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Separating Twins

Follow the amazing story of Trishna and Krishna, girls born joined at the head, as surgeons prepare to separate them. Airing February 8, 2012 at 9 pm on PBS Aired February 8, 2012 on PBS

Program Description

This is the incredible story of Trishna and Krishna, twin girls born joined at the head. Abandoned shortly after birth at an orphanage in Bangladesh, they had little chance of survival, until they were saved and taken to Australia by an aid worker. After two years battling for life, the twins are ready for a series of delicate operations that will prepare them for the ultimate challenge: a marathon separation surgery that will allow them to live truly separate lives. Since the beginning, surgeons knew there was no guarantee of survival for either of the girls—but without surgery there was no hope at all. With exclusive access to this extraordinary human and medical drama, our cameras have been with Trishna and Krishna and their caregivers at each moment of their journey.

Transcript

SEPARATING TWINS

PBS Airdate: February 8, 2012

NARRATOR: Two twins joined at the head:…

MOIRA KELLY (Children First Foundation): Your sister's there. That's her hand. She's there, next to you.

NARRATOR:…one is healthy; her sister is near death. If they can't be separated, they both will die.

WIRGINIA MAIXNER (Director of Neurosurgery): I've got no doubt they would have died.

NARRATOR: But can the doctors meet the challenge?

TONY HOLMES (Director of Craniofacial Surgery): To actually separate two brains without damaging either of them is the major difficulty.

NARRATOR: It's only been done a few times before. Each new case is so unique, it's a step into the unknown.

WIRGINIA MAIXNER: It's like standing on the precipice of a mountain,…

SURGEON : Okay, you ready to go?

WIRGINIA MAIXNER: …and you're never sure how you're going to end up when you get to the bottom.

TONY HOLMES: Ethically, you wonder, "Should it be done at all?"

WIRGINIA MAIXNER: Okay, we're not out of the poo yet. We got a fair bit of bleeding going on, guys.

We had to decide that this really was in the best interests of the children.

NARRATOR: Plucked from certain death by a powerful love, can they be freed from each other by the skill of their surgeons? And, if so, will these children be able to walk, talk, lead normal lives? Separating Twins, next on NOVA.

Once in every two and a half million births, an extraordinary event takes place. It happened in Bangladesh, a few years ago, when conjoined twins were born: two girls attached at the head.

Their parents, too poor to care for them, handed them over to an orphanage founded by Mother Teresa. They had little chance of survival. The plight of the twins moved an Australian volunteer to search for help. She understood that in order for the twins, Krishna and Trishna, to survive, they would have to get to a modern pediatric hospital.

DANIELLE NOBLE (Australian Youth Ambassador): It was kind of obvious. Krishna looked unwell, right from the beginning. She was smaller. She was more stressed. She was upset. She just looked more unhealthy than her sister. She'd cry every time anyone touched her, because she was in pain and tired and scared. She was just pleading with people, "Just give me a chance."

It was distressing to think that if these children were to stay in Bangladesh, they would die.

NARRATOR: Danielle reached out to a Bangladeshi businessman and philanthropist, who agreed to help.

ATOM RAHMAN (Philanthropist): I was, obviously, very disturbed seeing them. At that time, I think, they were only eight months old.

NARRATOR: Atom knew of a charity in Australia that had arranged life-changing surgery for hundreds of children. The founder was a nurse, Moira Kelly.

MOIRA KELLY: I just thought how tiny they were. And when suddenly, when you got there, in your face, you thought, "Oh, my god, this is real. These little children, they're really here."

BANGLADESHI DOCTOR: And what is…you are? You are, like, an escorting nurse?

MOIRA KELLY: Yes, yes. We do assessments to see if they can be separated.

ATOM RAHMAN: On our way, from Dhaka road all the way to the airport.

NARRATOR: Moira and Atom were granted joint custody. They arranged for an emergency medical transfer to the Royal Children's Hospital, in Melbourne, Australia, but Moira was worried.

MOIRA KELLY: Trishna was always robust, and she was healthy and strong, but of course her life depended on her sister's life, and her sister's life was…very sick.

NARRATOR: The smaller twin, Krishna, had a long list of life-threatening medical conditions: pneumonia, a malfunctioning enlarged heart, kidney trouble and high blood pressure, but the twins survived the arduous flight.

Conjoined twins are identical twins that fail to fully separate shortly after conception. About one out of a thousand sets of identical twins are conjoined. The attachment can take place anywhere along the body. The chest, the shoulders, the pelvis, but it's twins joined at the head that are the most rare and the hardest to separate. And this confronted the medical team at Melbourne's Royal Children's Hospital with an ethical dilemma.

WIRGINIA MAIXNER: We had to decide that this really was in the best interests of the children.

NARRATOR: Neurosurgeon Wirginia Maixner had to assess the children and weigh the risks.

WIRGINIA MAIXNER: We couldn't choose to sacrifice one child for the sake of the other: either save both, or they both die. There was about a one in four chance that we could get them through okay and about a one in four chance they would die.

NARRATOR: Once the twins are scanned, surgeons see what they are facing. The brains are pressed tightly together inside one neural sac. Their neurons may be joined in places, and the circulatory system in the head is intertwined.

WIRGINIA MAIXNER: It looks like she's still giving a lot. The problem is, this is actually Trishna, and this is backflow into that vein. When they arrived, the blood was mostly dumping from Trishna into Krishna, which is why she had heart failure.

NARRATOR: Where their brains meet, the veins of the two twins flow into each other. Veins are blood vessels that bring blood back to the heart. But now, too much blood is flowing into Krishna's heart, which is causing it to pump too hard and too fast. If the girls are to survive, the neurosurgeons will have to stop the excess flow of blood flooding Krishna's heart.

TONY HOLMES: One of them was dying of heart failure, and the other one would have then died shortly thereafter. There was no choice.

