Annette says she just got sick one day.
“I was completely out of it, and they had to take me to the hospital,” she says. “I didn’t know where I was or who I was.”
Doctors at a community hospital not long after identified the cause of her constellation of symptoms—liver failure, from a condition called nonalcoholic steatohepatitis, or fatty liver disease. It’s difficult to determine the exact cause of this disease, but it develops and worsens over many years.
Annette’s doctor recommended she seek a transplant from UC Health, the only health system in Greater Cincinnati able to perform liver transplants.
What was more—the disease had also affected her kidney, meaning she would need two organ transplants.
After a rigorous series of tests—bone, stress, heart and more—Annette was cleared. In early spring, she was placed on the transplant list, activating an intricate, extensive and well-oiled force in place at UC Health.
The full spectrum of physicians, clinicians and support staff in the UC Health Transplant program travel the road toward transplantation with their patients every day—from the moment they’re identified as in need of a new organ for the rest of their lives.
“It requires a whole team of people—not only to get the patient on the list, but then a whole team to get the patient to the operating room; in the operating room, there’s probably about 20, 25 people just to do a liver transplant, and then afterward a whole army of professionals,” said Shimul Shah, MD, UC Health surgeon and director of the transplant division, and James and Catherine Orr Endowed Chair in Liver Transplantation and professor of surgery at the University of Cincinnati College of Medicine.
“And I think that’s what makes many of us enjoy being a part of and leading a great team that is committed to helping patients, is we have about 100, 250 people that are involved in the whole process for one patient. That’s a lot of resources, and that’s a lot care.”
Dr. Shah argues a liver transplant is perhaps the “most onerous and resource-intensive” operation in modern medicine.
“When you think about the highest risk after surgery…It’s not brain surgery, it’s not heart surgery. Believe it or not, it’s actually a liver transplant, in terms of needing the expertise and the multidisciplinary care that an academic health center provides.”
Why? The liver has more than 500 identified vital functions. When someone enters UC Health’s liver transplant program, they are too sick for community hospitals—instead, they need the expert experience that truly only lives at places like UC Health.
“It is a life or death prospect for them, and we need to constantly—every hour, every day—weigh how we can get organs for them and how to get them transplanted and then help them heal and survive,” he says.
It’s why Dr. Shah, and the other transplant providers, dedicate their lives to these patients.
“It’s why when we’re driving in the middle of the night [on the way to the hospital], it’s never an issue,” he said. “I jump out of bed and I’m ready to go because you see the result the very next day after their transplant how much better they look.”
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On the morning of July 16, 2018, Annette was watching TV when her husband, Larry, picked up the phone. It was her pre-transplant coordinator, delivering what transplant recipients refer to as “the Call.”
Within a few hours, Annette was relaxing in a hospital bed at UC Medical Center with her husband by her side, ready.
Dr. Shah visits his patient at 4:30 p.m. He explains that surgeons may wait up to 24 hours after performing the liver transplant to do the same for her new kidney. This down time allows patients to become stable so that once the kidney is transplanted, it’s able to begin working immediately.
“You look pretty good,” Dr. Shah says to Annette. “Let’s get this done.”
Larry, her husband, looks across the bed at Dr. Shah and claps his hands together.
6:30 a.m., Tuesday
It’s dark outside, but white lights fill every corner of Operating Room No. 17.
As surgeons and a surgical tech prepare Annette to receive her new liver, Dr. Shah prepares the new organ as it floats in a plastic-lined metal bowl of sterile ice water.
With a pair of forceps, he delicately lifts one of the blood vessels connected to the new liver. It looks like the end of a deflated balloon. The smooth flesh of the liver arcs above the water. Dr. Shah loops one end of a suture through the opening of the blood vessel and rests the other end outside of the bowl, joining several others pulled taut evenly around its perimeter.
Two medical students join Dr. Shah around the tray.
“Try to pull up on that artery,” he instructs one of the students. “See that? That’s all you’ve got to do.”
Surgeons like Dr. Shah often are in the practice of narrating what they do—it’s just one way they teach the next generation of physicians, who study and train at academic health systems like UC Health.
Students from the UC College of Medicine rotate from service to service—one being general surgery. These rotations, which comprise their third year, help students choose a specialty for their careers.
Residents and fellows—medical school graduates training in their specialties—also learn from renowned physicians like Dr. Shah.
“How you doing, boss?” Dr. Shah says across the OR, not looking up from his work. Dr. Tayyab Diwan, the attending surgeon transplanting the liver, responds confidently: “Fine.”
Dr. Diwan stands at the patient’s side with Dr. Amanda Bailey, senior fellow. The two work in concert with the surgical tech, who keeps watch over the vast array of shining sterile instruments.
This tech works wordlessly. Within seconds of a surgeon’s request, she passes the correct tool from the tray to the physicians’ hands; often, it seems as though she can read their minds and anticipate their needs.
Dr. Diwan and Dr. Bailey cut and cauterize with precision and steady focus.
It’s past 8 o’clock now.
