The Jessica Santillan's CASE

by Gerald M. Morris, Executive Director of Legal Affairs at Holy Cross Hospital and Michael Funk, PA-C, Assistant Professor Nova Southeastern University

 The following site contains extensive coverage of the case: -



(Washington Post)

Hospital Had Data Before Transplant Error

Associated Press
Thursday, February 20, 2003; Page A14

DURHAM, N.C., Feb. 19 -- Duke University Hospital surgeons declined a heart and lungs offered for transplant in two cases before one doctor requested them -- but for a teenager with the wrong blood type, two organ-procurement agencies said.

The girl's surgeons may also have committed themselves to the transplant too early, removing her own damaged organs before the replacements arrived and the mismatch could be discovered.

Correct information about the blood type was given to a Duke surgical team that flew to Boston to extract the donor organs Feb. 7, said the New England Organ Bank, the Newton, Mass., organization that offered the organs.

Duke hospital officials had no comment today on why doctors sought the type-A organs for Jesica Santillan, a type-O-positive patient who is now near death as her body rejects the transplants.

"We are just really struggling with how a surgical transplant team did not have the ability to find the facts, to talk to the two other surgeons at Duke that these organs were solicited to, and how did they make an outside solicitation for organs that weren't for this child and not be told" that they were of the wrong blood type, said Renee McCormick, a spokeswoman for the Franklin County charity that is helping pay the girl's medical bills.

Jesica, 17, was in critical condition today as antibodies in her blood tried to destroy the transplanted organs. Doctors estimated before the operation that she had no more than six months to live.

Durham-based Carolina Donor Services, which alerted Duke transplant surgeons that the organs were available, said it "received the donor's medical and lab information, including the blood type," from the New England Organ Bank.

CDS said it forwarded all the information to Duke.

© 2003 The Washington Post Company


(Washington Post)

Girl Has Second Transplant After Error

By Rob Stein
Washington Post Staff Writer
Friday, February 21, 2003; Page A01

A teenage girl who was near death after surgeons mistakenly implanted a heart and lungs with the wrong blood type into her chest underwent an emergency second transplant yesterday in a desperate attempt to save her life.

Jesica Santillan, 17, was in critical condition in the pediatric intensive care unit after her second four-hour heart-lung transplant at Duke University Hospital in Durham, N.C., where the original mix-up occurred.

The case again focused attention on the problem of mistakes in medicine. The National Academy of Sciences estimates they cause as many as 100,000 deaths a year in the United States.

"This particular incident is as horrendous an error as one can imagine," said Thomas Murray, president of the Hastings Center in Garrison, N.Y., a medical ethics think tank. "I was quite shocked to know that there were not multiple independent checks of things as critical as blood type before the organs were even accepted for transplant."

The second transplant operation began at about 6 a.m. yesterday after doctors located new organs that were the right blood type and size. To guard against another mistake, the hospital had three doctors check independently to confirm that the organs matched correctly this time, officials said.

The girl's new heart and lungs were working and she was taken off life-support, officials said. Doctors were optimistic about Santillan's prospects, but said it was too soon to know whether she would recover. About half of heart-lung transplant recipients survive five years, and Santillan may have suffered damage to other organs because of the botched transplant.

"She's as critical as a person can be, " said Duane Davis, a surgeon on the transplant team. "She has a number of hurdles to overcome."

Santillan's family was ecstatic that new organs were found so quickly. "Her parents feel some relief right now," said Renee McCormick, spokeswoman for a charity raising money for the teenager's care. "Everyone is incredibly hopeful and we're just so pleased, so thankful."

The United Network for Organ Sharing (UNOS) in Richmond, which coordinates organ distribution nationwide, is investigating the incident. Duke officials said the mistake occurred because doctors incorrectly assumed the blood type of the organ donor matched the recipient and failed to check for themselves. The hospital will now require additional compatibility checks in all transplants to make sure it does not happen again, officials said.

