When in doubt, first do no harm

How do we respond to so many collective emergencies?

Photo by John Fowler on Unsplash

I awoke to a heavy, moody gray sky amplifying the heaviness in my heart.  What could I possibly write, I wondered, that offers anything to this moment as an emergency of violence of yet another war bursts into global awareness¹? As I awake, I anxiously wonder what has happened while I slept and check my sources of news.  

Like you, I am barraged with voluminous yet, sketchy information, some true, some not some much.  Well-meaning journalists and others do their best to tell what they know and what they don’t.  This early in the crisis, we don’t truly know very much. Some voices feed off the fear, make stuff up, purposely feeding lies into the public chaotic conversation for less than honorable purposes.  With so much information coming at us at any given time, and particularly in evolving emergency situations, it’s very hard to have any certainty about what is real and what is not.  And yet we must try…for our own safety and to be helpful if we can.  At least, that’s how I think about it.  How do we act in rapidly evolving situations when our collective conversation quickly fills with chaos, fear, and vitriol which is often louder than what is real?  These are questions I’m asking myself. 

First, do no harm. That’s the answer I have - not much of an answer, but useful for the moment.  I have no special knowledge of Mideastern affairs. I have no Jewish, Palestinian, or Arab ancestors and I’ve studied nothing about this except for news coverage (which is totally based on my interest and attention - thus inherently biased). My childhood in fundamentalist Christianity would see this instability as significant evidence of the ‘end times’, something to be anticipated with excitement and foreboding.  Likely millions around the world are responding consciously or unconsciously based on beliefs around Armageddon prophesies - something to be aware of but not very helpful for guiding me through this present moment.

The phrase “First, do no harm”, or in Latin primum non nocere, is a value I learned in medical school.  A bit like a mantra, it’s something we repeat to ourselves when the path is unclear, or an emergency is unfolding.  Of course, at a literal level, harm is unavoidable, because action and change involve destruction and often pain, which are versions of harm depending upon one thinks about it.  Nonetheless, I find the phrase to be a useful reminder, an indicator of the boundary where risk and benefit converge.  Too much action or intervention can cause unnecessary suffering, with diminishing benefit. Too little action or inaction may be neglectful. Finding the right balance is an ever-moving challenge, guided by doing the most good and with the least bad side effects.

Although attributed to Hippocrates and the Hippocratic Oath, the phrase isn’t in the Oath².  Its origins are disputed, sometimes attributed to a nineteenth century English physician, Thomas Sydenham³. Others suggest it was a mistranslation of Greece into Latin from a different writing by Hippocrates called Epidemics⁴.  I read neither Greek nor Latin, so that’s about all I can offer on the correctness of translations, so I’ll leave the argument to academic scholars and move on. 

The point is this; during emergencies we need simple things to fall back on because our minds, or rather our executive functioning of our prefrontal cortex, work differently when we go into emergency mode. Our limbic systems are activated focusing our bodies and thoughts on personal survival and on those we care about most.  Our more expansive, abstract, and universal ways of thinking and considering are not available, go off-line, until we calm down and the emergency subsides.  We only have our instincts, our biologic survival responses, our emergency memory, and some of our experience to draw from.

When war breaks out, when natural disasters occur, when other terrifying things happen, we quickly flip into emergency mode. That’s why people who work in emergency situations train, so we have useful information available in simple-to-remember form available, so we take useful action, despite our emergency brain activation. 

As a young doctor in training, I spent much of my time terrified.  We were put in emergency situations without the skills needed, taught be people only slightly more skilled.  Teaching was transmitted from senior person to more junior, down the line…see one, do one, teach one was the saying thus, one learned whatever one’s senior person believed to be right action.

Prior to availability of formal resussitation programs, while still a resident, I prioritized going to conferences on emergency pediatrics because I wanted to do the best I could by my patients in a crisis and reduce my fear.  My fear was that I would fail someone in their time of need, and they might die or be permanently injured because I didn’t know what to do. Really bad things happen at unexpected times and being prepared was my best strategy.

As a young pediatrician in training in those days, I was on call in the hospital as the first line of defense even though my skills were limited⁵. A child in critical condition could easily die while waiting for a higher-level physician to drive in from home. I put a lot of effort into making sure that didn’t happen because of my lack of preparedness, and thankfully, it didn’t. I prioritized identifying the most important thing I needed to do to keep someone alive until more sophisticated help arrived. I’d learn that skill, then the next, then the next. That started with gaining expertise in establishing an airway (ensuring air could get in and out) and breathing. I studied and gained skills of intubation (breathing tubes) and running ventilators. I got good at starting lines (IVs and others) to give medications and fluids.  The more skills I had, the less terror I felt. 

