The Perfect Hand Transplant
ON MONDAY, JANUARY 26, 2015, JONATHAN KOCH AWOKE feeling awful. God, I’m sweaty, he thought. Even my knees are aching. And what’s up with my freezing-cold feet?
Jonathan was supposed to fly from Los Angeles to Washington; as the co-runner of a reality TV production company, he was expected at a conference that afternoon. Instead, he headed not to the airport but to a medical centre, where doctors – finding no cause for his discomfort – gave him a shot of morphine and sent him on his way. He made it to Washington, checked in to his hotel, and fell into bed by midnight.
The next morning, he could barely get up. Why does my body feel like concrete? he wondered. His eyes were beyond bloodshot. He stopped by a pharmacy to buy an over-the-counter pain reliever, eye drops and an energy drink, then dragged himself to his first meeting. Midway through the second meeting, Jonathan looked at a colleague and saw three of her. When he stumbled in the hallway a minute later, she insisted on taking him to the emergency department. “You’ve got work to do,” Jonathan told her. “I can get there on my own.”
A taxi dropped him off at George Washington University Hospital around 11am. His temperature was 38.8°C.
Other than a knee surgery and a history of kidney stones, Jonathan Koch’s body had never failed him, and he’d always returned the favour. At 1.85 metres tall and 102 kilograms, the 49 year old was an exercise addict who led a daily predawn workout for friends. He didn’t drink or smoke, ate a high-protein diet and loved his sleep. He and his girlfriend, Jennifer Gunkel, were typically in bed by 9pm.
Now doctors wondered if he had pneumonia. Despite a battery of examinations and pain surging through his limbs, he managed to text Jennifer: “They are killing me in here, baby.”
Tuesday night fell, and the hospital admitted Jonathan to the ICU. His condition remained a mystery, and the pain was beyond debilitating. His circulation slowed; his hands and feet were turning blue as his body pulled blood from his limbs to protect his vital organs. Around 2am, Dr Lynn Abell levelled with Jonathan. “Text everyone you love,” she said. “You’re probably going to die tonight.”
By the time Jennifer arrived in Washington on Wednesday night, doctors had put her partner into a propofol- induced coma. The next day, he was in full-blown septic shock. With his outer extremities deprived of oxygenated blood, gangrene set in. Despite huge doses of antibiotics, Jonathan’s body “was getting ready to die”. Chance of survival: ten per cent.
MOST OF US THINK THAT
patients who are put into a medically induced coma fall into a peaceful sleep. In fact, many people who’ve been ‘put under’ have terrifying hallucinations or nightmares. As Jonathan lay unconscious over the following weeks, he had both. He believed he was being held hostage by a family of ghouls with giant faces and jagged teeth. Lashed to a wooden bench, he was bitten repeatedly by snakes. He sensed the presence of his 15-yearold daughter, Ariana, despite her being more than 4800 km away. (With Jonathan’s condition so uncertain, Ariana, who had bronchitis, stayed at home with her mother.) Jonathan and his daughter had a tight bond. Each February since pre- kindergarten,
they’d attended her school’s father– daughter dance. Now he was missing it for the first time.
On the final day of his two-and-ahalf-week coma, Jonathan saw himself in an empty, misty room with two doors. He understood that one door was the way back to existence; the other, the way out. Then he heard a deep voice. “If you choose to live, there will be a price that is so heavy that at times you’ll regret it,” the voice said. “If you decide to go back, it will be the fight of your life.” Jonathan knew his answer. A fight? Bring it.
In an instant, he was propelled upwards like a torpedo through dark water that grew lighter and lighter. Finally he burst through. His first words were “How did I get here?” Then he looked down at his feet, which were strangely black and beginning to shrivel. “Wow,” he said. “Impressive.”
During Jonathan’s 39 days at George Washington, his hands and feet became necrotic, or as he put it, downright ‘Egyptian’ – leathery, mummified, charcoal black. Doctors sought to discover what had thrown his system into chaos, ruling out candidates one by one. He didn’t have measles or Lyme disease. There was evidence that he had antibodies to the Epstein-Barr virus, which can result in chronic fatigue syndrome, but 95 per cent of adults have the virus and do not develop complications. For a while, doctors thought he might have a rare bone marrow cancer and started him on chemotherapy. Their strategy: treat every possibility at the same time. And it worked; he survived.
