It is a beautiful hand: strong, with long, slender fingers and smooth skin, its nails ridgeless and pink. If you didn’t know Jonathan Koch—if you first met him, say, on the courts at the Calabasas Tennis & Swim Club—you might not suspect that his hand previously belonged to someone else. The straight line of a scar on his outer left forearm offers no tip-off. There is a bulge where Jonathan’s and the donor’s tendons are woven together, but the mark itself doesn’t catch the eye. The Y-shaped seam on his inner arm does. This scar is a stark reminder of the technical mastery that underlies a medical miracle.
In January, about three months after Jonathan and this hand became one, his wife, Jennifer, aims a video camera his way and asks how he is. “I feel great,” he replies, grinning. To see his muscles straining under a gray Under Armour T-shirt, it’s easy to forget what he’s endured. “My hand’s getting stronger every day. It’s more attractive than the hand I used to have, so I’m getting a lot of attention,” he quips, adding that the transplant has earned him a few stalkers. A moment later, though, he’s dead serious. “I wasn’t left-handed,” he says, “but I am now.”
An Iron Man Goes Missing
Precisely two years earlier, as the 2015 Realscreen Summit kicked off, the movers and shakers of the unscripted television business arrived in Washington, D.C., a bit more sober than they had been the year before. Reality TV—once a guaranteed hit factory—was starting to struggle in an increasingly fragmented media landscape. Jonathan Koch was under particular pressure. In December 2013, he and his business partner, Steve Michaels, had sold their production company, Asylum Entertainment, for north of $100 million. They continued to run it, determined to keep it expanding for the new owners. Deals made at Realscreen would be key to delivering on that promise. So, as conference attendees listened to presentations titled “Amping Up Unscripted” and “Pitch Perfect: What Works, What Doesn’t, What’s Real and What’s Not,” it was only a matter of time before somebody asked: Where was Jonathan Koch?
Jonathan was one of Hollywood’s great closers. Whether pitching a series called How Sex Changed the World to the History Channel, or an episode of 30 for 30 to ESPN, or a miniseries like 2011’s The Kennedys (which starred Katie Holmes and won four Emmys), he knew how to intrigue, inform, and get a deal done. Endowed with a relentless positivity, he was a hilarious storyteller who was known for keeping his word. Add to that his reputation as an indefatigable iron man: At six feet one and 225 pounds, the 49-year-old former wrestler was an exercise addict who led a daily predawn workout for friends. If anyone symbolized the strength of this hard-charging business, it was Jonathan. During Realscreen—dubbed “The Reality Prom” by some of the agents, network and cable execs, and content creators who attend each year—he was the quarterback and Mr. Congeniality rolled into one.
His own story was a classic reinvention tale. Fresh out of college in 1987, Jonathan had driven his Toyota Celica from Pennsylvania to Los Angeles with little more than $300 and a half-eaten Hostess snack cake. His car would be stolen two weeks later. After a stint as what he called “the worst nonworking actor in town,” he tried real estate, talent management, even game show development. Jumping ahead two decades, he was now nimble at creating compelling content.
“Text everyone you love,” she said. “You’re probably going to die tonight.”
Jonathan had been confirmed on the first plane from LAX to Dulles on Monday, January 26, 2015. But he’d awakened feeling awful—God, I’m sweaty, he thought. Even my knees are aching. And what’s up with my freezing-cold feet? Skipping the gym, he headed not to the airport but to Providence Tarzana Medical Center, where doctors—finding no underlying cause of his discomfort—gave him a shot of morphine and sent him on his way. At midday in Los Angeles, Jonathan e-mailed his partner, who was already in the air: “You have Wi-Fi?” “Sure do,” Michaels shot back. “Flying out at 2pm. Will be ready!” Jonathan promised. “Kick ass,” Michaels replied, relieved that his partner was rallying. “Are you dying or you feel okay?” For months to come, Michaels would wish he’d phrased his question another way.