"This has been a difficult and heart-wrenching time for many people. At Duke, it has resulted in a tense reexamination of internal controls in transplantation," said William Fulkerson, the hospital's chief executive officer.

The hospital, UNOS and Carolina Donor Services, which obtained the organs, would not identify the new donor. The only details released were that the organs were not the result of a "directed donation," in which a donor's family specifies who will get the organs. But officials said Santillan received no preferential treatment.

Outside experts speculated that Santillan's rapidly deteriorating condition pushed her to the top of the waiting list to receive any suitable organs that became available.

Santillan was born in Guzman, Mexico, a small town near Guadalajara, with a deformed heart that caused a fatal condition known as restrictive cardiomyopathy. Three years ago, the teenager's parents paid a smuggler to spirit the family into the United States in hopes of getting her a transplant.

They settled in Louisburg, N.C., near Duke, but the girl's condition deteriorated and the family could not afford the $500,000 operation.

After hearing about her plight, a local building contractor, Mack Mahoney, established a foundation to raise the money for her transplant, which was performed Feb. 7.

The surgery went well, but doctors immediately realized their mistake when the teenager's body started rejecting the new organs. The organs were from a donor with type A blood; Santillan has type O blood.

The case illustrates that despite years of warnings, many hospitals have yet to add backup checks to life-and-death decisions, experts said.

"Carpenters have a rule: Measure twice, cut once. If it's good enough for carpenters it ought to be good enough for transplants," said Murray, the ethicist.

Kenneth McCurry, director of heart and lung transplantation at the University of Pittsburgh, said Santillan's prospects for survival were diminished somewhat since she had probably suffered damage to her kidney and liver from being kept on life-support machines after the first transplant.

Vital organs can be damaged while on life support because of a lack of adequate blood flow. She also faces a higher risk of infection from having undergone two operations.

"If these organs function well and she makes it through this period and the other organs recover, then she will have as good a chance of surviving as well as any other patient," McCurry said. "Only time will tell."

McCurry worried that the negative publicity from the case might discourage people from donating organs, exacerbating what is already a severe shortage. "There are literally thousands and thousands of transplants each year in the United States, and these things happen very infrequently," he said. "We need more organs, not fewer."

Santillan's second surgery was made possible when another donor was found at about 11:30 p.m. Wednesday. After the compatibility of the organs was confirmed, Santillan's family was notified early yesterday morning, and the second surgery was scheduled to be performed by James Jaggers, who did the first operation.

Santillan will be monitored "extremely carefully," said Davis, the surgeon. While "many body parts . . . aren't working as well as we'd like them to be working," there is "nothing that we know of that says any of the damage is irreversible," he said.

Since 1988, there have been nearly 800 heart-lung transplants in the United States. In 10 cases, the operation was performed twice on the same person, according to UNOS, but never before for this reason.

Santillan's benefactor, Mahoney, complained that Duke waited too long to admit its mistake. If Duke had taken action a few days earlier, Santillan would not have had to spend so much time on life support, he said.

"If you make a mistake, admit your mistake and take care of that child," Mahoney said.

Heather Adams, 12, a friend of Santillan's, made a brief, tearful appearance at the hospital's briefing on the teen's condition. "It was terrible when I found out, but now I just hope she makes it," she said. When a reporter asked Heather what she would ask others to do, she said: "Pray for her."

Special correspondent Bill Hatfield contributed to this report from Durham.

© 2003 The Washington Post Company



Brain Damage Found in Teen Given 2 Transplants

By Shankar Vedantam
Washington Post Staff Writer
Saturday, February 22, 2003; Page A02

A 17-year-old girl who underwent two heart and lung transplants at Duke University this month has suffered irreversible brain damage, according to doctors treating her.

Brian damage is a risk whenever doctors place patients on heart-lung machines, and Jesica Santillan had to undergo lengthy periods on the machine after doctors botched her first transplant by giving her organs not matched to her O-positive blood type. She had a second transplant Thursday with organs that matched her blood type.

