Lynt Johnson still remembers the patient—a teacher from Baltimore whose husband was a doctor. It was 1994, a year after Dr. Johnson had started a liver-transplant program at the University of Maryland Medical Center.
Johnson’s first transplant patient had died in the operating room; his second was doing well. The Harvard-trained surgeon was troubled by what he considered a 50-percent survival rate.
“We’re not God,” his wife, Gloria, would tell him. “God gave us talents, but God’s in control.”
Johnson had convinced his bosses at Maryland that he could build a program from scratch, even though he’d only recently finished his medical fellowship. He was 35, and he was transporting organs in Igloo coolers in the trunk of his Toyota.
When he got the call that a doctor’s wife was coming in with acute liver failure after a reaction to medication, Johnson wasn’t sure he should be the one to help. The patient was comatose. If she didn’t get a liver in the next eight hours, she would die.
“Maybe we should transfer her to another hospital, a program that’s a little more experienced,” Johnson told the woman’s husband.
The man listened and said he’d let Johnson know. He came back later that night. “I met with my rabbi,” he said. “We’ve decided our fate is with you.”
The woman’s liver was so badly damaged that she’d been placed at the top of the transplant list. Johnson got an organ offer the same evening—a liver from a teenager whose lungs had failed. The teen had spent time on a coronary-bypass machine, which malfunctioned, leaving him brain-dead. Doctors had never used an organ like this for transplantation—there was a chance the machine had damaged the teen’s liver—but it was the only organ Johnson had.
“Nobody’s done this before,” he told the woman’s husband. “I think we ought to give it a shot.”
When Lynt Johnson was in college, a dean once told him that Harvard Medical School must have lowered its standards if he got accepted. Johnson took the remark as motivation: Soon he was a medical resident flying from Boston to Charlottesville in a small jet at sunrise to recover an organ that would change someone’s life.
“It would almost be a handoff,” Johnson says. “You had one team that took the organ out and another team back at the hospital starting the operation.”
Johnson, now chief of transplant surgery at Georgetown University Hospital, has performed more than 1,000 transplants since he helped save the teacher from Baltimore. He came to DC to open the hospital’s multi-abdominal-transplant institute in 1998. The program, the only one in Washington performing liver transplants, now has one of the highest post-transplant survival rates in the country: Ninety-four percent of its liver-transplant patients make it through the first year, when the body is most likely to reject a new organ.
When Johnson started doing transplants 15 years ago, about 35,000 Americans were waiting for organs. With medical advances keeping patients alive longer and with rates of kidney disease rising, that number has nearly tripled. “You line up everybody that’s waiting on an organ, you could fill FedEx Field,” he says.
In the Washington area, nearly 1,600 people need a kidney—the District has the nation’s highest rate of kidney disease—and 170 are waiting for a liver. More than 150 patients are waiting for a pancreas, intestine, or lung. Thirty-two people need a new heart.
According to Donate Life America, while 90 percent of Americans say they support organ and tissue donation, only 56 percent of those who could designate themselves as donors—by signing up on a driver’s license or donor registry—say they would be willing to donate. Eighteen people die in this country every day waiting for an organ. Johnson has had patients travel to China, against his advice, to buy one.
About half of Johnson’s kidney transplants now involve living donors. The hospital recently performed its first paired kidney exchange. In such a procedure, a patient who has a willing donor—but isn’t a match with that person—exchanges donors with someone else, resulting in two transplants. Doctors at Georgetown are planning a three-way kidney exchange.
Georgetown’s Dr. Keith Melancon, whom Johnson recruited last year from Johns Hopkins, has introduced a blood-cleansing process that allows kidney recipients to receive an organ from a donor with an incompatible blood type. The procedure, called plasma pheresis, recently saved a Silver Spring woman who was able to receive her sister’s kidney without rejecting it.
Last year, Johnson performed 12 live-donor liver transplants. Because the liver regenerates, surgeons can extract part of the organ and give it to someone else; both livers grow back to normal size. The surgery is risky enough that donors have to go through counseling before they sign on. Georgetown is now doing laparoscopic-assisted live-donor liver transplants, a surgical approach Johnson never thought he’d see. Donors are left with a scar of about three to four inches.
