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> The face surgeons go first. But since organs are precious and face transplants are not lifesaving, if the donor’s condition started to decline, the team would

> The face surgeons go first. But since organs are precious and face transplants are not lifesaving, if the donor’s condition started to decline, the team would have to abandon its work to allow other surgeons to collect the donated organs. What exactly is meant with "if the donor's condition started to decline"? How does one monitor the condition of organs in a dead body? What technology is used to monitor the state of organs in a dead body?

goodells 8y ago
I’m only an EMT, but I can try to answer this for you. The organ donor was brain dead, but the heart continued to beat and a ventilator was used. The organs would stay perfused with oxygen and nutrients and the surgery would be performed as if the donor were otherwise alive. Surgery is inherently risky - risks include spontaneous bleeding or clotting that could abruptly end the organ recovery. I believe this is the situation they are referring to.
- DoctorOetker 8y ago
  As an EMT do you frequently witness people being pronounced/determined brain dead? If so what does it look like? I can't imagine an EEG device being attached to each presumed dead patient to double check? Or is that in fact what happens to each patient dying in the care of a hospital? I am very fascinated about the possible technology involved for monitorinng the state of these organs while the face was being removed. Or am I overimagining and its mostly heart rate, and blood content (oxygen, glucose, what others?) ? Us normal citizens -seldom in contact with death- we must have an oversimplified view of alive vs dead: atomic (before and after) and monolithic (the whole person is dead, or the whole person is alive), while we are in fact multicellular organisms and some cells have more demanding needs to be met depending on cell type, location in the body, and so on. I can imagine a failing human body prioritizes the functionality of some organs over others? In the text they mention that donor side and acceptor side can initiate communication through the centralized authority, without obligation to respond, and if they both consent they are allowed to meet each othe as happened here. Here they had to request explicit permission for the face. What happens if there was not enough time for properly removing the face yet the donor's next of kin try to ccontact the (non-existent) acceptor? Do they get by policy a "no counterparty response" boilerplate, or are they informed that in fact there was no recipient due to complications?
  - goodells 8y ago
    As EMTs we are trained to provide the best possible care for all of our patients unless very obvious signs of death are present - brain death is not something we really consider because that's something the hospital determines. Obvious signs of death include dependent lividity (blood settling to the lowest point in the body) and decapitation, among other things. EMTs are not qualified to make such judgements in the field (outside of a mass casualty incident and triaging) and opt to be "better safe than sorry" and let someone with an MD after their name and malpractice insurance worry about making the final call. I expect the signs and symptoms of someone with brain death would be indistinguishable from any other apneic unconscious patient without a pupillary response, but some of those can be saved, so we transport them all. At the hospital, protocols for determining brain death vary depending on the institution, but we have more advanced tools than just EEG now. I see a lot of radiological investigations that measure cerebral metabolism with scintigraphy - here's an example of what that looks like with a poor outcome (I am not a radiologist by any means, and I explored this outside of being an EMT) [1]. Notice how the brainstem is dark but the rest of the brain isn't doing much. Other investigations such as some MRI sequences may prove useful to identify ischemic insults and damage that strongly correlate with poor outcomes. Based on the phrasing of your question, I would point out that these tests would only be performed on a patient where brain death were clinically suspected based on e.g. prolonged cerebral hypoxia from a drug overdose... not every dying patient. I don't know enough about the medicolegal or surgical side of things to go into more detail there. [1] - https://img.medscapestatic.com/pi/meds/ckb/59/26659tn.jpg https://img.medscapestatic.com/pi/meds/ckb/59/26659tn.jpg
  - azernik 8y ago
    There's a very interesting New Yorker article on this topic, specifically when it comes to organ transplantation: https://www.newyorker.com/magazine/2018/02/05/what-does-it-mean-to-die https://www.newyorker.com/magazine/2018/02/05/what-does-it-m...
detaro 8y ago
Given the 3 days between death and operation and the ventilator, sounds like a case of someone in a coma and being declared dead due to brain function ceasing. In such cases basic stuff like heartbeat etc is still running on its own (otherwise the tissue wouldn't be supplied with oxygen and die), so there's still vital signs to monitor.
- DoctorOetker 8y ago
  Thanks for explaining They mentioned cocaine, I never realized you could die by cocaine? What is LD50 of cocaine in street units, say "lines"? Why are some people in coma declared dead and others kept alive? Have people ever "recovered" from coma? Is it a question of permission from next of kin to keep the patient alive? Or does it boil down to a financial question?
  - Hextinium 8y ago
    LD50 for cocaine in mice is 94 mg/kg and a line is 35 - 100 mg according to wikipedia. So a large line per kilogram will probably kill you.
    - DoctorOetker 8y ago
      I can't imagine myself being able to continue preparing lines of cocaine and inhaling them for ~7.5 grams on end!? thats 75 of the larger lines or ~214 of the smaller kind of lines. I could try my best but I am pretty sure I would simply fail to sniff 75 average lines. It seems impossible to succeed.
      - Hextinium 8y ago
        That is if you are doing lines, if injected or smoked the chance of OD is higher but remember that is LD50 you can still die at much lower doses.
  - roguecoder 8y ago
    "Coma" can mean a wide variety of things, and a persistent vegetative state still isn't considered "dead", as was the case here. Judgement of death relies on specific tests that establish the absence of cerebral and brainstem functions. See, for example: http://n.neurology.org/content/neurology/45/5/1012.full.pdf http://n.neurology.org/content/neurology/45/5/1012.full.pdf When the brain stops functioning systems such as electrolyte balance and internal temperature control often go as well, and we don't know yet how to keep bodies without brain function functional for extended periods of time (as opposed to comas where the patient's brain can still control autonomic processes.) In cases where a patient isn't dead, they or their health care proxy have the right to turn down treatments, including those necessary for life. Not everyone wants to be kept alive in a persistent vegetative state, even if they are not dead, and for plenty of reasons other than the cost.

goodells 8y ago

I’m only an EMT, but I can try to answer this for you. The organ donor was brain dead, but the heart continued to beat and a ventilator was used. The organs would stay perfused with oxygen and nutrients and the surgery would be performed as if the donor were otherwise alive. Surgery is inherently risky - risks include spontaneous bleeding or clotting that could abruptly end the organ recovery. I believe this is the situation they are referring to.

