Soldier Gets a Rare Double Arm Transplant
Brendan Marrocco was on patrol in Iraq 3 years ago when an explosion claimed all four of his limbs. He was the first Army soldier to survive a quadruple amputation. Now, he is the first soldier to receive a very rare double arm transplant at the Johns Hopkins Hospital. He is 26 years old.
• Logistics: The surgeons practiced four times on cadavers before the real thing. There were 4 teams of 3 surgeons each: one for each arm from donor and recipient. The deceased donor and living recipient do not need to match in gender, but in size, skin color, tissue and blood type.
• How They Did it: First, the skin is peeled back and bones are sawed at an angle to dovetail into each other when attached by metal plates- good carpentry, in essence. Next, the muscles and tendons are tagged with pieces of light blue sterile bandage that are sewn in place and labeled in permanent black marker, before being connected. The arteries and veins are painstakingly attached under a microscope, and finally the skin is sewn together.
• What was New: Brendan was given an infusion of bone marrow from vertebrae in the donor’s lower spine. This lowered the chance of rejection and cut back on the use of potentially dangerous drugs.
• Two Thumbs Up: Brendan’s nerves will grow into his new arms at a rate of an inch a month. In the one month since his landmark surgery, he can already move one arm around. Eventually, patients are expected to be able to “tie shoes, use chopsticks and put their hair in ponytails”. Brendan might consider growing his hair longer for that 🙂
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A great story, and a credit to JHU — thanks, Rajini Rao.
One of the few times when I was glad that I opened my “junk” email, William McGarvey 🙂
The happier kind of “black swan event”, indeed…
One thing that struck me, the scraps of metals that severed his arms and legs in the explosion were
so burningmolten hot, so that they cauterized the wounds, and prevented him from bleeding to death.Andrea Caranti , I didn’t know that. So that’s why he was lucky to survive. The article mentioned that most army amputations are quite high in the limb, so it makes the transplant more challenging (because the donor’s nerves are dead and all nerve connections must be from the patient).
That s great news Rajini Rao. Blessed b the doner
Is the rejection rate of transplanted arms or legs lower than that of internal organs?
Hear, hear, Samia Elsaid … indeed.
Rajini Rao I had read a couple of articles about the guy a couple of days ago, and found them striking. This is a guy that loves life, and has the most positive attitude towards it.
Samia Elsaid , Yes, special kudos to donors and their families. Limb requests must be unusual too.
David Nicholl , I would guess they are about the same? It depends also on how the patient tolerates powerful immunosuppressant drugs.
Shockingly the rejection rate for prosthetic limbs is quite high: from 30-60% judging by a quick search. The surgeon explained that younger people have higher rates of rejecting prosthetics which is why they opted for the limb transplant.
That is amazing. Now maybe soon they could do the same for his legs. The sky’s the limit for our vets.
Mike Morris , the first double leg transplant was done less than two years ago, in Spain. Hopefully, more will follow.
wow
quite amazing
Gnotic Pasta I am sure you are right. I was quoting from
http://www.cbsnews.com/8301-204_162-57566465/double-arm-transplant-veteran-brendan-marrocco-looking-forward-to-swimming-driving/
[Brendan Marrocco] described the thing that took his limbs as a “copper dart” that was “molten hot,” saying it “cauterized my wounds.” The New York native said he has marveled at the fact that he survived, when others did not, adding that his friend who died “wasn’t hurt nearly as bad as I was.”
Thanks, both accounts/links are not for faint hearts or weak stomachs! 🙂 Imagine a tourniquet applied on the abdomen to stem blood flow from a double leg loss. Hats off to the field doctors and emergency personnel.
Gnotic Pasta , is that an army T-shirt the young man is wearing? What does Chive on mean (as in Keep calm and chive on)? 🙂
Errr..ooops. Never mind 😀
Amazing story. I just love how the young vet now can be a bit more independent and get his life back.
