The Evolution of Organ Transplantation with Linda Ohler

Dr. Samra sits down with Linda Ohler. Having had an illustrious career which started in the 1960s, and she doesnt show any sign of slowing down. Linda is currently working on another book. She is a nurse, a leader, an author, a mentor and a life long learner and educator. 

She discusses how she has dedicated her life to Transplantation, and it will always be a part of her identity. Starting as a nurse coordinator in heart transplantation, to becoming an author and educator starting with writing a book called Transplantation nursing secrets followed by the core curriculum for bedside nurses. She has lectured nationally and internationally in 10 countries. She shares what ISHLT(International society of heart and lung transplant), NATCO (North american transplant coorindators organization) and AST(american society of transplantation) are. Groups like this have really helped transplant professionals learn form one another 

In 1971 there was a life magazine article that showed 7 heart transplanta patients die and it was in the 1980s that we began to get better immunsouporewison , liek cyclosporine. 

The evolution of the multisdisciplinary team. 

She is now writing a book about >200 transplant professionals and looking at the evolution of each organ system in transplant. 

They talk about who a donor is, brain death and circulatory death and the laws around this. 

They talk about donor care units where brain death patients may need further work up before donation is consented to and alloccated it. They are staffed by ICU clinicians that could be from the hospital or the OPO (organ procurement organizations). The US non- profit organizations responsible for recovering organs for transplantation were established as a national network following the National Organ Transplant Act of 1984. When the National Organ Transplant Act (NOTA) was signed into law in 1984 it created the National Organ Procurement and Transplant. 

They talk about the applications of AI in transplant and concerns such as accuracy and how important it is to keep the human in the loop. They talk about xenotransplantation being part of the future of Transplantation and past successes. 

At the conclusion, Linda states that patients should become familiar with the SRTR so that they know how the transplant programs they are being evaluated at, listed and transplanted at are performing. 

https://srtr.hrsa.gov/

https://orcid.org/0000-0003-2360-7078

Please note this is not medical advice. It is meant for entertainment purposes only. 

Transcript

SPEAKER_00 0:00

Hello everyone. Welcome back to another episode of Totally Transplant. This is your host, Manfreet Samra. We have a very special guest with us today. Someone I have closely worked with, Linda Ohler. She continues to have a phenomenal and illustrious career. And um without further ado, um, Linda, if you could introduce yourself to the audience. Thank you, Memphis.

SPEAKER_01 0:26

I am Linda Ohler, and I have worked in transplantation basically since 1987. And it started, I was teaching at that time. I was teaching at Catholic University in Washington, DC, and two of my students, I was teaching cardiovascular nursing, and two of my students were in transplant, and they wrote their final paper on the care of heart transplant patients. And I got so intrigued by that that I set up time with each one of them to talk to them about what they were doing. And the one was going to be leaving her job because it was summer and her husband was a surgical fellow and he had taken a position up in Boston. So she was going to be leaving. So she said, Why don't you at least do the summer? Take the summer and cover for me while they find someone to replace me. Well, I went in and I worked for the summer and I fell in love with the patients. I had so much fun with the patients. They knew I was a vegetarian, so one used to bring his cup grass to me every day in a paper bag and say, Here, I made lunch for you. Just teasing me. And they had a little sign up, uh bulletin board with a cartoon that said, Since you're a vegetarian, we're going to give you an artichill card. And it was just so cute. And I just fell in love with these patients, and they hadn't found anybody yet. So I resigned my faculty position and I started in transplant in 1988 and I have I haven't left. I mean, I thought it was an addiction. I kept saying to people, I think I'm addicted to it, but when in fact I think it is my identity now. It really can be dangerous to have your identity be your job. But we work at it such long hours and weekends and evenings and that oh, it's we put so much into this, and I have put so much into it. I got involved after working in the clinic and going in the middle of the night, because as heart coordinators, we used to have to go in in the 80s and early 90s. We used to have to go in to help set up for the patient to be transplanted. So the family would come in. Not all of the patients were in the hospital at that time, because this was, you know, in the late 80s. So usually it was just the patients that were on medications or in the ICU that got transplanted, but occasionally those from home. And then we'd have to go in to be with them and be with the family and the OR and get everything all set up for it. So I would put in many hours, and there were times when I'd get home at eight o'clock at night and have to go back in because we were doing a transplant at 11. So you just put everything into it and it just became really special to me. And then they have a certification, I guess, exam for nurses, and I decided to take it, but I didn't know what it would be like, so I contacted them and asked them to send me a little information on how to prepare for the exam. And they sent it to me, and it was all about the kidney. And I went, I'm a heart coordinator, you sent me the wrong thing. And they went, No, you have to take it. It's on all organs. Well, I didn't know that. So this was in 1990, 1991. And so I set up a group here in Washington, D.C., where I had liver coordinator, heart coordinator, lung coordinate there, it wasn't lung at the time. We had just started lung, so that wasn't on the exam yet. And so I had coordinators from the different organs, and we met every month and prepared people for the exam because there was no other way to study for it. It was then that I decided it needed a book. So a colleague and I wrote a book called Transplantation Nursing Secrets, and that's what nurses began using to study with. But that was more for coordinators. So then we did one called the Core Curriculum, and that went the core curriculum went for the bedside nurse to allow that person to become certified. So, and now we're doing second editions of of each of these books. So yeah, that's kept me pretty busy over the years. But you can see where getting involved, getting involved in AST, getting involved in ISHLT, getting involved in NATCO, all of those things get you so involved nationally and internationally, so that I've actually lectured in ten countries. Yeah, including India, Russia, Japan, in Brazil. I've done five in Brazil alone.

