Upper-Limb Prosthetics: Part 4: Insights about Acquired Loss of Both Arms

Upper-Limb Prosthetics: Part 4: Insights about Acquired Loss of Both Arms

– by Douglas G. Smith, MD

Acquired bilateral upper-limb loss (the loss of both arms) often results from explosions, electrical injuries, accidents involving vehicles or machinery and burn injury. Recently, we have seen increasing numbers of Intensive Care Unit (ICU) survivors with loss of both arms.

Dramatic hypotension (low blood pressure) can be caused by severe sepsis (blood poisoning) and extreme blood loss. ICU teams and procedures have improved to the point that many individuals survive dramatic hypotension, but as blood is shunted (diverted) to the heart and brain, blood flow to the hands and feet is drastically reduced. Sometimes called ICU ischemia, this process can lead to acquired loss of multiple limbs.

People with acquired loss of both arms are far more likely to experience difficulty, both physically and emotionally, in adjusting to life without hands than those who are born without hands. Individuals who are born without arms naturally learn a unique method to use their feet for feeding, grooming and other hand functions. Adults with acquired loss of both arms simply don’t have the experience, flexibility or foot dexterity of a person who has lived all of his or her life without upper limbs. Therefore, prosthetics usually become mandatory for most people with acquired bilateral upperlimb loss.

Upper-limb prosthetic solutions involve a great deal of individualized planning. What does the person need help doing, and what kind of device will suit him or her best? Because of the wide range of ways we use our hands, upper-limb prostheses are far more complex than those for lower limbs. No single prosthesis can provide for all of one person’s needs. Upper-limb prosthetic rehabilitation takes a lot of mental energy to learn and remember how to operate devices differently. For this reason, some people find that an identical mechanical or electronic device for each arm is easier and more efficient. Other individuals develop improved function with different terminal devices and combinations of body-powered and electronic prosthetic devices.

Let’s Go to the Movies!

A good illustration of the challenges faced by people with acquired bilateral upper-limb loss is the character Homer Parrish in the 1946 Academy Award-winning film, The Best Years of Our Lives. Homer, played by real-life bilateral amputee Harold Russell, was a star football player in high school before joining the Navy during World War II, where he lost both arms below the elbows. (In real life, Mr. Russell lost his upper limbs while handling a defective explosive during the making of an Army training film.)

The movie is full of powerful scenes and images from beginning to end. Early scenes of Homer and other servicemen flying home dramatically contrast Homer’s naturally upbeat personality and his abilities with his prosthetic limbs, his emotional vulnerabilities to his limb loss and the thought of the way his loved ones will react when they see him again.

One of the servicemen offers Homer a cigarette (remember, this film was made before the dangers of smoking were documented). Eyeing Homer’s limb loss, he starts to take a cigarette from the pack for him, but Homer says, “That’s all right; I can get it,” and uses one of his prosthetic hooks to take it. In a display of prosthetic skills, Homer pulls a matchbook from his pocket, takes out a match, strikes it and lights the others’ cigarettes. “Boy, you ought to see me open a bottle of beer!” he tells the others.

Homer’s mood becomes matter-of-fact as he discusses how he lost his hands when his ship was sunk during battle. “When I came to, I was on a cruiser and my hands were off,” Homer says. “After that, I had it easy.” “Easy?!” one of the others says in surprise. “They took care of me fine,” Homer tells him. “They trained me to use these things,” he says, referring to his prostheses. “I can dial telephones. I can drive a car. I can even put nickels in the jukebox. I’m all right.” Then Homer admits his concerns about seeing his girlfriend, Wilma, again. He grows pensive and says, “Wilma’s only a kid; she’s never seen anything like these hands.”

When Loving Help Can Hurt

When Homer gets home, we sense his feelings of isolation and vulnerability as he steps out of a taxi and stands alone on his front lawn. As Wilma appears and hugs him, he stands unresponsive with his arms at his side. Then, Homer waves goodbye with one prosthetic hook to the other two servicemen as the cab pulls away. Homer’s mother notices the hook, gasps, and muffles a sob. Not wanting to draw attention to his permanent loss, she says of her reaction, “It’s nothing.”

These powerful scenes pack so much emotional information. They show how Homer’s feelings are so complex and conflicted – one minute, he’s excited and happy; seconds later, he’s worried and concerned. This illustrates the feelings experienced by many amputees: the desire to get on with things, to continue living one’s life, clashing with concern about the future and how to cope with a life that is permanently changed. These scenes also help convey the mixed feelings of family members and loved ones: How can I help? Should I offer to help? What the heck are we supposed to do?

The movie, which won seven Academy Awards, is filled with scenes that are emotionally moving while educating the viewer about limb loss, our reaction to it, and the actions and reactions of others. During a gathering in Homer’s house, Wilma’s father lights a cigar, refusing Homer’s assistance, then asks if Homer is looking for work. Wilma interjects, saying, “Father, it’s much too soon for Homer to be thinking about a job. He’s just out of the hospital.”