Resuscitation protocols and Code Blue concepts are recent developments in human history. CPR (cardiopulmonary resuscitation) was first introduced in the 1960s; citizen and first responder training began in earnest in the 1970s⁶.  ACLS (Advanced Cardiac Life Support), a training for medical professionals to improve survival for people suffering cardiac arrest, was first publish in 1975.  By the time I was in medical school in the early 1980s, algorithms were starting to be used for Code Blue (cardiac and respiratory arrest) situations, but I was not offered the formal courses CPR or ACLS courses⁷.  We learned ABC - airway, breathing, circulation - with actions and procedures for each letter⁸. To learn this, we got situational bedside training accompanied by lectures, and “pimping” in the hallway.  Pimping referred to being grilled by the attending (head) physician on patient rounds (with the whole team of people looking on), which consisted of rapid-fire questioning, with public humiliation for a wrong answer. 

Once formal programs like ACLS, became available, people could learn in simulated emergencies which was so much better, and the consequences of making a mistake were greatly reduced⁹.  Patient survival dramatically improved. I was first allowed to take ACLS in 1989, after I had been out of residency for a year.  Even though I was in pediatrics and ACLS focused on adults, I was relieved to have knowledge to apply so I could be helpful in the remote hospital where I worked.  Having a plan and having access to that plan¹⁰ in an emergency makes huge difference in managing oneself in a crisis.

Formal pediatric resuscitation programs were introduced in 1988, right after I completed my residency training, and I was eager to take them. I took them in 1989, as soon as I had access. I updated my training regularly until my retirement. The standardized training of Neonatal and Pediatric Advanced Life Support (NLS and PALS) made all the difference for me. I was able to manage my body’s emergency responses much more effectively and act clearly because I knew what to do without second guessing right action.  I went from being a terrified resident and young doctor, to calmly managing complicated emergency situations and leading teams through them.  Some of the proudest and most meaningful moments of my life were in successfully leading my teams through life and death situations with sick newborn babies. 

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My point in all of this, is not about me, but about how people respond in emergencies. All of us will be in emergencies of some sort - our health or someone else’s, an accident, a loss of infrastructure, or a host of other things.  And now, we live in times where we not only experience our own emergencies, but we are aware of emergencies all over the world all the time. And those emergencies feel like they are our own¹¹.

To respond well in an emergency, we need something to go on, some advance planning and awareness, otherwise we will respond by instinct.  While instinct may serve us well when we need to run from a lion, instinct alone may not be very helpful in our complex modern civilization.  Fight, flight, freeze, and faint are very important for raw survival. Developing awareness of how we respond in fearful situations can be useful when a true emergency occurs, giving us a bit more choice in our responses. I invite you to consider how you respond when you are afraid. What might help you be more prepared, to be ready to respond as effectively, as helpfully as possible?

Because I spent most of my professional years on alert for emergencies or actively addressing them, I tend to see every challenge as an emergency. I’ve been trying to increase my awareness and temper my responses so they are more proportionate to the situation. While numerous true emergencies are happening at any given moment, few require my action.  As I am writing this, the top emergency is the outbreak of war between Israel and Hamas. Many people are directly involved in this state of emergency. Governments, institutions, and first responders will have activated emergency response protocols. They will be acting based on their training and their past experience.  For all of us, our instincts will drive emotions and actions - to survive.

We don’t have our best ideas in these states. 

That’s why we need training, practice simulations, algorithms to follow.  But these are not enough; we need solid ethics and values that have already internalized. Otherwise, people can easily get into the “I was just following orders” scenarios and do horrible things. Most people will not have considered any of these things, and will rely on their leaders.

As an acute emergency lessens or we enter into prolonged high alert situations, people often don’t have time for deep complex, abstract consideration to guide action. That’s when we need phrases, mantras, or rhymes to remind us what we believe in, what we stand for, who we are.  Of course, we also need strong connection to inner guidance, to that greater-than-self GPS. 

For me, “Do no harm” represented one such helpful ethical reminder. I knew that meant for me to do the most good while causing the least amount of damage, and I know by feel what that means to me.  That informs my ability to decide. 

Training and protocols only take us so far. We inevitably reach decision points; we need to be able to alter course. More importantly, we must know when to stop.  Knowing when to stop is vital - in health care, in war, in policing, in rescue operations.  Failing to stop, to pause, to reconsider, to ‘allow cooler heads to prevail’ may be the thing that gets we humans into the most trouble.  Stop.  Reconsider. Do no harm.

Foundational in my work as a physician was the imperative to reassess as soon as an emergency began to settle.  Reassessment has many permutations depending upon whether your field is health care, or business, or security services or otherwise. What this means is that during the crisis - in my case, during a Code Blue - one just does the drill, does what one’s trained for.  When training (the drill) isn’t followed, like as alleged for example, in the horrific school shooting in Uvalde Texas¹², then outcomes are awful, and people die or are further traumatized.  But once things settle a bit, then is the time to reassess.  Although this practice of reassessment can be used to lay blame, that misses the point. The point is that to do better the next time a similar emergency happens (and there is always a next time) we much reassess what caused the emergency, what was done, and what the outcomes were. And specifically, I review my own actions and what I might have done better or differently. This sounds simple, but even during the reassessment phase, people are emotionally elevated, biased, often traumatized, which can make reassessment challenging and charged.   Nonetheless, reassessment is built into any good emergency protocol or guideline.  Decide, act, reassess, decide, act, reassess. 

