Henry was eating breakfast with his family and was not aware of his distracted state until his wife asked, "What is bothering you this morning?"
Henry replied, "I have my monthly review meeting with Joseph this morning. He changed the meeting schedule to allow for a full hour instead of the usual 15 minutes. I have been wondering why the change?"
She responded, "You will know soon enough. For now our children are more important."
Henry brought himself back to the present and helped his wife get the children ready for school. The drive to work allowed him more time to think about the upcoming meeting. Joseph was a stickler for punctuality and he had never before extended the monthly review past the normal 15 minutes. His mind wandered back to his first meeting with Joseph six years prior. He had just started looking for a job, when his program director told him about the opportunity at the "International Transplant Institute." They were looking for a director of transplant services. Joseph had called his program director and asked specifically about Henry and his availability. Apparently Henry's small research project regarding the potential of spinal cord transplantation had intrigued Joseph.
Henry had been flown in a private jet to the interview setting. The lush corporate setting was in marked contrast to the small, crippled figure sitting in a wheelchair across from him. It took Henry several minutes to realize that the mind contained in that crippled body was extremely astute and in complete control of the situation. The institute was relatively new, but the goal was to establish a world class transplantation center. As a private foundation, which was richly endowed by Joseph himself, they had the means of instituting a protocol of "Bereavement Settlement." It was amazing how much more willing families were to donate the viable organs of their deceased loved ones when a substantial bereavement payment was made. This had allowed the institute to quickly become a major source of organs for the medical community worldwide.
The increased funding which became available from recipients who made "charitable contributions" to the institute, allowed the institute to develop a major research facility and now a specialized hospital for transplantation surgery. Joseph was seeking a surgeon with a research emphasis on brain and spinal cord transplantation. His small research project had interested Joseph and resulted in the interview. The interview ranged over a large variety of topics, including ethics and morality. Joseph knew that many in the medical community objected to his "Bereavement Settlement" policy. Henry was able to honestly say that the overall benefit to humanity from increased organ availability made the concept a necessary evil. Joseph was apparently satisfied with this limited approval and offered him the position. The past six years had been a professional paradise. He had not only been allowed but strongly encouraged to continue his research on the spinal cord. In addition they had succeeded in developing a world-class transplantation program at their center. His work, which had previously been ignored by his colleagues, was starting to attract legitimate scientific interest. By transplanting the spinal cord with the head, all of the neural connections were made with peripheral nerves, which had a much better chance of healing. Spinal cord regeneration was still way beyond their present ability, but peripheral nerves re-grew fairly well. By taking advantage of this improved re-growth, Henry had successfully transplanted a head from one dog to the body of another dog. As the nerves re-grew, the dog regained its ability to walk. His research was done with no known usable objective; it was research simply for the sake of science.
As Henry parked his car and walked into the institute, he felt a sense of pride. He was a major part of the success of the institute, and took ownership in a small way of the institute itself. He took the elevator to the top floor and entered the office of the director. Mary was as cheerful and polite as always. She said Joseph would be ready in a few minutes and offered him coffee. He accepted the coffee and asked if she knew why the meeting time had been extended. Mary shrugged her shoulders and said, "I am sure Joseph has his reasons."
At exactly 9:00 A.M. the intercom on Mary's desk came to life and asked her to send Henry in. They smiled at each other and Mary said, "Joseph is ready for you now, right on time as usual."
Henry gave her the thumbs up sign as he opened the door and entered Joseph's office. Joseph welcomed him in with a wave and said, "Henry, it is good to see you as always. Come and help me move into my wheelchair so we can visit at the coffee table."
Joseph was all but hidden behind his desk, which was covered with more computer stuff than Henry had ever seen in one place before. He helped Joseph move his frail distorted body from the custom rocking chair at his desk to the power wheelchair. He knew academically that rheumatoid arthritis could result in severe deformities. Seeing Joseph's horribly deformed body made the academic knowledge seem trivial in comparison to the reality of the disease. They moved back to the coffee table and Henry poured them both a cup of tea. It was all the Joseph could do to manage a cup with his mangled hands. Joseph asked about Henry's wife and children. Joseph always wanted to know everything about his kids and was always sending them small gifts. After a few more minutes of visiting, Joseph asked him about his ongoing research. Henry told him about the effectiveness of the nerve growth stimulant they were using. They discussed the new endoscopic equipment which allowed a less traumatic dissection of the spinal cord.
