what assumptions about the surgery profession was gawande able to expose and challenge

Affiliate 1
The Problem of Extreme Complication

Some time ago I read a case study in the Annals of Thoracic Surgery. Information technology was, in the dry out prose of a medical journal article, the story of a nightmare. In a minor Austrian town in the Alps, a female parent and father had been out on a walk in the forest with their three-year-old girl. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents frantically jumped in afterwards her. But she was lost below the surface for xxx minutes earlier they finally found her on the pond bottom. They pulled her to the surface and got her to the shore. Following instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation.

Rescue personnel arrived eight minutes later and took the first recordings of the girl's condition. She was unresponsive. She had no blood pressure or pulse or sign of animate. Her body temperature was just 66 degrees. Her pupils were dilated and unreactive to light, indicating abeyance of encephalon part. She was gone.

The Checklist Manifesto: How to Get Things Right
By Atul Gawande
Hardcover, 224 pages
Metropolitan Books
List toll: $24.50

But the emergency technicians continued CPR anyway. A helicopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crew straddling her on the gurney, pumping her chest. A surgical team got her onto a centre-lung bypass machine every bit quickly equally it could. The surgeon had to cut down through the peel of the child's right groin and sew one of the desk- size auto's silicone rubber tubes into her femoral artery to take the claret out of her, then another into her femoral vein to transport the claret back. A perfusionist turned the pump on, and every bit he adjusted the oxygen and temperature and menstruum through the system, the clear tubing turned maroon with her claret. Only then did they stop the girl's chest compressions.

Betwixt the transport time and the time information technology took to plug the machine into her, she had been lifeless for an hour and a half. Past the ii-hour mark, however, her body temperature had risen about 10 degrees, and her heart began to crush. It was her commencement organ to come back.

After six hours, the girl's core reached 98.6 degrees, normal torso temperature. The squad tried to shift her from the bypass machine to a mechanical ventilator, merely the pond water and debris had damaged her lungs too severely for the oxygen pumped in through the animate tube to reach her blood. So they switched her instead to an bogus-lung system known as ECMO — extracorporeal membrane oxygenation. To practice this, the surgeons had to open her chest down the middle with a ability saw and sew the lines to and from the portable ECMO unit of measurement directly into her aorta and her beating eye.

The ECMO machine at present took over. The surgeons removed the centre- lung bypass machine tubing. They repaired the vessels and airtight her groin incision. The surgical squad moved the girl into intensive intendance, with her chest however open and covered with sterile plastic foil. Through the day and night, the intensive care unit of measurement team worked on suctioning the h2o and debris from her lungs with a fiberoptic bronchoscope. Past the adjacent solar day, her lungs had recovered sufficiently for the squad to switch her from ECMO to a mechanical ventilator, which required taking her back to the operating room to unplug the tubing, repair the holes, and close her chest.

Over the next two days, all the girl'south organs recovered — her liver, her kidneys, her intestines, everything except her brain. A CT scan showed global brain swelling, which is a sign of diffuse impairment, but no actual expressionless zones. So the squad escalated the care i step further. Information technology drilled a hole into the girl's skull, threaded a probe into the brain to monitor the pressure, and kept that force per unit area tightly controlled through constant adjustments in her fluids and medications. For more than a week, she lay comatose. So, slowly, she came back to life.

First, her pupils started to react to calorie-free. Next, she began to breathe on her ain. And, one day, she simply awoke. Two weeks subsequently her accident, she went domicile. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. Merely she underwent extensive outpatient therapy. By age five, she had recovered her faculties completely. Physical and neurological examinations were normal. She was similar whatever little girl again.

What makes this recovery astounding isn't but the idea that someone could be brought back after two hours in a state that would once have been considered death. It'southward also the thought that a group of people in a random infirmary could manage to pull off something so enormously complicated. Rescuing a drowning victim is nothing similar information technology looks on boob tube shows, where a few chest compressions and some oral fissure- to- mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled middle coughing and sputtering back to life. To salvage this one child, scores of people had to conduct out thousands of steps correctly: placing the center- pump tubing into her without letting in air bubbling; maintaining the sterility of her lines, her open breast, the exposed fluid in her brain; keeping a temperamental battery of machines upwardly and running. The degree of difficulty in any one of these steps is substantial. Then y'all must add the difficulties of orchestrating them in the right sequence, with zip dropped, leaving some room for improvisation, but not too much.

