Quadruple amputee veteran works to regain his life and plans to try for a double arm transplant

From the front page of The NY Times:

WASHINGTON -- Brendan Marrocco (pictured) and his brother, Michael, were constructing a summer bucket list, to get them out and about, trying new things. A Washington Nationals game versus their beloved Yankees — sure, since they were stuck here rather than home on Staten Island. Perhaps a ride on the Metro, with its reliable elevators. Pizza: definitely.

How about going to an amusement park? Michael suggested optimistically.

“Would that really be safe?” asked Brendan, a smirk crossing his lips.

The beach? “I don’t do beach anymore,” Brendan replied. Then what about the National Zoo, the one with the pandas? “They got pandas?” Brendan said, razzing his brother again. “Why didn’t you mention that?”

Clutching a pen firmly in his oversize rubber hand, Brendan Marrocco completed the lineup. A trip to Annapolis, Md. A ride on a boat. And, his personal favorite, firing guns. He drew a miniature picture of a handgun next to that one.

Each would be a major accomplishment for Brendan Marrocco, who a year before had come so close to death that doctors still marvel over how he dodged it. At 22, he was a spry, charming infantryman in the United States Army with a slicing wit and a stubborn streak. Then, on Easter Sunday 2009, a roadside bomb exploded under his vehicle, and he became the first veteran of the wars in Iraq and Afghanistan to lose all four limbs in combat and survive.

In the nearly 15 months since, Specialist Marrocco has pushed past pain and exhaustion to learn to use his four prosthetics, though he can walk for only 15 minutes at a time. He has met sports stars like Jorge Posada and Tiger Woods — and become something of a star himself here at Walter Reed Army Medical Center, where his moxie and humor are an inspiration to hundreds of other wounded service members. He has also met, fallen in love with and proposed marriage to a young woman who sees what is there rather than what is missing, though Specialist Marrocco has lately been questioning the relationship.

Now he is preparing for a rare and risky double arm transplant at the University of Pittsburgh Medical Center that could profoundly improve his independence. One of the first things he will ask of his new arms is to drive a stick shift (the one time he got behind the wheel, in an empty parking lot, his rubber hand became unscrewed and was left dangling).

There have now been 988 service members who have lost limbs in combat since the first of the wars began in 2001, but Specialist Marrocco’s many wounds raised so many questions. Would he crumble mentally? Was his brain intact? How would he ever cope with daily needs like eating, bathing, even simply getting out of bed and putting on clothes?

“I would close my eyes and see a head and a torso,” his mother, Michelle Marrocco, 50, said of the early days. “How much worse could it be?”

But Specialist Marrocco, who was promoted from private in November, “has exceeded the expectations of everyone but himself,” said Maj. Benjamin Kyle Potter, 35, the orthopedic surgeon who has treated him since he arrived at Walter Reed last year, in April.

He can already write legibly (if left-handed), use a computer (but not play video games), work on a model car (with some help) and text furiously (a generational requirement).

He has not done it alone. His brother, Michael, 26, gave up a good-paying job at Citigroup to move into Walter Reed and, as he put it, “hang” with Brendan, shedding his tentative nature along the way. Their long-estranged parents, an engineer and a nurse, learned to communicate again as they kept vigil by Brendan’s bedside in the early months. And his indefatigable physical and occupational therapists take him out for Chinese food or watch ballgames with him on television long after their shifts end.

A contrarian by nature, Specialist Marrocco has become a bit of a homebody, preferring the haven of Walter Reed — where he is a role model — to the awkwardness of the larger world. And despite 14 operations, he refuses to let a dentist’s needle near his mouth to replace the eight teeth he lost in the blast.

One sweltering day this spring, a Marine sat in a wheelchair outside while Specialist Marrocco practiced walking nearby. The Marine had arrived at Walter Reed in May and was waiting for a shuttle bus. He lost both his arms and legs in Afghanistan, and is the wars’ second quadruple amputee.

The Marine watched Specialist Marrocco amble up an incline, determined to tame his prosthetics. “I’m hoping to be just like you soon, man,” he shouted.