Doped up on morphine, Jonathan made it through his flight to D.C., checked in to his hotel, and fell into bed by midnight. The next morning, though, he could barely get up. Why does my body feel like concrete? he wondered. His eyes were beyond bloodshot. He stopped by Rite Aid for some Aleve, Clear Eyes, 5-Hour Energy Extra Strength, and gel to tame his thick brown hair, then dragged himself to his first meeting. Midway through his second, Jonathan looked at an Asylum colleague, Joan Harrison, and saw three of her. When he stumbled in the hallway a minute later, Harrison insisted she take her boss to the emergency room. “You’ve got work to do,” Jonathan told her. “I can get there on my own.” A taxi dropped him off at George Washington University Hospital around 11 a.m. His temperature was 102 degrees.
Getting Ready To Die
Other than a knee surgery and a history of kidney stones, Jonathan Koch’s body had never failed him, and he’d always returned the favor. He didn’t drink alcohol, didn’t smoke, and hadn’t tried a single recreational drug. He ate a high-protein diet and loved his sleep; his idea of an exciting evening was watching Breaking Bad with a bowl of Honey Nut Cheerios. Typically he and his fiancée, Jennifer Gunkel, were in bed in their Calabasas home by 9 p.m. Just six months before the Realscreen Summit, on a visit to Canyon Ranch, the exclusive Arizona spa, he’d been told he had the cardiovascular fitness of a professional athlete. Now doctors in D.C. were wondering: Does he have pneumonia? Between all the tests, the blood draws, and the worsening pain that surged through his limbs, he texted Jennifer: “They are killing me in here, baby.” As he often did, he distracted himself with humor, sending Stan Hubbard, the chairman and CEO of the cable channel Reelz, a selfie—bloated in a white hospital gown, an IV protruding from his neck. His caption: “Conference is not going great.”
Across town, word of Jonathan’s illness hit the Reality Prom. Jonathan Koch? Hospitalized? It didn’t compute. Wasn’t he the one who always organized Realscreen’s subfreezing five-mile run around the Lincoln Memorial and the Washington Monument? Cori Abraham, a top executive at Oxygen Media, had bonded with Jonathan on those runs, even nicknaming him “Superman.” Hearing he was sick, she rushed to the hospital, where she rubbed his icicle-like toes. Lauren Gellert, a WE tv exec, visited as well between meetings, as did two executives from the Discovery Channel, Denise Contis and Sean Boyle. It was Contis who told Michaels how sick his partner really was. “Denise had just come back from the hospital,” Michaels told me. “And she was like, ‘This doesn’t look right. I’ve seen things’—because she works at Discovery, after all. ‘This is not the flu. This is something way worse.’ ”
Tuesday night fell, and the hospital admitted Jonathan into the Intensive Care Unit. His condition remained a mystery. “I am really not well,” he texted Jennifer at 7:25 p.m. The pain was beyond debilitating. Around 2 a.m., Dr. Lynn Abell leveled with Jonathan. “Text everyone you love,” she said. “You’re probably going to die tonight.” Again he texted Jennifer: “Call me when you get this, baby.”
Jennifer dialed and, for the first time in their seven years together, heard fear in his voice. She booked the next flight to D.C., texting that she loved him and would see him soon. “Me, too,” Jonathan replied. “Let’s make it happen.” Then he went silent. By the time her plane landed Wednesday night, doctors had put her fiancé into a propofol-induced coma. The next day Jonathan was in full-blown septic shock, his blood barely circulating. His hands and feet were blue and beginning to blister as his body pulled blood from his limbs to protect his brain and other vital organs. His immune system was in overdrive, his lymph nodes were swollen. With his outer extremities deprived of oxygenated blood, gangrene set in. Terrified and bewildered, Jennifer listened to his doctors as she scribbled furiously in a notebook. Despite huge doses of antibiotics, her fiancé’s body “was getting ready to die,” the experts told her. Chance of survival: 10 percent.
I wish I’d gotten one more hug before he left, Jennifer thought as she searched her memory for what could have triggered this nightmare. Jonathan had played tennis on Sunday, then they’d tried a new vegan restaurant. Could he have ingested bacteria there, and if so, why wasn’t she sick? Until a few months before, Jennifer had worked as a social media producer on shows like Scandal and Grey’s Anatomy. Now, armed with her notebook and pen, she aimed her considerable organizational talents at the most important job she’d ever have—keeping Jonathan alive.
