A Surgeon Reflects On Death, Life And The 'Incredible Gift' Of Organ Transplant | Connecticut Public Radio
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A Surgeon Reflects On Death, Life And The 'Incredible Gift' Of Organ Transplant

Jan 14, 2019
Originally published on January 21, 2019 8:40 am

When Joshua Mezrich was a medical student on the first day of surgical rotation, he was called into the operating room to witness a kidney transplant.

What he saw that day changed him.

After the donor kidney came out of ice and the clamps on it were released, he says, "it turned pink and literally, in front of my eyes, this urine just started squirting out onto the field."

Mezrich was blown away: "I just had this sense like, 'This is so amazing, what we're doing, and what an incredible gift. And could I ever do this? Could I ever be part of this exchange, this beautiful thing?' "

He went on to become a transplant surgeon and has since performed hundreds of kidney, liver and pancreas transplants. He also has assisted in operations involving other organs.

Each organ responds to transplant in a different way.

"The liver will start pouring bile. The lungs start essentially breathing," Mezrich says. "Maybe the most dramatic organ, of course, is the heart, because you put it in and you kind of hit it like you hit a computer, maybe you give a little shock and it just starts beating, and that's pretty darn dramatic."

Mezrich is an associate professor in the division of multiorgan transplantation at the University of Wisconsin School of Medicine and Public Health in Madison. He reflects on his experiences as a transplant surgeon and shares stories from the operating room in his book, When Death Becomes Life.


Interview Highlights

On the different types of organ donors

There are a few different scenarios [where] we take organs from deceased donors, the most common being those that are brain-dead. Those patients have no blood flow to their brain, so they're considered legally dead, but their heart is still beating, their organs are getting blood flow, and they're often in a fairly stable situation, so we can take our time.

... it's an interesting thing, because you really think about what really is death? How is it defined? Do patients feel the same way as we do? - Joshua Mezrich, transplant surgeon

There's a second type of donor, which we call "DCD," or donation after circulatory death. These patients are actually still officially alive, but they've reached the point where the decision has been made to withdraw support. And in those patients, we wait to withdraw support until everything has been discussed, and often the family is in the room when that support is withdrawn by their primary doctor, not by us. ...

You know, it's an interesting thing, because you really think about what really is death? How is it defined? Do patients feel the same way as we do? These are kind of some of the really interesting challenging parts of being in this field.

On how transplant takes a long time and requires stamina from doctors

I train a lot of people in transplantation, we call them fellows. ... These are people who've finished their general surgery residency and now they're getting additional training [in] transplant, and they're excellent. ... Being a surgeon, particularly liver transplant, is all about kind of intestinal fortitude or inner strength. You've just gotta keep your wits and stay strong through all the different things that maybe can go wrong and fight through it. That's certainly what a liver transplant is like.

On having to make the judgment call about giving livers to patients with alcoholic liver disease

Transplant is one of those things that it's an amazing science and the surgery is very heroic, but if there isn't the social support and the ability to take care of the organ, it'll surely fail. You have to take all these medications to prevent rejection. You have to follow up a lot. Sometimes you have to battle through different complications, and so it really requires a village, if you will, to support any type of transplant.

This is a really important topic when we think about liver transplantation. So in the early days of liver transplant — '60s, '70s — initially people decided not to transplant patients with alcoholic liver disease because of the thought that they did this to themselves and maybe they didn't deserve it. I think now most people would agree that alcoholism is a disease, and it's a disease that is hard to treat and it can come back.

So rather than maybe think about it as, "These people are being stupid," or they're like your silly friends who drink too much, they truly have this addiction and it's a disease like other diseases, like hepatitis C, like the other things we transplant with more complex names. And it's been shown that we can get good outcomes in patients with alcoholic liver disease, as long as they have insight into their disease, and kind of have a support system to try and deal with the transplant afterwards.

But it is controversial, because patients with alcoholic liver disease often have a lot of failed relationships, have a lot of challenges in their life, don't have great family support. It's challenging to talk about some of these patients and wonder if we are going to get the best outcome, if this transplant is actually going to fix their problem or not. I think our health care system likes these heroic treatments like a liver transplant, but we don't put enough into prevention, into really understanding and managing the disease, and that can be sometimes a challenge. We've had many incredible victories with transplanting livers into [patients with] alcoholic liver disease but we've also had some dramatic failures.

On what it's like talking to the families of donors

This is really one of, in my opinion, the most special parts of being in my field of being a transplant surgeon. I was really nervous the first time I met a donor family because I thought they were gonna look at me and think I'm this vulture who is taking the organs out of their loved one, and I could only imagine the images they might have had.