NOT quite six months into his combat tour, Private First Class Marrocco sat behind the wheel of an armored vehicle as it made its way back to Forward Operating Base Summerall in Baiji, a town in northern Iraq. His was the last truck in a four-vehicle convoy on a routine mission escorting a group of soldiers from one base to another. A machine gunner, Private Marrocco had become a driver a few days before.

“It was one of my first driving missions,” he remembered. “I wasn’t driving the truck I was supposed to drive.”

He had arrived in Iraq on Halloween 2008, eager to fight. But by then, there was little fight left in Iraq. Violence had diminished; American forces were dropping in number. His days were spent mostly on patrol, conducting occasional raids and lifting weights at the base’s makeshift gym.

Growing up in the Huguenot section of Staten Island, Brendan had been smart and outgoing, but preferred racing cars to taking tests. His parents enrolled him at Staten Island Academy, hoping the prep-school atmosphere would knock sense into him. It did not.

“He is a very headstrong individual,” explained his mother. “He has taken it to an art form at this point.”

College did not stick, either, so he enlisted in the Army. When he got to Fort Benning, Ga., in January 2008 for basic training, he felt grounded for the first time in his life. Here was a career he could love.

“You kept the danger in the back of your mind,” he said. “You didn’t want it to happen, but you had to train for it.”

It is difficult, though, to train for hidden bombs, which is what makes the wars in Iraq and Afghanistan so insidious. All he can recall of that Easter Sunday drive back to his base is the flash of light against the black of the early morning. “I hit a pressure wire,” he said. “It was across the road.”

The bomb, a particularly lethal one known as an explosively formed penetrator, shredded his armored vehicle. His best Army buddy, Specialist Michael J. Anaya, was killed. Another soldier was wounded; the fourth man in the truck walked away unharmed. Roadside bombs do that — choose the soldier on the right but not the left, the one from Florida but not Georgia.

Maj. Jayson Aydelotte, 38, the trauma surgeon on duty at nearby Camp Speicher, got the call before dawn. Incoming wounded. He shook the sleep from his eyes and got into his scrubs.

Private Marrocco was rushed in. Within eight minutes, his clothes were off and he was connected to a giant bag of intravenous fluid. Both arms and a leg had been sheared off. The other leg, the left, “was hanging literally by a thread,” Major Aydelotte recalled.

Doctors quickly began pumping blood into Private Marrocco’s body, but it sprayed straight onto the ceiling and walls. Aghast, Major Aydelotte looked more closely. One of the two carotid arteries, which carry blood from the heart to the brain, was severed, an injury so lethal it can kill within minutes. “When fragments fly, they make tons of holes in you,” the doctor explained. “He had a hole in his neck. But we didn’t suspect it to be a carotid injury because it wasn’t bleeding.”

It was not bleeding because there was so little blood left in his body — 80 percent of it had spilled out in the field. “Any one of his injuries was life-threatening,” Major Aydelotte said. “It’s incredible.”

The medical team cleaned out each amputation wound, took a vein from his groin to reconstruct the carotid, and sewed him up top to bottom. The same day, he was transferred 85 miles to a larger base in Balad, and then on to Germany. He had survived the initial trauma and surgery. But other serious threats loomed: Infection. Pneumonia. Brain injury.

One day a couple of months ago, Major Aydelotte happened to run into Specialist Marrocco at Walter Reed. “I didn’t tell him who I was,” said Major Aydelotte, who had quietly kept tabs on his patient’s progress. “I didn’t want any kind of accolades from him. His life was saved, but I didn’t do it. He was meant to be saved.”

BRENDAN’S father let the phone ring again and again. Nobody important ever called his home number. Plus, it was Easter Sunday. The ringing was so maddeningly persistent, though, he finally picked up.

“Mr. Alex Marrocco?” the official-sounding voice said. Mr. Marrocco hung up, assuming it was a telemarketer. Then the ringing started again. A houseguest answered. “It’s a major such-and-such from Hawaii,” she reported.

