UL - 71065586 AU - Ingall JR TI - Transplantation and the local physician. LA - Eng MH - Heart/* TRANSPLANTATION MH - *Heart Transplantation MH - Human MH - Patient Care Team MH - *Physicians MH - Transplantation, Homologous PT - JOURNAL ARTICLE DA - 710210 DP - 1971 Jan 15 IS - 0028-7628 TA -N Y State J Med PG - 248-52 ZN - Z1.107.567.875 IP -2 VI - 71 JC - OBA EM - 7103 SO -N Y State J Med 1971 Jan 15;71(2):248-52 caw Wow saculd we BOS ET EE HES ud 6 Be Pen ve ‘ ie y ere : 1 race JOHM ROE. INGALL, MUD. Butfaia, New York FRCS. Duecior, Regional Medics! Program for Western tla Yorn, Stato University of New York at Buffalo Dolly we hear about the fanias te achiovenonts of our colleagues in the realm of transplantation sin this field undoubtedly J aya sure » the wi in facilit eating vhis The most dramatic for ‘ invelve replacement of the cart, sul ject of the practitioner’s rae work is of cor sider ob 2 pertinc matey, mesing je ude gmente Which wi of this reals: of in munslety CAL gery expeditiously to the pati ient. The role of the ailending physician is vital. Liis judsment and participation in vise "clinical phere in decisions cn which the patient and h's fam a must axree, ere of the utmost importance. An G 5 force ae the benefits diolugy, and sur understanding of the complex factors that nreced s decision for transplantation aud a well- maifermed capacity for judgment must be consid ered our obli- gations in the future. This is part cubanhy true in relation te the potertial do nors ny, an estah lished protecol fcr transplar tac ‘Phere are inany recels to be ing a well-disciplined considared in cffect- system in the New Yors ares, indeed in any area. We cannet afford to porpeaa- ate the naive attitude which compos us to geck a “first? in anything other then a teara effort. in other words, a desire to perform a techn vically feasi- ble bit of curgicel skill before another group snould not cornmpromise judgment; the decision as to sual: ability ef donor or recipient lies dominantly wiih the bnmunologist. ‘The compctitive appro agach can only serve to the detriment of the patient, and in the case of cardiac transplantation the cutcome may be fatal. approach the problem? Jn ihis article Eshall make a few observations and sugges: Boe Presented tothe New York State Heart Assembly, May, 164, at Bufinio, New York. "945 Now Yark State Journal of Medicine / January 15, 1974 - blood ser in the hent. of ay caper offores: det af ihe Rosinnal Mearcal Pre tions. enee ail know - a+ . ai, 5 AT gram for Western sew York. rE eyed he achatca! OXPO heart for perfernuing transplanta exists in mere than ene insiicctien mi ESE Ne Wort, Kyuerienced mien who are nthusissws we possibility of Gos Lrans. throughout sovernl ereas. such @ vital factor, indeed af e chong device a cousoruun of Crese well-drained gon Gt Gan center, ayrecd on py all, ac whiel: all the week should be dove, pealive this view will nol be sna rd by all, Having i. io one of my colleagues, plants ar Where MePyayve! be a preminess, } VW ei a al thie YONeu tras 5 ae aN yee ” iL wees ite pines) by fi ta an Inchercent tovet.? “Pue é eniewen inshinrc, per se, Snes service and research is not unten ai re . able. The bo can continue without aris fee] i *y + yeategares, I34 tah way bys fee SOP Oe ohvigs rene) yu any LSS E nfial: (Vk + tho immanolks (5) the | and (3) the cost—-niot the least YECIPHCMAS; 1 ay ransplentation ecater Lo be develey pod CY eu: smportanut. A scventh port ast also be cons vontion Ace we in any way cymving th to the Cetuiment of pissy noon’ hisve lationstin te funds Soveds pyre- BOPVICes goa, Wai re: aareayt Ovals * Vt we +, voal are able, the right Y ey tee gs + cpr Lhe perspective om Lae pe salpeyn? Pave we, ethucelty af Po ge- raven adhe correcy Sire we Le (the ayer | OMe. and mm all pron! aver Gra: otic, eapechal tends io gel oul oF per speelacnianly cugiing some! hin have been Moved 9 happen does wad to over. shadow, indecd completely obliterate, the uv {Be SCY of the Jess drariatic causative ment, Rheumatic fever still cxists In Western New York; this disease, and.c rongenital dcicets, which predcter nine the probicms for which br area &- tion (or indecd any cardiac euryery, is poquired should be tackled with: the negiension they ner) H, Tf we ave te look for financial support in the sphere of carciac or any other of ireneplantation, then we mau ft do se as & COIN vosiie atiack an the congenital and acouiied problems. Merny of our patients would nol demand tran plan! tnijons hud ihe rool, cause for theiy detericestion been tackied. vy 5 , 5 forms ’ cope see § pe sm MB chee committe matinee te : foaeesaeas eens ASD oot eee ca age Mee ime cette a Donor group . Let me consider the first of the categories within the system I have mentioned, namely, the donor group. J pul this first because the recipient group as such is well defined. ‘Transplant recipients are usually confined in one of our hospitals and un- doubtedly have had their immunologic portraits well detailed. They await. donors with compatible templates. The donors, however, are a prore Con plex problem, and we commonly have less time for preparation, often they are miles removed from the site of the potential recipient. The comparative urgency in heart transplantation has resulted in surgery first and typing afterwards. ‘This 38 ac- knowledged to be the wrong sequence of events. The larger the donor panel the greater the ikel- hood of a perfect match. Indeed, it might be said that a surplus should be devisea; recipicnis in no sense are expendable whereas organs may be. In our attempt to develop a panel of ideal donors, or most suitably matched donors, we are depend- ent on a large arca as catchment for these people. Within such a large area it is iraportant that the physicians of the entire region understand the system to be established. 