Gnotic Pasta , according to the internets, the word chive is a combination of Chicago and Venice (Beach?) where the two founders of that website originated. And apparently the phrase means to stay the course, no matter what. Okay, I learned some new pop culture 😉
Seen this on the news and internet today. What an achievement from doctors using latest medical technology, biomedical and knowdledge in medicine.
Tom Lee , I’m equally struck by the adaptability of the tissues in our body and that they can regenerate given the right connections.
what a wonderful doctors they are it is not all about money but it is all about great personality thanks for your great contribution when i heard it i feel as if you gave a medicine to but not too him!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Roelf Renkema , I’m not one to put warriors on a pedestal but neither do I demonize them. In my view, aggression is in the hands of policy makers and politicians who are the kings and crusaders of today. The justice and ethics of war are beyond this post.. let’s appreciate a medical marvel for now.
Joe Lopez personally, I prefer to experiment rather than f**k with cells, but that’s just me 😉
Roelf Renkema the medical oath entails saving all life regardless of who the person is or what he/she does. Enemy combatants are routinely treated and saved by doctors on the opposing side. It would not even be logical to expect a physician to make any moral judgement on a patient.
How awesome to see the Hippocratic Oath reproduced in full in a G+ comment! ❤
Regardless of the ethics or morals of military operations, it is through treating battlefield injuries that have advanced our medical technological development more than anything else. The Vietnam war taught us more about head injuries than we had ever known.
Roelf Renkema , I do care. My point only is that the ethics of war have to be separated from care of the sick/wounded. If it were not, then a terrible can of worms opens where doctors could refuse treatment based on all sorts of perceived morals and ethics. One man’s morals may be completely different from another’s.
What a great story, here’s the link to the 1st person in the US to have the story http://www.cbsnews.com/8301-504763_162-57511517-10391704/texas-mother-of-three-to-get-first-double-arm-transplant-in-the-u.s/
Angie Creasy-Thompson , that’s a heart warming story, thanks! Sobering to think that one can get a Strep infection and lose all four limbs.
Roelf Renkema Your argument reminds me of the trolley problem – http://en.wikipedia.org/wiki/Trolley_problem
You say your logic is simple but it really isn’t. I have thought long and hard about this myself and have come to the conclusion that there is no right or wrong answer. The issue you bring up is even harder than the trolley problem because it requires knowledge about the future, knowledge you can never have.
Should doctors base their decision to save someone’s life on the probability that their patient kills again? I would argue that the Hippocratic oath asks the opposite, that doctors refrain from moral judgement and instead do everything in their power to save the life in front of them regardless of his past (and possible future) crimes.
Even if doctors could somehow see into the future and would be able to tell with absolute certainty whether the patient in front of them would kill again, would you suggest they let this patient die? If a doctor could save a man’s life but chooses not to, does he not become a murderer himself?
A more direct application of the trolley problem to the field of medicine occurs when doctors are required to choose between victims, knowing that time will limit their ability to save everyone. In such harrowing situations, they make decisions based on the amount of life they can save, pushing a few fat men, who might have been saved with intensive time consuming work, onto the track to save the lives of many more. This differs from the earlier problem in which there is no time constraint and only one victim. We know it’s impossible to predict the future with absolute certainty so here time makes all the difference in the world; there is always a possibility that you or someone else talks him out of killing again.
Rajini Rao Your G+ page is one of the very few pages that stops me and makes me read! 😀 :D….so I don’t forget how to read 😀 😀 Wonderful medical breakthrough!
For me it’s not an axiom because I can’t make up my mind whether the needs of one outweigh those of the many or the other way around. It all depends on the context of the situation, the definition of needs and what you think is right. My rational mind says I should kill a man if it directly results in saving a 100 others but when push comes to shove (ahem :p), I don’t think I would be able to do it. This gets harder if you are the fat man and there is no one around to push you…
I guess it would be interesting to see how soldiers would respond to being asked to uphold the oath by extension. Perhaps just having it read to them might make them think twice the next time they take a life. Many don’t have much choice though, once you enlist, you can’t just quit. Then again, as the trolley problem illustrates, sometimes taking a life, saves more lives in the process. Who is to say that by making a soldier swear to never kill again, that you are not enabling genocide? What if a bullet he would have fired in the future would have stopped the murder of 100s of innocents?
