Medicosnext
WHEN LETTING GO HEALS
Dr. Niran Maharjan is a senior consultant plastic surgeon at Bir Hospital, specializing in reconstructive and cosmetic surgery. He completed his MBBS in China and advanced his training with an MS in General Surgery followed by an MCh in Plastic Surgery at NAMS, Bir Hospital.
With experience spanning Dhulikhel Hospital, College of Medical Sciences, and Alka Hospital, Dr. Maharjan brings over a decade of surgical expertise. He has also contributed to medical research, publishing several papers in respected Nepalese journals.
In medicine, as in life, courage is often not in holding on—but in knowing when to let go.
Letting Go: A Reflection on Difficult Choices in Medicine
This is not a story of surgical heroism, nor of a miraculous turnaround. Rather, it is an honest reflection on the challenges and difficult choices we face when attempting something different—with only a noble cause in mind.
We often hear that “taking a step back is wise when the situation is not favorable.” It sounds simple, even logical. But in reality, letting go—whether of objects, relationships, or even parts of our own body—is rarely easy. Humans are wired to hold on. We cling to what is familiar, even if it causes us pain, because the idea of losing it feels far more frightening than the suffering it brings.
The unused tools that pile up in a corner, the gallbladder that has long ceased to function, or the paralyzed limbs that only add to a patient’s burden—all reflect the same instinct. We prefer the comfort of possession over the uncertainty of absence. Yet, medicine teaches us a profound truth: sometimes the act of letting go is not a loss at all, but a release—a chance to restore health, dignity, and freedom.
In surgery, this truth often emerges: when an organ becomes more of a burden than a benefit, the wisest decision is to remove it. That is why an inflamed appendix is excised, or a gallbladder with stones is taken out. But there are other conditions, less often spoken of, where the same principle applies.
The Silent Burden of Pressure Injury
Pressure injuries, commonly known as bed sores, usually afflict those who are bedridden for long periods—whether from chronic illness, paralysis after spinal injury, or following neurological surgeries. Constant pressure on the same area cuts off circulation, leading to tissue death, and eventually, large foul-smelling wounds.
Prevention is possible through frequent repositioning, but for paralyzed patients, this is often impossible without assistance. In such cases, the lower limbs—once symbols of mobility—turn into a source of misery. Patients cannot move them, cannot use them, yet they cling to their limbs as symbols of wholeness. The thought of life without them feels unbearable, even if keeping them perpetuates repeated wounds, infections, dependency, and despair.
Clinical Practice Challenges
In daily practice, these situations appear frequently. For patients who can still move, wounds are often managed with daily dressings or covered with a flap procedure to facilitate healing with minimal complications, allowing them to return to normal life as quickly as possible.
The greatest challenge arises with young or middle-aged patients who have been paralyzed for years. They understand deep down that their limbs will never carry them again, yet they refuse to part with them. This presents not only a medical challenge but also a profound ethical and emotional dilemma for the surgical team.
Letting Go: The Struggle Beyond Wound Healing
The very limbs that cause repeated wounds and prevent proper positioning are still held onto as if they were a lifeline.
For doctors, the challenge is not just wound care—dressings, flaps, and debridements—but in shifting mindsets. Patients and families often focus solely on healing the wound. Without addressing the root cause, the cycle of suffering continues.
When patients and families visit, their only demand is to “heal the wound.” For them, removing the underlying cause is not even a consideration. Our priority is also to heal—but how can a permanent solution be expected without addressing the very factor causing the problem? This reluctance fosters dependence on caregivers while wounds recur, again and again.
A Seventeen-Year-Old’s Journey
A 17-year-old girl arrived with severe pressure injuries. Three years earlier, she had fallen from a tree, leaving her paralyzed and bedridden. Her poor but devoted family had provided home care, but over time, her wounds worsened—deep, infected, and malodorous.
Upon arrival at our hospital, she was wasted, depressed, and in constant pain. Intensive wound care, nutritional support, and caregiver education were initiated. When amputation was advised, her family resisted, unable to accept the loss of her limbs. Even when limb salvage through debridement and flap coverage failed, the decision weighed heavily on them.
Her mother eventually relented, but the patient herself initially said no. The sight of her paralyzed limbs prevented her from imagining a future where she could be independent in a wheelchair. Weeks of counseling, reassurance, and careful explanation followed.
Finally, she agreed. Over a month, she underwent staged hip disarticulations, using tissue from her thighs to cover her pelvic wounds.
The History and Philosophy of Amputation
Amputation is as old as medicine itself. Ancient Egyptian texts (~1500 BC) describe the surgical removal of damaged tissue as a lifesaving intervention. Hippocrates and Roman surgeons like Celsus advocated amputation to prevent gangrene, long before microbes or antiseptics were known.
Historically, amputation was a desperate measure, often performed on battlefields or during severe infections. Over centuries, advances in surgical technique, anesthesia, antisepsis, and prosthetics transformed amputation from a crude last resort into a therapeutic choice—offering patients survival and a chance at renewed independence.
Today, the same philosophy applies: when a part of the body becomes a source of suffering rather than strength, removal can be the path to healing.
The Transformation
The change in the patient was profound. She gradually learned to sit up, transfer to a wheelchair, and regain control over bladder and bowel function. The odor, dependency, and despair gave way to mobility, dignity, and renewed zest for life.
The limbs she had once thought essential were actually the source of her greatest suffering. Their removal freed her physically, emotionally, and socially. Her family also found relief, as the burden of constant wound care lifted.
A Lesson Beyond One Patient
This story is more than one young woman’s journey. It is a lesson for paralyzed patients and their families who hesitate to take the difficult step of letting go. Sometimes, what we cling to as precious may actually hold us back from a better life.
In medicine, as in life, courage is often not in holding on—but in knowing when to let go.
