In this entry of Doctor Diaries, Dr. Ganapathy Krishnan, an acclaimed Neurosurgeon, gives an inside view of the first multiple organ transplant in South Asia that took place at the Apollo Hospitals, Madras on Christmas Day 1995.

It was almost 54 years ago that my English teacher D.O. Perry (whom we irreverently but affectionately addressed, by the first four letters of his name, behind his back of course!) had asked me what the phrase ‘have a heart’ meant. With the ingenuousness of youth, I had translated it to the literal meaning- ‘offering a heart’. Not being in a co-ed school, and at that time, a paragon of virtue and simplicity personified, it never struck me that I could offer my heart to someone else! That was to happen 11 years later.

Even then, I never dreamt that 20 years after this initial offering, I would one day, literally be telling a cardiac surgeon, ‘Here, have a heart!’

Though stout-hearted, it would have broken Mr. Perry's heart to have heard me talk thus. A man who held the Queen’s English sacrosanct, who felt that Tweedledum was different from Tweedledee, he would have considered such talk blasphemy. With a twinkle in his eye, in an emotionally-charged voice, he would have narrated how cupid's bow had mended many a broken heart.

Chicken-hearted in front of him, we dared not question the great man. We were just enthralled to hear all that the heart stood for. To, therefore authorise, that a human heart, beating in all its magnificent glory and still pumping the elixir of life could be removed, meant becoming stone-hearted.

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It all started with a telephone call at 10 pm on 22nd December 1995. A 30-year old man driving a scooter had been knocked down by a lorry, a few hours earlier. He had become deeply comatose from the moment of the accident and had stopped breathing with both pupils dilated. Artificial respiration had been started immediately in a nearby hospital.

Following this he was transferred to Apollo Hospitals, Madras (as it was then known), a hi-tech tertiary care hospital. A CT-scan revealed that the entire brain had been very badly damaged. The heart was beating strongly, the blood pressure was stable, and the kidneys were secreting adequate urine. The relatives and close friends were informed that the condition was very critical and that recovery was very unlikely. Treatment was initiated and carried out with an enthusiasm that was self-deceptive.

After all, justice delayed is justice denied. Justice must not only be rendered but seen to be rendered. Imminent death cannot be accepted suddenly, with equanimity.

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When is enough, enough? When does the doctor treating a critically ill patient say, "This far and no farther?"

Unfortunately, notwithstanding all the rhetoric, there are no definite rules. More important, the art of medicine is different from the science of medicine. A second and third opinion from a neurologist and a neurosurgeon was obtained.

This confirmed the hopeless prognosis. The human mind in a desperate situation will grope at every straw. After all, it is better to light a candle than to curse the darkness. The fact that like all candles, the illumination is only temporary is at that time, lost sight of.

Twenty hours after the accident, at 4 pm the next day, the situation was reviewed with the patient's brother, close relatives, and friends. The ground was laid to make them accept the inevitable. Twenty-four hours had elapsed and there was still no spontaneous breathing. It was pointed out that though the heart was beating, brain death had already occurred.

The topic of organ transplantation was introduced. The relatives were informed that the decision to donate the organs, was entirely theirs. Treatment would continue to be as vigorous as ever. A meeting was scheduled at 6 am the following morning, when the relatives could give their decision. This would give them 14 hours more to discuss among themselves, the issue threadbare.

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Though the law permitted certification of brain death after six hours, as a matter of abundant precaution 36 hours was decided upon. In keeping with the highest traditions of medical ethics, the neurosurgeon primarily in charge of the patient was totally unaware of the identity of the possible recipients.

The transplant surgeons were equally in the dark, at that point in time, of a possible donor. The total absence of any word or deed, which could even remotely, be later on construed as an act of coercion was crucial. Similarly, no time frames were given as deadlines. This was vital, to ensure that at all times, the relatives realised, that it was the individual patient alone who mattered to the attending doctor and not the recipients.

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Man proposes, but God disposes. The best-laid plans of men and mice often go awry.

At midnight, 30 hours after the accident I was informed that the blood pressure was falling and that an irreversible cardiac arrest could soon occur. To save the life of a waiting recipient, the heart had to be removed before this. Easier said than done. The final consent for organ donation had still not been given. Now we were racing against time.

What transpired in the next 6 hours, would have done any international crisis committee proud. Scores of telephone calls were made, and vehicles dispatched all over the city. The various teams involved in multiple organ transplantation were placed on red alert. So was the blood bank, the various laboratories, operation theatres, nursing personnel and a host of other paramedical support service teams.

Doctors authorised by the government, to declare brain death were contacted. Legal experts reviewed the gazette notification of the Transplantation of Human Organs Rules 1995. Photocopies of various proformas were taken. Effortlessly two secretaries had already appeared at 3 am. The whole atmosphere was charged with a palpable tension.

