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Psychosocial consequences of upper limb injury
P S Y C H O S O C I A L C O N S E Q U E N C E S OF U P P E R LIMB I N J U R Y M. C. PATERSON and F. D. BURKE
From the Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK Upper limb surgeons have little in the way of training in the identification or management of the psychological aspects of limb injury. Surgeons in training tend to see their speciality in technical terms, only slowly appreciating that the psychological state of the patient profoundly affects outcome in many cases. The case report that follows charts the psychological progress of a patient following severe upper limb injury. Surgeons usually view rehabilitation in physical terms. This report emphasizes the psychological aspects of a major limb injury to a policeman (MP) who subsequently studied psychology at PhD level. Journal of Hand Surgery (British and European Volume, 1995) 20B: 6." 776 781 and also of "ghostly" shapes around me, none of which were clearly identifiable. My exposure to the light did not last, however. I remember waking up from my druginduced sleep later that evening, still feeling contented, and being what could only be described as "close to God". Apparently I had "died" during the operation and had been revived. Whether my heart stopped and I was defibrillated I am unsure. I was moved from the Intensive Care Unit to an orthopaedic ward after about 3 days. I remember feeling elated following my move to the orthopaedic ward. It may have had something to do with the fact that I was receiving regular medication for pain and anxiety; however, I felt that I could have done without the drugs and asked for them to be stopped. Strangely enough, I was still feeling good in myself. In hindsight, I know that I was denying the reality of the situation despite being quite conscious of the fact that both my arms were gone. I think that through denial of reality, I allowed myself time to prepare for more problemfocused coping at a later stage. I had four operations within 2 weeks. The first operation set my left leg in traction and took care of what was left of my arms with amputation at mid-upper arm level on the right and mid-forearm on the left. An attempt was made to replant my left arm but this was abandoned during the operation due to the extent of tissue damage. The three later visits to theatre involved additional skin grafting to my left leg. It is interesting how others saw my situation. The orthopaedic registrar on duty that day told me that when he received notification that I was requiring major limb surgery he knew that he had time to finish with the previous patient. This he did quite calmly. When I was brought in to his operating theatre, feelings crept in which he knew should not be there. He told me that he felt concern that one human being could do this to another. He also said that he could visualize a Soviet factory worker calmly producing the weapon of destruction. He was aware that feelings such as these would interfere with his ability to do his job, therefore he had to block them out of his conscious thought. Around the time of my move to the orthopaedic
CASE REPORT (written by MP) In 1981, I was a constable in the Royal Ulster Constabulary, serving in west Belfast. On the 28 September 1981, my wife's 25th birthday, and the 21st day after my wedding, I lost both arms in a terrorist rocket attack on my armoured Landrover. In addition, I had my left femur smashed and received severe lacerations to my lower limbs. My immediate reaction was one of disbelief as I felt that this could not happen on my wife's birthday. However, severe pain made me realise that it was for real! Fortunately, the intense pain I was experiencing did not last for long as beta-endorphins quickly took effect. I was taken by ambulance to the Royal Victoria Hospital (RVH), Belfast, where I received emergency surgery. The ambulance journey from where the incident took place to the RVH only took a few minutes. Being in west Belfast, the RVH is the most convenient hospital with an Accident and Emergency Department. On arrival at the Accident Department, I was aware of the extent of my loss, having remained conscious from the time of my injury. 1 remember the helpless feeling as my body armour was removed and my clothes cut from me. I also felt concerned that my wife did not know that I was in hospital and, in an attempt to get word to her, I asked repeatedly for someone to contact my wife. I was continually ignored, so much so that I began to feel distress. At this point, a nurse said that she would contact my wife. Certain of the fact that my wife would be informed, I happily slipped into unconsciousness, probably due to the drugs which were being applied intravenously. I am informed that I was taken soon after to the orthopaedic theatre for the first of a series of operations. During my emergency operation, I had what is commonly known as a "near death experience". I felt myself travelling down a long dark tunnel towards a bright light at the end. As I approached the light, I had feelings of apprehension, not knowing what was ahead, but certainly no feeling of fear. I am informed that many people who have the "near death experience" never actually reach the light, but I did! Whilst in the light, I was aware of a sense of inner peace and contentment, 776
PSYCHOSOCIALCONSEQUENCESOF INJURY ward, I was introduced to my therapists. A team of occupational therapists (OTs) came to visit me, presumably to try and establish what they could do to help me help myself. The most inexperienced therapist drew the short straw and was assigned to me. I was fitted with a made-to-measure Jobst jacket to reduce the swelling on my stumps. The OT was innovative in that she adapted cutlery so that I could feed myself. This involved attaching the cutlery to straps around my stumps and bending the implements to those angles which best suited collecting food. This idea worked well but required a lot of effort on my part. I must admit that on many occasions it was easier to be spoon fed! A toothbrush and pen were also fitted to straps for me to use but I found this somewhat less successful. In addition to the OT, I received many visits from a physiotherapist. In an attempt to maintain muscle tone m my arms and shoulders, she fitted me with a customized "multigym". Springs were attached to the head of my bed and to straps around my stumps. I exercised quite happily in this way until one day my returning strength ripped one of the springs from the head of the bed and projected it across the room. Needless to say, that was the end of that! While I was receiving attention from physiotherapy and OT, the caring routine on the ward continued unabated. Although I always had the thought in my mind that certain hospital staff may place any sympathies for the terrorist before their caring role, I developed trusting relationships with several of the nurses. I only felt truly at ease if they were present when my dressings were being done. As time passed, I became inquisitive about artificial arms and how they worked, but nobody seemed to be able to give me an answer. Therapists, nurses and doctors up to senior registrar level openly admitted that they knew little about prosthetic arms. Looking back from 14 years on, it would seem that perhaps only consultants are well-informed with regard to artificial limbs, for none admitted to a lack of information! When I was in hospital, a consultant who was involved with the Artificial Limb and Appliance Centre came to see me. He had a friendly approach which I welcomed. Nonetheless, this did not prepare me for the shock of seeing a prosthetic glove designed to cover an artificial hand. Although the glove was flesh coloured, and had veins and skin pores, it resembled a washing-up glove when not filled by a hand. I was told that I would soon be fitted with a set of mechanical prosthesis, but the myo-electric arm which I had been promised by my own consultant had to be obtained elsewhere due to the lack of expertise in Northern Ireland at that time. The prosthetist responsible for upper limb prostheses in Belfast visited me shortly afterwards. He promised me that the first set of prostheses I received "would not be a good job". Apparently taking a plaster cast of a stump when a patient is lying down results in the
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prosthetist not being able to place the stump at the optimum angle. I felt somewhat angry with the prosthetist. It seemed that everybody else had been doing their best for me and now I was being given something second-rate! In mid-December 1981 my left leg was disconnected from traction and I was fitted with a polypropylene cast brace. Once I had demonstrated my mobility, I was discharged t'rom hospital into a vastly different world. My feeling on leaving hospital was one of excitement. I looked forward to going to my own home and being with my wife for periods longer than hospital visiting time. On my way home, I realised that the incident in which I was injured had left a psychological scar. A sudden flash of sunlight startled me and caused a momentary increase in heart-rate and a feeling of fear. On arriving home, I almost fell over as the road outside my house was on an incline--I had only learned to walk on level floors in hospital! It was at this point that my rehabilitation really started.
