Jesica’s Story See System Failures

In February 2003, Jesica Santillian was scheduled for a heart-lung transplant. Jesica was looking forward to receiving her new heart and lung. The thought of feeling better, not having fainting spells and having more energy excited her.

The doctors assured the Santillians that Jesica was an excellent candidate for the transplant. Jesica was 17 and she had her whole life to look forward too. Jesica had been born with a heart defect and she was small for her age, only 90 pounds. This transplant was a chance for a new beginning. After all, Duke University Hospital was one of the leading hospitals in the country. A few years earlier, the Santillian’s had come from Mexico to America in order to receive the best care for Jesica.

After surgery, when Jesica was removed from the heart bypass equipment, something began to go terribly wrong. Jesica’s vital signs were not responding the way they should have and the operating room team had to put her back on cardiac bypass. The new organs weren’t functioning. Shortly after the OR team realized that Jesica was in trouble a call came from the laboratory. Jesica’s new heart and lung had incompatible blood. She had “O” positive blood and the organ donor had type “A”. This combination causes the most severe form of a blood reaction.

Although an attempt was made to reverse the blood reaction and Jesica was given a new heart and lung, it was too late. By February 21, 2003, doctors realized that Jesica had irreversible brain damage. Jesica died on February 22, 2003.

WHAT WENT WRONG?

Jesica died as a result of a hemolytic blood reaction. The official autopsy report stated, “Given the historical circumstances and the autopsy findings, it is my opinion that this young woman's death was the result of global cerebral hypoxic injury that was a complication of the rejection of an ... incompatible heart-lung transplant,’ said the autopsy report signed by Dr. John Butts, the chief state medical examiner,” in North Carolina.¹

Hemolytic reactions are rare. When they do occur they are very serious and can be fatal. This reaction is also known as ABO incompatibility. Jesica’s blood, type “O” had no ability to handle blood cells with “A” antigens. She had antibodies within her blood plasma that would attack either an “A” or “B” donor’s blood cells.

Often a hemolytic reaction can lead to a condition known as Disseminated Intravascular Coagulation (DIC). DIC is a problematical and complex condition which starts with microscopic bleeding and eventually leads to an over reaction of the body’s blood clotting system. Tiny blood clots develop throughout the body and ultimately lead to lack of oxygen for vital organs, including the brain (in Jesica’s case). Kidney failure, heart failure and death ensue.

Santillan's transplant surgeon, said he takes responsibility for the organ mix-up. Because a surgeon is technically in charge of the surgical case, Dr. Jaggers assumed accountability for the medical error. Conversely, he is not fully responsible for it. No one person, no human error alone is to blame. The medical error that took Jesica’s life was the result of system design failures.

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