Duke Disaster.

[dcw135]

Interesting that all over the news we have two things not discussed here: malpractice damage award caps on one hand and this horrible case down at Duke (can't resist the alliteration). Does anyone have thoughts on the matters? I?ve noticed more people writing about ways to get out of medicine after an MD, which I applaud btw, but no one seems to care, or care to write, about this interesting case, particularly in light of recent talk about malpractice reform.

How about this, under whose responsibility does the death lie? The sending service did not make sure they were sending organs to a compatible patient, but did mark the box. The attending, I believe this is the case with many transplants, may have assumed that they wouldn't have sent it if the blood types hadn't checked out OK. But then again, this one was kinda off the books, a special request. The attending has admitted responsibility, a brave move that will raise the eventual settlement a few thousand. But is he really to blame, or was it a system mistake?

What does anyone think about our nation's health care crisis (who will pay for the estimated 25% increase in medical spending from last year to this, which I read in CNN's business section?), and which gives an expensive procedure to foreign nationals (although she did raise 100,000 or so and I have no idea who paid or even if)?

The actual mistake was so simple, while the complexity of the case so great. Is medicine a victim of its own success? That is, people now literally expect miracles and are loath to accept death. Which sucks for people in this business because everyone dies.

Was it right to put the second set (really the third set) of organs into her? By then, from what I can gather, she was in DIC. Her prognosis was terrible with or without another major surgery. Putting those organs into her turned out to be useless, a waste of resources. Something any medicine consult could have probably told the surgery team ? again only speculation ? but what was her pre-op mortality?

How much money do you think should be awarded to the family? What do you think they?ll settle for? This girl was going to die without the transplant and I do not think the transplant life is very long for heart/lung (average 4 years). I think a better question is should Duke have to pay for the second set of heart/lungs that could have saved THREE people.

Finally, do you think this will affect malpractice reform? This will probably become a poster for the trial lawyers: The Duke Debacle Deserves Disciplinary Damages! I know, alliteration annoys, but it?s just too easy.

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[Ramphaus]

certainly I will not reveal anything about the case that isn't already public knowledge from the associated press...

That said, I would like to mention how outrageous i think it is that the media has taken the opportunity to be as biased as possible. The fact of the matter is that it is a sexy topic about an even-more sexy procedure.

First of all, it was a mistake. We can't around that, nor would we want to.

Secondly, the news says that we tried to "hide" the mistake, which just is not true. The family was notified immediately, but the news media was not. When was the last time you remember an institution calling CNN themselves to say, "Hey, could you come do a story about our f-up?"

Thirdly, the surgeon, who happens to be technically brilliant will forever have a career (one that he spent 11 years after medical school getting to) marred by the tattoo of "Oh he's the surgeon who...."

We are human. We are fallible. And for all the naysayers, as I've been trying to teach my 1 year old nephew to say, "Get off me!"

 

[Annette]

The mistake could have happened anywhere. I very much respect the Duke surgeon who stood up and took full responsibilty for what was a systems mistake. I can only begin to imagine the pressure he was under to keep from saying anything.

If we removed the threat of litigation, we could more fully investigate the reasons for "mistakes", and hopefully put into practice ways to prevent them, just like the aviation industry does. A fund should be set up by practicing physicians, to compensate patients for any economic damages they may have from medical mistakes, without regard to if the doctor committing malpractice. Another arm should investigate the physician for malpractice, and be able to discipline appropriately anyone committing malpractice. This arm should be able to enforce its ruling nationally, not state by state as it is now. Only after the physician has been "convicted" of malpractice, would the patient/family be able to sue for pain and suffering due to malpractice.

We already supposedly have a way to deal with malpractice and incompetence, but people can often escape restrictions by simply moving to another state. We would need a national system, with teeth, and enough guts to gain the public's trust.

I know there are probably alot of holes in this theory, but similar systems have worked in other areas, such as the adverse vaccine reaction fund. The whole medical industry is about to implode if we dont' do something.

 

[Apollyon]

Originally posted by Ramphaus
Thirdly, the surgeon, who happens to be technically brilliant will forever have a career (one that he spent 11 years after medical school getting to) marred by the tattoo of "Oh he's the surgeon who...."

