Doing Harm

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Today I held a 2-year-old's chin in place so a man could slit her throat. She had an infected cyst in her neck that needed removing, and I knew the surgery would heal her. But I was startled to find my mind flashing to those two small children on New York's Upper West Side allegedly slain by their nanny a few years ago. And I worried that my finger, hooked under the little girl's jaw, would leave a bruise.

When the surgery was over we pulled off the blue sterile draping, exposing the child's strawberry blonde ringlets, and she began to wake up. She was screaming, fighting the intubation. She pulled out her IV, splattering her stretcher and her hospital-issue tiger-patterned pajamas with fresh red blood. We tried to calm her. Finally one of the residents, a new dad himself, picked her up and cradled her in his arms. She was groggy but calm when we brought her back to her parents. I was glad they hadn't seen her a few minutes earlier.

That kind of scene has been repeating itself during my third year of medical school, now that we have left the classroom behind for the wards in hospitals around New York City. The first two years of medical school are the sanitized, textbook version of medicine. We don't talk about how to absorb the details of a patient's suicide attempt. Or what it's like to talk to patients shortly after they have been stabbed, raped or beaten.

And our textbooks definitely don't guide us on an even more challenging task: We not only have to adjust to seeing pain in the hospital. We have to get used to causing it, too.

I'm thinking of the time I helped drain a patient's abscess as he screamed "Why? Why?" over and over again, so loudly that, when I went to go get more supplies from the next emergency room bay, I could hear him shouting from down the corridor. His infection resolved because of the drainage, but I still find myself questioning whether we should have done something differently. And I can still hear him yelling.

Another time, I performed a rectal exam on a man who spoke no English. My supervising intern, whose workload that day was heavy, pressed me to hurry so we could move to the next patient. I tried as best I could with the help of a translator on speakerphone to explain to the patient why this was necessary and what I was doing. And the exam showed that he was bleeding from his gut, giving us the answer to why his blood counts had been dropping. But for the rest of the day I felt I had somehow violated him.

More and more I'm learning that "do no harm" is simplistic. Pain and trauma are ever-present on the wards. It's my job to learn to minimize it, but sometimes I have to hurt my patients to help them. Some of them will never forget the pain they suffered at the hands of the medical student I am now, or the doctor I will become. I know I won't.