"A brief history of industry" behind the rise and fall of hand surgery
China News Weekly reporter/Du Wei
Published in the 951th issue of China News Weekly on 2020.6.15
Li Yun, 62, is lying on a hospital bed in the Ninth People's Hospital of Wuxi City. His right hand is wrapped in dark green flannel and placed under a baking lamp. Six days ago, she went to work at a factory in Sizao Town, Dongtai, Jiangsu. She accidentally operated and saw the three blades in her right hand with the saw blade washed down by the machine. After a simple bandage at the local hospital, she took three fingers and was taken to the Ninth People's Hospital of Wuxi City. From 2:30 in the afternoon to 12 in the night, Qian Jun, deputy chief physician of hand surgery, performed a replantation of her finger for nearly 10 hours.
The predecessor of Wuxi Jiuyuan was Wuxi Hand Surgery Hospital, which was the first special hand surgery hospital in China. A few streets away, you can see the hospital's towering 20-story inpatient department building from afar. Today, hundreds of hand surgery emergency patients are treated here every day, and 20 to 30 hand surgery operations are completed. Compared with ten years ago, although the number of patients receiving hand trauma is still increasing, the growth rate and the degree of trauma have begun to decrease.
Hand surgery is a four-level discipline subdivided under the three-level discipline of orthopedics. Over the past 60 years, thanks to the economic take-off, China’s hand surgery has ranked among the highest in the world, but as domestic industry upgrades, hand surgery has begun to fall into a downturn and needs to be repositioned.
Prosperity under industrial development
After graduating from Suzhou Medical College in 1993, Mi Jingyi entered Wuxi Hand Surgery Hospital. Before that, he had only heard of the name of the hospital on the radio.
Wuxi is the birthplace of modern Chinese industry and commerce and modern township industry. The sociologist Fei Xiaotong called the way of developing township enterprises in rural areas represented by Wuxi the "Southern Jiangsu Model". Driven by township and village enterprises, since 1984, Wuxi has successively created several "billion yuan townships" and "billion yuan villages". However, the factory's irregular labor, outdated machinery, and extensive development have caused hand injuries to a large number of local workers. Mi Jingyi said to China News Weekly that it is precisely because of this huge medical demand and in search of a more flexible income distribution mechanism, in 1984, Shou Kuishui and several directors of orthopedics at the First People’s Hospital of Wuxi City A colleague resigned and established a hand injury treatment center in Heqi Hospital, a township hospital in the western suburbs of Wuxi City. At that time, there were only 26 beds, 3 equipment, and 5 medical staff. Soon, medical resources were in short supply.
In 1986, 50 beds in one ward of the treatment center were not enough, and extra beds were needed in the corridor. In 1988, after expansion, seven or eighty beds equivalent to two wards became overcrowded. In September 1989, in order to meet the needs of medical treatment, based on the treatment center, Shou Kuishui and others established Wuxi Hand Surgery Hospital, which was under the collective ownership. At the end of the 1980s, the hospital had about 1,000 cases of surgery every year.
Mi Jingyi recalled that in the 1990s, on the road leading to the entrance of the hospital, it was often possible to see the wounded being sent to the hospital first, and the coworkers carrying the broken limbs or the broken fingers they found and then came to the scene. During the high incidence of hand trauma, the hospital's team of 3 to 4 doctors in this hospital and 2 to 3 advanced doctors must complete 30 to 40 emergency hand surgery operations within 24 hours. In the early days of the establishment of the hospital, the majority of the local wounded were. With the opening of the Shanghai-Nanjing Expressway in 1996, patients from Nanjing and Suzhou also arrived. By 2002, the annual number of surgical operations in the hospital had reached more than 9,000, and then entered a steady development period of nearly ten years. Today, the hospital's hand surgery has 4 wards, more than 280 beds, and nearly 15,000 operations per year.
In fact, the development of Chinese hand surgery originated in the early 1950s, which is 20 years later than the European and American countries where hand surgery originated during World War II. Huashan Hospital affiliated to Fudan University is one of the birthplaces of hand surgery in China. Gu Yudong, director of hand surgery at the hospital, now 83-year-old veteran of Chinese hand surgery, and academician of the Chinese Academy of Engineering, told China News Weekly that at that time, Beijing, Tianjin, and Shanghai, the industrially developed areas, were the first to establish hand surgery. In 1958, Wang Shuhuan took the lead in establishing a hand surgery department in Beijing Jishuitan Hospital. In 1963, Chen Zhongwei, the Sixth People's Hospital of Shanghai, completed the world's first replantation of a broken hand, and was called the "father of replantation of a broken limb in the world." Huashan Hospital established the Hand Surgery Unit under the Department of Orthopedics in 1960. In 1966, Gu Yudong and Yang Dongyue, the organizer of the Hand Surgery Department of Huashan Hospital, initiated a 22-hour surgery to reconstruct the thumb with the second toe "demolition of the east wall to fill the west wall". This technique was used in the United States until 1972 when Nixon visited China. It has just been a success.
