| The Nasty Side of Organ Transplanting Second Edition Norm Barber Copyright End Notes and Appendix 1. The Weekend Australian newspaper. Gentle Persuader by Roy Eccleston. 9 August, 1997 2. Nilges, R.G. et al. Beyond Brain Death. Harvard Medical School Ad Hoc Committee to Examine the Definition of Brain Death 2a The file containing brain death testing procedures is at http://www.anzics.com.au/files/brain_death_organ_donation.pdf and the home page is http://www.anzics.com.au/contact.htm 2b Dr Peter Doyle, British Department of Health, in personal correspondence to the author 3. Guardian Newspaper, United Kingdom. Sarah Boseley, Health Correspondent. 19 August 2000 www.guardianunlimited.co.uk 4. Guardian Newspaper, United Kingdom. Sarah Boseley, Health Correspondent. 19 August 2000 www.guardianunlimited.co.uk 5. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 164 6. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 152 7. Machado, Nora, Using The Bodies of the Dead ,Dartmouth Publishers, England, 1997. Dr Machado is quoting from Veatch:1993:18. Veatch, R. The Impending Collapse of the Whole Brain Definition of Death. Hastings Centre Report 1993a p 18-24. 8. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 see note 51 on page 156 9. Professor Shewmon spoke on "All In the Mind", Radio National, Australian Broadcasting Corporation. www.abc.net.au and www.abc.net.au/rn/science/mind/s746719.htm 10. David Wainwright Evans, former cardiologist at Papworth Hospital, Cambridgeshire, United Kingdom. Personal correspondence to the author. 11. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 144 12. Watanabe, Yoshio. "Why do I stand against the movement for cardiac transplantation in Japan". from the Cardiovascular Institute, Fujita Health University School of Medicine. Toyoake, Japan July 21, 1994 Dr Watanabe recommends the following for further reference; Dowie, M. We Have A Donor. A Bold New World of Organ Transplanting, Japanese translation by M. Hirasawa, Heibon-sha, Tokyo 1990 Kimbrel, S. The Human Body Shop. The Engineering and Marketing of Life, Japanese translation by S. Fukuoka Tokyo, Kagaku Dojin-sha 1995 13. Young & Matta Editorial. Anaesthesia 2000;55;105-6 Correspondence Anaesthesia 2000 55;695-6 14. Coimbra CG (1999) Implications of ischaemic penumbra for the diagnosis of brain death. Brazilian J Med Biol Res; 32:1538-1545 Study available at www. epm.br/neuro/brdeath.html 15. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 178 16. Thanks to Dr David J. Hill MA FRCA (Emeritus consultant anaesthetist) of Cambridgeshire, England, U.K. for help in interpretation 17. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 18. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 173 19. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 20. Dr David Wainwright Evans, former cardiologist at Papworth Hospital, Cambridgeshire, United Kingdom. Personal correspondence to the author. 21. Watanabe, Yoshio. "Why do I stand against the movement for cardiac transplantation in Japan". from the Cardiovascular Institute, Fujita Health University School of Medicine. Toyoake, Japan July 21, 1994 22. Finn, Robert. Organ Transplants. O�Reilly and Associates Publishers, Sebastopol, California USA 2000 23. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 p 108 24. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 25. Barnard, Christiaan and Curtis Bill Pepper. One Life. Australasian Publishing Company, Sydney, Australia 1972 26. Clendinnen, Inga; Tiger�s Eye � A Memoir, The Text Publishing Company, Melbourne, Australia, 2000 p281 27. Clendinnen, Inga; Tiger�s Eye � A Memoir, The Text Publishing Company, Melbourne, Australia, 2000 p286 28. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 page 177 29. Black, Sir Douglas et al, A Code of Practice for the Diagnosis of Brain Stem Death � including guidelines for the identification and management of potential organ and tissue donors. Department of Health, United Kingdom. March 1998 30. Black, Sir Douglas et al, A Code of Practice for the Diagnosis of Brain Stem Death � including guidelines for the identification and management of potential organ and tissue donors. Department of Health, United Kingdom. March 1998 31. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 256 32. Australia New Zealand Organ Donor Registry (ANZOD) Annual Report 2000, editors Karen Herbertt and Graham Russ, ANZDATA Registry, Queen Elizabeth Hospital, Woodville, South Australia 33. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 256 34. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 256 35. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 36. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 37. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p187 38. Adelaide Advertiser Newspaper, Adelaide, Australia. March 29,30, 2001 39. Personal correspondence with the author. The writer has not given permission for her name to be printed. 40. Deng, Mario C., Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure severity BMJ 2000;321:540-545 ( 2 September,2000 ), Available at British Medical Journal web site at www.bmj.com/cgi/content/full/321/7260/540 41. Dr David Wainwright Evans, former Cardiologist, Papworth Hospital, United Kingdom, Personal correspondence with the author. Dr Evans says, �The "hunger for scarce resources" has, indeed, deprived many worthy citizens of the chance of useful extension of life via the tried and tested surgical procedures - valve replacements, coronary bypass grafts etc. - which units like ours at Papworth were set up to provide. Three such patients died in one month for lack of operations which, but for heart transplants, they would have received while with us; as it was, they were sent out to await the availability of facilities (particularly ITU beds) and perished ere they could be re-admitted. In one 18-month period we lost 14 patients similarly.� 41a The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) Queen Elizabeth Hospital, Woodville, South Australia http://www.anzdata.org.au 42. Orange County Register Newspaper, California. U.S.A. Body Broker Series. April16-20, 2000. www.ocregister.com/health/body/index.shtml 43. Orange County Register Newspaper, California. U.S.A. Body Broker Series. April16-20, 2000. www.ocregister.com/health/body/index.shtml 44. Glaxo-Wellcome (now known as Glaxo-Smith-Kline) has funded the Victorian Donor Registry in Australia with $400,000 Fujisawa, who manufacturer Tacrolimus under the tradename Prograf, fund production of What Every Patient Needs To Know, a publication of the United Network for Organ Sharing (UNOS) the world�s largest organ allocation and transplant promotion organisation. UNOS holds the government contracted monopoly on organ allocation for the whole of the United States. The booklet includes finding a transplant team with a high survival rate, maximising government and insurance payments and, if you don�t have enough money, asking for donations from churches, service groups and contacting media to run sad case stories and running charity fundraising campaigns with you as the principal beneficiary. On page one it says, "UNOS gratefully acknowledges Fujisawa HealthCare, Inc. whose generous education grant made possible the production of What Every Patient Needs To Know." But why does Fujisawa so kindly provide funding for UNOS, well, the booklet doesn�t mention this but UNOS owns a shadow organisation called the UNOS Foundation which itself owns something called Transplant Informatics Institute run by UNOS staffers which analyses and sells organ network data to guess who, Fujisawa HealthCare which wants their product, Tacrolimus, to replace the current favourite, cyclosporin, which is produced by rival drug company, Novartis. Drug companies sponsoring organ allocation and donor promotion organisations isn�t unusual, but perhaps the dubious aspect is UNOS thanking Fujisawa thus creating the impression it is a gift rather than a commercial trade agreement between businesses. And what else does the booklet tell us? Cyclosporin, the most popular anti-rejection drug made by rival company, Novartis, is merely "A drug" which suppresses "the body�s defence system" while the less popular Tacrolimis (Prograf), produced by Fujisawa, is "A powerful immunosuppressant" which "turns down the body�s immune response" It pays to give money to UNOS. (see page 8 and 10 of the booklet) 45. Orange County Register Newspaper, California. U.S.A. Body Broker Series. 16-20 April, 2000. www.ocregister.com/health/body/index.shtml 46. Orange County Register Newspaper, California. U.S.A. Body Broker Series. 16-20 April, 2000. www.ocregister.com/health/body/index.shtml Another product is Restylane; a non-animal stabilised Hyaluronic Acid, which is injected into the lips. It is made from culturing in-vitro cells removed from the swollen joints associated with arthritis. Cosmetic technicians inject Restylane into the face causing arthritic swelling, which removes wrinkles. It can also be used to swell thin, cruel lips making them look pouting and attractive. It costs $395 and lasts one year. Yet another wrinkle reducer is made from botulism. It paralyses the facial muscle so the customer can�t smile or grimace nor produce laugh lines. These products are advertised in glossy magazines devoted to the subject of cosmetic surgical procedures and include bum implants for men who want their buttocks to stick out. Much of the transplant industry feeds neurosis and wastes resources that should go to preventative medicine and medical help for poorer people of the world. Who would want a bum implant, anyway? 