Limb-fitting and rehabilitation A few days after leaving hospital, I travelled to the Princess Margaret Rose Hospital (PMR) Edinburgh to be assessed for a myoelectric arm. I returned home the same day having learned that I was to receive a belowelbow prosthesis, and not the full set as I had imagined. 2 days later, in Belfast, I took delivery of my first set of mechanical artificial arms. As the prosthetist promised, the arms were "not a great job". For example, when I held a fork or spoon in my split hook I was unable to get either to reach my mouth. This was perhaps one of the most frustrating aspects of trying to deal with my disability. In the end, I reverted to using the OT-customized knife, fork and spoon strapped to my prostheses. The following week, accompanied by my police "minders", I attended specialist training in the use of upper limb prostheses at the OT Department of Belfast City Hospital. The aim of this training was to try to get me to look natural in my movements. This was somewhat difficult to achieve at that time. I had no wrists, my left leg was locked in extension in the cast brace, and as I had lost my right elbow, my right-handedness had to change to left-handedness. The training commenced with me lifting and moving small wooden blocks across a table. Such a task, although difficult then, is second nature now. Christmas 1981 passed without event and I prepared to go to the P M R for fitting of my myoelectric arm. This was to require a 6-week stay in Edinburgh. My wife, who worked for the Northern Ireland Civil Service, was able to obtain a temporary transfer to accompany me. On arrival at P M R an OT asked me to perform the block-moving test. By this stage, I was becoming proficient and carried out my assignment with ease.
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Concurrent with this, a physiotherapist commenced the task of trying to get my knee to bend following its prolonged period in extension. I enjoyed visits to the hydrotherapy pool where I realised I could still swim, albeit in circles! Upon receipt of the myoelectric prosthesis, I again carried out the block-moving task and showed that I was proficient with my new arm. I proudly returned home convinced that total independence was around the corner, but I became disillusioned quite quickly. The myoelectric arm was slow to respond to my signals for it to open (or close) or for the wrist to rotate. It was also clumsy as I was unable to carry out tasks which required some manual dexterity. Nevertheless, I persevered for 3 months, until the myoelectric arm broke down. I sent it off to P M R and received the repaired arm 3 months later. In the meantime, I had become expert in the use o f the split hook, but did try to make the best of the myoelectric arm. It was to no avail; the greater independence allowed by the split hook was reflected in my preference for it. To this day, I wear a split hook on my left side and a mechanical hand or a split hook on my right. At the same time as learning to use the myoelectric hand, I attended a rehabilitation centre in Belfast. I was told that the physiotherapists would work on bending my knee to its maximum flexion, and that I would develop some independence skills with an OT. On my first meeting with the OT I was asked to lift and move some small wooden blocks across a table. By then my dexterity with the myoelectric hand had improved tremendously so I saw the block moving task as menial and therefore felt angry and insulted. Things improved after that! As the flexion returned to my knee, and I developed some muscle tone through gym exercises and swimming, I started jogging in an attempt to regain some of the fitness I had enjoyed prior to the fateful day. I did achieve a reasonable degree of fitness through training, but this has now ceased due to cartilage trouble in both my knees.
Psychosociai development O f some concern during my time in the RVH in Belfast was the fact that after about 3 to 4 weeks I had not shown sadness or grief at the loss of both my arms. My "realization" came when one day I saw the patchwork quilt effect of skin grafting on my left leg together with the scarring on my left stump. I cried for a few minutes and felt comforted by one o f my "trusted" nurses. In the 6 months or so following discharge, I did get frustrated on occasions and cried. The short bouts of self-pity worked as a safety valve, after which things did not look as bad as I had previously thought. I had heard that I could experience flashbacks or nightmares about the incident in which I was maimed. I do sometimes reflect on the events which I can still
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recall vividly. Thankfully, I have dreamed about the fateful event on only three occasions. In these dreams I have been an onlooker and not an active participant. Over the years, I have been asked by many people how I feel towards the people that maimed me and killed my colleague. I am glad to say that I do not have a pathological hatred. Indeed, I have always answered questions truthfully by saying that I do not forgive my attackers but have put the experience behind me and always look to the future. Something which I found difficult to deal with in the early stages following discharge from hospital was the people staring. Even today, I am not entirely comfortable when adults or older children stare, but, surprisingly, I am completely tolerant of small children. Despite my intolerance, I can understand why people stare. Wearing a split hook makes me look different to other people, therefore, it attracts a natural curiosity. However, I dislike it when people assume that because I have a physical impairment, I am mentally impaired as well! Yes, the "does he take sugar?" scenario happened to me. When my wife was asked the question, I interjected with "No, he does not!" Also, at my local supermarket, some staff at the check-out slowed down their speech and pronounced every word carefully. I found that the best course of action was just to be mannerly and behave "normally". I feel that my relationship with my wife suffered after I was injured. She was unable to experience "normal" life for the period I was in hospital. This was exacerbated by the fact that her father became ill and died in another hospital 1 month after my incident. On discharge from hospital my wife had to shoulder the burden of my frustration. She too experienced frustration and in many ways mirrored my emotions. As time passed, proficiency with my prosthesis improved as did my independence and fitness, and, ultimately, my self-esteem. I knew that in the police I would not be able to compete for promotion on equal terms with my peers and would be disqualified on the grounds of inexperience (despite a policy of "equal opportunity"). I felt confident that I could start on a new career although I had left school with only two 'O' levels to my credit. In September 1982, I commenced two part-time 'A' level courses at a local further education college. I saw this as a challenge and was prepared to "give it a go", with the forethought that if I failed the exams it would not matter too much. I surprised myself by passing the exams the following June and being accepted to read for a degree in social sciences at the University of Ulster. In July 1987, I graduated with a BSc with first class honours in Psychology, and then commenced my PhD research at The Queen's University of Belfast in October 1987. I finished that degree in November 1990 and then subsequently found employment firstly with Queen's University as a research fellow, and then as a government statistician with the Northern Ireland Civil Service.
