Madeline Stroup was looking forward to a weekend away at the family cabin in the Okanagan-Similkameen region of BC, with her boyfriend, Hayden Turcotte, and friend Tyrell Gait. That Friday in July 2019, they began the drive east from Maple Ridge. According to Stroup’s sister, they took their time, enjoying one another’s company and sharing stories. Shortly after Stroup turned around to face Gait in the back seat, the driver of an SUV sped through a stop sign, crashing into the driver’s side of their car.

Turcotte died instantly. Gait had minor injuries. For Stroup, the impact resulted in serious head trauma, and she was airlifted to the Royal Columbian Hospital, in New Westminster. In the ICU, Stroup remained unconscious. She was twenty-three, so doctors were hopeful that she would come out of the coma. As they waited, the nurses did everything they could to care for Stroup. They carefully washed her light-brown hair. They braided it. They talked to her.

Four days after the accident, tests showed that the swelling in Stroup’s brain had significantly worsened. Now, there was no chance she’d wake up. A couple of years before the accident, Stroup had signed her name to the provincial donor registry. So, for the next three days, she was kept on life support as hospital staff ran tests to determine how well her heart, kidneys, and liver were functioning and to see if she was a match for any recipients on the transplant wait list. She was, and she saved five lives. But she had sustained chest injuries in the accident, and despite Stroup having consented to also give away her lungs, tests showed that they were too damaged to transplant.

Many people hope to donate their organs after death, wanting to help others in need, but some never get to complete this final act of service. Canadian Blood Services estimates that 32 percent of Canadians have registered their decision about whether to donate. But only about 1 or 2 percent of deaths in hospital happen in a way that allows for organ donation, and registered donors who die outside a hospital typically can’t donate their organs since the tissue can’t be monitored or transported fast enough to keep it viable.

Transplant doctors refuse donor lungs with infections, like pneumonia, as well as lungs with blood clots or tumors. Other times, the donor and the recipient might be in different cities, and the hours it takes to fly or drive the tissue to another hospital increase the risk that the organ will no longer be healthy enough. Transplant surgeons need to be cautious, says Jayan Nagendran, the surgical director of lung transplantation at the University of Alberta Hospital and an associate professor in the department of surgery at the University of Alberta. There is no way to check whether an organ’s function plummeted in the hours between its removal from the donor and transplantation. And transplanting a sick or injured organ into a recipient who is already ill could have catastrophic consequences.

All of this means that we’re not saving as many lives as we could be. In 2020, over 4,000 patients in Canada were waiting on a transplant; 276 of them died that year, up from 250 in 2019. As life expectancy has increased in recent decades, so too has the need for organs. Part of the problem is that the pool of transplant candidates is too small to begin with.

One province has taken legislative steps to deal with the shortage. In 2021, Nova Scotia became the first jurisdiction in North America to enact a “presumed consent” policy, which holds that all medically eligible individuals (those over the age of nineteen, who have lived in the province for more than twelve months, and so on) can have their organs donated when they die unless they specifically opt out. Other provinces have been discussing such a law for years, but no legislation has been passed. According to a 2015 article for the World Health Organization, countries with opt-out laws have donation rates 25 to 30 percent higher than those requiring donors to opt in.

“One in three of my patients waiting for lungs dies. We may have saved at least three or four of those lives.”

But legislative changes won’t address why so few of the organs already available can’t be used. This problem is particularly acute with lung transplants. Although more Canadians experience liver and kidney failure than lung failure, patients waiting for lung transplants die at a disproportionately higher rate, with only one in three receiving the life-saving organ. At the end of 2020, over 200 patients across Canada were waiting for a lung transplant due to diseases from cystic fibrosis to COVID-19, but just 20 percent of all donor lungs from deceased patients are considered acceptable for transplant. Now, new research is promising to significantly improve this state of affairs—not by expanding the pool of organ donors but by rescuing lungs that have been deemed too fragile or ill.

Much needs to align for a donor’s organs to get to a patient waiting for transplant surgery. Following the donor’s consent, their death, and the consent of their family, numerous medical teams conduct tests to determine eligibility. Then a match is found, determined by factors like blood type and whether the height and weight of the organ recipient are comparable to those of the donor.