But I'll never forget that interaction and most that I've had with the donors: They hung on every word. ... They wanted to know about the recipients. It truly was this beautiful legacy of their loved one, often who has died unexpectedly, sometimes a young person, and it gives them this positive thing to hold onto in this otherwise terrible time.

It is so incredibly special, and I truly believe the donors, even the deceased donors, are our patients just as much as the recipients. It's so important that we connect with the family, that we let them understand the process, that we are able to do a great job to make this incredible gift work. It's quite emotional. It really is an incredible bond when we interact with these families.

On saying a few words about the donor before the operation begins

I want to reiterate as many times as possible how important the donors are, how much they're heroes to us, and we always want to remember their stories and this gift that they're giving. It's very emotional when we go on these procurements, and in our group when we go on a procurement, when we're in the operating room, we always take a pause and our people from our organ procurement team will, after a moment of silence, will read something. Often it's a poem or something that one of the loved ones asked us to say about the person, maybe a little bit about who they were, what was important to them. Sometimes it has a religious base, sometimes it doesn't.

And we all kind of sit and think about it, and it is very special. It's emotional. And then the second that's over, we move on and really go after the task at hand. So it's interesting. You have this emotional experience, and then you have to very quickly kind of push it out of the way and and move on to the operation, but it's always very special.

Sam Briger and Mooj Zadie produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Scott Hensley adapted it for the Web.

Copyright 2019 Fresh Air. To see more, visit Fresh Air.

DAVE DAVIES, HOST:

This is FRESH AIR. I'm Dave Davies in for Terry Gross, who's off this week. Our guest, Joshua Mezrich, makes a living doing things that were the stuff of science fiction just a few decades ago. He extracts organs from one body and plants them in another, often saving the life of the organ recipient. Mezrich has performed hundreds of kidney, liver and pancreas transplants, and he's assisted in operations involving other organs. He has a new book about his own experience, including some pretty gripping stories from the operating room and about the development of transplant surgery and the pioneers responsible for advances in transplant medicine.

Joshua Mezrich is an associate professor in the division of multi-organ transplantation at the University of Wisconsin School of Medicine and Public Health. His new book is "When Death Becomes Life: Notes From A Transplant Surgeon."

Well, Joshua Mezrich, welcome to FRESH AIR. You begin and end this book with scenes in small airplanes, where you're either heading to someone who - from whom you are going to extract organs, or you're heading somewhere else with a cooler in the airplane with a couple of kidneys in it. It never really occurred to me that a transplant surgeon needs to go and extract the organs. You do this a lot, don't you?

JOSHUA MEZRICH: Yeah, we do. And I did start and end with that on purpose because I know a lot of people, including my good friends, were surprised to hear that we actually go out. And it's one of the many exciting parts of our job - unusual parts of our job.

DAVIES: Right. And you're not flying commercial, like, trying to get an aisle seat here.

MEZRICH: No. We fly - there are lots of different ways different centers do it. At our center, we have some pilots who fly for the state who are on-call for us, and typically we fly in a Pilatus, which is a single-engine turboprop. It is true that organs sometimes get sent on commercial planes, kidneys in particular. So if you ever see a cooler in between the pilots as you board, it's probably a kidney.

DAVIES: And when you've arrived at a hospital where there is someone who may have, you know, gotten a head injury in a motorcycle accident, there's a family there who's, you know, in grief and trauma. What is your conversation with them like?

MEZRICH: This is really one of, in my opinion, the most special parts of being in my field of being a transplant surgeon. I was really nervous the first time I met a donor family because I thought they were going to look at me and think I'm this vulture who's, you know, taking the organs out of their loved one, and I could only imagine the images they might have had. But I'll never forget that interaction and most that I've had with the donors. They hung on every word. They loved to hear about it. They wanted to know about the recipients.

It truly was this beautiful legacy of their loved one often who has died unexpectedly, sometimes a young person, and it gives them this positive thing to hold on to in this otherwise terrible time. And it is so incredibly special. And I truly believe the donors, even the deceased donors, are our patients just as much as the recipients. And it's so important that we connect with the family, that we let them understand the process and that we are able to do a great job to make this incredible gift work. It's quite emotional. It really is an incredible bond when we interact with these families.

DAVIES: And when you're talking and having these really important conversation, is there a clock ticking in the back of your head saying, I want these organs as soon as I can get them?

