1: “First, do no harm.”
This statement is attributed to the ancient Greek physician Hippocrates.
“It succinctly states the physician’s primary responsibility, which is to not kill our patients or do anything that might make their condition worse instead of better,” Dr. Peter Attia writes in his book Outlive: The Science and Art of Longevity.
There are only three problems with this statement, Peter tells us:
First, “Hippocrates never actually said these words.”
Second, “It’s sanctimonious bullshit.”
And, third, “It’s unhelpful on multiple levels.”
All right then.
2: One night, while Peter was working as a surgical resident at Johns Hopkins in Baltimore, a seventeen-year-old young man showed up in the Emergency Room with a single stab wound in his upper abdomen.
“He seemed to be stable when he rolled in, but then he started acting odd, becoming very anxious.
“A quick ultrasound suggested he might have some fluid in his pericardium, the tough fibrous sac around the heart.
“This was now a full-blown emergency, because if enough fluid collected in there, it would stop his heart and kill him within a minute or two,” Peter writes.
The clock was ticking. There wasn’t time to take the patient up to the Operating Room because he might die in the elevator.
“As he lost consciousness,” Peter writes, “I had to make a split-second decision to cut into his chest right then and there and slice open his pericardium to relieve the pressure on his heart.”
Which is what Peter did.
“It was stressful and bloody, but it worked,” he recalls, “and his vital signs soon stabilized. No doubt the procedure was hugely risky and caused him great short-term harm, but had I not done it, he might have died waiting for a safer and more sterile procedure in the operating room.”
3: “Do no harm”? Seriously?” Peter asks.
“The reason I had to act so dramatically in the moment was that the risk was so asymmetric: doing nothing—avoiding ‘harm’—would likely have resulted in his death,” he writes.
“Conversely, even if I was wrong in my diagnosis, the hasty chest surgery we performed was quite survivable, though obviously not how one might wish to spend a Wednesday night.”
Once the young man’s condition stabilized, Peter determined that the knife had just barely punctured his pulmonary artery. It was fixed with two stitches. He went home four nights later.
What bothers Peter about “First, do no harm,” is its insinuation that the best treatment is always the one with the least immediate downside risk.
“Every doctor worth their diploma has a story to disprove this nonsense,” he observes.
Sometimes, we must take the leap. Sometimes, doing nothing is the riskiest choice of all.
This approach applies to other less stressful medical situations, too. Like “subjecting a patient to a colonoscopy, with its slight but real risk of injury, versus not doing the examination and potentially missing a cancer diagnosis.”
Peter’s bigger point?
“Risk is not something to be avoided at all costs,” he writes. “Rather, it’s something we need to understand, analyze, and work with. Every single thing we do, in medicine and in life, is based on calculation of risk versus reward.”
More tomorrow.
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Reflection: How does Peter’s story apply to my life?
Action: Discuss with a colleague, friend, or family member
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