Advanced technology, transplant help young mother breathe on her own again

Nicole Jenkins

Front row from left are: Tracey Francescon, BSN, RN, post-transplant nurse coordinator, Jennifer Iuppa, PharmD, pharmacist, Nicole Jenkins, Rene Hofstetter MSN, ANP-BC, nurse practitioner, and Kelly Morris, BSN, RN, pre-transplant nurse coordinator. Back row from left are: Alexander Krupnick, MD, transplant surgeon, Chad Witt, MD, pulmonologist, Aki Itoh, MD, cardiothoracic surgeon, and Dan Kreisel, MD, PhD, transplant surgeon.

As an operating room nurse in her hometown of Salem, Ill., Nicole Jenkins knows what it’s like to be there to help others in a time of need. However, she wasn’t prepared to become a patient, fighting for her life. Her journey started with a 104-degree fever in September 2013. It ended with her walking out of Barnes-Jewish Hospital with a new set of lungs, thanks to the effort of a multi-disciplinary team that could only be found at one of the top academic medical centers in the country.

A nurse for the last nine years, Jenkins, 30, was determined to go to work despite not feeling well one Monday in September. She left work early and the next day, finding it difficult to breathe, was forced to take quick, shallow breaths. She was admitted to her local hospital, with the hope that a quick treatment of IV antibiotics would return her to health in time for a family trip to Florida four days later.

“But it didn’t help, and I continued to get worse instead of better,” Jenkins says.

Unfortunately, the Jenkins family wasn’t able to take their daughter Madison, 7, to Florida. Instead, Jenkins was airlifted to a larger hospital in Springfield, Ill., when her oxygen level sank to 50 percent.

“I was so scared and frustrated because I could tell I needed to be intubated,” says Jenkins. “I was having such a hard time getting a good breath.”

She spent several weeks in the hospital, but her condition deteriorated so rapidly, doctors there only had one life-saving option remaining—they decided to transfer her to Barnes-Jewish Hospital. Jenkins was taken immediately to the cardiothoracic intensive care unit, 56ICU, on Oct. 3 to begin extracorporeal membrane oxygenation (ECMO) treatment.

ECMO involves running a patient’s blood through a machine that removes carbon dioxide and adds oxygen before blood is returned to the heart and pumped to the rest of the body. It essentially performs the role of a healthy heart and lungs, adding oxygen to the body. This specialized treatment has been shown to benefit some patients with extremely severe cases of respiratory illness. ECMO treatment is very complex and is used on approximately 90 cases annually at Barnes-Jewish—typically heart failure and respiratory failure patients. Barnes-Jewish is one of the largest providers of ECMO treatments in the country.

“We came to St. Louis to see if being on ECMO could keep her alive,” says Bryce Jenkins, Nicole’s childhood friend and husband of 12 years. “It was our last hope.”

Aki Itoh, MD, Washington University cardiothoracic surgeon at Barnes-Jewish Hospital and Scott Silvestry, MD, former Washington University cardiothoracic surgeon at Barnes-Jewish Hospital, performed the initial ECMO procedure on Jenkins and continued to care for her throughout her time in the hospital. Jenkins arrived at Barnes-Jewish with arterial oxygen partial pressure (how well your lungs are able to move oxygen into the blood) of 39, even on the maximum mechanical ventilator support. It should have been in the 90s.

“We thought she might have a chance of recovering by using ECMO to let her lungs rest,” says Dr. Silvestry, former surgical director of heart transplant at Washington University and Barnes-Jewish Hospital. “Patients are sedated and paralyzed so that their lungs can heal while the machine does the work.”

Dan Kreisel, MD, PhD, and Alexander Krupnick, MD, Washington University transplant surgeons at Barnes-Jewish Hospital, did a biopsy procedure on Jenkins Oct. 15 to assess the extent of damage to her lungs.

“When we opened her chest, we found her lungs were just scar tissue,” says Dr. Kreisel. “Her lungs were completely damaged and not working at all.”