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DISCUSSION This section draws on a number of points raised in the above narrative and broadens the debate into more distal amputations where similar principles apply. Some of the more practical aspects of patient management are addressed, while psychological theory is provided in explanation for other experiences. The psychological consequences of upper limb injury receive little prominence in relevant surgical text-books or journals despite the important role they may play in outcome. Pulvertaft (1975) highlighted the problem in a paper on the subject which introduced the topic in these terms: Human relationship is a matter of fundamental importance in the care of the patient, whether he be a child or an adult. You have all been through a long and arduous training, designed to fit you for many decisions and actions you are called upon to make. Few, if any, of you will have had formal instruction in the art of rapport. Busy clinics, lack of experience and perpendicular relationships (white-coated vertical doctors with attendant minions and pajama-clad horizontal patients) may often undermine the art of rapport between doctor and patient. If satisfactory rapport is obtained, it is frequently with therapists or nurses. Clinical psychologists (Mendelson et al, 1986) are too rare a breed in most state health systems to deal with the many patients with psychological disturbances following injury. It is important that some members of the hand team take responsibility for this important aspect of the patient's care and that it is not overlooked. The hospital system rarely allows sufficient time for extensive private discussion with patients. In a hierarchical system, the consultant may be particularly poorly placed to play this role for the patient, crowding too many activities into the working day and rarely seeing the patients alone in the early stages after injury. On many occasions, the junior doctor who initially assesses the patient remains the physician who gains the patient's trust and confidence. MP was an in-patient for many weeks and sought comfort from some of the ward nurses. Most limb or digital amputations are hospitalized for short l~eriods of time and the role more logically falls to the hand therapists. The psychological experience could be considered the most important aspect of major limb injury. How the patient is treated can affect what is a potentially volatile emotional state. In this case, no obvious symptoms of post-traumatic stress disorder (PTSD) were present despite the fact that people have been noted as experiencing psychological upset having only witnessed a terrorist bombing (Hadden et al, 1978; Lyons, 1974). Why this was the case for MP could be due to a number of factors considered below. When in the accident room of the RVH a nurse
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prevented MP from becoming too distressed by saying that she would contact his wife. In hindsight, it is clear that police colleagues would inform next-of-kin, yet a patient finds it difficult to think rationally. The nurse recognized the distress and alleviated it by reassurance, a simple act which removed an additional stress or when the patient was having to face the most stressful event of his life~ The doctor's initial assessment of the injured limb is an important part of the psychological management of the patient. In this case, the severity of the injury precluded discussion. More distal amputations or injuries that are not life-threatening permit detailed history and examination. This allows the doctor to plan the initial treatment, instituting a programme which may be modified by subsequent findings at surgery or by the patient's response to treatment. The patient's needs at this important assessment must also be considered. They need preliminary information about the extent of their injury and some indication as to the likely period of hospitalization, rehabilitation and outcome. Pulvertaft (1975) considered that rehabilitation starts at the moment of injury and felt the preliminary assessment was the appropriate opportunity to get the patient's confidence and trust: I do not mean to infer that it is right to be unduly optimistic and give promises that cannot be honoured. There are ways in which we can combine sympathy with truth. The near-death experience seems akin to that reported regularly by many people. Scientifically speaking, the whole experience could well be attributable to an altered state of consciousness, rather than to anything spiritual. Perhaps the tunnel phenomenon is due to oxygen depri= vation in the outer part of the receptive field of the retina and that only those cells in the centre of the receptive field are stimulated, thus creating a perception of light surrounded by darkness. However, this does not explain the subsequent bright light in which "ghostly" figures were present. MP retains an open mind on this subject. Flash-backs and nightmares are extremely common phenomena after upper limb injury (Grunert et al, 1992). They report 80% of patients experiencing flash-backs immediately after the injury, dropping to 40% at 18 months. The patient rarely reports these complaints to medical staff. Therapists who spend more time with the patients have an important role in reassuring the patient that they are not alone in their experiences and that the phenomena are a normal and usually transitory response to their injury. When on the hospital ward in the RVH, MP did not show any grief at the loss of his limbs for about 3 or 4 weeks. Parkes (1972) perceives the reaction to all types of loss to be akin to the grief reaction in bereavement where failure to cry indicates an abnormal grief reaction. The normal bereavement process following loss of limb, as in death of a loved one, can be seen as characterized
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by four stages: shock-denial; anxiety-distress; despondency and then reorganization. There are no time limits on these stages, and passage through them can vary depending on the individual. Within the stages following loss, people experience a wide range of emotions. In this case, these stages were met and passed through without major upset. The circumstances surrounding an injury (and the patient's response to the situation) may play a large part in determining the duration and extent of disability. MP does not forgive this assault, but considers it a closed chapter in his life. This may be contrasted with the case histories of two patients attending the Pulvertaft Hand Centre. Two patients attended within the same week with apparently identical injuries (amputation of the non-dominant middle fingertip). One had been caused by what the patient described as his own carelessness while using a power saw at home. The other injury had been caused by a bite from the patient's neighbour's dog. Both patients were distressed by the discomfort and loss of the fingertip, but the dog-bite patient considered his injury to be an assault and was extremely aggrieved from the outset. The late-night homeimprovement enthusiast had apparently come to terms with his loss emotionally and physically within 6 weeks, while the patient with the dog-bite continued to experience major disability both functionally and emotionally 2 years after injury. An assault of any type may prejudice the speed and completeness of recovery. It should be appreciated that many injuries at work are perceived by the patient as an assault, particularly if employer/employee relationships are poor. The OT who treated MP in hospital (RVH) gave the patient control of several situations within the hospital environment where people are expected to adopt a sick role. This may well have led to an increase in self-esteem and internal locus of control. Internal locus of control is seen as a learned state where one perceives that events which occur are due to one's behaviour or one's individual characteristics (Rotter, 1966; 1975). An external locus of control occurs when events are perceived to be contingent upon other people or chance. Evidence in the scientific literature (Sarason et al, 1983) suggests that an internal locus of control can buffer the effects of life stress when combined with high levels of social support. This is termed the "buffering hypothesis". Although this testimony is purely anecdotal, MP feels that he was buffered from the effects of the incident. With respect to the buffering mechanism proposed by Sarason et al (1983), he did learn that he had a degree of personal control in the hospital environment. Furthermore, he did have a lot of active social support from family, colleagues and hospital staff, and also tacit support from the large number of well-wishers who wrote to him at the hospital following features in several newspapers. His sense of control and social support perhaps interacted in some way to protect him from the
