Primum Non Nocere

To the Editor:

We appreciate the editorial by Dr. Filice (June 2004)¹ that accompanied our article on spontaneous pneumothorax as a specific complication of severe acute respiratory syndrome (SARS).² We agree with Dr. Filice that the best possible care of the patient takes precedence over the personal well-being of the health-care provider.

During the SARS crisis in Hong Kong, our health-care workers faced a challenge of unprecedented magnitude and responded with selfless endeavor. In the two hospitals discussed in our article, literally dozens of doctors, nurses, and auxiliary staff were stricken with SARS while doing their utmost to care for patients. Two of those providers died. In our very own cardiothoracic surgery team, two colleagues were severely afflicted almost to the point of death, and required prolonged ICU support. Their suffering has been well-documented elsewhere.^{3 4} Although routine surgical services were brought to a standstill, emergency operations were still performed in both hospitals for those in need.

Dr. Filice has chosen to highlight the nonsurgical management of the six patients reported in our article as a point of controversy over ethics. We had already mentioned that concern for the safety of health-care workers was only one of several factors in the consideration of surgery in the four patients who did not refuse intervention outright. It was certainly not an overriding concern, and in none of the patients was it the sole factor. As we stated in our article, the high anesthetic risk, the abundant pleural adhesions, and the severely diseased lung parenchyma in these patients all suggested that surgery may be fraught with grave potential complications against which the potential benefits may not be great. Ultimately, the clinical outcomes in none of the six patients were adversely affected by adopting nonsurgical management. Nonetheless, we do agree that had there been a failure of nonsurgical management in these patients, there is no question that surgery would have been offered.

As Dr. Filice correctly pointed out, video-assisted thoracic surgery is now the accepted definitive treatment for primary spontaneous pneumothorax (PSP) complicated by bilateral pneumothorax, recurrent pneumothorax, and persistent air leak, and for selected cases of secondary pneumothorax. As thoracic surgeons and strong proponents of video-assisted thoracic surgery for the treatment of PSP,⁵ we are particularly familiar with the indications for surgery. However, as we have discussed in our article, the pneumothorax secondary to SARS may represent a distinct clinical condition, and is certainly unlike conventional PSP. Barring the nightmare of a recurrent SARS epidemic, there are insufficient clinical data to suggest what the optimal management strategy is for patients with SARS-related pneumothorax. Our limited experience thus far demonstrates that in six patients, nonsurgical management offered symptomatic relief with no adverse effect on their final clinical outcomes.

The primary aim of our article was to alert clinicians to the existence of pneumothorax as a discrete complication of SARS, which is a completely new disease entity itself. As such, the protocols for its management warrant careful consideration, not simple transliteration of protocols from PSP. To rush in for surgery while dogmatically citing surgical indications for conventional PSP may possibly have created more harm than good in our six patients, as is sometimes the case for patients with secondary pneumothorax.⁶ It would be wise and prudent for clinicians facing such new challenges to remember the famous dictum of Hippocrates: “First, do no harm.”