On board a train to Kochi, a gang was harassing women passengers when a 30-year-old man, Manu objected. The fight took an ugly turn and he was pushed out of the running train. That fateful night, for hours, Manu lay next to a nondescript railway track. He had sustained serious injuries and lost a lot of blood. A passer-by heard his cries and arranged for help so that he could be taken to the nearest hospital. By the time they reached the hospital, Manu had turned pale due to massive blood loss and was gasping for breath. He had a severe concussion and injuries all over. While the doctors succeeded in driving death away, Manu lost both his hands in the accident.
Few tragedies can be as devastating for a person as losing both hands. A split second had changed Manu’s life completely. All he could think of was being dependent on someone else for his entire life. He thought about the loss of income, his independence and how much distress this would bring to his entire family. While prosthetic hands are available, Manu knew that they could never substitute ‘real’ human hands. The only way a patient with an amputation of both hands can recover is through a hand transplant.
The first successful hand transplant was performed in 1997 in the US and the patient is doing well till date. However, hand transplants are one of the most complex and challenging surgeries. It isn’t merely about surgical precision. Hand transplant requires significant organisational effort to establish a centre that can accomplish this difficult yet rewarding task. A large multidisciplinary team of plastic and microvascular surgeons, orthopaedic surgeons, anaesthetists, immunologists, rehabilitation experts, transplant nurses and social workers are essential for executing successful hand transplants.
I have been practising plastic and reconstructive surgery for the past 30 years, but it was on 13 January 2015, almost 18 years after the US case, that I helped carry out India’s first-hand transplant surgery. For the first time, an Indian patient received a double hand transplant at the Amrita Institute of Medical Sciences in Kochi, and the recipient was none other than Manu. After that ill-fated night, Manu had turned into a recluse and had thought of ending his life on several occasions. When I saw him for the first time in the OPD, I was moved to tears by his plight. By that time, our preparation for setting up a hand-transplant unit was almost complete. I could not think of anyone more deserving and suitable than Manu as a candidate for a bilateral hand transplant.
Of all transplant surgeries, hand transplants are probably the most demanding and difficult in every way. ‘Hands’, being the organs in question here, can only be harvested from a brain-dead donor. This also means that a mutilating procedure must be performed on the donor who would have to be buried or cremated sans the hands. Although awareness about organ transplant has increased considerably over the years, culturally, body-mutilating organ donation is yet to receive acceptability in India. We had to wait for a consenting donor family who would be magnanimous enough to donate the hands of their brain-dead family member. It felt like a ceaseless, unending wait.
In our quest of finding a donor, we would show the pictures of prosthetic hands that would be fitted to the donor’s body as well as a picture of Manu without his hands to every prospective donor family. We would beg them to donate the hands so that life could be improved. As family after family rejected our requests, the thought of whether we’ll ever find a family that would allow such a mutilating organ donation haunted us. Our chief transplant coordinator, Prasad, left no stones stone unturned in sensitising his team, along with the other teams in the state, regarding the need for such a donation. Usually, once a potential organ donor is identified, the treating team counsels the immediate family about the possible option of organ donation. If the family shows some inclination towards organ donation, they undergo more rounds of counselling by the transplant coordinators. The donation of internal organs is widely known, so it is comparatively easier to explain.
It is not an easy task for the counselling team to encourage the donor family for organ donation. What drives the team, though, is the thought that their efforts may save or improve the lives of four to six patients. Although they are a very dedicated lot, we did not want to leave the counselling for the hand donation to them. Prasad and I took this task upon ourselves, with the support of the team.
Four consecutive families consented for donation of other organs but refused the donation of hands. In fact, one of these families had initially considered donation but declined later. It is an extremely sensitive matter. The mother and brother of the donor could not bear the thought of hand donation and burying their family member without his hands. We couldn’t press too hard as we feared that they may back out from donating the internal organs as well. At such times, emotions are usually running high and most families are not able to accept the idea of body mutilation of their loved ones.
We had almost given up when, after a few months and multiple refusals, the family of 24-year-old Binoy consented. A brilliantly talented glass painter, Binoy was declared brain-dead after a motorbike accident. He was the sole breadwinner of his family and the only support for his ailing father who had been paralysed from the waist down for the last 14 years. Manu was indeed fortunate to receive a pair of such gifted hands. When we started the process on the night of 12 January 2015, it felt like we had stepped into a different world. I spoke to Manu and his brother once again in detail, before we took him for surgery, to ensure that they understood the enormity of the procedure.
This was the most momentous time of my career. The stakes were extremely high. At that time, it did not matter to me that the outcomes of this procedure would be watched keenly by not just my team but professional colleagues and the general public from all over the world. Our main concern was the safe and successful execution of the surgical procedure. In all honesty, it was the unfamiliarity with the task ahead that made it seem even more enormous. Our discussion with Manu and his brother helped a great deal at that time. Their positive affirmation and faith in our capability was encouraging and reassuring.
Finally, when we began the procedure, the atmosphere in the OT, as described by one of our residents, was ‘electrifying’. The surgery would take at least 14 to 16 hours and for many of us, it would be without rest in-between. There were many crises during the surgery and split-second decisions had to be taken. Four teams worked on four different tables. As the leader of the team, I had the challenging task of maintaining seamless coordination between all four teams.
We had a few worrisome moments too. Initially, due to an old trauma, there was no blood flow in the transplanted hands. It took hours of tireless efforts for Manu’s blood to start flowing through Binoy’s transplanted hands. A sigh of relief was heard all around the OT. The next day, when Manu moved his fingers, I thought how—both professionally and personally—nothing could be more beautiful, touching and satisfying.
Four days later, we attended a function in Varapuzha, a suburb of Kochi. Binoy (our donor) belonged to this village. The function was held to publicly appreciate Binoy’s family. Manu was still in the ICU. He was doing well and, luckily, there were no signs of immediate rejection. We spoke to him about the function and asked him what we should say on his behalf. He still could not speak much, but he requested a paper and pen. With great difficulty with his transplanted hands, he wrote three legible words, ‘Binoy, thank you.’ During my talk, when I projected pictures of Manu moving his hands and finally his thank-you note, written using Binoy’s hands, the entire audience was choked with emotions. It was, undoubtedly, one of the best thank-you slides I have prepared in my career.
Dr Subramania Iyer had higher surgical training in head and neck surgery and plastic surgery from the All India Institute of Medical Sciences, New Delhi, Medical College Calicut and various centres in the UK. He initiated the plastic surgery and head and neck surgery departments at the Amrita Institute of Medical Sciences (AIMS), Kochi.
This excerpt from Dear People, with Love and Care, Your Doctors by Debraj Shome & Aparna Govil has been published with permission from Bloomsbury India.