Don’t Worry About the Government (Hospitals)

I recently had the opportunity to work in the Indian Government Hospital setting as a transplant surgery adviser to the Government of Rajasthan and it reminded me of the #drbarryindia, liver transplant, organ donation, kidney transplant, #Rajasthan, Dr Christopher Taylor BarryVeteran’s Administration Hospitals in the US. Any big bureaucracy anywhere in the world is bound to have inefficiencies and strange cultural quirks. When trying to move forward with a complex endeavor such as transplant, there will be resistance and frustrations involved. Here are ten observations from my experience, most of which now seem amusing but when they were happening in real time, they often made for head-exploding moments. Please note that these comments are not confined to India (I adore this country and respect it in so many ways), they are just examples of goofy bureaucracies world wide.

  1. The longer I keep you waiting, the more important I am.

This is a common power-wielding tactic throughout humanity, but in the strangely plastic time-space warp that exists in India, significant delays and inefficiencies can result. My time is important. Our time is important. Please don’t disrespect us to calm your own insecurities.

  1. Let me show you how powerful I am by wasting your time.

This is actually a corollary to #1, but deserves its own entry. I was in a meeting where the bureaucrat paused in the middle to dictate a letter to his assistant about what we had just been discussing. Okay, it only took 10 minutes, but c’mon…really?

  1. Yes, yes of course (absolutely not).

I was warned about this one before I came to India. Everyone nodding in agreement out of politeness and fear of saying no. Sometimes it takes a while to figure out people’s real intentions and much valuable time can be wasted. Please just tell me if you can’t or do not want to do it; I will find someone else who is willing to help me.

  1. There is no central purchasing department; please navigate the labyrinth yourself.

If you want the government hospital to purchase equipment or supplies on your behalf #drbarryindia, liver transplant, organ donation, kidney transplant, #Rajasthan, Dr Christopher Taylor Barry(that is, if you are lucky enough that they are willing to spend money on you), then you have to do almost everything yourself. Write down each item. Detail the specifications for each. Identify all potential suppliers so they can competitively bid.

You must spend your valuable time doing this instead of saving the lives of your patients….Aargh!

  1. I am simply interested in looking good for a promotion or not doing anything controversial before retiring.

Sad but true, most of us will try to position ourselves for advancement or protect ourselves from change when it comes to our jobs. My issue with this is that so many people try to do this without doing any actual work. Those trying to look good will rely on the hard work of others (usually their subordinates) and those trying to stay safe will simply not lift a finger.

  1. The 10am-3pm shift is charity work—those patients be damned. Cash flow starts with the private clinic from 3-11pm.

Okay, this one is a little harsh and I know that Government doctors in India are not lazy. don't worry about the government (hospitals), #drbarryindia, Dr Christopher Taylor Barry, liver transplant, kidney transplant, pancreas transplant, laparoscopic donor nephrectomy, laparoscopic hepatectomy, organ donation, bLifeNYThey are incredibly intelligent (appointment to a Government Hospital is entirely merit based, so they are the cream of the crop) but their pay is very little compared to the private sector. Out of necessity (we all gotta eat!), many government doctors conduct private clinics in their off hours to provide the bulk of their income. Unfortunately, this situation sometimes instills an attitude of less attention toward the government hospital patients because the doctor is not necessarily available 24/7 for emergency consultation.

  1. Accountability and transparency are foreign concepts to be resisted.

The lack of accountability and transparency in all aspects of Indian society needs to change if India really wants to be regarded as a serious world stage player. Particularly for a field like transplantation, every active transplant center needs to be answerable to their performance and outcomes relative to everyone else. Only in this way will superior and suboptimal practices be unveiled so that real and steady progress can be achieved. Transparency is also paramount to gain the trust of the public and nontransplant medical professionals.

  1. Cherish inertia and shun innovation.

The thought of change can be uncomfortable. But in a country like India where one’s very survival depends on a constant state of adaptation to change, I find it curious that maintaining the status quo is as valued as is everywhere else in the world. Sure, people work hard to get to where they are professionally and change can be threatening, but moving forward and trying something new are critical for realizing innovation. And everyone knows that India’s great promise as a future world leader depends on her people’s innovation and creativity.

  1. What is quality?

Quality assurance and outcomes-based assessments are relatively new concepts even in Western medicine, but India cannot afford to ignore these trends. After all, the practice of medicine should really at its heart be all about the patient’s well being. Things should not happen just because they can. Attention to quality at every level—from whether a patient lives or dies to whether the family is satisfied with the cleanliness of their loved one’s hospital room—is so important in gaining international respect and attracting business. Oh yeah, it’s also best for the patient!

  1. Don’t challenge my VIP-ness.

I’m still trying to understand the prevalent “VIP culture” here in India. Exaggerated don't worry about the government (hospitals), #drbarryindia, Dr Christopher Taylor Barry, liver transplant, kidney transplant, pancreas transplant, laparoscopic donor nephrectomy, laparoscopic hepatectomy, organ donation, bLifeNYfeelings of self importance exist everywhere in this world, but it seems to me that there are more VIP wanna-be’s among the Indians (and NRIs) I know compared to my non-Indian friends. As a result, doctors, hospital administrators and politicians are all more prone to having their feelings hurt if they feel slighted or threatened. This is a minefield that deserves respect and attention, but can make the chess game of advancing an agenda so much more complicated.

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A Chennai Bicycle Ride

Coming from America, I initially resisted riding a two wheeler in traffic crazy Chennai. Buta Chennai bicycle ride, Dr. Christopher Taylor Barry, #drbarryindia, Hercules bicycle, Anna Nagar, Chennai politeness after 7 months in India (and some practice in Jaipur for a while), I screwed up the courage to buy a “Hercules” (made in Chennai) street bicycle to ride from my flat in West Mambalam to work in Anna Nagar. It’s a great ride, particularly when the traffic isn’t so bad, taking 20 minutes under ideal circumstances (about 7 kilometers).

From Brindavan Street in West Mambalam, I head east into T Nagar and take Usman Road north. There is a flyover at Kodumbakkam High Road. I fear the flyovers. Too many stories of people flying off the flyovers for one reason or another. Not good. Interestingly, I have no problems with the underpasses.a Chennai bicycle ride, Dr. Christopher Taylor Barry, #drbarryindia, Hercules bicycle, Anna Nagar, Chennai politeness Maybe the thought of getting squished against a wall is more palatable than flying off a flyover.

So, for now, I’m going under the flyover. Sometimes crossing the street takes some time. Occasionally, and somewhat surprisingly, a driver will slow down to let me cross. So nice.

Then up to Loyola College hugging her around Mahalingam to Tank Bund to Nelson Manickam Road. Ampa Skywalk Mall leads to Anna Arch Road, the gateway to Annaa Chennai bicycle ride, Dr. Christopher Taylor Barry, #drbarryindia, Hercules bicycle, Anna Nagar, Chennai politeness Nagar. This is the most “exciting” part of the ride because it involves getting on a major thoroughfare (Poonamalle High Road or Route 114) for a brief period and merging into Anna Arch.

I’m already learning some tricks to stay safe on a bicycle in Chennai traffic, like “skipping” (one foot skipping on the ground, the other foot pedaling), ringing my bell and always being careful of the person in front of me (you never know when they will randomly stop). My worst fear is getting sideswiped on the right from behind. The two wheelers and autos can be soooo intimate and the buses can be intimidating and annoying.

It helps that, in the city, no one is ever going so fast as to make cycling prohibitively dangerous. Maybe a few broken bones here and there, but—oddly—I don’t fear for my life (most of the time…I have to be always careful…cycling in Chennai really makes you feel alive). And since I’m in India, if I die I die, it’s fate isn’t it?

Once in Anna Nagar, it’s nice to enjoy this upscale neighborhood. Kilpauk is close by and worth a visit.