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effects of PTSD, and perhaps modify the grief reaction experienced when losing one's arms. Although there was adequate social support, there were experiences with health professionals that could have been handled better. Firstly, health professionals tended to have little, or no, experience of prosthetic limbs, and lacked readily available literature on the subject. Although reporting on events 14 years ago, more recent enquiries on the Derby Hand Course reveal that the situation remains the same. As registrars, house officers, nurses and therapists are in daily contact with patients prior to limb fitting, it may be worthwhile for them to be more aware of the prostheses and aids available, and be shown how prosthetic limbs are made and fitted. Having used a myoelectric arm as a dominant limb, MP discovered that he could do more with the much cheaper split hook. It is right that medical consultants should want the best technology available for their patients, but when the technology is likely to result in reduced function for the patient then the expenditure should be considered carefully. From this experience, MP considers that unilateral arm amputees should receive most benefit from a myoelectric arm as they would be likely to depend on their intact arm and use the myoelectric prosthesis as a secondary limb. In this role, the myoelectric prosthesis would perform well and also be cosmetically aesthetic. The reader may have noted the use of the term "stump" in referring to the remnants of the arms. This term is commonplace amongst health professionals and, by implication, labels what was a functional limb as something lifeless and useless. When MP first heard his arms called stumps, it hurt him emotionally. Even now, he considers himself as having arms even though they may not fit the anatomical description. Health professionals working with amputees may wish to consider this point before using the expression freely. Interestingly, if the left arm had been replanted after it had been severed then it would have been termed "an arm", though probably it would have been less functional than the prosthetic arm fitted with a split hook. Clearly, surgeons are faced with a dilemma when the opportunity to replant a limb is available. Without a psychosocial profile of the patient, how would they know whether function or cosmetic appearance would be the most important to the client? In this case, MP feels that events forced the best option upon him. A similar dilemma occurs much more frequently with more distal limb amputations considered for replantation. Brown (1982) explored the relationship between motivation and disability following distal upper limb amputations. The paper is an important reference in understanding the psychological background to digital amputation. 104 surgeons were interviewed who had suffered digital loss. A wide variety of single digits and multiple digit loss had occurred and approximately half occurred before becoming surgeons and half after their
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training. Only three of the surgeons admitted to noticeable loss of dexterity and eight to minor loss. Only three surgeons abandoned their careers after injury. No less than 29 surgeons considered the amputation to have improved their professional situation and eight considered their rehabilitation to be returning to work. A hand surgeon surveying the article observes "often a well healed stump is functionally psychologically and vocationally the best thing for many patients, rather than retention of a poorly functioning digit". The paper particularly questions the loss of dexterity following amputation of the thumb or amputation of the index finger in well motivated patients. A one-armed ophthalmologist, from an injury when 17 years of age, considered his amputation to cause him no disability and observed that handicap is a state of mind and not a state of fact. Upon discharge from hospital, MP realised that he was stigmatized and that there existed in society a somewhat negative reaction to him as a "disabled" person. Goffman ( 1963; 1974) indicated that stigmatized people are "discredited" (i.e. those whose differences are observable, or known about). With stigma related to visible deformity, the "does he take sugar?" phenomenon occurs where society generalizes a stereotypic belief that as disabled people are inferior in some ways, they are obviously inferior in others (Lindemann, 1987). Doctors frequently underestimate the stress involved in return to work after upper limb amputation or injury. In MP's case the extent and severity of injury precluded a full role in the police force which prompted a complete change of career. Less severe injuries must also be dealt with sensitively even if the residual difficulties seem minor and compatible with the previous occupation. Employers may be insensitive to the patient's psychological difficulties. A reluctance to return to work on a machine which caused personal injury does not necessarily indicate moral turpitude. M a n y p a t i e n t s admit to significant stress and apprehension on passing through the work's gates on the first day back to duty. Grunert (1992) states that more than one-third of patients reported a fear of re-injury 18 months after the incident. Family certainly suffered as a result of this injury. However, MP feels that as he was in the early stages of married life when he lost his arms, he and his wife were better able to deal °with the problem. The circumplex model of marital and family systems (Olson, 1986; Olson et al, 1979; 1980; 1983; 1985; 1988) sees a "balanced" family system as one where there is a harmonious blend of both adaptability and cohesion. MP and his wife fell within the "flexibly-connected" category, one of two family types common to newly-married couples (Olson et al, 1983). Both were cohesive and adaptive to new
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situations and now have a "normal" family life where the impairment plays a secondary role. The authors hope that this paper has been informative by illustrating the role of psychology in patient care and rehabilitation. As can be seen from cases referred to in the text, not all patients can have as good an outcome as MP. In the absence of clinical psychology services, the onus ,,is on medical, nursing and therapy staff to create an' optimal environment for the psychological adjustment of their patients. References BROWN, P. W. (1982). Less than ten: surgeons with amputated fingers. Journal of Hand Surgery, 7: 1: 31-37. GOFFMAN, E. (1963). Stigma: Notes on the Management of a Spoiled Identity. Englewood Cliffs, Prentice-Hall, ? ? GOFFMAN, E. Stigma and Social Identity. In: D. M. Bowell and J. M. Wingrove (Eds). The Handicapped Person in the Community. London, Tavistock, 1974. GRUNERT, B. K., DEVINE, C. A., MATLOUB, H. S. et al. (1992). Psychological adjustment following work--related hand injury. Annals of Plastic Surgery, 29: 6: 537-542. HADDEN, W. A., RUTHERFORD, W. H. and MERRETT, J. D. (1978 ). The injuries of terrorist bombing: A study of 1532 consecutive cases. British Journal of Surgery, 65: 525-531. LINDEMANN, J. E. Psychological and Behavioural Aspects of Physical Disability. New York, Plenum, 1987. LYONS, H. A. (1974). Terrorists' bombing and the psychological sequelae. Journal of the Irish Medical Association, 67: 15-19. MENDELSON, R. L., BURECH, J. G., POLACK, E. P. and KAPPEL, D. A. (1986). The psychological impact of traumatic amputations. Hand Clinics, 2: 3: 577-583. OLSON, D. H. (1986). Cireumplex model VII: Validation studies and FACES III. Family Process, 25: 337-351. OLSON, D. H., LAVEE, Y. and McCUBBIN, H. I. Types of Families and Family Response to Stress across the Family Life Cycle. In: D. M. Klein and J. Aldous (Eds). Social Stress and Family Development. New York, Guilford Press, 1988. OLSON, D. H., PORTNER, J. and LAVEE Y. FACES 111. St Paul, Family Social Science, 1985. OLSON, D. H., RUSSELL, C. S. and SPRENKLE, D. H. Circumplex Model of Marital and Family Systems II: Empirical Studies and Clinical Intervention. In: Vincent J.P. (Ed.). Advances in Family Intervention, Assessment and Theory. Vol. 1. Greenwich, JAI Press, 1980. OLSON, D. H., RUSSELL, C. S. and SPRENKLE, D. H. (1983). Circumplex model of marital and family systems: VI. Theoretical update. Family Process, 22: 69-83. OLSON, D. H., SPRENKLE, D. H. and RUSSELL, C. S. (1979). Circumplex model of marital and family systems: I. Cohesion and adaptability dimensions, family types, and clinical applications. Family Process, 18: 3-28. PARKES, C. M. (1972). Components of the reaction to loss of limb, spouse or home. Journal of Psychosomatic Research, 16, 343-349. PULVERTAFT, R. G. (1975). Psychological aspects of hand injuries. The Hand, 7: 2: 93-103. ROTTER, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80: 1-28. ROTTER, J. B. (1975). Some problems and misconceptions related to the construct of internal versus external control of reinforcement. Journal of Consulting and Clinical Psychology, 43: 56-67. SARASON, I. G., LEVINE, H. M., BASHAM, R. B. and SARASON, B. R. (1983). Assessing social support: The social support questionnaire. Journal of Personality and Social Psychology, 44, 127-139.
