Friday, March 09, 2007

The First Duty

"With great power comes great responsibility"

What is the first duty of a doctor? Of a nurse? A paramedic? A first-aider?

What is the first duty of the medical profession itself?
There comes a moment in every medical student’s life, when he realises that all he’s learning is not just for exams, that one day he will be out there on his own, with real live patients and no medical professor leaning over his shoulder to guide him.

I knew it would happen.

And this week it did.

Something happened to me last week that reminded me why I'm doing what I do. And that I'm far, far away from becoming a doctor, despite the fact that I technically become one in 4 years.

And so I wrote a post on it for Medscape. Since it was posted, I have received over 50 comments, as well as numerous emails from fellow medics here at Cambridge who saw it happen. I am not proud of what I did that day. I have questioned myself countless times over the past few weeks, on my ideals, my motivation, and what it really means to be a doctor.

Read the full post on Medscape.


Dr Michelle Tempest said...

As for the legal side... in France they have the good samaritan act, meaning that doctors are legally bound to help out anyone in need of medical assistance, plus they are legally covered. I remember the first patient I ever had to treat was someone who had fallen down the stairs in town; it was the day of the last exam in my medical finals. It was a strange day! Keep up the good work... it is worth it in the end! Michelle

HospitalPhoenix said...
This comment has been removed by the author.
Anonymous said...

You were quite correct to think about it before rushing in.

Not so long ago, I saw a man stagger into a busy road, collapse and have a seizure, stopping the traffic. I pulled over my car and rushed out, as did a nice couple. We managed to lift the (heavy) unconscious man and carry him onto the pavement so he didn't get hit by any cars.

Then a young man came and barged us all aside and shouted 'I'm a medical student, I'm a medical student.'

I was a little surprised, and I asked him whether he knew the recovery position. He looked a bit sheepish and said no. As I put the unconscious man into the recovery position, I asked the student what year he was in. He informed me he'd just started second year.

I probably should have reported him to his Dean, but the look of horror on his face when the ambulance crew drew up and greeted me by name was enough to convince me he wouldn't be such a fuckwit again in the near future.

Anonymous said...

I'm not sure how I stumbled upon your blog but this is my first visit here and I'm glad found you. I was captivated by your story and all the responses and am compelled to respond.

Your story is not unusual - at least not here in the US. I am an MD that has been practicing for 5 years. I had an excellent medical school education, but as a medical student, I would also have hesitated at being the first to jump to the fainted girl's aid. As a student, I think I just realized that sometimes a little knowledge can actually be dangerous. That doesn't mean I wouldn not have helped; it just means that I would have paused and assessed the situation first and prepared myself mentally before acting.

Once I was a resident however, I felt much more confident in treating people in urgent or emergent situations. Maybe that's all just a consequence of our America medical school education. Probably is. Still, as a resident, I never lost that rush of adrenaline, but I was able to ACT in those types of situations. I attribute much of my learning to the nursing staff in the hospital because they are the ones who do that kind of stuff all the time, especially the highly experienced nurses. They were great! Doctors, on the other hand, were actually NOT so good in emergent situations. Probably because they just didn't deal with them as much. Some nurses, however, were great.

My specialty now is far removed from first aid and I rarely encounter any opportunity for urgent medical care or first aid. That said, I have volunteered extensively for providing medical care at running races for many years. As someone else mentioned in a comment, there are volunteer activities where you can learn what to do when someone collapses or otherwise becomes acutely ill. The are opportunities to learn how to triage and recognize almost instinctively what needs to be done. These volunteer positions at long endurance running events turned me into one of those cool and confident first responders who knows what to do and what not to do. Like someone else also said, practice helps. It did for me. It also helps to have good mentors.