Joseph asked him specifically about the new vascular anastomosis clips they had developed. These miniature, tissue compatible, plugs acted like "quick connect" hose connections which allowed for endoscopic repair of the small blood vessels that nourish the spinal cord. Henry's biggest challenge in the surgery had been maintaining the vascular viability of the spinal cord for transplantation. The cord is nourished by small penetrating blood vessels which had to be carefully preserved and reconnected for the transplant to work. The new clips improved the success of lower cord rejuvenation significantly. Henry summarized his work by saying, "We have improved significantly with more than 90 percent success of the upper body nerve re-growth. The new vascular clips have improved our lower body and cord success to 50 percent. The problem of vascular compromise of the small penetrating vessels remains paramount."
Joseph asked, "Do you think the problem is technological or biological?"
Henry responded, "I think we have a pretty good handle on the biological issues. The technical difficulty of working within the confines of the spinal column is the major hurdle. We have not been able to speed the rate of healing and are limited to 1 mm per day of nerve re-growth. A head transplant would be more feasible if we could solve the issue of spinal cord regeneration. I do not see this happening in our lifetimes. A combined transplant of both the head and the spinal cord is our best option at this time."
Joseph sat and sipped his tea. When he spoke again, the topic was his own health. He said, "My kidneys are failing and I will need to start dialysis soon. It seems that every new medicine that we try to control my arthritis ends up destroying something else."
Henry's response was automatic, "You should just have a kidney transplant."
Joseph smiled and said, "My liver is severely damaged also."
With a little more reserve Henry said, "A liver transplant too."
"I also have a progressive myocardiopathy and pulmonary fibrosis from the medication. I have lost most of the feeling in my hands and feet from the peripheral neuropathy caused by the rheumatoid arthritis. I live with a constant burning sensation in addition to my joint pain."
All Henry could say was, "Shit, you need a new body."
Joseph agreed saying, "Our work for the past 10 years, here at the institute, has been in preparation of this. I knew that my body would fail, so I dedicated my efforts to making a transplant possible. I would like to be the first human to benefit from your research."
Henry objected saying, "We are not ready for human trials."
Joseph nodded in agreement but responded, "Henry, we may not be ready for human trial
s but I am dying. This body is so destroyed, despite the best medical efforts my money can buy, I live in constant pain. My weight has dropped to 93 pounds even with all of the metal implants I have. I can no longer even go to the bathroom by myself, and have not been able to walk for several years. I am ready."
Henry countered, "It would be unethical to perform the surgery because of the inherent dangers." He added, "Besides, I would hate to lose you."
Joseph smiled and said gently, "I greatly appreciate your concerns, but I am dying. Without your surgery I will die within a year or two, with your help I may live. The chance to live, makes the risk worthwhile."
Henry said, "We should wait until we can perfect the vascular connectors."
Joseph shook his head no and said, "The only thing left functional is my mind. If I go the route of dialysis and multiple organ transplants, I will almost certainly lose some of what I have left. My slow death is accelerating and I am willing to gamble on a chance to live."
Henry finally objected, "I'm afraid to lose someone I consider a friend because of my surgical limitations."
"I have no argument other than to say that you are the best. I trust you and your work. I ask that you do not condemn me because of your own fears. It is my life to risk and I just ask that you do your best. President Grant died a horrible death because his physicians were afraid to operate on him to remove his throat cancer. The surgery was being performed with success, but there was some danger of dying from surgical blood loss. Their fear of losing the former 'President of the United States' during surgery cost him his only chance for life. Please do not allow your fear to cost me my chance to live."
"Can I think on it?"
"Absolutely."
Joseph then brought up another sensitive issue. He said, "Henry, you and I have disagreed about the institute's 'Preferred Recipient Status'. The endowment that has resulted from this program has allowed us to greatly expand our 'Bereavement Settlement' program and allowed a dramatic increase in research funding. Is there any way of making you more comfortable with this program?"
Henry replied, "Preferential treatment seems unethical. I must admit the institute's program has resulted in a dramatic increase in organ donations. In a perfect world a'>Bereavement Settlement' program would not be required. Everyone should be willing to act as a donor and organs should be used according to need. The ideal was not working and the institute's program has been a fantastic success. The realist in me says the end justifies the means."
Joseph accepted this position. He quietly said, "I will be putting my name at the top of our recipient list. I was hoping that you would be willing to accept this ethical dilemma. I know utilizing my position is not fair. This organization was built to meet my own needs in addition to benefiting society in general."
Henry said, "I would not deny you the right for preferential treatment considering all that you have done. I know that the institute's policies are not perfect, but they're practical."
Henry began thinking about all the requirements a donor would have to meet and was lost in his mental review for several moments. When he returned to the present Joseph smiled and said, "You have been thinking. Are you ready to share your thoughts?"
