Center For Donation & Transplant

1. Center For Donation & Transplant Organ Donation for EMS Providers January 9, 2007 by Barbara York, BA, OPC, EMTP The Center for Donation & Transplant Albany, New York

2. Center For Donation & Transplant Removing the Veil of Mystery About Organ & Tissue Donation January 9, 2007 by Barbara York, BA, OPC, EMTP The Center for Donation & Transplant Albany, New York

3. Everyone has a personal story

4. Center for Donation & Transplant CDT is a Organ Procurement Organization (OPO) 5 OPO’s in New York CDT service area (dark green) 46 Hospitals: 6 in Vermont 1 in Mass. 39 in New York

5. Trends in Organ Donation and Transplantation 2005 Organ Donors Transplant Recipients Patients on Waiting List

6. What Organs Can Be Transplanted http://www.transplantliving.org/beforethetransplant/organfacts/default.aspx Lungs Heart & Heart Valves (Heart & Lung) Kidneys (Kidney and Pancreas) Liver Pancreas (Kidney & Pancreas) Intestine

7. Factors Influencing the Potential Supply of Organs Number of brain deaths annually: 20,000 - Only about 7,500 (38%) become organ donors - Estimated loss of transplantable organs: >56,000 Public willingness to donate: - 90% of people support organ and tissue donation - 56% likely to donate their own organs - 33% know the steps to take to ensure their wishes regarding donation are fulfilled

8. Major Legislation 1968 Uniform Anatomical Gift Act. 1978 Uniform Brain Death Act 1980 Uniform Determination of Death Act 1984 National Organ Transplant Act • Omnibus Budget Reconciliation Act 1996 Medicare/Medicaid Existing regulations published May 2, 1996; Final rule, CMS-3064-F, published May 31, 2006 1998 Required Referral Law

9. Required Referral When the death of a person in a hospital has occurred or is imminent, the hospital shall contact the federally designated organ procurement organization in order to make a preliminary determination of the suitability of the person for organ donation.

10. CMS: The Final Rule In order for hospitals to participate in Medicare and Medicaid reimbursement, they must follow the CMS Conditions of Participation. The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has adopted the provisions of the regulation and these standards.

11. Imminent Death • Imminent death is a term that applies to patients who are on a ventilator and have had an insult or injury to the brain. • When patients are on a ventilator and have a Glasgow Coma Scale of less than or equal to 5, or appear to have irreversible loss of brain function, death is considered to be imminent and CDT must be notified immediately. • CDT must be notified before the patient is removed from the ventilator.

12. Pre hospital BRAIN DEATH Head Trauma, CVA, asphyxia: Patient has interrupted blood flow to the brain with no oxygen supply and cell death begins. Pre hospital CARDIAC DEATH Patient has lethal cardiac activity - no “pump” for oxygen supply and cell death begins. People Die in Two Ways The brain takes an anoxic hit, begins to swell and often leads to brain death… … even if the cause of the interruption of blood flow or oxygen is transient or cardiac rhythm is restored.

14. The Storm • Catecholimine Storm • Cushings Triad • Psuedo MI • Usually will progress in 24 – 48 hours

15. Pathways to Donation • Standard Path, Patient is Brain Dead • Declared brain dead but still with cardiac function • Standard donor • Taken to OR • Never extubated • Aorta is cross clamped

16. Clinical Criteria for Brain Death • No response to external stimuli • No reflex activity except of spinal cord origin • No pupillary response to light • No corneal reflex

17. Clinical Criteria for Brain Death • No gag reflex • No cough reflex • No eye movement with caloric testing or doll’s eyes maneuver • Apnea in the presence of adequate CO2 stimulation – Apnea Test

18. Confirmatory Testing • EEG • Cerebral Blood Flow Studies • Nuclear Flow Study • Cerebral Angiography

19. Pathways to Donation • Donation After Cardiac Death (DCD) Path • NOT brain dead with cardiac function • Extended criteria donor • They may have many of the clinical signs that EMS has come to know as indicators of brain activity; pupils, cough, gag, etc. • Remember, they are NOT brain dead

20. Donation After Cardiac Death • This is an option offered to families when all indications are that the patient has sustained fatal, non survivable injury and will remain in a vegetative state • Taken to OR • Extubated and pray patient goes asystolic very soon - within 60 minutes

