Dr Prisca Bradshaw
Physician, Anaesthesia and Intensive Care, San Fernando General Hospital, Trinidad and Tobago, W.I.
My first exposure to organ donation and transplantation in Trinidad and Tobago occurred as a junior doctor. I was a house officer in the Department of Anaesthetics and Intensive Care and a team from the National Organ Transplant Unit (NOTU) gave a lecture at our monthly department meeting. I had to admit that I was not sold on this idea of transplantation at the time. It seemed like a dressing on an infected wound that would only continue to fester and worsen. I felt that we should focus on preventing patients from progressing to end-stage organ failure rather than focussing on such a cumbersome process.
It was the year 2010 and this negative opinion towards transplantation was not to be tolerated for much longer. The universe was keen on presenting opportunities to me to further expand my knowledge on organ donation and transplantation. A senior colleague, unable to attend a local training programme called “Champions of Transplant”, asked if I was interested in participating in the course. I obliged and spent 5 days learning about organ donation and transplantation. The course, facilitated by NOTU and the One Legacy team from the USA, was attended by physicians and nurses from the major hospitals in Trinidad and Tobago in the various medical fields. I enjoyed the course and was persuaded that organ transplantation was a necessity. For me, it was back to the regularly scheduled programme.
The following year, the staff from NOTU contacted my hospital’s management about a site visit with a consultancy team from Barcelona, Spain. The Donation and Transplantation Institute (DTI) was collaborating with the Ministry of Health, NOTU, the Pan-American Health Organization (PAHO) and Repsol Foundation to establish a deceased organ donation programme and improve the living kidney donor programme. As the lone doctor from my hospital who attended the course, I was invited to join the discussions. I guided the team through the Emergency Department, the Intensive Care Unit and the Operating Theatre suite. The meeting served to give the visitors a perspective on our local health care system and its strengths and deficits in promoting a successful kidney transplant programme. The team thanked me for my assistance and that was a wrap.
The team from DTI decided to use the Port-of-Spain General Hospital (POSGH) as the pilot project for implementing deceased kidney donation. It was the only centre with consistent neurosurgical services at that time. The plan included training of two doctors in the 5-day Advanced International Transplant Procurement Management (TPM) course in Barcelona, followed by a four-week internship. Unfortunately, the doctors from POSGH previously trained at the 2010 local course were unable to attend. One suitable candidate was selected from that hospital and the second spot was offered to me (even though I worked at another hospital). There was no turning back now for me. What started off as a mild curiosity now became a passion and an additional duty, as I now had the basic training to be a TPM.
The Spanish model is one of the best examples of a successful organ donation and transplantation programme. It identified key components that were necessary such as appropriate legislation, a central office that provides support for the system (NOTU in our case), experienced transplant teams, in-hospital transplant coordinators or TPMs, quality controls systems and investment in training and education of staff. Organs can be sourced from live or deceased donors. The living donor programme is managed by NOTU as well as the recipient waiting list amongst other administrative duties.
My main duty as a TPM is to look for potential deceased organ donors and convert them to actual donors. The process of realizing an actual donor starts with detection and identification of potential donors in the ICU/ED setting. A successful donor is the result of multiple processes including confirmation of brainstem testing, ensuring the deceased patient is suitability of donor (no infection risk and healthy organs), approaching and obtaining consent by the deceased patient’s relatives with appropriate documentation, organ maintenance until harvesting occurs and finally transplantation of organs into suitable recipients.
2012 marked the start of a lot of hard work for my colleagues and me in terms of implementing a successful deceased kidney donation programme. It involved audits, local staff training, implementation of legislation to permit Coroner’s cases to be used as donors, establishing protocols for various processes and lots of meetings with the various parties involved. It was a whirlwind. In addition to my normal clinical duties, I was also in the midst of post-graduate studies. The groundwork was tiring and eventually the first deceased kidney donor since our training was realized at POSGH at the end of 2012. For my hospital, our first successful donor came in 2014 and to date, we have had 4 donors with 8 kidneys being transplanted.
Since then, I have had further training and exposure to organ donation and transplantation. The team at my hospital as well as nationally have expanded significantly, so there is a lot more support available when we have a donor. There have been moments of frustrations when dealing with systematic issues or family refusal that result in a potential donor not converting to an actual donor. At present, this service remains a voluntary service for TPMs throughout the country. However, we continue this labour of love as we understand the importance of transplants to patients with end-stage renal disease. The possibility of one or two persons having an improved quality of life for every successful deceased donor is an amazing feeling.
Being a TPM is not an easy task. A donor presents itself at any given time and it is not often convenient in terms of personal time or work schedules, but it is an opportunity that should not be missed. For me, it is often difficult to face a family who has just received the news that their loved one has died and in the midst of their acceptance of this, to ask them to give permission for their loved one’s organs. In our country, where the knowledge of organ donation is not as widespread as it should be, there is often mistrust of doctors and a myriad of reasons why relatives refuse donation. The act of donation is completely altruistic and may often be a bit of a burden to the family in terms of their time and closure, whilst all the parts are falling in place for organ harvesting and transplantation to occur. However, most families appreciate something good coming out of their relatives’ deaths with the opportunities to help others and the same applies to the medical professionals involved in this process. We also have the responsibility to ensure that every process is above board and legislation and protocols are adhered to.
As the number of patients with end-stage renal disease increase, the demand for organs and transplantation continue to rise. Deceased organ donation provides the best option for reducing the transplant waiting list. Though the number of deceased organ donors is still small, we hope that one day we may have the formula to obtain the best result possible. Until then, we keep on striving to improve the process.