Henry replied, "I was thinking about the specific requirements that a donor would have to meet. The fatal injury would have to be limited to head trauma and the donor would have to be kept physiologically alive for the transplant to be successful. The tissue match needs to be good and the donor in good general health. A young but mature body would be required to prevent any growth of the spinal column which would damage your spinal cord. Size would also be a critical concern because the spinal cords need to be of equal length. We may need to use a female donor to match your spinal cord length. "
Joseph nodded in agreement. He said, "I need a healthy body and at this point I do not care what sex it is."
Henry's response was a simple, "Why not?"
Joseph said, "I have missed most of the experiences people associate with living. My disease and treatment have left me not only sterile but essentially asexual. I may never be able to experience the high of climbing a mountain, so I will settle for whatever life experiences I can get. My goal is to live my life to the fullest. I am making the choice to seek life and want to experience as much of life as I can no matter which gender I end up as." Joseph was some what embarrassed by his declaration and started to apologize.
Henry interrupted, "You need not apologize. I forget the freedom of movement and activity I enjoy. Whenever I am with you, I become more thankful for the health I have. I have not yet agreed to proceed, but I will honor your wishes if we do."
The meeting ended with some general discussion and Henry's pledge to let Joseph know in two days. Henry left the office and noticed that it was exactly 10 A.M.. He smiled at Mary and said, "Right on time." Mary waved to him as he departed the office. The rest of the day passed in a fog. His attention kept returning to Joseph's request. He spent the time driving home arguing with himself about the ethics of performing the surgery. The commotion of his young children managed to keep him centered in the present for a while. After the household had settled down, he shared Joseph's request with his wife.
She responded in her very straightforward fashion, "Joseph's request is very reasonable and you should help him if you can." She was not at all bothered by his gender neutrality. She said, "Men place way too much importance on their sex. Living as a women, would be better than dying as a man."
Henry had trouble sleeping because of a recurrent nightmare. He kept visualizing the surgery which was complicated by massive bleeding. The dissected head of Joseph was telling him, "Henry, you need to control the bleeding." When he awoke in the morning, he felt exhausted from working all night. It was not until he walked into the operating room that he returned fully to the present. The concentration of surgery allowed his mind to hide from the decision he had to make. The evening hours were again filled with his personal debate about Joseph's request. He knew that his colleagues would consider the procedure unethical mostly because of the surgical risk. Professional jealousy would be a component of their disapproval. He was bothered less by this than the nightmare. He was not sure how he would live with himself if the surgery failed.
It was his wife's astute reasoning that allowed him to sleep more soundly. She said, "Is it more important to help someone in pain or to worry about what your colleagues will think?"
He countered, "I took a vow to first do no harm."
She replied, "It would seem that allowing someone to die in pain and loneliness because of your fears would be worse than losing the patient in surgery."
Henry knew that his wife was right. He could think of many academic arguments, but knew in the end it was a choice between Joseph's potential for life and his fear of failure. He decided to try.
He sleep was better. He called Joseph first thing in the morning. He tried to summarize the ethical dilemma, but had trouble making the arguments seem significant. Once he had made the decision it was much more obvious how the dilemma was based on his own fears of failure. He finally said, "I will try."
Joseph's response was a simple, "Thank you."
Henry started to discuss the issues of obtaining an appropriate donor. Joseph interrupted him saying, "We have an organ procurement department. They can handle this task. I will make sure my affairs are in order. You need to concentrate on making sure the surgical details are looked after." Henry was glad someone else had the job of securing the donor.
The director of procurement was not surprised when Joseph called. Joseph's calls usually meant that a high-profile patient required a specific tissue match organ. It was his job to find the organ that was needed. He had established a network of contacts in most of the trauma centers. His ability to offer families a significant "Bereavement Settlement" had made his task relatively easy. This request was more complicated. The donor ha
d to be a very small adult between the ages of 18 and 35. The genetic analysis had to be free of significant abnormalities. The general health had to be excellent without any spinal injuries or arthritis. The tissue match characteristics were not too difficult. He was authorized to offer their highest level of "Bereavement Settlement."
She was a junior at a small western college. It was a beautiful spring day and the offer for a ride on the motorcycle was too good to pass up. She was young and free and did not need to wear a helmet. It was an exhilarating ride until the truck pulled out in front of them. She did not have time for fear. The motorcycle struck the side of the truck at a high speed. Her future was ended, and with it the family's dream of a daughter moving out of poverty. Her massive head injuries insured her death. The strength of her youth kept her alive for transport to the hospital. The physiological life of her body was maintained with a respirator, but there was no hope for her. It was a parent's worst nightmare. The family, in shock, was not able to consider donating their daughter's organs for transplant. They wanted their tragedy ended. They could not afford much of a funeral. They would do their best.
