Former U.S. Army Sgt. Brendan Marrocco lost both arms and legs in Iraq in 2009. Soldiering on, he received a rare double arm transplant in 2012 and is now going through physical therapy at Walter Reed. (Nicki DeMarco and Michel du Cille/The Washington Post)

Brendan Marrocco sits at a table in the occupational therapy room and with the help of his teeth straps the exercise hooks to his wrists.

His new flesh-and-blood hands are not yet strong enough to grip the pull-up bar, so the hooks must do for now.

He slides out of his wheelchair, walks a few steps on the stumps of his legs and looks up at the bar.

“I have to prepare myself to do this,” he says. He reaches up, latches the wrist hooks to the bar and curses. “I’m so not ready right now.”

His occupational therapist, Joe Butkus, who is watching, says: “You got it. This is easy.”

Then the retired Army sergeant, who has no legs and has transplanted arms joined with plates and screws, begins.

One, two, three . . .

“Yeahhh,” Butkus says.

Four, five, six . . .

Marrocco’s belly tattoo peeks from under his black polo shirt.

Seven, eight, nine . . .

With a grunt and a grimace, he stops at 10, unhooks from the bar and tears off the straps with his teeth.

“Awesome job,” Butkus says.

Marrocco, at occupational therapy at the Military Advanced Training Center at Walter Reed National Military Medical Center in Bethesda. At the time of his injury, he was the first service member from the wars in Iraq and Afghanistan to survive the loss of four limbs. (Michel du Cille/The Washington Post)
‘I feel great’

It has been 18 months since Marrocco, 27, of Staten Island, underwent a rare double arm transplant at Johns Hopkins Hospital in Baltimore.

He had lost both legs and parts of both arms to a makeshift bomb in Iraq on Easter 2009.

At the time of his injury, he was the first service member from the wars in Iraq and Afghanistan to survive the loss of four limbs.

He then became the first service member to receive a double arm transplant and still is one of only seven people in the United States who have successfully undergone the procedure.

He spent several months recovering in Baltimore and last year moved to Walter Reed National Military Medical Center in Bethesda for intensive rehabilitation.

Over the past two months, in his first extensive interviews since the announcement of the surgery, he spoke about his recovery, his past and his future and showed how much his arms have progressed.

“I feel great,” he said as he sat in Walter Reed’s occupational and physical therapy complex, the Military Advanced Training Center (MATC), in early May.

“Arms feel great,” he said. “I can’t complain about anything with the arms, really.”

He can do pull-ups, push-ups and drive a car. He produces a robust Twitter feed and has a Facebook page where he describes himself as a “wounded warrior — very wounded.”

His left arm, which had been amputated below the elbow, is progressing faster than the right arm, which he lost above the elbow.

But his wrists are still thin. And his hands are a work in progress. He has some dexterity in his left hand and can sign his name. He used to be right-handed. “Not so much anymore,” he said.

He has limited use of his right hand. The fingers are in the position of a slightly closed fist — a phenomenon called “clawing,” his chief doctor said.

But his therapy includes wearing spring-loaded splints on his fingers that work to keep the hand open.

You can see where the transplanted limbs were attached because the donor arm’s skin tone seems slightly darker than Marrocco’s, and one of Marrocco’s old arm tattoos is now cut short.

There is also some loose skin around the connection sites, left over from extensive post-operative swelling, his doctors said.

At first, Marrocco said, the simple weight of the transplanted arms made his back sore.

“It hurt just to have the arms attached, just hanging on there,” he said. “I spent three and half, four years without arms. It was a shock to my back, I guess.”

Joe Butkus, an occupational therapy supervisor, works Marrocco’s fingers. His hands are a work in progress. He can sign his name with his left hand and has to wear spring-loaded splints on his right one to keep it open. (Michel du Cille/The Washington Post)

Marrocco, who wears a T-shirt that says “Keep Calm and Chive On,” talks with physician Jamie Shores. He undergoes hours of occupational therapy to help him get back on his prosthetic legs, which he said he had essentially stopped using three years ago. (Michel du Cille/The Washington Post)

But the new arms had a surprising benefit. They gave him better balance when he walked on his prosthetic legs. Before the transplant, he often fell while using his artificial legs. Since the transplant, he has not fallen at all, he said.

