Scores
of organs — mostly kidneys — are trashed each year and many more become
critically delayed while being shipped on commercial airliners, a new
investigation finds.
By JoNel Aleccia FEBRUARY
10, 2020
When a
human heart was left behind by mistake on a Southwest Airlines plane in 2018, transplant officials
downplayed the incident. They emphasized that the organ was used for valves and
tissues, not to save the life of a waiting patient, so the delay was
inconsequential.
“It got
to us on time, so that was the most important thing,” said Doug Wilson, an
executive vice president for LifeNet Health, which runs the Seattle-area
operation that processed the tissue.
That
high-profile event was dismissed as an anomaly, but a new analysis of
transplant data finds that a startling number of lifesaving organs are lost or
delayed after being shipped on commercial flights, the delays often rendering
them unusable.
In a
nation where nearly 113,000 people
are waiting for transplants, scores of organs — mostly kidneys — are discarded
after they don’t reach their destination in time.
Between
2014 and 2019, nearly 170 organs could not be transplanted and almost 370
endured “near misses,” with delays of two hours or more, after transportation
problems, according to an investigation by Kaiser Health News and Reveal from
the Center for Investigative Reporting. The media organizations reviewed data
from more than 8,800 organ and tissue shipments collected voluntarily and
shared upon request by the United Network for Organ Sharing, or UNOS, the
nonprofit government contractor that oversees the nation’s transplant system.
Twenty-two additional organs classified as transportation “failures” were
ultimately able to be transplanted elsewhere.
Surgeons
themselves often go to hospitals to collect and transport hearts, which survive
only four to six hours out of the body. But kidneys and pancreases — which have
longer shelf lives — often travel commercial, as cargo. As such, they can end
up missing connecting flights or delayed like lost luggage. Worse still, they
are typically tracked with a primitive system of phone calls and paper
manifests, with no GPS or other electronic tracking required.
Transplant
surgeons around the country, irate and distressed, told KHN they have lost the
chance to transplant otherwise usable kidneys because of logistics.
“We’ve
had organs that are left on airplanes, organs that arrive at an airport and
then can’t get taken off the aircraft in a timely fashion and spend an extra
two or three or four hours waiting for somebody to get them,” said Dr. David
Axelrod, a transplant surgeon at the University of Iowa.
One
contributing factor is the lack of a national system to transfer organs from
one region to another because they match a distant patient in need.
Instead,
the U.S. relies on a patchwork of 58 nonprofit organizations called organ
procurement organizations, or OPOs, to collect the organs from hospitals and
package them. Teams from the OPOs monitor surgeries to remove organs from donors
and then make sure the organs are properly boxed and labeled for shipping and
delivery.
From
there, however, the OPOs often rely on commercial couriers and airlines, which
are not formally held accountable for any ensuing problems. If an airline
forgets to put a kidney on a plane or a courier misses a flight because he got
lost or stuck in traffic, there is no consequence, said Ginny McBride,
executive director of OurLegacy, an OPO
in Orlando, Florida.
In an
era when consumers can precisely monitor a FedEx package or a DoorDash dinner
delivery, there are no requirements to track shipments of organs in real time —
or to assess how many may be damaged or lost in transit.
“If
Amazon can figure out when your paper towels and your dog food is going to
arrive within 20 to 30 minutes, it certainly should be reasonable that we ought
to track lifesaving organs, which are in chronic shortage,” Axelrod said.
For
years, organs were distributed locally and regionally first, a system that
resulted in wide disparities in organ waiting times across the country. In
recent years, UNOS officials and the transplant community, with federal urging,
have been working, organ by organ, to restructure how it’s done.
Amid
those ongoing efforts to allocate organs more fairly — and, recently, a Trump administration effort to
overhaul kidney care — the waste of some of these precious resources donated by
good Samaritans has been overlooked. Last year, an average of nine people a day
died while waiting for a new kidney.
Donor
families and waiting patients may never know what’s happened to an organ
provided by a loved one or why a surgery is canceled at the last minute.
“We
have been unaware of how many kidneys have been waylaid,” said McBride, of the
Orlando procurement agency. “That’s not a number that’s been transparent to
us.”
But,
she added, she’s aware of the risk: “I say a prayer and hold my breath every
time a kidney leaves our office.”
46
Minutes To Spare
In
October, a kidney en route from McBride’s OPO in Florida to a patient in North
Carolina missed its connection in Atlanta. The box was prominently marked as a
human organ and displayed a phone number to call. Apparently unaware of the
urgency, a Delta cargo worker merely set it aside for a later flight.
The
waiting transplant surgeon in Greensboro, North Carolina, “was having a fit,”
said Kim Young, the OurLegacy organ recovery coordinator. If the kidney didn’t
get to the hospital by 7 a.m., he wouldn’t be able to use it. Both the risk of
organ failure and the chance of death increase with every hour a kidney
is out of the body.