I hate violence as much as the next guy and would love to cut military spending around the world but as long as we don’t all agree on that, we are paradoxically going to need soldiers to fight other soldiers, just like we need guns to keep other guns at bay. 😦
Roelf Renkema , On a practical level, a doctor cannot accurately link ethics with treatment. That’s the bottom line as far as this particular post is concerned. Let’s save this ethical dilemma for a different post.
Roelf Renkema You are talking about some hypothetical utopian place. Not that we should stop but obviously just asking people to not use violence doesn’t work. We shouldn’t even think ourselves above it. The stanford prison experiment proves that we are all capable of atrocious things when primed by the circumstances. Would you not fight to feed your child if there wasn’t enough of it?
It seems to me that the oath is clear and doctors apply it correctly, it is you who wants to introduce an orwellian version, allowing them to let people die if their patient doesn’t agree with their point of view. Some soldiers really do save lives with their actions and not every bullet fired creates a terrorist. Even if it did, should France have refused to help the citizens of Mali because it might mean more people will join islamist terrorist forces? One could argue that doing nothing, letting them kill the non religious population, would have created a safe harbor. This in turn would have meant that every child born in that region would end up a child soldier.
It pains me to say it but sometimes there is no good choice and you simply have to pick the lesser of two evils. The only way to deal with this practically is through politics with non proliferation treaties and agreements that reduce the amount of arms and soldiers bilaterally.
Whoops, sorry Rajini, late refresh 🙂
on topic; it’s amazing the kind of transplantations we can perform these days. Not long ago I read an update on the first face transplant. http://www.bbc.co.uk/news/magazine-20493572 – she looks amazing!
Sooo… how about them brains eey? 😉
http://en.wikipedia.org/wiki/Brain_transplant
This is simply incredible.
Thanks, Roelf Renkema .
Koen De Paus , I can envision a brain-computer interface in the future. Add Google Glasses, and we’re all set.
I was just reading up on that brain transplant wiki page and I was wondering;
“One of the most significant barriers to the procedure is the inability of nerve tissue to heal properly; scarred nerve tissue does not transmit signals well (this is why a spinal cord injury is so devastating). Even if all the nerves are connected successfully, they may still be connected wrongly, thus not transmitting the same information as the same nerve connection in the previous body. For example, a nerve that used to control the right index finger’s muscle group might be connected to a different finger’s muscle group, or another body part entirely. If this were to happen to a large number of connections, the person undergoing the transplant might end up with a body which transmitted sensory input to the wrong destination, making it incomprehensible and potentially requiring many years of rehabilitation.”
You described how they reconnected the muscles, hopefully without mix ups, but what about his nerves? Does he have feeling in his arms?
Edit: I can only find popular newspaper articles but they mention that; “Currently, I don’t really have feeling or motion in my hands. But we’ll get there.” The wiki talked about how nerves don’t normally transmit signals very well after being severed but perhaps they tried anyway? goo.gl/kOoY6 – it sure looks pretty complicated.
Edit2: A news release from hopkins medicine itself states that; “His transplants involved the connection of bones, blood vessels, muscles, tendons, nerves and skin on both arms.” So they did reconnect nerve tissue… I wonder how they got around that scarring problem or whether they are simply hoping that the reduced ability to transmit signals will still be worth it.
What a brave guy!
Maybe Google will have some awesome-ness for people like him in the near future? Vic Gundotra ? Anything related in the works?
Amazing! Are bone marrow infusions common in other transplant procedures?
