Case of a Hindu donor, Muslim recipient and Christian surgeon

In July last year, I wrote about two weddings I attended, one in Karachi and the other in Mombasa, and ended the column with a brief surgical twist. I want to revisit Karachi and relate a moving surgical story I came across there. Before I do so, let me give my readers a brief background of Pakistan.

The new country was carved out of Mother India on the 14th of August 1946, as a result of a resolution passed by the Muslim League of India in 1940 and resolutely fought for by its leader, Muhammed Ali Jinnah. The resolution was based on the Two Nation theory, a brain child of the brilliant Urdu poet, Allama Iqbal. Arising from it, it was proposed that the five provinces of India which had a Muslim majority would form a separate country, Pakistan, and the British were urged to create it before they quit India.

I was a first year medical student in Miraj in southern India when India was partitioned and, soon after, there were riots, where my family lived. They fled and sailed in dhows as refugees and ended up in Karachi where, eventually, they settled and flourished. Not to interrupt my medical studies, it was decided that I continue studying in Miraj.

When I qualified, I decided to specialise as a surgeon. By then, all democratic institutions in Pakistan had collapsed and Ayub Khan, a military ruler, had assumed power and had promulgated martial law, under which all newly qualified doctors were conscripted into the military for three years. I was, therefore, advised to proceed directly to England to obtain my fellowship in surgery. So when I got it, I faced a tough decision, conveniently deferred. I was determined to go back to the developing world from where I came, to serve my people. The fact that I was a victim of partition did not diminish my desire to work and help the developing world I came from.

I did not want to be an early casualty of what became known many years later as “brain drain.” Also my family had invested in me financially and emotionally and I had promises to keep. The call from them was loud and clear and the fact that it emanated from a different land did not make it any less anguished.

My only constraint was that though I had left from India, where I had my roots, I had lost all connections there and had to return to Pakistan where my displaced family had settled. So after considerable soul searching, Marie and I sailed to Karachi in early March 1959. In doing so I felt like a sailor coming triumphantly home and finding that the shore had moved, the familiar lighthouse was not beckoning and the sand under his feet was not the same.

For these reasons, sadly for all, we could not settle in the radically changed circumstances and, after an unhappy stay of under a year, just before Christmas of 1959, we sailed in a cargo ship to Liverpool. What happened thereafter is well documented both in my autobiography and the Surgeon’s Diary, which I don’t want to repeat here.

What is relevant to this story is the fact that my Karachi family and we have been very close and time and distance has not affected the family affection. There have been frequent visits both ways and my last visit to Karachi with Jan was in Christmas time in 2014 to attend the wedding of my grand nephew. I have given a full account of the wedding in this column before so this time I am devoting it to a poignant surgical episode.

IMPORTANT CLUES

As usual, after the wedding, while we were waiting for the weekly direct flight to London, my hands started missing my scalpel and I was developing withdrawal symptoms. I asked my younger brother, who is a leading chest physician in Karachi and attached to various hospitals there, to arrange for me to attend surgical ward rounds.

Accordingly, while I was accompanying Prof Khwaja on his teaching ward rounds, I saw a man lying in one of the beds. What caught my eye were his forearms which looked darker than his arms. “What is this case?” I inquired.

“Oh, his name is Firoz Khan and he is a very interesting case,” replied the professor. “He comes for physiotherapy as an outpatient and I asked the physiotherapist to send him here so that you could see him.” He then threw a challenge.

“While I am teaching the students, why don’t you examine him and see if you can solve the riddle of his different looking arms and forearms. Over lunch in the consultants’ mess after I complete the rounds, you can tell me what you think.” He then gently cautioned me. “The diagnosis is in the history, so talking to the patient is strictly not allowed.”

Like a student who has been promised an award, in utter silence, an order observed by both parties, I embarked on examining Firoz. As I teach my students, I start with “Inspection” or “Look” and fully exposed both his upper limbs and looked at them for a while. That, by itself, provided an important clue. There was no doubt about the change in colour, but now I could see irregular surgical scars between the arms and forearms.

The next step was “Palpation” or “Feel” and, in this case, it included feeling his pulses and checking his sensations. I felt his wrists and found a normal pulse present on both sides. I then checked his touch sensation by gently stroking his forearms with cotton wool and pain sensation by pricking him with a pin. I found both on the examination tray, thoughtfully placed by the ward sister in her Pakistani three piece white uniform.

Both sensations were dull though Firoz could feel and locate them with his eyes closed. Hot and cold water tubes were not available, so I skipped checking his temperature sensation. I then checked if he could actively move his elbows, wrists and fingers. The former two, he could move in slow motion. He had difficulty in moving his fingers and that is the only time he spoke and defied the professor’s instructions.

“Daily physiotherapy is helping me in regaining my movements,” he said in Urdu. Finally, I needed to see if he had the finer sensation of joint position. “Close your eyes please,” I said in his language and bent his left index finger. “Tell me in what position is your left index finger.”

FASCINATING STORY

He took a little time and then replied. “It is straight.” His wrong reply, though disappointing, supported my provisional guess. When I finished examining Firoz, I caught up with Prof Khwaja and he escorted me to the mess on the top floor.

As he introduced me to his colleagues, I felt at home because I had done the same for many years. We washed our hands at the wash-basin and served ourselves from the buffet which consisted of fresh salad, meat samosas and kebabs. There was also chicken biryani for those who fancied a big lunch and could have a siesta. For drinks, there was sweet and salty lassi and fresh grape juice. As we settled down with our tray in a quiet corner, Prof Khwaja asked: “So what do you think?”

Diffidently I replied, “I haven’t seen anything like this before, so this is a long shot, but I think that the young man has had a transplant of both his forearms.”

“You have hit the bull’s eye,” Prof Khwaja was excited. “I will tell you the full story now.” Over our delicious samosas and kebabs, he told me a fascinating story. “Firoz Khan went on a business trip to Kabul, capital of Afghanistan, last year. While he was there, the hotel he was staying in was blown up by a Taliban suicide bomber and Firoz lost both his forearms. After emergency treatment, he was sent here and was admitted under my care. We were going to fit him with hand prosthesis, when his wounds healed.”

“That is exactly what we would have done in Nairobi,” I interjected. Because Rotary Club of Nairobi-Utumishi – utumishi is Swahili for service – is doing the project of hand prosthesis.”

“But luck was in his favour,” Prof Khwaja continued. “A transplant surgeon, Dr Mathews, working in the mission hospital in Vellore, in south India, was with me doing the FRCS course in Edinburgh and we have kept in touch. I wrote to him about Firoz to see if he had any bright ideas. He sent me an email to say that he was starting a limb transplant unit and by sheer coincidence had a patient, brain-dead after a car accident, and he had been persuading the wife to let him turn the life-support off.

Since Firoz would make an ideal candidate, he talked to Mrs Reddy about him and when she heard his tragic story and visualised her husband’s forearms living in a needy patient’s body, she readily agreed. “So we flew Firoz and his wife there.” As the professor’s face glowed and he saw me listening with astonishment on my face, he went on. “Fortunately, everything went off well and Firoz returned triumphantly with his wife last month and is continuing his physiotherapy here.”

“I have always believed that truth is stranger than fiction,” I replied, totally dazed with the story of Firoz. “It has not escaped my attention, by the names you have given, that the donor is a Hindu, the recipient is a Muslim, and the surgeon a Christian. Sounds strange in a sub-continent divided on the basis of religion!”