Road to Resilience
Road to Resilience
The Historic Triple Transplant
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When 46-year-old Mack Godbee’s heart, kidneys, and liver all began to fail, doctors at Mount Sinai faced the extraordinary challenge of performing the first-ever triple organ transplant in New York State. In this episode, surgeons Drs. Ani Anyanwu and Sandy Fuhrman recount the historic procedure, the teamwork that made it possible, and the resilience of a patient who beat the odds.
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Visit https://www.mountsinai.org/clinical-trials to see if you're eligible to enroll in a clinical trial with the Mount Sinai Health System. Check out more episodes of Road to Resilience—as well as guest pictures, transcripts, and more—on the Mount Sinai website.
00;00;04;20 - 00;00;27;09
Stephen
For the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria. Mount Sinai is director of podcasting. On this episode, we welcome doctors Annie Anyanwu and Doctor Sandy Forman, who pulled off the very first triple transplant of a heart, kidney and liver in New York State history.
00;00;27;09 - 00;00;28;24
Stephen
Gentlemen, welcome.
00;00;28;26 - 00;00;30;02
Dr. Florman
Thank you.
00;00;30;05 - 00;00;45;27
Stephen
So our first question really is a general one. How do doctors like yourself get involved in transplanting multiple organs? I assume this is not something that most people have to go through in medical school.
00;00;46;00 - 00;01;13;23
Dr. Anyanwu
Well, I think it's how do we get involved in transplanting organs in the first place. So I think we the multi-organ transplant is just a combination of different transplant procedures. So basically it's a combination of doing for in this case a heart transplant a liver transplant and a kidney transplant. And really the the only way differs. The main way differs from transplanted single organs.
00;01;13;23 - 00;01;45;21
Dr. Anyanwu
Just bringing all these three organs together so that they have various different pathways by which doctors end up transplanting organs, for example, from the thoracic point of view, because I'm a cardiothoracic surgeon, we, do heart surgeries and lung surgeries, and some of us specialize in transplanting these organs as well. The pathway in abdominal sort of abdominal transplant, which is the bulk of transplants is done, are in the abdominal organs, which stop the
flow and can expand on the pathway.
00;01;45;21 - 00;01;47;08
Dr. AnyanwuThat's a bit different how you end up.
00;01;47;14 - 00;02;05;26
Dr. Florman
Or why does a patient need all three of these? We do these because there's a need, because we had a patient who had the need for a heart transplant, but couldn't have it because he also had kidney failure and he didn't have a good liver. So the patient drove this not so much that we thought, hey, let's just replace a bunch of organs.
00;02;05;28 - 00;02;32;20
Dr. Florman
But, you know, follow up with what doctor on Anyanwu said, transplant surgeons for the abdominal organs go through general surgery and then train in liver, kidney, pancreas, intestine transplant. And ultimately most specialize in one or several of those. So the expertise lies with the individual and what the experiences. We have a lot of experience in each of these organs individually.
00;02;32;27 - 00;02;42;01
Dr. Florman
So when a patient comes and has the need for multiple organs, because that's what their disease process requires to be fixed, we do it.
00;02;42;03 - 00;02;50;01
Stephen
What is the history of this kind of transplantation of multiple organs? Is it something that's relatively common or pretty rare?
00;02;50;03 - 00;03;15;02
Dr. Florman
Historically, it was rare, but, the better the outcomes have been with each organ individually and the better the techniques have become. And the immunosuppressant medications have become. The, indications have expanded. So historically, we wouldn't think of doing a heart and a liver transplant, particularly those two, because the the expertise needed is on both sides of the diaphragm.
00;03;15;04 - 00;03;39;14
Dr. Florman
And so it really requires not only the expertise in each of those organs, but it requires the surgeons and the team's medical and surgical pre transplant in the operating room and after transplant, to have the willingness and the ability to work together. And that might be one of the things that separates our ability to do this from others who haven't done this.
00;03;39;16 - 00;04;06;28Stephen
Not having gone to medical school, this is not my area, but I have to imagine that the transplantation of multiple organs like this is something that, wasn't attempted a whole lot because it was pretty risky. Is this something like this, this particular transplantation of these three organs? Is it something that had been attempted very often in New York State specifically?
00;04;07;01 - 00;04;31;24
Dr. Anyanwu
Well, it's not something that's attempted often anywhere, period. Like, the, the in the United States of the transplants I tracked. So we know how many transplants are done every year. And it's been tracked since the late 1980s, and I think on record in the United States, about somewhere like 54, 55 patients have had this particular operation over the last 30 years or so.
00;04;31;26 - 00;04;53;23
Dr. Anyanwu
So it's not a common operation, but part of the reason it's not common is because we don't have patients that need it. So just to put in perspective, every there are several thousand patients get a heart transplant or a liver transplant or a lung transplant. But every year, the number of patients that would need, for example, a heart and a liver was is small.
00;04;53;23 - 00;05;27;06
Dr. Anyanwu
It's going to be less than 100 in the country. So the need is not is different because thankfully most patients don't suffer. And stage disease was the reason we do transplantation is basically because an organ has been damaged beyond repair. So you don't usually have end stage disease in in multiple organs at the same time, thankfully. And then when you do a lot of patients that have such multiple what we call multi-organ failure, a lot of them, so sick that they're not really candidates for surgery.
00;05;27;06 - 00;05;47;12
Dr. Anyanwu
So then there's selection that goes on. So to be a patient who has multiple organs failing and yet you're a candidate for transplant. So we're talking a very few patients. And then to find hospitals or doctors, you know teams that are able to do the surgery. And that even narrows it down even more. So these are rare, rare procedures.
00;05;47;12 - 00;06;01;12
Stephen
Generally speaking, because these are so rare. How does a doctor prepare for something like this. And in this specific case, how do you procure the three organs at once for a patient who is in dire need of them?
