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Do No Harm

Do no harm. It’s a simple principle often repeated by medical and non-medical personnel alike. I remember one occasion when a friend asked me, “why do no harm?” He asked why the axiom was a statement phrased in the negative rather than in the positive. Why is the phrase not something more positive like, “Do good?”

During the first 3 weeks of the Internal Medicine rotation I had the opportunity to take part in the care of one Mr. S. He was a 65 year-old smoker who was admitted for a COPD exacerbation. By the time we, the medicine team, had seen the patient, the ED doctors had already seen Mr. S. In the ED, he had received breathing treatments and antibiotics; he also had a chest x-ray performed. The ED Physician’s note, though, had a short comment regarding his negative chest x-ray. It noted that the x-ray was suboptimal and this was probably due to the patient being dehydrated at the time.

The team read the note and put an order for Mr. S to have a repeat chest x-ray the following morning after he had the chance to be rehydrated. No one suspected how much this one order would change the course of Mr. S’s hospitalization. The next morning’s x-ray revealed a new suspicious mass. The reading from the follow-up CT scan reported a new 1.5 cm speculated lesion and an enlarging 2 cm lesion.

After a biopsy that would later reveal that Mr. S had lung cancer, he developed a pneumothorax for which a pigtail chest tube was placed. Somehow the tube ended up out of place – at least that is how the thinking goes. Mr. S subsequently developed massive subcutaneous emphysema. On physical exam, crepitus could be felt from his temples to his ankles. When his airways became compromised, he was transferred to the CCU for intubation and sedation.

Prior to the transfer to the CCU, there was about an hour’s worth of time in which Mr. S slowly ballooned up to the point where breathing was difficult. As a student, one often feels helpless. That feeling is compounded when the rest of the team is also unsure of what to do. In this case, everyone was unsure of how to stop the expanding emphysema. After the transfer, he was no longer under our care so I stopped knowing the details of what happened next. But I heard that Mr. S remained intubated and sedated for days as his body was allowed to reabsorb the air. I stopped hearing updates about him, but I kept thinking about it. The events that led to his emphysema and subsequent intubation and sedation were iatrogenic. It was our fault. We did not notice a misplaced pigtail chest tube until it was too late. Had we failed in doing “no harm?” I don’t know. But we certainly would have failed if the goal was to “do good.”

Perhaps it is all semantics, but I began to think that doing “no harm” is a much more attainable goal than to “do good.” Because doing “no harm” is a more passive approach. And there are times when we just don’t have a “good” option to do. We can merely attempt to do things that won’t make a patient worse while we allow the human body to heal itself. Which is exactly what it felt like we were doing for Mr. S. I kept asking anyone who would hear, “why can’t we do something?” It is a tough thought to accept for people who enter medicine with the intention of doing something. But maybe this slight difference in semantics will help those of us who are in medicine keep our sanity, to feel like we accomplished something – or at least that we are not failures at such a lofty goal as “doing good.”

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Angry Patients

“Oh, you guys get to go home, huh,” the man in the black t-shirt sad with a grin.

I heard my classmate laugh as the four of us continued walking through the waiting room towards the exit. We had just concluded a one-hour lecture and it was time to go home for the weekend. But in order to get from the conference room to the parking lot, we had to go through a waiting room half-full with people had been waiting for who-knows-how-long.

“How can you just leave when there are people waiting here?!” A second patient yelled out sarcastically. At least I thought she was saying this in fun. In response I smiled at her.

But after I rounded the corner, I whispered to my classmate, “I think she was serious.”

So far, I have been fortunate enough to avoid personal encounters with angry patients. I have watched as attendings talked to frustrated and angry patients. I have heard stories of patients telling other students that they don’t like them or other stories of angry patients yelling at medical students. But I have never had the misfortune of experiencing this first-hand.

I fear, though, that it is inevitable. Anyone who deals with patients will eventually have to deal with angry patients. I just hope that when the time comes, I will be able to handle it well.

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Medical Humor – Four Doctors Go Hunting…

Four docs went on a duck-hunting trip together: a family practitioner, a gynecologist, a surgeon, and a pathologist.

As a bird flew overhead, the family practitioner started to shoot but decided not to because he wasn’t absolutely sure it was a duck.

The gynecologist also started to shoot, but lowered his gun when he realized he didn’t know whether it was a male or a female duck.

The surgeon, meanwhile, blew the bird away, turned to the pathologist and said, “Go see if that was a duck.”

– Brought to you by the Internet
Source: Link

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Whoops, It Was A Good Day

Today was the first day of my 3 weeks of outpatient internal medicine. Some people refer to it as Ambulatory Medicine. Maybe that’s because the patients, for the most part, walk in.

I was putting on my shoes on the way to the 7:30 AM orientation session when I noticed a text message on my phone. It was from a classmate. It read, “Where are you?”

It was 7:15. Plenty of time for me to get to the hospital for the orientation. But with the text, I realized my mea culpa. It was a 7:00 AM orientation.

But what can you do? Whoops. So I strolled in to the conference room 30 minutes late and took a seat.

And that was my entrance into Ambulatory Medicine. It was a fitting start to the day. Because for the rest of the day I felt a little bit lost. Ok, fine. I felt a whole lot lost. Whether it was what to do with the patient after I had finished up with them, or where to send them when my attending wanted a STAT X-ray, I was totally in the dark.

A number of times I walked to the friendliest looking nurse and asked what I was supposed to do. What do I do with this chart? This patient is ready to go, do I just send them outside?

I saw a total of three patients today. None of them were terribly complicated patients. Their problems were manageable. But the situation was uncomfortable — for me.

But when it was all said and done, it was nice to have seen the patients. The population at a VA is a unique one. I remember one elderly patient who was in the US Army Airborne back in his day. Served 3 tours of active duty. He also showed me pieces of shrapnel under his skin that were still just coming up to the surface some 30 years after his injuries.

Crazy day. A day that started with a “whoops” and was filled with almost a constant sense of being lost. But it was a good day.