Still, most of the organs Johnson uses come from people who have died suddenly from trauma, strokes, or aneurysms. That’s the part of the job he doesn’t like to think about.
Johnson was a third-grader when he visited his grandmother in the hospital and noticed she looked different. After she died, relatives told him she had jaundice, a problem with her liver that she got from drinking too much Pepsi.
Growing up in Savannah, Johnson enjoyed going to the pediatrician, even when he had to get shots. He decided he’d be a doctor one day.
Photograph by Matthew Worden.
He went to Duke on an academic scholarship and wanted to study pediatrics, but he didn’t have the patience for it. His professors gave students keys to the anatomy lab, so he’d go back after class and dissect cadavers. He realized surgery would be a better fit.
Johnson was intrigued by all that the liver could do: make proteins and energy, store glucose, break down fats, detoxify. There wasn’t any other organ like it.
When he was in medical school, many patients weren’t surviving liver surgery—the three-pound organ is intertwined with blood vessels and bile ducts, making it complicated to operate on. Kidney patients can go on dialysis; there’s no end-stage therapy for people with liver disease.
Johnson was shadowing a surgeon on rounds when he met a patient who was dying from liver failure. He saw her again a few days later, after her transplant, and she was eating and talking to him.
Liver transplantation was a new field when Johnson finished training in the early 1990s at Boston’s Massachusetts General Hospital. The University of Maryland was doing kidneys, pancreases, and some lungs and hearts; Johnson was hired to build a liver program.
If an organ was available for one of his patients, it was his job to get it. If the donor hospital was nearby, he’d drive there, store it on ice, and bring it back. Then he’d perform the transplant, often in the middle of the night.
His first transplant patient, a woman in her fifties, didn’t survive surgery. The patient’s mother was in the waiting room. He’d never had to do this before. He was expecting her to yell at him.
“I told her the surgery didn’t go well and there were some problems and her daughter had died,” Johnson says.
“Come here—I want to give you a hug,” the woman said, “because I know you did the best you could for my daughter.”
No, he thought: I didn’t do the best I could. I should’ve done better.
That first transplant stuck with him. Johnson had never operated with the team he was working with that night. He knew he probably couldn’t have prevented what happened, but he decided he should be in charge of every detail of an operation—from how the room was cleaned to how anesthesia was delivered.
Assume nothing, trust no one, check everything, he’d say.
Johnson and his wife, Gloria, lived in Ellicott City with their two small children. Gloria had decided as a medical student that life would be too complicated if both she and her husband were surgeons, so she’d specialized in obstetrics and gynecology.
The two had met when Gloria was an undergrad at Georgetown and Johnson was giving a talk about how to get into med school. He invited her to see The Woman in Red; they spent a year dating long distance before marrying in 1987.
Johnson was consumed by the lifesaving potential of transplants, often sleeping on the couch in his office. Gloria was an attending physician at Bethesda Naval Hospital, pregnant with their second child. They tried to coordinate their on-call schedules. They would have nine nannies by the time their oldest daughter turned nine. (They now have four children.)
After five years at Maryland, Johnson wanted a change. His program was competing for patients with Johns Hopkins.
“Washington was the only big city in the country that didn’t have a major multi-abdominal-transplant program,” he says.
He came to Georgetown with a Rolodex and started making calls. He brought one surgeon with him and recruited others; some of his patients followed him to DC. Georgetown had only a small kidney program when Johnson was hired in 1998, so he trained staff in caring for transplant patients.
“The operating room, the blood bank, the lab—all those places need to have a special way of doing things,” says Johnson, who also treats patients with liver and pancreatic cancer.
He wanted a team approach to transplants. All of his doctors would know about all the cases. Surgeons, critical-care physicians, anesthesiologists, and nurses would work under one umbrella.
Johnson and his colleagues did 14 liver transplants their first year. Johnson operated on the hospital’s first live liver donor—a mother donating to her 17-year-old daughter.
