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me glucagon and call EMS. I'd come to at Baptist East in the emergency room. It was not good. And it was going to kill me. It was going to kill me." She went on like this for years. Finally, when she had fve of these incidents in a month, she made her frst visit to Mokshagundam at Joslin Diabetes Center, then still housed in Floyd Memorial Hospital in New Albany. He heard her story once and didn't want to mess around. "I think you need a transplant," he said. "I went 'Whoa! I think I'll think about that for a while. Tat seems like a drastic solution,'" Greenwell says. But she switched her care to Mokshagundam. Still, she had to be hospitalized almost every month. Finally, in the summer of 2011, after another episode that landed her in the hospital, Mokshagundam called her. A doctor at Jewish was doing pancreas transplants, he told her. "Can I give him your name and number?" Finally, she said yes. O nly a small subset of diabetics really need transplant surgery, says Dr. Michael Hughes of Jewish Hospital. Even fewer actually get a transplant, and that's because they're unaware of the option. Although the frst pancreas transplant was done in the late 1970s, it remains uncommon. For instance, there are upwards of 90,000 people on the waiting list for a kidney transplant, he estimates. But there are only 1,000 waiting for a pancreas, which is probably just as well, because donors are not easy to fnd. Not every pancreas will work. Donors must be young and lean and have no signifcant insulin resistance. Usually, a pancreas transplant is done in tandem with a kidney transplant, because kidney failure is often a problem for diabetic patients. "Susan's a bit unusual in the sense that her diabetes was so bad, but her kidney function was still preserved," Hughes says. It wasn't normal, but it was OK. Still, a year would pass before she could even go on the transplant list; a case of fungal pneumonia made a transplant impossible. Until it was cleared, there was no way she could go on the immunosuppressive drugs a transplant requires. In a way, the pneumonia itself was a sign of how serious her diabetes had become. "Fungal pneumonia is not a very common way to develop pneumonia," Hughes says. "Diabetics have a propensity for infections. Because of their high blood sugars, their immune cells don't work — just like everything else. Diabetes beats up on the whole body." For the frst two hours of Greenwell's surgery, Hughes' attention was fxed on the donor pancreas, a delicate and squishy organ the color and consistency of raw fsh, about the size of your hand. It's kept on ice in a stainless-steel basin, preserved at 4 degrees Celsius (about 39 Fahrenheit) in a special solution that provides sugar and electrolytes to maintain the integrity of its cells. Before transplant, all the surrounding tissue is cleared away from the organ, including any fat, which can get infected. An attached section of intestine is cleaned to minimize lingering but inevitable fungus and bacteria. Any areas of potential bleeding are tied up, and the donor organ arteries prepared to sew into the patient. Attaching the pancreas to Greenwell took another four hours. "We have to be careful how we handle it," Hughes says. Te more one squeezes and manipulates the pancreas, the greater the chance of damaging the organ. "We try to transplant without hardly ever touching it. When we take it from the donor, we grab it by the bowel and spleen," the surgeon says. "Te pancreas can get very angry if we don't show it proper respect." Te donor pancreas's attached piece of small intestine is where the organ, in a second function, releases digestive enzymes. Since Green- well's original pancreas would still fll that function, the donor segment of intestine was instead attached to her bladder, where it would play an important role. "Te difculty we run into is monitoring the pancreas for rejection. When we transplant a kidney and pancreas together, the kidney tells us there is rejection because it's easy to monitor kidney function," Hughes says. When he can attach the donor intestine to the bladder — which is not always possible — urine tests will reveal increased risk of rejection by the levels of certain pancreatic enzymes it contains. "Actually performing the transplant is not really the most challenging part," Hughes says. "Te most challenging thing is dealing with all the diferent medical conditions that this diabetic population has shortly after transplant." Greenwell was in and out of the hospital a lot after her transplant, dealing with reactions to one of the anti-rejection drugs, which put her in renal failure once. Damage to her blood vessels from diabetes makes it difcult for her to maintain her blood pressure. When she stands, her blood pressure falls, which can make her dizzy or even faint. Te vessel damage also means she's easily dehydrated. "It felt like it was a revolving door at Jewish Hospital for a while," she says. "For the frst couple of months, there was actually more work involved," her son Brett says. "Everybody was on pins and needles: Is this actually going to work? At the same time, you think, is this too good to be true?" Her husband still worries. It's the curse of knowing too much. "You can't undergo the stresses and strains that she's undergone and not worry about the future," he says. "We didn't erase all of the damage that was done with diabetes. I know too much about what the disease can do to people. To say everything is copacetic and back to normal — let's get real. Tat's not true. I'm not sayng she's not better of for it. She is. But I've been doing this too long." F our months after her surgery, Greenwell sits in the family room of her Saint Matthews home, trying to calm one of the two golden retrievers she just let into the house. Five-year-old Sophie watches the action placidly while 10-year-old Duke bounds around like Tigger. "Duke! Can you sit? Down!" Greenwell says. Te dog obeys for a picosecond and bounces up again. It was a scratch from playful Duke that led to the MRSA infection that turned her diabetes vicious. Greenwell has one leg in a brace. She broke it when she bent over to look in the refrigerator and got dizzy. "It's just ridiculous," she says. "I wish I could say I was skiing in the Rockies." In front of her is a giant pill organizer flled with a cheerful collection of purple, blue, pink and yellow medications. She takes 40 pills every day, down from 60, which is what she took immediately after her transplant — from anti-rejection medications to the normal medicines of middle age such as a statin to lower cholesterol. Tere are vitamins to deal with an electrolyte-balance problem and medications for acute respiratory distress syndrome. But she wouldn't have missed this for the world. "Mike and our children were probably the biggest incentive to do it, because what I had put them through, through no fault of my own, was unspeakable," she says. "And to try to save them from that, and to have a life diferent than the one I knew, that was worth everything." Now, no one has to check on her. She can be home by herself. "It's like a get-out-of-jail-free card," Greenwell says. "It's nice to be able to eat dinner in your pajamas if you want to, you know?" 2.13 LOUISVILLE MAGAZINE 3 9