“Harvesting” Part 4 by Gary Edgar Grist RN CCP Emeritus

ECMO Donor

As the years passed, I moved on to another job at a children’s hospital. I had no organ harvesting duties on this job.  I was the chief perfusionist and it was part of my responsibility to facilitate the development of an ECMO program. I helped to set the program up, designed the ECMO pump configuration, and trained ICU nurses to operate it. A patient can be on ECMO for 24 hours a day, day after day, and maybe week after week.  Our small perfusion staff could not sit and operate this equipment endlessly, so the more numerous ICU nurses were trained to tend the ECMO equipment.

The Agonizing Decision

One day, a grade-school-age girl had a cardiac arrest in the ICU. Why? I don’t remember. But after 30 minutes of resuscitation with chest compressions, her heart would not start. The decision was made to put her on ECMO, either until her heart started or she could be transferred on ECMO to another hospital for a heart transplant. Unfortunately, it was soon discovered by an electroencephalogram that she was brain dead. Eventually, her parents made the agonizing decision to donate the child’s lungs, kidneys, and liver, which were not damaged during our attempts at resuscitation.

Cockroaches In Bright Light

This would be our first organ donor on ECMO. There was no formal clinical guidance for organ donation on ECMO at that time, but the pump needed to remain working to maintain the viability of the organs to be donated. As the chief perfusionist, I took over the operation of the ECMO pump, not knowing what to expect and not wanting my staff perfusionists or ECMO-trained ICU nurses to be caught unprepared for an unanticipated situation. The United Network for Organ Sharing was called and three harvest teams from out of town would soon arrive; one team for the lungs, one for the kidneys, and one for the liver. Once the child was declared dead and the parents left the unit, all charting ceased and the ICU physicians disappeared from the bedside like cockroaches in bright light, leaving just me and the nurses. We needed to move the patient to the OR for the harvest, and typically an anesthesia physician would accompany such a patient and oversee care during transport.  But when I called my anesthesia friends to come help, they refused (more cockroaches).  Without recourse, I, a couple of ECMO-trained ICU nurses, and a respiratory therapist (RT) started pushing the bed and heavy ECMO pump down the corridor towards the OR. The RT continually used a manual ventilation bag to ensure that the lungs did not collapse and consolidate.  Normally, this would be the job of an anesthesiologist. Once in the OR, we transferred the child to the OR table and called the harvest teams who had recently arrived.  I was having trouble keeping the blood pressure up, even with the pump. So, I tried calling my anesthesia friends again to come to help me with some of their medications for hypotension. Still, their answer was “No.” The first harvest team came in to get the kidneys. The second team came in to get the lungs.  After this, I could turn the pump off because the liver does not need any perfusion in an organ harvest situation such as this.

True Death

I had turned off ECMO pumps before when a patient failed to improve with no hope for survival and the agonizing decision was made to terminate life support. Stopping the ECMO pump meant that the patient would die immediately. In those instances, a parent often held their baby as it died when the pump stopped. Or if the child was too big, the parents could hold the child’s hand and stroke the child’s face as the life-giving blood flow stopped. The clergy was often present. But this time there was no parent, no hand-holding, no face-stroking, no clergy, even though this child had a soul, a spirit, an essence that was present in her earthly vessel until the blood stopped flowing and true death ensued.

Closing Wounds
As was often the case in my experience, the least-senior, least-skilled doctor of the harvest teams (or possibly only an accompanying medical student) was assigned to close the incision that ran from the child’s neck to her pubis. He used a running heavy prolene stitch (essentially a 20-pound test fishing line) to sloppily close the skin.  He did not close the sternum or any of the abdominal muscles, which would have been the proper and most respectful way to do it. My problem was that the bloodlines from the ECMO pump were still connected to the cannulae in the child’s neck.  I cut the bloodlines and capped the cannulae and called my surgeon friends to come to remove the cannulae properly. More cockroaches! I had to leave the cannulae in place for some ham-handed mortician to remove, leaving a slapdash wound in the neck. I worried that the shoddily closed incisions might be seen by her parents at some point. And I remember thinking that the child could not be embalmed properly because major sections of her vascular system had been cut or removed, preventing the embalming fluid from doing its work. Mortification might set in early and disfigure her face and body even more. I was worried that this might be upsetting at the funeral.

What Did I Learn?

What did I learn from this organ harvest? Sometimes the compassionate humanitarians you think are your friends aren’t. This was a great disappointment for me personally after working with them for many years. In the end, I felt that old familiar guilt returning to my gut, heart, and soul that I felt 40 years before. I was happy to never be on a harvest team again.  A few years later I retired. That was fortunate because soon thereafter the cardiac surgery department started a heart transplant program that, no doubt, would have required me to participate in organ harvesting once again. It was not until I started writing this memoir that I realized I really hated organ harvesting, or as I prefer to call it “pro…cure…ment”.