For every drowned and pulseless child rescued, there are scores more who don't make it — and not simply because their bodies are too far gone. Machines break down; a team can't get moving fast enough; someone fails to wash his hands and an infection takes hold. Such cases don't get written up in the Register of Thoracic Surgery, but they are the norm, though people may not realize it.

I think nosotros have been fooled near what we tin can expect from medicine — fooled, 1 could say, by penicillin. Alexander Fleming'due south 1928 discovery held out a beguiling vision of health care and how it would treat affliction or injury in the future: a simple pill or injection would be capable of curing not just one condition simply perhaps many. Penicillin, afterwards all, seemed to be effective against an astonishing variety of previously untreatable infectious diseases. So why not a similar cure-all for the dissimilar kinds of cancer? And why not something equally simple to cook away pare burns or to contrary cardiovascular disease and strokes?

Medicine didn't turn out this way, though. After a century of incredible discovery, most diseases have proved to be far more particular and difficult to treat. This is true even for the infections doctors one time treated with penicillin: not all bacterial strains were susceptible and those that were soon developed resistance. Infections today require highly individualized treatment, sometimes with multiple therapies, based on a given strain's pattern of anti biotic susceptibility, the condition of the patient, and which organ systems are affected. The model of medicine in the modern age seems less and less like penicillin and more and more than similar what was required for the girl who nearly drowned. Medicine has become the art of managing extreme complexity — and a test of whether such complexity tin, in fact, be humanly mastered.

The 9th edition of the World Health Arrangement'southward international classification of diseases has grown to distinguish more than than thirteen m different diseases, syndromes, and types of injury — more than 13 thousand different ways, in other words, that the body can fail. And, for about all of them, science has given the states things nosotros can do to aid. If we cannot cure the illness, and then nosotros can unremarkably reduce the harm and misery information technology causes. But for each condition the steps are dissimilar and they are most never simple. Clinicians now have at their disposal some six g drugs and iv thousand medical and surgical procedures, each with different requirements, risks, and considerations. It is a lot to get right.

There is a community clinic in Boston's Kenmore Square affiliated with my hospital. The word dispensary makes the place sound tiny, but it'due south nothing of the sort. Founded in 1969, and now chosen Harvard Vanguard, it aimed to provide people with the total range of outpatient medical services they might need over the course of their lives. It has since tried to stick with that programme, but doing then hasn't been piece of cake. To keep up with the explosive growth in medical capabilities, the clinic has had to build more than than twenty facilities and utilize some six hundred doctors and a thou other health professionals covering fifty-nine specialties, many of which did not be when the clinic start opened. Walking the fifty steps from the fifth-floor lift to the full general surgery department, I laissez passer offices for general internal medicine, endocrinology, genetics, mitt surgery, laboratory testing, nephrology, ophthalmology, orthopedics, radiology scheduling, and urology — and that's just one hallway.

To handle the complexity, we've split up up the tasks among diverse specialties. Just even divvied up, the work can become overwhelming. In the course of one solar day on general surgery telephone call at the infirmary, for instance, the labor floor asked me to see a twenty-five-yr-one-time woman with mounting right lower intestinal pain, fever, and nausea, which raised business organization about appendicitis, but she was pregnant, and then getting a CT browse to rule out the possibility posed a hazard to the fetus. A gynecological oncologist paged me to the operating room about a woman with an ovarian mass that upon removal appeared to be a metastasis from pancreatic cancer; my colleague wanted me to examine her pancreas and make up one's mind whether to biopsy it. A dr. at a nearby infirmary phoned me to transfer a patient in intensive care with a large cancer that had grown to obstruct her kidneys and bowel and produce bleeding that they were having trouble decision-making. Our internal medicine service called me to see a lx-ane-year-old homo with emphysema so severe he had been refused hip surgery considering of insufficient lung reserves; now he had a severe colon infection — an astute diverticulitis — that had worsened despite three days of antibiotics, and surgery seemed his only choice. Another service asked for assist with a l-two-year-sometime man with diabetes, coronary artery disease, high blood pressure, chronic kidney failure, severe obesity, a stroke, and now a strangulating groin hernia. And an internist called about a young, otherwise healthy woman with a possible rectal abscess to be lanced.

