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The Second Law of Medicine

Sandra Relyea ~

I sit in the cab of an old pickup truck on my father’s farm, listening to the water gurgling through irrigation tubes alongside a field. The truck is parked next to a barbed-wire fence. I’m waiting for the water to reach the far side of the field so I can pull the tubes and reset them in the next field.

As I wait, I watch the setting sun turn the Sangre De Cristo Mountains red and orange. Crickets chirp in the tall grass; frogs start their evening chorus. Smells of alfalfa and milkweed blossoms scent the air. Peace settles over me as the light fades.

To my left, I notice a little spider spinning an orb web between the fence wires. A mosquito buzzes around my face, looking for a good landing spot. I catch it between two fingers and try to place it in the spider’s web.

Unfortunately, the web tears.

The spider scurries off, leaving the hapless mosquito, with its crushed wings, struggling in the web. I feel bad–my efforts to intervene in nature have gone amiss. Silently, I vow not to let this happen again.

Fast forward several years. I’m in medical school. I learn the Hippocratic Oath and think back to the spider whose web I damaged.

If “Do no harm” is the first law of medicine, I wonder, what’s the second one?

After graduation, I begin working for a federally qualified health clinic in Northern California. I spend one day a week on a mobile medical van that serves the homeless and uninsured; we’re also part of the county disaster-response team. The rest of the week, I work in the outpatient pediatrics department.

I usually wear wash-and-wear clothes to work, because the homeless team often works outdoors, and in pediatrics you never know when a baby is going to spit up on you.

One summer day, my team is scheduled to attend an all-day meeting. We’ll meet in a board room that’s usually too frigidly air-conditioned for my taste, so I decide to wear a red silk blouse that my sister and her husband gave me. I seldom have an opportunity to wear this blouse, and I love its embroidered figures and brocade button loops.

This silk will help me stay warm in that room, I think, also donning a nice pair of dress shoes.

At the clinic, I’m told that the meeting has been canceled: Governor Schwarzenegger has activated regional disaster-response teams, due to predicted temperatures of 117 degrees or higher for the day. Our team will be the area’s only responders, because the sheriff’s office, police and hospitals are otherwise occupied.

We’ll be spread pretty thin–and we’ll have to work fast, racing the rising temperatures to reach all the folks who may need help. I don’t have time to go home and change my clothes.

With Michael, a college student who’s assisting us, I load bottled water into my car, and we set out to visit all the trailer parks in town. We knock on doors, checking on folks who are elderly, ill or don’t have adequate resources for the heat. Anybody who doesn’t have enough water or air conditioning is referred to the shelter downtown. We rescue an elderly lady from her sweltering house, a young mother who’s living in her car with her two-month-old, and a stray dog with newborn puppies.

My car’s interior gets so hot that the steering wheel burns my hands, and I can’t even hold my metal water bottle. Sweat trickles down my chest and back, staining my red silk blouse.

At the door of one mobile home, we hear a small window-mounted air cooler struggling to keep running. It’s now 118 degrees.

“Who’s there, and what the hell do you want?” croaks a thin voice. We step through the unlatched door and introduce ourselves.

“It’s about time somebody gave a rat’s ass and showed up here,” says the scrawny, unshaven, elderly man lying on a sofa bed in the living room.

He wears a thin, soiled hospital gown. Protruding from his nose, along with some grey hairs, is a nasal tube hooked up to an oxygen tank. A urine bottle filled with foul-smelling brown liquid hangs from one bed rail. The sheets are stained with drainage from old gauze dressings covering the man’s buttocks. Thick, yellowish liquid seeps from his sunken eyes, and spittle sprays as he scolds and sputters at us.

I send Michael, wide-eyed, back to the clinic to get the man a new egg-crate mattress.

A scowling middle-aged woman emerges from a nearby trailer and walks up the front steps. Reeking of cigarette smoke and beer, she says, “I’m his caretaker.”

She informs me that the county is paying her. “If there’s something wrong, it’s because I’ve been away for a few days.”

The man begins cursing at her, and she retreats to her trailer.

When Michael returns, I have him stand on the opposite side of the bed. I put my arms around the old man and roll him towards me onto his side, so that Michael can slide the new mattress under him. As the man curses into my ear, drool runs down his face and drips onto my silk shirt.

You’ve got to be kidding me! I think. Why am I doing this? We should just walk out of here and leave this guy to his fate.

Then I have a flashback to that distant, peaceful evening on my father’s farm, watching the sunset paint the mountain peaks. I look at the cranky man in my arms and wonder, How did I get here from there?