Staring Down the Demons
The TV-production community is tight-knit, especially on the unscripted side. Having invented a new genre from scratch, people tend to be loyal to those with whom they blazed the reality-TV trail. So as actual reality intruded, the producers of Duck Dynasty, Hoarders, Hell’s Kitchen, and Deadliest Catch reached out, as did writers, directors, and top executives at every TV and cable network. SallyAnn Salsano, creator of Jersey Shore, e-mailed Jonathan “a hug and a kick in the ass. I figure you need both.” In an e-mail to Michaels, Jessica Zalkind, the senior vice president of talent and series development at MTV, summarized what everyone was thinking: “If there is anyone who is strong enough to pull through, it’s Jonathan.”
He would need that strength. Most of us think that patients who are put into a medically induced coma fall into a peaceful sleep, beyond pain’s reach, oblivious of their own mortality. In fact, it’s common for people who’ve been “put under” to have terrifying hallucinations or nightmares. As Jonathan lay unconscious over the next two-and-a-half weeks, he would have both of those, and more. He believed he was being held against his will by a family of ghouls with giant faces and jagged teeth. Lashed to a wood bench, he found it impossible to escape, even though the only thing keeping him there was a single length of unknotted twine. His hands weren’t bound, but he couldn’t move them. It was as if he was tied down by the idea that he was tied down.
The ghouls would surround him and talk about him but never address him directly. He’d hear them say, “Don’t worry, he can’t get up.” Every morning they would bring a milk crate full of writhing venomous snakes. They’d let the serpents bite him, one by one, to find out which posed the biggest threat to their livestock.
Growing up in the town of State College, the home of Penn State University, Jonathan had faced other traumas. His dad, a successful clothing salesman, was brilliant and charismatic. But at home he was cruel. When Jonathan was little, his father showed him how to tie his shoes a single time, then banished the boy to the basement until he figured it out. “I was down there for, like, 12 hours,” Jonathan would say as he recounted the story for friends and colleagues. He tried to find the absurdity in his past. In Hollywood, where everyone appreciates a well-told tale, Jonathan’s “dad stories” had become legend: how his dad gave him a sports jersey with “Iggy” inscribed on the back (for ignoramus), or made him wretch by forcing him, at age eight, to smoke an entire cigar, or kept an itemized tally (complete with repayment plan) of what Jonathan’s childhood had cost him.
Jonathan considered his father “a spectacularly awful parent” but credited the man with giving him a life-altering gift: He took Jonathan to a drive-in to see Rocky when he was 11. The boy loved that while Rocky Balboa didn’t beat Apollo Creed in the final match, “he won the fight that he wanted to win, which was to survive.” Jonathan had been a wrestler since he was five, and Rocky redoubled his devotion to the sport—its stoicism, the unflinching work ethic. Now he made a calendar that showed how many days remained until his 18th birthday and taped it to the underside of his desk, out of sight. Every day he’d put an X through another 24 hours, one beat closer to freedom.
“A lot of people that have childhoods like Jonathan’s don’t end up so well. So why did he? Because from a very young age, he cultivated a strong relationship with himself,” the singer and actress Jewel, who became Jonathan’s friend after they worked on a TV movie together, tells me. “He had the will to notice when he wasn’t OK and to find very ingenious solutions,” she says, singling out his sense of humor. “He learned that optimism is a choice. You know, the glass is half full and half empty simultaneously. It comes down to a choice.”
Lying in the ICU, Jonathan was about to have to choose once more. Doctors had performed a tracheotomy to avoid a breathing-tube infection. At one point his eyes opened, staring ahead, unseeing. “I wonder where Jonathan is?” asked his only sibling, Lisa, who had joined Jennifer at the hospital. In his mind, at least, he was traveling vast distances, closing deals. The snake-wielding family gave way to another delusion: Jonathan and Jennifer had flown to Japan and sold the Detroit Tigers for $500 million. Then, on the final day of his coma, Jonathan saw himself in an empty, misty room with two doors. He understood, without anybody telling him, that one door was the way back to existence; the other, the way out. As he walked across the damp concrete floor, he felt everything that had ever happened, not just in his lifetime but in everyone’s. He could sense the presence of all the people he’d ever known, chief among them Jennifer and his 15-year-old daughter, Ariana.
