Interviewed by Gina So
Dr. Scott Livingstone is a liver transplant surgeon at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. He specializes in multi-organ transplants, hepatobiliary surgeries and general surgeries. When he was 14, Dr. Livingstone was diagnosed with alpha-1 antitrypsin deficiency which resulted in him requiring two liver transplants. He recently underwent a third transplant in 2019. We had the pleasure of speaking with Dr. Livingstone about his journey to becoming a transplant surgeon and the importance of organ donation.
Can you give us a brief introduction of who you are and what you do?
L: My name is Scott Livingstone, and I am originally from Calgary, Alberta but I live in Halifax now. I am a surgeon who does transplant surgery (liver and kidney), hepatobiliary surgery, which is mostly liver and pancreas surgery, as well as some general surgery. My undergraduate and medical school degrees were done in Calgary and my general surgery residency and master’s degree were completed at Dalhousie University. Finally, I went to University of Alberta in Edmonton to do my fellowship training in abdominal transplantation and hepatobiliary surgery which is the bulk of my current practice.
Tell us about your journey of being a liver transplant recipient. What was the waiting process for a liver like?
L: When I was young, I was diagnosed with alpha-1 antitrypsin deficiency which caused cirrhosis and I required a liver transplant in 1993. I had to have a second one at the time because the first one had an arterial complication. After the first two transplants I recovered and was able to live a normal life with the exception of taking a few medications. I completed school, participated in sports, and was able to achieve my new desire of becoming a transplant physician, allowing me to help others receive the same second chance that I received. I met my wife during residency, and we have two children aged 8 and 5 who are wonderful. Unfortunately, my transplant from when I was 14 eventually failed and I had to undergo a third transplant in October 2019. Thankfully I’ve recovered well and am back at work as of October 2020.
When I was younger, there was a different process for the waitlist. But I didn’t know much about it at the time because I was only 14 and I was sick. Now in 2020, the waitlist categorizes each patient by their MELD score: a combination score based on parameters that assess your liver and your kidney function. The higher your score is, the higher you are up on the waitlist. It predicts your risk of dying due to your liver disease over the next 3 months. This time around, I was pretty sick and had a very high MELD score, so I didn’t wait a long time for my transplant. Waiting can be a bit of an emotional roller coaster because in essence you’re waiting for something tragic to happen to someone else, which is not something that you would wish on another human being. It’s a difficult process for people most of the time. Unfortunately, there are more people in need of a liver transplant than there are available organs, and about 20% of people that are waiting pass away before being called for transplant.
Did your experience of being a previous transplant recipient at a young age inspire you to become a transplant surgeon?
L: Absolutely. I got sick when I was 14, in the summer between grade 8 and grade 9, and had the transplant during the fall. I always liked science growing up and in high school, but that experience definitely pushed me to an interest in medicine. Once I was in medicine, it pushed me to an interest in surgery. From there I gravitated towards surgeries on the liver and transplants, so it’s definitely had a huge effect.
Does your experience being a transplant recipient affect how you interact with your patients that are going through similar things as you did?
L: It absolutely does – especially when you see people in consultation for a liver transplant. I don’t tell everybody about my story – I do it if I think it’ll help them to get through the whole process. Having a better understanding of what people are going through definitely makes it easier for you to be empathetic. Sometimes when I see people struggle with a decision or process, I can help give them a little more confidence and reassurance by sharing my story. It helps me to understand where patients are coming from.
What is the greatest challenge you face as a transplant surgeon?
L: I think the biggest challenge faced by transplant surgeons in general is the lack of donor organs. It would be great if we had enough donor organs for everybody that needed a transplant and then there wouldn’t be long waitlists, and also people wouldn’t become increasingly sicker as they wait. It is kind of like a double edged sword because to get higher on the waitlist for a liver, you have to be sicker and the sicker you are, the harder it is to make it through surgery without complications and recover. It makes everything more challenging.
The other challenge is that people who have liver failure have multiple health problems, so they are extremely sick patients. The surgery is a high stress surgery that involves a lot of bleeding and there are times that things can go seriously wrong. But the biggest challenge is not so much the technical aspect of the surgery, but it’s about getting people to the transplant.
What are your opinions on the organ donation and transplantation process? Is there anything you would change?
L: I think it’s essential to have strong public awareness for organ donation. You can tell that there is increased awareness when there are a tragic event and people start donating. For example, following the Humboldt Broncos bus crash in Saskatchewan there was a large increase in people donating organs for a while because one of the crash victims donated his organs. Whenever high-profile cases occur and are shared in the media, donor rates go up for a while, but the increase is never really sustained. I think the best thing we can do is to really try to increase the understanding of the donation process. Educating the public about what’s involved with organ donation and about the whole process is important so that when families come to that step, they understand what is happening.