The one thing that the news media (msnbc.com) said about Dr. Jaggers is that, where he was a resident, this happened twice (wrong blood type allograft), in 1991 and 1994; he was in the program for one of those years. However, there was no mention that he was on the team; just a good ol' smear goin' on.

http://www.msnbc.com/news/876221.asp

 

[Jomad5]

As you probably know, the Philadelphia region is facing one of the worst 'insurance' crisis in the nation... I thought you might find it interesting how a local columnist is spinning the duke error as he sells out to the typical Philadelphia reader (insert joke here), and unfortunately, juror (begin CYA practices here)!

http://www.philly.com/mld/philly/news/columnists/john_grogan/5254937.htm[/URL]

 

[secretwave101]

Once upon a time, the only two people involved with medicine was the doctor and the patient. Once it became clear that so much money was involved, lots of other people have jumped in to pick up some of the cash. Trial lawyers should have nothing to do with medicine - except in very rare situations. Insurance companies created jobs for themselves while simultaneously helping the profession become more costly in general.

It is sad that the girl had to die. But she was dying anyway. Everything they did for her was an attempt to stave off the inevitable. NO ONE should be liable for her death, because it was already coming. The surgical team should be saluted for trying to beat the odds - nevermind the reason for the failure.

The case was probably a charity thing in the first place, and will now end up costing Duke some obscene amount of money. Was the doctor negligent? It depends on your definition of the word - but did he CARE about doing the surgery right? Just ask anyone who ever worked with him - the man cares about doing stuff right, money is totally secondary. This is true for ANY lead surgeon.

I think trial lawyers (and malpractice insurers) are the greatest threat to medicine in America today. Doctors endure some of - if not THE - most stringent screening procedures to enter their profession. With extreme exception, they are the LAST people who should be required to pay monetarily for their mistakes, other than the cost to repair the mistake itself.

No one works harder at preventing mistakes than doctors, and NO ONE should get rich from the times when things go awry.

 

[smackdaddy]

couple of things-
the accepting physician made the mistake. if that was indeed Dr. J, then it was his responsibility to make sure the blood type matched. if there was a systems failure, it was in that there was no built in redundancy to double check those things. otherwise it was not a systems mistake. if the newsweek article was correct and she was not on the list, that is what likely allowed this error to occur. had she been on the list, her blood type would have been prominently displayed during the consideration for her organs. if she was on the list, the sending person didn't check carefully, but it is still the receiving person's responsability.

very sorry, and agreed, it could have happened to anyone. in a way, if it did happen to someone, i'm glad it happened to someone who has years of experience and is already very highly regarded. if this was your first case out of training, bye bye career. and who knows how this happened? maybe he asked the medical student standing next to him, she is blood type a right? and the student brainfarted or just silently agreed. a whole bunch of terrible scenarios could have occurred which don't change the tragedy.

lastly, you guys should know from a legal standpoint, negligence has nothing to do with intent. the point isn't that they were donating their time and money and resources and whatever, or that the girl likely would hae died soon anyway or that she shouldn't even have been in the country or whatever. the point is that there was an obvious avoidable error creating treatment out of line with the standard of care.
trial lawyers like to assign blame, so rather than accidents/mistakes, negligence causes incidents which are actionable.

hope this ruin doesn't your day.
happy doctoring!

 

[secretwave101]

That's a good point smackdaddy - intent and negligence ARE legally separable at the moment. Its the entire notion of negligence that is problematic - it needs to be redefined. The bar to prove it and claim it needs to be raised significantly, in all fields.

99% of all mistakes were in some way avoidable before they happened. If "avoidability" is the criteria for negligence - trial lawyers will continue to make the best salaries in medicine.

 

[Ramphaus]

Originally posted by Apollyon
The one thing that the news media (msnbc.com) said about Dr. Jaggers is that, where he was a resident, this happened twice (wrong blood type allograft), in 1991 and 1994; he was in the program for one of those years. However, there was no mention that he was on the team; just a good ol' smear goin' on.

http://www.msnbc.com/news/876221.asp

It actually happened only once...one of the times they caught it and stopped the procedure. But anyway, I understand your point; and it's one that I endorse - the media sucks. The funny thing is that you know where they're going to want to come when they have a problem. They're not going to want to go to Podunk Community Hospital.

 

[afmsboy]

It has been interesting and saddening reading about the error and the loss of life that ensued. It comes as no surprise that most people in medicine are both concerned that it happened but also very understanding. We all know it could have happened at any institution in the country and the fact that it happened at one of the greatest confirms that.