That March, hoping to discover what had caused his illness, Jonathan made the difficult decision to leave the hospital to travel to the Mayo Clinic in Rochester, Minnesota. “The one thing I don’t understand,” he admitted to Abell on his last day, “is, why did this happen?” The doctor’s response: “Jonathan, the reason you took such great care of yourself was not to avoid this. It was to survive this.”
Still, Jonathan’s time at Mayo was rough; his limbs were in constant, unspeakable pain. He lost 18 kilograms. His hands and feet, wrapped in gauze, looked like paws. Doctors at Mayo began to discuss the possibility of amputations and, perhaps eventually, a transplant for his ruined left hand.
On April 20, 2015, 85 days after Jonathan had been admitted to George Washington, he and Jennifer told Mayo they wanted to return to Los Angeles for Ariana’s 16th birthday. That was when someone mentioned a doctor whose name they’d never heard before: Kodi Azari.
AZAR I ,
48, is the surgical d i rec tor of the Hand Transplant Program at the University of California at Los Angeles (UCLA). The field is still relatively new. The first hand transplant to achieve prolonged success was performed in 1991 in Kentucky; by 2015, fewer than 85 procedures had been undertaken worldwide. But Kodi Azari is at the forefront. He has performed as a lead surgeon in five hand transplants, including the first double-hand transplant and the first arm transplant in the US.
The doctor had some hypotheses he wanted to test, provided he could find a patient with the ideal requirements: excellent health, enormous self-discipline, and – rarest of all – a limb that needed to be replaced but had not yet been amputated. Most hand transplant candidates have been injured in accidents or in battle, when a catastrophic event forces an emergency amputation to minimise suffering.
Generally that means the arm is severed closer to the elbow than to the wrist, and the nerves and tendons are trimmed and tucked inward to lessen discomfort. All those tucked- in nerves and tendons tend to merge over time into a jumble that is difficult to connect to a new hand with precision.
Wouldn’t it be great, Azari postulated, if a transplant recipient’s arm could be amputated in a way that prepped it specifically to receive a new limb? How much more quickly would a patient recover if each tendon, nerve, artery and vein were left in place and marked like so many coloured speaker wires to be hooked up to a matching apparatus? Azari believed this fantasy patient would awaken post- op, look at the new hand, and be able to move the fingers right away. Now all he needed was the right patient.
And then he met Jonathan. Azari set about examining his patient a week after his return from the Mayo Clinic.
He started with Jonathan’s ruined left hand, with its charred-looking exterior except for a tiny patch of palm. The right hand was better off; while the fingers and thumb were blackened, the rest could be saved. Damage to the left foot was mostly confined to the toes, but the right looked as if it had been fashioned wholly out of charcoal briquettes. “Get rid of it,” Azari said. “It’s a no- brainer.” Something about his manner – direct, gentle, kind around the eyes – calmed Jonathan and Jennifer. “I will make you this promise,” the surgeon said. “I will not do anything to make you worse.”
ON JUNE 23, 2015, DE
TERMINED TO save as much healthy tissue as possible, Azari amputated Jonathan’s left hand and about half of each finger on his right. Severing the left hand closer to the wrist than to the elbow, Azari kept all the nerves and tendons long and extended, which would give him plenty to work with later.
There was much to prepare. UCLA, where Azari hoped to perform the surgery, required Jonathan to undergo myriad physical and psychological tests. Then came the challenge of matching a donor’s left hand with Jonathan’s in terms of size, skin tone and hair pattern. While he waited, Jonathan tried to relearn tasks that he’d once taken for granted. He taught himself to hold a fork using the stubs of the fingers that remained on his right hand and learned to use a stylus to type on his phone.
On August 17, 2015, Jonathan and Jennifer were married in a tiny ceremony in their backyard. The next day, doctors amputated Jonathan’s right leg midway between his knee and his ankle and snipped off the necrotic toes on his left foot. Jonathan tried to joke about the horror of watching parts of himself disappear, calling himself Mr Potato Head after the children’s toy. But the loss of his foot hit hard. “The hardest part for me has been in the period of subtraction,” he said. “This is the beginning of the period of addition.”
