Indian Transplant Newsletter Vol. II Issue NO.: 6 (June 2000)
Print ISSN 0972 - 1568

A Gift of Life-Dr.K.Ganapathy

Indian Transplant Newsletter.
Vol. II Issue NO.: 6 (June 2000)
Print ISSN 0972 - 1568
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Editor’s note: Dr. K. Ganapathy has certified the first multi-organ brain dead donor in the country. This is his account of the event that created history.

 

Courtesy “The Hindu” January 21, 1996.


“There ought to be a law that parents must die first. When I was lighting the funeral pyre of my son, I thought-should it not have been him, lighting mine instead.”

 

-A grief-stricken father.

“Vex not his ghost: O! Let him pass; he hates him that would upon the rack of his stuff world stretch him out longer.”

 

  King Lear, Act V. Scene iii


It was almost 30 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 was meant by the phrase “have a heart”. With the ingeniousness of youth I had transplanted it to literally mean “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 ten years later. Even then, I never dreamt those twenty years after this offering, I would one day, literally, be telling a cardiac surgeon: “Here, have a heart”.

 

Though he was stout-hearted, it would have broken Mr. Parry’s heart to have heard me talk thus. A man who held 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-heart 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, authorize that a human heart, beating in all its magnificent glory and still pumping the elixir of life could be removed, meant becoming stony hearted.

 

It all started with a telephone call at 10 PM on December 22 last year. A 30-years-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; both pupils were dilated. Artificial respiration had been started immediately in a nearby hospital. Following this he was transferred to the Apollo Hospitals. A CT scan revealed that the brain had been badly damaged. The heart was beating strongly, blood pressure was stable and the kidneys were secreting enough urine.

 

Relatives and friends were told that the condition was critical and the recovery was most unlikely. Treatment was initiated and carried out with the enthusiasm that was self-deceptive. After all justice delayed was justice denied. Justice must not only be rendered but seen to be rendered. Imminent death cannot be accepted suddenly, with equanimity.

 

When is enough enough? When does the doctor treating a critically ill patient say: “This far, and no farther?” Unfortunately, not withstanding all the rhetoric, there are no definite rules. More important, the art of medicine is different from the science of medicine. A second and a third opinion from a neurologist and a neurosurgeon were obtained. They 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; 24 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.  24 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 vigorous as ever. A meeting was scheduled for 6 AM the following day, when the relatives could give their decision. This would give those 14 hours more to discuss the issue among them. Though the law permitted certification of brain death after 6 hours, as a matter of abundant precaution 36 hours were decided upon.

 

In keeping with the 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 ignorant at the point of time, of a possible donor. The total absence of any word or deed which could come, even remotely, be later construed as an act of coercion was crucial. This was vital to ensure that all times that the relatives realized that it was the individual patient alone who mattered to the attending doctor and not the recipients.

 

Man proposes but God disposes. At midnight, 30 hours after accident I was informed that blood pressure was falling and that an irreversible cardiac arrest could soon occur. To save the life of the waiting recipient, the heart had to be removed. This earlier 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 six hours, would have done any international crisis committee proud. Scores of telephone calls were made, vehicles dispatched all over the city. The various teams involved in multiple organ transplantation were placed on red alert. So were the blood bank, the various laboratories, operation theaters, nursing personnel and a host of other paramedical support service teams.

 

 The hospital contacted doctors authorized by government to declare brain death. Legal experts reviewed the gazette notification of the Transplantation of Human Organ Rules 1995. Two secretaries had already appeared at 3 a.m. 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 their bit. It was a dramatic demonstration of the whole being greater than the sum of its parts .in meantime the doctor primarily in charge of the patients. 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 a stick was used. The greatest motivation apparently was self motivation. a chain is only as strong as the link which make it up and in those few hours every single link was crucial.

 

 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 savior faire at its best. To do thing quickly without at the same time appearing unduly anxious about the ultimate outcome: knowing when to push and when to exercise 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 one’s gut feelings.

 

A brief review of all that had transpired was made .it was pointed out that the five specialists who had confirmed irreversible brain death had between them 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?

