The Case of the Vanishing Lung
By Alex Green
In medical logistics, your mistakes—or not even your mistakes, but mistakes that you’re responsible for—can cost lives. I learned this the hard way.
I was managing NFO—Next Flight Out shipments—where we routinely transported organs for transplant. This particular case involved a lung heading to Denver. These organs remain viable for 72-96 hours as long as they’re kept cold, typically in a validated polystyrene box with wet ice inside. That timeframe allows us to transport them by air anywhere in the country.
Everything started perfectly according to protocol. We put the lung on the flight, and it landed safely in Denver. The courier picked it up at the airport—no issues there. But then something happened that still makes my blood run cold when I think about it:
The courier placed the box containing the lung on the roof of his car while he got his keys out. Then he got in the car and drove off. When he arrived at the hospital, the box was gone.
“What the hell do you mean you don’t know where it is?” I remember shouting into the phone.
It took us hours to find it. The courier drove back along the entire route, scanning ditches and shoulders. When he finally called back, I knew from his voice it wasn’t good news.
He had found the box in a ditch on the side of the road. After tumbling off the car roof, it bounced several times before rolling off the highway. The lung was no longer in a condition to be used for transplant.
Today, I can’t stop thinking about how we could have prevented this tragedy. If we had Sensos tracking Labels back then, we would have seen alerts about tilt and shock, and would have noticed immediately when the package stopped moving along the highway.
I would have called the driver right away: “What the hell just happened? Did you flip end to end in your car?” We would have found that lung within minutes, not hours. Someone’s life could have been saved.
This job is incredibly stressful, and people endure that pressure because they know they’re changing the world. The work is meaningful, but that doesn’t make it any less stressful or painful when things go wrong.
That incident haunts me to this day because I was responsible for a system that failed at the most critical moment.