Because her lungs were not likely to recover, Jenkins was added to the wait list for a lung transplant. Her transplant team did not think she would be a good candidate to recover fully from a transplant if she continued to wait for lungs while in her medically induced coma. The effects of being sedentary for such a long time began to tax her body.

Most patients on ECMO have an access line put in the neck and leg that runs to the heart. Dr. Silvestry suggested the team create a modified version of the treatment, using a converted ECMO that allows the line to be placed in the chest instead of the neck and leg.

“To help her recover from a transplant, we needed her to be able to move around and be more likely to accept the new lungs,” says Dr. Itoh. “We use this often for heart patients on 56ICU, but we have never used it as a bridge to lung transplant. With this conversion, she could sit up, walk and eat on her own, while still reaping the benefits of the ECMO machine.”

After a month of being the traditional ECMO patient, Jenkins was brought out of the coma. She was still on ECMO, but could get out of bed.

“I remember feeling like Frankenstein with all the tubes and machines keeping me alive, and I was scared to death,” she says. “I remember thinking I was going to die because my breathing was so shallow.”

As a nurse, she was shocked to wake up from her coma to learn that she did not have any bed sores.

“I had lost so much weight and was so boney, I was probably down to 80 or 90 pounds,” she says. “To me, that tells me how hard the nurses worked to keep me from staying in one position too long. I know how hard that is, and I am so appreciative of the nursing care here.”

Slowly, she made progress and was able to eat soft foods, drink her favorite sweet tea and walk across her room with the ECMO machine. But now she faced another battle.

While on ECMO, a patient receives many blood transfusions. This caused Jenkins’ blood to be filled with various antibodies—cells that can attack foreign tissues. The more antibodies a person has, the chance of any organ being a correct match is diminished. That means only one percent of donor lungs would have been a match for Jenkins.

“The eligible donor pool for her was very small,” says Dr. Kreisel. “We knew our chances of finding a match for lungs would be extremely slim, but we had to try.”

Just in time for the holidays, the Jenkins family prepared for the gift of lungs—a rare match had been found in St. Louis.

Drs. Kreisel and Krupnick performed her transplant and she was simultaneously removed from the ECMO machine. By the end of the 5-hour operation she relied only on her new lungs to breathe.

After a month-long recovery from the transplant surgery, Jenkins left the hospital in February without supplemental oxygen. She still does not know what caused her to get sick in the first place.

“We expect lung transplant patients to leave us without oxygen, but her case was remarkable because of her journey prior to transplant,” says Dr. Kreisel. “I think most of us didn’t think she would walk out of the hospital at all because of the small chance of getting a donor.”

“This is something the entire hospital should be proud of,” says G. Alexander Patterson, MD, Washington University chief of thoracic surgery and surgical director of lung transplant at Washington University and Barnes-Jewish Hospital. “The entire team from various hospital divisions worked together to give this young mother the opportunity to live a full life.”

Jenkins will continue her physical therapy program and does pulmonary rehab five times a week. She will stay close to the hospital for three months, and then, like most patients, she should be ready to go back to her hometown.

“As long as she continues to progress the way she is now, we expect that her lung function will continue to improve over the next 6 to 12 months, which is typical lung transplant recipients,” says Chad Witt, MD, Washington University pulmonologist at Barnes-Jewish Hospital who participates in her care post-transplant.

Jenkins says she is thankful for the entire team who worked together to save her life.

“It has been an amazing, life-changing journey,” she says. “I’m thankful for little things now, like being able to eat what I want. I was thrilled the day I could eat on my own again and right now, I’m still enjoying eating everything I can get my hands on.”

 

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Category: Patient Stories, Transplant

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Barnes-Jewish Hospital at Washington University Medical Center is the largest hospital in Missouri and the largest private employer in the St. Louis region. An affiliated teaching hospital of Washington University School of Medicine, Barnes-Jewish Hospital has a 1,800 member medical staff with many who are recognized as "Best Doctors in America." They are supported by residents, interns and fellows, in addition to nurses, technicians and other health-care professionals.

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