| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
Lynchburg, VA
Dr. Gianokos is Associate Professor of Clinical Family Medicine, University of Virginia.
Correspondence to: Dean Gianakos, MD, FCCP, Associate Director, Lynchburg Family Practice Residency, 2097 Langhorne Rd, Lynchburg, VA 24501; e-mail: deangianakos{at}yahoo.com
Imagine you are the only pulmonologist in town. You have no surgical backup. The nearest hospital is 100 miles away. In the middle of the night, acute respiratory failure develops in your 24-year-old asthma patient, who will die without an artificial airway. You attempt intubation without success. Bilevel pressure ventilation is not an option. The patient needs a tracheotomy. You have never done one before. You look around the room. All eyes are on you. The family urges you to do something! Now you know how the main character feels in Mikhail Bulgakov’s "The Steel Windpipe." In this short story, a young Russian physician finds himself alone in a rural community, where he encounters medical emergencies that severely test his skills. A closer look at the story reveals lessons for even experienced physicians as they struggle to achieve medical competence.
Mikhail Bulgakov (1891–1940) was a Russian physician-writer whose doctor stories are based on his experience as a rural physician in a small village called Nikolskoye in the province of Smolensk.1(p8) Nikolskoye was his first assignment after studying medicine at Kiev University. He was the lone doctor responsible for a busy, 40-bed hospital.2 All but one of his six doctor’s stories were originally published in a medical journal called Meditsinkii Rabotnik (the Medical Worker) from 1925 to 1927, and later compiled in a Collected Prose edition in 1966.3 After 18 months in Nikolskoye, he went on to specialize in venereology in Kiev. Shortly thereafter, he gave up a career in medicine for writing.
Readers are probably more familiar with another Russian physician-writer, Anton Chekhov. Like Chekhov, Bulgakov portrays characters in a realistic fashion, with special attention to the concrete details of place and time. The first sentences of "The Steel Windpipe" are excellent examples of such description: "So I was alone, surrounded by November gloom and whirling snow; the house was smothered in it and there was a moaning in the chimneys. I had spent all twenty-four years of my life in a huge city and thought that blizzards only howled in novels. It appeared they howled in real life."1(p29) The doctor is alone in a small village in Russia, where he must attend to the medical needs of poor peasants who come to him with all sorts of problems, many he has not seen or managed before. When a young girl near death presents to the hospital with stridor and a presumptive diagnosis of diphtheria, the narrator is presented with the dilemma that defines the story: to cut or not to cut the girl’s throat.
Before the girl arrives at the hospital, Bulgakov’s doctor worries about the medical emergencies he may face. He is inexperienced, and he knows it. As a medical school student, he was more of an observer than a doer: "suppose they bring me a woman in labor and there are complications? Or, say, a patient with a strangulated hernia? ... Once I watched a professor operating on a strangulated hernia. He did it, while I sat in the amphitheatre. And I only just managed to survive... "1(p29)
In this situation, the facetious medical school rule "see one, do one, teach one" hardly applies. The doctor barely survived watching the operation, let alone doing one! Now he must decide whether or not to perform a tracheotomy on a girl who will likely die without one. The decision to cut is extremely difficult for the doctor. Bulgakov provides much psychological detail of the doctor’s "inner conflict, turmoil, and vacillations."4 Despite his inner doubts, he tries to appear outwardly confident and self-assured in front of the family, as though he knows what he is doing.
He faces many challenges. He has many other patients to see, no consultants to rely on, inadequate anesthesia, and poor lighting. The girl’s mother and grandmother insist that he treat the girl medically rather than surgically. He considers the surgical option, but frets about hastening a girl’s death by operating, a girl who likely will die with or without an operation. Most of all, he questions his ability to do an unfamiliar operation: "The thought flashed through my mind: What if she agrees to it?"1(p32) He also knows that his reputation is at stake. However, at a deeper psychological level, he understands surgery is the girl’s only hope. Later in the story, he tells the family: "You’re condemning the baby to death. You must consent. Have you no pity?"1(p33)
His irritation with the family reminds the reader of another doctor’s story, "The Use of Force" by William Carlos Williams.5 In that story, the doctor severely reproaches a family that interferes with his attempts to open the mouth of a child whom he believes has diphtheria. Williams’ doctor shows none of the indecision of Bulgakov’s doctor. Rather, he loses control, becomes enraged at the girl for not cooperating, and overpowers her to make a diagnosis. The psychology of Bulgakov’s doctor is different: he shudders at the thought of doing an operation he has never done before.
