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Last Updated: Monday, 13 August 2007, 09:10 GMT 10:10 UK
It's tough at the sharp end of medicine
By Dr Daniel Sokol
Medical ethicist

Hernia operation
Doctors in India must be ready for anything
Medical ethicist Daniel Sokol gives a personal account of his first-hand experiences of medicine in India.

A month ago, old Rajendran's leg was amputated without his knowledge.

As he repeatedly refused the life-saving operation, his family and surgeon told him that surgery on his thigh was needed to allow the blood to flow afresh to his gangrenous foot.

Fooled by their false reassurance, Rajendran agreed to go under the knife.

In the following weeks, he held different beliefs about his missing leg.

He first believed that the severed portion would be reattached once the operative wound had healed.

Later, the surgeon told him that a 'walking implement' would be fitted to his stump.

Still later, he suffered from phantom limb syndrome and believed his leg to be whole, sometimes gingerly feeling the vacant area beyond the stump.

Finally the truth

Last Wednesday, the surgeon told him the truth.

He told me a doctor would only do what's best for him

He revealed the well-intentioned deception and explained the reasoning behind it.

An exchange between the surgeon and patient ensued, which ended in Rajendran shaking the surgeon's hand.

"You see," said the surgeon, "he told me a doctor would only do what's best for him. He's happy."

That evening, I asked two nurses if Rajendran was satisfied.

"No," answered one. "He's angry at his wife and sons for having lied to him".

Was the deception justified? Without it, Rajendran would probably be dead by now. Is this reason enough to violate his autonomy? This is no ethics lecture. You can draw your own conclusions.

Tuberculosis menace

Since my last article, dozens of patients have been and gone.

A young girl arrives in the hospital, holding an X-ray showing the cotton-like appearance of tuberculous lungs.

As part of a government eradication programme, she will receive the drugs at no cost.

The condition is so common that the local government hospital has a separate TB ward.

One elderly man shuffles into the consultation room with six boils around the circumference of his head.

The largest one, on his forehead, gives him the appearance of a human unicorn.

Daniel Sokol
Dr Sokol has found marked differences in medical practice

The surgeon tells him to donate his hair to the Hindu gods.

This will also clear the way for a proper look.

Twenty minutes later, the patient returns with a shaved scalp.

The surgeon inserts scissors into each boil, forming craters which ooze rivulets of pus and blood.

The pain is such that I hold the patient's kicking feet.

"Should we not give some anaesthetic?" I ask.

"Only if he says it's intolerable" comes the answer.

Pump accident

A crying eight-year-old boy arrives with a finger split in two.

He got it caught in a water pump as his mother was drawing water.

Again, in the consultation room itself, the dangling halves are stitched up there and then.

This is medicine as magic. One moment, a 40-year-old woman lies on a hospital bed with an enormous abdomen.

Her spleen is, in the language of the lab report, 'massive'.

That very afternoon, the monster is removed and the patient returns to her hospital bed with a deflated abdomen.

Other cases take longer to heal. A young chef at a nearby restaurant arrives with extensive burns on his face, chest and left arm, the victim of a toppled pan of boiling oil.

Recovery will be slow and his damaged eyes may require new corneas.

Suicide attempt

In one bed, a middle-aged lady, plagued by family problems, attempted suicide by dousing herself in kerosene and setting herself ablaze, while another patient, a pretty 17-year old girl with the same intent, ingested liberal amounts of insecticide following a quarrel at school.

I don't get shocked anymore

The young girl spent a month in a coma.

I ask the surgeon if after 20 years of practice anything still shocks him.

"No" he answers, smiling. "Once, a man came in carrying his own severed arm. I don't get shocked anymore."

In the UK, North America and other parts of the world, medical specialties and subspecialties abound, and more are created as our knowledge grows.

Many doctors are becoming super-specialists, knowing more and more about less and less, while generalists are a dying breed.

"I don't know about this," my surgeon friends might say back in London, "it's medicine, not surgery".

Wide ranging remit

Here, in rural Tamil Nadu, surgeons, anaesthetists, paediatricians and other specialists do general outpatient work, as well as their specialist cases.

If stranded on a desert island with the choice of a single doctor, an Indian-trained rural surgeon would be a wise choice.

Children pumping water
The potential for accident is everywhere

As my time in India nears its end, I reflect on the lessons learnt.

There are too many to mention, but the single greatest lesson has been a reaffirmation of the late Jean Bernard's observation that medicine is fundamentally about man.

The common feature transcending all of medicine is that each practitioner, whatever his speciality, location or century, aims ultimately for the good of man, often at a time of vulnerability and weakness.

This obvious truth, in this era of specialisation, technology, stringent rules and protocols, can quite easily be forgotten.

Medicine is practised for man, but also by man. It is a team effort.

An operation, for example, is not a tête-à-tête between a surgeon and a patient.

It may involve a small crowd of nurses, assistants, anaesthetists, surgeons, and students.

Man's involvement at both the giving and receiving end of medicine makes it a fallible and challenging affair.

When it works, however, even in the most remote corners of the world, the flickering star of humanity twinkles.

  • Dr Daniel Sokol is a medical ethicist at St George's Hospital Medical School, London, and Director of the Applied Clinical Ethics course at Imperial College London.


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