Transcript

Thomas Fitts: I am Tom Fitts and I got into transplantation I think in probably a quite unique way. I was a young assistant professor in surgery in Charleston, SC. I was interested in trauma at that time primarily; I had just gotten back from putting some Vietnamese together. The university wanted me to do some research, that’s what they brought me there for. And so that was perking in my mind, but what really happened was a very strange set of events.

It started in a small cancer hospital in California and some of the people that were treating those patients thought it would be really effective if they could introduce their chemotherapy, if they could put it into the thoracic duct and this for some reason they thought would be a wonderful thing.

Thomas Peters: You are saying how many channels of the thoracic duct?

Thomas Fitts: Well mostly the valves. The valves would make that impossible and that is exactly what happened. So they would up with the lymph coming out all the time and they found something that was really interesting, they found that these people that were draining large amounts of lymph, those are the cancer patients who were in renal failure, did not need to be dialyzed anymore, so they published it.

And some nephrologists in Galveston then picked it up and said, “Well maybe we can instead of dialyzing blood or the peritoneal cavity, we’ll dialyze by this method.” And then the nephrologists at Charleston got interested in this and they wanted a surgeon to find and put a canula in the thoracic duct and that’s how I started. I said, “Okay, I’ll do that for you” and I did. And I got really very interested in the whole process because it clearly became evident over the next year that patients were being able to be dialyzed at the same time that they were being immunosuppressed because the data was pouring in from a lot of places which showed that thoracic duct depletion did show definite evidence of immunosuppression.

So I went back to my basic life, I was a boy born on a…and raised on a dairy farm in Tennessee and cows were the only thing that you could really work in, the size of them and the amount of thoracic duct lymph you had allowed that to happen. So I started a research effort with the cows to try to decide how much the immunosuppression was, how long did it take to get it, etc. and I got a grant for that. And I spent at least two years at which time the residents on the surgical floor had a chart that they kept of Bessie and every morning when we had rounds, they had written up what happened that last night and the things that had happened to me, which kept things kind of fun.

But the fact was that it dawned on me that we were in a unique position in our little niche at that time in that we had a patient population that needed a kidney and was on dialysis and automatically on, being on dialysis they were being immunosuppressed. And we did some high-tech things like we had two people in a room and I managed to wrangle the two of them to let me take a skin graft from each of them and take them over. One was a thoracic duct depleted patient and one wasn’t. As far as I know, that patient that was thoracic duct depleted is one of those slides that I have shown for years, it still probably…it stayed there all his life. So I knew, I knew an awful lot about the degree of immunosuppression that existed in that.

Thomas Peters: You started one of the first transplant programs in the Southeast, can you tell us about that?

Thomas Fitts: Um starting the transplant program in the small university in Charleston at that time was a fascinating endeavor one way or another. I was absolutely convinced that this was something that was going to be a great benefit and that were, that we would be stupid if we did not take advantage of this setup that I have just described but I couldn’t get anybody to help me. Nobody really thought much of it.

So I took my life in my hands and went straight to the Dean and as any academician knows, that’s a deadly thing to do. I’m crossing and jumping over the Chief of Surgery; I am crossing over the Chief of Nephrology; and I’m crossing over the Medicine Chief, all of whom I thought were hindering me and not helping me. The Dean was a delightful man and he immediately sent off a letter to each of those individuals and said that it would be a first-option deal as far as he was concerned that our school did need a transplant program. Well as you can imagine, the repercussions from this were (Laughs) were not good and I know that my chairman, my Surgical Chairman, I think tenure was all that saved me at the time.

But I found out and it is fascinating to me, I finally I got a word in and I said, “Well doctor, why are you so opposed to this, this idea?” And he said very simply, a very good man, he said, “Look this is just a shot in the…You know, this is not going to pan out to be a real thing. Transplantation is a flash in the pan, it’s not going to do it.” and I was astounded.

But anyway, the Dean’s…The Dean, God bless his soul, actually they turned around and quit impeding me and I actually was able to get together a small team, myself and a couple of other people, not no other surgeons, and I set upon doing that.

And then December the second, 1968, I did the first transplant in Charleston under thoracic duct depletion. Well I knew nothing about Imuran and prednisone. The Chairman of Surgery had said, “Well you don’t know how to put a kidney in” and he sent me to [Joseph] Murray so that I would learn how to do that. I stayed a week there, they gave me a patient to operate on, and so I came back and told the Chairman that I had worked that out and I knew how to put a kidney in now and got over that problem.