There is an interesting politeness and humanity in the chaos of Chennai traffic. I haven’t a Chennai bicycle ride, Dr. Christopher Taylor Barry, #drbarryindia, Hercules bicycle, Anna Nagar, Chennai politenessseen any “real” road rage here, despite being in situations that if happened in the US I’d be fearing for my personal safety. There are unwritten rules of courtesy even though few follow all the traffic rules. Everyone is trying to get somewhere and that is respected by all. And the roads of Chennai carry on with their crazy politeness.

 

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Organ Donation in Rajasthan Part 2: The Challenges Ahead

I reported on the miraculous success of Rajasthan’s nascent deceased donor transplant program in my last postorgan donation in Rajasthan, #drbarryindia, deceased donor kidney transplant in India, liver transplant in India, #ArvindKejriwal, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, #NarendraModi, #Chennai, #TamilNadu, Rajasthan liver transplant, #RonnyEdry, #HuffingtonPostBlog, promising to outline the very real but surmountable challenges ahead in this post. I will focus on these challenges in the Government Hospital setting in India because successful organ donation and deceased donor transplant in the public sector sends the most powerful message to the public and the nontransplant medical community that this life saving therapy can be fairly and transparently available to all members of Indian society regardless of socioeconomic status, thereby building trust in this currently less than completely trusted medical specialty. The other reason for focusing on the challenges of transplant in the public sector is that, for a number of reasons, it is more difficult to establish a complex medical care delivery system in government hospitals compared to private hospitals.

The first challenge to continued growth of deceased donor transplant in India in general and Rajasthan in particular is the lack of professional transplant training. As I have written in the past, there are few fully trained transplant surgeons in India and the current training systems in the US and UK are expensive and time consuming for an aspiring Indian transplant surgeon. Therefore, in addition to trying to establish abbreviated “power fellowships” (training abroad that is more than a simple observership but slightly less than a formal fellowship) and hoping for the “reverse Indian brain drain” that is happening already in transplant to happen more quickly, sincere and committed efforts need to be initiated by the Indian transplant community to build respectable and effective indigenous transplant fellowships. All of this will take time, perhaps at least 5-10 years.

Now, multiply this problem of the dearth of transplant surgical training by all of the other specialties that need to be a part of an effective transplant team: intensivists, nurses, anesthesiolgists, hepatologists, nephrologists, cardiologists, immunologists, pathologists, infectious disease experts, radiologists, transplant coordinators, pharmacists, social workers, psychiatrists (and this list is not exhaustive). With a true commitment to quality patient care and optimal transplant outcomes, all of these team members and their ancillary staffs can be trained in parallel to build the multidisciplinary team that is absolutely essential for success in this incredibly complicated endeavor. All aspects of preoperative, perioperative and postoperative care demand meticulous attention and commitment to quality care.

As an example, Rajasthan currently does not have a trained liver transplant surgeon. Logic would have it that a successful liver transplant program needs a competent liver transplant surgeon to lead the way. Such a surgical leader could play a vital role in assuring that progress is made in training his or her anesthesia, critical care, hepatology and nursing colleagues.

A second challenge is the deficiency of necessary infrastructure elements to build a successful deceased donor transplant program. Three examples are 1) hospital hygiene, 2) transplant immunology and 3) ICU (intensive care unit) care.

Meticulous attention to general hospital hygiene concepts and a dedicated Transplant organ donation in Rajasthan, #drbarryindia, deceased donor kidney transplant in India, liver transplant in India, #ArvindKejriwal, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, #NarendraModi, #Chennai, #TamilNadu, Rajasthan liver transplant, #RonnyEdry, #HuffingtonPostBlog, challenges to organ donation in RajasthanInfectious Disease expert are necessary to help avoid the number one killer of transplant recipients in the immediate postoperative phase: infection. The operating theaters and postoperative care ICUs need to be clean enough to safely perform a transplant, especially a liver transplant where infectious complications can be much more serious. HEPA (High-Efficiency Particulate Arrestance) filters, enclosed and controllable patient care spaces, and regular cleaning (to the point of being obsessive) of “high touch” surfaces such as bed railings, table tops and computers, all demand consideration in diminishing hospital acquired infections. An Infectious Disease physician with experience in transplant-specific infections is a highly desirable asset, although such superspecialization luxuries can be hard to come by even in the most well funded environments (including the USA).

Transplant immunology facilities and expertise should be as sophisticated as possible, but the minimal requirement for a successful deceased donor kidney transplant program is to be able to perform multiplexed (many at a time) flow cytometry (state of the art sensitive test) crossmatch testing in a short period of time (4-6 hours) in order to optimize organ allocation to immunologically compatible recipients throughout a large region. Deceased donor transplantation involves equitable sharing of donor organs among a group of regional hospitals via a web registry waiting list (such as the Rajasthan Network of Organ Sharing or RNOS) and universally agreed upon sharing rules. At least 2-3 patients need to be tested for each kidney available so that “crossmatch negative” (immunologically compatible) and transplantable patients are identified.

ICU care in transplant involves basic resuscitation of all patients who enter the hospital, stabilization and maintenance of potential organ donors, and postoperative care. Systems need to be in place at any hospital to try to save the lives of everyone who enters the hospital. A cultural dedication to basic principals of Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) by the entire hospital staff will maximize the actual number of lives saved and also help identify potential organ donors. If a patient unfortunately progresses to brain death, then “donor Maintenance” protocols can be initiated while family consent for organ donation is being contemplated. Postoperatively, the specialized ICU care is paramount, especially in the cases of liver, heart and lung transplant, in order to assure optimal patient outcomes.

A third challenge involves the social and cultural idiosyncracies of hospital bureaucracies. These are particularly acute in the public sector setting and not confined to India; even in the West, bureaucracies can be frustratingly slow and often incomprehensible. The typical work culture in Indian Government Hospitals allows doctors to come to work at 10 am and leave by 3 pm. After hours work by doctors and even ancillary staff (ultrasonography and pathology technicians, immunology lab staff, etc.) can be difficult to ensure. The rigid top down bureaucracy discourages young rising talent to take on new and special challenges such as transplant. Transplant, and especially deceased donor transplant, requires a 24/7/365 devotion by all team members. One possible solution is to establish “transplant institutes” in government hospitals where an autonomous team is identified and permitted to independently function within the hospital.

There also should be general awareness among all hospital staff, transplant and nontransplant, including the sweeper boys, about the benefits of organ donation and transplant. This will create a culture where transplant is trusted as the miracle it really is and suspicions of unfairness are abolished (or at least attenuated).

Each transplant program needs several leaders and advocates. Although there should be organ donation in Rajasthan, #drbarryindia, deceased donor kidney transplant in India, liver transplant in India, #ArvindKejriwal, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, #NarendraModi, #Chennai, #TamilNadu, Rajasthan liver transplant, #RonnyEdry, #HuffingtonPostBlog, challenges to organ donation in Rajasthanan identified point person in charge of the entire program, everyone involved needs to know that they are part of something very special. Nurses, young doctors, scientists, transplant coordinators and sweeper boys should all be respected and acknowledged for their contributions.

These challenges require radical rethinking and restructuring of hospital cultures (particularly in the public sector) but they can be overcome. The potential exists to have at least one donor per week within one year and at least 3 donors per week in 3 years in Jaipur alone. People need to “step up to the plate” and, more importantly, they need to be allowed to step up to the plate to realize this potential.

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Organ Donation in Rajasthan Part 1: The Thrill of Victory

History was made twice in Rajasthan in February 2015. On 6 February, the first organ donation and abdominal organ recovery was performed at Mahatma Gandhi Hospital in Jaipur, resulting in the first deceased donor kidney transplant in Rajasthan and sharing of the liver with the Institute of Liver and Biliary Sciences in Delhi via a green corridor for urgent transplant of a 6 year old.

