He is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times.

Peter J. McDonnell, MD

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A friend of mine, a physician, handed me a brief document. “You do transplant surgery,” she said. “You need to read this.”

The document is a “statement of concern” issued by the American College of Physicians (ACP). It describes a procedure termed “normothermic regional perfusion (NRP) with controlled donation after ccirculatory determination of death (cDCD).”

NRP-cDCD is performed in an effort to obtain healthier organs for donation when those organs are more susceptible to ischemic injury after cessation of circulation. 

Keeping the organs perfused in situ allows additional time to assess the organ’s function before it is transplanted. 

Performed in other countries, it is now being proposed for use in the U.S.

The way NRP-cDCD works is that after a patient is deemed to have “circulatory death” (defined as death confirmed by the irreversible cessation of circulatory and respiratory functions), the chest is opened and the large vessels are connected to a bypass machine or ECMO (extracorporeal membrane oxygenation)-circuit.

Circulation of the blood is thereby restored to preserve the organs for donation, but only after the carotid and vertebral arteries are occluded to prevent cerebral reperfusion. 

The heart may then resume beating, calling into question the determination of irreversibility that was required for the diagnosis of circulatory death. 

Because the brain is denied a blood supply, the term “regional perfusion” is used, and brain death promptly ensues.

The ACP statement says this procedure called “organ retrieval after cardiopulmonary arrest and induction of brain death” and it questions the ethics of this approach.

The “dead donor rule” says that donors cannot be made dead in order to obtain their organs and that organ retrieval cannot cause death. 

NRP does resuscitate the patient, except for the brain. 

Almost famous: Ophthalmologist gained worldwide attention in 1910


The ACP asks “Is declaring a patient dead by irreversible circulatory criteria, then rendering the patient brain dead before restoring circulation honest, transparent and respectful of patient autonomy and dignity?”

What if the donor or donor’s family had given consent? Can laypersons who are not physicians or medical experts be made aware of the full details of what this protocol involves? 

The ACP says “informed consent by itself cannot confer ethical legitimacy on NRP-cDCD." 

Moreover, standards of medical ethics do not permit consent to supersede all other ethical considerations.

There are existing alternatives. Organs can be harvested and subsequently reperfused using machines outside the body. 

Living forward: We still have to understand backward

In what strikes me as a definite understatement, the ACP says “there is a large and ethically significant difference between perfusing an organ versus perfusing an individual.”

My driver’s license testifies to my willingness to be an organ donor should the situation arise. But I hope they do not do NRP-cDCD to me.

“So what is your response to this?” asked my physician friend.

“We do not do any of this with cornea donors,” I answered.

Articles

A word from Chief Medical Editor Peter J. McDonnell, MD. 

Organ donation: "Dead donor rule" sets guidelines or harvesting organs


Born in Ohio in 1822, Hiram Ulysses Grant went on to lead the Union Army to victory during the American Civil War. A national hero, he became the 18th president of the United States. 

During his time in office, he created the Justice Department and used it to aggressively suppress the Ku Klux Klan.

William Halsey Jr, born in New Jersey in 1882, became the second-highest ranking American naval officer in the Pacific in World War II. 

Described as “flamboyant, vulgar, aggressive, and spectacularly ugly,” the admiral was loved by his troops. 

An intelligence officer described the reaction to the news that Admiral Halsey had been ordered to take command during the Guadalcanal campaign: 

“One minute, we were too limp with malaria to crawl out of our foxholes. The next, we were running around, whooping like kids.”

Halsey’s leadership is credited with turning impending defeat into a major Allied victory. He was decorated with the Navy Cross, the Navy Distinguished Service Medal, and the Army Distinguished Service Medal.

Joe Jamail Jr, born in Texas in 1925, served in the US Marine Corps for over 2 years in the Pacific in World War II before becoming an attorney. 

He became known as the “King of Torts” in recognition of his victories against large corporations, winning more than 200 verdicts, or settlements, of at least $1 million. 

 proclaimed him the nation’s richest practicing lawyer, and 

 magazine estimated his net worth at $1.65 billion.

Aside from military service, what do these 3 gentlemen have in common? 

The common thread that strikes me is that all 3—while enrolled in the schools that would prepare them for their subsequent meteoric careers—were considered mediocre by their professors. 

At West Point Military, Grant proved himself a talented horseman, but ranked in the bottom half of the class, which prevented him from qualifying for a position in the cavalry upon graduation. 

Halsey proved himself a talented athlete at the US Naval Academy in Annapolis, Maryland, but graduated in the bottom third of his class. And as a law student at the University of Texas at Austin, Jamail’s professor flunked him in the class on torts.

