10 April 2012

Illegal Immigrant Receives Kidney Transplant

Story first appeared in The New York Times.

When restaurant customers learned that the waiter they liked was in the hospital with kidney failure, they stuffed bills into a collection jar to help support his family. His brother offered something more precious: a healthy kidney to restore his life.

But for two years, the obstacles to the transplant seemed insuperable. The patient, the father of two American-born children, is an illegal immigrant. And a maze of conflicting health care and immigration policies meant that while the government would pay for a lifetime of dialysis, costing $75,000 yearly, it would not pay for a $100,000 transplant that would make dialysis unnecessary.  A Raleigh Immigration Lawyer is following the case.

Yet Tuesday morning, he and his brother were undergoing the surgery in adjacent operating rooms at Mount Sinai Medical Center. And all the other barriers receded in importance as doctors swabbed bare skin with antiseptic and prepared to cut.

The brothers had hugged when they met at 4 a.m. at a subway station in Brooklyn for the trip to Mount Sinai, in Upper Manhattan. Now, under the cool green lights of one operating room, the healthy brother was covered with blue sterile drapes, and his flesh was pierced with the tools of laparoscopic surgery, computer monitors showing an inner human landscape of pulsing blood vessels and vital organs.

In the second operating room, the patient, a small man in his 30s who had dwindled to 115 pounds during years of shuttling between work and dialysis, was soon draped too. Only his exposed abdomen and the beep of the heart monitor marked his living presence when the masked team prepared to slice and sew.

The patient's quest for a transplant was chronicled in a Dec. 21 article in The New York Times about a paradox in health care rules. In New York, Medicaid, the federal-state health insurance program for the poor, covers the cost of dialysis, considering it an emergency measure, regardless of whether the patient is a legal resident of the United States. But while a transplant is far cheaper in the long run, that procedure is covered by Medicare, which does not extend to illegal immigrants.  It would make sense to go ahead with the transplant regardless of the national status of the patient as long as it took care of the problem without extenuating circumstances, states an Immigration Lawyer in Raleigh.

The article drew more than 600 comments online, many expressing anger at illegal immigrants or frustration at the impasse in national immigration and health care policies. Others called for compassion and asked where they could send donations. About $14,000 from readers was collected with the help of a health lawyer at the New York Legal Assistance Group.

A wealthy Texas rancher pledged $75,000, which he felt should be enough to pay the whole cost of the operation. But it was not enough, and the confusion that reigns over health care costs, combined with philanthropic complications, almost derailed everything.

Mount Sinai, one of the world’s leading transplant centers, had originally set the price for the operation at $200,000 in advance, to cover any possible postoperative complications; it lowered that to $150,000, given the youth and health of the brothers, but barred further reductions as a slippery slope to unaffordable demands for uncompensated care.

A surgeon and the associate director of Mount Sinai’s Recanati/Miller Transplant Institute, had been trying to help the patient and refused to give up. In February, at her request, a former patient from Florida sent $75,000, to match the Texan’s pledge. But the Texan dropped out, irritated that what he called “legal aid” was collecting the donations, he said, and upset that the operation was going to cost more than it would at a Texas hospital where he is a trustee.

North Shore University Hospital volunteered to consider the brothers for a transplant and to absorb the cost. The patient, who like his brother did not want to be fully identified for fear of provoking immigration authorities, was grateful for North Shore’s offer, but decided not to start all over with tests there while doctors at Mount Sinai were still trying.

In the end, the associate director raised an additional $18,000 from an anonymous donor, and after much soul-searching, the hospital agreed to do the surgery for $100,000, the Medicare rate.

It was done by teams with years of experience, as diverse as the city itself. One doctor, a native of the Patagonia region of Argentina, maneuvered tiny tools that cut and cauterized at the same time, separating the healthy kidney from connective tissue in several hours of painstaking work.

He unfurled a special zip-lock bag inside the brother’s abdomen, first enveloping the kidney, and only then cutting it free from the blood supply and the bladder, and pulling the bagged organ through a small incision into the waiting hands of the director of the transplant institute.

The director of the institute, who grew up in Louisville, Ky., carried the kidney, cleaned and cooled, to the second operating theater, where a surgical technician born in Haiti was deftly reordering an array of scalpels, syringes and sutures.

In a safety ritual, a nurse from the Philippines called “time out,” invoking the patient’s name, birth date and blood type, and the organ he was about to receive.

The goal was to connect the kidney to the recipient’s blood flow in less than 45 minutes. It took 30.

For more health care related news, visit the Healthcare and Medical News blog.

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