Repairing a Blown-Up Hand

Dr. Dimitri Anastakis featured in a Globe and Mail article.

Prior to the first in a series of reconstructive surgeries, Dylan Birch’s doctor took this photo of his patient displaying the hand he mangled in a rocket-building accident. (Peter Cheney)

By Grade 7, Dylan Birch was chasing the dream that would nearly kill him. He collected pencils, aluminum pop cans and a sheet of sandpaper – the materials for his first rocket.

The pencils would be hollowed out, then filled with a homemade fuel propelled by the powdered aluminum that Dylan manufactured by sanding down the cans. His father managed a Canadian Tire store, so tools were easy to come by. And, in the age of the Internet, so was the knowledge – Dylan studied the website of the U.S. National Aeronautics and Space Administration, soaking up the rudiments of rocket science.

“It was all there,” he says. “All you had to do was look.”

Dylan was a born inventor, an adolescent Leonardo da Vinci who loved nothing better than building a solar-heating system for his parents’ new pool or designing an airplane online with Google Sketch-Up. Now, he was obsessed with rockets.

His early, pencil-based models were powerful enough to shoot a skateboard across his parents’ driveway, but Dylan wanted more. He scaled up his efforts, using cardboard mailing tubes for his rocket bodies instead.

By February of 2008, as he turned 15, Dylan was ready for the next step. His parents had just finished building their dream house, a beautiful two-storey building on a treed lot outside Pembroke, Ont., in the Ottawa Valley. It was a Friday night, the start of March Break, but Dylan wasn’t out partying. Instead, he was in the basement workshop, a perfect place for a teenage inventor, with workbenches, bins filled with mechanical parts and rows of neatly racked tools.

Dylan had discovered a length of large-diameter copper pipe the plumbers had left behind – in his mind, it was a home-made Apollo booster. He made a rocket nozzle from a steel nut, crimped the top of the pipe shut and set out beakers filled with homemade rocket fuel. On his science teacher’s advice, he had started wearing a clear, plastic face shield and respirator. He slipped them on and started loading the fuel.

It had to be packed into the rocket without gaps that could disturb the combustion process. Dylan decided to try a new technique, feeding in the fuel with a power drill running in reverse – the bit acted as an auger, dropping in the aluminum powder like grain running into a silo. He held the rocket in his left hand, his thumb wrapped around the copper pipe.

In hindsight, the events of the next few seconds are easy enough to predict. But not for a boy obsessed with an ongoing experiment, with a sense of teenage invulnerability.

There was a burst of white light and Dylan found himself in a strange world of silence and altered vision – as he would later learn, his contact lenses had fused onto his eyeballs. The drill had generated a spark, instantly igniting the fuel. The pipe exploded into razor-edged shrapnel that flew through the workshop.

A chunk the size of an iPod Nano blew into Dylan’s thigh, ripping through the muscle and tissue before smashing into the bone of his femur. His face mask was glazed with blood and atomized tissue, and the air was filled with white smoke, but Dylan caught a glimpse of his left hand – the thumb and fingers appeared to be gone and white bones stuck out like the frame of a shattered umbrella.
Dylan moved toward the basement stairs, trailing a river of blood. His brother met him at the landing. His mother was calling 911.

For Dylan, that day in March, 2008, was the beginning of a medical odyssey that has yet to end. His accident plunged him into a world he never knew existed – of advanced physiotherapy and high-tech hand surgery.

He spent months in the hospital, undergoing a series of operations to save his life and stabilize his ruined hand. Five stainless-steel pins were driven through the remains of the hand’s shattered skeleton, holding it together so bone and tissue could reassemble themselves as best they could.

For weeks at a time, he was on powerful painkillers that induced strange visions. The pattern in a hardwood floor swarmed with living figures, like a Hieronymus Bosch frieze; or, he was shackled to a table at Area 51, where aliens gradually stole his body parts as if he were a stolen Porsche in a chop shop.

Then there was one where he had two perfect hands. “They were my hands,” he says. “The way they used to be.”

Web of destruction

Although young people often have injured themselves playing with explosives, the rise of the Internet has both accelerated the pace and upped the damage.

