Teen Near Death After Transplant Error

Medicine & Biotech Forum

A 17-year-old girl lay near death Tuesday after mistakenly receiving a heart and lung transplant from a donor with the wrong blood type, and hospital officials held out little hope of finding a new set of organs in time.

Jesica Santillan's condition steadily deteriorated after the botched operation Feb. 7. She suffered a heart attack Feb. 10 and a seizure on Sunday, and was in critical condition with a machine keeping her heart and lungs going.

"Right now my daughter is between life and death. She could die at any moment," her mother, Magdalena Santillan, said in Spanish through an interpreter. "My daughter needs a transplant of a heart and lungs to survive. It's the only hope that we have because the doctors made an error."

A family friend said the girl has only a few days left.

The girl has type O-positive blood but was given organs from a donor with type-A blood during the operation at Duke University Hospital.

Hospital spokesman Richard Puff said he could not specify how the mistake was made. But he said that the hospital staff believed the organs were compatible and that compatibility had been confirmed.

Jesica's body was rejecting the new organs because of the different blood types. Antibodies in her blood attacked the organs as foreign objects.

Puff said the girl is a candidate for another transplant and "we remain hopeful that will happen." But he said the hospital can do little to improve her odds.

"We're going through the usual system of transplant agencies. That's all we can do," he said.

Jesica remained on the national waiting list kept by the United Network for Organ Sharing. Spokeswoman Anne Paschke said the national organ procurement group cannot specifically search for a heart and lungs for Jesica.

"Unfortunately, there are very few organs available," Paschke said. The organs not only have to be the right blood type, they have to be the right size to fit into the girl's chest cavity.

Mack Mahoney, the family friend, said Jesica is small for her age - 5-foot-2 and 85 pounds - and any donated organs would probably come from a child.

"We have a good chance of saving this child's life if we find a donor in the next couple of days," he said.

In the meantime, he said, the life-support apparatus was hurting Jesica, raising the danger of bleeding, stroke and kidney damage.

Jesica, who is from a small town near Guadalajara, Mexico, needed the transplant because a heart deformity kept her lungs from getting oxygen into her blood. Mahoney said she would have died within six months without a transplant.

The donated organs were flown in from Boston. They were sent with paperwork correctly listing the donor's type-A blood, said Sean Fitzpatrick of the New England Organ Bank, which sent the organs.

The hospital's chief executive, Dr. William Fulkerson, said it was still investigating how the mistake happened and whether any staff members should be disciplined. He said the hospital will add new confirmation requirements to ensure organ compatibility.

"This was a tragic event and our expectation is that, with these new procedures, this will not happen again," said Puff, the hospital spokesman. "We've done thousands of organ transplants and it's never happened before."

Organ network spokesman Bob Spieldenner said he knows of two similar cases in the past decade, both at Oregon Health Sciences University, now called Oregon Health and Science University.

In 1991, the hospital put a heart with the wrong blood type into a patient, but discovered the error. It gave him another heart and he survived. Three years later, surgeons opened the chest of a 15-year-old boy for a heart transplant, but discovered the organ was the wrong blood type and closed him up. The boy died 10 days later.

Heart and lung transplants are rare for teenagers: In the first 11 months of last year, there were four nationwide for children between the ages of 11 and 17, UNOS' records show. The previous year, there were four.

The Santillans moved to North Carolina nearly three years ago from Tamazula.

Mahoney, a businessman in Louiseburg, got involved after he read news reports of the girl's ailment and her family's lack of money. He and his wife joined community efforts to raise money to pay for her medical care, and Jesica's parents gave Mahoney power of attorney for their daughter.

"I've been trying to save this girl's life," Mahoney said. "It's been a fight all the way."

Jesica's newest heart beating on its own after second transplant

Jesica Santillan's newest heart was beating on its own Thursday after her second heart-lung transplant, supporters said, almost two weeks after she was mistakenly given incompatible organs that nearly cost her life.
Jesica, who has type O-positive blood, was given a heart and lungs from a donor with type A blood in a transplant Feb. 7 at Duke University Hospital. Her condition steadily deteriorated as her body rejected the new organs. A second set of organs was located late Wednesday and transplanted into Jesica in a four-hour operation Thursday morning, hospital spokesman Jeffrey Molter said.

Renee McCormick, spokeswoman for a charity raising money for Jesica's care, said her heart was beating on its own afterward. Molter said she was still breathing with the help of a ventilator and was in critical condition, which is standard in such cases.

"This is a very serious surgery," Molter said. "We are hopeful that these organs will support her."

