One weekend, while taking hand trauma call, we received a pre-arrival page about an incoming patient, a plastic surgeon, who had injured himself while moving a glass table. The information we received was devastating — a wrist laceration through the median nerve of his dominant hand. After his arrival in the ED and the formulaic introductions at the beginning of any encounter, he frankly asked, “So, honestly, do I need to start thinking about finding a new career?”
This injury offers a stark reminder of the fragility of the human condition and highlights how integral the hand is with respect to the formation of human identity.
This man’s identity as a plastic surgeon, a life-long cultivation, was possibly stripped from him by an event lasting only fractions of a second. This connection between the hand and identity is especially true in a capitalist society where one’s identity and livelihood are intimately related to the type of work one does.
The reality compounds this significance: in the U.S. private sector in 2019, hand injuries were the second most common workplace injury (13.6%), second only to back injuries (21.1%). If hand (13.6%), finger (8.9%), and wrist (3.7%) injuries are combined. However, injuries to the functional unit of the hand become the most common (26.2%). The most common population to sustain work-related injuries are manual laborers. It is no coincidence that the general descriptor of this working population, “manual,” is derived from the Latin word “manualis” meaning “of or pertaining to the hand,” given how important the hand is for the jobs these workers perform. This hand-identity phenomenon is not reserved for manual laborers, however.
A plastic surgeon with a hand injury cannot perform surgery, nor can a mother with a sprained thumb hold and comfort her child. Even Jamie Lannister — arguably the greatest swordsman in all of Westeros, is forced to forge a new identity after losing his dominant right hand.
The importance of the hand extends further than to just defining human identity. It is crucial to the expression of that identity as well. People reveal their identity through expressive behaviors — emoting, art, clothing choices, career choices, and political leanings. One cannot realize an identity without the ability to express it. The human hand is routinely a vessel for that expression. We have numerous emojis that are designed to express emotion through cartoons of hand gestures.
Direct communication through speech reigns as the most important of all the ways to express. The hand is once again invaluable in this endeavor. Indeed, the social psychology literature committed to the study of the importance and nuanced nature of hand gestures in communication reveals that conversational hand gestures aid in the formulation of speech and convey both semantic and non-semantic information. And when speech cannot convey information, the hand takes over. It is no coincidence that there are hundreds of different sign languages around the world.
Given the importance of the hand in human identity and expression, a hand injury is not simply a functional deficit or deformity — it is an insult to one’s deeper being.
By immobilizing patients’ hands in splints, surgeons quite literally suppress patients’ abilities to emote and express their identities. Therefore, it is not surprising that hand injuries and mental illness, especially depression, are intimately intertwined. There has also been research studying the connections between a patient’s sense of coherence (SOC) and hand surgery outcomes. A sense of coherence is a measure of ones coping abilities and includes three dimensions — comprehensibility, manageability, and meaningfulness.
High SOC scores seem to promote health and increased quality of life after or during medical illness. Moreover, patients with low SOC scores after severe acute hand injuries showed significantly lower satisfaction in daily occupations, higher hand disability scores, lower mental quality of life, and more sleep disturbances and bodily pain. These studies reveal that the success of treating hand injuries must include a focus on mental illness and coping strategies.
The evolution of opposable thumbs separated us from our animal ancestors and provided humans with appendages that have become cornerstones to human identity and expression. They are not simply functional tools but highly nuanced instruments used to facilitate human communication, expression, and connection. Thus, approaching a hand injury cannot simply focus on fixing a mechanical deficit. It must also include a careful analysis of how the injury, surgery, and rehabilitation will affect the patient’s psychosocial sphere.
The clinical decision-making between the patient and surgeon should not only consider the technical feasibility of the surgery, but it should also focus on the timing of the surgery in the patient’s life, the duration and intensity of post-operative rehabilitation, risk factors for mental illness, an analysis of coping strategies and ways to improve them, and evaluation of support systems.
Many of these aspects will be out of the surgeon’s expertise, indicating that hand injuries should be treated using a multidisciplinary team, including the surgeon, physical and occupational therapist, primary care physicians, and mental health practitioners. David Ring has already written about the importance of “comprehensive orthopedic care” that incorporates the collaboration and co-location of mental health practitioners and surgeons.
He describes four key components of this comprehensive care framework:
- Clinicians should strive to recognize the signs of stress and less effective coping mechanisms in patients.
- Surgeons should strive to provide empathetic and relationship-centered care to form a therapeutic alliance with the patient focused on addressing patient motivation and coping mechanisms.
- Surgeons should commit to learning and understanding basic psychology and communication science to help improve mental health.
- They should offer teaching to help improve mental health colleagues’ understanding of hand medicine to continue to improve health.
Given the intricacy and importance of the human hand to all aspects of our patients’ lives, it is only fair that we, as surgeons, strive to treat their injuries with a commitment to comprehensive care.
Peter T. Hetzler is a plastic and reconstructive surgeon.
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