I credit my Brooklyn posse—four close girlfriends I’d met singing in a local choir—with helping me piece together my recollections of the accident and its early aftermath, which they did over an evening of gently persistent questioning shortly after I moved back into my apartment. But my surgery was a big blank page in the story that took months of research, and several interviews with Dr. Vargas, to fill.
Walking into the operating room for my surgery, I learned, Dr. Vargas had to sweep a host of competing thoughts out of his mind to get into “the zone” for the event. As chief resident of Bellevue’s hand-surgery team, a rotating position held by sixth-year plastic surgery residents, his responsibilities were diverse and consuming.
Beginning at seven o’clock each morning he checked on postoperative hand patients recovering in the wards, while engaging the junior residents accompanying him in instructive dialogue about each case. From midafternoon until the day’s slate was clean, he performed and supervised hand surgeries, sometimes running back and forth between operating rooms when the volume and severity of cases demanded concurrent procedures. Two mornings per week he followed up with discharged patients at Bellevue’s outpatient clinic; and during any of these activities, he could be summoned to the emergency department or wards to advise staff on hand-trauma cases—just as he had been for mine.
The job would be demanding in any large hospital, but it could be crushing at Bellevue, a major referral center for highly complex medical problems, including acute trauma. As a patient and later a volunteer there myself, I saw reattached fingers that had been severed by circular saws, machetes, and industrial equipment; hands shot through by guns and run over by trucks; arms smashed by construction materials and degloved in traffic accidents. Bellevue staff saw more and worse.
Dr. Vargas was well prepared for the job, having performed hundreds of relevant procedures during his residency to date. But my spaghetti wrist was a big deal, even at Bellevue, even for the chief. While the hand-surgery team repaired severed tendons, nerves, and blood vessels every day, they rarely confronted so many severed structures in a single patient, especially in the dominant hand of a person with many years yet to live and earn.
The severed radial artery—the most alarming part of the injury from my perspective—actually posed the least threat to my well-being going into the surgery, since I’d stopped its bleeding in my apartment, and Dr. Vargas had confirmed that my hand received adequate blood flow without it.
But my hand’s entire ability to sense, grasp, and manipulate objects depended upon the combined function of the other severed structures: the median nerve, which drives motor and sensory function for most of the hand, and the flexor tendons, which enable the hand’s digits to curl in toward the palm. In its injured state, my hand was just a big, floppy fork to push things around with, or a weird, warm paperweight to keep stuff from blowing away.
Restoration of any function at all would require a three-legged relay. First, Dr. Vargas would have to bring and stitch the stumps of the severed structures together, because they wouldn’t otherwise reconnect. Then nature would have to permanently knit them in place and grow an extension of the median nerve to replace the severed stretch. And with an occupational therapist’s help, I’d have to spend hundreds of hours teaching my “replanted” hand how to move again. Even if all that went well, my hand would never be “good as new.” But we could hope that I’d recover sufficient strength, range of motion, and sensation in the hand to continue living much as I had before the accident.
To ace his part of the relay, Dr. Vargas needed tendon stumps with edges strong and straight enough to hold stitches. If they’d been torn or crushed in the explosion, he’d have to consider more complicated procedures for restoring function to my hand, with poorer chances of success. Their condition was undiscernible to the naked eye, however. Until he could explore them under strong magnification in the operating room, he wouldn’t know whether the odds of an optimal outcome ran for or against me.
If Dr. Vargas and I had met as healer and patient at various earlier points in history, we’d have much more to worry about than just my future hand function. At the most basic level, modern surgery—meaning surgery that is safe, effective, and humane—depends on the ability to control blood flow, because too much bleeding will kill a patient quickly, and too little blood to limbs or organs will maim or kill a patient slowly. It depends upon a thorough understanding of human anatomy—of what’s what, how it works with everything else to produce a result, and how to handle different tissue types least invasively—so that a surgeon can devise a repair strategy that will help, not harm.
