- Email: [email protected]
For their love of Carrie
For their love of Carrie Florence Whitten,
RN
The persistent ringing of the telephone roused me from a deep sleep. As I pulled it off the hook, I groaned inside. We had been working on a critically injured man brought in at midnight from a freeway accident. After working on him throughout the night, I had just gotten into my comfortable bed. “Yes, this is Johnson speaking.” I tried to sound pleasant. “Hi. This is Miss Rasmussen from Community Hospital. We have an unusual case for you this morning, a bilateral nephrectomy,” she said firmly. Florence W h i t t e n ,
RN. i s an emergency nurse a t
John M u i r M e m o r i a l H o s p i t a l in W a l n u t Creek, C a l i f and a member o f
AORN o f C o n t r a Costa
County. She is g r a d u a t e d f r o m t h e Provident C o l lege of Nursing, At present she i s taking classes i n journalism a t D i a b l o V a l l e y C o l l e g e , Pleasant H i l l , Calif. This a r t i c l e received t h e f i r s t prize o f $500 i n the
annual
AORN writer’s a w a r d contest spon-
sored b y DePuy, Inc. The award was presented a t t h e Congress banquet i n Chicago.
April 1973
“You don’t mean bilateral, do you?” I lapsed into silence. “Yes, I mean bilateral,” she answered positively. I couldn’t believe my ears. Removal of both kidneys meant certain death. Perhaps my mind was clouded from lack of sleep and I had misunderstood. My fingers clutched the phone as if its cold hardness would bring me back to reality. With this long pause, my supervisor sounded anxious as she tried to rouse me. “Mrs Johnson, are you there?”
“Yes, I’m listening,” I answered slowly. “Remember that code zero we had four days ago? No, I guess you were off that day. Anyway, a little threeyear-old girl had drowned in a neighbor’s swimming pool. Dr Brown and the emergency Max team’ did complete cardio-pulmonary resuscitation on her. She rallied for 36 hours but
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then her condition deteriorated. Did you hear about her?” “No, I’m sorry I didn’t.” I no longer felt sleepy. She continued her explanation. “The child is just barely alive but Dr Brown and Dr Romanoff think that cerebral death occurred yesterday when her electrical brain activity ceased. With a flat EEG she has had irreversible brain damage and can no longer function as a normal child.” “How sad,” I murmured. “According to all signs, the doctors expect complete death within the hour.” Miss Rasmussen’s voice was almost inaudible. “Because the Ebkes realize their baby is dying and because they can’t bear the thought of her death . . . for their love of Carrie . . . they are donating her kidneys so that part of their child will live on,” she said quietly. “How wonderful of them to think of their child in this way,” I mused. “We have the patient on the Bennett so that oxygen will continue to reach a11 her organs. We expect the kidney transplant team from the San Francisco Medical Center to arrive any minute, so you’d better make tracks.” “Okay, I’ll be there just as soon as I can.” When I hung up the phone my heart pounded and the thought of the parents’ suffering sent a wave of depression over me. I felt uneasy about this operation on a dead child. What doctor could be so callous that he could devote his life to transplant work? m e * thoughts occupied my mind as I sped toward the Fifteen minutes later, I parked my car and rushed into the hospital.
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Picking up my surgery keys from the nursing office, I hurried to the elevator which took me to the fifth floor operating suite. I changed into my hospital blues and dialed Miss Rasmussen. “I’m here. I’m going to get surgery ready. Have the doctors arrived yet? How is the child doing?” My words tumbled out. “Hold on, everything is fine. Dr Kountz2 and his assistants have just walked in the door. They will stay with the parents for a while. There are papers to sign and Carrie’s heart is still beating.” “It seems so cold-blooded to just sit around and wait for her to die.” “Well, it may seem so, but there’s just no other way to do it. The kidneys will only remain viable two hours after death. Legally there must be a 20-minute wait after the patient’s heart stops before the kidneys can be removed. After she dies, we’lI have to hurry.”
‘‘Iknow. Well, I’ll be ready in ten minutes, but Dottie hasn’t come in yet.” “Give her time, she’ll come. Dr Chew and his surgical technician are on their way up with the equipment and they will inform you of anything extra they will need.” She sounded hurried. “Okay. Let me know when you’re about ready to come down so I can open the packs,” I answered. “I will.” The line went dead as she hung up the phone. Unlocking the surgery door, I hurr i d down the dark empty hall to the end room next to the sterile supplies. I wheeled the ring stand into the substerile room and placed the packs I
AORN Journal
would need on it. As I distributed the packs in their proper places, I realized that I should include some delicate vascular clamps from the instrument room. Taking these from the shelves, I placed them in a wire basket, shoved it into the autoclave, and twisted the heavy steel door shut. After turning the starting dial, I returned to the OR and checked the sutures. The whine of the high-speed autoclave pushing steam into the inner chamber almost drowned out the greeting shouted to me by Dottie Smith, my working partner. “Hi, Johnny,” she shouted from the other end of the hall. “Hi, Smitty. I’m glad you finally got here,” I replied. “You’d better hurry though. We’re due to start a nephrectomy pretty soon.’’ I decided to fill her in after she had dressed. “I’ll hurry and change.” With a quick smile and a wave she disappeared into the nurses’ lounge. “What a relief,” I thought. I knew we couldn’t start the operation without her help. With everything picked for the operation, I decided to find out what was taking place in intensive care. Sitting at the main desk, I dialed their number. “This is Johnson in surgery. May I speak to Miss Rasmussen, please?” I tapped my pencil nervously on the desk while I waited for her to answer the phone. “Hi, Miss Rasmussen. This is Johnson. Dottie Smith came, but I haven’t seen any doctors yet.” “Yes, Johnson. The doctors should be there any minute now. Don’t worry about it. The patient’s con-
April 1973
dition remains unchanged, but I want you to stay in your department because we’ll be needing you soon.”
