The evaluation was a detailed process. In addition to evaluating Garcia’s medical past and present, the team had to consider his likely future—his chances for a life that was productive and healthy. Hand transplantation was a huge investment in high-tech hope—a giant gamble on the fortunate few selected to receive transplants. As Miranda had pointed out to me weeks before, saying yes to Garcia meant saying no to a host of other applicants, other people who’d lost hands to disease or trauma. The transplant team needed to feel confident that the investment and the gamble could pay off, not just for Garcia but also for society. That meant they needed to assess a host of factors: Apart from the injury to his hands, was Garcia’s health good? Did he fully understand the potential risks? Could he faithfully follow the postoperative protocols for physical therapy, infection control, and the lifelong medications required to suppress his immune system and prevent rejection? Was he psychologically prepared for the daunting endeavor—and robust enough to deal with failure, if the transplant didn’t succeed? What would be lost, to Garcia and the world, if he didn’t receive a transplant? What might be gained if he did?
I gained a better perspective on the complex considerations of transplant evaluations when I called J. T. McLaughlin, a former undergraduate student of mine who’d gone on to become a nephrologist—a kidney specialist—in Montgomery, Alabama. J.T. hadn’t performed any kidney transplants himself, but several of his patients had received transplants at the University of Alabama’s medical center in Birmingham.
After I’d described Garcia’s injuries—which J.T. found personally horrifying but medically fascinating—he peppered me with questions. “Is he a smoker?”
“Heavens no.” I couldn’t imagine Garcia, who was immaculate almost to the point of fastidiousness, smoking a cigarette. “Does that strengthen his case much?”
“Sure. Smokers have lousy circulatory systems. Lousy blood supply everywhere in the body, and that jeopardizes anything that gets transplanted to them. That lowers the odds of a successful outcome. Has he ever had a transfusion—either because of the trauma to his hands or because of some prior injury or illness?”
“I don’t know,” I confessed. “Why does that matter?”
“If he has, his immune system’s been sensitized; that means he’d be more likely to reject the transplant. But the Emory people are on top of that—they’re among the nation’s leaders in transplant compatibility. They’ve developed something called the Emory algorithm, which is used all over the country, to help predict rejection. And I think they’re about to start clinical trials on a new immunosuppressant drug—supposedly the biggest advance in fighting transplant rejection in thirty years.”
“Sounds like he’s in the right place.”
J.T. wasn’t through with his questions. “How old is he?”
“Forty. Ish.”
“That’s good. He’s fairly young, which helps in a couple of ways. For one thing, he’s likely to rebound more quickly; his blood vessels and nerves would regenerate faster than some geezer’s would. He’d potentially get a lot more benefit from a transplant than a geezer, too, and could contribute more to society. Helps that he’s a doc, too.”
“Doctors helping doctors? He’s already a member of the club?”
“Well, that doesn’t hurt,” he hedged, “though nobody would ever put it that crassly. What I really meant was, as a physician he’s highly educated and he already knows medicine. That means he understands the risks, he knows he’ll have to take immunosuppressants for the rest of his life, and he realizes that the immunosuppressants have side effects and complications of their own—they can cause diabetes, and they make him more vulnerable to diseases. In a way it’s like signing up for HIV or AIDS, for the sake of the transplant. The procedure’s very risky, and the risk never fully goes away.”
“That’s discouraging,” I said. “On the surface a hand transplant sounds like it would be a miracle for him.”
“It might well be,” he responded. “But there’s no free lunch. Some medical miracles cost a hell of a lot.”
He paused, then added, “Speaking of that, can he even afford it? His health insurance would probably cover the cost of prostheses, but it isn’t going to cover a dime of an elective, experimental procedure like this.”
“I hadn’t even thought of that,” I confessed.
“Emory will sure think of it,” he said. “I imagine this is a million-dollar procedure. But maybe they’ve got some research funding that would help underwrite the costs. Money aside, what’s your friend’s support network like? You think the wife would help him through the ups and the downs?”
“Absolutely. She’s smart and strong. She’d be great—supportive, but I’m sure she could get tough with him if she needed to.”
“Anything about him that might raise a red flag to a psychiatrist?”
“What does a psychiatrist have to do with it?”
“It’s experimental surgery. Incredibly rare, very risky. They’re gonna want a shrink’s opinion. Can he handle the stress, follow the rules, do his physical therapy, take the meds religiously, handle the disappointment if the surgery fails? What’s your take on his overall mental health?”