THEN, I was threatened with the unmentionable. Yes, a law suit. The law suit never happened, nor did that person actually say they were going to sue, but it became pretty frickin' apparent based on that person's not so veiled threats and interrogations of me and my intentions and actions. It was a person who was AT a race, not even someone who was actually running the race! The person became ill and severely dehydrated. I provided first aid and had the person transported via EMS to the ER where they received 7 liters of IV fluids. A quick and full recovery ensued and everybody was happy and healthy and no harm was ever done and only good came from this situation that could have turned bad had I not intervened appropriately.

THEN, several days after the incident, I started to get a multitude of questions and interrogations, and the not-so- veiled threats of being sued by this person. For the life of me, I could not understand why this person would do this. Was s/he being coached by someone else? It was very difficult to not take it personally. I hate to admit it for sounding like a wimp, but I felt deeply hurt. Why would this person bite the hand that fed it?? I became very angry as well, and still am a bit angry.

In the end, when the interrogations and accusations escalated, I felt I needed to consult my lawyer. My lawyer heard the story and then laughed and told me to tell this person to go the fuck away and leave me alone. The lawyer said no harm was done - period - and that person had better leave me alone.

It was crazy. Just nuts. While I always knew that anyone could sue anyone and that I was doing my gosh darn best to help people in an area in which I have significant medical experience, this one "bad apple" opened my eyes to the other side of the world of possibilities. I am certain (like the lawyer said) that no lawyer would even have taken this person'a case (but then again, there are always a few dumb assess out there) and I was sure I was 100% clean on this case - objectively and in my conscience. Still, it demonstrated to me that, as a medical professional - at least in the US - one cannot pounce boldly onto a scene yelling, Let me help, I'm a doctor! No, instead, I would take 5 or 10 seconds to assess the situation, THEN leap...unless I am SURE from the gun. In this particular case, if I had to do it all over again, I would have acted in exactly the same way.

It's not a good feeling to have someone talk of suing you; it SUCKS to have someone question your motives, which are pure and altruistic. It blunts your naivety and makes you more aware.
Unfortunately, despite my own best effort, I became a bit cynical. (I've witnessed that in others too that have endured similar unfair situations.) There may be only one bad apple in a world of tons of good ones, but if you help enough people, you will stumble across that one person sooner or later. It's good to at least know that before it happens.

So, yes, of course, I still help people. Yes, of course, at this point in my medical experience, I would NOT have hesitated an instant to help the fainted girl. Yes, I will continue to help runners because I do it well and it is appreciated. But yes, I will also be cautious in my mind. I will think and act decisively and defensively. I will not take my own graciousness for granted. Like being cheated on by a lover, the experience of a lawsuit - or even the threat of one - changes you a little, makes you a little more aware.

That said, the world needs each and every "healer" - medics/paramedics/nurses/doctors/interns/residents/first-responders/ civilians, all those who help those in need. These are some of the best people in the world. They all - YOU all - deserve a thank you, a pat on the back, a side-hug, and a smile of gratitude for what you do. It is a privelege to be a healer. With that privelege comes responsibility and yes, power. We have the power to heal and the power to hurt. It is so very rewarding to help someone heal - in whatever way that is. That's what real life is all about.

Best of luck in your training and life. You are already a good healer because the story of the fainted girl left enough of an impression on you that you wrote about it and you questioned why you did what you did ...and then you welcomed feedback from others. Next time, you will be more mentally prepared to act.

Thank you for starting an excellent discussion.

carmelo said...

Its always right to hesistate.. back to basic first aid: SAFETY first. I realise in this situation safety isn't quite the main priorty but if it helps how's this for a story:

First day driving an ambulance about 3 weeks ago. Coming back along the motorway, see fire engines and police cars screaming past us and a massive jam. As we pull up to the jam the instructor tells my collegue, who's driving, to go down the hard shoulder, if we can help out. Needless to say at this point I was bricking it. When we got there, thankfully, there were no injuries, and we continued on. My collegues in the back commented on how I seemed to fall apart about it. I've learnt from it now, and all we can both do is the best we can with the skills we've got so far.