I could hear someone asking questions and Miss Rasmussen put her hand over the mouthpiece while she answered. I waited patiently for her to come back on the line. “Sorry, Johnson, but things are busy here. Both of you stand by. You’ll have to really hurry once we bring the patient down.” “Thanks, Miss Rasmussen. I’ll tell Smitty everything and we’ll be here.” At that moment, the elevator doors opened and two men emerged, pushing a shiny stainless steel machine. “That equipment certainly looks impressive,” I thought, as I moved forward to greet them. “Good morning, Doctor. I’m Mrs Johnson.” “Good morning. I’m Dr Chew and this is my surgical technician, Ted Long.” I nodded to the tall young man who was lifting the heavy cover from the top of the Belzer kidney preservation machine, revealing two plastic see-through domes on top. A panel of dials to regulate the Belzer made up the whole lower part.
“Is everything ready, Mrs Johnson?” Dr Chew asked. “Yes, Dr Chew. I have set up for
a routine nephrectomy. I put some vascular clamps in the autoclave. Is there anything else you’ll need?” “That will be fine. Mr Long will scrub up and help Dr Kountz regulate the machine. We’ll need a separate set-up in the room for the kidney biopsy. A Mayo stand will be sufficient.”
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“Ok, Doctor.” Dr Chew followed Mr Long into the doctors’ dressing room. I hurried down the hall to tell Dottie the latest developments. As we were talking, Dr Chew and his technician appeared at the door, dressed in their operating room clothes. “Where can I plug this Belzer in?” “You can use that one behind the Bovie, sir.” After putting on a cap and mask, Ted Long pushed the heavy equipment into the room. Dr Chew turned to me. “Good, you can check the status of the patient now. We’ll be ready in ten minutes,” he said calmly. “The last I heard the patient hadn’t expired yet.” I was a little shocked by this matter-of-fact approach. “Please check now. We can estimate pretty well,” he said flatly. “Yes, sir.” I walked out of the room glancing over my shoulder as I did so. The surgical technician was adjusting some dials as Dr Chew looked at the domes which would soon hold the cadaver kidneys in their aseptic interiors. The kidneys would be continually bathed in a chemical-plasma solution which almost duplicated normal body fluids. Under a certain cool temperature and pressure, the kidneys could be kept viable for at least 72 hours. This machine has saved many lives. I was anxious to find out more about it, but I knew this wasn’t the time to ask questions. Miss Rasmussen sounded relieved when I brought her up to date on the events taking place in surgery.
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“You certainly timed everything just right. Dr Brown just pronounced the patient dead. D r Kountz is getting the donation papers signed by the parents. We’ll bring the child right away. Even though we don’t think it will do much good because her heart isn’t beating, we’ll have her on an ambu bag, so don’t be surprised.” “Okay. We’ll be waiting.” “Now we must really rush,” I thought. I found Smitty putting some sterile supplies away. “Smitty, I’m going to scrub now. The baby died a few minutes ago, so they’ll be bringing her down right away. Dr Kountz wants you to know that the kidneys will only be viable for two hours after death, so we must make every minute count.”
As I was talking, we were walking into the scrub room lined with large white procelain sinks. I hit one of the handles, which protruded f r o m underneath the sink, with my knee. The water gushing out from the sink faucet sent a fine spray over my hands and arms. “I guess that Belzer keeps the cadaver kidney in good condition for a while till they can find the right patient.” Dottie seemed to be voicing her thoughts out loud. “You are absolutely right,” I answered. “Oh, I forgot to tell you, I’ll set up a Mayo stand for the kidney biopsy.” The irritating drone of the autoclave bell cut sharply into our conversation. Dottie left me to turn i t off. I could tell by her actions that she was having a few qualms about operating on a dead child, too.
AORN Journal
It was 9:45 am when Miss Rasmussen, accompanied by Dr Kountz, pushed a guerney out of the elevator. Still scrubbing my hands and arms, I walked a few steps away from the scrub sink to see down the hall. I was anxious to get a look a t Dr Kountz, who was well known for his kidney transplant work, but he had disappeared into the doctors’ dressing room. It wasn’t long before Dr Kountz, talking and smiling, led the procession down the hall toward me. As he introduced himself, I felt calmer. Dottie had pushed the guerney into the OR and Dr Kountz was gently lifting the dead child onto the OR table as I walked into the room. She looked almost alive. Her golden curls gleamed under the bright circle of light which shone from the ceiling. The sight of the lifeless child brought tears to my eyes. I turned my back on the scene to dry my dripping arms. I mustn’t let this get me down, I thought. I must hurry now if I’m to be ready by the time the doctors finish scrubbing. When I finally turned around, Dottie was having sympathetic pangs. When her eyes met mine, they looked pained. As she tied the back of my gown, we both tried not to notice the empty anesthesiologist’s chair which usually held one of the most important members of the operating room team. Dr Kountz, still scrubbing, walked to the open door to reprove us. “Let’s hurry now. We have wasted precious time. We only have an hour and 20 minutes to get those kidneys out.’’