00;06;01;19 - 00;06;23;17Dr. Florman
Well, the preparation is to get a little sleep before you do it. You know, the funny part is we procure these organs from donors all the time. And most donors, we try to take the liver, the kidneys, the heart, and transplant as many people as possible. Good donor can probably save eight people's lives with solid organs.
00;06;23;17 - 00;06;46;14
Dr. Florman
So it's not unusual to take those organs out. But we need all three organs from the same donor. And the rules allow for that. The sickest organ drives it. And so in this case, the heart is the sickest organ and was life saving for this patient. And so the liver and the kidney, by design, by the rules that are allowed in the country, they are allowed to be given to the same patient.
00;06;46;14 - 00;06;52;11
Dr. Florman
that. So that part's not that different than what we normally do. It's just having a patient that needs
00;06;52;13 - 00;07;05;11
Stephen
What kinds of ethical dilemmas do you run into regarding who receives an organ and who doesn't? Are there any guidelines around that? Or can just anyone, at any time receive an organ that they need now?
00;07;05;11 - 00;07;27;01
Dr. Florman
Transplantation is highly regulated everywhere. And there are we have large groups here that review this and what we call recipient review committees, where we present the patients and what their needs are. There are significant ethical considerations, especially when you're going to give more than one organ to one patient. It means that those two organs, those three organs weren't used in a different patient.
00;07;27;04 - 00;07;49;00
Dr. Florman
So you really have a responsibility to do this ethically. We we don't do this for futility. We do this because we really believe the patient's going to come out of this on the other side and be able to live life in what doctor on Yahoo said was absolutely accurate, that, most of the patients who would have multiple organ failure would never be dreamed of as candidates.
00;07;49;00 - 00;07;59;29
Dr. Florman
So it just lines up that when we found a patient or patients that needed more than one organ and they had a meaningful chance for survival, that's how we try to make those decisions.00;08;00;06 - 00;08;14;26
Stephen
But let's say there is a patient who perhaps engages in certain behaviors that damages a particular organ. How do you navigate that? Does that person not receive that organ or are they less likely to?
00;08;14;29 - 00;08;41;07
Dr. Florman
Well, it's a tricky thing because many of our diseases are caused by people's behaviors. Some aren't. Some are things that people are born with. Some are things that they've potentially participated in and done to themselves. But, we don't judge that. We're just trying to provide care. We have some guidelines. We're not doing people who are actively doing certain things, and they have to commit to a certain lifestyle, and they have to be willing to take the medicines afterwards.
00;08;41;07 - 00;08;57;28
Dr. Florman
And there's a committee not just made up of surgeons and not just made up of medical people, but also, we sometimes when it's indicated we have ethicists, we have social workers, we have all different kinds of people who participate in the process to make sure that we're making rational decisions. And sometimes it is controversial.
00;08;58;01 - 00;09;24;12
Dr. Anyanwu
And, part of the, evaluation for any organ transplant involves a social worker and often sometimes even a psychiatrist. And if there's, any of these behaviors that we feel could potentially threaten the benefits of the organ or the survival of the patient for example, let's say a patient, drinks a lot of alcohol and that we think that might damage the transplanted organ.
00;09;24;14 - 00;09;46;03
Dr. Anyanwu
Then the patient would would have to have in place a strategy by which we think that the patient can stay off the alcohol and that that's going to succeed. So we involve the social workers and a whole team to evaluate and have a plan in place to prevent that from happening. And usually most of the time it's successful, sometimes it's not.
00;09;46;03 - 00;10;12;15
Dr. Anyanwu
But, we, we would certainly through our due diligence in that way and try because as you said, there are ethics for each person you transplant. You end up denying another person an opportunity to transplant. So what we want is we want to do our best to make sure as many of these organs end up in recipients, in patients who will take care of them and get a long, long benefit from them.
00;10;12;17 - 00;10;35;18
Dr. Florman
Of course. Well, this is a critical point. So there are about 120,000 people in the United States right now waiting for an organ. And many of them, most of those people are actually waiting for
kidneys. About 90,000. About half of them won't ever get a kidney. There just aren't enough
organs to go around. So how we use the ones that we do have is, highly regulated and involves
a lot of ethics and moral considerations.
00;10;35;20 - 00;10;54;18
Dr. Florman
We do, as a country give extra priority to children if you're under 18. That sounds fair. But at 24 year old and a 64 year old get the same consideration based on age. Maybe that's right. Maybe that's wrong. These are very difficult issues to try to sort out and try to understand who should get more priority or who should get less.
00;10;54;20 - 00;10;58;28
Stephen
Why? Kidneys? Why are kidneys the most in-demand organ?
00;10;59;01 - 00;11;18;11
Dr. Florman
Because of that, there are about half a million people with kidney failure. United States, and
90,000 of them are on the kidney transplant waiting list. Probably if we had more organs to go around, a lot more of those people would be considered. And also, you'd be shocked by the success, the success of kidney transplant and liver and heart transplant are remarkable.
00;11;18;11 - 00;11;35;23
Dr. Florman
So as the success has improved, so have the indications. And we've we used to not transplant people over 50 than over 60 than over 70. And we've done the kidney transplant here in an 86 year old. That's not going to be every day. And it's not going to be every person but their age doesn't seem to be the limitation anymore.
00;11;35;23 - 00;11;45;25
Dr. Florman
So the indications have expanded, which means there are more people waiting and yet there aren't enough organs. So if there's a big plug today, it's, donate your organs.
00;11;45;27 - 00;11;55;17
Stephen
Just as an aside, though, we heard a few years back about the 3D printing of new organs. Isthat a thing? It should. We should we be optimistic about that?