On 25 February 2015, the first abdominal organ recovery was performed at a Rajasthani organ donation in Rajasthan, #drbarryindia, deceased donor kidney transplant in India, liver transplant in India, #ArvindKejriwal, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, #NarendraModi, #Chennai, #TamilNadu, Rajasthan liver transplant, #RonnyEdry, #HuffingtonPostBlogGovernment Hospital (Sawai Man Singh—SMS—in Jaipur) resulting in two successful kidney transplants and sharing of the liver with Army R&R in Delhi for a successful liver transplant. The SMS Hospital achievement is particularly important because it demonstrates proof of principle that organ donation and transplantation can be available to all strata of Indian society.

On 23 February, a young girl was admitted to SMS after falling from a height. When impending brain death was recognized by Dr. Jitendra Hingonia in the Poly Trauma ICU, he immediately notified me and the MOHAN Foundation Jaipur Citizen’s Forum (MFJCF) Transplant Facilitator. In the future, it really shouldn’t happen this way (the transplant ball is supposed to get rolling only after brain death is declared), but we were the only ones who could teach them how to resuscitate the girl and maintain her in optimal condition should organ donation be considered.

We came in the middle of the night and stayed several hours. After stabilization, the SMS organ donation in Rajasthan, #drbarryindia, deceased donor kidney transplant in India, liver transplant in India, #ArvindKejriwal, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, #NarendraModi, #Chennai, #TamilNadu, Rajasthan liver transplant, #RonnyEdry, #HuffingtonPostBlogBrain Death Committee performed the first brain death exam and confirmatory apnea test. The girl was brain dead. The family was consoled. What brain death really means (the brain is dead, there is no longer any blood flow to the brain, she can never get better because brain death is different from coma) was compassionately explained to the family.

Bhavna Jagwani and Dilip Jain of MFJCF then joined Kamlesh Verma, the SMS Transplant Coordinator, to speak with the family about the notion of organ donation. As is usual with such sensitive and intense discussions, the decision to consent to organ donation by the entire family took several hours. But they said yes. They said “yes we consent to donating life saving organs from our deceased daughter in order to save the lives of others” even at a time of extreme emotional duress. This decision continuously impresses on me the miraculous kindness and Daan of the Indian people and donor families all over the world.

We started organizing the immunologic crossmatch testing that is imperative before proceeding with a kidney transplant (if the crossmatch test is “positive” this means that the recipient will immediately reject the new kidney, so another “crossmatch negative” patient must be identified). We had all agreed to share the organs in Rajasthan in a transparent and fair fashion using the Rajasthan Network for Organ Sharing (RNOS) web registry “waiting list”. The top two blood type compatible, crossmatch negative patients would be offered the organs. This is no small task. There could be crossmatch positive results, there could be certain patients on the list who would not be ready for transplant because they were too sick or they were simply out of station, there could be people on the list who wanted to continue waiting. In order to figure this out, we needed to test at least 4-6 top candidates and get the results back as soon as possible.

Jaipur at that point did not have the capability to do such testing (despite my identifying organ donation in Rajasthan, #drbarryindia, deceased donor kidney transplant in India, liver transplant in India, #ArvindKejriwal, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, #NarendraModi, #Chennai, #TamilNadu, Rajasthan liver transplant, #RonnyEdry, #HuffingtonPostBlogthis as a major problem back in November 2014). We turned, once again, to Dr. Vimarsh Raina from Medanta HLA Lab in Gurgaon. Dr. Raina had graciously provided his services back on 6 February for the first history-making event at MGH and he was prepared to do so again for SMS. So we waited until we could collect enough representative blood samples, then sent them up by road (5 hour drive) to Gurgaon.

The second brain death exam was performed and confirmed. We were ready to go to the Operation Theater (OT) for the recovery surgery for kidneys and liver. Army R&R Hospital in Delhi had a recipient waiting and Dr. Sanjay Sharma trusted me to perfoorgan donation in Rajasthan, #drbarryindia, deceased donor kidney transplant in India, liver transplant in India, #ArvindKejriwal, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, #NarendraModi, #Chennai, #TamilNadu, Rajasthan liver transplant, #RonnyEdry, #HuffingtonPostBlogrm the liver recovery on their behalf.

The organ recovery surgery proceeded flawlessly. It was as if they had all done it before. The liver was shared with Army and one life was saved. The kidneys were transplanted into recipients at SMS and two more lives were saved. We made history again.

So Rajasthan is now on the map as a green corridor player, but there remain many challenges ahead, particularly when trying to do organ transplantation in a Government Hospital setting. In my next post I will outline the issues of professional transplant training, infrastructure deficiencies and social/cultural idiosyncracies of hospital bureaucracies. All are surmountable challenges, as demonstrated by Rajasthan’s incredible success.

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Is Liver Transplant in India Proceeding with Reckless Abandon?

The answer to the question “is liver transplant in India proceeding with reckless abandon?” is, as with almost anything in this wonderfully complicated country, yes and no. I have had the pleasure to meet several talented transplant surgeons who are leaders or team members of excellent #drbarryindia, liver transplant in India, reckless abandon, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, MFJCF, #NarendraModi, Rajasthan liver transplantprograms (predominately performing living donor liver transplants but with increasing interest in deceased donor transplants). I have also met a few surgeons interested in establishing liver transplant centers who truly understand the magnitude of complexities involved. Unfortunately, many doctors and hospital administrators here have simply been bitten by the liver transplant bug and want to start performing liver transplants yesterday.

In order to establish a quality, sustainable liver transplant program, many things must first come into place. Aside from the obvious knowledge and technical skills needed by the surgeons, hepatologists, anesthesiologists, radiologists, nurses, immunologists, etc., many policies, procedures and protocols are critical before embarking on this incredibly complex endeavor. My concern is that there is a mad rush to start doing liver transplants here in India, often with reckless abandon.

As I have written before, surgeons need to be properly trained in the safe and proper conduct of organ retrieval, transplantation and perioperative care. It’s not nearly enough #drbarryindia, liver transplant in India, reckless abandon, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, MFJCF, #NarendraModi, Rajasthan liver transplantto simply observe a few surgeries performed by other established expert surgeons then have the expectation that one is ready to try on his or her own. Training requires graduated responsibility with hands on experience so that after a period of at least two years, the surgeon is competent to carry out this most complicated of surgeries. The same goes for all of the other team members, especially hepatologists, anesthesiologists, critical care doctors and nursing staff.

As for policies, procedures and protocols,  everyone on the team (of at least twenty dedicated caregivers) and non-transplant physicians and personnel as well needs marching orders. To begin with, what are the criteria for listing a patient for transplant? Is the patient fit for surgery? Are there absolute contraindications such as malignancy or other comorbid conditions? Does the patient have a potential living donor available and is that person appropriate for surgery? How will donor organs be allocated to the listed recipients?

Once a potential brain dead donor becomes available for organ donation and deceased donor transplant, how to proceed? Is the hospital-appointed and legally required Brain Death Committee established, competent and willing to declare brain death? When should the Transplant Coordinator be notified to begin consoling the family and introducing the notion of organ donation? If consent is obtained, how is it properly documented and what lab tests need to be performed (blood group, viral serologies, immunologic testing, etc.)? How to maintain the potential donor in optimal condition while waiting for the second brain death exam and mobilization of the various organ recovery surgical teams? How is information regarding the donor communicated to the accepting transplant surgeons?

Exactly how should the organ recovery surgery be performed? What are the medicolegal procedures necessary (if any)? How to organize the logistics of organ transport to the accepting transplant center? How is the transplant itself performed in a way to maximize the chances of a successful outcome? How should the patient be managed postoperatively and what medicines are necessary? What is necessary for long-term follow up to ensure that the new liver lasts at least fifteen years?

I know the answers to all of these questions, but no one is listening to me.

Indian doctors, hospital administrators and politicians like to be the first to do something important and impressive. But this is a very dangerous mindset when the live’s of others are involved. Above all, everyone should be concerned about the patient’s survival, both in the short run and the long run. Furthermore, sustainability of quality performance can only occur if each case is conducted according to universally agreed upon policies, procedures and protocols.