47. Orange County Register Newspaper, California. U.S.A. Body Broker Series. 16-20 April, 2000. www.ocregister.com/health/body/index.shtml 48. Orange County Register Newspaper, California. U.S.A. Body Broker Series. 16-20 April, 2000. www.ocregister.com/health/body/index.shtml 48a. Adelaide Advertiser Newspaper, Adelaide, South Australia, Australia. 7 January, 2002 49. Potts, Michael; Byrne, Paul A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p 163 50. OrganKeeperTM is a Trademark name owned by Duane Horton of Rhode Island, U.S.A. who operates www.organkeeper.com 51. Time Magazine (Australian Edition), Sydney, Australia. 26 February 2001 52. Scheper-Hughes, Nancy; Organs Watch at the University of California, Berkeley http://sunsite.berkeley.edu/biotech/organswatch/ 53. Finn, Robert. Organ Transplants. O�Reilly and Associates Publishers, Sebastopol, California USA 2000 p90 54. Dowie, Mark; We Have A Donor, St Martin's Press, 175 Fifth Avenue New York. p116 55. Watanabe, Yoshio. "Why do I stand against the movement for cardiac transplantation in Japan". from the Cardiovascular Institute, Fujita Health University School of Medicine. Toyoake, Japan July 21, 1994 56. Personal correspondence with the author. Dr Robert Claxton was asked by the Sydney Diocese Secretariat of the Anglican Church to respond to questions put to them. 57. His Holiness Pope John Paul II, in his address to the International Conference of the Transplantation Society on 29 August, 2000. The full transcript of the Pope�s address and the International Statement Opposing "brain death," can be obtained from Earl Appleby Jr at CURE, 812 Stephen Street, Berkeley Springs, WA 25411 USA. The CURE Website is www.cureltd.home.netcom.com 58. Queensland Right To Life, Personal Correspondence with the author. 59. His Holiness Pope John Paul II said in his address to the International Conference of the Transplantation Society on 29 August, 2000. The full transcript of the Pope�s address and the International Statement Opposing "brain death," can be obtained from Earl Appleby Jr at CURE, 812 Stephen Street, Berkeley Springs, WA 25411 USA. The CURE Website is www.cureltd.home.netcom.com 60. Chang, Garma C.C.; The Six Yogas of Naropa and Teaching on Mahamudra, Snow Lion Publications, New York, USA 61. Scheper-Hughes, Nancy; Organ Watch at the University of California, Berkeley http://sunsite.berkeley.edu/biotech/organswatch 62. South Australian Organ Donation Agency, Legal and Ethical Aspects, circa 1995, Adelaide South Australia 63. Personal Correspondence with the author. Japan Organ Transplant Network, www.jotnw.or.jp, email [email protected] They accept and respond to correspondence in English. 64. South Australian Organ Donation Agency, Legal and Ethical Aspects, circa 1995, Adelaide South Australia 65. Personal communication to the author from Janine Werneberg of the Church of Scientology in Australia 66. Australia New Zealand Organ Donor (ANZOD) Annual Report 2000, editors Karen Herbertt and Graham Russ, ANZDATA Registry, Queen Elizabeth Hospital, Woodville, South Australia 67. Deng, Mario C., Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure severity BMJ 2000;321:540-545 ( 2 September,2000 ), Available at British Medical Journal web site at www.bmj.com/cgi/content/full/321/7260/540 67a Anyanwu AC, Rogers CA, Murday AJ; Steering Group. Intrathoracic organ transplantation in the United Kingdom 1995-99: results from the UK cardiothoracic transplant audit. The UK Cardiothoracic Transplant Audit, Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK. 68. Deng, Mario C., Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure severity BMJ 2000;321:540-545 ( 2 September,2000 ), Available at British Medical Journal web site at www.bmj.com/cgi/content/full/321/7260/540 69. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 70. Barnard, Christiaan and Curtis Bill Pepper. One Life. Australasian Publishing Company, Sydney, Australia 1972 71. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 p36-37 72. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 p24 73. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 74. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 p204 75. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 76. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 The authors say this report came from The New Indian Express, February 2, 1999 76a Brumm, Judith. This Little Piggy Went to the Biotech Market. Nursing Spectrum Magazine, United States. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=8146 77. Cooke, Jennifer, Cannibals, Cows and the CJD Catastrophe, Random House, Milsons Point, NSW 1998 78. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. This independent inquiry was funded by the government after public opinion and victims� relatives wouldn�t accept the Australian government�s own investigation. A more popular and readable version of hGH and CJD is found in Jennifer Cooke�s Cannibals, Cows and the CJD Catastrophe. 79. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994 80. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. P 75-79 81. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. P71 82. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. P69 83. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. P 392,393,396 84. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. P391 85. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. 86. Allars, Margaret. Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease, Australian Govt Publishing Services, Canberra, Australia. 1994. 87. Cooke, Jennifer, Cannibals, Cows and the CJD Catastrophe, Random House, Milsons Point, NSW 1998 88. Scheper-Hughes, Nancy; Organ Watch at the University of California, Berkeley http://sunsite.berkeley.edu/biotech/organswatch/ 89. Healey, Kaye, Editor, Organ Transplants, Spinney Press, Balmain, New South Wales, Australia. 1996 90. Scheper-Hughes, Nancy; Organ Watch at the University of California, Berkeley http://sunsite.berkeley.edu/biotech/organswatch/ La Stampa, 26 November, 1993. 91. Yallop, David; To The Ends of the Earth. Jonathan Cape, London 1993 p286-288. 295,296,297 92. GM Guiraudon personal communication with Cardiologist Yoshio Watanabe written in "Why do I stand against the movement for cardiac transplantation in Japan". from the Cardiovascular Institute, Fujita Health University School of Medicine. Toyoake, Japan July 21, 1994 93. Watanabe, Yoshio. "Why do I stand against the movement for cardiac transplantation in Japan". from the Cardiovascular Institute, Fujita Health University School of Medicine. Toyoake, Japan July 21, 1994 94. Prasad, K.R. and Lodge, J.P.A.; Transplantation of the Liver and Pancreas; British Medical Journal, United Kingdom 7 April, 2001 95. Scheper-Hughes, Nancy; Organ Watch at the University of California, Berkeley http://sunsite.berkeley.edu/biotech/organswatch/ 96. Personal correspondence with the author. The writer has not given permission for her name to be printed. 96a. Potts, Michael; Byrne, Paul A. and Nilgais, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p166 A. and Nilges, Richard, editors. Beyond Brain Death. Kluwer Academic Publications, London, United Kingdom. 2000 p186 98. Barnard, Christiaan; The Second Life: Memoirs, Hodder and Stoughton, Sydney, Australia 1993. P33 99. Cooper, D.K.C. and Lanza, R.P. Xeno. Oxford University Press, New York, NY 2000 p134,135 Appendix One Dr David Wainwright Evans Cerebral angiography is an old and quite dangerous technique for demonstration of blood flow in the major arteries and veins inside the skull. It involves the injection of a radio-opaque contrast medium (often known colloquially as �dye�) into the carotid - and, maybe, the vertebral - arteries. This contrast medium is not radioactive. Its presence in the intracranial vessels can only be ascertained by taking X-ray pictures from several angles. It is a relatively insensitive technique because the thick bony skull poses problems for X-ray imaging and, crucially, because quite a lot of contrast has to get into the intracranial (i.c.) vessels to guarantee a �shadow� on the film. It is, therefore, easy enough to see things like displacement of well-filled vessels (e.g. in cerebral tumour etc.) but difficult or impossible to rule out some blood flow in some parts of a generally swollen brain. It is entirely possible for an angiogram to be reported as showing no evidence of i.c. flow although there may be just enough oxygenated blood getting through to keep brain tissue in some areas alive (cf. Coimbra�s �ischemic penumbra�). For these reasons - and because the technique may exacerbate the brain damage or even cause fatal collapse in the X-ray room (shades of the apnoea test �.) - cerebral angiography has never been a popular investigation where so-called brain death is concerned, even in those centres where the technique is readily available. By contrast (no pun intended!), radioisotope studies do, as their name suggests, use radioactive tracer substances in their attempt to detect intracranial blood flow. This, also, is a relatively insensitive means of demonstrating minimal flows - for many of the same reasons - but it is much less dangerous (though not generally available). Doppler flow studies, which use ultrasound, are even safer but still less reliable. Some centres use these techniques, chiefly