It is also interesting to note that the Surgeon took responsibility as any proud professional should (but few probably do). He stands in the company of Captains and Generals that have taken responsibility for the actions of their sailors or troops. He also stands in stark contrast to that highest paid class, the corporate CEO. No one has claimed responsibility for ENRON, Anderson, AOL-Time-Warner, etc. And the mistakes of these companies affect the livelihood if not the lives of many more. They also get paid a whole lot more without worrying about insurance premiums and trial lawyers. Around the country people are released from death row for all sorts of reasons but no lawyers, judges or detectives ever stand up to take responsibility for putting the wrong person in jail. Notice how when the economy is in a tatters no one takes responsibility for putting it there, but when things get better every politician takes credit.

So I have empathy for the Duke surgeon, and even more for the Chief Resident, the poor intern and med students on that team. Think how much **** they must have caught. However, this was clearly a systems failure. Unless my understanding is totally naive, not only ABO typing but HLA Class I and II are bare minimums for such a procedure. If that is the case surely the NC state organ board that made the organs available must have done even a perfunctory check. Surely the Duke receiving team would have confirmed the match prior to accepting the organs, harvesting and transporting them. Something failed somewhere and the Top Dog took the fall.

There are lessons to be learnt here. One will be that the culture of assigning blame on individuals so as to shield institutions is not only dangerous but also counterproductive. Systems failures need to be searched for, identified and fixed. This week's NEJM addresses some of these issues. Another lesson, at least for me, is not to be so hard on those physicians who seem to want to check everything for themselves. You know who I am talking about, those cranky folk that won't accept your word for and check the labs themselves and when they dont like it go over to the Lab to look at slides themselves. Maybe they know something afterall.

My 2.5 cents

 

[smackdaddy]

Originally posted by afmsboy
It has been interesting and saddening reading about the error and the loss of life that ensued. It comes as no surprise that most people in medicine are both concerned that it happened but also very understanding. We all know it could have happened at any institution in the country and the fact that it happened at one of the greatest confirms that.

It is also interesting to note that the Surgeon took responsibility as any proud professional should (but few probably do). He stands in the company of Captains and Generals that have taken responsibility for the actions of their sailors or troops. He also stands in stark contrast to that highest paid class, the corporate CEO. No one has claimed responsibility for ENRON, Anderson, AOL-Time-Warner, etc. And the mistakes of these companies affect the livelihood if not the lives of many more. They also get paid a whole lot more without worrying about insurance premiums and trial lawyers. Around the country people are released from death row for all sorts of reasons but no lawyers, judges or detectives ever stand up to take responsibility for putting the wrong person in jail. Notice how when the economy is in a tatters no one takes responsibility for putting it there, but when things get better every politician takes credit.

So I have empathy for the Duke surgeon, and even more for the Chief Resident, the poor intern and med students on that team. Think how much **** they must have caught. However, this was clearly a systems failure. Unless my understanding is totally naive, not only ABO typing but HLA Class I and II are bare minimums for such a procedure. If that is the case surely the NC state organ board that made the organs available must have done even a perfunctory check. Surely the Duke receiving team would have confirmed the match prior to accepting the organs, harvesting and transporting them. Something failed somewhere and the Top Dog took the fall.

There are lessons to be learnt here. One will be that the culture of assigning blame on individuals so as to shield institutions is not only dangerous but also counterproductive. Systems failures need to be searched for, identified and fixed. This week's NEJM addresses some of these issues. Another lesson, at least for me, is not to be so hard on those physicians who seem to want to check everything for themselves. You know who I am talking about, those cranky folk that won't accept your word for and check the labs themselves and when they dont like it go over to the Lab to look at slides themselves. Maybe they know something afterall.

My 2.5 cents

the error was that he thought he had a type A patient, not in the typing of the patient or the donor. again, if the patient was not on the list (as reported), there was no systems error because she was not on the list. if she was on the list, he still accepted them and it is his responsibility to check, assuming he is the accepting transplant physician.
who else's fault would it be?
the system says that it is the accepting transplant physician's responsibility to verify the blood types match. if you want to blame the system for this error, fine.
no surgeon is going to stand there and blame the system for this type of error if he wants to keep his job.

 

[dcw135]

Smack:
the system says that it is the accepting transplant physician's responsibility to verify the blood types match. if you want to blame the system for this error, fine.
no surgeon is going to stand there and blame the system for this type of error if he wants to keep his job.