April 1973
With those words, Dottie and I were galvanized into action. I worked quickly setting up my back table and the Mayo stand. Dottie pulled on her thin sterile gloves and pushed the prep stand over to the OR table. She concentrated on washing the small abdomen of the child’s body. We kept reminding ourselves that, in removing these kidneys from the dead baby, two other children would be kept alive. We were ready when the doctors walked into the OR from the scrub room with their hands and arms dripping soapy water onto the darktiled floor. After gowning and gloving the doctors, I handed the first drape towel to Dr Kountz. Dottie pushed the prep stand away from the table, stripped her gloves from her hands, threw them into the waste basket, and proceeded to tie the back of the doctor’s gown. The patient was quickly draped, leaving the abdomen exposed to the bright light. Dottie moved my back table into place while I handed the doctor the suction tubing and the Bovie cord. Dr Kountz clamped the Bovie cord on his side while Dr Chew, standing opposite him, put the suction tubing at the top of the lap sheet. Dr Kountz glanced at the clock as he held out his hand for the skin knife. I noted that it was now 10:30 am. We had exactly one hour to complete the whole procedure if we were to save the kidneys. Carefully I placed the knife into his hand. With scalpel poised above the operative site, Dr Kountz asked, “IS everybody ready?’’ He looked a t Ted Long standing ready near the kidney machine.
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“Yes, Doctor, the pressure and temperature remain stable,” he answered quietly. Dr Kountz studied the small abdomen beneath his knife. He made a positive long incision starting a t the sternum, and with one stroke he laid open the skin and fatty layer down to the pubis. Both doctors clamped the tiny oozing blood vessels with the mosquito forceps I slapped into their hands.
I took the skin knife away and replaced it with a deep knife. Dr Kountz held out his other hand to receive the thumb forceps I handed him. Carefully, but quickly, he cut through the layers, picked up the fragile peritoneum with the tiny forceps and nicked it with the sharp point of the scalpel. He clamped the edges of this tissue with more masquitoes, while Dr Chew retracted the outside layers. Dr Kountz’s main concern was t o remove the kidneys with the ureters and the blood supply intact. Wet tapes packed the intestines and other organs out of the way. With another long incision, Dr Kountz exposed the retro-peritoneal kidneys. He had used a mid-line incision t o dissect the large blood vessels a t the highest point in the chest and to follow them down into the kidneys, keeping the whole system together. Vascular clamps were placed as high on the large vessels as possible. With great skill, Dr Kountz dissected and tied until, almost before I realized he was finished, he had put the whole system of kidneys, ureters and blood vessels into a sterile pan, and was walking to the Mayo set-up near the kidney machine. Dr Chew followed. I was left standing a t the OR table, looking down a t the gaping red hole. Placing
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a sterile lap tape over the wound, I become conscious again of the still form whose face was covered with drapes.
I focused my attention on the hasty procedure taking place in the back of the room. Time was running short; it was now 11:05 am. I could feel the tension mounting. Carefully dissecting a thin sliver of kidney tissue, Dr Kountz picked up the 3-0gastrointestinal suture and sewed i t back together. He flushed the kidneys and attached vessels with the chemical-plasma solution. Dr Chew moved back to the OR table, being careful not to contaminate himself. We needed samples of lymph nodes for compatability tissue studies. As he pulled the lap tapes from the abdomen to expose the omentum, he was distracted by Dr Kountz, who was connecting the blood vessels t o some plastic tubing located near the two sterile plastic containers at the top of the kidney preservation machine. With cool chemical-plasma to fill the vessels, Dr Kountz exerted the full amount of pressure. Both doctors wondered if the cadaver kidneys would hold together and be able to function without leakage. “Please retract, Mrs Johnson.” The business-like tones of Dr Chew brought me back to the work a t hand. “Yes, sir . . .” The room grew still as we worked. Dr Chew held the thin omentum in smooth forceps with one hand and was trying to dissect the small lymph nodes with the other while I retracted with a Richardson. They kept slipping away from his fingers.
AORN Journal
“Mrs Johnson, I want you to pick up the lymph nodes with your forceps and I will cut them. Please put some saline in a cup and put it right here.” He indicated the spot with the small Metzs he held in his hand. “These are the nodes I want you to pick up.” He pointed to some small lumps dotting the thin apron of tissue. We worked rather quickly. Once a lymph node slipped from my forceps just as he started to cut it. “Sorry, Doctor,” I murmured. “That’s okay. Try to locate the larger ones now,” he instructed. “Why do you need so many lymph nodes, Doctor?”
I grasped a very large node with my forceps. As he started to cut it, he explained: “We need these and the other samples to get the closest possible match between the donor and recipient. We not only take this information from the cadaver kidneys, but we also obtain biopsies from the recipient. We feed information on the tissue studies into a computer and we are able to get a close match.” Dr Chew paused and looked down at the node he was dissecting out. “DO many people donate kidneys when they have loved ones who have been critically injured?” I was really interested in his answer. “Some people do, but not nearly enough. There are about 3.000 kidney-diseased patients waiting for donors in the United States. These patients can be maintained on kidney dialysis machines, but the procedure is expensive and trying for the patient.”
April 1973
“Could you explain more about the tissue studies?” We had gathered about 20 nodes and I was struggling to locate the largest to hold for the doctor to cut. Dr Chew seemed enthusiastic about giving me information and he continued talking while he worked. “Recently, Dr Kountz, some of his colleagues, and researchers from the Irwin Memorial Blood Bank found that cells from the kidney are better to match with those of the donor than the white cells they have been using,” he explained. “We used to spend hours studying different tissues from the donor and recipient to determine which cadaver kidney belonged in which ailing patient. We had many rejections. Now we feed this information into the computer. Within seconds the computer makes the choice, eliminating guesswork and making a true match. This more scientific approach lowers rejections.” Pausing, Dr Chew questioned Dr Kountz, “What about it, Sam? Do they leak?” “They’re working just fine, Bob,” he answered happily, “and just in time, too.” Everyone looked at the clock. It was 11:25 am. “That was close.” I breathed a sigh of relief. The tension seemed to vanish as we turned back to our work. Dr Chew continued: “With the development of the kidney preservation machine and the tissue compatability studies, and with the help of the computer, much of the heartache has been taken out of kidney transplant surgery.”
