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The unchecked blood-type assumption that killed Jesica Santillan · Healthcare Scandal Investigations

• 0:03
  Speaker 1: A heart and two lungs arrived packed in ice from
• 0:06
  Speaker 1: Boston on the morning of February 7th, 2003. The surgical
• 0:11
  Speaker 1: team at Duke University Hospital was ready. The organs went in.
• 0:16
  Speaker 1: Only when the last suture was placed did someone check
• 0:18
  Speaker 1: the one thing that should have been confirmed before the
• 0:21
  Speaker 1: first incision was ever made. The blood type was wrong.
• 0:26
  Speaker 1: Jessica Santillan was 17 years old. She had crossed a
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  Speaker 1: desert to reach that operating table survived a robbery along
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  Speaker 1: the way, and waited years on a transplant list for
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  Speaker 1: exactly this morning. The system built to save her had
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  Speaker 1: just handed her immune system a foreign target, and it
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  Speaker 1: would spend the next 13 days destroying it. Two unchecked
• 0:45
  Speaker 1: assumptions were about to cost one family everything. Neither assumption
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  Speaker 1: would be spoken aloud until it was already too late
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  Speaker 1: to matter. She was born in Tamazula, a small city
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  Speaker 1: in the Mexican state of Durango, some 275 miles west
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  Speaker 1: of Mexico City. on December 26, 1985. The city sits
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  Speaker 1: in a valley ringed by mountains, and from most points
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  Speaker 1: in town, you cannot see past them. From her earliest years,
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  Speaker 1: something was wrong with her heart. Doctors eventually named two
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  Speaker 1: conditions working together. Restrictive cardiomyopathy, which hardens the heart muscle
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  Speaker 1: until it loses the ability to fill with blood properly.
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  Speaker 1: And secondary non-reactive pulmonary hypertension, dangerous pressure building in the
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  Speaker 1: vessels that feed the lungs. a direct consequence of the
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  Speaker 1: first condition. Together they were a clock, and nobody in
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  Speaker 1: Tamazula could stop it counting down. Life there moved slowly,
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  Speaker 1: and for a family like hers, the horizon had a
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  Speaker 1: single shape. The border. In 2001, her mother, Magdalena Santillan,
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  Speaker 1: made a decision. She, her partner Malesio Huerta, Jessica, and
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  Speaker 1: two younger siblings would cross into the United States. They
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  Speaker 1: paid a coyote to guide them through heat, exposure, and
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  Speaker 1: the constant risk of being caught. It was the kind
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  Speaker 1: of crossing that is dangerous for the same reasons every time.
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  Speaker 1: No shelter beyond what the land offers. No water beyond
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  Speaker 1: what you can carry. And no way to call for
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  Speaker 1: help if something goes wrong. Somewhere along the route, thieves
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  Speaker 1: found the family and took everything they carried. Every dollar
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  Speaker 1: saved for the trip. And the small gold earrings Jessica
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  Speaker 1: had brought with her from home. They reached Durham. North Carolina,
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  Speaker 1: with nothing. What happened next depended entirely on a man
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  Speaker 1: they had never met. Mack Mahoney was a local businessman
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  Speaker 1: who heard about the girl from Tamazula through community connections
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  Speaker 1: and decided her situation was now his problem to solve.
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  Speaker 1: He started raising money. He learned, on behalf of a
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  Speaker 1: family with no insurance, no legal status, and no institutional
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  Speaker 1: knowledge of any of it, the maze of paperwork the
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  Speaker 1: American transplant system demanded. Insurance authorizations. Hospital evaluation committees. The
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  Speaker 1: layers of proof a candidate has to clear before a
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  Speaker 1: hospital will even agree to list them, all of it
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  Speaker 1: written in a language the family was still learning. Without him,
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  Speaker 1: Jessica would never have reached the national waiting list at all.
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  Speaker 1: In January 2002, she was registered with the United Network
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  Speaker 1: for organ sharing for a heart transplant. Four months later,
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  Speaker 1: her listing changed. The disease had advanced, and she now
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  Speaker 1: needed a heart and both lungs. replaced together in a
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  Speaker 1: single operation, a category of surgery among the rarest and
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  Speaker 1: most technically demanding in all of medicine. Every dimension of
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  Speaker 1: the match had to hold at once, size, tissue type,
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  Speaker 1: and blood type. hers was O positive. She spent the
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  Speaker 1: months that followed the way people on transplant lists spend
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  Speaker 1: their months. Measuring time in appointments, managing symptoms, waiting for
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  Speaker 1: a phone call that might never come. Her family settled
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  Speaker 1: into Durham. She went to school. She was learning English.
