In Our Hands

A Hand Surgeon's Tales of the Body's Most Exquisite Instrument

Arnold Arem, M.D.

Times Books

In Our Hands
PART I
Tales of the Hand
I.
A Nice Touch
I never met Muppet-master Jim Henson. But I did meet the germ that killed him. I know it was the same implacable foe, because it left behind its business card: a near-dead human being with both legs and one hand amputated, and the remaining right hand a blackened husk with a few remnants of fingers pinkly peeking through the necrotic char. The encounter had the illusory quality of a dream, spoiled by the rude fact that it was very real. It played like a Hollywood movie scripted by a madman.
There was a time when I relished the schoolboy excitement of being urgently called in to deal with monstrous challenges. In my general surgery days there were the ruptured aortic aneurisms, gunshot wounds, and motorcycle wipeouts to joust with. Lots of blood out and in. Tears and anguish. The sound of wailing sirens and wailing relatives mixed together in a surreal cacophony.
But no longer. Years of sleepless nights in agitated, noisy emergency rooms and tense, hushed operating rooms cured me of all of it. I've traded quantity-of-life for quality-of-life issues. Hand surgery is a gentlemen's specialty. No more standing for hours over a steaming abdomen, draining thick yellow pus or closing bowel. I've come to enjoy more refined problems, predictability in my schedule, and time off with my family.
So I was not happy, not happy at all, when Ted Abelson's orthopedic surgeon called, described the situation in sober tones, and asked me to see Ted at the hospital and assume responsibility for his care.
Responsibility. Now there's a euphemistic term that doesn't do justice to the harsh reality of what I would be facing. A prosperous, athletic forty-two-year-old accountant had, six weeks earlier, developed a flu-like illness, sore throat, fever, and malaise. No big deal, or so it seemed at first. But within thirty-six hours he was near death, in liver and kidney shutdown. Emergency blood cultures were drawn, and he was placed on life support and given massive doses of intravenous antibiotics. But the toxins from the overwhelming bacterial insult had produced a catastrophic complication--his blood was clotting inside his own bloodstream. Infected blood clots, called septic emboli, were being propelled by his still strong heart out into his extremities where they lodged in the major arteries, choking off all nourishment and producing rapid gangrene. Before the infection could be controlled, both legs had to be amputated below the knee and the left arm amputated at mid-forearm.
Responsibility. Who or what was responsible? The microbe? The microbe was streptococcus, a chameleon ready to dole out a strep throat, rheumatic fever, or death--take your pick. The victim? Unlucky genetics, poor host defenses, bad karma. His doctors? It took several days of frantic work just to make the diagnosis of "lethal strep" while keeping him alive. Jim Henson's medical team didn't make it in time to save him. So Ted was lucky--wasn't he?
Responsibility. It's a horrible burden that ages me far beyond my fifty-eight years. Is the burden like the torture of Sisyphus, toiling to push a boulder uphill, nearly reaching the pinnacle, only to have it roll back to the bottom? Is the burden our system of medical care, training the populace to depend on doctors for miracles? Or is it just me, a hopeless perfectionist striving for normal function as I reconstruct hands? Hands that allow us to be human beings. Hands that earn a living, feed and dress, brush teeth, comb hair, build roads, write poetry, make furniture, make love. Hands deformed by arthritis or crippled by trauma. Hands distorted by accidents of birth.
But hands gone? That's a tough one.
As I drove to the hospital to meet Ted I yielded to the temptation of second-guessing what I would encounter. I couldn't help recalling a specific "sick joke" I've carried with me since adolescence.
Sick jokes--tiny parables so obscenely offensive the brain's anger fizzles out in helpless frustration and they become funny. They endure because of a grim truth underneath. This particular one dealt with two boys asking Mrs. Jones if Bobby could come outside and play baseball. "But Billy, you know Bobby is a four-limb amputee." "Oh--then can we use him for second base?" I only hoped Ted himself wasn't succumbing to the same hopeless line of thinking.
So I tried, as I pulled myself up the hospital stairs, to steel myself against the unknown. It would have pleased me to enter the room and find a callous, unpleasant human being, a whiner bitching about the food, the nurses, and the unfairness of life. At least that would save me the energy of identifying with him. It would allow me the extra luxury of remaining cool and indifferent. Yes, Mr. Abelson, life is inherently unfair, it's just a matter of degree.
