Time was running out. In a few hours, they would all be dead. All 48 million of them. Only one man could save them. That was Phoolchand. And no one knew where Phoolchand Agrahari was!There was no way I could be involved. Posters with my name were pasted on the shelters at the Bus Stop and the railway station. There were pamphlets distributed from the post office and other shops. I had committed to a camp at Lanja. I do that each mango season! Lanja nestles in Ratnagiri District, Alphonso Mango country. Ratnagiri is 350km from Mumbai and almost 200 from Panjim, the closest airports. The trains at this time of the year resemble the railroad cars filled with prisoners during the world war! We were traveling in a hired Tata Winger. I was in constant touch with Dr Charul Bhanji of RMS. He was desperate. The mix-up was my fault. Yet, the bliss I was experiencing was only an expression of my ignorance of all that was transpiring!Dr. Charul was in Vizag. The information he ferreted out from Shushrusha Hospital had yielded a mobile telephone number and an address someplace in Siddharthnagar, UP. The mobile was switched off! The address, remote. Dr. Charul’s soft and quiet demeanor was deceptive. He would not give up! He called up the Lucknow franchisee of RMS as he looked up Siddharthnagar on Google Maps. With a groan he realized that this was one impossible task. Siddharthnagar was located in UP, close to the Nepal border! The Lucknow franchisee put him touch with Vinodji whose brother resided in Siddharthnagar. A stroke of luck! . Dhananjay was duly contacted. But the spanner was still in the works! Thana Pathara Bazaar was 40kms from there. And no one wanted to travel! I shouldv’e known, it was Friday the 13th!
After my outpatients at Laud Clinic, I left to join the family and the Jacobs on our journey to Gogate Niwas, Gholap, Ratnagiri. Chitra and Nitish were coming along as was Parikshith, Sujatha’s nephew. I was to spend the night at Gholap, travel to Lanja (17kms) the next morning and return to Gholap by evening. If any patients came in on Sunday or if I had to conduct any surgery, I would be required to return. We skipped the mandatory Wada-Pav at Datta snacks and headed on to Wadhkhal, hoping to stop at Kshudha Shanti. The stretch from Pen to Wadkhal took over two hours and we finally arrived in Gholap at 2.30am! Enroute, I spoke to Sanjay (RMS) and tried to reason out with him. We could reschedule for Monday, as (mistakenly) planned! He was adamant. He said he’d check with the lab and let me know. Charul was unrelenting. I called Amod Kale, a colleague at the Clinic and requested him to cover for me and make suitable emergency arrangements on Saturday. He readily did. As usual. At least one end was sewn up. But of course, Phoolchand was still among the missing!
Charul decided to try out another lead. He called Loop Mobile and requested them to give him the address of the number he had for Phoolchand. The phone was switched off yet. Loop Mobile, thankfully, declined. I subscribe to the same service you know! He even tried his high-ranking contact from the local constabulary. This information was sacrosanct. Even they could not access it. Only the commissioner may probably have been able to pry it out. And he was out of bounds, presently. It was getting late. Charul was getting frustrated. He ‘Googled’ Siddharthnagar and found a ‘Maulana Azad Degree college’ there! He managed to get the telephone number of Dr. Mallick, PhD of the college and spoke to the gentleman. Having understood the import of the effort, Dr Mallick readily offered his help. This lead, despite the endeavor, dried up soon.