00;11;55;19 - 00;12;12;10
Dr. Florman
Well, you heard about it. So it's a thing, you know, hope springs eternal, and I'm sure there's optimism. There's. We're not there yet. There's a lot of buzz around about using pig organs. That's getting closer, but it's still not today.
00;12;12;12 - 00;12;32;08
Stephen
Now, before we get to the patient himself in this situation, how do you choreograph a triple transplant among multiple teams? What does that look like? How do you do that? It's, I imagine, difficult enough with one organ, let alone with three.
00;12;32;10 - 00;12;58;20
Dr. Anyanwu
Can I? I think as surgeons, we take care of many complex patients scenarios. So this is this is one of them having to, you know, execute such an operation. But there are we are used to our surgeons dealing with complex scenarios, difficult procedures, procedures that require multiple disciplines. So we actually do that or very often as surgeons we work in teams.
00;12;58;20 - 00;13;25;26
Dr. Anyanwu
And we we not infrequently have to involve other specialties so that we're used to. So we're used to working and coordinating with each other on various operations which are not necessarily transplant procedures. So when it comes to transplantation, it's it's no different. So we we do what we do out like an inquiry center like Mount Sinai is, is all about team based medicine.
00;13;25;26 - 00;13;54;19
Dr. Anyanwu
There are some things that we do that, you know, isolated practitioners and can deliver the. treatment. But for most of the treatments we do it. So even within just doing a heart transplant or a liver transplant, only it's there's still a lot of, you know, coordination and, going on. So I think adding, you know, a heart transplant or a liver transplant or a kidney transplant, I don't think that really makes, it it doesn't really.
00;13;54;19 - 00;14;15;17
Dr. Anyanwu
It's not as hard as it sounds in terms of the complex. And we do a lot of we've been doing multi organ transplant for years. So we do have long transplants. We do heart kidney transplants liver kidney you know kidney pancreas. So there's it's not a new concept but it's just that we're doing you know three at the same time.00;14;15;20 - 00;14;31;28
Dr. Florman
And here I thought the heart surgeon was going to say I just tell them what to do. And they do it. It's not quite like that. I mean, we have a very good rapport, and I think this is one of the special things about Mount Sinai and what I enjoy about being here. We have expertise in heart, obviously monstrous.
00;14;31;28 - 00;14;52;09
Dr. Florman
And and heart surgery and and heart transplant. We have expertise in liver transplant. We've done 6000 liver transplants, expertise in kidney transplant. But you also have to have expertise in the medical care. Let us not leave out the anesthesiologist the ability to manage a patient like this intraoperative leaf or whatever it is, 15, 18, 20 hours is extraordinary.
00;14;52;15 - 00;15;13;01
Dr. Florman
And they're very few places that can put all of this together without playing the blame game
when something goes wrong. And we've learned how to disagree and we've learned how to take
care of patients together. Who's going to manage the fluids afterwards? Who's going to manage
the immunosuppression afterwards? It's a little different for each organ. So, it really requires a
true team.
00;15;13;01 - 00;15;18;14
Dr. Florman
And I think that's special. And that's probably one of the reasons why this doesn't happen at a
lot of places.
00;15;18;22 - 00;15;36;27
Stephen
And to that point, Doctor Forman, you've talked about how there are only a few places in
America that could pull off an operation like this. What is it do you think about Mount Sinai, other
than the teams that you mentioned technologically, culturally, perhaps about Mount Sinai? What
do you think it is that makes this place?
00;15;36;27 - 00;15;58;18
Dr. Florman
I think there are lots of places that have extreme expertise in liver transplant, lots places of
extreme expertise in heart transplant or in kidney transplant. It's bringing that all together, with
the medical teams, with the anesthesiologist, with everybody involved. It just practically doesn't
happen that often. Particularly when you cross the diaphragm. I live on the on the lower side.
00;15;58;18 - 00;16;21;09Dr. Florman
He was on the upper side. Heart and lung. They talk to each other every day. They speak the
same language. Livers, kidneys, pancreas. We tend to speak the same language, too. It's it's
when you try to combine that, that it's it's more challenging. And there aren't a lot of places that
want to take on this type of transplant with people that are this sick, because the chances of
success are dramatically lower.
00;16;21;09 - 00;16;26;24
Dr. Florman
Any time you add one more organ, the chances of success go down.
00;16;26;26 - 00;16;49;16
Dr. Anyanwu
And I think also they obviously the technical aspects of the surgery because we're surgeons, I'm
very different and need a lot of modifications. So for example, Doctor Florian is going to be
doing a liver transplant on a patient who's just had a heart transplant, and the chest is still open
and the patient's on a kind of a bypass machine to circulate the blood, which is not usual.
00;16;49;16 - 00;17;15;11
Dr. Anyanwu
And I'm doing a heart transplant, which we have to conclude on a patient who's just had a liver
transplant. It's it's very different. And, and I last doctor months has been able to have teams that
can work together and do all these little parts that they all, you know, gel in the middle. It's, it's
heart is well, it's harder.
00;17;15;13 - 00;17;32;11
Dr. Anyanwu
And I think that's probably why a lot of, of, of hospitals can't pull it off. And even like the
anesthesia you mentioned, like for the whole procedure you would have about at least two
teams of any sociologists because the anesthesia for doing a liver transplant is very, very
different from a heart transplant.
00;17;32;14 - 00;17;56;13
Dr. Florman
Well, it's highly specialized. We have a separate liver anesthesia transplant team. We have a
separate heart anesthesia transplant team. And these are outstanding clinicians. But we
actually switch teams during this operation. The heart anesthesia team will switch to the liver
team when I start the liver transplant. But amazingly, they stay around and they all talk to each
other because the fluid management, the blood management, the how do you manage these
patients?
