Ep 47-Fatal Mismatch: A Transplant Tragedy

A teenage girl crosses a border for a chance at life—and loses it to a mistake so basic it should have been impossible. We dive into the case of Jesica Santillán, the 17-year-old who received an incompatible heart-lung transplant, and trace how a single missed safeguard exposed cracks across donor services, hospital protocols, and communication chains. This isn’t a story about rare complications or experimental risk; it’s about the simplest check in medicine—blood type matching—and how failing it changed transplant safety nationwide.

If the episode moved you, share it with a friend who works in healthcare, leave a review to help others find the show, and follow us for more cases that challenge and change the way we think about medicine.

Resources: 

https://www.cbsnews.com/news/anatomy-of-a-mistake-04-09-2003/ 

https://www.nejm.org/doi/pdf/10.1056/NEJMp030033?download=true 

https://pubmed.ncbi.nlm.nih.gov/25077248/ 

https://en.wikipedia.org/wiki/Jesica_Santillan 

https://www.jstor.org/stable/3528375?read-now=1&seq=2#page_scan_tab_contents 

https://www.wral.com/10-years-later-questions-surround-jesica-s-hope-chest-charity/12997462/ 

https://corporate.dukehealth.org/news/duke-releases-letter-unos-concerning-jesica-santillan 

https://www.nytimes.com/2003/02/23/us/girl-in-transplant-mix-up-dies-after-two-weeks.html 

Transcript

SPEAKER_02 0:45

Oh man! Hi. I don't know. My screen looked weird. I didn't know if we'd actually started, but we have. I see little speech envelopes.

SPEAKER_00 0:55

Okay, yeah. I was gonna say mine must just be like super far over to the right because I was like, where are my speech envelopes?

SPEAKER_02 1:01

Found them. Oh man. Well, happy Christmas. And by the time this comes out, we'll be talking next year. This is our next one.

SPEAKER_00 1:09

Yeah, we'll be in the new year.

SPEAKER_02 1:11

Oh my gosh.

SPEAKER_00 1:13

Right? It comes out on the second, I think.

SPEAKER_02 1:15

Yeah. Yeah, whatever Friday is. I don't know. It's all going too fast. But I used to, I want to say, I used to be like, oh, I'm gonna make resolutions. And it got to the point where because our family, we used to write our resolutions out and then put them in our stockings, and then the next year we get out of resolutions. Yeah. So I just started recycling mine because be super healthy, get fit, save money. You know, it's all you know, yeah. Spend time with family. It was just all stuff that you could just so we started recycling it. And I was like, you know what, this is not meaningful. So for the last couple of years, I've just been more about okay, what's on my bucket list for 2026? So, Amanda, I want to ask you. What's your bucket list for 2026? I know there's a big one.

SPEAKER_00 2:03

Okay, yeah. I'll I guess learn how to be a mom.

SPEAKER_02 2:07

You don't need to learn. It's in young girl. You're gonna be a good mom, but you're gonna be a mom. So that's your bucket list.

SPEAKER_00 2:13

Yeah. So yep, big item this year. Been waiting for this item, motherhood.

SPEAKER_02 2:20

It's a little item.

SPEAKER_00 2:23

Hey, that didn't take me long to pick something, so that worked out well for me.

SPEAKER_02 2:29

It's inevitable. I mean, that's the big, big, big, big life marker right there. So I'm really excited for you and baby and Adam. And reason.

SPEAKER_00 2:40

Thank you.

SPEAKER_02 2:41

So what's your bucket list then? My bucket list is to be auntie to the new baby. But also, I feel like I need to do I I've got a travel bug and it hasn't been satisfied in a while. So I feel like I just need to go somewhere just because. Not because of a conference, not because of, you know, gotta take the kids somewhere. I want to go somewhere just because I want to travel. So that's on my bucket list.

SPEAKER_00 3:13

Do you have a passport you need to dust off?

SPEAKER_02 3:17

Yeah, well, it's so it's so dusty it's expired. So also on the bucket to-do list is we knew that sucker.

SPEAKER_00 3:26

Yeah, maybe maybe this year you do a domestic travel and then 2027 international.

SPEAKER_02 3:33

There you go. Or maybe you get wild this year and do both. Yeah, I might go wild and around the US. Who knows? I mean, there's a lot of the United States is so big that it's it's you know, a lot of the states are almost like a different country. Like, for example, even within a state, I feel like I'm in a different country right now, being quite way up north, and such a big difference in cultures and really interesting customs and food and ways of speaking and mannerisms. So yeah, there's just there's just a lot to explore. So I think that's on my bucket list for 2026.

SPEAKER_00 4:12

I'll have that for you.

SPEAKER_02 4:16

Um we have something to celebrate. Oh, I thought I just emailed you. Oh, yeah, okay, yes.

SPEAKER_00 4:23

I do know. I was like, what is it?

SPEAKER_02 4:25

Like I forget what it's called. So I just got an email from somebody from feetspot.com and they do like rankings and groupings of the podcast. And they said, Well, congratulations, you are and they look across, you know, it's a global thing. The most popular podcasts in different genres. And we appeared in the top 10 best medical true crime podcasts.

SPEAKER_01 4:53

We appeared as number three.

SPEAKER_00 4:55

Yeah, I know. She sent that to me, and I was like, holy cats.

SPEAKER_01 4:59

Number three.

SPEAKER_02 5:00

And the number two is it Mr. Bollin's medical mysteries, which I follow and I just absolutely love. He's on a wondery platform. So listen, Wonder if you want to pick us up. We're up there with Mr. Bollin. We're Bollin. So uh Bollin at number three.

unknown 5:15

Us up.

SPEAKER_02 5:17

So um, yay, go us.

SPEAKER_00 5:19

Um thank you to all of our listeners for downloading, reviewing, subscribing, commenting, old things.

