From errare humanum est to primum non nocere – a solved dilemma

From errare humanum est to primum non nocere – a solved dilemma

  • Issue 73

Gabriel M. Gurman, Chief Editor

Both these Latin well-known expressions have accompanied me throughout my career as a physician and anaesthesiologist. The dilemma stayed with me for a good part of my training. On one side, we have been taught that man is not a robot, the human organism is not a machine. We do not have all the data about each of our patients, we do not always understand his/her disease and we are not able to prevent each incident, since we all are humans. Thus the mistakes are part of our routine activity.

But at the same time, Hippocrates’ well-known precept obliges us, the clinicians, to do everything that is needed in order to help the patient, and first of all it is forbidden to induce a lesion or an injury of an iatrogenic aetiology.

Needless to say, the reality is completely different from our hopes and wishes. Here are some recent data, taken from the pertinent literature. Every year some 400,000 Americans die from a medical error, this being the third cause of death in that country. Nonfatal iatrogenic disease resulting in disability is present in 3.5 million Americans every year. More than this: for every 600 non-reportable medical incidents, there are 30 reportable incidents (an incident being defined as “incomplete hole in the slices of the Swiss cheese model”), 10 accidents, and one fatal accident.

So, the need for continuous learning and practice with the aim of getting more experience and skills is more than obvious and this desiderate stays with medicine and its servants from the beginning of the art of healing.

But times change. Learning while making errors is obsolete. Achieving new techniques by using the well-known formula ‘try and err’ is no longer acceptable. Professional ethics and the medico-legal aspects of our daily activity do not permit any more learning and teaching in a setup that includes a real risk for the patient.

Not too long ago I met for the first time a term whose meaning I did not know. It is called andragogy (my Greek colleagues and friends would immediately discover this word’s origin!). Its definition is science related to adult education. No doubt that it has a clear connotation with the medical profession and mainly with our specialty.

Some fifty years ago, in the ‘60s of the last century, Laerdal invented a mannequin for teaching an elementary resuscitation technique: mouth-to-mouth resuscitation. Two decades later on a new machine, one which reproduced phonocardiographic records to teach heart sounds and murmurs, became part of routine equipment for educating medical students and young residents. And thus we entered the era of simulation. It was defined as a practical implementation in a context that closely resembles the actual clinical context.1

I had in the past some opportunities to remind our readers of the fact that anaesthesiology as a profession is a mixture of art and science. If science can be learned and taught from textbooks and scientific papers, skills and clinical judgment need exercise and learning manual procedures. No other medical specialty is more prone to use simulation in order to help achieving good practical results, without jeopardizing the patient’s security.

I am sure that our readers would agree with me that our profession leads the list of medical domains that use blind techniques as part of the routine activity. Needless to say, this is one clear aspect of our practice that needs the help of simulation in order to overcome the natural obstacles and difficulties in performing manual procedures. But even so-called procedures under view can become complicated, and accumulating skills is a compulsory demand for every single young anaesthesiologist.

Simulation includes repetitive manoeuvers in order to maintain a necessary level for performing manual techniques. Some years ago we proved that the ability to maintain tracheal intubation skills taught on mannequins needed repeated teaching, since the level of success after six months of lack of occasions to repeat the procedure was reduced by 50%.2 Simulation is not restricted to manual procedures. Clinical skills and problem-solving are also part of education through simulation.

The field of aviation offered us a good example to follow. Many years ago, simulating incidents and accidents during flying became part of a compulsory education program.

The new technology of simulation equipment gives a possibility to stage an accident or an untoward effect of anaesthesia drugs, developing various clinical scenarios, and finding the proper solution for each of them. This kind of teaching contributes to the creation of a successful clinician and responds to the old saying: it is better to be prepared for an opportunity and not to have one than to have an opportunity and not be prepared to face it.

One of the most exciting experiences is the use of ultrasound for teaching the performance of peripheral nerve blocks. Data from literature indicate that when using ultrasound techniques, clinical results achieve a high percentage of success.3

The ‘classical’ concept of teaching and learning by using simulation refers only to the young student or physician. It starts from the correct understanding of the reality, that the unskilled beginner needs a lot of help in order to accumulate manual and clinical experience.

But an interesting recently published paper4 presented some clear data about the influence of age on the cognitive, motor, and sensorial abilities of the anaesthesiologist: ‘Anaesthetists, like the rest of population, start to undergo a variable age-related psychophysiological decline once they pass 55 years of age. The latter may be responsible for impairment of competence, which in turn, could have a negative impact on patient outcomes.’

If so, it becomes clear that the second target group that needs to be helped by using simulation techniques includes our colleagues for whom age plays not only the usual positive role, of enhanced experience and judgment, but also might impair their professional abilities to cope with the daily tasks in the operating room and outside it.

A group of young specialists in anaesthesiology publish in this issue of our Newsletter a comprehensive view of the aging colleagues’ need to use simulation in order to keep their professional performance at a high level. It is our hope that this initiative would be followed in many countries and medical centres.

Introduction of simulation in our daily activity demands initiative and not only that. It needs vivid interest, cooperation, and also financial resources. But it seems that there is no other way to solve the problem of preventing incidents and accidents as a result of patient management. We are witnessing a continuous increase in the number of simulation centres, affiliated with either hospitals or medical schools. They are manned and managed by enthusiastic professionals, ready to help and to offer their competence in order to improve their colleagues’ performance.

The ESA Newsletter is ready to host any article or written opinion that would contribute to the enlargement of this blessed development and propose original solutions related to the art of education through simulation.


  1. Pandit JJ, Heidegger T. Putting the ‘point’ back into the ritual: a binary approach to difficult airway prediction. Anaesthesia. 2017;72:283-8.
  2. Weksler N, Tarnopolski A, Klein M, et al. Insertion of the endotracheal tube, laryngeal mask airway and oesophageal-tracheal combitube. Eur J Anaesthiol. 2005;20:337-40.
  3. Ilfeld BM, Grant SA. Ultrasound-guided percutaneous peripheral nerve stimulation for postoperative analgesia. Reg Anesth Pain Med. 2016;41:720-22.
  4. Giacalone M, Zaouter C, Mion S, Hemmerling TM. Impact of age on anaesthesiologists’ competence. Eur J Anaesthiol. 2016;33:787-93.