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THE NASTY SIDE OF ORGAN TRANSPLANTING - THE CANNIBALISTIC NATURE OF TRANSPLANT MEDICINE

 

by Norm Barber

 

Chapter 1

An Invented Death

Transplant surgeons, just like movie vampires and Frankenstein doctors, like their bodies fresh and not quite dead. They need beating hearts in perfect health from warm, soft bodies to make the transfer of organs worthwhile. Their initial legal problem was that this process constituted murder of the donor.

The imperative of developing an artificial concept of death became apparent after Christiaan Barnard᾿s historic heart transplant in December 1967. Barnard proved that heart transplants could be done, but had faced the problem of the risk of the donor heart damaging itself during the dying process.

Louis Washkansky was the world᾿s first human heart transplant recipient. He was a Lithuanian Jew from the town of Slabodka who was deported to the Crimea when the Russians said the Jews were German spies. Louis later moved to South Africa and worked as a grocer.

Denise Durval, the world᾿s first heart donor, was hit by a vehicle while walking to her car from a fast food shop in South Africa. Brain tissue began leaking from her ear. Denise was dying. Her father consented to the removal of her heart.

Louis Washkansky, desperately living each day at a time, was on the operating table. Hovering surgeons in full gown had opened up Denise, eagerly awaiting her heart to stop forever, but it kept vigorously beating.

Christiaan Barnard was worried the slow process of Denise᾿s death would ruin her strong heart. Her brain was so damaged and a number of bodily functions were failing and Barnard was worried the heart in particular would suffer damage before it stopped.

When a person suffers what is called catastrophic brain damage, the body temperature, blood pressure control, renal and endocrine function and a variety of other processes progressively malfunction before the body dies, and it is this dying process that can ruin the organs. The heart is particularly vulnerable to damage during this process.

To avoid this natural shutdown medical technicians may inject a cardioplegic solution into the heart while it is still beating in the donor body. This action immediately stops the heart, thus minimising the damage it may sustain as death progresses. The injection also gives it a longer shelf life before it is sewn into the recipient. It also kills the patient. Barnard couldn᾿t do this in 1967 in South Africa because he would have been charged with murder.

When Denise᾿s heart finally stopped, there was confusion in the operating rooms. Incredibly, Christiaan Barnard thought his brother Marius, also a surgeon, would remove the heart and he, Christiaan, would transplant it. It was resolved that Christiaan would do both, but by the time he removed Denise᾿s healthy, pink heart it had declined to a morbid greyish-blue. It was put into a dish and taken to the anaesthetised Washkansky waiting in the next room. There was a feeling of pessimism and doubt that this heart could be restarted.

But Barnard recounts that after a few electrical shocks, Denise᾿s heart began beating strongly and pumping lifesaving blood throughout Washkansky᾿s body, but he died anyway, eighteen days later.

The autopsy of Louis Washkansky᾿s body showed that Denise᾿s heart had transplanted perfectly and, despite the patient᾿s death, surgeons around the world rejoiced at the world᾿s first successful human heart transplant. But there was still another problem. The South Africans had been lucky, but heart damage would likely still occur during future donor death processes, so it would be necessary to paralyse and remove the heart before it stopped naturally. The other problem was that in South Africa and most other countries, this was considered murder. Transplant surgeons, the medical hierarchy and drug companies needed a remedy to meet the demands of this brave new medical advance.

 

An Invented Death

After the Washkansky transplant, the Harvard Medical School set up an Ad Hoc Committee to Examine the Definition of Brain Death - or, rather, to invent a new style of death.

This committee of thirteen neurologists, neurosurgeons, lawyers, philosophers and an anaesthetist decided in August 1968 that death could be proclaimed if a patient failed to respond to a series of reflex tests. They called it the Harvard Criteria of Brain Death Test. This allowed a patient with a healthy, beating heart and fully operating renal and endocrine system to be defined as dead, just like a cold corpse[2].

Most western countries adopted a de facto version of the Harvard Criteria of Brain Death during the 1970s and early 1980s. Some commentators say this new concept of death was devised to justify turning off expensive life-support machines used for patients not expected to recover consciousness. However, this new version of death was to the everlasting pleasure of transplant surgeons, who could now declare patients dead before their hearts stopped, then remove their vital organs and no longer worry about a murder charge. What one day was murder was the next day a brilliant surgical technique.

