July 31, 2020

Mayra Ramirez, 28, spent six weeks on a ventilator after she contracted Covid-19, and later became the first Covid-19 patient in the United States to receive a double lung transplant. Now, more than three months after she was admitted to the hospital, she's going home, Denise Grady reports for the New York Times.

Here are 5 key tactics to attract and retain transplant patients

Ramirez's bout with Covid-19

Before she got sick, Ramirez worked from home as a paralegal, enjoyed running, and cared for her two boisterous dogs. However, while she was in generally good health, she did have an autoimmune condition called neuromyelitis optica, which required her to take immunosuppressants that could have made her more vulnerable to the new coronavirus, Grady reports.

Ramirez fell ill in April. For about two weeks, she managed the illness at her home. On April 26, however, she developed severe symptoms—a 105-degree fever and extreme fatigue—and a friend eventually drove her to the hospital. Providers diagnosed Ramirez with Covid-19, the disease caused by the coronavirus.

Despite her symptoms, Ramirez said she didn't think she'd be in the hospital for long. "I thought I'd just be there for a couple of days, max, and get back to my normal life," she said.

Instead, however, Ramirez's condition worsened. According to Ankit Bharat, chief of thoracic surgery and surgical director for Northwestern Medicine's lung transplant program who performed Ramirez's surgery, Ramirez developed secondary bacterial infections that couldn't be treated with antibiotics because of the extent of lung damage she'd experienced. Eventually, her heart and other organs began to fail because of a lack of oxygen.

Doctors placed Ramirez on a ventilator—which she used for six weeks—and then on an extracorporeal membrane oxygenation device while they waited for her coronavirus infection to clear. "The entire time, I had nightmares," Ramirez said.

On June 5, after Ramirez no longer was positive for the virus, she underwent a 10-hour transplant surgery. The surgery took much longer than most lung transplant surgeries because the inflammation the coronavirus had caused in Ramirez's lungs left them "completely plastered to tissue around them, the heart, the chest wall, and diaphragm," Bharat said.

According to Bharat, Ramirez was the sickest person on whom he's ever performed a transplant—and she had the worst lung damage he'd ever seen.

A long road to recovery

When Ramirez woke up days after her transplant, she was bruised, thirsty, and not able to speak—and, "with all these tubes coming out of [her]," she found herself unable to "recognize [her] own body," she said.

When nurses asked her whether she knew the date, Ramirez guessed it was early May—but it was the middle of June, Grady reports. Providers then told Ramirez that she'd had a lung transplant.

"I couldn't process it," Ramirez said. "I was just struggling to breathe and I was thirsty. It wasn't until weeks later that I could be grateful, and think there was a family out there who had lost someone."

On July 29, Ramirez finally got to return home, where she's using and strengthening her lungs every day, she said. "I definitely feel like I have a purpose," Ramirez said. "It may be to help other people going through the same situation that I am, maybe even just sharing my story and helping young people realize that if this happened to me it could happen to them, and to protect themselves and protect others around them who are more vulnerable. And to motivate and help other centers around the world to realize that lung transplantation is an option for terminally ill Covid patients."

Bharat said Ramirez will "continue to get stronger and stronger." She'll be on anti-rejection medications the rest of her life, and while transplanted lungs can be rejected, he said he's seen some last 20 years before a patient needs another transplant.

The implications of Ramirez's surgery

Generally, lung transplants are considered a last option only performed on patients with irreversible lung damage, Grady reports. But Ramirez's surgery suggests a "paradigm change" for the procedure, Bharat said.

"Lung transplant has not been considered a treatment option for an infectious disease, so people need to get a little bit more of a comfort level with it," he said. (Bharat, since Rameriz's operation, has performed a similar surgery on Brian Kuhns, 62, who had also contracted the coronavirus, and Northwestern currently has two additional Covid-19 patients waiting for transplants.)

In some cases, hospitals have waited too long to recommend a Covid-19 patient receive a transplant, while in other cases, the reluctance of health insurers to cover the surgery or pay for related travel has caused delays, Bharat said. "I think people need to recognize this option earlier and just start at least talking about it before it gets to that point," he said.

"This is so new to our field," Tiago Machuca—a doctor at the University of Florida Health Shands Hospital, where another Covid-19 patient received a double lung transplant—said. "It will be a challenge for physicians to determine which patients truly are candidates and what's the timing. We don't want to do it too early when the patient still can recover from Covid lung disease and resume with good quality of life, but also you don’t want to miss the boat and have a patient where it's futile, the patient is too sick" (Grady, New York Times, 7/30).

Here are 5 key tactics to attract and retain transplant patients

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