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Wednesday, March 9, 2011

First Do No Harm


Primum non nocere.

Of course we all recognize this as the cardinal rule of any medical practice. Nonmaleficence, meaning that it is entirely possible that the best course of action for me to take in an emergency is to actually do nothing. That doing nothing, and thus not causing further harm, may be better than being wrong in a manner that leaves my patient in worse shape. Now take all of that and combine it and roll it into a big ball and realize that I grapple with this in a split second when my patient has stopped breathing. That instant that truly seems like an eternity. The great void between the realization that your  patient is indeed pulseless and apneic, and the pushing of the big blue button that will trigger the calling of a Code Blue. In my career, I have had situations where I go back and think about  a patient and wonder if me reaching any conclusions sooner would have changed an outcome. And thus far, I have had the luxury of being able to say that I don’t feel as if I have harmed anyone.

Last night, I had to face that possibility when, after some aggressive airway management for a patient who wasn’t ventilating well, I witnessed the spiral. First the oxygen saturation starts to drop. And then the blood pressure is low, followed by the slowing of the heart rate. Finally you reach that chasm where the heart ceases to beat, whether it be a pulseless ventricular rhythm or completely asystolic. The patient is dead. Expired. And you can do all you can and whip out everything you have learned in years of education and professional experience in the hopes that it will help. That the heart will resume beating. (Not so much the breathing because, honey, I can make anyone breathe with the right equipment.) But this happened last night. While I was there with my hands on that patient, taking the opportunity to teach a new ICU nurse about ventilator basics. I have never had that happen to me. And after we got her back not once, but twice, and they finally got the stat chest film for which I kept begging, it was determined my patient had a pneumothorax. And so when the family arrived at the bedside and told us to stop all efforts at resuscitation due to patient wishes, in the blink of an eye, my role switched from caring for the patient to caring for the family. To help them find some peace in her death. I did all I knew to do. I extubated her, washed her face, smoothed her hair, tucked her in, and left the room so they could have those final moments with her on her death bed.

And then I went into my back office in the ICU and I cried. Actually I started crying before I got there, prompting fellow ICU staff to follow me to make sure I was okay. I was. I was still breathing. My patient wasn’t. It was the first time in my career where I was physically working with a patient when they went down, and my instantaneous thought was, “Did I do that? Did I hurt her?” Of course after logically recounting the steps to her demise, it is obvious to me that she suffered the pneumothorax before I did anything that could have caused it, and thus I cannot blame myself. But it just did something to me, and I cannot really explain why.

I love my job. Love it. But I have always had confidence in my professional skills and training. I haven’t really doubted myself before this. Well, I have, but not in the manner that I had to stop and think on whether or not I did damage. I have always said that the most dangerous person in healthcare is the one who will not admit that they don’t know everything. So with that in mind, there has always been a healthy dose of fear. There has to be when you are literally running someone’s life support. But that fear cannot be so great that in inhibits one’s performance, one’s ability to be on their toes when a true life-and-death emergency strikes.

Lately, as a senior therapist, I have been mainly working the critical care units. Once in a blue moon, my boss will give me something else so I don’t go insane, but it isn’t very often. And the thing about this is that I am in a teaching hospital. Meaning when there is an emergency and the code team assembles, it really is a team effort. In other areas of the hospital, this may not necessarily be the case because there are more seasoned physicians running the show. But in the ICU’s, you get residents. And the presence of “MD” behind their names has yet to give them the idea that they know all because of their education level. They know that an experienced ICU nurse or therapist has seen a lot and can help them. I work with them on intubations, on managing pulmonary issues. I give crash courses in blood gas interpretation or ventilator management. And in a code, when we get to the point where we have exhausted all possible causes, or in one where the cause is obviously pulmonary in nature, they look to the therapist. Me.

I don’t know what I’m getting at here. I think it is just that I had to think last night that it was possible that I hurt a patient. And even after coming to the conclusion that I did not, the fact that I could have just seemed to linger. And of course this has made me think of my role in the hospital even more than I have before. The pressure. The weight. The responsibility.

I upheld my ethical commitment last night. I did no harm. But I had to come face to face with the idea that I hold lives in my hands when I go to work and clock in at night. That I very well could hurt someone. I think it just caught up with me.


  1. First let me give you a big hug.

    Now let me remind you that you did not interact with this patient at the mall -- she was at the hospital. Because she was sick or injured. In other words, EVERYONE you see is already in bad shape.

    My father in law is dying. He was in the hospital and we frankly had to fight to be able to take him home. I don't know if he is going to die tonight or next week or next month. But no matter what, if he stopped breathing, it wouldn't be the RT's fault. It would be because it was time for him to go.

    That probably doesn't make it any easier. . .

    Here's another hug!

  2. Thanks Mary. And I know, I know. It's still just hard.

    And I am so sorry about your grandfather. That must be so difficult for you.