Accepted: 6 May 1995 Mr F.D. Burke, MB BS, FRCS, The Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, DE1 2QY, UK. © 1995 The British Societyfor Surgery of the Hand
From the Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK Upper limb surgeons have little in the way of training in the identification or management of the psychological aspects of limb injury. Surgeons in training tend to see their speciality in technical terms, only slowly appreciating that the psychological state of the patient profoundly affects outcome in many cases. The case report that follows charts the psychological progress of a patient following severe upper limb injury. Surgeons usually view rehabilitation in physical terms. This report emphasizes the psychological aspects of a major limb injury to a policeman (MP) who subsequently studied psychology at PhD level. Journal of Hand Surgery (British and European Volume, 1995) 20B: 6." 776 781 and also of "ghostly" shapes around me, none of which were clearly identifiable. My exposure to the light did not last, however. I remember waking up from my druginduced sleep later that evening, still feeling contented, and being what could only be described as "close to God". Apparently I had "died" during the operation and had been revived. Whether my heart stopped and I was defibrillated I am unsure. I was moved from the Intensive Care Unit to an orthopaedic ward after about 3 days. I remember feeling elated following my move to the orthopaedic ward. It may have had something to do with the fact that I was receiving regular medication for pain and anxiety; however, I felt that I could have done without the drugs and asked for them to be stopped. Strangely enough, I was still feeling good in myself. In hindsight, I know that I was denying the reality of the situation despite being quite conscious of the fact that both my arms were gone. I think that through denial of reality, I allowed myself time to prepare for more problemfocused coping at a later stage. I had four operations within 2 weeks. The first operation set my left leg in traction and took care of what was left of my arms with amputation at mid-upper arm level on the right and mid-forearm on the left. An attempt was made to replant my left arm but this was abandoned during the operation due to the extent of tissue damage. The three later visits to theatre involved additional skin grafting to my left leg. It is interesting how others saw my situation. The orthopaedic registrar on duty that day told me that when he received notification that I was requiring major limb surgery he knew that he had time to finish with the previous patient. This he did quite calmly. When I was brought in to his operating theatre, feelings crept in which he knew should not be there. He told me that he felt concern that one human being could do this to another. He also said that he could visualize a Soviet factory worker calmly producing the weapon of destruction. He was aware that feelings such as these would interfere with his ability to do his job, therefore he had to block them out of his conscious thought. Around the time of my move to the orthopaedic
CASE REPORT (written by MP) In 1981, I was a constable in the Royal Ulster Constabulary, serving in west Belfast. On the 28 September 1981, my wife's 25th birthday, and the 21st day after my wedding, I lost both arms in a terrorist rocket attack on my armoured Landrover. In addition, I had my left femur smashed and received severe lacerations to my lower limbs. My immediate reaction was one of disbelief as I felt that this could not happen on my wife's birthday. However, severe pain made me realise that it was for real! Fortunately, the intense pain I was experiencing did not last for long as beta-endorphins quickly took effect. I was taken by ambulance to the Royal Victoria Hospital (RVH), Belfast, where I received emergency surgery. The ambulance journey from where the incident took place to the RVH only took a few minutes. Being in west Belfast, the RVH is the most convenient hospital with an Accident and Emergency Department. On arrival at the Accident Department, I was aware of the extent of my loss, having remained conscious from the time of my injury. 1 remember the helpless feeling as my body armour was removed and my clothes cut from me. I also felt concerned that my wife did not know that I was in hospital and, in an attempt to get word to her, I asked repeatedly for someone to contact my wife. I was continually ignored, so much so that I began to feel distress. At this point, a nurse said that she would contact my wife. Certain of the fact that my wife would be informed, I happily slipped into unconsciousness, probably due to the drugs which were being applied intravenously. I am informed that I was taken soon after to the orthopaedic theatre for the first of a series of operations. During my emergency operation, I had what is commonly known as a "near death experience". I felt myself travelling down a long dark tunnel towards a bright light at the end. As I approached the light, I had feelings of apprehension, not knowing what was ahead, but certainly no feeling of fear. I am informed that many people who have the "near death experience" never actually reach the light, but I did! Whilst in the light, I was aware of a sense of inner peace and contentment, 776
PSYCHOSOCIALCONSEQUENCESOF INJURY ward, I was introduced to my therapists. A team of occupational therapists (OTs) came to visit me, presumably to try and establish what they could do to help me help myself. The most inexperienced therapist drew the short straw and was assigned to me. I was fitted with a made-to-measure Jobst jacket to reduce the swelling on my stumps. The OT was innovative in that she adapted cutlery so that I could feed myself. This involved attaching the cutlery to straps around my stumps and bending the implements to those angles which best suited collecting food. This idea worked well but required a lot of effort on my part. I must admit that on many occasions it was easier to be spoon fed! A toothbrush and pen were also fitted to straps for me to use but I found this somewhat less successful. In addition to the OT, I received many visits from a physiotherapist. In an attempt to maintain muscle tone m my arms and shoulders, she fitted me with a customized "multigym". Springs were attached to the head of my bed and to straps around my stumps. I exercised quite happily in this way until one day my returning strength ripped one of the springs from the head of the bed and projected it across the room. Needless to say, that was the end of that! While I was receiving attention from physiotherapy and OT, the caring routine on the ward continued unabated. Although I always had the thought in my mind that certain hospital staff may place any sympathies for the terrorist before their caring role, I developed trusting relationships with several of the nurses. I only felt truly at ease if they were present when my dressings were being done. As time passed, I became inquisitive about artificial arms and how they worked, but nobody seemed to be able to give me an answer. Therapists, nurses and doctors up to senior registrar level openly admitted that they knew little about prosthetic arms. Looking back from 14 years on, it would seem that perhaps only consultants are well-informed with regard to artificial limbs, for none admitted to a lack of information! When I was in hospital, a consultant who was involved with the Artificial Limb and Appliance Centre came to see me. He had a friendly approach which I welcomed. Nonetheless, this did not prepare me for the shock of seeing a prosthetic glove designed to cover an artificial hand. Although the glove was flesh coloured, and had veins and skin pores, it resembled a washing-up glove when not filled by a hand. I was told that I would soon be fitted with a set of mechanical prosthesis, but the myo-electric arm which I had been promised by my own consultant had to be obtained elsewhere due to the lack of expertise in Northern Ireland at that time. The prosthetist responsible for upper limb prostheses in Belfast visited me shortly afterwards. He promised me that the first set of prostheses I received "would not be a good job". Apparently taking a plaster cast of a stump when a patient is lying down results in the
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prosthetist not being able to place the stump at the optimum angle. I felt somewhat angry with the prosthetist. It seemed that everybody else had been doing their best for me and now I was being given something second-rate! In mid-December 1981 my left leg was disconnected from traction and I was fitted with a polypropylene cast brace. Once I had demonstrated my mobility, I was discharged t'rom hospital into a vastly different world. My feeling on leaving hospital was one of excitement. I looked forward to going to my own home and being with my wife for periods longer than hospital visiting time. On my way home, I realised that the incident in which I was injured had left a psychological scar. A sudden flash of sunlight startled me and caused a momentary increase in heart-rate and a feeling of fear. On arriving home, I almost fell over as the road outside my house was on an incline--I had only learned to walk on level floors in hospital! It was at this point that my rehabilitation really started.