 

 Mention was made of a newspaper reports in the U.S. where a mother who consented to multiple organ transplantation had said:”my son never died- he is travelling in different people,” like saying: “the king is dead. Long live the king”. After a 20 minutes discussion it was suggested that the father hold an in camera dialogue with the other family members. It was repeatedly stressed that their decision would be final. Five minutes later the family members present gave the authorization to proceed with the necessary formalities. However it was morally and legally essential that the wife took her own independent decision. A vehicle was dispatched and a heart broken young woman was brought in.

 

Even if the attending doctor gives the full information to the wife of a brain-dead patient is it reasonable to expect her to take a calm, unruffled, calculated decision after weighing the pros and cons, all in a Critical care setting? In my heart of hearts, I knew that ultimately I would have to strike a chord which would resonate with the wife’s ideas. Any irrevocable decision-making process, involving life and death, is after all influenced by one’s education, cultural and social milieu.

 

  The wife was asked to describe the personality of her husband. Would he have wanted his organs to be donated? Ultimately this would be pivotal question. She pointed out that he was interested in social service. Could there be a nobler way to leave this world – with an indelible mark – than to save four dying persons and give eye sight to two: the question was posed.

 

They had been married just three years and the next day would be his birthday followed a week later by the wedding anniversary. I broke down. The stiff upper lip of the British, the years of professional training, the knowledge that the end justifies the means, all this meant naught. I made no attempt to stop the tears. After all William Boyd, the famous pathologist, had once said. “The sorrow that has no vent in tears makes other organs weak”. Here was I, at 5 Am., asking a young woman permission to remove the beating heart of the husband. “You Doctors have a heart,” Mr. Perry would have remarked.

 

It was probably a ludicrous sight to see a hard- hearted neurosurgeon like this. After all I had certified hundred’s of deaths and even been involved in certifying brain stem death for purposes of disconnecting the ventilator – but never for removing a beating heart. Retrospectively, this display of one’s basic instincts probably reinforced the subtle message that the medical men on the team were human beings first, specialists second and trained technicians in a tertiary care hospital last.

 

Accompanying the woman to the ICU and watching her look expectantly at the ECG and blood pressure monitor displaying good activity of her husband’s heart, literally broke my heart. “Et tu Brute?” she seemed to be implying. Is this the heart you are all waiting for? With one last unwavering look and full of determination she asked for the relevant forms and signed them.

 

The last entry made in the case records was: Blood pressure 110/70 (with dopamine). Heart sounds well heard. No spontaneous respiration. Both pupils dilated. No response to any form of stimuli. Patient has features of irreversible brain stem death. Consent obtained from wife and father for organ donation. To be sent to operation theatre for removal of heart, liver, kidney and both corneas.

 

Hardly had these entries been made when I was sent for again by the wife. She wanted a reassurance before the organs were removed – that they would not be misused. Putting the rest of the activities on “hold” (by now they were on autopilot and no one really knew from where that dozens of orders were coming), the credibility of the hospital and the teams were vouched for. If there was the slightest of misgivings, she was assured that we would not think twice of destroying the consent forms and calling off the whole exercise.

 

The rest as they say is history. With ruthless efficiency born of decades of professionalism the heart, the liver, the two kidneys and the corneas were removed. Teams of anesthetists and surgeons swung into action. I still wonder where they 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 time this would have been herculean, possibly impossible, task. On 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 dozen. This extraordinary display of camaraderie, of espirit 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.

 

In 1993 throughout the world, 315,737 kidneys, 34,307 livers, 20,395 hearts and 1,476 pancreas had been transplanted, besides lungs and certain other organs. (Data from Russia and China not available. Source: Bulletin of American College of Surgeons August 1995).

 

 

It is true that it will take a long time before organ transplant (particularly multiple organs) gets the propriety it deserves. There will always be sceptics who will question these “heroic attempts when there are major public health problems. The first multiple organ transplant done under Apollo Hospitals, Madras is symbolic of India’s rapid progress in health care. It is indeed a matter of justifiable pride that slowly but surely one – sixth of the world’s population, will eventually have access to 21st century health care. As Rakesh Sharma, India’s first astronaut said, “For India, the sky is no longer the limit”.  


To cite : Shroff S, Navin S. A Gift of Life-Dr.K.Ganapathy. Indian Transplant Newsletter Vol. II Issue NO.: 6 (June 2000).
Available at:
https://www.itnnews.co.in/indian-transplant-newsletter/issue6/A-Gift-of-Life-143.htm

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