In an Indian village hospital, doctors separate twins to script medical history
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vivek chhabra
Jun 26, 2012, 1:18:26 AM6/26/12
to Indi go, a2 batch, Medcolegal queries, afmcites afmcites, uk afmc, unconventional medicine
In a village hospital, doctors separate twins to script medical history
Pritha Chatterjee: Betul, Sun Jun 24 2012, 01:36 hrs: Indian Express: On
June 20, six friends from the 1982 batch of Christian Medical College
(CMC) in Vellore and their former professor operated in the same
theatre, after nearly 30 years. In a small missionary hospital tucked
away in a village in Betul district, 200 km from Bhopal, near the
southern border of Madhya Pradesh, the doctors performed the first
successful separation of conjoined twins in a rural setting in the
country.
The twins Stuti and Aradhana—christened by the hospital staff—were delivered in Padhar Hospital in May 2011. The "shocked" parents, a couple from Chicholi block, 40 km from Betul, told hospital authorities they would not be able to take them home. Formal adoption procedures were initiated at the district collector’s office, and the babies were "donated" to the hospital.
Barely a month after their birth, Dr Rajiv Choudhrie, medical superintendent of the hospital and a general surgeon, contacted his friends, over the phone—Dr Sanjeeth Peter, cardiothoracic surgeon based in Nadiad in Gujarat, Dr Gordon Thomas, paediatric liver transplant surgeon in Sydney and Dr Anil Kuruvilla, head of the department of neonatology in CMC, Vellore.
"Back then, I did not know if separation was even possible, let alone in this remote hospital of ours. I simply sought their medical opinion on the state of the fusion, and asked them if any intervention was possible," Choudhrie recalls.
Over the next few weeks, Dr Deepa Choudhrie, Rajeev’s wife, and a radiologist at the hospital, prepared extensive reports—CT scans, MRIs and ECGs that were emailed to Peters and Thomas. Their examination brought good news. "It was a form of conjoinment known as thoraco–omphalophagus, i.e. the twins had two separate hearts in a common sack, that is called the pericardium sack, and is crucial for supplying blood to the heart. Secondly, their livers had separate blood supplies, but were joined by a bridge of the liver tissue—so it was a big joint mass of liver between them," Brown explained. The condition merited surgical intervention. "Luckily, the case was not very complicated, because both the organs, the hearts and the liver, were separate it was just that they were joined. We had to separate the hearts and make two sacks out of the existing one, and decided the proportions in which we would distribute the liver. We felt sure it could be done," Peter added. Dr Rebecca Jacob, a former professor of anaesthesia at CMC, was the first to come for a recce in the hospital, in November last year. "My students often contact me for advise if there are complications. My first reaction when I saw the hospital was to move the babies to another setting for surgery. They had one anaesthesia workstation to give the drugs, that too for adults, and one ventilator that was also for adults. It seemed impossible to me at first," Jacob recalls.
Choudhrie says he was bombarded with similar reactions—ranging from voices of concern to outright laughter—at his idea. Today, as people laud him for his resolute, almost obstinate, decision to do whatever it took to perform the surgery in the village, he says there was no bravado involved. "I did not decide right in the beginning that we would to do it here. But after I approached so many specialists and took in their opinions, somewhere along the way I decided I wanted to do this. It was a tempting idea to send the babies away—everything would be so much easier in a setting that had all the facilities, but I kept myself from falling for it," he explains.
There were offers—from reputed centres and specialists—including Dr. Devi Shetty, to move the kids, and take over the procedure. Instead of accepting the offers, the team worked towards overhauling the existing set–up—preparing the infrastructure and putting together a team to perform the surgery. Over the next eight months, more doctors were contacted. Thomas approached a paediatric surgeon in Sydney, Dr Albert Shun, who has operated on thee conjoined twins so far. "Clinically I have dealt with more complicated surgeries. But this one had so many more challenges, it was a team put together from across the world in a rural setting and we had to literally build the operation theatre and the ICU for post–surgical care. This was my first time in India, and I have never seen so much intricate planning anywhere else in the world," says Shun.
Jacob contacted a paediatric anaesthesiologist in Sydney, Dr David Baines, who also had experience in operating on conjoined twins. "It’s amazing how much fun we have had, though there were no commercial gains—even our travel here was not funded for. It was a huge challenge and we took it. Now it’s a statement to India and the world: such a procedure can be performed in this setting provided doctors care enough," Baines says.