When the director of organ procurement received a call regarding the patient status, he mobilized his team. The local agent requested an opportunity to meet with the family. She very sincerely offered her condolences and shared the concerns of parenthood. She then discussed the possibility of a "Bereavement Settlement" with them. She assured them that only the needed organs would be used, and the remainder of the body would be returned for burial or cremation. When the family realized this person was sincerely offering to help, not only with the funeral, but also by providing $100,000 as a "Bereavement Settlement," they reconsidered. They did not want to "sell" their daughter's body, but the money would allow them to send their other children to college. They agreed, and asked only that their daughter's remains be cremated, and returned to them for a funeral. The agent was able to assure them that the cremated remains would be available in 48 hours for the funeral. They were satisfied and arrangements were made. Joseph's well-organized staff expedited the transfer of the donor body on full life support to their transplant center.
Henry received a call at 5:00 A.M., notifying him that the donor would be arriving in three hours. He was happy that the call had come in the early morning. He had slept without worrying about the surgery. His wife did not usually hear the telephone at night; she was tuned to the sounds of her children. This early morning call did awaken her and she asked, "Do you have to go in?"
Henry replied, "I will have to leave earlier this morning. Joseph's donor body is on the way."
"I'll make you breakfast, while you get ready. We need to do everything possible to ensure success for Joseph." Henry enjoyed the breakfast with his wife. The absence of their children gave them time to talk about the risk Joseph was taking. Henry still had his doubts, but his wife insisted that Joseph deserved the chance. Her reinforcement always boosted his confidence. His drive to the center was strictly on autopilot, as he reviewed the surgical protocol in his mind. He had learned from his college football coach that visualizing successful completion of a task was the most important step toward accomplishing a goal. He had carried this lesson forward in his professional life with good results.
The donor body arrived just ahead of him. He went directly to the intake room for his personal examination of the donor. He knew that the procurement team had already completed all of the genetic and blood testing. His examination was meant mostly to satisfy his own requirements for health status and size suitability. He ignored the grizzly evidence of head trauma and concentrated on measuring the length of the spinal column to make sure that it was compatible with Joseph's spinal cord. The donor was an athletic appearing small female without obvious deformities or surgical scars. He reviewed the MRI scans. The radiologist had measured spinal cord length and documented an acceptable match. Henry could see no reason not to proceed.
Henry called Joseph's office and was a little surprised when Mary answered the phone. He said, "You are up early this morning."
"As are you, Doctor. It is an exciting day."
"May I speak to Joseph please?"
Mary replied, "He has been expecting your call. I will put you through."
Joseph answered the phone almost immediately and said, "Good morning Henry, I hope that you had a good rest. I assume everything is 'a go' for today."
Henry replied, "I am satisfied with the donor and the anatomical fit. It is a female body. I need to make sure that you really want to go ahead with this. Ethically I must review the procedure, risk and possible alternatives with you."
Henry, I appreciate your concern and I do not care about the gender as long as all other parameters are acceptable. I think that I understand the procedure and risk as well as anyone. I see no viable alternatives. I am ready to proceed. Are you ready?"
Henry said, "I do not suppose it is possible to ever be fully prepared for something like this. I have reviewed the procedure hundreds of times in my mind. I see no way to be more prepared until we have developed improved technology for performing the vascular connections. I am ready to assume the responsibility for your surgery. I am still scared of failure, but I will do my best."
"All anyone can ask is that you do your best. It is my decision to proceed, and I do not want you to bear any guilt if the surgery is not successful. I have run out of time. It is best that we proceed now."
"My wife asked me to tell you that she is keeping you in her prayers and agrees with your decision. If prayers do work, we can use the help. I will notify the OR crew to proceed. I would expect that they will be ready for you in about two hours."
Joseph simply replied, "Thank you."
Henry entered the operating room before scrubbing, just to make sure everything was ready. They had the finest surgical crew in the country. His assistant surgeon and the surgical fellows were very capable. They had pushed the technology of vascular and nerve connections way beyond any other center. Just being in the operating room bolstered Henry's confidence. He asked, "Is everything ready?"
The anesthesiologist had already changed the life support system of the donor over to his operating room equipment. He said, "She is stable and I am ready." The chief nurse gave him a thumbs up sign. His assistant surgeon nodded in the affirmative.
Henry said, "Finish prepping her and I will get scrubbed."