Modern surgery depends on the ability to control patients’ pain and level of consciousness—not only to keep patients comfortable, but also to keep them perfectly still, so that surgeons can accurately “throw” the smallest of sutures within the smallest of structures. And it depends on the ability to prevent and treat infection, lest surgeons’ best efforts in the operating room be bested later by the pernicious bacteria constantly seeking human hosts in which to breed and feed.
We take this body of knowledge and capability for granted today, but it emerged in literally painful fits and starts over millennia, and only became (more or less) complete and pervasive in Western medical practice in the twentieth century, when antibiotics became widely available. Why so long and late? Of course, there’s the fact that innovation requires discovery, discovery involves luck, and luck (tragically contrary to idiom) doesn’t always favor the prepared, even if they’re trying to save lives. But innumerable other, interconnected reasons exist; and a few among them stand out.
For one, excepting a relatively brief heyday in ancient Alexandria, cultural and religious objections to human cadaveric dissection, as well as a lack of appreciation for its value in medical education, limited its practice until the thirteenth and fourteenth centuries. Even then, misconceptions of human anatomy based on animal dissection (dogs, pigs, and monkeys being the preferred models) persisted until the mid-sixteenth century, when physician Andreas Vesalius exposed them through closely observed human dissection, leading to its broad recognition as an essential teaching tool.
Further, lacking modern methods of observation and experimentation, surgeons often couldn’t conclusively determine whether the interventions they performed worked or not. Thus their patients suffered mightily while surgeons inflicted, and debated the theoretical merits of, deadly treatments like bloodletting, and promoting “laudable pus” in a wound.
Even when surgeons did land on an effective intervention, factors that still frustrate the medical profession today might bedevil its broad adoption. Perhaps it wasn’t communicated in a channel or language accessible to a specific population of practitioners. Or surgeons rejected it because the evidence in its favor, however sound, contradicted their personal experience or beliefs. And then, some effective interventions just mysteriously slipped out of practice, only to resurface decades or centuries later.
But neither ignorance nor the agony and mortal peril of their patients tempered the astonishing ambition of Dr. Vargas’s professional ancestors. In prehistoric times, they bored holes into each other’s heads—whether for medical or ritualistic purposes, we’ll never know. In ancient times they amputated limbs, removed bladder stones, and reconstructed leprosy-ravaged noses. They sewed up lacerated nerves and intestines in the Middle Ages, and repaired aneurysms during the Renaissance. And in a nineteenth-century coup de non-grâce, a team of them in France performed a mastectomy on novelist Fanny Burney. Sans anesthetic.
Several body parts tingle in sympathetic offense as I type up these examples, and I wonder which current medical practices will horrify us in another quarter century—when, no doubt, I’ll enjoy the convenience of performing my own hip replacement at home with the help of my robotic canine companion. But in fairness to those whose cringeworthy work I’ve highlighted, historical accounts suggest that they sometimes achieved their objectives, sometimes without killing their patients (at the risk of splitting hairs, I must point out that amputating a leg, and preventing the amputee’s death by hemorrhage or infection, are two different things). Burney’s was one such case, and she wrote an account of the ordeal, though you’ll want to give it a pass if you had any trouble stomaching the first chapter of this book.
Also, medicine cannot advance without ethical experimentation and practice. Given I had no choice but to join the living objects of such endeavors, then, I’m ecstatic to have done so in an era when my surgical team knew how to keep me alive and comfortable during the procedure, and give me the best shot at functional recovery that the latest scientific evidence could afford.
By the time my ER bed and I rolled into the operating room on Bellevue’s eleventh floor, the party in my honor was in full swing. A generous handful of nurses and doctors busied themselves in various corners of the bright, cold space, laying out instruments and supplies and setting up equipment. They had worked together on numerous occasions, and most had trained in the particulars of hand surgery related to their roles, so they knew the procedure I’d undergo and each other’s working preferences well.
After I’d awkwardly scooched onto the operating table from the rolling bed, the scrub nurse secured my outstretched right arm to a slim extension of the table. Dr. Vargas and his assisting resident, Dr. Matthews, already sat facing each other on either side of the extension—Dr. Vargas’s left side to my right—and began quietly conferring and gesturing around my wrist.