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  Speaker 1: She liked music. She was, by every account, a teenager
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  Speaker 1: doing what teenagers do, making small plans and assuming there
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  Speaker 1: would be time to keep them. None of those small
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  Speaker 1: plans depended on her at all. They depended on a
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  Speaker 1: cooler somewhere hundreds of miles away and on a phone
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  Speaker 1: call between two institutions that nobody had made yet. They
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  Speaker 1: depended on a hospital lab and a surgical team she
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  Speaker 1: would never meet before the morning it mattered, doing one
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  Speaker 1: simple thing correctly. On the morning of February 7, 2003,
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  Speaker 1: a set of donor organs was packed in Boston and
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  Speaker 1: driven south by Carolina Donor Services. Donor organs only tolerate
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  Speaker 1: a limited number of hours outside a body, cold and
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  Speaker 1: sealed in ice, and once they leave the donor, that
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  Speaker 1: clock does not stop for anyone. At Duke University Hospital,
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  Speaker 1: the surgical team, led by Dr. James Jaggers, was assembled
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  Speaker 1: and ready. Every person in that room had trained for years,
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  Speaker 1: in some cases decades, for exactly this kind of morning.
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  Speaker 1: The question that would define everything after it was not complicated.
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  Speaker 1: It is the same question every person who later heard
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  Speaker 1: this story would ask. How does a surgical team at
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  Speaker 1: one of the most respected hospitals in the United States
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  Speaker 1: begin a transplant without confirming, out loud, that the donor
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  Speaker 1: organs match the patient on the table? Somewhere between those
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  Speaker 1: two points, A laboratory in one city and an operating
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  Speaker 1: room in another. A single question was supposed to travel
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  Speaker 1: down the line and come back answered. Do these organs
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  Speaker 1: match this patient's blood type? Nobody asked it out loud.
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  Speaker 1: Two separate safeguards existed at Duke specifically to catch a
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  Speaker 1: mismatch before any incision was made. One required written verification
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  Speaker 1: of blood compatibility between donor and recipient. The other required
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  Speaker 1: a verbal confirmation, spoken between the surgical team and the
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  Speaker 1: donor agency. one person saying the words and another person
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  Speaker 1: hearing them. On this particular morning, neither one happened. The
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  Speaker 1: surgeon assumed the match had already been confirmed. The donor
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  Speaker 1: agency assumed Duke had already checked its own records. Two institutions,
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  Speaker 1: two sets of trained professionals, and the one sentence that
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  Speaker 1: could have stopped everything passed silently between them, unspoken, because
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  Speaker 1: each side believed the other had already said it. Jessica
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  Speaker 1: Santillan's blood was type O, positive, The heart and lungs
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  Speaker 1: from Boston were type A. In transplant medicine, that gap
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  Speaker 1: is not paperwork. It is a verdict. The type O
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  Speaker 1: immune system meets type A tissue and reads it as
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  Speaker 1: an invasion, and it does not negotiate. The surgery lasted hours. Technically,
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  Speaker 1: it worked. The new heart was placed. The new lungs
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  Speaker 1: were seated. Blood began moving through tissue that had come
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  Speaker 1: from a stranger's body. and the team closed her up.
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  Speaker 1: It was only then, with the work finished and Jessica
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  Speaker 1: still on the table, that Duke's Clinical Transplant Immunology Laboratory
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  Speaker 1: delivered its report. The organs were incompatible. By then, there
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  Speaker 1: was nothing left to do but watch her body do
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  Speaker 1: what bodies are built to do when they recognize an enemy.
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  Speaker 1: Breed the new tissue and begin, cell by cell, to
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  Speaker 1: fight it. The medical team spent the days that followed
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  Speaker 1: trying to hold the rejection back high-dose immunosuppressant drugs, plasmapheresis,
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  Speaker 1: a process that filters the blood clean of the antibodies
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  Speaker 1: driving the attack. They worked and watched and waited. In
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  Speaker 1: those early days, there was one moment Magdalena Santillan would
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  Speaker 1: hold onto for the rest of her life. Her daughter
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  Speaker 1: squeezed her hand. Her feet moved, faintly, in response to
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  Speaker 1: voices in the room. It was small. It was also
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  Speaker 1: the only documented sign across all 13 days, that some
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  Speaker 1: part of Jessica was still answering when someone spoke to her.
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  Speaker 1: A mother held on to that the way you hold
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  Speaker 1: on to anything small when there is nothing large left
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  Speaker 1: to hold. She never regained consciousness. On February 10, three
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  Speaker 1: days after the transplant, her heart stopped. The team placed
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  Speaker 1: her on a machine that performed the work of both
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  Speaker 1: her heart and her lungs from outside her body. standing
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  Speaker 1: in for organs that could not yet do their own
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  Speaker 1: work while the rest of her tried to survive what
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  Speaker 1: her own immune system had been built to do. It
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  Speaker 1: kept her alive. It could not keep her well. On
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  Speaker 1: February 16, she had a seizure. On February 18, her
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  Speaker 1: kidneys failed, and dialysis began. Each complication landed like a
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  Speaker 1: door closing somewhere down a long hallway. You could not
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  Speaker 1: see the door. You could only hear it shut. Then,
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  Speaker 1: On February 19th, two things happened on the same day.