NARRATOR: But, because so much blood is coursing through the shared central vein in their head, surgery is not yet an option. The twins would bleed to death. So the surgeons try something that's never been done in conjoined twins: an expert radiologist will thread a tiny coil, through a vein, up into the top of the head, to restrict the excess blood flow to Krishna.

WIRGINIA MAIXNER: It's quite a complex procedure. You need to be able to navigate that catheter up a lot of torturous bends, in a very small child.

NARRATOR: They'll be able to tell if the procedure is working by monitoring Krishna's blood pressure.

As soon as the coil is in position, to everyone's relief, Krishna's blood pressure drops.

WIRGINIA MAIXNER: We started to see some of the major blood pressure changes and volume changes between the two children, as we stopped the communication from one side to the other.

Hi. It's Wirginia Maixner speaking. Is Moira there? Um, it's all gone very well. They're now just gone back into I.C.U. They look very, very stable. So, it's all looking really good at this stage.

NARRATOR: With the success of this procedure, the twins are able to leave the hospital, at least for a while.

MOIRA KELLY: Cheep, cheep, cheep. Hear the birdies? Much nicer than the hospital, isn't it?

NARRATOR: And the surgeons have a chance to plan. They know that they are treading in new territory.

TONY HOLMES: There's hardly been any craniopagus twins separated, anywhere, that have been entirely neurologically normal at the end of the procedure, and that is what we are aiming at.

WIRGINIA MAIXNER: The problem is that there is a really large complex of veins where they're joined together. So if you just chop straight through, they'll have severe brain injury and die.

NARRATOR: Dr. Maixner is holding a 3D model created from C.T. and M.R.I. scans. It gives the surgeons a roadmap of the twins' intertwined veins.

WIRGINIA MAIXNER: What we need to do is very slowly change the vein circulation, by dividing the veins that join the two. I initially thought this would be a one- stage separation, where you just try and recreate a new venous circulation. What became apparent was the risks of death from that sort of surgery were unacceptably high.

NARRATOR: So they came up with a new plan to separate the twins gradually, one section of the brain at a time, spreading the surgeries out over many months.

MOIRA KELLY: One, two, three. Whoa!

The kids are very, very, different. Trishna's boisterous. She's a real tomboy, and she's got a beautiful smile. There's something electric about Trishna. And Krishna's a very gentle soul. She's a little lady.

NARRATOR: Krishna is stronger, but she's still struggling. Her kidneys and her lungs are weak. And, to help her breathe, she's had a tracheotomy. The trach gives her lungs a rest but bypasses her vocal chords. This means she has no voice, and no one can hear her cry. But she's figured out that if she pulls her sister's hair, Trishna will do the crying for her.

WIRGINIA MAIXNER: Trying to operate on these children is like standing on the precipice of a mountain, just to launch yourself off the edge takes a huge amount of courage to say, "Okay, let's do it."

The incision, probably, we still need to get to this point. You need to bring it 'round. You need to bring it 'round a little there. Okay, can you turn it 'round?

NARRATOR: The goal of this surgery is to start the lengthy process of cutting and sealing the veins, one by one, most of them on Trishna's side.

WIRGINIA MAIXNER: So, what you can see here is the brain, and these are the series of veins, which are draining up to a conjoined vein. And what we need to do is divide all these veins, so ultimately Trishna will take the vein, and Krishna has to find a new way to circulate.

NARRATOR: Blood finds a new way to circulate, not by creating new veins but by filling unused and minor vessels for the first time.

WIRGINIA MAIXNER: If you look at that, to there, to there, it's almost about…there.

NARRATOR: The neurosurgeon must be careful to control bleeding. It's a grave danger to the brain.

WIRGINIA MAIXNER: You can't afford to injure these venous structures; otherwise, you'd have significant hemorrhage.

NARRATOR: The surgery appears to have gone well, but sometimes complications don't show up until afterwards. They won't know for certain until the children wake up.

WIRGINIA MAIXNER: Every time that we do the surgery, we risk death or major stroke or unconsciousness.

NARRATOR: So, in the recovery room, everyone is anxious for the slightest sign of responsiveness.

MOIRA KELLY: She's awake. Is she?

DOCTOR: Yeah, she's with us. That's okay.

NARRATOR: Trishna is awake, but Moira is waiting for a sign that Krishna is all right, as well.

MOIRA KELLY: You don't know about the movement on the side, on the right-hand side? Have you seen a movement at all? Has she?

Oh! Oh really?

Oh, my god. Oh, my god. That's fantastic.

Hi, sweetheart! It's Moira. There's my girl. That's what you love doing, putting your hands in my mouth, don't you? I know. Hello, beautiful girl! Who's my girl? Are you looking for your sister? She's there. Your sister's there. That's her hand. She's there. Look, you're holding hands with your sister. The three of us are holding hands. Look at that. She's there. That's her. She's there next to you. That's her. The two of you are together.

WIRGINIA MAIXNER: The next 24, 48 hours are going to be fairly stormy, as they sort of readjust to a new way of how things are inside the head.

MOIRA KELLY: Put your hands in my mouth. See? It's me. See? It's me. It's all right.

NARRATOR: At least a month is needed between surgeries for the blood vessels to develop a new circulation pattern in the brain.

Moira tends to them at home, which now resembles a hospital ward. The staged surgeries will take months to complete, but there's another clock ticking: the key windows for the children's development. At fourteen months, the twins are clearly behind.

MOIRA KELLY: Every time I see a baby in the street, or I see a mother with a little toddler, I say, "Excuse me, how old is your baby?" And, "Tell me, what does he do?" I'm thinking, "My goodness. God, my girls, they don't do that." That's all the things they should be doing, you know?

NARRATOR: The girls seem alert and engaged, but some of their development is on hold.

TONY HOLMES: The pediatricians are particularly worried about these two children. By now they should be running around and developing all their neural pathways. These kids can't even see each other without a mirror. What's going to happen when they get separated?

NARRATOR: As the next stage of surgery approaches, Moira goes through the agonizing process of giving consent.