Henry spent 10 minutes scrubbing his hands. He used the time to visualize the entire procedure in his mind one more time. He entered the OR with his hands held high in front of him with the water dripping off his elbows. The surgical nurse draped a sterile towel over his hands and he proceeded to carefully dry them from the fingers to the elbows. She then held out his gown and he slipped his arms through the sleeves. The circulating nurse tied his gown in the back as he pushed first his right hand and then his left hand into the surgical gloves. The nurse held the outer gown tie as he rotated in a circle. He tied a simple knot to secure his sterile cocoon and he was ready. They had already draped the donor with adherent plastic sheets that formed a continuous seal around her. He stepped up to the table and before starting said a silent prayer, "For Joseph's sake, let this go well." Out loud he said, "Operating on dead people who are still alive is more than a little strange, but it is the task before us. You are the best surgical team in the world. With your help maybe we can give Joseph his new body."
Henry held out his hand for the scalpel. The OR nurse placed it in his palm ready for use just as she had done a thousand times before. They worked well together and Henry almost never had to ask for anything. He simply held out his hand and she placed the proper instrument in it. This teamwork not only speeded up the surgery, but it also allowed Henry to keep his attention focused on the operation. Everyone had their own duties and it was the smooth integration of their efforts that made this surgery team special. They chatted about a variety
of things and the jokes flowed freely. During critical points in the procedure the crew automatically assumed the appropriate serious mode and only the quiet sounds of the respirator could be heard over the sounds of the classical music playing in the background.
Henry made the horizontal neck incision which was extended into a flattened "W" on each side of the neck. The skin flaps were elevated and the muscle insertion points identified. The neck muscles were divided, preserving the attachment points for the transplantation. The vagus and phrenic nerves were identified and anastomotic clips were placed. These clips held a special computer chip which would be monitored and identify the matching nerve clip. These clips also contained the nerve regrowth stimulating compounds. The major vessels of the neck were freed from the surrounding tissue. The vascular clips were placed and the vessels divided. The donor's head was now deprived of all blood, and life was maintained in the body only by mechanical support, and the intrinsic capability of the organs to continue functioning. The large brachial plexus nerves extending into the arms were identified and the appropriate nerve clips applied. The thyroid gland was freed from the underlying trachea and left attached to the body. The larynx was cut free of the trachea below the cricoid cartilage. The breathing tube was reinserted into the open trachea. The esophagus was cut inferior to the trachea to help prevent scarring.
Henry stretched as they used an x-ray to document the C7-T1 vertebral junction. The spinal column was divided at this level. The spinal cord was amputated. The posterior dissection of the muscles proceeded quickly and the final skin incision was made as an inverted "V" to help reduce scarring. Seeing the human head cut free from the body made even this highly trained crew shudder. Henry tried to ease the tension by saying, "Remember, she was already dead." They passed the donor's head off the table. It was sent to the funeral home for cremation and return to the family for their funeral service.
Henry began the delicate task of freeing the spinal cord from the backbone. He inserted a special endoscope and carefully identified each thoracic nerve. The nerve was clipped as it exited the spinal cord with the coded nerve clips. Working in this confined space was a challenge they had only partially overcome with instruments they had developed. The spinal cord was nourished with multiple perforating vessels which had to be carefully freed from their attachments and secured with the vascular clips. The dissection continued inferiorly to the large lumbar and sacral nerve plexus. They used a nerve stimulator to identify specific branches of the plexus, before placing the clips and cutting them. The coded nerve clips were again used. With gentle traction Henry was now able to remove the entire cord. He inspected the sheath which had contained the cord and was encouraged to see he had managed the removal of the cord without damaging the sheath. The donor was now ready.
Henry turned his attention to Joseph. They had divided the large operating room into two sections for this procedure. Joseph had already undergone his anesthesia, and was prepped and draped for surgery. They had difficulty inserting the endotracheal tube because of his severe deformities. The anesthesiologist had to use a flexible endoscope to pass the tube through Joseph's nose and into his trachea. An infusion of alcohol was used to prevent gelling of Joseph's blood. The alcohol concentration in Joseph's blood was increased to 0.3 percent. The anesthetic agents had to be reduced to compensate for this high-level of intoxication. The next step in preparation was a significant cooling of Joseph. This severe hypothermia added to the anesthesiologist's problems. They used high levels of anti-inflammatory drugs to further protect Joseph's brain. It was time for Henry to begin.
