Linking Arms
From Alumni Bulletin - January 16, 2014
The twenty-six-year-old patient on the operating table had neither arms nor legs, but if he’d been awake, he would have been smiling.
Brendan Marrocco had been waiting for this moment for years. The young Army infantryman had been the first veteran of the wars in Iraq and Afghanistan to survive losing all four limbs. In 2009, a roadside bomb pierced the armor of his Humvee, shearing off his limbs and severing one of his carotid arteries. Marrocco, who later told reporters that he’d felt no pain at the time, lost his best friend in the blast. Now, more than three years later, a group of sixteen surgeons hovered over him, mentally preparing for what would turn out to be a thirteen-hour operation. If they succeeded, Marrocco would gain a measure of independence and become an inspiration for the wars’ many amputees.
The December 2012 operation was to be the first limb transplant ever conducted at Johns Hopkins Hospital, and the most difficult yet performed in the United States. Two Kenyon graduates, a husband and wife, were key members of the team that made it happen. Damon Cooney ’95 was a lead surgeon during the operation. Carisa Cooney ’96, who has her masters in public health, helped oversee the study that led to the surgery, as well as drum up the funding. (The U.S. Department of Defense footed a large part of the bill.)
Damon Cooney had helped perform two double-arm transplants prior to Marrocco’s and remains in awe of what the operation can do. In one case, “[the patient] signed the consent form with a pen in his teeth, and when he left the hospital he shook my hand,” he says. “It’s just a privilege to be able to do that.”
Surgeons have long dreamed of transplanting body parts from brain-dead donors to living recipients. But it wasn’t until the late 1990s that a hand was successfully transplanted. Since then, transplant surgeries have become more and more complex, with face transplants and double-arm transplants increasingly common. (Six patients underwent double-arm procedures in the United States before Marrocco.)
But reconstructive surgeons are still hampered by some of the same obstacles as their predecessors. Immune response is perhaps the biggest hurdle. To prevent the body from rejecting the graft, transplant patients must take immunosuppressive medications for the rest of their lives. In most cases, high doses of three medications are required, with side effects including an increased risk of cancer, renal failure, and infection.
The Hopkins team, however, is researching a new tactic. Known as the Pittsburgh Protocol, it allows their patients to take low doses of just one medication. The protocol involves infusing the patient with a dose of bone marrow cells from the donor, effectively tricking the immune system into accepting the graft.
The Cooneys are both actively involved in this research. Many of Damon Cooney’s patients are rats and mice; through experiments in the lab, he and his colleagues hope one day to dispense with immunosuppressive medications altogether. And as clinical research manager in Johns Hopkins’ Department of Plastic and Reconstructive Surgery, Carisa Cooney oversees research involving human beings, including the study of which Marrocco was a part.
As undergrads at Kenyon, the pair could not have foreseen that one day they would share a passion for reconstructive transplantation. When they met, Damon was a chemistry tutor, and Carisa—then Carisa Miller—his student. “I actually ended up dropping the class, but I kept the tutor,” says Carisa, who was a studio art major. Damon majored in chemistry and biology.
The couple married in 1999 back at Kenyon, in the Church of the Holy Spirit. Just over a decade later, they landed at Johns Hopkins, and it wasn’t long before their paths intersected with that of Brendan Marrocco. Aside from her many managerial duties—grant-writing, coordinating with the military, making sure studies are conducted ethically—Carisa is in charge of screening potential candidates for transplant surgery. This is no small matter, because limb transplant patients, with their dependence on immunosuppressive drugs and potential for complications, are patients for life. “It’s kind of like courting when you screen people,” she laughs. “Okay, can we live with this person for the rest of our lives?”
And because limb transplantation is in its infancy, the screening process is quite rigorous. A candidate must have an injury that would benefit from a transplant. He or she must also be free of immunological problems and have a strong, engaged social support group. (Recovery from surgery can take years—nerves regenerate at a rate of just one inch per month.) Finally, the candidate must be psychologically prepared for the intensive physical therapy and medication regimen that follows the operation.
“Having the right attitude is a very important component,” Carisa says. “The stick-to-it-iveness—sometimes the family members would say stubbornness—to see it through. Because there are some rough times.”
By that measure, Brendan Marrocco would appear to be the ideal candidate. An upbeat charmer with a mischievous sense of humor, his Twitter feed bears the slogan “You’re only young once but you can be immature forever.” He’s been avidly tweeting his recovery. (April 24: “Today was pretty fun. Got dressed up Went to a congress hearing about military medicine on Capt. Hill and actually spoke in the hearing.”) The media fell in love with Marrocco following the surgery, and even the surgeons were affected by his sunny disposition. “The patient was awesome,” Damon says. “You wanted to help that guy.”
The call came late on a Sunday in mid-December: Marrocco had a donor. The team contacted him and his family, who headed for Hopkins. Meanwhile, Cooney boarded a plane with other members of the surgical team and flew through a dense fog to collect the arms from the donor, who was in another state. (For privacy reasons, the transplant team has not revealed the identity or location of the donor. Donor arms are matched to the recipient’s skin tone, blood type, and size, but not necessarily gender.)
Once they’d arrived, the two teams, one for each limb, removed the arms from the donor. The surgeons put canulas in the arteries, flushed the blood out, and replaced it with a solution that would help preserve the limbs until they arrived back in Baltimore. Then the arms were put on ice and the surgeons rushed back to Johns Hopkins. When they arrived, some four hours after they’d departed, Marrocco was waiting in the operating room. The doctors had to act quickly to attach the donor arteries and veins to Marrocco’s, because with no blood flow the donor arms were in danger of becoming simply dead flesh. “No one really knows how long you have,” Damon says. “You want to do it in as little time as possible.”
The surgeons divided into four teams and worked simultaneously, drawing on several practice sessions they’d had with cadavers. Two of the teams prepared the donor limbs (one team on each arm), peeling back the skin and arranging the vessels, bones, and tendons. The other two teams worked to do the same on Marrocco’s arms. Their job was dicier; because of the force of the bomb blast, arteries and veins were not in their normal places and the stumps of the patient’s arms were a mass of scar tissue.
On one of the arms, because of the nature of Marrocco’s injuries, each component had to be connected at a different level. Bones were attached at one length, muscles another, and nerves as far down the arm as possible to speed recovery. Damon oversaw one recipient team and one donor team. Marrocco’s arms were the fifth and sixth he’d transplanted, but he was as moved by the process as if they had been his first.
“When you take those clamps off and the tissue goes from being pale, dead, sort of deflated looking, and it starts to swell up and turn pink again and come alive . . . there’s nothing like it,” he says. “You step back and you have a patient who has arms again.”
Marrocco, who according to news reports has returned to his home in Staten Island, has thus far exceeded surgeons’ expectations in terms of his recovery. He can grasp objects, throw a ball, use an iPad. “He’s come out of it like a champ,” Damon says. As Marrocco recovers, the team is actively screening new candidates for transplants, and hoping donors materialize.
On the home front, the Cooneys appear to be raising another limb-transplant expert. When their daughter Boudicea was just three years old, a teacher at daycare asked, “How do you think doctors help people?” The children wrote their answers on a posterboard. Most of the responses pointed out that doctors give shots. Boudicea’s read: “My dad is a doctor and he cuts people so he can put them back together. When their hands get black, they cut it off and then they have to stay at my dad’s office.”
“What do her teachers think I do?” Damon laughs. Fortunately, the daycare is affiliated with Johns Hopkins, so her teachers likely have an inkling. “If she were in a public school, we’d probably have a cop car out front.”
By Andrea Appleton