In 2005, Dr. Thomas Fishbein, whom Johnson had recruited to head the hospital’s new small-bowel transplant program, led a surgical team in a rare six-organ transplant: A 43-year-old man received a liver, kidney, pancreas, small bowel, colon, and stomach. Two years ago, the hospital performed its first split-liver transplant, in which a young woman who needed a liver agreed to sacrifice a portion of her new organ to give it to a baby girl. The deceased-donor liver was a match for both patients; they’re both doing well.
In September 2007, a 35-year-old Alexandria man became the hospital’s 500th liver-transplant patient. The same day, Johnson’s team performed a small-bowel-and-pancreas transplant and helped save a three-month-old.
The phone rings at the Washington Regional Transplant Community (WRTC) in Annandale whenever someone dies at a local hospital—about 15,000 times a year. Hospitals report every death; WRTC works with a patient’s medical team to determine whether that person is a potential donor.
Only about 1 to 2 percent of deaths in the United States are brain deaths, the main criterion for organ donation. Donors typically have to die of a neurological injury. A patient is declared brain-dead, but a ventilator keeps the person’s heart beating and blood flowing. Every minute counts: Most organs have to be transplanted within 6 to 12 hours; kidneys can last longer. A single organ donor can save up to eight lives.
In rare instances, a person who sustains a non-survivable brain injury but doesn’t become brain-dead can still be a candidate for donation. In such cases, known as “donation after cardiac death,” the option of donation is offered after a patient’s family elects to have the ventilator withdrawn. Last year, 15 people in Washington who died of cardiac arrest became organ donors.
WRTC has a team of “recovery coordinators” who go into hospitals after a potential donor has died and speak with the family. When a patient has organs viable for transplant but didn’t registered as a donor, it’s up to the next of kin to decide whether to allow donation. Coordinators have had family members yell at them or ask them to leave.
“A family doesn’t come into the hospital expecting their loved one to be an organ donor,” says Johnson. “They usually come in with the expectation that their loved one is going to get better.”
Recovery coordinators stay until they’re sure a family understands the choices. They’ve heard from families who have said no, then regretted it. One of WRTC’s volunteers, NaTasha Driggers, had a kidney-and-pancreas transplant in 1998 after struggling with juvenile diabetes. When her uncle came to visit her at Inova Fairfax Hospital, he got off the elevator, then turned around and left. He couldn’t face his niece: When he’d lost his wife nine years earlier, he’d said no to donating her organs. “I believe he felt bad,” says Driggers, who lives in Clinton. “He didn’t understand until it hit close to home.”
Last year, about 72 percent of medically suitable deceased patients in Washington had their organs donated. That’s close to the federal goal of 75 percent.
Johnson says some families don’t feel comfortable saying yes because they don’t know whether their loved one would have wanted to donate.
As a surgeon, Johnson rarely talks with donor families. He’s not involved in a donor’s medical care until it’s time to recover organs.
“There are people that feel like, ‘If I’m an organ donor, hospitals won’t care for me like they would if I weren’t a donor—they’ll just want me for my organs,’ ” he says. “It’s a myth.”
Johnson can’t predict when he’ll have organs for his patients. “The frustration comes when we have patients who you know will do well with a transplant and you watch them decline so much that they wouldn’t be able to tolerate one.”
He used to be busier in the summer, when young people had more car accidents, but tougher seat-belt laws have changed that. Now he sees more older donors who have had strokes. He may go a month without an organ offer, then have one every day for a week.
Johnson logs onto the United Network for Organ Sharing (UNOS) Web site one afternoon and finds an organ offer in progress. Local organ-procurement organizations notify UNOS whenever there’s a donor. UNOS posts donor information online—cause of death, medical history, vital signs, labs—and notifies doctors whose patients might be a match.
As soon as Johnson pulls up the Web site, his nurse calls. She’s already been paged about the organ—a kidney from a 42-year-old man—and wants to know if Johnson’s interested. He has an hour to accept it or turn it down.
“The blood pressure’s a little high, but it’s come down,” he says. “I don’t see any obvious issues.”
Johnson’s patient is number 11 on the list of potential recipients, so ten people have to turn down this kidney before it would go to his patient.