Surgeons began the harvesting process while the donor᾿s beating heart was keeping the kidneys, liver, lungs and pancreas in optimum health and thus minimising organ damage during the dying process when heart function and circulation gradually collapsed.

The donor bodies were warm, pink and essentially healthy and the harvesting process killed the donor patient, but legally it was okay.

Combined with the Washkansky breakthrough and, more importantly, Barnard᾿s second 1967 heart transplant into Phillip Blaiberg, who lived eighteen months, this legal “brain death” provided the impetus for the rush towards mass transplanting. The introduction of cyclosporin in 1983 gave the transplant industry its next big boost.

 

The Brain Death Test

The prime candidates for organ harvesting are usually those suffering catastrophic brain trauma, with haemorrhage and swelling caused by car and motorcycle smashes, cyclists or pedestrians hit by cars, gunshot or knife wounds to the head or simply being hit in the head. In these instances an artery is broken within the skull. Surging blood spills into the skull but with nowhere to go the pressure builds up in the brain and may force the brain stem downward. With little blood leaving the brain very little can enter. Circulation slows in the brain and its cells run out of oxygen resulting in brain damage and eventual death.

Brain damage from oxygen deprivation due to heart attacks, heart failure, asphyxiation from smoke inhalation or strangulation where circulation of oxygen rich blood to the brain stops, causing global cerebral ischemia, may also make a patient a harvest candidate.

The body reacts to these injuries by shutting down functions and going into a deep coma where breathing may cease resulting in death. Ambulance crews reacting in time will blow air into the patient᾿s lungs until they reach the hospital where a specialist will probably put the person on a mechanical ventilator to artificially maintain the patient᾿s breathing.

Ambulance arrivals in this condition alert hospital staff to treat the patient with two views, the first being to aid recovery from injuries and, secondly, that they have a potential candidate for organ harvesting. Hospital staff may check the organ donor register and personal belongings for donor registration. The transplant coordinator may even contact next of kin and prepare for tissue matching before the patient is declared brain dead.

Depending on the country, hospital staff may spend four hours observing the patient for signs of recovery. If recovery isn᾿t forthcoming, a doctor performs the first brain death test and, if “brain death” is indicated, then a few hours later another doctor performs a final test.

However, there are many varied protocols around the world to the above that are rarely, if ever, enshrined in legislation. This allows doctors to devise their own methods to determine brain death. For example, the United Kingdom Code of Practice doesn᾿t specify time periods between tests and repeat testing may be a formality.

The Australia New Zealand Intensive Care Society (ANZICS) recommends a series of tests, but the doctor doesn᾿t have any obligation to use them. The Society refused to provide their recommended criteria for brain death testing perhaps demonstrating how the transplant industry doesn᾿t want potential donors to be informed on the subject. After this monograph was published on the Web they quickly added their recommendations to their web site. However, these do not include the controversial apnoea test. ANZICS cannot decide whether it should be used or not[2a].

 

The Test For Death Begins

Doctors usually prevent relatives observing the brain death testing as they may object to the diagnosis of death or feel sickened by the physical rigour of the testing and the appearance that the doctor is harming their loved one. The test itself is not a pretty sight.

The doctor begins by shining a strong light into the patient᾿s pupils. They should adjust in size to changing light and failure indicates brain injury. This won᾿t be done if the eyes are full of blood. The doctor then holds the eyelids open and abruptly moves the head from side to side observing if the eyes move normally or remain staring straight ahead. This won᾿t be done if the patient has a broken neck. The eyeball is poked with a cotton covered prod and painful pressure applied to the eye-socket to check for reaction. Failure to react in pain may indicate brain damage.

A catheter is stuck down the windpipe to see if the injured person coughs this being an indication of some remaining brain function. A probe is stuck into the mouth to check for gag reflex. The doctor turns the head sideways and pours 50 millilitres (two ounces) of freezing salt water into the ear. Salt water is colder than the freezing point of fresh water and when poured onto a delicate eardrum creates shock – to say the least. Painful stimulus is applied to various parts of the body to measure arms, legs and trunk reaction. Atropine may, depending on the country, be injected into the patient᾿s blood stream. An increased heart rate of less than 10% indicates some brain death.

Some countries may also use the cerebral angiography where a dye is injected into the bloodstream and X-Rays observe the flow of blood to the brain. A lack of dye moving to the brain indicates a lack of circulation and possible brain death.