MOIRA KELLY: Every time you've got to sign these papers and know that this one's stroke, and this one's maybe death, and this one's...okay, Moira…well, this one, she may never wake up. I couldn't imagine life without them, so it's very hard.

NARRATOR: As she leaves Trishna and Krishna in the operating room for the next stage of the separation surgery, the realization that she might never see them alive again overwhelms her.

Throughout the world, there have only been five attempts of this kind of risky surgery, the slow and carefully staged separation of conjoined twins over time, and the results have been mixed. The surgeons are now moving on to dissect the next section of the brain.

Each section is new territory. And this time, they may have to cut through brain tissue as well as veins. The team is acutely aware of how quickly something could go wrong that might lead to neurological deficits.

WIRGINIA MAIXNER: The deficits could be anything from a minor limp or hand weakness to vegetative. We estimate the chance of some deficit being at least maybe one in two, 50 percent chance.

NARRATOR: The shape of their brains is so distorted that it's not easy to figure out which functional area is at risk.

WIRGINIA MAIXNER: Could be they're not moving one side, or they could lose language, or both, but right now, there is really not much room for emotion. You just have to do the things you have to do.

What we're trying to achieve today is to divide where the two brains are actually abutting each other, and then to take veins that are still important draining veins, that are connecting the two brains together.

NARRATOR: To avoid trouble, surgeons are constantly on the lookout for bleeding or swelling in the brain.

WIRGINIA MAIXNER: The brain is actually nicely, relatively, relaxed.

NARRATOR: As each surgery nears its end, the surgeons place thin silicone sheets between the brains. This prevents scarring and it stops the blood from finding new ways to flow across the divide, undoing all their meticulous work.

WIRGINIA MAIXNER: This needs a bit more silicone, please. It's beautiful.

NARRATOR: Because there are two patients, the surgical staff is doubled. There are multiple neurosurgeons, craniofacial surgeons, anesthesiologists, nurses and technicians, all aware that they are taking part in medical history.

WIRGINIA MAIXNER: Any neurosurgeon would be lucky to do one of these cases in a lifetime. I don't think you could ever repeat this experience.

NARRATOR: As the children recover, Moira finds a new way to engage them.

MOIRA KELLY: When the girls had this mirror…they had never seen each other before. Now, I was thinking to introduce them to each other, but, actually, what happened was we were introducing them to themselves.

NARRATOR: This is the age, about a year and a half, when most children are able to recognize themselves in a mirror. But in conjoined twins, where there are areas of common sensation and shared body parts, the sense of self is a bit more complex.

MOIRA KELLY:…the two of you, the one time. And you both think I'm talking to you, 'cause you can see me and you can see me.

WIRGINIA MAIXNER: From the medical viewpoint, it's fascinating. They do function completely independently, the two children, in some ways, and in other ways they function as one being.

MOIRA KELLY: Hello, how are you?

NARRATOR: Between operations, the twins are helped to learn better coordination skills.

OCCUPATIONAL THERAPIST ONE: Good girl. My gosh, you're a machine today. Have you been practicing, Moira?

One problem we have had with Trishna is that she's quite fearful of being lifted and moved into different positions. And you can see the fear in her eyes. And she'll actually grab and hold onto me very firmly.

Good girl. More music!

OCCUPATIONAL THERAPIST TWO: When we first started playing with Krishna, she didn't really know how to play many games, and she didn't know how to do tasks that were useful. But as soon as we started stimulating them like we stimulate normal children, they have done fabulous. And they are normal children, they are just stuck.

NARRATOR: In fact, their heads and necks have been stuck in one position for so long, they will eventually need many hours of physical therapy to sit up, stand straight or walk with ease.

Part of their therapy is to play with other children at a farm owned by Moira's Children First Foundation where children come to recuperate from all kinds of major surgery.

MOIRA KELLY: Talk. Talk?

NARRATOR: Krishna has found a way to overcome one of her biggest handicaps. She's discovered that she can make sounds by covering the opening in her throat. It's a huge breakthrough for the smaller twin.

MOIRA KELLY: You hear this wonderful voice, but, of course, Trishna's not used to it. She gets scared when she hears this noise coming from the other side.

Come on, say "Yeah!"

NARRATOR: Every four to five weeks, Moira and her twins return to the hospital to continue the staged brain separations.

WIRGINIA MAIXNER: And there is still a little bit of vein here, which is the last return of Trishna to Krishna, which we take last of all.

NARRATOR: As the surgeons grow confident that they've cut most of the shared veins, their attention must now turn to how to get enough skin to cover the girls' skulls when their heads are finally separated.

TONY HOLMES: The girls' skulls are grossly abnormally shaped. So when they're divided, we need a huge amount of tissue to make sure this operation works.

NARRATOR: It's the job of the craniofacial surgeons to create new skulls and cover them with living scalp tissue once the girls are separate.

TONY HOLMES: The join of the heads is this big. So, what you're looking at is two bread and butter plates. Each child's a bread and butter plate of skin that has to be made.

NARRATOR: The only way to do this is by expanding their skin gradually, over a period of months. They will use artificial silicone balloons, placed under the scalp, that are inflated slowly with liquid.

TONY HOLMES: We've got an expander here, and we've got an expander here, but we've really got this whole flap here.

We don't like tissue-expanding young children. It's difficult. They can't understand what's going on, and we're after enormous amount of skin.

NARRATOR: Craniofacial surgeon Andrew Greensmith uses a tiny camera attached to a probe, in a technique called keyhole surgery. It minimizes scarring, bleeding and damage to the skin.

TONY HOLMES: Andrew's been separating the scalp from the skull. We only have tiny little holes. There's no blood loss while we're doing this. The expanders are just fancy balloons with a valve, so that we can then blow them up gradually. So then the tissues stretch slowly, just like a pregnant tummy.

NARRATOR: In order to have enough skin, the twins now have to wait until their heads are about twice their normal size. The process is fraught with danger.

TONY HOLMES: The children will be unrecognizable within four weeks. The smallest infection will be a disaster…not out of the woods at all.