SPEAKER_02 5:27

Absolutely. So go us, go you listeners. It just shows that what our little hobby is turning into something that people enjoy. Yeah. And what I enjoy almost as much as like the research and doing the podcast is being able to spend time with my friend Amanda. I know, I'm on a regular basis. So cool. And so cool.

SPEAKER_00 5:49

Since you've moved, I probably well, I mean, other than your immediate family, of course, I probably get to see you more than anybody.

SPEAKER_02 5:54

I know. So everyone, and happy 2026. Yeah. Some of us started early. No, just kidding. That was the baby.

SPEAKER_00 6:07

Yeah, yeah, totally. It's my case today, and you know, I got that heartburn hiccup situation. So they're gonna be there. You know what? They're just gonna be there.

SPEAKER_02 6:18

We just feel like it's it's baby Dr.

SPEAKER_00 6:20

House just interjecting or they're like, hey, this is fun. We do this every week. Here's my input.

SPEAKER_02 6:28

Oh yeah. Do we have any corrections? Did Rich ever get back our listener with uh the Bristol expertise?

SPEAKER_00 6:36

Yes, he said no corrections. Well covered. Thank you, Rich.

SPEAKER_02 6:42

Well done. Well done. Shout out to Rich or thanks, Rich.

SPEAKER_00 6:46

I guess I don't think that you replied to this yet, Rich. If you did, I missed it. I need to go back and look. But what the heck are weather pants? If you guys follow us on social media, Rich is an active participant on our Facebook page, and he sent a picture of his holiday, and it was like a coastal beach, beautiful, as we were stuck in a blizzard, and he mentioned he had his weather pants. And I said, What are weather pants? Because little old me in Minnesota, United States, I don't know what weather pants are.

SPEAKER_02 7:24

You know what else is funny is that he's he's British, he's from the UK. So when they use the word pants, that means underwear. So Richie, that's what I'm saying. Maybe they're long underwear to stay warm then.

SPEAKER_00 7:37

I need to know more.

SPEAKER_02 7:39

So right now, let us know. Let our listeners know.

SPEAKER_00 7:42

That is about underwear. I guess. Sorry I brought it up on the pod, but also you brought it up on Facebook.

SPEAKER_02 7:46

So no, it's fair, it's fair game.

SPEAKER_00 7:49

Now everybody's I was thinking like snow pants, but he's by water, so like yeah, rain water pants. I don't know. Let us know. Anyone from the UK, let us know what water pants are.

SPEAKER_02 8:01

We're on the edge of our seats. We're on the edge of our eggs.

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SPEAKER_00 8:05

Yeah, my weather pants. Well, yeah, whatever those are. So, you know, as we mentioned, this year is coming to a close, and it's that time of year where we start thinking about improving our health because that's usually everyone's go-to for resolution.

SPEAKER_02 8:22

Right.

SPEAKER_00 8:23

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SPEAKER_01 8:50

Not our sponsors. No, no, no.

SPEAKER_00 8:56

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SPEAKER_02 9:54

Amen.

SPEAKER_00 9:55

Amen. Nothing like working out hard, eating good, and then you're still bloated. Yay, gut health. Elevate your protein game with clear whey protein powder, lactose-free, sugar-free, and refreshingly delicious. Perfect for a flavorful protein-packed boost. Visit clearprotein.com to receive an exclusive 20% off any product when you use our promo code STAYSUSPicious. And again, that's clear with a K. Visit ClearProtein.com and use our code stay suspicious for 20% off your products today. Nice. You know, I just scrolled to trigger warnings. I'm like, hmm, didn't actually think about if there were any. It's just a sad case. I don't think there's any trigger warnings. I will say if anybody is Spanish speaking, a trigger warning for you, I guess, is I'm not. So if I I uh pronouncing, so they should not be pronounced is because I uh me hablo inglés, el only. So so sorry. Solamente Inglés. Okay. Yeah, okay. So I guess I forgot I was gonna Google this earlier, but the name Jessica in English, like how would that be pronounced in Spanish? Jessica. Jessica? Jessica? Okay.

SPEAKER_02 11:19

But because she's called Jessica, I mean that's an American name. It's kind of a Spanish name.

SPEAKER_00 11:24

Well, okay, so actually I typed it with two S's because my word dot kept telling me it was wrong and I can't handle squiggles underneath the so it really is J-E-S-I-C-A.

SPEAKER_02 11:35

So be Jessica Santillum.

SPEAKER_00 11:37

Okay. Shall we just uh get into it? No trigger warnings other than me trying to read Spanish words.

SPEAKER_02 11:42

Let's do it. You'll be great.

Trigger Warnings And Pronunciations

The Jesica Santillán Transplant Case Begins

SPEAKER_00 11:44

Okay, cool. Also, pre-apologies. I'm to the point of my pregnancy too where I get out of breath really easily. So hiccups, out of breath, and bad Spanish skills. But if you can handle that, we got this. Cool, cool, cool, cool, cool, cool. No doubt, no doubt. Here we go. Okay. Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS, three causes that receive far more public attention. In fact, more people die annually from medication errors than from workplace injuries. Add the financial costs to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. Which brings us to today's case, where we will discuss Jesica Sentien. Jesica was born on December 26, 1985, in a small town near Guadalajara, Mexico, to Meiko Hierta and Magdalena Sentien. She was reportedly a sick child from the moment she came home. She vomited blood on her first night and had severe, frequent headaches and vomiting as a young child. When she was just five years old, a doctor diagnosed her with anemia and prescribed her iron pills. But as she grew, it became clear that something was wrong. Hesica, she tired easily and struggled to breathe. Ordinary childhood exertion left her exhausted and over time her symptoms worsened. Poor baby. I know, poor sweet baby. Later, another doctor suggested that she might have a heart murmur, which prompted her parents to take her to Victoria, Texas, where an American doctor discovered that she had restricted cardiomyopathy, a fatal condition in which the left ventricle of the heart does not fill with enough blood to provide the body with adequate oxygen. The disease also caused progressive pulmonary hypertension, placing immense strain on her heart and lungs. In Mexico, the treatment options were limited. Jesica's condition was terminal without a transplant, and a heart-lung transplantation was not readily available to a family that had no money, no political connections, and no access to specialized care. In March of 1999, the family, who did not speak English, decided that they needed to take Hesica to the United States to get treatment. Magdalena had a sister who lived in Lewisburg, North Carolina, who had told them that they should go there and go to Duke Medical Center for help. They paid$5,000 to a smuggler to move the whole family, including her siblings, across the border.

unknown 14:43

Oh man.