Mr. Marrocco blanched, his mind reeling back to what he had learned at basic training graduation back at Fort Benning: If you get a knock at the door, the soldier is dead. If you get a phone call, the soldier is wounded.

The official-sounding voice, hoping to cushion the blow, asked when he had last spoken to Brendan. The day before. They had talked about a motorcycle that the father was eyeing. The son, a motor head, was urging him to buy it; one day, they could ride side by side.

Not wishing to delay the inevitable, Mr. Marrocco demanded, “Tell me what happened and where it happened.” The voice paused, then said, “I’m sorry to have to tell you this, but Brendan was involved in an explosion and he lost both his legs and both his arms.”

Mr. Marrocco’s knees buckled. He fell on the kitchen floor.

His ex-wife was in her car that morning after church and checked the voice mail on her cellphone. There was an urgent message from the Army: “Brendan has been involved in an accident.”

The hours that followed were a blur. To stay focused, Mrs. Marrocco tucked her despair under her nurse’s cap and digested the facts from the doctors at Landstuhl Regional Medical Center in Germany. Her son’s legs were both amputated above the knee. His right arm was amputated above the elbow. The left arm retained its elbow; thank God for small favors, she thought.

His cheekbone had collapsed, and the retina in his left eye was badly damaged. The beefed-up body armor and helmet had fulfilled their missions. Private Marrocco’s torso — his internal organs — and his head were mostly intact. Then she heard about the carotid.

“How did he live?” Mrs. Marrocco asked.

“We don’t know how he lived,” the doctor said.

The parents, who separated seven years ago, flew together to Germany, where their son was in a medically induced coma. He was swollen and burnt and stitched, with a patch over one eye. His hair was the texture of a Brillo pad. His lips were puffed out of proportion.

“Had I not been told it was my son, I would not have recognized him,” Mr. Marrocco said. Mrs. Marrocco struggled to see beyond the wounds, the respirator and the missing arms and legs. Her son, who was small to begin with, had all but disappeared. “I could not accept it,” she said last month. “And I haven’t accepted it.”

By Wednesday night, about 90 hours after the blast, Private Marrocco was in Washington in Walter Reed’s intensive care unit. He drifted in and out of consciousness. In time, he began to realize something was wrong with his arms, though he could not see them well at first, in part because one eye was swollen shut.

“He looked up at me and lifted his arms up,” his father recalled. “He kind of looked at them and realized they were bandaged and they were different sizes. He couldn’t talk. He had a tube down his throat. But he mouthed the words, ‘I have no hands.’ I nodded to him. And that was it. He put his arms down. ‘O.K.’ ”

Mr. Marrocco did not have the heart to tell his son about his legs. “During that first week, Brendan kept pleading, ‘Dad, Dad, take my boots off. My feet are burning. My feet are burning.’ I would say, ‘Brendan, your boots are off.’ ”

SITTING by her son’s bedside the next week, shortly after he emerged from an operation, Mrs. Marrocco noticed that his left residual leg looked particularly bloody. The nurse on duty said a doctor would come by soon to take a look. Mrs. Marrocco demanded one immediately. Then her son’s blood pressure began to drop precipitously.

“That was one of the worst experiences of my life without a doubt,” she said. “I went back to my room and called one of my best friends, whose son is a youth minister, to get the children to pray. God hears children’s prayers better. I said, ‘Get the prayer chain going. I’m losing him. I’m losing him.’

“If I hadn’t been there,” she added, “I feel I would have lost him.”

In those early weeks, the worst of the pain often seized Private Marrocco in the middle of the night. On good nights, he slept 20 minutes and then wrestled with pain for three or four hours. He tossed and turned. He bobbed up and down. And his father sat watching, unable to do anything to alleviate the agony. It was, Mr. Marrocco said, “the hardest thing for me to bear.”

The family wondered about Brendan’s brain. Bomb blasts are notorious for shaking up the head so severely they leave tracks of destruction, despite the Kevlar helmets. Soldiers who return home with even moderate brain injuries can have trouble holding jobs or remembering to pick up a child at day care.