The procedure has a 50-50 success rate, said Mack Mahoney, a leader in fund-raising efforts to pay for the girl's medical care.

"So far, so good," McCormick said. "Her parents feel some relief right now. Everyone is incredibly hopeful and we're just so pleased, so thankful."

Family supporters said they had no information about the donor of the second set of organs. "Hopefully, the donor family will come forward and we can get these families reunited at some point in time," McCormick said.

Lloyd Jordan of Carolina Donor Services said the donor family had requested anonymity. He said the donation was not "directed" - that is, the family did not specifically request that the organs be given to Jesica.

"We consider all donors and their families to be heroes," Jordan said. "These are the people who make the gift of life possible."

Jesica, who is from a small town near Guadalajara, Mexico, needed a transplant because a heart deformity kept her lungs from getting oxygen into her blood. Doctors said she would have died within six months without it.

The fact that a new set of compatible organs became available as Jesica neared death was "an amazingly good thing," Molter said. He noted that 80 percent of people awaiting transplants die before organs can be found.

"I think the word is getting out about organ donations. And in some ways, I think Jesica is a very lucky little girl," he said.

Heart-lung transplants have been routine since the mid-1980s. About 70 percent of recipients survive at least one year, and 40 percent are still alive after five years. Common causes of death include failure of the transplanted organs and lung inflammation.

Jesica was not out of the woods after Thursday's operation. She suffered kidney damage and may have brain damage or paralysis from the machines used to keep her alive in the two weeks after the first transplant, Mahoney said.

"We'll have to deal with those if they occur," he said.

Dr. James Jaggers, lead surgeon on the first transplant, performed the second operation Thursday, and Mahoney said he doesn't blame the doctor for the failure of the first.

"We have faith in the surgeon," he said. "We feel there was a grave mistake made. We do not question his skill as a surgeon."

Molter said several times that Duke acknowledges its mistake.

"We do apologize again for the blood type mismatch," he said. "That did in fact make her condition worse."

Jaggers said Wednesday he believed appropriate checks were made before the first set of organs was offered to the girl. After that surgery, the hospital added another level of verification for organ compatibility, and Molter said the new procedures were followed before Thursday's surgery.

A spokeswoman for the United Network for Organ Sharing, which matches organs and recipients, said her organization has asked Duke, along with the two organ procurement agencies that helped arrange the donation, to draft written accounts of the events leading to Jesica's transplant surgery.

The Richmond, Va.-based UNOS will review Duke's written accounts, along with those from the organ procurement agencies, and make a private determination about the sequence of events. Spokeswoman Anne Paschke said recommendations are made for corrective action, not punishment.

Duke must also answer to the agency that accredits hospitals, which investigates unusual deaths that might signal a problem with the hospital's system.

Those probes are likely to take several weeks.

Transplant Patient Has Brain Damage

Teenager Jesica Santillan, who underwent a second heart-lung transplant after the first was botched, has severe and irreversible brain injury, hospital officials said Friday.

Source: Washington Post

Real slick work there, people. There's nothing like human error to botch up perfectly operational computer data systems. Certainly computers were used to match up available organs for the patient.. certainly it was a human who hosed the order/shipment.

Teenager Who Got Botched Transplant Dies

Jesica Santillan, the teenager who survived a botched heart-lung transplant long enough to get an odds-shattering second set of donated organs, died Saturday afternoon.

Jesica was declared brain dead at 1:25 p.m., and taken off life-support machines at about 5 p.m., said Duke University Medical Center spokesman Richard Puff.

Earlier Saturday, a lawyer for the 17-year-old's family said they would not agree to remove her from life-support until they were allowed to get an outside doctor's opinion on her condition. Puff said he did not know if the hospital had the Santillans' consent to turn off the machines.

He said the family declined to donate any organs from Jesica's body, including the heart and lungs that had been donated to her in an operation Thursday. He did not know if those organs had been in any condition to use in a second transplant.

The Santillan family declined to donate any organs from Jesica's body, Puff said. Although the newest organs transplanted into Jesica were performing well, her brain began swelling and bleeding shortly after the second transplant, doctors said.

Jesica had been in a coma since the first transplant Feb. 7. Her health deteriorated as her body rejected the donor organs, which didn't match her blood type. By the time a match was found and new organs were transplanted early Thursday, she was in critical condition.

Autopsy Planned on Teenager Who Died After Botched Transplant

Medical examiners will determine what ultimately killed a teenager who survived a botched heart-lung transplant but died two days after receiving a second set of organs.