00;17;56;13 - 00;18;17;08
Dr. FlormanIntraoperative is dramatically different between the two organs, which might be something easily
overlooked. But for us this is about as important as it gets. He uses a bypass machine. They
research the blood around the heart so that they can remove the heart. There's no heart, in liver.
We don't necessarily have to do any of that. So it's just dramatically different.
00;18;17;11 - 00;18;28;06
Stephen
And that brings us to the patient in question. Mack Godbee, what were the facts of his case,
initially when he came to you and what jumped out at you?
00;18;28;07 - 00;18;50;27
Dr. Anyanwu
Well, he was a gentleman who had already had a heart transplant many years, like three
decades before. So that even brings another ethical question in that he's getting a second
transplant. And in screening for the second transplant, one of the problems with, with
transplantation is the medications have a lot of side effects, and you have to take medicines to
stop your body rejecting the organs.
00;18;50;27 - 00;19;19;01
Dr. Anyanwu
And these medications have side effects, which include some damage to the kidney. So over
the years his kidneys haven't been active, have been declining in function. And then when the
heart is failing, which his heart has been gradually failing over the last, say, five, ten years, it
then puts a lot of back pressure of blood onto the liver, because the liver just is underneath the
heart, and his liver gets congested with what we call congest, which is full of blood engorged
with blood.
00;19;19;03 - 00;19;43;28
Dr. Anyanwu
And that engorgement of blood starts damaging the liver, and the liver starts getting scarred and
you get stuck in scar tissue for me. So his liver was now getting disease too. And the problem
we faced is that if we were to do another heart transplant and just transplant his heart, very
likely during the operation, the liver would fail completely and then he wouldn't survive it.
00;19;44;00 - 00;19;53;21
Dr. Anyanwu
And then the kidneys was also failed. But when kidneys fail, you can go on dialysis. So the only
solution to try and save his life was to transplant those three organs.
00;19;53;23 - 00;20;13;13
Dr. Florman
Yeah. I will point out we we've. This is not something you jump into. We've had a gradual
increase in experience. So it was only maybe two years or so years ago that we did our firstheart liver transplant. That was a big deal. These are all a big deal. And we've probably done a
dozen of those now. We've done many heart, kidneys, many liver, kidneys.
00;20;13;20 - 00;20;34;19
Dr. Florman
And so putting that all together, we all got together and said, you know, there's no reason we
couldn't do this. And it makes perfect sense that this is what he would need. So remember, this
is driven by the patient. It's not driven by us offering a procedure. It's driven by the patient with
the patient needs. And then I would be remiss, we would all be remiss to say without a donor,
there is no transplant.
00;20;34;19 - 00;20;54;18
Dr. Florman
So it's this is only through the gift of life that a family in the worst time they can imagine when
one of their loved ones has a stroke or an accident, agrees to donate their organs to try and
save somebody else's life. So there is no transplant without the donor, and there is no triple,
double, or any transplant without the patient who needs that operation.
00;20;54;20 - 00;21;17;00
Stephen
And to the point about the patient. The show is called Road to Resilience, and Mack's story is, if
nothing else, a resilience story and incredible resilience story. What role does a patient's
resilience play in the likelihood that they'll even receive the transplanted organs, let alone if
they'll, come out the other side? Okay.
00;21;17;02 - 00;21;40;08
Dr. Florman
Oh, I think it's a great question. I mean, this is a brave patient. I'm not sure everybody's signing
up to have their heart, liver, heart again, liver and kidney replaced. I mean, the risk for this is
quite real, quite substantial. And so I think he his story is remarkable. His daughter, he's an ems
sky, his daughter resuscitate him when he has a cardiac arrest, he makes it into the hospital.
00;21;40;10 - 00;22;00;22
Dr. Florman
He ultimately survives enough only on machines, and only because of the incredible medical
care that he gets, including dialysis, including, heart pump, and is ultimately able to survive long
enough for us to find organs and do a successful transplant. It's a remarkable story about
resilience.
00;22;00;24 - 00;22;08;16
Dr. Anyanwu
And get back to working within two months of surgery to yeah, going back to work, which is truly
amazing.00;22;08;17 - 00;22;22;25
Stephen
Extraordinary. Yeah. Now, this being an operation that required multiple organs, multiple teams,
so much coordination, what was going through your minds as the surgeons in the hours before
the first incision?
00;22;22;28 - 00;22;29;09
Dr. Florman
I'm hoping that he starts around 8:00 at night so I can start around 8:00 in the morning.
00;22;29;11 - 00;22;37;19
Dr. Anyanwu
Well, we. Well, for us, it's really like any other surgery. We just, you know, we plan for it. Like we
plan for any operation.
00;22;37;21 - 00;22;54;21
Dr. Florman
We meet and have a cup of coffee, literally, usually before these and we map out how are we
going to do this and who goes first? Which catheters are we to put? Are we going to put which
side are we going to put the catheters on. It's different for him than it is for me. And we both try
to make sure that all the teams are organized and ready for this.
00;22;54;23 - 00;23;17;00
Dr. Florman
And it's a tour de force. There's just no question about that. And then we coordinate the donor.
We have to both agree that the donor is appropriate for all of these organs. We have to send our
teams to go get these organs often, bring them back. The timing of this is critical. And then we
understand each other when when he replaces the heart, he lets me know where he's at.
00;23;17;00 - 00;23;35;00
Dr. Florman
And at a certain point I come in, do the liver, do the kidney, and he comes. He's readily
available. He's still here, the teams are still here. There's a there is a lot of coordination effort.
But at the end of the day, what we do is the same thing we do. If it was just the liver alone, the
heart alone or the kidney alone, but it is a dance.