“If it’s a good donor, I’m probably not going to get it,” he says.
When Johnson became a surgeon, most organs were allocated based on how long patients had been on the list. That was especially tough on people with liver disease. Many of Johnson’s transplant patients have cirrhosis—often caused by alcoholic liver disease or hepatitis C. Others have autoimmune disorders or early-stage liver cancer.
“If your doctor wasn’t savvy enough to get you on the list early and your disease was progressive, you would be behind somebody who had waited longer but was healthier than you were,” he says.
In 2000, the federal government changed the rules: Most organs would be allocated based on medical urgency. Patients get a score based on the Model for End-Stage Liver Disease. The higher your score, the better your chances of getting an organ.
Patients with acute liver failure get top priority. Acute liver failure—often caused by a medication overdose or a virus such as hepatitis—can come on so quickly that the patient seems healthy until the liver is days away from shutting down.
“We’ve had the ironic situation where people come in for a transplant, become brain-dead, and go from being a potential transplant recipient to a donor,” says Johnson. “The kidneys, heart, and lungs are okay, but the liver has failed and they’ve died of brain swelling.”
Kidney allocation is more complicated. Because people with kidney failure can live on dialysis, says Johnson, “it’s harder to clearly define who’s the sickest patient.” The current system considers how long someone has been waiting for a kidney along with other factors. There’s a controversial proposal out from UNOS that would make age a determining factor.
“They’re trying to match younger kidneys to younger recipients,” says Johnson. “Today there’s a 65-year-old lady who’s going to get a 17-year-old kidney—the way the list is now, she’s allocated that organ. The question is: Is that the best way to utilize a resource you don’t have enough of?”
Organs are typically allocated locally first; if there isn’t a match, an organ is allocated regionally. In rare cases, such as a perfectly matched kidney, an organ might be flown across the country.
Most of Johnson’s patients ask about their donor, but he can’t say much. Donor information is private unless a family wants to share it.
“Most patients are very appreciative of the gifts they get,” says Johnson. “Most realize how close to death they were.”
He’s had a few patients who didn’t seem grateful. He’d think: Don’t you get it? Somebody died so you can live.
Last summer, one of Johnson’s patients got a liver from a young man who’d flipped over while riding an all-terrain vehicle. Johnson came home that night and told his 12-year-old son, Brandon, that he never wanted him riding an ATV.
“Every transplant we do is tied to a tragic incident,” says Johnson. “It’s particularly hard when it’s young people.”
He used to have a hard time getting patients off his mind—he’d find himself replaying surgeries in his head. Now he doesn’t like to talk about medicine after work. He comes home to McLean and watches sports with his kids.
“That’s the surgeon in him,” says his wife, Gloria, whose office at Georgetown Hospital is a short walk from his. “He takes care of it, deals with it, and that’s the end of it.”
He has other things to think about, such as the fact that his daughter’s going to college soon. Weekends are filled with the kids’ basketball games, travel soccer tournaments, and the occasional golf or fishing trip. “When I finish my career as a surgeon,” Johnson says, “I’m gonna get a charter fishing boat and take people fishing.”
He and Gloria try to fit in dates when they’re not on call, but if his pager goes off, he’ll often go back to the hospital. If it’s a tough case, he wants to be there.
Says Gloria: “It’s not a date if you have to drive in separate cars.”
Johnson’s kids aren’t interested in medicine. “They look at how hard we work, and I don’t think they want to do that,” Gloria says.
She stays at the hospital overnight once a week to deliver babies; Johnson never knows when he’ll have a transplant. He likes when he gets home after surgery and feels washed out, then sleeps for three hours and does it again, but it’s hard when his seven-year-old is asking questions about NFL quarterbacks while he’s trying to finish a PowerPoint on organ allocation.
Jazz music, heavy on the saxophone, fills the operating room as Johnson’s gloved hand grasps a young patient’s liver. A metal crucifix hangs on the wall beneath the clock.
Johnson lets residents decide what will play from the iPod when he’s doing surgery. He talks and teaches while he operates. The piles of paper in his office stress him out—everything, even prescriptions, should be computerized, he says—but an operating room puts him at ease. He was more nervous about the birth of his children than he was about most of his transplants.