“You can’t rehab a brain-dead individual,” Mrs. Marrocco said. “How would you show him to do a situp if he doesn’t understand that?”

After Private Marrocco’s brain passed a battery of tests, his family then fretted about his mental health. Could he avoid the powerful punch of depression and post-traumatic stress, a one-two so harrowing it can cripple a soldier as easily as a bullet? Not long after Private Marrocco regained consciousness, Sgt. Justin Minisall, who had been wounded in the bombing, ducked in for a visit. Private Marrocco asked how Specialist Anaya, the gunner in the truck that day, was doing.

“The sergeant looked at me with wide eyes, and I looked at him,” the private’s father said. “The sergeant told him, ‘He didn’t survive.’ Brendan just laid there and, kind of like everything else, took it in and didn’t really say much.”

A week or two later, Brendan told his father, “I am really sorry that Mike died, but I am glad to be alive.” Mr. Marrocco, knowing how close the two were, saw that as a good omen for his mental health. Survivor guilt can sometimes cut too deeply. “That moment made me think, ‘He will be O.K.’ ”

As the weeks passed, the Marroccos were forced to look further down the road. The parents each considered quitting work, but each had a mortgage to pay. And the son, while grateful for his divorced parents’ dedication, was afraid they might suffocate him. He was a grown man. He had fought in a war.

Then his brother did something nobody expected: he volunteered to leave his friends, his social life and his job in information technology at Citigroup, and move to Washington.

The brothers were close, but they were opposites: Brendan the brash, outgoing, rule-defying joker; Michael, reserved and shy, the kind of guy who prefers melting into the background. Mrs. Marrocco worried that Michael, not a caregiver by nature, was not up to the painstaking job.

“It needed to be done, and I was best prepared to do it,” Michael explained in retrospect. “Instead of making a company a million dollars, I can see where my efforts are going.”

Since May 2009, the brothers have lived on the Walter Reed campus in connecting dormitory-style rooms, with a kitchen and maid service. The Army does not charge Michael rent and it gives him $64 a day for living expenses. The military also underwrites all of Brendan’s expenses, including the hand transplants, and pays him a $2,400 monthly salary.

“This tragedy has made Michael a better person,” Mrs. Marrocco said. “He is more talkative, more interactive than he’s ever been, more forthcoming, and he makes plans for himself and for the future, which is different from where Michael was.”

THE two brothers spend most waking hours together; Michael takes time for himself while Brendan has his daily nap. They watch television in the evenings, or at least argue about watching television. Michael wants “South Park.” Brendan wants “Law & Order” or “NCIS.” The older brother wakes the younger each morning, gives him his pills and a glass of water, and “that’s about it,” Michael said. Brendan has come a long way from when he struggled to put on his own T-shirt and brush his teeth. The two leave at 9 a.m. for physical therapy, a short wheelchair ride away.

Michael also keeps track of his brother’s many mechanical parts. “So many things to remember,” Specialist Marrocco joked. “Arms. Legs. We’ll get out the door and down the block and I’ll say, ‘Mike, you got my arm?’ ”

His left arm is a rubber myoelectric model, complete with a hand, that responds to muscle impulses; he wears it most of the time. The right is a primitive body-pressure hook that he puts on mainly for therapy sessions. He has the high-tech C-Leg X2, which has a knee joint sensor and is not yet available to the general public.

He mastered standing in his prostheses within two months, and walking a few steps shortly after that. But walking long stretches is infinitely more difficult, a bit like balancing on stilts, only without the benefit of knees or real arms for balance. He spends a lot of time doing situps and side body lifts to build up core strength, then transfers to the parallel bars to walk with support if he needs it. Unlike other soldiers, he does not listen to an iPod while exercising, so he can fully concentrate on the instructions of his therapist, Luis Garcia, a former medic in the Army Reserve.

Of all the leg amputees Mr. Garcia has worked with over five years at Walter Reed, Specialist Marrocco has been the quickest to adjust to his legs. “He has incredible balance, incredible drive,” Mr. Garcia said.