A brain scan conducted early yesterday showed swelling in her brain along with some bleeding, said Karen Frush, Duke's medical director for children's services. A neurologist assessed Santillan and concluded that "irreversible brain damage" had occurred.

Doctors said that Santillan's family, who brought her from Mexico to the United States for the potentially lifesaving operation, had been informed.

Santillan's new heart and lungs appeared to be working well, despite the teenager's critical condition, Duke doctors said.

Last evening, Duke officials sent a letter to the United Network for Organ Sharing, which is investigating the case, acknowledging that doctors' errors had led to transplanting mismatched organs into Santillan, and laying out a list of procedures that the hospital is implementing to prevent such a mistake from happening again.

While brain damage is a risk whenever patients require a heart-lung machine to purify and pump their blood, the teenager was placed on a machine for longer periods than usual because of the back-to-back surgeries she required.

Santillan's brain damage was caused by one of two scenarios, said Kenneth McCurry, director of lung and heart lung transplantation at the University of Pittsburgh Medical.

Before patients can be placed on a blood purifying machine, doctors need to thin patients' blood to reduce the risk of clotting, McCurry said. The same thinning process, however, increases the risk of bleeding and brain damage.

After receiving blood thinner, Santillan could have bled into or around her brain, he said. If significant bleeding occurred, the blood could have put pressure on the brain and, since the skull is a confined space, the pressure would have caused the brain to swell in response to the injury. Eventually, he said, the process can lead to brain death.

An alternate hypothesis is that Santillan may have been deprived of oxygen or blood pressure during the various procedures she underwent. Eventually, that could also have led to brain damage and swelling, and the same prognosis.

"There's not a whole lot you can do under those circumstances," said McCurry. "They were forced to use the machine to keep her alive. Under those conditions you try to use enough blood thinner, but not an excessive amount and you try to control the blood pressure as much as you can. And then you hope there's not a whole lot of injury."

Santillan's case first made headlines after doctors admitted they had transplanted the teenager with organs from a type-A donor from Boston. After the operation on Feb. 7, Santillan suffered a heart attack on Feb. 10, and a seizure on Feb. 16, as her body's immune system -- sensing the presence of foreign proteins -- began to attack the organs.

Doctors and the family appealed for new organs, and at 11:30 p.m. Wednesday, Duke doctors were informed that a match had been found. McCurry said that Duke's doctors had likely determined that Santillan was not suffering from brain damage, since surgeons will not transplant scarce organs into patients unlikely to survive.

While patients who need organs are usually placed on long waiting lists, a computer algorithm moves patients who are at serious risk of death to the front of the line, said Anne Paschke, spokeswoman for the United Network for Organ Sharing in Richmond, which keeps track of organ requests and organ donations and matches them.

"There are a whole lot of factors; for each match there is a different ranked list," she said, adding that Santillan's second set of organs were not made available to her because the case was so publicized. "Location and geography play a role. With Jesica's case, the thoracic organs, heart and lung, have a much shorter preservation time, so we look at geography a little differently."

At 12:30 a.m. Thursday, Santillan's family was briefed and consented to a second transplant. She was wheeled into the operating room a few hours later, and the transplant operation was finished by 10:15 a.m. Thursday.

According to Duke, the warning sign that something was seriously wrong came at 3 a.m. yesterday -- and a neurologist confirmed that Santillan's brain damage was irreversible.

McCurry said that, in general, doctors are sometimes able to retrieve a transplanted heart from a patient who did not survive and use it to save another recipient's life. He said that lungs, which tend to suffer injury during surgery, are less likely to be reused.

The outcome of Santillan's case is likely to intensify the ethical debate over re-transplantation. However, R. Alta Charo, an ethicist at the University of Wisconsin, pointed out that Santillan's case is unusual, in that it was medical error that caused the first transplant to fail.

"This is not a case to generalize from," she said. "This is a sadly unique situation."

© 2003 The Washington Post Company

 (Washington Post)

Duke's Announces Teen's Death

DURHAM, N.C. -- Following a series of tests, doctors at Duke University Hospital determined that Jesica Santillan, 17, meets the criteria for the declaration of brain death. She was pronounced dead at 1:25 pm today (Feb. 22).