Confronted with cases of such variety and intricacy — in one solar day, I'd had half-dozen patients with six completely dissimilar primary medical problems and a full of twenty-6 different boosted diagnoses — information technology'due south tempting to believe that no one else'due south job could be as complex as mine. But farthermost complication is the rule for almost anybody. I asked the people in Harvard Vanguard's medical records department if they would query the electronic organization for how many unlike kinds of patient issues the boilerplate dr. in that location sees annually. The answer that came back flabbergasted me. Over the course of a twelvemonth of office practice — which, by definition, excludes the patients seen in the hospital — physicians each evaluated an boilerplate of 250 different master diseases and conditions. Their patients had more than than nine hundred other active medical problems that had to be taken into account. The doctors each prescribed some three hundred medications, ordered more a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures — from vaccinations to setting fractures.

Even considering but the office work, the statistics all the same didn't catch all the diseases and weather. One of the most common diagnoses, information technology turned out, was "Other." On a hectic day, when y'all're running two hours behind and the people in the waiting room are getting irate, you lot may not take the fourth dimension to record the precise diagnostic codes in the database. Simply, even when you practise have the fourth dimension, you commonly notice that the particular diseases your patients take do not actually exist in the computer system.

The software used in almost American electronic records has non managed to include all the diseases that have been discovered and distinguished from ane another in contempo years. I once saw a patient with a ganglioneuroblastoma (a rare blazon of tumor of the adrenal gland) and another with a nightmarish genetic condition chosen Li-Fraumeni syndrome, which causes inheritors to develop cancers in organs all over their bodies. Neither affliction had withal made information technology into the pull-down menus. All I could record was, in so many words, "Other." Scientists continue to report of import new genetic findings, subtypes of cancer, and other diagnoses — non to mention treatments — almost weekly. The complexity is increasing so fast that even the computers cannot proceed up.

But information technology'southward non but the breadth and quantity of noesis that has made medicine complicated. It is also the execution — the practical matter of what noesis requires clinicians to do. The infirmary is where you encounter merely how formidable the task can be. A prime example is the place the daughter who about drowned spent well-nigh of her recovery — the intensive intendance unit.

Information technology's an opaque term, intensive care. Specialists in the field prefer to call what they do critical intendance, but that still doesn't exactly clarify matters. The nonmedical term life support gets u.s. closer. The damage that the human trunk can survive these days is as awesome every bit it is horrible: crushing, burning, bombing, a burst aorta, a ruptured colon, a massive heart attack, rampaging infection. These maladies were one time uniformly fatal. Now survival is commonplace, and a substantial office of the credit goes to the abilities intensive intendance units have developed to take artificial control of failing bodies. Typically, this requires a panoply of technology — a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don't work. If you are unconscious and can't eat, silicone tubing can be surgically inserted into your stomach or intestines for formula feeding. If your intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into your bloodstream.

On any given day in the United states of america alone, some xc g people are admitted to intensive care. Over a year, an estimated v million Americans will be, and over a normal lifetime nearly all of u.s.a. volition come to know the glassed bay of an ICU from the inside. Wide swaths of medicine now depend on the life support systems that ICUs provide: care for premature infants; for victims of trauma, strokes, and heart attacks; for patients who have had surgery on their brains, hearts, lungs, or major claret vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, ICUs barely existed. Now, to accept a recent random twenty-four hour period in my hospital, 155 of our virtually 700 patients are in intensive care. The average stay of an ICU patient is iv days, and the survival rate is 86 pct. Going into an ICU, existence put on a mechanical ventilator, having tubes and wires run into and out of y'all, is not a sentence of death. Only the days will be the about precarious of your life.

Fifteen years ago, Israeli scientists published a study in which engineers observed patient care in ICUs for 20-four-hour stretches. They plant that the average patient required 178 individual deportment per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to brand an error in just one percent of these deportment — but that however amounted to an average of ii errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm depression enough for the odds of doing expert to prevail. This is hard. In that location are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Force per unit area ulcers form. Veins begin to clot. You accept to stretch and practise patients' flaccid limbs daily to avoid contractures; you lot have to give subcutaneous injections of blood thinners at to the lowest degree twice a 24-hour interval, turn patients in bed every few hours, breast-stroke them and alter their sheets without knocking out a tube or a line, castor their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and the care of open up wounds, and the difficulties simply accumulate.

The story of one of my patients makes the point. Anthony DeFilippo was a forty-eight-yr-old limousine driver from Everett, Massachusetts, who started to hemorrhage at a community hospital during surgery for a hernia and gallstones. The surgeon was finally able to stop the bleeding but DeFilippo's liver was severely damaged, and over the next few days he became also sick for the hospital's facilities. I accepted him for transfer in order to stabilize him and effigy out what to do. When he arrived in our ICU, at 1:30 a.m. on a Sun, his ragged blackness hair was plastered to his sweaty forehead, his body was shaking, and his eye was racing at 114 beats a minute. He was delirious from fever, stupor, and depression oxygen levels.

