I cannot do it

Rural and remote medical and surgical practice often parachute practitioners into unfamiliar territory. How we land on uncharted ground is a combination of circumstance, preparation,  and courage.

A classic circumstance I recall is that of a ten year old Nepali boy with a badly malunited fracture of the right forearm, which had united so badly he could not bring food to his mouth. He was the son of a laborer who had travelled to our hospital from Nepal, working his way by hoisting loads onto the tops of public buses, a process which took him one and a half months. Arriving at our hospital, he sat his boy down in front of me, the only surgeon here, and asked hopefully  if his boy’s forearm could be fixed.

I have no training in orthopedic surgery. I expressed that to the father and watched his face fall and his shoulders slump. When I asked him what was wrong, he acquainted me with the process of his arrival in Manali. He went on to say that he really did not have much more money or time to take his boy elsewhere and he would now have to work his way back to Nepal, with his boy’s forearm unchanged.  It was my turn to slump.

What can we do when confronted with such situations? It backs us  up against an unyielding wall of social and economic reality. We can either be quite justified by refusing to emerge from  our field of familiarity and practice, or  choose to engage in an unfamiliar arena.

I asked him to return in a few days, and used those days to read up the available resources I had. I found that  Darrach resection, or resection of the ulnar head could re establish pronation and supination, and restore some degree of function to the malunited wrist. I explained to the father that I was not an orthopedic surgeon, but was willing to perform this operation provided he understood the implications and potential complications.  The father consented and his boy successfully went through this procedure, and healed well.

Later, on my meanders through the Manali market,  I passed the bus stand.  I saw  this little boy clambering up the metal ladder at the back of our public buses, carrying the rope his father uses to hoist loads up to the top. They were both working their way back home, and he shot me a grateful smile that will stay forever in my heart. 

Viewed  from the legal and academic perspective, my reach had extended beyond my lawful jurisdiction. I had taken a risk, and included the patient in that gamble.  In this instance, it paid off.  An  unanswered question is what if the outcome was bad? Would a remote practitioner still be justified and validated in his altruistic attempt? How many risks will we take, and how far will our reach exceed our grasp?

Over the years, I hold  to  some truths that have guided me as a lamp in dark places. Altruism alone, is not justification enough for a bad surgery. We cannot gamble with our patients just because we want to help them.  Neither does a rural or remote location warrant substandard or suboptimal  care. If I can deliver a standard of care that the patient would receive at a higher centre, even if that procedure is one that I am unfamiliar with, I would err on the side of attempting it for the patient, rather than refusing to help him or her in the absence of other alternatives.  This entails much reading, soul searching and preparation, personally and for the team delivering this care. It can mean educating the staff in new techniques and methods. It means rehearsing the procedure in your mind and going through this uncharted territory mentally many times prior to the surgical incision.

And what if our altruism causes complications that beset the best of procedures, intrinsically bound within the fibre of disrupting live anatomy? Will not the lurking doubt rear its ugly head with the question “Maybe I should never have attempted this here?” How can we then live with this question?

We remain in these remote regions reluctant pathfinders through the tangled scrub of good intention mingled with delivering appropriate care, touching lives, or marring them, forever.