"All of us at Duke University Hospital are deeply saddened by this," said William Fulkerson, M.D., CEO of the hospital. "We want Jesica’s family and supporters to know that we share their loss and their grief. We very much regret these tragic circumstances."

Jesica suffered for several years from cardiomyopathy, a life-threatening condition that left her heart and lungs weak.

She received her first heart-lung transplant at Duke on Feb. 7. Because of a blood-type mismatch the organs were rejected by Jesica's body.

A second set of compatible organs was located on Feb. 19 and transplanted on Feb. 20. As a result of new procedures Duke instituted after Jesica's first transplant, three physicians were involved in ensuring organ compatibility before the second operation.

Doctors treating Jesica detected significant worsening of brain function less than a day after her second transplant. Despite aggressive medical support, her condition worsened.

A review of events leading up to this mismatch has led to revised procedures at Duke University Hospital to prevent such errors in the future.

"All of us at Duke have agonized over the problems in Jesica's treatment and we have taken actions to ensure that nothing like this will ever happen again," said Fulkerson. "This has been a very tragic time and Jesica has had an enormous impact on all of us here. We are doing everything humanly possible to provide the best care for all our patients, and we are committed to upholding the highest medical standards as we move forward."

© 2003 The Washington Post Company

Sunday, February 23, 2003

(Washington Post)

Teenage Girl in Botched Organ Transplant Dies

By Rob Stein
Washington Post Staff Writer
Sunday, February 23, 2003; Page A01

A teenage girl who underwent a second heart-lung transplant after doctors bungled the first one by giving her mismatched organs died yesterday from complications of her surgeries, officials said.

Jesica Santillan, 17, was pronounced dead at Duke University Hospital in Durham, N.C., at 1:25 p.m. after she suffered brain damage following the second operation, and repeated tests failed to find blood flow to her brain or any brain activity, officials said.

The teenager's death immediately sparked a confrontation between the hospital and the teenager's parents, who are deeply religious. Santillan's parents had demanded a second opinion before their daughter was taken off life support, a request hospital officials first offered and then withdrew, according to Kurt Dixon, the family's lawyer.

"The family was very distraught," Dixon said. "The family does not want to remove Jesica from life support. As you might expect, Jesica's family . . . [is] devastated by this tragic turn of events."

Hospital officials did not release details about the family's complaints, but a spokesperson later said the teenager was removed from the respirator at 5 p.m. without a second opinion, and the family "did not protest."

"All of us at Duke University Hospital are deeply saddened by this," the hospital's chief executive officer, William Fulkerson, said in a statement. "We want Jesica's family and supporters to know that we share their loss and their grief. We very much regret these tragic circumstances."

Legal and medical ethics experts said that a patient who is declared brain dead is deemed legally dead in every state, and hospitals have the legal power to withdraw life support without a family's consent.

"You never want to be in a position when you're offering someone choices when it comes to removing someone from life support," said Arthur Caplan, chairman of the department of medical ethics at the University of Pennsylvania. "Things have gotten so out of control at Duke. This is the worst ending to a horrible sequence of events."

After Santillan was declared dead at 1:25 p.m., life support was continued throughout the afternoon so family and friends could say good-bye, according to Duke's chronology. Medications for the heart were discontinued at 5 p.m., and her heart rate began to slow. Her heart stopped at 5:07 p.m., and ventilator support was discontinued at 5:10 p.m.

Aside from the human tragedy, the case has refocused attention on the problem of medical errors and the allocation of scarce organs for transplantation. Since the error became public, experts have criticized Duke for failing to have adequate safeguards to prevent such an egregious error, but noted that such deficiencies remain common in American medicine.

At the same time, some experts have questioned whether Santillan was given preferential treatment, especially when she received a second set of organs even though her chances of survival were low. "I have a lot of questions about this case," Caplan said. "How did the organs come out of the national system mismatched? How did she get the second set of organs? Who else was on the waiting list for the second set of organs that got passed over?"

