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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  • Good post. Or should I say, “Your post wasn’t bad.”

  • Great post! I’ll be starting my clinical rotations on January 3rd, and I’m beginning with internal medicine. Hope I too become as wise through my experiences as you obviously are. 🙂

  • Thank you. Although I hardly think I can call myself wise.

    Good luck as you start your clinical rotations! Patients can be amazing teachers. And have fun 🙂

  • smoking is a big cause of massive subcutaneous emphysema ?
    very dangerous disease it seems 🙁

  • Definitely always aim to do no harm…
    And seek to do good 🙂

  • In the medical profession, these kind of “doing no harm” situations are commonly encountered. Hopefully, experience would teach us how to successfully deal with it.