Given that Mike was such a seasoned member of our team, I could only assume that this particular flight was going badly. When the pilots glanced back to see the source of the screaming and cursing, I could make out the fear in their eyes. I looked at the spinning altimeter and noted that our plane was popping up and down as much as a thousand feet at a time. Outside the window, the lightning was shooting horizontally. The rain was constant and loud, and I was sure I heard pieces of hail hitting the windshield.

One unique part of the discipline of transplantation is the procurement of organs from donors. While we do perform transplants, particularly kidneys, with organs from living donors, the majority comes from people who have just died. Rather than transporting donors, who typically remain on a ventilator, brain dead but with a beating heart, we send a team out first, to meet with their families to thank them for their gift and then to perform the surgery to remove their organs. We then take those organs back for transplant into waiting patients.

On this particular day, I’d received a phone call at around 5:00 p.m. telling me to come to the OPO (organ procurement organization) at 9:00 p.m., for wheels up at 9:30. The thirty-minute flight from Madison to La Crosse had been without incident. We arrived at the donor hospital at around 10:30. The donor was a young man (almost a boy) who had died in a motorcycle accident. That detail is easy to remember, as Wisconsin, being the land of Harley (not to mention a state where wearing a helmet is frowned upon), produces a never-ending supply of donors who’ve died in motorcycle accidents. In the winter, it’s snowmobile accidents, the snowmobile being the vehicle of choice for bar hopping in the evenings—which sounds like fun but is also incredibly dangerous, given the power of those machines.

After we examined the donor at the hospital in La Crosse, confirming his identity and blood type, and went over the paperwork, including the declaration of brain death, we met with his family.

This continues to be one of the most difficult and, at the same time, most rewarding aspects of my job. No matter how tired I am, the interaction with the donor family always reminds me how wonderful and cathartic the donation process is. These people are going through the worst experience of their lives, as most donors die far too young and unexpectedly. Often, the family members have not even had the opportunity to say good-bye. Perhaps the one positive notion that family members can hold on to is this: with this ultimate gift, their loved one will save the lives of, and live on in, as many as seven other people. Their gift of life will be a legacy their families can cherish amid the brutal pangs of loss they have to endure.

We have a picture in our transplant unit of a mother whose teenage daughter died in a tragic car accident. This young girl saved at least seven lives. Some years later, the mother met the heart recipient at a transplant picnic we sponsored, and a picture was taken of her using a stethoscope to listen to her daughter’s heart beating in the chest of the man she had saved.

This family tonight in La Crosse was no different. They asked how and when they could possibly make contact with the recipients, a process that we can help facilitate down the road if all parties agree. Then, once all their questions were answered, they said their final good-byes.

Once the donor was transferred to the operating table and prepped, we scrubbed in and placed the sterile drapes. At this point, all emotions from the encounter with the donor’s family were pushed out of our minds. We had a job to do: to get all the transplantable organs out and flushed so that they would spring to life when placed in their new “owners.” Our team, which had come for the abdominal organs, was not the only one in the operating room that night; there were two others: heart and lung teams, waiting to take their respective organs. We stood around the operating table, separated by the patient’s diaphragm. They focused on the chest, and we focused on the belly.

I took a scalpel and made a long incision from “stem to stern,” or from the notch at the bottom of the neck down to the pubis. As I dissected through the tissues and entered the belly, the cardiac team took a saw and began opening the chest. I quickly grabbed a malleable (a long, bendable steel retractor) and held it in front of the liver, to make sure they didn’t get a little careless with the saw and injure this beautiful organ.

There is a natural conflict between a cardiothoracic team and an abdominal team. We all realize the importance of the incredible gifts the donor is giving, and we are all the stewards of these organs. At the same time, the procurement team always gets blamed for anything that goes wrong with the recipient operations that follow.

“Why is the upper cuff of the liver so short?”

“Why didn’t I get more vena cava below my heart?”

We’re all trying to bring back the best organs we can. So, everyone protects his turf.

I think about operations in steps. Step one: open the belly. Step two: mobilize the right colon and duodenum, and expose the aorta and vena cava. Step three: loop the aorta to prepare for cannulation (i.e., the insertion of a plastic tube into an artery that will allow us to flush the blood out).

That night, we got through our steps, which included freeing up attachments to the liver and separating the liver from the diaphragm and retroperitoneum. We dissected out the porta hepatis, identifying the hepatic artery and the bile duct. We divided the bile duct, letting the golden bile pour out into the abdomen. Then we cleared off the portal vein. Next, we mobilized the spleen and exposed the pancreas. As we neared the end, we identified the renal veins and arteries, which lead to the kidneys.

By now the cardiac team had scrubbed out and was standing behind us anxiously. Our portion of the operation is always much more involved than theirs, and as usual, they were constantly asking us when we would be ready. In their defense, their recipient surgeons (often hundreds of miles away) typically have already taken their patients to the operating room and begun opening their chests and getting them ready to be placed on bypass for removal of their sick hearts or lungs.