Organ procurement officials have denied that Santillan was given special treatment, and Fulkerson said the hospital had changed its procedures to guarantee that doctors confirm that donated organs match recipients in the future.

Santillan's parents smuggled the family into the United States from Mexico three years ago in hopes of getting medical care for their daughter, who was born with a fatal heart condition. They settled near Duke because of its reputation for medical care.

Mack Mahoney, a local developer, heard about Santillan's deteriorating condition and started a foundation to raise money for her $500,000 operation. After Mahoney and his foundation finally raised enough money, and after waiting three years for a donor, Santillan underwent a transplant Feb. 7.

Duke officials said the lead surgeon, James Jaggers, failed to confirm that the organs matched Santillan's blood type. Santillan had type O blood; the organs were type A.

Several groups are investigating the error, including the United Network for Organ Sharing (UNOS) of Richmond, which coordinates organ allocation nationwide.

After the hospital publicly disclosed the error earlier last week, the case became the focus of international attention. Another set of organs with the right blood type and size was quickly found, and Santillan underwent a second operation Thursday. Duke officials said they had three doctors independently confirm that the organs matched this time.

But the teenager's body had been weakened by being on life-support machines between the two operations. Her brain began swelling and bleeding almost immediately after the four-hour surgery.

In a telephone interview yesterday, Mahoney said he was distraught by the girl's fate. "I've done everything within my power to help that child. I'm devastated. I just really need to get my life back together and go through my grieving process," he said. "I'm very heart-saddened."

The family, too, was distraught, Mahoney said. "They're not holding up very well. They just lost their daughter," Mahoney said. "They're a couple of very tired parents now with a dead child."

Mahoney blamed Duke officials for failing to make their mistake public soon enough. "They tried to cover up and stalled too long. The hospital didn't want to fess up to it. And when they finally did, it was too late," he said.

Duke officials have denied any attempt to conceal the mistake, saying they notified the family immediately. Yesterday, Jaggers expressed regret that Santillan did not benefit from the rare heart-lung transplant.

He said the process of matching organs to recipients is complex: "Unfortunately, in this case human errors were made during the process. As Jesica's surgeon, I am ultimately responsible for the team and for this error. I personally told the Santillan family about the errors that were made and then tried to do everything medically possible to treat Jesica and try to save her life. . . . We all join the family in their sense of devastation."

When patients on life support die, hospitals sometimes bring in a second physician to confirm a diagnosis of brain death, if for no other reason than to reassure family members, said R. Alta Charo, a lawyer and medical ethicist at the University of Wisconsin in Madison. And hospitals sometimes keep brain-dead patients on life support for a few hours, even days in some cases, to help families accept their loved one's death, she said. But doctors have the legal right to declare someone brain dead and remove him or her from life support.

"You don't want to be inhumane about it, and if you need a couple hours to come to grips with it, then fine," Caplan said. "But you don't want to be spending time and resources, especially in intensive care, dealing with dead people."

At the hastily arranged news briefing where Dixon initially announced Santillan's death, Renee McCormick, another family friend, said a prayer for the teen. "Jesica is now yours. She's your child, Lord."

© 2003 The Washington Post Company

(Sun Sentinel)

Efforts to save Jésica, 17, fail after transplant

By Thomas H. Maugh II
National correspondent

February 23, 2003
Jésica Santillán's four-year journey from Mexico to the United States for a new heart and lungs ended in futility Saturday when she died at the Duke University Medical, victim of a transplant surgeon's fatal error.

Physicians at the Durham, N.C., hospital, who mistakenly had transplanted organs with an incompatible blood type, declared Jésica, 17, brain dead at 1:25 a.m. and removed her from life-support machinery about 5 p.m., Medical spokesman Richard Puff said.

They had determined that no blood was reaching her brain and that her brain cells were exhibiting no activity.

Jésica's convoluted and controversial story took on another layer of intrigue Saturday because of the possibility that Duke physicians removed her from life support without her parent's permission -- a legally correct but perhaps morally questionable decision.