SPEAKER_02 14:43

Can you imagine how rough that was?

SPEAKER_00 14:46

No. No, and you just want to help your baby. So while they were traveling through the Sonoran desert to add insults, injury here, thieves stole all of the family's money and items of value, such as Hesica's earrings were even stolen. So they had literally nothing more than hope at this point, and each other, I suppose. So when they arrived in Lewisburg, her dad took work in construction and her mom took work as a housekeeper for Lewisburg College. Hesika's condition continued to worsen. She developed pulmonary hypertension and was short of breath whenever she exerted herself. She was evaluated at Duke University Hospital, one of the country's leading transplant centers. In the spring of 2000, doctors there confirmed what the family already knew: that without a combined heart-lung transplant, she would not survive. But the family could not afford the$500,000 operation. They did not qualify for Medicaid given their status as illegal immigrants. Despite her undocumented status and lack of financial resources, Duke agreed to place her on the national transplant waiting list for a heart-lung transplant, which, of course, is a difficult and high-risk procedure. And it's actually performed fewer than 30 times per year in the United States.

SPEAKER_02 16:08

Oh my gosh. That just reminded me of the episode where you talked about, you know, how how many surgeries somebody needs to do to be considered a specialist. Does anyone know how to do this?

SPEAKER_00 16:30

And this is now 25 years ago. So like maybe it's gone up a little bit. But if you think about it like a dual heart-lung transplant, I can't imagine it's gone up much more. Right. Right?

SPEAKER_02 16:45

Oh my goodness.

SPEAKER_00 16:48

So Hesica was listed, but the wait would be long, and every day was a race against time. The family began raising money for the operation with the help of local churches and civic groups. For nearly three years, Hesica waited. Her condition worsened steadily, and she required constant oxygen and frequent hospitalizations. Despite all odds, seemingly against her, she still attended school when she could, learned English, and remained hopeful. Those who met her described her as gentle, polite, and unfailingly grateful. Throughout this entire time, her family continued to raise money for the operation while they lived simply in a trailer. Then, a forceful North Carolina businessman named Mac Mahoney, a Lewisburg home builder, read Jessica's Jessica's story in a newspaper and adopted her cause, befriending the family. He created a grassroots foundation to begin raising money by building houses with donated materials and then selling them. All the proceeds were to pay for the life-saving transplant. He became the family's advocate and spokesperson and served as a bridge between the Centelian family and institutions they didn't know how to navigate. He even spent tens of thousands of dollars of his own money for several of her heart operations in August of 2000. He established a nonprofit foundation called Hesica's Hope Chest to raise money and pay her medical bills.

SPEAKER_02 18:17

Oh wow.

SPEAKER_00 18:19

Right?

SPEAKER_02 18:19

Wow, my goodness.