And the question that came up, the operation went fine and there were headlines in the little town of Charleston about it. Then the nephrologists came along (Laughs) and they were all prepared to put Imuran and Prednisone in the mix for this patient. And I said, “Boys, no we’re not going to do that. This man is severely immunosuppressed; I wouldn’t dare put Imuran and Prednisone on that additionally. I know that he will be suppressed severely for a matter of a month, I spent years seeing that happen and so we’re not going to use that. We’re going to go with the thoracic duct depletion.”

And their response to that was a six-month period when they went to nephrologists all over the country asking if they wouldn’t support the fact that this program that I had just started was malpractice. There were things that you had to fight to get done; there isn’t any question about that.

Thomas Peters: You were a charter member of several organizations in transplantation. Tell us about the years; tell us about those years and your self-introduction into transplant organizations?

Thomas Fitts: Right. the milieu in which, the environment that I then stepped into, not having really thought a whole not about it, but I, I rapidly became aware of a group that I really take David Hume as probably the guy that set it out the most. But we had a very unusual thing and I found that quickly and we became a charter member of what became, what was known as the Southeastern Organ Procurement Foundation.

Now this was in ’68 and it dealt with Virginia, North Carolina, South Carolina, Florida, the Southeast is what it was. And it was run by the doctors and it was a haven, oh my goodness with nobody with experience of anything and just one person, me, boy finding, finding the Southeastern Organ Procurement Foundation was like finding a momma and I can’t really put anything ahead of that organization as a symptom of an organization that worked. It was you know, UNOS preempted it and I guess it certainly did need to be… the idea did need to be national, but we lost the all-doctor deal when the feds came in and it got to be not the… It became different than what SEOP was. So I think that if I ever had an organization that helped me tremendously, I would say it was that Southeastern Organ Procurement Foundation.

Thomas Peters: Were you a charter member of the ASTS as well, and what are your memories of the early days with the ASTS?

Thomas Fitts: Well I never…The early days, I didn’t have much - I didn’t have a lot of spare time, period. There was just one person, that was me, and I did everything. I did, I had a girl that was the Director of the organ procurement area, and we started that. But I had to call for the patients, I had to take the patients, I had to take the kidneys out, I had to do everything.

And my periods of watching the activities of the organizations were somewhat…What I remember was that the nephrologists and the histocompatability people and the surgeons, that’s too many people; it wasn’t going to really work too well, in my opinion, not like SEOP was. So I wasn’t…I wasn’t…When Rajagopalan, who was the first man to come to work with me, when he came in ’74, by then I think the fights had been over and it was a, a normal surgical society at that time.

Well the program then did well. You know we had passed most of the fierce hurdles and we were actually having people who were supporting us. And by 1991, we had Clint, Clint Baum had found me an excellent man, Joe Cofer that was trained and we had a liver program that went very smoothly. And Jonathan Bromberg whom I think Clyde Barker sent to me was a strong support and the pancreas program, again also went a little more difficultly than the liver but it came alright. And by that time, we were doing a hundred or more kidneys routinely and the program survived and actually thrived in that period of time.

Thomas Peters: Can you tell us a few vignettes or humorous stories

Tom Fitts: There are three things that occurred that I will never forget that characterized our program very adequately in my mind. The first one is in the days that there was just me, I did everything, I called a patient. We probably had six people on the list or what not, from some small rural town in South Carolina. And there was a young man there that was on the list and so I called to get him to bring him in.

Well his mother answered the telephone and she said, “Well he’s not here.” And I said, “Well can you get him?” And she said, “Well actually” she said, “He is with my husband and they’re shooting pool and I can’t get there. I don’t have a car and the tractor is not working so I don’t know how I’m going to get a hold of him.” And I said, “Well ma’am it’s really important.” I said, “We’ve got a kidney for him and I need to get something going.” And she said, “Well I’m thinking about it, well doctor would it be alright with you if we came and picked it up next Monday?” (Laughter in room)

Now I’m listening to that and thinking and I say, “Well somehow I’ve got to make this work” and I did. I made it work, I looked at… I thought, “Well this is what I’ll do.” And I said, “Ma’am it will plum spoil by then, plum spoiled.” And any momma knew that if something was spoiled it wasn’t any good and she said, “Well I’ll get uncle Earl to do it and he’ll come do it” and we got it. But I will never forget that lady saying that.

