Wrist & Hand: Punched, Cut & Crucified
and (glancing at my own thin, veinèd wrist)
In such a little tremor of the blood
The whole strong clamour of a vehement soul
Doth utter itself distinct
Elizabeth Barrett Browning, Aurora Leigh
SATURDAY NIGHT SHIFT in the emergency department: payday weekend. The double doors onto the street have been like a storm drain, all the madness and misery of humanity pouring through them. At the end of my shift I navigate my way towards the changing room, between the old ladies on gurneys and queuing paramedics, handcuffed prisoners and policemen. Ambulance sirens are getting closer, a roar of shouts is coming from the waiting room, and from the noises in the resuscitation room I hear they’re working on a cardiac arrest.
The changing room is windowless. Laundered green scrubs are stacked in piles on shelves, and a large bin of dirtied ones leans against one wall. The scrubs are made of some synthetic blood-proof cloth, and as they slide over my head they crackle with static electricity. I open my locker, throw in my name badge, and sift out my clothes from the discarded blood tubes, pens, surgical gloves and disposable scissors that have accumulated over the months. A colleague is changing into clean scrubs, beginning his ten-hour day shift. ‘Good luck,’ I say to him. ‘You’ll need it.’
Standing in the shower at home, scrubbing off the dried blood from my cheek and the smell of hospital disinfectant from my hands, I do a mental tally of the people I attended through the night: the overdosed and toxic; psychotic and broken; burned and convulsed. Seen from the corridors of an emergency department the world is mad, bad and, like the poet said, incorrigibly plural. ‘How can you face it?’ a friend asked me. ‘So many of the people you see must have brought their misery on themselves.’ Does that matter? I remember thinking. Few of us manage to be who we aspire to be. I like that in the emergency department life is extreme and unfiltered: there is no preferential treatment for those with power and money. Everyone sits together on the same hard plastic chairs, and is stitched up and in the same curtained cubicles. There is an unarguable democracy to ‘triage’: being prioritised on the basis of medical need, rather than influence.
Once out of the shower I notice it is 9 a.m. and tumble into bed the way a shipwrecked sailor would throw himself onto a beach. There are eight hours before I have to go back. The shifts come in a relentless tide: fourteen-hour night shifts, ten-hour day shifts, a couple of days off then straight back to the nights. All the time I work in adult emergency medicine I reverse my body clock through twenty-four hours every week or so.
The idea behind my training there was to learn how to approach every injury and intoxication that humanity can inflict on itself, but what I didn’t bargain for were the stories. As I collapse into bed, my body twitching with fatigue, my neck and shoulders already tense at the thought of the next shift, it is those stories that keep me from sleep.
A MAN LIES on a gurney trembling, a hospital gown over his legs and chest. Beneath the pressed institutional cotton his body has a toned, athletic form; well tanned with the musculature of someone who doesn’t waste his gym subscription. At the entrance to his cubicle I glance down at the clipboard: ‘Mr Adrianson?’ I say to him. He nods and I walk in, pulling the curtain closed behind me.
Tea towels are wrapped around his left forearm. Once a dirty white they are now a deep and lustrous scarlet. The topmost one, a souvenir from Majorca, has come partly undone and lies loosely at his elbow. Blood is pouring over his skin like a wet sunset, pooling in the crevice formed by his buttock and the rubber gurney mattress. ‘I’m bleeding,’ he says pointlessly as I reach to rewrap the arm with the towel, and begin to press hard.
‘You’re going to be fine,’ I say, though I’ve no idea what’s under the towels yet. Maybe he won’t be; maybe the arteries are severed and the tendons too. Into the undamaged crook of his right elbow I push a 16-gauge cannula – as thick and long as a hat pin – pulling out the steel introducer as I nudge in its clear plastic conduit. Once the plastic wings of the cannula are taped down I draw off blood samples for haemoglobin and crossmatching, then hook up an IV drip of plasma substitute. ‘Are you left-handed?’ I ask him. He nods. ‘What’s your job?’