Koen De Paus , I mentioned in the post that nerves regenerate at the rate of about 1 inch per month. That’s why the higher that original amputation, the more challenging it is to get full arm function back, because the patient’s nerves need to grow into the donor’s arm. The donor’s nerves are apparently useless. In Brendan’s case, he has more control over the arm which was cut off below the elbow compared to the other one. Now, if they could figure out a way to “seed” the nerve junctions with neural stem cells or hasten the regeneration with the right neurotrophic growth factors, that would be another breakthrough.
Lisa Borel , you bring up a good point about bravery. Unlike organ transplants that are usually essential to continue life, limb transplants affect the quality of life. So the young man would have to weigh the risks of a long and complicated surgery plus immunosuppressants that can increase risks of cancer and other complications against having his arms back.
Shannan Muskopf , that’s a great question, thanks! Bone marrow transplants may mean that one day we could have organ transplants even without tissue matching (which is a huge limitation). See http://www.nature.com/news/drug-free-organ-transplants-without-tissue-matching-1.10188
You mentioned that his own nerves grow into the donated arm, which would imply they didn’t connect them to the nerves present in the donor arm but the Hopkins article mentions that they did reconnect nerves and I was wondering if perhaps they had managed to find a way around tissue scarring? – http://www.hopkinsmedicine.org/news/stories/double_arm_transplant.html – although apparently not because if they did reconnect perfectly then the arm should be fully functional already.
Good point, I didn’t get what you were saying at first.
Koen De Paus , I read around a bit but in the end Wiki said it best:
“Neuroregeneration in the peripheral nervous system (PNS) occurs to a significant degree. Axonal sprouts form at the proximal stump and grow until they enter the distal stump. The growth of the sprouts are governed by chemotactic factors secreted from Schwann cells. Injury to the peripheral nervous system immediately elicits the migration of phagocytes, Schwann cells, and macrophages to the lesion site in order to clear away debris such as damaged tissue. When a nerve axon is severed, the end still attached to the cell body is labeled the proximal segment, while the other end is called the distal segment. After injury, the proximal end swells and experiences some retrograde degeneration, but once the debris is cleared, it begins to sprout axons and the presence of growth cones can be detected. The proximal axons are able to regrow as long as the cell body is intact, and they have made contact with the Schwann cells in the endoneurial channel. Human axon growth rates can reach 2 mm/day in small nerves and 5 mm/day in large nerves. The distal segment, however, experiences Wallerian degeneration within hours of the injury; the axons and myelin degenerate, but the endoneurium remains. In the later stages of regeneration the remaining endoneurial tube directs axon growth back to the correct targets.
In brief, the axon (main signaling extension of the neuron) has to regenerate at the slow rate mentioned. However, the donor/dead end remains as a tubing or a channel to guide the axon to it’s target. That’s why they need to connect the nerves at both ends.
From: http://en.wikipedia.org/wiki/Neuroregeneration#Peripheral_nervous_system_regeneration
I did not know something as crazy as this was even possible, the possibility of connecting each and every artery and vein to the person’s arm to the donor would seem impossible but new techniques and medicine are being developed at an exponential rate which could be a good thing and a bad thing…
It’s a good thing, Sunite Lauchande ! 🙂
Thanks – goo.gl/y8eZj to the rescue. ^^
LOL, Koen De Paus !
To some, it would be viewed as being saved and happy for regaining something lost, but most medical things usually have a ethical side to which religion and personal opinions can sometimes over the benefits of such things. I’m in no way disagreeing, just pointing out some things out.
Very true. In fact, if you have the patience to scroll up the comments there was quite an ethics debate ongoing here.
Martin Geoffrey Lake Interesting, I know that my medical knowledge is not as advanced as yours. You learn something new everyday!
Man, it seems like a weekly occurrence now: to come across a bit of science news that makes you think “Remember when, just a few seconds ago, I and pretty much everyone else thought this kind of stuff only happened in science fiction about the far future?”
I wonder if the guy will get a double-leg transplant, too.
Martin Geoffrey Lake
if grey matter or brain matter is the same as nerves then the brain is not in fact localized in one place as we assume.
