|Section 5. Case Study
By Ridgely Ochs
First of a series
Dr. Lewis Teperman called for someone to "kill the music for a
The Billy Joel tune came to a halt, and Teperman leaned over the
yawning chest of the patient on the surgical table. Suddenly he stood
up, and in his cupped hands was a section of human liver. Moments ago
it had belonged to 21-year-old Jessica Whelan.
He stepped back off his stool, turned and walked rapidly, hunched
over, some blood dripping to the operating room floor. He reached a
small table and placed the precious brown blob into a steel basin
filled with heparin, an anticoagulant produced in the liver, and
In less than an hour, having bathed the organ -- actually the right
lobe of Jessica's liver -- and located and cleansed all the bile ducts
and vessels, he covered the basin in a baby blue cloth and carried it
like a casserole to the operating room across the hall.
"It looks beautiful," he announced to the expectant blue-gowned team
of surgeons and nurses, each of whom looked up from their patient on
the table. "It went perfectly. No surprises."
These are among the most dramatic moments in one of what is
undoubtedly the most dramatic and technically demanding surgeries in
medicine: a live donor liver transplant. In what an observer called "a
slow ballet," one surgical team from New York University Medical
Center had begun more than six hours earlier, on a hot, humid day in
July, to cut out about 60 percent of the liver from Jessica, a healthy
college student who lives in Levittown. It was then placed inside her
46-year-old father, Kenneth, of North Babylon, whose own diseased
liver, if not removed, would eventually kill him.
Another five hours of surgery remained as the second team began the
exacting, tedious job of cutting out the diseased organ and connecting
all major ducts and vessels to the new liver. If all went well -- and
that was not an inconsiderable "if" -- within weeks both patients
would have fully regrown livers (the liver is the only internal organ
that regenerates) and be on their way to resuming their normal lives.
This would end a process for Jessica and Ken that had begun the
previous summer and included innumerable meetings with doctors, nurses
and social workers, countless tests and much soul-searching.
For one of the questions raised since the death of liver donors
Michael Hurewitz in January at Mount Sinai Hospital and Danny Lee
Boone at University of North Carolina Hospitals at Chapel Hill in July
1999, is whether a healthy person desperate to save the life of a
loved one can truly understand the risks of an operation like this.
Prompted by such profound altruism, can there be true informed
Indeed, there is no consensus in the transplant field on how to ensure
that donors truly understand what they are doing, no clear guidelines
on which donors are the best candidates, no long-term data on how
their health is affected by such a surgery, no oversight on which
centers are qualified to perform transplants and no agreement among
surgeons on how precisely the surgery should be done.
"There are an incredible number of unanswered questions," said Dr.
Mitchell Shiffman, director of the transplantation center at Virginia
Commonwealth University Medical System in Richmond. "That does not
mean you should not go forward. It does mean we have to look
Last year, 408 live adult-to-adult liver transplants were performed,
according to the United Network for Organ Sharing, a nonprofit organ
procurement group. And that number is likely to rise precipitously
within the next few years. Right now 17,491 critically ill Americans
are waiting for a liver, yet last year the traditional source --
cadavers -- met only a little more than a quarter of that number. With
nearly 3 million infected with the chronic form of hepatitis C -- a
disease that destroys the liver -- the waiting list is expected to
triple within the next decade.
NYU is the only one of the 120 transplant units across the country
that perform live donor transplants to assign a social worker to both
the donor and recipient to ensure that everyone understands the risks,
that no one is feeling unduly pressured, Teperman said.
"I think it has doubled the work but it has been a very important
safeguard and we've learned from it," said Teperman, head of NYU's
liver transplant unit. He performs about three live liver transplants
a month, along with about seven or eight transplants using organs
donated from cadavers. He estimated that, all told, at least 50 people
are involved at one point or another with each $200,000-plus
In this one, each player seemed larger than life. Jessica, a top
student who has been on the dean's list for three semesters at Molloy
College, where she has a softball scholarship and is studying to be a
teacher, appeared unwavering in her determination to help her father,
despite her fear of needles and blood.
And even before his liver disease began to take its toll, her father,
a building supervisor in a Nassau County school district, had endured
enough life-threatening conditions -- from a nearly severed leg when
he was 7 that required multiple operations, to a recent bout of
meningitis that put him in a coma -- for several people. In fact, it
was blood transfusions during the many leg surgeries that were the
source of the hepatitis C that was destroying his liver.
(Since 1992, a test has screened blood for the virus.)
Like Jessica, he exuded a deep determination and strength -- as well
as a father's guilt and profound anxiety that his need was going to
result in harm to his daughter.