Limb-fitting and rehabilitation A few days after leaving hospital, I travelled to the Princess Margaret Rose Hospital (PMR) Edinburgh to be assessed for a myoelectric arm. I returned home the same day having learned that I was to receive a belowelbow prosthesis, and not the full set as I had imagined. 2 days later, in Belfast, I took delivery of my first set of mechanical artificial arms. As the prosthetist promised, the arms were "not a great job". For example, when I held a fork or spoon in my split hook I was unable to get either to reach my mouth. This was perhaps one of the most frustrating aspects of trying to deal with my disability. In the end, I reverted to using the OT-customized knife, fork and spoon strapped to my prostheses. The following week, accompanied by my police "minders", I attended specialist training in the use of upper limb prostheses at the OT Department of Belfast City Hospital. The aim of this training was to try to get me to look natural in my movements. This was somewhat difficult to achieve at that time. I had no wrists, my left leg was locked in extension in the cast brace, and as I had lost my right elbow, my right-handedness had to change to left-handedness. The training commenced with me lifting and moving small wooden blocks across a table. Such a task, although difficult then, is second nature now. Christmas 1981 passed without event and I prepared to go to the P M R for fitting of my myoelectric arm. This was to require a 6-week stay in Edinburgh. My wife, who worked for the Northern Ireland Civil Service, was able to obtain a temporary transfer to accompany me. On arrival at P M R an OT asked me to perform the block-moving test. By this stage, I was becoming proficient and carried out my assignment with ease.
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Concurrent with this, a physiotherapist commenced the task of trying to get my knee to bend following its prolonged period in extension. I enjoyed visits to the hydrotherapy pool where I realised I could still swim, albeit in circles! Upon receipt of the myoelectric prosthesis, I again carried out the block-moving task and showed that I was proficient with my new arm. I proudly returned home convinced that total independence was around the corner, but I became disillusioned quite quickly. The myoelectric arm was slow to respond to my signals for it to open (or close) or for the wrist to rotate. It was also clumsy as I was unable to carry out tasks which required some manual dexterity. Nevertheless, I persevered for 3 months, until the myoelectric arm broke down. I sent it off to P M R and received the repaired arm 3 months later. In the meantime, I had become expert in the use o f the split hook, but did try to make the best of the myoelectric arm. It was to no avail; the greater independence allowed by the split hook was reflected in my preference for it. To this day, I wear a split hook on my left side and a mechanical hand or a split hook on my right. At the same time as learning to use the myoelectric hand, I attended a rehabilitation centre in Belfast. I was told that the physiotherapists would work on bending my knee to its maximum flexion, and that I would develop some independence skills with an OT. On my first meeting with the OT I was asked to lift and move some small wooden blocks across a table. By then my dexterity with the myoelectric hand had improved tremendously so I saw the block moving task as menial and therefore felt angry and insulted. Things improved after that! As the flexion returned to my knee, and I developed some muscle tone through gym exercises and swimming, I started jogging in an attempt to regain some of the fitness I had enjoyed prior to the fateful day. I did achieve a reasonable degree of fitness through training, but this has now ceased due to cartilage trouble in both my knees.
Psychosociai development O f some concern during my time in the RVH in Belfast was the fact that after about 3 to 4 weeks I had not shown sadness or grief at the loss of both my arms. My "realization" came when one day I saw the patchwork quilt effect of skin grafting on my left leg together with the scarring on my left stump. I cried for a few minutes and felt comforted by one o f my "trusted" nurses. In the 6 months or so following discharge, I did get frustrated on occasions and cried. The short bouts of self-pity worked as a safety valve, after which things did not look as bad as I had previously thought. I had heard that I could experience flashbacks or nightmares about the incident in which I was maimed. I do sometimes reflect on the events which I can still
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recall vividly. Thankfully, I have dreamed about the fateful event on only three occasions. In these dreams I have been an onlooker and not an active participant. Over the years, I have been asked by many people how I feel towards the people that maimed me and killed my colleague. I am glad to say that I do not have a pathological hatred. Indeed, I have always answered questions truthfully by saying that I do not forgive my attackers but have put the experience behind me and always look to the future. Something which I found difficult to deal with in the early stages following discharge from hospital was the people staring. Even today, I am not entirely comfortable when adults or older children stare, but, surprisingly, I am completely tolerant of small children. Despite my intolerance, I can understand why people stare. Wearing a split hook makes me look different to other people, therefore, it attracts a natural curiosity. However, I dislike it when people assume that because I have a physical impairment, I am mentally impaired as well! Yes, the "does he take sugar?" scenario happened to me. When my wife was asked the question, I interjected with "No, he does not!" Also, at my local supermarket, some staff at the check-out slowed down their speech and pronounced every word carefully. I found that the best course of action was just to be mannerly and behave "normally". I feel that my relationship with my wife suffered after I was injured. She was unable to experience "normal" life for the period I was in hospital. This was exacerbated by the fact that her father became ill and died in another hospital 1 month after my incident. On discharge from hospital my wife had to shoulder the burden of my frustration. She too experienced frustration and in many ways mirrored my emotions. As time passed, proficiency with my prosthesis improved as did my independence and fitness, and, ultimately, my self-esteem. I knew that in the police I would not be able to compete for promotion on equal terms with my peers and would be disqualified on the grounds of inexperience (despite a policy of "equal opportunity"). I felt confident that I could start on a new career although I had left school with only two 'O' levels to my credit. In September 1982, I commenced two part-time 'A' level courses at a local further education college. I saw this as a challenge and was prepared to "give it a go", with the forethought that if I failed the exams it would not matter too much. I surprised myself by passing the exams the following June and being accepted to read for a degree in social sciences at the University of Ulster. In July 1987, I graduated with a BSc with first class honours in Psychology, and then commenced my PhD research at The Queen's University of Belfast in October 1987. I finished that degree in November 1990 and then subsequently found employment firstly with Queen's University as a research fellow, and then as a government statistician with the Northern Ireland Civil Service.