Live-donor liver transplants used to be tougher on donors. The surgery left them with a 24-to-30-inch incision that looked like a Mercedes-Benz insignia. During a laparoscopic-assisted procedure like this one, Johnson makes two small incisions for instruments and a third for his hand. Donors are usually home in four or five days.
Johnson, who wears orange clogs in surgery—a gift from a cancer patient—keeps one hand inside the woman’s abdomen and the other on the laparoscope, a thin surgical tool with a video camera attached. The laparoscope allows him to see the patient’s liver magnified on a screen next to him. It also helps him dissect—he has to cut tissue away from the liver before he divides it into two pieces.
Johnson’s patient is a 21-year-old aspiring veterinarian named Tovah. Her cousin, Jessica, a ninth-grader, is in the next room. It’s Johnson’s job to remove the left lobe of Tovah’s liver and hand it off to Jessica’s surgeon, who will perform the second part of the transplant. Johnson has done this operation many times, but he knows there can be surprises.
“I don’t think there’s ever going to be a time when I’ve got this mastered to the point where I’m never going to be fooled,” he says.
Tovah’s mother, Jacqueline Dorsey, raised Jessica, her niece, and the girls grew up like sisters. Jessica got in the car after dance class three years ago and told Jacqueline she couldn’t keep up anymore. She’d fall asleep at dinner and wake up disoriented. She was diagnosed with a form of liver disease likely caused by an autoimmune disorder.
Doctors told Jacqueline that Jessica had three to five years to live. Jacqueline assumed her niece would get a new liver if she needed one, the same way she’d get stitches or a cast. When she realized Jessica might not get a liver—there were hundreds waiting who had a higher score than she did—Jacqueline started looking for a living donor. Tovah was a match.
The stakes are high with donors like Tovah: They come into surgery healthy.
“Every other operation we do, regardless of how risky, is done with the intent of making the patient better,” he says. “With donors, there’s absolutely nothing wrong. We can only try to keep them as close to their health as they were.”
It’s more dangerous to donate a liver than a kidney because kidneys don’t have to be split. Johnson says that about 20 percent of liver donors nationwide have minor complications; two have died. That’s why Johnson operates on donors, not recipients, during transplants like this—he wants the responsibility to lie with him.
Potential donors, such as Tovah, have to be approved by a committee at Georgetown before the transplant can happen. The committee, which includes a retired surgeon, a psychiatrist, a donor advocate, and a risk-management consultant, decides whether a donor is mentally and physically fit for surgery. About 80 percent of live-donor kidney and liver transplants at Georgetown go forward; committee members might say no if they don’t believe a donor understands the risks. Donors occasionally change their minds.
The hospital used to require all liver donors to have an emotional bond with the recipient—you couldn’t donate part of your liver to an acquaintance or a stranger, the way you could a kidney. After months of consideration, the committee recently allowed one patient to receive part of a liver from someone in his church whom the man didn’t know.
“Our beliefs are evolving,” says Johnson. “We were very restrictive starting out because of the risks involved. The question is: Are we being too paternalistic by making these arbitrary decisions about who can and who can’t? What right does an individual have if they really want to go forward with something like this?”
As Jacqueline Dorsey sits in the waiting room, her daughter in one room and her niece in another, she remembers when she felt helpless—when she realized she couldn’t get Jessica the one thing she needed.
“Don’t cry for me, Aunt Jacquie,” Jessica had said.
Jessica had shown her the letter she wrote to Tovah, thanking her for giving her a second chance. A priest had made prayer shawls for both girls. Today’s surgery, Dorsey says, is a miracle.
A nurse stops by about an hour into the transplant. Tovah’s surgery is going well; Jessica’s asleep.
“I know the waiting is hard,” the nurse says. “They’re in the best of hands.”
“And those hands are in bigger hands,” Jacqueline says.
Johnson walks into the waiting room a few hours later and leads Dorsey and other relatives to a private room.