Another disturbing fact about liver transplant in India is the lack of long-term follow up, documentation and management of postoperative complications. No one knows what the long-term outcomes for liver transplant are in this country because there is no national transplant database for which outcomes are required to be recorded. Furthermore, transplant recipients risk immunologic rejection, infection, malignancy and technical complications related to the surgery. All to often, the required expertise to look for and manage these complications (interventional radiologists, infectious disease experts, transplant pharmacists, social workers) is absent.

Everyone just wants to jump in and do a transplant for the sake of doing it. Too few transplant professionals seem to genuinely care whether their patient survives or not. Too many would-be liver transplant surgeons want to immediately start with living donor liver transplant and I strongly advise against this because living donor transplant is orders of magnitude more complicated than deceased donor transplant and it’s best to cut one’s teeth on the latter (for at least a few years) before embarking on the former. The risks of a donor death or a suboptimal outcome in the recipient are simply intolerable if an inexperienced team barges ahead.

Doctors in India are intelligent, skilled and for the most part well trained just short of #drbarryindia, liver transplant in India, reckless abandon, organ donation, deceased donor liver transplant in India, living donor transplant in India, Dr Chris Barry, MOHAN Foundation, MFJCF, #NarendraModi, Rajasthan liver transplantbeing ready to do liver transplants. Without the proper safeguards and advanced training in place, I predict some successes but also some disasters that will only hurt the progress of liver transplant here. I know that it can be done here and the potential to save lives is vast, but it takes years, not months, to make sure that everything is as perfect as possible before acting. We owe this to our patients and the people of India.

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The Magic Jaipur Night for Organ Donation

Last Thursday night, I was informed by Dr. TC Sadasukhi, Transplant Urologist at magic Jaipur night, organ donation, multiorgan recovery, deceased donor transplant, Jaipur transplant, Rajasthan transplant, organ sharing, Rajasthan Network for Organ Sharing, MOHAN Foundation, MFJCF, deceased donor kidney transplant, deceased donor liver transplant, green corridor, Mahatma Gandhi Hospital, Institute for Liver and Biliary Sciences, Delhi deceased donor transplant, Dr. Christopher Taylor Barry, #drbarryindiaMahatma Gandhi Hospital (MGH), that a 7 year old boy was potentially brain dead and the family was interested in organ donation. Coincidentally, as Transplant Consultant to the Government of Rajasthan and MOHAN Foundation Advisory Board Member, I was visiting MGH that morning to deliver a lecture on “Brain Death Declaration and Donor Organ Management”. It was time for some on the job training!

MGH, along with five other hospitals in Rajasthan (SMS, Monilek, Apex, Narayana and Aastha) had recently been granted privileges by the State Government to engage in deceased donor kidney transplantation and multiorgan recovery surgery. Rajasthan to this date had no deceased donor transplant program and it was my mission to help establish such programs by educating and training physicians and surgeons about necessary magic Jaipur night, organ donation, multiorgan recovery, deceased donor transplant, Jaipur transplant, Rajasthan transplant, organ sharing, Rajasthan Network for Organ Sharing, MOHAN Foundation, MFJCF, deceased donor kidney transplant, deceased donor liver transplant, green corridor, Mahatma Gandhi Hospital, Institute for Liver and Biliary Sciences, Delhi deceased donor transplant, Dr. Christopher Taylor Barry, #drbarryindiaprotocols, infrastructure, policies, procedures, laws and surgical techniques that are needed to realize safe and sustainable transplant programs. The Government of Rajasthan has been 100% supportive of these efforts, including establishment of deceased donor liver transplant activity as well.

I examined the boy, conferred with the treating Intensive Care Doctors and agreed that he likely met brain death criteria after having suffered an irreversible brain injury. I immediately made recommendations to stabilize the child, as impending brain death is associated with blood pressure instability, oxygen delivery challenges and a host of metabolic and endocrine abnormalities. We needed to make sure that if organ donation consent was obtained from the family, that the organs would be in the optimal condition for transplantation. The MGH Brain Death Committee (approved by the Rajasthani Government and the hospital administration) was consulted and performed the first brain death exam followed by the confirmatory apnea test. These tests established beyond doubt that the boy was indeed brain dead.

The hospital-appointed Transplant Coordinator, Mr. Kishore Sharma, was then called into action to counsel the family about organ donation. He received assistance from Mr. Dilip Jain, Transplant Facilitator from the MOHAN Foundation Jaipur Citizen’s Forum (MFJCF). The boy’s father graciously consented to organ donation, saying that his son must have done something wonderful in a previous life since he is now able to help save the lives of so many by donating his organs.

I then began informing interested parties about the organ allocation process. The Rajasthan Network for Organ Sharing (RNOS) Web Registry had recently been launched with 59 patients listed for kidney transplant from the 6 stakeholder hospitals. As per universally agreed upon organ sharing guidelines, the first kidney was to stay at MGH (if they had a blood type and immunologically compatible recipient) and the second kidney was to go to the SMS Government Hospital. However, this was an unusual medical circumstance because the kidneys from the boy were so small that they should only be transplanted into like-sized children or both kidneys should be transplanted “en-bloc” to an adult. Unfortunately, there were no blood type compatible children on the RNOS Web Registry, so the decision was accepted by all stakeholder hospitals and Rajasthan Government officials that both kidneys should be transplanted into the top MGH recipient, a 51 year old man on chronic dialysis.

Since there are no active liver transplant programs in Rajasthan (yet!), I began contacting centers in Delhi, including Army R&R and the Institute of Liver and Biliary Sciences (ILBS), to inform them of a potential donor. Fortunately, ILBS had a blood type compatible 6 year old boy who desperately needed a transplant. With the help of ILBS Transplant Coordinator Vibhuti Sharma and MOHAN Foundation Transplant Coordinator Pallavi Kumar, arrangements were made to send a liver recovery team, led by Dr. Senthil Kumar Muthukumaraswamy, down to Jaipur.

The crossmatch testing, necessary to ensure that the donor and kidney recipients are immunologically compatible, was facilitated by Dr. Vimarsh Raina of Medanta Hospital in Gurgaon, who personally drove down to MGH to collect the blood samples and immediately took them back to his lab for testing. Three potential recipients were tested for compatibility with the donor in just 4 hours. Fortunately, the top recipient on the wait list was a match, but surprisingly, the other two patients were incompatibible (“crossmatch positive”), demonstrating the importance of sensitive testing that can be performed rapidly on a number of patients simultaneously. Crossmatch positivity is an absolute contraindication to kidney transplant because the organ will fail immediately from hyperacute rejection.

After the second brain death exam and confirmatory apnea test (as required by Indianmagic Jaipur night, organ donation, multiorgan recovery, deceased donor transplant, Jaipur transplant, Rajasthan transplant, organ sharing, Rajasthan Network for Organ Sharing, MOHAN Foundation, MFJCF, deceased donor kidney transplant, deceased donor liver transplant, green corridor, Mahatma Gandhi Hospital, Institute for Liver and Biliary Sciences, Delhi deceased donor transplant, Dr. Christopher Taylor Barry, #drbarryindia law), the teams were ready to proceed to the operating theater for organ recovery. Mr. Neeraj Pawan, Rajasthan IAS Officer charged with overseeing the deceased donor transplant program, was present all through the night to ensure that all procedures were being followed properly. He also signed a Government Order allowing sharing of the donated liver between Rajasthan and Delhi. Also present throughout the night for moral support were Bhavna Jagwani, founder of MFJCF, and Dilip Jain, MFJCF Transplant Facilitator extraordinaire. Dr. Suraj Godara, MGH Transplant Nephrologist, was also continuously present overseeing and coordinating details of care for both the donor and recipient.