In Canada, donor organs are prioritized based on location; the University of Alberta Hospital’s catchment area includes northern British Columbia, the Northwest Territories, Alberta, Saskatchewan, and Manitoba. This could mean a donor organ is quickly transported by ambulance, or it could mean a long flight from a remote region. The hospital’s cardiothoracic transplant centre is the most geographically isolated in the world: no other similar program covers a 6 million square kilometre catchment area.

Transplant teams travel to the hospital where the donor is located to further evaluate whether the organ is viable for their patient. If it is, the visiting medical team removes the donor organ, putting it in a plastic bag and then placing it in an insulated cooler full of ice—“It’s the exact same thing you would see at a barbecue,” says Nagendran. The organ is then transported back to the transplant centre, but this presents a logistical challenge.

“There have been cases where I’ve gotten a call in the middle of the night from the operating room in Vancouver, where they say, ‘Our team has decided not to take these lungs, would you use them?’” Nagendran says. “But my best recipient for those organs might be in Winnipeg. There’s no way for me to coordinate that process in time.”

This timing is particularly tricky for lungs, contributing to their high discard rate. On ice, lungs can survive six to eight hours. After ten hours, there will be irreversible damage. After twelve hours, donor lungs can’t be used for transplantation. This window is wider for donor livers, which can still be transplanted around twelve hours after removal, and kidneys, which can be used up to thirty-six hours after removal.

Finding a match; cross-country, inter-hospital communication; making sure the donor organ is transported back to the transplant centre before its function deteriorates; and coordinating operating schedules are all obstacles. Factor in bad weather and flight cancellations and it’s easy to see how the process can fall apart.

The system is still saving lives, says Nagendran, but it could be doing better. “In fact, most metrics would say it’s not working well.”

Several years ago, Nagendran and his colleague Darren Freed began to develop a new device to bridge the gap. The technology could not only keep donor lungs viable for longer but also improve the health of the organs.

In 2007, as a young cardiac surgeon in Winnipeg, Freed was frustrated to see that the supply of healthy donor hearts wasn’t nearly large enough. His patients were dying on the wait list, and so many of the hearts they were offered just weren’t viable for transplantation. The way he saw it, increasing the donor organ supply meant somehow turning injured, unhealthy hearts into healthy, transplantable ones. It meant finding a way to support those organs outside a human body while also evaluating how well they were functioning.

Freed, currently a cardiac surgeon and professor of surgery at the University of Alberta Hospital, began studying ex-vivo organ perfusion: the preservation of organs outside of the body, in a machine kept at body temperature and with blood continuously flowing through them. At that time, there were few ex-vivo machines in existence, and most existing machines didn’t help organs the way they should have. They were also too difficult for doctors to use and too expensive for hospital administrators to justify purchasing. It was rare to see this technology in hospitals at all.

“My approach to organ perfusion has always been that we don’t really know what we’re doing with machines,” says Freed. “So, instead, let’s try to replicate what the body does—our own physiology.”

So Freed bought old heart and lung machine components off eBay, broke them apart in his garage, tinkered with them, and rebuilt them with slight changes. By 2013, he had moved to Edmonton and joined forces with Nagendran. The research continued, growing into an ex-vivo organ perfusion lab. In 2016, a donor consented to give their lungs to Freed and Nagendran for research purposes—and that changed everything.

“We said, ‘Let’s take them to the lab. We can evaluate our device with human lungs.’ At that point, we’d been using animal organs,” says Freed. “After about twenty-four hours of treating these lungs on [our] lung device, they looked beautiful.” The lungs, once riddled with pneumonia and rejected by transplant surgeons, now appeared transplantable.

That resulted in a prototype they named the Ex-Vivo Organ Support System (EVOSS), a creation that exactly mimics how the human body functions.

“We saw that the way devices to date had treated the lungs . . . was not the way you and I breathe. [They] force air into them by putting a breathing tube down the airways, like we do in the ICU, blowing air in,” says Nagendran, adding that this damages the lungs. “We breathe because our diaphragm contracts and our chest expands. [Negative pressure] draws air into our lungs—nothing is pushing air from the atmosphere inside of our lungs.”