How could their professors have failed to recognize the future superstars they would become? 

Are the traits that allow doing well in class so different from those that predict 

Do our professors value the wrong things? 

Or is it the case that these young men matured and blossomed later in life, finally focusing on what was needed to rise to the top of their respective professions?

I wonder about this when it comes to how we train our young physicians and surgeons. 

In your residency, did your faculty emphasize the right things? Did they recognize your future promise?

Do grades predict performance?


A body is discovered buried in the cellar of a London home. The head, hands and all the bones had been dissected away, leaving only the organs and soft tissues. 

Needless to say, in 1910 there was no ability to confirm identity with DNA. 

The disappearance of the husband, in the company of his secretary/girlfriend Ethel Le Neve, naturally made him the leading suspect, but he eluded the authorities, escaped from England and seemingly had disappeared.

The suspect, Hawley Harvey Crippen, an American, decided to travel by ship from his hiding place on the European continent back to the United States. Ethel, her hair cut short, pretended to be his son. 

Unfortunately for the abscondees, the ship’s captain saw through their disguises. 

And also unfortunately, the ship was one of a relatively small number of vessels equipped with the recent technology developed by Guglielmo Marconi known as wireless telegraphy. 

The captain messaged his observations back to London, resulting in a Scotland Yard detective immediately setting sail on a newer and faster ship in order to apprehend the suspects before they could vanish into the giant North American continent.

Worldwide attention focused on the flight of the couple, the effort to capture them and the role of the new technology of the earliest radio devices. 

Front pages of newspapers around the world included daily updates, with locations of the ships and observations about the fugitives.

Crippen was arrested by the Scotland Yard detective, returned to England, and promptly tried for murder.



Although he maintained his innocence, the jury deliberated for less than half an hour before finding him guilty. Three weeks later he was hanged.

I've heard of the case, but what I had not known before reading 

was that Crippen was a U.S.-trained physician, and not only a physician but an ophthalmologist! 

He attended medical school at the Cleveland Homeopathic Hospital (homeopathy was very popular in the United States around the 1880s) and then moved to study “ocular medicine” at the New York Ophthalmic Hospital at Third Avenue and 23rd Street, graduating in 1887. 

In his murder trial, prosecutors argued that his medical training gave the defendant access to poisons such as henbane (then commonly used in ophthalmic treatments) and conjectured that he had administered such a drug to his wife before dissecting her corpse. Cora Crippen was the victim. 

Big Brother is watching: Technology is looking out for me

Author Erik Larson makes clear she was an egotistical unsympathetic character who was emotionally abusive and probably unfaithful to her husband. 

Some readers may take pride in knowing an ophthalmologist briefly became the most talked about man in the world, taking the view that all publicity is good publicity. 

But while a lot of things may have changed in terms of societal mores in the past 111 years, and while the American Academy of Ophthalmology’s Code of Ethics does not explicitly condemn it, I hope we can all agree that ophthalmologists should refrain from murdering their spouses, children (including teenagers!) and even in-laws.

 – unattributed proverb ridiculing people who compulsively pursue accumulation of material possessions. 

When I was a young corneal surgeon recently out of fellowship, my belief was that the best way to put my training to use was to perform as many surgeries as possible on as many people as possible, allowing them to see better and live better lives. Sort of like the quote above, but with corneal transplants and cataract extractions instead of sports cars and yachts.

From time to time when we would decide to schedule surgery, a patient would ask me how many of these surgeries I had done already, or they would encourage me to be sure and get a good night’s sleep the night before. But one day a patient who had been referred to me for a corneal transplant asked me something I had never been asked before. “How many of these surgeries do you perform in a typical day?” he inquired. I think my answer was “about 8.” He responded: “Then, please make mine your third operation.”

I was intrigued. This person was a very intelligent and successful entrepreneur but had no medical background. “I am happy to put you third on the schedule. But please tell me why you want that,” I said.

He explained. “When you first start operating that day, I figure you will be warming up, because you haven’t operated for a couple of days. By the time you finish operating on eye No. 2, I figure you will really be in the swing of things. But by the time you get to eyes 7 and 8, I think it is only natural that you might start getting a bit tired. So I think being third or fourth in the sequence would be optimal.”

“That’s a very interesting analysis,” I said, smiling. 

Everything went well with this gentleman’s operation, and I have never heard of anyone doing a study to see if the order of surgical procedures is an important variable contributing to surgical outcomes. I do know some surgeons who place patients at the end of the day who they think might be at higher risk for complications (due to something like pseudoexfoliation syndrome or a bad outcome in the fellow eye).