MEZRICH: There's usually no rush at this point. There are a few different scenarios we take organs from deceased donors, the most common being those that are brain-dead. And those patients have no blood flow to their brain, so they're considered legally dead. But their heart is still beating. Their organs are getting blood flow, and they're in - often in a fairly stable situation, so we can take our time.

There's a second type of donor which we call DCD, or donation after circulatory death. These patients are actually still officially alive, but they've reached the point where the decision has been made to withdraw support. And in those patients, we wait to withdraw support until everything has been discussed. And often the family is in the room when that support is withdrawn by their primary doctor, not by us.

DAVIES: Right. So in that circumstance, like, a breathing tube may be removed or other devices so that the patient will gradually die.

MEZRICH: That's exactly right. So their doctor will withdraw support just like they would in an ICU or any other scenario. So they'll take out the breathing tube, take off the medicine supporting their blood pressure. And then if they die quickly, we sort of usher the family out and then quickly take organs out for transplant. So at that point, time is of the essence.

DAVIES: Right. And are there differences in use, utility and viability of the organs in the different circumstances, someone who's brain-dead but the heart is beating and another one...

MEZRICH: Yeah.

DAVIES: ...Who's been allowed to expire?

MEZRICH: Yes, absolutely. So they are very different scenarios. So with brain-dead scenario, we can use more organs. So for instance, we don't use the heart in DCD donors. So right off the bat, that's out.

DAVIES: So this is someone who - someone's been unplugged and allowed to die. You don't use the heart, right?

MEZRICH: That's right.

DAVIES: And that's why.

MEZRICH: Yeah because it's - with the heart, it's so critical that it starts working right away. And there's a major concern that when you withdraw support, the organs are getting less and less blood flow. The oxygen is decreasing, and there's an initial hit or damage to these organs. And with the heart, it's thought to be maybe too much - too risky to try and use that.

It's - we know the outcomes are a little bit worse with livers, although we use them. And really with all organs, it's a bit of a risk factor, but there just aren't enough brain-dead donors to go around. And, you know, it's an interesting thing because you really think about what really is death. How is it defined? You know, do patients feel the same way as we do? These are kind of some of the really interesting, challenging parts of being in this field.

DAVIES: Right. And points of view have changed over time about what's acceptable, too.

MEZRICH: That's absolutely right. I discuss this in the book because I think the history of brain death is so incredibly fascinating. But transplant - Joe Murray in particular, who's probably the most famous transplant surgeon, played a very central role in defining brain death and moving towards making that a legal definition of death.

So the first major article was written in 1968 in JAMA, Journal of American Medical Association. And it took, I would say, about 10 to - 10 years or so for the public to kind of get their heads around the idea that brain death was legally - could be legally equivalent to death. And it became law in most states in the early - around 1980 or right around there. But in that period, there was a lot of controversy, a few different transplant surgeons who were accused of murder.

DAVIES: So these surgeons were essentially seen as extracting organs from living people, and people were appalled. But...

MEZRICH: Yeah.

DAVIES: That's changed.

MEZRICH: Yeah, that's absolutely right. I mean, in those early - when transplant first started really in the early '50s, there were just a few kidneys being done, and nobody really thought much about it. Things started to get a little bit better with transplant as we got into the '60s - the 1960s. I think when heart transplant began in 1967, 1968, that both gripped the public because it was so dramatic, but it also got people really scared that maybe these doctors were taking out people's organs and, you know - make sure you don't sign up to be an organ donor. So it was, in a way, a rough period for the field, but it did push this forward.

And of course brain death is important for a lot of different reasons. I think when you think about futility in ICU patients, there was a period where the family still would have to make a decision about withdrawing support. And at least with brain death, that's sort of a definition that's been accepted as death or, I should say, legal death so that families don't have to be asked whether they want to discontinue support.

There's a lot of ethicists at this point that are calling to question whether brain death should be a real definition, that it was in many ways made up and lots of people don't accept it. I think there can be a lot of confusion about what's death, and I often see that when I go on these procurements, when I talk to families and they're not sure where - what state their loved one is in.

DAVIES: So let's talk about what these operations are like. Most of us have no idea what really goes on in operating rooms. I'm told there's rock music from time to time. It's interesting that you write that before you begin extracting the organs from a donor, you typically stop and say something about the patient, right?

MEZRICH: That's right. Again, I just - I want to reiterate as many times as possible how important the donors are, how much they're heroes to us. And we always want to remember their stories and this gift that they're giving. It's very emotional when we go on these procurements. And in our group, when we go on a procurement, when we're in the operating room, we always take a pause and our - people from our organ procurement team will - after a moment of silence will read something.