Initially, he said, he turned down Jessica's offer to be a donor,
instead turning to his wife, Susan, who had also volunteered. But the
vein structure of Susan's liver turned out to be potentially
incompatible with Ken's system. Jessica met the two main requirements
-- her blood type was compatible and her size (5-foot-4 and 116
pounds) was close enough to her father's (5-foot-8 and 185 pounds).
Other tests showed that her liver was healthy and had a suitable
structure. And so Ken, facing the clear prospect of liver cancer,
reluctantly allowed Jessica to be the donor.
In the weeks before the operation, Ken had asked his daughter over and
over if she was sure she wanted to go through with it. Over and over
he said, "No parent wants to do harm to their children. This is very,
very upsetting." Over and over he said: "I just want everyone to know
what a hero she is."
Those two weren't the only ones to loom large. Teperman and the 21
other surgeons, nurses, anesthesiologists and pump technicians stood
hour after hour, many without a break -- a tableau of unwavering
focus. Teperman headed the team working on Jessica; Dr. Thomas Diflo
led Ken's team. Their work, as they hovered elbow to elbow over their
blue-swathed patients in the small operating rooms lined with
machines, appeared seamless.
And yet, these very heroic qualities are emerging in a setting that
lacks two critical elements: long-term data on patient survival and
Those voids have prompted questions about whether this is an operation
that can -- or should -- be practiced widely.
"Those are things we are struggling with," said Dr. Nancy Ascher, head
of a Health and Human Services advisory panel on transplantation,
which is expected to make recommendations on these issues to HHS
Secretary Tommy Thompson in the fall. "I did not get the impression
the secretary did not want progress in this field, but he desperately
wants it done safely."
The fear that donors, driven by their desire to save a loved one,
won't understand what they're undertaking is of particular concern to
Mary Ellen Olbrisch, a clinical psychologist in the transplant center
at Virginia Commonwealth University in Richmond, said it's important
to go over the informed consent form -- the document the hospital has
drawn up that outlines the risks -- three or four times with a
prospective donor, "even if they don't want to know."
Dr. Mark Fox, who chairs the ethics committee for UNOS, the
organ-sharing network, and also is the director of the program in
transplant ethics and policy at the University of Rochester, said it
takes somebody committed to making sure the patient is fully informed,
someone who says: " 'I have to go the extra mile to try as best as I
can to get this person to reflect back to me what these concerns
As Teperman, a smiling, high-energy man who appears to care deeply for
his patients, said more than once: "I know the minute that I take one
thing for granted, when I relax at all, that's when we're going to
The story of this daughter-to-father transplant begins the evening
before the surgery:
6 p.m. Wednesday:
Jessica appears in the waiting room outside her hospital room, her
eyes rimmed in red. She admits to crying after an IV needle was placed
in her arm. "I just hate needles," she says. Asked how she's feeling,
she says, "I'm, like, all right. I'm a little more nervous."
Teperman stops in and tells her -- as he has many times before -- that
he expects her to coach his 10-year-old son in softball when the
It's an old joke between them, and she smiles a little.
On the next hall, her father lies in bed, preparing to have a catheter
inserted through his neck and run into his heart to monitor its
function. He too loves to tease and is giving the nurse a good-natured
hard time, but he's a little groggy and his words are slurring
slightly. He admits he didn't sleep well the night before. "I just
want to get it over with," he says.
7:30 a.m. Thursday:
Jessica is wheeled to a hallway outside the OR. It's lined with so
much equipment her gurney appears almost lost.
Once more she is asked to review what is called the informed consent,
this time with the co-chief of cardiothoracic and transplant
anesthesia, Dr. Marc Kanchuger. It's his job this last time to make
sure she understands what she is doing and the risks of the operation
-- even though Jessica has been through this process a half-dozen
times over the past months with Teperman and her social worker.
Kanchuger is in charge not only of putting Jessica to sleep but also
of keeping her alive during the next 12 hours.
"What are we doing here today?" he asks.
"We're going to have a transplant," she replies calmly.
"No, what are we really doing?" Kanchuger says. Jessica looks a little
blank and says nothing. He then reviews the possible things that can
happen to her -- including death -- during the operation.
"This is a big procedure. You are doing a big thing for your father.
But it's not a walk in the park," Kanchuger says. "I promise I'll take
good care of you.
One of us is with you all of the time and I'm in charge." He adds:
"You're pretty brave. I've got to give you credit."
8 a.m.: Jessica is wheeled into the OR, the nurses drape and
prep her and Kanchuger begins administering anesthesia.
9:07: The first incision is made. Called the "Mercedes cut"
because it resembles the emblem on the car, it entails cutting
horizontally across her entire chest under the breast and then
vertically down her stomach to a couple inches above the belly button.
