The Gift

The first time her alarm screeched the sun may have been just dipping over the horizon behind the clouds, but by the time Justine had snoozed nine minutes four times in an effort to sink back into her dream, it was completely dark outside. By almost halfway through her second year of general surgery residency she was used to waking up in early morning dark, but it cruel that even on night shift she had to wake up in the evening dark. Unfortunately for her, nightfall came early in Seattle in November. She realized it was 5:10pm and cursed herself for not getting up with enough time to do anything besides get ready for work and grab a protein bar to eat on the walk.

As she trudged uphill in the drizzle, she tried to remember what she had liked about ICU rotation as a medical student. Back then it was all fascinating physiology and a chance to be close to the life-or-death scenarios she had grown up watching on TV, but she never felt adequately prepared to address the concerns of the ICU nurses who knew much more than she did about critical care. Even worse, the overnight team was smaller and the senior resident was often out of the unit operating or dealing with crises on the wards so she was the one who had to have most of the difficult conversations with family members.  

She slowed her steps slightly in the block before the hospital as she remembered that if nothing surprising had showed up in the lab results, the procurement procedure for Max was likely to be that night, and she could be part of it if the other patients remained stable. Although she had no desire to sign up for the unpredictable operating room and call schedules of transplant surgery for a career, she was fascinated by the recipient selection process –the closest a conference room of professionals came to playing God in modern medicine – and the donor prioritization system. Donation after cardiac death was much less common than donation after brain death, plus she had already decided to use it as one of her required weekly case presentations and it would be much easier to discuss if she was there for the procedure. Her academic interests were in combination with the fact that she was there three nights ago when Max was brought in by paramedics. He had been assaulted by a man in the process of trying to kick him out of the bar where he worked as a doorman, and she had been the one to explain the devastating extent of his brain and spinal cord injuries to his girlfriend Serena when she arrived at the hospital. 

While Justine tried to never let it affect her clinical decision making, she did realize the degree of emotional connection with her patients and their families varied in a complex arithmetic of whether she had admitted them, how long they had been in the ICU, and the nebulous feelings she developed from details of their lives she gleaned from family members and visiting friends. After updating Serena as honestly but gently as she could, she listened to Serena describe the tumultuous relationship Max had with his parents and how this drove him to enlist in the Army. He was discharged during basic training for an ankle injury then, forced to return home, spent a year overusing pain medication and alcohol. Eventually he had gotten clean and managed to stay sober even while working at a bar, and had moved into his own apartment. He started to talk about volunteering at a shelter for male veterans, and Serena acknowledged through her tears that he would have been happy to at least help others in his death.  

Despite the severity of Max’s injuries, the tests showed he still had a small amount of persistent brain activity and therefore donation after cardiac death was the only possibility. Because he had registered as an organ donor when he renewed his driver’s license, the donor evaluation process began as soon as it was clear he had no chance of movement below the neck or meaningful brain function. With Max and Serena on her mind, Justine walked out of the dark cold drizzle into the too-bright florescent lights of the hospital lobby and started winding through the back staircases and corridors to the ICU for sign out.  

As Justine sat down at the conference room table and started to take notes on the patient updates from the day shift, nine miles north of Harborview, Eloise was sitting down to dinner at her kitchen counter when the landline phone rang. There was no chance either of her sons would be calling and interrupting 7pm dinner (even living alone, she remained a creature of routine) and she didn’t feel like dealing with a telemarketer so she ignored it. As she was about to take her first bite, she heard the faint jingle of her cell phone in her purse by the front door. Almost no one had that number so she thought she should at least see who was calling. She shuffled over, dug the phone out, and was startled to see an unknown Seattle number with “Possibly: Virginia Mason” underneath the number. In the months that followed she would recall every detail about getting the call – the navy blue shirt she was wearing, the chicken and steamed broccoli getting cold in the kitchen, the dark mist droplets coating the large window in her door – but at the time she rushed to answer before her voicemail picked up since, embarrassing, she didn’t know how to check her voicemails.  

At Harborview after sign out, Justine took her usual start-of-shift lap around the unit, checking in with each nurse to see if they needed any orders or had any concerns about the patients. She paused in Max’s room to confirm with the nurse and the transplant organization representative that the procurement was scheduled for around 11:00, and that his family was aware and on the way. His face looked calm and peaceful and for a minute she was able to isolate it from the bulky white gauze bandage on his head with the slim metal pressure monitor emerging at the top of his head, rigid cervical collar, the dark purple bruise on his left forearm, and splint on his right wrist (she couldn’t keep the phrase “defense injuries” from popping into her brain).  

A few new trauma patients came to the ICU from the emergency room, but they didn’t very much attention. Around 9:30 Justine was had time to grab the world’s most disappointingly wilted sandwich from the cafeteria and was scarfing that down in the work room when Dr. Garcia, her attending, appeared. Together they went over the protocol and the transplant organization representative poked her head in to tell them the abdominal organ transplant team was coming from Virginia Mason. The short transport time for the organ could mean better initial function which made Justine happy for the recipients.  