The organ recovery surgery went on flawlessly. Dr. Senthil and his team recovered the liver, Drs. Barry and Sadashuki recovered the kidneys and Dr. Murtaza Ahemed Chisti recovered the heart for valves. Dr. Senthil’s ILBS team returned to Delhi with the liver via a “Green Corridor” organized by the Rajasthan and Delhi Police Forces. This allowed timely transport of the precious organ so that it could be transplanted into the 6 year old recipient. The liver transplant surgery was a success and the young boy now has a new life with his new liver.

Back at MGH, I helped Dr. Sadasukhi and his team perform the first deceased donor kidney transplant in Rajasthan. Adding to the complexity was the fact that it was a “pediatric en-bloc” transplant, requiring my expertise in organ vascular reconstruction and implantation. The surgery was a success with the patient making “buckets” of urine immediately for the first time in several years. Both liver and kidney recipients, as of this writing, are recovering stably from their operations.

So it was a “magic Jaipur night” of many firsts: the first multiorgan recovery, the firstmagic Jaipur night, organ donation, multiorgan recovery, deceased donor transplant, Jaipur transplant, Rajasthan transplant, organ sharing, Rajasthan Network for Organ Sharing, MOHAN Foundation, MFJCF, deceased donor kidney transplant, deceased donor liver transplant, green corridor, Mahatma Gandhi Hospital, Institute for Liver and Biliary Sciences, Delhi deceased donor transplant, Dr. Christopher Taylor Barry, #drbarryindia deceased donor transplant, the first sharing of a donor liver with a hospital outside the state, the first heart valve recovery and the first “Green Corridor” between Jaipur and Delhi. This milestone was only possible through the cooperation and support of the doctors/nurses/staff (both transplant and nontransplant), NGO support (MOHAN Foundation and MFJCF) and the Government of Rajasthan. It was true teamwork and devotion to this noble cause at its best. Our success will hopefully inspire others to support organ donation and deceased donor transplantation throughout Rajasthan and the rest of India too.

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Vital Infrastructure Issues for a Successful Deceased Donor Transplant Program in India

India is an exciting place to be right now for many reasons. Perhaps one of the most exciting is the emergence of deceased donor transplantation, thatdeceased donor transplant India, #organdonation, transplant program infrastructure, living donor transplant in India, deceased donor transplant in India, #drbarryindia, MOHAN Foundation, #Rajasthan, #Jaipur, Dr. Chris Barry, brain death, HOTTA is, organ transplantation from brain dead, family consented donors. India is among the world leaders in living donor transplant volume (kidneys and liver), but lags seriously behind in deceased donor transplant activity. Of the approximately 1,700 kidney transplants performed in 2013, only 548 (30%) were from deceased donors and of the 871 liver transplants performed that year, 257 (30%) were from deceased donors. In order for successful and sustainable deceased donor transplant programs to take off and thrive in India, several vital infrastructure issues must be addressed.deceased donor transplant India, #organdonation, transplant program infrastructure, living donor transplant in India, deceased donor transplant in India, #drbarryindia, MOHAN Foundation, #Rajasthan, #Jaipur, Dr. Chris Barry, brain death, HOTTA

The first step in even considering organ donation for deceased donor transplantation is the proper declaration of brain death. By law (the Human Organ and Tissue Transplantation Act or HOTTA), any government certified transplant center or non-transplant organ retrieval center (NTORC) must have a Brain Death Panel in place. This panel consists of four physicians: 1) the Registered Medical Practitioner (RMP) in charge of the hospital, 2) an independent RMP nominated by (1) and approved by the State Appropriate Authority, 3) a government appointed RMP and 4) the RMP treating the patient. It is the responsibility of the Brain Death Panel to perform the clinical brain death exam and confirmatory apnea test twice, at an interval of at least six hours. It is also the responsibility of the Brain Death Panel to explain to the patient’s family the purpose and meaning of declaring brain death, completing the appropriate certifying documentation (e.g., Form 10) and to notify the hospital’s Transplant Coordinator after the first brain death exam. It should not be the responsibility of the Brain Death Panel to discuss organ donation with the family as this is the prevue of the Transplant Coordinator.

Every transplant center and NTORC must have an in-house Transplant Coordinator who is responsible for obtaining consent for organ donation from the deceased’s family, organizing organ allocation per the State’s transplant recipient web registry (“waiting list”) and overseeing all logistical aspects regarding the organ recovery surgery and organ transportation to receiving transplant centers. Transplant Coordinators play a Herculean role in the organ donation process because they are the point of contact between the patient’s family, the treating physicians, the organ allocation Convener, medicolegal representatives if necessary (including the Forensic physician and the Police) and all transplant surgical teams who have accepted their respective organs for their recipients. They require special training in grief counseling, organ allocation and communication with medical professionals.

Laboratory support is critical, including transplant immunology, blood bank and microbiology. For kidney and pancreas transplants, an immunologic test called a “crossmatch” is absolutely necessary before proceeding with the surgery. The crossmatch tests whether a potential recipient has preformed antibodies to the donor’s tissues. If the crossmatch is positive, then that particular recipient cannot receive that donor’s organ, otherwise the organ would be rejected immediately. Since organs are being shared by many different transplant centers and the possibility of a positive crossmatch exists, it is important that the transplant immunology lab be able to perform this test on several patients simultaneously (at least four) and that the results are available within four hours. Tissue typing (or “HLA” testing) is performed for living donor kidney transplants but not for deceased donor transplants due to cost constraints in India.

The blood bank must be able to reliably confirm that the donor and recipients are ABO compatible prior to proceeding with the surgery. Blood type compatibility is essential for organ allocation (e.g., a blood type A donor organ must be offered to an A recipient) and this compatibility must be checked at multiple points along the way, from allocation to organ recovery surgery to transplant. The blood bank must also be capable of providing sufficient amounts of blood products (red blood cells, fresh frozen plasma, platelets, cryoprecipitate) for the transplant surgery, especially in the case of liver transplant where sometimes massive amounts of products are needed.

The microbiology lab must be able to rapidly test for viruses in the donor, at least HIV, HBV, HCV and CMV. Other tests may be necessary depending on the medical history of the donor. Inadvertent infection in the transplant recipient must be avoided at all costs.

A skilled anesthesia/critical care team and a well-equipped ICU and OT are obvious requirements, both for the proper preoperative management of potential recipients and brain dead donors as well as the interoperative and postoperative management of the recipient. These teams require specialized training in managing liver failure, heart failure, organ donor management, organ transplantation and post-transplant care.

The organ recovery surgery must be performed properly and uniformly to assure that each organ recovered has the maximum likelihood of functioning immediately upon transplant. Care must be taken to not damage the organs and to preserve them properly before they are transported to their respective transplant centers. The transplant surgeries themselves require dedicated teams of nurses, surgeons, anesthesiologists and support staff who are well versed in transplanting their particular organ. Everyone must work together in a coordinated and informed manner in order to assure success.

Ancillary services to support transplant must be in place, including radiology, pathology and infectious disease. The radiologists must be available 24/7 to perform diagnostic studies immediately after each transplant, sometimes during the transplant surgery and any time afterwards when a complication is suspected. Interventional Radiology (catheter based interventions using imaging techniques) should be available as well as diagnostic radiology, especially in the case of liver transplant where such interventions can often spare a patient from a return trip to the OT.

Information technology support must also exist both for patient listing and organ allocation as well as tracking short-term and long-term outcomes. Although only basic computer skills are needed for web registry and outcomes database data entry, more sophisticated IT support will be needed for creating regional and national transplant databases.

Such a transplant infrastructure requires a multidisciplinary team dedicated to the besthttp://www.livercancergenomics.com/doctors-reluctance-to-declare-brain-death-in-india/ care for the patients. It also requires the absolute support from hospital administration, given the magnitude and complexity of the enterprise. Such systems are already in place in a few hospitals in India and expansion of deceased donor transplant activity will certainly thrive if attention to the details discussed above is given the utmost respect. Don’t do deceased donor transplants just because you can, do it right!