Once, on the streets of Hong Kong, I saw a Chinese beggar who had obviously sustained third-degree burns to his face and hands. His fingers looked as if they had melted together into a fused slag. His face was a Halloween skeleton covered by thin desiccated leather, the nose like an alpine mountain weathered flat by eons of erosion and wear, the eyes perpetually open and red from dense scarring and complete loss of eyelids. Life is both unfair and cheap in that part of the world and no help was, or would be, coming. I shed the tears his deformed eyes could no longer manufacture and emptied my pockets into his cup.
So what I wanted to meet was a wimp. I wanted to meet someone I fundamentally didn't like, who could ease my burden of guilt, guilt over being whole, by allowing me not to care much for him.
For the first--and only--time, Ted Abelson disappointed me.
His good-natured calm surprised me most. His intelligent eyes still twinkled with what I interpreted as some hidden amusement. I surveyed the wreckage of his body suspended on the hospital bed. His three healed stumps reminded me of a great oak whose limbs had been pruned without mercy, except no branches would ever again sprout from them into new life. We were down to one, or fractions of one, and how to make what was left (or would be when my work was completed) serve all of his needs for the next forty or fifty years.
It was evident from our conversations that Ted had come through an extraordinary experience. What was miraculous was that he was alive. What was marvelous was that he had all his mental faculties, not just unscathed but deepened in an unfathomable way. Like a voyager beamed back in a macabre Star Trek episode, all his molecules had been scrambled and unscrambled, and this left him with an inner wisdom sought with a passion by the ancient mystics. Ted had experienced a near death, seen the white light, and, willingly or not, had come back. As I talked with him about the surgery he would need, more pain to go through, more uncertainty, more difficulties, he reassured me. I was talking to him in a parched voice about the wrath of God and he was reassuring me, for Christ's sake! I liked him immensely.
If you're a hand surgeon, toes don't rate but fingers do. Unlike the toes, we don't number fingers, we name them. They are like old friends and each deserves acknowledgment. The opposable thumb is special and in a class by itself. Worth 50 percent of the hand (at least, according to the industrial insurance companies), the rotated thumb is an ironic twist of evolution. Without one, you can smoke cigarettes and pick your nose but not do too much else. With one, you can shoot a pistol or play a flute. I prayed for a thumb.
With gentle care I unwrapped Ted's right hand to take inventory, peeling back the medicated gauze slowly to minimize the pain, and began to perspire. The small finger--black as coal down to the knuckle joint, dry and mummified. So much for proper etiquette drinking tea. The index finger, the same. The ring finger was a little better, but not much, shriveled and lifeless from its midportion to the tip. The long finger, though, had possibilities. Only the tip was nonviable, down to the base of the nail. The key would be to preserve mobility of the joints. And the thumb. Ah, the thumb. Only partial necrosis of the tip on the side away from what would be the contact area with the long and (maybe) ring fingers. It would take three hours of surgery to clean up the mess and complete the amputations but, barring any new infections, new clots, or hidden pitfalls there would, at least, be something.
So we took stock of each other, and though he was the one semiclad in typically elegant hospital style, I felt stripped naked under his gaze. Like a seasoned Las Vegas veteran sizing up the table with practiced cool, he processed my explanations without visible emotion, and his questions were relevant and to the point. The stakes were, after all, pretty high.
"Doc," he said, "you have me at a disadvantage."
He was wrong about that, but he didn't know it yet.
"Mr. Abelson--"
"Ted."
"Ted--what do I have? For starters, I want to catch my breath, then I want to take things one step at a time--just as you've been doing."
Ted tried to scratch his nose with the rounded end of his left forearm amputation stump. The same process of ejecting infected blood clots into his circulation wasn't limited to his arms and legs. A deadly swarm of tiny clots had showered into the small blood vessels of his face. Wherever they lodged, the skin perished, giving the impression he had some weird sort of black measles. Tiny islands of dead skin studded his face, and the myriad sores itched as they tried to heal. "Yeah. It's been a while since anything that happens has been up to me. I started plunging headlong down a tunnel more than a month ago and it's been a rough ride, let me tell you. But the light at the end of the tunnel wasn't the proverbial train coming toward me. That locomotive ran over me right at the beginning, chewed me up and spat me out. No--the light in the tunnel appeared when I died in the hospital in Albuquerque."
"Oh, I see." Sure I did. The room was cool, so why was I sweating again?
I longed to find out more about the mysterious light, but at that moment Ted's wife, Janice, and their teenage son came in and the conversation shifted to concrete strategies and immediate plans.
