The Checklist Manifesto_ How to Get Things Right - Atul Gawande [2]
John said they thought of that, too. The airway was fine. And as for the lab tests, they would take at least twenty minutes to get results, by which point it would be too late.
Could it be a collapsed lung—a pneumothorax? There were no signs of it. They listened with a stethoscope and heard good air movement on both sides of the chest.
The cause therefore had to be a pulmonary embolism, I said—a blood clot must have traveled to the patient’s heart and plugged off his circulation. It’s rare, but patients with cancer undergoing major surgery are at risk, and if it happens there’s not much that can be done. One could give a bolus of epinephrine—adrenalin—to try to jump-start the heart, but it wouldn’t likely do much good.
John said that his team had come to the same conclusion. After fifteen minutes of pumping up and down on the patient’s chest, the line on the screen still flat as death, the situation seemed hopeless. Among those who arrived to help, however, was a senior anesthesiologist who had been in the room when the patient was being put to sleep. When he left, nothing seemed remotely off-kilter. He kept thinking to himself, someone must have done something wrong.
He asked the anesthesiologist in the room if he had done anything different in the fifteen minutes before the cardiac arrest.
No. Wait. Yes. The patient had had a low potassium level on routine labs that were sent during the first part of the case, when all otherwise seemed fine, and the anesthesiologist had given him a dose of potassium to correct it.
I was chagrined at having missed this possibility. An abnormal level of potassium is a classic cause of asystole. It’s mentioned in every textbook. I couldn’t believe I overlooked it. Severely low potassium levels can stop the heart, in which case a corrective dose of potassium is the remedy. And too much potassium can stop the heart, as well—that’s how states execute prisoners.
The senior anesthesiologist asked to see the potassium bag that had been hanging. Someone fished it out of the trash and that was when they figured it out. The anesthesiologist had used the wrong concentration of potassium, a concentration one hundred times higher than he’d intended. He had, in other words, given the patient a lethal overdose of potassium.
After so much time, it wasn’t clear whether the patient could be revived. It might well have been too late. But from that point on, they did everything they were supposed to do. They gave injections of insulin and glucose to lower the toxic potassium level. Knowing that the medications would take a good fifteen minutes to kick in—way too long—they also gave intravenous calcium and inhaled doses of a drug called albuterol, which act more quickly. The potassium levels dropped rapidly. And the patient’s heartbeat did indeed come back.
The surgical team was so shaken they weren’t sure they could finish the operation. They’d not only nearly killed the man but also failed to recognize how. They did finish the procedure, though. John went out and told the family what had happened. He and the patient were lucky. The man recovered—almost as if the whole episode had never occurred.
The stories surgeons tell one another are often about the shock of the unexpected—the bayonet in San Francisco, the cardiac arrest when all seemed fine—and sometimes about regret over missed possibilities. We talk about our great saves but also about our great failures, and we all have them. They are part of what we do. We like to think of ourselves as in control. But John’s stories got me thinking about what is really in our control and what is not.
In the 1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read during my surgical training and haven’t stopped pondering since. The question they sought to answer was why we fail at what we set out to do in the world. One reason, they observed, is “necessary fallibility”—some things we want to do are simply beyond our