‘I’m a pickpocket,’ he says with a wry smile, ‘what’s it to you?’
‘Just checking you’re not a concert pianist.’
‘I fell through a window,’ he says and looks away, though the nurses have already told me another story. When the paramedics arrived at his house there was a woman sobbing in the corner, who told them that he’d been about to punch her but punched a door instead. The window panels of the door shattered badly, and I wonder if he has fractured the bones of his hand in the punch. As I press on the forearm I lift his hand and glance at his fingertips: nice and pink, so there’s plenty of blood still getting down to them. I press hard on the pulp of his thumb, release the pressure, and count the number of seconds it takes to pink up. It’s less than two, so inwardly I relax a little. The knuckles are in bad shape though, and as expected his little finger looks shorter than it should, and turned in at an unnatural angle. He has snapped the bone in the hand that supports it: a ‘boxer’s fracture’.
As I push on the forearm, trying to get the oozing to stop, I’m thinking of another boxer’s fracture I dealt with earlier in the week. The metacarpal in question had belonged to a prison warder’s fist, and only moments before assessing him I’d diagnosed his prisoner with a broken jaw. The two men sat in adjacent cubicles. The connection between the injuries was so obvious that it seemed almost discourteous to mention it. The warder had told me he’d been interrogating the prisoner about a disturbance and had his hands over the back of a chair, when the prisoner had kicked a desk which slid across the floor and made a bullseye collision with his knuckles. ‘Is there any other way you can get a fracture like this?’ he had asked me, nervously.
‘No,’ I’d said firmly. ‘It’s called a boxer’s fracture. It happens when you punch something harder than the bones of your fist – or someone.’
The blood wells up more slowly now, so I pull back the tea towel and peep underneath. There is a long gouge in his forearm extending onto the wrist, as if he’d been mauled by a lion. And within the wound lie his muscles and tendons, glistening.
The nurses had already ordered an X-ray, and from looking at it I know that there is a sickle-shaped spicule of glass embedded somewhere in the wound. I elevate the skin around that wound now, dabbing with gauze and looking for the piece of glass. At last I find it, by touch rather than by sight, marbled with strings of clotting blood and tearing into the tissues like a poisoned thorn. I hold up the shard to the strip light and then walk over to the light box where the X-ray images are displayed. The bones of the forearm – the radius and ulna – are outlined in ghostly elegance as if etched on glass. I can see that his fifth metacarpal, the bone that supports the little finger within the heel of the hand, is fractured but not so badly that I’ll have to twist it straight. I hold the shard up to the sickle-shaped opacity on the light box and find that the two shapes match one another completely.
‘Good news,’ I tell Adrianson. ‘There are no more bits of glass.’
I sit down at the side of his trolley, and look down on the muscles of his forearm as they gather towards the wrist. The tendons of the superficial finger flexors glint in the light: the thick bands of collagen are like the quills of a feather, but in place of the barbs and vanes of a feather are fleshy chevrons of muscle. I ask him to flex his fingers, and marvel at the sight of the muscles bunching – the extraordinary intricacy of the pulley systems that control the fingers. How mechanical we are. The tendons are all intact; he can grip my fingers as strongly on the left as on the right, and I can’t see any nicks in the surface of the tendons as they move in and out of view.
‘When can I get home?’ he asks.
‘Just as soon as I’ve stitched these wounds and strapped up your broken finger.’