Now he must be patient. With the muscle, skin, bone and blood vessels connected, he must wait for his body’s nerves to grow into the transplanted arms.

The new arms will not return to 100 percent function, his doctors have said, but similar patients get enough dexterity to do such things as tie their shoes and use chopsticks.

Meanwhile, he must keep the other parts of both arms strong and flexible.

This requires constant occupational therapy. Exercises, dexterity drills, wearing the finger splints and special elastic tape, and stretching his fingers.

In addition, he undergoes hours of physical therapy to help him get back on his prosthetic legs, which he said he had essentially stopped using three years ago.

“I got to admit, it does suck at times,” Marrocco said as he sat wearing green shorts. A neck chain held an image of a pistol, and a pair of blue-tinted sunglasses hung on his shirt.

“Has to be done,” he said. “It doesn’t matter how tired or hung over you are.”

‘I don’t have any demons’

On a Friday in May, Marrocco rolled his wheelchair quietly into the MATC for his occupational therapy session. (He lives on the hospital campus with his older brother, Michael, 30, who has been with him for most of the past five years.)

He wore a blue polo shirt, had a red cord tied around his left wrist and was chewing gum. He sipped a Red Bull.

A thoughtful, fair-skinned young man with short blond hair, he said his body feels like it’s 40 although “mentally, I’m still like 21 or 22.”

He owns a souped-up black Dodge Charger and a Ford Raptor pickup. His dream is to have a “fleet of ridiculous cars” and a big spread in the country where he can tear around in them.

“I’ve been lucky enough to have things go pretty well for me since I got hurt,” he said. “I’m happy. I don’t have any demons in the sense of what happened to me.”

But his injuries were horrific. In addition to the loss of his limbs, his face and neck bear the scars of the blast, and his left eye is healing from a cornea transplant he had in February.

And at times, he wishes things were different.

“I wish . . . they were the way they were before,” he said, “but it’s not possible.”

“You . . . try to forget about a lot and kind of stay in the present,” he said, “just continue to push through all that.”

He is mostly bothered by his limitations in walking.

“It takes so much effort,” he said. His leg amputations are so high up the limbs that he has little leverage to move the artificial legs.

“You have a little bit of leg trying to support the prosthetic, and they’re pretty heavy,” he said. “So it takes a whole lot of effort and energy to just kind of get around the [exercise] track once. It’s extremely tiring.”

“Besides that, I think I’m managing it pretty well,” he said.

‘I’m going to do this’

Marrocco now has some feeling in both hands and has felt the gradual growth of the nerves along his arms. “I feel the pain moving lower,” he laughed.

On the upper portion of his arms, “everything is super sensitive,” he said.

On the lower parts, he said, “it kind of fades some and . . . feels kind of weird. But I’m able to feel all the way down my hands.”

His chief transplant doctor, W.P. Andrew Lee, professor and chairman of the Department of Plastic and Reconstructive Surgery at Johns Hopkins Hospital, said Marrocco is starting to have muscle contractions in his left hand.

“They’re tiny little muscles, but there are lots of them,” Lee said in an interview at the hospital in May. “Those fine muscles in the hand are important for dexterity.”

For example, as of a few months ago, Marrocco no longer needs his brother to squeeze toothpaste onto his toothbrush or set up the shower for him.

Meanwhile, he has been accomplishing other goals.

One was being able to do pull-ups, which he focused on after seeing a picture of a man doing them while strapped in a wheelchair.

He bought the pull-up hooks for $20 on the Internet and posted the photo of the man in the wheelchair.

“I was like, ‘You know, I’m going to do this soon,’ ” he said. “And I did.”

Marrocco demonstrates pull-ups during occupational therapy. (Michel du Cille/The Washington Post)

He was able to handle a cellphone within two months. And, as a huge NASCAR fan and student of automobile mechanics, he was overjoyed to be able to drive again, with hand controls, in December.

He had not driven a car in more than four years.

“Last time I drove, before this, was when I got blown up,” he said.