This scene depicts two insightful examples of “solicitous” help – the kind that’s intended to be good but works in reverse. Homer interprets Wilma’s and his mother’s comments to mean: He’s handicapped and can’t take care of himself. In situations like this, a person with limb loss can become frustrated, angry or both. And the person who offered the solicitous help doesn’t understand why. This scene ends with Wilma confused as Homer leaves the house.Her father says he knows that, but cautions that many opportunities won’t last. “You might think about my business, Homer: insurance,” he says. “We’ve taken on a number of veterans. They make very good salesmen, you know; men who have suffered from some kind of disability.” Feeling self-conscious, Homer spills his drink. His mother excuses his behavior and makes emotional matters worse by saying, “Wilma will hold it for you.”

The key to avoiding the appearance of giving solicitous help is to ask the person about it first. By assuming a person needs help, you may be unintentionally sending the message: Let me do this for you because you can’t. For example, imagine coming upon someone in a wheelchair who is trying to get up a hill. You might walk up and start pushing the wheelchair, believing you’re being helpful. But asking first makes all the difference. The person wants to be asked, “Would it help if I gave you a push?” This provides the option for the person to choose to reply, “Yes, thanks.” Or, “No, I can handle it.” Or even, “No, thanks, I need the exercise!”

Needing Help/Wanting to Help/Hating Help

Back to our movie. As Homer prepares for bed, his father helps him button his pajamas after his prosthetic arms are removed, again highlighting Homer’s need for help. Many people with acquired bilateral upper-limb loss need help with certain tasks. Homer is deeply concerned that he’ll need help with some things for the rest of his life. This scene profoundly illustrates how these sorts of tasks come to be done almost without acknowledgement. You don’t want to thank the other person for the help, nor do you want to get angry about it. You see Homer’s sadness; you see the sadness in his dad.

What makes this scene especially powerful is the silence. They both know what needs to be done and their feelings are communicated wordlessly: Homer needs the help, and he’s grateful for it, but he hates having to need it. His dad knows he has to help, and he wants to because he loves his son, but he also hates that his beloved son needs help. This scene is so very quiet – that’s what makes it so incredibly moving. Homer and his dad have fallen into a routine that is silent, understood and frustrating for both, but not discussed – all at the same time. The silence speaks loud and clear.

The depths of Homer’s feelings and anxieties are explored again in a repeat of the above scene, only now between Homer and Wilma. Homer shows Wilma that he can take off his prosthetic harness by himself, and then wiggles into his pajama top. Then he says, “But I can’t button them up.” Wilma buttons his pajama top as she looks up at him, affectionately. Homer laments, “This is when I know I’m helpless. My (prosthetic) hands are down there on the bed. I can’t put them on again without calling to somebody for help. I can’t smoke a cigarette or read a book. If that door should blow shut, I can’t open it and get out of this room. I’m as dependent as a baby that doesn’t know how to get anything except to cry for it.” Homer articulates his frustration and helplessness, as well as his understanding that he needs help and hates needing it.

Wilma reassures Homer of her love for him and that, together, they can work through these issues. She kisses him goodnight, turns out the light and thoughtfully leaves the door slightly ajar as she leaves. This simple, wordless act shows Wilma’s understanding of Homer’s needs and her willingness to help, without being solicitous or making him feel diminished.

People often have a harder time receiving help than giving it. An understanding must be developed between the person giving help and the person receiving it so that it won’t be perceived as demeaning nor create a sense of dependency. Helping can be consoling, reassuring and understanding without being solicitous in any way.

Courage

Wilma uses the word “courage” when talking about how she and others deal with Homer’s limb loss and his feelings. While we often discuss the courage of people who lose a limb or limbs, the courage of their loved ones is rarely spoken of. Wilma plainly, but effectively, articulates that courage is a necessary element for all involved. Wilma and Homer’s love for each other is borne from character, courage, inner strength and understanding. Homer’s limb loss is something they will live and work with together.

The movie concludes with Homer and Wilma’s wedding. Wilma holds one of Homer’s prosthetic hooks as they recite their vows. Homer, the anxious groom, stumbles nervously over a few words during the recitation. Then it’s Wilma’s turn to show nervousness. During the phrase, “For better, for worse, for richer, for poorer…” we see Homer steady Wilma’s trembling hand. He skillfully uses his prosthesis to slide the wedding band onto the ring finger of her left hand. This scene captures both Homer and Wilma’s incredible courage and trust in each other. Homer, missing both arms, has the courage and trust that he can do the things a husband needs to do and should do. Wilma has the courage and trust to understand and admire the ways Homer moves forward in life and to accept that their lives are not the norm, but are unique and singularly special.

As you may guess, I definitely give this movie two thumbs up! You owe it to yourself to see this one. Although we focused on Homer and Wilma and their struggles and adjustments, the film also examines other issues faced by injured veterans and their loved ones. The film is set in the World War II era, but its insights are timeless. The issues faced by Homer and Wilma are just as relevant today for the brave military veterans coming home from foreign lands to resume their lives, sometimes profoundly changed.