“Her surgery went fine—we didn’t have any trouble at all,” he says. “Our only concern at this point is that the left lobe of the liver is a little smaller than what the MRI indicated. That’s not a problem for Tovah at all, but we’re more concerned about Jessica.”
Johnson explains that Jessica’s blood flow can overwhelm such a small piece of liver. Doctors are trying to slow it down.
“There aren’t many things you can do in life that are greater than this,” Johnson says of Tovah. “We’ll keep our fingers crossed.”
When Johnson asks his residents what they should do first when they run into bleeding, most of them say, “Stop the bleeding. Put in a stitch.”
He corrects them: “The first thing you do is you don’t panic.”
He once had a patient who donated part of his liver to his wife and developed a blood clot during surgery. The man’s wife was doing well, but his own liver started to fail. Johnson was envisioning a tragedy. He had to decide whether to try to nurse the man through or get him listed. He’d never had to transplant to a donor before; he did it, and it worked.
“Anytime we go into the operating room, it’s a possibility—any operation can go bad,” says Johnson, who now plays golf with the man every year. “There are times when you’re in an operation, everything’s going fine, and all of the sudden the patient’s heart stops. If you make the right decisions, oftentimes you get them right back.”
Johnson doesn’t accept every organ he’s offered. He weighs the risks. He can’t find out everything about every deceased donor—some families share information; others don’t. A donor might have a history of drug or alcohol abuse or a previous illness. Many people who have had cancer can’t be organ donors, although they can sometimes donate skin, corneas, bone, and other tissue. He’s had patients who didn’t want an organ from an older donor.
Johnson has to decide if his patient is better off with a donor organ or without it. It’s not always easy: He had an organ from a 19-year-old donor who tested positive for hepatitis C, and the liver looked better than any he’d seen in months.
“If I had a patient that had acute liver failure and the only organ I got was a hepatitis-C organ, I would’ve taken it,” he says, “because here’s what I’m faced with: I may give her hepatitis C—or she may die.”
He was in the Georgetown cafeteria last summer, between transplants, when a colleague called from the operating room to tell him his patient had hypertension in the arteries in his lung. The patient was hours from getting a new liver, but after consulting with the anesthesiologist, Johnson called it off—there was a high risk of heart failure. The organ would go to a backup patient, who was waiting at home for a call. Someone would have to tell the man he wasn’t getting a transplant that day. He did get an organ later.
“They come in with this anticipation,” Johnson says. “A patient can come into the hospital and we go out and get the organ and find out it’s not good. It can happen where patients are under anesthesia and we have to back out—they wake up and think they’ve had a transplant.”
The couch in Johnson’s office doesn’t get much use anymore. He’s head of the department—he doesn’t have to be there for every operation. Every so often, he’ll have a day that doesn’t end: He and his partner recently did six transplants in 36 hours. Johnson did three livers and a kidney.
One of his patients, a 34-year-old named Amy who has primary sclerosing cholangitis, the same rare liver disease that struck football star Walter Payton, was getting her second transplant. Johnson had performed Amy’s first transplant two months earlier, but an artery clotted when she got home. He had to put her back on the transplant list.
If you’re doing big operations with big risks, he has realized, things won’t always turn out the way you expect them to.
When Johnson visits Amy in intensive care in January, a few days after her transplant, she’s pale and sore. Her side hurts and her legs are swollen, but she has managed three laps around the hallway and is trying to sit up. She wants to know when she can go home.
“She’s getting spunky, Doc,” her father says.
Johnson wants to know if she’s eating. “Food is . . . ?” he asks.
“The food is okay,” she says.
“That’s not the right answer,” Johnson laughs. “Food is medicine.”
Many of Johnson’s transplant patients go on to live normal lives—his first live-donor liver-transplant patient had a baby a few years later; Jessica should be able to dance again. The new organ functions as any healthy one would.
Johnson tells Amy he’s moving her to a regular floor, where it’s quieter and she can get more sleep. He notices a photo next to her bed. “Little ones?” he asks.
Amy shows him the picture of her baby girl, who’s turning nine months in a few days.
“We’re gonna get you home soon,” he tells her.
“Thank you,” her father says, “from a very grateful dad.”