Jonathan and his daughter had a tight bond. Each February since pre-kindergarten, they would attend her school’s father-daughter dance. Early on, Ariana was so little that she mostly just stood on his feet as he shuffled around, but the dance became such a ritual that once they even crashed another school’s event. Now he was missing the dance for the first time.
Jonathan was the kind of proud father who would call his kid a “masterpiece.” Instead of just bragging about Ariana, though, he had tried to instill in her the resilience she’d need to thrive. When she was six, he worried that she was too quick to fold in the face of adversity; she’d put her tiny hand on her forehead, lie down on the bed, and say, “I can’t take it anymore.” So he borrowed a stethoscope from a doctor friend, placed it in her ears, and helped her listen to his heart. “Honey, I think you’re old enough to know,” he told her. “I was born with the heart of a champion, and I never quit. I’m not capable of it because when you have the heart of a champion, you just go until you don’t have anything left.” Then he put the stethoscope on her chest. Her eyes got big; their hearts sounded exactly the same. “I have the heart of a champion?” she asked. “You do,” he said. “And from this day forward, our family motto is Never Give Up.” He liked to say that Ariana had always been true to that credo: “Fierce, like you can’t even believe.”
He could feel her fierceness now, despite her being nearly 3,000 miles away. (With Jonathan’s condition so uncertain, the decision had been made to keep Ariana, who had bronchitis, at home with her mom, the actress Cory Oliver.) Jonathan could feel Jennifer, too, sitting near his bedside, rooting for him. His shallow breathing sounded like his mother’s had on her deathbed. He understood he was about to die. Then he heard a deep voice.
“Do you want to keep doing what you’re doing?” the voice asked. His first response was no. Being attacked by snakes while held captive was something he hoped never to endure again. But the voice persisted: “If you choose to live, there will be a price to pay that is so heavy that at times you’ll regret it.” This choice is not just about living and dying, he thought. It’s about what does living mean? He merely had to choose. “If you do decide to go back, it will be the fight of your life,” the voice said. Which is when Jonathan knew his answer. A fight? he thought. No problem. Bring it.
“The one thing I don’t understand,” he admitted to Abell, “is why did this happen?”
In an instant, he was propelled upward like a torpedo through dark water that grew lighter and lighter. Finally he burst through. His first words were “How did I get here?” Then he looked down at his feet, which were strangely black and beginning to shrivel. “Wow,” he said. “Impressive.”
Moments after he awoke, Jennifer wrote this in her notebook: “Jonathan asked my dad for my hand in marriage. He said we needed to make changes and reevaluate our lives.” They’d been committed to each other for several years, but they’d always agreed there would be no wedding. They didn’t need the formality. Yet, postcoma, Jonathan’s feelings couldn’t have been more clear. He wanted to be married to Jennifer. She said yes.
A Body Battling Itself
In retrospect it seems crazy that in Jonathan Koch’s condition, he boarded a transcontinental flight en route to a reality-TV convention. But that decision arguably saved his life. Probably no hospital in the country was better equipped than George Washington University’s to help him survive. GW’s Intensive Care Unit was brand-new, and so was its Wound Healing and Limb Preservation Center. Perhaps most crucial, when Jonathan was admitted in January 2015, the hospital was engaged in a clinical trial to test a new method of removing toxicity from the blood. Doctors had asked Jennifer to approve his participation in that trial. “I made the choice to proceed,” she wrote in her notebook alongside Jonathan’s blood pressure readings, medication schedules, and white blood cell counts.
Nowhere in her notebook was the answer to her most nagging question: What had caused Jonathan to become so sick? Sepsis isn’t something you catch; it’s triggered by another condition. From the moment Jonathan was admitted, doctors sought to discover what had thrown his system into chaos, ruling out candidates one by one. He didn’t have measles or an antibiotic-resistant staph infection or Lyme disease. He had not been exposed to the Ebola virus. There was evidence that he had antibodies to the Epstein-Barr virus, which can result in chronic fatigue syndrome, but 95 percent of adults have the virus and do not develop complications. Yes, he’d been driving himself hard, but he always did that. Stress had been a lifelong constant. For a while doctors thought he might have a rare bone marrow cancer and started him on a course of chemotherapy. Their strategy: Treat every possibility at the same time. And it had worked. He had survived.