Santillán family lawyer Kurt Dixon said early Saturday that the family would seek a second opinion from an outside physician about her chances of recovery before taking the irrevocable step of removing her from life support.

It is not clear whether they were able to bring in an outside doctor or whether university officials would wait for such a consultation.

Puff said he did not know whether doctors had the family's permission to turn off the life support equipment.

"The family of Jésica Santillán and the family of Mack Mahoney are obviously devastated by this tragic turn of events," Dixon said.

Mahoney, 55, a North Carolina contractor, was Jésica's chief fund-raiser.

Dixon said the family and its supporters would have no further comment on the case for the time being.

"All of us at Duke University Hospital are deeply saddened by this," said Dr. William Fulkerson, the hospital's chief executive officer. "We want Jésica's family and supporters to know that we share their loss and their grief. We very much regret these tragic circumstances."

Jésica was born with a heart defect that did not allow her blood to carry enough oxygen to the rest of her body.

Because the required transplant was not available in Mexico, her family saved money for more than a year to pay a smuggler to bring them into the United States for treatment.

They chose Duke because of its excellent reputation as a transplant center and because it is one of the few hospitals that perform the rare combined heart-lung transplants.

Mahoney was so moved when he read a story about the 5-foot-2, 80-pound girl living in a trailer that he organized a charity called Jésica's Hope Chest and spearheaded the drive to raise the $500,000 to pay for the procedure.

Among other things, he donated his time to build homes using donated materials, then sold them with all the profits going to the foundation.

Jésica waited three years until an apparently suitable set of organs became available on Feb. 7.

But Dr. James Jaggers had no sooner completed the long-anticipated procedure when it became clear that Jesica's body was rejecting the donor organs.

The transplant team members quickly learned that they had implanted organs from a donor with type A blood into Jesica, who had type O blood -- a glaring error in transplants because such a mismatch provokes a strong immune reaction. A subsequent investigation revealed that Jaggers and others failed to confirm the compatibility of the donated organs before the surgery began.

Jésica was kept on life support most of the time while surgeons searched frantically for another set of organs. Finally they did, and the heart and lungs were implanted Thursday morning.

By the middle of that night, it was apparent that even though the newly implanted organs were working perfectly, Jésica was suffering from swelling and bleeding in her brain. Experts said the damage most likely resulted from the long time she spent connected to life-support machinery.

Friday, physicians said that the damage most likely was irreversible. Mahoney was incensed. In an emotionally charged news conference on Friday, he said, "If she dies, they will have murdered her."

In a statement released Saturday afternoon, Jaggers said: "As Jésica's surgeon, I am ultimately responsible for this team and this error. I personally told the Santillán family about the errors that were made and then tried to do everything medically possible to treat Jésica and save her life. We put our all into what was, unfortunately, a losing battle."

Thomas H. Maugh II writes for the Los Angeles Times, a Tribune Co. newspaper.

Copyright © 2003, South Florida Sun-Sentinel

Monday 2/24/03

(Sun Sentinel)

State orders autopsy for teen

By Emery P. Dalesio
The Associated Press

February 24, 2003

RALEIGH, N.C. · Medical examiners will determine what ultimately killed a teenager who survived a botched heart-lung transplant but died two days after receiving a second set of organs.

An autopsy was planned today on the body of Jésica Santillán, the state Medical Examiner's Office said. A lawyer for the 17-year-old's family said an autopsy was appropriate.

"We just want to make sure we know what the cause of death was," attorney Kurt Dixon said Sunday. "If there's going to be legal action down the road, you want to have a definite cause of death. You don't want to speculate about that."

Family and friends were planning memorial services for the teenager on Tuesday, one public and another private, said Mack Mahoney, a family friend and Santillán's chief benefactor. He said he thought the family, which was in seclusion, would return her body to their home country of Mexico for burial.

Santillán, whose heart had a deformity that kept her lungs from getting oxygen into her blood, died on Saturday.

