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Transplant deaths at USC a puzzle

Liver program's high fatality rate may be due to risky patients, subpar organs or other factors.

December 29, 2006|Tracy Weber and Charles Ornstein | Times Staff Writers

His liver rapidly failing, William McMurrough was running out of options.

He'd been removed from the waiting list for a transplant at UCLA Medical Center for using marijuana and skipping rehab.

The 50-year-old truck dispatcher was critically ill -- with a bacterial infection and other ailments -- when he landed at USC University Hospital. He thought it was his salvation.

Surgeons there were undeterred by his deteriorating health and recent drug use. "They just took him," his wife, Linda, recalled.

Days after joining USC's waiting list in January 2005, McMurrough got a new liver. His family rejoiced, hoping he'd meet the grandson he'd felt kicking in his daughter's belly.

Many hospitals would have turned McMurrough away outright, loath to risk wasting a scarce donor organ on such a risky patient. But USC was different. It took pride in giving chances to patients with few left.

After opening its liver program in 1996, the hospital just northeast of downtown Los Angeles developed a record of success.

Then, around 2003, its death rate started to climb.

Today USC's rate is among the worst in the country. In a span of 2 1/2 years, 38 of 164 patients died within a year of their transplants, twice as many as expected, according to the most recent national data. The data largely factor in the condition of patients and donated organs.

For now, the reasons for USC's declining success rate remain largely a mystery. Prompted by an article in The Times in July, regulators and outside experts hired by the hospital are investigating.

There are several possible explanations: It could be that the program was choosing the wrong patients for transplants or using organs of poor quality. It could be that the team mishandled surgeries or follow-up care. Or it could be a combination of reasons, including bad luck.

Officials at USC's Keck School of Medicine, which runs the clinical side of the program, and at the hospital, owned by Tenet Healthcare Corp., declined to be interviewed for this article.

In a joint statement in September, however, both pointed to an answer: They were consciously taking high-risk patients.

It was an effort, they said, to provide extremely sick people with "a chance at life despite the risks of lowering our survival statistics."

In some instances the program appears to have gone too far, according to top transplant experts who reviewed medical records for The Times.

"They're pushing it as hard as they can and having the results that you'd expect to see," said Dr. David Mulligan, chairman of transplant surgery at Mayo Clinic Hospital in Phoenix, who also sits on the board of a national oversight group.

USC's story illustrates how an aggressive program can lose its footing, especially in a major metropolitan area where the waiting list for livers is long and competition among transplant centers is stiff.

In fact, in recent years, USC's program has been under mounting pressure.

There were deep internal divisions over whether some patients were healthy or sober enough for a transplant, said five current and former transplant staffers who spoke on condition of anonymity for fear of jeopardizing their careers.

Beyond that, the transplant center was losing millions of dollars each year, according to its corporate owner. And staffers became enmeshed in professional and personal conflicts.

In such an environment, USC surgeons were struggling with the life-and-death medical decisions of any busy transplant center: Is the patient too sick to survive, even with a new liver? Is the donated organ good enough to save a life? Is a valuable liver going to waste?

One way that hospitals gauge whether they are making the right decisions is to keep a close eye on mortality rates. If deaths go up, doctors figure out why and make changes.

USC University Hospital apparently did not do that. Tenet said in an October statement that the hospital did not become aware of the mounting deaths until July, when national statistics were released. The statement did not address why the hospital had failed to act on data published six months earlier showing a similarly high death rate.

As for McMurrough, he died six weeks after his transplant, unable to overcome infections and other serious complications.

Linda McMurrough said she was never told why. "They kept telling us it wasn't their fault," she said.

Risk and nerve

Liver transplantation is immersed in risk. It takes training and practice.

It also takes nerve.

Dr. Rick Selby, USC's chief liver surgeon, honed his skills in the late 1980s at the vaunted University of Pittsburgh, where nerve was in generous supply.

It was the cradle of liver transplantation, led by Dr. Thomas Starzl -- who performed the world's first liver transplant and trained some of the country's most prominent surgeons.

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