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He had taken all the lymph nodes he needed and he was ready to sew up the long womd. I handed him the needle holder with the # 2 retention suture. The huge cutting needle gleamed in the high-intensity light. It looked almost as large as the small body lying there. “Well, that’s about it. Please put the biopsies into sterile test tubes in a little saline. Be sure to label them carefully, for without them this whole operation would be useless. It doesn’t do any good just to put any kidney into any body. They must match.” He finished his last stitch and held up the ends of the heavy suture for me to cut. “Thank you so much for telling me all you did, Dr Chew.” “You’re welcome. We need more interest in this procedure so that more people can tell our story intelligently.” He smiled as he took off his gown and mask. Everyone seemed pleased as the doctors followed Ted Long, who pushed the machine with the pulsating kidneys down the hall. Dr Kountz stopped in the hall. “Will you bring those biopsies to the desk? Be sure they are labeled properly and that you include the time and the date.” He smiled, his brown eyes softening. “We must rush these samples and the kidneys to the medical center just as soon as we can.” “Yes, Dr Kountz. We’ll have them for you right away.” I went back to the Mayo stand as he walked on down the hall. I labeled the sterile stoppered tubes, noting the type of tissue, the date and the time it had been removed. Gathering up the specimens
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I hurried after the doctors. As I walked toward the desk I felt rather strange leaving the body lying there alone. Once the most important object of our work, she would be pushed aside to await the coroner. I had to remember that we had really done the first part of an autopsy. The only reason she had been brought to surgery instead of the morgue was the fact we had to keep the kidneys in an aseptic condition in order not to infect the children who would be saved by the transplantations. With these facts in mind, I approached the nurses and aides who had gathered around the machine to watch the small kidneys, protected behind the transparent domes, pulsating and moving just like a small heart. The renal arteries were connected to some small plastic tubing which disappeared into the inside of the machine, while the renal veins and ureters were left free, lying next t o the kidneys. Dr Chew was answering questions while he waited for Dr Kountz to come out of the dressing room. “Doctor, what would happen if you put these small kidneys into a grown man?” I asked. “A child’s kidney, put into an adult, grows rapidly to handle the work of a larger body. If, on the other hand, you put an adult kidney in a child, it will shrink to compensate for the small amount of work it would be required to do.” Dr Chew smiled a t the wonder on my face.
“It’s difficult to believe, isn’t i t ? However, these kidneys will be transplanted into two critically ill children who have been kept alive by dialysis.”
AORN Journal
“How wonderful for those children and their parents. I think your work must be very rewarding,” I reflected. “Our work is very gratifying. With cadaver kidneys we are successful with 70% of the transplants. With relative-donated kidneys, our success climbs to 90%. Our sadness comes from the fact that we are forced to stand by and watch patients die for lack of donor kidneys. Because there is a complete lack of understanding, we need to inform the public that kidneys are removed only after death has occurred and critically ill kidney patients will survive ony if donor kidneys are available.” He paused to let his last statement be absorbed, then he continued thoughtfully. “Some families take comfort in the thought that, although their loved ones have died, in donating their kidneys they have given life to someone who may otherwise die.” When Dr Chew stopped talking, we all stood in awkward silence, moved by his emotional appeal. The spell was broken by the approach of Dr Kountz and Dottie Smith. “Thank you so much for your help, Mrs Johnson and Miss Smith. I can tell by this serious atmosphere that Dr Chew has been expounding on his favorite subject-kidney donors. Just pass the word along and some day we may have all the donors we need.”
Both doctors smiled at us and followed Ted Long into the elevator. A special van was waiting outside the emergency room doors to rush them with their precious cargo to the hospital in San Francisco. As Dottie and I watched the elevator slide silently downward, we looked a t each other, quietly dreading the thought of fixing the small body for the coroner. Together we returned to the operating room. Without saying a word, we removed the Foley catheter, the tracheostomy tube and the intravenous tubes, trying not to look at the angelic face of the dead child. As Dottie and I lifted the lifeless form back into the crib, I thought . . . “for their love of Carrie, her parents gave this gift of life
...
1,
Now two other children could live
...
%
REFERENCES I. The Max team is a group o f four nurses who have completed a cardiac care course. The Max Cart i s a mobile, self-contained unit with cardiopulmonary equipment including emergency drugs. The unit i s electrically operated with a standby rechargeable battery. Every shift has two teams assigned t o respond t o code zero. Available doctors also respond.
2. Samuel L Kountz, MD, now chairman, Department of Surgery a t Downstate Medical Center, Brooklyn, NY.
“Latest bulletin from Dr Samuel Kountz: Both children continue to do well on the donor kidneys.
Drugs figlrf g r u m posifive infecfions The cooperative interaction o f penicillin and a variety o f gonadal steroids may combate severe gram positive infections, according t o investigators Thomas Fiizgerald and W i l l i a m Yotis, the Medical Tribune reports. Investigators said steroids markedly reduce the growth and virulence o f staphylococcus aureus. The addition o f penicillin greatly enhanced the steroidal influences, they said. They cautioned that more detailed animal experimentation i s necessary, but preliminary experiments with mice have been very encouraging.
