It was the first half of the 20 century. Joseph Murray, a plastic surgeon, had just returned from the World War II. Back in Boston, he overheard some of his colleagues in general and vascular surgery talking about organ transplantation. Was it possible to transfer organs from one person to another? A human had two kidneys, but needed only one to live normally. Could one be taken from a normal man and transferred to a patient with kidney failure?
A little earlier, Alexis Carrel had found out that injured blood vessels could be joined by fine stitches placed all around. It was a tricky job but Carrel had perfected it in animals before trying it out on humans. He had succeeded.
Murray noted that the general consensus was that it was impossible. The artery and vein could be connected, and the transplanted organ would live. But what about the microscopic tubes called lymphatics and the even tinier nerves that were impossible to join? That was just a technical point. What about the body’s immune system that fought off foreign invaders like viruses and bacteria? By this time, it was well known that any cell from another human being would be destroyed by the body’s defence mechanism.
Intrigued, Murray turned to the lab and conducted a series of experiments. In one experiment, he removed both kidneys from an animal and put it back by joining the artery and the vein. He could do nothing about the lymphatics or the nerves. He expected the animal to die. But it survived and the kidney produced urine.
One day, a man suffering from kidney failure came to Murray. Murray looked at the array of friends and relatives accompanying the patient and was startled to see the man’s mirror image among them. An identical twin! Identical twins have the same genetic material. The body can’t distinguish one from the other. So, no rejection. That was how the first organ transplant was done.
Murray was later involved in researching drugs that could suppress immunity sufficiently to make organ transplant successful. Not everyone had an identical twin. There was a lot of resistance, as there were many deaths. But Murray fought on. Due to his efforts, organ transplantation became a reality. He got a Nobel Prize for his efforts, as did Alexis Carrel before him.
***
More than half a century later, in India, Manoj* fought a group of men who were harassing a woman on the train in which he was travelling. The rowdies pushed him out of the moving train. Though he didn’t die, both his hands were crushed and had to be taken off below the elbow. He was a hero. And, like many heroes in our society, he paid the price for his heroism.
***
It was 6.00 p.m.; my day, as a plastic micro-surgeon, was over. As I passed the surgical ICU, there was a commotion. There was a crowd around a middle-aged lady. “My son. No! Not my son.” The agonised wail pierced the hearts of the listeners.
“Another tragedy,” I thought sadly. Someone told me that the lady’s young son, an accident victim, had been declared brain dead. The recently amended laws had laid explicit rules for a person to be declared brain dead. It had to be confirmed by many experts. There were tests to make sure that no part of the brain was working. These patients are usually on ventilators that take care of breathing. The heart doesn’t need the brain to keep beating.
Once a patient was declared brain dead, he/she could be taken off the ventilator and all medicines that were helping keep the heart alive. The natural process of death can be allowed to continue. Or the ventilator and life-support systems could be kept temporarily to keep the heart alive… to offer hope for a host of terminally ill patients waiting for kidneys, livers or hearts.
I imagined Prasad, our transplant co-ordinator, going in with one of the transplant surgeons to talk to the dead patient’s relatives to get consent for organ donation. It must be one of the world’s most difficult jobs. “Your son is dead. Many human beings are dying. They want your son’s liver, kidney, heart. May we take them?” How on earth do you say that to a grieving parent? But time is ticking. The brain dead patient’s heart can give up at any moment. Then the organs can become useless.
You cannot use incentives or emotional blackmail. The images of waiting patients cannot be used. Desperate people on the waiting list cannot plead with the sad next of kin. The consent has to be a voluntary act. It is one of the ultimate sacrifices one can make. And it can be made only by proxy. The closest and dearest have to speak for the still-beating heart, which will never be part of any decision again.
The liver transplant surgeons and urologists may have a busy night today. The waiting patients were part of a state-wide registry and the cadaver organs, whenever they became available, were allotted by a closely monitored system.