NARRATOR: At first, their recovery seems on track, as they celebrate their second birthday.

WOMAN: To Trishna and Krishna! Cheers.

MOIRA KELLY: To dear Trishna and Krishna, two sweethearts, who changed many lives.

Yeah, I just can't believe it's two years old today. I mean, they even look two today. It's fantastic we can all share this together. This is something that we didn't know was going to happen. Wouldn't it be great to think if it was a third birthday next year, and they're running around?

They're expanding really well. They're doing better than expected, actually. We didn't think we'd be this far ahead, right now.

NARRATOR: But only three weeks later, the children are rushed to the hospital with a high fever.

ANDREW GREENSMITH (Craniofacial Surgeon): I'm going to shave a bit of their heads, so you can stick a dressing on top of the Betamine.

I smell something that doesn't smell very good, there. It smelled a bit like pus. Yeah, I think she's been scratching it. It's a bit fragile, full of infected fluid, which is very bad news…after all this work, it's just heartbreaking, really.

NARRATOR: Sometime after midnight, things turn from bad to worse. The hospital calls Moira.

MOIRA KELLY: One-thiry, I got the call, and they said the girls were very sick.

DOUG MCKAY (Craniofacial Surgeon): They were crash-intubated on the ward and then transferred down to the I.C.U….so, quite unstable, quite hypotensive.

MOIRA KELLY: I couldn't eat, I couldn't sleep. I was so sick. I didn't want to leave I.C.U. any second. I couldn't leave I.C.U.

Moira's here. Moira's here.

NARRATOR: The infection has entered the girls' bloodstream. The twins are fighting for their lives.

MOIRA KELLY: It was Trishna who dropped her blood pressure, and she usually has a very high blood pressure, and she was so sick. I knew this was the potential, that the children could die right now. And I didn't know if the girls would ever survive that night, really, you know?

WIRGINIA MAIXNER: Unlike adults, adults will tend to slow...you know, just gradually, slowly deteriorate, but children tend to stay well, and then, suddenly, they're desperately ill. You can manage these children, and then, all of a sudden, they're on death's door, where, you know, twenty-four hours earlier they weren't. Infection can be that dramatic.

NARRATOR: They are now too sick even to have the infected expanders removed. And it is not easy to treat their individual symptoms. Any medication given to one easily passes to the other.

ANDREW GREENSMITH: One of them was really on a knife edge and very close to dying.

WIRGINIA MAIXNER: We had to ventilate them, so…we had to breathe for them. They were very, very sick.

MOIRA KELLY: I was just too upset. I just stood in the hallway. I was close, but I just couldn't cope, myself. I was just terrified, just terrified. I remember just walking up and down the hallway, looking out there thinking, "My god, the whole world's asleep right now, and no one knows what's happening to Trishna and Krishna."

NARRATOR: No one knows for sure how the infection started, but the surface of the expanders gives bacteria an inviting place to grow.

MOIRA KELLY: Moira's here.

It wasn't mentally possible that this could happen after all they'd gone through, and we're nearly there, you know? At that stage, I said, "Just rip those damn things out." I said I'd take them out, myself.

NARRATOR: Finally, their vital signs recover just enough to do just that.

DOUG MCKAY: So we've decided to actually take everything out, which was probably the safest answer from their health, given how unwell they are.

NARRATOR: The team knows it will now be many months before the girls are able to tolerate further surgery.

ANDREW GREENSMITH: Big psychological setback for us, as surgeons, and the team and Moira, as the carer.

WIRGINIA MAIXNER: It just brought home how serious what we are doing is. When you see them really that sick, you sit there and go, "Hmmm, it really is this difficult."

MOIRA KELLY: Open wide your little mouth!

NARRATOR: But the pause in surgery gives the twins a chance to get back on track developmentally. The girls are now strong enough to sit up and support the weight of each other's head without assistance.

MOIRA KELLY: This is their version of dancing. Look, she's clapping her hands as they're going.

You think that's funny? It's not funny!

NARRATOR: And Trishna, still the stronger twin, is able to practice standing.

MOIRA KELLY: What are you doing? Can she have a little stand? Oh, good girl, Trish. Good girl. Yay! Yay! Good girls. Come on, sweethearts. Up you get.

NARRATOR: The girls are now two and a half years old. While the angle at which they're joined means they won't be able to walk until separated, they can sit up all by themselves.

MOIRA KELLY: Come on, sweethearts. Oh! Good girl. Yay! Up again, come on. Good girls. Good girls. Come on.

NARRATOR: Even Krishna, long the weaker twin, is getting much stronger.

MOIRA KELLY: Ever since Krishna's so well now, her true colors have come out. A long time ago we used to say that she was a lady, and she was the tomboy, but actually, she's actually the lady, and she's the tomboy.

NARRATOR: Krishna, now breathing on her own, has still not begun to talk,…

MOIRA KELLY: She's making all these noises with her mouth now.

NARRATOR:…but she's doing her best to communicate.

MOIRA KELLY: Every time she comes out of I.C.U., she does the same thing: makes that "thwpp" noise to let me know, "Moira, I'm okay."

She's pretty funny.

NARRATOR: And her sister Trishna is speaking like a two-year-old.

TRISHNA: No! No way!

MOIRA KELLY: I don't really think Krishna is going to go very far, until she's separated, because her sister's quite a strong personality. I think when they're separated, I think Krishna will be able to find her voice.

NARRATOR: But the surgeons are worried that the long delay, caused by the deadly infection, could set the girls back. Blood may have found a new way to flow across the now separated portions of their brains, around the silicone dividers.

WIRGINIA MAIXNER: My biggest concern is going backwards, that they'll find a new way to cross-connect again. And then they, potentially, could need more surgeries than what they otherwise might have.

NARRATOR: After eight months, a new set of expanders is finally put back in.

TRISHNA: I want Moira.

MOIRA KELLY: Yeah, Moira's here.

