David Johnston stood in a foreign airport, knowing he didn’t feel well — bad enough, in fact, to tell airport workers that he didn’t think he could board his next flight. What he didn’t know was that he was near death, and would need a combined liver transplant and open-heart surgery to survive.
Just a couple weeks before, his health wasn’t an issue. An avid runner, he’d flown to Bali to participate in a “mountain marathon” 15K race through a volcanic forest.
Now, he was on a medical journey that would eventually require the involvement of a U.S. ambassador and a willingness from a Pittsburgh hospital system to attempt a risky operation.
Johnston, 54, of Findlay, had made running a hobby for decades and, before his wife’s death in 2017, they would vacation around the world running in marathons and other races. Looking for a vacation last year, he decided to explore Bali by himself, planning the trip around the 15K (9.3-mile) mountain race.
Perfectly healthy when he took off, he started to get chills in the New York airport and on the connecting flight. By the time he landed for a connection in Qatar, he was fine, and felt great for the beginning of his vacation in Bali.
After a few days, however, he started to feel like he was maybe jet-lagged, or coming down with a cold. He got some medicine from the local pharmacy, which didn’t help much, but continued to travel as he felt sicker and sicker. The day of the 15K, he had trouble arranging transportation to the race site and decided to skip it. He continued traveling but felt worse, and at one point the owner of his Airbnb called him an ambulance to an urgent care. They recommended hospitalization, but Johnston was nearly at the end of his trip and thought he could make it back to the states.
On the way home, he realized that he couldn’t make it through the Bali airport without a wheelchair. And by the time he made it to Qatar, he realized he just couldn’t make it. “I knew that, if I board that next flight, there was no way I could survive it,” he said. “I just remember going to the information desk and saying, ‘Look, I need to go to the nearest hospital.’”
In Qatar, doctors realized pretty quickly that Johnston’s condition was extremely serious. He was in sepsis. An infection had attacked his heart, causing two valves to leak and damaging a section between the valves and resulting in heart failure. His failing heart had exacerbated an underlying liver condition, causing his liver to fail as well. The only solution was both a liver transplant and open heart surgery. And while doctors in Qatar were willing to try, Johnston and his family preferred to get him back to America for the surgery.
That plan required the intervention of the U.S. Ambassador to Qatar to get Johnston’s brother-in-law to escort him from the hospital there back home to Pittsburgh in his condition.
Once they arrived in Pittsburgh, an ambulance was waiting at the airport to take Johnston to Allegheny General Hospital.
At the North Side’s AGH, doctors had been working to come up with a plan. The problem with needing both major heart surgery and a liver transplant is that the heart doesn’t work well if the liver isn’t functioning, and vice versa.
“Performing major cardiac surgery on somebody who's in acute liver failure, the operative mortality is very, very high,” said Masaki Tsukashita, AHN cardiac surgeon. “So if I did open heart surgery on him without a liver transplant, he wouldn't have survived. The only way to save him was to perform open heart surgery and a liver transplant at the same time.”
Until just a few years ago, that would not have been an option: There wasn’t time to do both in one surgery. The open heart portion of the surgery needs to be performed first, and takes five or six hours. A donated liver could be placed on ice to slow its deterioration, but it wouldn’t last through the heart surgery without receiving blood flow.
About four years ago, the Food and Drug Administration approved a device known as a “liver in a box” that uses a pump to continually infuse the liver with blood, keeping it alive that way rather than through cold storage. The process keeps the liver healthier and extends the timeline that it is usable for transplant.
In addition to being very new, the devices are expensive and require additional staff. AHN had never used one but, because of Johnston’s situation, Tsukashita and transplant surgeon Tadahira Uemura requested emergency approval. They also had to wait to see whether Johnston’s health insurance would cover the risky operation.
“It was sort of nerve-wracking because without my insurance covering it, I’m gone,” said Johnston. “I thought, ‘I might as well make peace with whatever happened.’”
Both the emergency approval and the insurance approval came through. Donor livers are allocated to the sickest patients and because Johnston was so ill, he only waited about two days for a liver.
His surgeons knew the procedure would be risky, but were willing to attempt it because Johnston was relatively young and had been in such good shape before the surgery that they thought his body could handle it.
Still, there was a tight timeline and a lot of unknowns. “Honestly, I was scared,” said Uemura, the transplant surgeon. “I was scared because I may not be able to complete the liver transplant, but without a liver transplant he’s going to die, right? So I had no choice. This was a complicated procedure and it had to go quickly.”
The surgery took about 12 hours in total, but all went according to plan. And while Johnston had some complications during recovery and spent time between the hospital and a rehab center, he eventually made it home in August — more than three months after he left for Bali.
He is still working on building up his stamina and muscle, but is back to playing tennis, walking his dog and even running “slowly” for him, at a 13-minute-mile pace.
“Mentally and physically, I’m in a good place,” said Johnston, sitting with his doctors at AGH. “I’m blessed to have the capacity to be patient but still be diligent at the same time. It’s all in what you want.”
First Published: February 15, 2025, 10:30 a.m.
Updated: February 17, 2025, 2:10 p.m.
