The Checklist Manifesto_ How to Get Things Right - Atul Gawande [77]
I had one case, however, in which I know for sure the checklist saved my patient’s life. Mr. Hagerman, as we’ll call him, was a fifty-three-year-old father of two and the CEO of a local company, and I had brought him to the operating room to remove his right adrenal gland because of an unusual tumor growing inside it called a pheochromocytoma. Tumors like his pour out dangerous levels of adrenalin and can be difficult to remove. They are also exceedingly rare. But in recent years, I’ve developed alongside my general surgery practice a particular interest and expertise in endocrine surgery. I’ve now removed somewhere around forty adrenal tumors without complication. So when Mr. Hagerman came to see me about this strange mass in his right adrenal gland, I felt quite confident about my ability to help him. There is always a risk of serious complications, I explained—the primary danger occurs when you’re taking the gland off the vena cava, the main vessel returning blood to the heart, because injuring the vena cava can cause life-threatening bleeding. But the likelihood was low, I reassured him.
Once you’re in the operating room, however, you either have a complication or you don’t. And with him I did.
I was doing the operation laparoscopically, freeing the tumor with instruments I observed on a video monitor using a fiberoptic camera we put inside Mr. Hagerman. All was going smoothly. I was able to lift the liver up and out of the way, and underneath I found the soft, tan yellow mass, like the yolk of a hard-boiled egg. I began dissecting it free of the vena cava, and although doing so was painstaking, it didn’t seem unusually difficult. I’d gotten the tumor mostly separated when I did something I’d never done before: I made a tear in the vena cava.
This is a catastrophe. I might as well have made a hole directly in Mr. Hagerman’s heart. The bleeding that resulted was terrifying. He lost almost his entire volume of blood into his abdomen in about sixty seconds and went into cardiac arrest. I made a huge slashing incision to open his chest and belly as fast and wide as I could. I took his heart in my hand and began compressing it—one-two-three-squeeze, one-two-three-squeeze—to keep his blood flow going to his brain. The resident assisting me held pressure on the vena cava to slow the torrent. But in the grip of my fingers, I could feel the heart emptying out.
I thought it was over, that we’d never get Mr. Hagerman out of the operating room alive, that I had killed him. But we had run the checklist at the start of the case. When we had come to the part where I was supposed to discuss how much blood loss the team should be prepared for, I said, “I don’t expect much blood loss. I’ve never lost more than one hundred cc’s.” I was confident. I was looking forward to this operation. But I added that the tumor was pressed right up against the vena cava and that significant blood loss remained at least a theoretical concern. The nurse took that as a cue to check that four units of packed red cells had been set aside in the blood bank, like they were supposed to be—“just in case,” as she said.
They hadn’t been, it turned out. So the blood bank got the four units ready. And as a result, from this one step alone, the checklist saved my patient’s life.
Just as powerful, though, was the effect that the routine of the checklist—the discipline—had on us. Of all the people in the room as we started that operation—the anesthesiologist, the nurse anesthetist, the surgery resident, the scrub nurse, the circulating nurse, the medical student—I had worked with only two before, and I knew only the resident well. But as we went around the room