The Fatal Blood Type Error Uncovered

Chart Note: How Blood Types Work

SPEAKER_00 18:21

Glad Mac bought a newspaper that day. On February 7th, 2003, nearly three years after Hesica was placed on the transplant list, the call finally came. Donor organs were available through the New England Organ Bank. This bank had run a search on the National Registry of Potential Recipients and found two patients eligible at Duke, Hesica being one of them. This was the kind of story that hospitals use in upbeat brochures and public relation efforts, but a simple, avoidable error turned it into a deadly nightmare. Hesika was rushed into surgery at Duke for what everyone believed would be the operation that would save her life. Surgeons transplanted the new heart and lungs into her body, but something went terribly wrong. Surgeon Dr. James Jagers almost completed the operation when he learned that the organs came from a donor with type A blood. He said that everything was going smoothly during the operation until five hours into it when he got a call from a technician in the immunology lab saying that something was terribly wrong. Hesica's blood type was O positive. These blood types are not compatible, and this incompatibility should have been caught long before surgery. Blood type matching is one of the most basic and essential safeguards in organ transplantation. Yet the error was unnoticed until late in the operation after the organs had already been implanted. Dr. Yeager's said, quote, we had already put in the new organs and we had actually come off the heart-lung machine, so off bypass. And we were planning to get ready to close the chest and move her up to the ICU. And it was about that point, about an hour, an hour and 15 minutes after we had put the organs in, that we got the call that this was an incompatible transplant. And we, of course, knew what that meant at that point. End quote. The organs functioned well for 30 to 40 minutes after she was taken off by pass, but their function deteriorated quickly and her immune system started attacking them. Dr. Yeegers admitted his mistake to the Santeans and Mac Mahoney one hour after the surgery. According to Mahoney, Yeegers said, quote, Duke didn't make the mistake, I did, end quote. And then he whipped. Dr. Yeager Said that he was devastated. It's almost like death and dying reaction. It's that deep sort of sinking feeling, and it's completely helpless feeling that there's absolutely nothing you can do about it. I think my exact words to the family were that there had been a problem and that the organs we put into Hesica were type A organs and she's type O, and that's incompatible. And it's something that we didn't plan to do. It's an error, and we're going to do everything we can to make it work, he said. Duke promised to correct the error by attempting to get a new heart and lung for Hesica. They placed her back on the organ donation list as soon as the hospital learned of the mistake, although her odds for receiving a second set of organs quickly enough were very low. Less than 30 people, as I had mentioned, receive heart-lung transplantations in the United States in 2002, leaving 200 on the waiting list. The hospital also requested that the family and Mahoney not say anything to the media about the medical error while they attempted to get new organs. Hesica would be kept on life support systems while the second transplant was sought. The family and Mahoney initially agreed to keep things quiet about the air, but Mahoney didn't feel as though Duke was doing enough to try and procure new organs, so he began talking to reporters in hopes that media attention would encourage people to donate organs and improve Hezekiah's chances for a second implant. He told reporters that Duke made a mistake and they were dragging their feet and correcting the mistake. Additionally, he told reporters that he was asked to stay quiet about the mistake. Duke's spoke people would neither confirm nor deny the allegations. 60 Minutes presenter Ed Bradley asked, quote, How did an operation performed by a team of expert surgeons go so wrong? What it came down to was a failure to communicate basic information. Not one of the more than a dozen people working at Duke Hospital and the two organizations responsible for getting the new heart and lungs to Hesika Stantian ever cross-checked her blood type before the surgery to see if it was a match with the blood type of the donor, end quote. But this is a good question. How did the operation performed by these experts go so wrong? Ralph Snyderman, Chancellor for the Health Affairs at Duke Hospital, had said at the time, quote, we take responsibility for our part in the error, end quote. He had said that what was missing was a system of redundant checks, which would have prevented a single mistake from leading to a tragedy. But before we get more into the meat and potatoes of this story, it's time for a chart note. I don't know if I have enough breath. Take it away. Get it, Alley Cat. Welcome to the chart note segment where we learn about what's happening in medicine and healthcare. Naturally, I wanted to cover blood types for the chart note today. Seemed fitting. So this may be review for some, others, one of those like, oh yeah, I remember learning that 100 years ago, or perhaps new information altogether. So wherever, whatever camp you sit in, here we go. Blood type compatibility is ultimately a story about recognition, about how the immune system decides what belongs in the body and what does not. Every red blood cell carries identifying markers on its surface called antigens. When blood enters the body, the immune system scans these markers. If it encounters an antigen it does not recognize as itself, it treats it as a threat and launches an attack. This is why blood matching types before transfusion or I don't know, organ transplantation is so critical. Incompatible blood can trigger a rapid and life-threatening immune reaction. In the end, blood types are less about labels and more about communication between the cells and the immune system. Compatibility means harmony, antigens and antibodies that coexist without conflict, while incompatibility sets off an internal alarm. Understanding these relationships has turned blood transfusion, organ donations, even this is talked about even for my pregnancy, from a once-deadly gamble into modern medicine's most reliable life-saving tools. And there was like a whole list I could have shared with you about this blood can go with this blood, but if you want to know that you can look it up. Luckily, the baby has the same blood as me. But yeah, but yeah, isn't that it's just crazy?

SPEAKER_02 25:39

It is crazy that that can happen in the same body.

SPEAKER_00 25:42

Mm-hmm. Yeah. I mean, it I mean, you think about it more of like, oh yeah, this should definitely be compatible. I'm getting new organs.

SPEAKER_02 25:50

Yeah. I mean, it's like a clerical error, but that it's like so huge. But I mean, the surgeons are thinking on the higher level, like, how are we gonna preserve this? How are we gonna do the surgery? Like, all this stuff. And this is this basic thing that should have had multiple checkpoints. You know, is this a viable organ? Well, how do we know you know the state of the organ, how you know how viable it is? What type of should have been on that check? There should have been a checklist.

SPEAKER_00 26:22

I mean, there's a lot of we'll get into that, yeah. And and I'm like, this is a new question, and it probably makes me sound not smart, but I'm not an organ surgeon, transplant surgeon. And Adam can probably hear me from the living room, so he probably knows the answer to the question. But if you're taking organs out of somebody else and they no longer have that person's blood running through them, why are they still like a positive organs if your blood's gonna run through them?

SPEAKER_02 26:54

I don't know, there must be remnants. I don't know, that's a good Adam question or maybe a question for Adam. Smart. Come here. What else? I don't think this is the surgeon's fault. I think this is the system's fault.

SPEAKER_00 27:06

Hi. I just want you to know we're alive. But I have a question for you. Okay, so organ transplantation. If you've heard any of the story, the gal that got these organs, the blood type did not match. So her body's rejecting the organs. But I pose, I think, a good question. If my organs were taken out and donated to someone else, so like my blood's no longer running through them, why does that matter for then the body that you go into? Because their blood's gonna be the one running through the organs. Is that a good question? Thank you. Can you hear him? He said yeah. Do you know why? No, he's also not a transplant surgeon, neither of us, but I just thought you might know. Yeah, that's a great question. Thank you for your first appearance on the pod, my friend.

SPEAKER_01 28:07

Love ya. Love me too. We love you, Adam.

SPEAKER_02 28:13

We love your stories. We don't want any more medical mishaps from you, though, because they're too good.

SPEAKER_00 28:18

Oh, there's more.

SPEAKER_02 28:19

No, we don't want any new ones.

System Failure Versus Individual Blame

SPEAKER_00 28:22

Because Amanda needs some peace and quiet in her life. I thought you were gonna say, because it's Amanda's turn for a medical mishap. I was like, no, no, no, no. It's not enough for both of you. Yeah, agree. Okay, well, uh back to the story.

SPEAKER_02 28:38

I mean, maybe we'll talk about this later, but I honestly feel like it's not the surgeon's fault.

SPEAKER_00 28:43

We are gonna talk about that. It's a system fault. I agree. Everybody's fault. A system's fault on more than one system. I don't think it's just Duke's fault either.

unknown 28:53

Right.

SPEAKER_00 28:53

But we'll get into that. So Duke took responsibility for the error and began emergency efforts to save Hesica's life. She was placed on life support, as I mentioned, and they worked with United Network for Organs Sharing, so UNOS, to urgently locate another compatible set of organs. We would later learn how soon the breakdown of communication started. Dr. Jaegers, I don't know if it's Jaegers or Jagers. Sorry, sir.

