The Checklist Manifesto_ How to Get Things Right - Atul Gawande [60]
Walking through St. Mary’s sixteen operating rooms, I found they looked much the same as the ones where I work in Boston—high-tech, up-to-date. But surgical procedures seemed different at every stage. The patients were put to sleep outside the operating theater, instead of inside, and then wheeled in, which meant that the first part of the checklist would have to be changed. The anesthetists and circulating nurses didn’t wear masks, which seemed like sacrilege to me, although I had to admit their necessity is unproven for staff who do not work near the patient’s incision. Almost every term the surgical teams used was unfamiliar. We all supposedly spoke English, but I was often unsure what they were talking about.
In Jordan, the working environment was also at once recognizable and alien, but in a different way. The operating rooms in Amman had zero frills—this was a still-developing country and the equipment was older and heavily used—but they had most of the things I am used to as a surgeon, and the level of care seemed very good. One of the surgeons I met was Iraqi. He’d trained in Baghdad and practiced there until the chaos following the American invasion in 2003 forced him to flee with his family, abandoning their home, their savings, and his work. Before Saddam Hussein, in the last years of his rule, gutted the Iraqi medical system, Baghdad had provided some of the best medical care in the Middle East. But, the surgeon said, Jordan now seemed positioned to take that role and he felt fortunate to be there. I learned that more than 200,000 foreign patients travel to Jordan for their health care each year, generating as much as one billion dollars in revenues for the country.
What I couldn’t work out, though, was how the country’s strict gender divide was negotiated in its operating rooms. I remember sitting outside a restaurant the day I arrived, studying the people passing by. Men and women were virtually always separated. Most women covered their hair. I got to know one of the surgery residents, a young man in his late twenties who was my guide for the visit. We even went out to see a movie together. When I learned he had a girlfriend of two years, a graduate student, I asked him how long it was before he got to see her hair.
“I never have,” he said.
“C’mon. Never?”
“Never.” He’d seen a few strands. He knew she had dark brown hair. But even in the more modern dating relationship of a partly Westernized, highly educated couple, that was it.
In the operating rooms, all the surgeons were men. Most of the nurses were women. The anesthetists split half and half. Given the hierarchies, I wondered whether the kind of team-work envisioned by the checklist was even possible. The women wore their head scarves in the operating rooms. Most avoided eye contact with men. I slowly learned, however, that not all was what it seemed. The staff didn’t hesitate to discard the formalities when necessary. I saw a gallbladder operation in which the surgeon inadvertently contaminated his glove while adjusting the operating lights. He hadn’t noticed. But the nurse had.
“You have to change your glove,” the nurse told him in Arabic. (Someone translated for me.)
“It’s fine,” the surgeon said.
“No, it’s not,” the nurse said. “Don’t be stupid.” Then she made him change his glove.
For all the differences