Finger Fashionista

In orthopaedics, we usually get called down to do a finger refashioning at the emergency department. Just like manicure, finger refashioning makes the fingers look better, except that instead of cutting the nails short, we cut the whole finger short. Our intentions were good though, these fingers were already cut in the first place. We make them look nicer and less prone to infection. A typical mechanism of injury would be that of fingers stuck in factory machines. These fingers look horrible before being refashioned, depending on which machines they were stuck in. Sometimes they are crushed by stamp print machines, shredded by paper shredder machines, lacerated by grass cutter machines, rolled flat by paper roller machines, but the worst one I have seen are the ones stuck in sugarcane machines. They are crushed and shredded at the same time.

Usual patients are the migrant workers, because they are the ones working in factories to operate machines. It is sad to think that these people came here to Malaysia in search of a better future for their family but ended up losing a few fingers. So one day, I had a call to do a finger refashioning for a factory worker who got his fingers cut at a wood cutting factory . The poor guy was a Burmese, must be in his 30s. He was accompanied by a young man in neat corporate uniform, his supervisor. I learned from the supervisor that he just came from Myanmar and did not speak a word of Malay, and just a little bit of English. When saw him, he was in pain and had his right hand covered by a piece of cloth that was already half-soaked with blood. Slowly, I removed the piece of cloth and from the supervisor's story, what I saw was expected: the index finger was nearly total amputated. It was just dangling there, the only thing holding it in place is a layer of skin. The bone was totally crushed. But what bothers me is that the thumb was crushed as well. Of all the fingers of our hands, the thumb is the most that affect hand function. The level of amputation determines the extent of the functional deficit. I knew I had to take extra precaution to preserve the thumb length.

So I asked the supervisor to wait outside while I do what needed to be done. To tell the truth, I liked being called to do finger refashioning. When I am in the sterile scrubs, in the silent procedure room with just the medical assistant and the patient, I feel at ease as the frantic noise of the ED department outside drowns out. I get to escape from the hectic wards for a while. I feel a sense of calm and focus as I start to wield the blade. In experienced hands, finger refashioning should take just about 30 minutes. I took a tad bit longer, but in moments of intense focus, you barely notice the time pass. The fingers were still oozing blood. In a nutshell, I gave anaesthetics to make the fingers feel numb and insensitive to pain, stopped the bleeding, crushed the bones to make it shorter than the surrounding skin, trimmed the ragged edge of the remaining skin and soft tissue to make it look smoother, at the same time creating a skin flap to close the gaping hole, and sew the opposing skin together. Convinced that the bleeding was secured, I covered it with topical antibiotic gel, and then with a white cotton gauze.

I was satisfied with my finger work I did that day. I explained that he needs to take antibiotics as to prevent infection to the injured finger, and has to come to the local health clinic to get it cleaned up daily, and come again to our clinic to get the stitch removed and reassess the wound. I tried my best to explain to him in the simplest form of language. At the end of my explanation, I looked at him. He was looking at me with a blank stare. I looked at him, he looked at me. I was looking at him, he looked at me.

Okay that's it, this guy does not understand a word I said.

Exhausted of all effort to communicate near the end of my work shift, I showed him the 'thumbs up' sign, and said "Okeh?". Although in pain, but perhaps still numbed by the local anaesthetic I gave him, he looked at his thumb, now made shorter, covered with white gauze, lifted it up, trying his best to show me a 'thumbs up', and said:

"Bagus!" (Good!)

With his other hand, he gave pat on my shoulders.

Well, that was unexpected.

I called the supervisor in. I explained the same thing to him, hoping that he will have a way to communicate my instruction to this employee of his. I also mentioned to the supervisor that I had already explained to him, but I don't think he understood, and gave a quick remark that he understands the word "bagus" though. 

But the supervisor said "Uh, I don't think he understands the word, I think he was just imitating my boss".

"What do you mean?" I asked curiously.

"You see, at the factory, at the end of the day our boss will give a thumbs up to those who worked well, before they end their shift, and will give them a pat at the shoulders. They then will happily go punch out their attendance card at the punching machine".

I laughed out loud, and the supervisor had no idea why. The Burmese guy was still smiling, I wonder if he understood what was the conversation about. So he was merely imitating his boss at the factory, guessing that "bagus" with a thumbs up is a sign of appreciation. Oh well at least I know it means I did good job.

I looked at my watch and realized it was way pass my working hours. So after being told 'bagus!' and given that pat on the shoulders, I happily go punch out my attendance card at the punching machine, similar to what factory workers do every working day. In some way or another, we are all the same. I am a cogwheel in a white coat in this machinery called the Malaysian health care system.