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  Speaker 1: The brain scan showed no evidence of irreversible damage. Not yet.
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  Speaker 1: And for the first time in nearly two weeks, not
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  Speaker 1: yet was a phrase that pointed towards survival instead of
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  Speaker 1: away from it. And a compatible donor was found. The
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  Speaker 1: second heart. The second set of lungs. The right blood
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  Speaker 1: type this time, confirmed before anyone touched a scalpel. That
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  Speaker 1: was the image that would sit at the center of
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  Speaker 1: this whole story and refused to stay still. The girl
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  Speaker 1: given a second chance, on the same day the evidence
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  Speaker 1: said her brain might still be intact. On the worst
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  Speaker 1: stretch of Jessica's hospitalization, the one piece of evidence that
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  Speaker 1: mattered most said keep going, and the one resource that
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  Speaker 1: could make going possible had just become available. It felt,
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  Speaker 1: to everyone in that hospital, like the story bending back
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  Speaker 1: toward her. The second transplant took place on the morning
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  Speaker 1: of February 20th, beginning at 6 and finishing at 10.15.
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  Speaker 1: The new heart and lungs were placed. They worked. Reports
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  Speaker 1: from that morning described the organs as functioning adequately. The
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  Speaker 1: team had corrected the error that started all of this.
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  Speaker 1: The right tissue was finally inside. her for a few
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  Speaker 1: hours it looked like the story might end differently at
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  Speaker 1: two in the morning on february 21st jessica's condition collapsed
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  Speaker 1: the new brain scan showed what the scan two days
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  Speaker 1: earlier had not severe swelling herniation bleeding The brain had
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  Speaker 1: been starved of oxygen for longer than anyone reading that
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  Speaker 1: first hopeful scan could have known. Cerebral injury from oxygen
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  Speaker 1: loss does not always declare itself right away. The brain
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  Speaker 1: can sustain damage that simply does not show up on
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  Speaker 1: imaging for days. The absence of visible damage on February
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  Speaker 1: 19th had been real. It had also been incomplete, and
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  Speaker 1: nobody reading that scan on the day it mattered most
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  Speaker 1: could have told the difference. In the 13 days between
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  Speaker 1: the two surgeries, her body-fighting tissue it could not accept.
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  Speaker 1: Failing organ by organ, seizing, stopping, restarting, the damage had
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  Speaker 1: already crossed a line that imaging could not see until
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  Speaker 1: it was far too late to matter. Three separate tests followed,
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  Speaker 1: each built on a different principle, each asking the same
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  Speaker 1: question a different way. An electroencephalogram found no electrical activity.
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  Speaker 1: An apnea test found no independent breathing drive. A cerebral
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  Speaker 1: perfusion scan found no blood moving through brain tissue. Three instruments.
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  Speaker 1: One answer. At 1.25 in the afternoon on February 22nd,
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  Speaker 1: two independent neurological examinations confirmed it. Jessica Santillan, 17 years old,
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  Speaker 1: was brain dead. Her heart beat for the last time
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  Speaker 1: at 5 past 5 that evening. Three minutes later, the
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  Speaker 1: ventilator was removed. On the advice of their attorneys... Her
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  Speaker 1: family declined to donate her organs. The North Carolina chief
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  Speaker 1: medical examiner, Dr. John Butts, wrote the cause of death
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  Speaker 1: into the official record. Global cerebral hypoxic injury, a complication
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  Speaker 1: of rejection following an incompatible heart-lung transplant. Not the second surgery.
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  Speaker 1: Not the disease she had been born with. The record
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  Speaker 1: names the 13 days after February 7th, the days her
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  Speaker 1: body spent fighting an assumption nobody had checked as the cause.
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  Speaker 1: In 2004, Duke University Medical Center and the Santillan family
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  Speaker 1: settled outside of court. The terms were sealed. No dollar
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  Speaker 1: amount was ever disclosed, and no public statement of institutional
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  Speaker 1: responsibility came with it. No grand jury was convened. No
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  Speaker 1: criminal charges were filed against anyone involved in her care.
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  Speaker 1: The documented record does not show intentional wrongdoing by anyone.
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  Speaker 1: It shows two procedural safeguards that existed for exactly this scenario.