Even the food and beverages division, the lift operators, the ward boys, the electricians, the security, anyone who was someone in the hospital did whatever they could. It was a dramatic demonstration, of the whole being greater than the sum of its parts. In the meantime, the doctor primarily in charge of the patient, the medical superintendent and the managing director of the hospital discussed the game plan.

What was extraordinary, was the fact that neither a carrot nor stick was used. The greatest motivation apparently was self-motivation. A chain is only as strong as the links which make it up and in those few hours, every single link was crucial.

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Consent had still not been obtained and the clock was ticking. It had been decided that the primary physician would have the onerous task of getting the consent. Tact and diplomacy had to be supplemented with discretion, consideration, poise, and thoughtfulness. It was indeed savoir-faire at its best.

To do things quickly, without appearing to be unduly anxious about the ultimate outcome, knowing when to push and when to have restraint- this was the order of the day. Not having a degree in astrology nor being a member of the Indian Foreign Service, one had to depend on one's gut feeling.

A brief review of all that had transpired was made. It was pointed out that the five specialists who had confirmed irreversible brain death, between them had almost a hundred years of experience and that the intensive care unit had state of the art equipment and personnel. In other words, everything humanly possible, anywhere on terra firma had been done but to no avail.

Would they accept this and save four other people and give vision to two blind individuals? Even if full information is given is it reasonable to expect the wife of a brain-dead patient to take a calm, unruffled calculated decision, weighing the pros and cons, in an ICU setting?

I knew that I would have to strike a chord which would resonate with the wife's ideas. Any irrevocable decision, involving life and death, is after all influenced by one's education, cultural, and social milieu. Pregnant, she had been married three years ago and the next day would be the husband’s birthday followed a week later by their wedding anniversary.

At this stage, I unashamedly broke down. The stiff upper lip of the British, the years of professional training, the knowledge that the end justifies the means, all this gave way to naught. Tears spontaneously rolled down my cheeks. I made no attempt to brush it off. Here was I at 5 am asking a young woman permission to remove the beating heart of her husband! ‘Have a heart’, I told myself.

Watching the wife look at the ECG and BP monitor displaying good activity of her husband 's heart, literally broke my heart. With one last unwavering look, she asked for the relevant forms and signed it. As the teams were being mobilised I was told that she had changed her mind. All activities were put on hold (by now it was on autopilot and no one really knew from where the dozens of instructions were coming).

Another counseling session ensued. If she had the slightest of misgivings, she was assured that we would destroy the consent forms and call off the whole exercise. Though inexperienced and young, I had the foresight to foresee that a story of coercion in the media would do eternal harm to the entire cadaveric transplant programme. This readiness to implicitly abide by the family’s decision achieved its purpose. The young lady changed her mind, asked us to proceed and without looking back left the ICU.

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Like magic, there suddenly appeared dozens of individuals each attending to his work. Though there was no precedent, it was as if South Asia’s first cadaveric multi-organ transplant was part of a daily OT list. I still wonder where this group of individuals were when the discussions with the relatives were going on. It was a masterpiece in strategy that there appeared to be no undue activity at all before the final consent was obtained. For the liver transplant, 160 units of blood and blood products were made available. In the best of times, this would have been a Herculean, possibly impossible task.

On a Christmas eve Sunday as an emergency, to do this required a magician. Obviously, the blood bank medical officer and his team were magicians. Voluntary blood donors lined up by the dozens. This extraordinary display of camaraderie, of esprit de corps was all the more dramatic because it was done by ordinary people who had only one mission that Sunday, to ensure that the ultimate sacrifice made by a remarkable father and wife would not be in vain.

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Epilogue

23 years have passed. Awareness has increased exponentially. It is a matter of justifiable pride that the Apollo Hospital Group is today has one of the largest transplant units on the planet. At a personal level, I had published a paper in Neurology India in 1994, ‘Viewing the critically ill, head trauma patient as an organ donor’. This stirred up a hornet’s nest.

The fact that I took a pro-active measure in raising awareness of brain death and promoting organ donation made me an outcast in the neurosurgical community. I was even branded as an organ procurer. Over the next decade, realisation gradually dawned. Hostility ceased. Today, awareness is at an all-time high, but we still have a long way to go. It is my privilege to have played a very active role during the first 10 years until other enthusiasts took over.

It is impossible for hospital administrators and transplant surgeons of today to understand how the Indian health care system was in 1995. Information and Communication Technology was in its infancy. There were no smartphones, availability of bandwidth was in its embryonic stage, email services were rudimentary. There was no WhatsApp or Facebook. Awareness was at an all-time low. It was in this milieu that a team spontaneously came together and made the impossible possible. There was no precedent. Everything was a first. Today organ donation is slowly becoming an integral part of the health care delivery system. Let us not forget how it all started!

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This entry was originally published on November 2, 2018.