Often it's a poem or something that one of the loved ones asked us to say about the person, maybe a little bit about who they were, what was important to them. Sometimes it has a religious base. Sometimes it doesn't. And we all kind of sit and think about it. And it is very special. It's emotional. And then the second that's over, we move on and really go after the task at hand. So it's interesting. You have this emotional experience, and then you have to very quickly kind of push it out of the way and move on to the operation. But it's always very special.

DAVIES: How long does a transplanted liver or kidney typically last?

MEZRICH: Well, we talk a lot about averages and means. So for, like, a kidney transplant - for a living donor kidney, the half-life or the point where you've lost half the organs but half are going strong is probably about 15 years. For a deceased donor kidney, it may be more like 10 years. I usually think with liver, it's probably - the half-life is 12 to 15 years. The key is to avoid problems early.

DAVIES: And when you say half-life - does that mean when it's half gone, it's not going to be...

MEZRICH: No. I guess to clarify what I mean is that's the point where 50 percent of the people would have lost the organ, but 50 percent are still going strong. So it's kind of like the midpoint. I mean, transplant has only been a legitimate field, in my opinion, since around 1983. So there are still people that have organs, you know, working from the kind of early days when it was going well. But I think getting 15, 20 years out of an organ is pretty successful. There are people that go longer than that, but there's some that lose them earlier.

DAVIES: You know, a lot of the battle to make transplant surgery possible involved dealing with the reaction of the immune system rejecting a new organ. And so there are these immunosuppressive drugs which really changed the game. Just talk a little bit about how they work and the drawbacks. I mean, can they cause - what else can they do?

MEZRICH: Yeah. I mean, the immunosuppression - these drugs are what made transplant work. But in a lot of ways, they're the downside of transplant as well. I mean, they basically reduce the immune response because our immune systems are there to protect us from things like infections and tumors. But in a lot of ways, an organ transplant is like an infection. So it was designed to get rid of that. We have ways to suppress the immune system. But if we suppress it too much, like, say, irradiate a patient dramatically, then they're going to die of some infection.

So finding a way to push the immune system down enough to receive an organ but still be able to kind of fight off infection was a real challenge. Cyclosporine was maybe the most important drug that made transplant work, which was approved in 1983. We've since moved on to other medications, but they all similarly suppress the white cells, the T cells, other cells involved in the immune response. So the side effects, though, are many. I mean, certainly, you're at more risk for infection, more risk for cancer. Some patients develop diabetes.

Pretty much anything you can think of will be listed on a package insert for an immunosuppressive drug is the reality. I think we're getting better and better, and there are some strategies to try and alter the immune system without needing ongoing drugs. That's called - we call that tolerance. That may become a reality in the future as well.

DAVIES: Joshua Mezrich is a transplant surgeon at the University of Wisconsin School of Medicine and Public Health. His new book is "When Death Becomes Life: Notes From A Transplant Surgeon." We'll talk more in just a moment. This is FRESH AIR.

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DAVIES: This is FRESH AIR, and we're speaking with Dr. Joshua Mezrich. His new book is "When Death Becomes Life: Notes From A Transplant Surgeon."

One of the things I like about the book is that you talk a lot about what it feels like - the emotions you go through. And, you know, some things aren't so flattering. For example, you said that when you were an intern, you know, you would inflict pain on patients in the course of doing things like, you know, sticking needles and tubes in them and draining abscesses and that, over time, you became desensitized to their experience, which I think is something that a lot of people probably would identify with having experiences with medical personnel where it just seems like, gosh, you don't quite realize what you're doing to me. I'm wondering when you realized that and how it might've changed you.

MEZRICH: Yeah. I mean, this is something I think about a lot. I think, in general, I'm a kind of very empathetic, compassionate person. But when you're a resident on a busy surgical service, there is so much to get done during the day. And I'm also kind of the type of person who just - I get obsessed with trying to be perfect at whatever my job is. And I would have these gigantic lists with boxes next to them of tasks that needed to be done. And at some point, you have so much to do that it almost becomes more important to get the tasks done than to think about the patient that you're working on.

And I just can remember having to go through so many different procedures and tasks. And I'd come into the patient's room, and maybe they'd be eating. Maybe they'd be talking with family. And I had to get their chest tube out. And I'd be like, all right; we're doing this - just pull the tube out and move on. And when I look back on it, I do feel badly about some of that. There was just so much to do, and it became very easy to almost look at the patient as if they were in the way of getting these things done. I certainly don't feel that way now, and that's not the role I'm in now. But yeah, I feel kind of badly about some of that as I think back to it.