ANDREW GREENSMITH: Having had what happened last time, we really want to cover them constantly with antibiotics during the expansion phase.

NARRATOR: The long wait for the expanders to fill begins. This is the final step before the separation surgery. But Krishna has gone downhill again. Her weak kidney is now barely functioning, and the wait is almost unbearable.

MOIRA KELLY: You're lucky if you get wee every three days, so she's dialyzing her sister.

TONY HOLMES: Hi, Moira. How are you?

MOIRA KELLY: Not good.

NARRATOR: Moira calls an emergency meeting with Dr. Holmes. She's anxious to have the final surgery as soon as possible. She wants them separated a month earlier.

MOIRA KELLY: The girls have been really sick the last five weeks. It's been one thing after the other. And it's hard on us, as well, because you just look at this poor little thing, and what she's going through, and it's very, very hard. You wonder how long you can go on like this, you know?

TONY HOLMES: It'll be close. I can tell you now, this is the real reason we will not be changing the plan.

MOIRA KELLY: So we can't go early, even though the girls are doing not well?

TONY HOLMES: We'll only go earlier if we absolutely have to, and then…that's an emergency, and we have to cover that brain. Because exposed brain, they don't survive.

MOIRA KELLY: I started off as a nurse for them. I've just become a mother. It's a very, very scary time.

And one day you're going to go in here, Trish, aren't you? Go for a big swim?

NARRATOR: While Moira tries to keep the children healthy for the final surgery, the hospital staff is busy planning every move so there are no surprises.

TONY HOLMES: We've seen every conceivable complication. And we've tried to plan against this. This is the material that we'll be using to patch up any holes in the skull.

WIRGINIA MAIXNER: So, it's quite possible she loses a lot of blood at that last separation step.

So, it's not so much nervousness, it's really making sure we've got our head around everything that has to be thought about, so there's absolutely no surprises on the day.

MEDIA: One two three. One, two, three.

NARRATOR: A full two years after Trishna and Krishna arrived in Australia, the day of the final operation is here, and the world is taking notice. Atom Rahman, the twins' co-guardian, comes in from Bangladesh to support Moira and the girls.

The neurosurgeons anticipate a 14-hour operation. They will separate everything that remains connecting the twins, the last of the veins, skull and skin.

SURGEON: We need to do the bone, all the way from here to there?

NARRATOR: The craniofacial surgeons will cut the skin along a carefully planned contour that preserves key blood vessels and protects the twins' hairline. It's designed to allow the skin to be folded and stretched without kinking.

ANDREW GREENSMITH: So, if you like, it's an S-shape, so there are interlocking flaps coming from each child.

NARRATOR: After the separation takes place, and the brains are exposed, each twin will have her own team of surgeons working quickly to seal the brains and cover them with bone and the living skin flaps.

TONY HOLMES: We've got knife to skin at around about ten o'clock, so things have only really been going for a little while, but it's all been very good.

NEWS REPORTER: And it seems the whole of Australia, if not the world, is watching and hoping.

TONY HOLMES: Everything's going to plan, and we're all particularly pleased.

NARRATOR: Despite the rosy picture, Dr. Holmes worries that if the surgery takes longer than expected, it could lead to complications.

TONY HOLMES: The moment the tissue expanders come out, our flaps start to contract.

More importantly, with each passing hour, the brain needs to be moisturized, it can lose heat. The risk of infection, the risk of drying out, the risk of superficial thrombosis of the blood vessels on the surface, so these are all the reasons why we want to keep the operation going as fast as possible.

NARRATOR: With the twins attached at a 120-degree angle, correctly positioning them is a constant challenge.

IAN MCKENZIE (Director of Anesthesia): We've finished the bit with her…face-up bit; we've got them in position for the face-down bit. Just keep working well, and maybe we will finish this side of midnight.

WIRGINIA MAIXNER: So you can see, this is Trishna, on this side, and this Krishna, on this side. The line of separation will ultimately be down here, down here, and then a line that comes down here.

NARRATOR: Since the brains are so closely pressed together, there are sections where it is difficult for the surgeons to distinguish one brain from the other.

The craniofacial surgeons open up one last section of skull, giving the neurosurgeons access to a new and an unfamiliar portion of the twins' brains.

TONY HOLMES: This is the last bit of brain to be divided.

NARRATOR: The goal seems in sight.

WIRGINIA MAIXNER: Can I have some irrigation, please?

NARRATOR: But separating the brain tissue in this area is more complicated than they anticipated.

WIRGINIA MAIXNER: I'm getting loss of orientation here. Let's see if we can see this just a little bit better. I think we need to come down there. They had blood coming out both sides of the bone, so I'm not sure what it is. Keep going down this path. That looks like where we need to be.

NARRATOR: Then, something unexpected appears in the brain's outer protective membrane.

WIRGINIA MAIXNER: Looks like there's a big vein in the dura. Can I have a model holder, please? Down there, I need to see the veins inside.

NARRATOR: The model does not reflect what Dr. Maixner is seeing.

WIRGINIA MAIXNER: I can't see a big vein there, Alison.

NARRATOR: As feared, the long delay has created a complication. The blood has found a new way to cross between the brains, and a smaller, unused vein is now filled with blood.

TONY HOLMES: Most of the vessels have been predictable, but now and again, you get surprises. The brain connection was far greater than was expected.

NARRATOR: This is a major setback that will extend the surgery.

WIRGINIA MAIXNER: Hi, sweetheart. How's your studying going? Good. Oh, we'll be some many hours yet, so it may be that I don't expect to come home until the early hours of the morning.

NARRATOR: As the hours drag on, the risks are magnified.

TONY HOLMES: The longer the operation, the higher the complications. If you get a hemorrhage in this area, that's tantamount to a stroke and permanent damage.

WIRGINIA MAIXNER: I think, when we've got such a traumatized brain, with venous hyper-tension just in this area…

NARRATOR: Krishna's brain has become too swollen to operate.

WIRGINIA MAIXNER: …got to have a little break.