The anesthesiologist started an IV opiate in my left arm and, once I’d slipped out of consciousness seconds later, worked a breathing tube down my trachea. Then she began pumping an anesthetic gas through it, which would keep me unconscious and still (paralyzed, actually, but I’ll get to that in chapter 8) for the duration of the procedure. In the meantime, the scrub nurse placed a screen at my right shoulder, to separate the sterile operating field (my arm) from the non-sterile anesthesia equipment on the other side of my body, then draped a sterile blue sheet over the screen, my head, and the rest of my body, leaving my arm exposed. Finally, the team took their places for the main event.
“You can’t fix a watch in a bottle of ink,” said Sterling Bunnell, the granddaddy of American hand surgery, in the days of pocket watches and fountain pens. In other words, even the smallest traces of blood could obscure the minute structures Dr. Vargas needed to work on during the surgery. Before he could begin, then, he and Dr. Matthews needed to eliminate any blood remaining in the wound and ensure none would seep back in while they operated. They accomplished this through a procedure that goes by the deliciously disgusting term exsanguination.
First, they tightly wrapped a long, elasticized bandage from my fingertips to my bicep, progressively squeezing all the blood in the limb back into my trunk, like toothpaste out of a tube. To keep it there, they inflated a tourniquet cuff on my bicep, applying just enough pressure to close the vessels supplying the limb, but not so much as to damage the nerves there. Finally, they removed the bandage to expose the sutured wound.
My arm could do without blood for a while. But starved of it too long and cells would begin to die, threatening extensive tissue loss and gangrene. To stay well clear of that point, Dr. Vargas needed to complete the procedure in three hours—four at the absolute maximum. If he couldn’t finish in that time frame, they’d have to deflate the cuff to allow my arm to refill with blood; then once it had enjoyed a good feeding, exsanguinate it all over again. He set a timer on the inflated cuff for ninety minutes to remind them of the halfway point, sat down, and turned again to my wrist.
According to Dr. Vargas’s written report of the operation, he next “appreciated” the wound. I like to imagine him slowly shaking his head, muttering, “Man, that is one great wound.” But really, he was just considering whether he’d need to extend the laceration to create more room in which to work. Which he didn’t. Instead, he removed the stitches placed in the ER, donned glasses fitted with magnifying loops, tied off the artery stumps with silk thread, and set about locating each tendon in my wrist, noting which remained, which had been cut, which could be fixed—and how, given the condition of their stumps.
Because tendons are always under a bit of tension, like a slightly taut rubber band, they retract into opposite sides of a wound when severed. This made finding the stumps a sort of macabre Easter egg hunt. To locate those on the hand side of the wound, Dr. Vargas crimped and wiggled my fingers one at a time until the stumps popped back into the wound, tricked into acting as if they’d been pulled there by the muscles in the forearm to which they’d formerly been attached. To locate the stumps on the arm side of the wound, where mechanical manipulation of the tendons isn’t possible, he used forceps to carefully excavate along the path he knew that each tendon followed up the forearm.
Upon discovery, he marked each stump with a suture, then listed the name of the tendon it belonged to with a sterile pen on the margin of the blue sterile sheet draping my body . . . which is not as creepy as it sounds. Surgeons write on blue sheets all the time, because notepads compromise a sterile environment. The blue sheet list thus became the surgical plan: reconnect twelve tendon stumps, then two nerve stumps. Matching stumps for one other transected tendon couldn’t be found without causing more damage, but those that could were firm, and cleanly cut (well done, toilet!). Dr. Vargas would be able to stitch each to its original mate, sparing me the paw he’d warned of in our first meeting.
While this wouldn’t be a complex, puzzle-solving kind of surgery, like constructing an opposable thumb from a toe, it would be tricky, unforgiving work. Tendons are strong but slippery, and they are small at the wrist, about the width and shape of two pieces of linguine, stacked. And while the median nerve at the wrist is much thicker than the tendons there, it’s laughably fragile—like overcooked pasta wrapped in wet toilet paper, as Dr. Vargas later described it to me. He would have to precisely place many tiny stitches into these fussy structures, without damaging them. Moreover, because the hand’s numerous parts are so highly integrated, even a small error or complication during the surgery could significantly impair my functional recovery. “Big-wave surfing,” Dr. Vargas called the procedure. You have to get it right, or the consequences are dire.
