Kodi Azari - The Perfect Human Hand

 

So, when I was a young boy, I wanted to be a fighter pilot, nothing more than a fighter pilot. I'm not sure what attracted me to it, because I would never be able to kill someone. I would never be able to drop the bomb. But I think there was a sense of power within these machines, this sense of purpose, this sense of commitment, and the sense of the mission that there is no failure. You have to make this mission happen, and it has to be perfect, because you have a twenty-something-million-dollar plane in your hand. Except there was a problem. And the problem was that I'm Persian. I'm an immigrant from Iran. 

 

Any self-respecting Iranian parent would never let their child be anything more than a doctor, or a lawyer, or an engineer. Those were the three options, but mainly doctor or an engineer. There was no choice other than that. So, there was no way my parents were going to let me do anything otherwise. So, I had to tell a lie. And my lie was, "You know what? I'm going to become a physician." I said that just to get them off my back. And really, that's all it took. And then, all my family members started to accost me. And in one particular case, I remember this little old lady that was a family friend that lived in Pittsburgh. She would start sending me articles. She sent me articles about this young, pioneering transplant surgeon by the name of Tom Starzl. This was a man that was revolutionizing the field of transplantation by performing liver transplants.

 

Now, liver transplants are commonplace right now. But back then, they weren't. Liver transplants were unbelievable at that time. And to put it into perspective, these were bloody, bloody operations. Some of these operations would require 1,000 units of blood. 1,000 units of blood for one person. In fact, they were so bloody that in a large room, these were not small operating rooms, they would have to put blankets at the doors, so that the blood wouldn't gush out into the middle of the hallway. 

 

On top of that, for example, in the city of Pittsburgh, they would have to stop elective operations. They would stop them, because the city's run out of blood for this one patient. So, none of the other hospitals could do elective operations, because there's no blood available in the city. Add to that, the patients were dying. They either died on the table or they died in the ensuing weeks. Now, can you imagine what this young surgeon was going through? The hospital administration was after him, the public was after him, the media was after him. "Why are you doing these operations?" Yet, he had this conviction and he had this sense of purpose to, no, to push the operation forward. 

 

And now today, transplantation of livers is routine. In our hospital, for example, we do three in a given day. Yet it took this person's conviction to do that. So, I decided, you know what? I think I can. I'm going to be a transplant surgeon. So, I decided to go to medical school. Yet in medical school, a transformation happened to me. And the transformation was almost in gross-anatomy class, and it was the dissection of the human hand. The reason this transformation happened is I'm not a religious person, but if there's any evidence of divine intervention, it has to be the human hand. There is no greater source of functional anatomy other than the human hand. 

 

It's perfect. It's an organ of grasp, so I can grab things. It's an organ of strength, I can break bricks with my hand. It's an organ of precision, I can play the concert piano or the concert violin with the same hand. It's an organ of sight, I want you to close your eyes, touch anything in front of you without looking at them, you know exactly what you've touched. It's a sexual organ. And finally, it's an organ of expression. You all know what this means. You all know what this means. You all know what this means. And you certainly know the New York taxi-cab driver is the middle finger. [audience chuckles]

 

So, could we do hand transplantation? Could we actually take a hand from another human being and attach it to the arm of somebody that's lost one? Well, nobody had done it back then. It was only in thought. Yet the complexities were too great. So, I decided to become a hand surgeon, and go into hand-transplantation surgery. I thought it would be done, if it was going to be anywhere, it would be in Pittsburgh, where this young man was. So, I went and did a general-surgery residency, I did a plastic-surgery residency, I did a hand-and-microsurgery residency, and then I did a tissue-engineering fellowship. Wait, did I just do what my parents had wanted me to do? [audience laughter] A doctor, an engineer? I think so.

 

So, this was a grueling period. It was a grueling period of 110- to 120-work-hour weeks. I remember not having an entire day off in one year. In fact, I remember walking into the MRI unit with my wallet, I forgot to take it out, to push a patient in the middle of the night. And then, my wallet became demagnetized. So, my credit cards became demagnetized, and I had run out of cash. I couldn't use an ATM, and I wasn't able to go home at all, and I wasn't able to go to the bank and get my ATM reset, my credit card reset. So, I remember begging for money from my co-residents for about a 10-day period. "Listen, can I have your meal card? I'm really hungry." [audience chuckles] 

 

Anyways, 18 years after high school, I'm finished with training. [audience laughter] And now, I'm a hand surgeon. So, obviously, I take my first job in Pittsburgh, where we're trying to start a hand-transplantation program. This was a program that took almost seven years to put together. It took an extraordinary amount of effort to put this amazing program. And towards the end, we're ready to do a transplantation, except the next problem happened, and it happened to be my wife. My wife gave me the ultimatum. There was no way that she was going to take another winter in Pittsburgh. So, my only choice was move to California. 

 

So, right before we're able to finish this program and perform transplants in Pittsburgh, I moved to California. Yet there was no way I was going to be denied. I was going to absolutely participate in this program, and I was absolutely going to do this operation that I had devoted at least 18 years to learn how to do. But not many people had done it before. So, I'm in California, and it's March of 2009, and we receive a call. Our first patient that was on the transplantation list had received a match. We had a match. We had a donor for him. He was a young man. He was a 26-year-old Marine that had lost his dominant hand in a munition’s accident. I don't know what it means not to have a hand. I don't think many people do. 