NARRATOR: The team is forced to stop and wait, hoping the swelling will subside.

Moira passes the time alone in church.

MOIRA KELLY: There is nowhere else to go, and I don't want to talk to anyone.

NARRATOR: The swelling finally subsides enough for the vein to be cut.

WIRGINIA MAIXNER: That's another significant vein we took.

NARRATOR: And now, once the vein is cut and sealed, at last, good news.

WIRGINIA MAIXNER: I remember, like it did last time.

NARRATOR: A remarkable transformation is taking place.

ANDREW GREENSMITH: This work we have done, so far, seems to make them a lot more independent in terms of their circulation. The blood pressures have come back to almost equalizing.

NARRATOR: With the twins' circulation at last completely separate, Krishna's kidney starts to work.

ANDREW GREENSMITH: So far, there wasn't a drop of urine, and, suddenly, she is just starting to produce a little, which is great news.

NARRATOR: The final piece of bone connecting Trishna and Krishna is removed.

ANDREW GREENSMITH: …partly separated. We want to be not letting their heads just flop down.

TONY HOLMES: No, we're going to stay here. We'll hold it.

NARRATOR: With only skin and a small section of brain still connecting Trishna and Krishna, Dr. Greensmith cradles the girls' heads in his hands for 70 minutes while the neurosurgeons complete what has, so far, taken a full 24 hours.

TONY HOLMES: So, now, we've just got to come apart just enough so they can just see that last little bit.

WIRGINIA MAIXNER: Okay, microscope out, please. Slide Trishna slightly.

NARRATOR: They nudge the operating tables apart, ever so slightly.

WIRGINIA MAIXNER: Give me a second. I just want to make sure we are free, truly free…another one like this. Stop.

SURGEON: Okay, a little bit more movement. You ready for this?

TONY HOLMES: Yeah, go for it.

SURGEON: Okay, we're moving.

VOICE: Whoo hoo!

TONY HOLMES: We have separation guys. Congratulations!

VOICE: Well done, Wirginia.

WIRGINIA MAIXNER: Only taken me 20 long hours.

VOICE: Has anyone phoned Moira?

MARGARET SMITH (President, Children First Foundation): The brains are separate, Atom! The brains!

ATOM RAHMAN: Are you kidding?

MARGARET SMITH: No, they just rang.

ATOM RAHMAN: When? When? Just now?

MARGARET SMITH: Just now, just now.

ATOM RAHMAN: Oh! We have to go, then. We'll have to go and see it.

MARGARET SMITH: I was thinking, "We've just got to see it."

NARRATOR: Atom Rahman reaches Moira with the good news.

But the jeopardy is not over. Two sets of craniofacial surgeons, one for each twin, are now rushing to seal the brain, build a new skull and then cover the head with the new skin.

The heads will be misshapen, because, at this stage, all that matters is survival. Later, their skulls can be reconstructed for cosmetic purposes, and their brains will reshape themselves to the form of their new skull

TONY HOLMES: We're just going to make it, I think, without having to do a skin graft. So it looks as though it's good.

NARRATOR: Tony Holmes and his team have created a new head for Trishna.

TONY HOLMES: The tissue expansions worked out. The closures worked out. Everything's fine.

NARRATOR: Trishna leaves the operating theater and, for the first time in her young life, is in a different bed from her sister. Closing up Krishna takes 45 minutes longer, because her brain is larger than her remaining skull. The skull has to be built up with bone grafts before the scalp can be closed. This final separation surgery has been a 32-hour marathon, culminating a two-year-long drama.

TONY HOLMES: Look, it was fantastic, because what we've been afraid of was the unknown, some sudden catastrophic change that meant, you know, potentially a disaster. But it didn't happen.

NARRATOR: Now comes the wait for any sign of responsiveness from the twins. This has been, by far, the most traumatic of the operations.

ALISON WRAY (Neurosurgeon): At the moment, it's still a bit surreal, but once it happened, and seeing the two girls separate, it was an amazing feeling.

MOIRA KELLY: Hi, Andrew. Oh, can you believe it? Can you believe it?

ANDREW GREENSMITH: We made it. We made it.

MOIRA KELLY: I think I'm in shock.

NARRATOR: But no one can be sure if the girls will even wake up.

ALISON WRAY: We've just taken our gloves off, and the fat lady hasn't sung, yet.

WIRGINIA MAIXNER: We'll see what Krishna looks like. I think she'll be a bit swollen, Krishna.

NARRATOR: Still asleep, the children are taken for brain scans. Trishna seems to be okay, but everyone is anxiously awaiting the results for Krishna.

WIRGINIA MAIXNER: This is the longest two minutes and 24 seconds in the history of mankind.

Not bad. It's not bad.

NARRATOR: There are no abnormal dark or light spots that would indicate bleeding in the brain, major damage or a stroke.

MOIRA KELLY: She's sound. Oh, my god, she's sound. Did you hear? Did you hear? Did you hear? Were you here? Did she tell you? This is the sort of M.R.I. I like.

NARRATOR: Back in intensive care, Trishna is beginning to stir.

NURSING ASSISTANT: She open eyes.

TRISHNA: Num num.

MOIRA KELLY: Trishna. Trishna. Hi, Bubby. Hello. Oh, you're a bit scared. What's wrong sweetheart? Oh, you want a hug? Oh. I want a hug, too. Oh, I want a hug, too. I want a hug, too. It's okay.

NARRATOR: Within minutes of waking up, Trishna discovers a new world has opened up to her.

MOIRA KELLY: She's never leaned on that side before; first time ever.

Well, they're not conjoined twins anymore, they're twins.

Oh, that's a nice little noise. Good girl. Good girl, sitting up like a normal little girl. And listen, Krissy's here, Trishna. Krissy's here. She's right over here. She's in that other bed, and you're in your own bed.

CHIARA TEWIERIK (Physical Therapist): Ready? You're going to go up in the chair. One, two, three!

NARRATOR: For the first time, Trishna holds her head upright.