McBride
had to decide whether to charter a plane at a cost of $15,000 — or to find a
courier to drive the kidney through the night. She settled on the road trip,
and the organ arrived at 6:14 a.m. — with just 46 minutes to spare.
Four
months later, the transplant appears to have been a success, McBride said.
Delta
Air Lines officials declined repeated requests to comment on its organ
transport service or the specific incident McBride described.
Several
domestic airlines, including Delta, United, American, Southwest and Alaska, provide
special cargo services for organs with priority boarding, handling and
monitoring. They all declined to comment on organ transportation.
The
traveling public may not realize it, but thousands of transplant organs —
mostly kidneys, but some pancreases — fly on commercial flights each year.
Roger Brown, who runs the Organ Center at UNOS,
estimates that as many as 10 organs for transplant are on the move this way
every day.
UNOS
handles about 1,800 of these organ and tissue shipments a year, of which 1,400
are kidneys. That’s a fraction of the nearly 40,000 organs transplanted in the
U.S. last year, including more than 23,000 kidneys. About 1 in every 6
transplanted kidneys is shipped nationally, UNOS figures show.
Most of
the time, the organs get where they’re going without incident, Brown said.
“We’re
never going to get rid of flight delays. We’re never going to get rid of human
error,” he said. “We’re never going to get rid of the person who’s [trying to
be] a little too helpful and perhaps puts it someplace special, which then
maybe creates issues downstream.”
Troubling
Reports
Reports
of trouble abound. In August, transplant officials at Medical City Dallas
reported in a public forum that
they’d lost three kidneys just that month because of problems with commercial
flights.
“One
organ was delayed due to weather and the next available flight wasn’t till the
next day,” the report said. “Another organ made it to the airport, but was
never placed on the intended flight. The third organ was mistakenly taken to
the wrong airport and missed the intended flight.”
In
Kentucky, transplant surgeon Dr. Malay Shah said a kidney traveling on Delta
from Pensacola, Florida, via Atlanta, on Oct. 1 sat in the Lexington airport
for three hours before he was notified it was there. No one had noticed the box
with the label that said “human organ for transplant,” he said.
“It’s
scary,” Shah said. “Organs traveling by this mechanism are treated as simply
‘baggage’ or ‘cargo.’”
Before
the 9/11 terror attacks in 2001, OPO workers could take organs through airport
security and see them loaded onto the plane from the passenger gate, McBride
said. Because of changes in security protocol, airline employees now load
organs on the tarmac, where they fly in pressurized cargo holds.
While
anecdotes like Shah’s are common, there’s little data to show how often these
transportation problems occur. No federal agency, including the Health Resources and Services
Administration, or HRSA, which contracts with UNOS, requires
monitoring of transportation for transplant organs.
“Matters
involving the transportation methods used by organ procurement organizations
(OPOs) are arranged directly between OPOs and transplant centers,” HRSA
spokesperson David Bowman said in an email.
Airlines
log organ shipments in internal booking systems and on cargo manifests, but
those documents aren’t public and no summary is available, said Katherine
Estep, communications director for Airlines for America, an
industry trade group.
“Live
human organs receive the highest priority designation,” she said in a
statement.
UNOS
researchers noted the impact of transportation
problems in 2014. They found 30 organs discarded and 109 “near
misses” between July 2014 and June 2015.
But the
agency didn’t begin formally tracking transportation errors until 2016, when a
new computer system came online. Before that, Organ Center staff kept track of
problems informally, with pencil and paper, and the information wasn’t
verified, Brown said.
Calls
for closer tracking from within the system have been met with defensiveness —
or apathy, said Brianna Doby, an organ transplant community consultant for the
Johns Hopkins School of Medicine.
“If you
talk out loud about organ issues, they say it will drive down donation rates,”
Doby said. “It’s not OK for us to say, ‘Well, shipping is hard.’ That’s not an
acceptable answer.”
A
National Network
UNOS was established in 1984 after
Congress enacted the National Organ Transplant Act to
address a critical shortage of donor organs and to improve organ matching and
placement. It called for a national network to ensure that organs that couldn’t
be used in the area where they were donated would be transplanted to save lives
elsewhere. Before that, many organs were lost simply because transplant teams
couldn’t find compatible recipients in time.
The act
established the national Organ Procurement and Transplantation Network and
called for the OPTN to be operated by a private, nonprofit organization under
federal contract. UNOS, which has held the contract since the inception of
OPTN, is overseen by HRSA, an agency of the U.S. Department of Health and Human
Services.
Today,
UNOS typically handles organs with conditions that can make them hard to place.
That can include organs from older donors or those with medical or other
characteristics that make them difficult to match.
Overall,
about 7% of shipments handled by UNOS from July 2014 to November 2019
encountered transportation problems, the data obtained by KHN and Reveal
showed. UNOS wouldn’t release details about individual shipments, including
dates or places shipped or causes of the transportation failures or delays.
