The Miracle of Medical Mechanics
by Natalie GutierrezThe shrill ring of the telephone interrupts his silent slumber. The clock reads 3:30 a.m. Weary, but alert, Luis Angel, M.D., answers. Heís prepared for what the voice on the other end says - "A 25-year-old male Ö severe trauma to the head Ö he perished in a car accident." For Dr. Angel, assistant professor of medicine at The University of Texas Health Science Center at San Antonio, the tragic news is bittersweet. He knows this young manís death may bring life to another.
Within an hour Dr. Angel is at the accident victimís bedside. His lifeless body is hooked to a ventilator. Although this is the first time theyíve ever met, Dr. Angel knows intimate details about the young manís medical history - his birth date, how much he weighs and whether or not he was a smoker - details that are important for what Dr. Angel does next.
In an hour-long process, Dr. Angel performs a bronchoscopy, examining the manís lungs from the inside out. Itís a procedure Dr. Angel has done hundreds of times. He looks for signs of trauma to the chest and traces of blood. Then, like a meticulous medical mechanic, he begins to aspirate, suction and ventilate. The young manís chest heaves up and down. Although heís not alive his lungs are healthy, almost like new again - ready for someone who desperately needs them to survive.
A remarkable turn of events
Fourteen years ago, Austin resident Ronald Carroll noticed he was frequently out of breath doing simple tasks like climbing the stairs and walking around the block. On the advice of an Austin pulmonologist, Carroll traveled to the National Jewish Medical Research Center in Denver, Colo., one of the nationís leading treatment centers for respiratory, immune and allergic disorders, to seek a diagnosis.
Doctors there diagnosed Carroll with idiopathic pulmonary fibrosis, a mysterious disease that causes abnormal scarring of the lungs. According to the Pulmonary Fibrosis Foundation, as the disease progresses the lung tissues become thick and non-functioning. Breathing becomes difficult. It can run a slow course, remain unchanged, or run a swift course and be fatal. Approximately 5 million people worldwide are affected by the disease.
"The doctors told me my life expectancy was about two years without a lung transplant," Carroll said. "But the waiting period is two years for lung transplants nationwide. Fortunately, my disease progressed slowly, so I had time to prepare. The doctors in Denver suggested I visit The University of Texas Health Science Center at San Antonio." In 1996 Carroll visited the Health Science Centerís lung transplant program, underwent a series of physical and psychological tests, and was put on the universityís list to undergo a bilateral (two-lung) transplant. By this time, Carroll was unable to breathe without the use of liquid oxygen 24 hours a day, seven days a week.
"I knew my time was limited," Carroll said. "Miraculously, only two weeks after I was put on the list, I got a call from the Health Science Center. They told me they had two lungs for me. My partner, Elizabeth, and I left quickly. I drove the entire way to keep my mind occupied. We were there within two-and-a-half hours," he said.
In a delicate, 10-hour surgical procedure, Health Science Center physicians removed Carrollís diseased lungs and replaced them with a donorís lungs.
One month after surgery, Carroll was home and walking two miles daily around his neighborhood without supplementary oxygen. "It has been eight years since I had my lung transplant and I feel great," Carroll said. "This is a miracle. The team of transplant experts at the Health Science Center is amazing! The doctors gave me a second chance at life."
Ronald Carroll and his partner, Elizabeth Galic, at their home in Austin. In 1996 Carroll underwent lung transplant surgery on Elizabethís birthday, May 9. "Elizabeth has always been at my side, every step of the way," Carroll said. "We celebrate two birthdays on May 9 Ė hers and my other birthday Ė the day I got a second chance at life."
John Calhoon, M.D., head of the division of thoracic surgery, the J. Kent Trinkle Distinguished Professor and the Calhoon Presidentís Council Chair for Excellence in Surgery at the Health Science Center, said Drs. Angel and Levine lead an outstanding team of medical physicians. Scott Johnson, M.D., and Edward Sako, M.D., Ph.D., associate professors of surgery, who have each served the program for more than a decade, are the surgical leaders along with Andrea Carpenter, M.D., Ph.D., associate professor of surgery. Jay Peters, M.D., professor of medicine, is a founding member of the transplant program. Deborah Levine, M.D., assistant professor of medicine, who was the programís first fellow, is a pulmonologist. They work together with a top-notch team of anesthesiologists led by Jaydeep Shah, M.D., assistant professor of anesthesiology, to perform approximately 25 lung transplants each year. That number is rising because of advances in lung management procedures developed by Dr. Angel and his team, in collaboration with the Texas Organ Sharing Alliance (TOSA).