She never regained consciousness after her first heart-lung transplant, which her body rejected because the organs didn't match her blood type.

Doctors at Duke University Medical in Durham said they didn't check the compatibility before the surgery began Feb. 7.

By the time a matching set of organs was found and placed in her body early Thursday, she was near death.

The new organs performed well, but Santillán's brain had swelled and was bleeding on Friday. She was declared dead after more than a day without brain activity.

Dixon said Duke doctors took Santillán off life support before her family could contact other physicians to get a second opinion on her condition.

Dr. James Jaggers, the transplant surgeon, said in a taped statement released on Saturday by the hospital that he had hoped Santillán would be "one of those lucky few" awaiting heart-lung transplants who actually receive the surgery and do well.

"Unfortunately, in this case, human errors were made during the process" to match the organs with the patient, he said.

"I hope that we, and others, can learn from this tragic mistake."

Copyright © 2003, South Florida Sun-Sentinel


(Washington Post )

Surgical Expertise, Undone by Error
Chain of Miscommunication in Transplant Led to Teenager's Death

By Shankar Vedantam
Washington Post Staff Writer
Monday, February 24, 2003; Page A01

Jesica Santillan died Saturday at Duke University Medical, surrounded by an arsenal of medical technology, top doctors and a network of experts dedicated to transplanting her with organs that could save her life.

None of these measures, however, protected her from a misunderstanding between her doctor and a North Carolina organ bank. As a result, mismatched organs were transplanted into the 17-year-old and, despite heroic measures and a second transplant, she died.

It all began with so much hope on Thursday, Feb. 6, when organs she had awaited for three years suddenly became available. This account of the events that followed is based on chronologies issued by Duke University and Carolina Donor Services and interviews with transplant experts.

Late that Thursday, Carolina Donor Services received a call from the New England Organ Bank. Someone in that region had died, leaving organs available for transplant.

Time is desperately short when valuable organs such as the heart and lungs become available. A nationwide network -- the United Network for Organ Sharing -- maintains an extensive list of patients waiting for particular organs. The New England bank ran a search through the network's computers: It evaluated patients scattered across the country, giving preference to those who had waited longest, whose medical condition was the most serious, who were geographically close enough for the organs to be transplanted without delay -- and who had the same blood type as the donor, type A.

Two names popped up as potential heart recipients. Both were at Duke University Medical in North Carolina. Following standard organ-sharing procedures, the New England bank called its regional counterpart, Carolina Donor Services.

The Carolina organ bank called Carmelo Milano, the Duke surgeon on call for adult heart transplantations. Since the organ-matched Duke patient was a child, Milano referred the call to James Jaggers, the surgeon in charge of pediatric heart transplants.

The bank said it gave Jaggers information about the organ. Jaggers told Carolina Donor Services that the child on the computer's list was not medically ready for the transplant. The conversation might have ended there, but Jaggers remembered another patient.

What about Jesica Santillan, who had been on the national waiting list for three years? Her family had brought her to North Carolina from Mexico because she had a congenital heart defect called restrictive cardiomyopathy. It was threatening to kill her soon. Jaggers told Carolina Donor Services that Jesica needed a pair of lungs, too. He gave them her name, assuming they would look up her details on the national list, according to Duke's account. The bank said it would get back to him.

Already, the seeds for disaster had been sown. The bank assumed Jaggers was aware the organs were of blood type A, since the bank had turned over all the information about the heart to Duke, according to its chronology. Besides, both recipients that the computer had identified at Duke, including the patient Jaggers said was not suitable, had type A blood.

Jesica had type O blood.

Jaggers would say later he did not remember mentioning Jesica's blood type during the conversation. But since he had given the bank her name, he assumed that the bank would check the computerized list and make sure that patient and organs were properly matched. Jaggers has since taken responsibility for the misunderstanding.

The Carolina bank then called another Duke doctor to ask about the second candidate from the computerized list. Duane Davis, a surgeon at the Medical's adult heart transplant unit, asked about the size of the heart and decided that it was not the right size for his patient.

