Operating on Monika More: The saga of Mumbai’s First Bilateral Hand Transplant

30/09/2020

“All was well.”

With those words, the famous Harry Potter Series ended. And those were the words I closed my eyes with after fulfilling my 13-year-long dream. The unforeseen obstacles, a thing of yesterday. All was well.

Going back to 2007, during my first year of Plastic Surgery residency, I became enthralled by Dr Warren Briedenbach’s lecture. The surgeon who had performed the first successful hand transplant in the world was expanding our minds with the possibility of an arm amputee regaining freedom. The complexity of the procedure captivated my mind. I desired to make the difference that Dr Briedenbach had made to his patient. The resolve that has stayed with me since that day was: “If he could do it, I can too!”

Seven years later, when news channels broadcasted the story of Monika More, I was left thinking of how a hand transplant surgery could help improve her quality of life. I imagined what it would take to perform the procedure successfully. I was unaware of how entwined our fates would be years after her accident.

The 16-year-old student, while trying to board a packed local train at Ghatkopar station, fell into the gap between the train and the platform. As she fell, her arms went under the train, causing her left arm to get completely severed, while her right arm remained barely attached. Quick responding members of the public, retrieved the unconscious teenager and her severed arm.

Monika was rushed, to a hospital in Ghatkopar, where her condition stabilized, but her arms could not get re-attached. Her family took the call to shift her to a hospital where limb re-attachment procedures were conducted. However, too many precious hours had passed. The condition of the severed limbs had deteriorated; as a result, they could no longer get re-attached. Over six-years since her accident, Monika and I embarked on a thrilling journey together.

Blissfully unaware of the future, I focused on furthering my skills and expertise in the field of Hand Surgery and Reconstructive Microsurgery. Between 2012 and 2013, in Japan, I pursued my fellowship in hand surgery, brachial plexus and reconstructive microsurgery. The steps I have taken, since 2007 till I joined Global Hospital, Mumbai, inched me towards the fulfilment of my dream of performing one of the most complex forms of microsurgery.

Even after joining Global Hospital, I had to get several factors in order before I could even entertain the thought of performing a hand transplant. The first step was acquiring the licence permitting me to perform hand transplant surgery. At Global Hospital, a multidisciplinary team of plastic and microvascular surgeons, orthopaedic surgeons, anaesthetists, immunologists, rehabilitation experts, and transplant nurses, were put together. In 2016, I ultimately obtained the license for hand transplant surgery.

Over the years, Monika had captured national attention. Determined to reclaim control of her life, she continued her education and started using prosthetic hands.

Prosthetic limbs can be life-altering for an amputee. In the case of legs, prosthetics can assist a person to stand, walk and even run. Yet, even with advancements in the field of prosthetics, an artificial arm cannot replace a real one. From maintaining basic hygiene to the scrolling through Facebook on her phone, Monika needed to be assisted by her family.

In 2018, Monika and her father, Ashok More, met with Shreya Siddanagowder in Pune. The meeting with the first successful bilateral arm transplant patient in Asia encouraged the More family to dream of a better future for Monika. Shortly after the meeting with Shreya, I became a part of Monika’s journey.

Taking on a transplant patient is akin to adopting. Once they become your patient, you need to think and do what is best for them. Their health depends entirely on your medical judgement.

After getting in touch with the More family, I put Monika on the organ transplant waitlist.

When people talk about organ donation, they mostly think of donating internal organs like the heart, lungs, liver, kidney and so on. Awareness of Vascularized Composite Allograft/Allotransplantation (VCA) is limited in our country. VCA involve the grafting of many kinds of tissues like bone, muscle, nerves, skin, and blood vessels as a functional unit. Hand, arm and face transplants fall under this category.

Having internal organs retrieved from a donor body allows it to remain unaltered externally. Mutilating external organs for VCA can be traumatic for the family of the donor. The stigma attached to the mutilation of the body prevents many families from permitting the donation of external organs.

Even though Monika has been on the list since 2019, it took many months until a donor emerged. On more than one occasions, it seemed like a donor was ready. Due to various reasons ranging from the family changing their mind to the donor not being a match, we continued waiting.