April 1973
67
RN
The persistent ringing of the telephone roused me from a deep sleep. As I pulled it off the hook, I groaned inside. We had been working on a critically injured man brought in at midnight from a freeway accident. After working on him throughout the night, I had just gotten into my comfortable bed. “Yes, this is Johnson speaking.” I tried to sound pleasant. “Hi. This is Miss Rasmussen from Community Hospital. We have an unusual case for you this morning, a bilateral nephrectomy,” she said firmly. Florence W h i t t e n ,
RN. i s an emergency nurse a t
John M u i r M e m o r i a l H o s p i t a l in W a l n u t Creek, C a l i f and a member o f
AORN o f C o n t r a Costa
County. She is g r a d u a t e d f r o m t h e Provident C o l lege of Nursing, At present she i s taking classes i n journalism a t D i a b l o V a l l e y C o l l e g e , Pleasant H i l l , Calif. This a r t i c l e received t h e f i r s t prize o f $500 i n the
annual
AORN writer’s a w a r d contest spon-
sored b y DePuy, Inc. The award was presented a t t h e Congress banquet i n Chicago.
April 1973
“You don’t mean bilateral, do you?” I lapsed into silence. “Yes, I mean bilateral,” she answered positively. I couldn’t believe my ears. Removal of both kidneys meant certain death. Perhaps my mind was clouded from lack of sleep and I had misunderstood. My fingers clutched the phone as if its cold hardness would bring me back to reality. With this long pause, my supervisor sounded anxious as she tried to rouse me. “Mrs Johnson, are you there?”
“Yes, I’m listening,” I answered slowly. “Remember that code zero we had four days ago? No, I guess you were off that day. Anyway, a little threeyear-old girl had drowned in a neighbor’s swimming pool. Dr Brown and the emergency Max team’ did complete cardio-pulmonary resuscitation on her. She rallied for 36 hours but
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then her condition deteriorated. Did you hear about her?” “No, I’m sorry I didn’t.” I no longer felt sleepy. She continued her explanation. “The child is just barely alive but Dr Brown and Dr Romanoff think that cerebral death occurred yesterday when her electrical brain activity ceased. With a flat EEG she has had irreversible brain damage and can no longer function as a normal child.” “How sad,” I murmured. “According to all signs, the doctors expect complete death within the hour.” Miss Rasmussen’s voice was almost inaudible. “Because the Ebkes realize their baby is dying and because they can’t bear the thought of her death . . . for their love of Carrie . . . they are donating her kidneys so that part of their child will live on,” she said quietly. “How wonderful of them to think of their child in this way,” I mused. “We have the patient on the Bennett so that oxygen will continue to reach a11 her organs. We expect the kidney transplant team from the San Francisco Medical Center to arrive any minute, so you’d better make tracks.” “Okay, I’ll be there just as soon as I can.” When I hung up the phone my heart pounded and the thought of the parents’ suffering sent a wave of depression over me. I felt uneasy about this operation on a dead child. What doctor could be so callous that he could devote his life to transplant work? m e * thoughts occupied my mind as I sped toward the Fifteen minutes later, I parked my car and rushed into the hospital.
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Picking up my surgery keys from the nursing office, I hurried to the elevator which took me to the fifth floor operating suite. I changed into my hospital blues and dialed Miss Rasmussen. “I’m here. I’m going to get surgery ready. Have the doctors arrived yet? How is the child doing?” My words tumbled out. “Hold on, everything is fine. Dr Kountz2 and his assistants have just walked in the door. They will stay with the parents for a while. There are papers to sign and Carrie’s heart is still beating.” “It seems so cold-blooded to just sit around and wait for her to die.” “Well, it may seem so, but there’s just no other way to do it. The kidneys will only remain viable two hours after death. Legally there must be a 20-minute wait after the patient’s heart stops before the kidneys can be removed. After she dies, we’lI have to hurry.”
‘‘Iknow. Well, I’ll be ready in ten minutes, but Dottie hasn’t come in yet.” “Give her time, she’ll come. Dr Chew and his surgical technician are on their way up with the equipment and they will inform you of anything extra they will need.” She sounded hurried. “Okay. Let me know when you’re about ready to come down so I can open the packs,” I answered. “I will.” The line went dead as she hung up the phone. Unlocking the surgery door, I hurr i d down the dark empty hall to the end room next to the sterile supplies. I wheeled the ring stand into the substerile room and placed the packs I
AORN Journal
would need on it. As I distributed the packs in their proper places, I realized that I should include some delicate vascular clamps from the instrument room. Taking these from the shelves, I placed them in a wire basket, shoved it into the autoclave, and twisted the heavy steel door shut. After turning the starting dial, I returned to the OR and checked the sutures. The whine of the high-speed autoclave pushing steam into the inner chamber almost drowned out the greeting shouted to me by Dottie Smith, my working partner. “Hi, Johnny,” she shouted from the other end of the hall. “Hi, Smitty. I’m glad you finally got here,” I replied. “You’d better hurry though. We’re due to start a nephrectomy pretty soon.’’ I decided to fill her in after she had dressed. “I’ll hurry and change.” With a quick smile and a wave she disappeared into the nurses’ lounge. “What a relief,” I thought. I knew we couldn’t start the operation without her help. With everything picked for the operation, I decided to find out what was taking place in intensive care. Sitting at the main desk, I dialed their number. “This is Johnson in surgery. May I speak to Miss Rasmussen, please?” I tapped my pencil nervously on the desk while I waited for her to answer the phone. “Hi, Miss Rasmussen. This is Johnson. Dottie Smith came, but I haven’t seen any doctors yet.” “Yes, Johnson. The doctors should be there any minute now. Don’t worry about it. The patient’s con-
April 1973
dition remains unchanged, but I want you to stay in your department because we’ll be needing you soon.”