Both the computer's initial choices -- which had been screened for blood type and other details -- had been eliminated. Minutes were slipping by. The bank called Jaggers back and told him the heart and lungs could go to Jesica. It is unclear whether there were other candidates on the computer list: Organ banks will sometimes give organs to patients not on the list to keep them from being wasted.

Both Jaggers and Carolina Donor Services assumed the other had checked the blood type, according to accounts from both sides. The bank had given Duke all the details about the organs, and Jaggers had given the bank Jesica's name and access to her medical details. Each implicitly relied on the other.

And given the pressure of finding a recipient for fragile organs, neither apparently cross-checked. The hospital has since announced new measures to verify that patients and organs are properly matched.

Jaggers would later remember talking with the bank about the organ donor's height, weight, organ function and cause of death -- mentally checking off each item to match Jesica. But there was a reason Jesica was not on the original computerized list: Her blood type was not a proper match.

A Duke surgeon, accompanied by Carolina Donor Services staff, was dispatched to New England. The surgeon verified the organs were of good quality and relayed the message to Jaggers, who gave permission for the heart and lungs to be brought to North Carolina.

Meanwhile, Jesica was prepared for surgery at Duke's pediatric intensive care unit. A machine would do the work of her heart and lungs during the transplant, purifying her blood of carbon dioxide and pumping it back into her body. To prevent the blood from clotting, doctors gave Jesica blood-thinning drugs.

There was a risk that thinning the blood might cause bleeding inside her brain. Such bleeding can build up pressure and cause brain damage, even death. There was also the risk that periods of low blood pressure during the procedure would deprive her brain of oxygen, with the same risks of brain damage.

Weather had already delayed the return of the team that had been sent to New England to retrieve the organs. As soon as the organs arrived at Duke, surgeons began the operation.

It was 4:50 p.m. on Friday, Feb. 7.

The doctors cut open Jesica's chest and lifted out her heart and lungs. Over several hours, they attached the new organs to her, unaware that they were placing her in the gravest danger. Meanwhile, the heart-lung machine kept her alive, even as it increased her risk of brain damage. The surgeons finished around 10 p.m.

Then they got a call from Duke's Clinical Transplant Immunology Laboratory: The lab had determined that the organs were of the wrong blood type.

The doctors immediately knew what was happening inside Jesica. Her immune system would sense the new organs were different from her blood type, and it would develop antibodies, attacking the heart and lungs as if they were harmful.

Doctors pumped Jesica with drugs to suppress her immune system. They alerted Jesica's family to the mistake, and put her name back on the national waiting list -- as a candidate for a new heart and lungs. Over the next few days, Jesica's condition worsened. Her lungs deteriorated, and doctors had to place her on a mechanical ventilator.

On Wednesday, Feb. 19, a new heart and lungs were identified. This time, the national network's computer identified Jesica as a candidate.

Giving two heart and lung transplants to the same person within a matter of days is completely extraordinary. But Anne Paschke, a spokeswoman for the network, said that Jesica's dire medical situation, not the intense media attention that had focused on the case, had moved her to the head of the list.

Before Duke doctors performed the second transplant, they had to establish that Jesica had a reasonable chance of survival -- otherwise the organs would go to a candidate more likely to benefit. The doctors concluded there was no serious brain damage from the first transplant, and decided to go ahead, according to Duke.

On Thursday, Feb. 20, surgeons transplanted the new organs. Again, the operation required that the teenager's blood be thinned and that a heart-lung machine purify and pump blood for her.

By 10:15 that morning, the new heart and lung seemed to be working properly. But within 24 hours, doctors detected a sharp neurological decline. A brain scan found bleeding and swelling inside her brain. Doctors tried to drain the pressure, but it was too late. By Saturday, doctors declared there was no activity in her brain and removed life support. An autopsy was announced. Sixteen days after her doctor first took a phone call to save her life, Jessica was dead.
Staff writer Rob Stein contributed to this report.© 2003 The Washington Post Company

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