An autopsy was planned Monday on the body of Jesica Santillan, the state medical examiner's office said. A lawyer for the 17-year-old's family said an autopsy was appropriate.

"We just want to make sure we know what the cause of death was," attorney Kurt Dixon said Sunday. "If there's going to be legal action down the road, you want to have a definite cause of death. You don't want to speculate about that."

Family and friends were planning memorial services for the teenager on Tuesday, one public and another private, said Mack Mahoney, a family friend and Jesica's chief benefactor. He said he believed the family, who was in seclusion, would return her body to their home country of Mexico for burial.

Jesica, whose own heart had a deformity that kept her lungs from getting oxygen into her blood, died on Saturday.

She never regained consciousness after her first heart-lung transplant, which her body rejected because the organs didn't match her blood type. Doctors at Duke University Medical Center in Durham said they didn't check the compatibility before the surgery began Feb. 7.

By the time a matching set of organs was found and placed in her body early Thursday, she was near death.

The new organs performed well, but Jesica's brain had swelled and was bleeding Friday. She was declared dead after more than a day without brain activity.

Dixon said Duke doctors took Jesica off life support before her family could contact other physicians to get a second opinion on her condition.

Dr. James Jaggers, the transplant surgeon, said in a taped statement released Saturday by the hospital that he had hoped Jesica would be "one of those lucky few" awaiting heart-lung transplants who actually receive the surgery and do well.

"Unfortunately, in this case, human errors were made during the process" to match the organs with the patient, he said. "I hope that we, and others, can learn from this tragic mistake."

Jesica's family had paid a smuggler to bring them from their small town near Guadalajara, Mexico, to the United States so the teenager could get the medical care, relatives have said.

As Jesica Santillan's family grieves her death after a botched heart-lung transplant and a rare second one, it has become the target of criticism for refusing to make the girl an organ donor herself.

"We have received several scathing e-mails from people who are concerned that the family refused to donate Jesica's organs," said Mack Mahoney, head of the foundation created to pay for the girl's medical bills.

Like most details surrounding Jesica's death and the bungled transplant that preceded it, survivors and doctors at Duke University Medical Center differed Monday on why a family that benefited from two transplants in as many weeks would refuse to donate organs.

One medical ethicist said the criticism is unfair.

"My bottom line is - let the family grieve now," said Thomas Murray, president of The Hastings Center, a medical ethics think tank in Garrison, N.Y. "It's a horrendous thing to lose a child."

Laura Wright, who received a transplant of a kidney and a pancreas six years ago and heads a Charlotte transplant support group, said she doubted that any of Jesica's organs could have been reused.

"You've got tubes and wires everywhere," she said, "and the amount of drugs they pump through you is astronomical."

Jessica, a 17-year-old Mexican girl who moved to the United States with her family to receive care for a heart deformity, spent three years on a waiting list before receiving a heart-lung transplant at Duke Feb. 7.

But surgeons discovered they had mistakenly transplanted organs of the wrong blood type, causing the body to immediately reject them. She was near death by the time the second set was placed in her body last Thursday. Irreversible brain damage soon followed, and after more than a day without brain activity, she was declared dead Saturday afternoon.

According to Mahoney, Jesica's mother asked doctors about donating the girl's new heart and lungs as well as other organs. She was told the heart and lungs could not be reused and the kidneys and liver were ruined from being on life support machines for too long.

Other organs and tissues were so saturated with medications and anti-rejection drugs that they also would not be reusable, Mahoney said.

"By the time the doctors got around to telling the family that they may be able to use the corneas of Jesica's eyes," Mahoney said, "the family had been put through the worst ordeal a family could face.

"And a very tired and emotionally worn out mother took the advice of her legal counsel to leave Jesica as is, for the pending autopsy."

That autopsy was performed Monday by state medical examiners, but results won't be released until a final report on the case in six to eight weeks, said chief medical examiner Dr. John Butts.

Duke officials said doctors were told by Carolina Donor Services, the state's organ procurement agency, "that based on their initial assessment several organs may be viable for donation."

Jesica's mother declined to speak with the procurement agency, Duke said in a statement. A spokeswoman said hospital officials could not describe which organs were fit for donation because of patient confidentiality laws.

Carolina Donor Services was unable to discuss any aspect of Jesica's case because of confidentiality laws, spokeswoman Jane Corrado said Monday.

A public memorial service for Jesica was scheduled for Wednesday evening at Louisburg College, where her mother worked as a housekeeper.