1 would not like it mis- takenly assumed at this point that the system is in any way def ined. My purpose in bringing this point to your attention is, the larger the donor panel the more Vkelihoed of better service to the patients 1m necd, Good logistic planning must recede transplantation service. Jn other words, -‘Tfeel thet the basis of a good transplantation center is the donor reservoir, unprediciable as iiis. This in turn must have speedy access to 4 central irnmu- nology service, 4 service which I have suggested must be clinically oriented but not divorced from research. In studying the system and bringing it eff ‘ective- ly into being we should decide, for example in the Western New York area, on 4 uniform, familiar procedure to transport the donor orgen to the re- cipient. The experience of otbers in this realm should not he ignored. We have the capacity with- in the Regione! Medical Program to bring about a cooperative venture which will facilitate this transportation. The system and-its application, dependent as it is on the expertise of the immunologists, cannot function unless those engaged in medical practice throughout the area understand how they can participate. The regional physician must know how his sudden-accident patient, close to death or just deceased, can be put into the well-planned mechanism for matching the organs available to the ideal recipients. It is my personal view that the two most important components of a heart {transplantation center are the pnmunology service, on which we are absolutely dependent as surgeons, and the donor panel, without which nobody can receive an organ. ‘The development of organ banks remains in ai early stage, put eventually these may replace the “fresh? donors needed at the present time. Tam confident that (he surgeons in Western New York: ure available and qualified te performs trans- plantations of jeart, kidney, hver, hang, or pan- creas, ‘This would sceni (o me no problem. How- ever, In developing the system that Thave outlined, | the donors must munber as many as possible, and the immunology service must be well recognized as a center that functions twenty-four hours per day. There is no reason to differentiate one day from another, and the traditional concept of a week, indecd of days, night well need drastic read- justment. Our patients must be protected hy high-quality tiesue matching done at the earliest possible moment, without dangerous slack periods occurring on Saturdays, Sundays, and at night. It is not my purpose here to discuss the problems within an immunology cervice, nor do | feel compe- tent to do 80. asically, however, T think all must realize that the demonstration of the immune mechanisms, the difficnity with various scra, and the gradual puprovement of the technics in speed and accuracy are growing apace, and that fragmen- {ation in this sphere alone would undoubtedly be to the detriment of all. And J speak consciously and specifically about the patient here. We cer- tainty need the enthusiesm present in departments that may be fragmented, but in this most imper- tant concept ib is vital vu Have Oe department one caichment area. The construction of the donor panel 3s impor- tant; it can only be constructed with the approval of the majority of physicians in the region. The Jatter can only approve something which is under- standable. The system must be clearly explained, with the logistics, {he time intervals, the ethical considerations, the transportation, and other prob- Jems well defined. It would scem possible that in each of the major hospitals, certainly in those with a large joad of traffic accidents and neurosurgical cases, the responsibility should lic with one mem- ber of the staff who seeks the judgment of the al- tending physician, oF vice versa, when one patient is a possible donor, so that the earhest feasible no- tification of his pending contribution to another can be made. Undoubtedly, this macabre ap- proach needs good public relations. ‘The thought of our colleagves hovering around the bedside of the moribund patient like vultures is no image to give to the general public, nor is it, indecd, an image that would in any way be merited. We have to remember that our mission as physicians is to preserve life of good quahty, and itis for this reason alone that we are interested in the {transplantation of patients’ bearts and other organs. Another important factor in developing