Well, the entire nervous system (including the peripheral nervous system), is composed of nerve tissue. The brain is a specifically defined subset of that nervous system.
This may explain phantom arm syndrom when a person feels like the arm is there….it may be that half the ‘memories’ or electrical association from the arm still exist in the body…
Those in relevant fields can correct me if I’m wrong, but as far as we know, “phantom arm syndrome” is essentially the brain’s subconscious image of the physical self (at the level that’s involved in proprioception) not adapting to the fact that the body has lost an arm. As far as we can determine, it’s why mime-stroking a “phantom” arm can reliably soothe phantom arm pain, because while we consciously can tell ourselves that it’s just miming, we subconsciously perceive the stroking as interacting with where our arm should be.
The opposite effect has also been observed, where a subject with two perfectly healthy, physiologically functional legs, one day suddenly believes fervently that one of his legs isn’t his, and actually loses the conscious ability to control that leg at all.
Rajni, Thanks so much for such an informative post. I always wonder about nerves, their growth and their ability to regenerate. Human body is so amazing. What kind of bio-compatibility tests are done before selecting which cadaver arm to pick?
Thanks, Jagu Barot . There has to be a tissue compatibility match as well as a blood type match between the donor and recipient. If not, the body mounts an immune attack and the organ/limb is rejected (both painful and dangerous).
Rajini Rao, why it is not completely/perfectly possible not to give immunosuppressant drugs or to infuse bone marrow (in this case) even after matching of HLA & other matches?
Abhigyan Borah , it’s not possible to get a perfect match. Sometimes the transplant goes well with no complications. Other times, even though all precautions are taken, the body can reject the organ in a few months or a year. It means we don’t understand the immune response as well as we would like.
It is, obviously, different from blood transfusion. Talking particularly about rejection, possibly, one reason for no question of rejection for matching type in blood transfusion, I think, is blood cells die & replenish in their respective average time which is not possible in case of organ transplant. Isn’t it? Or is it simply becuase of no question of different types of tissues in blood unlike organs?
Abhigyan Borah , blood type and tissue type are completely different at the biochemical level, and therefore at the immunological level.
Do the recipients take any medication to avoid any immune attack despite the tissue+blood compatibility? Life long or for limited time if they must?
Congrats to your Academic / Medical research institution for blazing yet another new and exciting trail Rajini Rao
Jagu Barot , living with an organ transplant can mean a lifetime of medication, as much as 6-12 different ones per day. Doctors are getting much better in reducing immunosuppressants and finding the balance between preventing organ rejection and increasing susceptibility to infections. It’s not a good thing to have one’s immune system suppressed!
John Christopher , thanks! I’m quite matter of fact about working at Hopkins, but then something like this really makes me sit up and appreciate the hospital end of things. Usually, I’m touting the research side 🙂 For example, it’s really cool that JHU spends 2.1 billion in R&D- more than any other academic institution in the country.
Rajini Rao: Do you know which of their medical illustrators rendered the fantastic image you included? I have a hunch, but I wasn’t sure (I was a Hopkins SOM Anatomy student and I used to work with Art as Applied to Medicine).
Michael Habib , really? Delighted that you are from JHMI. I don’t know who did this one..there is a signature in the drawing that I don’t recognize. Did you take the medical anatomy course or the one with Cellular & Molecular Grad Students (Human Body)? David Rini and Miguel Schoen teach anatomy to our grad students.
Rajini Rao: I took the medical anatomy course my first year in grad school. I subsequently taught it alongside Mark Teaford, David Weishampel, Chris Ruff, and Valerie DeLeon. Miguel Schoen was also one of my mentors, and I was hooded at the same ceremony in which he received his lifetime achievement award. I was a thesis committee member for two students in Medical Anatomy: Fabian de Kok-Mercado and Julia Molnar. David and Miguel know them both well.