Henry looked down at this small crippled figure in front of him and thought, "I sure hope I am up to the task you have assigned me." He looked up at the anesthesiologist and asked, "Ready?" Hearing a positive response, he placed his hand palm up and the surgical nurse placed the scalpel in his hand. He now duplicated the neck incisions in an inverse fashion that he had made on the donor. He divided the muscles of the neck at their insertion points. He cut through the trachea and esophagus, taking great care to identify and preserve the nerves to the larynx. The phrenic nerve to the diaphragm was identified on each side. The nerve clips were applied for anastomosis and pacing to allow Joseph to breathe fairly naturally until nerve regeneration occurred. The brachial plexus branches were now visible and he applied the coded nerve clips before dividing the nerves. The anterior spine was now visible and he identified the first two thoracic vertebra. Using an air powered drill with water cooling he began removing the vertebra. The bone was soft and very weak from the steroids and other medicines Joseph had taken. He was able to drill away most of the bone in a few moments, and gained access to the spinal cord. After he had freed the spinal cord sheath from the bone anteriorly, Henry made a small incision for his surgical endoscopes. He was able to identify the thoracic nerves, and applied the nerve clips distal to the ganglions. Henry made sure that he left as much nerve attached to the cord as possible to facilitate rejoining them with the donor's nerves. The vascular perforators were treated with the vascular clips as they had been with the donor. Henry was swearing under his breath because of the arthritic narrowing and curvature of the spine frustrated his surgery. He was having trouble with the dissection of the lower lumbar and sacral nerve plexus. A different approach was needed.
He decided to open Joseph's abdominal cavity and approach the lower cord directly. The additional surgery slowed his progress, but he had no choice. His animal work had shown that the cord would survive for only 90 minutes, despite the cooling, once the perforating vessels had been clamped. Only the lowest perforating vessel remained and 35 minutes and already passed. If this one remaining vessel was not adequate to feed the spinal cord, the surgery would probably fail. Henry wasted no time in opening the lower abdomen and exposing the "Y" split in the aorta. He cut through the skin and abdominal muscles with one stroke of the scalpel. The intestines were simply placed in a retractor bag and held to the side. The fascial attachments were divided without regard to fixing them. His goal was to save the nerves. Everything else was worthless. He worked on the lower lumbar vertebra which were now visible. The bone drill quickly cut through the vertebral bodies exposing the spinal cord sheath. A small opening was again made which allowed the scopes and instruments to be inserted much more easily. The nerve stimulator was again used to identify specific branches and the corresponding nerve clips used. Henry now clipped the last remaining vascular supply to the spinal cord. The spinal cord was now free, and with luck, would tolerate the time required to reconnect the vascular supply.
Henry almost mechanically completed the dissection of the neck muscles and attachments posteriorly. He divided the bony ligaments which connected the C7 vertebra with the T1 vertebra. The only thing left connecting Joseph's head and body were the vessels. The two surgical tables were now placed head to head. The right carotid artery on Joseph was cut and a bypass tube inserted which had already been placed in the donor's right carotid artery. The clamp was removed and part of the blood feeding Joseph's brain was now coming from the donor. The right jugular vein was then connected in a similar fashion, allowing a return and mixing of the blood. The right vertebral artery was now connected. The right sided vessels were functioning, with the bypass tubes connecting Joseph's brain with the donor's body. The left sided vessels were then connected, using the same technique. Joseph's brain was now dependent solely on his new body for nourishment.
Henry began the delicate task of actually pulling the spinal cord out of the sheath. By using the inferior access he was able to use his endoscopes to help mobilize the cord as the body was slowly pulled away from its head. The head and cord were rotated 180 degrees, and Henry began inserting the cord into the spinal sheath of the donor. Passing the cord was like trying to push wet spaghetti noodles through a straw. He used saline irrigation to help float the new cord into position. The coded clips were used to connect th
e inferior nerves. As the clips were brought together, a sound signal was generated from the monitoring device, indicating whether it was a compatible clip or not. The inferior vascular perforating vessels were then approximated using the vascular clips. This produced some bleeding from the central portion of the cord, which was a mixed blessing. Bleeding proved that the vascular connections were working. It also complicated the surgery by obscuring Henry's vision. When the critical central perforating vessels were reconnected Henry stopped working and stretched. The nurse placed a straw under his mask allowing him to drink a glass of orange juice without contaminated his sterile status.
Joseph's thoracic nerves were then connected using the coded clips. When Henry was able to begin working on the brachial plexus nerves he relaxed. It seemed almost easy working in the open. The vertebral bodies were stabilized with rigid titanium plates. The plates attached with special screws. The healthy donor vertebra required Henry to drill holes and tap the holes for the threaded screws. Joseph's vertebra did not have enough strength for traditional screws. A coarse screw which looked like a simple wood screw was required. The esophagus was reconnected, then the trachea. The phrenic nerves were connected. A sensor was placed on Joseph's nerves and a stimulator was placed on the donor nerves to allow him to breathe in a normal fashion until nerve re-growth took place. The vessels were now connected directly and the bypass tubes removed. As Henry and his team began repairing the muscle attachments, the alcohol infusion was decreased slightly and the cooling moderated. It had seemed strange to Henry to be working on such cold tissues. Closing of the skin and subcutaneous tissue was performed in a mechanical fashion because everyone was tired. The drains were connected and dressings applied. Henry removed his gown and gloves. The anesthesiologist directed the crew in the move from the operating table to the bed. They used the sheets and a small transfer roller to move Joseph into the bed. Great care was used to prevent any bending of the neck during this move.