I could hear someone asking questions and Miss Rasmussen put her hand over the mouthpiece while she answered. I waited patiently for her to come back on the line. “Sorry, Johnson, but things are busy here. Both of you stand by. You’ll have to really hurry once we bring the patient down.” “Thanks, Miss Rasmussen. I’ll tell Smitty everything and we’ll be here.” At that moment, the elevator doors opened and two men emerged, pushing a shiny stainless steel machine. “That equipment certainly looks impressive,” I thought, as I moved forward to greet them. “Good morning, Doctor. I’m Mrs Johnson.” “Good morning. I’m Dr Chew and this is my surgical technician, Ted Long.” I nodded to the tall young man who was lifting the heavy cover from the top of the Belzer kidney preservation machine, revealing two plastic see-through domes on top. A panel of dials to regulate the Belzer made up the whole lower part.
“Is everything ready, Mrs Johnson?” Dr Chew asked. “Yes, Dr Chew. I have set up for
a routine nephrectomy. I put some vascular clamps in the autoclave. Is there anything else you’ll need?” “That will be fine. Mr Long will scrub up and help Dr Kountz regulate the machine. We’ll need a separate set-up in the room for the kidney biopsy. A Mayo stand will be sufficient.”
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“Ok, Doctor.” Dr Chew followed Mr Long into the doctors’ dressing room. I hurried down the hall to tell Dottie the latest developments. As we were talking, Dr Chew and his technician appeared at the door, dressed in their operating room clothes. “Where can I plug this Belzer in?” “You can use that one behind the Bovie, sir.” After putting on a cap and mask, Ted Long pushed the heavy equipment into the room. Dr Chew turned to me. “Good, you can check the status of the patient now. We’ll be ready in ten minutes,” he said calmly. “The last I heard the patient hadn’t expired yet.” I was a little shocked by this matter-of-fact approach. “Please check now. We can estimate pretty well,” he said flatly. “Yes, sir.” I walked out of the room glancing over my shoulder as I did so. The surgical technician was adjusting some dials as Dr Chew looked at the domes which would soon hold the cadaver kidneys in their aseptic interiors. The kidneys would be continually bathed in a chemical-plasma solution which almost duplicated normal body fluids. Under a certain cool temperature and pressure, the kidneys could be kept viable for at least 72 hours. This machine has saved many lives. I was anxious to find out more about it, but I knew this wasn’t the time to ask questions. Miss Rasmussen sounded relieved when I brought her up to date on the events taking place in surgery.
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“You certainly timed everything just right. Dr Brown just pronounced the patient dead. D r Kountz is getting the donation papers signed by the parents. We’ll bring the child right away. Even though we don’t think it will do much good because her heart isn’t beating, we’ll have her on an ambu bag, so don’t be surprised.” “Okay. We’ll be waiting.” “Now we must really rush,” I thought. I found Smitty putting some sterile supplies away. “Smitty, I’m going to scrub now. The baby died a few minutes ago, so they’ll be bringing her down right away. Dr Kountz wants you to know that the kidneys will only be viable for two hours after death, so we must make every minute count.”
As I was talking, we were walking into the scrub room lined with large white procelain sinks. I hit one of the handles, which protruded f r o m underneath the sink, with my knee. The water gushing out from the sink faucet sent a fine spray over my hands and arms. “I guess that Belzer keeps the cadaver kidney in good condition for a while till they can find the right patient.” Dottie seemed to be voicing her thoughts out loud. “You are absolutely right,” I answered. “Oh, I forgot to tell you, I’ll set up a Mayo stand for the kidney biopsy.” The irritating drone of the autoclave bell cut sharply into our conversation. Dottie left me to turn i t off. I could tell by her actions that she was having a few qualms about operating on a dead child, too.
AORN Journal
It was 9:45 am when Miss Rasmussen, accompanied by Dr Kountz, pushed a guerney out of the elevator. Still scrubbing my hands and arms, I walked a few steps away from the scrub sink to see down the hall. I was anxious to get a look a t Dr Kountz, who was well known for his kidney transplant work, but he had disappeared into the doctors’ dressing room. It wasn’t long before Dr Kountz, talking and smiling, led the procession down the hall toward me. As he introduced himself, I felt calmer. Dottie had pushed the guerney into the OR and Dr Kountz was gently lifting the dead child onto the OR table as I walked into the room. She looked almost alive. Her golden curls gleamed under the bright circle of light which shone from the ceiling. The sight of the lifeless child brought tears to my eyes. I turned my back on the scene to dry my dripping arms. I mustn’t let this get me down, I thought. I must hurry now if I’m to be ready by the time the doctors finish scrubbing. When I finally turned around, Dottie was having sympathetic pangs. When her eyes met mine, they looked pained. As she tied the back of my gown, we both tried not to notice the empty anesthesiologist’s chair which usually held one of the most important members of the operating room team. Dr Kountz, still scrubbing, walked to the open door to reprove us. “Let’s hurry now. We have wasted precious time. We only have an hour and 20 minutes to get those kidneys out.’’