DAVIES: Right. Well, you're in medical school now, right? And the rules have changed for residents, right? They can't quite drive them the way they used to. I mean, do you ever tell folks, remember that these are human beings?

(LAUGHTER)

MEZRICH: Yeah, we do. I mean, I think, you know, people that go into medicine truly are, generally, good people that want to help people, that want to be there for them. I really believe that. But when you get in there, you can get overwhelmed by the amount that's expected of you. I think, in many ways, things are better. Not only are there work hour restrictions, but I think, you know, thankfully, people are trying to think more about putting the patient first, which you would think would be obvious (laughter). But I do think, in general, things have gotten better that way. But it is - it's a tough balance because patients don't feel well. They maybe are scared. They maybe don't want something done to them, and you're tasked to do it. And kind of getting that right is - can be a challenge but something we can always do better, I think.

DAVIES: You also describe the thrill of transplant surgery and, I guess, the first time you got a - you had a kidney transplanted. Seeing it begin to function, I mean, right there on the operating table, what do you see?

MEZRICH: Yeah. I mean, this was an incredible experience. In many ways, I feel like I kind of fell into being a doctor. My dad went back to medical school later in life, and I was already in third grade. And I remember hearing his stories and thinking it sounded exciting. But I don't really remember making the decision to go into medicine. I just kind of, in a way, stumbled into it. But I'll never forget that day. It was really my first day on my surgical rotation. And of course, I come in and I'm nervous, and I suddenly find out I'm on call, which I didn't know. And I was running around in cases all day, didn't eat all day. Almost passed out during a case at, like, 11:00 at night.

I remember hanging - almost hanging onto the patient's side as I was about to fall into the wound, but I pushed through it. And then around midnight or so my resident, who's above me - I was a medical student - told me to go scrub on this other operation. And I just wanted to go to bed. But I said, fine. And I went into the room. I didn't even know what we were going to be doing. And it was a kidney transplant from a deceased donor.

And I just remember watching this operation, and watching this kidney come out of ice, and as they released the clamps and it turned pink and, literally in front of my eyes, this urine just started squirting out onto the field and there was classical music playing. And I just had this sense like, this is so amazing, what we're doing, and what an incredible gift. And, you know, could I ever do this? Could I ever be part of this exchange, this beautiful thing? I was really taken by it. And, like, after that day, I knew I wanted to see if I could possibly be a transplant surgeon.

DAVIES: Wow. So the kidney, it's like starting up an appliance? I mean, it turns pink and then excretes urine?

MEZRICH: It does. I mean, living donor kidneys almost always work right away. Deceased donors, interestingly, about two-thirds of them work right away, and a third of them don't - probably from the whole process of taking them out and putting them back in. I think maybe the most dramatic organ, of course, is the heart because you put it in, and you give it a little - you kind of hit it like you hit a computer. (Laughter). Maybe you give it a little shock. And it just starts beating. And that's pretty darn dramatic.

But each organ has its own thing. The kidney will start squirting urine. The liver will start pouring bile out. The lungs, you know, start, essentially, breathing. It's quite amazing and dramatic. And you can't help but think how much this person's life has just changed. And to be even a small part of that is very special.

DAVIES: Transplant surgeon Joshua Mezrich. His new book is, "When Death Becomes Life: Notes From A Transplant Surgeon." After a break, he'll talk about an operation that didn't go as planned and about how we decide who gets organs when there aren't enough for everyone who needs them. And Lloyd Schwartz reviews a new recording of the John Adams opera, "Doctor Atomic." I'm Dave Davies, and this is FRESH AIR.

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DAVIES: This is FRESH AIR. I'm Dave Davies in for Terry Gross, who's off this week. We're speaking with Dr. Joshua Mezrich, a transplant surgeon who specializes in kidneys and livers. His new book is both a history of the development of transplant surgery and a personal memoir. He shares the thrill of seeing transplanted organs come to life on the operating table and stories of some operations that didn't go so well. It's called, "When Death Becomes Life: Notes From A Transplant Surgeon."

Well, you know, I've never seen abdominal surgery. Most of us haven't. And I think we picture the human anatomy from models that we see in a doctor's office or charts where all the organs are clear and distinct. And so we kind of picture you, you know, putting a kidney in or a liver in and it's sort of plugging a part in. And they all kind of look alike. And what I get from your book is that it's all very, very much messier and more complicated and challenging. Maybe you could share with us an example of, you know, opening up a patient, finding something unexpected, how you dealt with it.