00;23;35;02 - 00;24;01;08
Dr. Anyanwu
But the preparation is, it's very simplified because it didn't really start that day or the day to day
at the surgery actually starts weeks, sometimes months before. So doctor, Foreman and I would
have already met and planned how we're going to do a particular surgery. And, for example, we
have a patient now who also had a previous transplant who needs a heart, liver and kidney.00;24;01;08 - 00;24;16;00
Dr. Anyanwu
But it's a much more complex scenario than this one. And we met about four weeks ago
planning what we would do. So whenever we get to do the patient's operation, we already have
our plan in mind and we just put it to place.
00;24;16;00 - 00;24;36;02
Dr. Florman
But tell them the punchline. We're having up a cup of coffee and a patient stops to say hello and
waves to him, and it turned out to be the patient that we're talking about, that we're talking
about, which was which was remarkable. You know, most of the time we don't actually talk to
each other the day of the transplant, other than make sure that we both agree on the donor
because we've already had these discussions.
00;24;36;02 - 00;24;41;04
Dr. Florman
We know it's coming. Just tell me what time. You know, we're going to go and we go. Yeah.
00;24;41;08 - 00;24;56;29
Stephen
So between your experience in the field, your preparation for a given surgery and the amount of
support you have from your respective teams, it's not like you're stepping into the operating
room and the true weight and emotional toll hits you.
00;24;57;01 - 00;25;13;03
Dr. Florman
No, no, but I will acknowledge. I mean, I've done a couple of thousand transplants. I can tell
you, this one, you know, these all give you, you want the patients to do. Well, you don't want to
do this and have a failure. Nobody wants to fail. But the stakes are high, and there are people
who don't make it through it.
00;25;13;03 - 00;25;20;24
Dr. Florman
So you have to believe in your in your decision making. You have to believe in your team. You
have to believe in your partners, and the patient has to believe in you.
00;25;20;26 - 00;25;35;26
Stephen
Well, to your point, the use of the word failure, what determines success or failure? If the patient
survived six months or a year and then perhaps passes away from something else, that's a a
success?00;25;36;03 - 00;25;55;12
Dr. Florman
Well, I think the failure surgeons are most concerned about is there's a real risk for
intraoperative death. You can die in the operating room, do this. Doing this either from the heart,
from the liver, from both. You can die immediately afterwards. I think getting out of the hospital is
a big triumph. You know, we have a rule.
00;25;55;12 - 00;26;18;14
Dr. Florman
We don't pound our chest till you go home and stay home. But, yes, I mean, people die. That's
that's the nature of life. So. But, you know, how do we measure success in the world of
transplant and insurance companies and oversight? One year of survival is a monstrous
measure of success. But, you know, the first part is to get out of the operating room and to
survive the operation and go home.
00;26;18;16 - 00;26;47;13
Dr. Anyanwu
And really, we want to basically give the patient the opportunity and all the the best shot at
surviving in the long term. So basically, that's what we're trying to achieve. As you say, they
could still succumb to an infection or stroke or a cancer and and not survive. You know, a year
or 2 or 3 later. But we want to put them in the best position that we can from the get go, which
will be a patient, you know, having all these organs functioning.
00;26;47;16 - 00;27;09;29
Dr. Anyanwu
The patient recovered no infection. And the patients, you know, goes back home to live an
independent life. And then hopefully with the the team taking care of the patient with
medications on the patients first will hopefully get long term, you know, improvement in quality of
life and survival. Sometimes it doesn't happen, but most of the times it does.
00;27;09;29 - 00;27;24;21
Dr. Anyanwu
Most of the times if you can get the patient home in a in a good, you know, good health
condition for the first 612 months after after surgery, most of those patients will go on to get
years of benefit from transplant.
00;27;24;23 - 00;27;36;02
Dr. Florman
And I would point out, this particular patient does not leave the hospital without a transplant. He
he dies in the hospital. So, you know, it's always a risk benefit consideration.
00;27;36;04 - 00;27;54;17
Dr. AnyanwuIn fact, this particular patient almost died. It was like Christmas last year. He was dying. We had
to rush him to the operating room some, some time. I think it was just after Christmas to put in
these heart pumps to save his life. He wouldn't have even have survived till the new year. It
was. It was not that bad.
00;27;54;19 - 00;28;13;26
Dr. Florman
But then, remember, I mean, we talked a little bit about this. We can't do this unless we believe
we're going to be successful. Because whenever we take an organ for one person, we've taken
it away from somebody else. There's a lot of, weight of that and responsibility that goes along
with that to try and make decisions that are sensible and that aren't futile.
00;28;13;28 - 00;28;33;22
Stephen
Well, also, in those sorts of situations where it is a true emergency and this patient is going to
die if they don't receive this organ immediately, I imagine those sorts of conversations and
ethical dilemmas are further enhanced because you're operating on such a limited timeline.
00;28;33;24 - 00;28;53;21
Dr. Florman
We're used to this and these types of complex decision making. These are not made alone. No
one person gets to say yes or no. But there are teams involved in this. But we really want
especially in patients this sick, this complex. We really don't want to do futile operations. We
want to do this because we really believe they're going to make it.
00;28;53;23 - 00;29;05;10
Dr. Florman
The proof is in the pudding. You know, he did fantastic and so did the next patient. But if one
doesn't make it, it doesn't mean it's the wrong decision. These are unbelievably high risk cases,
doctor.
00;29;05;10 - 00;29;29;23
Stephen
And you've talked about how it takes a village to get a patient through a procedure like this.
We've touched upon the role of teamwork, here. But could you reiterate, like, how many teams
truly, work on a patient like this? I don't think either of you folks would ever say that. It just
comes down to the surgeons.
00;29;29;29 - 00;29;34;10
Stephen
It comes down to, like, the entire unit working as almost a symphony.