Wonderful..all familiar and respected ‘greats’ at Hopkins! Anatomy was with Cell Biology around the time I started there (~1993) although it separated shortly after.
More information and another illustration can be found here, btw: http://www.hopkinsmedicine.org/transplant/programs/reconstructive_transplant/hand_transplant.html
Wow, the metal clamps are more prominently illustrated in this one. I hadn’t noticed them at first in the one I posted.
Indeed, I noticed the same thing. Oh, and I figured out the illustrator: it’s Devon Stuart, who graduated from the Hopkins Medical Art program in 2007. We had many of the same instructors (both anatomy and illustration; I took courses in the Art as Applied to Medicine program for a year under a special dispensation).
Great share Rajini Rao . My nephew had a liver transplant almost 20 years ago, he was only 9. He is doing well and he still goes in for check ups and such. We truly are blessed that he is doing so well.
I am glad to hear that the medical field is making some major progress in this area…
I just came across this article from last year on lab-grown genitals for soldiers who have stepped on bombs: http://goo.gl/SRfZD
Oh great ..
But who donate arms? Strange
romanticboy u , the arms are donated by a cadaver (dead person).
That’s a more accurate way of saying it, thanks Jan Costantini . When I dashed off that response, it sure did look odd to me 🙂
Very few donors, I’m guessing, mostly from lack of information or outreach? If there was an all-out campaign to sign up donors, it wouldn’t cost much but it would be enormous in impact.
I am glad people donate, otherwise my nephew would not be alive today.
My Mother was a really good example for our family. She donated her body to science to help progress in medicine. This was her way of giving from the heart and how much she truly cared about people.
I’ve checked the option on my driver’s license but I can’t remember if there is more I need to do? I don’t know any celebrities, Jan Costantini ; at least, not the type most people would care about 🙂
Margie D Casados , what an inspiration. Your mother made a difference to the end and beyond ❤
It also has to do with the framing of the question, and this is of interest to psychologists. Whereas in the past people had to opt in to become donors, the effectiveness increases dramatically when the default is to be a donor, with people given the choice to opt out. I believe that some states in the US have already implemented these changes, with huge gains in the number of donors.
These are related to the studies that show people behave differently when they are told that a certain behavior is associated with a 95 percent survival rate vs. when they are told that the behavior is associated with a five percent death rate, with the latter having a much more dampening effect on behavior as result of the cognitive heuristics that people commonly employ.
Thank you Rajini Rao , she was a very special woman. I am blessed she was/is my Mom:)
The effects I mentioned above were without any added donor campaigns or changes in any other variable. This is covered to some level of detail in Daniel Kahneman’s Thinking: Fast and Slow, as well as, I believe in Cass Sunstein’s Nudge, though I have not read the latter.
That’s fascinating, thanks Thomas Kang . You’re saying that organ donation is opt out in parts of the US? That would be laudable and very forward thinking!
I believe so, but I have not checked. I’m under this impressions from my readings, but I am not absolutely certain of this. That was either a hypothetical example to illustrate the concept I outlined or evidence from implemented examples.
I won’t be able to research this now, but I hope I can remember to check this evening.
As I looked this up, the memories came back to me. The comparisons were by country, not by state, and the US does not have opt-out.
http://goo.gl/ojwZs
Thomas Kang those donor rates, even for countries with opt-out plans, are depressingly low (Australia ranks highest with 15 donors per million!). I think the future lies in bio-engineering, prosthetics and artificial organs.
I agree, though Austria has a consent rate of 99.98 percent, as opposed to Germany’s 12 percent. I have to think something is wrong with the figures, though. It’s inconceivable to think that of a million people 999,985 of them are opting out.
I’m guessing that it means to say 15 percent of donors per million, though in that case the “per million” is superfluous. It’s Wikipedia, so the number would need some verification anyway.
If the US were to adopt an opt-out system, I’d bet that the donor rates would be fairly high, both because of people’s inertia and because of cultural considerations (generally supporting the ides of organ sharing).
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