SPEAKER_02 29:22

Doesn't matter. Let's keep going with Jaegers.

SPEAKER_00 29:24

Okay. Oh, I've said both, so that's why I mentioned. Yeah.

SPEAKER_02 29:27

Oh, okay.

unknown 29:29

Okay.

SPEAKER_00 29:29

So he received a phone call in the middle of the night because he was the on-call heart transplant surgeon and he received the call from Carolina Donor Services, which was the local agency responsible for placing organs with compatible recipients. They informed him that they found a donor in Boston for a different patient of Dr. Jaeger. Dr. Jaegers knew that he couldn't use the organs for the patient that they had called about, but asked the agency if the heart and lungs would be appropriate for Hesica. Several hours later, he was informed that he could have the organs because they called another doctor from somewhere else and were like, hey, do you want these? And he was like, No, it doesn't fit. Too small for the body cavity, blah, blah, blah, whatever. So they called Dr. Yeagers back and, like, you can have them. So Carolina Donor Services stated that Dr. Yeagers was informed of the donor's blood type, but Dr. Jaegers says that he has no memory of them talking about it. He did not ask for any blood type information. He said because, quote, I had satisfied in my own mind that if they offered me the organs that she was a match, end quote.

SPEAKER_02 30:34

This is the second time?

SPEAKER_00 30:36

No, this is for the first. Oh. So for the incompatible organs.

SPEAKER_02 30:40

First time? Okay.

SPEAKER_00 30:42

So now we're learning like how quickly that breakdown.

SPEAKER_02 30:45

Okay. This is the history. Okay. I thought it was like, okay, it didn't work. So they need to go back. And then he for the second time he didn't ask. Okay, okay. All right.

SPEAKER_00 30:54

So there's no organ. Yeah, no. No, this is background. So Dr. Jaeger still agonizes over the conversation, sharing, quote, I'm ultimately responsible for this because I was Hesica's doctor and I arranged all of this. But honestly, I look back and yeah, if I'd made one more phone call or if I had told someone else to make a phone call or done something different, maybe it would have turned out differently. But you know, those are all 2020 hindsight, end quote. As soon as Dr. Jaegers had found out that the heart and lungs were available for Hesica, he had sent a member of the transplant team, Dr. Lynn, to get them in Boston. And while there, Dr. Lynn was informed of the donor's blood type at least three times. Incredibly, he had never been told of Hesica's blood type. So he didn't know the organs were a mismatch, and that was yet another flaw in the system. From the donor to the recipient, there must have been at least a dozen doctors and nurses from Duke who were involved. So why did not one of them see that the donor did not match the recipient? Or here's another question. Rather than testing the donor's blood type over and over again, waiting for a light bulb. Or I'm sorry, rather than like the Carolina people donor people were like saying over and over what the donor's blood type was, waiting for a light bulb to go off in someone's head, why didn't they just flat out say they believed it was a mismatch?

SPEAKER_02 32:14

I mean, did they? Or was this just like their protocol? We just keep saying, it's this type of whatever.

SPEAKER_00 32:21

I mean, from the resources that I read, it did not say that they specifically, it just said that they kept mentioning to Dr. Lynn, like, this person's blood type is this, this person's blood type is this.

SPEAKER_02 32:31

So they didn't feel safe. Were they trying to trigger a light bulb? Were they cognizant of the mismatch? Or were they just sort of like, okay, I'm reading about this patient, date of birth, blood type, whatever. Assuming that other people were looking into it. But like, obviously, no light bulb went off. Because honestly, if they knew it was a mismatch and they carried on, then the onus is on them. Yeah. I I that's what it felt like. Yeah. So many opportunities for better communication. Yeah.

SPEAKER_00 32:58

Thank you. And then then it feels a little like CYA where they're like, no, we told him on the phone. And then he's like, I don't remember that, but I remember everything else about the phone call. I'm not pointing fingers, I'm just saying more could have been done on both ends to prevent this from happening.

SPEAKER_02 33:14

And and his whole thing was, well, they're offering these organs. Obviously, they found out that she was a match.

SPEAKER_00 33:19

And also, I made a note, why did they not demand testing prior to releasing the organs then? Yeah. I don't think they knew. Because it seems like that's a standard protocol, other places. Yeah, because why would you call me if you had organs that weren't a match?

SPEAKER_02 33:33

Yeah.

SPEAKER_00 33:33

So that was because the initial part of the phone call said it has a match for two people at in your care or whatever, and mentioned the other patient's name first. And he was like, Oh no, that's not gonna work. But what about this other one? So I don't know.

SPEAKER_02 33:47

An extra special breakdown right there. I mean, there's a lot of opportunities for improvement in communication, but that was an extra special breakdown right there because that gave them pause to go, I don't know, let me look, instead of yeah, yeah, yeah, let's offload these.

SPEAKER_00 34:02

Yeah. Especially when there's so few in a year and still 200 people left on the wait list.

SPEAKER_02 34:07

Like, yeah, because it deprives somebody else of the viable organs.

Second Transplant, Brain Death, And Fallout

SPEAKER_00 34:12

Mm-hmm. What may be the most disturbing is that UNOS, the national organization that oversees Carolina Donor Services and the New England Organ Bank, already had firm policies in place that should have prevented what happened to Hesica. Their policy requires that blood types of the donors and recipients be matched before the release of organs. Lloyd Jordan, who owned and operated Carolina Donor Services at that time, admitted that the company did not ensure that there was a match. We could have requested her blood type, and I wish we had, but we did not do that, he said.

SPEAKER_02 34:46

So they were just hoping, like, okay, if we throw the blood type out there now, still check. Not just saying we haven't checked. Yeah.

SPEAKER_00 34:55

Oh my. We didn't check. Did you guys check? 200 other people on the wait list, but bug it.