Specialists in paediatric surgery were also roped in, from the country’s other CMC in Ludhiana. The doctors, after their individual visits to Betul spread over November–February, sent their requirements to Choudhrie. "I got these huge lists, and despite some donations, we had no money. It was like having Rs 10 in your pocket and going to buy stuff worth thousands of dollars," Choudhrie laughs. There were requests for two of everything—high–end paediatric ventilators, monitors, heart and lung machines, suction tubes, internal defibrillators, cardiac monitors, pericardial patches, syringe drivers, vacuum machines and infusion pumps. "These were impossible lists. We at Padhar Hospital use innovative desi methods. We make dressing materials out of kitchen elastic wraps that achieve the same results as the kinds produced by vacuum machines–except the latter machine will cost Rs 10 lakh. Each ventilator was worth Rs 15 lakh," Choudhrie adds. However, none of the doctors wanted to compromise on the requirements. "This was a huge risk we were all taking— we wanted the surgery to be a success so that it would be a milestone for other rural hospitals to follow. We did not want to leave any stone unturned," Dr. Anil Kuruvilla, in–charge of the post–surgical critical care management team said.
When buying equipment did not work out with the existing donations, doctors approached companies to "loan" the equipment. "It’s not a practice that companies follow routinely. But after a lot of cajoling, they agreed to transport their equipment here for some time, with their service engineers, just for the duration of the surgery, and in return we buy some cheaper equipment from them later," Choudhrie says. For example, the hospital has to return both the paediatric ventilators once the children are better. Meanwhile, the babies were growing up in a dedicated centre in the hospital’s neonatal ICU. Two ayahs were appointed to look after them. Their mother, Maya Yadav was visiting them, though she had forfeited her rights to them. It was at this stage that another CMC classmate, Dr. Prabhakar Thyagarajan, a psychiatrist now working at Apollo Chennai, was also called in to Betul, to counsel the parents on the public outcry, on ways to bring leaders of their Yadav community–the decision–makers for the couple—on board, and prepare for a possible reconciliation of the family, post–surgery.
The first deadline for the surgery, fixed in March, had to be postponed. "We wanted to wait for the babies to grow up a bit, so they were healthy enough to sustain the procedure. We were also delayed because of the refusal from many companies to provide us the necessary equipment," Peters says. Doctors themselves brought a lot of disposables, many of which they did not end up using at all in the surgery. "We wanted to be over–cautious. The nearest tertiary hospital is 200 km away, so we knew the buck stopped with us. There are lots of wirings, tubes and drugs that are still lying in boxes," Jacob says.
From the second week of June, a team of 23 doctors from India and Australia arrived at Padhar Hospital. The children were examined and re–examined, their reports checked. A day before the procedure, a three–hour dummy surgery was fixed. "We got two dolls and stuck a plaster between them and took them to the operation theatre with the entire team. We colour–coded the tubings and separated ourselves into teams—the red team and the green team—encoding the wirings of each twin. Everything was fixed—the positioning of the various equipments, where the doctors, technicians and nursing staff would stand, everything," Peters recalls.
Anaesthetists joked about that dummy rehearsal being their first "bloodless surgery." Now, after achieving what many termed as unrealistic—with Stuti already off the ventilator and Aradhana looking well on the way to recovery—the doctors say the marathon 12–hour procedure seems like a dream.
In the four–part surgery, doctors first separated the hearts from the single sack, and stitched two patches on the existing pericardium– to make two sacks, and inserted the separate hearts inside each twin.
Then the liver was separated—after the proportion for each liver was fixed, and finally the sternum was cut into two. "In the last stage, I was so focused on cutting the sternum bone, I did not notice the anticipation that had come towards the end of the surgery. But just as I finished, the entire theatre erupted in cheers. Everybody was clapping. I know, for as long as I live and as many procedures I perform, I will never forget that sight," says Peter.
A week after the surgery, against the backdrop of the greenery along the Nagpur Hyderabad highway, it’s reunion time for the former classmates—playful jokes, recollections of an old college play, and memories of their "wild gang" days. "We are a close–knit batch. Six out of 60 of us are here—that’s 10 per cent of the batch—and our professor in anaesthesia. Barring old friends, who else would agree to such an adventure, in this setting, where the nearest tertiary hospital is in Nagpur or Bhopal, both at least 200 km away?" jokes Peter.
