The Checklist Manifesto_ How to Get Things Right - Atul Gawande [42]
Teamwork may just be hard in certain lines of work. Under conditions of extreme complexity, we inevitably rely on a division of tasks and expertise—in the operating room, for example, there is the surgeon, the surgical assistant, the scrub nurse, the circulating nurse, the anesthesiologist, and so on. They can each be technical masters at what they do. That’s what we train them to be, and that alone can take years. But the evidence suggests we need them to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results. This requires finding a way to ensure that the group lets nothing fall between the cracks and also adapts as a team to what ever problems might arise.
I had assumed that achieving this kind of teamwork was mostly a matter of luck. I’d certainly experienced it at times—difficult operations in which everyone was nonetheless firing on all cylinders, acting as one. I remember an eighty-year-old patient who required an emergency operation. He had undergone heart surgery the week before and had been recovering nicely. But during the night he’d developed a sudden, sharp, unrelenting pain in his abdomen, and over the course of the morning it had mounted steadily in severity. I was asked to see him from general surgery. I found him lying in bed, prostrate with pain. His heart rate was over one hundred and irregular. His blood pressure was dropping. And wherever I touched his abdomen, the sensation made him almost leap off the bed in agony.
He knew this was trouble. His mind was completely sharp. But he didn’t seem scared.
“What do we need to do?” he asked between gritted teeth.
I explained that I believed his body had thrown a clot into his intestine’s arterial supply. It was as if he’d had a stroke, only this one had cut off blood flow to his bowel, not his brain. Without blood flow, his bowel would turn gangrenous and rupture. This was not survivable without surgery. But, I also had to tell him, it was often not survivable even with surgery. Perhaps half of the patients in his circumstance make it through. If he was one of them, there would be many complications to worry about. He might need a ventilator or a feeding tube. He’d already been through one major operation. He was weak and not young. I asked him if he wanted to go ahead.
Yes, he said, but he wanted me to speak with his wife and son first. I reached them by phone. They too said to proceed. I called the operating room control desk and explained the situation. I needed an OR and a team right away. I’d take what ever and whoever were available.
We got him to the OR within the hour. And as people assembled and set to work, there was the sense of a genuine team taking form. Jay, the circulating nurse, introduced himself to the patient and briefly explained what everyone was doing. Steve, the scrub nurse, was already gowned and gloved, standing by with the sterile instruments at the ready. Zhi, the senior anesthesiologist, and Thor, his resident, were conferring, making sure they had their plans straight, as they set out their drugs and equipment. Joaquim, the surgery resident, stood by with a Foley catheter, ready to slip it into the patient’s bladder as soon as he was asleep.
The clock was ticking. The longer we took, the more bowel would die. The more bowel that died, the sicker the man would become and the lower his chance of survival. Everyone understood this, which by itself was a lot. People don’t always get it—really feel the urgency of the patient’s condition. But