Quadruple Transplant Brings New Perspective to One Patient and
His Care Team
The appreciative smile on Harry Toole Jr.’s face was there long before his kidney transplant. “Harry is perpetually enthusiastic,” said Mary O’Keefe, RN, BSN, the BWH nurse who provided him postoperative care in the Surgical Intermediate Care Unit. “He considered his new kidney a tremendous gift. He wanted to learn everything about managing his medications and to do things right.”
Toole was among the four patients who benefited from a quadruple transplant performed at BWH this past April. It was the second time that the hospital’s surgical teams had simultaneously transplanted organs from a single donor — a heart, two lungs and a kidney — into four different recipients. In 2000, BWH was the first hospital to ever accomplish this major feat. The challenge was to get the cardiac, thoracic and renal transplant teams and all the patient recipients to converge in a critically short time span because the cellular integrity of donated organs can be sustained externally for only about four hours.
“I’ll be there in five minutes,” Toole had responded. Born with renal disease, he had lost one kidney as a newborn. “When I was 15 years old, they told me I’d never make 21,” he said. “But that didn’t stop me from playing football and basketball, that is, until the coach found out I had only one kidney and it was going to conk out too.”
At age 33, the other failed. For more than two years, Toole was on dialysis — and borrowed time. He immediately asked to be placed on the transplant waiting list. “I’ve got two boys,” he said. “I wanted to see them grow up.”
His life has been transformed — no more gout, high blood pressure or time-consuming dialysis. But he’s also discovered that post-transplant care is serious business.
The first postoperative day consists of a lot of monitoring, said O’Keefe. Each hour, the staff measure the patient’s fluid intake and output. They also test for electrolytes, proteins and other factors in the urine and blood to assess the transplanted organ’s function. “A kidney from a living related donor generally is functioning within the first day, whereas an organ from a cadaver may take a little longer,” she said. “Most patients are discharged in five to seven days, if no complications arise.”
Aided by new anti-rejection drugs, surgical techniques and postsurgery guidelines, the science of organ transplantation continues to advance. In addition to expert surgeons,BWH has developed specialized teams of nurses to manage the care of kidney, heart and lung transplant patients.
Renal patients receive postoperative care in the Surgical Intermediate Care Unit, that was reorganized last fall and moved to Tower 7AB. The 31-bed unit also cares for patients who have undergone gastrointestinal, urologic, vascular or plastic/reconstructive surgery. “Since October, we have recruited and trained nearly half of the 50 nurses who work in these pods,” said Karyl Davenport, RN, MSN, who manages this unit and also the Burn/Trauma and Surgical Intensive Care Units.
To train the staff, John Powelson, MD, head of the renal transplant service, created a video series to demonstrate the step-by-step care of renal transplant patients. A clinical team also recently developed a new critical pathway for managing the care of patients receiving kidneys from living related donors.
“These resources act like a checklist of care,” said Davenport. “They outline the specific plan for patient care by each discipline, foreach day of hospitalization, to reach pregressive goals through discharge. For example, frequency of vital signs, monitoring of fluid intake and output, progression of diet and patient teaching about medications are documented and any variation in the plan is noted by the appropriate team member.”
Each team member’s responsibilities are clearly defined. About 15 staff are typically involved in the care of a renal transplant patient — nurses, physicians, surgeons, pharmacists, nutritionists, transplant coordinators, and physical and occupational therapists.
“BWH does between one and three kidney transplants a week,” said Robin Rossignoll, RN, BSN, assistant nurse manager on the unit. “Although this is a low population of patients, the work is very intense and requires a high level of expertise. Our nurses have been excited to help shape the service’s new care guidelines.”
Patient understanding and compliance is crucial to success. “We teach patients to faithfully take their medications, record fluid intake and output, and watch for fever and other signs of infection,” said O’Keefe. “Missing just a couple of doses of an immunosuppressant may lead to organ rejection. We stress they’ve been given a second chance, and it’s important to be compliant and responsible.”
Even with the best post-transplant care and commitment, patients can encounter rocky roads. Since his surgery, Toole has been readmitted twice for medical problems such as high blood glucose from diabetes, which developed from the steroids he now must take. But in a few months, he hopes to be back to work.
“You’ve got to make the best of everything,” said Toole, whose upbeat outlook continues to endear him to everyone at BWH.