Do No Harm

There’s this thin line in healthcare. On one side is the necessary pain or discomfort that comes along with tests and treatments aimed at improved health and well being. Much of healthcare is invasive, humiliating or painful – but people will agree to it because of its role in restoring or protecting our most valuable belonging – our body. We will sign our consents on the line of things that in any other setting for any other reason could qualify as torture and its perpetrators cruel. But as long as the potential for improved good weighs more heavily than the inflicted hurt, these actions are justified.

This good vs hurt exists on a spectrum, and it can be hard to discern when we’ve begun to creep across the line to where the actual harm becomes greater than the potential good.

It was really a rather routine exam that brought these thoughts to the forefront. I stood on the side of my elderly patient’s gurney and helped her roll to her side. Elastic pants were laboriously tugged over and under an ample bottom. She had the possibility of bleeding coming from her intestines and there’s a simple way to verify that. The doctor does a rectal exam – a generally quick but humiliatingly intimate encounter. I was primarily there to bear witness – and to help with the elastic. She was a little confused, but not very, which for your 8th decade of life is quite acceptable. The exam turned out to be immensely painful. She erupted in agonized cries and entreaties as the doctor probed “just a minute longer” to get the information he was seeking. I’m sure it only lasted a few minutes, yet I disturbed by the emotional impact the pain had on the old woman. She was left shaking and in a traumatized lapse into dementia began begging for her mother. I couldn’t help feeling we’d crossed that line.

I see this dilemma faced often in the ER. We are medical detectives in search of clues – clues that comes at times with ease and at times with great difficulty as we pursue them with our fingers, our probes, and our needles. We will at times go to great lengths to tease out these stubborn secrets from uncooperative bodies. How many times do you poke the flailing toddler with flat veins before you decide not knowing what’s in their blood is more acceptable than the pain you’re inflicting? Is it necessary to pursue a better IV site with a large bore needle in the terminal patient who’s asked for comfort care? How many ribs have we broken in CPR on frail old bodies in heroic efforts to add just a little more time to their life span?

We insulate ourselves – necessarily – from the emotional impact of regularly hurting people in hopes of healing them. But the insulation – along with the constant pressure of busyness – can cause us to miss those times when it starts to become unjustified. When we are in fact, doing harm.