15 February 2011

Reading palms

I spend most of my day touching people.

My patients might grasp my freshly alcohol-gelled hand when I offer it, walking into the room. And they might be too nervous or distracted. And they might be the ones who, overwhelmed, hug me before leaving (I’ve stopped counting those). And yet I touch them…everywhere. In that sense, nothing is sacred; but in the other sense, everything is.

Some doctors put on gloves for the entire exam.
I don’t.

I’ve learned both ways, and now, we choose things. It’s a mixture of universal precautions and respect – always, always gloves for any genital exam; always, always gloves when touching anything with secretions. A rash. The inside of the mouth. Anything bleeding or with pus. Anywhere the skin might be broken.
Otherwise, I wash my hands two to four times per patient visit. (Once outside the room. Once inside, prior to the physical exam. Perhaps once after, before leaving the room. And then maybe again in the hallway.)

Recently, I had a patient whose arm was in a cast. After a week, he suddenly spiked a fever and started to feel pain in his arm, which he hadn’t before. Common things being common, if you hear hoof beats think horses, not zebras (the platitudes of medicine), it’s probably a bread-and-butter pediatrics case. I.e., cold. Flu. But it could be something else, something we can’t see.
It felt like black box medicine. Diagnosing without seeing what you might be trying to either diagnose or rule out. What are the proxies. How can we see without seeing, know without knowing. The fingertips were visible – warm, well-perfused, good capillary refill, pulses intact bilaterally, sensation within normal limits. Nerves, vessels intact.
Then to the proximal side – the side closer to the body. I touched the arm above the cast. I touched the other arm in the same place. Cooler. Again. Both hands simultaneously. Switching hands. One hand at a time. I closed my eyes, trying to feel the temperature difference. There was one. It was subtle. But how subtle is subtle, and how warm is just from being enclosed in fiberglass?

It’s the way I learned to read PPDs (TB skin tests). That, too, was the first procedure. Sliding the needle in under the skin, shallow-angled, so superficial to the surface that you could see the metal tip gliding in. Inject and you see the wheal rise, or you should. (I placed so many. The wheal wasn’t always there as much; it wasn’t always perfect. How much did this end up mattering?) And two days later – 48 to 72 hours, we say – come back and we’ll check. Are you positive. Are you not. It depends on your risk factors – average risk, >15 mm is positive. High risk (includes living in a homeless shelter), > 5 mm is positive.
The spot is often red, two days later. It’s nerve-wracking for patient and for young provider who doesn’t know any better. But the redness doesn’t matter, apparently. Just the induration. The hard mound that mimics the wheal you injected in the first place. The best way to not confuse yourself is to close your eyes. Run your fingertips lightly over the skin of the forearm. Stop where they are stopped. Run back and forth, back and forth until you are sure.

Children are both afraid of and comforted by touch. The touch at the doctor’s office might include needles. Approach some children at all and they start crying. To get infants to stop crying, we gag them. Functionally. A gloved finger reaches into the mouth, up towards the palate, just as during breast or bottle feeding. And once you pass the lips and reach up and over the tooth-hard gums to the palate, the mouth clamps around your finger. It’s a neurologic test – this is an infant reflex. (We learn to survive). It’s a pharyngeal exam – is the palate high or low arched? Is it cleft? What about the tongue? And it’s a pacifier. One baby was so strong that I felt she was almost cutting off my circulation. Touch is reflex, exam, and bribe. Somehow, even the (must-taste-terrible) latex glove counts as something comforting.

In the nursery, we scrub once in the morning. Ritual. Because after you scrub, you dry your hands with paper towels, and you go about your day. Touching everything. We use the alcohol before and after touching babies. But other than that, I walk around the hospital, I go to the cafeteria, I wander by the lounge, I hug friends in the hallway, and I go back to the nursery, rub the evaporating alcohol on my hands, and I go back to touching babies.

The ritual of scrubbing in the nursery is the same as it is for the OR – I don’t know how to do it another way. I wonder if this is as ingrained in surgeons as bike-riding or writing or driving are for other people. Post-stroke, during dementia.

The little package, the little flat-curved plastic stick for under your nails, the brush/sponge that you soak in soap from the foot-activated dispenser. I forget how many times you’re actually supposed to count on each surface. I may only be doing five, now – should go back up to ten. Not sure. Each finger, including the finger tip, becomes a three-dimensional geometric object that you view in terms of planes. Equal attention. Up the wrists, the arms to the elbows, the other hand. The ritual of running each arm under the foot-activated water so the water drips down your hands; whatever you’ve scrubbed off goes away from you. It’s dance-like and graceful; we reach elegantly in diagonal directions. And then (this is for surgery, not for the nursery), you turn off the water with your foot and you back into the OR, hands up and out in front of you, dripping water onto the floor. You go where the scrub table is, and someone sterile lays a blue towel over one of your arms. Everyone has a different technique for how to dry your sterile hands with which side of the sterile towel. I can’t deduce the evidence-basis. There isn’t one. You might then drop the towel on the floor, or, if there’s a linen container close enough that you can open with your foot. Gown is next. You can’t touch yourself or anything. The scrub nurse gowns you – ritual in that. And anyone non-sterile comes to tie the gown on in the back. I like this part; I like doing it for others. It took time to feel comfortable maneuvering in the OR and not being afraid to be yelled at (still happens) or to unsterilize something or someone. It’s a gentle way we help each other, and it’s wordless. Someone is being gowned. You go tie them.

Next are the gloves. You dive one hand in, and then the other. You can’t touch your hands to anything before the first layer is on. Your fingers stay hidden and hesitant, until the last minute, within the sleeve. One glove, two gloves, and for the second pair you can actually help a little – now, you can touch things. Settle them on.
The last part of the dance. In your right hand, you take the color-coded card from around the waist of the gown. You hand it to someone – sterile or not, here everyone is equal – and they grasp the other half of the card. You spin to the left, they tear off the card, and you tie the gown in front.

Every time.

It takes awhile to be comfortable in the sea of blue. It’s not the view-of-the-ocean blue. It’s not the even-if-it’s-not-summer-I’ll-enjoy-being-outside-in-sun-today blue.

It’s don’t-touch-if-you’re-not-blue-blue.

Don’t touch.

“What you want to be when you grow up…in medicine.” Different theories: how do you learn best and why? What do you want your life to look like? Who are “your people”?

What part of you do you want to be using all day?
Maybe that’s another way to decide a specialty.

There’s so much talk about surgeons’ hands and how they insure them. Tens, hundreds of thousands. Millions. In surgery, scrubbed hands are encased in two pairs of gloves. Often, the half-size larger pair is underneath, sealed by the smaller pair. You want it to be as tight as possible, while your circulation is still good. I started off with 7 ½ size gloves. They do fit comfortably. And then I tried to tie suture in the OR. Next surgery, I went down to a size 7. I tied off sutures on the next case. And now I wear 6 ½. On the wall, I reach for the small gloves. It has to be a second skin. There can’t be extra movement. I brought home a pair of sterile gloves for practice – tying knots isn’t enough, but being able to tie knots in gloves, and then tying knots in wet gloves…

They have to be tight.

The point is that I’m actually far from my hands when I’m in surgery. They’re one of the few parts of me that, scrubbed and gowned, count as sterile. And they’re the only sterile things that aren’t blue. (Some inner gloves are blue. more are green). The white hands stand out, stretched over the white cuffs of the disposal blue gowns. The sterile window of the body extends from collarbone to navel, approximately. Hands and arms, technically only up to the elbows.
My hands are mobile, they’re fluent and fluid and flexible and nimble, but in terms of actually feeling things? Not much.


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