SPEAKER_02 35:00

I can't believe this kind of thing happened.

SPEAKER_00 35:02

But I can. I kind of can.

SPEAKER_02 35:03

I know. Yeah.

SPEAKER_00 35:05

So against all odds, a second donor was found nearly two weeks later through Hesica's status, or the but her status was near death by this point. On February 20th, 2003, Hesica underwent a second heart-lung transplant. Her body appeared to tolerate the second set of organs. But while she was busy receiving the second set of organs, Mahoney, Mac Mahoney, was busy attempting to hold his own press conference in a university's auditorium. He was once again accusing Duke of trying to cover up a mistake and trying to keep him from talking to the media. Her family and Mahoney blamed Duke, saying if they had gone public immediately, another set of organs would have been found sooner. Which I'm like, I understand that line of thinking, but if there's only 30 in a year, probably not.

SPEAKER_02 35:57

But the cover-up is unsavory. Yes, absolutely.

SPEAKER_00 36:01

Mm-hmm. They let that baby lay on that bed in there for days before they managed to do something about it, and before they decided to fess up to what they had done, Mahoney said to CBS News. And in the meantime, all of her organs were ruined, and she's probably going to have brain damage. And you know, guess whose fault that's going to be? He went on to say.

SPEAKER_02 36:20

Oh, well, he's he's definitely passionate, but he's also sensationalizing it. Like, I don't know. I don't know how I feel yet.

SPEAKER_00 36:28

Yeah. The day after her second surgery, she developed brain swelling and intracranial bleeding. Duke spokespeople announced that she had suffered a severe and irreversible brain injury. She had, in fact, suffered severe and irreversible brain damage from the prolonged rejection, oxygen deprivation, and repeated surgeries causing severe complications. On February 22nd, at 1.25 p.m., Duke physicians determined that Hesica had died. Tests showed that she was brain dead and only being kept alive through life support. An electroencephalencephalogram indicated no brain activity, and a perfusion showed no blood flow to the brain, a perfusion scan. Duke physicians, along with three interpreters and a priest, broke the news to the family. By now, though, the family didn't trust the physicians, and her mother didn't believe that her daughter had died. The physicians explained to the family that without the medications and machines that were assisting her to breathe, that she would no longer be alive, that she was brain dead. In response, the family gave doctors a copy of a document that they had signed earlier, which stated that they did not want life support discontinued without their permission. Her mother accused the doctors of trying to murder her daughter. Through a translator at a press conference, she said that she believed, quote, they were taking her off the medicine little by little in order to kill her. They wanted to rid themselves of this problem, end quote. Which is just such a heartbreaking statement by a mama who I can understand why her mind would go there. A simple lapse in communication caused all of this, after all, and she's going through the grief cycles, understandably cycling between anger and denial. I can't imagine. But on the other hand, as someone who is a healthcare professional, I think, like, of course, this wasn't intentional. Certainly a tragic mistake that easily could have been avoided by my favorite communication. Come on, communication, you guys. But I don't think that it was ill-intended with the purpose of murdering anybody. But then I think about it further and I remind myself that we're hosting a medical true crime podcast. So I can't really say that either. But I don't believe that that is true for this case. So the doctors explained that the document applied only to patients in a coma or vegetative state and not to patients who were brain dead. And under North Carolina law, physicians do not have a legal obligation to continue treating a patient who has been declared brain dead.

SPEAKER_02 39:14

Oh my gosh, I didn't know. I didn't know there they differentiated that. I didn't either. Brain dead, then the doctor could pull the plug.

SPEAKER_00 39:24

Yeah, I didn't know that either.

SPEAKER_02 39:25

Oh my gosh. Wow.