With the COVID-19 pandemic putting the country under lockdown, elective surgeries were low priority. On August 28, out of the blue, we were informed of a possible donor for Monika. As soon as the call came, around 8 am the team at Global Hospital geared up for the protracted battle ahead.

Before I could get Monika on the operating table, the hospital management had to jump through hoops of fire to make things fall into place.

The donor was a man in Chennai, whose family had agreed to donate his arms in addition to other organs. To perform the surgery in Mumbai several conditions had to be met:

  • The management at Global Hospital had to give the go-ahead after considering the finances and other aspects of the procedure.
  • Blood, tissue and cross-matching needed to be completed.
  • The organ needed to be transported successfully within a short time from Chennai to Mumbai after procurement.

Once the donor’s hands reached Global Hospital, my team and I could start the 15 to 16-hour long surgery. We were not aware of the additional obstacles that were about to pop up at every step of the way.

Hurdle at the starting line

Hand transplant is a complex, high-end and resource-intensive procedure. Monika’s family had been accumulating funds for her surgery. They had received some donations as well. However, since her father’s unfortunate passing in 2019, the family’s finances had suffered a setback. They were financially unprepared to meet the sudden opportunity.

Dr Vivek Talaulikar, CEO of the Global Hospital, Mumbai, was aware of the financial obstacle. While being aware of the impending cost of the procedure, he appreciated the importance of not letting the opportunity pass. If the surgery did not take place, it could be months or even years until another donor was found. The decision to go forward with the surgery would not only change Monika’s life but would also initiate an invaluable programme at the hospital which could contribute to raising societal awareness regarding VCA and external organ donation.

Having negotiated the hurdle at the starting line, the team waited for the transplant coordinator to embark on his journey.

Mumbai to Chennai

The organ needed to be transported from Chennai to Mumbai. Before the organ can be retrieved, transported and attached, cross-matching of the donor and the recipient must be completed. Human leukocyte antigen (HLA) matching needed to take place in Chennai. A sample of Monika’s blood had to be flown to the hospital there.

Due to the COVID-19 lockdown, getting Monika to come to the hospital would take too long. It was decided that the hospital’s transplant coordinator, Rahul Wasnik, and a nurse would go to Monika’s house in an ambulance. From there Rahul would take the sample, go directly to the airport and catch a commercial flight to Chennai.

Here we faced our first unforeseen obstacle. Monika’s amputation was done right below the elbow. The veins in the area could not be tapped for blood. We were informed of this conundrum. I advised the nurse to try and take a sample from Monika’s leg. At long last, she was able to draw blood and send Rahul off to the airport.

Unfortunately, by the time he reached the airport, it had been too late to catch the flight. The second unforeseen obstacle met us here.

Alternatives began to be discussed. Flights to Chennai via other cities could take too long. Organ procurement needed to take place right after the donor was pronounced brain dead. With his condition unstable the delays could cost us the opportunity.

While ignoring the further cost, it was decided that the hospital would charter a flight to deliver the sample to Chennai and bring the organ back to Mumbai. Rahul would take a commercial flight to Bangalore, board the chartered flight to Chennai and return to Mumbai on the same chartered aircraft.

Instead of reaching Chennai in the afternoon, the sample would reach the hospital in the evening. Having informed the other hospital of the delay, we awaited the flight to complete the first leg of the journey from Mumbai to Chennai.

Against the clock

The hospital management received information that the pilot would have to take off from Chennai by 10 pm. This was the third unforeseen obstacle that needed to be tackled.

If they could not fly by then, he would be forced to halt in the city for the night. The flight hour restrictions mandated him to rest till 4:30 am the next morning. So, the sample had to be taken to the hospital, and the organ had to be brought back to the airport by 10 pm.

Having reached Chennai after 6 pm, Rahul was already running against the clock.

Waiting for a match

Three hours is the standard time that HLA matching takes. Even though the hospital in Chennai sent an ambulance to the airport to fast-track the process, Rahul reached the hospital around 7:30 pm. The delays became the fourth unforeseen obstacle.

In the meantime, we had been informed that the donor’s condition had worsened around 7 pm.

The question of waiting for the HLA matching result arose. If the HLA did not match and the arms were retrieved then the donation would be in vain. There was no rushing the test. Organ retrieval could not be delayed as well.

