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School of Medicine
Dome - Too Numerous to Count
Dome March 2013
Too Numerous to Count
Date: March 1, 2013
A TRIUMPH OF TEAMWORK: Surgeons who participated in the double arm transplant gather in the operating room shortly after the historic surgery. W.P. Andrew Lee, center, director of the team, is flanked by surgeons from Johns Hopkins, the Curtis National Hand Center at MedStar Union Memorial Hospital, and Walter Reed National Military Medical Center. The flag behind them flew over the U.S. military base in Kandahar, Afghanistan, on Sept. 11, 2012.
Planning and support for the historic double arm transplant came from all levels of the hospital.
Last December, Brendan Marrocco became the first combat veteran to receive a double arm transplant, the most extensive surgery of its kind ever performed in the United States. Also the first to be conducted at The Johns Hopkins Hospital, the 13-hour operation required meticulous planning and rehearsal to accomplish the complex task of connecting bones, blood vessels, muscles, tendons, nerves and skin from donor to recipient.
A team of 16 plastic, orthopedic and microvascular surgeons led by W.P. Andrew Lee, director of the Department of Plastic and Reconstructive Surgery, performed the transplant. Marrocco also received an infusion of the deceased donor’s bone marrow cells to help prevent rejection of the new limbs.
In January, Marrocco and members of the surgical team explained the surgery and its outcome at a press conference that was broadcast internationally. Off camera, however, dozens of other physicians, nurses, technicians, therapists, pharmacists, facilities workers and support staff also played a role in giving the 26-year-old Iraq War veteran the opportunity to once again use his hands.
Transplant nurse practitioner Cindy Cohen describes the forces supporting this surgery as “TNTC: too numerous to count.” Planning for the transplant began almost two years ago, and the teamwork and planning by the nursing staff proved crucial, Lee says. The following details, provided by Cohen, nurse practitioner Kate Knott, operating room nurses Shruti Thomas and Mary Grace Hensell and nurse educator Dorothy McDevitt, capture the breadth of this collaborative effort.
“I think the resilience of the human spirit is overwhelming. It’s such a powerful thing that Brendan is who he is despite what he has faced, and that his family is so determined to see him through this.”
Complex Planning, Complex Surgery
The double arm transplant required coordinating four operations; a team of surgeons was assigned to preparing each arm of the patient and of the donor for surgery. Multidisciplinary teams discussed each stage of the endeavor, from the recovery of a suitable donor’s arms to the patient’s special needs after surgery. In addition, surgeons went through four rehearsals operating on cadavers at the Curtis National Hand Center at MedStar Union Memorial Hospital.
Transplant coordinators and operating room nurses scheduled regular meetings—one group met every week for almost two years—at The Johns Hopkins Hospital. Some meetings were held in the operating room on Sunday mornings. One goal was to determine how to configure the space for the roughly 35 people who would use it during the surgery, making room for 16 sitting stools for the surgeons, as well as two microscopes and other equipment.
During several run-throughs, stand-ins for the surgical staff were positioned around the two operating tables. Roughly 20 instrument trays, each holding 50 to 100 tools, were needed for this highly specialized transplant; some pieces of equipment, custom-made for the surgery, were ordered in advance. Planners also procured extra headlights for the surgeons and placed electricians on call in case any power problems occurred.
OR nurse leaders staged two trial runs of the phone tree call to surgery, making certain there were enough nurses and technicians to be able to work with the surgeons for 24 hours if the situation required it. They also filled thick back-up notebooks with detailed instructions of necessary preparations, including worksheets, diagrams of the room’s physical setup, lists of instruments and equipment and phone lists.
As Marrocco and his physicians waited for a donor who would be a good match for his arm size and skin color, transplant coordinators arranged for prosthetic arms that would eventually replace the donor’s own, basing their requirements on Marrocco’s own. (The gift of artificial arms enabled the donor’s family to have an open-casket viewing that was aesthetically appropriate, if that was their wish.)
“Kidney transplants, heart transplants and liver transplants save lives. Brendan’s transplant is life-changing. Hopefully we’ve given him a chance to do the things he couldn’t do. ”
On Dec. 16, when word came that a suitable donor was available, the countdown to surgery began. One surgeon was summoned from California, another was recalled from a Christmas trip to Austria. The next evening, Johns Hopkins surgeons flew to Pennsylvania to recover the arms from the deceased donor. (Because of dense fog in the Baltimore area, the team was forced to fly out of Dulles airport. Fortunately, the weather had improved sufficiently for them to return to Baltimore-Washington International Airport, saving time that was precious for the transplant.)
When Marrocco arrived at the hospital, numerous care providers prepared him for surgery, looking for potential medical problems, drawing his blood for tissue typing, and using ultrasound to make sure that the veins in what remained of his original arms—his left arm had been amputated below the elbow, his right arm above it—were located and properly marked to help the surgeons connect them. A counselor evaluated his psychological readiness.
As the patient entered the operating room a little past midnight on Dec. 18, he thanked the group who had spent months rehearsing for his arrival. They began their work. By mid-afternoon, Brendan Marrocco had two new arms.
“It’s amazing to me how many people at Hopkins went out of their way to help make Brendan’s surgery successful. The kind of planning and teamwork that were involved went way beyond any routine job description.”
—W.P. Andrew Lee
An Unforgettable Christmas
The young veteran spent the Christmas holidays in the surgical intensive care unit, where he benefited from another piece of advance planning. Because the postoperative stage of recovery required a temperature of 80 degrees to ensure good blood circulation, a facilities specialist removed the patient’s room from the building’s temperature-controlled power grid and reset it manually prior to the surgery.
When Marrocco was transferred to his room, more than a dozen nurses assisted in his care. They met regularly to update one another on his condition and to assemble reports that also might prove critical in caring for the next arm transplant patient.
Three days after surgery, Marrocco began working with Molly Ferris, a clinical hand therapist who continues to see him six days a week in the Johns Hopkins Outpatient Center. His doctors expect that it will take several years for nerves to reinnervate the muscles for maximum function of his new hands.