Dr Peter Doyle, of the British Department of Health, says the cerebral angiogram is unreliable and may register blood circulation in the brain one minute but four minutes later or earlier there might not have been any[2b].

Another test is the Radioisotope Study, where radioactive tracers are injected into the bloodstream. These radioisotopes emit radiation and their presence is detected by devices, like Geiger Counters, which respond to radioactivity. Since these radioisotopes are carried by the blood stream one can determine the flow of blood to the brain by the presence of radioisotopes inside the skull.

Many methods of determining brain injury are used around the world. There is no one perfect method because no reliable procedure for determining brain death has been invented. The difficulty in determining if patients are dead or alive may preclude them from being harvested.

Dr David Wainwright Evans from Queens College, Cambridge, gives some further description of angiograms and radioisotope studies in Appendix One.

 

The Apnoea Test

Doctor Turns Off The Breathing Machine

The Apnoea Test is the final procedure for brain death testing done to potential organ donors. If the patient doesn᾿t respond sufficiently to the above mentioned tests, the doctor turns off the ventilator, which has maintained the patient᾿s breathing, and leaves it disconnected for up to ten minutes, though it varies according to country and doctor.

Oxygen is pumped down the trachea into the still lungs, but the patient suffers oxygen deprivation because the ventilator is no longer raising and lowering the lungs. The theory behind this is that a brain that has recovered during the treatment in hospital will recommence the breathing process. However, if the apnoea test is performed just a few hours after admission then the theory becomes redundant.

If the patient doesn᾿t begin breathing without the machine, the doctor declares the patient “brain dead” and re-starts the ventilator.

 

Second Brain Death Test

Before commencing the harvest, a second doctor performs another brain death test. In Japan the second doctor waits six hours, in Spain twelve hours with adults and twenty-four hours with children. Australians wait two hours.

If the patient fails to respond to the second test, the doctor certifies him or her brain dead. The patient is no longer considered a legal entity, has no human rights and is referred to as the “heart-beating cadaver”. The ventilator is turned back on and the corpse, though legally dead, is kept alive on life support until surgeons have been assembled and transplant hopefuls brought to the hospital. This may take quite some hours or days.

All treatment to heal the injured brain will cease and doctors will administer high amounts of fluid drip, drugs to increase blood pressure and sometimes anti-psychotic psychiatric medications like chlorpromazine to maintain the harvestable organs. The patient, if it hasn᾿t already happened, may be transferred to a hospital better equipped to harvest organs though this is universally denied.

 

Various Types of Brain Death

Most European countries and some American states recognise the “whole brain death” criteria that requires “irreversible cessation of all functions of the entire brain, including the brainstem” as defining brain death.

The United Kingdom, most Commonwealth countries and some American states, particularly Minnesota, went further and have adopted the lesser “brain stem death”. The brain stem is situated between the brain and top of the spinal cord. It controls physical functions like breathing and regulation of blood pressure. The concept of “brain stem death” means part of the brain may be alive, but when the brain stem is destroyed this is considered identical to brain death which is identical to being legally dead, which is identical to being really dead, or so the logic goes.

 

Chapter 2

Donors May Need Anaesthetic

The residual doubts about the cadaver᾿s health status increases when it reaches the harvest table. Let us assume it is a twelve-year old girl, diagnosed “brain dead”, after being hit by a car while riding her bicycle. Her body is cleaned, shaved, tubes inserted and hooked up to various machines and everyone pretends it is a plain, dead corpse.

 

Donor Body Registers “Fear” to being Harvested

On the harvest table the surgeon draws a deep, clean slice down the middle of her torso cutting through skin, muscle and fat. But then a strange event occurs. Instead of lying dead and still like a corpse her twelve-year-old body registers fear and panic when the knife slices it open. Her heart and pulse speed up identically to a living human twelve-year-old cut with a knife.

More violent reactions would occur but don᾿t because the anaesthetist injects pancuronium or another paralysing drug. This prevents her torso jerking and arms and legs flailing about and what has been rarely described as coordinated attempts to “grab the knife”.

Anaesthetists trained to prevent pain during surgery may assuage their doubts and the distress of other theatre staff by anaesthetising donors to prevent possible pain. But hospitals and donation agencies bitterly resent medical staff using anaesthetic because they spend their working lives trying to persuade distressed friends and relatives that the patient has actually died. But many medical experts doubt this.