I thought of this patient recently when recently I heard an interview with Nobel Laureate Eugene F. Fama.

According to Fama, a professor of economics at Tthe University of Chicago Booth School of Business, one can only optimally perform work that requires careful thought for four hours per day. After that, he thinks, quality suffers. Is that right? If so, what does that portend for patients who are being operated upon towards the end of an 8- hour day in the operating room? 

Optimal performance has a limited window. 

The numbers game

Like most males of my generation, I am a fan of Clint Eastwood movies. A common element in his films is his portrayal of heroic, seemingly fearless, admirable characters (which presumably is only fair considering that he is often the lead actor and director as well as the one putting up funding for the movie).

, Eastwood’s role is that of a Marine gunnery sergeant who whips a group of dysfunctional misfits into a professional fighting force. He emphasizes repeatedly to his befuddled pupils that they will certainly encounter obstacles and that, as Marines, they will be expected to quickly improvise, adapt to the unanticipated circumstances, and prevail. His young fighters are soon deployed and comport themselves admirably and with the utmost professionalism.

Two years into our pandemic, I see a strong analogy between Eastwood’s young Marines and American ophthalmologists (in terms of them being professionals adapting to and successfully overcoming adversity rather than being dysfunctional misfits).

When we look back on how this all started 2 years ago, it was a little scary. Among the first physicians to report the disease and die from it was an ophthalmologist. We learned that the pathogen was spreading rapidly, and our country did not have sufficient personal protective equipment (PPE) to protect ourselves, our staff members, and our patients in our clinics. We read about hospitals filled to overflowing with seriously ill patients and ophthalmology residents being among the top 3 groups of specialists to become infected (along with emergency medicine and anesthesiology). Apparently, many hospitals did not have enough ventilators and, in many of those that did, subspecialists like ophthalmologists and dermatologists (many of whom probably cannot recall which end of the ventilator gets connected to the patient) were asked to work in intensive care units to care for these patients.

What did ophthalmologists do? They improvised (getting PPE from construction firms, making face shields and sneeze guards for our slit lamps), they adapted (changing patient flows, minimizing patients in waiting rooms, using telemedicine to the degree possible) and they overcame (with busy ophthalmology practices and surgery centers now providing world-class care to volumes of patients equal to or surpassing prepandemic levels while protecting themselves, their patients, and their staffs). We did what needed to be done, and we are continuing to improve.

Ophthalmologists continue to rise to the challenge amid myriad hurdles.

Pandemic proves our mettle

I was standing in the checkout line in my local grocery store and the time had come to pay for my comestibles. My preference is to purchase food items shortly before dinner, so I shop frequently—even daily—as they do in Europe and many other countries. It takes time, but the idea is that fresher ingredients almost always translates into a better meal.

My credit card was in my hand and I was about to insert it in the card reader when the lady behind the cash register asked “Would you like to make a donation for prostate cancer research?”

“Actually, I would like to make a donation for eye disease research. How do I do that?” I responded.

“Well, it seems to me that research into eye disease is extremely important,” I explained. “In fact, a recent survey of Americans revealed that we fear loss of vision more than we fear other diseases, including hearing loss and even cancer.1 Plus, when you think about it, everyone has eyes and is therefore at risk for eye disease, while only older men get prostate cancer. Thus, donations for eye disease research benefit everyone: men and women, young and old. Doesn’t that seem better than something that only benefits men?”

I was eager to know if my logic resonated with this store employee. “Who knows?” I thought to myself, “perhaps I can get this nationwide grocery store chain to start raising funds for eye research!” I waited to hear what she had to say.

It turns out that one of the job duties of department chairs these days is to raise funds, helping to support researchers and also medical student and resident teaching. And it just so happens that my counterpart in the Department of Urology in my medical school had wagered a bottle of wine that his department would raise more than my department. I began to imagine what might happen if I could convince this employee and her manager of the importance of vision research and start having the store ask people to support vision research when they pay. I began to think about what I might say to better get my point across.

The checkout lady looked at me quietly for a few moments. “Sir,” she said. “I just work here.”

Reading my mind, my friend who was in line with me touched my arm before I could go on with my argument. “Do not be obnoxious,” she said quietly. I looked at her, and then at the cashier, who looked relieved.

I inserted my credit card in the reader and paid my bill. “Have a nice day,” said the cashier. “You as well,” I replied.

1. Preidt, R; Blindness biggest fear for many Americans. August 4, 2016; WebMD, accessed October 6, 2021. www.webmd.com/eye-health/news/20160804/blindness-biggest-fear-for-many-americans

An experience at the grocery store serves as a reminder of the importance of fundraising for eye research. 