Septic shock kills as many as 50 percent of those it afflicts, and those who do die tend to do so quickly. Jennifer was thankful Jonathan had beaten the odds, but the ambiguity threatened to drive her crazy. Instead of falling apart, she kept taking notes, asking questions, becoming fluent in the special language—mostly acronyms and abbreviations—that physicians and nurses speak. “Thick/thin blood coag normal as of today,” she wrote in her notes. “Trach/feeding tube removed.” Dr. Victoria Shanmugam, a rheumatologist on GW’s Limb Preservation Team, told me that she and her colleagues saw Jennifer not just as Jonathan’s devoted fiancée but as one of them.
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During his 39 days at GW, Jonathan’s damaged hands and feet had become necrotic, or as he put it, downright “Egyptian”—leathery, mummified, charcoal black. What he needed was time in the hyperbaric chamber, but early on he was too weak to withstand it. The medical team got creative, using portable devices to administer oxygen in his room until he was well enough to be wheeled into the chamber itself.
When Ariana and her mother came to visit, Jonathan had to confront how diminished he’d become. Usually he could be tough for his daughter. Now he had difficulty hiding his pain. They’d agreed on their motto: Never Give Up. This medical marathon put that vow to the test. After Ariana saw her dad for the first time, she walked out of his room, collapsed on the floor, and wept. A moment later, though, she told her mom “Let’s do this,” and together they went back in.
That March, in the hope of discovering what had caused his illness, Jonathan and Jennifer made the difficult decision to leave GW to travel to the Mayo Clinic, in Rochester, Minnesota. On the day of their departure, Dr. Abell—who’d always conducted herself in a no-nonsense, even brusque, manner—had tears in her eyes. The display of emotion opened a door in Jonathan, and he expressed the unfairness of his situation for the first time out loud. Didn’t he exercise? Didn’t he eat right? “The one thing I don’t understand,” he admitted to Abell, “is why did this happen?” Abell’s response: “Jonathan, the reason you took such great care of yourself was not to avoid this. It was to survive this.”
His time in Minnesota was rough; Jonathan’s limbs were in constant, unspeakable pain. Doctors at Mayo had begun to discuss the possibility of amputations and, perhaps eventually, a hand transplant. Mayo had a division devoted to the procedure but had yet to perform one. Among the friends who visited Jonathan were Joel Surnow, the cocreator of the long-running TV series 24, and his wife, Colleen. He and Jonathan had become close while producing The Kennedys together. At one point, when funding fell through, “Jonathan kicked in,” Surnow told me. “I saw this intensity and tenacity that was otherworldly. He’s like one of those guys you have to kill to beat.” Like Jack Bauer, Jonathan Koch seemed built to prevail against impossible odds. So as the Surnows sat for hours by his side, seeing the frantic look in his fighter’s eyes, they never counted him out.
One day, though, when Jonathan was being moved to a new room, he “freaked,” Surnow recalled. “He said, ‘I can’t do this. I can’t stay here.’ I wheeled him onto a balcony, and he saw his reflection in the window.” The vision was shocking. He’d lost 40 pounds and now weighed 185, a number he hadn’t seen on the scale since high school. His hands and feet, wrapped in gauze, looked like paws. Jonathan had thought he was out of the woods. But now he was discovering, “The woods? They’re ongoing.”
Jonathan and Jennifer were homesick. On April 20, 2015, 85 days after he was admitted to GW, they told Mayo they wanted to return to L.A. to celebrate Ariana’s 16th birthday. That’s when someone mentioned for the first time a doctor whose name they’d never heard before: Kodi Azari.
The Doctor Is In
The human hand is an engineering marvel. There is no more impressive example of functional anatomy. It can grab and release, caress and defend. Learn karate, and you can break bricks with it. It’s a mechanism of precision and flexibility. A maestro can play the piano and the violin with the same hand. It’s a way of seeing. Close your eyes, and you can identify almost anything you touch. It’s an organ of sensuality—the fingers have more nerve endings than almost any other part of the body—and an organ of expression and communication. Not for nothing has Dr. Kodi Azari made the hand—its function, its reconstruction, and its transplantation—his life’s work.
“I’m not a religious person, but if there’s any evidence of divine intervention, it has to be the human hand,” he says. “It’s perfect.”