As a doctor I talk all day, taking histories and giving explanations. Sometimes I get to the end of a shift or a clinic and feel the need to be silent for hours, just to restore a balance. The verbal process of diagnosis works through sieves of possibilities, question and answer, weighing and measuring the patient’s responses and deciding when to question further, and when to move on. It’s a skill that takes years to develop: a medical history can take a student an hour, but as a GP or hospital consultant we have to try to make a decision within minutes. Practical tasks like stitching wounds or putting plaster of Paris on a broken limb offer a rare opportunity to spend time talking with a patient without that urgency; without directing the conversation towards a goal. There’s a deep pleasure in performing a skill that’s purely technical, with little of the intellect involved. Stitching is a technique, and like all techniques it can be done well or it can be done badly. Doing it well requires a level of focus that comes as a relief after the constant distractions of the emergency room floor.
I set up a sterile tray of instruments and suture thread, syringes of local anaesthetic, swab out his wounds again with antiseptic, and begin to stitch. He might need thirty or forty sutures, so this could take a while.
In the emergency room I’ve never seen someone die from slashing open the arteries of the wrist – generally they don’t bleed enough to risk death. The only person I’ve seen die after slashing her radial artery had also taken a knife to her own throat, and managed to cut her carotids as well. Arteries are only two or three millimetres wide at the wrist, and when they’re sliced open they often close themselves off as if in self-defence. But I have seen hundreds who scratch and cut their wrists not necessarily through a desire to die, but in an attempt to relieve extreme personal anguish, and demonstrate their rejection of the life they’re obliged to live.
Slashing at your wrists is a way of lashing out at life: through the pulse, the wrist is emblematic of life, testifying to the strength and vitality within. It’s a common way of giving release to feelings of tension: up to 4 per cent of the population admits to self-cutting (what is known as ‘deliberate self-harm’ or DSH), and though the wrist is the most popular, forearms, legs and hips are also common. Teenagers admit to much higher proportions, around 15 per cent, with girls more likely to come forward for help than boys. Cutting is often precipitated by feelings of extreme anxiety or distress, temporarily relieved by the act of drawing blood. As one self-harmer explained: ‘As the blood flows down the sink, so does the anger and anguish.’ An anthropologist who has studied self-harming behaviour called it ‘a strategy of withdrawal or self-abasement used to show those one must both love and obey that one is hurt by them’.
The self-harmers I see are often teenage girls who are placed in impossible situations: pulled between the expectations of their parents, the demands of their peers, and an anguish that’s partly about grieving their childhood, and partly about finding an adult identity. Cutting conveys the depth of conflict they feel, showing their families and friends just how appalling they feel inside. ‘Communication of emotional pain to others may result in validation of that pain’, wrote one group of DSH researchers, ‘and demonstration of the severity of problems may elicit help, or maintain a valuable relationship.’ From this perspective, to cut yourself is a rational decision.1
For the most part, the teenage girls I see haven’t suffered systematic, tormenting abuse at the hands of those who were supposed to look after them, but childhood abuse is often the precursor of such cutting: having been abused as a child quadruples your chances of self-harming as an adult. When I meet people who self-harm in clinic, I try to elicit whether they have been, or are being, abused, but how likely they are to admit that to me, I don’t know.
IN THE EMERGENCY DEPARTMENT there’s a ‘psych cubicle’: a room with more privacy than the usual cloth-curtained spaces, and stripped of anything which could be turned into a weapon. It’s telling that the room in which we assess patients who are mentally ill is the same room as that reserved for prisoners. It has two doors, so that a patient can’t get between you and your exit, and both of them are lockable.
Melissa wore cheap plastic trainers, stained pink jogging bottoms, and a shapeless pink pullover with ‘Gorgeous’ written across it. Her hair was unwashed, bourbon-brown, and her eyes were liquid with panic. I’d picked up her file on the wall outside – it had her name, date of birth and the address of some nearby supported accommodation: a place where those with severe mental health problems can live quasi-independently, helped by trained staff and social workers. Across the top of her file the triage nurse had written just ‘DSH’.
She sat in the psych cubicle looking at the floor, checking and rechecking the dressings on her forearms. The sleeves of her top were pushed up to the elbows to make them more visible. She had five or six adhesive dressings on each forearm, and spreading out from their margins I could see old scars: the skin surface was ridged and fissured as unpolished marble.