In a way I'm sort of envious of you, as the only real motivation you have to help somebody in the street is the "student medic" thing, while as we train in fully marked up ambos the pressure feels huge. Also having a uniform places a huge amount of responsibility on your shoulders too. As I suppose would saying "Stand back mortals, for I am a doctor!!" (in jest I assure you)

"I have questioned myself countless times over the past few weeks, on my ideals, my motivation, and what it really means to be a paramedic"

SNAP! Seriously, you can't question it too much. Trust me. If you do all the "what-ifs" and "buts" start to take a serious stranglehold, so when you do actullay need to do something you get paralysed.

I think we both need to bite the bullet.

Don't beat yourself up about it (tempted to end that sentence with "kid", but seemed patronising and rude from a spotty teenaged fool like myself)

the little medic said...

Thats strange, I had a free afternoon the other day and I spent it reading various internet sites on topics such as this. I've wondered for a while what to do in a situation like that, or indeed any situation where someone might be injured and require help.

The 'hero' in me is crying out to be the first on the scene of a multi-vehicle accident where I manage to save everyone but in reality, if that happened i'd be fucked! I know barely enough to be helpful to anyone really. Yes I know some basic first aid so might be of some use to your average joe colapsing in the street but for the most part I'd be useless.

I'm only about a year away from being a doctor and unless something miraculous happens between now and then I can't see the situation being much different then, I'd feel more confident saying I was a doctor rather than a medical student but in a year or so people will actually expect me to be useful. Shit.

Anyways, sounds to me like the whole room was a bit guilty by just staring but at least you were willing to help in the end. I've come to the conclusion after my afternoon of research that I should and will stop to help in such situations in the future even if all I can do is call an ambulance or reassure whoever needs help.

Great post dude.

Junior DocSpot said...

MPS/MDU both cover you for Good Samaritan Acts even as a medical student.

The only time I ever saw anything like that as a medical student was in a Youth Hostel.
A man started fitting. I went over to make sure he didn't injure himself unnecessarily. Then a girl ran over and barged me out of the way, yelling "Don't worry, I'm a life guard, I do first aid!" Clearly it was her moment of glory. I let her get on with it, but she buggered off as soon as he regained consciousness - even though he was post ictal and didn't know where he was and nobody knew him.

I had a Consultant tell me once that if I ever saw an accident or ill person, I should go over, just to make sure nobody else did anything stupid (eg taking helmet off motorcycle accident victim). Remember, you're as good as the next person at calling an ambulance ;)
Actually, reading some of the paramedic blogs, you would probably be better at it...

howling said...

Good story and really funny as well. I have to say you're not the only one who feels that way, especially now that people make money by litigation. I suppose if that happened to me as you - I mean as a student, I'd act the same way. But not as me now - and don't worry, you'd get there and as a doctor! LOL! I guess it's different when you already had been to a few similar situations. As a nurse this thing becomes quite instinctive now - not that I'm lifting my own chair here, it's just that at the back of your mind, you always think you have a responsibility. But the most I would do was probably just shout for help or find out if she's breathing or get someone to dial the numbers... then make sure that someone's looking - very important - so that you have witnesses and pound her chest. You can get away with the kissy thing now, apparently.

sisiphusledge said...

If it is any consolation, as a pre-reg house officer all those many years ago (cough) I came across a woman who had been knocked off her bicycle by a passing car. I was learning to drive at the time and my driving instructor asked me if I wanted to stop (knowing me as a junior doctor). I replied, "Of course", and ran over to the scene where another woman was leaning over the injured one. I asked whether I could help, without announcing that I was a doctor. I was told, sharply, "No, I'm a First-Aider, it's alright!". I did not have the confidence to say that in fact I was a doctor, but I also felt intimidated by the confidence of that First-Aider.


Bohemian Road Nurse... said...