"I need to get out!" he cried. "I need to get out!" He clawed at his gown, his oxygen mask, the dressings covering his abdominal wound.

"Tony, it'southward all right," a nurse said to him. "We're going to help you. You lot're in a hospital."

He shoved her out of the way — he was a big man — and tried to swing his legs out of the bed. We turned upward his oxygen flow, put his wrists in cloth restraints, and tried to reason with him. He eventually tired out and let the states depict blood and give him antibiotics.

The laboratory results came back showing liver failure and a steeply elevated white blood jail cell count, indicating infection. Information technology soon became evident from his empty urine bag that his kidneys had failed, too. In the adjacent few hours, his blood force per unit area barbarous, his breathing worsened, and he drifted from agitation to virtually unconsciousness. Each of his organ systems, including his encephalon, was shutting downwards.

I chosen his sister, his next of kin, and told her the state of affairs. "Do everything y'all tin can," she said.

So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his pharynx. Another resident "lined him upwardly." She inserted a sparse two-inch-long needle and catheter through his upturned correct wrist and into his radial artery, then sewed the line to his skin with a silk suture. Side by side, she put in a central line — a twelve-inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where information technology was supposed to — inside his vena cava at the entrance to his centre — she put a tertiary, slightly thicker line, for dialysis, through his right upper breast and into the subclavian vein, deep under the collarbone.

We hooked a animate tube up to a hose from a ventilator and set it to requite him fourteen forced breaths of 100 percent oxygen every infinitesimal. We dialed the ventilator pressures and gas period upwardly and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood force per unit area measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume done through this artificial kidney and back into his torso; a little adjustment hither and in that location, and we could modify the levels of potassium and bicarbonate and salt, as well. He was, we liked to imagine, a simple automobile in our hands.

Just he wasn't, of course. Information technology was as if we had gained a steering bike and a few gauges and controls, but on a runaway 18-wheeler hurtling down a mount. Keeping that patient's blood force per unit area normal required gallons of intravenous fluid and a chemist's shelf of drugs. He was on near- maximal ventilator support. His temperature climbed to 104 degrees. Less than five percent of patients with DeFilippo's degree of organ failure make it home. A single misstep could easily erase those slender chances.

For 10 days, though, we made progress. DeFilippo'south chief problem had been liver damage from his prior operation: the chief duct from his liver was severed and was leaking bile, which is caustic — it digests the fat in one'southward diet and was substantially eating him live from the inside. He had get also sick to survive an operation to repair the leak. And so once we had stabilized him, we tried a temporary solution — nosotros had radiologists place a plastic drain, using CT guidance, through his abdominal wall and into the severed duct in club to draw out the leaking bile. They institute so much that they had to identify three drains — one inside the duct and two around it. But, as the bile drained out, his fevers subsided. His need for oxygen and fluids macerated, and his claret pressure returned to normal. He was get-go to mend. So, on the eleventh day, only equally nosotros were getting gear up to take him off the ventilator, he again developed high, spiking fevers, his blood pressure sank, and his blood-oxygen levels plummeted again. His pare became clammy. He got shaking chills.

We couldn't sympathize what had happened. He seemed to have developed an infection, merely our X-rays and CT scans failed to turn upward a source. Even after we put him on four antibiotics, he connected to spike fevers. During one fever, his heart went into fibrillation. A Code Bluish was chosen. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him. His heart responded and went back into rhythm. It took 2 more days for united states to figure out what had gone incorrect. Nosotros considered the possibility that i of his lines had become infected, so we put in new lines and sent the onetime ones to the lab for culturing. Xl- eight hours afterward, the results returned. All the lines were infected. The infection had probably started in one line, which peradventure was contaminated during insertion, and spread through DeFilippo's bloodstream to the others. And so they all began spilling leaner into him, producing the fevers and steep decline.

This is the reality of intensive intendance: at any bespeak, nosotros are as apt to damage as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put 5 1000000 lines into patients each year, and national statistics show that afterwards ten days four percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. Afterward ten days with a urinary catheter, 4 percent of American ICU patients develop a bladder infection. After ten days on a ventilator, vi percent develop bacterial pneumonia, resulting in decease 40 to 45 percent of the time. All in all, about half of ICU patients end up experiencing a serious complication, and one time that occurs the chances of survival drop sharply.

