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Miscommunication doomed girl

| Monday, Feb. 24, 2003

Jesica Santillan died Saturday at Duke University Medical School, surrounded by an arsenal of medical technology, top doctors and a network of experts dedicated to transplanting her with organs that could save her life.

None of these measures, however, protected her from a misunderstanding between her doctor and a North Carolina organ bank. As a result, mismatched organs were transplanted into the 17-year-old and, despite heroic measures and a second transplant, she died.

It all began with so much hope on Feb. 6, when organs she had awaited for three years suddenly became available. This account of the events that followed is based on chronologies issued by Duke University and Carolina Donor Services and interviews with transplant experts.

Late on Feb. 6, Carolina Donor Services received a call from the New England Organ Bank. Someone in that region had died, leaving organs available for transplant.

Time is desperately short when valuable organs such as the heart and lungs become available. A nationwide network -- the United Network for Organ Sharing -- maintains an extensive list of patients waiting for particular organs. The New England bank ran a search through the network's computers: It evaluated patients across the country, giving preference to those who had waited longest, whose medical condition was the most serious, who were geographically close enough for the organs to be transplanted without delay -- and who had the same blood type as the donor, Type A.

Two names popped up as potential heart recipients. Both were at Duke University Medical Center in North Carolina. Following standard organ-sharing procedures, the New England bank called its regional counterpart, Carolina Donor Services.

The Carolina bank called Carmelo Milano, the Duke surgeon on call for adult heart transplantations. Since the organ-matched Duke patient was a child, Milano referred the call to James Jaggers, the surgeon in charge of pediatric heart transplants.

The bank said it gave Jaggers information about the organ. Jaggers told Carolina Donor Services that the child on the computer's list was not medically ready for the transplant. The conversation might have ended there, but Jaggers remembered another patient.

What about Jesica Santillan, who had been on the national waiting list for three years• Her family had brought her to North Carolina from Mexico because she had a congenital heart defect called restrictive cardiomyopathy. It was threatening to kill her soon. Jaggers told Carolina Donor Services that Jesica needed a pair of lungs, too. He gave them her name, assuming they would look up her details on the national list, according to Duke's account. The bank said it would get back to him.

Already, the seeds for disaster had been sown. The bank assumed Jaggers was aware the organs were of blood Type A, since the bank had turned over all the information about the heart to Duke, according to its chronology. Besides, both recipients that the computer had identified at Duke, including the patient Jaggers said was not suitable, had Type A blood.

Jesica had Type O blood.

Jaggers would say later he did not remember mentioning Jesica's blood type during the conversation. But since he had given the bank her name, he assumed the bank would check the computerized list and make sure that patient and organs were properly matched. Jaggers has since taken responsibility for the misunderstanding.

The Carolina bank then called another Duke doctor to ask about the second candidate from the computerized list. Duane Davis, a surgeon at the medical center's adult heart transplant unit, asked about the size of the heart and decided it was not the right size for his patient.

Both the computer's initial choices -- which had been screened for blood type and other details -- had been eliminated. Minutes were slipping by. The bank called Jaggers back and told him the heart and lungs could go to Jesica. It is unclear whether there were other candidates on the computer list: Organ banks will sometimes give organs to patients not on the list in order to keep them from being wasted.

Both Jaggers and Carolina Donor Services assumed the other had checked the blood type, according to accounts from both sides. The bank had given Duke all the details about the organs and Jaggers had given the bank Jesica's name and access to her medical details. Each implicitly relied on the other.

The hospital has since announced new measures to verify that patients and organs are properly matched.

Jaggers would later remember talking with the bank about the organ donor's height, weight, organ function and cause of death -- mentally checking off each item to match Jesica. But there was a reason Jesica was not on the original computerized list: Her blood type was not a proper match.

A Duke surgeon, accompanied by Carolina Donor Services staff, was dispatched to New England. The surgeon verified the organs were of good quality and relayed the message to Jaggers, who gave permission for the heart and lungs to be brought to North Carolina.

Meanwhile, Jesica was prepared for surgery at Duke's pediatric intensive care unit. A machine would do the work of her heart and lungs during the transplant, purifying her blood of carbon dioxide and pumping it back into her body. In order to prevent the blood from clotting, doctors gave Jesica blood-thinning drugs.

There was a risk that thinning the blood might cause bleeding inside her brain. Such bleeding can build up pressure and cause brain damage, even death. There was also the risk that periods of low blood pressure during the procedure would deprive her brain of oxygen, with the same risks of brain damage.

Weather had delayed the return of the team sent to New England to retrieve the organs. As soon as the organs arrived at Duke, surgeons began the operation.

It was 4:50 p.m. on Feb 7.

The doctors cut open Jesica's chest and lifted out her heart and lungs. Over several hours, they attached the new organs to her, unaware they were placing her in the gravest danger. Meanwhile, the heart-lung machine kept her alive, even as it increased her risk of brain damage. The surgeons finished around 10 p.m.

Then they got a call from Duke's Clinical Transplant Immunology Laboratory: The lab had determined that the organs were of the wrong blood type.

The doctors immediately knew what was happening inside Jesica. Her immune system would sense the new organs were different than her blood type, and would develop antibodies to attack the heart and lungs.

Doctors pumped Jesica with drugs to suppress her immune system. They alerted Jesica's family to the mistake, and put her name back on the national waiting list -- as a candidate for a new heart and lungs. Over the next few days, Jesica's condition worsened. Her lungs deteriorated, and doctors had to place her on a mechanical ventilator.

On Wednesday of last week, a new heart and lungs were identified. This time, the national network's computer identified Jesica as a candidate.

Giving two heart and lung transplants to the same person within a matter of days is extraordinary. But Anne Paschke, a spokesperson for the network, said Jesica's dire medical situation, not the intense media attention on the case, had moved her to the head of the list.

Before Duke doctors performed the second transplant, they had to establish that Jesica had a reasonable chance of survival -- otherwise the organs would go to a candidate more likely to benefit. The doctors concluded there was no serious brain damage from the first transplant, and decided to go ahead, according to Duke.

On Thursday surgeons transplanted the new organs. Again, the operation required that the teenager's blood be thinned and that a heart-lung machine purify and pump blood for her.

By 10:15 that morning, the new heart and lung seemed to be working properly. But within 24 hours, doctors detected a sharp neurological decline. A brain scan found bleeding and swelling inside her brain. Doctors tried to drain the pressure, but it was too late. By Saturday, doctors declared there was no activity in her brain and removed life support. An autopsy was announced.

Sixteen days after her doctor first took a phone call to save her life, Jesica was dead.

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