CHIARA TEWIERIK: The other thing we're trying to do is encourage Trishna to start using her neck muscles, herself, and also try to turn towards the side she was never able to turn towards.

NURSE: Wow, look. You're up, now. You're tall, big, tall. Wow.

NARRATOR: With Trishna awake, concern is mounting. When will Krishna regain consciousness?

WIRGINIA MAIXNER: She had much more brain work. And that's why she should stay asleep. Another day, I think, for her.

MOIRA KELLY: Right. So another 24 hours?

WIRGINIA MAIXNER: Tomorrow, I reckon tomorrow.

MOIRA KELLY: And she'll give me my raspberry? That's all I want.

NARRATOR: On dialysis, because her kidneys are still not fully functioning, Krishna has more to overcome than her sister.

STAFFER: Oh, come on, sweetie pie, give us a little raspberry. You want to do it for Moira, don't you?

MOIRA KELLY: Can you hear me? Hello, Krissy, you cheeky monkey! Thwpp.

When she does it, I'll know she's neurologically sound. To me, that's normal.

Are you trying to talk to me sweetheart? Oh, is that right? Are you trying to talk to me? I love you. I love you. I love you, Krissy. Krissy, I'm here. Moira's here.

NARRATOR: Another 24 hours pass. Krishna is not responding to Moira's pleas.

WIRGINIA MAIXNER: Well, she's been asleep for a few days, now.

MOIRA KELLY:Yeah, hasn't she, yeah? Oh, she's moving her fingers a little bit.

WIRGINIA MAIXNER: A little bit more movement in the right than in the left. I expected her to be a little bit, a little bit slower.

MOIRA KELLY: When I get the raspberry, I'm going to text you.

WIRGINIA MAIXNER: Okay. You do that.

NARRATOR: Nearby, a wide-awake Trishna is reaching out for a sister who's no longer there.

MOIRA KELLY: You feel nice, yeah? You feel good?

You want to open those eyes? It's a little bit hard, isn't it, though, beautiful? Come on. Moira's here. Do Moira's little raspberry. All better. Now you have Moira with you all the time. Yeah. Hi, sweetheart. You going to do something for us? Yeah? What are you going to do? Come on. Hi. Hiya. Thwpp. Thwpp. Hiya. Thwpp.

She did it! She did the raspberry. She did the raspberry! She did the raspberry! She did the raspberry! That's all I've been waiting for is the raspberry. She did the raspberry. She did the raspberry. Oh, my god, she did the raspberry! Thwpp! I told you, she does it all the time with me.

She's a cheeky girl. Thwpp to you, too, you cheeky monkey! Welcome back!

KRISHNA: Thwwp.

MOIRA KELLY: I'm not lying when I said it. I know no one believes me. It wasn't an exaggeration. And she really is a rough…now, you know I'm serious.

Oh, my god, you did the raspberry.

Well that was worth a million, million dollars. I'm a rich woman. I'm a rich woman.

NARRATOR: Having started the journey for the twins almost three years earlier, now, aid worker Danielle Noble is seeing them separated for the first time.

MOIRA KELLY: There's another one over there.

ATOM RAHMAN: A dream comes true, right?

DANIELLE NOBLE: You know, I always knew they would.

NARRATOR: Remarkably, less than a week after their marathon surgery, Trishna and Krishna are ready to move out of I.C.U. into a general ward.

MOIRA KELLY: Goodbye, everyone. I love you, but it's time to go home. Thank you, every, every, everyone. Six days!

NARRATOR: Approaching their third birthday, the twins finally see each other face to face.

MOIRA KELLY: Trishna, Moira, Krishna.

Oh, she's touched her. I don't believe she's touched her.

NARRATOR: During their month-long recovery on the ward, Trishna and Krishna experience many firsts.

MOIRA KELLY: Yay! Yay!

TONY HOLMES: There's a whole new story about their development to come, which will be fascinating.

MOIRA KELLY: She just can't sit up, yet. She's not there yet. Bonk.

It makes you understand the role of the mother. It's probably the best job in the world.

WIRGINIA MAIXNER: Such a cute laugh.

When you look at them, and they're so bright looking at you, and they laugh and smile, you know they'll be fine.

TONY HOLMES: I'm the old man around here, and I don't think I've had a prouder moment to be in this hospital. If these kids can come out of it and lead normal lives, that's the whole idea.

ATOM RAHMAN: I think that will be the moment: when they will actually be playing with my children, I think that is the moment I'm waiting for.

MOIRA KELLY: Home, sweet home, yeah!

DANIELLE NOBLE: I think that's the message of the twins' story. That even when it's hopeless, it's not really hopeless.

MOIRA KELLY: Happy birthday! I just really want the little girls to go to play group. I want them to go to swimming lessons. I want them to walk down the street and no one even notices that there was ever something different.

WIRGINIA MAIXNER: I just can see myself wanting to be at their 21st. I want to see them grow up. I want to see them be 10, and I want to see them be 21 and be adults.

MOIRA KELLY: Hip, hip, hooray!

NARRATOR: One year later, the reality is more complex. Just as one conjoined twin is usually healthier than the other, separating them also has unequal risks and benefits.

Trishna is a lively outgoing four-year-old, quickly catching up to children her age.

MOIRA KELLY: Trishy, you just marvel in everything she does. She's grabbing life. It's like inhaling it, every five minutes, can't get enough of it.

Now, they always say development begins at separation. Trishy, she's at a different stage than Krissy. Krissy is really a baby, still.

NARRATOR: For Krishna, the first year has been more difficult.

MOIRA KELLY: They are very, very different in personalities.

NARRATOR: Always the weaker twin, Krishna came home from the hospital with more medical and developmental problems.

MOIRA KELLY: Krissy, well she sleeps in my bed with me, at the moment, still. She suffers from post-traumatic stress, so she is affected by that. So it's…developmentally, you've got one who is a baby and likes to throw and open and close doors, and the other one, who is a toddler, who likes have constructive play and be praised.