Savoring the King of Mangoes
Plucking of mangoes in progress
As we used our teeth to scrape out the juicy pulp from the skin of the choicest Alphonso mangoes after breakfast, Jacob casually remarked that if we planted the seed of an Alphonso mango, the tree that grew would never yield Alphonso! Now that seemed far-fetched! How could a seed not beget like? Clarification on this point was immediately sought from the resident Horticulturist, Medha. She agreed! Alphonso mango trees are grafted. The stem of an Alphonso is grafted onto a Rivall (pronounced with the second “L” in Marathi!, Roll your tongue to get it right). The stock and scion graft. Usually at the 6-8 leaf stage. This is an asexual plant propagation method. In most cases, one plant is selected for its roots, and this is called the stock or rootstock. The other plant is selected for its stems, leaves, flowers, or fruits and is called the scion. The climate and the soil of this blessed land yields the best mango in the world, introduced incidentally, by the Portuguese fidalgo (nobleman) Afonso de Albuquerque in the 1500’s. Medha tends to around 250 mango trees on the property. Almost half of them fruit every year. Each tree yields five boxes of mangoes and each box has from 36 to 60 mangoes depending on the size. These mangoes are picked when green and sorted and packed in hay in the typical wooden crates with care. They then make the journey to Mumbai and are gifted or sold. This year the mangoes are fetching around Rs1500/- per box.
The Future IPL stars at the nets!
Jacob and I returned in a rickety rickshaw after the camp and we played cricket. We then walked to the shady glade which hid the little almost-dry river at the boundary of the property. I almost stumbled over a rock and just missed hurtling down the slope. I was following a large winged bird and finally spotted two of them. The Malabar pied hornbills! What a wonderful sight! I followed the birds until they flew up the mountain and left me panting way below. Little fluttering blue wings swooped onto unseen fish in the stagnant water and flew away into the overhanging trees. Curious, I crept closer to spot another marvelous bird. There were four Oriental Dwarf Kingfishers. While natures show carried on, the little nag kept worrying me.
Another call, no headway! Phoolchand stayed away from our clutches! Dhananjay, meanwhile got hold of Pramodkumar who was willing to travel to Phoolchands village. He demanded money! Rs.1500 plus actuals of Rs. 500. No assurance from Charul helped to get this man on the road. He wanted the money! A wire transfer through Western Union was effected. He left on his motorbike and assured Charul that he would call him after establishing contact with the family. Charul was on tenterhooks. An hour later, unable to bear the tension, he called Pramodkumar. This dude must be a complete ‘vela’ type youngster. He reported a punctured tyre as the cause for the delay. However, finally, he arrived at Phoolchands house only to find three women at home. Each more reluctant than the other to talk or part with information. Phoolchands father had gone to the “chowraha” and would return soon. Pramod waited. The father returned eventually only to be confused at what the stranger at his doorstep told him. I can imagine the consternation and concern of the father. Because, I think I forgot to mention this, Phoolchand had actually visited me two days ago! And here was this young man telling a father that his son had not reached Mumbai! Phoolchands Mumbai number and address were eventually conveyed to a relieved Charul who sms-ed it to all and sundry. He seeked and he had found!Fearing that Phoolchand would not return on the fixed date (12th), I had taken the liberty to set the date for his surgery on the 15th. I am sure, as I always am (), that I had conveyed this to RMS. Here is where things went wrong. Stem cells, you know, are delicate and finicky things.Phoolchand had suffered electrical burns of his right forearm a year ago. He had a compound distal radius fracture. He had been treated by a flow through radial artery flap from the opposite forearm. The infection was stronger than the flap and had fought its way back to the surface. The bone died and poor Phoolchand had a gap non-union with infection. Very high voltage electrical burns singe out the protein in the tissues and leave behind unhealthy tissues, incapable of healing. Naïve as I was, I tried implanting antibiotic impregnated cement beads and followed it up with a large iliac crest graft. The following couple of months saw my graft melting away leaving the yawning gap mocking at me through the frequent x-rays I took in absurd positions willing some new bone to sprout out and bail me out! Dr. Mukund Thatte resurfaced the thin forearm using an abdominal flap. The old time tested remedy came to our aid when even a modern microvascular flap may have failed.