Photograph by Michael Lewis
Azari, who is 48, is the surgical director of the Hand Transplant Program at UCLA, where he’s worked since 2008. The field is still in its relative infancy. The first hand transplant to achieve prolonged success was performed 18 years ago in Louisville; by 2015, fewer than 85 procedures had been undertaken worldwide. But Azari is at the forefront. He’s traveled the country as one of the lead surgeons in five hand transplants conducted at the University of Pittsburgh and at Johns Hopkins University, including the first double-hand transplant and the first arm transplant performed in the United States. Then, in 2011, he and a team of 16 others did the first hand transplant west of the Rockies, at UCLA. The recipient was Emily Fennell, a 26-year-old single mom who’d lost her right hand in a traffic accident.
Four years later, in 2015, Azari was laying the groundwork for UCLA’s second hand transplant. The doctor had some hypotheses he wanted to test, provided he could find a patient with the ideal requirements: excellent health, enormous self-discipline, a positive attitude, and—rarest of all—a limb that needed to be replaced but had not yet been amputated.
Azari knew he was hoping for a long shot. Most hand transplant candidates have been injured in accidents or in battle, when a catastrophic event forces an emergency amputation. These procedures are aimed at minimizing suffering and are usually carried out to facilitate future prosthetic use. Generally that means the arm is severed closer to the elbow than the wrist, and the nerves and tendons are trimmed back and tucked inward to lessen discomfort. That creates challenges, however, if a transplant is attempted later. All those tucked-in nerves and tendons tend to merge over time into a jumble of tissues that is difficult to connect to a new hand with precision.
Wouldn’t it be great, Azari thought, if a transplant recipient’s arm could be amputated in a way that prepped it specifically to receive a new limb? How much more quickly would a patient recover if each tendon, nerve, artery, and vein were left in place and marked—labeled, like so many colored speaker wires, to be hooked up to a matching apparatus? How much more functionality would the patient gain, and how rapidly would he or she gain it? Azari believed this fantasy patient would awaken post-op, look at the new hand, and be able to move the fingers right away.
Born in London, Azari lived in Iran until he was 11, when revolution forced his family to flee. His father had been the managing director of an oil company, and their assets had been seized. The family arrived in Connecticut, where Azari’s older sister had just completed her pediatric residency, with nearly nothing. Once the boy had dreamed of being a fighter pilot. In America he understood he must bring respect and security to his family. To his Iranian parents that meant pursuing one of two professions: engineering or medicine.
Azari wasn’t wild about the choices, but as he learned about his new country through a series of jobs—delivering newspapers, washing dishes in restaurants, painting sewer pipes—he found a way to make peace with his family. “I just told them a white lie. I said, ‘OK, I’ll be a doctor’—just to get them off my back,” he says.
Then a family friend began sending Azari articles about Dr. Thomas Starzl, a researcher at the University of Pittsburgh who’s considered the father of modern transplantation. Starzl had performed the first human liver transplant in 1963 and later the first simultaneous heart, kidney, and liver transplant, all while working on technical advances in organ procurement and preservation. “Pretty cool,” Azari remembers thinking.
Little by little, Azari’s white lie became the truth. After high school, he would train, as he likes to say, “for 18 years straight” to become a surgeon. He performed all kinds of operations—on hands, faces, abdominal walls—for UCLA patients, including wounded U.S. servicemen who came to Operation Mend for help (based at UCLA, this project provides care to veterans free of charge). Though he wasn’t much of a movie buff, there was one film that resonated: Sully, about pilot Chesley Sullenberger’s daring landing of a passenger jet on the Hudson River. Azari owned a copy and had watched it four times, struck by the fact that there was both an art and a science to being a pilot—an art developed over thousands of hours of practice. Being a surgeon was the same. “It all comes to bear,” Azari says, “and it comes to bear quickly.”
In the years since completing his first hand transplant at UCLA, Azari had been waking up in the middle of the night, thinking about how to improve on the next. He believes in visualizing efficiency. “I have this saying that there are good fast surgeons and bad fast surgeons but no good slow surgeons,” he says. “What makes you slow is that you don’t have a game plan you know in your mind.”
Azari had a game plan. Now all he needed was the right patient.