Twins on road to recovery Betul: At 5 am on June 23, nearly 55 hours after the surgery was completed, one of the twins, Stuti, has been taken off the ventilator. Stuti is crying, moving and is likely to be started on food soon. Aradhana is still on the ventilator but has started moving her hands and feet. Doctors changed her pericardial patch on Friday evening, and estimate another 24 hours of assisted breathing before she can be taken off the ventilator. Aradhana will also need some reconstructive surgery to cover the wound in her chest, in another two weeks. "The twins are lying on their back for the first time. Since they were conjoined, they would always lie facing each other, sideways. This is bringing a postural change in their haemodyanamic system, and we are waiting for them to adjust to it," Dr Sanjeeth Peter, cardiothoracic surgeon who is part of monitoring team, says.
The twins Stuti and Aradhana—christened by the hospital staff—were delivered in Padhar Hospital in May 2011. The "shocked" parents, a couple from Chicholi block, 40 km from Betul, told hospital authorities they would not be able to take them home. Formal adoption procedures were initiated at the district collector’s office, and the babies were "donated" to the hospital.
Barely a month after their birth, Dr Rajiv Choudhrie, medical superintendent of the hospital and a general surgeon, contacted his friends, over the phone—Dr Sanjeeth Peter, cardiothoracic surgeon based in Nadiad in Gujarat, Dr Gordon Thomas, paediatric liver transplant surgeon in Sydney and Dr Anil Kuruvilla, head of the department of neonatology in CMC, Vellore.
"Back then, I did not know if separation was even possible, let alone in this remote hospital of ours. I simply sought their medical opinion on the state of the fusion, and asked them if any intervention was possible," Choudhrie recalls.
Over the next few weeks, Dr Deepa Choudhrie, Rajeev’s wife, and a radiologist at the hospital, prepared extensive reports—CT scans, MRIs and ECGs that were emailed to Peters and Thomas. Their examination brought good news. "It was a form of conjoinment known as thoraco–omphalophagus, i.e. the twins had two separate hearts in a common sack, that is called the pericardium sack, and is crucial for supplying blood to the heart. Secondly, their livers had separate blood supplies, but were joined by a bridge of the liver tissue—so it was a big joint mass of liver between them," Brown explained. The condition merited surgical intervention. "Luckily, the case was not very complicated, because both the organs, the hearts and the liver, were separate it was just that they were joined. We had to separate the hearts and make two sacks out of the existing one, and decided the proportions in which we would distribute the liver. We felt sure it could be done," Peter added. Dr Rebecca Jacob, a former professor of anaesthesia at CMC, was the first to come for a recce in the hospital, in November last year. "My students often contact me for advise if there are complications. My first reaction when I saw the hospital was to move the babies to another setting for surgery. They had one anaesthesia workstation to give the drugs, that too for adults, and one ventilator that was also for adults. It seemed impossible to me at first," Jacob recalls.
Choudhrie says he was bombarded with similar reactions—ranging from voices of concern to outright laughter—at his idea. Today, as people laud him for his resolute, almost obstinate, decision to do whatever it took to perform the surgery in the village, he says there was no bravado involved. "I did not decide right in the beginning that we would to do it here. But after I approached so many specialists and took in their opinions, somewhere along the way I decided I wanted to do this. It was a tempting idea to send the babies away—everything would be so much easier in a setting that had all the facilities, but I kept myself from falling for it," he explains.
There were offers—from reputed centres and specialists—including Dr. Devi Shetty, to move the kids, and take over the procedure. Instead of accepting the offers, the team worked towards overhauling the existing set–up—preparing the infrastructure and putting together a team to perform the surgery. Over the next eight months, more doctors were contacted. Thomas approached a paediatric surgeon in Sydney, Dr Albert Shun, who has operated on thee conjoined twins so far. "Clinically I have dealt with more complicated surgeries. But this one had so many more challenges, it was a team put together from across the world in a rural setting and we had to literally build the operation theatre and the ICU for post–surgical care. This was my first time in India, and I have never seen so much intricate planning anywhere else in the world," says Shun.
Jacob contacted a paediatric anaesthesiologist in Sydney, Dr David Baines, who also had experience in operating on conjoined twins. "It’s amazing how much fun we have had, though there were no commercial gains—even our travel here was not funded for. It was a huge challenge and we took it. Now it’s a statement to India and the world: such a procedure can be performed in this setting provided doctors care enough," Baines says.