He and the team knew their performance over the next several hours would indelibly influence how I lived the rest of my life, so the mood in the room was sober. But it was also focused, keen. After all, they’d spent years training for this kind of work. To the peppy white noise of ’80s tunes playing softly on the operating room radio, Dr. Vargas reached for his forceps and dove in.
Responding to my machine-gun spray of questions about the procedure in a later checkup, Dr. Vargas could have discouraged my burning curiosity—which, after all, could only deepen a resident’s chronic time deficit. Instead, he tossed accelerant on it by recommending “the book that all the big surgeons give their protégés,” which I promptly ordered from Amazon.
A long, rapturous, and meticulously researched stroll through the evolution of reconstructive surgery, The Healing Hand: Man and Wound in the Ancient World gripped me throughout with its lucid prose, copious and uncommon visuals, and bone-dry wit (trust me). It transformed my medical science research from mere fact-finding about my injury and repair into a deeply satisfying end in itself, permeated with the joy of discovery and understanding, deepening my appreciation for my body, and giving me a powerful new lens through which to perceive common human experience.
Greedily consuming the book, I was struck by just how much the life-improving practice of surgery owes to the life-taking practice of war. Weapons innovation drives medical innovation, and apparently has since a hominin first planted an antelope femur in a neighbor’s skull, prompting another neighbor to attempt the aforementioned hole-boring treatment (called trepanation, in case you want to watch some do-it-yourself evangelists effuse about it on YouTube). Thus, as found cudgels gave way to slingshots and arrows, then progressively to cannons, muskets, machine guns, and improvised explosive devices, ancient healers and their professional descendants have scrambled to develop effective means of managing the increasingly devastating wounds wrought.
Sometimes they’ve succeeded, often while practicing in militaries during wartime, or as a result of that experience. That’s partly due to the central tragedy of war—the creation of a large number and diversity of casualties—which offers surgeons extensive opportunity to trial, refine, and teach new approaches to care, on patients young and otherwise fit enough to stand a chance of responding well to them.
But medical innovation needs more than opportunity to flourish, and war has often enabled it in other important ways, aggregating multidisciplinary medical experts, skilled supporting staff, and cutting-edge equipment and technology, and focusing the lot on collaborative resolution of some of the toughest medical and care-delivery problems in an era. Combined with the urgent need to return wounded soldiers to combat fitness, which gives personnel a mandate to challenge entrenched practices, these conditions create an innovation engine that’s difficult to replicate in ordinary circumstances. Modern hospital hygiene and sanitation protocols; the tourniquet and the ambulance; and numerous surgical techniques developed in this engine, as did the specialty of hand surgery.
Through the early decades of the twentieth century, good surgical solutions for many hand problems had yet to be identified. Further, most surgeons didn’t know existing best practices for reconstructing severely damaged hands, so they usually left them that way. On rare occasions when hand reconstruction was attempted, specialist surgeons divvied the job up by tissue type, with plastic, orthopedic, and neurosurgeons tackling damaged skin, bones, and peripheral nerves, respectively, and worked in uncommunicating succession, without considering what the functional outcome of their collective efforts would, or should, be.
As a result, hand parts made whole didn’t always work as a whole: Fractured fingers healed unable to oppose the thumb. Skin grafts lacked the slack to stretch over the knuckles of a closing hand. Poorly repaired nerves rendered otherwise-sound hands immobile. Disabling impairments were common.
In the US, where hand surgery professionalized somewhat earlier than in other Western countries, a smattering of surgeons rejected this status quo, including the aforementioned Bunnell. Unlike their mainstream colleagues, who viewed the hand as a collection of independent parts, they recognized the hand as a mobile system beginning in the arm, comprising numerous structures, and quickened by the nervous system. And they believed that maimed hands could be salvaged, if reconstruction strategies prioritized function of the hand system, rather than simply the integrity of its parts.
