By Leo T. Kroonen, MD

April 10, 2012.  Kandahar, Afghanistan.  I was part of a team of orthopedic surgeons stationed at the Role 3 Multinational Medical Unit.  We had a great team, free of any egos.  Everyone was willing to help each other whenever duty called.  We had already been in country for over 4 months, and knew the drill.  Be ready at any time for whatever might come in.

This day, they brought in a young Army Staff Sergeant, hit 10 minutes earlier by an IED.  He was brought in with tourniquets on all four extremities.  His legs had both been traumatically amputated.  His right arm was amputated above the elbow.  He was already a triple amputee.

His left hand is what he still held onto, but it had been injured, too.  His left hand had a bad blast injury, that in and of itself would have been a horrible injury.  But in the context of this triple amputee, it was what he had that we might be able to save.  I thought, this is the one limb he’s got.  I’m the only hand surgeon in southern Afghanistan.  It’s on me to try to save this.

The team agreed.  I examined his hand with one of the nurses, and one thing stood out to us both.  His wedding ring was still intact.  A little bit of gold shone through the crimson of his blood as a reminder to us that this was not just an Army soldier.  He was a husband and a son.  We learned later that he was also a new father.

We were able to remove the ring, and secured it prominently with his personal belongings, and then I went to work.  The ulnar three digits were not salvageable, so I quickly debrided away the devitalized tissues.  Then I looked at the thumb and index fingers.  As meticulously as I could, I carefully debrided away gross contamination, but found neurovascular bundles to both that were still providing perfusion.  I wouldn’t call the capillary refill brisk, but it was there.  Within just over an hour, we had his limbs debrided, and I had my fingers crossed.  I thought just maybe he had a chance to keep some part of a working hand.

The coming days got to me.  I kept thinking back over that case.  Did I do everything I could?  Did we do the right thing for this soldier?  What was his life going to be like as a triple, or possibly quadruple amputee?

Later that week we had our phone conference to learn from the higher echelons of care about how our patients did.  This particular patient lived to the next stop in northern Afghanistan.  At that point his injury had progressed.  They had to amputate his remaining left hand.  All the work, stress and worry I had over that hand was in vain.  However, he lived.

I’m happy to tell you that he still lives on today.  He is one of just a few surviving quadruple amputees, and he is an absolute inspiration to everyone who meets him.  I have had the privilege of meeting him again, and he doesn’t hold it against me.  So you might wonder why I’m telling this story.

Ultimately, on that crazy day in Afghanistan, I gave it my all to try to keep together a hand that did not survive.  However, that day is when I realized what skill set I brought to the table.  I was surrounded that day by talented orthopedic and general surgeons.  Those guys saved this soldier’s life.  I failed to save his hand.  However, we each brought our own unique skill set to the operating room that day.  My training as a hand surgeon made me the best person on that day to try to save his hand.  I was glad to be there, and felt a strong purpose.

Since that time, I have been challenged by cases and have continued to try to push myself forward in studying the art of hand surgery.  I’ve been blessed with the opportunity to work with outstanding mentors and colleagues, but perhaps none has been so meaningful to me as being a part of the Hand Transplant team led by Dr. Kodi Azari at UCLA.  After the experience of losing that hand in Afghanistan, I had the opportunity in October 2016 to assist with procuring a donor hand (ironically, doing an amputation), and then transplanting it onto a recipient patient who had lost his hands.  This was the ultimate resolution to my perceived failure in Kandahar.

Some days it is easy for us to get into a routine of doing bread-and-butter cases that seem easy to us.  How many more carpal tunnel releases or trigger fingers do we need to treat?  Yet every day, it is important to remind ourselves of the skills, the knowledge, and the talent that we bring to an integral part of the human body.  Even the easiest cases for us are done with a skill we have worked years to have the privilege of performing.  While I hope that no one ever needs to feel the stress I felt taking care of that Army Staff Sergeant, I hope each hand surgeon will remember that what we do is special.