Fred Banks apologizes for pausing mid-sentence to catch his breath. “I’m on oxygen 24/7,” explains the 65-year-old former wheat- and barley-farm worker.
On the waiting list for a double-lung transplant since December, Banks has twice made the trip by ferry from his home on the Olympic Peninsula to Seattle for the potentially life-saving surgery, the second time even going under anesthesia. Each time, his surgeons at the University of Washington Medical Center rejected the donated organs as not good enough to help him.
Then Covid-19 hit, raising the stakes for Banks and tens of thousands of others in his precarious position. His pulmonary fibrosis puts Banks at high risk for severe illness or death if he’s infected, even as the pandemic has slashed the supply of organs donated nationwide. While he waits for the next call, he makes limited trips to Walmart and a few other stores, sandwiching a HEPA filter meant for vacuum cleaners in between two homemade masks.
“The only thing that bothers me now, with this Covid-19 involved, is when I go for a transplant, my wife will only be able to see me for a few minutes inside the hospital where I go to surgery,” he said. “But you know, that’s the way it is.”
Organ transplant medicine is always a high-wire act, balancing too many people’s needs with too few matches. The coronavirus epidemic has only heightened the significant risks and hoped-for benefits of transplant surgery. Organ donations are down by a third and the health care system itself is in full-blown scarcity, triaging elective surgeries to some unknown future date so only emergency cases find their way into precious operating rooms and intensive care beds. As life-saving as they are, even many transplants are being put off.
“From the transplant perspective, all transplants are considered emergencies. It’s like trauma: There are patients that are listed we know are going to get sick and die if they don’t get an organ,” said Jorge Reyes, chief of transplant surgery at UW Medicine. “Having said that, we may feel certain patients could wait.”
For people who need a transplant, their fate depends on the organ and how sick they are. Pancreas transplants are on hold indefinitely, classified as “life-enhancing,” not life-saving because patients can survive on insulin. Kidney patients who can continue to function on dialysis have been taken off waiting lists while still accruing waiting time for the day when non-urgent transplants resume. Heart patients who are not already in the hospital on mechanical heart-assist devices and who may be able to wait a few weeks will do so.
Living donors also have to wait. It’s ethically questionable to put a healthy person in added harm’s way — from possible exposure to the coronavirus in the hospital — to donate a kidney or part of a liver.
Prospective transplant recipients can’t have Covid-19, either. The immune-suppression drugs they must take to prevent organ rejection would prevent them from fighting off the virus and make them super-shedders of the virus, placing those around them at hugely increased risk of being infected.
Transplant emergencies mean people who can’t wait another week or even another day. But these patients are also balancing on a knife’s edge: They have to be sick enough to be near death but well enough not to need long ICU stays in hospitals overwhelmed by coronavirus patients who need weeks on ventilators so they can breathe.
“Our ability to do a liver transplant is not always just about the [risk of Covid-19] exposure to the patient,” said David Mulligan, chief of transplantation surgery and immunology at Yale. “It’s also, do we have a bed? Do we have a ventilator to take care of the patient? Can we isolate the patient from other Covid-infected patients? Do we have enough time to do this operation, get them through it, keep them away from Covid, and then get them out of the hospital safely? That’s what we’re shooting for.”
Certain organ transplants require substantial quantities of blood products, which are in short supply because blood donations have dropped precipitously. Mulligan said in general, kidney transplants don’t require transfusions, but for liver transplants, his team plans on having more than 10 units of blood and 10 to 15 units of platelets on hand.
That all supposes there’s an organ to transplant, but organ donations have nose-dived nationally since mid-March by 37%.
Ordinarily, only 2% of deaths result in organ donation, a small sliver of deaths because the donor must have died in a hospital while on a ventilator to support organs after brain death — and without certain diseases like cancer. Now that pool of potential donors must also be tested for Covid-19 infection.
The widespread delays in testing people for the coronavirus have also meant delays in testing organs, said Gabriel Danovitch, medical director of UCLA’s kidney and pancreas transplant program. “When the virus was first detected, we didn’t have the capacity to test all potential donor organs. And a lot of organs were wasted because of concern of possible infection.”
Ventilators also have to be prioritized for treating Covid-19 patients rather than keeping the organs of a brain-dead potential donor functioning, Yale’s Mulligan said.
Another reason for the decrease in available organs may be that people are staying home, leading to a drop in traffic accidents and gun violence. Also, when people die of a stroke in small hospitals overwhelmed with Covid-19 cases, they might not be transferred to larger medical centers also facing a shortage of ICU beds, said Reyes, of the University of Washington.
In line with some less-urgent transplants being postponed, the number of new patients joining the national wait list maintained by UNOS has fallen from 1,423 the week ending March 14 to 1,057 the week ending April 11. Over that time, kidney transplants have fallen from 504 to 259 while heart transplants declined less, from 76 to 52.
It’s too early in the pandemic to tell whether more people are dying now while waiting for an organ, said Alexandra Glazier, president and CEO of New England Donor Services. “We would expect to see an impact on wait list mortality later in time, when those that are being deferred right now become critically urgent later.”
She’s bracing for a surge of patients whose transplants were postponed because they were deemed elective but whose later need will not be matched by a surge in donations — because donated organs can’t be deferred.
Deciding who gets a transplant when there are not enough donor organs is a complicated calculus, but it’s a familiar one, Glazier said. “Organ donation in transplant is the one area of medicine that has always been explicitly rationed. And while I don’t want to say we’re comfortable with that, it is the framework within which we work. And the idea of maximizing lives and life years is our reality every day.”
Organ Procurement Organizations like Glazier’s are trying to shorten the time they need to obtain a donation to minimize the use of ventilators, but it comes at a price. Under normal circumstances, a donation is coordinated roughly 36 hours after brain death has been declared. That’s been cut to 24 hours, but it means more extended tests of the organs are no longer conducted, including bronchoscopies to examine lung function. That’s a concern for lung transplants, which have fallen more than other organs, she said.
Just as the pandemic has rolled out in waves across the country, it’s beginning to recede in areas hit first. As Covid-19 cases decline in the Pacific Northwest, Reyes in Seattle said his team is already thinking about ramping up transplant operations again and how best to handle the backlog of patients.
Some patients who were offered a transplant in recent weeks declined because they didn’t want to come into the hospital or be exposed to the heightened risk of infection after transplant when they’re taking anti-rejection drugs, UCLA’s Danovitch said.
That’s not what Fred Banks decided.
“I’m on my way for possible Transplant,” he wrote in an email last Wednesday.
This time he got his lung transplant. From his hospital bed on Monday, he told his nurse, “Feeling better every day.”