‘It’s because I was abused,’ was the first thing she said. I nodded.
‘That’s awful,’ I said. At times it’s the only thing to say.
‘It was my grandpa – he’s dead now – got what he deserved.’
She had been cutting herself only half an hour before and the blood was still spreading through the dressings.
‘I didn’t stop it. I should have stopped it. I’m so stupid.’
I sighed, and shook my head. ‘How old were you when it started?’
She shrugged. ‘Two? Three?’
‘So you were just a tiny girl, how could you have stopped it? It wasn’t your fault.’ We sat in silence for a few moments together. Outside I could hear the clatter of trolleys and the arrival of ambulance sirens. ‘What tablets are you on?’
‘I don’t want any tablets.’
‘Are you sleeping?’
‘Not for three days.’
‘Well I could give you something to sleep at least, and let you rest.’
She nodded her head.
‘Will you let me take a look at your cuts?’
She nodded, and held out both forearms. I began peeling off the dressings: the cuts were just shallow grazes, not deep enough even to need paper butterfly stitches, far less needle and suture. Slowly I began washing the cuts, and covering them with fresh dressings.
‘You got down here to the hospital on your own, that was well done,’ I said. ‘You knew when you needed to get help.’
With teenage girls, sometimes just having their cutting acknowledged by those around them is enough – the habit stops when the family around change their own attitudes, or the girl grows old enough that the tensions of adolescence begin to resolve. Melissa’s anguish had far more sinister origins; I felt utterly powerless to help.
ANOTHER WEEKEND NIGHT, so busy the patients are queuing outside the waiting room and along the corridor. There’s a six-hour wait to be seen. At the nurses’ station there’s a radio tuned into the ambulance system; the police and the paramedics use it to alert the department when multiple, or very serious, casualties are on their way. It rings: a sound like a klaxon that makes even the most experienced staff jump.
‘Major RTA on the city bypass,’ says a voice in the radio, and requests an ambulance fitted out to carry two doctors to the accident scene. The ambulance staff don’t request it often because it takes two doctors from the emergency room floor, but if there are casualties trapped in a vehicle, then calling it out can save lives.
I won’t be going; I’m allocated to the minor injuries area for the night. But with only five doctors on the floor instead of seven the waiting time is going to get even longer. Braced for the fury that is about to break over me, I stand at the doorway of the waiting room to tell the patients.
‘At the moment it’s six hours to be seen,’ I shout out, ‘but two doctors have just been called away to deal with another emergency, so it will take longer. If you think you can go home for the night and be seen tomorrow, please come forward.’
The waiting room goes silent; everyone sits tight and glowers at me. In the front row I can see a girl with a bag of frozen peas on her ankle, a man holding a cloth over his eye, an old lady with a graze on her forehead – but each has been waiting some hours already, and no one wants to get up first. After a few moments, a man at the back wearing a boiler suit and work boots gets up. He’s young – in his early thirties – with long sideburns and a splendid keel of a nose. His hand is wrapped in an old beach towel. ‘I can probably come back tomorrow,’ he says. As he speaks, his Adam’s apple bobs up and down like a float.
I take him into the adjacent cubicle. His tells me his name is Francis, and as I unwrap the towel I jump back: there’s a nail through his palm.
‘There’s a nail through your palm,’ I say, pointlessly.
‘I know.’
‘What happened?’
‘I was working late on the house, was getting tired … and fired the nail gun by mistake.’ The nail is clean, about four inches long; the puncture wounds on each side are neat with a halo of dried blood. He laughs: ‘I was lucky it didn’t fire right into wood,’ he laughed, ‘or I might still be there, pinned to a beam like Jesus.’