MEZRICH: Yeah. I mean, I think a lot of people have this impression, like you mentioned, that it's just standard, and you open and shut and everything goes according to plan. Maybe like an airplane flight or, I don't know, a mechanic on a car. But it's really not like that. Every patient, I think, is quite different. I think maybe the best example might be in my experience with liver transplantation. You never know what a liver's going to be like until you open the patient up. There are some signs. If it's a re-do liver, or a re-operation, that's going to be harder. You know, if the liver looks really big on the scans, that's going to be harder.

DAVIES: When you say looks big, this is - you're extracting the liver, or you're putting one in?

MEZRICH: Yeah. I mean, I think often the hardest part of a liver transplant is taking out their own liver. So in a liver transplant, you remove their liver and then put the new one right where the old one sat. And that's different than, say, a kidney transplant, where you just put in an additional kidney. You don't remove the kidney. Actually, there are a bunch of people out there with four or five kidneys in if they've needed (laughter) retransplants.

DAVIES: Just lay one on top of the other, huh?

MEZRICH: (Laughter) We usually squeeze them in there - sounds sort of inglorious. But with the liver, you have to get the old liver out. And often it's gone through a lot of scarring through whatever the disease process is, and it can be really hard to get out.

So usually when you open the patient, and you kind of reach in and feel the liver, you can - you pretty quickly know, oh, gosh this is going to be bad, or, oh, we're good. You know, turn the music up. This is going to be easy. But if it's really stuck in there, and if it's really sick - and so the blood vessels that go into the liver get really swollen, and they give off these little veins that are really easy to get into - it can be a real challenge where you spend hours, and you lose ten times the person's blood volume trying to get the liver out.

DAVIES: Wow.

MEZRICH: So you never know. I mean, you might start - I always tell patients - I give a range of a liver transplant of five to eight hours, but it could take four, and it could take 15.

DAVIES: Yeah. You describe a patient named Tito (ph). You'll remember this guy. And then - and I think you said when you opened him up, his bowel was swollen, which meant it was actually hard to get the liver out and hard to get the new liver back in.

MEZRICH: It's funny. Most of the surgeries go well. But of course, we (laughter) remember the ones that didn't probably the best. When something really bad happens, and you start to think, I don't know if I'm going to get through this, then you start to picture, like, what it's going to be, like, to talk to the family and tell them, you know, you couldn't get through the operation. It's very humbling.

DAVIES: You tell the family, we're not - I don't think he's going to make it through surgery. You end up getting him through, ended up - I believe - finding him another liver, right?

MEZRICH: That's right.

DAVIES: And eventually did survive. But it sort of raised the question of whether - when surgeons get into that kind of a jam, how much stamina and determination and will matter. I mean, you said that remembering this patient's daughter - I guess - made a difference, made you more determined to make sure that you figured out a way.

MEZRICH: I train a lot of people in transplantation. We call them fellows. These are people who have finished their general surgery residency, and now they're getting additional training in transplant. And I always tell them being a surgeon, particularly liver transplant, is all about kind of intestinal fortitude or inner strength. You've just got to keep your wits and stay strong through all the different things that maybe can go wrong and fight through it. That's certainly what a liver transplant is like.

And I have to say, I - on that case, I kind of lost heart. I said - we had been there for hours. We had lost 100 liters of blood. I mean, that's an insane number. If you picture maybe - you have 5, 6 liters in your body, and we had lost 100 liters. It's like a swimming pool. And I went down. We had been in there for - I don't know - 10, 12 hours. I was soaked with sweat. And I went to talk to his daughter, Arinda (ph) - it was about - I don't know - 4 in the morning - to tell her that he wasn't going to come off the table. He was going to die.

And that was what I went to say. And when I started talking to her, she was very respectful and understanding. But she said, you know, I know you'll do everything you can to save my father. And it kind of hit me - like, why give up? We need to just - you know, we got to keep fighting. It looks bleak. I don't think this liver's going to work. But maybe forget about this liver that has been through the wringer. Just try and get him through this operation.

And I went back and had some partners join me, and we just started fighting for a few more hours trying to get control of things. And somehow we did. It was really - it was one of those moments I'll never forget. I knew this liver was kind of cooked because it had just been through too much in the operation. But you kind of change your goals and think, let's just get through this, and then we can figure out if we can get him a new one. And somehow he - we did, and he's doing amazing.

