Reviews and Reflections David A
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Reviews and reflections David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors There are a thousand ways that rective dose of potassium is the rem- things can go wrong when you’ve edy. And too much potassium can got a patient with a stab wound. But stop the heart, as well—that’s how everyone involved got almost every the states execute prisoners. step right—the head-to-toe exami- The senior anesthesiologist nation, the careful tracking of the asked to see the potassium bag that patient’s blood pressure and pulse had been hanging. Someone fished and rate of breathing, the monitor- it out of the trash and that was when ing of his consciousness, the fluids they figured it out. The anesthesiol- run in by IV, the call to the blood ogist had used the wrong concentra- bank to have blood ready, the place- tion of potassium, a concentration ment of a urinary catheter to make one hundred times higher than he’d sure his urine was running clear, intended. He had, in other words, everything. Except no one remem- given the patient a lethal dose of bered to ask the patient or the emer- potassium.p6 The Checklist Manifesto: How gency medical technicians what the To Get Things Right weapon was. Thepatientwasluckyandsurvived, “Your mind doesn’t think of a butGawandeusesthesestoriestoargue Atul Gawande bayonet in San Francisco,” John for a simple method to prevent such New York, Metropolitan Books, 2009 could only say.p3 errors, a checklist. In the first chapter Reviewed by David A. Bennahum, he writes about problems of extreme MD (AΩA, University of New Mexico, The staff knew that the patient had complexityandhowtrainingandprac- 1984) been stabbed, but he was comfortable tice can achieve astonishing results; and talking so no one thought to ask but he argues that in medicine we ex- withwhatandthenconsiderthepossi- pect miracles such as that offered by nThe Checklist Manifesto,hislatest bleconsequencesofadeepstabwound. penicillin. We have lost the discipline lucid and elegantly written analysis Inthesecondcase,apatientunder- that a methodical approach requires. Iof how to improve health care, Atul goingsurgerytoremoveacancerofthe More than 50 million operations are Gawande addresses the idea that the stomach suddenly went into cardiac performedannuallyintheUnitedStates simpleintroductionofcheckliststopa- arrest. Because the patient had a low and Americans undergo an average of tient care can reduce costs and save potassiumbeforesurgerytheanesthesi- seven operations in a lifetime. Yet we lives. In each of his books and essays ologisthadgivenhimcorrectivedoseof suffer150,000post-surgicaldeathseach Gawande has engaged the reader’s in- potassium.Gawandeinhisunderstated year.Gawandewrites: terestwithstoriesthatillustratespecific butdramaticstylequotesthesurgeon. points and problems. Here he begins Moreover, research has consistently with a surgical case that had been I was chagrined at having missed showed that at least half our deaths recounted to him by a physician this. An abnormal level of potas- and major complications are avoid- colleagueaboutapatientwho sium is a classic cause of asystole. able. The knowledge exists. But had almost exsanguinated It’s mentioned in every textbook. however supremely specialized and from an abdominal stab I couldn’t believe I overlooked it. trained we may have become, steps woundsodeepithad Severely low potassium levels can are still missed. Mistakes are still cuttheaorta. stop the heart, in which case a cor- made.p31 46 The Pharos/Winter2011 To better understand this idea Gawande finds that checklists “are Gawande turns to the introduction not comprehensive how-to guides, of checklists in 1935 by the U.S. Army whether for building a skyscraper or Aircorpswhenitwasflight-testingthe getting a plane out of trouble. They aircraft that would become the B17 are quick and simple tools aimed to bomber, the famous Flying Fortress. buttresstheskillsofexpertprofession- After a number of flight failures the als.”p128 He writes that on January 14, aeronauticalengineersrealizedthatthe 2009 the World Health Organization complexity of the modern airplane re- came out with a “Safe Surgery” check- quired not better test pilots but rather list.TheverynextdayCaptainChesley a simple method to prevent mistakes, B. Sullenberger III saved U.S. Airways thechecklist.Hefollowsthisbyremind- Flight1549afteraflockofCanadageese ingthereaderofthefourvitalsignsto flew into and stalled his aircraft’s en- which a fifth sign, pain, has recently gines. While the cool demeanor, good beenaddedandaskswhethertheseare judgment, and experience of the pilots notcheckliststhatguidenurses. andcrewwerecrucial,nolesssowere The Jump Artist Gawande recounts the remarkable theyearsofattentiontodetailandthe