The Checklist Manifesto_ How to Get Things Right - Atul Gawande [1]
“Which was crazy,” John said. Another surgeon joined to help and got a fist down on the aorta, above the puncture point. That stopped the worst of the bleeding and they began to get control of the situation. John’s colleague said he hadn’t seen an injury like it since Vietnam.
The description was pretty close, it turned out. The other guy at the costume party, John later learned, was dressed as a soldier—with a bayonet.
The patient was touch and go for a couple days. But he pulled through. John still shakes his head ruefully when he talks about the case.
There are a thousand ways that things can go wrong when you’ve got a patient with a stab wound. But everyone involved got almost every step right—the head-to-toe examination, the careful tracking of the patient’s blood pressure and pulse and rate of breathing, the monitoring of his consciousness, the fluids run in by IV, the call to the blood bank to have blood ready, the placement of a urinary catheter to make sure his urine was running clear, everything. Except no one remembered to ask the patient or the emergency medical technicians what the weapon was.
“Your mind doesn’t think of a bayonet in San Francisco,” John could only say.
He told me about another patient, who was undergoing an operation to remove a cancer of his stomach when his heart suddenly stopped.* John remembered looking up at the cardiac monitor and saying to the anesthesiologist, “Hey, is that asystole?” Asystole is total cessation of heart function. It looks like a flat line on the monitor, as if the monitor is not even hooked up to the patient.
The anesthesiologist said, “A lead must have fallen off,” because it seemed impossible to believe that the patient’s heart had stopped. The man was in his late forties and had been perfectly healthy. The tumor was found almost by chance. He had gone to see his physician about something else, a cough perhaps, and mentioned he’d been having some heartburn, too. Well, not heartburn exactly. He felt like food sometimes got stuck in his esophagus and wouldn’t go down and that gave him heartburn. The doctor ordered an imaging test that required him to swallow a milky barium drink while standing in front of an X-ray machine. And there on the images it was: a fleshy mouse-size mass, near the top of the stomach, intermittently pressing up against the entrance like a stopper. It had been caught early. There were no signs of spread. The only known cure was surgery, in this case a total gastrectomy, meaning removal of his entire stomach, a major four-hour undertaking.
The team members were halfway through the procedure. The cancer was out. There’d been no problems whatsoever. They were getting ready to reconstruct the patient’s digestive tract when the monitor went flat-line. It took them about five seconds to figure out that a lead had not fallen off. The anesthesiologist could feel no pulse in the patient’s carotid artery. His heart had stopped.
John tore the sterile drapes off the patient and started doing chest compressions, the patient’s intestines bulging in and out of his open abdomen with each push. A nurse called a Code Blue.
John paused here in telling the story and asked me to suppose I was in his situation. “So, now, what would you do?”
I tried to think it through. The asystole happened in the midst of major surgery. Therefore, massive blood loss would be at the top of my list. I would open fluids wide, I said, and look for bleeding.
That’s what the anesthesiologist said, too. But John had the patient’s abdomen completely open. There was no bleeding, and he told the anesthesiologist so.
“He couldn’t believe it,” John said. “He kept saying, ‘There must be massive bleeding! There must be massive bleeding!’ ” But there was none.
Lack of oxygen was also a possibility. I said I’d put the oxygen at 100 percent and check the airway. I’d also draw blood and send