Top 10 Medical Stories of 2008: No. 9

On the night of February 3, 2006, a transplant team, including surgeon Hootan Roozrokh, MD, was dispatched by the California Transplant Donor Network to the Sierra Vista Medical Center to harvest the organs of Ruben Navarro, a 25-year-old man with adrenoleukodystrophy and minimal brain function after cardiopulmonary arrest. What happened next is a function of the Rashomon effect, in which the involved medical professionals told differing accounts of a procedure gone wrong.*

What isn't disputed is that Roozrokh took over the end-of-life care of Navarro, in clear violation of general transplant procedures and Sierra Vista policy, and that Navarro didn't die within the required window of time to allow organ harvesting after being withdrawn from life support. An ensuing inquiry into the failed procedure led to an ongoing investigation by the Medical Board of California, civil suits filed by Navarro's mother, and 3 felony counts against Roozrokh: dependent-adult abuse; administering a harmful substance (oral Betadine); and the unlawful prescription of a controlled substance.

At the preliminary hearing in March for Roozrokh's criminal case, the judge dismissed 2 charges against the physician. First, conflicting or vague testimony could not establish that Roozrokh was the physician who administered Betadine to Navarro in the operating room. Second, the judge determined that the unlawful prescription of a controlled substance did not apply in this case, because the relevant California statute exempts drug orders for a patient in a licensed hospital.

At his criminal trial, Roozrokh testified that he stepped in to fill a void in physician care, while others characterized his actions as those of a callous and impatient surgeon, who ordered massive doses of morphine and Ativan (lorazepam) to hasten Navarro's death. Nevertheless, Roozrokh was acquitted of dependent-adult abuse by a 12-person jury last week. Defense attorney M. Gerald Schwartzbach (who successfully defended actor Robert Blake in his murder trial) had contended that his client "could not have violated the standard of care to merit [the charge]...because no such standard applies to the extraordinary circumstances of this case."

Indeed Schwartzbach's statement highlights the absence of a universal protocol for cardiac-death donation at the time of Navarro's death (despite Roozrokh's clear violation of standard transplant procedure). The California Transplant Donor Network did not require physicians or nurses to undergo specific training in cardiac-death donation until 1 year after Navarro's death, and, in fact, the criminal investigation prompted the adoption of training standards for the procedure by the Network. Roozrokh himself had assisted only one such procedure before the night of February 3, 2006.

The use of cardiac death (as opposed to brain death) to obtain organs for transplantation has been accepted practice for more than a decade in the United States, but hospital-based protocols can vary—thereby creating confusion among medical practitioners. In a prepared statement, the jury members in Roozrokh's criminal case expressed their desire for a uniform protocol, reported the San Luis Obispo Tribune:

"Ruben's case had identified that donation by cardiac death is in desperate need" of having a national refined protocol. "Refining the nationwide protocol of DCD organ procurements will be an important part of Ruben's legacy and for that we pay him our respect and owe him our thanks."

In August, ethicist Robert Veatch argued in the NEJM that heart donation after cardiac death raises a logical paradox. He proposed that, if the heart can be restarted in the graft recipient, then the donor could not have been dead in the first place on the basis of cardiac death. Moreover, the very act of removing the "restartable" heart from the donor is equivalent to killing the donor by means of organ removal. Veatch concluded that it is therefore impossible to legally harvest a heart in the setting of cardiac death and wrote that this paradox can only be resolved by either redefining brain death or altering laws to permit heart removal from living donors.

Veatch's argument was printed in the same NEJM issue that included a report of 3 heart transplantations in infants after the cardiac deaths of pediatric donors. 

For more details on the attempted organ donation of Ruben Navarro and a discussion of cardiac-death donation, check out...

• NYT Discovers California (and Roozrokh Case)
• More on Roozrokh Case: Lubarsky Testimony
• Continuing Coverage of Roozrokh Preliminary Hearing: Transplant Expert Testimony
• Roozrokh Prelim Hearing Continues: Conflicting Accounts and Neuro Testimony
• Roozrokh Prelim Hearing: See One, Botch One
• Roozrokh Prelim Hearing: Who Ordered What When?
• Roozrokh Prelim Hearing: Final Testimony
• Surgeon Roozrokh to Face 1 Charge; 2 Dismissed
• The Transplant Paradox: Heart Donation After Cardiac Death
• Transplant Surgeon Acquitted of Dependent-Adult Abuse

Also visit the web site of the San Luis Obispo Tribune for its excellent and complete coverage of the Roozrokh case.  

* Compounding the Rashomon effect in this case is the fact that, during the attempted procedure, no one recorded the administration of medications, and the vital-sign records were lost.