By: David Greenwald
Photography by Ann Johansson
At 2:55 in the afternoon on March 5, 2011 – one of those lovely sun-washed days in Los Angeles – Emily Fennell moves the index finger of her right hand. This wouldn’t be remarkable if not for the fact that just hours earlier Emily had no right hand at all.
But now, 16 hours after she was wheeled into O.R. 12 on the second floor of Ronald Reagan UCLA Medical Center, Emily has a new right hand of flesh and bone, with five long, slender fingers, and the hope of recapturing a more normal life. And with that slight, almost imperceptible stirring of her finger, Emily Fennell, a 26-year-old mother from Yuba City, California, becomes a part of history as the first patient in the Western United States to receive a hand transplant. And UCLA makes history as the first hospital west of the Rockies to perform the landmark surgery.
Gathered around Emily’s O.R. bed before she is brought back to her room in ICU for recovery, the surgical team that began its labors in the darkness of a Friday night and has concluded them in the light of a Saturday afternoon appears to be in awe. Nick Feduska can’t peel his gaze from her right hand, which is sheathed in a thick wrap of white gauze and bandage with just the fingers, slightly curled, exposed.
“It’s beautiful,” says the organ preservationist for the fledgling UCLA Hand Transplant Program and a member of the recovery team that flew by helicopter to San Diego to procure the donor limb. The match is uncanny; the size and shape of the hand, the taper of the fingers, the skin tone and even the hair pattern are so close to Emily’s own hand that the new limb already seems to wholly belong to her.
“It looks great,” Feduska murmurs. “It just looks great.” His eyes, like those of many others now drawn together around Emily, are brimming with tears.
Kodi Azari, M.D., is a dedicated surgeon and scientist, but he becomes lyrical when he speaks of the hand – an organ of both delicacy and strength that is capable of painting a masterwork, playing a musical instrument, picking up a tiny pin or wielding a sledgehammer. “There is something magical about the hand,” he says. Not only do we use it to touch and feel, but also to see and to express ourselves and communicate with others. “I am not a religious man,” Dr. Azari continues, “but if there is an argument for creation, it is the hand. It makes no sense to me that something as exquisite as this could have been formed by just random chance.”
The human hand is as complex as it is elegant. Wrapped tightly within that small package are 27 bones, 34 muscles to move the fingers and thumb, 48 named nerves, dozens of blood vessels and more than 100 ligaments and tendons. With all those moving parts, transplanting a hand is a highly intricate and technical procedure that requires a large team of specialized surgeons. For Emily’s operation, the O.R. team assembled by Dr. Azari, the surgical director of the UCLA Hand Transplant Program, numbers 19: nine surgeons with expertise in hand, orthopaedic and plastic surgery; three anesthesiologists; four nurses; an O.R. technician, a preservationist and a transplant coordinator.
All surgery carries risk, and this operation will be particularly lengthy. But the greater risk comes from the immunosuppressive medication that Emily must take for the rest of her life to prevent rejection of her new hand. Though rejection has not proven to be a significant problem in past cases, it remains a primary concern, says Sue McDiarmid, M.D., a transplant specialist who was instrumental in conceiving the UCLA Hand Transplant Program and now is its medical director. When Emily was first being considered for the program, Dr. McDiarmid laid out all the potential consequences of immunosuppression: the possibility of renal failure, hypertension, liver damage, elevated cholesterol, ulcers.
“I think I scared the living daylights out of her,” she says. In truth, Emily appreciated Dr. McDiarmid’s frankness. “She wasn’t just selling the program. She really cared about me as a patient and that I have all the information necessary to make my decision,” Emily says.
Emily also benefits from the fact that she, unlike the majority of transplant patients, is young and very healthy. “She is an ideal candidate,” Dr. McDiarmid says. “She has a terrific support system. She is very together medically, emotionally, family-wise, supportwise, and she seems to have the ability to achieve this balance in her life in spite of what obviously was a horrendous event for her, the loss of her hand.”
Once the operation is complete, the first post-surgical measure of success is whether or not the graft survives. After that, Dr. Azari says, “we will be judged on how much function and sensation returns.” Function – the ability to move and use the hand – is the first to return. Because the tendons in the new forearm and hand, which are like cables to deliver movement, are attached to those embedded within the patient’s existing arm, the capability for gross movement – wiggling the fingers or bending the wrist, for example – is almost instantaneous, though return of strength and function to the small, intrinsic muscles that enable fine movement takes much longer.