WITHIN THE PALM of the hand are four bones – the metacarpals – one for each finger. A fifth supports the base of the thumb. Between each bone are the delicate nerves that supply sensitivity to the fingers, some blood vessels, and also the muscles that splay the fingers or bring them tightly together (the muscles which bend or straighten the fingers lie in the forearm, not the hand). The metacarpal bases are bound to the bones of the wrist by tough ligaments, but further out, towards the fingers themselves, they are held fairly loosely. It’s quite possible to fire a nail through the palm of your hand without causing any major damage: the nerves are narrow and run close to the bone, and the main blood vessels run in a broad arch from the heel of the hand to the base of the thumb, away from the palm itself. Firing a nail through the wrist is a different matter: the wrist has a tight, seed-like intricacy of nerves, blood vessels and interlocking bones.
Francis might have joked about crucifixion, but if you wanted to nail someone to a piece of wood, you wouldn’t do it through the palm of the hand. The same anatomical features that allow a nail to pass through without causing serious damage mean that the structures of the hand aren’t strong enough to support the body’s weight. The tissues would rip and your hand would come free – mutilated and useless, but free.
Francis’s fingers were all flexing normally and his sensation was undamaged: none of his nerves or tendons were hit by the nail. The blood flowed to his fingers as it should. The X-ray of his hand showed the nail passing beautifully between the metacarpal bones, as if shot through the bars of a cage.
After cleaning up his wounds I sent him to the plastic surgeons. They would pull out the nail in an operating theatre, in order to have a proper look into the hole and make sure that no fragments had been left behind. No matter how neatly they closed up the wound, he’d be left with stigmata on either side of his hand; a lifelong reminder of the night he was almost nailed to a beam.
IN THE 1930S a zealous French surgeon called Pierre Barbet became passionately fascinated by the details of crucifixion. To test whether the hand could support the body’s weight he experimented by nailing cadavers to a wooden cross. Making a guess at Jesus’s weight and the position of the arms with respect to the torso during Roman crucifixion, he calculated that the nails must have been hammered through the small bones of the wrist rather than the palm. Those wrist bones – the ‘carpus’ – are held together very tightly by ligaments; Barbet found that if he nailed his corpses by the wrists rather than the palms, they didn’t tear out.
Pierre Barbet published his experiments on the nailing of a human body in the 1930s, but in 1968, in a burial cave near Jerusalem, a skeleton was found of a young man who’d been crucified during the Roman period. A nail about eleven centimetres long had been driven into the outside aspect of his right heel bone – the calcaneum – and traces of coarse olive wood, presumably used in the vertical stake of the crucifixion, were found under the head of the nail.
Dramatic claims were made after the find – the first direct evidence of Roman crucifixion – and the professor of anatomy at the Hebrew University suggested that a single nail had been put through both feet, that the forearms had been nailed, and that the victim’s legs had been broken, while still alive, in a coup de grâce. Fifteen years later two sceptical colleagues – Joseph Zias and Eliezer Sekeles – reexamined the remains and came to different conclusions: the nail had been passed through only one heel – the right (the other heel bone had been lost) and the arms showed no trace that they’d been nailed. They concluded that crucifixion, as practised by the Romans, involved tying the arms to a T-shaped cross-beam with rope, and nailing each heel to a vertical stave. Olive trees usually generate straight beams for only two to three metres at the most, and so victims would not have been hoisted very high.
That Roman crucifixion occurred through the palms is such a commonplace in Western culture that ‘stigmata’, the development of bleeding wounds over the points of the body where Jesus was said to have been nailed, have surfaced throughout the last millennium. I’ve read of them on palms, wrists, the flank (where Jesus was said to have been stabbed), and even on the tops of the feet. I haven’t heard of them happening on the side of the heel, and I’m yet to see someone fire a nail gun through their calcaneum.
Footnote
1 One strategy to reduce the scarring of DSH is to encourage those who do it to hold ice cubes against the skin until it hurts instead, or sting their skin by stretching and releasing an elastic band placed around the wrist.