 

Professional Opinion

Dr Phillip Keep, a consultant anaesthetist at the Norfolk and Norwich Hospital in the United Kingdom, risked his career by publicly saying what the anaesthetist profession had been debating privately for decades,

“Almost everyone will say they have felt uneasy about it. Nurses get really, really upset. You stick the knife in and the pulse and blood pressure shoot up. If you don᾿t give anything at all, the patient will start moving and wriggling around and its impossible to do the operation. The surgeon always asked us to paralyse the patient”[3].

Dr Keep adds,

“I don᾿t carry a donor card at the moment because I know what happens”[4],

Harvest theatre nurses also express doubt about the health status of the donor. Dr David Hill, also an anaesthetist, checked operating theatre registers at Addenbrooke Hospital in the United Kingdom and discovered that nurses recorded the time of death at the end of harvesting as if the donor had come in to the harvest room alive[5].

Dr David Wainwright Evans, a cardiologist, formerly of Papworth Hospital in Cambridgeshire, England, observes that,

“Nursing staff treat deep coma patients with continuing tenderness and address patients by name, as the coma deepens rather than lightens, perhaps from an intuitive feeling that hearing has been retained”.

Dr Evans says surgeons tell of persistent uneasiness at the unpleasant job of harvesting organs, particularly the heart. He says they don᾿t get over it despite doing it many times[6].

The Swedish medical writer, Nora Machado, quotes one expert as saying,

“...Even surgeons are sometimes heard to say that the patient "suffered brain death" one day and "died" the following day”[7].

D.A. Shewmon, Professor of Neurology and Paediatrics, University of California (Los Angeles) School of Medicine, in his presentation to the Linacre Centre for Health Care Ethics, also says some surgeons feel they are killing the donors[8]. When interviewed by the Australian Broadcasting Corporation he indicated a change of mind about brain death being the death of the patient[9].

Wendy Carlisle: So is brain death the death of the person, in your opinion?

Alan Shewmon: I used to think that it was. But in fact, during the 1980s and early ᾿90s, I read a number of articles and gave lectures supporting that idea, and since then I have had to change my opinion about it due to an accumulation of evidence to the contrary...

Wendy Carlisle: I think you᾿ve actually called somewhere the notion of brain death a medical fiction.

Alan Shewmon: A legal fiction.

Wendy Carlisle: A legal fiction. What does that mean, then, in your opinion for the whole donor debate?

Alan Shewmon: I guess it᾿s also a medical fiction. You᾿re right.

Dr David Evans is among a number of medical professionals who doubts that all organ donors diagnosed “brain dead” are actually brain dead:

“The reason why the heart goes on beating in patients pronounced "brain dead" is, usually, that their brain stems are not really and truly dead but still providing the "sympathetic tone" necessary for the support of the blood pressure. In other words, the state of "shock" (profound hypotension) that characterises the destruction of the brain stem has not occurred in those patients”[10].

Dr David Hill concurs saying,

“A measure of life is the continuing hypothalamic function which controls body temperature. If the patient is warm then that part of the brain is functioning”[11].

Despite scientific advances there still isn᾿t an absolute determination when a person is finally dead.

Japanese cardiologist, Dr Yoshio Watanabe, adds,

“...if the entire brain, including the brain stem, has indeed sustained irreversible damage, cardiorespiratory arrest would inevitably ensue, bringing about the person᾿s death. However, the duration of this stage may well last for several days to several weeks when a respirator is used and, hence, this stage at best only predicts that death of the individual is imminent, not that it is confirmed. The fact that some brain dead pregnant women have given birth to babies can be taken as strong evidence that the person is still alive, and the use of terms such as biomort or heart-beating cadaver is nothing but a sophism to conceal the contradiction in transplant protagonists᾿ logic”[12].

Medical and government authorities in the United Kingdom are now trying to stifle professional debate and public knowledge by telling medical staff in the government health system not to define death and avoid terms like “brain death”. The new term is “certified dead” which avoids uncomfortable medical definitions that are difficult to defend or explain. Death is then when a doctor says the patient is dead, regardless.

But once an idea based on fact gains credence no power can crush it. It was Drs Basil Matta and Peter Young who wrote the now famous editorial in “Anaesthesia”, the journal of the British Royal College of Anaesthetists, recommending the use of anaesthetic to prevent possible pain in donors. “The act of organ donation is a final altruistic one and we should ensure the provision of general anaesthesia at least sufficient to prevent the haemodynamic response to surgery”[13].