DoctorOetker 8y ago
As an EMT do you frequently witness people being pronounced/determined brain dead? If so what does it look like? I can't imagine an EEG device being attached to each presumed dead patient to double check? Or is that in fact what happens to each patient dying in the care of a hospital? I am very fascinated about the possible technology involved for monitorinng the state of these organs while the face was being removed. Or am I overimagining and its mostly heart rate, and blood content (oxygen, glucose, what others?) ? Us normal citizens -seldom in contact with death- we must have an oversimplified view of alive vs dead: atomic (before and after) and monolithic (the whole person is dead, or the whole person is alive), while we are in fact multicellular organisms and some cells have more demanding needs to be met depending on cell type, location in the body, and so on. I can imagine a failing human body prioritizes the functionality of some organs over others? In the text they mention that donor side and acceptor side can initiate communication through the centralized authority, without obligation to respond, and if they both consent they are allowed to meet each othe as happened here. Here they had to request explicit permission for the face. What happens if there was not enough time for properly removing the face yet the donor's next of kin try to ccontact the (non-existent) acceptor? Do they get by policy a "no counterparty response" boilerplate, or are they informed that in fact there was no recipient due to complications?
- goodells 8y ago
  As EMTs we are trained to provide the best possible care for all of our patients unless very obvious signs of death are present - brain death is not something we really consider because that's something the hospital determines. Obvious signs of death include dependent lividity (blood settling to the lowest point in the body) and decapitation, among other things. EMTs are not qualified to make such judgements in the field (outside of a mass casualty incident and triaging) and opt to be "better safe than sorry" and let someone with an MD after their name and malpractice insurance worry about making the final call. I expect the signs and symptoms of someone with brain death would be indistinguishable from any other apneic unconscious patient without a pupillary response, but some of those can be saved, so we transport them all. At the hospital, protocols for determining brain death vary depending on the institution, but we have more advanced tools than just EEG now. I see a lot of radiological investigations that measure cerebral metabolism with scintigraphy - here's an example of what that looks like with a poor outcome (I am not a radiologist by any means, and I explored this outside of being an EMT) [1]. Notice how the brainstem is dark but the rest of the brain isn't doing much. Other investigations such as some MRI sequences may prove useful to identify ischemic insults and damage that strongly correlate with poor outcomes. Based on the phrasing of your question, I would point out that these tests would only be performed on a patient where brain death were clinically suspected based on e.g. prolonged cerebral hypoxia from a drug overdose... not every dying patient. I don't know enough about the medicolegal or surgical side of things to go into more detail there. [1] - https://img.medscapestatic.com/pi/meds/ckb/59/26659tn.jpg https://img.medscapestatic.com/pi/meds/ckb/59/26659tn.jpg
- azernik 8y ago
  There's a very interesting New Yorker article on this topic, specifically when it comes to organ transplantation: https://www.newyorker.com/magazine/2018/02/05/what-does-it-mean-to-die https://www.newyorker.com/magazine/2018/02/05/what-does-it-m...

detaro 8y ago

Given the 3 days between death and operation and the ventilator, sounds like a case of someone in a coma and being declared dead due to brain function ceasing. In such cases basic stuff like heartbeat etc is still running on its own (otherwise the tissue wouldn't be supplied with oxygen and die), so there's still vital signs to monitor.

DoctorOetker 8y ago
Thanks for explaining They mentioned cocaine, I never realized you could die by cocaine? What is LD50 of cocaine in street units, say "lines"? Why are some people in coma declared dead and others kept alive? Have people ever "recovered" from coma? Is it a question of permission from next of kin to keep the patient alive? Or does it boil down to a financial question?
- Hextinium 8y ago
  LD50 for cocaine in mice is 94 mg/kg and a line is 35 - 100 mg according to wikipedia. So a large line per kilogram will probably kill you.
  - DoctorOetker 8y ago
    I can't imagine myself being able to continue preparing lines of cocaine and inhaling them for ~7.5 grams on end!? thats 75 of the larger lines or ~214 of the smaller kind of lines. I could try my best but I am pretty sure I would simply fail to sniff 75 average lines. It seems impossible to succeed.
    - Hextinium 8y ago
      That is if you are doing lines, if injected or smoked the chance of OD is higher but remember that is LD50 you can still die at much lower doses.
- roguecoder 8y ago
  "Coma" can mean a wide variety of things, and a persistent vegetative state still isn't considered "dead", as was the case here. Judgement of death relies on specific tests that establish the absence of cerebral and brainstem functions. See, for example: http://n.neurology.org/content/neurology/45/5/1012.full.pdf http://n.neurology.org/content/neurology/45/5/1012.full.pdf When the brain stops functioning systems such as electrolyte balance and internal temperature control often go as well, and we don't know yet how to keep bodies without brain function functional for extended periods of time (as opposed to comas where the patient's brain can still control autonomic processes.) In cases where a patient isn't dead, they or their health care proxy have the right to turn down treatments, including those necessary for life. Not everyone wants to be kept alive in a persistent vegetative state, even if they are not dead, and for plenty of reasons other than the cost.