But
Brown, of the UNOS Organ Center, said an internal analysis showed that more
than half of the transportation problems were related to commercial airlines or
airports. Of those, two-thirds were caused by weather delays, mechanical delays
and flight cancellations.
About
one-third of transportation problems were related to logistics providers or
ground couriers, mostly delays of package pickups. The rest were related to the
sender or receiver of the shipments. The most common issue was the package not
being ready for pickup at the designated time.
However,
Brown said, poor outcomes can’t be blamed directly on transportation problems,
even when they do occur.
“The
delay could be the primary reason an organ wasn’t transplanted,” he said. “It
could be a contributing factor or it could have nothing to do with the reason
that the organ is not transplanted.”
Other
transplant experts downplay the impact of transportation problems. Kelly Ranum,
president of the Association of Organ Procurement Organizations,
said she’s “surprised at how low” UNOS’ failure numbers are, considering the
volume of kidneys shipped.
Dr.
Kevin O’Connor, chief executive of LifeCenter Northwest, an OPO based in
Seattle, said transportation problems are “minimal” compared with the other
reasons organs — including about 3,500 donated kidneys — are discarded each
year. These typically include biopsy
findings, the inability to find a recipient and poor organ function.
“For
over 30 years and literally tens of thousands of organs being transported,” he
said, “I can count on the fingers of one hand the number of times that, because
of a transportation glitch, an organ was ultimately not transplanted.”
Still,
O’Connor acknowledged that “even one kidney being thrown away because of
transportation errors is unacceptable.”
Part of
the problem lies with the way organs are transported now, said Axelrod, who
also represents the American Society of Transplant Surgeons.
“We don’t
have an end-to-end unified transportation system,” Axelrod said. “We don’t have
a FedEx for transplant. We have a cobbled-together system of OPOs and couriers
and private aircraft and commercial aircraft.”
In
recent years, several courier companies have emerged to meet the market for
transplant organs. Don Jones, chief executive of the Nationwide
Organ Recovery Transport Alliance, or NORA, contracts with more than
15 OPOs and oversees about 400 organs a year on commercial flights.
“I
would say 99.8% of our transports on commercial airlines go perfectly fine,”
Jones said based on his estimate. Jones noted that his firm ships organs only
on direct flights and uses GPS tracking to monitor them.
However,
GPS tracking isn’t universal — or required by UNOS or HRSA. Some couriers and
airlines use it; many don’t. Many OPOs monitor organs through a combination of
verbal handoffs, automation and label scans, Brown said.
In
Ginny McBride’s misadventure last fall, she contracted with a courier, Sterling Global Aviation Logistics,
which used Delta Air Lines to ship the kidney.
Delta
uses GPS trackers on its Dash Critical shipments,
promising fast, guaranteed delivery of human organs. But on that night in
October, the kidney was shipped from Orlando to Atlanta without a GPS tracker.
In Atlanta, a cargo worker couldn’t find a GPS device to put on the box
containing the kidney, so the worker held the organ for a later flight. That
would have pushed it far beyond the window of viability.
An internal Delta report, obtained
by McBride, found that Delta didn’t have enough GPS devices available in
Atlanta that night. “Destination stations are not returning the devices in a
timely manner,” according to the report. “One way to mitigate this from
reoccurring is to have a larger inventory of GPS devises (sic) at each
station.”
Delta
declined to comment on the report.
The
average wait time for a kidney varies widely nationwide, from less than three
years to more than a decade. One proposal to put more organs to use called
for eliminating the 58 donation service
areas and 11 regions now used to allocate kidneys and replacing
them with a zone of up to 500 nautical miles from the donor hospital.
In
December, OPTN cut that range in half — to 250
nautical miles — in part because of an outcry about problems shipping kidneys
via commercial air.
“There
are certainly no technological barriers to doing GPS and to actually requiring
it,” Brown said.
A UNOS
committee is considering whether to collect data on transportation methods
and outcomes, but, so far, the question remains under review.
“If the
community wants it, they should ask for it,” Brown said. “We can help
facilitate and get it done for them.”
McBride,
who discussed solutions with her colleagues, hopes the transplant organizations
will come together to solve transportation problems, to make sure every
eligible donated kidney gets transplanted.
“Any
organ that’s wasted, in my opinion, is a loss to the patient and to the
community,” said Paul Conway, of the American Association of Kidney Patients,
an advocacy group, who is himself a kidney recipient. “With all of the advances
going on with drugs, with medical procedures, how can you have a logistics
error be the barrier?”
This
investigation and a related podcast represent a collaboration between Kaiser
Health News and Reveal, from The Center for Investigative Reporting (CIR), a nonprofit
news organization. Reveal, from CIR and PRX, is a nationally
broadcast public radio show and investigative reporting podcast. Kaiser Health News (KHN) is a nonprofit
news service covering health issues. It is an editorially independent program
of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
JoNel
Aleccia: jaleccia@kff.org, @JoNel_Aleccia
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