SPEAKER_00 5:26

For those that don't know, could you share what AST, ISHLT, and NATCO is? Oh, thank you.

SPEAKER_01 5:32

This was really important part of the evolution of transplantation was the development of groups such as the International Society for Heart Transplant. Initially it wasn't ISHLT, it was International Society of Heart Transplantation. And then once we got lungs in the mid-1990s, I think it changed its name to the International Society for Heart and Lung Transplantation. The American Society of Transplantation started out as the American Society of Transplant Physicians and then changed their name just to the American Society of Transplantation so that nurses and pharmacists and all could become part of that. Because we were becoming more than just, I mean, when we started transplantation, we actually started with just the critical care nurse and the the surgeon because the patients in the 1960s weren't being discharged from the hospital until the 1970s. And well, the kidneys were, but the hearts and livers weren't. So we became critical care nurses and surgeons. But no one had any way of learning from each other except by picking up the phone. So they started phoning, started developing these associations. So associations such as the International Society for Heart and Lung Transplant, the American Society for Transplantation, American Society for Transplant Surgeons, North American Transplant Coordinators Organization, International Transplant, all of these groups have gotten together and you have annual meetings and you learn so much from each other at these meetings. So these societies have been wonderful for us to learn from each other and learn from research, you know, the research that's presented. So that's been excellent too. Thank you for describing this. Thanks for suggesting that. It was a good idea. So now we're up to the 1990s and going into the 2000s. We started seeing better in 1971. There was a Life magazine that had a picture of six patients who had died after heart transplant, and it said it was something about the terrible outcomes in heart transplant. And it was very, very negative. And it was after that in the 1980s that we started getting more immunosuppression. Because at that point, in the 60s and 70s, all we had was immuran and steroids. And so once we started getting more drugs like cyclosporine 1983, 1984, I think it was the late part of 1983, I think November or December, 1984, that we came up with cyclosporine, that really helped. And then you started seeing this increase in transplantation, organ transplantation throughout the United States. So once we started getting those drugs, it was better. And then we started seeing the evolution of the multidisciplinary team. The drugs became so complex that we now needed a pharmacist on every team because we had drug-drug interaction, we had food-drug interactions. So we had all of all of these different um issues that we had to deal with. And the pharmacist, we have really gone above and beyond with these pharmacists. They are wonderful. They now have fellowships that they do in their PGY too, and they can specify that they want to be in transplant. And then they come out and they now have a certification process also for pharmacists. The social workers have a certification process. The dietitians have a certification process. Nurses, physicians have your board certifications. So we're all becoming so deeply involved in transplantation that I think we all have the potential for doing what I did. And that's where my identity is now transplant. And it's hard to see me as anything but that, Linda Oler. So as a wife, as a mom, I have to really focus on those things sometimes because I'm so involved in transplant. And getting involved in those societies adds to it as well. And like I said, the international society, international, and when you have an ATC meeting, the American Transplant Congress between ASTS and AST, you have thousands of people from all over the world getting together. It just makes it exuberant. You could become so involved, not only locally, nationally, but now internationally, and it's just wonderful. So those are the things that led me to being so occupied and loving what I do, and I do love what I do. It's really exciting. And now I'm doing a lot of writing about it as well. And I've interviewed over 200 people, 200 physicians, nurses, the whole multidisciplinary team. And I'm looking at the evolution of the history of transplantation, the evolution, each organ system I'm looking at with the interviews that I've done. So it's been really exciting to be a part of that. But now we have found that some of the potential donors may be in hospitals that don't have the equipment or the staff to manage a donor.