Cultural Note

Dr. Barry’s 10 Indian Traffic Rules

1. There are no rules.

2. You can almost always walk in front of a two-wheeler—they will usually weave around you.

3. Never walk in front of a moving bus—you won’t win.

4. Honk even if you don’t need to.

5. When crossing the street, often you just have to dive in and dodge.

6. Stop for cows (the only universally followed rule).

7. Drive on the wrong side of the street only when absolutely necessary or if you’re in a hurry.

8. When negotiating a fare, tell the autorickshaw driver “That’s too expensive” even if you think it’s a reasonable price.

9. You’re safer in a vehicle as opposed to being a pedestrian.

10. Avoid driving a vehicle if at all possible.

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Lack of Professional Transplant Training in India: A Solvable Problem

Transplant is hot in India these days, especially with the emergence of deceased donor transplant activity. Based on the success of deceased donor transplant programs in states such as Tamil Nadu, there is an increasing political will, public acceptance and professional interest in establishing and/or improving other such programs throughout India. The major problem to moving forward is the lack of adequately trained transplant professionals in India, but this is a solvable problem.

Transplant is not just about the surgery. Entire multidisciplinary teams will need to be lack of professional transplan training in India, deceased donor transplant in India, ASTS, transplant surgical training, Transplant of Human Organs and Tissue Rules, power fellowship, Indian reverse brain drain, #drbarryindia, Dr Chris Barry, MOHAN Foundation, organ donation, Indian transplant fellowshiptaught the intricacies of this very complex endeavor, including anesthesiologists, critical care doctors, nurses, hepatologists, nephrologists, pathologists, immunologists and radiologists, just to name a few. For the purposes of this article, I will focus on transplant surgical training, but keep in mind that so many other transplant professionals will have to be trained as well in order to build quality, robust and sustainable transplant programs.

Becoming a fully trained transplant surgeon is a long, arduous road. In the United States, a USMLE (US Medical License Exam) certified medical doctor must complete a 5 year residency in General Surgery to become Board Certified/Eligible before being accepted into an ASTS (American Society of Transplant Surgeons) certified transplant surgery fellowship. This fellowship lasts two years and involves structured surgical and didactic training with graduated responsibilities so that, by the end of the fellowship, the surgeon is qualified to perform multiorgan recovery surgeries, liver/kidney/pancreas transplants as the primary Attending Surgeon and is well versed in the preoperative, perioperative and postoperative care of this very complex patient population. Even after becoming an ASTS certified transplant surgeon, he or she will require additional “on the job” training at an established transplant center under the guidance of more experienced transplant surgeons.

According to the Transplantation of Human Organs and Tissues Rules (2014) in India, a registered liver transplant center must have a surgeon with the following qualifications:

“M.S. (Gen.) Surgery or equivalent qualification with three years post M.S. experience in the specialty and having one year training in the respective organ transplantation as an active member of team in an established transplant center”.

There is a complete dearth of such trained surgeons in India. Shockingly, I have heard that lack of professional transplan training in India, deceased donor transplant in India, ASTS, transplant surgical training, Transplant of Human Organs and Tissue Rules, power fellowship, Indian reverse brain drain, #drbarryindia, Dr Chris Barry, MOHAN Foundation, organ donation, Indian transplant fellowshipsometimes an Indian surgeon will travel abroad to participate in an unstructured “observership” for as little as 3 months and return to India to start a new program. If true, this practice would be extremely dangerous for the well being of the patients being transplanted at such a center. The surgical skills and knowledge of perioperative care required for decent surgical outcomes are simply too complex for a surgeon who has just seen a few (or even several) transplants.

So, how can India overcome this shortage of trained transplant surgeons? One solution is for surgeons to travel abroad and undergo the entire formal training process at a certified transplant center. This is a difficult proposition because the surgeon must first pass the USMLE (in the US, for example), likely repeat at least three years of general surgery residency training and then be accepted into a transplant fellowship lasting two years. That’s a lot of time and a lot of money.

A second solution would be to establish “power fellowships” where a US transplant center lack of professional transplan training in India, deceased donor transplant in India, ASTS, transplant surgical training, Transplant of Human Organs and Tissue Rules, power fellowship, Indian reverse brain drain, #drbarryindia, Dr Chris Barry, MOHAN Foundation, organ donation, Indian transplant fellowshipcould provide a focused, hands-on transplant experience (including formal didactics and time in the operating theater) short of the required 2 year ASTS transplant fellowship. A 6 month or one year experience could be envisioned. Then, after completion, the surgeon could be recognized by the Indian medical establishment as being sufficiently trained for the purpose of performing transplant surgery in India, but not in the US. Such “power fellowships” would require a vested interest by the foreign transplant center to provide a quality educational experience and also likely would require the official sanction of the ASTS (or equivalent body) and the Indian medical establishment. This process would still be time consuming and expensive for the surgeon, but far less so than solution number one above.

A third solution is to train transplant professionals at existing high volume transplant centers in India. Although most transplant activity in this country involves living donation for kidney and liver transplants, such an experience would nonetheless be invaluable. The challenge here is setting up the necessary MOUs (Memoranda of Understanding) and convincing the established centers that they would not simply be training their competition. My answer to the latter concern is that with increased deceased donor transplant activity, the “pie” will become very large indeed. India could at least double or triple its transplant volume if successful deceased donor transplant centers were established throughout the country.

A fourth solution is to take advantage of the “reverse Indian brain-drain” that is starting to happen in transplant. I have personally trained four Indian surgeons through the auspices of established ASTS fellowships and all of them have returned to their homeland. They are all very successful and three of them are exclusively performing deceased donor liver transplants. I also know of two critical care doctors (one trained in the UK and the other trained in Australia) who have returned to India to share their expertise in transplant perioperative care and donor management. Finally, I know of three other fully trained and experienced transplant surgeons who are planning to return to India to live and work.

I believe there needs to be a structured call to action among transplant professional NRIs lack of professional transplan training in India, deceased donor transplant in India, ASTS, transplant surgical training, Transplant of Human Organs and Tissue Rules, power fellowship, Indian reverse brain drain, #drbarryindia, Dr Chris Barry, MOHAN Foundation, organ donation, Indian transplant fellowship(Non Resident Indians) throughout the world imploring all to consider where their valuable skills could best be utilized (i.e., India!). They wouldn’t even need to come back permanently or even at all, for that matter. In today’s interconnected world, “virtual consultations” could become commonplace. For example, a transplant pathologist in the US could easily read a digital biopsy slide from across the globe and relay critical opinions for the better management of the patient. The same is true for all transplant related professionals, including surgeons, anesthesiologists, hepatologists, nephrologists, radiologists, immunologists and infectious disease experts.

The challenge of filling the void of transplant professionals in India needs to be approached “the Indian way”. The need is critical. Emerging deceased donor transplant centers are literally waiting for such expertise. Sadly, thousands of Indian citizens are dying from end stage organ failure and will continue to die until this matter is successfully tackled. But we can and we must move forward with all of these proposed solutions. India deserves this.

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Deceased Donor Transplantation in Kerala: An Interview with Dr. Barry

Q:  The deceased donor organ donation programme in India/Kerala is in a very nascent stage and obviously, a transplant scenario like the one in the US does not seem even remotely possible in the near future. How do you think an organ transplant programme can take off in low-resource settings like ours?

Dr. Barry: I think that India is perfectly capable of building a robust and sustainable kerala network for organ sharing, KNOS, deceased donor transplant in Kerala, deceased donor transplant in India, Dr. Chris Barry, #drbarryindia, Dr. Noble Gracious, MOHAN Foundation, Narendra Modi, organ donation, deceased donor liver transplantationNational Deceased Donor Transplant Network in which organs from brain dead individuals are allocated fairly and all transplant activity, including long term outcomes, is recorded in a publicly available database. For a national network to succeed, sincere commitments from the Government (both the Centre and States), hospitals, and the private sector are essential. Likely, such a network will first grow organically as successful states like Tamil Nadu and Kerala demonstrate to the rest of the country the best practices necessary for a deceased donor transplant program. The significant resources required can come from the Government, transplant patient self pay and insurance, corporate social responsibility (CSR) funds, and public-private partnerships with transplant NGOs.