the donor panel is to snform the public of what. can be done. ‘They must fecl assured that their loved January 15, 1971 / New York State Journal of Medicine 249 ones will not be eviscerated by surgical predators without consultation. I realize that the contact with patients’ relatives is generally extremely good; on the other hand there is an aura of mystique about this transplantation business which bas in some spheres alerted and frightened the general public. They alone are custodians of the bodies of their loved ones, and they alone can give per- mission. J therefore fecl that the public at large must be confident and informed not only about the privilege of taking one organ from one person to another, but also that the organ that is being con- tributed by them will be used in suitable fashion by those taking it. This whole concept must. also rely on an efficient closed-communication mecha- nism, the clements of which’we already possess. Recipients _ prejudice our results. tt e Now I come to the recipient group, those people who sufficiently need a transplant to preserve a useful Jife. The majority of. practicing physicians must have had the experience of arelatively young patient dying through sheer cardiac exhaustion or renal or hepatic failure. lt. is vital that a good panel be brought together, and this must include the regional physicians, to construct some guide lines, some criteria for the guidance of their col- leagues throughout the region in making judgments on the recipient. Specification of the qualitics of a yecipient should certainty be made at this time; rules which we have had a part in formulating and to which we can refer: a set of decisions to guide us and support opinions for or against transplanta- tion. Certainly these wil] be subject to pressure from time to time. Yielding to this pressure and calling it intelligent cormpromise would probably I sincerely believe that a yesponsible group is required now to construct, with all the advice available, some initial rules for reference. Heart transplantation has brought certain medi- cal, ethical, and Jegal questions into critica) focus. Paramount among these guestions is the determi- nation of death. The right of the prospective donor to the best possible medical care, a right which his potential role as an organ donor must not be allow- éd to abrogate, raust remain sacred. The growing ability-of medical science to maintain life in some form of biologic function for prolonged periods adds “to the difficulty of defining the point of irrever- sible dissolution. The cause of death must be evident and irreversible. The fact of death must be established by adequate current and accept- able scientific evidence in the opinion of the phy- sicians making the determination. Transplantation center Where would the recipient receive his trans- plant? I have tentatively suggested that there should be a transplantation center, an inslitution 250 New York State Journal of Medicine / January 15, as a separate entity or as part ofone of the estab- lished institutions where transplantation is done. The recipient group should all converge on this center, so that all things can be done with team work in av established fashion. I would reiterate that we as physicians must readjust our ideas on what isa workpig period. Ifwe are truly interested in the patient from the point of view of speed, ideal watch, and so forth, the transplantation service should develop. the attitude that there are 365 days in the year. The traditional seven-day week is now defunct as far as service is concerned or attitudes to it. ‘There are twenty-four hours in a day and none should be inconvenient or depleted as far as manpower oF equipment is concerned. The laboratories and ancillary services must like- wise be planned to ft into this conecpt without. loopholes. ‘The service that many of us are obliged to give, particularly when tired, getting up at night is no substitute for a good shift system. This applies especially to those involved in such a dramatic and important exercise as organ trans- plantation. 1 am perfectly well aware that there will be objections to this concept. 1] am equally aware that some of these comments apply to a first-rate accident service. When the transplan- tation service evolves, it js doubtful that we will perform more than, say, six heart transplants a year; but this figure wil] increase. 