Specialists in paediatric surgery were also roped in, from the country’s other CMC in Ludhiana. The doctors, after their individual visits to Betul spread over November–February, sent their requirements to Choudhrie. "I got these huge lists, and despite some donations, we had no money. It was like having Rs 10 in your pocket and going to buy stuff worth thousands of dollars," Choudhrie laughs. There were requests for two of everything—high–end paediatric ventilators, monitors, heart and lung machines, suction tubes, internal defibrillators, cardiac monitors, pericardial patches, syringe drivers, vacuum machines and infusion pumps. "These were impossible lists. We at Padhar Hospital use innovative desi methods. We make dressing materials out of kitchen elastic wraps that achieve the same results as the kinds produced by vacuum machines–except the latter machine will cost Rs 10 lakh. Each ventilator was worth Rs 15 lakh," Choudhrie adds. However, none of the doctors wanted to compromise on the requirements. "This was a huge risk we were all taking— we wanted the surgery to be a success so that it would be a milestone for other rural hospitals to follow. We did not want to leave any stone unturned," Dr. Anil Kuruvilla, in–charge of the post–surgical critical care management team said.
When buying equipment did not work out with the existing donations, doctors approached companies to "loan" the equipment. "It’s not a practice that companies follow routinely. But after a lot of cajoling, they agreed to transport their equipment here for some time, with their service engineers, just for the duration of the surgery, and in return we buy some cheaper equipment from them later," Choudhrie says. For example, the hospital has to return both the paediatric ventilators once the children are better. Meanwhile, the babies were growing up in a dedicated centre in the hospital’s neonatal ICU. Two ayahs were appointed to look after them. Their mother, Maya Yadav was visiting them, though she had forfeited her rights to them. It was at this stage that another CMC classmate, Dr. Prabhakar Thyagarajan, a psychiatrist now working at Apollo Chennai, was also called in to Betul, to counsel the parents on the public outcry, on ways to bring leaders of their Yadav community–the decision–makers for the couple—on board, and prepare for a possible reconciliation of the family, post–surgery.
The first deadline for the surgery, fixed in March, had to be postponed. "We wanted to wait for the babies to grow up a bit, so they were healthy enough to sustain the procedure. We were also delayed because of the refusal from many companies to provide us the necessary equipment," Peters says. Doctors themselves brought a lot of disposables, many of which they did not end up using at all in the surgery. "We wanted to be over–cautious. The nearest tertiary hospital is 200 km away, so we knew the buck stopped with us. There are lots of wirings, tubes and drugs that are still lying in boxes," Jacob says.
From the second week of June, a team of 23 doctors from India and Australia arrived at Padhar Hospital. The children were examined and re–examined, their reports checked. A day before the procedure, a three–hour dummy surgery was fixed. "We got two dolls and stuck a plaster between them and took them to the operation theatre with the entire team. We colour–coded the tubings and separated ourselves into teams—the red team and the green team—encoding the wirings of each twin. Everything was fixed—the positioning of the various equipments, where the doctors, technicians and nursing staff would stand, everything," Peters recalls.
Anaesthetists joked about that dummy rehearsal being their first "bloodless surgery." Now, after achieving what many termed as unrealistic—with Stuti already off the ventilator and Aradhana looking well on the way to recovery—the doctors say the marathon 12–hour procedure seems like a dream.
In the four–part surgery, doctors first separated the hearts from the single sack, and stitched two patches on the existing pericardium– to make two sacks, and inserted the separate hearts inside each twin.
Then the liver was separated—after the proportion for each liver was fixed, and finally the sternum was cut into two. "In the last stage, I was so focused on cutting the sternum bone, I did not notice the anticipation that had come towards the end of the surgery. But just as I finished, the entire theatre erupted in cheers. Everybody was clapping. I know, for as long as I live and as many procedures I perform, I will never forget that sight," says Peter.
A week after the surgery, against the backdrop of the greenery along the Nagpur Hyderabad highway, it’s reunion time for the former classmates—playful jokes, recollections of an old college play, and memories of their "wild gang" days. "We are a close–knit batch. Six out of 60 of us are here—that’s 10 per cent of the batch—and our professor in anaesthesia. Barring old friends, who else would agree to such an adventure, in this setting, where the nearest tertiary hospital is in Nagpur or Bhopal, both at least 200 km away?" jokes Peter.
Twins on road to recovery Betul: At 5 am on June 23, nearly 55 hours after the surgery was completed, one of the twins, Stuti, has been taken off the ventilator. Stuti is crying, moving and is likely to be started on food soon. Aradhana is still on the ventilator but has started moving her hands and feet. Doctors changed her pericardial patch on Friday evening, and estimate another 24 hours of assisted breathing before she can be taken off the ventilator. Aradhana will also need some reconstructive surgery to cover the wound in her chest, in another two weeks. "The twins are lying on their back for the first time. Since they were conjoined, they would always lie facing each other, sideways. This is bringing a postural change in their haemodyanamic system, and we are waiting for them to adjust to it," Dr Sanjeeth Peter, cardiothoracic surgeon who is part of monitoring team, says.
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