I agree with all you've said, but the fact the system allows for transplants outside of the system is a system error. Does the attending have to check every last item on every last patient or can there be any division of labor in medicine? It seems that 3000 years ago man and women took a great leap forward when some people became farmers, some became tool makers, some became bankers. Medicine is about 3000 years behind the times.

As horrible as we feel for the team, and as horrible as they feel, and as good as they are both in general competency and as people, a mistake was made resulting in a bad outcome in a young poor patient - the most likely situation to result in lawsuit. There is no question as to the mistake, and as horrible as it is to say, Duke, Duke's insurance company, the doctors, will probably face consequences.

What do you all think of putting the third set of organs into her? Mistake or not?

 

[anonymousEM]

While I am devistated for everyone involved in what was ultimately a terrible mistake, I am even more saddened for the family of the person who might have received the second transplant. I have been unable to verify my information, but I believe that the only way for her to receive a second set of organs was through a direct donor (perhaps she went back to the top of the list as the sickest, though?). We have the unenviable task of rationing scarce medical resources. If a patient who'd not yet had a transplant were in DIC, they would never be placed on the list. By convincing a family to say, "I want our child's organs to go to that poor girl we saw on TV at Duke" someone talked them into wasting the organs on someone who unfortunately did not have a chance of surviving the surgery. It is a shame that someone with a better chance of survival did not get their first chance at a new life that day.

 

[Hamster]

I have arisen from the dead.

I just could not resist this topic. I would like to re-re-reemphasize how wonderful it was for the attending to admit his mistake. (Assuming the mistake was truly his to admit.) The public is just unaware of how truly special this doctor is. Strangely enough, I struggled between choosing law and medicine in college. Medicine appealed to me because it seemed to deal more in truth and sincerity than fashioning contorted lies for the public, but now as I approach my clinical years...

What should happen to the Attending? Nothing. True, the team may be found negligent according to law but what punishment is greater than knowing you failed to achieve the one thing you set out to do. To have fate say "You know that thing you like doing so much, well you suck at it!" Is that not punishment enough? For a physician with a history of saving lives is that not a punishment undeserved?

I agree dcw 135 and will repeat for emphasis- "people now literally expect miracles and are loath to accept death. Which sucks for people in this business because everyone dies. " As physicians, we strive to do no harm, but as humans this is the risk we take when practicing medicine and as patients, this is the risk we take when receiving medicine.

A third set of organs, I thought were a bit much. But I am assuming it was just too hard to just watch her die. Another possibility: There is always hope for a miracle. Sometimes our knowledge blinds us from this, but for the family, who never took a pathology class, all they know is 'wrong organs given, take them out and give her the right organs'. I personally would have been too consumed with images of massive intravascular hemolysis and Type IV hypersensitivity to even consider such a thing. But I guess, stranger things have happened in medicine.

Although, it would sicken me to see someone who came into the country illegally to seek its benefits, and then, when found them lacking turn around and use its legal system to seek a reward, we know this is what the future brings. I won't even attempt to estimate a settlement. If the ordeal is dragged into the courtroom out of sheer greed, maybe, just maybe this will be the trial to publicize how ridiculous it is to expect medical perfection. More likely is the scenario where they will drag every last H &P he ever wrote to the judge and point out his 'pattern of gross negligence' " What's this?!! Chest pain radiating to the arm!! You failed to mention WHICH arm that was!! What kind of an MS1 student were you Dr. J!"

I wish him only the best. And for what it is worth, he can do my heart and lung transplant anytime (if I should ever need one)

 

[Thewonderer]

I am curious about the concepts of avoidable and gross negligence.

What is avoidable? Everything is avoidable. If a girl playing on the side of the street, all of the sudden jumps in front of a car and the car runs her over, well, that's avoidable if the driver stepped on the brake and stopped in time. But is it really avoidable? What if the driver only had 1 second to react?

Similarly, the girl is in the OR and is ready. Say, this is Dr. Jagger's 150th transplant case and every single one before this one had its type and screen done and matched with the organ corrected. So why should he do a type a screen this time?

I would only call it gross negligence and warrant a lawsuit if 1) the driver in the above scenario was having his eyes half-closed and listening to the book and 2) Dr. Jagger's had reason to even suspect that the organs don't match and still go ahead with the surgeries. in both cases, I would call them "accidents." But how can you call them gross negligence in either scenario?