For nascent programs to get off the ground, the two most important factors are State Government support and individual transplant champions such as Dr. Noble Gracious, the Nodal Director of the Kerala Network for Organ Sharing. Such leaders work tirelessly and selflessly to inspire, teach, and guide all of the transplant stakeholders to keep the momentum going and the programs growing.

Q: What is your impression of the deceased donor organ donation programme that has been kicked off in Kerala? From your interactions with our transplant surgeons and administrators, are we moving in the right direction?

Dr. Barry: The deceased donor transplant program in Kerala has been remarkably kerala network for organ sharing, KNOS, deceased donor transplant in Kerala, deceased donor transplant in India, Dr. Chris Barry, #drbarryindia, Dr. Noble Gracious, MOHAN Foundation, Narendra Modi, organ donation, deceased donor liver transplantationsuccessful with rapid growth and good success in its first two years. In 2012, 22 deceased donor transplants were performed, followed by 88 in 2013, and 102 so far in 2014. Currently, nearly 10% of all deceased donor transplants in India are performed in Kerala and this is likely to grow given the demonstrated commitment of transplant surgeons, hospital administrators, and government officials. An effort is well under way to establish a deceased donor liver transplant program at the Government Medical College Hospital in Trivandrum. Such a program will allow all members of Indian society to benefit from this life saving and highly successful procedure.

Q: Which are the areas where we should be giving more attention to?

Dr. Barry: Perhaps even greater than organ donation public awareness efforts, the main kerala network for organ sharing, KNOS, deceased donor transplant in Kerala, deceased donor transplant in India, Dr. Chris Barry, #drbarryindia, Dr. Noble Gracious, MOHAN Foundation, Narendra Modi, organ donation, deceased donor liver transplantationchallenges to the program’s success are the attitudes of neurosurgeons and neurologists regarding the declaration of brain death. Understandably, these doctors (and, often, their hospital’s administrators) do not want to be perceived as compromising their care for the sake of organ donation, but this myth must be busted. Of course these doctors work passionately, skillfully, and valiantly to save each and every life. But not everyone can be saved all of the time and, instead of seeing death as a failure, proceeding to organ donation is in fact a miraculous success. Potentially saving eight other people’s lives through organ donation is a remarkable and noble act, isn’t it?

So, much professional education needs to be done, including teaching the ICU doctors how to properly maintain brain dead patients prior to organ recovery, training transplant coordinators how best to counsel grieving families and obtain consent for donation, and teaching surgical teams how best to perform the recovery surgeries and properly preserve the organs prior to transplant. In parallel, public education must continue so that everyone knows the facts about organ donation and that transplantation is very successful.

Q: Logistics and manpower seems to be the key elements that are driving liver transplant programmes — and which we seriously want. Our surgeons also mostly learn transplant procedures while on the job and are not exclusively trained There is an argument that we start the transplant programme and then build on it, rather than wait for the full facilities to arrive. Where do we strike a balance here?

Dr. Barry: While there are certain essential requirements in establishing a viable and kerala network for organ sharing, KNOS, deceased donor transplant in Kerala, deceased donor transplant in India, Dr. Chris Barry, #drbarryindia, Dr. Noble Gracious, MOHAN Foundation, Narendra Modi, organ donation, deceased donor liver transplantationsustainable deceased donor transplant program, it is perhaps more realistic to start the program before all of the other highly recommended elements are in place. For example, surgeons, anesthesiologists, critical care doctors, interventional radiologists, pathologists, hepatologists, and transplant coordinators are all absolute requirements to get a deceased donor liver transplant program off the ground. But other positions such as database managers, transplant pharmacists, infectious disease experts, and nutritionists all greatly add value to a quality program. As a program grows and demonstrates continued success, these positions could be added at a later time.

Q: The reluctance of doctors to declare brain death seems to be one of the major impediments in the way of deceased organ donation. What do you think can be done to get them on board? Do we need to work on patient communication of doctors or hand over the job to grief counsellors? Do you face this kind of a situation in the U.S?

Dr. Barry: Reluctance of neurosurgeons, neurologists, and intensivists to declare brain death is THE major problem in India and is even a problem in the US to a lesser degree. Formal and informal discussions and presentations between transplant doctors and ICU doctors can go a long way to increasing understanding and acceptance, but we really need to identify and cultivate champions of transplant within the ICU and Neurosurgery communities themselves. As I mentioned previously, death should not be regarded as a failure if the ultimate outcome is successful organ donation. This, indeed, is a victory over death that brings profound comfort and closure to the surviving family members and brings new life to the transplant recipients. This is the change in perspective that we hope to achieve.

Q: Kerala has a very morbid population, with a high prevalence of diabetes, hypertension and coronary artery diseases. Don’t you think that this could affect the organ donation programme adversely — for both organ donor as well as potential recipient?

Dr. Barry: In addition to diabetes, hypertension, and cardiac disease, fatty liver disease is kerala network for organ sharing, KNOS, deceased donor transplant in Kerala, deceased donor transplant in India, Dr. Chris Barry, #drbarryindia, Dr. Noble Gracious, MOHAN Foundation, Narendra Modi, organ donation, deceased donor liver transplantationalso a growing problem in Kerala and throughout India. These chronic diseases can (and do) adversely affect the potential donor pool, especially in the cases of severe disease or longstanding disease. Many of the organ donors in Kerala are young road accident victims in whom these chronic diseases have yet to become manifest, but it would be ideal to recover organs from donors of any age. It is possible to transplant organs from donors with diabetes and fatty liver, but utmost care must be taken by the transplant surgeon to assess these organs (e.g., with laboratory data and biopsy results) to ensure that they will function adequately when transplanted.

With regards to transplant recipients, all of the diseases mentioned above can lead to end stage organ failure requiring transplant. Diabetes and hypertension are the main reasons why kidney transplants are performed. Fatty liver disease is predicted to be the major indication for liver transplant within the next 5 years. When these diseases present in combination, as they almost always do, the transplant procedures become more difficult. For example, a patient needing a liver transplant for fatty liver disease is likely to also have diabetes and heart disease, thus making their surgery much more high risk.

Q: Lifelong supply of immunosuppressant drugs is not an easy proposition for most of our transplant recipients, a chunk of whom come from indigent families. Most of them go into the transplant without realising the recurrent cost that the families would have to bear. How do you tackle this in the U.S?

Dr. Barry: In the US, if a person does not have insurance then s/he cannot have a kerala network for organ sharing, KNOS, deceased donor transplant in Kerala, deceased donor transplant in India, Dr. Chris Barry, #drbarryindia, Dr. Noble Gracious, MOHAN Foundation, Narendra Modi, organ donation, deceased donor liver transplantationtransplant. Not only are the costs of surgery and postoperative care extremely high, but lifelong immunosuppression to prevent rejection is costly as well. If a patient is uninsurable, then s/he is not even listed for transplant because the precious donor organ would be wasted if immunosuppressant drugs were not taken properly.

In India, transplant doctors must emphasize that the expenses do not stop after the surgery. How to pay for these ongoing costs is an evolving question as the health insurance field is not nearly as developed as in the US. Government schemes and, possibly, assistance from transplant-specific public private partnerships (yet to be established), will be necessary to assist those transplant recipients who cannot afford out of pocket expenses indefinitely.

Q: How do you ensure equity in organ distribution — especially livers — in the U.S? Given the huge number of patients waiting for livers here and the current system of allocating the organs to hospitals on a rota basis, there are genuine concerns here that only the rich patients and corporate hospitals would benefit from the liver transplant programme. Can you comment on this?