The operating room supervisor said, "The name Joseph no longer fits. I think we should use the name Jo." Everyone agreed. Jo was taken to the intensive care unit. Deep sedation and alcohol perfusion continued as the body slowly warmed.
Henry went to the surgical lounge and sat drinking a cup of coffee and eating chocolate cookies. He knew that he would get a pounding headache from the combination, he needed the sugar and stimulation. Six hours had passed almost instantly. His intense concentration had produced a "Runners High" and now he had to pay the price for the adrenaline rush. He let the surgical fellow complete the paperwork. Henry left to finish his coffee in the ICU. Jo was now connected to all of the monitoring equipment. The brain waves remained slow. The strength of Jo's young body was evident with the stable blood pressure and pulse. Henry hoped this strength would be enough for healing to occur. There was not really anything for him to do, so he just watched and kibitzed with the nurses. Jo was stable and Henry had done his best. He knew this, but leaving and returning to the pile of paperwork in his office just did not seem right. He finally remembered that he had promised to call his wife. Suppertime at his house was punctual at 6 P.M.. She ran a tight ship. It was almost seven o'clock.
When his wife answered the phone, he started to apologize for not calling sooner. She interrupted him by saying, "Henry, for God's sake, I know you have been busy. How did the surgery go?"
Henry replied, "The resection of Joseph's cord was difficult because of his deformities. The transplant went well otherwise. Jo seems to be stable."
"Who is Jo?"
Henry explained, "The donor was a young woman. It seemed natural to start using the name Jo."
She replied, "This should make for an interesting outcome. Will you be coming home tonight?"
"I should be home by 10 o'clock if everything stays stable. If not, I will call you. Give the kids a hug for me." Henry tried to do some paperwork, to no avail. He realized he was hungry and the Advil he had taken after surgery, was wearing off. He decided to head home and stopped for a hamburger on the way. He had no sooner walked in the door at home, when his beeper began summoning him. It was a simple question about the drains. It was enough of a scare to again raise his adrenaline level. He tried to relax by reading with minimal success. Henry's sleep was interrupted by many dreams one of which caused him to awaken in a sweat. His previous nightmare of Joseph's head telling him to control the bleeding was replaced by one where it asked him, "Are you sure you connected the nerves in the right order?" He got up and called the hospital to check on Jo. Everything was stable. His last few hours of sleep were less stressful. His kids knew that he had worked late, but his promise of discretion prevented him from sharing his accomplishment.
The next few days Henry almost lived in the ICU. He would make it home in time to share supper with his family, only to return in the evening for one final check on Jo. Whenever he awakened from his recurring dream, he would call and check on the status of Jo. By the fifth day, the alcohol and barbiturate levels had been dropped to the point that Jo regained consciousness. Awareness was intermittent, but the brain wave pattern showed a significant improvement. Henry tried to explain her condition, and she seemed to respond. He began to feel real hope. On the 7th day, Jo was weaned from the ventilator. When the breathing tube was removed, she had significant coughing and some bleeding from her nose. When these things settled down, she tried to talk. The phrenic nerve stimulators allowed her to breathe, but she had to learn to control her breath for speaking. Her speech had a staccato pattern, limited to only a few words per breath.
Her first words were, "Henry, thank you. I have...no pain."
Henry explained, "You are of course paralyzed and without sensation below your neck. We will have to wait and see how effective the nerve re-growth is."
Jo replied, "You do not... understand. For the first... time... I do not hurt."
Henry was amazed at Jo's rapid recovery. Almost all of his previous patients were older individuals. Operating on a young healthy body with its tremendous healing capacity was a new experience. Rehabilitation was begun almost immediately with electrical stimulation of the muscles to preserve them. Jo quickly progressed to using her computer with voice commands. She required 24-hour nursing care, but was assuming control of her life.
Word gradually leaked out about the surgery. The Institute was bombarded with requests for information. The public relations Dept. shielded Henry and Jo from this publicity. It was only after Jo began to interact using video-conferences that the identity of the transplant recipient was made public. She refused all interviews.