It was another calendar week before DeFilippo recovered sufficiently from his infections to come up off the ventilator and two months earlier he left the hospital. Weak and debilitated, he lost his limousine business and his home, and he had to movement in with his sister. The tube draining bile still dangled from his belly; when he was stronger, I was going to accept to do surgery to reconstruct the main bile duct from his liver. But he survived. About people in his situation practice not.

Hither, then, is the fundamental puzzle of modern medical care: you have a desperately ill patient and in order to have a chance of saving him you take to get the knowledge right and then you have to brand sure that the 178 daily tasks that follow are washed correctly — despite some monitor's alarm going off for God knows what reason, despite the patient in the side by side bed crashing, despite a nurse poking his head around the curtain to inquire whether someone could help "get this lady'due south chest open." There is complexity upon complexity. And even specialization has begun to seem inadequate. So what do you practise?

The medical profession's answer has been to go from specialization to superspecialization. I told DeFilippo's ICU story, for instance, every bit if I were the 1 tending to him hour by hour. That, however, was actually an intensivist (every bit intensive care specialists like to be called). Equally a general surgeon, I like to think I can handle nigh clinical situations. But, as the intricacies involved in intensive care have grown, responsibility has increasingly shifted to super-specialists. In the past decade, grooming programs focusing on critical care have opened in almost major American and European cities, and half of American ICUs now rely on superspecialists.

Expertise is the mantra of modernistic medicine. In the early twentieth century, you lot needed but a loftier schoolhouse diploma and a one-twelvemonth medical caste to practice medicine. By the century'southward end, all doctors had to have a college degree, a four-year medical degree, and an additional 3 to 7 years of residency grooming in an private field of practice — pediatrics, surgery, neurology, or the similar. In recent years, though, even this level of preparation has not been plenty for the new complexity of medicine. After their residencies, well-nigh young doctors today are going on to do fellowships, calculation one to three further years of preparation in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology, or critical intendance. A young doctor is not then young present; you typically don't offset in independent practice until your midthirties.

We alive in the era of the superspecialist — of clinicians who have taken the time to practice, practice, practice at one narrow thing until they can practise it better than anyone else. They have two advantages over ordinary specialists: greater knowledge of the details that matter and a learned ability to handle the complexities of the particular job. There are degrees of complexity, though, and medicine and other fields similar it take grown and then far across the usual kind that avoiding daily mistakes is proving incommunicable even for our most superspecialized.

There is perhaps no field that has taken specialization further than surgery. Call back of the operating room as a particularly aggressive intensive care unit. We have anesthesiologists just to handle pain control and patient stability, and even they have divided into subcategories. At that place are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists, and many others. Likewise, we no longer take but "operating room nurses." They too are often subspecialized for specific kinds of cases.

So of grade in that location are the surgeons. Surgeons are then absurdly ultraspecialized that when we joke about correct ear surgeons and left ear surgeons, we have to bank check to be sure they don't exist. I am trained as a general surgeon but, except in the most rural places, at that place is no such thing. You lot really can't practise everything anymore. I decided to heart my practice on surgical oncology — cancer surgery — but even this proved too wide. So, although I accept done all I tin can to hang on to a broad span of general surgical skills, peculiarly for emergencies, I've developed a detail expertise in removing cancers of endocrine glands.

The result of the recent decades of e'er-refined specialization has been a spectacular improvement in surgical capability and success. Where deaths were one time a double-digit take a chance of even minor operations, and prolonged recovery and inability was the norm, day surgery has become commonplace.

Yet given how much surgery is at present washed — Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty meg operations annually — the amount of impairment remains substantial. We continue to have upwardly of 150,000 deaths post-obit surgery every year — more than iii times the number of route traffic fatalities. Moreover, enquiry has consistently showed that at least one-half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are withal made.

Medicine, with its dazzling successes but besides frequent failures, therefore poses a meaning challenge: What do you do when expertise is not enough? What do you do when even the super-specialists fail? We've begun to see an answer, but it has come from an unexpected source — one that has nothing to exercise with medicine at all.

Excerpted from The Checklist Manifesto by Atul Gawande. Copyright 2009 by Atul Gawande. Published in 2010 by Henry Holt and Co. All rights reserved. This piece of work is protected under copyright laws and reproduction is strictly prohibited. Permission to reproduce the fabric in any manner or medium must be secured from the publisher.

joneswhippercunch.blogspot.com

Source: https://www.npr.org/templates/story/story.php?storyId=122226184

Share this post