Primum non nocere: Is it time for a new prime directive?
First do no harm is a worthy EMS goal, but should not supersede all others
Welcome to the first installment of EMS From a Distance, a bimonthly column that tackles big-picture topics in and around our industry.
Next to per diem, the Latin that EMS providers should know best is our prime directive: primum non nocere – first, do no harm. That’s a goal worth striving for, but I’m not convinced its priority should supersede all others.
Mostly, I wonder if primum non nocere is the best we can do. Sure, it makes sense not to want to hurt anyone, but is that really our chief mission in EMS? If so, what’s with all the pain we cause patients? Remember, this is the prime directive we’re talking about – not just any directive.
I could be confusing harm with hurt. According to my dictionary, harm can be “moral wrong,” a transgression causing damage more lasting than routine IV punctures. Sticking needles into people isn’t nice, but I wouldn’t want to make each invasive procedure a matter of principle.
What does primum non nocere suggest about risky but potentially lifesaving interventions? Doesn’t the possibility of harm, not to mention pain, rule out measures like cardioversion and cricothyrotomy? There’s no free pass for medications, either: If I administer adenosine diagnostically for wide-complex tachycardia – per ACLS – and the patient deteriorates, am I breaking the rule of all rules? These are things I think about when I can’t sleep, or when my column’s due or when I can’t sleep because my column’s due.
Perhaps we should downgrade primum non nocere to an advisory and look for a new prime directive – something less ambiguous that better reflects our street-level objectives. Here are some possibilities:
‘As if I were the patient’
The Golden Rule, a template for all prime directives, is pretty powerful stuff. “Do unto others as you would have them do unto you” covers most of the ethical dilemmas I’ve faced in the field; well, maybe not those involving elderly, disease-ridden, clinically dead people whose families insisted I attempt resuscitation. Please don’t try that on me. End-of-life decisions aside, though, I do think we should be guided by our own preferences when treating others.
‘My patient, myself’
There’s an amusing scene in the film, “Ambulance Girl,” where a dictatorial EMT instructor screams, “BSI, I’m number one!” at his students to emphasize how indispensable EMS providers are – relative to patients, at least (I think the screenwriters should have gone with “PPE, I’m in it for me,” but I digress).
Here’s where I depart from the party line, and where many of you will see me as wrong-headed: I think patients should come first. That’s actually more selfish than it sounds; I just don’t want to be burdened for all time with guilt over someone I didn’t try to save.
The public expects rescuers to be flexible about tactical self-preservation. Maybe that’s unfair, but I do think there’s plenty of ground between safe and reckless.
‘Be ready to be needed’
Among prehospital slogans, “It’s not your emergency” annoys me almost as much as “Nobody knows the troubles/horrors/sorrows I’ve seen.” I get the part about not obsessing over things we can’t control, but I don’t think caregivers should show up for work without a loading dose of empathy.
I like to think I’m all in when I respond to an emergency. It’s up to the public – not me – to decide who needs an ambulance. EMS is about answering 911 calls until someone comes up with a better plan.
‘Patients mean business’
There are fiscal realities in every revenue-enhancing endeavor, no matter how noble the purpose. Would it be so bad to view patients primarily as paying customers? Repeat business from word of mouth can be the difference between success and failure. If some families are more comfortable going to the hospital by ambulance instead of personal vehicle for sub-acute conditions, why deliver self-righteous lectures to them about real emergencies?
‘Do the best you can’
Elegant in its simplicity, “Do the best you can” fits almost any environment. That declaration’s only weakness is its lack of results-oriented accountability, a virtue that used to guide schools, companies and even families as recently as the 1970s. These days, being responsible for outcomes is often considered secondary to trying hard. I’m not sure that’s good enough for mission-critical work.
All the above phrases seem to be missing something. Credibility? Class? Maybe a little Latin would help. I mean, if I’m driving like a maniac and you shout Modero! from the back, I’m going to be very impressed with you even as I slow down. Perhaps the linguistically blessed among you could have a go at translating your favorite directives into epistulae that would impress even a Caesar.
It couldn’t hurt.