A study, conducted from 2001 to 2004 by Drs. Angel and Deborah Levine, determined that lungs from "marginal donors" (donors who are over the age of 55, who have a history of mild to moderate smoking or pulmonary disease, or who, at the initial evaluation, did not have ideal oxygen levels, clear chest X-rays or a normal bronchoscopy) could be used effectively in transplant surgery. Dr. Angel immediately went to work with Joe Nespral, director of clinical services at TOSA, to implement a new lung management protocol. The new protocol significantly improved the performance of marginal lungs.
"Dr. Angel has developed a physician-driven lung management protocol," Dr. Calhoon said. "He places a pulmonologist in the care of every potential lung donor. The pulmonologist manages the care of that donor to optimize the use of all organs, especially the lungs. Dr. Angel has become the best in the country at what he does," Dr. Calhoon said.
Nespral agrees. "With the new lung management protocol in place, the number of TOSA-procured lungs transplanted has jumped from 16 in 2000 (the year before the study began) to 43 in 2003," Nespral said. "Thatís an increase of 169 percent in three years. Last year, lungs accounted for 12 percent of the TOSA organs transplanted."
Nespral said the successful lung program is good news not only for San Antonio patients, but also for lung patients across the nation. Of the 43 TOSA lungs transplanted last year, 31 went to local patients, while another 12 went to patients at transplant centers outside of San Antonio. Nespral said the new protocol has made TOSAís lung procurement rate one of the highest in the nation.
"Of all the major organs, probably the most difficult to recover and transplant is the lung," Nespral said. "Because of the shortage of donors and transplantable organs in the United States, organ procurement programs are constantly looking for ways to make more organs available for transplantation. By liberalizing the criteria for lung donors, and by working with the Health Science Centerís transplant team to improve and maintain every donor, we are saving more lives without putting patients at risk."
Lung transplant recipient Frank Cimino with his wife, Susan.
And by increasing the number of donor lungs available, Health Science Center physicians have decreased the waiting period for lung transplant surgery. The program now has the shortest waiting period for lung transplant surgery in the nation. The national average is two years. At the Health Science Center the average waiting period is 44 days, but many transplants are performed sooner than that.
"We find lungs for very sick people," Dr. Angel said. "Only patients who are very ill are placed on the waiting list. Thus, when a lung becomes available, we are ready to use it for that particular patient."
Alberto Morales, 71, flew nearly 1,000 miles from Orizaba, Veracruz, Mexico, to be placed on the Health Science Center lung transplant programís waiting list. He was seriously ill with pulmonary fibrosis and couldnít walk a block without the aid of his oxygen tank. On June 10, 2004, Morales was officially placed on the transplant waiting list. Three days later, he had a new lung and a new lease on life.
"I think this was record time," said Moralesí son, Gerardo. "Lung transplants are not done successfully in Mexico, so we were blessed to find the Health Science Center."
"Maravilloso! Otra vida!" Morales exclaims in his native Spanish, describing how he feels just weeks after his surgery. He said he feels "marvelous" and "has another life" thanks to the Health Science Centerís transplant team. Morales said he was also impressed with the bilingual abilities of university physicians who made it easy for him and his family to understand the complexities involved in transplant surgery and recovery.
Caring physicians, devoted patients
Frank Cimino of Austin also attests to the supportive and caring nature of the transplant team. Cimino, who also was afflicted with pulmonary fibrosis, visited with physicians at the Mayo Clinic, as well as physicians at Baylor College of Medicine in Houston, before coming to the Health Science Center. "I just couldnít wait two years for a transplant. My family needed me. We had faith that Iíd be able to have the surgery in San Antonio sooner," Cimino said.
"After about two weeks of being on the Health Science Centerís waiting list, I was notified by phone that a lung was available for me," he said. "I was very frightened because the moment I had been waiting for was suddenly here, so quickly." On April 8, 2004, Cimino underwent transplant surgery to replace his left lung. He said Health Science Center physicians were in his hospital room at least twice a day before and after the surgery to bring him up to date on his condition.
"Up until the time I became ill with pulmonary fibrosis, I had never been in the hospital," Cimino said. "I was very appreciative of the way the doctors thoroughly explained every detail of the surgery and recovery process to me. This helped put me at ease."
Three months after his surgery, Cimino said he is recovering nicely. "Iím building up my strength and stamina, and I can breathe without an oxygen tank. Thatís really something," he said. Cimino plans to walk in Austinís annual Statesman Capitol 10K run/walk with his 12-year-old daughter, Francesca, just as he did in 2003.
"The doctors at the Health Science Center have given me more time, and for that Iím very grateful. I appreciate every day that I have now more than ever," Cimino said. "My life is a gift and I donít take that for granted. I take care of myself so I can be there for my family in the long run."
Dr. Angel and members of the transplant team continue to work around the clock, answering phone calls in the early morning hours, so they can in turn make calls to seriously ill patients - phone calls that bring hope for a second chance at life.
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