After the 1980s, hand surgery began to blossom all over the country. Hand surgery has been established in Qingdao, Weifang, Wuhan, Xi'an and other places. In 1977, 40-year-old Cheng Guoliang went to Beijing Jishuitan Hospital to study hand surgery techniques, then returned to the original 401 hospital (now the People's Liberation Army Navy No. 971 Hospital) to perform amputated finger replantation, after which he served as the vice hospital of 401 hospital Mayor and director of the Military Hand Surgery Center.
Around 1995, China's first private hand surgery hospital was born in the Pearl River Delta region, where reform and opening up began. Zhan Zhiyong, the current chairman of Guangzhou Hongkang Medical Information Co., Ltd., recalled to China News Weekly that in 1992, he served as an orthopedic surgeon at the First Affiliated Hospital of Guangdong University of Traditional Chinese Medicine and went to Qingdao Yuan401 Hospital with two other doctors. After studying, Guangzhou Hang Seng Hand Surgery Hospital was established in 1993. In the same period, private hospitals of almost the same size and reputation as Hang Seng Hand Surgery Hospital also include Guangdong Shunde Peace Hand Surgery Hospital and Guangzhou Xinjiang South Hand Surgery Hospital.
The "prosperity" of hand surgery in the Pearl River Delta region is also inseparable from the rugged industrial development model. A typical labor-intensive enterprise, workers frequently work continuously for more than 12 hours, and pre-job training and labor protection are not in place, resulting in a large number of broken fingers and broken palm accidents. Zhan Zhiyong and his colleagues spent 15 hours from 3 pm that day to the early morning of the next day to perform a finger replantation operation on a nine-finger severed injury.
Cheng Guoliang told China News Weekly that the golden period of Chinese hand surgery began around 1985 and continued until after 2000. In this golden 15 years, whether it is a public hospital, a private hospital, a big city hospital, a county town or even a township health center, it has opened hand surgery. He has done incomplete statistics. In 1994, there were more than 180 public hospitals in the country that set up hand surgery and set up 7040 special beds, with more than 780 professional doctors and more than 1120 part-time doctors. Around 2000, according to incomplete statistics, China has more than 40,000 cases of finger replantation, and the survival rate has remained above 90%.
Cheng Guoliang analyzed that China's hand surgery is among the highest in the world. The very important reason is that the population base is large. This has caused more cases of hand trauma than other countries in the process of industrialization. This has exercised to a certain extent. The skills of Chinese hand surgeons have formed some distinctive and leading technologies.
Income dilemma and transformation
Replanting a broken finger is a work of art. It can be regarded as embroidering time. It is delicate and requires most operations to be performed under a microscope. After the 1980s, the popularity of microscopy technology also promoted the development of hand surgery to a certain extent.
In the operation for Li Yun, Qian Jun first had to debride him, remove the foreign objects on the wound surface such as iron filings to avoid causing infection, and then use a Kirschner wire (a steel needle) to cut Li Yun's bones and The bones remaining at the broken finger are strung together and fixed back to the original position, which is like building a frame with steel bars when the house is rebuilt.
After the bones were fixed, he cut Li Yun with a sharp weapon and retracted the tendons of his palms to find out, and then sutured the two tendons, two arteries, two veins and two nerves that each finger extended and flexed. Vascular anastomosis is the key. The blood vessel shape of the finger is like a tree sticking out the branches, and the blood vessel at the root of the finger is thicker, with a diameter of 1 mm, and the fingertip is only about 0.3 mm. The thread that sews the blood vessels is at least in the micron level, thinner than the hairline, and it is difficult to see on the table. After the suture is completed, it is generally observed for 7-10 days to ensure smooth blood flow and avoid vasospasm or thrombosis in the blood vessels.
Hand trauma is mostly an emergency, and it takes about two hours to sew one index finger. Replanting three fingers like Li Yun completely disconnected can be regarded as high-intensity work. In this case, the doctor can only insist on it, "No one will do it for you. ". The day when I saw Qian Jun, it was more than 7 o'clock in the evening. It happened that he was on night shift. The patients with hand injuries before 7 o'clock the next morning were under the responsibility of his team.