I remember the spider and the mosquito and the first precept: “First, do no harm.” Again, I find myself wondering what the second law might be. Then it comes to me.

It might just be “Do what you can to relieve the suffering that’s in front of you.”

I relax. I focus on the man’s misery and what we can do to diminish it. His scoldings no longer seem personal, but rather cries of helplessness and pain. Michael and I change his linens, the urinal and his dressings. Before leaving, we set up a home health nurse to visit the next day. As we set things right, the man falls silent.

It’s still 118 degrees, but I leave the trailer feeling like I’ve found a way to be a better healer.

Back at home, I take the red blouse to the cleaners, and the stains, thankfully, come out without a trace. I’m reminded that I have the comfort of a loving family and fond memories of summer’s country evenings. As my passion grows for serving the disadvantaged, I find it ever harder to judge those who don’t have the blessings I’ve had.

There is joy in working for fellow humans from a base of personal good fortune. Still, the practice of medicine can be difficult. When that happens, I remember the first and second laws: “First do no harm” and “Do what you can to relieve the suffering that’s in front of you.”

These precepts keep me present, and that’s what keeps me sane.

About the author:

Sandra Relyea, a pediatric physician assistant for thirty-two years, works at Peninsula Children’s Clinic in Port Angeles, WA. Also an artist, she has created two shows centered on homelessness and human trafficking, which will open this fall in the Turtle Bay Museum in Redding, CA. Having struggled with clinician burnout for years before finding ways to ease stress through art, Balint groups and writing, Sandra is a Buddhist/Taoist. “I find solace and resilience in the acknowledgment that suffering is inevitable. It is the stories we tell ourselves about our pain that determine how we experience suffering. I also believe that sharing our stories creates community, brings solace to individuals and enables us to live examined lives. Writing is one of the best ways to access one another’s stories.”

Story editor:

Diane Guernsey


16 thoughts on “The Second Law of Medicine”

  1. Warren Holleman

    I loved this story. The arc takes the reader from an innocent but formative childhood experience to a challenging situation with an angry patient. The lesson from childhood made all the difference.

  2. Sandra, your formulation of medicine’s second law is doubly thoughtful and I will always teach it that way from now on. “Do what you can” acknowledges suffering’s inevitability and our limitations in the face of it; “the suffering that’s in front of you” reminds us that the key is simply to be present with each patient and to be aware of the different ways suffering manifests itself – not infrequently as gruffness and distrust.
    “Suffering is inevitable” – that may be the third law. It’s good to remember that we are not called on to eradicate suffering, even less to prevent it: just to actively seek it out, bear witness with empathy rather than judgment, and find joy in relieving whatever circumstances and our skills allow.

  3. Henry Schneiderman

    This is a wonderful story, Sandra, and I also love the comments that others have posted including the third rule. In a time when health care feels irretrievably broken and denigrated to something about money instead of about compassion, you have stood up for our calling and we need to be reminded of this essence daily. And by the way, to a Palliative Care clinician like myself, you have also given the credo of the specialty.

    1. Henry, that is interesting regarding the credo in your specialty. I haven’t often dealt with death in pediatrics. I imagine a healthy attitude when faced with its inevitability would be comforting. Thank you for the work you do!

  4. Carey Candrian

    Absolutely beautiful. Thank you for writing this piece. I love your second law: relieve the suffering that is in front of you.

  5. Thank you! This touched my heart and reminded me of the importance of taking a breath, slowing down and remembering why we chose our professions. Beautiful!

  6. Do no harm and relieve suffering. The exact right laws and the exact right time! Thank you for sharing your humanity.

  7. Spectacular, Sandra. Hello from Tucumcari, irrigated and dryland farming. I’ve always thought the experiences I had growing up in Montoya, NM were the template for whole-heartedness, endurance, sacrifice, and gratitude for the gift of mercies given and received.

    1. Tucumcari! Our farm was outside of Alamosa in the San Luis Valley of Colorado. We used to get our television signal from Albequerque via the tower on San Antone Mountain. Every day on the news we heard about the weather forecast for Tucumcari.

  8. Ronna Edelstein

    You have the skills of a healthcare provider and the soul of a poet, Sandra. What a beautiful story–a very realistic reminder that we all, no matter our socioeconomic status or any other characteristics, belong to the human race and have a responsibility to one another.

  9. Well done, Sandra. We all need reminding sometimes of why we do what we do. Suggestion for 3rd rule: All you can do is your best in that moment.

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