Bulgakov’s doctor draws courage from his first contact with the little girl. He is overwhelmed by her beauty and innocence: "the sight of her made me forget operative surgery, my loneliness, the load of useless knowledge acquired at university: it was all completely effaced by the beauty of this baby girl."1(p30) He is simply and remarkably struck by her humanity. She is a patient in need, and he is the only doctor available to help her. He also receives strength from his moral conviction that surgery is the right thing to do, despite the significant reservations he has about using his own skills. As the girl’s condition deteriorates, he becomes more convinced that surgery must be done, despite the strong objections from the mother and grandmother: "Come on, come on–you’ve got to agree! You must! Look, her nails are already turning blue!"1(p33)
He ultimately overcomes his "faintheartedness"6(p118) and begins the operation. Early on, he struggles (he can’t find the trachea!) and some of his original doubts recur: "Why did I ever do this? I needn’t have offered to do the operation, and Lidka could have died quietly in the ward. As it is she will die with her throat slit open and I can never prove that she would have died anyway, that I couldn’t have made it any worse.... The midwife wiped my brow in silence."1(p35) The midwife does more than wipe his brow. Her physical and psychological support bolster his courage and helps him through the difficult part of the surgery.
The surgery is a success. The girl survives. The doctor’s reputation and confidence grow. Patients flock to see him.
Like the doctor in Bulgakov’s "The Steel Windpipe," we learn what every experienced doctor knows: doing the right thing in medicine can be extremely tough. It requires doctors to keep the patient—not the doctor—at the center of any decision. It often requires great courage. Bulgakov’s doctor summons the courage to overcome the obstacles that prevent him from doing the right thing. He puts aside his fears, overrules the family, and accepts the fact that the girl will die without an operation. He finally cuts the girl’s throat to save her.
In this story, we learn that good doctoring often requires risk taking. When physicians take risks, they have the opportunity to not only help patients, but also to increase their competence and confidence. When things go well, physicians learn to believe in themselves. Haber describes the transformation of Bulgakov’s doctor in the following way: "And so the doctor once again transcends himself at a moment of crisis, a new self arising involuntarily and supplanting the ordinary, timorous conscious personality."6(p120) When things go poorly, physicians have the opportunity to learn from their mistakes so that future patients will benefit. Knowing when to take risks and when to avoid them distinguishes the wise, competent physician.
Good doctoring also requires teamwork. The support of the midwives—and the doctor’s willingness to accept it—was critical to his eventual success. So was a bit of luck...
Bulgakov’s honest portrayal of a young physician making tough decisions certainly helps us to empathize with inexperienced learners, especially medical students drawing blood for the first time, medical residents doing their first thoracentesis, or pulmonary fellows doing their first intubations. However, even experienced physicians bump up against novel situations that test their competence. Like young learners, these physicians must courageously rise to the occasion, overcome their fears, and handle unexpected complications, mistakes, and problems.
In summary, Mikhail Bulgakov’s "The Steel Windpipe" is the story of a young Russian doctor who finds himself in a dire situation. A little girl with diphtheria needs a tracheotomy. The doctor has never done the operation before. There is no consultant available. He is the only doctor in the village. What to do? With the help of midwives and his own moral fortitude, he overcomes his trepidations to perform the operation. This one was a success. However, we can be certain there were others that did not go as well. Bulgakov’s story reminds us that physicians will not always possess the knowledge and skills necessary to handle every situation they encounter in their careers. At times, they will feel anxious and fearful in difficult situations. Meeting these situations with moral courage will help physicians maintain competence throughout their careers.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
