In 1961, a defining milestone in renal health care was made when hemodialysis was performed for the first time in India at Christian Medical College (CMC) – Vellore in the state of Tamil Nadu. Travenol twin-coil disposable dialyzers, developed by Willem Kolff, PhD, were used to treat patients in this history-making moment. Prior to this, acute or chronic renal-impaired patients had no hope of a remedy—most of these patients were treated with local remedies, and almost always ended in mortality.
Five years later in 1966, young and eager to study something in the medical field and coming from a family without the means to afford graduate medical studies, I arrived in Vellore with the intention of joining a laboratory technician training course. Unfortunately, I was delayed in my arrival because of an unreliable transit system. As a result, I missed the entrance interview and was told the course was already full. In a stroke of luck, I was still able to meet with the interviewing physician, Dr. P. Koshy (one of the founders of the Indian Society of Nephrology) who asked me if I would be interested in a job as a technician in the “artificial kidney (AK) lab.” I had just traveled 12 hours by train to get to Vellore and didn’t have an alternative plan for employment, so I didn’t hesitate to say yes, despite not knowing a thing about kidneys or what the job would entail.
I began on-the-job training that same week. At the time, we were using the twin-coil dialyzers which provided a urea clearance of approximately 140 ml/minute. In order to use the system, the operator had to prime it with 1,200 to 1,800 ml of pooled donor blood. In addition, a 100-liter tank developed by Travenol Laboratories was used to create the dialysate. Dialysate fluid was based on acetate and in order to maintain the pH level of the dialysate, CO2 gas was continuously introduced in the dialysate fluid.
Advances in kidney care
In this era of a new treatment paradigm for renal patients, the majority of my training was hands on as a novice and technical improvements were discovered through trial and error. I didn’t have the supportive mentorship of senior technicians and therefore relied on complicated procedure manuals and Dr. Koshy’s US-based experience to form the foundation for my dialysis knowledge.
During the 1960s, there was no concept of chronic dialysis. Dialysis was only performed for acute injuries and the most common conditions we treated were septicemia, barbiturate poisoning, and snake bites. Access was only via the external Quinton-Scribner shunt, part of which was surgically inserted and part of which was made in the lab and sterilized for reuse. It was my job to make the accessories for the shunt and clean and sterilize them. A single dialysis treatment lasted about 12 hours and carried a high cost, which often restricted access to the required number of treatments for many patients.
In 1968, the Kiil dialyzer manufactured by the Milton Roy Company was a major advance in dialysis treatment. It used a 120 liter tank and was able to do recirculation and single pass dialysis. In order to remove more fluid during single pass dialysis, the length of the drain line from the Kiil dialyzer was extended to create more vacuum. Several years later in the early 1970s, Drake-Willock developed a new dialysis machine. The CMC-Vellore hospital purchased two of these machines and started doing central dialysis to replace the pre-prepared dialysate storage tank system. As better equipment and technology became accessible, it was also easier to expand renal care to other parts of India. In 1971, dialysis was performed for the first time in my home state of Kerala, India and I had the opportunity to be actively involved in doing the set up and training the staff.
It was a privilege for me to start my dialysis career at CMC-Vellore, hailed by many in the field as the birthplace of dialysis treatment in India. I spent 10 years there, working in all aspects of dialysis care, all while completing my bachelor’s degree in economics and law studies. So when I immigrated to the United States in 1976, I knew that I would look to build on that foundation and look for a job in the dialysis field. I accepted a dialysis technician position at Mount Sinai Medical Center, NY, which in 1948, had been the site of the first dialysis treatment in the U.S. As a wide-eyed newcomer to the U.S., I marveled at the modern dialysis machines and the concept of disposable dialyzers actually being discarded after a single use. It was such a stark difference from the conservative and financially constrained health care environment I came from halfway around the world. I came with motivation in my blood and a love for learning in my heart, and I knew that Mount Sinai would be the place to nurture both.
While the work was challenging, I knew there was still more I could offer. There were opportunities for me to enhance my learning, but also to train and create learning tools that were current for new technicians entering the dialysis field. In 1979, I became BONENT certified and through my involvement and interactions, eventually became Vice President of BONENT in 1993. One of my key priorities was to address the lack of study resources for dialysis technicians to prepare for the BONENT examination. In 1993, I wrote the first study guide for dialysis technicians that was published and released at a NANT-New York Chapter meeting. Since its original release, the study guide has helped prepare thousands of technicians and is now in its 5th edition, published by NANT.
NANT was an organization created entirely to represent and support dialysis technicians. In the 80s, it almost ceased to exist due to lack of participation and funding. I fought tirelessly along with a handful of leaders to revive the cause, boost membership, and to bring the NANT organization to the forefront of dialysis technician advocacy. After supporting NANT in various leadership roles, including president in 1996, I knew we had finally shifted the tide: membership was its highest and thousands of technicians were certified thanks in huge part to NANT and to the rigorous and comprehensive learning materials and forums that were available.
After 25 years of a tremendous career at Mount Sinai Hospital, I knew that it was time for me to use the patient care and dialysis skills I had practiced coupled with my deep knowledge of nephrology technology and take it to a setting where I could lead a dynamic team to impact and improve patient outcomes. In 1999, I joined a company where I was privileged to witness my new employer rename themselves to DaVita in 2000, which is an adaptation of the Italian phrase “giving life.” In some ways, I felt it fitting for this new turn in my career. In my role at DaVita as a facility administrator, I work with a multidisciplinary team to continuously optimize clinical outcomes, and to seek efficiencies in our resource utilization. Our unit’s clinical performance has been nationally recognized for service excellence and has often been used as a benchmark for best demonstrated practices.
So now, 50 years into my career, my daughters often ask me when will I finally retire and start to take it easy. And while the thought of it does sound appealing, a big part of who I am is what I’ve been able to do in my professional life—a professional life that started with struggle, leaving my thatched roof home at a young age to make something out of nothing. And it’s those roots and that hardship that fuels me to go back to underserved areas, and to inspire and educate technicians. As an India BONENT representative, I helped set up examination sites for Indian technicians to get certified. I also frequently attend nephrology meetings in Asia, where I’m able to share and exchange best practices. I have also participated in the Bridge of Life program through DaVita which brings free dialysis training and treatments to centers and patients in rural India. I have had the fortune to go back to CMC Vellore and also visit other dialysis centers throughout India, where I share new developments, better ways of performing dialysis, and my own experiences over the years as a technician and administrator.
Looking back at how it all started, it seemed accidental that I fell into this career. I came with aspirations for one job and ended up with another. One door closing while another is opening is a story that many can relate to. I look back at this journey and I realize that while drive and determination are at the core of my professional success, my greatest inspirations have been my mentors, my leaders, my teams, and my family. Each one of them offered a new perspective, a fresh outlook, and insights that helped shape my decisions. Each brought balance to my life, and were there beside me at some of the most defining moments of my 50-year journey.