BEYOND THE CALL

By Denise Grady

Shortly after 5 a.m., Teri Majewski marches purposefully into Rush-Presbyterian-St. Luke's Medical Center in Chicago. Strongly built and fit looking, the 34-year-old mother of two young children seems too healthy to be in a hospital. But she checks in at the day-surgery department and is summoned to an examining room, from which she emerges a few minutes later in a baggy blue hospital gown and the inevitable plastic bracelet. Suddenly, she looks vulnerable. This morning Majewski is scheduled to undergo a bone-marrow harvest, in which doctors will remove about a quart of her marrow to be transplanted into a young patient dying of leukemia. She has never met the patient, who lives in Europe. They do not even know each other's names. They have been brought together by a computer search, by the quirk of a few shared genetic traits and, above all, by Majewski's kindness and courage, her willingness to endure a painful procedure in the hope of saving the life of a perfect stranger.

Bone-marrow transplantation is often the last hope for people with devastating diseases: leukemia and other cancers, and certain genetic disorders of the blood, immune system or metabolism. Cure rates range from 20% to 80%, depending on the disease, its stage and the degree of compatibility between the donor's marrow and the recipient.

For the recipient, the process begins with massive doses of chemotherapy or radiation, or both, to wipe out the disease. But that treatment kills the patient's bone-marrow cells as well. Without this spongy tissue at the core of many larger bones, a person cannot live. Marrow contains the precious stem cells that produce all the body's 30,000 trillion red blood cells, many of its infection-fighting white cells and the platelets that are essential for clotting.

No patient can begin the drastic treatment that will destroy bone marrow unless it is certain that the marrow can be replaced. Some have autologous transplants, in which their own marrow is harvested and returned to them later; others must search for allogeneic transplants from donors--usually relatives. But even close relatives do not always have compatible marrow. In recent years about two-thirds of all patients needing allogeneic transplants have sought unrelated donors.

The American Bone Marrow Donor Registry, based in Worcester, Mass., and the National Marrow Donor Program in Minneapolis, Minn., keep computer files on about 4.4 million people worldwide who have volunteered as donors. The odds of finding a matching donor average about 1 in 20,000--better for whites, tougher for others. An estimated 30,000 bone-marrow transplants are performed each year worldwide. But it is estimated that 60,000 others needing transplants die without ever finding a donor.

Majewski and her husband first volunteered as donors 10 years ago, when a friend asked them to help a family member with leukemia. They underwent initial blood tests, known as HLA typing, for a series of four genetically determined traits that, along with two more traits tested at a second level, must closely match those of the patient for a transplant to be accepted by the body. Neither Teri Majewski nor her husband matched, but they let the American Bone Marrow Donor Registry keep their records.

Ten years passed, and then the Majewskis got a call saying Teri was a match for a desperately ill patient overseas. Teri had been hoping to become pregnant again, but expectant mothers cannot donate bone marrow. She decided to postpone the pregnancy in order to help, even though it would be months before the patient would be ready for the transplant. Majewski insists it was not hard to make up her mind. "There's no choice," she says. "You're talking about saving somebody's life. There is no decision."

Similarly, Majewski will not acknowledge that hers is a heroic act; it is simply the right thing to do. She says she is not scared. Her suffering will be nothing compared with that of the patient, she insists. "And I'll regenerate the marrow without a problem." If bone-marrow cells could transmit their owner's grit and determination, the person who gets Majewski's would have it made.

Hans Klingemann, the physician who directs the bone-marrow transplant center at Rush, is to perform Majewski's harvest, along with Sharon Manson, a clinical nurse specialist. Each has done the procedure hundreds of times. Still, Klingemann is always worried about the donors. Although the risks of allergic reaction or stroke (if a patient has general anesthesia, instead of the spinal Majewski had) and dangers of infection are very small, they are nonetheless real. People who have surgery take such risks, but they usually gain some benefit that makes the risks worthwhile. Bone-marrow donors like Majewski have nothing to gain, except perhaps a measure of grace.

Though Majewski will have only two punctures in her skin, Klingemann explains, by the time the harvest is finished her hip bones will have more than 20. If an X ray were taken after the procedure, the wounds would show. Her bones will take weeks to heal. Klingemann predicts she will be sore for several days and fatigued for at least a week. He estimates it will take her system two to four weeks to replenish the bone marrow. She will need to take iron for one to three months. "It is quite a commitment," Klingemann says. "Quite honestly, I'm not sure the donors realize it is an operation that they undergo." In years to come, he says, the painful bone-marrow harvest may be replaced by a procedure similar to a blood donation from which stem cells could be collected, but that approach is still being developed.

By 8 a.m., Majewski is lying prone on the operating table, numbed from the waist down by the spinal anesthetic, draped except for a rectangle across the small of her back. The marrow will be drawn from her pelvic bones on either side, parts of the skeleton known as the posterior iliac crests.

At 8:15, Klingemann, gloved, masked and gowned, is positioned at Majewski's left hip, Manson at her right, ready to start the harvest. Each wields an 11-gauge needle, a formidable-looking piece of hardware 4 in. long and about an eighth of an inch in diameter. Working independently, Klingemann and Manson thrust the needles into Majewski's back until they touch bone, and then dig a few millimeters further to tap into the marrow. They attach big plastic syringes to the needles and draw marrow into them. Each pull on the syringes yields just a few teaspoonfuls of bright red spongy fluid. They hand the syringes to an assistant who empties them into a calibrated sack. Working through the original puncture in Majewski's skin, they shift the needles to fresh targets in the bone and repeat the process again and again.

It requires force to pierce healthy bone; this is not a gentle procedure. But thanks to the spinal, Majewski is free of pain. It takes nearly an hour of thrusting and pulling to fill the sack. When a halt is finally called, the level exceeds a quart. Lab tests show that more than enough cells have been collected to re-establish the patient's marrow. And no more should be taken from Majewski. Much of the quart counts as blood loss, and to replace red cells she is given a transfusion of her own blood, which had been drawn weeks earlier.

Manson seals the bone marrow into smaller sacks and takes them to a courier, who packs them into a cooler. The courier also accepts a card from Majewski to the patient. "My prayers are with you," she has written. The courier hurries off to the airport, where security officials have already been alerted, so that guards will not insist on an X ray, which would ruin the marrow.

In the recovery room, Majewski lies bundled in blankets, shivering. A nurse wraps another heated blanket around her. Just before noon, she is wheeled into a regular hospital room. A bouquet, left by the courier, awaits her, along with a card. "Dear Donor," it reads, "I would like to say, Thank you for your help."

By 6 p.m., Majewski is ready to go home. Her back is bandaged and more than sore. Laughing, she says she thinks she is waddling like the comedian Tim Conway. But she has no regrets. Her children, a son, 4 1/2, and a daughter, 2 1/2, greet her with a puppet show. Majewski, looking tired and pale, cannot sit comfortably. But when one of the puppets shouts, "Hello, bone-marrow woman!" she grins.

Her recovery takes a little longer than predicted: the soreness is gone within two weeks, but the fatigue lasts somewhat longer. Knowing what she knows now, would Majewski ever do this again? "Oh, yes,"she says immediately. "I wonder if I'll have a chance to."