Sensation returns more slowly. Reinnervation, the restoration of nerve function, progresses at about 1 millimeter a day, Dr. Azari says. At that rate, it can take 12-to-18 months to reestablish a good level of sensation in the new hand.
UCLA’s hand-transplant program is the fourth in the country, and the first in the Western United States. The others are in Louisville, Kentucky; Atlanta, Georgia; and Pittsburgh, Pennsylvania, where Dr. Azari participated in four of the previous 12 hand transplants that had been done in the country. The first successful hand transplant was performed in 1998 in France, and more than 40 have been done worldwide.
Limb transplantation is a still-experimental new frontier in medicine that involves composite tissues. Unlike a liver or a kidney, which has a more homogenous tissue composition, the hand is bone and nerve and tendon and muscle and skin and blood vessels, and each has its own characteristics for healing and regeneration. “Since UCLA is one of the premier transplant programs in the country, it is natural for us to start doing composite- tissue transplantation,” says Ronald W. Busuttil, M.D., Ph.D., executive chair of the UCLA Department of Surgery and a groundbreaking liver-transplant surgeon.
When he and Dr. Azari brought the idea of establishing such a program to the UCLA Health System’s leadership, it was immediately embraced. “I’m trained as a psychiatrist, so I wait until people finish their sentence before responding,” says David T. Feinberg, M.D., M.B.A., CEO of UCLA Hospital System. “Had I not been trained like that, I would have said ‘yes’ before they finished their sentence. The answer was, ‘Of course!’”
That decision was not without some cost; because the procedure is experimental, it is not covered by insurance, so funds were secured from both within the health system and from outside sources to establish the program and to cover the first several participants.
In addition, embarking on such a program involves both ethical and economic concerns. Is it okay, for example, to potentially turn a healthy and well-adapted amputee into a transplant patient at risk for serious illness from a lifetime of immunosuppressive medication? What about the issue of identity? Would the recipient of a transplanted hand identify the limb as “self,” or would it create conflicts in identity? Is the cost of hand transplantation appropriate, given today’s constrained healthcare resources? After lengthy consideration and discussion with the principal physicians, members of the UCLA Ethics Committee were satisfied that all such concerns were being addressed.
At around 9:30 Friday morning, Lifesharing, a non-profit organ- and tissue-recovery organization for San Diego and Imperial Counties, notifies UCLA that there is a potential donor. E-mails and telephone calls fly back and forth. Is it a good visual match? Will the donor’s family consent? How soon can Emily be in Los Angeles? By early Friday afternoon, an e-mail message announces: “It’s a go!”
Emily is at work when she receives the call on her cell phone from Erin Core, the transplant coordinator, telling her there is a donor. Upon hearing the news, she bursts into tears. Emily calls one of her two sisters, Andrea, crying into the phone, “They have a hand!”
After a flight from Sacramento to Los Angeles, Emily and Andrea arrive at the front entrance to Ronald Reagan UCLA Medical Center at around 6:15 p.m.
While Emily is in the ICU to be prepped for surgery, Dr. Azari, Drs. Scott Mitchell and Tristan Hartzell, Feduska and Core take an elevator to the hospital roof, where a helicopter is waiting to fly them to San Diego to recover the donor limb.
A few hours later, the recovery team has completed its work. It is now time to bring Emily to the operating room. As she is rolled in her bed down the long corridor to the O.R. suites, Emily’s mother, Kim Herman, who arrived at the hospital shortly after her daughters, and Andrea follow. The procession stops at the red line on the floor, beyond which family cannot pass. It is the moment for Kim and Andrea to say good-bye. Each leans over to wrap Emily in a long, tight hug. The medical team has assured Emily that even at this stage, she can still change her mind about the surgery. “Are you sure?” Kim asks very softly. “Yes,” Emily responds. “I’m sure. I’m scared, but I’m sure.”
As Emily is undergoing further preparation, Dr. Azari and the procurement team enter the O.R., trailing a blue plastic cooler on wheels that contains the donor limb. “It went super well,” Dr. Azari says. “It could not have been better. The hand is, I think, perfect. We’re very excited.”
