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As anesthesiologists and acute pain medicine specialists, we will care for patients in the perioperative period who use cannabinoids for chronic pain and/or marijuana recreationally. We will have to address difficult questions from patients regarding the potential applications for cannabinoids in acute pain management. While we must remain compassionate and understand our patients’ desire to find relief from suffering using available non-opioid medications, we are ethically bound to do no harm and provide them with treatment options supported by the best available evidence. Today, we cannot support cannabinoids in the management of acute postoperative pain.

Publication of the First Do No Harm report from the Independent Medicines and Medical Devices Safety Review has highlighted the significant impact that adverse effects of medicines and medical devices has on those who have been harmed.1 The report, commissioned by the Secretary of State for Health and Social Care, focuses on the harms associated with hormone pregnancy tests, sodium valproate and pelvic mesh implants. One of the report’s themes explores the regulation of medicines and devices and the need for reform, recognising that the current regulatory systems for pharmaceutical products and medical devices have gaps and inefficiencies. The report stresses the importance of implementing some high-level changes in the regulation of medicines to strengthen patient safety, and recommends taking patients’ views into account during the decision-making process.1 With the UK’s involvement in the European Medicines Agency due to …

It would be hard to imagine providing care for an acutely unwell child without giving him/her supplemental oxygen. This is what we do, what advanced paediatric life support courses require; it is also what the public expects of us. Oxygen—in the developed world at least—is seen as the panacea that can do no harm, to not give it in a child’s hour of need would be considered by some to be negligent. Every television medical drama we are exposed to contains images of unwell patients, all with an oxygen mask to signify the degree of severity of their illness. So how did this potentially toxic byproduct of photosynthesis become the most commonly administered drug in hospitals? Oxygen unlocks the energy stored within the food we eat during the mitochondrial production of ATP: ‘oxidative phosphorylation’. If this process ceases, energy failure and hypoxic death usually follows. Thus, for decades our focus has been to ensure a steady flow of oxygen from the air we breathe to every cell in the body to maintain cellular aerobic respiration. Taking no chances, and supplying patients with excessive amounts of supplemental oxygen, was assumed to be the safest strategy. But as we know from other walks of life, too much of a good thing is rarely in our best interest. Joseph Priestley eloquently pointed this out to the world when reporting his discovery of oxygen: ‘…for, as a candle burns out much faster in dephlogisticated than in common air, so we might, as may be said, live out too fast and the animal powers be too soon exhausted …

I read about the death of an asylum seeker with sadness.1 Asylum seekers are refugees. The United Nations says that a refugee is a person who “owing to well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, …

Discussions about patient safety describe healthcare as an industry. If that’s the case then what is healthcare’s business? What does it manufacture? Health and wellbeing? Possibly. But we know for certain that healthcare manufactures harm. Look at the data from our new research paper on the prevalence, severity, and nature of preventable harm (doi:10.1136/bmj.l4185). Maria Panagioti and colleagues find that the prevalence of overall harm, preventable and non-preventable, is 12% across medical care settings. Around half of this is preventable. These data make something of a mockery of our principal professional oath …

Those who advocate training non-neurointerventional physicians to perform endovascular stroke therapy generally hold three assumptions. First, physicians with interventional experience in other vascular territories can become competent in stroke intervention with a relatively small number of neurointerventional cases. Second, the benefit of endovascular stroke intervention and the prognosis without it are so disparate that there is an obligation to provide the treatment when and where an experienced stroke neurointerventionalist is not available. Third, the time sensitive and emergent nature of acute stroke means that decentralization of care is necessary. In my opinion, the available evidence does not support any of these conclusions at present. There is an important difference between medical and procedural based therapies. Both require cognitive training and expertise to make a proper diagnosis and decide on the best treatment strategy. Procedural based therapies, however, require mental and physical dexterity in contradistinction to medical treatments which are generally operator independent. Assuming appropriate patient selection, the success, effectiveness or complications of medical treatment are the same irrespective of who administers the drug or treatment. Surgery and other procedural based treatments are obviously quite different. The same cognitive training is needed to decide when to operate but technical training is also crucial. The maximal theoretical benefit of any procedure is always compromised by the imperfection of the operator and is therefore inextricably linked to the experience and training of the operator. This is why we seek out ‘good hands’ in a surgeon after selection of therapy whereas such a consideration in a medical therapist is irrelevant. The risk of a surgical complication is particularly important when the recommended surgical treatment has a relatively narrow window of benefit over non-surgical management. Carotid artery stenting (CAS) is a good neurointerventional example of this situation. The absolute risk reduction with carotid endarterectomy for …

