Best Doctors 2011: Dr. Kevin Malone

A case I'll never forget: Reattaching an arm severed in a farm accident

I was at my daughter's swim meet when I got the first call from the hospital.

The details were sketchy. A 40-year-old woman was being brought in by helicopter from Wakeman. A farming accident had amputated the woman's left arm. She had an unclear injury to her right arm as well.

I wasn't on call that July evening, but once the patient arrived in the emergency department, I got a second call. This time it was a fellow orthopedic surgeon training with me in microsurgery. "I know you're not on call," he said, "but there's a patient here who needs your help."

Based on the details I had, I knew the case would be challenging. Farm accidents are notorious for involving a lot of bacteria that can be tough to eradicate. If I didn't remove that bacteria before reattaching her arm, she could develop a major infection.

Driving to the hospital, I felt a rush of adrenaline as I ran through a mental rehearsal of what needed to be done. I specialize in the arm and have additional training in microsurgical techniques that allow me to reattach tiny blood vessels and nerves. But major limb amputations like this one don't happen often, and risks of major complications or death are significant.

I arrived at the hospital to find the detached arm on ice and the patient alert and calm. She had little memory of the accident, but we were able to gradually piece together what had happened.

She'd stopped by her father's farm after work. He had recently suffered a stroke, and she offered to help out with some farm chores. She was in the fields, alone, working with a hay baler, when her right arm became trapped in the machine all the way to the shoulder. As she reached around with her left arm, likely trying to free herself, it was sliced off cleanly, just above the elbow, by the baler's sharp blades. It was an hour before someone found her and called for help.

As the emergency team examined her other injuries, they found that although she could not feel or move her right arm, it had amazingly not sustained any fractures despite being trapped in the machine more than an hour. That arm was swollen but otherwise looked normal, and only time would heal the nerves and muscles that had been squeezed in the accident.

When I start a case like this, I zone out everything else around me and focus on my work. I had to act quickly because when a limb has been amputated, there's a window of opportunity — about six hours if it's warm or 12 if it's on ice — to replant it successfully.

My first task was to remove the grass, dirt and bacteria from the arm. That involved cutting back bone, veins and other exposed tissue and irrigating the rest. Once the patient arrived in the operating room, I had to repeat that process on the other half of her arm. Anything that didn't look healthy was cut out.

We reattached the bone using two plates and many screws. Then we repaired her artery, veins, muscles and even tiny nerves using the microscope and sutures that are finer than a human hair.

It took about six hours to reattach this woman's arm, and it was just the first of many surgeries to come. At the end, I was exhausted, physically and mentally. We'd worked through the night on her, so getting through the following day's schedule was challenging.

But I felt good that I was able to help this patient. Her right arm has regained range of motion and sensation and is about 85 percent of the way to complete recovery. Her reattached left arm will never again function normally, but we hope she'll be able to feel sensations and grasp things with her hand one day.

Seeing her come in today, with a huge smile on her face, that's why we do the things we do.

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