April 1973
With those words, Dottie and I were galvanized into action. I worked quickly setting up my back table and the Mayo stand. Dottie pulled on her thin sterile gloves and pushed the prep stand over to the OR table. She concentrated on washing the small abdomen of the child’s body. We kept reminding ourselves that, in removing these kidneys from the dead baby, two other children would be kept alive. We were ready when the doctors walked into the OR from the scrub room with their hands and arms dripping soapy water onto the darktiled floor. After gowning and gloving the doctors, I handed the first drape towel to Dr Kountz. Dottie pushed the prep stand away from the table, stripped her gloves from her hands, threw them into the waste basket, and proceeded to tie the back of the doctor’s gown. The patient was quickly draped, leaving the abdomen exposed to the bright light. Dottie moved my back table into place while I handed the doctor the suction tubing and the Bovie cord. Dr Kountz clamped the Bovie cord on his side while Dr Chew, standing opposite him, put the suction tubing at the top of the lap sheet. Dr Kountz glanced at the clock as he held out his hand for the skin knife. I noted that it was now 10:30 am. We had exactly one hour to complete the whole procedure if we were to save the kidneys. Carefully I placed the knife into his hand. With scalpel poised above the operative site, Dr Kountz asked, “IS everybody ready?’’ He looked a t Ted Long standing ready near the kidney machine.
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“Yes, Doctor, the pressure and temperature remain stable,” he answered quietly. Dr Kountz studied the small abdomen beneath his knife. He made a positive long incision starting a t the sternum, and with one stroke he laid open the skin and fatty layer down to the pubis. Both doctors clamped the tiny oozing blood vessels with the mosquito forceps I slapped into their hands.
I took the skin knife away and replaced it with a deep knife. Dr Kountz held out his other hand to receive the thumb forceps I handed him. Carefully, but quickly, he cut through the layers, picked up the fragile peritoneum with the tiny forceps and nicked it with the sharp point of the scalpel. He clamped the edges of this tissue with more masquitoes, while Dr Chew retracted the outside layers. Dr Kountz’s main concern was t o remove the kidneys with the ureters and the blood supply intact. Wet tapes packed the intestines and other organs out of the way. With another long incision, Dr Kountz exposed the retro-peritoneal kidneys. He had used a mid-line incision t o dissect the large blood vessels a t the highest point in the chest and to follow them down into the kidneys, keeping the whole system together. Vascular clamps were placed as high on the large vessels as possible. With great skill, Dr Kountz dissected and tied until, almost before I realized he was finished, he had put the whole system of kidneys, ureters and blood vessels into a sterile pan, and was walking to the Mayo set-up near the kidney machine. Dr Chew followed. I was left standing a t the OR table, looking down a t the gaping red hole. Placing
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a sterile lap tape over the wound, I become conscious again of the still form whose face was covered with drapes.
I focused my attention on the hasty procedure taking place in the back of the room. Time was running short; it was now 11:05 am. I could feel the tension mounting. Carefully dissecting a thin sliver of kidney tissue, Dr Kountz picked up the 3-0gastrointestinal suture and sewed i t back together. He flushed the kidneys and attached vessels with the chemical-plasma solution. Dr Chew moved back to the OR table, being careful not to contaminate himself. We needed samples of lymph nodes for compatability tissue studies. As he pulled the lap tapes from the abdomen to expose the omentum, he was distracted by Dr Kountz, who was connecting the blood vessels t o some plastic tubing located near the two sterile plastic containers at the top of the kidney preservation machine. With cool chemical-plasma to fill the vessels, Dr Kountz exerted the full amount of pressure. Both doctors wondered if the cadaver kidneys would hold together and be able to function without leakage. “Please retract, Mrs Johnson.” The business-like tones of Dr Chew brought me back to the work a t hand. “Yes, sir . . .” The room grew still as we worked. Dr Chew held the thin omentum in smooth forceps with one hand and was trying to dissect the small lymph nodes with the other while I retracted with a Richardson. They kept slipping away from his fingers.
AORN Journal
“Mrs Johnson, I want you to pick up the lymph nodes with your forceps and I will cut them. Please put some saline in a cup and put it right here.” He indicated the spot with the small Metzs he held in his hand. “These are the nodes I want you to pick up.” He pointed to some small lumps dotting the thin apron of tissue. We worked rather quickly. Once a lymph node slipped from my forceps just as he started to cut it. “Sorry, Doctor,” I murmured. “That’s okay. Try to locate the larger ones now,” he instructed. “Why do you need so many lymph nodes, Doctor?”
I grasped a very large node with my forceps. As he started to cut it, he explained: “We need these and the other samples to get the closest possible match between the donor and recipient. We not only take this information from the cadaver kidneys, but we also obtain biopsies from the recipient. We feed information on the tissue studies into a computer and we are able to get a close match.” Dr Chew paused and looked down at the node he was dissecting out. “DO many people donate kidneys when they have loved ones who have been critically injured?” I was really interested in his answer. “Some people do, but not nearly enough. There are about 3.000 kidney-diseased patients waiting for donors in the United States. These patients can be maintained on kidney dialysis machines, but the procedure is expensive and trying for the patient.”
April 1973
“Could you explain more about the tissue studies?” We had gathered about 20 nodes and I was struggling to locate the largest to hold for the doctor to cut. Dr Chew seemed enthusiastic about giving me information and he continued talking while he worked. “Recently, Dr Kountz, some of his colleagues, and researchers from the Irwin Memorial Blood Bank found that cells from the kidney are better to match with those of the donor than the white cells they have been using,” he explained. “We used to spend hours studying different tissues from the donor and recipient to determine which cadaver kidney belonged in which ailing patient. We had many rejections. Now we feed this information into the computer. Within seconds the computer makes the choice, eliminating guesswork and making a true match. This more scientific approach lowers rejections.” Pausing, Dr Chew questioned Dr Kountz, “What about it, Sam? Do they leak?” “They’re working just fine, Bob,” he answered happily, “and just in time, too.” Everyone looked at the clock. It was 11:25 am. “That was close.” I breathed a sigh of relief. The tension seemed to vanish as we turned back to our work. Dr Chew continued: “With the development of the kidney preservation machine and the tissue compatability studies, and with the help of the computer, much of the heartache has been taken out of kidney transplant surgery.”