 

[Behcet]

perhaps the worst possible outcome of this whole mess is that now the family's lawyers are apparently making statements that this case is proof that malpractice damage awards shouldn't be capped by Congress. to turn this whole thing into a political platform...no wonder lawyers get their reputation

 

[smackdaddy]

Originally posted by dcw135

I agree with all you've said, but the fact the system allows for transplants outside of the system is a system error. Does the attending have to check every last item on every last patient or can there be any division of labor in medicine? It seems that 3000 years ago man and women took a great leap forward when some people became farmers, some became tool makers, some became bankers. Medicine is about 3000 years behind the times.

there is a division of labor. the task we are discussing is specifically the accepting physician's responsibility. that is why he accepted responsibility. it's not like we are debating whether it was mislabeled or the wrong patient's organs. why is this so hard for you guys to understand?

all systems have errors. physicians as a group do not like to be regimented and have no decision making capability. if you want to say allowing transplants outside of the system is a system error, fine. we seem as a society to be removing individual responsibility anyways (except for physicians apparently). my kid can't read because the system failed to educate him, not because he spent all day playing games or whatever. who can i sue?

 

[afmsboy]

Smackdaddy,

Our positions are not very different. Yes the surgeon as captain is responsible for everything that happens on his watch. But it still is very commendable that he stepped forward and accepted full responsibility.

I still maintain that the system also failed. I have never been on a transplant service and so have no idea what the details for offering and accepting organs are but I would assume on the bare minimum they are at least as rigourous as that of a blood transfusion. For someone to receive the organs I assume there exists a checklist of steps to be completed on both the receiving and donating side. I assume more than one person would be involved in this process, thus when major bloopers like this occur, more than one person played a role.

If that was not the case here and the only person that had to check the Match was the attending surgeon then the systems failure was one of omission. The absence of a credible system.

To extend your analogy, yes the parent is responsible if the child has not learned to read and spends all the time watching TV. But dont you think the school that hires and pays teachers to send that child home with perfect grades and stars knowing full well the deficiencies of that child has played a role?

 

[smackdaddy]

Originally posted by afmsboy
Smackdaddy,
I still maintain that the system also failed. I have never been on a transplant service and so have no idea what the details for offering and accepting organs are but I would assume on the bare minimum they are at least as rigourous as that of a blood transfusion. For someone to receive the organs I assume there exists a checklist of steps to be completed on both the receiving and donating side. I assume more than one person would be involved in this process, thus when major bloopers like this occur, more than one person played a role.

If that was not the case here and the only person that had to check the Match was the attending surgeon then the systems failure was one of omission. The absence of a credible system.

after you do transplant training , then get back to me.
be careful what you wish for, you may get it.
you may find that in creating the systems you have in mind, you are little more than a guy checking off boxes on a list. MOST physicians actively resist these types of innovations.

 

[smackdaddy]

Originally posted by afmsboy
Smackdaddy,
To extend your analogy, yes the parent is responsible if the child has not learned to read and spends all the time watching TV. But dont you think the school that hires and pays teachers to send that child home with perfect grades and stars knowing full well the deficiencies of that child has played a role?

i have yet to see a kid that couldn't read receive perfect grades. yes they skate by and there are a lot of external pressures to give passing grades, but i highly doubt there were no warning signs along the way. whatever, if you can't see what i am trying to say then it's not really a good example for you.

i am not saying reforming the system is a bad idea. i just disagree that about how much personal responsibility the person versus the system should accept. and doing it publicly is just a matter of the profile of this case. again, i think your relative inexperience with transplants is coloring your opinion. my inability to explain the degree of responsibility is probably the reason i can't get through.

it would sort of be on a level with you admitting a patient with hypertensive emergency and treating him without ever checking the blood pressure. on a very fundamental level you f'd up. should a system then be created where the pharmacy cross checks every order you write with the diagnosis in the computer and calls you at all hours to ask you to either amend the diagnosis list or change the order? and it should work backwards to figure out why certain medications weren't ordered? or should we just say you screwed up, and everyone is reminded to be vigilant.

 

[Gradient Echo]

Originally posted by afmsboy
Unless my understanding is totally naive, not only ABO typing but HLA Class I and II are bare minimums for such a procedure. If that is the case surely the NC state organ board that made the organs available must have done even a perfunctory check.

thats my understanding too, but I'd like some clarification on that if anybody knows more specifics.