"Doctor," she asked after the introductions, "be frank with us. What are Ted's chances for having useful function with his hand?" A slim, attractive woman with auburn hair and finely chiseled features,she wore an expression of grim resolve as her voice winced with the anticipation of bad news. She had the shell-shocked look of a trauma victim. Dark shadows (rather than makeup) silhouetted her moist eyes and I wondered with a great sadness how she was rewriting her own life story.
"Mrs. Abelson--Janice--whatever remains of Ted's right hand, I'm going to work my damnedest to make it functional. Anything he has there will be useful since it's all he has left. It's the consummate example of the expression, 'In the land of the blind, the one-eyed man is king.' She grimaced at my choice of words."My job will be to salvage everything. I'll fight like hell to make it all work. It won't be easy."
"That's no surprise," she said. "Nothing has been so far."
"The outcome will depend on three things: what I can accomplish in the operating room tomorrow, what Ted can do in therapy afterward, and some luck thrown in."
I outlined my analysis for them, my plans for surgery the next day, and hoped I sounded upbeat. We chatted for a while longer. Ted's son, diminutive and frail, hovered quietly in the background. A mute apparition, like the Ghost of Christmas Future--did his demeanor foreshadow this family's destiny? Young boys at his age need their fathers. What, I wondered, would substitute for flying kites or playing baseball? I commiserated with the grief which I suspected had to be feeding like a vulture on all of their future expectations. As Janice massaged Ted's shoulders and thighs, I left.
 
Most people don't realize it, but the operating room is generally filled with good-natured and, at times, risque banter. Familiarity breeds casual acceptance. Despite the awesome array of instruments and equipment, to those of us who daily toil there it's not especially threatening, just a place to work.
For Ted's surgery, however, the mood in the room was uncharacteristic. It was somber--partly because he was awake (only his right arm asleep with an anesthetic block) but largely because of the gravity of the problem. Trite conversation or humor seemed not only out of place but rude.
All major hand surgery requires the use of a pneumatic tourniquet, a special type of blood pressure cuff that can be inflated above arterial pressure and safely held there, with the arm squeezed and emptied of its blood, for as long as two hours at a time. You can't repair a Rolex watch at the bottom of an inkwell, and you can't repair hand anatomy with its delicate structures obscured by bleeding. Ted was afraid of the tourniquet. The thought of even the most unlikely complication spooked him, but the infection, like a typhoon blown out to sea, was long past and the risks were negligible. It was my turn to reassure him.
As the operation got under way it was immediately evident that, for the most part, the major demarcation lines separating living from dead tissue seemed pretty clear. That was the good news. The bad news was that scattered through the healthy-looking skin and fat were pockets of dusky, gray, really questionable stuff. The dilemma I faced was that excessive trimming might not only delete parts that were destined to make it but might compromise the coordinated activity of remaining fingers. On the other hand, inadequate trimming that left dead tissue behind would promote pain, retard healing, and increase the risk of infection. I felt trapped. I looked around, but all eyes were on me and there was no white knight standing behind me to bail me out or tell me what to do. So I said a prayer and did the best I could. The general public, convinced by television and the National Enquirer that miracles are routine in medicine, would be horror-stricken to learn surgeons are not only human but, with distressing frequency, have to make impossibly difficult judgments based on inadequate data.
The operating room radio had been swiped, and I tried to hum as I worked. At least the air-conditioning was on. I dislike amputating fingers. To discard any part of the hand is a negation of the principles I have studied and worked for. But sometimes you have to. When a lifeboat is dangerously weighted down, something needs to be thrown overboard to ensure the survival of the group. As I began the amputations of the small, index, and ring fingers, I stopped humming.
A remarkable transformation of Ted's hand occurred with the shriveled, black digits removed. Even with two and a half fingersgone, it looked better. A built-in abhorrence of that cadaveric, mummified appearance must be part of our primordial memory, and I was reassured as pink prevailed once again. The thumb and long fingers were for the most part intact, with enough of the ring to make a three-point pinch, with the thumb touching the other fingertips, possible. A far cry from normal, but better than the worst-case scenario. As I applied the bandages I was cautiously optimistic. The collective sigh in the room when the tourniquet was deflated was not lost on Ted, his face shrouded behind the sterile drapes.
"You're pleased?" he asked.
"Yes. No," I said. "I mean, I accomplished my goals and all went fine. What's left should heal OK. But that doesn't mean I have to like it."
