Caveat lector.....Not everything in the papers is fact....Journalist heal thyself!

To manage organ donation well, a course in transplant coordination - Hindustan Times

The accompanying graphic (Hindustan times Delhi 24th September) totally misrepresents the situation regarding organ donation in the city of Delhi. I wish the reporter had taken the trouble to verify the numbers she was getting from her 'sources'. Caveat lector (reader beware) would be my advice. I am sure the reporter meant well, but the figures mentioned could lull the readers into some utopian fantasy and complacency.

If the numbers were true, particularly those at AIIMS, all transplant surgeons and physicians would be clapping their hands in a rapturous delight. These numbers while still far below what is needed, would herald a happy change in the embarrassingly depressing 'real' situation in India.

It is a welcome development that Delhi doctors are being trained in transplant coordination by experts from Barcelona. The province of Catalunya in Spain, where Barcelona lies, has the distinction of the highest organ donation in the world about 35 per million ( It is 25 per million in US and only 0.04 in India). The province of Catalunya is a torchbearer in the field of organ donation and whatever we can imbibe from their protocols will be welcome to shed our title of being a 'selfish nation'. However blindly aping their system is unlikely to work because they have a great penetration of socialised medicine paid for by state insurance while India is struggling with social medicine even in primary care. We will have to take inspiration from them and find locally applicable solutions to shed this dubious distinction.

The plan being worked out indicates that the powers that be have taken initiative to a felt need in the society, but this alone is unlikely to yield dividends. The strategy has to be multi-pronged and should simultaneously target education, legislation, professional training and societal change. A good staring point would be to take measures to restore faith of society in initiatives of the powers that be in looking after their welfare. Unless this faith is restored, we will be hard pressed to change the status quo no matter what rosy hyperbole is presented in the press.

Special 'mirror image' donor saves two in death

Recently a brain dead 49 year old donated his kidneys that could end up saving two precious lives. The supreme gesture should be saluted like every such noble gesture for community benefit. This donor had an anatomical anomaly called situs inversus totalis.

Situs inversus is an anomaly where the organs are placed in mirror image position from their typical orientation (situs solitus). Situs inversus may occur in various levels with total inversion being called situs inversus totalis the more common form is right sided heart (dextrocardia) with situs solitus.

Situs inversus totalis is usually a benign condition though about 20% are associated with Kartegener's syndrome ( infertility, respiratory disease and situs inversus).

Situs inversus being rare causes an unfamiliar surgical environment for the surgeons who may have never encountered such anatomy during their training. When an deceased organ donor has situs inversus it may pose minor problems and the surgeon has to constantly be aware of the altered anatomy to avoid inadvertent injury to vital structures.

When a living donor has situs inversus it can be problematic to position the graft particularly the right lobe which has to be placed in the left side of recipient. This can lead to angulation of the graft that can compromise its outflow by causing kinking. There are few such reports in literature requiring innovative methods like placement of tissue expanders to prevent angulation.

Cadaveric whole liver may need to be rotated 180 degrees to facilitate tension free vascular anastomosis.

Surgeons in the history of liver transplantation have had to innovate frequently to successfully use scarce donor organs successfully.

Ganesha Chathurti.... celebrate the God of Transplantation

According to Hindu mythology, the elephant headed son of Shiva and Parvati is the first recipient of a transplant although it was a xenotransplant ( from non identical species).

According to the story, Ganesha was asked by his mother Parvati not to allow anyone to enter the house while she bathed. When Shiva, Parvati's husband and father of Ganesha, sought to enter the house he was prevented from doing so by Ganesha siting his mother's orders. The enraged Shiva sent several of his minions to force Ganesha to allow him entry but all these were sent packing by the obedient Ganesha. Blinded by rage, Shiva attacked Ganesha and beheaded him for his impertinence. Seeing this Parvati was livid and threatened to curse the Gods for causing the death of her son. In order to placate Parvati, the celestial physician asked the Gods to fetch the head of the first animal they came across which turned out to be an elephant. The elephant head was transplanted onto Ganesha's body and he was given an elixir to drink which may have been a potent immunosuppressant to prevent rejection of the xenograft.

