Primum non nocere. First, do no harm. It’s the first thing you’re taught when you study the health sciences. But anyone with a medical degree will tell you it’s easier said than done.
Consider this: How do you care for a patient who is simultaneously needs more water in their body AND has an excess of it? This is the paradox that we commonly encounter in the Pediatric Intensive Care Unit with dengue patients.
For the common population, dengue hemorrhagic fever (DHF) is a straightforward illness: your platelet count goes down and so you just may bleed to death. But it actually is far more complicated than that.
Given that the platelet count is down, of course, puts patients at risk for internal and external bleeding. Aside from this, their albumin count, which is responsible for maintainting the osmotic gradient in the blood, also may go down. A combination of the two means that blood or fluid in the blood may seep out of the blood vessels and into other spaces in the body. Without enough fluid in the blood, blood pressure goes down. Now, think of the cardiovascular system as the plumbing of your body. You need the right amount of pressure to ensure that every household has a consistent supply of water. If there isn’t enough water in the system, it is impossible to maintain this pressure. The “households” in your body are your vital organs. Without the “water” (i.e. blood), they will die.
But that isn’t the only thing that’s going on. Remember that the fluid that seeps out of the blood actually goes somewhere, into other spaces in the body. The most visible sign of this is the edema that critical dengue patients experience. Fluids basically stay in the spaces just under the skin, making the skin look swollen and taut. Even more dangerous is when the fluids seep in the peritoneal cavity or the spaces within the abdomen, making it swollen and firm to the touch. But even worse than that is when the fluids enter spaces in the lungs, basically drowning the patient from within. (As a side note: Parents usually anxiously look out for the platelet count, which while helpful for the diagnosis can sometimes not be reflective of the actual severity of DHF. Once, we had a patient in the ward who had a platelet count of only 3 million but did not experience any complications throughout the course of her illness. Some other patients with higher counts would later need intensive care. Better to watch out for physical signs like difficulty in breathing, a firm and distending abdomen, irritability, edema etc.)
Given that, it is always a difficult choice between to hydrate and not to hydrate. Because in this case, sometimes the only thing that can save the kid is the same thing that could kill them. You may do harm by doing something. And yet you may also do harm by doing nothing.
Sure, we know what to do and how to do it. Sure, our best Pediatric Intensivist has the procedures for this covered to a T. But still we also know that behind each patient, life and death is not as simple as give-this-or-give-that. We know that doing everything right doesn’t mean everything will also end right, because so much is going on within the patient that is beyond our control. Because there is, as of date, no cure for dengue. In essence, what we’re doing is treating the manifestations and complications, and praying that the patient fights the infection on time.
And this is all for just one. So much trouble and so much doubt, all for saving the life of just one person.
During today’s emergency coordination training, I couldn’t help but imagine how difficult it must be to manage the lives of many. Of course, in this case, it’s a completely different situation. But still, the complexity also goes up the scale considering you’re not worrying only about hearts and lungs and livers and platelets and albumin but also of politics and culture and social dynamics. The idea of it sometimes makes me think that it makes assisting a neurosurgeon look like a piece of cake.
When everything is so complicated and the mandate is “Do No Harm”, you’re constantly treading the line and double-checking yourself. Because even when “Do No Harm” becomes impossible due to the many limitations of reality, you still have to answer for it at the end of the day.
Why do we even bother?
Alright, I’ll tell you why we even bother.
A year or two ago, a young girl was admitted to the PICU for dengue. Her blood pressure dropped so dangerously low, we had to hydrate her and give the holy trinity of BP meds: Dopamine, Dobutamine and Levophed. We gave her transfusions of platelet and albumin.
Fluid got into her lungs, and so the doctor had to sedate her and intubate her, and her breathing soon became dependent on a machine. As the days passed, she even developed a complication called pulmonary hypertension.
Despite everything we did, her blood pressure remained extremely unstable. Many times, we could barely hear it and we’d have each other recheck just to convince us that it was actually really there.
We had to feed her through a tube in her nose. Many times, we couldn’t feed her during the scheduled time, because her blood pressure was so low it would be too risky.
We didn’t think she’d make it. We thought only a miracle would save her. But we didn’t give up. Nope.
First of all, the reason why we bother is because medicine, for all its limitations, actually works. It may not save everyone 100% of the time, but it does work.
Second, we bother because we know what it feels like to be in pain, to be helpless, to be alone, to be uncomfortable, to be insecure. And we know what wonders a sure and caring hand can do to help relieve all that.
Third, we bother because we hope. And, occasionally, we do see miracles happen.
That patient I was talking about?
I can still imagine her laughing and running all over the hallways of the hospital within days after being transferred out of the PICU. That, among the many other things I’ve seen, is not something I’ll forget easily.
As a healthcare worker, I will never, ever deny the importance of at least attempting to adhere to the principle of “Do No Harm”. But I always try to remember another thing besides that: “Do Something Good.” It’s not the same thing.