"If I've got some fingers to use," he said, "I'll like it well enough."
 
The next few months were consumed with physical therapy and hope for the future. Ted was fitted with ankle and shoe-bearing below-knee prostheses, and adapted to them expertly. Within a short time he was bouncing around the hospital ward with heartwarming agility, and I swear there was even a bit of a swagger to his step. As I got to know Ted better my already substantial respect for him increased. He began to make serious plans for reconstructing his shattered life, and my visits took on a reflective, if lighthearted, tone.
"Hi, Ted," I said as I came in. "I know what to get you as a Christmas present."
"Oh? What's that?"
"A set of Rollerblades," I said with a straight face. "We can have your prosthetist engineer your BKs to accommodate a whole spectrum of specially modified gadgets. Just snap 'em on. Shoes are boring anyway. When you want to roll right over somebody, a pair of tank treads. Use the blades when you want to make a quick escape."
"Quick escape, huh?" he snorted. "Where were you when I needed you? Albuquerque was where I needed a quick escape. Although I did make an exit there, I must say."
"Ted, you never did get to finish telling me about that tunnel. That was when you went into liver and kidney failure and started throwing blood clots. Please tell me the rest."
For a few moments he was lost in thought. "Okay. As you know, I got pretty sick very quickly. Most of the time I was only semiconscious, except for the pain. There was lots of pain." He was quiet for a moment. "Then I flipped into a space that was totally serene and calm. I felt like I was moving fast, I could feel the wind on my face. I didn't have any real sense of detail. The landscape around me was indistinct. I sensed the presence of people and got an impression of age, great age, as if I were passing through the world extending back to creation.
"As I barreled along, my surroundings became more luminous. Not more clearly defined, just brighter in an odd way. How can I describe it?" For a moment he paused, searching for words. "Light was coming from up ahead, and no point of origin was visible, but I had an inner certainty that I was approaching a source of immense power. As I got closer, I could feel the energy pulse through me and it made me so ecstatic I wanted to cry with joy. I was pulled toward it hypnotically and I wanted to lose myself in it. I was at peace. I knew everything was okay and I would be fine. I was going to receive all the answers to every question I had ever asked."
Ted's expression was becoming increasingly animated. He looked younger. All of the scabs had come off, leaving a tight layer of healed skin that rejuvenated his facial appearance. A chemical peel, the hard way.
"Then I suddenly got a message: Go back. With a jolt, I did an about-face and, before I knew it, I was in the intensive care unit again, in pain, with a sense of loss. The only answer I got was that it wasn't time yet. So here I am. And you know?" For a passing moment, there was a hint of anguish in his voice. "Now that I'm here, I don't know what I'm supposed to do."
"Oh, is that all?" I said. "I don't know what I'm supposed to do, either, but I didn't have to die to find out."
Ted smiled. He had been doing a lot of it in recent days, and itwas especially becoming. "Some people are just naturally dense. Try bungee jumping and ask about the meaning of life as you leap into thin air, wise guy!"
"But that's what I'd like to be, Ted, a wise guy. I want to learn from your experience--vicariously, of course. I've read a lot of secondand third-hand accounts but I've never before had a chance to talk to someone who's been down that tunnel and come back. I want to know ... ."
What did I want to know? Suddenly, I wasn't sure. I had been anticipating this moment, the rare opportunity to learn of the secrets of existence from one who knew, one who'd been there, a traveler who had visited what Hamlet called "that undiscovered country" and returned. But, as Hamlet also surmised, the notion of it puzzles the will. I found myself speechless.
"At least I've learned this much," Ted said. "I know I'm here for a purpose, although I don't know what the purpose is. My presence has a meaning that extends beyond myself. We make plans, but things don't always work out that way." He laughed, his eyes twinkling with the same amusement I'd seen in his hospital room. "One look at me should convince anyone of that. We take the cards we're given and play them as well as we can. But I'll tell you something--I'll never be afraid again."
I met his gaze and saw in his face a far look, a look of pure equanimity, a resolute inner calm bought at an exceedingly great price. A price I knew I was not prepared to pay. Who had whom at a disadvantage now? I felt awed in the presence of a remarkable human being, remarkable in that all the layers of surface veneer had been stripped off, leaving a purity of essence truly inspiring in its integrity. If Janice had nothing else to be soothed by, she could have done worse. Although a few fingers thrown in were nice. A nice touch, no pun intended.
Copyright © 2002 by Arnold Arem, M.D. All rights reserved.