Transplant organs are precious. About 50 percent of children who have received a heart-lung transplant are alive after five years, and only 20 percent after 10 years. "These poor outcomes," Jaggers says, "beg the question of whether we should offer this high-risk and expensive procedure to any patients." Since 1988, moreover, only five children--and five adults--have received a second heart-lung transplant. Jesica's survival was questionable. Besides, she had been unable to speak since the third day after surgery; neurological tests hinted at brain damage. However noble the intent, why give more organs to a girl who might slip into brain death from the stress of another major operation?
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"Little hints." The trouble was that neurological tests can mean everything--or nothing. "There's nothing to measure directly, as there is with the heart and lungs," says Ira Cheifetz, director of the pediatric intensive care unit--the PICU--that had been Jesica's home for two weeks. EEG readings of the tiny impulses of the brain are unreliable in the electrical storm that crackles through a PICU. "And it was made even more difficult with Jesica," he adds, "because she was sedated and on morphine," both of which damp down the nervous system.
The negative findings were small, says Cheifetz, and potentially reversible. Moreover, Jesica had opened her eyes and could squeeze her hand. "All we really had," he says, "were CT scans and EEGs, and a few little hints that she was in there, she was aware." The PICU team voted to go ahead.
Duke's decision was bound to draw criticism. "Some of my colleagues, other transplant surgeons, have said it was unethical to transplant that girl again, her chances were so poor," says Robert Robbins, director of adult heart, lung, and heart-lung transplant at Stanford Hospital and Clinics. "But that's what I would have done. You can't discount your commitment to the patient."
At the family's request, Jaggers was still the lead surgeon. This time, however, Duane Davis was with him. It was not for lack of trust, says Peter Smith, who as chief of the division of thoracic and cardiovascular surgery made the decision. Given the glare of publicity in Jesica's case, he says, "I did not want Dr. Jaggers to have to be responsible for all decisions on his own." Davis took on the job of trimming the lungs to fit, removing a lobe--about a third of the mass--from the right lung and a smaller portion from the left one. The surgeons moved along at a good clip, finishing up in just over four hours.
A lock of hair. At 2 the following morning, Cheifetz paged Karen Frush, chief medical director for children's services, to come to the PICU. Jesica's brain was herniating--bulging under growing pressure. Frush called Jesica's parents at the Ronald McDonald House next to the hospital. A CT scan at 3 a.m. indicated significant brain swelling and bleeding. "We told them it was highly unlikely she could regain brain function," says Frush. At 9 a.m., neurological tests showed no brain activity. There was one more neurological exam, at 1 p.m. At 1:25 p.m., Jesica was pronounced brain dead. "You tell [families] the terrible news gently," says Frush. "We said we were very, very sorry, but Jesica had died." Magdalena refused to accept the verdict and angrily turned away a question about donation. "You murdered Jesica," she cried in agony. "Why would we give you organs to murder other people?"
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