SPEAKER_00 11:02

Before we go into that, can you share more about what a donor is and how important a donor is in the life of a recipient?

SPEAKER_01 11:10

Sure. Potential donor is one who usually is brain death is the number one thing. And there was no definition of brain death back in the early 1960s and 70s. As a matter of fact, one of the surgeons from Richmond, Virginia, Dr. Lauer, he actually was charged with killing a patient because he took the heart from that patient. So he was charged with murder because there were no brain death laws in the state of Virginia back in the 1960s. He was exonerated after two years of courts and all of that. But he was finally exonerated and he never did go to jail for that. But I he's one of the people I interviewed, and he talked about the fact that the court was right across the street from the hospital, so he would be doing surgery and then he'd have to go in and testify and then come back. But the people from Harvard Law Ethics came down and actually supported him. So there weren't any brain death laws at that time, but now there are. We've got these brain death laws. And patients would be brain death, and you have to take those organs from them. And it becomes a real challenge for the family. We have to support the family during that process. And then they say yes to each organ, whatever organ they want to donate. And there are some great stories that go along with that. Another thing that we've learned to do is after cardiac death or circulatory death, we can take certain organs. It's still being worked on. There's still some learning going on with that. The kidney and the liver have been more popular to be able more accessible than the heart and the lungs. It's been harder to do the heart and lungs, but we're getting there and we're doing some. But the problem is if the heart is in one state and the donor is in another state, how do you get that heart or those lungs to that donor within a prescribed amount of time? We like it to be four hours or less to get into the recipient. So we have things we we cool them off and keep them cold and in ice and get them back and forth. The heart people and the lung people usually stay with the donor from the time you might pick it up in Missouri and take it to New York or take it to Washington, D.C. So you have to look at your time element as well. But what has happened now is we're finding that there's hospitals, we're losing some donors, some potential donors, because maybe there's not enough staff, maybe they don't have the equipment, such as an MRI or a CT. They don't have the equipment in some of the smaller outlying hospitals. So we have been working with our organ procurement colleagues, and we have developed agreements with them, and they have helped find the a particular center, such as NYU, such as University of Pennsylvania, where they actually now have a donor care unit. And these donor care units, the patient is determined to be brain deaf at one hospital, at a smaller hospital, let's say, but needs more, needs a cardiac cath, needs things that they may not have the capacity to do at this other hospital. So the organ procurement people ask the family to if we can transfer the patient to a donor care center, and they give permission to do that, and then the patient is taken over to this donor care, the one closest to them. So they take it to, let's say, Penn, or they take it to NYU. Those are the two that I know the best. So what then happens is they get to that hospital, but that doesn't mean that the organs are going to go to that hospital. The staff takes care of that patient, they do the biopsies, they do anything that's required, they do the MRIs, they do all the testing to ensure that each organ that they're going to donate is going to be in good condition. But in doing so, they have to get consent from the family for each organ, and they have to then say, yes, we took care of this patient, but the organs are going to, let's say NYU is going to up to their competition to Columbia University or to Mount Sinai. But that's okay because that's the deal. You know that this donor center is taking care of this patient, but those organs may not, not one of them may stay at NYU or stay at the University of Pennsylvania. They go to wherever they were allocated. So that still goes through the allocation process at UNOS.