‘It was what I needed’

Early on April 12, 2009, Marrocco was at the wheel of a huge armored truck called an MRAP — for Mine Resistant Ambush Protected vehicle — returning to base after a night mission.

The former car dealership mechanic was 22, had been in the Army a little more than a year and loved it. “Best days of my life,” he said. He has posted numerous pictures via Twitter that show a boyish-looking soldier in full battle gear posing with friends.

There were other soldiers in the vehicle with him that morning, one a good friend named Michael J. Anaya. As they traveled through the darkness near Siniya, about 130 miles north of Baghdad, the MRAP was struck by an explosive device, which shredded it.

“I remember the flash and people yelling inside the truck,” Marrocco said. “I didn’t feel anything. . . . I was trying to find out who was yelling.”

He recalls little else and said he woke up in the old Walter Reed Army Medical Center in Washington about 90 hours later.

He had lost his limbs and his buddy, Anaya, who had been killed in the attack. Marrocco later got two angel’s wings tattooed on his chest and back as a memorial to his fallen comrade.

At Walter Reed, he began his recovery. The blast had severed his left carotid artery, broken his nose, eye socket and facial bones, and cost him eight teeth.

Slowly, his wounds began to heal. He came to terms with his injuries and mastered the use of cumbersome artificial arms and legs.

As he got better, he also became a celebrity. He did news media interviews, attended charity events, and met sports and movie stars.

His case was a model for the four subsequent quadruple amputee service members.

He eventually left the hospital and returned to Staten Island, where a charitable organization had built a special home for him.

His life, he would later say, was fine.

Then, on Dec. 16, 2012, in an excited announcement on Twitter, he wrote: “Holy mother of god I was just told I might be having my transplant tomorrow!”

He had learned about the transplant possibility about two years earlier and had seized on it.

“The second I was asked if I wanted do it, it was: ‘Yes. I’m in. I want to do it,’ ” he said. “It was what I needed, physically, mentally, emotionally.”

“I’ve been saying this for years, ever since I lost them: Arms are a huge part of your personality,” he said. “You talk with them. Really, there’s not much you do without your arms.”

In a double transplant, four teams of surgeons operate simultaneously — two teams preparing the patient’s arms and the other two preparing the donor limbs. This is the basic procedure:
‘We’ll get there’

The surgery was done by a group of experts headed by Lee, who noted that the group had rehearsed the procedure extensively, practicing on cadavers.

The operation took about 13 hours.

Marrocco said he does not know who the donor was. The hospital declined to identify the donor, citing privacy. Marrocco said he would love to thank the family someday.

After the surgery, he woke up miserable in a hospital room that was superheated to promote healing, he said. His arms were very swollen at the connection sites. It was the only time he had a twinge of regret.

But he rapidly got better.

Six weeks later, on Jan. 29, 2013, he rolled his wheelchair to the front of a conference room at Johns Hopkins Hospital that was jammed with reporters.

His arms were in bandages and splints. He wore a tan T-shirt that read “Keep Calm and Chive On.”

Again a celebrity, he fielded an array of questions. At that point, he had no feeling in his hands and couldn’t move his right arm. “But we’ll get there,” he said. He had hated not having arms, he said, and was grateful to have a chance to get them back.

Already, he said, they felt like they were his.

‘A different person’

A year and a half after the transplant, his doctors say he is still very early in the healing process.

Lee, his chief doctor, said it could take two to three more years for his progress to maximize. “He’s made much greater progress than we had expected in the beginning,” he said.

Marrocco said he thinks he might stay at Walter Reed until the end of the year because it’s the best place for him now.

As they sat in the MATC in early May, his occupational therapist, Joe Butkus, asked him if he thought he was functionally better off yet with the transplants than with artificial arms.

“I wouldn’t particularly say that I’m better with these arms,” Marrocco said. “But I physically feel better with them. . . . Confidence from Day One of having the surgery has been through the roof. Emotionally, I feel better about myself.”

“I came back a different person,” he said.

“It was just like the snap of a finger. I realized one day that I had arms again.”

Michel du Cille contributed to this report.