DAVIES: Joshua Mezrich is a transplant surgeon at the University of Wisconsin School of Medicine and Public Health. His new book is "When Death Becomes Life: Notes From A Transplant Surgeon." We'll talk more in a moment. This is FRESH AIR.

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DAVIES: This is FRESH AIR, and we're speaking with Dr. Joshua Mezrich. His new book is "When Death Becomes Life: Notes From A Transplant Surgeon." You have this liver selection meeting at 1 o'clock every Wednesday in which you have to make some pretty important decisions about who's going to get the available livers. How do you do it?

MEZRICH: Yeah. So each patient has listed next to their name a MELD score. MELD stands for Model For End-Stage Liver Disease. But it's a number that's taken from lab values that essentially predicts how well their liver's functioning. So if your MELD score is low, it means your liver's functioning well. If your MELD score is high, it means the liver is failing. Interestingly, it also correlates with how likely you are to die without a transplant. So someone whose MELD score is at the top of this scale - say, a 40 - is extremely likely to die over the next few weeks.

So as we discuss the patients, we know what their MELD score is. And we understand kind of the importance of the decision we're making. If we turn down a patient with a MELD score of 40, they're surely going to die. And it's a pretty heavy decision because, on the one hand, you may have a treatment that truly could save them. But we really have to assess, you know, whether they're going to be able to take care of that organ, this incredible gift that they're getting, and whether they're going to be able to thrive with it.

DAVIES: So what do you mean by whether they'll be able to take care of that organ?

MEZRICH: Well, when we - you know, a transplant is one of those things that it's an amazing science, and the surgery is very heroic. But if there isn't the social support and the ability to take care of the organ, it'll surely fail. You have to take all these medications to prevent rejection. You have to follow up a lot. Sometimes you have to battle through different complications. And so it really - (laughter) it really requires a village, if you will, to support any type of transplant.

DAVIES: And you raise the question in the book of giving livers to alcoholics, particularly ones who may continue to drink. How do you assess that?

MEZRICH: Yeah, this is a really important topic when we think about liver transplantation. So in the early days of liver transplant - '60s, '70s - initially, people decided not to transplant patients with alcoholic liver disease because of the thought that they - you know, they did this to themselves, and maybe they didn't deserve it. I think now most people would agree that alcoholism is a disease, and it's a disease that is hard to treat. And it can come back. So rather than maybe think about it as these people are being stupid or they're, like, your silly friends who drink too much - they truly have this addiction. And it's a disease like other diseases, like hepatitis C, like the other things we transplant with more complex names.

And it's been shown that we can get good outcomes in patients with alcoholic liver disease as long as they have insight into their disease and kind of have a support system to try and deal with the transplant afterwards. But it is controversial because patients with alcoholic liver disease often have, you know, a lot of failed relationships, have a lot of challenges in their life, don't have great family support. And it's challenging to talk about some of these patients and wonder if we are going to get the best outcome - if this transplant is actually going to fix their problem or not. I think our health care system likes these heroic treatments like a liver transplant, but we don't put enough into prevention - into really understanding and managing the disease. And that can be sometimes a challenge. We've had many incredible victories with transplanting livers into alcoholic liver disease, but we've also had some dramatic failures.

DAVIES: So when you make these decisions, you're not driven by a numerical score. You make judgments.

MEZRICH: That's exactly right. I mean, we have the score to assess their liver function. But we really make a judgment looking at both the medical issues, the surgical issues and then the input from the social workers, the addiction specialists who really try to understand, does the patient have insight; are they going to be able to commit to sobriety and take care of this liver? And it's a big decision because if you say no, often, you're essentially saying this patient dies.

DAVIES: You also write that when there is - someone voluntarily donates an organ - my sister-in-law in Connecticut recently donated a kidney to her husband. But when that happens, it has a ripple effect, right?

MEZRICH: It's really amazing. And I have so much joy out of taking care of these living donors - these kind of true heroes. And yet, having so much joy, it also causes probably the most angst as well because these people are volunteering to undergo surgery who don't actually need the operation. And although they may be excited to donate, it's a very unusual situation as a surgeon because, you know, the whole concept of do no harm is a little funny when you're operating on someone who doesn't need the surgery.

But the living donor kidneys do better than deceased donor kidneys. They last longer. They start working right away. They're definitely the way to go if that's possible. But typically, you have to have a donor to get one. We do the donor surgery through the laparoscope, so small incisions with a camera. And I even do some through the bellybutton at this point where they have almost no incision. But it's still an operation with risks and always a potential for something to go wrong. The donors typically do very well.