***
Joseph Murray, the pioneer of human transplantation, was originally a plastic reconstructive surgeon. But we were now far away from this area. The liver and kidney surgeons were the ones usually involved. Rarer were the heart transplants.
We, reconstructive micro-surgeons, were adept at joining arteries and veins, especially tiny ones. Stitching together veins and arteries that were one millimetre or less in diameter under the microscope was our primary skill. It was useful in re-attaching severed limbs and fingers and also in small vessel, nerve and tendon repairs. It was also used in free tissue transfer where skin, bone or muscle is taken from one part of the body and attached to an area where it has been lost. In some centres, micro-surgeons were called to join the tiny hepatic artery as part of a liver transplant, especially in children. Usually that was as far as our involvement with transplantation went.
But this time there was a very slight possibility that I could be called. Dr. Subramania Iyer, the Plastic, Hand and Reconstructive Micro-surgery Chief, was a man with a vision. Over the past few years, he had worked systematically to ensure that we could, in this centre, do hand transplantation. The special government approval needed was already obtained.
But when the request was made to the relatives of brain dead patients, it was turned down. Take everything else, they said, not the hands. We had become resigned to the fact that we may never do the hand transplant. The hands were too external, too personal. It was like mutilating a dead person’s body.
***
I got a call from Dr. Iyer around 8.00 p.m. “Come, we may have to do the hand transplant today.” I silently thanked the dead man’s relatives. Five of us micro-surgeons were in the anteroom of the operation theatre at 9.00 p.m. We had a preparatory meeting and went through each step. Mohit, Kishore and I had worked out all the technical details almost three months earlier.
The surgery that we were about to undertake was arduous. Manoj was already in the hospital, having been summoned two hours ago. Both hands were to be given to Manoj. We felt that lifelong immune suppression was justified if both hands were restored.
The two bones of the forearm had to be joined first by plate and screws. Then there were a mind-boggling variety of fine structures that had to be joined together. Two arteries and at least three or four veins had to be joined by circumferential sutures that were many times smaller than a human hair under the microscope. This would infuse life into the attached hand. But the hands were useless without sensation. The fine muscles inside the hands will work and the sense of touch will come only when the nerves are joined and the nerve fibres grow over a period of months. Many nerves had to be tackled: the ulnar nerve, the median nerve and various other nerves. Then over 20 muscles had to be dissected, tagged, identified and carefully joined. All this was for one hand, and we had to attach two.
Only about 100 hand transplants had ever been done all over the world. If we succeeded, this would be India’s first. It was big for Manoj. I had seen him in the waiting room. Hope gleamed in his eyes. His life was now riddled with distasteful dependence on others. Lifelong immune suppression was no joke. Patients with kidney or liver failure had no choice. They would die if they didn’t get an organ to be transplanted. Patients considered for hand transplant were, like Manoj, young men in the prime of their life. The ethics of the procedure were still being debated all over the world. But now it was generally agreed that, with the patient’s full voluntary and informed consent after a counselling outlining all the risks, the procedure was worth it. Immune suppression drugs and related science is progressing rapidly every day. There is always the hope that, after a few years, medical advances would bring down complications even further. Manoj knew all the risks. He wanted hands. He wanted to work and make a living with dignity.
We had been through the drill six months ago, as a dress rehearsal. We were divided into four teams. All our duties were assigned with precision. The brain dead patient was wheeled into the theatre at 2.00 a.m. Two teams, apart from ours, were ready and waiting. A team from another hospital had come to take the liver and one kidney. The urology team from our own hospital was to take the other kidney.
We were to go first. Sundeep and I had to harvest the right hand and Dr. Iyer the left one. The main artery to the hand and forearm was exposed at the elbow joint and a special solution was infused into the artery. One main vein was cut open and the blood was allowed to flow out till the clear solution started coming out through the vein. The idea was to replace all the blood in the limb with the solution. After that, we removed the hand at the elbow joint after cutting all the structures and tying the blood vessels. A prosthetic hand was fitted on the body so that there was no disfiguration when the body was given back to the family.
