Upper hand¹ is difficult.  I’m having trouble wrapping my brain around it and it will take even longer for it to be second nature.  But I’m assuming that everyone else is having the same problem, right?

The “Build and Consume” Model

Simple premise.  You build up stacks of upper hand (up to 2) with certain abilities and consume upper hand with others.  Upper hand also provides passive bonuses with certain talents just for being up.  More on this later.

How You Build Stacks

For purposes of this article, I’m only including heals that build, not offensive abilities.

• Underworld Medicine via the talent Exploratory Surgery (2 points).  Every time you cast Underworld Medicine, you will build one stack, guaranteed.
• Slow Release Medpac via Medpac Mastery (I recommend 3 points).  With every tick of the Slow Release Medpac (not every cast), you have a chance to proc a stack of Upper Hand.

What You Spend It On

Well, all sorts of fun things!  Remember each of these eats one charge of Upper Hand, not 2.

• Kolto Pack – A nice big heal
• Emergency Medpac – An instant heal
• Pugnacity – Energy regen

How Do I Know That It’s Up?

Now, when it was only put up by Underworld Medicine, you knew it was up because you had just cast… Underworld Medicine.  Not rocket science.  But now that it can proc off slow release medpack, it’s less predictable and you have to pay more attention.

Buff Icon

There’s a teeny weeny buff icon that appears on your character’s buff bar with all the other buffs.  It’s frightfully small and annoying.  I rarely notice it.

Abilities Lit Up

This is the “ghetto Power Aura” so to speak.  If your Kolto Pack/Emergency Medpac is available, you have upper hand.  If it’s grayed out, you don’t.  This won’t tell you how many stacks you have or how long it will remain up.

Now it’s up

Now it’s not

Sound

This is crazy but… there’s a giggle or a snicker.  A little titter when you proc upper hand off slow release medpac.  Listen for it!  It helps me know that I have a stack to spend, even if I’m focusing on health bars at the moment.

Keeping Up Versus Spending ASAP

You get passive bonuses for having upper hand up.  Healing Hand gives you a boost to healing which is the same regardless of whether you have 1 stack or 2 stacks up.  So it’s good to always have a stack up.

But if you don’t spend it, it’s a waste and a drain on energy.  What is the best course of action, but might be difficult, is to spend a stack only if you are at 2 stacks.  So you always have 1 remaining stack of upper hand up for the bonuses but you can still use it.  Once you get the second stack, feel free to spend it again.

Another reason you might want to keep 2 stacks active is that it takes time for the game to register that it’s up.  If you have zero stacks, then hit underworld medicine and then try to cast Kolto Pack at the end of it, there will be a delay where the game insists that you do NOT have upper hand active at all.