The iconic depiction of Ganesha is the head of an elephant on a pot bellied body which some have likened to the fat deposition resultant from steroid induced immunosuppression.

Ganesha's vehicle the mouse 'Mooshak' has been compared by some to the importance of mouse models in transplant related research.

Although all these could well be considered myths or a figment of a fertile imagination by agnostics and disbelievers, hindu literature is replete with such miracles that today are considered achievable by modern medicine.

In a lighter vein, one of my fellow transplant surgeons commented that Ganesha did not receive the head of an elephant but an elephant received the body of a human being! This made Ganesha the first human organ donor and not transplant recipient!!

The Social Network....will it provide the tipping point for organ donation?

Facebook, social media can boost organ, tissue donation

Social networking sites today connect millions even billions of people across the world.

They provide an uninhibited and egalitarian environment that transgresses caste, colour, class, creed and national barriers for person to person interactions. Such interactions have not been possible in the history of the human race.

Social networking sites have amply demonstrated their prowess in being instruments of social change. The Arab Spring protests globally and the Anna Hazare movement locally have bear poignant testimony to the fact that these sites can provide 'the tipping point' to a undercurrent of discontent brewing in people regarding their surroundings and their way of life.

The study referred to in the article revealed that a simple survey regarding willingness to donate organs on a popular social networking site saw a significant spike in donations which then subsided. This indicates that only persistent messages and motivation can sustain this trend.

I hope this provides the much needed tipping point to the sad organ donation story in this country

Kudos Mumbaikers.....What about Delhi ke dilwaley

Two more cadaver donations in city

Its very encouraging to see the increased rate of organ donations in the city of Mumbai. Its laudable to note that the city that never sleeps has a conscience that has awakened.

Now will Delhi ke dilwaley find it in their heart to make this noble gesture?

Watch this space

Rally to simplify organ donation by Mumbaikers

The wait for a donor’s organ - Indian Express Mobile

The people's movement begins. Let us hope it opens eyes all over the country.

An unselfish act....Kudos and solemn homage.

http://www.business-standard.com/generalnews/news/ganga-ram-trust-chairman-gives-new-life-to-3-even-in-death/54194/

Kudos and homage to the late Shri Tej Ram, Chairman of the Sir Ganga Ram Trust may his soul rest in peace.

Following a massive stroke at the age  of 88, Shri Tej Ram was deemed to have no brain stem function. His family honouring his life-time wish agreed to donate his organs without any fanfare and to not-so privileged individuals. The liver and kidneys have been transplanted into three needy individuals who otherwise were staring at near certain death due to advanced organ failure.

This selfless and honourable act from a person of high-standing in society comes as a breath of fresh air in an environment that has been sullied by greed, avarice and moral corruption restoring faith in the humanity that is the very essence of the human race.

Let us take a moment to bow and pay our solemn homage to Shri Tej Ram whose last human act has immortalised him. He continues to live in the three individuals can now look forward to a healthy life thanks to him.

I hope such individuals will continue to stand out as paragons of virtue to inspire more and more people and their families towards such selfless acts . 

Transplant coordination: what it really means...it's no mean feat!

The Transplantation of Human Organs Act mandates that hospitals who undertake organ transplant have a designated transplant coordinator but is quite silent on what role that individual is required to play in the transplant process.

The person appointed as transplant coordinator should be either a registered nurse, a medical graduate or a social worker who has been preferably trained in transplant coordination. Some universities and foundations run such accredited courses in India. However few working coordinators have such training in practice.The transplant coordinator usually ends up being reduced to a secretary, business manager or propaganda specialist. Without training even medical doctors are unable to understand the intricacies of the transplant process so their coordination is symbolic at best.

