A doctor's dilemma

Pain. A four letter word that conveys powerful emotions of the noxious and unpleasant kind. We’ve all experienced pain at some point in our lives. Sometimes it is linked to something good, such as getting well. I have always associated pain with hospitals. I remember how as a child, I would hold on tightly to my mother’s hand as we walked down the corridor from the doctor’s office. The barren silence and the antiseptic smells combined to heighten my already considerable sense of trepidation. Approaching the injection room with trembling knees, I always knew what to expect. A nurse would step out in her crisply starched white uniform, retrieve my file and check the prescription. She would then retire behind a curtain to prepare my pain. All mental preparation gave way to panic in those final moments when she’d poke her head around the curtain and beckon me to agony.
Walking hesitantly towards her, I’d cast a forlorn look at my mother. “Go on” she’d say as she shooed me away, “I’ll be here waiting”. I never understood how she could be so insouciant as I stepped behind the curtain, swallowed up by fear. Her complicity in my pain appeared to be the worst form of treachery. The most terrifying part was always seeing the needle and wondering how such an instrument of torment could ever hold any good for me. When it was all over I’d weep bitterly in my mother’s arms as she massaged my throbbing behind, but a few days later, raucously chasing a soccer ball with my friends, the doctor’s office became a distant memory. As I grew older, my fear of needles ebbed with each unaccompanied trip, but my loathing of hospitals remained. It still amazes me today how I ended up becoming a doctor myself.
I recall how as a medical student, inflicting the slightest iota of pain on a patient was the worst possible infraction; the unpardonable sin. In a clinical exam, you could have had the most richly rewarding academic discourse with your professor but if while you were physically examining the patient there was so much as a wince or worse still a groan, you could kiss a passing grade goodbye. Any such incident was expectedly met with protestations and assurances of utmost care and consideration; those were the rules.
It’s strange though, how the rules changed once I actually did start practicing. Being a primary health physician in a country like mine is beyond challenging. It’s not just that it’s a resource poor setting, or that the facilities are often outdated or even that the people are so poor and helpless. It’s the way the entire system colludes to break your spirit and leave you with no recourse. I realized early on that to make any kind of career for myself, I would have to pass “the steel test”. By disengaging my emotions and moderating my conscience, maybe I could just simply do my job. It’s a useful approach when you have to turn away a dying person, or you have to stop treatment for a child due to a lack of funds or equipment. Scarce resources were always carefully rationed and meted out. Once, I sutured an extensive gash on the calf of a six year old girl using only the barest amount of lidocaine; the bottom dregs of the final vial. As she screamed and squirmed praying for mercy and relief, I had her restrained, grit my teeth and closed the wound without batting an eyelid. I knew I’d finally conquered the steel test after that. It wasn’t that I was impervious to the pain of others, it was just that we were all susceptible to a common pain which superceded all else. Desperation in the face of poverty and lack, coupled with a feeling of helplessness left a perpetual wound in our collective soul which no anesthetic could dull.
The concept of pain took on a whole new meaning for me after I started to work at a maternity center. Walking into the labor ward day after day, hearing the tortured cries of women in different stages of labor and knowing there was only so much I could do for them filled me with consternation. After a while I stopped hearing them; I would walk into the ward and head for the bedside of the woman who made the least noise, perhaps the others might take the hint and the cacophony would reduce. There was a hospital protocol which I always tried to follow as best as I could. An opioid injection at the onset of established labor, repeated after 3 to 4 hours if necessary but not within the late stages of labor. It was often not enough but what could I do? For those excessively sensitive women who would not stop screaming, we sometimes resorted to a hot towel massage of the lower back along with soporific platitudes which we jocularly referred to in the local parlance as “pele pele” anesthesia.
I remember a particular night when I was on call; there was this woman in labor who could not have been more different from the women I usually saw. Apart from the way she occasionally bit her lip and arched her back when the contractions hit, there was no sign that she was already in established labor. A pelvic examination quickly assured me that she was, and quite far along at that. “This woman must have been laboring for hours” I remarked to the midwife on duty, “I wonder why she didn’t come in earlier”. “She’s Fulani” was the simple reply. I looked at the patient again; her features were clearly typical of the nomadic tribe of cattle rearers from the far north of Nigeria. Their women had a legendary reputation of expressing no pain during childbirth. The majority of them choose to deliver their babies at home, often unassisted. Those that choose to come to the hospital often show up very late. They had their babies with little or no fuss and went home thereafter. She was too far along for the usual analgesic injections. Although her records showed that she was having a baby for the first time, I was hopeful that with her we would have no drama. I set up an IV infusion, made some documentation and left to attend to some other business.