Before and after lunch in the cafeteria he has occupational therapy: writing, picking up small items like popcorn, positioning a pin on a beret, baking a cake, opening a can. In his wheelchair, a BlackBerry balanced on his thigh, Specialist Marrocco pecks furiously at the keys with his rubber hand or with his “fluffy finger,” an upside-down pencil contraption created just for this task.

Unlike using the prosthetic legs, using mechanical arms does not hurt physically. But the tasks are mentally taxing, and Specialist Marrocco occasionally nods off at the table.

“I want Brendan to be able to eat cereal,” his brother told Maj. Sarah Mitsch, the occupational therapist, one spring afternoon.

“We’ll have to get a swivel spoon,” Major Mitsch replied.

Around Walter Reed, Specialist Marrocco is a celebrity. Tour groups stop by to wish him well. Invitations pour in for sporting events. At the Military Advanced Training Center, where the wounded learn anew how to walk, run, box and climb, he inspires with his toughness and wit.

“It’s funny the complaining that goes on when Brendan’s not there,” Mr. Garcia said. “And then when he’s there, everybody shuts up. It puts things in perspective for them. It puts things in perspective for me, too.

“I never catch him feeling sorry for himself. I’ve never heard him say, ‘I wish this had never happened.’ ”

There are times, though, when Specialist Marrocco’s optimism and confidence are no match for his discomfort and fatigue. He rarely sleeps more than four hours a night and still suffers phantom pain in his right arm. He can be cranky and not keen on visitors; one of his pet peeves is people who talk too much. He jokingly calls his comrades with below-the-knee amputations “the paper cuts.”

But he does not blame the military or curse the war. If he had his way, he said, he would be back in Iraq, behind a machine gun. “I have no idea why I’m so happy,” he said.

It did not take long after the bombing for his wry, dark humor to break through. “Look at all the legroom I got!” he announced after boarding a first-class flight to Hawaii in November 2009, to reunite with his unit as it returned from Iraq. And, he explained, being able to feel your arms and legs when they are not actually there — which happens after traumatized nerves go awry — has its advantages. “I can move my hand around and give someone the finger,” he said. “I can do these things, and no one can see.”

Once, when he asked for a glass of water, a startled woman responded, “but you don’t have any arms or legs!” His tart retort: “I have a mouth!”

But Specialist Marrocco does admit to “down days,” and acknowledged, “This does suck.”

“You know, Mama,” Mrs. Marrocco recalled him saying quietly one day, “it would have been really nice if they left me even one hand.”

KATE BARTO, a beautiful, grounded 23-year-old from Johnstown, Pa., who was an intern with a nonprofit group at Walter Reed last summer, could not help but notice Specialist Marrocco in his wheelchair. But it was his charming wisecracks that really got her attention.

“He had a great spirit about him,” said Ms. Barto, who now works for Hope for the Warriors, another organization that supports wounded service members. “And we became friends.”

The two talked on the phone constantly. “I would fall asleep on the phone with him,” she said. Her only hesitation in getting more involved was that she had just come out of a three-year relationship. The rest, she said, she could handle.

Her family and friends worried. They feared empathy was overriding common sense. But Ms. Barto has a gift: She can see clearly and comfortably past Specialist Marrocco’s disfigurement and disabilities.

“One of my mom’s concerns was that I was feeling sorry for him,” Ms. Barto said. “ ‘Do you really love him? Do you pity him?’ There is no reason to pity him. He had a horrible thing happen to him. But he is no less of a person.

“Our lives will be as difficult as we make them,” she added. “As long as he believes I am going to be around and I love him, we’re going to be O.K.”

On Thanksgiving, Ms. Barto and Specialist Marrocco were playing the question game in his room. She would ask a question and he would answer, then vice versa. “He suddenly asked, ‘Will you marry me?’ ” Ms. Barto recalled. “I said, ‘Is this for real?’ Yes, he replied, ‘Will you marry me?’ ” She said yes.

A couple of weeks later, he slipped the ring, with three diamonds, into his wheelchair pocket for her to find. “It completely blew me away,” she said.