High precision and high strength are the normal practice of hand surgeons. Compared with such efforts, the income of hand surgeons cannot be considered high, or the cost performance is low. Taking hand surgery and orthopedics as a tertiary discipline as an example, before the medical treatment was marketed in the 1990s, the income gap between the two was not large. After the medical marketization, the income gap between hand surgeons and orthopedics began to widen. The contradiction between the labor intensity of the hand surgeon and the income and treatment is more prominent.
Analysis of Cheng Guoliang said that in orthopedics, which is characterized by the use of consumables, doctors earn a lot of money, and replantation of the broken finger is a craft, and the consumables are few, so the hand surgeon has worked hard for several years, not as good as an orthopedist. The annual gains are high. This is also an important reason why many public hospitals were reluctant to set up hand surgery for income generation considerations in the late 1990s and beyond, and private hospitals were able to break out of the world.
The low price of hand surgery medical services and the long-term unchanged is also a major factor restricting the income increase of hand surgeons. In Jiangsu Province, the price for the operation of replanting each finger (toe) is 1,800 yuan. Mi Jingyi said that this price has not been adjusted for almost 10 years, and the cost of this operation is very small nationwide. Some provinces and cities can exceed 2,000 yuan.
In this context, hand surgery has gradually become a department that people are not interested in. Gu Yudong said that unlike the best students who were willing to devote themselves to hand surgery, more people now prefer orthopedics. “Two hospital orthopedics recruits, but seven or eight apply for it. Only those who are brushed go to hand surgery.” As a PhD graduate in hand surgery at Huashan Hospital, Mi Jingyi estimates that in recent years, only about 50% of doctors in hand surgery at the hospital have also worked as hand surgeons. Qian Jun said that so far, he is the only one of his classmates who is still doing hand surgery, and many of his hand surgery friends have transformed to do plastic surgery.
At the same time, another direct problem faced by hand surgeons over the years is that there are fewer and fewer patients with hand trauma. Against the background of the development of advanced manufacturing, high-tech industries, and technological innovation, as equipment upgrades and automation levels increase, the chances of workers being injured are greatly reduced.
Focus on industries such as machinery and electronics, as well as strategic emerging industries represented by the Internet of Things and new energy, and relocate some heavy industries to northern cities such as Yancheng. Qian Jun said that under this circumstance, the number of local patients in Wuxi decreased, and the degree of injury was reduced, but at the same time, the scope of hospital consultations was expanding, and now patients from northern Jiangsu such as Huaiyin and Suqian can often be received. Mi Jingyi said that in recent years, the number of hand trauma patients hospitalized in hospitals has been increasing because of the wider source of patients, but the growth rate has slowed down. Some private hand surgery hospitals chose to close due to fewer patients.
Guangdong Shunde Peace Hand Surgery Hospital was once famous, but now it has been renamed as "Peace Orthopedics Hospital". Zhan Zhiyong said that after 2005, the business volume of the Hang Seng Hand Surgery Hospital has fallen by nearly half. Later, because of the year-on-year decrease in patients and bottlenecks in the development of hand surgery, the hospital once changed the name to Trauma Hospital.
Leading hand surgery hospitals like Wuxi Jiuyuan and Shanghai Huashan Hospital are also transforming. In an interview with China News Weekly, Xu Wendong, vice president of Huashan Hospital, said that compared with the 1990s, the hospital had more than a dozen patients with emergency hand injury in one night, and now there are only about 3 emergency cases for hand injury every night. The proportion of hand trauma in the patients received is only about 30%, and the remaining patients are peripheral nerve compression, stroke, sports injury, arthritis, and congenital hand deformities.
Gu Yudong analyzed that the reduction in the number of patients with hand trauma leads to a reduction in the number of doctors who treat hand trauma, which is inevitable. A trend now and in the future is that hand surgery, such as Huashan Hospital and Beijing Jishuitan Hospital, is necessary for the establishment of hand surgery, but the scale of personnel will not be further expanded to guide the development of disciplines and solve incurable diseases; In other hospitals and even more basic hospitals, it is not necessary to set up hand surgery alone. It should be merged into orthopedics and become a hand surgery group under orthopedics. This is a characteristic of the discipline's development in line with the development of the times.
(In order to protect the privacy of the interviewee, Li Yun is a pseudonym)
"China News Weekly" No. 21, 2020
Statement: The publication of the "China News Weekly" manuscript is subject to written authorization