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RNs Participate in Hand Transplants

Nurses at Jewish Hospital & St. Mary's Healthcare have unique opportunity to participate in hand transplantation.

Nurses from the Jewish Hospital & St. Mary's Healthcare in Louisville, KY, participate in what's still considered an experimental procedure: hand transplantation. RNs within the facility's Hand Care Center - specially designed to treat hand injuries and diseases, including elective and urgent extremity care - care for patients during and after what can be up to a 16-hour procedure.

The operation generally involves a six-member hand surgical team, with 12 hand fellows assisting and a two-member anesthesiology team. A hand transplant, unlike a solid organ transplant, involves multiple tissues (skin, muscle, tendon, bone, cartilage, fat, nerves and blood vessels) and is called composite tissue allotransplantation.

"The multidisciplinary team, including hand and microsurgeons, and researchers from Kleinert, Kutz and Associates and the University of Louisville, were assembled to conduct this type of procedure," said Barbara Smeland, MSN, RN, the director of the Hand Care Center and Outpatient Care Center, administrator of the perioperative hand transplant team, and a member of the composite tissue allotransplantation team. "This team also includes nursing who work collaboratively to provide individualized care to each patient. We are leaders in the world for composite tissue allotransplantation."

The Surgery

Hand transplantation is an extremely complex procedure, but may not be as difficult as a hand replantation in that a replantation usually involves crushed or mangled bones, tendons and ligaments. The surgery progresses with tissue repair in the following order: bone fixation, tendon repair, artery repair, nerve repair and vein repair. The surgery can last from 12-16 hours. Typical post-operative complications include blockage of the blood supply, infections and rejection.

"This is a unique experience for our nurses because of the complexity of the procedure," said Smeland. "This type of transplantation works with several layers of tissue, bone, tendons, nerves, blood vessels and skin, which all impact whether or not the surgery will be successful. It is not just a single organ. We use different techniques and different materials depending on which area we are working on. The medication regime following the transplantation is also specialized."

A partnership of physicians and researchers, surgeons from Kleinert, Kutz and Associates Hand Care Center, and the University of Louisville, has performed four hand transplants at the hospital. To date, there have been a total of 40 hands transplanted on 32 patients around the world.

Patient Care

Nursing is involved in every aspect of the care provided to the hand transplant patient. An RN research coordinator is responsible for all recipient recruitment, candidate presentation and preparation of approved recipients for hand transplantation. The hand and microsurgery nursing unit, 8 Towers, in Jewish Hospital is dedicated to hand surgery. These nurses are trained in the preparation and post-surgical monitoring of these patients. The surgical team consisting of pre-operative, operating room (OR) and recovery nurses all have specialized training in this patient population.

The anesthesia providers consist of anesthesiologists and nurse anesthetists. The retrieval team has an OR nurse as one of its members. The transplant nurse coordinator and transplant physician round daily on the patients after the procedure has been performed.

"Interdisciplinary teams meet on a routine basis to coordinate and evaluate the care that is being provided," said Smeland. "These patients continue to be monitored even after they are discharged. We have established protocols that we follow on every aspect of the patient's care. Personally, it is great to be a part of a medical team that is a world leader in this type of transplantation, including our nurses who are an integral part of the program's success."

Leslie Feldman is a frequent contributor to ADVANCE.

(L-R:) Rita Pardee, RN, Jewish Hospital Hand Care Center, and Ruben Gonzalez, MD, remove the bandages from the nation's fourth hand transplant, Dave Armstrong, as his mother, Linda Armstrong and wife, Regina Armstrong look on.

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