Eight weeks after his foot surgery, Jonathan was fitted for his first prosthesis; he walked right away. Soon he would upgrade to a Triton smart ankle, a bionic contraption he could adjust for whatever type of movement he needed to do. He’d also have a prosthesis for running called a Rush Foot. “Eventually I’ll have a special tuxedo leg for the Emmys,” he joked.
Azari was less at ease. “Hand
“THE HARD PART HAS BEEN THE PERIOD OF SUBTRACTION,” JONATHAN SAID. “THIS IS THE BEGINNING OF THE ADDITION”
transplants throw you curveballs,” he said. “And there is no cookbook on how to do it.” So like a chef trying out a dish before serving it, Azari and his team practised Jonathan’s surgery several times in the anatomy lab.
On October 24, 2016, a donor candidate was found who shared Jonathan’s blood type and had a hand that matched his. The next morning, Jonathan walked into the medical centre at 9.45. Azari met him with a promise: “We’re going to do this.” As Jonathan was prepared for surgery, the surgeon headed to another hospital. It was time to pick up Jonathan’s new hand.
When Azari arrived, the donor was on life support, and the doctor had the rare opportunity to meet the donor’s brother and pastor.
AT 3.32PM, the first cut was made to prepare Jonathan’s arm. Azari arrived within the hour and joined his team. The first curveball came right away. The doctors had planned to sever the radius and ulna bones at about 11 cm above the wrist. But after opening up Jonathan’s arm, preserving more bone seemed possible. This approach might enable the arm to heal better and have more range of motion, but there were no guarantees. The surgeons came to a unanimous decision: preserve another 7 cm of each bone, affixing the hand just 4 cm above the wrist.
Tick, tick, tick. They were only a few hours in, with at least a dozen more to go. The team sutured a few key tendons together. Then the doctors moved on to the arteries and veins. Here came the second curveball. Because of the gangrene and the lack of use, Jonathan’s veins and arteries were very small – “like chives”, Azari says. They were also tough with scar tissue, which made suturing them more difficult.
As the team continued repairing the musculature of the arm, pulling it more tightly together, the arteries and veins they’d attached early on began to protrude, like a loop of extra yarn. The surgeons had expected this. Those vessels were shortened and resutured.
Various tendons were similarly tightened, particularly in Jonathan’s pointer, middle and ring fingers. “We went back and did these three tendons many times until we got them right,” Azari says. The tendons of the
forearm, meanwhile, were woven into one another over a 7.6-cm span to maximise strength and resist tearing.
At 11.01pm, after the doctors had removed the tourniquets and clamps, Jonathan’s new hand went from white to pink to red. The fullness returned to the tissue, and the pulse began to pound. It was exhilarating.
The surgeons worked to complete repairs on the remaining tendons. At 7.07am, the hospital called Jennifer to tell her that the team was closing and suturing. They’d been at it for 17 hours and 37 minutes.
Jonathan’s first words after emerging from the anaesthesia were “Did you do it?” When Azari answered, “Yes”, Jonathan looked down at his new hand and started singing the theme song from Rocky. Jennifer arrived at the hospital about an hour later. It was her birthday, and she was ready for her gift. “Move your thumb,” she told Jonathan. And he did.
THE TOTAL COST OF JONATHAN’S
transplant and care is impossible to measure, but some past procedures have cost more than US$1 million.
So what made him sick? He will never know for sure. Jonathan says the consensus is that exposure to the Epstein-Barr virus, combined with stress, may have triggered “a one-in20-million event”.
Now he is focused on what’s ahead. He is back to leading intense workouts for friends, and he’s learning to use a set of prosthetic fingers fitted to his right hand.
Recently, Jonathan put on a suit and tie, his Triton smart ankle, and a pair of black leather high-tops and took Ariana, a senior in secondary school, to their final father–daughter dance. Decorating his lapel were 14 red hearts – one for each dance they’d attended together. Few people other than Ariana knew that his attendance itself was a miracle.
Jonathan Koch before his 17-hour hand-transplant surgery
The day after Jonathan and Jennifer’s wedding, doctors amputated his right leg
Jonathan Koch wasn’t a lefty before his hand transplant surgery, but he is now