Dang it and by all that is holy, but I SURVIVED THE DANG FLU, hallelujah! (And thank you for your note of encouragement, Angry Medic---one of these days I'm gonna come over there and visit you with Nurse Ratched!) In fact, I feel so much better than I just might steal "Hospital Phoenix's" blog name, heh! Because I have definitely "arisen out the ashes"!

dan said...

wow. your barney impression was superb. it was my favourite part of the play. hoorah. you must do barney more often.

docwhisperer said...

Hi Angry Medic,
You did the right thing. Chalk it up to experience. Once you've run dozens of codes as a resident and taken Basic Life Support certification and recertifications, you'll have the confidence to deal when the next situation arises.
Regarding the fear of being sued, if you're planning to become a physician, especially in the US, welcome to our world. But it doesn't mean we don't step in and help anyway, when we can. If you don't want to be sued ever, do something else, don't practice medicine.

JustCallMeJo said...

Really good post and good discussion.


I'm flabberghasted by the number of people telling you it was right to hesitate on grounds of potential for malpractice.

It is understandable and logical that you hesitate. I do not fault you at all, forgive yourself for the deer-in-headlights thing. You don't do this every day. As an MD, unless you work ER, you won't. It will not be you stepping in for the triage saves. Nurses do that.

Once you're out and about and someone falls down go boom, it's simple: Airway. Breathing. Circulation. Protect the head/neck/spine in that order. You cannot fsck up by calling for help/911 in the U.S., and offering basic help.

You're going to be a doctor, you're not a savior. You will never save anybody's life. Get over it now. Pastoral types do this. You will do your job and go home. Nobody's life is ever in one person's hands. Nursing understands this and medicine does not.

As you train, you will get over it and you will do this: You will shout "Somebody call for a medic/EMT/paramedic/whatever!" You will dash over and check if she's breathing and immediately assess for blood, abrasions, pallor, etc. You will see that she's breathing, and try and talk to her, roll her into the recovery position once you assess that she's breathing and has a pulse. You will look at her pupils and ask her about her orientation, ask her to move her fingers and toes.

She will not sue you for that. And if you find some crazy bugger who finds out you're an MD and decides to see if he can sue....You will go in front of a judge/magistrate and say you did those things, and the judge will roll his/her eyes and dismiss the case.

Don't beat yourself up for thinking as you did. I think there are aspects of medical school that poison good people everywhere with archaic ideas. Nursing school does the same thing for good people who want to do nursing. Some of those ideas need to go out the window.

You got into this to help people, right? For the intellectual challenge and for the betterment of yourself, for your community? I did, too.

Bugger everybody who told you to fear for your coming license instead of honoring your good instincts.

(If you did it for the money, I don't want to know. :D )

/jo, who stopped an arterial bleed yesterday and didn't think once about getting sued

JustCallMeJo said...


Your story was inspiration for a diatribe:

Thanks. :D

Cal said...

Great article, Angry, and so very true. Unfortunately, I think most us would hesitate, mainly because this suing culture has become so large and so vast, with people suing over ridiculous amounts for the littlest of things.

It's so mind-boggling, in a way, because we chose to become doctors to help people. Yet, when our opportunity comes, we have to be careful and wait and think about ourselves and the future of our career over the person lying there who may really, really need your help.

It's good you hesitated though. It shows that at least you were thinking ahead!

skinnyminny8 said...

At my med school we had teaching on this.. from what I took in, we DON't have the good samaritan act in the uk, you are under no obligation to do anything, but being a good medical student, you probably will..

You can be sued, of course, but it is unusual (in the UK- not sure about those litigation happy Americans).

Re: First aid vs Medicine:
Lots of doctors admit they suck at first aid. Your standard GP is not going to be as accomplished as a paramedics. The role is different. As 2nd year med students we were given a compulsorary first aid course as the med sch told us that invariably we will be in a situation where something happens and a good mate will point at you and say "he's a med student, he can help" and you will be thrust forward.

Re: Final year medical student.
I've been told that making the jump from med student to real doctor is incredibly scary, but HO's or FY1s as they are now called have the knowledge, just not the confidence to put it into practise, that will come with experience.