21. Donation After Cardiac Death • Was original way donation occurred • Resurgence in popularity because of need for organs for transplant • Organs have poor graft survival rates due to increased anoxia hit to organs • Extubation & DCD is difficult to wrap your arms around in hospital OR environment

23. Circling the Drain • Bad things happen to good people • Bad things happen to bad people You or I didn’t kill them…

24. Chain of EMS Or did we? We are only as strong as our weakest link…

25. EMS & Donor Connection • Airway, airway, airway • Good BLS before ALS • Documentation. Do YOU leave it at the hospital? Or do it at the end of the day? Don’t answer that out loud!

26. EMS & Donor Connection • Just like you paint the picture for the ED, you are our eyes and ears on scene. • Your documentation and description of any downtime and treatment is paramount to our ability to paint a picture of an organ donor to a transplant surgeon later.

27. Which heart would you want your transplant surgeon to pick for you? “18 YO F with unknown PMHX was found down at home yesterday by a family member with unknown downtime. EMS/ACLS was performed, but she never regained neuro status, CT showed ICH. This morning she deteriorated and was pronounced brain dead at 11:53.” “18 YO F with a PMHX of PSVT was found slumped over on the couch unconscious by a family member after they came back into the living room from the bathroom. Per 911 she was breathing without a pulse. EMS was activated with a 3 min. response time. EMS found her in care of Father, chest compressions being done. No signs of drug or alcohol use on scene. Upon assessment, patient was found to be in SVT, breathing at 6 but pulseless and was transported to the ED with ACLS. #7 nasal ET confirmed by LS. – epigastric sounds and end tidal color change. Pt. converted to NSR with 12 mg. adenosine but had a GCS=3 upon arrival to the ED. She was PEARL and ocassionally clenching her mouth. CT showed ICH. This morning she deteriorated and was pronounced brain dead at 11:53.”

28. Chain of Donation • EMS gets the call and delivers patient to “definitive care.” • Attending MD. and neurology assesses patient • CDT is paged • Donor evaluation (often on site); serologies drawn • Family approached • Consent (hopefully) • Donor management by OPC that includes bedside hemodynamic monitoring and node procurement for antigen matching if patient is a kidney donor • Coordinate placement of organs and arrival of transplant teams • Coordinate OR recovery, packaging of organs and transportation, delivery of organs to recipient transplant center

29. The Operating Room

30. Organ Hierarchy: Lungs & Heart First

31. Small space, many hands

32. Liver

33. Kidneys

34. Aortic Valve Pulmonary Valve Cardiac Allografts

35. Vascular Allografts • Saphenous Vein • Femoral Vein/Artery • Superficial Femoral Vein Valve

36. Corneal Transplant

37. Humerus Radius Ulna Ribs Iliac Crest Femur Tibia Fibula Tendons Ligaments Fascia Lata Bone & Connective Tissues that CDT Recovers

38. Uses for Bone and Tissue • Skin for burn victims • Orthopedic surgery • Neurosurgery • Plastic surgery • Dentistry

39. Center for Donation & Transplant Q: Why isn’t there a policy or protocol for trauma/cardiac arrest and organ donation?

40. Center for Donation & Transplant A: Ethicists and the Department for Health and Human Services feel that the subject of organ donation should be addressed with families in a way that promotes consideration and consent, by trained personnel. Interestingly, the myth that a hospital provider or EMS provider would be more likely NOT to provide life saving care in favor of creating an organ donor still exists in 2007.

41. The Fast Track to Organ Donation • Drive a motorcycle recklessly on a dark, gravel-filled back road • Drive head on into a tree with or without your seat belt • Dive from a tall bridge, play handgun roulette with your friends or • Never visit your PCP and treat your HTN

42. The Fast Track to Organ Donation • Tell your loved ones what your wishes are • Ask your loved ones what their wishes are • Fill out a Health Care Proxy • Register when you renew your license • Go on the web to: • http://www.health.state.ny.us/nysdoh/donor/form.htm

43. Your Very Patient, Thanks! Thank you for your time! Barbara York, BA, OPC, EMTP Center for Donation & Transplant 218 Great Oaks Blvd. Albany, NY 12203 byork@cdtny.org 518-928-8387