“I’m taking the liver out.” Mere seconds pass. This is the moment for which everyone in the room has trained.
The old organ, the one with which the patient was born but now is spent, is deposited into another bowl and carried to an empty tray that has been waiting against the wall. The liver is small, beet-red.
The patient now without a liver, the clinicians pick up their pace. Dr. Diwan talks to his colleagues nearly nonstop as he works.
“Can I have a vessel loop, please?”
“Maybe just one more little cut, and that’s it.”
Nurse circulators, who are responsible for fetching equipment, bustle around the OR, opening packages of new tools, bringing in frozen donor blood in a cooler.
It’s not long before the moment of transplantation arrives.
Dr. Bailey sweeps around the patient’s table, carries over the bowl with the new organ from its tray and sets it down safely at the end of the patient’s table.
Carefully, with reverence for the gravity of the moment, in honor of the torch-passing from one life to the next, Dr. Diwan dips his hands into the sterile bath underneath the organ. He lifts the liver from the liquid. For just a moment, it gleams under the overhead lights, pristine, beautiful, a textbook liver. Just larger than a football, its lobes slope downward on either side like the wings of a stingray.
“Out of ice, 8:30.”
The surgeons nestle the organ into its new home. The clock starts.
Dr. Bailey’s task is suturing the donor liver’s vessels to the patient’s, now clamped to stop blood flow. The surgeon brings the sutures through, forever connecting donor to recipient. Her handwork is steady, crucial to the transplantation’s success.
“Come on,” Dr. Diwan cheers her on. Dr. Bailey pulls a suture through with a tool. “There you go. Good.” A senior fellow, Dr. Bailey is in the final years of her training.
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“One more and then we move, OK?” Dr. Diwan instructs.
8:42 a.m. is when surgeons first mark their time. Minutes tick. The physicians move with purpose.
“Seven minutes.” That’s how much longer Dr. Bailey anticipates she needs.
It’s now 8:57 a.m.
“Reperfuse,” Dr. Diwan says. “Reperfuse,” two nurses echo in unison.
Surgeons unclamp the patient’s vessels, releasing blood into what is now Annette’s liver.
Debra Egbert, RN, transplant coordinator, knocks on the door to Annette’s room, a red UC Health bag stuffed with pamphlets and packets swinging from her arm.
It’s been about one week since Annette’s initial liver transplant surgery, which was followed just 12 hours later with a kidney transplant. She has since been moved from an intensive care unit to a floor with patients requiring less demanding medical care.
Joining her is her husband, sitting on a chair in the room, and her two adult daughters, Ashley and Barbara, sitting together on a couch. Annette wears a tranquil smile; the color in her face has returned.
Debra is just one of several transplant coordinators, whose jobs are to ensure patients have all the tools they need for long-term success. Debra is Annette’s inpatient coordinator; when Annette leaves the hospital, she will partner with a post-transplant coordinator.
It’s not just coordinators who see the tall task of success through to fruition. Throughout the entire course of this process, all transplant patients meet social workers, gastroenterologists, surgeons, psychiatrists, psychologists, dieticians and pharmacists all dedicated to each individual.
“Teaching never stops,” Debra says. “Education begins when you start the process, but it never really ends.”
It’s no secret that there are a finite number of donated organs. Because they are such precious gifts, UC Health properly educates and evaluates all transplant candidates to ensure only the highest rate of success. This means confirming the patient has adequate support systems in place to undertake such a commitment—from taking anti-rejection medications daily to refraining from foods like sushi and sunny-side-up eggs to minimize the risk of foodborne illnesses.
The dos and don’ts of life after a transplant is what fills Debra’s bag when she visits Annette and her family for an hour on Tuesday.
“I don’t just hand it to them,” Debra says. “I go over it with them.”
She pulls papers and pamphlets out one-by-one. In her recovery period, Annette must remember a litany of restrictions and requirements—drink eight 8-ounce glasses of water a day, don’t take anti-inflammatory medications like ibuprofen, take blood pressure, weight, temperature and blood sugar levels every day.
If she forgets anything, or something feels off, Annette doesn’t have to guess until her next weekly clinic appointment. A transplant coordinator is on call to answer these questions, 24 hours every day. They will always answer.
“Even when you’re at home and you feel all alone, you’re really not alone,” Debra tells her patient. “We always have someone there for you.”
After an hour has passed, and the bag has been emptied and then refilled, Debra hands it over to her patient. She smiles.
“Congratulations,” she says. “This is an exciting time. You are doing fantastic.”
She leaves Annette to finish the rest of the seventh day of her second life, ready to help the next patient as they journey together through new beginnings.
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Annette, two months post-transplant, is flourishing.
After she was discharged from UC Medical Center, she stayed at UC Health’s Daniel Drake Center for Post-Acute Care for about two weeks. There, she received physical and occupational therapy. Annette recovered so well that she went home early, with the help of a visiting nurse.
“I’m really thankful to the family of the donor and to Dr. Shah and his team.”