone, which I call the Transition Zone. I am sitting here in a jet, quietly cruising along at 500 miles per hour, 40,000 feet over the largely dormant population below. It is the middle of the night. Unlike the other zones, there is nothing to do, no details to think about; there is time to reflect. This is a bizarre and surreal space. I envision the one pound piece of flesh sterilely wrapped and packed in ice in the cooler at my feet. We are both in transition. I am in the middle of a major mood swing. I think of what a difference this little one pound piece of muscle will make. I think of the intense sadness and even depression in the Donor Zone and the joy, anticipation, and hope in the Recipient Zone. The people in each zone are aware of the other, and mutually empathetic, but are, quite rightly, concentrating on their respective jobs at hand. All of this requires an airplane that goes 500 miles an hour, the pilots who fly it, and the FAA system to safely get us between zones, enabling the process to happen in a time frame that allows the heart to recover without damage. The Transition Zone is the interface of medical science, medical technology, aeronautical engineering, as well as aviation and medical professionalism.
As I glance out the window, it is a dark, moonless night. The density of the stars in the sky, and the lights on the dark earth below, are about the same. In the absence of a horizon, they blend together and it looks like we are in space. From this strange perspective, it dawns on me that even though I understand scientifically how each individual part of this happens, the process as a whole still fills me with awe and wonder. The way it can change an individual life, a family, a community, remains a mystery. In the meantime, in the center of it all, in the Transition Zone, the pound of muscle lies cool, totally relaxed, in between jobs. If I were wise, I would do the same.
J. Terrance Davis, MDProfessor of Clinical Surgery, The Ohio State UniversityThe Heart Center, Columbus Children’s HospitalColumbus, Ohio