00;29;34;13 - 00;30;07;28Dr. Anyanwu
It's an entire unit. Like, for example, the the. We haven't talked about the intensive care, for
example, the effort in terms of the nursing care and the the physicians taking care of the patient
in intensive care in the first say, week after a combined organ is phenomenal. Like, we, I mean,
we put in a lot of work, but in a way pales in comparison because we might focus very heavily
for, say, 24 hours in doing the surgeon, fixing the patient.
00;30;07;28 - 00;30;18;14
Dr. Anyanwu
But without what comes next, the patient stands no chance. Like it's it's a real rough road for the
next week or two to get them through.
00;30;18;16 - 00;30;38;10
Dr. Florman
It's I will say to to get them to the surgery the the cardiologists, the nephrologist, the
hepatologist, the intensive. Everybody taking care of them leading up to the surgery is equally
as complex. I mean, I've always people say, well, how do you operate for so long? I don't know
about you, but for me, every operation feels like it was 20 minutes.
00;30;38;10 - 00;30;56;07
Dr. Florman
I mean, I'm in my zone. I'm doing my thing. I do what I love, and we do. We tend to get a lot of
the glory, but it's it's it's we. This is what we love doing. I mean, but we got to do it with other
people and manage this in a way that the patient succeeds and that is successful and that
there's the trick.
00;30;56;09 - 00;31;00;15
Stephen
Could you talk about the role of nurses and nurse practitioners on your teams?
00;31;00;18 - 00;31;25;23
Dr. Florman
Wow. You know, the doctors get so much credit. But look, none of this happens without
everybody. I mean, the nurses are a huge part of this. In that operating room during either our
portion of the procedure are multiple surgeons, mostly nurses, y'all. Just there's also a veritable
army of nurses. Perfusion is to man some of these pumps circulating nurses who get the
equipment that scrub nurses who pass us the instruments, this is all part of it.
00;31;25;23 - 00;31;41;22
Dr. Florman
I can't have somebody who's used to passing a hard instrument pass me my instrument. So I
need the liver people to come. And and they know their job. They know what I need before I ask
for it. That's the sign of a great nurse. Love the nurses. And none of this is possible, of course,without them also.
00;31;41;24 - 00;32;03;00
Dr. Anyanwu
And really, the entire transplant process is run by our nurses. So like we have, we call them
transplant coordinators, but they're they're largely nurses and nurse practitioners that it's in
terms of the patient care, an organization that goes around, you know, putting everyone
together. These coordinators run the show. You can't do it without you.
00;32;03;00 - 00;32;23;18
Dr. Florman
Think the complexity of the transplant, setting this up, the transportation to send the team to
another hospital, in another city, the airplane, the ambulances getting that back, setting up the
operating room, the blood bank, all those logistics. If he and I were responsible for them, I don't
think any of this would ever happen. This is done by our our our nurses and our nurse
practitioners and our coordinators.
00;32;23;23 - 00;32;33;02
Stephen
And what do you think this procedure specifically says about the future of transplant surgery,
both here at Mount Sinai and more broadly?
00;32;33;04 - 00;32;56;05
Dr. Florman
Well, we're already seeing this. So since we did this, we now have, I think, 4 or 5 patients that
want to have this, you know, the more success you have, the more people come. But I think this
just shows just, to me, this is almost magical. This is just the the incredible part of medicine and
about being a part of something like transplant and team work that you could even think to do
something like this.
00;32;56;05 - 00;33;14;18
Dr. Florman
So I'm sure the next time is going to be somebody who needs four organs. You know, we have
to do it based on what the patient needs, but, the better your experience, the better the
teamwork, the better the institutional support, the more likely we are to see the indications get
expanded even further.
00;33;14;21 - 00;33;37;09
Dr. Anyanwu
And it will also extends to solving other problems. So when when you have teams that can work
so well together, you also find other applications like for example, doctor from I have a patient
who needs a kidney transplant or a liver transplant but has a heart problem. And we'll say, well,
maybe we can coordinate and fix the heart at the same time as fixing the liver or the kidney.00;33;37;09 - 00;34;11;17
Dr. Anyanwu
And when you have teams that work together in that way, you'll you'll find you reach out. So
many, so many more patients because there will be patients who will need specific treatments
that cannot be delivered by a, you know, integrated team approach and things that might not
have been thought of or done before. But once you can say, well, if we can put together a whole
team of, you know, a few hundred people to pull a heart, kidney, liver transplant, then maybe we
can take care of a patient who has a pancreas problem and a lung problem.
00;34;11;21 - 00;34;12;29
Dr. Anyanwu
There must be a solution.
00;34;12;29 - 00;34;36;02
Dr. Florman
That's exactly right. And also it drives innovation. It drives research. We now have a lab a
perfusion lab where we're pumping multiple organs on perfusion pumps to see how that works.
We've even talked about, putting these organs in together as one unit instead of separating
them. It's been done in a small number of places. Maybe that's part of our future, but, absolutely.
00;34;36;02 - 00;34;42;11
Dr. Florman
Having this collaborate and the ability to do this drives other innovations and drives patient care.
00;34;42;13 - 00;35;01;24
Stephen
Now, for many of our millions of, listeners and, viewers out there, we imagine there are a great
many folks who are either in medical school or aspiring to become, doctors themselves. What
advice do you give to those folks who are just starting out and wanting to make a positive
difference?
00;35;01;26 - 00;35;24;04
Dr. Florman
Well, first of all, if there are millions of people I gotta say. Hi, mom. Yeah, I'd be remiss. Look, I
think Mount Sinai has an incredible place. Medicine is incredible place. The technology keeps
keeps increasing. I have had no regrets. I work hard, we all work. Really hard. This is a labor of
love. There are so many other things I could do that weren't this hard.
00;35;24;06 - 00;35;42;29
Dr. Florman
That would probably be more lucrative. Less days in the office, weekends, nights. But I love
what I do. And I think if you love what you do, it almost doesn't matter what your job is, you'regoing to be really good at it. So I would encourage people to pursue these types of careers. And
I think nowhere better than to come to Mount Sinai and try to do it.