All we could do was wait and hope.

After a few hours we were no longer left waiting for a match as the report was in. It was a match! The organ could be flown to Mumbai for the final step.

As fate would have it

Soon after we were notified that the organ had left Chennai, the fifth unforeseen obstacle left us worried. It started raining around 11:30 pm in Mumbai. If the rain continued or picked up, the flight would not be able to land. It would instead be forced to land at other airports like in Pune. It had already been hours since the organ had been retrieved. Waiting for the organ to come by road was not an option.

On the eve of Ganapati Visarjan, we were left praying to the universe’s first transplant recipient, Lord Ganapati.

As fate would have it, the flight was able to land in Mumbai. From the airport an ambulance sped the organs to the hospital, covering the nearly 15kilometer distance in only 16 minutes.

Smooth sailing

While waiting for updates throughout the day, I took the time to discuss with surgeons who had already performed similar surgeries in India. I was also fortunate enough to have my teacher and mentor Dr.AmreshBaliarsing as a key member of my team.

Having waited since the news of the donor in the morning, I was finally able to step into the operating theatre with my large, well-prepared team.

Not only was I stepping up to the task of a hand transplant, but I was also about to perform a bilateral hand transplant. We were ready.

Failure was not an option!

As we began, the sense of gratitude for the donor and his family filled me. Concurrently, I felt overwhelming excitement, as I was finally able to get the rare opportunity and help Monika return to a life of normalcy.

Working as a well-oiled machine, my team was able to finish the surgery without a single hitch. The 16-hour procedure was smooth sailing. The skill and efforts of all my surgical and anaesthesia colleagues ensured the safety and technical success of the surgery.

Finally, after shifting Monika from the operating theatre, I could breathe a sigh of relief.

All was well

Once Monika was shifted to the Intensive Care Unit, the team continued monitoring her condition. After the 40-hour-long day, I was able to head back home with a sense of achievement.

My understanding and supportive wife was elated that I was able to realise my dream. Other family members, who had previously been baffled by the fact that hands could also be transplanted, congratulated me.

Two members of my family, however, needed some special attention once I got home.

As I was getting to spend quality time at home during the lockdown, my sons and I had been watching one Harry Potter movie a day. I had left my sons waiting for the conclusion of the series when I had to scrub in. I had delayed the screening of Harry Potter and the Deathly Hallows Part 2!

While I assured them that we would complete the series together, my thought drifted back to the families of the donor and Monika.

As my mind began to rest, it began processing the events of the day. I could not stop thinking that if Monika had received the apt treatment instantly after the accident, she would not have required the transplant surgery. At the same time, if the magnanimous family of the donor backed out, all of us would have been left waiting for an unpredictable amount of time. While sudden hurdles were cropping up all day, fate and the tireless human effort made the surgery possible.

I knew the sleep that night would not be easy. My mind stayed occupied with the thought of Monika recovering at the hospital. Her recovery journey had only just begun.

Her family would not be able to meet her in the hospital. Immunosuppressants meant to allow her body to accept the donor's hands, also makes her susceptible to infections. For days, she would not be allowed to meet her family as it could put her at risk of contracting the novel coronavirus. Even if her family was allowed to be physically present, Monika would miss the presence of her father.

Monika, her family and I will forever regret the fact that a donor could not be found earlier. Ashok More would have been able to see his beloved daughter putting Mehendi on her hands if there was greater awareness surrounding VCA and the donation of external organs.

With Mumbai’s first bilateral hand transplant in the books, I hope that more people will become aware of and understand the difference organ donation makes. There are more patients on the list, waiting eagerly to get a chance at life like Monika now has. Normalising external organ donation may be a thing of the future, but Monika’s story will act as a key pillar.

My mind was filled with eternal gratitude towards all the those who played their roles to help navigate the dramatic events in the last 2 days.

Having finally turned my dream into reality, I drifted off, and all was well.

Dr Nilesh G Satbhai,
Consultant - Plastic, Aesthetic, Reconstructive Microsurgeon & Hand Transplant Surgeon,
Global Hospitals, Parel, Mumbai.

Disclaimer:  The views and opinions expressed in this article belong solely to the author. They do not reflect the opinions or views of the organization.

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