 

Chapter 3

The Apnoea Brain Death Test May Kill Patient

As disquieting as the possibility that donors may feel pain during organ harvesting is a body of scientific research opinion that says the brain death test not only falsely attributes death to the donor but also injures the patient and delays crucial treatment.

Associate Professor Cicero Galli Coimbra, Head of the Neurology and Neurosurgery Department at the Federal University of Sao Paulo, Brazil, has completed the study, “Implications of ischemic penumbra for the diagnosis of brain death. Apnoea testing may induce rather than diagnose brain death”[14].

The study discovers that where there is brain damage there may be an area of the brain that is destroyed plus an uninjured section (even if there is no apparent function) and between the two a penumbra where brain cells are not functioning but recoverable. In severe cases a person may be wrongly declared brain stem dead or brain dead.

Coimbra᾿s research shows that the testing for brain death both delays treatment for the patient and that the actual Apnoea test may bring on that state.

Coimbra shows there are two ways of treating severe brain injury that may produce recovery even in apparently hopeless situations. One is hypothermia that reduces the brain᾿s use of oxygen and gives doctors more time to treat the patient before further damage occurs due to lack of oxygen.

Another is the controversial, and some say unproven, hyperventilation that is intended to increase the amount of oxygen reaching the brain. Both treatments are intended to minimise oxygen deprivation in the brain, hyperventilation by maximising oxygen reaching the brain and hypothermia by minimising the brain᾿s oxygen requirements by slowing the metabolism[15].

Coimbra and other critics claim apnoea brain death testing produces the opposite of the recuperative treatments and accelerates brain damage.

Tests to establish brain death require a normal body temperature and by taking the patient off the ventilator (though still pumping oxygen into the trachea) result in increased carbon dioxide levels in the blood. Coimbra shows this combination may be fatal to otherwise recoverable brain cells[16].

For a more technical description by Dr David Evans, see Appendix Two

 

Healing Treatments Denied To Potential Donors

Dr Yoshio Watanabe, an academic and cardiologist at the Cardiovascular Institute, Fujita Health University School of Medicine in Toyoake, Japan, writing in Beyond Brain Death, states his considered view that applying the damaging apnoea test before hyperventilation and hypothermia treatment may constitute murder or at least a malpractice suit. He says a large fluid drip and drugs to increase blood pressure to maintain organs for harvesting actually accelerate brain injury. He says there are examples of apnoea tests repeated many times. In one instance a woman was brought to the Kochi Red Cross Hospital with a subarachnoid (and perhaps cerebral) haemorrhage. Instead of giving drugs to lower high blood pressure and using surgery to remove an intracranial hematoma, doctors told the family, who needed to give permission for harvesting, that she was in the state of “impending brain death”. A clinical diagnosis of brain death was made, despite Phenobarbital administration that makes an accurate evaluation of brain function difficult. Surgeons harvested her heart, liver and two kidneys[17].

In another incident at Osaka University Hospital in 1990, a crime victim was brought in with brain injury and three days before diagnostic tests were done for brain death doctors put him on a brain damaging treatment regime to keep his organs fresh and transplantable. This included drugs that elevate blood pressure, large amounts of drip infusion which rather than healing an injured brain “aggravate brain oedema, increase intracranial pressure and accelerate the process of brain death”. Then they threatened his wife to agree to donate organs without telling her that the treatment to keep the organs transplantable would increase brain damage[18].

 

Hypothermia

Dr Watanabe shares the view of associate Professor Coimbra of Brazil that hypothermia treatment should precede apnoea testing.

He cites reports from a team of neurosurgeons in the emergency care department of Nihon University Hospital in Tokyo[19].

They used computer-controlled brain hypothermia with maintenance of adequate intracranial pressure to treat 20 cases of acute subdural hematoma with diffuse brain injury (collections of blood within the skull) and 12 cases of global cerebral ischemia due to cardiac arrest (lack of oxygen to brain because of heart failure). They were on the verge of brain death and going downhill, but the team avoided the apnoea test in the fear of aggravating the brain damage. 14 of the 20 and 6 of the 12 recovered. Watanabe says this implies the hypothermia treatment gives a clear shift away from the point of no return and brain death.

