- Associated Press - Friday, February 7, 2014

ST. LOUIS (AP) - When 12-year-old Devin Graham came into the emergency room at a Wichita, Kan., hospital with his hand nearly torn off by a rope, surgeons there could only amputate. Calls went out to the big medical centers nearby in Kansas City and more than seven hours away in St. Louis, to see if they could save the hand.

The technical hand surgery requires a team of skilled surgeons, an operating room for hours and equipment - all of which experts worry are getting harder to come by. Even for hospitals with the ability, deciding to amass the resources to work though the night on a risky case is not easy, the St. Louis Post-Dispatch (https://bit.ly/1fBsxU5 ) reports.

A physician at St. Louis Children’s Hospital agreed to try. “I wasn’t sure I was going to be able to help him, and I had some trepidation about asking a family to come all the way here and have it be a major disappointment,” said Dr. Charles Goldfarb, an orthopedic surgeon. “But I also think as a 12-year-old, he has deserved every chance to try and save his hand.”

Repair was going to be especially tricky, he said, because the rope caused a “wide zone” of trauma across the middle of Devin’s hand, unlike the more precise and typical injury from a sharp object. Children’s hands are also smaller, adding to the challenge.

A 50-50 chance of success. That’s what Devin’s mom, Marla Graham, said she was given. But odds have never been in the Grahams’ favor. Seems they are always flipping a double-sided coin.

A year ago, Devin’s father committed suicide after being diagnosed with Crohn’s disease, an inflammatory disorder of the digestive tract that can be painful and debilitating. Devin’s aunt had just died of the disease, after six years of being cared for by the family. Devin also recently lost his grandparents, as well as a neighbor. Six years ago, his older brother was hit by a car while riding his bike to school, leaving him with a metal plate as his jaw.

And now, Devin’s hand was seriously injured. He hurt it when he and his mom were driving home from school Jan. 14. They stopped to help a panicked teenager in a truck who had gotten his cargo trailer stuck in deep mud, Marla Graham said.

She and Devin pulled on one top corner with a rope to try to tip the trailer on its side, and the driver pulled on the other with a rope attached to his truck. The truck went too fast, ripping the rope - which Devin had wrapped around his palm and index finger - away from them.

Marla Graham didn’t hesitate to put Devin on the hour-and-a-half ride on a small airplane to St. Louis. She was worried about money, her older daughter at home, her dogs and her house. But she had to try.

“He deserves this,” she said.

By 11 p.m., Devin was in the operating room. Goldfarb said he and his team worked until nearly 4 a.m., using wires to set five broken bones and sewing together severed arteries and veins to “revascularize” the hand. The tendons and nerves were traumatized, but thankfully still intact. In time, they should heal.

Devin - whose 13th birthday came while in the hospital - was released Jan. 24, 10 days after the accident. With intense physical therapy, he is expected to regain good use of his hand within a year, Goldfarb said, adding, “It’s great.”

Goldfarb said medical centers are increasingly not performing such intensive and risky “replants” because the reimbursement - especially from public insurance like the Grahams have - doesn’t pay well for the team of experts required, the high-tech equipment and lengthy surgery, which tends to be late at night.

“The trend is that people don’t want to do this type of surgery,” he said. “Fewer places want to do this kind of work.”

Dr. Tom Barber, who serves as the chairman of the advocacy council for American Academy of Orthopaedic Surgeons and practices in Oakland, Calif., said only two centers in the sprawling San Francisco Bay Area perform hand replants, and one only during the day.

That’s because of the complex system needed to perform replant surgeries, Barber said. A team of highly skilled specialists must be available at any time and have long access to a high-tech operating room.

“To have people waiting 24 hours a day for something that, in the Bay Area, might happen once or twice a week . ,” Barber said. “You have a huge staff on call for something that is very uncommon, and that is hard.”

Dr. Scott Levin, director of the Penn Medicine hand transplant program and chairman of the trauma task force for the American Society for Surgery of the Hand, called the situation a huge crisis in hand trauma that has been brewing for the past decade.

“There are many patients who are candidates for a limb-saving procedure that just can’t reach a center that does it … who are told, ‘All we can offer is an amputation,’” Levin said. “You should not be told, ‘We can’t do this, and we can’t find anyone who can.’”

He has been a strong advocate for creating regional hand care programs, similar to burn units or trauma centers, which amass the expertise and resources that are getting harder to come by. Patients can be treated near where they live, which will also lead to more successful outcomes.

“So all physicians and the public know exactly where to send patients and can get access to care like Devin did,” Levin said.

For Devin’s surgery, two more Washington University School of Medicine hand surgeons were on standby just in case Goldfarb needed additional expertise, said one of those surgeons, Dr. Martin Boyer.

“You’re speaking to a nationwide issue that has really been struggled with at the highest levels of surgical and hospital leadership,” Boyer said. The struggle is between staying profitable while also providing the best care.

“When you have a child in front of you whose limb has to be amputated, reimbursement is furthest thing from your mind,” Boyer said. “There has to be an understanding that we do what is best for the patient regardless of what that entails in terms of cost, in terms of inconvenience for the providers, in terms of anything.”

Seems this time, the Grahams actually got lucky.


Information from: St. Louis Post-Dispatch, https://www.stltoday.com

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