Now we had a good skin cover. We had overcome the infection. The gap in the bone still needed to be bridged. A microvascular fibula bone transfer? Discussions with Samir and Shrirang only resulted in reluctance and uncertainty, given the odds. That’s when Charul and Sanjay stepped in and offered Stem Cell therapy! We harvested some bone marrow from Phoolchand’s iliac crest. This was whisked off to Lonavla. There, Dr. Vinayak Kedage, the young Lab Director and his team took over. They hemolysed the red cells, separated out and counted the bone progenitor cells by flow cytometry and finally started culturing Phoolchand’s bone cells in media in the lab under the most wonderfully maintained sterile conditions. Each cell would divide into two and then the two would into four and so on. Until there were 48 million cells in roughly 36 to 45 days. These cells would then be harvested and the medium separated and the cells would then be transferred into four ampoules with a minimal supporting medium to keep them viable. From the time these stem cells are sealed into ampoules, the countdown begins. They will retain their useful vitality only for 72 hours more. Reminds me yet again of the world war railroad cars filled with prisoners. The attrition and death rate, after a short interval, would climb relentlessly until the entire population would be rendered powerless and eventually get wiped out. That’s why bringing in Phoolchand was imperative.
The multiplication of osteoblasts in serial passages
Stem cells have been the focus of attention of the medical world in the past few years. In fact, stem cells are being isolated and injected into any ailing tissue be it ageing, arthritis, paralysis or cancer. The race for the “first to report” in every field is on. Manipulated and spurious results abound. Quacks are raking in the moolah. Claims, counterclaims and absurd claims are misleading patients all over the globe. Hope springs eternal when a miracle is within reach. Well researched, peer reviewed and ethical use of technology is the need of the hour. RMS has taken the lead and I am glad I could visit the lab and understand firsthand, the enormity of the enterprise. The precision and care required call for meticulous planning and continuous surveillance. Most of the 22 technical personnel at RMS have spent between 3 – 6 months in South Korea, training and perfecting this cutting edge technology. Babycell, a division of RMS, has already an impressive number of clients. They bank cord blood and cord mesenchymal tissue at the time of birth of a child. Cord blood is the best source of stem cells and has been used in the successful treatment of various blood disorders like thalassemia and leukemias. The tissues are cryo-preserved in temperatures below -150°C (actually at -193°C) using liquid nitrogen. Samples are cataloged by bar coding them and then they are stored in a pre-arranged order for ease of audit and retrieval. The lab is built on earthquake safe and flood free land. Computer and Power back-up requirements are phenomenal. If all fails, the nitrogen in the chamber will still maintain the temperature for 14 days, time enough to re-establish status-quo.All of this seems straight out of a science fiction movie. In fact, on a rainy day way back in 1973, Sunil, my brother, had asked me to look across between the C and the F block in Nairwadi and see if Chandan Talkies was screening “Sleuth” starring Lawrence Olivier and Michael Caine. The tarpaulin awning half covered the name of the movie (usually painted with water colors on a glass panel). I confirmed that I could only see the first three letters of the name of the movie. It read “SLE”. We got our tickets and sat down to enjoy the much acclaimed award winning movie. After the trailers and the Indian News Review, the main movie came on. To our dismay, the movie that came on was Woody Allen’s “Sleeper”. They did that in those days. If a movie did not do well, they pulled it off midweek and replaced it with another.
Woody Allen is a gifted madman, who surely had seen the future in the distant past! What seemed an impossible and silly dream then, is reality today! In Sleeper, Woody Allen dies on the table during a gall-stone operation and is cryo-preserved for 200 years and thawed in a new world! The comic escapade is frighteningly close to the truth today. Even the cloning part. In the hilarious climax, Woody holds the King’s nose at gun point as hostage! It’s the only tissue of the king to have survived a carnage and there were plans, by his subjects, to clone the king back to life! A comical science fiction story 38 years ago, it’s almost true in 2011. I must watch that one again. And of course, I am sure it’s out there somewhere. I must have that Orgasmotron!Phoolchand’s brother was quite upset that the “companywalle” had hunted them down like criminals! A bewildered father had called and expressed his disquiet. He protested that he had already arrived and was given final instructions by Dr. Warrier! They promised to get Phoolchand admitted on Sunday and we rescheduled surgery to Monday morning at 7 a.m. Well within the 72 hour period. I would be back in time to join Amod at Shushrusha for the implantation. Amod had a tough time trying to request surgeons to shift their OT slots by an hour. We surgeons are an inconsiderate lot!