From what I remember about immuno, HLA class I, II are composed of a heterotrimer with 3 distinct subloci, with each subloci having up to 200 different alleles. (HLA class III encodes complement cascade proteins and thus does not need to be matched).

MHC class II locus has 3 loci (DP, DQ, DR) with each loci having 2 subloci (alpha/beta). The number of alleles for each subloci is as follows:

DP alpha = 80
DP beta = 12
DQ alpha = 20
DQ beta = 35
DR alpha = 1
DR beta = 239

So, the total number of possible "different" MHC class IIs in the human population is (80*12*20*35*1*239) = 160 million.

For MHC class I, there are 3 loci (A,B,C) with the following numbers of alleles:

A: 95
B: 207
C: 50

So that means (95*207*50) = 983,000 different possible combinations.

All protein domains expressed by the loci/subloci of both MHC I and II are extracellular, meaning all of them can elicit an antibody response (theoretically), so I would assume that all of them need to be matched for. But that really cant be right, because if you needed an exact match for both MHC I and II that means theres only a (983e3 * 1.6e6) = 157 trillion chance of finding another person with an exact type match for all loci of both MHC I and II.

So theres 2 other possibilities that I can think of:

1) Alleles for both MHC I and II are not evenly spread across the population (i.e. a large portion of humans share a smaller subset of alleles than the total number of possible alleles available)

2) Clinically, you dont need an exact match because the immunosuppressants can help to prevent antibody complexing.

I have no idea if theres any evidence for #1, but can somebody clear up #2? How much of a match is needed given the fact that immunosuppressants can help to eliminate possible immune responses against the organs? Is a 50% match good enough? What about a 25% match? Is MHC I or II more important to match for or are they both roughly equally important? Are there certain portions of the heterotrimer and certain loci that are more important to match than others?

 

[dcw135]

Originally posted by smackdaddy
there is a division of labor. the task we are discussing is specifically the accepting physician's responsibility. that is why he accepted responsibility. it's not like we are debating whether it was mislabeled or the wrong patient's organs. why is this so hard for you guys to understand?

all systems have errors. physicians as a group do not like to be regimented and have no decision making capability. if you want to say allowing transplants outside of the system is a system error, fine. we seem as a society to be removing individual responsibility anyways (except for physicians apparently). my kid can't read because the system failed to educate him, not because he spent all day playing games or whatever. who can i sue?

It's not hard to understand. The stupidity of medicine (and the doctors who are responsible) where there is no regimented system is what's diffficult to understand. Anesthesia has done wonders by regulating the dials, colors, placement of different controls for all anesthesia machines. The rest of medicine will eventually follow, but if we can take a lesson from Seimellweiss' residents who didn't wash their hands for the next 50 years, it'll take a while.

To me this was both a system error and individual error. Perhaps not equal parts, but who knows, an argument could be and probably will be made along this line during a deposition.

As far as your kid, the video game industry has deep pockets.

Hey HLA guys, how did this thread degenerate into nerd talk?

 

[Apollyon]

Originally posted by Gradient Echo
From what I remember about immuno, HLA class I, II are composed of a heterotrimer with 3 distinct subloci, with each subloci having up to 200 different alleles. (HLA class III encodes complement cascade proteins and thus does not need to be matched).

MHC class II locus has 3 loci (DP, DQ, DR) with each loci having 2 subloci (alpha/beta). The number of alleles for each subloci is as follows:

DP alpha = 80
DP beta = 12
DQ alpha = 20
DQ beta = 35
DR alpha = 1
DR beta = 239

So, the total number of possible "different" MHC class IIs in the human population is (80*12*20*35*1*239) = 160 million.

For MHC class I, there are 3 loci (A,B,C) with the following numbers of alleles:

A: 95
B: 207
C: 50

So that means (95*207*50) = 983,000 different possible combinations.

All protein domains expressed by the loci/subloci of both MHC I and II are extracellular, meaning all of them can elicit an antibody response (theoretically), so I would assume that all of them need to be matched for. But that really cant be right, because if you needed an exact match for both MHC I and II that means theres only a (983e3 * 1.6e6) = 157 trillion chance of finding another person with an exact type match for all loci of both MHC I and II.

This is what you REMEMBER? Off the top of your head?