Nothing in the demeanor of the ward attendant who later summoned me back to the delivery room prepared me for what I experienced that night. There was my Fulani patient just newly delivered of her baby, feet up in stirrups bleeding torrentially. A quick examination showed that she was hemorrhaging from a rather unusually extensive episiotomy. I turned to the midwife, my eyes silently accusatory “there was no need for a cut this deep” I said in a measured tone. She was apologetic; the baby was huge, the scissors too sharp. I had no time for remonstrations, I prepared for a possible emergency transfusion and set forth to stop the bleeding. As I surveyed the instruments already set out, one thing was conspicuously missing; no lidocaine. “How am I supposed to do this with no anesthesia?” I asked no one in particular. The response was typical; last vial used up on the previous patient, requisition made to pharmacy not yet filled. I applied a vaginal pack and waited while someone made a quick dash to the pharmacy. The feedback was not at all encouraging, the anesthetic was out of stock and all surrounding private pharmacies had closed for the night. I looked at the patient who had maintained her stoic calmness in all of this, while possibly exsanguinating. To save her life I had to do what I had to do, I told myself.
I geared up, gloves, masks, apron and instruments ready and quickly explained the situation of things to the poor woman as I prepped her for the procedure. When the cognition hit her that I was about to close her up with no anesthetic, her wall of imperturbability came crumbling down. She started to shiver all over and her trembling hands reached down to cover her bloody genitals. “Don’t do that!” I admonished her. Some of the nurses present were quick to reach for her arms pinning them down by her side. I explained in hyperbolic terms that I was doing this for her own good, to save her life so that she could take care of her newborn. As I reached into the bloody pool fishing for the ragged edges of the offending cut, I realized that I wasn’t as disturbed by all this as I should be. I had long passed the steel test with flying colors. The first piercing of the curved needle brought out a shrill, prolonged cry of agony from the woman. It was then I noticed that I had barely heard her voice all evening. It seemed that her fortitude in labor was limited to just that. She broke into a cold sweat and her shivering turned into violent spasms of pain. Spitting out torturous verbiage in her native language, I caught snippets which suggested that she was calling out to God for help. Ignoring her cries, I continued with my act of mercy.
With the second piercing of the needle, she kicked out violently at me. It was probably involuntary but I was very upset. “Keep still so I can help you!” I yelled in frustration, “I do not want to get hurt trying to save your life”. I brushed aside her profuse apologies and focused on damming the river of blood between her legs. As the needle pierced her a third time, her entire body contorted with violent spasms. A spark of pain exploded in my brain; the needle had slipped out and gone straight into my index finger. I yelled out in pain. I don’t know who screamed louder her or me. I tore off my gloves and held my throbbing finger under a gushing tap, pressing out a drop of blood into the sink. The midwife informed me that the patient had been properly screened throughout her pregnancy. “She’s not infected”, she assured me knowingly. Applying a new set of gloves, I returned to the patient and warned her in the strictest possible manner to cooperate as I proceeded. Slowly but surely, the bleeding stopped and everything took on the appearance of normalcy. As I applied the last stitches, the consultant on call walked in for a routine check of the ward. “What happened here?” he enquired and I gave him a brief report. “Do you mean to tell me that you sutured a patient without anesthesia?” he asked incredulously. My explanations of the direness and helplessness of the situation fell on deaf ears. “The overriding maxim of medical practice is; ‘first do no harm’” he stated, “a number of complications could arise from what you just did”. After I assured him that the situation would not be repeated, he examined the patient and satisfied that she was in stable condition, he went back home.
I looked in on her the next morning. Still exhausted from her ordeal the night before, she gingerly tried to breastfeed her baby. She looked very happy to see me, “thank you doctor for all you did last night”. The thought of the pain appeared to be a thing of the past as she cradled her baby in her arms. “Oh that was nothing” I replied, my index finger still throbbing gently. I gave her a cursory examination, she had no complaints and appeared very content lying there with her nuzzling infant. “Take good care of your baby” I smiled as I left mother and child alone together, after all “all’s well that ends well”. First do no harm, yes. But sometimes in certain circumstances, one has to do some harm before one can do any good. Right?