Dr Watanabe says, based on the Coimbra conclusions, that,

“...a hastened judgment of brain death without trying such new therapeutic measures would well constitute murder, or at least a malpractice case. If all transplant protagonists try to ignore these observations, while at the same time claim the validity of current diagnostic criteria of brain death, and continue to give apnoea tests to aggravate ischaemic brain injury, I must conclude that the use of terms such as biomort or heart-beating cadaver is nothing but a sophism to disguise their real intention that the only thing they want is transplantable organs. They are not at all interested in saving those donor candidates.

Other critics in Japan say the apnoea test has been repeatedly performed there to achieve brain death rather than diagnose it.

 

Appendix One

Dr David Wainwright Evans

Cerebral angiography is an old and quite dangerous technique for demonstration of blood flow in the major arteries and veins inside the skull. It involves the injection of a radio-opaque contrast medium (often known colloquially as “dye”) into the carotid - and, maybe, the vertebral - arteries.

This contrast medium is not radioactive. Its presence in the intracranial vessels can only be ascertained by taking X-ray pictures from several angles. It is a relatively insensitive technique, because the thick bony skull poses problems for X-ray imaging and, crucially, because quite a lot of contrast has to get into the intracranial (i.c.) vessels to guarantee a “shadow” on the film. It is, therefore, easy enough to see things like displacement of well-filled vessels (e.g. in cerebral tumour etc.) but difficult or impossible to rule out some blood flow in some parts of a generally swollen brain.

It is entirely possible for an angiogram to be reported as showing no evidence of i.c. flow although there may be just enough oxygenated blood getting through to keep brain tissue in some areas alive (cf. Coimbra᾿s “ischemic penumbra”). For these reasons - and because the technique may exacerbate the brain damage or even cause fatal collapse in the X-ray room (shades of the apnoea test...) - cerebral angiography has never been a popular investigation where so-called brain death is concerned, even in those centres where the technique is readily available.

By contrast (no pun intended!), radioisotope studies do, as their name suggests, use radioactive tracer substances in their attempt to detect intracranial blood flow. This, also, is a relatively insensitive means of demonstrating minimal flows - for many of the same reasons - but it is much less dangerous (though not generally available).

Doppler flow studies, which use ultrasound, are even safer but still less reliable. Some centres use these techniques, chiefly in research studies aimed at justifying the clinical diagnosis of brain death, but they have never been popular here and are not required for the diagnosis of “death for transplant purposes” on the basis of the Department of Health᾿s “Code of Practice”. Were they to be carried out on some of those certified “dead” under those rules, it is exceedingly likely that some would show evidence of persisting i.c. blood flow - an additional and very powerful reason not to use such “confirmatory techniques”.

 

Appendix Two

Dr David Wainwright Evans

We are talking about severe, usually traumatic, brain injury. There will be parts of the brain which have been destroyed by the injury itself, by the extravasation of blood or by total deprivation of blood supply - due to rupture or occlusion of critical vessels perhaps, but also because the blood supply to the brain as a whole becomes compromised by the rise in intracranial pressure (due to the brain swelling/oedema which accompanies the initial trauma).

The “global ischemic penumbra” of which Coimbra speaks is that potentially very large part of the brain (hence the term “global”) which has not been destroyed by the interruption of circulation but is nevertheless so severely compromised by it (i.e. getting such an absolutely minimal trickle of blood - just enough to keep it alive but not enough to allow it to function) that it shows no sign of life (is functionless for the time being) and will die if the circulation is not restored very quickly or if it is not somehow protected from the effects of anoxia while the supply of oxygen and nutrients remains inadequate. There are means of protecting this apparently functionless and severely compromised brain tissue from further ischemic damage during the crucial few hours after the index injury. They include drugs and hypothermia and they work by limiting or actively reducing the swelling (so that some blood can get into the skull against the elevated intracranial pressure which tends to keep it out) and by reducing the demand for oxygen and nutrients while the blood flow is critically inadequate. This latter is the way in which moderate hypothermia is thought to work.

Whether or not it can really achieve much salvage is still a matter of debate. The most recent studies of which I am aware indicate that it is the intracranial pressure which is of paramount importance and that attempts to increase the perfusion pressure do not help. It looks as if the emphasis should be on measures to reduce the “reactive oedema” and to keep the brain reasonably cool (and perhaps “sedated”) during the early hours in the hope that circulation will be restored to the “penumbra” brain tissue in time for it to regain function and viability.