Doctors have a “duty” to speak up about the risks that Brexit poses to patients, the BMA has said. Chaand Nagpaul, the association’s chair of council, said that the UK’s departure from the EU might prevent doctors giving their patients the care they need. “As doctors, we have an ingrained duty of care and we adhere to the maxim of ‘do no harm,’” he said. “We have a professional responsibility to raise concerns when we believe there will be detriment to patient care. We must as doctors speak out when necessary.” Nagpaul was speaking at an event organised by …

McCartney is spot on in her column about the reasons for the current NHS crisis.1 Huge amounts of money been wasted on initiatives like the internal market, the white elephant Darzi centres, and the ultimate in futility that is the Care Quality Commission. But much worse is that these and other unproved and time consuming ideas (like the Quality and …

What does “first do no harm” mean for an overstretched doctor working in an under-resourced health service? Does it mean protecting patients from potentially harmful government policies, as when junior doctors withdrew their provision of emergency care to protect patients from unsafe service provision in the future? Does it mean providing preventive treatments to broad groups of …

Many public figures and celebrities write autobiographies billed as confessions, but the memoirs of the neurosurgeon Henry Marsh are strikingly candid and unreserved. Throughout Do No Harm: Stories of Life, Death and Brain Surgery Marsh reflects on harrowing moments in his career, always with clarity and honesty, cross examining his past actions in a manner suggestive of someone who remains deeply troubled by these events. And no wonder. The results of neurosurgery gone wrong are shown to be truly horrifying and desperately sad. The image of a mother “pushing her mute and disfigured daughter in her wheelchair” or of a …

by Henry Marsh. 2014. Publisher: W&N. This book review has to start with a declaration of interests. As a neurologist, I have a respectful, gasping admiration for the work and writing of Henry Marsh. I have lapped up this book and his TV programmes. I have referred patients to him, and they enjoyed seeing him. He will push his own patients to the scanner; he has been filmed dictating letters while riding his bicycle between hospitals, and before medicine did PPE in Oxford. He has driven to Ukraine to help develop neurosurgery, taking with him equipment the National Health Service (NHS) had discarded. He is every clinician's ideal father-in-law. If he needed to operate on me I would sign the form and ask him to do an awake craniotomy so that when I told people all about it I could end by saying, with my best Max Boyce conviction ‘I know; I was there.’ Clinically, he has certainly been there; I doubt there is a neurosurgical awkwardness—conversation, technique, success, failure, over-involvement, compassion fatigue—with which he has not had to contend. He tunes in, effortlessly, to the narrative-base of clinical medicine even though the …

[][1] By Henry Marsh. Publisher: W&N Inspired by reports of neurology book clubs in Boston, USA, and Cardiff,1 we recently started one at St George's, London, replacing the usual Tuesday lunchtime journal club every 8 weeks. All doctors working in neurology and stroke are invited to a round-table discussion, lasting about an hour and to suggest appropriate books for future meetings, which individual doctors usually buy. At our last meeting, Henry Marsh, one of our consultant neurosurgeons, kindly agreed to discuss his new book. The book's title refers to the Hippocratic Oath. ‘First do no harm’ is a wonderful principle; however, in neurosurgery, as the author explains, no matter how accomplished the surgeon, some patients inevitably will be harmed. Often, making the decision to operate is harder than the operation itself. Henry Marsh has previously made two award-winning films about his life as a neurosurgeon and this book is the literary equivalent of a ‘fly … [1]: /embed/graphic-1.gif