This “systems view” illuminated new possibilities for addressing previously insoluble hand problems, and following World War I, these pioneering surgeons worked independently to explore and develop them. It also highlighted the need for a new kind of surgical specialist—one who would take full responsibility for the overall function of a reconstructed hand system and could skillfully operate on all tissue types in order to maximize it.
The innovation engine revved up by World War II enabled the creation of that specialist job in the US. Compared to World War I, more devastating weapons, better war-zone trauma care, newly available antibiotics, and faster evacuation to well-equipped stateside hospitals in World War II meant that more soldiers were surviving with more severe injuries than in the prior conflict. Injuries mostly involved the extremities, very often the hand. Determined to avoid the manpower losses suffered in World War I due to incapacitating hand injuries, the US Army invested heavily in transforming treatment of the combat-injured hand, relying on the pioneering surgeons, and Bunnell in particular, to develop and implement the strategy for doing so.
Toward this end, the pioneers set up services in hospitals across the US dedicated to treatment of patients who required “formidable reconstruction of the hand” (as did I, according to their criteria). They defined rigorous qualifications for the new hand specialty, including “ingenuity” and a talent for teaching, on top of the already big ask of plastic, orthopedic, and neurosurgical skills. They trained a cohort of surgeons to meet them, led by Bunnell. And keen to embed their knowledge in common medical practice after World War II, they set up a professional association that still defines the specialty’s US training and certification requirements, and facilitates the exchange of knowledge with colleagues abroad.
Today’s hand-surgery pioneers are conducting military-funded research to improve outcomes for the steady flow of hand-injured enlistees and civilians created by armed conflicts. Thus, the vicious-virtuous circle of war and innovation persists, and Dr. Vargas could address my devastating injury with state-of-the-art techniques, on half a day’s notice, in a civilian hospital. And thus, my uneasy gratitude for good fortune born of violence.
In the safety of the Bellevue operating room, scar tissue was Dr. Vargas’s biggest enemy. Or frenemy, really, because it’s the body’s main mechanism for healing. A wound anywhere in the body causes tissue cell damage, hence a gap in healthy tissue that must be filled in order to restore function. In an elegant solution to this problem, the damaged cells release chemicals that trigger generation of healthy replacements. But the body doesn’t replace the former with their own kind; it does so with its all-purpose adhesive, scar tissue. Soft but strong and stretchy, scar tissue is ace for any human DIY repair job, from smoothing over a skinned knee to knitting up a torn ligament.
What’s the problem? While generated at the wound site, scar tissue doesn’t stay there. Left to its nature, it indiscriminately oozes into the spaces in and around any other tissue it encounters, like foam insulation injected into a wall cavity, and sticks to it. And in excess or in the wrong place, it impedes function of the very structures it is designed to mend. Not so elegant.
The double-edged nature of scar tissue informs every aspect of hand repair: When you do it, which must be before scarring glues retracted tendon and nerve stumps to their accidental resting places in the hand and forearm. How you do it, with the most delicate instruments and fewest necessary stitches, because even a minuscule suture hole is just a wound waiting for scar tissue to fill and spill out of it. Scar tissue even determines whether you attempt repair at all, because sometimes its likely impact outweighs any potential functional gain from a procedure. As such, it demanded Dr. Vargas’s consideration throughout the surgery, beginning with repair of the tendons.
Tendons are the boss of bones. As described in chapter 4, they’re activated by the muscles they emerge from on one end, and they make the bones to which they’re attached on the other assume whatever position the central nervous system commands. But like puppet strings, they can only pull, not push, their object. So whatever direction a bone needs to move in, there’s a tendon to pull it that way.
In the hand, this means that when you make a fist, your flexor tendons pull the bones of your digits down and in toward your palm; and when you wave, your extensor tendons pull your digits out and away from your palm. And however you move your hand, tendons are gliding back and forth through tissue and over joints.
To give me the best shot at full range of motion, then, Dr. Vargas had to stitch my transected tendons together in a way that enabled gliding. Working stump pair by stump pair, he did so by checking that the tendons weren’t twisted, and by aligning matching stumps on cross-section to preclude bulging edges. Then he used forceps to manipulate his needles—needles not threaded but seamlessly crimped to both ends of a plastic filament—in a clever stitch pattern that surgeons have been tinkering with since the 1970s.