00;35;42;29 - 00;35;54;14
Dr. Florman
There's a lot going on. Maybe you won't do this for the rest of your life. Maybe you won't be
involved in transplant, but just seeing it, just experiencing it and understanding what's possible.
And I think it opens up incredible horizons for people.
00;35;54;16 - 00;36;22;08
Dr. Anyanwu
And just to mention technology, that's the doctor someone just brought of technology. The
technology has is evolving rapidly. And when we started doing these, combined heart liver
transplants about three years ago, the technology since then has allowed us to give patients like
Mr. Godbee a chance, because before we were limited a lot. Because when you take out an
organ from the body, it can only survive a particular amount of time out of the organ.
00;36;22;09 - 00;36;43;00
Dr. Anyanwu
So for a heart, maybe after 4 or 5 hours, you start getting concerned. The liver may be, what,
eight hours, 7 or 8 hours, and then you start running into problems. So it made it very difficult for
us to do these multi organ transplants. But now we have machines that can keep these organs
alive for 12 hours, 24 hours even longer.
00;36;43;00 - 00;36;43;23
Dr. Florman
Game changer.
00;36;43;27 - 00;37;07;26
Dr. Anyanwu
Which have really changed the way we can do these surgeries. So we can perform these multi
organ transplants in a much more controlled way, not hurried. With we can also procure them
from distant donors or we can go very far away, get the organs. You're not under the pressure of
time. And it allows us to do these procedures much more safer than we could even just three
years ago.
00;37;07;26 - 00;37;24;06
Dr. Florman
So it's not by accident that those devices became more available just 2 or 3 years ago when we
started doing more, these two years ago, because the idea that we can keep the organs out of
the body longer while we wait for one organ to be put in, is a game changer.
00;37;24;08 - 00;37;37;25Stephen
Do you see a difference among patients in terms of their progress and their ultimate outcomes,
when they have a significant amount of support, social support, familial support?
00;37;37;27 - 00;37;53;24
Dr. Florman
Well, it's part of the evaluation. I mean, you have to have the ability. You're not gonna be able to
take care of yourself for a while. So, we decline people who don't have adequate support, but
we also have a responsibility to try and help people who don't have actual support gained that
support. So we have a lot of resources.
00;37;53;24 - 00;38;00;06
Dr. Florman
And, you know, we're here to help people. And, but it is an important facet of a transplant
consideration. No question.
00;38;00;06 - 00;38;14;23
Stephen
Well, I mean, yeah, from the point of view of someone who might get rejected based on not
having what is deemed to be adequate familial support, they don't want to feel like they're being
penalized just because they don't have the support that someone else might.
00;38;14;29 - 00;38;42;00
Dr. Florman
We work very hard to help provide that. There is a limit, of course, but we work very, very hard.
And we're we're agnostic. We're blind to financial ability and all this. I mean, every other day
we're here to take care of patients, and we should use our resources to help people get over
this hump. The goal of transplant is to be no matter what we're going to do is to have a better
life and to live longer and to restore you to what's as close to normal as possible.
00;38;42;07 - 00;38;51;19
Dr. Florman
And Chris Klug won an Olympic downhill bronze medal. Snowboarding. Six months after a liver
transplant. There's nothing you could think of doing that somebody hasn't done with a
transplant.
00;38;51;21 - 00;39;09;06
Dr. Anyanwu
And I wouldn't use the term rejection. We don't really reject people on those basis. We might
defer the, you know, the transplant. And we say, look, we have this barrier. How do we solve it.
So it means that the patient doesn't have social support. The question is what can we do and
how can we work with the patient.00;39;09;07 - 00;39;21;15
Dr. Anyanwu
So we wouldn't like reject a patient on that basis. Well, we've try and find a way to to work
around that. And sometimes we're successful and sometimes there are barriers that we really
can't overcome.
00;39;21;17 - 00;39;42;01
Dr. Florman
It also depends on what the what the scenario is. I mean, for kidney transplant you can wait on
dialysis. There's no emergency. Me dialysis isn't fun, but it does keep you alive. And it is a way
to save it. That doesn't exist. So much for heart and liver transplant. There's a little bit of that.
We have some devices that can help, but there's generally not a rush, so we.
00;39;42;01 - 00;40;00;21
Dr. Florman
I like the way you put that. I mean, it's not about rejection. There are some people who get
rejected for good reason. I mean, if you're injecting intravenous drugs, you're almost certainly
not going to be a candidate unless you can give that up, improve your sobriety. But we do try
that at transplant. Not for everybody. I transplant is one stop on the continuum of patient care.
00;40;00;24 - 00;40;08;25
Stephen
Sure, sure. How would you say Mack's extraordinary story has changed? You?
00;40;08;28 - 00;40;37;09
Dr. Anyanwu
I mean, I wouldn't say it's changed me. Like, I see my role in this as a doctor, so I. I actually
don't see, you know, my encounter with Max any different from, say, maybe a child with
meningitis that I might have taken care of when I was working in emergency room in Africa, 30
years ago. I it's just someone who is sick and is in need of care, and we deliver that care.
00;40;37;10 - 00;40;48;17
Dr. Anyanwu
His happened to be very complex and complicated, but I just see the person I see doing my
duty as a doctor, I don't I don't see it as anything different.
00;40;48;21 - 00;41;10;23
Dr. Florman
Yeah, I think I feel the same. Look, it's gratifying to see somebody do well, who's that sick? I
mean, it's amazing and it's gratifying to know that we work with teams that are capable of
coming together and providing this kind of care. You know, the truth is, I met Mack a week before
his operation, right. And I see him a few times afterwards.00;41;10;23 - 00;41;23;00
Dr. Florman
But it's gratifying to know that somebody can be that sick, go back to life, enjoy their family, and
live the life that they may have been able to live without those diseases. I find it very gratifying.
