Pins and needles - a lesson on communication

A welcome break from medical politics – I wrote this a long time ago … it still applies just as much now as it did then.

All a doctor’s knowledge, skill, patience and dedication are valueless without intuition. When all else lets us down, all the tests and special investigations, it is often the small quiet voice of intuition that guides us onto the path of discovery and ultimate healing. But intuition cannot be taught, only learnt through experience. I realised its extreme importance through an early lesson in my career. I also learned to listen exactly to what my patient had to say to me, even across a language barrier, and that to ignore any part was to invite disaster.

Young and inexperienced, in 1989 I took a position for three months as a locum medical officer in a west coast mining town shortly after being released from military service. Among the labour force in the town were a small number of Xhosa men who had been transported thousands of kilometres across the width of South Africa to mine the sands of the Kalahari. Many were bed rock sweepers, faced with the arduous task of sweeping diamond bearing gravel from crevices exposed by removing tons of sand off the bedrock.

Namaqualand was everything that the Transkei was not, dry, cold and inhospitable. Separated from their wives, homes and families for long periods, the men were aliens in an unfamiliar land, and not surprisingly many of them developed stress-related conditions.

So, a peptic ulcer was high on the list of probabilities when I saw a young Xhosa man complaining of “pins and needles” in his stomach. Through an interpreter I established that he had had the pains for just over a week, and that he was otherwise well, only missing his family badly.

Physical examination revealed nothing unusual except a slightly tender abdomen, and, confident that my patient had an ulcer, I admitted him to the ward and started anti-ulcer therapy. Two days later his pains had neither improved nor worsened. Anxious to confirm my diagnosis, I arranged a gastroscopy, still a new technology at the time, an examination of the inside of the stomach through an endoscope, which is swallowed by the patient while still awake. The results of this uncomfortable procedure showed his stomach to be perfectly healthy. I ordered further blood tests, all of which were normal. Several days went by, and still his pins and needles persisted. His tummy remained tender to the touch and none of the medications appeared to be helping him in any way.

The lack of a diagnosis was perturbing. Each and every day the young man’s symptoms remained the same, “pins and needles in the stomach”. His mood remained constant, but language differences made it difficult to communicate with him. A social worker picked up evidence of emotional problems due to his feelings of isolation, and I put him onto anxiolytics, hoping they would make a difference. They did not. Eventually the decision was made to refer him to a specialist in Cape Town where hopefully a diagnosis would be made.

I prepared a letter of referral in my office. Under “Occupation” in his company file I found the following entry, “Tailor and upholsterers’ assistant,” which I wondered at. Unlike the other Xhosa men in the town who were mostly bedrock sweepers, as had I assumed him to be, it was an unusual job to be doing on the mine.

I knew there was something important in this revelation, but for a while I could just not place it. And then intuition kicked in … pins and needles! In his stomach, in the same place, day after day! I ran through to his bed and, very carefully, looked closely at the skin of his abdomen. There, just visible under good light, were a dozen healed pinpoints, much the same as that left by a hypodermic syringe, or a needle.

The abdominal X-ray revealed them, nine in all. Three- inch long upholsterer’s needles, buried deep into the skin and muscle, where he had forced them in a silent cry for help. A two-hour operation managed to locate them all, and several days later he went home to the Transkei, where he chose to remain.

I learned a valuable lesson with that young man; that all the training and theoretical knowledge in the world is sometimes inadequate or useless. I hadn’t needed it — he had told me himself at least part of what was troubling him, across a language barrier that for me at the time proved insurmountable — “pins and needles in the stomach, doctor.”

I just hadn’t listened nor understood carefully enough.