I don't know about hearts and lungs (although I thought that lungs were more forgiving), but, for livers, you just need the blood type to match. For kidneys, blood type, and as many HLA antigens as possible (zero or 1 means not good for survival, 2 is good, 3 is excellent, and rare, and 4 is nearly impossible (ie, twin)).

So the recurring thing is blood type.

 

[Hamster]

dmsf and gradient echo, I believe that only ABO typing and HLA class I are neccesary for most organ translplants. Immunosuppressive drugs are given to smooth out the rough edges from imperfect HLA II matches. HLA class II typing is reserved for BMW transplants...maybe a few others like kidney. This in addition to not yet discovered 'minor' histoincompatablility types is the theoretical reasoning behind unexplained chronic organ rejection takes place in with most transplants. I am just a MS2 so all of this is a poor attempt to recall previously tested material.

I agree this is more likely to be a system error than a individual error. Which is all the more reason I salute Dr. J for taking the fall. Like it or not, people see us ( physicians) as the 'captain' of the ship. It would be oh so easy to place the blame on the sleeping watchman but that would not help the fate of the ship. Now with the crew's fear removed from becoming a fall guy, maybe we can concentrate on preventing this scenario from ever occuring again ( which I believe Duke has already done) or to continue with our metaphor, keep the ship running.

 

[Gradient Echo]

Originally posted by Apollyon
This is what you REMEMBER? Off the top of your head?

I don't know about hearts and lungs (although I thought that lungs were more forgiving), but, for livers, you just need the blood type to match. For kidneys, blood type, and as many HLA antigens as possible (zero or 1 means not good for survival, 2 is good, 3 is excellent, and rare, and 4 is nearly impossible (ie, twin)).

So the recurring thing is blood type.

Well I had to quickly look up the exact number of alleles at each locus, but fortunately I retained the basic concepts of how its supposed to work. We just finished immunology about 3 months ago, so most of it is somewhat fresh in my head. I'm sure that will change by the time I have to take Step I.

After reading your post I did some more research and found that for unspecified reasons, the HLA (MHC) loci at DR, A, and B are preferentially matched over the other locations. That seems to correspond to the point system you laid out (i.e. match at DR locus is one point, having all 3 loci match is 3 points) and I guess theres an extra locus not specified by my source that is used for the 4th match point.

However, even with using only those 3 loci for donor-host match points, thats still (1*239*95*207) = 4.6 million possibilities which is still alot but I guess global immunosuppression drugs than modulate the risk.

Do hepatocytes not express MHC class I or II? Why is HLA matching not needed for liver transplants?

 

[Gradient Echo]

Originally posted by Hamster
dmsf and gradient echo, I believe that only ABO typing and HLA class I are neccesary for most organ translplants. Immunosuppressive drugs are given to smooth out the rough edges from imperfect HLA II matches. HLA class II typing is reserved for BMW transplants...maybe a few others like kidney. This in addition to not yet discovered 'minor' histoincompatablility types is the theoretical reasoning behind unexplained chronic organ rejection takes place in with most transplants. I am just a MS2 so all of this is a poor attempt to recall previously tested material.

This makes sense. I know that there are up to 50 loci encoding minor histocompatibility regions, but I dont think that organ-donor crossmatching typically takes these into account because their effects can likewise be mitigated by immunosuppressives, and at any rate we dont know enough about it to prevent errant matching.

 

[droliver]

As I understand it from doing transplant last year. ABO compatibility is the only absolute requirement for any of the solid organs. A "6 antigen (HLA)" match is preferred when possible as it lowers the amount of immunsupression required, but for 1-5 antigen matches they're all treated with similar medicine regimines & have similar long-term outcomes. Six antigen matches are pretty rare & when they happen organs may be transferred out of your UNOS region to those recipients because of the higher success rates unless you have donor requests prohibiting it specifically from leaving your state/area.

The problem @ Duke was clearly a systemic thing, probably from complacency due to their long success record with the procedure. There are multiple levels of checks & balances on these things & it appears that at every level,someone thought that someone else had checked on the simplest antigen match involved with the process. The surgeons are usually the least involved in the whole process & rely heavily on the transplant coordinators & state organ tranplant programs to oversee most of the details. It's not an excuse, but its an explanation for the episode. Again, its a problem of complacency for a complex task that has become routine.I liked the analogy in NEWSWEEK "It's was like launching the space shutlle with the nose pointed down".