“When you get into the larger aircraft it becomes like a hotel, with dozens of staff supporting the plane based in a galley area down below. You have very comprehensive cooking facilities, and on larger aircraft we have looked at theatres, with spiral staircases and a Steinway grand piano. The limitations for what you can put inside a plane are pretty much the limits of physics, and even money cannot always overcome that. Even so, people are still always trying to push [the limits]. ”
Saving lives, one flight at a time
After the injured first officer stumbled out of the Cessna Citation that crash-landed at Birmingham [England] Airport last November, he explained to the first firefighter on the scene that the wreckage contained a donated organ, according to BBC News. Firefighters helped the seriously injured pilot and then recovered the organ, a well-insulated liver that was on its way to nearby Queen Elizabeth Hospital. A police motorcycle officer took the liver there, and the transplant was successfully carried out.
Though the crash was unusual, the use of chartered aircraft to transport donated organs is anything but. A typical year in the UK sees 100 to 300 such flights, according to the National Health Service's Blood and Transplant Office. In the U.S., where the numbers are much higher, 58 federally chartered Organ Procurement Organizations (OPOs) manage the process of arranging for patient selection, organ assignment and transportation. Generally, an OPO first makes organs available to patients within its territory, but if there is no optimum match by blood, tissue type and size, the organization will contact another nearby OPO to see whether a match can be made.
Typically, about 110,000 people in the U.S. are awaiting an organ transplant, according to Rebecca Ousley, spokeswoman for OPO Lifesource, which covers Minnesota, North and South Dakota and part of western Wisconsin. Each day, she explained, 18 people die before they can receive a transplant and 100 people are added to the national transplant waiting list. One person can save or heal up to 60 lives through organ and tissue donation, according to Ousley.
Within Lifesource's territory are more than 200 hospitals where donors might end up and eight transplant centers. Because of the large area it covers, said chief administrative officer Peter Farstead, "We use air travel probably more than other OPOs."
Last year, Lifesource arranged 150 donation cases (many involving multiple organs), and 90 of those required flights. The decision to fly depends on the locations of the donor and recipient. Generally, if the two involved hospitals are more than an hour's drive apart, Lifesource will arrange for a flight. If the trip is less than 400 miles, it will use a turboprop; if it's longer, it will charter a jet. For OPO California Transplant Donor Network (CTDN) in Oakland, Calif., the drive/fly cutoff point is 100 miles, according to Luis Mayen, manager of placement services.
The major transplantable organs–heart, lungs, liver, pancreas and kidneys–have different viability times. "The one with the shortest ability to tolerate being out of the body is the heart, at about four hours," said transplant surgeon William Bry, who works at California Pacific Medical Center in San Francisco. The kidneys can survive the longest, about 24 hours, while lungs can go eight and livers 12 hours. However, Bry said, just because a harvested organ can survive for a certain period doesn't mean it makes sense to wait. "Those are outside extremes," he explained. "If I had a kidney now, I would do [a transplant] tonight and not wait for tomorrow morning."
Because the viability time for heart and lungs is much shorter than for liver, kidney and pancreas, the logistical dance begins well before the organs are removed and must be carefully choreographed to ensure the best possible outcome. In the U.S., the process starts in one of the many hospitals that are part of an OPO's network. Potential donors most often are stroke patients, according to CTDN's Mayen, but also people with head injuries. If brain death can't be prevented, the hospital calls the OPO, which contacts a placement specialist.
In 38 U.S. states, if a person has indicated on a driver's license application or otherwise registered to be a donor, that desire is legally binding. If the person hasn't registered, Mayen said, "we talk to the family and offer donation as a possibility."
The advent of registries has dramatically increased the number of available organs, he added. "When a family is offered that opportunity [after a death], they're going through one of the most traumatic times in their life and it's really difficult for them to make that decision," said Mayen, who added that he hears from many people who prevented a donation and later wish they'd allowed it.
In cases where all of a donor's organs are viable, the OPO may send two teams for the recovery. Sometimes several airplanes will converge on the airport nearest the donor's hospital, and a helicopter may be used at the transplant end of the trip to hasten a heart to its destination. If one transplant center is involved, then CTDN will arrange for one charter to carry up to eight people, including two staff members and two surgical teams, for thoracic and abdominal organs.
The thoracic team goes first and then flies back to the transplant center to perform the surgery, while the abdominal team remains behind and completes its work. Meanwhile, the pilots drop off the thoracic team and return to collect the abdominal team.
"When a heart is donated," said surgeon Bry, "they get out of there quickly because of the four-hour constraint. Often it's a good hour to two hours after the heart team leaves before the abdominal team gets out."
To operate the flights, CDTN contracts with charter broker Transplant Transportation of Petaluma, Calif., which is owned by Scott Pritchard, who helped coordinate transplant flights when he worked for Sunset Aviation. With its large area to cover, OPO Lifesource uses eight charter companies, according to administrative officer Farstead. "Many of the pilots want to staff these flights because of the meaning associated with transplants," he added.
While transporting a lifesaving organ is obviously of paramount importance, the cargo doesn't take precedence over safety, Farstead said. "We make it clear that the pilot is in charge at all times," he added.
Pritchard spoke similarly. "You can tell who's operating safely," he said. "And we're not reluctant to tell someone we're not able to work with them."
Obviously, the temptation to cut corners does exist with these missions. "You are often operating with minimal call-out time, at night, sometimes into mountainous terrain and on the back-side of the clock," said Dan Drohan, now CEO of charter/management firm Solarius Aviation, who got his start in the charter business flying for a tissue bank, then won a contract to fly organs for the California Transplant Donor Network.
"The threat of 'we have to get this done or else' cannot be anywhere in the equation," he said. "That is a recipe for disaster." Indeed, an organ-transportation flight operated for the University of Michigan Health Systems (UMHS) crashed in June 2007, killing two university employees and two pilots.
Pentastar Aviation, a charter and aviation services provider in Waterford, Mich., now handles all organ-donor flights for UMHS, using a Citation Encore jet and three helicopters. "One of things that brought us together with [the university]," said Pentastar director of sales John Scicluna, "is that every trip is conducted with safety in mind."
Scicluna called it "an honor and privilege to be part of such a great program" and others spoke similarly. "The last flight I did as a crewmember was to procure the organs of two toddlers, siblings who had drowned in a swimming pool," recalled Drohan. "You cannot imagine the sadness around the situation, especially for me as the father of young kids.
"At the same time," Drohan continued, "an amazing reversal of situational energy takes place as you depart the destination to bring the medical team home. You are so motivated to make sure the trip goes smoothly and safely, because you know that the organs of these two kids were now going to save the lives of more than just a handful of other kids."
Said Pritchard: "This is a part of the business that I think is most important and rewarding." And he added, "Without the charter industry, it wouldn't be possible to do what we do. The airlines aren't dependable enough and don't understand the sense of urgency."
BY THE NUMBERS
58 – The number of federally chartered procurement organizations in the U.S. that manage the process for arranging of patient selection, organ assignment and transportation.
100,000 – The number of people in the U.S. who are awaiting an organ transplant.
18 – The number of people who die each day awaiting a transplant.
100 – The number of people added to the national transplant waiting list each day.
60 – The number of people who can be saved or healed through an organ and tissue donation by one person.
4 – The number of hours a heart can survive after harvesting.