Very nice, Trish.

NARRATOR: But Krishna is slowly moving forward. She's begun to crawl…

MOIRA KELLY: (Singing) Over the hills and far away.

NARRATOR:…and recently learned to say "Mama." With each small step, Moira is hopeful for more.

MOIRA KELLY: I'd like to see her walking. I could dream when she talks. It'd be just a wonderful thing to see her do that.

BERNADETTE LUI (Physical Therapist): Krishna has developed very much at her own rate. So the next goal is to get her walking independently.

We're getting her standing nicely, here.

That's a nice big stretch you are having, Krissy.

NARRATOR: Her therapist is helping Krishna learn to use one side of her body, where her sister had once been.

BERNADETTE LUI: Her favorite position is, as you can see, is on her side.

NARRATOR: She is making slow but steady progress.

BERNADETTE LUI: Good girl.

MOIRA KELLY: She's had to work so hard, as a child, a very sick little girl with a lot of chronic conditions, attached to her sister who was a healthy robust little girl, and now, we just have to give her time.

NARRATOR: The twins are clearly on different paths. Krishna, still a baby; Trishna, off to school next year, but had they not been separated, neither would have survived to reach this point.

MOIRA KELLY: Tickle them!

NARRATOR: Thanks to a fortunate combination of love and skill, they have been given the gift of life.

Broadcast Credits

SEPARATING TWINS

WRITTEN AND PRODUCED BY
Wayne Dyer
PRODUCED FOR NOVA BY
Melanie Wallace
CO-PRODUCED FOR NOVA BY
Raoul Rosenberg
DIRECTOR
Ben Shackleford
EDITED BY
Raoul Rosenberg
Dave Redman
NARRATED BY
Lance Lewman
DIRECTOR OF PHOTOGRAPHY
Campbell Munro
RESEARCHER
Narrelle Vance
FIELD PRODUCER
Damian Estall
ASSOCIATE PRODUCER
Neil Mitchell
CAMERA
John Hall
Scott James
Mick Purdy
SOUND RECORDISTS
Justin Feenstra
Peter Graham
John Peterson
Chris Rynn
ASSISTANT EDITORS
Bill Kalajdziovski
Mat Jones
Alice Smith
COLORIST
John O’Neil
ORIGINAL MUSIC
Nerida Tyson-Chew
ADDITIONAL MUSIC
Music courtesy of APM Music
PRODUCTION SUPERVISOR
Stephen Rees
AUDIO POST PRODUCTION
Tristan Meredith
MEDICAL GRAPHICS
Animated Biomedical Productions
MOTION GRAPHICS
Raoul Rosenberg
PRODUCTION MANAGER
Chris Perkins
UNIT MANAGER
Judy Davenport
FACILITIES
twoONEzero POST
LEGAL
Anna George
Ben Nguyen
FINANCE
Tracey Hastie
Gerard Rowan
PRODUCED WITH THE COOPERATION OF
Children First Foundation
The Royal Children’s Hospital Melbourne
SPECIAL THANKS TO:
All The Doctors, Nurses & Staff at
Australian High Commission, Bangladesh
AXS Biomedical Animation Studio
Andy Christensen
Cold Spring Harbor Laboratory’s Dolan DNA Learning Center
Dr. Katrina Firlik
Dr. James T. Goodrich
DIRECTOR OF PRODUCTION FOR WTFN
Steve Oemcke
EXECUTIVE PRODUCERS FOR WTFN
Daryl Talbot
Ben Ulm
ONLINE EDITOR
Michael H. Amundson
AUDIO MIX
John Jenkins
NOVA SERIES GRAPHICS
yU + co.
NOVA THEME MUSIC
Walter Werzowa
John Luker
Musikvergnuegen, Inc.
ADDITIONAL NOVA THEME MUSIC
Ray Loring
Rob Morsberger
POST PRODUCTION ONLINE EDITOR
Spencer Gentry
CLOSED CAPTIONING
The Caption Center
MARKETING AND PUBLICITY
Karen Laverty
PUBLICITY
Eileen Campion
Victoria Louie
SENIOR RESEARCHER
Kate Becker
NOVA ADMINISTRATOR
Kristen Sommerhalter
PRODUCTION COORDINATOR
Linda Callahan
PARALEGAL
Sarah Erlandson
TALENT RELATIONS
Scott Kardel, Esq.
Janice Flood
LEGAL COUNSEL
Susan Rosen
DIRECTOR OF EDUCATION
Rachel Connolly
DIGITAL PROJECTS MANAGER
Kristine Allington
DIRECTOR OF NEW MEDIA
Lauren Aguirre
ASSOCIATE PRODUCER
POST PRODUCTION
Patrick Carey
POST PRODUCTION EDITOR
Rebecca Nieto
POST PRODUCTION MANAGER
Nathan Gunner
COMPLIANCE MANAGER
Linzy Emery
DEVELOPMENT PRODUCERS
Pamela Rosenstein
David Condon
SENIOR PRODUCER AND PROJECT DIRECTOR
Lisa Mirowitz
COORDINATING PRODUCER
Laurie Cahalane
SENIOR SCIENCE EDITOR
Evan Hadingham
SENIOR SERIES PRODUCER
Melanie Wallace
MANAGING DIRECTOR
Alan Ritsko
SENIOR EXECUTIVE PRODUCER
Paula S. Apsell
Presented by electricsky.com
A WTFN Production for NOVA
© 2010 WTFN
Additional Material © 2011 WGBH Educational Foundation

Image

(doctors operating)
Courtesy Robert Reitmaier, The Royal Children's Hospital Melbourne

Participants

Almaz
20 years old
Ana Mari & Clotilde
Ayehu
25 years old
Barbara
Beth Van de Bussche
Concepcion & Patricia
Evan Johnson & Jeffrey Grattan
Westmont High School westmont.cuhsd.org/
Fikre
Ayehu's friend
Lee
Physicist: von Braun Team

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