Shortly after, Emily is sedated. Dr. Azari opens the cooler, digs his hands into the ice and lifts out the limb that will become her new hand. It is wrapped in blue cloth and gauze. Once removed from its swaddling, the limb, which is small and delicate, with a yellowish cast, is placed palm-up on a steel tray that has been covered in a layer of ice and a slate-blue towel saturated with frigid water. It is necessary to keep the hand as cold as possible throughout the procedure to minimize degradation of the tissues – an environment that leaves the surgeons’ fingers chilled and aching as they work.
At one minute before midnight Friday, Dr. Azari makes the first long incision along the inner forearm of the donor limb. The surgery has begun. Two surgical teams work simultaneously, one to prepare the donor limb and the other to ready Emily’s arm to receive her new hand. For both teams, the task is essentially the same: dissect the limbs to reveal, identify and preserve the important internal structures – the bones, tendons, blood vessels and nerves – that must be connected to successfully accomplish the transplant.
Chatter in the O.R. is minimal. “How’s it looking, Prosper?” Dr. Azari asks the team working on Emily’s forearm at 12:45 a.m. “Veins okay?” “We have two really nice ones,” responds Prosper Benhaim, M.D., the lead surgeon working on Emily. “I can’t tell you how happy that makes me,” Dr. Azari says.
It is a slow, laborious process. After each structure is revealed and carefully trimmed away from the surrounding tissue, a small piece of blue cloth marked in indelible ink with an identifying abbreviation is sutured on: FDPs (flexor digitorum profundus tendon to the small finger); BV (basilic vein); PL (palmaris longus tendon), and so on. These bits of cloth are essential; when it is time to join the donor hand with Emily’s arm, they will ensure that the corresponding structures can be correctly matched and sewn together. The surgeons will tag 23 tendons, two arteries, four veins and three nerves.
By 3 a.m., the dissections of both the donor limb and Emily’s arm are completed. The bones of the donor forearm are then cut, so the length of Emily’s two arms will match. A pair of teal-green titanium plates are screwed onto the ulna and radius bones of the donor forearm and, after fluoroscopically confirming the positioning of the plates, the limb is carried across the O.R. to the table where Emily lies. The donor limb and Emily’s arm are aligned, and the surgeons screw the plates down onto Emily’s bones. At 4:30 a.m. – 4-½ hours after the operation began – Dr. Azari lifts Emily’s arm with the now-joined donor limb and announces, “Emily has a new hand.”
There are still 10 hours to go before the surgery is finished.
Emily lost her hand on June 11, 2006, when a car she was riding in rolled over as the driver tried to avoid another vehicle that turned in front of them on a street in Inglewood, California. When the car started to tumble, Emily put her right arm up to brace herself, but her hand went out the open sunroof and was trapped between the top of the car and the roadway as the vehicle slid upside down. It was, in Dr. Azari’s words, “a complete degloving injury.” Emily’s hand was so badly mangled that surgeons at UCLA , where she was taken, had no choice but to amputate about 1-1/2 inches proximal to her wrist. Neither the driver nor another passenger in the back seat was seriously injured.
On the underside of Emily’s left forearm is a tattoo that reads “Believe.” “After I had my accident, I just had to believe that I could get through it,” she says, scratching the ears of her white Lab, Duke, and talking on the back patio of the house in Yuba City that she and her 6-year-old daughter share with Emily’s father, Danny. She could have made another choice – “Woe is me, take drugs the rest of my life and be high and become the kind of person that nobody wants to be around,” she says – but instead, she recognized that “I was alive, I would still get to see my daughter grow up, I could still live my life.”
Before her accident, Emily was right-handed. Though she was fitted with both a myoelectric prosthetic hand and a traditional “hook,” she found them uncomfortable and awkward to use. With therapy, she learned to do everything with her left hand: groom herself, dress and tie her shoes, cook, write, drive, type (45 words a minute, fast enough to hold a job as an office assistant), and perform the basic skills necessary to take care of her child.
But she can’t put her hair in a ponytail. She can’t teach her daughter how to tie her shoes. She can’t ride a jet ski or snowboard. She can’t cut her food. “It’s been the little things that I think have been the hardest to overcome,” Emily says. And she can’t improve her typing enough to advance to the next level in her work to better support herself and her child.