Smoke rises and there is the smell of burning flesh as Teperman uses a
cauterizing knife called a Bovie that both cuts and cauterizes flesh
and abdominal muscle, thus minimizing blood loss.
9:18: The liver, the largest internal organ and the one that
performs the most functions, is exposed. Jessica's chest is held wide
open with a metal clamp called a retractor. The first thing Teperman
does is to identify, divide and tie off the blood vessels on the far
side of the liver. The smaller vessels, of which there are hundreds,
can be cauterized or clipped, but each of the half-dozen bigger ones
must be sewn. Every time he begins to cut, the knife beeps.
9:41: The choice of music has been a problem. Softish rock has
been playing, and a voice asks for "something a little funkier." A
nurse puts on a Ricky Martin CD and, as if in unison, the eyes visible
over surgical masks register distaste. Teperman remarks that the music
selection is not his fault: Someone has taken his CDs.
10:51: No music is playing as an X-ray machine that resembles a
large beauty parlor hair dryer is wheeled in to take pictures of
Jessica's liver and bile ducts "to make sure there are no surprises,"
Teperman says. Even though she had undergone an MRI scan, sometimes
undetected anatomical anomalies or problems don't become obvious until
the person is on the operating table.
11:07: "There are no surprises," Teperman announces.
"Everything is as expected. You can send for the recipient." This
means Ken will soon be wheeled into the other OR, and the other team
will start to scrub in. The music resumes with a CD of Billy Joel's
11:27: One nurse hands Jessica's gallbladder, about the size of
a baby's fist, to another, who puts it in a small bottle of solution.
The organ, which lies just below the right lobe of the liver and
stores bile, is taken out forever because, Teperman says, with the
right lobe about to be gone there is no place for it anymore. The body
can function fine without it.
12:09 p.m.: "All right, the structures are divided," Teperman
announces. This means that all the major vessels and ducts of the
right lobe have been separated from the left lobe and preserved, and
the actual severing of the right lobe can begin.
12:27: Ken's gurney arrives outside his OR. "How's Jess making
out?" he asks. Teperman comes out to reassure him she's fine and to
say, "You're in great hands."
12:28: Back in the OR, Teperman begins cutting through the
liver. He uses an ultrasound knife called a Cusa that cuts easily
through liver tissue but stops at blood vessels, each of which has to
be sewn, clipped or cauterized. The knife makes a low buzzing sound
not unlike someone cutting a hedge.
2:25: The liver is cut completely in two.
3:22: Teperman carries the liver lobe from his OR to Diflo's.
3:26: Teperman has washed up and, putting on a white coat, goes
to talk to Jessica's mother, Anna Moses, and her stepfather, Jerry,
who have been waiting in a small room on another floor. He tells them
that the operation went "as we expected" and that she should be out of
the OR in about an hour and a quarter. "You have a great, great
daughter. I am continually impressed with the human spirit and she has
a great one," he tells them. Sitting side by side in the otherwise
empty room, they both smile and Anna asks Teperman to sign the teddy
bear they have bought for Jessica.
She seems eager to talk and tells two stories about Jessica's
altruism. In one, Jessica was bumped by a car when she got out of her
car to help a blind lady in a wheelchair off the side of Hempstead
Turnpike. In another, Jessica was waiting at a left-turning light when
she noticed that cars were going around a stalled vehicle. She got out
of her car and saw that the driver had collapsed on the steering
wheel. She called 911, then went to the hospital to check on the
driver, who had had a heart attack. "She has too big of a heart," her
4:36: Jessica's chest is sewn up and a drain inserted to take
care of blood and excess fluid the body produces after such a trauma.
She'll then be taken into intensive care, where she will stay for the
next three days.
4:45: "How are you doing?" Teperman asks as he walks into the
other OR, which is booming with the Rolling Stones. "We're just about
to take it out," Diflo says of Ken's liver. Teperman joins Diflo's
team at the surgical table and, within minutes, the liver is out and
unceremoniously set aside in an empty metal tray at the foot of the
table. Unlike Jessica's liver, which is smooth, soft and a deep rich
brown, Ken's is a pale gray-brown, stiff, hard, bumpy and shrunken
4:58: Diflo takes Jessica's liver from the bowl and begins the
complex, tedious task of sewing it to Ken's blood vessels and bile
5:35: "It's in," Diflo announces, as the new liver's veins are
connected to Ken's, allowing the blood to flow through it. The hepatic
artery and bile ducts still have to be connected, any bleeding has to
be stanched and abdominal drains have to be put in place. In about
three more hours, Ken will be wheeled into intensive care, where he
will stay for the next five days.
Jessica left the hospital a week after her operation. She experienced
post-op stiffness and pain that were pretty grueling, and at first she
had a hard time following orders to get out of bed and start walking.