We took the hands to the other room. They were placed on a slush of ice covered by a polythene sheet. This was to minimise damage to the tissues due to lack of blood supply. The forearms were opened and each artery, vein, nerve and tendon was tagged by stitching each with blue rubber sheets on which its name was written. The final prepared forearm looked like an abstract pattern festooned with blue rectangles. The ice almost froze our hands.
While we were working on the donated hands, Manoj was already under anaesthesia in the next room. Doctors Kishore and Mohit were working on the stumps of his amputated hands. They had opened his forearms and repeated the process of identifying and marking each structure. The bone ends were cut to the appropriate lengths and connected by plates and screws. Our orthopaedic colleagues helped with that.
We took turns joining the minute arteries and veins. I did one artery and two veins on one side. We released the clamps and allowed the blood flow to occur. Blood started flowing from Manoj’s hand to the attached hand. Then the extensive task of joining the myriad tendons, muscles and nerves commenced. I relieved Kishore to join one more artery and vein on the other side. We should have heaved a sigh of relief after clamp release but we didn’t. There was no pink-up.
Pink-up refers to the immediate return of pink colour to the skin of an attached body part after the clamps are released and blood flow returns. We see it almost immediately when we re-attach a severed digit or in a free tissue transfer. Here, the attached hands remained white though the arteries and veins were working satisfactorily. “It is all right. Let us continue. It may take some time,” said Dr. Iyer.
It was like a marathon run. We were used to long surgeries. But the sheer enormity of what we were doing wore us out. Overwhelming responsibility rested on our shoulders. The surgical community of the country and even abroad were watching us with a critical eye. The surgery was almost over. It was about 16 hours since we started. Still, no pink-up.
Had something gone horribly wrong? Was the patient too cold? Did he lose too much blood? Jerry, our anaesthesiologist, was checking everything. Would our transplant turn out to be a dismal failure? Would we be criticised for doing something that no one in the country had ever tried before? That was the thing about being a pioneer. If you fail, you fall flat. If you succeed, that is good. Only success condones risk. That is true of any medical procedure in general. Yet, failures are inevitable. If one becomes disheartened by them, then you might end up doing nothing.
In this case, we may not get a second chance. If it is a primary failure, with the hands not working, even for a short time, it means our technical capability may also be questioned. I prayed. Sometimes, one can do only that. I didn’t have much to eat and the cold air in the theatre was piercing through the thick surgical gown. I shivered.
A young male nursing student stood watching the surgery. Men were becoming rare in nursing. I looked at his smooth and brown hands. Hands that feed, clothe and minister patients. Or help someone who didn’t have hands. Suddenly I had a vision of a young man taking care of a very ill old man; wiping him tenderly and lovingly; feeding him; talking to him while looking into his eyes. I felt a presence looking over my shoulder. I turned, but there was no one. “The dead boy’s soul must be watching us.” Dr. Kishore said to nobody in particular.
“It is pinking up,” Mohit cried. It was true. From deathly pale, the hands slowly became faintly pink. Soon it turned rosy. Everyone cheered.
Not only the dead man’s soul, but the legacies of Joseph Murray and Alexis Carrel hung over us that day. The inventors of immunosuppressive drugs like cyclosporine and others. Louis Pasteur, Joseph Lister and the great Susruta. Thousands of men of science and their patrons who had built up the massive edifice of human intellectual endeavour and used it to help their fellowmen. The people who had built and managed this excellent medical facility were there in spirit. Without the canvas how will one paint a picture?
The surgery was a success. Years of follow-up, careful immune suppression and other hurdles probably lay in the future. But we had succeeded in this small initial step.
A few days later, I learned that Biju*, the young man who had died, had a paralysed father. Biju had been taking care of most of his needs for the past 12 years. A handsome gift, from one hero to another.
Dr. Jimmy Mathew is a Professor and Reconstructive Micro-surgeon at Amrita Institute, Kochi.
*All names other than that of the professionals involved have been changed.