SPEAKER_00 16:00

Yes. So who takes care of these donor care units?

SPEAKER_01 16:04

Well, a lot of it are OPO people will actually be there or they'll do the training of some of the nurses. Some of them are ICUs. Some of them have a completely separate ICU that the donor is taken care of in, and the staff is from the OPO, maybe, or OPO and hospital staff taking care of these patients. So you have a collaborative working group that is trained especially for the care of a donor. Whether it's your what an OPO is. I'm sorry. An OPO is an organ procurement organization. The organ procurement organization came out of 1986. That with the NOTA, it was a bill from Washington, D.C. And this bill said that we now had organ procurement organizations, and they make a determination of where, based on what you know, so the United Network for Organ Sharing, the United Network for Organ Sharing determines where an organ would go based on blood type. It's different for each organ as to what the requirements are. So the OPO and a transplant center, such as Penn, University of Pennsylvania or NLIU, have a an agreement to work together at this intensive care unit and they take care of the patient. They already know where the organs are going to go. So they then send them up to those places. It doesn't necessarily mean that because you put all this work into that patient that you're going to get any organs from that patient. They're going to go where the computer determined at UNOS.

SPEAKER_00 17:45

Fascinating. And with these donor care units, do we know if there's a higher transplant rate and a lower organ discard rate when compared to marginal smaller hospitals?

SPEAKER_01 17:58

It's only been in the past two years. So I'm not sure we have all of that data yet. But that was the reason for doing this is because we were losing organs because we couldn't get the testing done on them and they didn't have the staff to take care of them. So by having these donor care units, now these major transplant centers or major hospitals, it doesn't have to be a transplant center, just big hospitals with all of these, this equipment and staff can help with this and make sure that we aren't going to be losing organs because we were. We had so many discarded organs. We're trying to decrease that num that volume of discarded organs so that we can now preserve the hearts and get them into someone who needs it or a kidney into someone who needed it and not lose them because we don't have the staff to take care of it or the equipment to determine whether it's healthy enough to go into someone else. I know, but it's only been two or three years that most of these are developed, and I they're still opening these. I think the one at NYU just opened recently too. So and Penn also I've been had the opportunity to been through on a tour of the one at Penn. It was great. It was really fascinating to see the staff and how dedicated they were and the OPO staff there and how well they work together.

SPEAKER_00 19:25

Yes. It highlights again that collaboration that that we come to every day in transplant, whether it's OPOs and transplant centers collaborating together, whether it's the multidisciplinary teams collaborating together and all with the same aim to transplant patients. Yes.

SPEAKER_01 19:44

The multidisciplinary teams are perfect for showing how well people can work together, collaborating, because when you're a surgeon, you don't necessarily know the psychosocial aspects. You want to know them, but the social worker is going to be able to drill down and get that information with the education that person has had. And the um pharmacists, oh my God, do we love our pharmacists? I find them to be so amazing because they understand that drug drug, that drug food interactions, and they work with the dietitian on that, or they work with the surgeon on that, or they work with the physician on determining what's best for this patient. So when you're on rounds with this multidisciplinary team, that's exactly what you have. You have collaboration all the way around. Everybody's just working together as a team to do the best for this patient.

SPEAKER_00 20:41

Yes, that's amazing. Well, we're going to be looking out for those, and it'll be interesting to see as they continue to develop because we clearly need them.

SPEAKER_01 20:48

We too definitely need them. But I think right now I'm really concerned about our pharmacists because they're super busy. And I've had a couple of manuscripts sent to me and had a hard time finding a pharmacist to review them because they're so busy. So that concerns me how busy we're keeping them at this particular time too. We s when I started at NYU, we had just two pharmacists, one for the thoracic team, one for the abdominal team. And now we have one for each organ.

SPEAKER_00 21:19

Right.

SPEAKER_01 21:20

Yeah, you really do need them.

SPEAKER_00 21:22

They're such a vital part of the team. They really are. They really are. So along those lines, Linda, where do you think the future of transplantation is going?