In medicine, we would have debriefing sessions shortly after an event, followed later by a case review. We also had data collection systems that helped track outcomes so that we could improve our care for future patients and to inform to changes in the protocols. This all sounds very cold and perhaps boring, but data is useful for this sort of thing where our emotional biases and instincts may trick us into believing things that aren’t true. Changing our responses takes effort. But if we don’t reassess and change when necessary, we just keep doing the same unhelpful things.

Think about bleeding people with leaches, for example.  Seemed like a good idea at the time.

Where am I going with all of this?  Well, perhaps these structures that enable groups of trained people to act effectively together in emergencies -imperfect though they may be - can inform us in our personal responses to the realities of modern, connected society wherein every moment feels like an emergency.

These past few days, as the events unfolded in Israel and Gaza, I found myself hyper alert, focused on news of what was unfolding.   I am not directly involved, yet horrible suffering is happening. Red alert! And yet, I have nothing to do in this emergency; I am not personally immediately threatened nor am I likely to be.  I do not need to have my emergency systems activated. I will be most helpful if I am calm, centered, curious.

I watch public responses unfold. People want to quickly lay blame. Who allowed this to happen?  People call out for death, destruction, for extermination of presumed or actual perpetrators.  Everyone is suddenly an expert, calling on others to join them. People harass, threaten, belittle, even bully others. I do not want to feed or amplify this behavior.

As I watch horrifying events unfold from the safety of my desk and computer on this autumn day in Montana, I have only my words to offer. I am not running a Code Blue. I don’t know what is really going on. I don’t know what is going to happen, next, or even what to hope for on a practical basis. I fear that ancient traumas are being reenacted and I don’t understand them.But, I know little about Middle East history, religion, or politics.

Right now, militaries, medical responders, and governments are working under their emergency protocols. I pray and hope that training serves us all well, that we hold true to our deepest morals and values, and that each can offer their best to the situation.

Most of all I pray that we and especially those in power know when to stop.

Stop, think, reassess. Be willing to not know, not understand, not judge.

I recognize, I don’t know what is going on, what might happen, what any of this means. I will continue to inform myself, to learn, to hold my desires for calm, ethical ‘heads’ to prevail in the short term and for peace and love to prevail in the long term.

All I have in this moment, then, is recognize how little I know and to endeavor to “First, do no harm” with my words.

1. As I write this post, Israel has declared war on Hama following brutal surprise attacks by Hamas deep into Israel. Nearly 2000 people are dead as I write this and Israel is beginning a ground assault on Gaza.

2. Here’s a link to the full text of the Hippocratic Oath. It’s actually terribly outdated. Although I took the oath in a mass reading at medical school graduation, I have since renounced the oath. If you read it, you will likely understand why.

3. The evidence for this is sketchy to my research, but there may be more reliable sources I haven’t found. Here are two links; I find neither very reliable. https://www.nlm.nih.gov/hmd/greek/greek_oath.html , https://www.kevinmd.com/2023/06/unveiling-the-true-origin-of-first-do-no-harm-in-medicine-discover-the-father-of-clinical-medicine.html

4. Here’s the source article for that attribution.

5. This lack of supervision is no longer allowed.

6. The American Heart Association pioneered this type of training and continues to steward it to this day. Here is a link to the timeline of the development of CPR. I thought it was pretty interesting.

7. These courses may have been offered to students and residents at other medical schools, but since curriculum is standardized, I doubt it.

8. I still remember the cardiac code ditty. “Shock, shock, shock. Everybody shock. Big shock, little shock. Shock, shock, shock. Though obsolete, it informed the sequence of actions in a cardiac arrest. Everybody = epinephrine, big = bicarb, little = lidocaine, and shock was, of course, defribrillation.

9. Remember, this was before the days of computer simulation so these were done with dummies, paper, buzzers, and lights.

10. Training one can’t access or remember in an emergency is pretty useless. Thus, these protocols might posted in emergency room bays, but I carried cards with the protocols in my pocket at all times. Now, the information is instantly available on computers when needed…unless the computers go down.

11. Of course, on a soul level and a species level, we are all connected and what happens to one happens to all. But being in a constant state of emergency harms ourselves and limits our ability to respond appropriately and effectively to honor that connection, that oneness.

12. Here’s one follow up story about how police failed to follow what they were expected to do in a horrific emergency in Uvalde.