“There is definitely a dark side to the Internet,” says Christopher R. Forrest, chief of the plastic-surgery division at Toronto’s Hospital for Sick Children. “There’s a tremendous amount of great information on it, but it also allows people to do some things they shouldn’t.”

Although there are no comprehensive statistics, medical experts believe there is a rising number of accidents such as Dylan’s. (Among the patients Dr. Forrest has treated are a father and son who made a makeshift bomb by packing sparklers into a metal golf-club shaft.)

According to the Atlanta-based Centres for Disease Control and Prevention, injuries due to homemade explosives began rising in the mid-1990s, as Internet use became widespread.

Although serious bomb makers could always dig up obscure military and academic texts, many trace the democratization of bomb making to The Anarchist Cookbook , published in 1971 by William Powell amid the protests against the Vietnam War. Back then, dog-eared copies were passed around among insiders. Now, much of its deadly information has gone mainstream, available to anyone with decent Googling skills.

Some U.S. states have gleaned data through a system called Hazardous Substances Emergency Events Surveillance (HSEES). The system documented 29 accidents involving homemade chemical bombs from 1993 to 2003, and found that more than three-quarters of them involved males 18 or younger.

That doesn’t surprise Barbara Morrongiello, a University of Guelph psychologist who has spent years studying risk-taking behaviour. Teenagers take far more chances than adults, and teenage boys are the biggest risk-takers of all.

“Boys and girls appraise risk differently,” she says. “Boys are more optimistic about risk. They tend to think that they can manage it or evade it.”

Dr. Morrongiello says neurological testing shows that as humans mature, they gradually develop behavioural-control systems that steer them away from risky situations. But most teenagers don’t have them yet.

“It’s part of a behavioural continuum,” she says. “If you can get them through the teen years, things will take care of themselves.”

Collateral damage

By the spring of this year, Dylan had learned to live with his mangled left hand. It looked like a flipper – the thumb was gone and the fingers looked like mashed-up toes. But in the meantime Dylan had taught himself to weld and built a snowmobile trailer in the garage, using an engineering program to design the suspension. After months of experimentation, he also had come up with a way to tie his own shoes, gripping the laces between the stumps of his fingers.

The accident had not been easy on his family. His father had taken significant amounts of time away from his busy Canadian Tire store and his mother from her teaching job. The blood had been cleaned up and the basement repaired, but the psychological ramifications were harder to deal with – Dylan’s parents suffered from painful second-guessing, wondering if they should have seen the accident coming.

“In hindsight, we should have been stricter,” says John Birch. “But you can always second-guess. He’s a good kid. He was always learning. You couldn’t stop him. We knew there were risks, but we thought he knew what he was doing. He had the science behind him. What if someone had stopped the Wright brothers?”

The marriage had been under strain before the accident, and Dylan’s injury was yet another blow. The couple decided to separate. Mr. Birch’s wife moved to New Brunswick with Dylan’s brother. Mr. Birch and Dylan had the new house to themselves.

A few weeks ago, they drove to Toronto. After months of consultation, Dylan was scheduled to begin a series of operations with Dimitri Anastakis, a plastic surgeon who is on the leading edge of reconstructive surgery.

Dr. Anastakis specializes in hand and arm injuries, and has done procedures that would have been unimaginable a few decades ago. He has repaired thousands of hands. Among his patients are an 18-year-old forestry worker who chopped off his hand in a log-splitting machine. Quick-thinking co-workers put it in a cooler and called an air ambulance. Dr. Anastakis put it back where it belonged.

But blast injuries like Dylan’s present the toughest challenge of all because they destroy much of the hand’s structure, forcing a surgeon to come up novel solutions.

The treatment was pioneered by early combat surgeons, but modern equipment and techniques have created a whole range of new possibilities, including biomechanical prostheses and the reconnection of severed limbs.

Once an experimenter, Dylan has become an experiment: By the end of next year, he may have a biomechanical thumb to replace the one blown up by his failed rocket.