Jo had her hands full trying to learn what it meant to be a woman. Henry watched the transformation, and used his wife's advice to help. The private nurses did their best to help, but it was a struggle. Everything was a little different. Even her eyeglasses had to be changed to fit the new image. Henry suggested that Jo allow a dermatologist to use a laser to speed the regression of her beard. The facial hair was just beginning to change because of the change in hormonal stimulation. Henry found it hard to interact with Jo as a woman when she had a beard shadow. Jo agreed to the change and put up with the discomfort.
Soon, Jo was navigating in a motorized wheelchair she controlled with subtle head motions and voice commands. Henry was discussing her progress, and asked Jo if there were any other problems.
Jo responded, "I had a major problem this morning. I noticed a blood spot on the floor when I moved my wheelchair. I thought I was hemorrhaging. I called my nurse and she told me I was having a menstrual period. She plugged me up with a tampon. Knowing about menstruation and experiencing it are two different things."
Henry asked, "Did you notice any of the premenstrual symptoms?"
"I had been feeling irritable. I suppose my paralysis prevented me from enjoying the physical signs. I wanted to experience life. This just happens to be part of life that I had not planned on experiencing."
Henry was trying not to laugh without much success. He said, "We can fix this if it is too much of a bother."
Jo responded, "I'll put up with the hassle for now."
The weeks wore onto months and rehab efforts continued. When nerve testing revealed a return of function in the upper arm muscles, Jo had a party. It may have been the smallest party Henry ever attended. Despite Jo's improving health she remained reclusive. The party consisted of her secretary Mary, the private nurses, the rehab team and Henry. The highlight of the party was when Jo raised a toast using a glass taped to her hand. Her shoulder and arm muscles were strong enough to raise the glass, but she needed help to actually drink from it. A cheer arose spontaneously from the small crowd! Progress was much more rapid for the next several months as more nerves re-grew. Some of the connections failed, and Jo had some areas of numbness and other areas with a constant tingling sensation.
Henry awoke early with anticipation of the one year anniversary evaluation of Jo's surgery. His meeting with Jo was scheduled at 9:00 A.M. as customary. He enjoyed breakfast with his family before leaving for work. He arrived at Jo's office a few minutes before nine. Mary greeted him with a friendly hello and offered him coffee. She said, "Jo will be with you in a few minutes."
Henry smiled and accepted the coffee asking, "As punctual as ever?"
"We will see."
At 9:00 A.M. a voice over the intercom asked Mary to send Henry in. Henry smiled and gave Mary the thumbs up sign. He entered the office which now had a more feminine flare. The jumble of computer paraphernalia had been replaced by a single sleek computer monitor and fresh flowers. Henry had become accustomed to seeing Jo as a middle-aged woman with a young body. Her dress was a conservative business suite in a dark blue. This worked well with the slight graying of her hair which was nicely styled. Her greeting was genuinely pleasant and she asked specifically about his wife and their children. Henry updated her on the family. Jo asked about Henry's ongoing research and he summarized the status for her. It was then Henry's turn to ask questions. They had already decided that the one year anniversary would be the final assessment. Henry wanted to know the status of the nerve function.
Jo said, "I have enough arm and leg strength to walk with a walker. I have only fair sensation in my feet but pretty good sensation in my hands. The fine motor function is less than ideal and I am very clumsy. Most importantly though, there has been no return of the rheumatoid arthritis."
Henry said, "This has been a very dramatic treatment option for rheumatoid arthritis. I would prefer to think that we are now able to prevent the horrible complications you incurred. You should expect to get some further improvement in your fine motor skills. Your result is not perfect, but I am happy that you are doing this well."
Jo said, "I am now more mobile then I was before the surgery. The horrible fatigue that I suffered from is gone. Instead of being constantly cold, I am always warm. It is a joy not to be living in constant pain. Adapting to my status as a woman is an ongoing struggle."
"Despite watching you adapt, I cannot even imagine the changes that are required."
Jo replied, "I was the one who said that any suitable donor was acceptable. I had no idea how different it would be to be a female. The menstrual thing is just a very small part of the change. My mood swings have been hardest to adapt to. As Joseph, I ate very little. Now with this young body I need to eat all of the time, and I crave chocolate which I never even liked before."
As the meeting was ending Jo said, "One other thing, I'm pregnant."
Henry was very surprised and said, "I didn't think you were getting out."
Jo replied, "Artificial insemination."
"Why so soon?"
"I have a young body, but my pituitary gland is middle aged. The fertility doctors thought I was already starting to enter menopause. It was now or never."
Henry asked quietly, "Who is the father?"
Jo said, "I am. I made a deposit in a sperm bank before I started my first round of chemotherapy."
The End