Monday, 19 January 2015

Primum non nocere

"If the patient is going to be damaged, I'd rather
let God do the damage, than do it myself.
That's a very on-the-button dilemma for those "in charge".  When I was young and foolish, we didn't get The Boy immunized, either for MMR (measles-mumps-rubella) or DPT (diphtheria-pertussis-tetanus) and in due course he got measles (aged 2) and whooping-cough/pertussis (aged 12). When he arrived in Boston aged 5 and enrolled for a Community Health Plan, the medicos were shocked that a white, middle class child had contracted measles. We had some woofle-think arguments in favour of the no-vaccinate position but it basically came down to not wanting to take responsibility if he turned autistic from his MMR - preferring God-given blindness, deafness and more serious brain damage from his not-MMR.  20 years later, we had grown up and got the girls the full set of shots - didn't prevent Dau.I from getting mumps as a teenager though!

I got a late Xmas present from my mother Do No Harm: Stories of Life, Death and Brain Surgery by Henry Marsh, neurosurgeon. The title is derived from the Hippocratic Injunction primum non nocere [above all do no harm] which is not in the Hippocratic Oath and indeed seems to have been conjured up in the mid 19thC by Dr. Thomas Sydenham. The reason I have that header-quote is because it was advice or a musing given to Mr Marsh by his neurosurgical mentor. I've been ripping through it: the last book I finished Nate Silver's Signal and Noise took me 10 months. S&N was good stuff: chock-full of interesting and thought provoking material but I could put it down.  It's interesting that DoNoHa has no illustrations: the writing is so lucid that you don't need a picture to save 1000 words.  And this is not to say that the language is for reading-age=7; the horrendous tumours Marsh has dealt with are all properly labelled and acronymed and adequately described. I had to look up wikipedia, though, to find out why ITU is his preferred acronym but used interchangeably for Intensive Care Unit (answer: Treatment)

The neat little chapters each start with a medical war-story and use that as a springboard to further discursions on matters that engage the great man. Rather like the small but perfectly formed radio-essays by Alistair Cooke. Some of the themes:
  • Compassion vs Detachment. Surgeons don't operate on their own family because their judgement is sure to be clouded by their anxiety to Do No Harm.
  • In obtaining informed consent, you can tilt the discussion by saying that intervention may lead the patient to be disabled which guilts the family into believing/asserting that, of course, they will look after the damaged goods (forever!). That makes it emotionally easy for the medics and usually leads to them doing something OR you can ask "what would your boy want (for himself and for you)" which leads to a difficult and prolonged discussion to resolve the competing emotional needs of parents, siblings, wife, children and sometimes falls in with Hippocrates by doing nothing.
  • You should never allow anecdotal thinking to cloud your judgement - just because you've been caught once by a vanishingly rare concurrence of circumstances and killed or 'wrecked' your patient does not make those circumstances more common or likely.
  • After an explanation or a discussion, either brief or prolonged, nobody reads the multi-page informed consent form before they sign it.
  • Moral hazard abounds in  the National Health. If the patient or the relatives insist, an expensive and medically doubtful procedure may be carried out in order to prolong life for a few weeks or months.  As no new surgery can be carried out unless a post-operative bed is known to be available, 93 year old Mrs Doohickey's biopsy may block the prerequisite emergency admission bed for, and so condemn, a young wage-earner with school-age children.
  • Mistakes in surgery are usually mistaken decisions rather than slipping scalpels or operating on the wrong leg. In neurosurgery, the key is knowing when to leave well enough alone: going for the last tricky bit of adhering tumour is what rips the artery.
  • You never get any experience if you do nothing. 
  • Young doctors do not get sufficient experience if they are compelled to work less than 48 hours in a week by a European Working Time Directive EWTD. Young Marsh worked 1 in 2 as a trainee doctor: on top of a working week he was on-call (sleeping in his clothes) every other night and every other weekend to be available for about 120/168 hours.
  •  Experience is built on mistakes [L view of Mr Marsh's St George's Hospital from where much of his experience is laid to rest].
  • EWTD might result in more coherent decisions by doctors who are not woozy from sleep deprivation but it makes a monkey of continuous patient care: nobody really knows the base line status of patients in A&E or on the ward if they haven't been on the firing step for long enough to establish the base line.
  • Ethics is hard
Listening to Mr Marsh talking about his book to medical students at UCL is a long hour well-spent (it will save you having to read the book if you're very busy-and-important). In the final Q&A session he shares a favorite analogy to show just how crude are the surgical tools at his disposal: one of his standard slides contrasts a pin-head with the bucket of a bulldozer which he claims is in the same proportion as his finest 2mm micro-surgical probe compared to the 1µm width of a single neuron. In all my classes I emphasise these questions of scale to help students appreciate relative size - an essential prerequisite for getting a feeling for the organism.  You can find other reviews of the book in all the British broadsheets.  You should think about reading this book even if you don't have a brain tumour.

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