Positive Turn For Jesica: CAT Scan Reveals Brain Activity
Posted February 19, 2003
DURHAM, N.C. — A CAT scan conducted Wednesday on a 17-year-old girl who received organs that did not match her blood type revealed that she has brain activity and remains eligible for another transplant.
Doctors say Jesica Santillan has just hours or days to live if she does not receive a healthy heart and lungs. The CAT scan was ordered to see if she had suffered any brain damage that would rule out any possibility of a second transplant.
Santillan is still listed in critical condition at the hospital and remains at the top of the donor priority list. A lawyer for Santillan's family asked Duke for her medical records, so they can get opinions from a neurologist and transplant surgeon who are not affiliated with Duke.
A thorough review of the events leading up to the blood type mismatch that occurred during the Feb. 7 heart-lung transplant for Santillan is still ongoing.
Information provided by James Jaggers, M.D., the Duke transplant surgeon for Santillan, confirmed the need for better communication and a better understanding of individual responsibilities during the transplant process. He has reported to Duke that the event was based on human error, with an assumption being made that blood type match had been confirmed.
"I am heartbroken about what happened to Jesica," Jaggers said. "My focus has been on providing her with the heart and lungs she needs so she could lead a normal life.
"Early in the morning of Feb. 7, I received a call from Carolina Donor Services and was informed of available organs. I assumed that after providing Jesica's name to the organ procurement organization, and after the organs were released to me for Jesica, that the organs were compatible. I informed Jesica's parents immediately after the operation that an error had been made and that the organs were blood type A and Jesica was blood type O, and that this was an incompatible transplant.
"I continue to oversee Jesica's care and have been devastated by this tragic event," Jaggers said.
Organ transplant agencies say a Duke surgeon asked for lungs and a heart for Santillan's transplant even though they were known to be the wrong tissue type.
The surgeons who operated on Santillan also may have removed her diseased heart and lungs too soon before the mismatched transplants arrived in North Carolina from Massachusetts.
The New England Organ Bank says it told the Duke surgeons that the tissue type was "A." But Santillan required type "O-positive."
Changes have already been made to improve the organ transplant program at Duke, and the complete review is expected shortly.
"As a result of this tragic event, it is clear to us at Duke that we need to have more robust processes internally and a better understanding of the responsibilities of all partners involved in the organ procurement process," said William Fulkerson, M.D., CEO of Duke University Hospital.
"To make sure that something like this never happens again, it is our intent to work even closer with organ procurement organizations to ensure that all steps are taken to maximize patient safety. Ultimately, however, our patients are our responsibility."