the NHS double lung transplant that saved the Covid patient

“When I woke up I was confused. I remembered that the doctors at St George’s Hospital had decided to intubate me. But when I woke up from the intubation, I had been transferred to another hospital, St Thomas’, and was on a life support machine. I wondered how things got so bad and how I went from just being sick to being, you know, really close to death.

Cesar Franco is reliving how he became very ill with Covid-19 late last year and ended up in the intensive care unit (ICU) of St Thomas’s hospital in central London, helpless, struggling to breathe and only still alive thanks to the silent pumping of an extracorporeal membrane oxygenation (ECMO) machine. It was the start of what became a grueling and precarious five months in ICU on Ecmo. That’s an unusually long time, even for a Covid patient, to receive what, for some but not all, proves to be life-saving treatments.

Those five months were hard for Franco, both physically and emotionally. The specter of death was always present. Covid had devastated his lungs. Over time, his inability to breathe normally took a toll on his heart and other organs. But his stint in intensive care culminated in Franco becoming the first person in Britain to receive a double lung transplant as a direct result of Covid. A stranger’s lungs and some of the best care the NHS can provide have given him a second chance at life.

“Cesar is great advertising for the wonders of medical science,” says Prof. John Dunning, the surgeon who performed the operation at Harefield Hospital, an often life-saving specialist heart and lung care provider on the edge of the capital. “It’s also a great advertisement for the NHS and the care it can provide seriously ill patients in incredibly complex situations. He delivers it 24 hours a day, seven days a week.

His prospects were rather bleak. He was actually a prisoner in intensive care and there was no other exit strategy for him than a transplant

Prof John Dunning

When Franco fell ill, he was a fit and active 49-year-old building services engineer. “I worked in a five star hotel. Every day we were around 120, all together. We had a problem with people getting infected. There have been times when more than 10 of my colleagues a week have contracted the virus. I was hoping it wasn’t me, but then I got infected.”

He isolated himself, but his health deteriorated rapidly, so – on December 23 – he called an ambulance. After a few days at St George’s he was transferred to St Thomas’, opposite Parliament. St Thomas’s is one of the UK’s leading respiratory medicine centers and also where Boris Johnson was treated when he contracted Covid at the start of the pandemic. The drugs Franco received in the hospital’s intensive care unit induced hallucinations. “I have seen dead people, as if they come to visit me. Saw 70’s rock stars like Jim Morrison and Roy Orbison and some demonic faces.

Franco hated being in the hospital; because he was hooked up to the Ecmo machine, he was bedridden and suddenly dependent on nurses for all of his basic functions. Ecmo is the highest form of life-saving assistance the NHS can provide to those who can no longer breathe on their own. It uses two large tubes inserted into the veins in the groin to first extract the patient’s deoxygenated blood, then clean and re-oxygenate it outside the body, and finally reinsert it. It aims to boost the patient’s lung function. Franco needed the Ecmo to work because his lungs were only working at 40% capacity, but it didn’t.

“Even after five months my situation has not improved. The doctors at St Thomas’ told me: ‘Unfortunately we can’t help you.’ It got to the point where the only option would be a double lung transplant. It was the only thing that would have helped me survive,” recalls Franco. He had hoped to recover naturally, but had come to accept that that would not happen. He considered the risks involved – a stroke or severe bleeding during surgery surgery or his body rejecting the new organ – and he moved on.He had no choice.

Franco at home in South London. Photography: Linda Nylind/The Guardian

In his tiny shared office at Harefield hospital, Dunning recalls his first meeting with Franco. “His lungs had been destroyed by Covid. She had acute Covid-induced pneumonia, which causes inflammation and ultimately fibrosis-scarring-of the lungs. Normal lungs are soft and springy, like a sponge, but Cesar’s lungs were firm and non-compressible, like liver tissue or nutmeg. His lungs had practically stopped working.

“If he hadn’t had a double lung transplant, he couldn’t have left the hospital free of machinery. So in the end, he was going to die, because if we stopped the [Ecmo] machine that would not have been able to ventilate by itself. His prospects were rather bleak. He was actually a prisoner in intensive care and there was no other exit strategy for him than a transplant.

The procedure in Harefield in August lasted 11 hours. Franco’s new lungs came from a healthy young man. The patient’s confidentiality means that he knows nothing of the tragedy that saved him. “Cesar received the only life-saving and life-prolonging therapy available to treat the complications of Covid-induced lung disease,” says Dunning, a veteran of nearly 900 transplants. “He’s blossomed from there and he’s continued to recover excellently and is once again independent and living life to the fullest.” Although the procedure had already been performed on some Covid-ravaged patients in the US and Europe, this was new territory for the NHS.

A transplant is a wonderful thing. It gave me a chance to be with my family, to be alive, to be in this world again

Cesare Franco

Why was Franco the first Covid patient in the UK to need a double lung transplant? Dunning replies that his patient was “unfortunate” because, while others with recoverable lung disease have had their ventilators or Ecmos successfully removed, “Cesar was unable to get to that point because his lungs were so badly destroyed that he needed something else.”

Franco wasn’t vaccinated when he caught Covid. This could help explain why the gym-goer with no medical history suddenly found his or her life in grave danger. At home in south London, the Mexican – his name is pronounced “Caesar” – explains: “I waited to get the vaccine because I had my doubts about it, about the side effects, and also about the speed with which it was approved without more extensive testing. I was also reluctant because when my wife got vaccinated, she ended up being hospitalized after having an allergic reaction to the vaccine.” He has now been immunized.

On this, Dunning says only: “We will always try to provide first-class care to people in their time of need, regardless of their personal circumstances and their decisions regarding vaccination.”

Relaxed in his living room four months after surgery, Franco is looking remarkably good. However, an eight and a half inch scar down the center of his chest, from just below his throat to just above his belly button, tells the story of him. Atop his shelves are photographs of him with his wife, Gosia, and their son, Gabriel, and postcards celebrating his survival and his recent 50th birthday. One is from St Thomas staff wishing him luck when he leaves for his transplant. A stationary bike is aiding his positive but slow recovery. Now he can walk 20 minutes a day. He is delighted to be back in the family and happy to be alive.

What prompted him to endure all this? “The support of my family has really helped me, as have all the nurses, doctors and other staff at the three hospitals where I spent eight months in all. I cannot describe in words how well they took care of me. They were special people. They gave me emotional support as well as physical. They always told me: ‘Don’t give up. You are very strong and you will make it.’ The care I got was fantastic,” says Franco.

He would like to meet his donor’s family to convey his deep gratitude. His contact with death taught him that “a transplant is a wonderful thing. He gave me the opportunity to be with my family, to be alive, to be in this world again. Transplants are wonderful gifts that come from another human being and help people who cannot be alive by any other means. Transplants are a gift of life.”

As Franco approaches the anniversary of his death from Covid, he still bears the scars – mental as well as physical – of his ordeal. At one point silent tears flow as he recalls how during his time at St Thomas’s he reconciled to what seemed like an inevitable end.

Life is beautiful again. “Being able to breathe normally now is just amazing. When I was hooked up to the Ecmo machine and before the transplant, I had to really get some air. It was just awful. Now I can walk, I can move, I can breathe normally. It feels good. I mean, it’s just amazing, you know. It’s just amazing.

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