The wedding present

One of Dr. Anastakis’s proudest achievements is the left hand of Kurt Tanninen, a 27-year-old Sault Ste. Marie, Ont., man whose case bears an eerie resemblance to Dylan’s. In November of 2000, when he was 18 years old, Mr. Tanninen decided to make a high-powered firecracker for a cousin’s wedding.

Like many boys, Mr. Tanninen and his friends had experimented with explosives. They bought Ladyfinger crackers, M-80s and Roman candles at fireworks shops, and learned to make bombs by encasing bundles of sparklers in tightly wrapped electrical tape.

“You could feel the concussion from 70 feet away,” he says.

But the wedding firecracker turned out to be Mr. Tanninen’s Waterloo, involving the same brand of strategic error that nearly cost Dylan Birch his life.

Mr. Tanninen assembled his firecracker in his bedroom. His family was downstairs, at a pre-wedding party. He had a pile of gunpowder harvested from old bullets, and a discarded carbon-dioxide cartridge from an air rifle. He clamped the cartridge in a drill press and enlarged the hole in its neck. He poured in the gunpowder with a paper funnel, then inserted a firecracker wick and plugged the cartridge with a lump of wax.

Then he decided to improve the seal by melting the wax slightly – using a cigarette lighter. Suddenly, he saw the wick sparking.

“All I had time to do was move my hand away from my face,” Mr. Tanninen says.

When he recovered consciousness, every surface in the room was spattered with blood. His left thumb and first finger were gone and the rest of the hand looked like butchered meat.

Over the next two years, Mr. Tanninen underwent a series of operations. In May of 2001, he drove to Toronto to meet Dr. Anastakis, who came up with a radical proposal – the doctor wanted to amputate his big toe and graft it onto his left hand to replace his thumb.

“I’d never heard of such a thing,” Mr. Tanninen says. “It sounded insane.” But by the end of the meeting, he told Dr. Anastakis to go ahead.

There would be two surgeries. Working through a microscope, Dr. Anastakis would have to mate the toe’s blood vessels, muscles and ligaments to the ones in Mr. Tanninen’s damaged hand, and modify the bones and joints to support it. It was like building a ship in a bottle.

A few months later, Mr. Tanninen’s big toe was on his hand.

At first, it looked like something out of Frankenstein – the black surgical stitches stuck out, and post-surgical swelling had made the thumb nearly twice its normal size.

But to Mr. Tanninen’s amazement, it worked. The thumb gradually shrank. Within a few months, he was able to grip a door knob, hold a coffee cup and drive a car. Now, eight years later, many people don’t even notice it. And although he will never be a concert pianist, Mr. Tanninen can even plunk out a few notes.

“I was pretty skeptical,” he says. “But you’d be amazed how good it is.”

A delicate operation

Last month, Dr. Anastakis’s reconstruction mission with Dylan finally got under way. On a Tuesday at 7 a.m., Dylan was in the surgical waiting area of Toronto Western Hospital with his dad. The area had the look of an airport lounge, filled with dozens of patients.

A few had their heads shaved and marked with felt pens in preparation for brain surgery, and some had electrodes glued to their skin. One woman huddled with her husband, crying.

Dr. Anastakis arrived, trailing a pair of young surgical residents who were eager to learn from a master. He kept the mood light, joking about his collection of surgical caps (by tradition, nurses make them for doctors they like).

“I’ve got 300 of them,” he laughed. “I’m Mr. Popularity.”

Dr. Anastakis took Dylan’s damaged left hand in his own, and carefully drew a series of lines on it with a black Sharpie pen, outlining the cuts he was about to make, like the borders on a butcher’s meat chart. Dylan asked Dr. Anastakis a few technical questions, as if his hand were a science project instead of a part of his own body that was about to be sliced apart.

Dr. Anastakis had been studying X-rays and photographs of Dylan’s hand for months, considering the best way to fix it. For a while, he had considered a toe transplant like Mr. Tanninen’s, but the blast had destroyed too much of Dylan’s outer metacarpal bone, a key piece of supporting structure. At this point, he was leaning toward a biomechanical thumb that would be controlled by electrical impulses from Dylan’s nerves.

