The Checklist Manifesto_ How to Get Things Right - Atul Gawande [43]
The patient was a big man with a short neck and not much lung reserve, making it potentially difficult to place a breathing tube when Zhi sent him off to sleep. But Zhi had warned us of the possibility of trouble and everyone was ready with a backup plan and the instruments he and Thor might need. When Joaquim and I opened up the patient, we found that the right colon was black with gangrene—it had died—but it had not ruptured, and the remaining three-fourths of the colon and all the small bowel seemed to be okay. This was actually good news. The problem was limited. As we began removing the right colon, however, it became evident that the rest of the colon was not, in fact, in good shape. Where it should have been healthy pink, we found scattered dime-and quarter-sized patches of purple. The blood clots that had blocked off the main artery to the right colon had also showered into the arterial branches of the left side. We would have to remove the patient’s entire colon, all four feet of it, and give him an ostomy—a bag for his excreted wastes. Steve, thinking ahead, asked Jay to grab a retractor we’d need. Joaquim nudged me to make the abdominal incision bigger, and he stayed with me at every step, clamping, cutting, and tying as we proceeded inch by inch through the blood vessels tethering the patient’s colon. The patient began oozing blood from every raw surface—toxins from the gangrene were causing him to lose his ability to clot. But Zhi and Thor kept up with the fluid requirements and the patient’s blood pressure was actually better halfway through than it had been at the beginning. When I mentioned that I thought the patient would need an ICU, Zhi told me he’d already arranged it and briefed the intensivist.
Because we’d worked as a single unit, not as separate technicians, the man survived. We were done with the operation in little more than two hours; his vital signs were stable; and he would leave the hospital just a few days later. The family gave me the credit, and I wish I could have taken it. But the operation had been symphonic, a thing of orchestral beauty.
Perhaps I could claim that the teamwork itself had been my doing. But its origins were mysterious to me. I’d have said it was just the good fortune of the circumstances—the accidental result of the individuals who happened to be available for the case and their particular chemistry on that particular afternoon. Although I operated with Zhi frequently, I hadn’t worked with Jay or Steve in months, Joaquim in even longer. I’d worked with Thor just once. As a group of six, we’d never before done an operation together. Such a situation is not uncommon in hospitals of any significant size. My hospital has forty-two operating rooms, staffed by more than a thousand personnel. We have new nurses, technicians, residents, and physician staff almost constantly. We’re virtually always adding strangers to our teams. As a consequence, the level of teamwork—an unspoken but critical component of success in surgery—is unpredictable. Yet somehow, from the moment we six were all dropped together into this particular case, things clicked. It had been almost criminally enjoyable.
This seemed like luck, as I say. But suppose it wasn’t. That’s what the checklists from Toronto and Hopkins and Kaiser raised as a possibility. Their insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork—a kind of team huddle, as it were. So was another step that these checklists employed, one that was quite unusual in my experience: surgical staff members were expected to stop and make sure that everyone knew one another’s names.
The Johns Hopkins checklist spelled this out most explicitly. Before starting an operation with a new team, there was a check to ensure everyone introduced themselves by name and role: “I’m Atul Gawande, the attending surgeon