8/13/2019 A shared wave is a clinical test of healthand
humanity
1/2
PERSONAL VIEW
A shared wave is a clinical test of healthand humanityThe
exchange of waved hands between doctor and patient can reveal much
more than you mightthink, writes J Edward Fitzgerald
J Edward Fitzgeraldgeneral surgery registrar, Association of
Surgeons in Training, Royal Collegeof Surgeons of England, London
WC2A 3PE, UK
It was Saturday night as the general surgery registrar on
call,
and I was halfway through a three shift weekend stretch. In
our
emergency department the psychological darkness of the busy
early hours was punctuated by the piercing call of a crash
bleep.
Switchboards disembodied voice rose from my pager and
repeated itself loudlyand firmly, summoningme to thesurgical
ward. Clerking interrupted, abrupt apologies given, notes
abandoned, and three flights of stairs climbed, culminating
in
a breathless, anxious arrival.
The medical and anaesthetic team was already there and made
it clear that the immediate crisis did not require
operating.
Instead, I stood there, watching the battle unfold,
wondering
how I could help. Standing at the foot of the bed I looked
down
at the elderly patient, who was dyspnoeic and audibly
wheezy.
He looked back at me as the acute medical team took charge.
Now was not the time to push in for a social chat. He was
too
ill, with too much happening, too many people, and too much
noise. Instead I stood and raised my hand high over the
medical
crowd and gave him a friendly wave. He looked back again.
Had he seen me? Then, hesitantly at first, slowly and
shakily,
he raised his wiry right arm off the bed and waved back with
a
half cocked, reciprocal greeting. It was a social exchange
in
which no words were spoken, but much was said.What did my waving
tell him? Id like to think it told him that
I was there for him, a friendly face in his stormy night. Id
like
to think that despite the carefully choreographed chaos of
the
surrounding team, it told him that he was still an individual
to
be greeted andacknowledged, not anyanonymous patient. There
was a real problem, yes, but he was our focus, not the
problem.
I hope that reached him through the commotion.
What did his wave back tell me? From a medical viewpoint, it
told me a great deal. It told me his visual acuity was
sufficient
to focus on my gesture, that at least one ageing cornea
wasclear,
andthat he had sufficient retinal photoreceptors to stimulate
his
optic nerve. It told me that his lateral geniculate nucleus in
his
thalamus could receive these visual signals and that the
opticradiations could convey them through to his visual cortex.
His brain could compute this visual stimulus and excite his
upper motor neurones, which descend from his primary motor
cortex through the brainstem and into his ventromedial
spinal
column. Across synapses, these triggered lower motor
neurones
in the anterior horn of his spinal cord, which in turn could
exit
unhindered in the motor roots of his spinal nerves. These
lower
motor neurones passed through his brachial plexus, carrying
their action potentials to the neuromuscular junction. And
his
muscles had sufficient coordination and power to overcome
gravity and wave back.
Albeit medically correct and informative, reducing his
actions
to a series of successful transmissions across synapses
misses
the point. In such an adverse situation, what struck me was
that
he had the will to return this gesture and give me a wave.
It
meant he had not given up. He was still engaged.
Although returning a wave may be considered a reflex action
for many, it is a social reflex rather than the true
physiological
reflex arc we learn at medical school. Yet such a reflex
gesture
still has many merits. With the exception of being mistaken
for
the offensive Greek gesture called themoutza,1 a friendly
wave
may be a universal mode of visual language. It crosses
cultures,
languages, and doctor-patient barriers. This is
understandable
if the gestural origin theory of language development
isaccepted, with such gestures described as behavioural fossils
coupled to our speech.2 The advent of functional magnetic
resonance imaging allows these fossil remnants to be
visualised.
Processing takes place in the inferior frontal (Brocas) and
posterior temporal (Wernickes) regions,suggesting that
gestures
andspoken language are processed by a common neural system.3
Gesticulation seems to be deeply embedded within our
evolutionary origins. The neuroscience and psychology of
such
non-verbal communication seeks to better understand the
interaction of language and body. In the discipline of
cognitive
psychology, studies are beginning to unravel these
complexities,
with evidence indicating that gestures play a significant role
in
processing and learning language.4
Against this background,the power of a simple friendly wave
should not be
underestimated.
[email protected]
For personal use only: See rights and reprints
http://www.bmj.com/permissions Subscribe:
http://www.bmj.com/subscribe
BMJ2014;348:g281 doi: 10.1136/bmj.g281 (Published 17 January
2014) Page 1 of 2
Views & Reviews
VIEWS & REVIEWS
http://www.bmj.com/permissionshttp://www.bmj.com/subscribehttp://crossmark.crossref.org/dialog/?doi=10.1136/bmj.g281&domain=pdf&date_stamp=2014-01-17http://www.bmj.com/subscribehttp://www.bmj.com/permissions
8/13/2019 A shared wave is a clinical test of healthand
humanity
2/2
There are many clinical tests described in medicine, but this
so
called waving sign is notable for also testing the examiner.
Both
patient and doctor require intact visual and neurological
pathways, with higher cortical function to recognise and
respond
appropriately. But, crucially, the doctor must also
demonstrate
humanity and empathy in initiating the engagement. In doingso,
the assessment may only take a few seconds, but the
beneficial social outcomes will likely last considerably
longer.
Next time I find myself standing at the end of a patients
bed,
taking in the scene, be it arriving for the first time,
directing a
crisis, or merely pausing in passing, I will remember this
quick
test of my own humanity and acknowledge my patient with a
friendly gesture. I hope they are waving sign positive in
return.
I thank Sarosh Irani for neurological advice.
Competinginterests: I have read andunderstood theBMJ Group
policy
on declaration of interests and have no relevant interests to
declare.
Follow the author on Twitter: @Diathermy
Patient consent not needed (patientanonymised, dead, or
hypothetical).
Provenance and peer review: Not commissioned; externally
peer
reviewed.
1 Mountza. Wikipedia. 14 Dec
2013.http://en.wikipedia.org/wiki/Mountza.
2 Corballis M. The gestural origins of language.American
Scientist1999;87:138.
3 Xu J, Gannon PJ, Emmorey K, Smith JF, Braun AR. Symbolic
gestures and spoken
language are processed by a common neural system. Proc Nat Acad
Sci U S A
2009;106:20664-9.
4 Goldin-MeadowS, Alibali MW.Gestures rolein
speaking,learning,and creatinglanguage.
Annu Rev Psychol2013;64:257-83.
Cite this as:BMJ2014;348:g281
BMJ Publishi ng Group Ltd 2014
For personal use only: See rights and reprints
http://www.bmj.com/permissions Subscribe:
http://www.bmj.com/subscribe
BMJ2014;348:g281 doi: 10.1136/bmj.g281 (Published 17 January
2014) Page 2 of 2
VIEWS & REVIEWS
http://en.wikipedia.org/wiki/Mountzahttp://www.bmj.com/permissionshttp://www.bmj.com/subscribehttp://www.bmj.com/subscribehttp://www.bmj.com/permissionshttp://en.wikipedia.org/wiki/Mountza