in research studies aimed at justifying the clinical diagnosis of brain death, but they have never been popular here and are not required for the diagnosis of �death for transplant purposes� on the basis of the Department of Health�s �Code of Practice�. Were they to be carried out on some of those certified �dead� under those rules, it is exceedingly likely that some would show evidence of persisting i.c. blood flow - an additional and very powerful reason not to use such �confirmatory techniques�. Appendix Two Dr David Wainwright Evans We are talking about severe, usually traumatic, brain injury. There will be parts of the brain which have been destroyed by the injury itself, by the extravasation of blood or by total deprivation of blood supply - due to rupture or occlusion of critical vessels perhaps but also because the blood supply to the brain as a whole becomes compromised by the rise in intracranial pressure (due to the brain swelling/oedema which accompanies the initial trauma). The �global ischemic penumbra� of which Coimbra speaks is that potentially very large part of the brain (hence the term �global�) which has not been destroyed by the interruption of circulation but is nevertheless so severely compromised by it (i.e. getting such an absolutely minimal trickle of blood - just enough to keep it alive but not enough to allow it to function) that it shows no sign of life (is functionless for the time being) and will die if the circulation is not restored very quickly or if it is not somehow protected from the effects of anoxia while the supply of oxygen and nutrients remains inadequate. There are means of protecting this apparently functionless and severely compromised brain tissue from further ischemic damage during the crucial few hours after the index injury. They include drugs and hypothermia and they work by limiting or actively reducing the swelling (so that some blood can get into the skull against the elevated intracranial pressure which tends to keep it out) and by reducing the demand for oxygen and nutrients while the blood flow is critically inadequate. This latter is the way in which moderate hypothermia is thought to work. Whether or not it can really achieve much salvage is still a matter of debate. The most recent studies of which I am aware indicate that it is the intracranial pressure which is of paramount importance and that attempts to increase the perfusion pressure do not help. It looks as if the emphasis should be on measures to reduce the �reactive oedema� and to keep the brain reasonably cool (and perhaps �sedated�) during the early hours in the hope that circulation will be restored to the �penumbra� brain tissue in time for it to regain function and viability. To sum up : The management of severe brain injury in its early phase is dominated by (1) attempts to reduce swelling of the brain within the rigid skull so that as much blood as possible may get in against the rising intracranial pressure which is �trying� to keep it out, and (2) attempts to minimize the demand for oxygen and nutrients of those (perhaps large) parts of the brain which might survive if they could be protected from handing in their cards before the swelling goes down and an adequate blood supply returns in consequence. The measures used in pursuance of (1) include drugs and the prevention of hypertension and overhydration. Hypothermia (not profound hypothermia, which is cooling to very much lower temperatures for different purposes) is favoured by some in pursuance of (2) but many are unconvinced of its value and there is vigorous debate about the validity of the trial findings. What matters is, as Coimbra says, that all the efforts in the early hours be made with the purpose of preserving as much compromised brain tissue as possible. The details of management will (properly) differ from centre to centre - and in due course consensus may emerge. That is the way genuine progress is made. What should be said is that the treatment of severe head injury should be optimised to that end, in the critical early stages particularly. That means that potentially harmful procedures (such as apnoea testing, which can cause lethal reduction in the perfusion of severely compromised tissue in the �penumbra� regions) must be avoided. Likewise overhydration, hyperthermia etc. The avoidance of measures which might exacerbate the brain damage, by whatever mechanism, is at least as important in the optimal management of these patients as the deployment of specific therapies. It is just such optimal management (aimed at maximizing salvage and therefore prospects of recovery) which is so conspicuously absent when the patient is regarded as a potential organ donor - perhaps from the first. |