Reforms, Media Scrutiny, And Legacy

SPEAKER_00 39:28

It was Dr. Eva Grake, an attending physician in the PICU, who turned off the machines. That was unquestionably the most difficult situation that I've been in, or painful situation. I wanted so badly to have something else to tell them, but I had to keep telling them, you know, she, this isn't a coma. This isn't a vegetative state. She's dead. We're so sorry, but she's dead, end quote. Hessica died at just 17 years old, and her funeral was four days later. Duke Hospital CEO William Fulkerson said, quote, the vast majority of the time when medical errors occur, they don't occur because people are bad. They occur because organizations haven't yet developed the kind of systems that we need to be able to catch errors and prevent errors. Medicine is a very human endeavor, and humans are fallible, end quote. Duke Hospital went on to put steps into place to prevent such a tragedy from happening ever again. Everyone directly involved in the organ transplant process is now required to check and double check the blood type of an organ donor and recipient before a transplant ever takes place. Dr. Fulkerson said that in regard to the impact, this air. Had on Hesica's family, quote, I can understand their sadness and their despair about all this. And I think that all of us have a really tragic sense about loss about this, of loss about this. But I'm confident that we did everything we possibly could for Hesica. We acknowledged that an error was made. We did everything we could to save her, to get her new organs, to treat her medically. And as tragic as that is, sometimes things don't go the way we want them to. A couple weeks after her death, CBS investigative program 60 Minutes broadcast an episode titled Anatomy of a Mistake, which detailed the simple error that killed Hesica and fun fact was a large resource for this episode. Not the video. I couldn't find the video, but I had a transcript. Her case also made headlines in the New York Times Sunday magazine, with the headline reading half of what doctors know is wrong, and devoted the issue to exploring medicine and its myths. It was a bad time for American medicine in the media, and ironically also came during annual Patient Safety Week. Hmm, dun dun dun. Both of these media coverages reached millions on the same day, focusing public attention on the related problems of medical errors, transplant mistakes, and malpractice messes. Only four days later, the New England Journal of Medicine published a damning perspective article about Hesica's case entitled A Death at Duke. It said, quote, when a medical mistake receives this much attention, it affects the medical profession and even public policy, end quote. Her death sparked national outrage, and the case became a symbol of preventable medical error. Not a failure of technology, but a failure of systems, communication, and accountability. Duke did publicly acknowledge responsibility, calling the mistake unacceptable. Hospital leadership promised reforms, including multiple independent blood type verification checks before transplant surgeries. And the transplant community nationwide reviewed their protocols in response to Hesica's death. Privately, Duke reached a financial settlement with the Santean family. The terms were never fully disclosed, but the hospital also established a perpetual charitable fund in Hesica's name to support pediatric care and patient safety initiatives. No criminal charges were ever filed, and no individual physician was publicly disciplined, though internal reviews were conducted. A very obvious lesson that was hopefully learned by Duke and its staff is that it is very important to strive for honesty and candor when communicating with patients about medical mistakes. Medical mistakes can destroy the trust that patients and families have in providers and organizations. If patients and families suspect that a provider or the organization is attempting a cover-up, they may become understandably distrustful and vindictive. Dr. Yeagers, to his credit, did admit his mistakes soon after it happened, showing a great deal of candor and integrity. The same could not be said of the Duke Medical Center, you know, with them telling people to keep their mouth shut. In the years that followed, Hesica's hope chest continued to exist, raising money in her name. As the funds grew, Mahoney said that the remaining money would be used to help other sick children. Later investigations by journalists raised questions about the nonprofit's financial transparency and how funds were distributed. Over a 10-year period before and after her death, the charity brought in more than 450,000 in donations and revenue from home sales. Tax records show that the charity gave about 100,000 in assistance to families, and another 83,000 went to grants and allocations, but there's no explanation given on what those things were. Multiple board members for Hesica's Hope Chest said that they were never allowed to see any financial statements. So this financial discovery prior to Hesica's Hope Chest eventually dissolving, it's no longer a thing, added a complicated and controversial postscript to Hesica's story. But what remained undisputed, however, was that her life and death had changed transplant medicine. Hesika Santian came to the United States seeking a miracle, and instead she became a warning. Her story exposed how vulnerable patients, especially immigrants, children, and the poor, can fall through the cracks of even the most advanced medical systems. Today her name is still taught in ethics courses and patient safety discussions. Her story is a reminder that in medicine, the simplest of mistakes can carry the heaviest of costs. Her story, as tragic as it is, can teach us important lessons about patient safety, medical fallibility, honesty, and trust.

SPEAKER_02 45:40

Wow. Well, first of all, thank you for an excellent rendering of this case and for bringing this up. It's definitely important. And I'm probably gonna say something that's super unpopular, but the thought came to mind no one, no good deed goes unpunished, right? We have an undocumented immigrant, and the Duke Medical Center decided, well, we can't turn this person away. We need to take them on in all good faith. I don't think that, like you said, that they had any criminal or nefarious intent. And by the way, yes, we are a true crime in healthcare podcast, but I think we're bringing to light issues in healthcare, whether they were intentionally criminal or not. And this is this is a really, really good one. So she may have actually lived longer just because she was able to come to the states and be treated here. And I'm not saying that's satisfactory. I'm not saying that's a win. I'm just saying, you know, what are the odds that she was the one who had to pay the price for the systemic failures here? And I don't think it was Duke. I think this could have happened at Johns Hopkins or Mayo, any of the other big organizations, which is why her death is not in vain. I think her death has led to realization of the checklist, the constant communication, the things that you cannot assume that are important and vital in every of these cases. So her death wasn't in vain. It's definitely a tragedy. The charity that was uh raised in her honor to be suspect and and um not transparent, that's disgusting. I mean, nobody deserves that in a life. Yeah. I hope that that isn't true. I hope that people benefited from the fundraising, but ugh, I hate to see that. But I do understand that systemic, that unintentional errors are part of what we need to embrace as a culture of safety so that we can get better. And it's like so we need a culture of safety where we encourage learning from these system failures so that everybody takes a part, not just not just the physician, not just the nurse, not just Duke, but like organ transplant companies and everybody in general, like wow, unfortunately, this major error happened, and all of us had a part in that. So, how can we make it better? So rather than punitive, like learning how to recreate a system that works, and that's the only way we get better. But also, I'm so sad that Jessica didn't make it. She was 17. I mean, I feel like she lived a lot longer than she might have with that sort of abnormality in her heart. Right.

SPEAKER_00 48:41

And if anything, they lived with hope during that time, yeah, which they didn't have before they went to North Carolina. Yeah. I mean, they knew it was a dead end just waiting to happen before they went there.

SPEAKER_02 48:54

Still tragic that it didn't work out, but I feel bad not only for the family and obviously Jessica herself, but feel bad for the surgeon because you know he's trying he's he tried to do his best to take ownership, and I'm sure that he felt really culpable, but honestly, it was bigger than it feels like he really took that on personally.

SPEAKER_00 49:14

Yeah. It was bigger than him. And I agree with his statement of if a donor bank called me and offered me organs, I'm gonna assume they're a match.

SPEAKER_03 49:25

Yeah.

SPEAKER_00 49:26

Could they have had that conversation? Sure. Hindsight 2020. But like, why are you calling me about organs if it's not even viable?

SPEAKER_02 49:35

Yeah. Oh, fascinating case. Thank you. Thank you, Amanda, for bringing that up.

SPEAKER_00 49:42

You're welcome. All right. So for our second and last sponsor of the day, I think it's gonna have to be our last mention of Molly Bees because of the aforementioned New Year, New You Goals with sponsor number one. But so for the last time to round out 2026, Molly Bees.

SPEAKER_02 50:02

Unless you get everybody else eating cookies so you can look.

SPEAKER_00 50:07

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SPEAKER_02 51:15

Stay suspicious. Shushus. Is it time for a medical mishap? Tis time. Do we sing? Do we sing these?

SPEAKER_00 51:26

I don't know. I'm so out of breath. I ain't singing anything.

