REFLECTIONS Providing Care or Caring By Jonathan T. Miller, MD What do you want to do?” Matt asked. I looked up from the blue, gasping baby to the physician asking the question. “Well, back home I would have intubated her already.” “Then you should do that here,” he responded. Intubating the newborn was easy, and as the adrenaline rush passed, I looked up and asked the obvious question, “Now what?” “Now you bag her until you think she can be extubated... or you think it’s futile.” He headed for the door. “I’ll be back. Emergency called with a critical patient.” For the next half hour, I stood at the infant warmer, sweating in the tropical heat trapped so effectively by the concrete block, bagging the baby. I prayed, asking God for the child’s life. It shouldn’t be like this. There should be a NICU, a ventilator, a neonatologist. But this child had only me: a jetlagged visitor on his first day in Papua New Guinea (PNG), unsure of what to do next as the flies buzzed in and out of the open window behind me. She had endured 12 hours of labor that stalled. When we delivered her by C-section a thick slime of meconium stained the amniotic fluid. Suctioning worked well enough and the nurse whisked her off to the nursery.
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The same nurse returned shortly after. “The baby is not breathing well,” she said, understating the issue. Walking into the nursery, I spotted our recent delivery: ashen, blue-gray color with agonal respirations. I intubated her, the nurse moved on to attend to other newborns, and Matt went to emergency. I was left alone with the baby, the heat, and my prayers as I bagged.
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Five years ago, I was asking Matt what he wanted to do. He was my intern then. “Let's tap it,” he said without hesitation. “You know how?” I asked. He replied confidently, prepped the patient and performed a good arthrocentesis. As we walked away, I asked Matt how many he had done before. “None. I watched it on YouTube,” he replied. “You've never done that procedure?” “Nope.” “But I asked if you knew how to do it.” “I do. I just never had.” The boldness he displayed in residency has made him an excellent physician in this resource-constrained environment. The baby was pink now and breathing regularly on her own. Relieved, I extubated her shortly before Matt returned. Over
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the next week, her respirations improved steadily. When we saw her later that month in outpatient clinic she had become a happy, healthy baby. In PNG, children are not named until three months of age, given the prevalent infant mortality, but in a gesture of faith, her mother had already named her. Returning to practice in the United States, I see that I provide much care. I order tests, call consultants, per- form procedures, but none of that work requires me to care. Most of it keeps me from the patient’s bedside. In PNG, without those distractions, I had to provide care in an environment that exposed my limitations. The acute knowledge of my limitations fostered greater empathy for the suffering patient and allowed me to care boldly for them. In the United States, I provide technologically superior care. In PNG, I was able to provide emotionally superior care precisely because the technology was absent. I couldn’t put a patient on a ventilator and walk away. I couldn’t create emotional distance between myself and the patient. I was tied to the bedside by the lack of technology. Within these limits, I found the freedom to be a physician. "Providing Care or Caring" was reprinted from the November 2019 issue of Academic Emergency Medicine journal.
ABOUT THE AUTHOR Dr. Jonathan T. Miller is associate program director for the University of Pittsburgh Medical Center (UPMC) Hamot Emergency Medicine Residency, Hamot Hospital, Erie, PA.