SPEAKER_01 21:33

Well, that's interesting. I think for sure AI is getting into it. As we were talking before we started here today, about two or three years ago, I read something at Mayo Clinic about applications of AI to transplant. And it was hard. And of course, that's what my background is. That's where my degree is, is in cardiovascular nursing. So I contacted the author of that article and asked about. If he would be willing to do an educational program with AST. And he was delighted to do that. So I started looking up in PubMed to see if others were doing this. And I found it. And so I found five different physicians, starting with Doris Segev at NYU, and going to each one and having them present applications of AI. So I think we're going to see a lot more help from AI because it's gotten so complex that you really need machine learning to help us figure all of this out, to go through all of these articles. Like I said, I found five of them, but there were a lot more. And it would have been wonderful if I could have figured out how to use AI at the time, but I'm just still learning with ChatGPT and Claude and all of these groups that how to use them. I was in a meeting recently, and I had called the meeting with the International Transplant Nurses Group Society, ITNS. We're working on patient education books. We're updating those patient education books. And I must have hit something to record it in AI. And I didn't even realize I had. But on now I'm learning how to do that. Because we got the minutes, like 10 minutes after we finished the meeting, outcomes these minutes. And it was so accurate. It was unbelievable. I sent it around to everybody on the committee, and they're all just astounded. So I think that's going to be a real asset to us. I'm concerned about it too, but I've got my concerns. But I'm also learning more about it and learning the applications. And that was the title of this series that we did through the American Society of Transplantation. And we had over a hundred people almost on most of those educational programs sign in because people were just really curious. What can AI do for me? Most of them were about pathology. One was about the patient, uh, what is it called? The meeting in the morning where you're deciding whether somebody goes on the list of patients collection. One of the speakers was speaking how AI could be applied to that as well. So I think there's some opportunities there. I think xenotransplantation may be on our future too. We've done a couple. They're still not perfected, but it's something worth looking at. I like that people are working on it without getting terribly discouraged, but there's three or four centers in the United States that are still working on that. And I wish them well. I know we have actually transplanted at least one kidney into a woman that was a kidney from a genetically modified pig. She did pretty well, but ended up losing it long term. So I don't have an answer for that yet, but I'm glad people are trying to look at that because there aren't enough organs to go around. And that's why we're using the donor care centers to try to get more organs. We're trying to look at animals. I mean, I have an article from 1673 where they were looking at how to transplant something from an animal into a human. From 1673, from the Royal Society of of Surgeons in England. It's really interesting to see that they were trying back then to do that. So we've been trying to do this for over 400 years. Basically, yes. Basically, we're trying to find more organs for people because it does work. We are seeing now. I have several of my heart patients that are in the 30, 31, 32, 33, 35 years post-heart transplant. So that's exciting. And some of the lung patients are going longer now, too. They were the hardest. Uh, lung transplant and intestinal transplants are two of the toughest ones to keep because they have so many infection problems. Breathing in the air.

SPEAKER_00 26:17

You had said that you have some concerns about AI. Can you share what those are?

SPEAKER_01 26:22

Accuracy is number one. A machine looking at a research project and analyzing it concerns me. Do they have all of the data? Have they looked at it properly? I I just worry about that. I think humans have a better way of doing that. It takes longer. And I think we have to be careful that this shortened time that we can get information from a machine, I just hope the accuracy, that's my biggest concern right now, is the accuracy. I think the applications are so broad. We're so fortunate to be able to make these applications, but I need to know that this accuracy is.

SPEAKER_00 27:08

I think that is so important that if and as AI um is integrated within transplant, there always has to be a human in the loop. I agree. I think so too. That really concerned me. But thank you so much, Linda, for today's interview. Thank you for having me. This has been so wonderful. Um are there any parting words or advice that you'd have for patients? For patients?

SPEAKER_01 27:38

Yes. What I always like is that patients teach them, make sure they know how to use the SRTR so that they can go in and determine where they want to get their transplant. And your hospital will teach you how to do that. Going to your pre-transplant coordinator or your nephrologist or your cardiologist, and they can help you understand how to go into the SRTR and look up the different hospitals and their outcomes, because that's important to know how many are they doing in a year and what are their outcomes. I think those are two things that I would tell a patient. Thank you.

SPEAKER_00 28:22

And thank you all.