Finally, we were ready. We placed our cannula in the aorta. The cardiac team then placed a cross-clamp on the aorta and started infusing cardioplegia solution (which causes the heart to stop beating). Then they got ready to cut into the vena cava right before it entered the heart. (We made sure to protect as much vena cava as we could from those bastards. They didn’t need it for their transplant, but we did for ours.) Once they cut it, the blood started to well up and out of the chest cavity. We started our flush through the aorta and then placed a second cannula in the portal vein. In poured the cold “University of Wisconsin solution,” the wonderful solution, invented at our own institution, that preserves the organs and helps make all this possible.

The blood turned clear as it flushed out into our suction devices. We then poured buckets of ice into the abdominal cavity. Our hands began to cramp and ache from the ice as we held our cannulas in place. The good news was that, after a couple of minutes, the pain dissipated (as did all other feeling in our hands). The organs were cut out, flushed some more, and placed in bags.

Then we all went our separate ways.

That evening, I called Dr. D’Alessandro on the way out and told him we had a perfect liver. Of course, he was sleeping soundly in his bed. He would direct the OR team back in Madison to take the recipient patient to the operating room and start removing the old liver.

We took a cab back to the airport. It was about 1:45 a.m. at this point. We were all exhausted, but also filled with the satisfying feeling that always accompanies an operation gone well. The added bonus was that our cooler was filled with four organs that would go into three separate patients—a liver, a kidney, and a combined kidney and pancreas (called “simultaneous pancreas and kidney,” or SPK). At the airport, we walked out onto the tarmac, where the pilots were waiting.

The pilot turned to me and asked if I thought we should go. We both looked over at the cooler with the sticker reading “Organs for Transplant.” I mentioned to him that he shouldn’t worry about the organs; thanks to UW solution, the carefully designed preservation solution that would allow the organs to be metabolically inactive, they could wait awhile. I could always call Dr. D’Alessandro and tell him to delay the recipient.

Instead, I asked the junior pilot if he thought it was safe. I say “junior” because he looked all of about ten years old.

“It should be,” he said. I detected a slight tremor in his voice.

Not that convincing, but I agreed to go.

We took off, and everything seemed pretty smooth. But about ten minutes in, things started to get crazy.

As the plane bucked and the alarms sounded, I really did think this was it. I thought about my family, particularly my little girl, born two weeks before we moved to Madison for my fellowship. I was bothered by the idea that someone at my funeral would say I’d died doing what I really loved. That’s bullshit. There is really no great way to die, certainly not in a stupid little plane in the middle of the night.

We finally got through the storm, and as quickly as it started, it stopped. The pounding rain and the turbulence subsided, the plane settled, and we sat in silence for the last five minutes of the flight.

After we landed, I asked one of the pilots how commercial planes could possibly be landing in this weather. He said, “Oh no. The airport is totally closed, only open for emergencies.” I remember feeling somewhat pissed about this, but in a way, what we had just done qualified as an emergency.

The donor liver was truly a perfect organ. I cleaned the extra tissue off it and meticulously tied off all the small vessels that came off the cava (though, of course I would still be blamed for any bleeding they got into after reperfusion). I then separated the pancreas (which we’d also use) from the liver, making sure not to injure either and to leave enough portal vein and artery for both transplants. I placed the pancreas in its own bag, which I would bring back down to the “lab.” This organ would be prepared and transplanted in the morning into a type 1 diabetic, along with one of the donor kidneys we’d just procured. The other kidney would go into a different recipient. In two other states, two different patients were receiving the heart and the lungs from our donor in La Crosse.

I never cease to find this remarkable.

Once the liver was ready, I brought it into the recipient room, where the team was waiting. When they saw me, Dr. D’Alessandro took the Klintmalm clamp and placed it on the last remaining attachment to the liver, the hepatic veins going into the vena cava. He cut the recipient’s liver out. I watched over his shoulder.

There is no more amazing sight in surgery than the abdomen once the liver has been removed. The vena cava—the large vein that brings blood from the legs back to the heart, which is normally enveloped by the liver—is fully exposed, coursing from bottom to top, and there is a huge, empty space around it. It is an unnatural but weirdly beautiful sight.

Dr. D’Alessandro took the new liver and started sewing it in—in steps. Upper cuff first. Then portal vein. Then flush. Then re perfuse. The liver pinked up and looked beautiful. Everyone looked happy.

Then Dr. D’Alessandro mentioned that I needed to go. There was another procurement, up in Green Bay.

My projects are my patients. Each one requires something cut out, glued in, or fixed up until it’s time for me to move on to another. Cindy was a particularly memorable “project.” When I first did a liver transplant on her, she was gravely ill, probably within a day or two of dying. I had gone to bed early the night before. At around two o’clock in the morning I got the phone call. I answered it on the first ring because, when I’m on call, as I was that night, I sleep with one eye open.

It was one of our coordinators for organ offers, Pamela. “We have a liver offer. It looks like a good one. He is a forty-four-year-old male, died of a drug overdose. Twenty minutes of CPR. Perfect liver numbers.” Pamela spent the next five minutes giving various details about the donor’s stability, previous medical histor...