Two firsts this last week. The first time I cut open a human hand (albeit a dead one), and the first time I held a child sized stethoscope to the chest of an eight week old baby. Both were startling and humbling moments.
The human hand took two days of dissection to unravel. In part because the skin and connective tissue on the palm of the hand is so tightly connected to the underlying tissues, which is no divine accident. Without that tight skin, we would not be able to grip anything, let alone open up a stubborn lid on a jar, or twist a screwdriver. So removing that skin and connective tissue is like trying to take super glue off the tips of your fingers – it pulls and tears at the underlying vessels and tissues. We tried hard to not damage any blood vessels or nerves underneath, as we needed to identify them, but of course, since we don’t yet have the skilled hands of a practiced surgeon, we cut the recurrent branch of the median nerve, which supplies the muscles that move your thumb. Oh well, he wasn’t going to be moving his thumb anymore anyhow.
But it’s not just the connective tissue that demanded our time, and our meticulousness; there are 19, yes 19, muscles in the human hand. Now compare that with the fact that there are also 19 muscles in the shoulder region (to move your arm), and 19 muscles in the forearm (to move your wrist, forearm, and your hand). The muscles and supporting arteries, veins, and nerves, get continuously smaller as they flow downward. The muscles in the hand are tiny and so specific: four to move the thumb in its myriad directions, three to move the pinky finger, and lots in between to move the other digits. I won’t bore you with the names, but they are long Latin trains, such as abductor pollicis brevis, flexor digiti minimi brevis, and palmar interosseous muscles, to name just a few.
The hand is truly astonishing. Those 19 muscles are attaching to 27 bones in the hand and fingers. No wonder we have such dexterity with our hands. I found it so ironic that I had to use the incredible dexterity of my own hand, in order to dissect Larry’s hand. (OK, we finally decided to name Mr. Old Man, Larry. He’s 6 foot tall, white, and we decided given his great musculature for a 89 year old man, he MUST have been a basketball player, and so we named him after that famous Bird character from the Celtics, plus we don’t have any friends named Larry, and no one in our class is named Larry – that we have met so far anyway). The tools you use in dissection are simple. The scalpel is used only to cut the skin. If used under the skin, it tends to cut vessels and structures that we need to identify (not to mention that we are being evaluated on our dissections). Under the skin we do what’s called blunt dissection, which is taking a closed set of rounded ended scissors, and then opening them up inside the tissue, in other words, we use the scissors backwards. This tends to separate out the connective tissue (which is literally everywhere) from the muscles and vessels. Then we can pick up small structures, very carefully, with some forceps, to pull or tug on them, oh so gently, to try to determine where the vessel goes, and from this information, guess what it is. Nerves and arteries and veins all look alike when there is no blood coursing through the blood vessels.
It is so easy to get so absorbed into the small musculature of the hand, that I forget the smell in the room, the ache in my low back from bending over, the time ceases to exist, and I even forget that the hand is connected to a body that was once alive. A hand that once opened jars, grabbed screwdrivers, gripped the steering wheel of his first car, caressed the palm of his first lover, and hopefully, held the tiny body of his first grandchild.
That thought leads me to the second first of the last week. The first day in my clinical preceptorship. I am teamed up with a family practice doctor, and I will meet with her every Thursday afternoon until next June. I love that I am with a family practice doctor, as opposed to a specialist, which will come next year. With this doctor I will get to see all ages, all sexes, and all different types of disease processes. Already in the first day I learned about gout, chronic pain, infectious viruses such as mononucleosis or cytelomegalovirus, prostrate hyperplasia, as well as stage 3 kidney disease. I don’t know anything about them yet, (we don’t learn any pathology until we finish learning normal anatomy and physiology), but I can see what all my years of studying will eventually create – a solid but always expanding body of knowledge that I can use to help others heal.
The highlight of the day came of course when we did a well baby checkup for an 8 week old girl. The parents were so attentive, and loving, and asked all kinds of questions about their baby. When to introduce solid foods, how to lay the baby down in the crib (to avoid that monster SIDS), and whether or not to use bumpers in the crib. Then came the exam time. The parents gave permission for me to examine their little girl along with the physician. I put the stethoscope to her heart, and heard…..nothing. I pretended to hear what I knew would be a very fast heart, and while the doctor was talking and examining, I turned the stethoscope around so that the valve was open to the small diaphragm, and not the adult sized one. Whoops…..no one seemed to notice my inadequacy though, as the baby cooed and smiled. After the doctor checked all her limbs, and abdomen, and neck, and hips, I put the stethoscope on the baby’s chest one more time, this time in the open position, and heard the most wonderful music. The fast lub dub – lub dub – lub dub of a smiling, precious little angel.
So thanks Larry, and thanks little girl; I’ll remember you letting me practice on you both, in the first steps on this highway of medicine.
So whatever your hands find to do
You must do with all your heart
There are thoughts enough
To blow men’s minds and tear great worlds apart
There’s a healing touch to find you
On that broad highway somewhere
To lift you high
As music flying
Through the angel’s hair.
Don’t ask what you are not doing
Because your voice cannot command
In time we will move mountains
And it will come through your hands
John Hiatt, Through Your Hands