DAVIES: You extract a kidney with almost no incision?

MEZRICH: It's pretty wild. Some of us do it through the bellybutton, where we actually are able to make a small incision right into the bellybutton, kind of dilate it up a little bit and put all our ports straight through this tiny hole. It's almost like a - I don't know. We get the kidney in a bag, and then we kind of gently coax it out of this incision and close it back up. And after it heals - and many patients who can't even see the incision.

DAVIES: Wow.

MEZRICH: It takes a little bit of experience to make sure you don't damage the kidney on its way out (laughter).

DAVIES: You write about the bonds between the recipients and then the families of donors, particularly ones who have died. Talk about some of those cases and what - how these people have kept in touch with each other.

MEZRICH: Yeah. So after we do the transplant, a lot of, both donors and recipients, will ask if they can - like, the family of the donor and their recipients will ask if they can interact. And typically, we won't let them interact initially, but we tell them recover. And after a month or two, they write a letter to our organ procurement center. And then that center will reach out to the other party and ask if they would like to receive the letter. Sometimes donor families don't feel ready or don't want to know about it. But more often than not, they do. And often, they end up going on to meet. And it can be this incredibly special bond.

I think for the donor family, it can feel like they've gained more members of their family. They, in a lot of ways, feel like their loved one is still living on because their - I don't know - their heart is still beating; their liver is still working; their kidney is working. And it's really a piece of them that lives on. And they can become very close with the recipient. And I think the recipients can have this wonderful relationship knowing - you know, wanting to know more about this person that has really saved their life. There are all these great stories - and I mentioned some of them - where the recipient will suddenly develop a taste for some food, and they don't know why. And then they find out the donor loved that food.

DAVIES: Hamburgers in one case, I remember.

MEZRICH: Yeah. So in one story, which is one of my favorite stories in the book, the recipient woke up and was like, I want a hamburger, which was weird because she didn't really eat much meat. And then it turned out that was the donor's favorite food. But hard to know how real that is, but it's really cool to hear about. And it's one of the most special things. And I just find that amazing. That bond is something that is just really special.

DAVIES: You know, you said that you wanted to be honest with this book to tell people how this world really works. And it's powerful. And I'm wondering if there's any concern that someone who might be a willing donor transplant might see these graphic descriptions and say, heavens, I don't know that I really want to know this.

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MEZRICH: Yeah. I mean, I love transplant, and I love living donation. But it is a very honest book. I will tell you that living donors are not only amazing people, but almost all of them will tell me once it's said and done, this is the best thing I've ever done. And, like, I feel like bringing up - so you can donate a kidney to a loved one. And that's great. But we also have these other options. So there's something called paired exchange where, say, you want to donate a kidney to your brother, and you're not a compatible blood type. You're the wrong blood type. We can set up a swap where you donate your kidney to someone else, and their donor donates to your brother.

That can actually get even more complex and involve more than two pairs. But there's this other thing - and we work with this organization called the National Kidney Registry, and they organize these swaps. We also do these chains where - say you decide, I want to donate a kidney just to save someone. When we have a scenario like that, through the NKR you can donate your kidney to someone who has a donor that can donate to them.

And that donor can donate to someone, and that donor can donate to someone. And this can start a chain that goes back and forth across the whole country. And we had one chain - I think it was the biggest one through the NKR - that had something like over 30 donor and recipient pairs. It got all these different people transplanted.

And I went to a talk. And one of the donors of one of these chains was up there, and it was very powerful. She said, you know, you surgeons, you do all these things that save people. And that's not something I normally have the opportunity to do. But she was like, I actually had the opportunity to save 30 people. And I just went through a little discomfort and a little recovery. And I will never do anything in my life that's as great as that.

And it really is true. It's this incredible thing. But again, it's like running into a burning building to save someone. There's a little bit of risk there. The risk is low, but it's not zero. But it can be so worth it.

DAVIES: Well, Joshua Mezrich, thanks so much for speaking with us.

MEZRICH: Thank you so much.

DAVIES: Joshua Mezrich is an associate professor in the division of multi-organ transplantation at the University of Wisconsin School of Medicine and Public Health. His new book is "When Death Becomes Life: Notes From A Transplant Surgeon." Coming up, Lloyd Schwartz reviews a new recording of the John Adams opera "Doctor Atomic." This is FRESH AIR.

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