First, Do No Harm

In the U.S., every July a new batch of interns experiences the delight and terror of their first days as a “doctor.” During this time, most of us worry about the potential to do something wrong and harm a patient. That worry fades over time but never completely goes away. We are trained to think about the benefits of our treatments but also the risks. In Ethiopia, the mentality can be quite different.

Yesterday, a nurse aide came running to get me. A patient with a severe machete wound to his wrist was in our treatment room. As I entered the room, I quickly realized why the nurse aide was so concerned. One of our fresh-out-of-school nurses stared up at me as I glanced at his hands. He had penetrated the distal end of a severed tendon with a huge suturing needle, and was in prime position to suture the tendon to…absolutely nothing. When a machete makes a deep cut through the back of someone’s wrist, it sometimes cuts the little tendons that allow us to extend our wrist upward. If this happens, the proximal ends of the tendons (part closer to the elbow) retract up the arm as the muscle pulls on them. It takes some incising and dissecting to find these ends. I never got to ask the young nurse what the heck he was planning on doing with his needle in one end of the tendon, but gave him a stern talking to and asked him to step aside. The health officer and I proceeded with the procedure, taking almost two hours to find the proximal ends of three severed tendons and then suture everything up.

I’ve thought much about this young nurse mentioned in this scenario. He is intelligent, hard-working, caring, and interested. But his over-confidence and unwillingness to ask for help or advice is just plain dangerous. He told me yesterday that he had never done a tendon repair before, yet he was apparently eager to attempt this procedure alone. He once sent a “semi-conscious patient” to the lab all afternoon and didn’t come to tell me about him until his malaria blood film result was back, at which point I rushed him into our inpatient ward for medicine and IV fluids. The fear of doing more harm than good instilled in us in US medical schools can sometimes be unnecessarily anxiety-provoking. We are well-trained and should realize our capabilities. But the reverse can be much more detrimental. When one doesn’t realize the potential harms they can inflict in practicing medicine, the consequences are much greater.