At 10:45, Justine, Dr. Garcia, and the nurse carefully rolled Max and his complement of IV poles with hanging bags of fluids and medication down to the operating room while the respiratory therapist walked alongside the bed hand ventilating him. She had gone through this meticulous transport ritual many times in the preceding three weeks. Nothing seemed different about this time until they arrived in the bright light of the operating room and found the Virginia Mason transplant surgeon and assistant there instead of an anesthesiologist. The visitors gave a nod but were explicitly forbidden from talking to avoid the appearance of a conflict of interest, and immediately returned to reviewing the instrument table set up with the surgical technician. Justine and the nurses gently rolled Max from his bed onto the operating room table, taking care to not displace any of this IVs or the intracranial pressure monitor. Max was positioned correctly and attached to the ventilator and shortly afterwards the transplant team washed their hands, put on their sterile gowns, and began cleaning Max from his neck to his mid-thighs with the sterile prep solution. Once they finished, the surgical technician set up two layers of sterile drapes and the operating room nurse cover the top drape with a blanket, taking care not to touch the sterile surfaces.

The operating room nurse confirmed that everyone was ready, and went out to the waiting room to retrieve the family. The ICU nurse, attentive to every detail, had already plugged her phone into a portable speaker next to the anesthesia machine, something she usually did for similar situations in the ICU. The door swung open and the operating room nurse guided Serena and another young woman who must be Max’s older sister to his right arm outstretched on a board, quietly requesting they not touch the blankets covering the rest of his body. The ICU nurse asked if he had a favorite kind of music and they glanced at each other and simultaneously said “80s hair metal”. As the music started, Dr. Garcia explained the process of removing the breathing tube, and then waiting for his heart to stop. The family would be allowed to say goodbye then would be ushered out so that after exactly 5 minutes elapsed from the time of death, the transplant team could come in and begin the process of opening his chest and abdomen to remove the liver and kidneys as efficiently as possible. Justine was proud of Dr. Garcia because although he could be gruff and impatient with the residents and medical students, he was calm and gentle with these two sniffling women.   

As planned, the ICU nurse made sure adequate pain and sedation medicine was flowing, and the respiratory therapist removed the breathing tube in a single smooth motion. Just as everyone’s eyes turned to the monitor of vital signs, the Van Halen song “Running with the Devil” came on in shuffle mode. Justine gasped quietly and the ICU nurse’s finger darted to the fast forward button, but Serena broke the tension with a rueful laugh as his sister said “This is perfect, he would love this! He’s probably having the time of his life down in hell waiting for us!” and everyone relaxed. The seconds ticked by slowly but after a little more than four minutes his heart slowed, fluttered, and stopped. With relief, Justine checked his pulse manually and gently pronounced time of death (Dr. Garcia had mentioned to Justine earlier that sometimes the patient’s heart doesn’t stop within the five minute window in which case the transplant procedure is called off and the patient has to be transported back to the ICU to continue dying, a devastating turn for a family counting on the patient donating to salvage some tiny glimmer of good from a horrible tragedy). Justine gave Serena a hug as she walked out, fighting back the tears for a loss that wasn’t hers. She couldn’t dwell on Max though because she got an urgent page about low oxygen saturations in one of the other patients and had to dash back to the ICU.

The early morning hours passed steadily, and Justine even managed to find time to work on the slides for her case presentation. She mostly stayed focused on the pertinent facts and research articles she had found on function of the transplanted liver after this type of donation, but at one point did have to shake off her incredulity at why Max’s parents, who Serena had told her still lived just outside the city, had chosen not to come for his final moments. Right after she clicked save on the slides, it was time to check morning labs and prepare for sign out. The herd of day team residents and students came in with a coffee for her and she felt the bleary delight of handing over the pager to the oncoming resident. They all reviewed the night’s events and Justine decided there was no way she was making it to the gym before going home to crash into bed for the day. She walked the back corridors and stairs in reverse and emerged through the expanse of the main hospital lobby into the brisk air under bright blue cloudless sky.  

A few blocks north, Eloise sat in a stretcher, naked under her gown, in the preoperative holding area. One of the nurses nearby said something that sounded like “Did you see the sunrise this morning?” to her colleague but the idea of sun in November was foreign to Eloise, who was mostly focused on sending one last “headed to surgery now, love you forever” text message to her sons. She tucked her phone into her plastic bag labeled Patient Belongings on the chair next to her stretched and the cheerful anesthesiologist she had met earlier arrived and asked if she was ready for surgery. She nodded nervously and after patting her shoulder, he unlocked her bed and rolled her through a set of double doors into the middle of a huddle of people in blue scrubs and blue hats. The crowd moved to the walls to let her pass instinctively and without breaking eye contact with each other, and Eloise continue to roll down a long windowless back hallway decorated with underwater photographs of fish and bright coral before arriving at a door labeled OR 9. The anesthesiologist paused to don a mask before entering a huge room with brighter overhead lights than she had ever seen. Suddenly she was surrounded with people murmuring explanations which they moved her, and attached monitors. As she heard “you’re going to off to sleep now, the medicine might burn a little bit in your IV”, she started to felt like she was floating towards the ceiling but held on to consciousness long enough to say a prayer for the donor who had died to give her this liver even though she was certain he or she had already arrived in heaven.