But theirs is not a fairy tale. In April, Ms. Barto said, Specialist Marrocco grew increasingly stressed as the calendar ticked toward his “alive day” — the anniversary of the explosion that nearly killed him — and he broke off their relationship. They reconciled, but then last week decided to take another break.

“We still talk,” Ms. Barto said on Friday, her voice cracking with emotion. “We’re backing off, giving the relationship a rest, giving him the space I think he needs.” She still has the ring.

Despite his remarkable progress, Specialist Marrocco is still struggling to find his place in the wider world. His family tries to coax him out of his Walter Reed fortress for more trips to shopping malls, restaurants and sporting events. But he finds such outings draining and awkward. People stare, or look away. They ramble, not knowing what to say. “I just tell them I got blown up,” he shrugged. “I don’t like it, but I can’t do anything about it. I just pretend they are not looking.”

His mother was more direct: “He hates it. He absolutely hates it.”

He is, however, eagerly anticipating leaving Walter Reed to get a new pair of arms.

THE donor has to be a man. The blood and tissue types have to match, of course. But so do the skin tone and size. The call could come at any time, and the Marrocco brothers will jump into Michael’s black Monte Carlo and high-tail it 237 miles to the University of Pittsburgh to prepare for surgery. They have 10 hours to get there to give the doctors enough time to do their work.

Dr. W. P. Andrew Lee, the hospital’s chief of plastic surgery, will lead four teams of more than 20 surgeons to give Specialist Marrocco, as he put it, the chance to live “a normal life” (a fifth team will handle the donor). His legs would still be missing. But new, human arms would mean he could put on the prosthetics himself. And: hug tightly, drive, twist open pill containers, catch himself when he falls, fix an engine, play Modern Warfare 2 and greatly increase his chances of getting a job.

“It’s going to give me so much more independence to do more stuff on my own,” Specialist Marrocco noted.

Nine people in the United States and about 34 others around the world have received hand or arm transplants since the first successful one in France in 1998. Dr. Lee has performed three in the past 14 months; in May 2009, his team did the first double hand transplant in the United States, and in February, the nation’s first double transplant that extended above the elbow, like Specialist Marrocco’s.

The transplant is mind-boggling in its complexity. The doctors must attach nerves, blood vessels, muscles, tendons and elbow joints, all within about 11 hours. A new antirejection protocol that Dr. Lee formulated should reduce the risk of infection, organ damage and diabetes.

Specialist Marrocco’s nerves would begin regenerating one inch a month — it could be a year or two before he gains feeling in the fingertips. It will never be like before the blast, Dr. Lee said, but the new arms can be almost as good in terms of touch and motor skills.

Unlike a heart or liver transplant, “a hand transplant does not save lives,” Dr. Lee noted. “It improves the quality of life.” He added, “We have to be very careful to balance benefits versus the risk.”

Specialist Marrocco wonders whether he will be able to get tattoo artists to make house calls to decorate the new specimens; he wants something to memorialize Specialist Anaya.

“You’ve got to give them a reason to come,” said Mr. Garcia, the physical therapist.

How about, “I have no arms and no legs and I’m in a wheelchair,” Specialist Marrocco answered.

He expects to spend six months rehabilitating in Pittsburgh (his brother will move there with him). The time there may set back his leg progress, so he will likely return to Walter Reed for further therapy.

Back home in Staten Island, several charities — the Stephen Siller Children’s Foundation, Building Homes for Heroes and a fund dedicated to Specialist Marrocco — have been raising money to build him a wheelchair-accessible house. In August, the actor Gary Sinise, who played a combative double amputee Vietnam veteran in “Forrest Gump,” is scheduled, with his Lt. Dan Band, to support the effort.

Ms. Barto is still hoping to move to New York with him, after a wedding at the National World War II Memorial on the Mall here in Washington. She said they had talked about having children, and that Specialist Marrocco wanted a girl, if only so he could answer the door when a date arrived and say the words, “You should see what happened to the other guy.”