Medical Mishap: The Monitor Was Right

SPEAKER_02 51:30

All right. Well, I'm gonna shall I read this one? Sure. Okay, so the subject line is the monitor was right even when everyone else was wrong. Uh-oh. And it starts. Hi, Jenna and Amanda. I work nights at a big hospital system and oftentimes listen to podcasts on the night shift to help pass time. I'm a telemetry tech, and this is a story I've never shared publicly. Mostly because for a long time I wasn't sure anyone would believe me, but also hip hop. Uh-oh. Rest assured, this story is complain. Oh, good. Oh my god. I was like, are we gonna so at work I sit in a windowless room watching dozens of heart rhythms at once? Most ships are quiet in the way only constant vigilance can be. That sounds really hard. Alarms go off, nurses respond, things settle, but one night something didn't settle. I was watching a patient admitted for quote generalized weakness, unquote. Nothing cardiac, no chest pain, no history that screamed danger. The rhythm had been steady all evening. Sinus, a little slow, but nothing alarming. Around 2 40 in the morning, I noticed a change. It was subtle at first. The rhythm looked off. There were slight pauses and then a longer one. The monitor flagged it as an artifact, but my gut said it wasn't. So I called the floor. The nurse told me the patient was sleeping and she just checked on them, and the vitals are fine. She said she'd keep an eye on it. Five minutes later, the pauses were even longer. The rhythm slipped into something that made my stomach drop, so I called again and I was firm this time. I said, check the patient. I wrote that more aggressively than it was in real life, but that's how I wanted to come through the phone. I mean, it was all in chatty caps. They look fine, I was told. We'll check when we can. At 2 58 a.m., the line went flat. I froze for half a second, then hit the code button and called the unit again, my voice shaking as I said, they're in a systole. This is not an artifact. The code came around fast too fast for how long that flat line had already been there. The patient was pulseless when they reached the room. They got them back barely. Later, after ICU transfer and paperwork and silence, our physician came down to telemetry. He stood behind me watching the playback. That was an artifact and said quietly. No one ever blamed me, but no one ever apologized either. The nurse said she'd followed protocol. The monitor had slid it in correctly. Everyone did what they were supposed to do, except the patient's heart didn't care about protocols. I think about that night a lot, about how the quietest person in the hospital can see the loudest warning signs, about how technology can be right and still ignored, about how close we came to a very different ending.

SPEAKER_00 54:42

I didn't mean to laugh, but my dog just farted so loud on the floor. And if for some reason my microphone picked that up, I swear.

SPEAKER_02 54:52

I'm so sorry. I was like, this is a poignant moment, and you're laughing your ass up.

SPEAKER_00 54:56

I know, I'm so sorry, but if she's even sitting up now, she's like, What?

SPEAKER_02 55:02

Whoo, sister. Oh my god. Raven, you're farting at an inappropriate moment. All right, breathe through your mouth. Breathe through your mouth. All right, so back to the email. The patient survived, thank God, but with significant complications. I don't know what their life looks like now. I just know that every time someone calls telemetry, just a monitor watcher, I remember that flat line and how close it came to being permanent. Thank you for giving space to the stories that happen behind the scenes, the ones no one sees but everyone depends on. Andy. Oh my gosh, Andy. Oh my gosh. Well, it seems to me that people have belittled your significant contribution to maintaining life. So God bless you and carry on doing the work that you're doing.

SPEAKER_00 55:49

If your position wasn't important, it wouldn't exist. Exactly.

SPEAKER_02 55:54

Oh my goodness. And thank you so much for writing in about your story.

SPEAKER_00 55:57

And I'm so sorry I interrupted with a dog fart.

SPEAKER_02 56:01

I mean, we needed a moment of levity, I suppose. Raven, you need your timing, needs a little work.

Next Week Teaser And Calls To Action

SPEAKER_00 56:09

She just stumbled out of here. Uh Adam, she needs to go. But yes, and what a perfect story for this case, also. It's like, well, we followed the protocol. It's like, okay, but sometimes your brains can be. We gotta communicate. So, Jenna, what can we expect to hear next week?

SPEAKER_02 56:34

Well, next week we're going to talk about toxic skincare products. Ooh. Yeah. So you're gonna be shocked. I you're gonna I was so shocked. You're gonna be shocked. So it's a really good episode. I've dug really deep into the research and I can't wait to talk about it. But until then, don't miss a beat. Subscribe or follow Doctoring the Truth wherever you enjoy your podcasts for stories that shock, intrigue, and educate. Trust, after all, is a delicate thing. You can text us directly on our website at Doctoringthe Truth at Buzzsprout.com or email us your own story ideas and comments at Doctoringthe Truth at Gmail. And we do take your story ideas and and run with them. So keep them coming. Be sure to follow us on Instagram at Doctoring the Truth Podcast and on Facebook at Doctoring the Truth. We're on TikTok at Doctoring the Truth and ed oddpod e-d-a-ud. Don't forget to download, rate, and review so we can be sure to bring you more content next week. But until then, listeners, stay safe and stay suspicious.

SPEAKER_00 57:45

Please stay suspicious. Please suspicious.

Signoff And Closing Chatter

SPEAKER_02 57:51

So so suspicious. Yeah, you can go to TikTok and search your personal 2025 exit song and it gives you a song. It's so funny.

SPEAKER_00 58:05

I would be curious what the ed odd pods one is. Because I this is very daunting music on there.

SPEAKER_02 58:10

I know. Let's look at what Ed Odd Pods exit song is. But until then. Just search Exit Song. Oh. Exit song. Okay, I'll do that. 2025 Exit Song.

SPEAKER_00 58:24

Okay, goodbye. That's the exit song. No, I was saying goodbye to you. I'm saying goodbye to everybody. Oh! Oh, okay. Bye.

unknown 58:34

All right.

SPEAKER_00 58:34

Are we gonna stop recording? Three. Okay.

SPEAKER_02 58:37

One, a two, a bottle.