Some of the changes that are happening now are good. For example, in Nova Scotia, there is a push towards a universal opt-out donor-process, instead of our traditional opt-in process. This is nice because you can capture people who maybe wouldn’t have considered becoming a donor. But even if we have universal donation or someone has signed their donor card, it is not a good idea to move forward with donation if family members are opposed to it because it brings hard feeling and potentially bad press to your program which can be detrimental.
In addition to cadaveric donation, you can also take a portion of a liver from a health person and transplant it into another individual. Live donors are most beneficial for pediatric patients because they can use part of someone’s left lobe which is pretty low risk to the donor, and the children do extremely well with these transplants. Live donation is also used for adult patients, usually using the right lobe which comprises about 60% of the donor’s liver volume. This is a much higher risk operation with a ~1/500 risk of death to the donor, although no donor deaths have occurred in Canada to date. However, it would be nice if there were enough cadaveric organs so we wouldn’t have to resort to live donors. Kidney donation, on the other hand, is a much lower risk procedure for the donor and the chances of a donor going on to develop kidney failure of their own is quite low, so live donation is a big source of organs for kidney transplantation with great success rates.
Why should people sign up to be an organ donor?
L: The main reason is how many lives can be saved and made better by just one donor. Transplantable organs include heart, lung, liver kidney, pancreas and small intestine. There are also numerous tissues that can be used such corneas, bone grafts, heart valves etc. In fellowship, I held information sessions for university students about donating. We had a slideshow where we went through the process of involving different kinds of donors and what happens in the ICU when their family decides to donate. We showed people what the incision would look like and what organs would be retrieved. As part of the session, we had a family member of an organ donor come and speak. She told us of her experience when her teenage son passed away and how the decision to donate his organs and tissues brought some comfort in knowing that he was living on in saving lives and helping numerous other people. In total his donation had helped over 40 people who had received his organs and tissues. These types of sessions allow us to educate people as to what is involved but also shows how the donation process can also be therapeutic for the families of donors.
There tends to be a lot of misunderstanding surrounding being an organ donor results in doctors not trying as hard to save your life. Can you tell us more about this?
L: That whole issue surrounds donations after cardiac death. These “DCD” donors are different than the classic brain-dead donors (DBD). DBD’s have to be officially diagnosed as brain dead. They have a clinical exam as well as an imaging test that shows there is no blood flow to the brain. Donation after cardiac death involves people that have some sort of catastrophic brain injury but don’t fully meet the criteria for brain death. However, based on the assessment of the critical care doctors if it is felt that their chances for recovery are essentially nonexistent or then a discussion will be had with the family regarding withdrawal of care and organ donation. In that circumstance if the family agrees, they withdraw all life support measures and patient has to have their heart completely stop. Then there is a minimum 5-minute period where nobody can touch the patient and then they declare them dead if there is no pulse. Following this the potential donor is then rushed to the operating suite to proceed with organ retrieval. The media has reported a few cases of individuals who have made miraculous recoveries from catastrophic injuries. These have been branded as “near miss” events and used to argue against DCD donation. The fact is that the decisions about withdrawal of care are made by the critical care team (who are not involved in the transplantation process) and is made based on the patient’s prognosis, always keeping the best interest of the patient in mind. It is not until after the decision to withdraw care has been made that there is any discussion regarding organ donation. Transplant physicians are never involved in the decision-making process about proceeding with organ donation. In addition once care is withdrawn the patient must be legally declared dead of a cardiac arrest prior to proceeding with organ retrieval, taking away any uncertainty that the patient could have recovered prior to organ removal. Donation after cardiac death makes up a smaller portion of cadaveric donors than brain dead donors. They are a good source of organs, but I would never want to take patients that could recover and unnecessarily turn them into donors. There are very specific standards and protocols set by each institution that must be adhered to for these types of donors. This is why one of the reasons why I think it is important to educate the public about the whole process of organ donation and the different types of organ donors.
Anything else you would like to add?
L: Transplantation is very important to me and is the biggest focus for me in my field. I would love to be able to do just organ transplants, but we don’t have enough donor organs to allow that. It is, however, the only surgery that I perform where I can take someone and make them feel and look multiple years younger and is a direct life-saving operation. A lot of surgeries that we do for cancer prolong people’s lives but often don’t result in a cure. With a transplant you get the immediate gratification of seeing someone improve virtually immediately while offering them a new lease on life. It is extremely satisfying to help someone in that way. Most people that receive transplants are extremely grateful for the gift they have been given and they try to live their life to reflect that. It’s something that allows people to get a second chance and they rarely waste it.
Dr. Livingstone’s story and insight demonstrates the importance of organ donation and the need for public education. It is undeniable that there is currently a shortage of organ donors and we must continue to spread awareness about how organ transplants have the ability to transform people’s lives, much like it did for Dr. Livingstone. We hope that the information from this interview inspires you to become involved with organ donation and advocacy.