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Thursday, March 20, 2003The events were set in motion when Dr. Jaggers received a phone call in the middle of the night. Carolina Donor Services, the local agency responsible for placing organs with compatible recipients, said it had found a donor in Boston for another one of Jaggers’ patients. Dr. Jaggers said he couldn’t use the organs for that patient, and asked the agency if the heart and lungs would be appropriate for Jesica Santillan. Several hours later, he was told he could have the organs. Carolina Donor Services says Dr. Jaggers was informed of the donor’s blood type. Dr. Jaggers has no memory of them talking about it. He did not ask for any blood type information, he says, because “I had satisfied in my own mind that if they had offered the organs for me that she was a match.” He is still agonizing over that conversation. “I'm ultimately responsible for this because I'm Jesica's doctor and I'm arranging all this,” he says. “But honestly, I look back, and yeah, if I'd made one more phone call or if I had told somebody else to make a phone call or done something different, maybe it would have turned out differently. But you know, those are all 20/20 hindsight.” As soon as Dr Jaggers found out that a heart and lungs were available for Jesica Santillan, he sent a member of his transplant team, Dr. Shu Lin, to procure them from the New England Organ Bank in Boston. While he was there, Dr. Lin was informed of the donor’s blood type at least three times. Incredibly, he’d never been told Jesica’s blood type, and so he didn’t know the organs were a mismatch. And that was yet another flaw in the system, According to Dr. Duane Davis, head of Duke’s transplant unit, that was not a part of the process. “Should we as a group have made it mandatory that the procuring surgeon knew that? Yes. But it wasn't Dr. Lynn's fault that he didn't know, because that information wasn't conveyed to him,” Dr. Davis says. From the donor to the recipient there must have been at least a dozen doctors and nurses from Duke who were involved. Why did not one among them see that the donor didn’t match the recipient? Dr. Davis notes that there was an initial misassumption, and no one later went back to check it. The initial mistake, Davis says, was made by Dr. Jaggers. “I would say that it’s routine for those of us who do this on a regular basis to ask what the blood type is,” Dr. Davis says. Nonetheless, he acknowledges that it was a failure of the system as well as the individual. What may be most disturbing is that UNOS, the national organization that oversees Carolina Donor Services and the New England Organ Bank, already had firm policies in place that should have prevented what happened to Jesica Santillan. Their policy requires that the blood types of donors and recipients be matched before releasing any organs. Lloyd Jordan, who runs Carolina Donor Services, admits that the company did not ensure that there was a match. “We could have requested her blood type, and I wish we had, but we did not do that,” he says. Yesterday, Carolina Donor Services backtracked. Unlike Dr. Jaggers, they aren’t willing to admit culpability. posted by Sydney on 3/20/2003 07:25:00 AM 0 comments 0 Comments: |
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