To sum up: The management of severe brain injury in its early phase is dominated by (1) attempts to reduce swelling of the brain within the rigid skull so that as much blood as possible may get in against the rising intracranial pressure which is “trying” to keep it out, and (2) attempts to minimize the demand for oxygen and nutrients of those (perhaps large) parts of the brain which might survive if they could be protected from handing in their cards before the swelling goes down and an adequate blood supply returns in consequence. The measures used in pursuance of (1) include drugs and the prevention of hypertension and overhydration. Hypothermia (not profound hypothermia, which is cooling to very much lower temperatures for different purposes) is favoured by some in pursuance of (2) but many are unconvinced of its value and there is vigorous debate about the validity of the trial findings.

What matters is, as Coimbra says, that all the efforts in the early hours be made with the purpose of preserving as much compromised brain tissue as possible. The details of management will (properly) differ from centre to centre - and in due course consensus may emerge. That is the way genuine progress is made. What should be said is that the treatment of severe head injury should be optimised to that end, in the critical early stages particularly. That means that potentially harmful procedures (such as apnoea testing, which can cause lethal reduction in the perfusion of severely compromised tissue in the “penumbra” regions) must be avoided. Likewise overhydration, hyperthermia etc. The avoidance of measures which might exacerbate the brain damage, by whatever mechanism, is at least as important in the optimal management of these patients as the deployment of specific therapies. It is just such optimal management (aimed at maximizing salvage and therefore prospects of recovery) which is so conspicuously absent when the patient is regarded as a potential organ donor - perhaps from the first.

 


 

NOTES

[1]. The Weekend Australian newspaper. Gentle Persuader by Roy Eccleston. 9 August, 1997.

[2]. Nilges, R.G. et al. Beyond Brain Death. Harvard Medical School Ad Hoc Committee to Examine the Definition of Brain Death a) The file containing brain death testing procedures is at http://www.anzics.com.au/files/brain_death_organ_donation.pdf and the home page is http://www.anzics.com.au/contact.htm b) Dr Peter Doyle, British Department of Health, in personal correspondence to the author.

[3]. Guardian Newspaper, United Kingdom. Sarah Boseley, Health Correspondent, 19 August 2000. www.guardianunlimited.co.uk

[4]. Guardian Newspaper, United Kingdom. Sarah Boseley, Health Correspondent, 19 August 2000. www.guardianunlimited.co.uk

[5]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000; p. 164.

[6]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000; p. 152.

[7]. Machado, Nora, Using The Bodies of the Dead, Dartmouth Publishers, England, 1997. Dr Machado is quoting from Veatch:1993:18. Veatch, R. The Impending Collapse of the Whole Brain Definition of Death. Hastings Centre Report 1993, pp. 18-24.

[8]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000; see note 51 on page 156.

[9]. Professor Shewmon spoke on All In the Mind, Radio National, Australian Broadcasting Corporation. www.abc.net.au and www.abc.net.au/rn/science/mind/s746719.htm

[10]. David Wainwright Evans, former cardiologist at Papworth Hospital, Cambridgeshire, United Kingdom. Personal correspondence to the author.

[11]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000; p. 144.

[12]. Watanabe, Yoshio. Why do I stand against the movement for cardiac transplantation in Japan, from the Cardiovascular Institute, Fujita Health University School of Medicine. Toyoake, Japan July 21, 1994. Dr Watanabe recommends the following for further reference; Dowie, M. We Have A Donor. A Bold New World of Organ Transplanting, Japanese translation by M. Hirasawa, Heibon-sha, Tokyo 1990 Kimbrel, S. The Human Body Shop. The Engineering and Marketing of Life, Japanese translation by S. Fukuoka Tokyo, Kagaku Dojin-sha 1995.

[13]. Young & Matta Editorial. Anaesthesia 2000;55;105-6 Correspondence Anaesthesia 2000, 55; 695-6.

[14]. Coimbra CG (1999) Implications of ischaemic penumbra for the diagnosis of brain death. Brazilian J Med Biol Res; 32:1538-1545. Study available at www.epm.br/neuro/brdeath.html

[15]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000; p. 178.

[16]. Thanks to Dr David J. Hill MA FRCA (Emeritus consultant anaesthetist) of Cambridgeshire, England, U.K. for help in interpretation.

[17]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000.

[18]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000; p. 173.

[19]. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom, 2000.

 


 

(Second Edition. Copyright 2003 Norm Barber)

 


 

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