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The Art of Medicine

First, do no (more) harm

Grant, Jill PA-C, MMS, MS

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Journal of the American Academy of PAs: November 2013 - Volume 26 - Issue 11 - p 1-2
doi: 10.1097/01.JAA.0000436689.21423.f0
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Just as it had done exactly 116 times before, this year's Boston Marathon got off to a beautiful start. From the Start Line in Hopkinton, through the cheering crowds in Wellesley, up (and up) Heartbreak Hill, and finally down Boylston Street into Copley Square, runners accomplished an amazing feat as each made a final surge across the finish line. Both inspired and inspiring, these athletes defined the meaning in such a way as only a proud few had done before them.

And to be sure, none of us can ever forget what happened next. Cheers turned to screams, celebration devolved to chaos, and strangers became lifesavers. Ironically, the line to which so many had been running all day now became the line from which they fled.

I was not in Boston that day. For me as for so many others, simply watching these events unfold on a high-definition screen was horrifying enough. I struggled with many emotions throughout the week that followed—as a human, as a mother, as a recreational runner, as an American. And certainly as someone who took an oath to care for others.

I have thought so often of the numerous victims on Boylston Street on that fateful April day. And perhaps just as often, I have thought of those healthcare providers who worked as volunteers in the medical tents, treating dehydration and muscle cramps throughout the day until they were asked to risk life and limb to save the lives and limbs of others. I have thought of those who rode along in ambulances, traveling what must have seemed an interminable distance between the finish line and the ambulance bay. I have thought of those who stood gowned and gloved in emergency departments and operating rooms, awaiting the arrival of those to whom so much harm had come.

Though it actually weighs very little, the white coat must have laid heavily on the shoulders of many that day. The luxury of time had all but evaporated in the blast of the nails and the ball bearings and the glass. Decisions, both life-altering and life-saving, were made in an instant for the sake of first doing no (more) harm. To be sure, in a moment like that, the meaning in the words of Hippocrates merely blended into the actions taken, losses counted as gain for the greater good.

Not at the time, of course, but much later, I thought more carefully about what it must have meant in those moments to “first, do no harm.” The tenets of the oath we take as healthcare providers are rooted in the belief that the intent of goodness in our care must outweigh the potential for harm. This concept seems easy enough to understand in the face of borderline hypertension or a sprained ankle. Even terminal illness or injury spurs us onward in our quest to provide comfort and care, in spite of knowing the good in the outcome may be different from what we hoped for. But what happens when the harm that befalls our patients is so carefully planned by others? When days and weeks and months are spent stitching together the grievous plot that will tear apart so many? How does one separate the horror at work from the job at hand?

Out of necessity, each practitioner who provided care for someone brought in from Boylston Street on that day was able to do just that. In many ways, they undoubtedly did what they do every day. Resuscitations, stabilizations, and operations were performed time and time again. And as the smoke slowly filtered away, it became clear that all but a precious few would survive. For a time during that harrowing week, even those who had planted these devastating devices went on with their lives, unnoticed and unscathed, until a series of events more befitting a screenplay of horror unfolded in Watertown. Ironically enough, some of the same healthcare providers were again called into action—this time, to mend the wounds of one who was suspected of doing much harm indeed.

What grace, what dignity, what honor was brought upon the work we do every day by the work carried out in Boston on that day (and in the many days that followed). I am amazed as I reflect on the selflessness, the coordination, and the quality of the care given to those many innocent victims at Tufts and at St. Elizabeth's, at Beth Israel Deaconess and Boston Medical Center, at Boston Children's Hospital, at the Brigham and Women's Hospital, and at Mass General. It is a testament to the strength of each and every person who cared for another on that day, to be sure. But it is so much more than that.

Each one of us, when we stand with pride to take our oath as a medical caregiver, makes a pact with the rest of humanity. We take on the weight of everything it means to have others place their care, their well-being—often their very lives—in our hands. We don a white coat, place a stethoscope around our necks, and agree to face head-on whatever the day might bring, always with the intent of placing the needs of our patients above our own. On most days, we are able to live the words of the oath we take without a second thought. To “first, do no harm” is as natural a gesture as any, and we find ourselves grateful for the chance to simply do what we do. Truth be told, I am certain that day in Boston was really no different in that regard.

Yet I remain grateful for the inspiration I continue to find in those who bridged every gap on that day. Those who knelt on sidewalks with only a T-shirt or a belt to staunch the bleeding of complete strangers. Those who raced down Boylston Street pushing wheelchairs toward overcrowded ambulances waiting to forge through the chaos. Those who delegated, intubated, operated—and at times, even amputated—all for the singular cause of fulfilling an oath taken long before. Since that unforgettable April day, I am reminded as one who also took that oath that harm will, of course, come to patients in my care. But I can only hope that the strength it takes to “first, do no (more) harm” in the presence of such horror lies within me, just as it was found in each of those who provided care on that day. It is a rare kind of inspiring strength, a different kind of strong.

It's Boston Strong.

© 2013 American Academy of Physician Assistants.