Sure.
00;41;23;02 - 00;41;56;06
Dr. Anyanwu
But I tell you what is I think is most gratifying, which Doctor Foreman said earlier is that a family
in that time of grief have brought such you know, improvement to another human being because
this would never have happened if a family in a very difficult time donated their organs. And I
think that's where, you know, that's the most gratifying thing I've seen in my life, is that there's a
family somewhere that, you know, they they had a great loss for something positive happened.
00;41;56;06 - 00;42;00;16
Dr. Anyanwu
This that's that's that's why, you know, a difficult time.
00;42;00;19 - 00;42;16;26
Stephen
Finally, for all of those millions of, viewers out there in radio land, a great many of them are likely
medical professionals themselves. What do you think it's important for medical professionals
and doctors specifically to take from this surgery?
00;42;16;29 - 00;42;41;15
Dr. Florman
Well, I think even within our own great institution, sometimes there's a failure of imagination.
There's nothing wrong with asking. Could this patient have more than one organ? Are these
things possible? Frequently, the answer is no. But, you know, sometimes the answer is yes. So I
think that's part of it. I also think getting back to donation, you know, signing the back of your
driver's license is nice.
00;42;41;15 - 00;43;00;14
Dr. Florman
That's not really something we enforce legally. We might be able to, but, you know, somebody
would probably go on the corner and say they coerced me and call CNN. And the thing is, you
have to talk to your loved ones, the people involved in your life who make the decisions. I have
to do that. You have to do that and make sure they know that you know something untimely or
untoward happens to me.
00;43;00;16 - 00;43;19;16
Dr. Florman
I want you to know that this is what I wanted. I wanted to try and help save somebody else. Wedon't ask for bad things to happen to other people. We just try to make something good come
out of it and you know, only a certain way. There are 3000 hospitals in the United States. There
are only about 250 or so transplant programs.
00;43;19;18 - 00;43;29;01
Dr. Florman
donating organs.
Right. So the vast majority of hospitals don't do transplant. Yet. All of us can help save a life by
00;43;29;03 - 00;43;55;21
Dr. Anyanwu
And I think the only other thing I'll add to that is for doctors use the use the people you know
that's around you. There are so many of your colleagues and both, you know, physicians and
non physicians with expertise around you. Use them and you can find that if you work together
rather than against each other competing with each other, you can you can achieve a lot of
great things because like we wouldn't be discussing this if like we don't work together.
00;43;55;21 - 00;44;20;02
Dr. Anyanwu
And also working together is just the tip of the iceberg. There's so many, you know, other
doctors, nurses, technicians, everyone's putting together and build a good team like this. Things
like this can't happen without a good team. You have to have a good team. Like for example. So
we do the heart transplant doctor, flower man does the liver transplant, kidney transplant during
that period of time he's operating I just go and have a rest.
00;44;20;02 - 00;44;35;14
Dr. Anyanwu
I don't even think about what's going on, because I know that the patient is being taken care of
in whatever, in the way I would want the patient taken care go and vice versa. So you have to
have it surround yourself with a team you can trust and build that.
00;44;35;17 - 00;44;55;04
Dr. Florman
When I also just point out you asked about Mr. Godbee, everything we've done hasn't always
resulted in such a success. So one of the things about his case is a reminder that we are
successful, even in some of our failures. Not every patient has done perfectly. That's part of the
as part of the risk. That's part of what we signed up for.
00;44;55;11 - 00;45;16;05
Dr. Florman
So there has to be real trust, not just between the two of us, but between the entire team and
institutional support for this, that these things don't happen by chance or by accident. They have
to be built over time, with institutional investment and with resources and with every facet of thishas to be in place, or you just shouldn't be doing it.
00;45;16;07 - 00;45;28;12
Stephen
Last question. This was a 20 hour surgery, and in something that long do you listen to music
and is there a music that's best to listen to when you're conducting a transplant surgery?
00;45;28;17 - 00;45;29;13
Dr. Florman
Why are you.
00;45;29;13 - 00;45;47;17
Dr. Anyanwu
First? Well, I listen to what I let the team take what we listen to. And, you know, and I tell them,
like, if you want me to, you know, finish up quickly, then you better not put music that's going to
send me to sleep so they know what they put on. And we just keep suturing quickly. Well, yeah.
00;45;47;17 - 00;46;06;15
Dr. Florman
You know, I get asked that so frequently. I also let the team do it, but I have certain rules. No
country or Western. I softened up a little on that, not too into punk, and I definitely don't like the
N-word. And it has to be a little low in the background. I will tell you, that I actually, sewing in the
liver should be very inspiring.
00;46;06;20 - 00;46;20;27
Dr. Florman
And somebody chose Country Road. Take me home during Mr. Gotti's transplant. I'm not going
to ever forget that. And we had to quickly switch to, AC, DC. But, you know, the music should be
secondary. And that's what I tell everybody. But yes, we listened to music.
00;46;20;29 - 00;46;42;23
Stephen
Doctor Sandy Foreman and Annie Onion. Well, thank you so much for your time and expertise.
Thanks again to Doctor Zani Anyanwu and Sandy Foreman for their time and expertise. That's
all for this episode of Road to Resilience. If you enjoyed it, please rate, review and subscribe to
our podcast on your favorite podcast platform. Want to get in touch with the show or is it just an
idea for a future episode?
00;46;42;26 - 00;46;58;02
Stephen
Email us at podcasts at Mount sinai.org. Road to resilience is a production of the Mount Sinai
Health System. It's produced by me, Stephen Calabria and our executive producer, Lucy Lee.
From all of us here at Mount Sinai. Thanks for listening and we'll catch you next time.