The second thing is all the transplants I did that I remembered were in the middle of the night. I don’t know why every other transplant surgeon is the same way. But I had…I had done the first transplant of two that I was going to do one night and I had finished the one, the first one and it was about 2:30 in the morning. So I went into my office because things in the academic they don’t necessarily go as fast they do outside.

But at any rate, I was waiting for the second transplant to be in the operating room and I was expecting a call from the operating room. And the phone rang and I picked it up and a woman named Mary Lou Bessik whom I knew as a patient that I had transplanted about a month or so earlier and that she was, she was about the most homely woman I ever saw but she had five husbands. I didn’t understand all that, but anyway I knew her. I said, “Well Mary Lou, what do you want?”

Well she said, “Well you know doctor, you never have told me what I should eat.” At 3:00 in the dad gum morning, this was what she told me. And I thought to myself, I said, “The
woman thinks that I live here.” Not only that, she wants to do what she thinks… I was just overwhelmed with it at 3:30 in the morning and after a while I said to her, “Ma’am, what you should eat is food” and hung up, one way or another.

The most weird surgical debacle I have had worked out alright. It was a young boy that ultimately became known as “Hot Tub Friarson.” And he was a young man, about 26-years-old with renal failure and he was going to get a transplant and when he got the transplant, he was going to marry his bride and all of that transpired. We got him a kidney and he marched out of there doing fine and he celebrated his marriage. And then I think the first thing they did was get in a hot tub and he fell over the back of the hot tub like this and he didn’t pee a drop after that.

And so on the Sunday, on an Easter Sunday I was called by his nephrologist who told me, “He hasn’t done a drop.” And so I said, “Well send him here immediately.” He came immediately and I did an arteriogram and I was down in the suite and obviously the kidney had pulled the artery completely lose from the sub…the artery that it was sewed in and I said, we’ve got to get him to the operating room immediately.

And again, the…the academic world didn’t spin as fast as it should. And so I immediately left this and I was walking out the radiologist Davin Vuchi said, “Tommy, do you want me to leave a balloon catheter in here? I could do that.” And I said, “You could do it if you want to, but I’m going…I’ve got to get to the operating room right now.” And he said, “Well I have a big syringe here and if you want to use it, there it is, it will be there.”

And I ran up to the operating there and he wasn’t in the operating room, some orderly had taken him to his own room. And by that time, he had…He had become a…I mean he was so bad that they had the team out to keep him going on way or another and I ran up to that room and the room was filled. That had every anesthesiologist, everybody in the whole room, everybody trying to get this guy well. I couldn’t even get a word in edgewise. And I.

But I heard enough to tell me that he was dying, no question about it. So I had to kind of climb and then come in between the, two or three of the people that were working there and find that syringe. And I did like that on a 50cc syringe and I waited for about 5 minutes and I said, “Is he doing any better?” They said, “Yeah he’s working fine.”

So I managed to get him to an operating room and he did alright. But he was forever after known as “Hot Tub Friarson” and I’ll never forget the kid. Those are the ones that the most, the ones that I remember that I like.

Tom Fitts: I think that I would like to encourage anybody that is young and looking in transplant as a world, please look at the fact that we have still…I still don’t see significant progress in long-term stability in transplants, especially kidneys. And I think that we are depending too much on the pharmacy people. I don’t think we’re ever going to find a drug that does what we want done. I believe that you’re going to study more hard and do harder work on the physiology of humans and the physiology of animals and that would just be my, a point that I…Looking back at the course now, I think we have slowed down. I know there are reasons for it, but boys you’re going to have to work on the physiology of our animals, both human and in the animal plan.

Thomas Peters: Tommy, what happened to the thoracic duct drainage that was so promising.

Tom Fitts: The thoracic duct drainage is a fascinating thing. Obviously it went caput when the money came out. The format was you brought a person in and you put him in a room and you drained his thoracic duct and then he was in automatically the first shot at a kidney and that’s how it operated and we did sixteen through that. And then the money system you know, that began and the hospital began to scream because I was using at that time, grant money to keep…and anyway, it became impractical.

Now there were several other places where it was looked it. It was looked at in Galveston. It was looked at in Vanderbilt. It was looked at I Chicago and it was looked at in Boston and everybody had the same problem. But as a fact of exactly what I am talking about, Nick Tilney, who did the last paper that I remember about thoracic duct depletion, found a significant increase in the longevity of renal transplants. And it’s my feeling that it may resurface as a segment of patients who are identified as a high-risk at a…getting longevity in a transplant, there may be, there may be some use for that. It may re comeback.

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