Last week was my first week back after some leave time in the US. On Thursday, we had a patient that broke my heart. Her smile was huge and full of joy. I greeted her and her mother as the little 8-year-old girl waited to go back to the operating room for surgery. She used to be able to walk; then, around the age 4, she fell ill and lost her ability to walk. Her legs now have permanently contracted at 90 degree angles at her hips and knees due to non-use. Our plan was to straighten her legs so that she could stand again and at least be able to walk with braces. It was my first time meeting this little girl. When I went to pick her up under her shoulders, so that I could carry her back to the operating room, her shoulders gave way to the pressure, unable to support her body weight. I had to cradle her like an infant – as I did, I realized that under that nightgown, I could feel every rib, every bone. Her body was wasting away. My anesthetic could kill this fragile little girl; I shared my concern with the surgeon and he gladly agreed to postpone surgery until more workup could be done to see what was causing her to lose all the muscle and fat that a child should have. My suspicion is a muscular dystrophy of some sort that will end her life early and not a cerebral palsy that she came diagnosed with from elsewhere.
As I thought about the little girl above and what I could write about, doing no harm came to mind. As I went through the day today I had three more patients that confirmed the lesson. It was kind of weird. It was one of those days when nothing went smoothly – almost every potential surgery had an issue.
The first scheduled surgery today has active malaria and has been on treatment for only one day. Not a problem that I am used to dealing with in the US. How long do we delay surgery for this? Our surgeon is able to expertly answer that question after practicing medicine in Africa for so many years.
A little boy has a wet cough and wheezing – he also has club feet and a dislocated hip. He comes from very far away. Still, it is safer and better to delay surgery.
A 2 year old girl comes to clinic with her spica hip cast broken – the kind that covers both legs and her hips and leaves a little hole for changing a diaper through. It needs to be changed because it is split and badly soiled. She smells strongly of urine. Everything in me wants to put her asleep and put a clean cast on her today. But she has a fever and is acting weak. Safer to wait a few days to see why she is having a fever and treat that before undergoing anesthesia.
These are difficult decisions. The families are always so disappointed – often mistaking the delay for thinking their child will never have surgery. Tempted to give up a hope of cure, sometimes the cultural and language barriers make understanding impossible and the family and patient go away, never to be seen again. The holes left by the cancellations can sometimes not be filled because of the late notice – also difficult, given the long waiting list that we have. The Hippocratic Oath, however, states something like, “First, do no harm.” Wise advice. The first goal of every physician needs to be to not hurt the patient – to not make them worse off than they were than when they came to see you. Sometimes this happens despite one’s best intentions and wise decision making. When on the face of it, it seems likely that harm could result, a physician is obligated to not act, to not treat. CURE International takes this concept very seriously. From the first time I ever had a discussion with CURE as an organization, this was stressed. These kids are to be treated as the prized possessions they are – sacred human life, their lives never to be risked.
And the Lord has declared this day that you are his people, his treasured possession… Deuteronomy 26:18a
Originally posted at: http://ethiopia.thebernards.org/2012/08/14/first-do-no-harm/.