State medical examiner, organ agency celebrate transplant work

Under the watchful eyes of a team of Brazilian doctors, a surgery last month at a Columbia, Mo., hospital demonstrated how tissue from a fatal carcrash victim in Arkansas can help a patient with joint pain.

Operating under a time crunch, a medical examiner from Arkansas approved a doctor taking cartilage tissue from the victim. The tissue was then matched with a patient at the Missouri Orthopaedic Institute who needed similar tissue replaced in his knee. The Brazilians were hoping to observe and learn the procedure, called an osteochondral allograft transplantation.

The collaboration — which began in Little Rock and will resonate in the South American country, several Arkansans involved said — is the latest example of the “unique” relationship between the Arkansas medical examiner’s office and the Arkansas Regional Organ Recovery Agency, or ARORA.

While the Arkansas Regional Organ Recovery Agency identifies eligible organ donors and gets any needed permission from the families, the medical examiner’s office gives the OK to say which organs, if any, can be collected from bodies in its jurisdiction. It doesn’t do the tissue collection itself.

This Friday, the recovery agency plans to honor the medical examiner’s office for its latest aid in the Missouri operation and for nearly three decades of collaboration.

“Had this graft not been released, [the Brazilian team’s] experience here would have been pretty much nothing,” said Catherine Hankins, the manager of tissue recovery at Arkansas Regional Organ Recovery Agency.

Arkansas’ chief medical examiner, Dr. Charles Kokes, has been a leader in his field in working with organ procurement organizations such as the Arkansas Regional Organ Recovery Agency, Hankins said.

Medical examiners often are hesitant to approve giving away organs and other tissues for fear that it will interfere with their work, Kokes and Hankins said. Medical examiners have the task of determining causes of death in myriad circumstances that require official review, such as murder cases.

But for Kokes, his first job at Maryland’s Office of the Chief Medical Examiner in Baltimore guided his attitude toward organ donation. He later brought that attitude to Arkansas. Across the country in the early 1980s, organ recovery mostly involved kidney transplants, Kokes said, and was largely limited to major hospitals in urban areas.

“Early on in my career, the realization came not only to me but to a lot of other people that this is an area that those of us who deal so much with death and trauma and that sort of thing can actually do something to help the living,” Kokes said.

Since he took the medical examiner’s job in Little Rock, Kokes said, the ability of doctors to transplant tissues and organs has grown to commonly include lungs, hearts, heart valves and tendons.

Kokes said his office has had to learn which action is appropriate in given situations.

For example, a victim with a gunshot wound in the head, Kokes said, could be a clear-cut candidate for organ donation. Other cases, such as those involving long-term abuse, may require erring on the side of caution.

And there are sometimes law-enforcement concerns.

“The fear … with organ tissue donation is that if organs and tissues are removed before the autopsy, that that might somehow jeopardize a prosecution down the road,” Kokes said. “A lot of time, that just simply is not the case.”

In most cases, Kokes said, surgeons harvesting organs and tissues don’t have the option of waiting until after an autopsy is performed. Organs, for example, often have to be harvested from a braindead person whose body is being kept alive by a machine.

And in cases in which tissue can be harvested from a cardiac-dead patient, harvesting has to be done quickly.

“We have about 24 hours after the pronounced death time” to collect tissue, said Gerald Curtis, the funeral home and coroner liaison for the Arkansas Regional Organ Recovery Agency.

That often leaves quick decisions up to Kokes and his team. Younger members of his staff are often more hesitant to give the OK to have organs or tissues removed, Kokes said, and sometimes he’ll step in to give assurances.

“Nobody wants to mess up, but that’s one of the benefits of being in the profession for as long as I have. You get a better sense of when that potential is there,” Kokes said.

There are no documented instances in which a decision to harvest organs negatively affected a “medicolegal case,” according to a 2014 policy paper by the National Association of Medical Examiners, which reaffirmed the group’s support for examiners permitting the procurement of organs.

As many as 70 percent of potential donors fall under the jurisdiction of medical examiners and coroners, the paper reported.

In Arkansas, donations approved by the medical examiner’s office make up about 10 percent of the Arkansas Regional Organ Recovery Agency’s caseload, Curtis said. This year, that included about 38 cases of tissue donations such as those used for the Missouri operation.

Curtis said ahead of Friday’s luncheon that the Arkansas Regional Organ Recovery Agency is working to get a better picture of the number of cases that went through the medical examiner’s office.

Kokes did not give the final approval in the case that led to tissue being used in Missouri. The medical examiner who did was away last week for the Thanksgiving holiday and unavailable to talk, he said.

The Arkansas Regional Organ Recovery Agency was unable to connect a reporter with the recipient of the donation in Missouri.

Nationally, there are more than 116,000 Americans on waiting lists to receive kidneys, hearts, livers or other vital organs, according to the United Network for Organ Sharing.