I feel guilty, I was on the tube up to hospital for day one of surgical rotation and somebody, on the other end of my carriage had a heart attack..

I couldn't see what had happened and nervously looked down at the book I was reading... "Oxford book of clinical medicine" shit.. had anyone noticed I was a pseudomedical person?? The loudspeaker asked if a doctor was on the tube. I resolved to wait and come forward if there wasn't, but a young woman rushed into the carriage.

I felt very guilty about my actions, but truthfully I didn't think I could have done any good, I knew very little about what to do at that point in the year re: medical emergencies. This is why I think it is of the greatest importance to hang around and be involved in medical emergencies as a student and see what actually happens.

Finally: sorry long post.

A friend of mine tells me of a recently qualified doctor on holiday. He was (morbidly) excited when a man on the flight collapsed and rushed to help explaining he was a junior doctor. A guy bending over the passenger glared at him,... "I'm a consultant cardiologist," hmmm!!

Cal said...

PS: I really hope that your revue is going well. I kind of wish that I was in Cambridge just so that I could go and see it, but it'd probably be full of inside jokes about your lecturers that I wouldn't understand...

Anonymous said...

Yeah I've been to see Cambridge footlights productions at the Edinburgh festival fringe.

It was incredibly boring as I didn't get any of the jokes. I think you had to 'be there' (Cambridge not Edinburgh) to get it.

tunku halim said...

Angry Medic - you'll be facing this dilemma all your life. Not just in emergency situations but in day-to-day medical practise. Money v. Genuine Help. The former mental. The latter visceral.

Dan said...

fear not. some day Good Engineering will save us all. :P

zewt said...

Yo medic,

Don't get yourself too stressed up by that incident. after all, you're still a medic-al student... not exactly a doc yet. the most important thing is that you learnt something from that incident. and also... she did recover in the end and you did offer your assistance to the senior first aider.

dont carry the guilt, it will kill you.

Patient Anonymous said...

Similar to your first commenter, we also have a Good Samaritan Law in Canada that protects First Aiders (I'm a First Aider and not a Medic/Doctor obviously.)

Another thing that you may have experienced is a psychological phenomenon called "bystander intervention" or the bystander effect. What it means is that a person is less likely to intervene when there are more people around to offer help.

I always jump right in to assist (trying to remember the, yes, basic rules of "Safety First" as another poster mentioned.) I won't be any good to the person in destress/who is injured if I become injured myself.

And yes, if the person is conscious, they do have the right to refuse treatment.

kuhan said...

An effort is better then none. You thought of helping, thats better then most who just sat and stared. I can understand how you feel, being in the same boat. Nevertheless, I believe confidence comes with experience. It's the first step that's always the hardest.

Nice post mate.

Anonymous said...

It's good to put some thought into what happened but don't dwell on it too long. You'll only make yourself feel worse.

If you're anything like what i think you are, you'll make a GREAT doc one day :)


Kenny Mah said...

Don't be too hard on yourself. The fact you stopped to think is a useful skill. I doubt you can rely on instinct alone even when you become a full-fledged doctor. A calm mind which can analyse the situation objectively is far more useful.

As for the reasons behind your hesitation, hey, we are all human! :)

I think your response and subsequent soul-searching says much more about your as a person, and that surely comes first.

The Quiet Storm said...

The trials and thromboses of being a doctor! I'm pretty sure that you'll be a good medic albeit an angry one, but a good one nonetheless!

My Own Woman said...

Quick, get the AED and shock yourself into reality. All of us, at one time or another have been a little slow on the uptake when it comes to care vs. litigation; but thankfully, care wins out the majority of the time, if not all of the time.

The Angry Medic said...

Sigh. Thanks guys. This had me agonising for some time. Every single comment here has helped a lot. Every single one, especially the stories that you cared enough to relate here. Thank you all so much. I'm going to be much more careful next time. (And make sure I have my Medical Defense Union membership card in my pocket at all times. --Ed)