When most people think of organ donation, they conjure up a Hollywood version of it. An emergency department staff member urgently approaches the family of a brain-dead patient, and asks them to donate organs while a patient needing a heart or lung or kidney waits nearby.
“People think that's what goes on in the emergency department,” said Clifton W. Callaway, MD, PhD, an associate professor and the executive vice chair of emergency medicine at the University of Pittsburgh School of Medicine. As the leader of a federally funded project to increase organ donation through the emergency department, he knows that this is far from what actually happens. Most people are approached about organ donation when a loved one is in the intensive care unit or on the floor of a hospital. After 18 months of working through the ethics and logistics of a plan to increase organ donation after cardiac arrest in the emergency department, Dr. Callaway has yet to achieve a successful donation.
The biggest concern was the ethics of doing it in the emergency department, and whether it would affect emergency care, he said. “As an emergency physician, I felt there was no way. I don't know they are an organ donor until I call CORE, and they look it up on a list. There would be no tainting of resuscitation efforts based on organ donor status,” Dr. Callaway said. Only patients for whom everything has been done and who cannot be revived are considered, he said. The donation occurs after cardiac death — no heartbeat, no breathing.
Logistics was another issue, he said. His department's protocol mandated that the ED call the medical examiner and the organ procurement organization. “Like all emergency physicians, I handed it to the charge nurse, and the patient was whisked to the morgue,” he said.
But European nations, particularly Spain, developed a process that increases the rate of organ donation through the emergency department, and Dr. Callaway said he mimicked many of the features in that country in setting up his program, adapting the Spanish program to his hospital. He also built firewalls to prevent even the appearance that care would be less than optimum for potential organ donors. “Anyone involved in organ procurement could not be working in the emergency department that day,” he said. The call list was set up based on those criteria.
“After a patient has been pronounced, a separate team arrives to put the patient on perfusion,” he said. They use a special solution delivered through catheters to cool and preserve the organs until a surgeon can arrive and take the liver or kidney out, the two organs on which they decided to concentrate their donation efforts.
“We got different pieces of the hospital to work together,” he said. “The responding physicians who came in to place the catheters turned out to be me and other emergency physicians [who were not in the hospital at the time]. We worked with perfusionists who helped us set up for the catheters. We got a pump to do the perfusion, and kept it in the emergency department.”
Possible donors were taken to the operating room, and transplant surgeons were paged to determine which cases were suitable for donation, Dr. Callaway said. “We decided to do this only on people who had designated themselves as organ donors on their driver's licenses or on the list with the CORE. The family's comfort and opinion is of interest, but the donor's designation cannot be undone,” he said. “However, if the family was in distress or found this unpalatable, any member of the team could call it off.”
Time proved the biggest challenge, he said. “The clock starts when resuscitation stops. We need to have cannulas in and organs cold within 30 minutes if you are to consider a liver and within an hour for a kidney. It sounds great on paper.”
In practice, it was harder. The pager goes off, and the doctor drives to the hospital, but is usually not in the room with the donor until 35 minutes or more have elapsed. “Sometimes it went smoothly, and sometimes it took 20 to 25 minutes to place lines,” he said.
It also turned out that organ donors from the ED were relatively rare. Although the trauma center has 52,000 visits a year, only five cases activated the process since it was started 18 months earlier. “We are in the middle of Pittsburgh and a referral center. ‘Dead in the emergency department’ is not as common as it was once was. We looked at the log. People die elsewhere (in the hospital),” Dr. Callaway said.
Other factors played a role as well. Only about 40 percent of residents in the area are designated as donors, and Pittsburgh paramedics pronounce at the scene, transporting cardiac arrest patients only if they get a pulse back. Of the five cases for which the donation team was activated, they ran out of time on some, and in one, procured kidneys could not be matched to a recipient. While Dr. Callaway said he was disappointed, he said was glad the process worked. His institution is pondering how to continue now that grant funds have run out, perhaps activating the protocol only on cases where circumstances are on their side.
Glen Michael, MD, an emergency medicine fellow at the University of Virginia School of Medicine in Charlottesville, and Robert E. O'Connor, MD, said successful donation is more likely if donors are referred from the emergency department. (Acad Emerg Med 2009;16:850.) In evaluating more than 6,700 donor referrals, they found that younger age, mechanism of injury, and referral from the emergency department were significantly associated with successful organ retrieval.
Dr. Michael said, however, that referral means only making contact with the organ procurement organization. The donation request is made by a member of that organization, not by the emergency physician, to guard against a perceived conflict of interest. He agreed that Pittsburgh faced a critical time crunch. “In donation after cardiac death, a very, very short window of time exists in which a patient's organs may be retrieved and be healthy enough to be transplanted. They have mere minutes to make a determination and then proceed to the operating room where the organs can be retrieved.”
Streamlining the referral to the organ procurement organization could improve the process, Dr. Michael said, adding that some EDs are refining the process to make it less burdensome on ED staff. “This is exciting because it has the potential to increase referrals from the ED, and have a meaningful impact on the number of organs successfully donated,” he said.
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