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DISCUSSION This section draws on a number of points raised in the above narrative and broadens the debate into more distal amputations where similar principles apply. Some of the more practical aspects of patient management are addressed, while psychological theory is provided in explanation for other experiences. The psychological consequences of upper limb injury receive little prominence in relevant surgical text-books or journals despite the important role they may play in outcome. Pulvertaft (1975) highlighted the problem in a paper on the subject which introduced the topic in these terms: Human relationship is a matter of fundamental importance in the care of the patient, whether he be a child or an adult. You have all been through a long and arduous training, designed to fit you for many decisions and actions you are called upon to make. Few, if any, of you will have had formal instruction in the art of rapport. Busy clinics, lack of experience and perpendicular relationships (white-coated vertical doctors with attendant minions and pajama-clad horizontal patients) may often undermine the art of rapport between doctor and patient. If satisfactory rapport is obtained, it is frequently with therapists or nurses. Clinical psychologists (Mendelson et al, 1986) are too rare a breed in most state health systems to deal with the many patients with psychological disturbances following injury. It is important that some members of the hand team take responsibility for this important aspect of the patient's care and that it is not overlooked. The hospital system rarely allows sufficient time for extensive private discussion with patients. In a hierarchical system, the consultant may be particularly poorly placed to play this role for the patient, crowding too many activities into the working day and rarely seeing the patients alone in the early stages after injury. On many occasions, the junior doctor who initially assesses the patient remains the physician who gains the patient's trust and confidence. MP was an in-patient for many weeks and sought comfort from some of the ward nurses. Most limb or digital amputations are hospitalized for short l~eriods of time and the role more logically falls to the hand therapists. The psychological experience could be considered the most important aspect of major limb injury. How the patient is treated can affect what is a potentially volatile emotional state. In this case, no obvious symptoms of post-traumatic stress disorder (PTSD) were present despite the fact that people have been noted as experiencing psychological upset having only witnessed a terrorist bombing (Hadden et al, 1978; Lyons, 1974). Why this was the case for MP could be due to a number of factors considered below. When in the accident room of the RVH a nurse
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prevented MP from becoming too distressed by saying that she would contact his wife. In hindsight, it is clear that police colleagues would inform next-of-kin, yet a patient finds it difficult to think rationally. The nurse recognized the distress and alleviated it by reassurance, a simple act which removed an additional stress or when the patient was having to face the most stressful event of his life~ The doctor's initial assessment of the injured limb is an important part of the psychological management of the patient. In this case, the severity of the injury precluded discussion. More distal amputations or injuries that are not life-threatening permit detailed history and examination. This allows the doctor to plan the initial treatment, instituting a programme which may be modified by subsequent findings at surgery or by the patient's response to treatment. The patient's needs at this important assessment must also be considered. They need preliminary information about the extent of their injury and some indication as to the likely period of hospitalization, rehabilitation and outcome. Pulvertaft (1975) considered that rehabilitation starts at the moment of injury and felt the preliminary assessment was the appropriate opportunity to get the patient's confidence and trust: I do not mean to infer that it is right to be unduly optimistic and give promises that cannot be honoured. There are ways in which we can combine sympathy with truth. The near-death experience seems akin to that reported regularly by many people. Scientifically speaking, the whole experience could well be attributable to an altered state of consciousness, rather than to anything spiritual. Perhaps the tunnel phenomenon is due to oxygen depri= vation in the outer part of the receptive field of the retina and that only those cells in the centre of the receptive field are stimulated, thus creating a perception of light surrounded by darkness. However, this does not explain the subsequent bright light in which "ghostly" figures were present. MP retains an open mind on this subject. Flash-backs and nightmares are extremely common phenomena after upper limb injury (Grunert et al, 1992). They report 80% of patients experiencing flash-backs immediately after the injury, dropping to 40% at 18 months. The patient rarely reports these complaints to medical staff. Therapists who spend more time with the patients have an important role in reassuring the patient that they are not alone in their experiences and that the phenomena are a normal and usually transitory response to their injury. When on the hospital ward in the RVH, MP did not show any grief at the loss of his limbs for about 3 or 4 weeks. Parkes (1972) perceives the reaction to all types of loss to be akin to the grief reaction in bereavement where failure to cry indicates an abnormal grief reaction. The normal bereavement process following loss of limb, as in death of a loved one, can be seen as characterized
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by four stages: shock-denial; anxiety-distress; despondency and then reorganization. There are no time limits on these stages, and passage through them can vary depending on the individual. Within the stages following loss, people experience a wide range of emotions. In this case, these stages were met and passed through without major upset. The circumstances surrounding an injury (and the patient's response to the situation) may play a large part in determining the duration and extent of disability. MP does not forgive this assault, but considers it a closed chapter in his life. This may be contrasted with the case histories of two patients attending the Pulvertaft Hand Centre. Two patients attended within the same week with apparently identical injuries (amputation of the non-dominant middle fingertip). One had been caused by what the patient described as his own carelessness while using a power saw at home. The other injury had been caused by a bite from the patient's neighbour's dog. Both patients were distressed by the discomfort and loss of the fingertip, but the dog-bite patient considered his injury to be an assault and was extremely aggrieved from the outset. The late-night homeimprovement enthusiast had apparently come to terms with his loss emotionally and physically within 6 weeks, while the patient with the dog-bite continued to experience major disability both functionally and emotionally 2 years after injury. An assault of any type may prejudice the speed and completeness of recovery. It should be appreciated that many injuries at work are perceived by the patient as an assault, particularly if employer/employee relationships are poor. The OT who treated MP in hospital (RVH) gave the patient control of several situations within the hospital environment where people are expected to adopt a sick role. This may well have led to an increase in self-esteem and internal locus of control. Internal locus of control is seen as a learned state where one perceives that events which occur are due to one's behaviour or one's individual characteristics (Rotter, 1966; 1975). An external locus of control occurs when events are perceived to be contingent upon other people or chance. Evidence in the scientific literature (Sarason et al, 1983) suggests that an internal locus of control can buffer the effects of life stress when combined with high levels of social support. This is termed the "buffering hypothesis". Although this testimony is purely anecdotal, MP feels that he was buffered from the effects of the incident. With respect to the buffering mechanism proposed by Sarason et al (1983), he did learn that he had a degree of personal control in the hospital environment. Furthermore, he did have a lot of active social support from family, colleagues and hospital staff, and also tacit support from the large number of well-wishers who wrote to him at the hospital following features in several newspapers. His sense of control and social support perhaps interacted in some way to protect him from the