In the year ending 31 March 1999 British Airways carried 36.8 million passengers and there were 3386 reported in-flight medical incidents: about 1 per 11 000 passengers. Though 70% were managed by cabin crew without the assistance of an on-board health professional, in almost 1000 incidents doctors and nurses were asked to help with the management of ill passengers. This article discusses the conditions most likely to lead to the announcement “If there is a doctor of medicine on board the aircraft, would they please make themselves known to one of the cabin crew.” Summary points About three quarters of in-flight medical emergencies are managed by cabin crew The range of equipment and drugs on board varies but can be extensive Doctors who volunteer to help the crew manage an incident should remember to “do no harm” and practise within the limits of their training and knowledge

We were interested to read the letter from Diabetes UK’s director of communications defending the organisation’s recent campaign designed to raise awareness of the seriousness of type 2 diabetes.1 The campaign, showing various versions of tearful adults, offered no concrete knowledge message except for the emotional devastation associated with diabetes. Such fear campaigns do not help prompt preventive health action unless they also offer the target audience meaningful ways to engage in reducing the …

First do no harm; everything else is a bonus—few of us have much confidence when we first start out. Indeed, when on medical elective there is not much students can offer in terms of self directed and useful clinical practice, and so equally little they can do to detract from the work of the host institution. This is in part why electives are not only ethically justified, but also constitute an intrinsic rite of passage, because they can offer a great opportunity for personal development, not only clinically but also socially and culturally. I am about to embark on a 10 week elective—provided I pass finals—and, having already undertaken a two week placement in obstetrics and gynaecology in Mahamodara Hospital, Sri Lanka, I have a better idea of what to pack (fewer gloves), and what to expect from a foreign healthcare system. However, this practical awareness is of far less consequence than the unexpected insight I gained into the differences between the United Kingdom’s health …

Most countries in the world have heeded the World Health Organization’s call to include hepatitis B vaccine in childhood immunisation programmes. But six countries in Northern Europe, including the United Kingdom, have not. Why are they holding out? Hepatitis B infects two billion people worldwide, causing hundreds of millions of chronic infections and early deaths from liver disease. About 14 million people in Europe are chronically infected. Such high numbers help Pierre Van Damme and colleagues make a good case for the remaining six European countries to fall into line (doi:10.1136/bmj.f4057). The alternative approaches—targeting people at high risk and preventing perinatal transmission—are …

In the 2500 or so years since Hippocrates and his followers penned the first medical guidelines, things have come a long way. “Do no harm” is a reasonable starting point, but a physician treating just about any disease imaginable could do with, and indeed can now call on, a little more help than that. And so guidelines are rightly ubiquitous. The collating of research, sharing of experience and dissemination of best practice are …

On the issue of obesity,1 we welcome the decision by the European Medicines Agency to refuse marketing authorisation for the fixed dose combination of topiramate (an antiepileptic) and phentermine (an appetite suppressant amphetamine).2 The loss of a few kilograms cannot justify …

Mackenzie highlights the lack of guidance on use of inhaled corticosteroids (ICS) and risk of adrenal suppression.1 The Medicines and Healthcare Products Regulatory Agency recommends issuing a steroid treatment card,2 but there is concern that this may alarm patients and reduce adherence. There is also no consensus on what constitutes a high dose. High potency combination inhalers (ICS …

First, Do No Harm: Being a Resilient Doctor in the 21st Century Michael Kidd, Leanne Rowe. London, UK: McGraw-Hill Medical, 2009. ISBN-13: 978-0-070-27697-0. Price: £15.99. Pages: 142 (paperback) The aim of this book is to help doctors become more resilient to burnout and stress. It might equally have been called ‘Physician Heal Thyself’ or even ‘Self-help for Doctors’, though the latter wouldn't be the most appropriate title since doctors rarely think they need help. The book describes eight principles for resilience, namely: (1) make home a sanctuary; (2) value strong relationships; (3) have an annual preventive health assessment; (4) control stress not people; (5) recognise conflict as an opportunity; (6) manage bullying and violence assertively; (7) make our medical organisations work for us; and (8) create a legacy. The book does not directly follow …

