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02 December 2009

A doctor remembers

It's 42 years since the first heart transplant. An exclusive interview with the team's neurosurgeon who declared the donor brain-dead.

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By Olivia Rose-Innes

The story of the first heart transplant is part of my family’s mythology. But the protagonist in our version wasn’t Chris Barnard, urging that new heart to beat in the recipient’s chest; it was my father, witnessing the donor’s brain darken and die.

 My father, Peter Rose-Innes, was the neurosurgeon tasked with deciding when to declare Denise Darvall brain-dead so that her heart could be removed and given to Louis Washkansky, who would become the world’s first successful heart transplant patient.

Heart death versus brain death
Now that we’re well into the 21st century and grappling with the complicated medical ethics of cloning and genetic manipulation, it seems almost quaint that transplantation used to be so controversial. But when Barnard performed his historic operation over forty years ago, it was a highly charged issue.

My father explained it thus: "There is something very emotional and symbolic about the heart; to many, it is symbolic of life itself. This is partly why the first successful heart transplant made such an impression, in a way that previous transplant operations – such as the kidney – did not."

It is also why heart transplant pioneers encountered opposition: many people considered the moment of death to be when the heart stopped, not when the brain did.

"These days, the idea that life ends with brain death is much more widely accepted than it was in the 60s. But the belief that a beating heart meant life was quite a common viewpoint at the time – and one of the more controversial aspects of the heart transplant."

The ethics of brain death
Despite opposing views from many lay persons and some doctors at the time, said my father, it was nonetheless relatively well-established in several specialised neurosurgical departments to consider brain death as the true end of life.

"With head injury, it is often the case that patients are brain-dead before their other organs stop functioning – before they are 'fully dead'.

"We’d been developing the concept of brain death, even before the heart transplant brought it to the fore, as a very important ethical and philosophical research area. It was a means to avoid prolonging the sad, futile business of keeping a human body alive after the brain had shut down; to move away from pretending to treat the untreatable.

"For a couple of years already before discussions with Barnard about a potential donor suitable for a heart transplant, we’d been withdrawing treatment from brain-dead patients."

"A difficult man"
It was never easy to get my father to talk badly about Barnard, whom he always referred to as "a truly exceptional doctor – a genius", but with some prompting he would conceded that the heart surgeon was also often "impossible":

"Chris was a difficult man, hugely ambitious, very domineering; he rubbed just about everyone up the wrong way. But we got on well, for some reason – I think because of our early backgrounds, which we had in common and often chatted about in the hospital tea room." (My father and Barnard both grew up as Karoo "barefoot boys", in Prince Albert and Beaufort West, respectively.)

"He could have got a top job anywhere, but he chose to return and stay here, in large part because, I think, he had such an affection for the country, for Cape Town, for Groote Schuur."

Lead-up to the transplant
"Chris had approached me some time before, saying that his team was ready to do a viable heart transplant, and we agreed that I would alert him should we get a suitable donor.

"I was called out late on the night of 2 December 1967, to take charge of and assess a patient – a young woman who’d been brought in with a severe head injury from a car accident.

"During the night her condition became obviously irretrievable. Knowing that Chris was waiting for such a donor, I offered this patient on the condition that I could first diagnose her as absolutely brain dead. I knew that if the heart team succeeded, there would be enormous publicity, and I couldn’t risk making a mistake. That, together with the great emotional associations of removing a person’s heart…we had to be 100% certain.

"We eventually formulated a very strict and reliable set of rules for diagnosing brain-death. But at the time of the heart transplant, there weren’t yet established criteria; these were still in the process of being discussed and evaluated. Basically, though, there were three important criteria we applied:

"One: there had to be a background of injury likely to lead to brain death.

"Two: the patient had to be neurologically totally unreactive.

"Three: enough time needed to pass so we could be convinced that the patient was brain-dead. There was considerable uncertainty about how long this should be, but I felt confirmation would need several hours.

"During this waiting period we moved the patient, at Chris' request, from neurosurgery to a high-care single-bed room in the cardiac ward. But I insisted she remain a neuro patient. In fact, we wouldn’t let anyone from the cardiac team into the room; they were in offices just across the passage. There was great pressure to hurry up! Chris marched up and down the passage outside, and kept peering in at us through the window in the door.

"It was stressful, but not too different to the typical stresses experienced by a neurosurgeon treating any serious head injury, which you deal with many times during your training and practice.

"In retrospect, I don’t think I was too conservative in how long I took. I’m satisfied we took the right length of time – which was a couple of hours – to make the diagnosis of brain death.

"And so, I handed over the donor to the cardiac team, and went home in the early hours of 3 December 1967. It didn’t feel right for me to stay on in the theatre."

- (Olivia Rose-Innes, Health24, from an interview in December 2007 to commemorate the 40th anniversary of the first heart transplant. Updated December 2009.)

 
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