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effects of PTSD, and perhaps modify the grief reaction experienced when losing one's arms. Although there was adequate social support, there were experiences with health professionals that could have been handled better. Firstly, health professionals tended to have little, or no, experience of prosthetic limbs, and lacked readily available literature on the subject. Although reporting on events 14 years ago, more recent enquiries on the Derby Hand Course reveal that the situation remains the same. As registrars, house officers, nurses and therapists are in daily contact with patients prior to limb fitting, it may be worthwhile for them to be more aware of the prostheses and aids available, and be shown how prosthetic limbs are made and fitted. Having used a myoelectric arm as a dominant limb, MP discovered that he could do more with the much cheaper split hook. It is right that medical consultants should want the best technology available for their patients, but when the technology is likely to result in reduced function for the patient then the expenditure should be considered carefully. From this experience, MP considers that unilateral arm amputees should receive most benefit from a myoelectric arm as they would be likely to depend on their intact arm and use the myoelectric prosthesis as a secondary limb. In this role, the myoelectric prosthesis would perform well and also be cosmetically aesthetic. The reader may have noted the use of the term "stump" in referring to the remnants of the arms. This term is commonplace amongst health professionals and, by implication, labels what was a functional limb as something lifeless and useless. When MP first heard his arms called stumps, it hurt him emotionally. Even now, he considers himself as having arms even though they may not fit the anatomical description. Health professionals working with amputees may wish to consider this point before using the expression freely. Interestingly, if the left arm had been replanted after it had been severed then it would have been termed "an arm", though probably it would have been less functional than the prosthetic arm fitted with a split hook. Clearly, surgeons are faced with a dilemma when the opportunity to replant a limb is available. Without a psychosocial profile of the patient, how would they know whether function or cosmetic appearance would be the most important to the client? In this case, MP feels that events forced the best option upon him. A similar dilemma occurs much more frequently with more distal limb amputations considered for replantation. Brown (1982) explored the relationship between motivation and disability following distal upper limb amputations. The paper is an important reference in understanding the psychological background to digital amputation. 104 surgeons were interviewed who had suffered digital loss. A wide variety of single digits and multiple digit loss had occurred and approximately half occurred before becoming surgeons and half after their
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training. Only three of the surgeons admitted to noticeable loss of dexterity and eight to minor loss. Only three surgeons abandoned their careers after injury. No less than 29 surgeons considered the amputation to have improved their professional situation and eight considered their rehabilitation to be returning to work. A hand surgeon surveying the article observes "often a well healed stump is functionally psychologically and vocationally the best thing for many patients, rather than retention of a poorly functioning digit". The paper particularly questions the loss of dexterity following amputation of the thumb or amputation of the index finger in well motivated patients. A one-armed ophthalmologist, from an injury when 17 years of age, considered his amputation to cause him no disability and observed that handicap is a state of mind and not a state of fact. Upon discharge from hospital, MP realised that he was stigmatized and that there existed in society a somewhat negative reaction to him as a "disabled" person. Goffman ( 1963; 1974) indicated that stigmatized people are "discredited" (i.e. those whose differences are observable, or known about). With stigma related to visible deformity, the "does he take sugar?" phenomenon occurs where society generalizes a stereotypic belief that as disabled people are inferior in some ways, they are obviously inferior in others (Lindemann, 1987). Doctors frequently underestimate the stress involved in return to work after upper limb amputation or injury. In MP's case the extent and severity of injury precluded a full role in the police force which prompted a complete change of career. Less severe injuries must also be dealt with sensitively even if the residual difficulties seem minor and compatible with the previous occupation. Employers may be insensitive to the patient's psychological difficulties. A reluctance to return to work on a machine which caused personal injury does not necessarily indicate moral turpitude. M a n y p a t i e n t s admit to significant stress and apprehension on passing through the work's gates on the first day back to duty. Grunert (1992) states that more than one-third of patients reported a fear of re-injury 18 months after the incident. Family certainly suffered as a result of this injury. However, MP feels that as he was in the early stages of married life when he lost his arms, he and his wife were better able to deal °with the problem. The circumplex model of marital and family systems (Olson, 1986; Olson et al, 1979; 1980; 1983; 1985; 1988) sees a "balanced" family system as one where there is a harmonious blend of both adaptability and cohesion. MP and his wife fell within the "flexibly-connected" category, one of two family types common to newly-married couples (Olson et al, 1983). Both were cohesive and adaptive to new
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situations and now have a "normal" family life where the impairment plays a secondary role. The authors hope that this paper has been informative by illustrating the role of psychology in patient care and rehabilitation. As can be seen from cases referred to in the text, not all patients can have as good an outcome as MP. In the absence of clinical psychology services, the onus ,,is on medical, nursing and therapy staff to create an' optimal environment for the psychological adjustment of their patients. References BROWN, P. W. (1982). Less than ten: surgeons with amputated fingers. Journal of Hand Surgery, 7: 1: 31-37. GOFFMAN, E. (1963). Stigma: Notes on the Management of a Spoiled Identity. Englewood Cliffs, Prentice-Hall, ? ? GOFFMAN, E. Stigma and Social Identity. In: D. M. Bowell and J. M. Wingrove (Eds). The Handicapped Person in the Community. London, Tavistock, 1974. GRUNERT, B. K., DEVINE, C. A., MATLOUB, H. S. et al. (1992). Psychological adjustment following work--related hand injury. Annals of Plastic Surgery, 29: 6: 537-542. HADDEN, W. A., RUTHERFORD, W. H. and MERRETT, J. D. (1978 ). The injuries of terrorist bombing: A study of 1532 consecutive cases. British Journal of Surgery, 65: 525-531. LINDEMANN, J. E. Psychological and Behavioural Aspects of Physical Disability. New York, Plenum, 1987. LYONS, H. A. (1974). Terrorists' bombing and the psychological sequelae. Journal of the Irish Medical Association, 67: 15-19. MENDELSON, R. L., BURECH, J. G., POLACK, E. P. and KAPPEL, D. A. (1986). The psychological impact of traumatic amputations. Hand Clinics, 2: 3: 577-583. OLSON, D. H. (1986). Cireumplex model VII: Validation studies and FACES III. Family Process, 25: 337-351. OLSON, D. H., LAVEE, Y. and McCUBBIN, H. I. Types of Families and Family Response to Stress across the Family Life Cycle. In: D. M. Klein and J. Aldous (Eds). Social Stress and Family Development. New York, Guilford Press, 1988. OLSON, D. H., PORTNER, J. and LAVEE Y. FACES 111. St Paul, Family Social Science, 1985. OLSON, D. H., RUSSELL, C. S. and SPRENKLE, D. H. Circumplex Model of Marital and Family Systems II: Empirical Studies and Clinical Intervention. In: Vincent J.P. (Ed.). Advances in Family Intervention, Assessment and Theory. Vol. 1. Greenwich, JAI Press, 1980. OLSON, D. H., RUSSELL, C. S. and SPRENKLE, D. H. (1983). Circumplex model of marital and family systems: VI. Theoretical update. Family Process, 22: 69-83. OLSON, D. H., SPRENKLE, D. H. and RUSSELL, C. S. (1979). Circumplex model of marital and family systems: I. Cohesion and adaptability dimensions, family types, and clinical applications. Family Process, 18: 3-28. PARKES, C. M. (1972). Components of the reaction to loss of limb, spouse or home. Journal of Psychosomatic Research, 16, 343-349. PULVERTAFT, R. G. (1975). Psychological aspects of hand injuries. The Hand, 7: 2: 93-103. ROTTER, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80: 1-28. ROTTER, J. B. (1975). Some problems and misconceptions related to the construct of internal versus external control of reinforcement. Journal of Consulting and Clinical Psychology, 43: 56-67. SARASON, I. G., LEVINE, H. M., BASHAM, R. B. and SARASON, B. R. (1983). Assessing social support: The social support questionnaire. Journal of Personality and Social Psychology, 44, 127-139.
Accepted: 6 May 1995 Mr F.D. Burke, MB BS, FRCS, The Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, DE1 2QY, UK. © 1995 The British Societyfor Surgery of the Hand