Magazine
It’s Not Just Cold Chain; It’s Personal
A family tragedy highlights the importance of temperature control
By Kevin O’Donnell
Recent events in my personal life have brought the critical importance of maintaining the cold-chain to the fore. It can mean the difference between life and death. It’s as simple as that.
On a beautiful Saturday morning this past September, I received a phone call from one of my sisters. It was the type of phone call that can take the legs right out from underneath you. “There’s been an accident,” she said, “it’s Kathleen. She fell. They’re air-lifting her to the University of Wisconsin Hospital and Clinics in Madison.”
Kathleen is my baby sister. She slipped on the second story landing in her home that morning and tumbled down the entire flight of stairs. Her injuries were extensive — her skull was crushed; she had multiple facial fractures, two cracked vertebrae in her neck, and fractures to both her arms. Most damaging of all: she suffered massive, irreversible brain trauma. She underwent a heroic emergency surgery to stop the bleeding in her brain and relieve the swelling. The vigil by the hospital staff and arriving members of my family during the next 48 hours following her surgery eventually revealed what successive EEG and CT scans had confirmed. Our worst fears had been realized; Kathleen would never recover. She would never regain consciousness, never breathe on her own, never open her eyes, and never know that we were even there.
Kathleen had no living will. My siblings and I, along with her husband and son, had the unenviable task of determining what to do next. Her fate was in our hands. Although the miracles of modern science would allow for her to be kept alive, we all agreed that she, at age 45, would not want to spend the rest of her days in a vegetative state, in a nursing home, on a respirator and feeding tube, with round-the-clock care. We all agreed that it would be in her best interest to remove her from life support.
My sister has always enjoyed a reputation for her kindness and generosity. If there was the remotest possibility that she could save someone else through self-sacrifice, she would be the first to volunteer. Knowing this, we inquired about the possibility of organ donation, a rare opportunity given to only about 4% of the population.1 The nature and extent of her injuries made her an excellent candidate for the program. It then became a race against time as Kathleen’s condition was extremely unstable and her brain could shut down her vital functions at any time. She was administered a (2-8º C) parenteral drug to reduce her heart rate, which had escalated to 150 beats per minute. A circulation mat, through which chilled water was pumped, was placed underneath her to reduce her fever and maintain a constant body temperature.
Members of The University of Wisconsin Hospitals’ Organ Procurement Organization sat down with the family and detailed the entire organ donation process with great patience, compassion and sensitivity. Under the direction of a Surgical Recovery Coordinator (SRC), blood samples were taken and a battery of necessary serological screening tests was performed. The results indicated that Kathleen’s lungs, kidneys, pancreas, heart valve, skin tissue from her hip, and corneas were all viable for transplantation. Through the careful choreography of the SRC, the neediest suitable matching recipients were identified and contacted from a waiting list of more than 104,000 individuals from across the nation. Three patients were transported to the University hospital, including one from the state of Florida, and preparations were made for their respective solid organ transplant surgeries. The Lions Eye Bank of Wisconsin in Madison and the Musculoskeletal Transplant Foundation located in Milwaukee were also contacted.
Kathleen was prepared for surgery and the family, in full surgical scrubs, was allowed to enter the operating room to say their goodbyes. The most critical time came when her ventilator was removed and only a very small window of opportunity for recovering her organs existed. I am convinced, by the serenity everyone noticed on Kathleen’s face, that she sensed the urgency, for once the ventilator was removed she never drew a breath on her own and the peaks and valleys of the sine waves on her monitor diminished like ripples on a pond until they became one, continuous horizontal line. The family was led from the room while the surgical team quickly proceeded to procure all of her viable solid organs.
According to a specific hospital protocol, the procedures used for organ recovery are rigidly followed by policies and guidelines set forth by the United Network for Organ Sharing (UNOS), a non-profit organization that manages and administers the nation’s only Organ Procurement and Transplantation Network (OPTN), established in 1984 by the U.S. Congress. Kathleen’s kidneys, pancreas, and lungs were the first to be recovered and handed over to the SRC who prepared them on a back table. The entire recovery process requires a sterile environment. The organs, except for the lungs, are individually placed in sterile jars containing a preservation solution that must be kept at 2-8º C and over-packed in a secondary rigid container and sealed closed. This assembly is placed into a sterile bag and an insulated transport container, the specifications of which are clearly defined in UNOS SOP 5.0 “Standardized Packaging and Transporting of Organs and Tissue Typing Materials.” The document specifically states “proper insulation and temperature-controlled packaging, including adequate ice or refrigeration shall be used to protect the organs during transport.”2
A series of red and white “Igloo-type” insulated containers were lined up along the back wall for just such purposes. After the assembled packages containing the solid organs were carefully placed inside the insulated containers, they were filled to capacity with wet ice. The goal is to keep the organs in a refrigerated state but to avoid freezing at all costs. For this reason, only wet ice — with its phase change temperature of 0º C — is used. Frozen PCMs are never employed. A security seal was applied to the transport containers and the identification tags with standard UNOS labeling specifications were applied, checked and rechecked. The highly specialized, well-trained and frequently audited SRC whisked the containers out of the room and delivered them to nearby operating suites, where the recipients awaited their new leases on life. (If the transplantations are to occur off-site, SRCs hand-carry the organs to the awaiting facility, often utilizing police escort and chartered planes when necessary.)
Once the solid organs were procured, the SRCs from the Lions Eye Bank of Wisconsin (corneas) and the Musculoskeletal Trans-plant Foundation (other tissues) procured their respective tissues using the same procedures. Placed in preservation solution, they were maintained in a controlled 2-8º C storage facility until transplantation.
Within six hours from the time we said goodbye to Kathleen, she had saved the lives of three people: a cystic fibrosis patient received both of Kathleen’s lungs; one kidney went to a dialysis patient, and her pancreas and her other kidney to another patient. In the weeks that followed, skin grafts were transplanted to a victim of an auto accident in Milwaukee who required facial reconstruction. Kathleen’s heart valve was used in a life-saving coronary operation, and the love I had always seen in Kathleen’s eyes soon provided the restoration of sight to a grateful someone in need of a cornea transplant. By her courage she provided permanent and positive change in the lives of six total strangers and brought joy and renewed hope to all who love them. By any definition, Kathleen is a hero.
So should you ever become complacent about the work we do — and should you think that cold chain is just an anonymous, thankless process — I can find six individuals who would be glad to share their stories and tell you otherwise.
References
- “Organ Donation Following Brain Death,” University of Wisconsin Organ Procurement Organization, p.2. http://www.uwhealth.org/organdonation/madisonwisconsin/10868
- Procedure 5.0, Standardized Packaging and Transporting of Organs and Tissue Typing Materials, UNOS,http://www.unos.org/ PoliciesBylaws2/policies/pdfs/policy_17.pdf
I would like to thank James Anderson, Christine Monaghan and Kathy Schultz of the University of Wisconsin Hospital and Clinics Organ Procurement Organization for their kind assistance in the preparation of this article.