 

I know what it means when I get a paper cut, I can't type that day and my finger is sticking out. But I don't know what it really means not to have a hand. Yet we have a hand for this man. And why it's such an incredible experience is it's difficult to find a hand. Not only do we have to have the exact same match, so it has to be a blood-group match just like any other organ, but this is an external organ. It has to be matched according to size. It has to be the same size, it has to be the same color, the same skin tones, it has to be the same hair patterns as this Marine. And we found that. Yet I'm in California, and the hand's in Pittsburgh. 

 

I got the call during the middle of the day. It was a Thursday, and I was already in the operating room, and I certainly couldn't stop my operations. I finished my operations that day and took my car, went to the airport, and bought the first ticket out of Los Angeles. Now, visions of 9/11 are happening to me, because there's this crazy guy saying, "I got to get to Pittsburgh. I got to get to Pittsburgh," with a credit card. "I don't care if it's one-way or not." [audience laughter] Took the red-eye and I was in Pittsburgh. 

 

Now, it's 24 hours that I've been awake. And in the plane, I was this caged animal. I couldn't sleep. My legs are shaking. I can sense that when I look at boxers, they're just standing there when they're giving the instructions by the referee, they're like these animals that want to explode, yet something, they're just waiting to go. And I was just waiting to go. Yet at the same time, I was filled with this incredible sense of dread. "Can I stay awake for another 15 hours? I've already been up 24 hours. Can I really stay up and have my faculties intact to do this incredible operation?" 

 

Once I got into the operating room, something happened, and that's called the zone. Athletes talk about the zone. Yet I don't know how to explain it. I was an athlete when I was younger, and I remember setting the high-school record in the 100-meter dash. I felt this sense of moving effortlessly through time, effortlessly through space, and everybody else stood still. I think that's what athletes meant. And doing this operation was really the same way. It was this effortless motion where you're looking down a goggle. 

 

You don't know what's going on around you. You almost can't hear. All you're seeing is the task ahead of you. You're moving very, very quickly, yet everybody else is moving in slow motion. It's really an incredible feeling that I've only felt this one time in my life. We begin this operation. This is a difficult operation. You have to attach the bones. There are two bones. You have to get them the right length. You have to make sure they're absolutely the right length to attach them. Then you do the tendons. You have 23 tendons. You have to find the scarred tendons in the forearm of this individual. 

 

Well, there's no markings on it. You have to find out where they are, and then you have to attach it to the new hand. But you have to do it in the absolute perfect balance. The reason we can use our hands so well is because the tendons in the palm and the tendons in the back are in absolute harmony. Their tensions are set appropriately. Yet there is no cookbook of how to put these tendon tensions together. This hasn't been really done before. 

 

Then come the nerves. Well, the reason everything moves is because the nerves have been appropriately put back together. And nerves are like coaxial cable in your TV, except there's no red-to-red, green-to-green, yellow-to-yellow coding. [audience laughter] And you have to put those back together. Then come the vessels, arteries, and the veins. And these are tiny structures. The veins were one millimeter. In fact, we have to use a microscope, magnify it 30 times, and then you're using sutures that are just a quarter size of the human hair. You actually can't see them with your eyes. You have to absolutely perfectly bring them back together in order for it to work. Otherwise, the graft will fail. You'll get a clot and it'll fail. 

 

And to add to the tension of all this is we haven't done this before. There is no cookbook of how to do it. And to make it even harder, your hands are frozen. We have to do this on ice to preserve the hand. So, my hands were burning, they were so cold. And all I could think about was, "I wish somebody could pour warm water on my fingers." 15 hours later, the operation is done, and we take this young Marine into the recovery area. It was this great sense doing this operation that I felt, it was a sense of, failure is not an option. I'm not going to be denied. There's no way this is going to fail.

 

I remember at the same time thinking, I wonder if this is what the jet-fighter pilots feel like when they're trying to land this multimillion-dollar plane on top of an aircraft carrier in the middle of the night in some unknown gulf somewhere. The Marine is back into the operating room. He's finished, he's back into the recovery area. I asked him to move his fingers when he woke up. Started with the thumb. There's a flicker of the thumb. He hasn't had a hand for six years. Then the index finger, then the small finger. By the time we're at the small finger, there's not a dry eye in the room, and I'm continuously sobbing. It's an incredible feeling to be able to give back to someone that's given so much to you. 

 

I went back to California, and then I met him a year later. I met him back at the Pentagon. Outside of family events, this was really one of the most incredible events of my life, is because I looked at his face and I shook his hand. The hand was warm, it was strong, and it was sweaty. Human hands are sweaty if they have nerve function. And of course, I'm going to get a pose, I'm going to get a photo op, so I'm like, "Well, let's get one arm-wrestling." [audience laughter] Next thing you know, this young Marine has pinned me and I can't get out. [audience laughter] Not really a great photo op. [audience laughter]

 

So, my practice has changed in Los Angeles in that I've been involved with this incredible organization, where we reconstruct our wounded service members’ hands. When they're injured in these two conflicts, we pay for their operations, we take care of them. So, a good portion of my practice is taking care of these guys, reconstructing their hands, to those that have given so much. Yeah, I'm not flying fighter jets, but I'm reconstructing those that have been injured doing so.