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  Speaker 1: and both of them failing on the same morning. The
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  Speaker 1: record assigns no primary responsibility, not to the surgical team,
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  Speaker 1: not to the donor agency, for the one verification that
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  Speaker 1: never happened. The failure the record describes in plain language,
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  Speaker 1: two safeguards, both absent on the same morning, was resolved
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  Speaker 1: in private and closed behind a confidentiality agreement. Mack Mahoney,
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  Speaker 1: the man who had spent years raising money so a
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  Speaker 1: girl from Tamazula could even reach a transplant list, later
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  Speaker 1: said Duke had misled the family in the days after
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  Speaker 1: the error became public. That accusation is his. What the
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  Speaker 1: record independently confirms is narrower, and still damning enough on
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  Speaker 1: its own, that he had to press the institution, repeatedly,
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  Speaker 1: before it acknowledged the mistake at all. The foundation he
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  Speaker 1: built in her name, Jessica's Hope Chest, carried her story
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  Speaker 1: forward for years, until, a decade later, allegations of financial
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  Speaker 1: mismanagement surfaced around it. Those allegations were never resolved in
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  Speaker 1: any documented record. They belong in this story anyway, because
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  Speaker 1: they are part of what her name became attached to
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  Speaker 1: after she could no longer speak for it herself. The
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  Speaker 1: name can outlive the person who carried it, and it
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  Speaker 1: does not always get to choose what gets attached to
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  Speaker 1: it next. The question the record leaves open is not
• 13:53
  Speaker 1: whether the system failed her. The record is clear on that.
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  Speaker 1: The question is, what a system that had already failed
• 14:00
  Speaker 1: her did with what it learned. Jessica Santillan never asked
• 14:03
  Speaker 1: for any of this to become a case study. She
• 14:06
  Speaker 1: asked to breathe without a machine. She asked to grow up.
• 14:11
  Speaker 1: Transplant centers did change their protocols afterward. Written checklists for
• 14:16
  Speaker 1: blood type verification before transport. The rule that someone has
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  Speaker 1: to say the blood type out loud and someone else
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  Speaker 1: has to hear it before an organ ever reaches a table.
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  Speaker 1: Whether that is enough is a question every transplant center
• 14:29
  Speaker 1: answers again each time a cooler crosses state lines. It
• 14:33
  Speaker 1: is a small thing to add to a checklist. It
• 14:36
  Speaker 1: is also the smallest possible fix for the largest possible failure,
• 14:40
  Speaker 1: which is exactly why it took a death for anyone
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  Speaker 1: to write it down. Here is the sentence that explains
• 14:45
  Speaker 1: all of it, and it is shorter than everything that
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  Speaker 1: came after it. Nobody said, confirm the blood type. Nobody said,
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  Speaker 1: I need to hear you say it matches. One spoken
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  Speaker 1: sentence sat unsaid somewhere between a laboratory in Boston and
• 15:00
  Speaker 1: an operating room in Durham. and 17 years of a
• 15:03
  Speaker 1: life fit inside the space where it should have been.
• 15:06
  Speaker 1: If you have ever sat in a waiting room while
• 15:08
  Speaker 1: someone you love was on a table, you already know
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  Speaker 1: how much trust that silence requires. You are trusting that
• 15:14
  Speaker 1: everyone in that room said that sentence to each other,
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  Speaker 1: out loud, before anyone picked up an instrument. On February 7, 2003,
• 15:21
  Speaker 1: they did not, and there was no way for anyone
• 15:24
  Speaker 1: outside that room to know it until it was already
• 15:26
  Speaker 1: too late to matter. You were not in that room,
• 15:30
  Speaker 1: and neither was Magdalena Santillan, And that is exactly the point.
• 15:34
  Speaker 1: The whole system only works because the people who love
• 15:36
  Speaker 1: the patient are not the ones checking the label on
• 15:39
  Speaker 1: the cooler. There is one detail that never made it
• 15:42
  Speaker 1: into any medical record, because it has nothing to do
• 15:44
  Speaker 1: with medicine. When the family crossed the border, thieves took everything.
• 15:50
  Speaker 1: The money saved for the journey. The documents. And the
• 15:54
  Speaker 1: small gold earrings Jessica had worn from Tamazula. She arrived
• 15:58
  Speaker 1: in Durham with nothing that had been hers back home.
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  Speaker 1: Everything that came after, the waiting list, the surgeon, the assumption,
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  Speaker 1: the 13 days, happened to a girl who had already
• 16:08
  Speaker 1: lost the one thing she carried across the desert herself.
• 16:12
  Speaker 1: She had been born 275 miles from Mexico City and
• 16:15
  Speaker 1: died thousands of miles north of it, in Durham, North Carolina,
• 16:19
  Speaker 1: still far from home. The earrings were never recovered. This
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  Speaker 1: show is made by Oboe Media.