The transplant coordinator should act as the advisor, counsellor, friend and confidante of the patient and the family. Ideally the coordinator should facilitate the preparation, logistics of the operation and ensure smooth transition from hospital and domiciliary care. Listing and prioritisation of patient on the list for a cadaveric transplant is also the role of the coordinator. The coordinator should liase with the organ distribution network and help in selection of the deceased donor in conjunction with the retrieval team and hospital. The coordinator should frequently be available to update the family and answer any questions.Once discharged the coordinator should maintain records of the status of the patient, schedule follow up visits and ensure compliance with medication, investigation and rehabilitation. To sum up the coordinator should be the bridge between the patient and the transplant physicians and surgeons. Doing all this is no mean feat.

Rapid action......let's do the same for the other absurd rules

Absurd organ donation rule on kitchen-sharing dropped

Postmortem can be done after organ retrieval, suggests DGHS

Two significant  news reports in the Times of India that could impact organ donation scenario in this country significantly

It appears that the rule for not so near relatives proving that they have shared the same kitchen for more than 10 years with the recipient to be a live donor is unlikely to be incorporated in the amendment to the  Human Organ Transplant Rules.

Several absurd rules and conventions have entered the organ donation stage. I have personally known officials from authorisation committee ask for a 'same womb' certificate to be furnished when a sibling is donating to another. I have found this quite drole not to mention unnecessary. Who on earth could issue such a certificate? Birth certificates or school certificates or government documents where parents names are entered should suffice. Unfortunately nobody has gone over this absurdity with a critical eye.

The focus should be on facilitating donations while keeping a sentinel to deter inducements and impersonation. Like all laws in this country, the spirit of the law is salutary but it's letter needs a lot of modification.

The second news item that is of great relevance to the deceased donor situation is the suggestion of the Director General of Health services that post-mortem could be done after organ retrieval.

Brain stem death usually occurs in two situations : following trauma or following a cerebrovascular accident. With India's killer roads, motor vehicular accidents account or a large quantum of head injuries that present to trauma centres.  While this is a sad situation and cries out for improvement in roads and helmets, since most of these individuals are younger and active, their uninjured organs are likely to be in excellent shape and hence transplantable.When the injury is severe and brain death supervenes, even if consent for organ donation is provided by the next of kin, once of the major hurdles to organ donation comes in the form of performance of the medicolegal post mortem. Since post-mortem is not possible outside government institutions and medical colleges, having a forensic pathologist present during the organ retrieval (as mandated by rules currently) can be a logistical nightmare. This is due to understaffing of forensic departments, lack of motivation and sometimes rank callousness.

This suggestion to use technology like CT or MRI to image organs before retrieval or obtain samples of required organs during retrieval if a forensic pathologist  is a welcome proposal and is likely to simplify organ retrieval in medico-legal cases significantly. A post-mortem can always be performed after retrieval if needed.

This suggestion if accepted will allow timely retrieval of many more transplantable organs and save lives.

Organ donation rules....need for transparency not toughening

The Times of India on 4th September 2012 has reported a proposal by the ministry of health to amend rules in the organ transplant act to include 'not so near' relatives.

Suggested modalities to establish the relationship with live donor include

1. Old photographs of donor and recipient together
2. Staying together and sharing same kitchen for more than 10 years
3. Establishment of relationship between donor and recipient by a senior embassy official (for foreign nationals)

Greater caution has been recommended in case of female donors.

To the best of my knowledge, this is anyway a standard practice today and in camera interviews of donor and relatives are the norm in most if not all authorisation committees. 

Having had significant experience in this field, what I believe we in India are lacking is the spirit of the law. As an insider, I can safely vouch that the letter of the law is followed to the 't' wherever I have had the occasion to study the system.

What I think needs to be strictly followed and enforced is

Donor to be evaluated and counselled by medical team who is not treating the recipient. This will avoid any potential conflict of interest.

Counselling of the donor privately and offering a medical opt-out in case of his/her refusal to donate. this will avoid pressure from family.

Donor advocacy team consisting of social worker and physician to be present during the authorisation committee meeting. 

Until deceased donor organs are available to meet the need, living donation will be the need of the hour. Rather than make it difficult to donate by tightening rules and norms, what should be insisted on is greater transparency, dissipation of information, detailed counselling, donor advocacy and avoidance of coercion or inducement in any form.