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Duke Hospital Admits to Botching Transplant

Feb 17, 2003 | Duke Herald Sun

Duke University Hospital on Monday admitted a "tragic error" in transplanting the heart and lungs from a donor with the wrong blood type into a 17-year-old girl, who is now in critical condition and facing death without the right organs.

Mack Mahoney, a Louisburg benefactor who raised money for the procedure for Jesica Santillan, said the transplant made her condition worse and that doctors told him she might have had an additional six months before the botched surgery. Mahoney has medical power of attorney for Santillan because her parents do not speak English, he said.

Duke would not comment on details of the case but admitted its error in a written statement released Monday evening.

"In our efforts to identify organs for this desperately ill patient, regrettably, a mistake occurred. We are taking immediate steps to further strengthen those processes within our control here at Duke and will work to identify ways to improve the entire organ procurement process," said William Fulkerson, a medical doctor and chief executive officer of Duke Hospital. "This was a tragic error, and we accept responsibility for our part. This is an especially sad situation since we intended this operation to save the life of a girl whose prognosis was grave. Jesica continues to remain at the top of the national organ donation list.

"We have performed thousands of successful solid organ transplants here at Duke and while this is the first such error, we are strengthening processes to make sure nothing like this can happen again," Fulkerson said. "Every effort is being made to save Jesica’s life. Our primary concern has always been for Jesica and her family."

Heart was too big

Santillan’s original heart was too big and touched her lungs, cutting off blood. The surgery took place Feb. 7.

The teenager has O-positive blood but received a heart and lungs from an A blood type donor from New England, an organ donation official there confirmed Monday. Other than in some cases with infants, whose immune systems are not fully formed, heart and lung transplant donors and recipients must share blood types, said Joel Newman, a spokesman for the United Network for Organ Sharing [UNOS]. Otherwise, the body rejects the organs.

Additional safeguards Duke announced Monday "include multiple confirmations of donor match by members of the care team before the transplantation process begins and improved communications between Duke and the organ procurement organization," according to the statement.

UNOS maintains the national list of the 80,000-plus patients waiting for organs of all kinds to become available.

Different criteria help decide who is next as organs become available. For a heart-lung transplant, the main factors are matching the blood type and physical size of the organs and looking at how long the person has been waiting, Newman said.

Once a person becomes brain dead, a local organ procurement center is notified and next of kin are asked if organs can be used. Once permission is given, the UNOS list is consulted, and a computer searches geographically for a match. The local OPC is Carolina Donor Services on University Drive.

Only two cases of the wrong organs reaching patients have been recorded, with both occurring in Oregon, Newman said on Monday. One patient died and the other did not.

Eight-hour deadline

In Santillan’s case, the New England Organ Bank found the type A heart and lungs and somehow O positive Santillan was matched with them. The mismatch was not caught in pre-surgery protocol.

Matches do not strictly come from the national list, said Sean Fitzpatrick of the New England Organ Bank. He would not comment on Santillan’s case but said sometimes large transplant centers like Duke are contacted if a more local person is not found for the organs, and no one on the national list immediately surfaces.

Officials at Duke, or a like facility, are then free to find a suitable patient to use the organs before they expire, after about eight hours in the case of a heart and lungs, Fitzpatrick said.

As Santillan remained in critical condition Monday, Mahoney stayed at the Brookwood Inn at Duke University across from the hospital.

"I’ve been at this hospital for 10 days. I can’t sleep. Every time I go to sleep I hear that baby beggin’ me to help her," he said.

"She was awake and she was begging me in Spanish, saying, ‘Ayude, ayude, I can’t breathe, I’m dying, please help.’ And I said, ‘Baby, you’re not dying; you’ve just had a transplant,’ and she started hemorrhaging from the nose and they ordered me out, and the child’s never been awake since."

Across the country, 80,552 are people waiting for organs to become available, and 197 waiting for heart-lung sets. Those 197 people, like Santillan, have to compete with those who only need one organ or the other. There are now 3,821 waiting for lungs and 3,867 waiting for hearts, Fitzpatrick said. About 6,000 die each year waiting for organs that never become available.

Jesica’s Hope Chest

Mahoney and his wife Nita started a foundation called Jesica’s Hope Chest and raise money for the care of terminally ill children. They live in Louisburg in Franklin County and read about Santillan’s story in the local newspaper several years ago.

It "touched our hearts," Nita said.

Santillan and her family are originally from Mexico and do not speak much English, Mahoney said. Three years ago, immigration officials were threatening to deport the family until Mahoney traveled to Washington and spoke with then-U.S. Sen. Jesse Helms, a Republican. The senator made some calls, and the Mexican family was then left alone, Mahoney said. Now they are in an amnesty program and are applying for residency, he said.

"[Helms] told me to go back to Louisburg and as long as they stayed out of trouble they didn’t have anything to worry about," Mahoney remembered.

The businessman and philanthropist owns a building company and arranges for builders and subcontractors to donate time and material. They build homes and then sell them, with the proceeds going to the Jesica’s Hope Chest fund.

He and his wife have become emotionally involved and feel like their own granddaughter is dying, he said.

"What I’m trying to do is find my baby some organs and talking to the donor services and Duke Hospital. I’ve got to find this child some organs; she’s suffering," he said. "I’ve got to find away to do this. I can’t sleep; I can’t rest until I’ve succeeded."

Soon after Santillan fell unconscious, Duke informed Mahoney and the girl’s parents about the mix-up, he said.

"My God, I was horrified. That doctor told me they had transplanted the wrong organ and he had made a mistake and that he was sorry. I told them, ‘I’m sorry I can’t translate it to her and tell this grieving mother. You need to get somebody who has bereavement experience.’ They got a hospital translator and they told her, and the mother almost fainted."

Jesica’s Hope Chest recently had 10 children on its list, but two of the children have died in recent months, Mahoney said.

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