first do no harm

Sunday, March 11, 2018

If sport is supposed to teach teamwork, ethics and fair play, it has been a difficult week. From high school kids to pros, win at all costs should not include intentionally trying to injure an opponent. Two videos, one from a high school basketball game and the other from the NHL

Somehow the concept of sportsmanship and protecting an opponent was lost. It’s one time where medicine might be able to teach sport.

First do no harm

  • In ancient Greece, the Hippocratic Oath included the promise “to abstain from doing harm”
  • Thomas Sydenham was considered the father of English medicine and in the 1600s wrote the textbook of medicine that was the standard of care for more than 200 years. He wrote “”I have consulted my patients’ safety and my own reputation most effectually by doing nothing at all”
  • In the late 1700s, Auguste Francois Chomel, a French medical professor routinely lectured “it is only the second law of therapeutics to do good, its first law being this – not to do harm”

Medicine has become very technical and based on scientific research, but with all the therapies available, it’s important to balance the benefit and risk of those treatments. Stepping back and deciding how best to offer care to those in need, is to be reminded that patients have some say in decision making.

Consider the guidelines published by the American College of Cardiology regarding the treatment of atrial fibrillation and the need to use anticoagulation to prevent stroke. Patients in A Fib need to be risk stratified to help decide what treatment might best fit a specific patient’s situation, because one size does not fit all when it comes to blood thinning. In A Fib, the atrium (upper chamber of the heart) does not beat regularly but instead jiggles. This allows small blood clots to form along the atrium walls; they can break off and travel to brain, clogging arteries, preventing blood flow to brain tissue and causing a stroke. While it might have been easier just to list recommendations, the first guideline reveals more than a little wisdom and compassion:

“(anticoagulation) therapy should be individualized based on shared decision making afterdiscussion of the absolute risks and relative risks of stroke and bleeding and the patient’svalues and preferences”

Throughout the guidelines, there are discussion points about benefits and risks of specific treatments. Aspirin, once a mainstay of treatment, may or may not be an appropriate treatment for stroke prevention in atrial fibrillation. 125 patients have to be treated to prevent just one stroke and those 125 are put at risk for bleeding, especially from the stomach.

Balancing risk reward, has become routine in the practice of medicine. Unless a solid indication exists to prescribe antibiotic, the risk of complications likely outweighs taking the drug. Complications include drug resistance, opportunistic infections (where good bacteria are wiped out and others invade…like C. Diff) or allergic reaction. Similar risk reward discussions happen with ordering x-rays and CT scans, and rule and guidelines have been developed to help direct when a test will be helpful and when it might be a waste of time and radiation.

First, do no harm, primum non nocere. Small steps happen to prevent errors. In pre-op, surgeons visit with patients and confirm the upcoming surgery, often writing on the patient in magic marker “not this leg”. Nurses have their colleagues check labels and dosage before injecting medicines into an IV. Everybody who touches a patient, usually asks their name and birthdate. Taking things for granted no longer is acceptable in modern medicine,

Sadly, there are times when mistakes happen and medical culture is changing. Instead of finger pointing, critical incident reports occur to understand why a mistake occurred and not just to lay blame. While one mistake might be tolerable, the second is not so much. Team play has become a realistic goal when it comes to patients, families and health care providers.

First do no harm…after that medicine should be a lot easier.








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