So she must “Believe,” and she has faith that she can overcome this next trial as well, first the surgery and then the long post-surgery therapy – six days a week, three-to-six hours a day – and the years of ongoing rehabilitation. “If you believe you can get through something that is difficult, then you can,” she says.
The first connections Dr. Azari makes are the tendons. “It is one of the hardest parts of the surgery,” he says. The challenge is to establish the right tension and balance. If the tendons are too tight, Emily will have difficulty curling her fingers and closing her hand. If they are too loose, her fingers will be floppy. Getting it right “is an art,” Dr. Azari says. As he and Dr. Benhaim work, splicing and weaving the tendons together before suturing, they are assisted by Dr. Hartzell and Roee Rubinstein, M.D., and as they progress, they periodically stop to curl and flex the fingers to evaluate the quality of their connections.
By 8 a.m. Saturday, they are done with the tendons, and it is time to connect the blood vessels – first the veins and then the arteries. Working with a magnifying scope, microsurgeons Christopher Crisera, M.D., Jaco Festekjian, M.D., and Charles Tseng, M.D., skillfully manipulate and stitch the small vessels together. Once connection of the veins is completed, it is time to establish blood flow to Emily’s new hand.
Connection of the first artery is a milestone; it is finished at 9:39 a.m., and the tourniquet that has been restricting the circulation to Emily’s arm throughout the surgery is released and blood again flows through her vessels. As the blood courses through the newly connected artery into the donor hand, which has been without blood for more than 12 hours, it warms and slowly turns from a dull, lifeless pallor to pink and takes on the appearance of a living hand. The surgeons then connect the second artery. A Doppler is attached to Emily’s arm, and the whoosh-whoosh of blood flowing through her arm and new hand can be heard throughout the operating room. Finally, the nerves are connected. By 1:30 p.m., the skin flaps have been closed in an elongated zig-zag incision line. Drain lines are inserted and sewn into place, and final closures are made.
It is 2:30 p.m. More than 14 hours after Dr. Azari made the first cut, the surgery is over.
As Emily slowly emerges from anesthesia, Erin Core, the transplant coordinator, stands at the head of her bed. She asks Emily if she can see her new hand and then gently lifts Emily’s head so she can look. Though she is sill very groggy, Emily casts her eyes down to her right arm. “Can you see it?” Core asks. Emily nods slightly. “Thumb,” she says. A few moments later, in response to Core’s encouragement, she moves her finger for the first time.
Upstairs in the ICU a short while later, Kim stands outside her daughter’s room as the nurses settle Emily back in following surgery. As Kim watches, she struggles to stay calm. “When you are about to become a mother,” she says, “one of the things that you hope for is that your baby will have all her fingers and all her toes.” Kim’s composure suddenly fractures. She presses her fingers to her lips and her eyes moisten.
“Emily lost that. But now she has all her fingers and all her toes,” Kim continues, her voice choking as she looks at her child lying in bed with her new right hand resting beside her. “I’m so grateful. Now she has that back.”
David Greenwald is editor of UCLA Medicine.
As Kodi Azari, M.D., surgical director of the UCLA Hand Transplant Program, notes, “No single person can do this by himself. It requires an enormous group of people who are dedicated, willing and believe in the mission. Without everyone giving 100 percent, this would not be possible.” His team in the O.R. for the first hand-transplant surgery performed at UCLA numbered 19. They were:
Kodi Azari, M.D. (hand surgery, orthopaedic surgery and plastic surgery)
Prosper Benhaim, M.D. (hand surgery, orthopaedic surgery and plastic surgery)
Christopher Crisera, M.D. (plastic surgery)
Jaco Festekjian, M.D. (plastic surgery)
Tristan Hartzell, M.D. (hand surgery, orthopaedic surgery and plastic surgery)
Timothy Miller, M.D. (plastic surgery)
Scott Mitchell, M.D. (hand surgery, orthopaedic surgery)
Roee Rubinstein, M.D. (hand surgery, orthopaedic surgery and plastic surgery)
Charles Tseng, M.D. (plastic surgery)
Neesa Patel, M.D.
Randolph Steadman, M.D.
Bita Zadeh, M.D.
Kristine Alessandrini, R.N.
Andrew Aybar, R.N.
Donna Russel-Larson, R.N.
Anna Wang-Matheson, R.N.