1 do not, how- over, fecl Unat it is many way justified that in such importeut matters a person OF tecan tired from pre- vigus work or obliged to return from other involve- ments, which they undoubtedly must have, should pe committed to the service of any such patients as Ihave outlined. It may be worth reviewing the situation of trans- plantation as an entity; would it be reasonable that we as physicians in Western New York ask for a transplantation center rather than the old organ- oriented institutes so common throughout the world? Would it not be more imaginative to acknowledge we are dependent on an immu- nology service to devise this whole transplantation program ground the typing and matching-up lab- oratory procedures which are such a vital compo- nent? We are dependent on the immunologist, and he even may be the focus of the entire system. Phere are many difficulties ioherent in this view: on the other hand, the services to one organ are al- most identical to the services to another. if we develop a kidney transplant unit at one point, 4 heart transplant umit at another, and liver and Jung transplant units in yet other areas, we are not Jooking at the whole problem in the best systematic manner. ‘the laboratory in which the typing, electromicroscopy, and pathology are carried on ghonld probably be all in the same geographic sit- uation. Tam well aware that in these days of good com- munication and good transportation a center such ‘ag we envisage has no need to be structurally at one 1971 os a cae rere me Mite ‘= Jocation. A system or an organization can he a single entity if the Tinks between the components of the system are firm. I have Jong felt that the concept of all being one biy happy family in one place is fraught with many difficulties, including petty squabbles augmented to internecine war. Indeed, many families work better when (he men- bers leave home than when they live with mother! The unit concept, however, must he seriously considered when we talk of laboratories, trans- plantations, and ancillary services. We have neither the people nor the money to permit frag- mentation, and the ime is long past for competing to give this cervice: | would like to think the social scene alone as it has evolved will demand coopera- tion. This problem has been discussed many times, and the consensus of those whom I have asked for an opinion would seem to favor a center for irans- plantation. Over-all, my colleagues, with some notable exceptions, have suggested that a center would be best organized around the immunology department. On the other hana, there are some immediate logistic problems which suggest the service involved in the transplantation wark should be adjacent to the clinical transplantation center. This would need reappraisal by the surgeons, the immunologists, and the others as to the best way of doing this: in other words, in the words of a well- known limerick, “oho does which and with what andia whom.” Administrative problems alone are legion, and it is vital to extablish rules for the administration of the system, to devise a flow pattern $0 that the detailed administrative affairs repugnant Co ynost of us involved in clinical matters be dealt with by someone of adrninistrative authority and experi- ence, To delegate the responsibility for this to such a person would undoubtedly alleviate the pressure that these affairs have on the components of any ststem, transplantation, blood manage-’ ment, or otherwise. Immunology service The third factor in the plan as again outlined to you earlier was the immunology service. ‘The information explosion in all facets of medicine has been nowhere greater than in immunology. Indeed, it would seem that most of the Nobel prizes are going (o those involved in this sphere or those closely adjacent to it. Giving the label “service” means that we can apply the criteria in matching that are already well established, ‘This is the very meaning of the word “service.” The science-L0- service concept would be very well exemplified should a {transplantation unit have this com ponent built in. We must realize, however, that to divorce the research and service elements inanim munalogist’s work is ridiculous, for undoubtedly the information January that will cmerpe fram the service given is in itself a valuable rescarch entity and will provide. infor- mation from which we can improve the services rendered. In devising & method by which the clinically applicable advances that emerge fro the laboratory can come immediately to the paticnt’s bedside, it would seem to me that the immunology component, laboratory, What you will, that is part of our transplantation services should be closely associated with the research entity, should in fact be indivisible from it. We in Buffalo are fortunate to have world au- thorities in this sphere. Perhaps we have not done transplantations any earlier because the caution of these knowledgeable men has been an important factor in making sure that the material, or poten- tial motoriel, that our surgical colleagues have to work with is the best. As J said earher, we are really looking for the best and not the first. Dempster, Melrose, and Bentall! acclaimed the first human transplantation as @ milestone in the treatment of heart disease. However, they also state that a long time and an immense effort he between this first technical achievement and even- tua) routine therapeutic application. They point out that cardiac transplantation could have been gone in their own hospital. This is not ‘sour grapes.” The practical, moral, and legal consid- eration convinced them that such a procedure was unjustifiable when large numbers of people are on their waiting lists for more routine, acceptable, and proved therapies. We must remember that medical practitioners rust subject themselves to thoughtful intraspec- _tion