Do No Harm: The Student’s Paradox

This is my first post for ‘Com(med)ore,’ my new blog. Here, I hope to chronicle my experiences as a medical student at Vanderbilt University over the next four years, from White Coat Ceremony to Match Day. In the lead-up to medical school, I’d like to share some of my essays reflecting on my time as an emergency medical technician during my undergraduate years. Thanks for reading; any feedback and comments are welcome!

What happens when medicine’s cardinal dictum meets its steep learning curve?

Primum, non nocere. First, do no harm. This is medicine’s golden rule, every health professions student’s North Star of guidance. For in medicine, there is much that appears futile, much that weakens our foundational preconceptions of ‘right’ and ‘wrong,’ much that offers some distant, plausible benefit beyond the horizon. All this, we justify with the understanding that, if nothing else, we leave our patients no worse off than as we found them.

Except, that is, when the task requires it.

To the novice EMT student, the teaching hospital is a daunting place. Everyone—except you—seems to have a defined task and purpose. The attendings review charts, the residents conduct physical examinations and obtain histories, and the nurses administer procedures and monitor patients. Amidst the structured chaos of the emergency department, it’s hard for a learner to not feel like a weed in the grass, an inessential intrusion lacking roles or responsibilities. In the overcrowded county ED, where beds of agonized patients spill out the exam rooms into the hallways, even observing from a corner means being in the way.

I was only too happy, then, when a voice barked, “You, student, get over here.” I looked up clumsily and, seeing a nurse across the room gesturing in my direction, hastily obliged. Without even a glance away from the computer screen, she thrust a plastic bag of supplies into my hands. “Here, make yourself useful. Bed 23 needs an IV.”

I walked over to ‘Bed 23,’ whose name was Ms. Suarez, an elderly Latino woman whose grandmotherly, pleasant demeanor belied the throbbing pains and swelling in her leg. Recalling our classroom instruction, I recited the didactics in my head. Position the arm. Apply the tourniquet. Arrange your equipment. Flush the extension set. Sure enough, there it was: a bouncy, blue-green line right in the crease of her elbow. I swabbed the site, unsheathed the catheter and mumbled, in a hesitant tone that surely betrayed my naivete, “A little poke; un poco dolor!”

Tensing to subdue the quiver in my hand and heart, I readied myself for the plunge. Just like class. This is just another manikin … except, one with nerves, emotions, and probably, a temper if you don’t get this right. With a deft motion, I pulled back the wrinkled skin and inserted the beveled tip into Ms. Suarez’s arm. Anxiously, I fixed my gaze upon the catheter, hoping desperately for the flash of scarlet that meant a job well done. Nothing—damn. I looked up to Ms. Suarez, her pained, yet forgiving, gray eyes meeting mine as if to say, “There, there.”

And here, I thought it was the healthcare provider’s role to do the caring and comforting.

A band-aid later, I again prepared myself, determined not to let down this frail grandmother who reminded me so much of my own. Place tourniquet. Flush tubing. Palpate vein. Cleanse site. Unpackage catheter. Insert stylette. Bevel down. Aim shallow—not too shallow. Once more, I searched in anguish for a flash in the catheter, but found nothing.

“Dig around in there,” a resident at the next bed advised, “Sometimes, you’ve got to explore nearby to nail it.” My eyes darted from the catheter, to Ms. Suarez, and back. With every additional failed attempt, with each futile dig, I saw her flinch in agony, her lip steadfastly bitten in attempt to mute her expressions of pain.

Finally, head down and tail between my legs, I sheepishly returned to the nurse’s station and admitted that I hadn’t been able to perform the most elementary of tasks. I watched as she, almost effortlessly, placed the IV, my eyes too ashamed to confront Ms. Suarez’s once more. “Don’t sweat it,” the nurse casually remarked, “Some people just have bad veins.” As if the responsibility for my errors wasn’t mine, but the fault of Ms. Suarez and her ‘bad veins.’

We always default to ‘do no harm’; it’s as much a staple of medicine as the white coat, pager, or stethoscope draped over the collar. Yet in the natural learning curve of patient care, to err, to fail, and to hurt are almost inevitable. That first blown IV, the first failed intubation attempt, the first perceptual error by the novice diagnostician—these are the unavoidable costs of developing mastery. If we don’t try and fail on the first patient, it’ll be on the next person, or the one after that; the climb to competency must start somewhere. As reluctant as I was to make further attempts after my struggles with Ms. Suarez, I acknowledged that continually trying—even if it sometimes meant failing—was the only way to eventually emerge a proficient provider.

When doing harm is likely, or probable, or seemingly inevitable, how can we, as students, respond?

First, we can find mentors that don’t berate failure, but comfortably acknowledge and constructively address it. The pressure to perform and the stigma against failure that pervade cultures of healthcare often don’t prevent mistakes, but perpetuate them. As Clayton Christensen said, an organizational philosophy of ‘failure is not an option’ is really an unwillingness to discuss or improve upon failure.

Second, we can ‘bend’ the learning curve through practice. No manikin, drill, or application can truly replicate the bedside experience, but they can approximate it. After my first unsuccessful intubation attempt, my preceptor challenged me to practice the task until I could do it correctly and under time for 100 repetitions. The next attempt, then, was simply my 101st consecutive success; muscle memory and the comfort of experience made the difference.

Finally, and most critically, we can offer our patients the gratitude, humility, and candor they deserve for being our most important educators. Despite our best efforts, harm happens. The best we can do for our patients is to thank them for walking with us up that steep learning curve, so that we can someday provide for our future patients and community the highest standards of care.

In this patient encounter, names, events, and details have been altered and fictionalized to protect patient anonymity.

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