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He had taken all the lymph nodes he needed and he was ready to sew up the long womd. I handed him the needle holder with the # 2 retention suture. The huge cutting needle gleamed in the high-intensity light. It looked almost as large as the small body lying there. “Well, that’s about it. Please put the biopsies into sterile test tubes in a little saline. Be sure to label them carefully, for without them this whole operation would be useless. It doesn’t do any good just to put any kidney into any body. They must match.” He finished his last stitch and held up the ends of the heavy suture for me to cut. “Thank you so much for telling me all you did, Dr Chew.” “You’re welcome. We need more interest in this procedure so that more people can tell our story intelligently.” He smiled as he took off his gown and mask. Everyone seemed pleased as the doctors followed Ted Long, who pushed the machine with the pulsating kidneys down the hall. Dr Kountz stopped in the hall. “Will you bring those biopsies to the desk? Be sure they are labeled properly and that you include the time and the date.” He smiled, his brown eyes softening. “We must rush these samples and the kidneys to the medical center just as soon as we can.” “Yes, Dr Kountz. We’ll have them for you right away.” I went back to the Mayo stand as he walked on down the hall. I labeled the sterile stoppered tubes, noting the type of tissue, the date and the time it had been removed. Gathering up the specimens
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I hurried after the doctors. As I walked toward the desk I felt rather strange leaving the body lying there alone. Once the most important object of our work, she would be pushed aside to await the coroner. I had to remember that we had really done the first part of an autopsy. The only reason she had been brought to surgery instead of the morgue was the fact we had to keep the kidneys in an aseptic condition in order not to infect the children who would be saved by the transplantations. With these facts in mind, I approached the nurses and aides who had gathered around the machine to watch the small kidneys, protected behind the transparent domes, pulsating and moving just like a small heart. The renal arteries were connected to some small plastic tubing which disappeared into the inside of the machine, while the renal veins and ureters were left free, lying next t o the kidneys. Dr Chew was answering questions while he waited for Dr Kountz to come out of the dressing room. “Doctor, what would happen if you put these small kidneys into a grown man?” I asked. “A child’s kidney, put into an adult, grows rapidly to handle the work of a larger body. If, on the other hand, you put an adult kidney in a child, it will shrink to compensate for the small amount of work it would be required to do.” Dr Chew smiled a t the wonder on my face.
“It’s difficult to believe, isn’t i t ? However, these kidneys will be transplanted into two critically ill children who have been kept alive by dialysis.”
AORN Journal
“How wonderful for those children and their parents. I think your work must be very rewarding,” I reflected. “Our work is very gratifying. With cadaver kidneys we are successful with 70% of the transplants. With relative-donated kidneys, our success climbs to 90%. Our sadness comes from the fact that we are forced to stand by and watch patients die for lack of donor kidneys. Because there is a complete lack of understanding, we need to inform the public that kidneys are removed only after death has occurred and critically ill kidney patients will survive ony if donor kidneys are available.” He paused to let his last statement be absorbed, then he continued thoughtfully. “Some families take comfort in the thought that, although their loved ones have died, in donating their kidneys they have given life to someone who may otherwise die.” When Dr Chew stopped talking, we all stood in awkward silence, moved by his emotional appeal. The spell was broken by the approach of Dr Kountz and Dottie Smith. “Thank you so much for your help, Mrs Johnson and Miss Smith. I can tell by this serious atmosphere that Dr Chew has been expounding on his favorite subject-kidney donors. Just pass the word along and some day we may have all the donors we need.”
Both doctors smiled at us and followed Ted Long into the elevator. A special van was waiting outside the emergency room doors to rush them with their precious cargo to the hospital in San Francisco. As Dottie and I watched the elevator slide silently downward, we looked a t each other, quietly dreading the thought of fixing the small body for the coroner. Together we returned to the operating room. Without saying a word, we removed the Foley catheter, the tracheostomy tube and the intravenous tubes, trying not to look at the angelic face of the dead child. As Dottie and I lifted the lifeless form back into the crib, I thought . . . “for their love of Carrie, her parents gave this gift of life
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Now two other children could live
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REFERENCES I. The Max team is a group o f four nurses who have completed a cardiac care course. The Max Cart i s a mobile, self-contained unit with cardiopulmonary equipment including emergency drugs. The unit i s electrically operated with a standby rechargeable battery. Every shift has two teams assigned t o respond t o code zero. Available doctors also respond.
2. Samuel L Kountz, MD, now chairman, Department of Surgery a t Downstate Medical Center, Brooklyn, NY.
“Latest bulletin from Dr Samuel Kountz: Both children continue to do well on the donor kidneys.
Drugs figlrf g r u m posifive infecfions The cooperative interaction o f penicillin and a variety o f gonadal steroids may combate severe gram positive infections, according t o investigators Thomas Fiizgerald and W i l l i a m Yotis, the Medical Tribune reports. Investigators said steroids markedly reduce the growth and virulence o f staphylococcus aureus. The addition o f penicillin greatly enhanced the steroidal influences, they said. They cautioned that more detailed animal experimentation i s necessary, but preliminary experiments with mice have been very encouraging.
April 1973
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