The pleasures of a simple life style at Gogate Niwas, Gholap
The Bhatye beach at Ratnagiri was the ideal place to celebrate the occasion. That evening we watched the Mumbai Indians getting thrashed at the IPL by the Deccan Chargers. As the first rays of the sun lit up the horizon, the bird calls began building up to a deafening crescendo. I crept out of bed, freshened up and softly padded around to collect the binoculars and the bird book. Mynas, bulbuls, magpie robins and drongo’s were all over. As I got drawn deeper into the thickly wooded backyard, I spotted a pair of the brilliantly colored scarlet minivets (the female is yellow!). The family of the rufous woodpeckers were busy wood pecking together. The majestic Brahminy Kite, perched almost 300 meters away on a clear treetop caught the glint of my lens and stared back until I blinked! Black headed orioles, fly catchers, thrushes, coucals, wagtails and sunbirds cluttered Medha’s backyard. Medha made some aley wala chai and as we sipped the hot, refreshing brew, I showed her the birds in her backyard, through the binoculars. She exclaimed about the clarity and the colors of the birds that had always been all around her. She had barely even noticed them in all these years. Her next buy, but surely, has got to be a pair of binoculars and Salim Ali’s book! The hornbills came to our backyard to bid us goodbye. They perched in full view and posed until we had enough pictures of them!
The next morning, while Medha busied herself with the stems of Alphonso scions, I injected the stem cells into Phoolchands forearm. Her scions contain the desired genes to be duplicated in future production by the stock-scion plant. Hapus Mangoes in coming seasons. Phoolchand is also on his way. His stem cells will become his radius during this monsoon. Thanks to the advances in modern medicine and the perseverance of men like Charul.
Two weeks later, we witnessed another curious genetic aberration! Theres a shop in Lonavla which sells eggs with two yolks! The omlettes are just to die for! Two yolks, what else do you expect! We were in Lonavla to visit the RMS lab. Later that night, we lay gazing at the sky, on the rooftop of the officers’ mess atop a mountain, it was well past midnight, when the rushing wisps of clouds swirled past us. The chill of monsoon clouds! The rains will be here soon, I must savor the last of the Alphonsos of the season!
In the coming days, the fruits of the grafted stems will surely disappear until the next mango season, but for Phoolchands sake, I eagerly await the fruition of his stem cells.13-15, May 2011 – Lanja & 29th May, 2011 – Lonavla
- Humbly and gratefully acknowledge Mr Satyen- Director RMS, Dr Charul Bhanji and Mr. Sanjay Verma of Regenerative Medical Services Pvt. Ltd (RMS) for their unstinted efforts and for the 48 million cells free of cost , as a special favor for a needy patient with his back to the wall and a surgeon whose confidence and ego were lower than a snakes belly!
- Siddharthnagar is the birthplace of Lord Buddha.
- hoolchand Agrahari has consented to the use of his case for this article. Patient confidentiality has not been breached.
- The name could easily have been changed. But ‘Phoolchand Agrahari’ has a wonderful ring of authenticity to it, doesn’t it?
- Phoolchand’s brother explained that his phone was lost. Thus, our inability to establish contact on the given number.
- The case-paper at Shushrusha in fact, had three telephone numbers listed for Phoolchand. Had the clerk read through all the numbers and conveyed them to Dr Charul the first time around, this wild goose chase may have been prevented.
- The Pincode number was mentioned and that is what made it possible to trace the address so ‘easily’. Always state the Pincode !
- Some cells are retained by the lab and cryo-preserved for two years. This permits re-culturing. 48 million more cells can be made! But it would cost just the same all over again!
- For the cord blood and cord tissue preservation, it needs to be collected during the delivery. RMS has trained para-medics and supplied them with the special kits for the same.
- RMS has a tie-up with TNT couriers. Samples and cells can be transported from and to any remote corner of our country. They also fly in samples from many other countries. The cryo-shipper is used for this.
- Wonder how they time the normal deliveries to match the flight timings, cancellations, diversions and flight delays though!