Biting in and out of the stiff exterior and squishy interior of the tendon stumps, Dr. Vargas secured two strands of thread in each, so that their loose ends (four per stump) dangled into the juncture between paired stumps. He then pulled the eight dangling strands together and knotted them, bringing each pair of stumps together. And that was that: Dr. Vargas’s best effort, aligned with best practices of the day, at a repair posing minimal risk of scarring, and strong enough to hold while I did gentle hand exercises to keep joints supple until the tendons fully healed.
The median-nerve repair required a very different approach from that of the tendons. A day or two after the accident, the median-nerve axons below the wound—which had died when severed from their cell bodies in or near the spinal cord—would disintegrate, leaving the nerve’s outermost sheath intact. Hopefully, the live ends of the axons—those above the wound, thus still connected to their cell bodies—would regenerate, per another of humanity’s magnificent survival programs that I’ll explore more fully in chapter 12.
To reestablish their feedback loop with the central nervous system, regenerating axons would first need to cross the wound, and Dr. Vargas aimed to help them do so by reconnecting the stumps of the nerve sheath, thus forming a covered bridge over the wound. Next, the axons would need to reach their designated patches of tissue in the forearm and hand, with motor and sensory axons each terminating at different types of non-neuronal cells (which I’ll generalize as “target cells”). Chances were slim that many axons would make the journey successfully. But almost certainly, none would if Dr. Vargas didn’t execute a good nerve-sheath repair.
A good sheath repair begins with alignment of the sheath stumps on cross-section, so that regenerating motor axons might “stick to their lanes” and find motor target cells, and regenerating sensory axons might likewise find sensory target cells. If motor axons try to dock at sensory target cells and vice versa, well, that’s like trying to plug an iPhone charger into an Android phone. No juice. To achieve alignment, Dr. Vargas would use the tiny, faint blood vessels running longitudinally through the sheath as landmarks in finding the correct orientation of stumps to each other, as if matching up the red stripes on a broken candy cane, but harder. Then he’d secure the stumps together with knots at six even intervals around the sheath’s circumference.
Dr. Vargas did all this fine work looking through the lenses of a powerful standing microscope positioned over my wrist—sitting with elbows cradled by rests to help still his hands; using forceps to manipulate needles the length and curvature of an eyelash and no thicker; fingers barely moving; gently throwing stitches, pulling up slack, and knotting and clipping—until he’d finally crossed the last item off the long list of repairs on my blue sheet.
Three and a half hours after he began, Dr. Vargas deflated the tourniquet cuff to let my arm refill with blood, used an electric cautery to close some small vessels unlikely to clot on their own, and closed my wound for the last time. Then he raised my forearm off the table, took hold of my hand at the wrist joint, and carefully moved it back and forth.
In a hand with properly functioning tendons, the fingers naturally fall into a cascade as the wrist moves forward, like Adam’s in Michelangelo’s Sistine Chapel painting of creation, and they form a loose fist as the wrist moves back, like babies’ hands do when they sleep on their backs. And so did my fingers as Dr. Vargas moved my wrist. The repaired tendons had passed their first test. They could still rupture, axons could still fail to regrow, and scar tissue could still gum up the repaired structures. But the surgery, at least, had gone very well.
While Drs. Vargas and Matthews set my wrist and hand in a light plaster cast, the room came alive again as the rest of the team briskly cleaned, set up for the next surgery, and hurried out of the room. If they were hopeful or worried about the surgery or my future, they couldn’t dwell on those feelings. They had to clear me from their minds and hearts so they could give the next patient their best, too. That was the job; for many, their calling.
However they felt about their work, to me it was an aligning of stars—of extraordinary knowledge, skill, and determination, wrung from sacrifice and compounded over centuries, finally available and summoned on my behalf at 3:00 p.m. on a Friday afternoon in 2006. And invested by the team in me, a stranger, with nothing expected in return, it was an act of compassion—of love, even—as healing as anything else that happened in the operating room that day.