Simply put, lungs function best in the environment they’ve always functioned in: one that is 37.4 degrees and in which air is pulled into the lungs rather than pushed. In this warm, natural environment, Nagendran and Freed found that donor lungs could be preserved for up to forty-eight hours. In 2018, the EVOSS went through its first clinical trial, in Edmonton, and the results were published in the peer-reviewed scientific journal Nature Communications in November 2020. Twelve patients waiting for lung transplants were recruited to the 2018 study, and twelve pairs of donor lungs that were too damaged or unhealthy for transplantation were placed in the EVOSS. The outcome surprised even its creators.

“We were able to convert all twelve of them into good quality organs,” says Nagendran. One set of lungs in the trial was so bad—filled with fluid and unable to fill with air—that Nagendran wasn’t sure its health would improve enough to enable a life-saving transplant. “But those lungs miraculously turned around in a couple of hours.”

“All these patients are alive over a year after transplantation,” Nagendran adds. “The fact that we don’t use three-quarters of [donated] lungs means one in three of my patients waiting for lungs dies. . . . I feel that we may have saved at least three or four of those lives that would never have gotten an organ.”

In 2015, the pair co-founded their company, Tevosol, which designed a marketable prototype in 2020. A black box with a removable tablet on one side, it looks remarkably like an air fryer (though its creators liken it more to a picnic cooler).

Nagendran says the EVOSS has the potential to improve both the quantity and quality of donor lungs in Canada. The two-day transplant window eases the time constraints surgeons typically face. Lungs that have been damaged because the donor was ill or injured can be repaired: sick lungs can get antibiotics, and blood clots can be removed with clot-busting medication. The EVOSS also displays data like blood pressure, oxygen level, and elasticity, proving to doctors that the lungs are working well.

The co-founders say the EVOSS is set to launch commercially in Canada in late 2022, subject to Health Canada approval, and later in other countries, with subsequent versions in the works to hold hearts, livers, kidneys, and limbs.

The EVOSS isn’t the only technology on the horizon to improve organ supply. Researchers are attempting to reduce the immune system’s rejection of donor organs by altering or removing the proteins that generate this response in a recipient, making organs universally donatable. Scientists are looking into the 3D bioprinting of temporary organ structures, or scaffolds, to help repair tissue damage and even grow artificial organs. Aboard the International Space Station, scientists are manufacturing organs to research how gravity affects tissue building—knowledge that could be used, way in the future, to optimize the growth of new organs for transplantation.

Technology that expands the supply of organs could also help avoid the ethical grey area of presumed consent. Marika Warren, an assistant professor in the department of bioethics at Dalhousie University, explains that not opting out doesn’t necessarily signal consent to donate one’s organs after death. “When consent is explicit, then we can be really clear in how we interpret that action,” says Warren. “In the case of [presumed] consent, we’re trying to interpret an inaction.”

People who are hard to reach with public education and awareness campaigns, perhaps because they live in rural or remote regions or because English isn’t their first language, are at risk of having their disadvantages compounded, says Warren. It’s essential that the benefits of increasing the supply of donor organs don’t come at a disproportionate cost to already marginalized groups.

“I think the crux of the issue is, Is there a better way?” Warren says of presumed consent. “And, if there is a better way that achieves the same or similar benefits without the [human and ethical] cost, then I would argue the ethical obligation is to go with the way that has fewer costs associated with it,” she adds. “In terms of organ donation and using various technologies that might optimize [donation] or that might reduce the need for donor organs, I think certainly investment in those directions is much less restrictive than things like presumed consent.”

For now, when a transplant does happen successfully, when all the stars align and a match is found and the timing works, it can feel like a rare stroke of luck for a patient who’s been waiting years for this moment. They have a second shot at life, and they’re forever grateful to the donor who lost their own. Of course, for donors’ loved ones, knowing this doesn’t undo the car accident or the long illness. For them, the world is still forever changed. But, during a family’s time of grief, knowing they fulfilled their loved one’s final wish to save a life can, at the very least, bring some closure.

Karin Olafson
Karin Olafson is a Vancouver-based writer who focuses on stories about health, science, fitness, and the outdoors.
Zachary Monteiro
Zachary Monteiro is a Toronto-based multidisciplinary designer focusing on illustration and art direction.