in ethical and humanitarian terms, consider- jing whether prolongation of life, or in some cases prolongation of dying, is worth the price that is sometimes paid in human suffering and burdens on socicty.? Blood service A few words about the blood service. Undoubt- edly, comprehens) vencess of blood transfusion and adequate service 3g In itself an enormous factor 1 the region. ‘Phis has heen under discugsion during the jast few years, @ nd J genuinely believe that very shortly the authorities who have studied this will be able to devise 4 system that will not only benefit the transplantation group, if and when this 5 eS- tablished, but also the entire Western New ¥ ork region. This is in itself an enormous subject, but it has to be considered in this matter under discus- sion. Cost Now J come somewhat uncomfortably to cost. This is certainly not the least important of the matters that concern us as physicians in the area. This includes the cost of the actual transplan- 15, 1971 / New York State Journal of Medicine 251 ‘ a 4 4 4 Nels pe eet Fesrithaiiyci DENE Boe! (ation, the cost of the service, and the cost of the rehabilitation of the patient. Jt is redpndant (o go into all the facets with which ] am sure you are fainiliar, but in considering this matter we have fo look on the problem from the point of view of the relatives, the patients, and the team involved, It is unreasonable fo underestimate the cust of anything these days, and if we ere to make any judgment on the money required this should be done in relationship to previous experience which is considerable throughout the country, indeed throughout the world. The astronomical expense surely cannot be borne by the patient and the relatives. It wil] have to be decided that under no circumstances should the patient subjected - to this procedure have to pay in part or in whole. If we solve the immunologic problem, which ] think we can, and if we solve our team approach to the program, which is obviously possible, we must not fail to solve the problem of cost to the patient, who always comes first. The rehabilitation services which embrace sev- eral disciplines, psychiatric and others, have to be given their part in the over-all plan. Lip service to their part in returning the patient to useful life is no longer acceptable. Prevention Finally, I would like to make a few comunents about this transplantation concept that we have in mind, and try to bring the whole inatter into some perspective in relationship tc our approach to dhe health of the population at large. The question is, are we in any way evolving these strv- ices without considering the potential in the pre- ventive aspects of our profession? We are, ub-— doubtedly, going to be judged as were those who cured cholera and sent their patients back to drink infected waters. We will be judged on not only the transplantation that we are capable of doing, but also on whether we are in any way preventing the need for a transplantation, Active programs in Buffalo and elsewhere have been conducted in prevention of kidney discase, especially in children, and in screening for rheu- 252 New York Stato Journal of Modicine / January 15, 1971 matie fever; i is an embarrassment, indeed a tragedy, that rheumatic fever should still exist in this region. In the genetic field, we have possl- bilities of obviating the occurrence of cardiac anoinalies which eventually lead to the demise of their hosts. TP would suggest to the reader that i thinking of a transplantation service, and certainly in deciding to apply for monies to carry on such a fayereaching and advanced immunosurgical exer- cise, (hat. the mood of those in a position to support an enterprise of this nature ig in no way disposed favorably to what has been called the “obsessive” blinker approach to a problem which ignores the root cause of the same. J’ven Washington has the capacity to learn, and recent fiscal parsimony has been jnost useful in stimulating thought. If T can draw a topical comparison, if is an unimaginative effort to try and get underprivileged persons into medical school without improving the asic education of this group. We must show our intent not only to tackle the dramatic problems that have evolved but also we must show our wish to rectify the problems that underlie these, the pre- determinants of the malady. Conclusion Some provocative statements have been made in this article. This is not written with: . any inflammatory intent; it is done in the hope that you may think of the problem and glean sore in- formation wbout ii; that the practicing physician wil} voice an opinion that can help these in & pasi- tion to do something about: it. This cen only come about if physicians ln genera] remain informed about the problem of transplantation and see clear- ly where they fit into this dramatic picture. 9929 Main Street References J,. Dempster, W. d.; Melrose, PD. G., and Bentall, H. He: Scientific, technical, and cihical considerations in cardiac transplantedons, Brit. M. dob: 177 (1868). 9. Long, PE: The quantity and quality of life: 1, Fruit- less longevity, Resident Physician 6: GO (1969).