Dr. Barry: Allocation of donor livers for transplant in the US is based on severity of illness. kerala network for organ sharing, KNOS, deceased donor transplant in Kerala, deceased donor transplant in India, Dr. Chris Barry, #drbarryindia, Dr. Noble Gracious, MOHAN Foundation, Narendra Modi, organ donation, deceased donor liver transplantationAn objective score based on three simple blood tests (the MELD score, or Model for End-Stage Liver Disease) is calculated for every patient on the waiting list. The sicker the patient, the higher the MELD score and the higher the patient is on the list. This system assures that the liver goes to the patient who needs it the most. Strict rules are followed including when a super urgent case can override the highest MELD score and when exception points to the MELD score may be granted (for example, in the case of liver cancer). Non-adherence to these rules can result in the closing down of a transplant center by overseeing authorities.

The US system in this regard is quite fair because of its objectivity, transparency and accountability. These principles absolutely must be replicated here in India in order to foster public trust in the system. No one should be able to “jump the list” because they are politically important, rich or famous. I personally think that the rota basis of allocation practiced here in India is problematic, because the liver is offered to the transplant center’s list of patients instead of the next sickest patient who may be listed at a different center. This fact should be seriously debated by the liver transplant community in India and hopefully an allocation system unique to India’s needs will emerge that is as fair as possible.

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The Vital Roles of Nursing in Transplant’s Success

A successful deceased donor transplant program entails many elements, but perhaps onetransplant nurse, vital role of nursing in transplant's success, deceased donor transplant in India, organ donation, #drbarryindia, brain death, Dr Chris Barry, MOHAN Foundation, MFJCF, Jaipur, Rajasthan, bLifeNY, MOHAN Foundation, Narendra Modi, Priyanka Chopra orga donation of the most vital elements is a well informed and dedicated nursing staff. Transplant nursing expertise must be present on many levels, from the ICU to the Operating Theater to the patient wards to the outpatient clinic.

First and foremost, any nurse involved in the transplant process at whichever point must be devoted to the cause. Transplantation and organ donation are true modern day miracles. People’s lives are saved. People’s lives are improved. People’s lives are transformed. Organ donation brings great meaning and honor to the donor and thetransplant nurse, vital role of nursing in transplant's success, deceased donor transplant in India, organ donation, #drbarryindia, brain death, Dr Chris Barry, MOHAN Foundation, MFJCF, Jaipur, Rajasthan, bLifeNY, MOHAN Foundation, Narendra Modi, Priyanka Chopra orga donation donor’s family and loved ones. Nurses who understand these points and honestly believe in them will be the most effective caregivers and patient/family advocates.

Nurses in the ICU and even in the Emergency Rooms can play an important role in the organ donation process by recognizing impending or suspected brain death cases and informing the physicians and other caregivers in a timely fashion. Simple bedside observations, such as an absent gag reflex, absence of spontaneous respirations over ventilator support and fixed and dilated pupils, should prompt further investigations leading to consultation for a formal brain death exam. These clinical triggers can easily be protocolized so that the entire nursing staff is sensitized to calling an early alert. Timely recognition of brain death is important for a number of reasons: it allows for the consideration of organ donation, it can save significantly on hospital costs by avoiding unnecessary and expensive ICU care and, most importantly, it gives time for the healthcare team to engage with and compassionately educate family members on exactly what brain death is.

Once brain death has been declared and clearly explained to the family, the Transplant Coordinator is introduced who counsels the family during their grief and, when appropriate, begins discussion about the possibility of organ donation. If the family consents to organ donation, then the ICU nurses and doctors must work together to keep the potential donor stable before the recovery operation to remove the organs for transplant. This period of time is variable, depending how long it takes to mobilize the various surgical teams to come to recover the different organs, but can last anywhere from a few hours to even a few days. During this time, nurses stay with the patient to maintain the blood pressure, oxygenation and correct any metabolic abnormalities. They also interact with the family and the Transplant Coordinator during this profoundly difficult period of tragedy and loss. This is often when families come to terms with their loss by realizing that their loved one is a true hero, saving other people’s lives and living on in others.

The Liver Transplant Nursing Team in the operating theater must be well versed in thetransplant nurse, vital role of nursing in transplant's success, deceased donor transplant in India, organ donation, #drbarryindia, brain death, Dr Chris Barry, MOHAN Foundation, MFJCF, Jaipur, Rajasthan, bLifeNY, MOHAN Foundation, Narendra Modi, Priyanka Chopra orga donation conduct of this difficult surgery and be absolutely devoted to the cause. They, as everyone else involved, are part of something very special. In this critical moment, their skill and attention to detail is every bit as important as the surgeons’ and anesthesiologists’ expertise. By necessity, a core group—the Liver Transplant Nursing Team—needs to be ready at a moment’s notice to devote many challenging hours in the operating theater to ensure that the patient does well and that the patient’s family has a positive experience. Nurses have an innate ability for emotional support and attention to the patient’s comfort and these qualities are just as important as their knowledge of such complicated procedures as liver transplant.

Back in the ICU, the nursing team must pay special attention to the specific needs of thetransplant nurse, vital role of nursing in transplant's success, deceased donor transplant in India, organ donation, #drbarryindia, brain death, Dr Chris Barry, MOHAN Foundation, MFJCF, Jaipur, Rajasthan, bLifeNY, MOHAN Foundation, Narendra Modi, Priyanka Chopra orga donation transplant patient. They must understand what was done in the OT so they can look out for potential complications associated with the surgery. They work closely with the rest of the Transplant Team, including Surgeons and Intensivists, Hepatologists. Nurses are usually the first to detect any problems or deviations from a normal postoperative course, so their effective communication skills are valued and respected by the entire team.

On the Transplant Ward, there also needs to be a core group of dedicated Transplant Nurses who understand the expected postoperative course, follow clearly delineated protocols for patient management and can rapidly identify complications as they occur. Meticulous attention must be paid toward medication dosing, potential drug-drug interactions and any signs that the patient may require the doctor’s immediate attention or the patient needs to be shifted back to a higher level of care. In an uncomplicated postoperative course (which is usually the case), nurses have the opportunity to form strong and meaningful bonds with the patients and their families. They quickly become the patient’s strongest advocate.

The same level of expertise and attention to detail is required for the Outpatienttransplant nurse, vital role of nursing in transplant's success, deceased donor transplant in India, organ donation, #drbarryindia, brain death, Dr Chris Barry, MOHAN Foundation, MFJCF, Jaipur, Rajasthan, bLifeNY, MOHAN Foundation, Narendra Modi, Priyanka Chopra orga donation Transplant Nursing Staff in Clinic. Transplantation is a lifelong commitment, both for the patient and the entire Transplant Team. Successful long term outcomes in transplant are only possible by practicing continuous diligence and attention to the patient’s needs. A basic knowledge of immunosuppression medications (antirejection drugs) and their potential side effects is mandatory for the Transplant Outpatient Nurse to deliver optimal care.

Being a Transplant Nurse is not for everyone. It requires a special dedication to the causes of transplantation and organ donation, additional training on transplant related issues and a willingness to go the extra mile for transplant recipients before, during and long after their actual surgery. But being a nurse who is well informed about transplantation and organ donation is potentially for everyone. Obviously, the support and understanding for transplant even among nurses not directly involved in this miraculous process is essential so that countless lives may be saved and transformed.

Cultural Note

Pronunciation and comprehension are very important in learning a new language. As I start to learn Hindi, I am well aware of this after my friend Dilip ji told me the following story.

A prominent political leader from India (I don’t know exactly whom, but I know it was not Narendra Modi) was preparing for his trip to the United States to meet President Obama. He wanted to learn a little English, so his tutor instructed him that when one says “How are you?” the response is “I’m fine”. Then you should respond “Me too”. So the dignitary arrives and he asks the President “WHO are you?” Mr. Obama responded humbly and jokingly: “I’m the husband of Michelle Obama” to which the dignitary said “Me too”!

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