experience of Dr. Peter Pronovost at relentless discipline of their aviation Austin Ratner JohnsHopkinsin2001.Provonostiden- checklists. New York, Bellevue Literary Press, 2009 tified five steps that a physician must This is a marvelous and elegant Reviewed by Jeffrey L. Ponsky, take to place a central line and then book.Itisanimportantifverysimple— MD (AΩA, Case Western Reserve asked the nurses to observe whether butnotsimplistic—contributiontothe University, 1971) every physician unfailingly followed medical literature, as is almost every- each step. In more than a third of the thingthatGawandewrites.Whilemost patients, doctors skipped at least one. of the book focuses on the application nthetraditionofChekhov,Somerset Pronovost then persuaded the hospital ofcheckliststotechnicalpractice,there Maugham, and William Carlos administration to allow the nurses to isonepointthatIfoundveryappealing. IWilliamscomesanotherMDwhowrites stop any physician who had skipped a Gawande describes that as a surgeon beautiful and compelling literary fic- step. Over the next year “the ten-day introducing the checklist to his own tion.AustinRatner,agraduateofJohns line-infectionratewentfrom11percent surgical teams he now asks that they HopkinsMedicalSchool,turnedtofic- to zero.”p38 Only two line infections begin each operation by reintroducing tionasacareerafterreceivinghisMD. occurredoverthenextfifteenmonths! themselvestoeachother,therebylevel- His debut novel, The Jump Artist is a Pronovost had proven that checklists ingthedistinctionsbetweenphysicians, worthyadditiontotheranksofliterary raisedbaselineperformance. nurses, and technicians and creating historicalfiction. Gawandethengoesontoexplorethe a team of the moment for the ben- Thehistorythatformsthebasisfor use of checklists in several industries efitofthepatient.CaptainSullenberger thenovelisfascinatingandlargelyun- and the literature on complexity. He pointed out that he and his crew were known.PhilippeHalsmanwasayoung reports that researchers have defined also a team, each equally important to Latvian Jew hiking with his father in three categories of problems: simple, the final outcome. At the core of The the Tyrolean Alps when his father such as baking a cake; complicated, Checklist Manifestoisapleaforanethic fell to his death while walking behind such as sending a rocket to the moon; ofrelationshipbetweenindividualswho Philippe on the hiking path. In an af- andcomplex,suchasraisingachild.He worktogetheronanyprojectandespe- fair dubbed in Europe “The Austrian notestheevidenceinfavorofchecklists cially for those with a commitment to Dreyfuss Affair,” Philippe was arrested for simple and complicated problems, excellentpatientcare. and convicted of his father’s murder then asks whether checklists are also and imprisoned in an Austrian jail for helpful in situations of great complex- Dr.Bennahumisabookrevieweditorfor two years, despite only circumstantial ity. To address that question he cites The Pharosandamemberofitseditorial evidence. The young, still adolescent data from the building industry about board.Heisemeritus professorofInternal Halsman was thrown into a world of the construction of massive skyscrap- MedicineattheUniversityofNewMexico horror and only released by a pardon, ers.Andthereagainhefoundchecklists SchoolofMedicine.Hisaddressis: not an exoneration, after the tireless ateveryleveland“anannualavoidable 1707NotreDameDriveNE efforts of his sister Liouba and the as- failure rate of less than 0.00002 per- Albuquerque,NewMexico87106 sistance of human rights activists all cent.”p71 E-mail:[email protected] overtheworld,includingsuchnotables The Pharos/Winter2011 47 Reviews and reflections asAlbertEinstein,ThomasMann,and worldand,asthenovelbuilds,weroot family afloat financially and to further EleanorRoosevelt.Afterbeingreleased forhissuccess,hopinghewillovercome herfavoritechild’sambitiousgoals.This from prison, the young Halsman was thetragedyofhisyouth.Itisnotjustthe storyisinterwovenwiththehistoryof expelledfromAustriapermanentlyand storythatstayswithyou,itisHalsman the gradual recognition of Hodgkin’s went to Paris, to try fulfill his father’s thehumanbeing. disease as an entity, from Thomas dreamforhimofbecominganengineer As physicians we are always strug- Hodgkin’s original cases to Dorothy ordoctor.Aftermuchstruggle,Philippe gling to understand the human condi- Reed’s defining pathologic description, becameawell-knownParisianphotog- tion.Thisstunningnoveldoeswhatall aswellasthedevelopmentofradiation rapher,onlytofleeParisastheNazisin- truly fine novels should do. It illumi- therapy from a scientific curiosity to a vaded.Pennilessandstateless,Philippe nates an understanding of the human emigratedtotheUnitedStatesandrose condition through its moving explora- to become one of the country’s