In caring for their patients, physicians strive to uphold the fundamental principle of medicine: primum non nocere – first do no harm. However, previous studies have reported that more than 80% of physicians come to work when they are ill.1–4 Numerous infections can be transmitted nosocomially, with some of the most common being the respiratory tract infections (RTIs).5 6 To explore this phenomenon, we created and sent three versions of an online survey to third year medical students, internal medicine and surgical residents, and staff physicians from the University of Toronto between June and August 2006. The questionnaire explored the frequency of working with an RTI and the factors that influenced this behaviour. The response rates for medical students, residents and staff physicians were 149/202 (73.8%), 317/650 (48.9%) and 202/350 (57.7%), respectively. The vast majority of respondents were ill for 1–2 days or more. Linear regression showed that when compared with residents, staff physicians reported an average of 0.9 fewer days with an RTI (p = 0.001) and students …

First do no harm, “primum non nocere”, is a doctrine as old as medicine itself, frequently but probably inaccurately attributed to Hippocrates, the wise old man of our profession. Prevention of injury and illness is another significant aspect of medical practice. The profound impacts it has had on society, largely taken for granted in the industrialised world but less so elsewhere, are extraordinary; immunisation, sanitation, screening programmes, road safety initiatives—the list goes on—have changed our lives to degrees unimaginable even 30, let alone 100 years ago. Although it is an important component of our profession it is underplayed in both training and our day-to-day activity. It is encouraging to know that it will be part of our new curriculum, despite the time constraints and rationalisation imposed by the modernising medical careers platform. This is consistent with the philosophy of the World Health Organisation1 which emphasises the role that doctors have …

When a physician acts as both doctor and researcher conflicts can develop. When a doctor does not know whether a patient is taking active drug or placebo, any new medical problems can result in a dilemma. Is the patient's suffering a side effect of the medication or is this a new medical problem? Mrs W's case demonstrates the problem that can occur when the physician is blinded in the name of research.

A 9 day old infant presented to hospital with an erythematous, diffusely swollen right foot, shown in figs 1 and 2. Figure 1 Figure 2 The infant had been slow to establish breast feeding and was not discharged from hospital until day 7 of life. Her father had noticed the inflamed foot during a nappy change earlier that morning. Both parents felt the infection was the result of a tight …

In the time it will take you to read this editorial eight patients will be injured, and one will die, from preventable medical errors. Medication error—wrong drug, wrong dose, wrong route of administration, wrong patient, wrong time—is the most common single preventable cause of patient injury. When all sources of error are added up the likelihood that a mishap will injure a patient in hospital is at least 3% and probably much higher.1–4 This is a serious public health problem. When one considers that a typical airline handles customers' baggage at a far lower error rate than we handle the administration of drugs to patients, it is also an embarrassment. Given the prevalence of errors in our work, and given also that one of our first principles is “first do no harm,” it is strange that we talk so little in our hospitals and consulting rooms about this problem. Perhaps it is because we tend to view most errors as …

When I was a student in Vienna in the 1930s great emphasis was laid on medical ethics. Our first lectures were in the anatomical institute where the inscription above the professor's lectern read in large letters: Primum non nocere (firstly, do no harm). Among other advice we were told never to admit to patients that they had a fatal illness, still less that they were about to die. It was assumed that they could not take such information, that they would be driven to despair and …

Once upon a time when people gave up the ghost that was it. Now they are at serious risk from the enthusiastic bystander keen to pummel the ghost back into the body. If you want to die choose your place of departure with care. Even castaways will soon find life support machines already installed with resuscitation officers on call to parachute in. This is great if it is what you want but not if you do not. Resuscitation is the prolongation of life at its most dramatic. Hippocrates would have cheered. Or would he? I have observed a more subtle version of the Hippocratic tradition that is far more worrying. This is to be seen in wards where the elderly are being cared for. From antibiotics to tube feeding, the professionals have an armamentarium of treatments to keep the very old and infirm alive a few days longer. Fair enough, if this is what the patient wants. But how often are the doctors right in their judgment of what the patient wants? How often are they swayed by thoughts of dissatisfied relatives or predatory lawyers? Their Hippocratic oath states that a doctor should do no harm …