But first, there would be a series of four operations to repair the hand and finger bones. This day, he would straighten the index and middle-finger metacarpals. The next three operations would focus on Dylan’s fingers, adding fat tissue and muscle. It would be a painful and time-consuming procedure – at one point, Dylan’s fingers will be cut open and then sewn into a flap in his chest wall for three weeks, so his body can generate new tissue.

Most surgical procedures have been perfected through long practice, by teams that do identical operations again and again. Cardiac teams have turned bypass surgery into an assembly-line procedure, and there are hospitals that do nothing but hernia operations. But the kind of reconstructive surgery that Dr. Anastakis was about to perform was different.

“No two cases are the same,” he says. “You have to make some things up as you go. That’s what’s so cool about it.”

By 8 a.m., Dylan was on a cruciform operating table, his left arm supported on a stainless-steel wing and surrounded by half a dozen doctors and nurses. An X-ray of his hand was up on a monitor – it looked like the broken white claw of a giant bird. He was technically awake, but heavily sedated with drugs that left him in a dream-like state. His arm and hand were numbed with a regional anesthetic and his vital statistics, including brain activity, blipped across a screen.

Dr. Anastakis sliced open the top of Dylan’s hand. A resident pulled back the skin with stainless-steel hooks. Because they had applied a tourniquet, there was almost no blood – the white bones and silvery ligaments looked like the parts of a machine.

Now, it was time to cut apart the metacarpal bones and reshape them, straightening Dylan’s hand. Dr. Anastakis pressed a toothbrush-sized vibrating saw onto the bone. A small vapour cloud of pulverized bone and body fluid rose above the table.

Dr. Anastakis called for a chisel – a tiny, stainless-steel version of the carpenter’s tool – and began striking it with a hammer like a sculptor chipping a piece of marble, shaping the end of the severed bone.

A nurse brought out a steel case filled with surgical screws sorted by size – some big enough to build a fence with, others tiny, jewel-like fasteners that could barely be seen without a magnifier. The dimensions were critical: If the screws were too small, they wouldn’t torque down hard enough. If they were too big, they could split the bone.

A few minutes later, Dr. Anastakis was drilling holes.

“This is why I chose plastic surgery,” he says. “There’s an inventiveness to these operations. You have principles and procedures, but you also have to interpret. You can’t just open a book and look for ‘How to Fix a Hand that Got Blown Up by a Bomb.'”

Three and a half hours after it started, the operation was over. Dylan’s hand was straighter than before, and the stage was set for the next round.

Dr. Anastakis plans to work on Dylan’s hand for at least another year and a half. When he’s finished, the hand will look closer to what it once was. Yet it will never come close to the perfection Dylan once took for granted.

“I’m okay with it,” Dylan says. “I can’t go back in time.”

Fresh turns

The accident has altered Dylan’s perspective. For years, he had dreamed of being hired by NASA and working with rockets. Now he has no interest in working with explosive fuels, and has shifted his sights to engineering or architecture. In his laptop computer, he shows a visitor a building he designed in Sketch-Up.

“It was fun to do,” he says.

Mr. Tanninen’s trajectory was also changed by his accident. Instead of continuing his apprenticeship as a machinist, he became an electrician, got married and fathered a child.

Not long ago, he found himself at a hardware store, where he watched as a group of teenage boys shopped for a collection of supplies he found suspicious.

When he asked them what they were doing, they told they were building an acetylene-powered gun that would fire chunks of potato. Mr. Tanninen cautioned them, but the boys weren’t very receptive.

Finally, he held up his left hand, with its big-toe thumb and missing finger. “Look what can happen,” he said. Now the boys were listening. They looked at the hand, then returned the gun components to the shelf.

Like Dylan, Mr. Tanninen is philosophical about the accident that maimed him. “We were doing a lot of experimenting,” he says. “It was dangerous stuff, but we didn’t know, and I don’t think anyone could tell us.

“I’m religious, and my view is that we needed to be taught something. I don’t know why God chose me. Maybe he thought I could handle it better than the others. I’m not sure, but this was his plan. And I accept it.”