But once she did, she began to regain strength and the pain began to
ease. After 10 days, she was still experiencing pain at night and was
getting up every 45 minutes to walk around. She was also looking
forward to getting rid of the drain in her abdomen.
But she said she had no regrets: "I'm absolutely glad I did it. Now I
know I did everything I could for my father. I'm glad it's over with."
A month later, she was back to college and driving her new car. Her
prognosis for the long term? "She should be playing as good a game of
ball as ever," Teperman said.
Ken, remarkably, was out of the hospital after 10 days, and on his
first day home was teasing and joking with a caller -- despite three
tubes hanging from his abdomen, the constant monitoring of his
temperature and blood pressure and figuring out the fistfuls of
medications -- he was taking nine different medications three times a
day -- prescribed to prevent infection or rejection.
He said he hadn't experienced as much post-op pain as Jessica had,
crediting the high dose of steroids he was given. And he said he was
up and walking 21/2 days after the operation -- even before Jessica.
The hardest time was seeing his daughter in pain. "Looking at her made
me die a thousand deaths," he said. "I thought I would gladly die."
In fact, he did have an unanticipated side effect. A week after his
operation, a heart monitor picked up two bouts of tachycardia,
abnormal heartbeats, which Teperman said were possibly due to the
medications. Ken said he felt neither episode but, to ensure his heart
was still healthy, he underwent a cardiac catheterization, in which a
tube is inserted in the arteries to see if there is a blockage. His
arteries were clean, he said, and he believes he'll be able to stop
the heart medication that he was given after the tachycardia episodes.
Eventually, Teperman said, he hopes Ken will take only one drug to
prevent rejection of the liver -- which costs between $5,000 and
$10,000 a year. But for now, much of his time is spent taking pills at
precise intervals throughout the day.
"In the scope of things, if that's the biggest price I have to pay,
well ... " And he immediately added: "My biggest happiness and relief
is that Jess's up and around and almost back to normal."
Copyright © 2002,
Widow Fights for Oversight of Surgeries
By Ridgely Ochs
Vickie Hurewitz has tried to forge a life for herself and bring
meaning to the death of her husband, Michael, by campaigning for
governmental oversight of live donor transplants.
Michael, 57, died Jan. 13 at Mount Sinai Hospital after he donated
a section of liver to his brother, Adam, 54, of Setauket, chief of
pulmonary and critical care medicine at Winthrop-University Hospital
Since then, Vickie Hurewitz has moved from upstate Schuylerville to
a log cabin on 10 acres outside of Albany and is buying a horse, a
young Belgian Freisian mare -- coincidentally, she and Rhonda Boone of
Burnsville, N.C., whose husband, Danny, died in 1999 after he was a
liver donor, both live in log cabins, drive pickup trucks and own and
ride horses. They have also become friends.
Hurewitz said she has been working to set up the Mike Hurewitz
Living Organ Donation Project. The project, affiliated with a state
consumer advocate group called the Senior Action Council, will be an
"effort to get living organs regulated," she said. "We have to do
something. It's too unspeakable." Hurewitz, who works as a consultant
for a nonprofit group that serves low-income New Yorkers, said she
favors halting all live donor transplants and supports a policy of
"presumed consent," in which organs from brain-dead people would be
available unless the person had specifically stated otherwise.
"But I have been told there's no political will for this," she
said, "so I'm asking for a moratorium [on live donor liver
transplants] until we have regulations."
She plans to attend Tuesday's meeting of the state Committee on
Quality Improvement in Living Liver Donation, appointed by Health
Commissioner Antonia Novello in March. The panel is expected to
propose improvements to the donor's informed consent process, and the
standards of care and post-operative care. (In addition to Mount
Sinai, New York University Medical Center, New York Presbyterian
Hospital, Westchester Medical Center and University of Rochester
Medical Center also perform live-donor liver transplants.)
The Health Department's March report on Hurewitz's death depicted a
transplant unit too understaffed and too slow to react to his
worsening condition. Novello said the care was "fragmented at best"
and "shocking," fined the hospital $48,000 and imposed a six-month
moratorium on such liver transplants at the hospital.
The state is also investigating 123 cases alleging poor care at
Mount Sinai that were filed after Hurewitz's death. Health Department
spokesman Rob Kenny said many have been completed. "However, the
decision on what should be released and when still hasn't been made,"
he said, adding that each complainant would receive a personal letter.
Eighty-two of the cases involve the liver transplant unit.
Six involve donor care; the rest pertain to liver transplant
recipients or those awaiting livers.
Kenny said "nothing has been decided" on whether the state will
allow Mount Sinai to resume performing adult-to-adult live liver
transplants on Sept. 12, the end of the six-month moratorium.
Copyright © 2002,